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Unnecessary Procedures (unnecessary + procedure)
Selected AbstractsExercise-induced cholangitis and pancreatitisHPB, Issue 2 2005JOHN G. TOUZIOS Abstract Background. Cholangitis requires bactibilia and increased biliary pressure. Pancreatitis may be initiated by elevated intraductal pressure. The sphincter of Oddi regulates pancreatobiliary pressures and prevents reflux of duodenal contents. However, following biliary bypass or pancreatoduodenectomy, increased intra-abdominal pressure may be transmitted into the bile ducts and/or pancreas. The aim of this analysis is to document that cholangitis or pancreatitis may be exercise-induced. Methods. The records of patients with one or more episodes of cholangitis or pancreatitis precipitated by exercise and documented to have patent hepatico- or pancreatojejunostomies were reviewed. Cholangitis was defined as fever with or without abdominal pain and transiently abnormal liver tests. Pancreatitis was defined as abdominal pain, with transient elevation of serum amylase and documented by peripancreatic inflammation on computerized tomography. Results. Twelve episodes of cholangitis occurred in six patients who had undergone hepaticojejunostomy for biliary stricture (N=3), Type I choledochal cyst (N=2), or pancreatoduodenectomy for renal cell carcinoma metastatic to the pancreas (N=1). Four episodes of pancreatitis occurred in two patients who had undergone pancreatoduodenectomy for ampullary carcinoma or chronic pancreatitis. Workup and subsequent follow-up for a median of 21 months have not documented anastomotic stricture. Each episode of cholangitis and pancreatitis was brought on by heavy exercise and avoidance of this level of exercise has prevented future episodes. Conclusion. Following biliary bypass or pancreatoduodenectomy, significant exercise may increase intra-abdominal pressure and cause cholangitis or pancreatitis. Awareness of this entity and behavior modification will avoid unnecessary procedures in these patients. [source] Revenue-driven in TB control,three cases in ChinaINTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT, Issue S1 2004Shaokang Zhan Abstract One quarter of all TB cases occur in China, which, during the past 20 years has moved from a planned economy to a socialist market economy. In the health sector, an important proportion of the financing originates from user payment. TB control is not an exception and different programmatic models are in place. This study examines, using a case study approach, three different TB programmes, one supposed to provide free service, one subsidized service and one with full cost recovery. The aim was to better understand the driving forces for programme performance in terms of case detection, case management and patient payments. The study found for all models that control and case management approaches were, to some extent, adapted to generate maximum income to the providers. The drive for income led to fewer cases detected, administration of unnecessary procedures and drugs, and a higher than necessary cost to the patients. The latter possibly leading to exclusion of poor people from the services. If user charges are to stay, TB control programmes need to be designed to take advantage of the financial incentives to improve performance. The referral system needs to be restructured, not to provide disincentives for good practices. Copyright © 2004 John Wiley & Sons, Ltd. [source] Tissue harmonic sonography in the diagnosis of common bile duct stones: A comparison with endoscopic retrograde cholangiographyJOURNAL OF CLINICAL ULTRASOUND, Issue 9 2009Tomás Ripollés MD Abstract Purpose To revisit the diagnostic accuracy of sonography in the detection of choledocholithiasis using modern equipment with tissue harmonic imaging (THI) and endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy as the gold standard. Methods A total of 107 patients with clinically suspected choledocholithiasis were examined with THI before undergoing ERCP. The sonographic findings that were prospectively evaluated included the presence of choledocholithiasis, size of common bile duct, sonographic view and patient position that best visualized the stone(s), visualization of the distal common duct, and duration of examination. The accuracy of sonography compared with ERCP and sphincterotomy was calculated. Results Sonography correctly detected stones in 65 of 76 patients (sensitivity of 86%). The specificity and the overall accuracy were 87% and 86%, respectively. The sensitivity of sonography was higher with dilated extrahepatic duct (44% in patients with common bile duct measuring less than 6 mm in diameter, 82% between 6 and 10 mm, and 100% with common bile duct larger than 10 mm). The lateral approach with the patient in left lateral decubitus position of the patient was the most effective in 47% of the cases. Conclusion Sonography with THI is an accurate technique for the detection of choledocholithiasis that may be used as the first-choice technique to avoid unnecessary procedures in a high percentage of patients, especially those with dilated biliary tree. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound, 2009 [source] Clinical Judgment Versus Decision Analysis for Managing Device AdvisoriesPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 10 2008MITESH S. AMIN M.D. Introduction: Implantable cardioverter-defibrillator (ICD) and pacemaker (PM) advisories may have a significant impact on patient management. Surveys of clinical practice have shown a great deal of variability in patient management after a device advisory. We compared our management of consecutive patients in a single large university practice with device advisories to the "best" patient management strategy predicted by a decision analysis model. Methods: We performed a retrospective review of all patients who had implanted devices affected by an advisory at our medical center between March 2005 and May 2006 and compared our actual patient management strategy with that subsequently predicted by a decision analysis model. Results: Over 14 months, 11 advisories from three different manufacturers affected 436 patients. Twelve patients (2.8%) were deceased and 39 patients (8.9%) were followed at outside facilities. Management of the 385 remaining patients varied based on type of malfunction or potential malfunction, manufacturer recommendations, device dependency, and patient or physician preferences. Management consisted of the following: 57 device replacements (15.2%), 44 devices reprogrammed or magnets issued (11.7%), and 268 patients underwent more frequent follow-up (71.3%). No major complications, related to device malfunction or device replacement, occurred among any patient affected with a device advisory. Concordance between the decision analysis model and our management strategy occurred in 57.1% of cases and 25 devices were replaced when it was not the preferred treatment strategy predicted by the decision model (43.9%, 37.3% when excluding devices replaced based on patient preference). The decision analysis favored replacement for all patients with PM dependency, but only for four patients with ICDs for secondary prevention. No devices were left implanted that the decision analysis model predicted should have been replaced. Conclusions: We found that despite a fairly conservative device replacement strategy for advisories, we still replaced more devices when it was not the preferred device management strategy predicted by a decision analysis model. This study demonstrates that even when risks and benefits are being considered by experienced clinicians, a formal decision analysis can help to develop a systematic evidence based approach and potentially avoid unnecessary procedures. [source] Scrotal involvement in childhood Henoch-Schönlein purpuraACTA PAEDIATRICA, Issue 4 2007Tae-Sun Ha Abstract Aim: Henoch-Schönlein purpura (HSP) is a common childhood systemic vasculitis involving the skin, gastrointestinal tract, joint, kidneys and even scrotum. Methods: We retrospectively reviewed the clinical and laboratory data of 120 male patients with HSP and also evaluated the risk factors for scrotal involvement and the relation between scrotal involvement and other clinical features. Twenty-six out of 120 boys (21.7%) diagnosed with HSP had scrotal involvement. Results: Scrotal symptoms manifested as swelling in 88.5% and pain (or tenderness) in 69.2% of HSP patients with scrotal involvement. Neurologic symptoms, mainly headache and localized edema among various manifestations and high serum C3 level of laboratory profiles were more frequently observed in scrotal-involved group than in those of non-involved group. However, there was no difference in the outcomes of scrotal symptoms according to therapeutic modalities and the occurrence of scrotal involvement had no correlation with renal involvement from acute to chronic phase. Conclusions: We found that neurologic symptoms, localized edema and high serum C3 level show a significant relation with scrotal involvement in male HSP patients. Because scrotal involvement in male HSP patients is not rare, the accurate early diagnosis of HSP is mandatory by the early notification of purpura and imaging evaluations in order to avoid unnecessary procedures. [source] | ||||||||||