Unneeded Interventions Research Articles

An unknown situs viscerum inversus totalis, accidentally discovered after computed tomography

Benign situs inversus totalis of the viscerum is often diagnosed accidentally, rarely in adults, and more frequently in children and neonates, affecting both sexes. In this report, a young female patient accidentally discovered a situs inversus totalis after computed tomography for acute abdominal pain. In this uncommon anatomical abnormality, the major visceral organs are reversed in the opposite direction. This report highlights the importance of being aware of and considering situs inversus in clinical practice, particularly when interpreting imaging findings and planning medical procedures. This is critical for differential diagnosis and comorbidities that may affect those patients. The cause of situs inversus totalis is still unknown; however, this condition is frequently asymptomatic, particularly in infants, and is sometimes associated with other syndromes. The patient arrived at the emergency department with left flank pain, nausea, and fever. In the first ultrasonography, a strange anatomy was suspected; thus, a contrasted computed tomography was performed. The patient had never had a computed tomography scan before. The identification of situs inversus totalis was unexpected and coincidental; the computed tomography images were carefully examined. In patients with chest or abdominal pain, clinicians may consider situs inversus totalis based on computed tomography, particularly if without clinical and imaging history. This knowledge can help in the differential diagnosis, avoiding unneeded interventions. Moreover, comorbidities that affect several systems, particularly cardiovascular and pulmonary systems, affect quite a few patients with situs inversus totalis, who require careful examination and lifelong monitoring.

A successful, cost-effective low back pain triage system: a pilot study

Background: Effective triage - directing patients with low back pain to appropriate treatment or correct referral - is fundamental to quality care. Without guidelines, a physician's initial decision may lead to unnecessary investigation, unneeded intervention or unwarranted consultation.Methods: To compare the functional outcomes of patients triaged by a classification based on clinical presentation with those of patients selected at the clinicians’ discretion, an insurance-owned hospital network employed forty-seven specially-trained physical therapists, working within participating primary care practices, to classify low back pain patients into specific Patterns of Pain. Between October 2017 and April 2019, the primary care physicians used this classification, derived entirely from the patient's history and physical examination, to direct subsequent treatment for 260 consecutive low back pain patients. Patients with systemic symptoms, recent substantial trauma or non-mechanical diagnoses indicative of spinal infections or possible malignancy were excluded. Functional outcome measures were spinal imaging, opioid use, length of treatment and number of visits, back-related unplanned care, frequency of spinal surgery and back-related episode cost. These were compared with a control group of 256 propensity-matched patients and, for assessing the financial impact, with a historic cohort of 111 previously treated, non-classified patients.Results: Spinal imaging: study group 24.5%; controls 42.2% (P< .001). Narcotic use: study group 4.6%; controls 13.3% (P< .001). Treatment length: study group 62.2 days; controls 74.5 days (P=.10). Treatment visits: study group 1528 visits; controls 2,046 visits (P=.003). Unplanned care: study group 1.9%; controls 12.8% (P< .001). Spine surgery: study group 15.4%; controls 26.2% (P=.005). Episode cost: study group $1453; controls $2334 (P=.005).Conclusions: A well-defined clinically-based triage system produced meaningful reductions in imaging, opioid use, treatment duration, unplanned interventions, surgery and cost of care.

Incorporating a Trauma-Informed Care Protocol Into Pediatric Trauma Evaluation: The Pediatric PAUSE Does Not Delay Imaging or Disposition.

Trauma evaluation in the emergency department (ED) can be a stressful event for children. With the goal of minimizing pain, anxiety, and unneeded interventions in stable patients, we implemented the Pediatric PAUSE at our level 1 adult/level 2 pediatric trauma center. The Pediatric PAUSE is a brief protocol performed after the primary survey, which addresses Pain/Privacy, Anxiety/IV Access, Urinary Catheter/Rectal exam/Genital exam, Support from family or staff, and Explain to patient/Engage with PICU team. The aim was to assess whether performing the PAUSE interfered with timeliness of emergent imaging in pediatric patients and their disposition. We identified all patients aged 0 to 18 years evaluated as trauma activations at our institution after the Pediatric PAUSE was implemented (October 1, 2016-March 31, 2017) as well as 2 analogous 6-month pre-PAUSE periods. Patient demographics, time to imaging studies, and time to ED disposition were analyzed. One hundred seventy-two patients met the study criteria, with a mean age of 10.9 years and mean injury severity score of 10.6. One hundred fifteen participants (68.5%) were transferred from other hospitals, and 101 (87.8%) had ≥1 imaging study performed before arrival. The Pediatric PAUSE was performed for 41 (25%) of 163 study participants. There was no difference in time to first imaging study in participants for whom the PAUSE was performed (18.4 vs 15.0 minutes, P = 0.09). The PAUSE is a practice intervention designed to address the psychosocial needs of pediatric trauma patients and their families to help prevent posttraumatic stress symptoms. Implementation did not interfere with the timeliness of first imaging in pediatric trauma patients.

Late diagnosis of duodenal obstruction associated with down syndrome: Similar presentation of different pathologies

Down syndrome is the most common chromosomal abnormality and is associated with a high incidence of upper gastrointestinal anomalies. Although these anomalies are commonly identified antenatally or in the early prenatal period, delayed presentation is possible. Herein, we describe two patients with Down syndrome who presented with persistent vomiting associated to a partial duodenal obstruction. Both patients presented for evaluation after a prolonged period of vomiting and severe dehydration. In both cases, gastrointestinal reflux had been suspected, resulting in inappropriate treatment. We proceeded with upper gastrointestinal radiographic series and endoscopy in both cases, which revealed classic features of duodenal obstruction, including dilation of the stomach and first/second segments of the duodenum. Laparotomy was used to confirm the diagnosis in both cases. In case one, findings of massive dilation of the esophagus and the stomach were reflective of a long-standing obstruction. In the second case, examination revealed a duodenal bulb with an annular structure and no appreciable lumen. Both patients were treated via open laparotomy, with a corrective duodeno-duodenostomy procedure performed for the patient in case one with annular pancreas and enterotomy and transverse closure performed for the patient in case 2 with an external obstruction. Both patients recovered without complications, with complete resolution of symptoms. As delayed diagnosis is associated with significant morbidities and unneeded interventions, physicians treating children with Down syndrome should have a high index of suspicion of the possibility of late presenting duodenal obstruction.

18F-FET PET for Diagnosis of Pseudoprogression of Brain Metastases in Patients With Non-Small Cell Lung Cancer.

To evaluate whether F-fluoroethyltyrosine (FET) PET can discriminate progression from pseudoprogression of brain metastases in patients with non-small cell lung cancer undergoing immunotherapy and radiotherapy to the brain. Retrospective analysis of F-FET PET scans in cases with documented progression of brain metastases on MRI in a cohort of 53 patients with non-small cell lung cancer receiving immune-checkpoint inhibitors and radiotherapy of brain metastases at the University Hospital of Zürich from June 2015 until January 2019. Response to radiotherapy was assessed by MRI. In case of equivocal findings and/or radiological progression in clinically asymptomatic patients, further assessment with F-FET PET was performed. From the cohort of 53 patients, the restaging MRI showed in 30 patients (56.6%) progression of at least 1 treated metastasis. Thereof, F-FET PET was performed in 11 patients, based on the absence of neurological symptoms or presence of systemic response and physicians' decision. F-FET PET correctly identified pseudoprogression in 9 of 11 patients (81.8%). In patients who did not undergo F-FET PET, 5 of 19 (26.3%) were diagnosed with pseudoprogression. Pseudoprogression of brain metastases occurred in 50% of patients diagnosed with progression on MRI. F-FET PET may help differentiate pseudoprogression from real progression in order to avoid discontinuation of effective therapy or unneeded interventions.

Incorporating a Trauma-Informed Care Protocol into Pediatric Trauma Evaluation: The Pediatric PAUSE© Does Not Delay Imaging or Disposition

Background: Trauma evaluation in the Emergency Department (ED) can be a stressful event for children. With the goal of minimizing pain, anxiety, and unneeded interventions in stable patients, we implemented a Pediatric PAUSE© at our Level 1 Adult/Level 2 Pediatric Trauma Center. The Pediatric PAUSE© is a brief protocol performed after the primary survey, which addresses Pain/Privacy, Anxiety/IV Access, Urinary Catheter/Rectal exam/Genital exam, Support from family or staff, and Explain to patient/Engage with PICU team. The aim was to assess whether performing the PAUSE© interfered with timeliness of emergent imaging in pediatric patients and their disposition. Methods: We identified all patients aged 0-18 years evaluated as trauma activations at our institution after the Pediatric PAUSE© was implemented (10/1/16-3/31/17) as well as two analogous 6-month pre-PAUSE© time periods. Patient demographics, time to imaging studies, and time to ED disposition were analyzed. Findings: One hundred and seventy-two patients met study criteria, with a mean age of 10.9 years and mean Injury Severity Score of 10.6. One hundred fifteen participants (68.5 %) were transferred from other hospitals, and 101 (87.8%) had ≥1 imaging study performed prior to arrival. The Pediatric PAUSE© was performed for 41/163 (25%) study participants. There was no difference in time to first imaging study in participants for whom the PAUSE© was performed (18.4 min vs 15.0 min, p=0.09). Interpretation: The PAUSE© is a practice intervention designed to address the psychosocial needs of pediatric trauma patients and their families to help prevent PTS symptoms. Implementation did not interfere with the timeliness of first imaging in pediatric trauma patients. Funding Statement: The authors state: No funding to disclose. Declaration of Interests: The authors declare: No conflicts of interests.' Ethics Approval Statement: The study protocol was approved by the Committee for the Protection of Human Subjects at our institution, granting access to our institution’s existing trauma database and the electronic health records of study patients (Dartmouth College Committee for the Protection of Human Subjections: Study #00030129).

1270. Are HIV-Related Diagnostics Excessively Ordered? A Pilot Intervention Study to Improve Test Use in the Inpatient Setting

BackgroundExcessive ordering of HIV-related laboratory tests (CD4 counts, HIV RNA levels, and HIV genotypes) may result in increased healthcare costs, unneeded interventions (e.g., response to low CD4 in acute illness), and patient anxiety. Recent data have evaluated methods to reduce excessive testing in outpatients, but there are limited data in the inpatient setting. The purpose of this study was to evaluate if implementation of a pharmacist-driven intervention protocol based on published guidelines improved utilization of HIV-related diagnostics in the inpatient setting.MethodsA pre-interventional study performed on HIV diagnostics usage over a 1-year period, followed by a 3-month post-interventional study at a large academic medical center to evaluate and improve HIV test ordering. Patients were included if ≥18 years old with suspected or documented HIV infection and CD4 count, HIV RNA level, or HIV genotype ordered. A pharmacist-driven intervention was undertaken in which ordered tests were evaluated and canceled if deemed inappropriate per pre-specified criteria based on CDC and DHHS guidelines, and clinicians were provided education on appropriate ordering. Results were tabulated and presented as descriptive statistics, and financial data were calculated based on in-hospital costs.ResultsIn the pre-intervention arm, 87% (296/341) of total tests ordered did not meet criteria for appropriate ordering (160 unneeded CD4 counts, 126 RNA levels, and 10 genotypes). These tests resulted in excessive financial burden of $24,600. Post-intervention, 63% (32/51) of HIV-related tests were canceled netting an initial savings of $2,700. Most common cancelation reason was recent outpatient laboratories readily available. Post-intervention, HIV-related testing decreased over time, likely due to the intervention audit and feedback provided to clinicians.ConclusionA pharmacist-driven intervention reduced the number of unnecessary HIV-associated tests by 63% and offered significant cost savings. These data suggest the importance of evaluating the appropriateness of HIV-related diagnostic testing in the inpatient setting to improve test usage and reduce excessive healthcare costs.Disclosures All authors: No reported disclosures.

To image or not in noncyclic breast pain? A systematic review.

Investigation of noncyclic mastalgia in women without signs or risk factors for cancer is controversial. An initial imaging strategy can diagnose breast cancer early, potentially leading to better treatment and survival. However, cancer diagnosis is very uncommon in these cases, and this approach can be harmful, as false positives or suspicion results will lead to unneeded interventions and follow-up. The purpose of this review is to analyse the trade-offs between desirable and undesirable consequences of initial imaging tests against clinical follow-up. We found seven relevant studies, all observational, with some methodological limitations and very low-quality evidence. They showed low breast cancer prevalence (around 1-2%, increasing with age), high sensitivity to rule out disease but moderate specificity to rule it in using mammography and echography, and lacked evidence on follow-up and final outcomes. There is a low prevalence of breast cancer in patients with painful breast with negative physical examination, and very little research to inform about the effect of performing or avoiding initial imaging test on outcomes of interest. With such limited evidence, only a weak recommendation to reinforce shared decision making about what should be done in the primary care setting can be made, with the backup of a specialized breast unit.

The opinion of Turkish cardiologists on current malpractice system and an alternative patient compensation system proposal: PCS study group.

Cardiologists participate in the diagnosis and interventional treatment of numerous high-risk patients. The goal of this study was to investigate how the current malpractice system in Turkey influences cardiologists' diagnostic and interventional behavior and to obtain their opinions about an alternative patient compensation system. The present cross-sectional study assessed the practice of defensive medicine among cardiologists who are actively working in various types of workplace within the Turkish healthcare system. A 24-item questionnaire was distributed to cardiology residents, specialists, and academics in Turkey in print format, by electronic mail, or via cell phone message. A total of 253 cardiologists responded to the survey. Among them, 29 (11.6%) had been sued for malpractice claims in the past. Of the cardiologists who had been sued, 2 (6.9%) had been ordered to pay financial compensation, and 1 (3.4%) was given a sentence of imprisonment due to negligence. In all, 132 (52.8%) of the surveyed cardiologists reported that they had changed their practices due to fear of litigation, and 232 (92.8%) reported that they would prefer the new proposed patient compensation system to the current malpractice system. Among the cardiologists surveyed, 78.8% indicated that malpractice fear had affected their decision-making with regard to requesting computed tomography angiography or thallium scintigraphy, 71.6% for coronary angiography, 20% for stent implantation, and 83.2% for avoiding treating high-risk patients. The results of this survey demonstrated that cardiologists may request unnecessary tests and perform unneeded interventions due to the fear of malpractice litigation fear. Many also avoid high-risk patients and interventions. The majority indicated that they would prefer the proposed alternative patient compensation system to the current malpractice system.

Cortical Blindness, Transient and Otherwise, Associated with Detachable Coil Embolization of Intracranial Aneurysms

Cortical visual loss is a rare complication of cerebral angiography without a definitive pathophysiology. Given the rapid increase in endovascular procedures used to treat cerebral aneurysms, we explored the prevalence of this complication and whether we could add to the understanding of this disorder. We performed a retrospective review of all procedures performed with the same contrast agent and detachable coils for treatment of posterior circulation aneurysms by 1 endovascular surgery service from 1996 to 2006. All patients were evaluated before and after each procedure by a team that included a neuro-ophthalmologist. Of 137 intra-arterial treatment procedures performed for posterior circulation aneurysms, we identified 4 patients with cerebral vision loss complications. During the same time period, >500 aneurysms of the anterior cerebral circulation were treated without this complication. The visual field loss was unilateral in 2 and bilateral in 2 patients. Recovery was complete in 3 and almost normal in the fourth patient. The amount of contrast used and the duration of the procedure were similar among all patients. The 4 patients had no identified specific risk factors for developing procedure-associated occipital dysfunction, all 4 had undergone prior angiography, and 1 patient had undergone repeat coiling, without complication. The 2.9% prevalence of cerebral visual loss with endovascular coil treatment of posterior circulation aneurysms is higher than that for angiography alone. Our patients recovered well with corticosteroid and intravenous hydration treatment. Recognizing the self-limiting nature of this problem might prevent an unneeded intervention.

ST-segment analysis of the fetal electrocardiogram improves fetal heart rate tracing interpretation and clinical decision making

Introduction: Since its introduction into clinical use, the efficacy of electronic fetal heart rate (FHR) monitoring (EFM) has been questionable. This has been due partly to the marked variation in interpretation of the FHR pattern and subsequent decisions for obstetric intervention, (e.g., the need for prompt delivery). Current application of EFM is limited to the assessment of FHR patterns and uterine contractions. Recent development of higher-order FHR analysis has yielded monitoring systems that can add automated fetal electrocardiographic ST segment analysis to the standard FHR and uterine contraction information. Our goal was to evaluate the effect of adding ST segment analysis to standard FHR information on observer agreement for clinical decision making.Methods: Seven practitioners who were trained and experienced in combined FHR and ST monitoring reviewed 51 fetal monitor tracings, ranging from 2 to 4 h in length. Reviews were conducted in two sessions and at different times. The first session presented only the FHR and uterine contraction information, following which the participants determined the time at which intervention (decision for operative vaginal or Cesarean section delivery) was indicated. In the second session, the participants were provided with a randomized sequence of the same tracings with the addition of ST segment information, as produced by the STAN monitor system (Neoventa Medical, Gothenburg, Sweden). Observer agreement was based on the proportion of participants who agreed on the need for an intervention, and the per cent agreement on the timing of the intervention within 20 min before or after the median time of intervention.Results: Of the 51 cases included in this study there were ten fetuses with umbilical artery (UA) pH between 7.05 and 7.14, and nine with UA pH of < 7.05. Observer agreement increased significantly for required intervention when the ST segment information was available for tracing analysis as compared with review of the standard tracing alone (0.96 vs. 0.80, p<0.05) and the timing of intervention (0.92 vs. 0.66, respectively, p<0.05). Similarly, correct identification for needed interventions on fetuses with abnormal outcomes increased from 86 to 93% while unneeded interventions on normal fetuses decreased from 43 to 6%.Conclusion: The addition of ST analysis to standard FHR monitoring improves observer consistency in both the decision for and timing of obstetric interventions. The incorporation of ST segment data with the standard FHR tracing may reduce the number of unneeded obstetric interventions when fetal compromise is absent.

Screening for asymptomatic internal carotid artery stenosis: duplex criteria for discriminating 60% to 99% stenosis.

The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy reduces stroke risk in symptom-free patients with 60% or greater internal carotid artery (ICA) stenosis. This will surely lead to the performance of an increased number of screening duplex examinations. Assuming that positive study results will lead to arteriography or endarterectomy and keeping in mind the modest benefit for prophylactic endarterectomy demonstrated by ACAS (absolute risk reduction for ipsilateral stroke of 5.8% at 5 years), duplex criteria for 60% or greater ICA stenosis must have high positive predictive values (PPV). Determining criteria for 60% or greater stenosis, which emphasized high accuracy and PPV, forms the basis for this study. Stenoses detected by angiography in 352 ICAs were blindly compared with those detected by duplex scanning. Duplex criteria were determined for highest overall accuracy in detection of 60% or greater ICA stenosis and for 95% or greater PPV. Maximal accuracy for detection of 60% or greater stenosis was 90%. This was achieved by the combination of a peak systolic velocity of 260 cm/sec or greater and an end diastolic velocity of 70 cm/sec or greater (sensitivity 84%, specificity 94%, PPV 92%). The 95% PPV for 60% or greater stenosis results from combining peak systolic velocity of 290 cm/sec or greater and end diastolic velocity of 80 cm/sec or greater. With use of these criteria duplex scanning accurately detects with high PPVs the threshold level of ICA stenosis defined in ACAS as receiving stroke reduction benefit from prophylactic carotid endarterectomy. These criteria should be useful for carotid artery screening and minimizing unneeded intervention.