Cystic fibrosis: when neonatal screening is unsatisfactory for early diagnosis / Fibrose cística: quando a triagem neonatal é insatisfatória para o diagnóstico precoce

Abstract Introduction: cystic fibrosis newborn screening must enable its earlier diagnosis, which may enhance outcomes. This study was a series case of delayed-diagnosis children submitted to cystic fibrosis newborn screening. Description: fourteen children were included; eight (57.1%) were due to false-negative screening, while six (42.9%) were due to processing errors. Two samples collected after 30 days of life were incorrectly classified as negative, and four infants with a positive test could not be located due to screening processing errors. Cystic fibrosis diagnosis was confirmed at a median (IQR) age of 5.3 (4.2-7.4) months. Poor nutritional status was the most prevalent clinical sign at diagnosis, being present in 78.6% of infants. The mean (SD) weight-for-length and length-for-age Z-scores were -3.46 (0.84) and -3.99 (1.16), respectively. Half of the children had Pseudo-Bartter syndrome, and 42.9% had breathing difficulties. Twelve children (85.7%) required hospitalization, with a median (IQR) length of stay of 17.0 (11.5-26.5) days. Discussion: newborn screening had some faults, from incorrect collections to inefficient active search. Early identification of these children in which screening was unsatisfactory is essential, emphasizing the importance and efforts to not miss them. In the case of a failed test, healthcare professionals must be prepared to recognize the main symptoms and signs of the disease.

Resumo Introdução: a triagem neonatal para fibrose cística deve contribuir para diagnóstico precoce e melhor prognóstico da doença. O estudo é uma série de casos com lactentes submetidos à triagem, porém com diagnóstico tardio da doença. Descrição: quatorze crianças foram incluídas; oito (57,1%) com triagem falso-negativo e seis (42,9%) com erros processuais na triagem neonatal. Duas amostras foram coletadas tardiamente, sendo incorretamente classificadas como negativas e quatro lactentes com triagem positiva não foram localizados, por erros na busca ativa. Confirmou-se o diagnóstico da fibrose cística com idade mediana (IIQ) de 5,3 (4,2-7,4) meses. O Comprometimento nutricional precoce foi o sinal clínico mais prevalente ao diagnóstico, presente em 78,6% das crianças. Os Z escores médios (SD) do peso para altura e altura para idade foram -3,46 (0,84) e -3,99 (1,16), respectivamente. Metade das crianças teve síndrome de Pseudo-Bartter e 42,9% dificuldade respiratória. Doze crianças (85,7%) precisaram hospitalização com tempo mediano de permanência de 17 dias. Discussão: a triagem neonatal para fibrose cística apresentou falhas, desde testes falso-negativos, coletas incorretas, até problemas com a busca ativa. Entretanto, o diagnóstico ágil é essencial e os profissionais de saúde devem reconhecer os sintomas e sinais precoces da doença, mesmo quando a triagem neonatal não for satisfatória.

A case of stage Ⅲ pneumoconiosis with large shadow by burr-like changes misdiagnosed as lung cancer / 中华劳动卫生职业病杂志

Pneumoconiosis is characterized by chronic lung inflammation and fibrosis, and inflammation can promote pulmonary fibrosis, which in turn leads to pneumoconiosis. When a large shadow with a long diameter of not less than 2 cm and a short diameter of not less than 1 cm appears in the lung, it can be classified as stage Ⅲ pneumoconiosis. This paper reports a case of stage Ⅲ pneumoconiosis with a large shadow in the upper right lung accompanied by burr-like changes misdiagnosed as lung cancer by CT examination.When the large shadow lesions in patients with pneumoconiosis and lung cancer are difficult to distinguish on CT, an additional MRI examination, particularly T(2)W imaging sequence is useful sequence for identifying the two.

Analysis of the clinical characteristics and misdiagnosis of area postrema syndrome manifesting as intractable nausea, vomiting, and hiccups in neuromyelitis optica spectrum disorders / 中华内科杂志

Objective: To investigate the misdiagnosis of area postrema syndrome (APS) manifesting as intractable nausea, vomiting and hiccups in neuromyelitis optic spectrum disease (NMOSD) and reduce the risk of misdiagnosis. Methods: We retrospectively analyzed data from NMOSD patients attending the Department of Neurology at the First Medical Center of PLA General Hospital between January 2019 and July 2021. SPSS25.0 was then used to analyze the manifestations, misdiagnosis, and mistreatment of APS. Results: A total of 207 patients with NMOSD were included, including 21 males and 186 females. The mean age of onset was 39±15 years (range: 5-72 years). The proportion of patients who were positive for serum aquaporin 4 antibody was 82.6% (171/207). In total, 35.7% (74/207) of the NMOSD patients experienced APS during the disease course; of these patients, 70.3% (52/74) had APS as the first symptom and 29.7% (22/74) had APS as a secondary symptom. The misdiagnosis rates for these conditions were 90.4% (47/52) and 50.0% (11/22), respectively. As the first symptom, 19.2% (10/52) of patients during APS presented only with intractable nausea, vomiting and hiccups; 80.8% (42/52) of patients experienced other neurological symptoms. The Departments of Gastroenterology and General Medicine were the departments that most frequently made the first diagnosis of APS, accounting for 54.1% and 17.6% of patients, respectively. The most common misdiagnoses related to diseases of the digestive system and the median duration of misdiagnosis was 37 days. Conclusions: APS is a common symptom of NMOSD and is associated with a high rate of misdiagnosis. Other concomitant symptoms often occur with APS. Gaining an increased awareness of this disease/syndrome, obtaining a detailed patient history, and performing physical examinations are essential if we are to reduce and avoid misdiagnosis.

Diagnóstico audiológico de lactentes após falha na triagem auditiva neonatal universal / Hearing assessment after referral in universal newborn hearing screening

RESUMO Objetivo Estudar o processo de diagnóstico audiológico de lactentes que falharam na Triagem Auditiva Neonatal Universal (TANU). Métodos Análise dos prontuários de 51 lactentes que falharam na TANU nas maternidades do munícipio e que foram encaminhados a um centro de referência em saúde auditiva para diagnóstico audiológico, entre janeiro e junho de 2021. Foram identificados os lactentes que finalizaram o diagnóstico, aqueles que não compareceram ao agendamento para exames ou evadiram durante o processo. Tentativas de contato foram realizadas com os responsáveis pelos lactentes que evadiram, para identificar o motivo da evasão. Resultados O comparecimento ao diagnóstico ficou em 75%, com evasões entre o encaminhamento da maternidade para o centro de referência, bem como durante o processo de diagnóstico. Cinquenta por cento dos sujeitos concluíram as avaliações audiológicas até os 3 meses de vida. A tentativa de contato foi bem-sucedida com os responsáveis pelos lactentes que evadiram, sendo os motivos mais frequentes: adoecimento do lactente, distância entre a moradia e o centro de referência, horário de trabalho dos pais. Conclusão Na etapa de diagnóstico, o índice de comparecimento e o tempo de conclusão até o terceiro mês de vida da criança ficaram abaixo dos índices recomendados, diminuindo a efetividade do Programa de Triagem Auditiva Neonatal Universal (PTANU). A busca ativa por contato telefônico e uso de aplicativo de mensagem telefônico foi importante para reduzir a evasão em 76%. Outras ferramentas que aprimorem o processo para um diagnóstico não prolongado, evitando evasões, necessitam ser estudadas.

ABSTRACT Purpose To study the process of hearing assessment in infants who were referred by professionals responsible for Universal Newborn Hearing Screening (UNHS). Methods Analysis of the medical records of 51 infants referred by maternity hospitals where UNHS was performed and were referred to a Hearing Health Center, between January and June 2021. Infants who completed hearing assessment, who never attended the appointments, or were lost during the diagnostic process were identified. Attempts were made to contact infants' guardians in order to understand the reason for missing the appointments. Results The attendance to the diagnosis was 75%. Fifty percent of the infants completed hearing assessment as recommended, up to 3 months of life. The attempt to contact parents who missed the appointments was successful, and the most frequent reasons are: the infant was ill on the day of scheduled appointment, distance from home to the hearing health center, parents' working hours. Conclusion For the diagnostic stage, the attendance rate and the age for completing hearing assessment were below the recommended. The active search for telephone contact and use of phone messaging application was important to reduce evasion by seventy-six percent. Tools that optimize the diagnostic process with less infants missing still must be studied.

Patient safety culture at the unit level of a tertiary hospital in South Africa: a survey study

Background. Patient safety research is scarce in developing countries. Estimates of patient harm due to healthcare processes in resource-poor settings are thought to be greater than those in developed countries. Ideally, errors in healthcare should be seen as opportunities to improve the future quality of care. Objective. This study aimed to investigate patient safety culture within high-risk units of a tertiary hospital in South Africa. Methods. A quantitative, descriptive, cross-sectional methodology, using a survey questionnaire that measured 10 safety dimensions and one outcome measure among clinical and nursing staff, was employed. Results. Two hundred participants completed the survey questionnaire. Areas of strength identified by the participants included organizational learning (91.09%), staff attitudes (88.83%), and perceptions of patient safety (76.65%). Dimensions that have potential for improvement included awareness and training (74.04%), litigation (73.53%), feedback and communication about errors (70.77%), non-punitive response to error reporting (51.01%), size and tertiary level of the hospital (53.76%), and infrastructure and resources (58.07%). The only dimension identified as weak was teamwork and staffing (43.72%). In terms of the patient safety grade, respondents graded their own units highly but graded the hospital as a whole as having a poor patient safety grade. Conclusion. There are still significant gaps in the quality of care provided at this tertiary hospital. The current patient safety culture is perceived as punitive in nature with regard to reporting adverse events. It is advised that targeted patient safety improvements be made, followed by further investigation

Osteomielite crônica como uma armadilha ao diagnóstico na prática do dermatologista / Chronic osteomyelitis as a diagnostic pitfall in the practice of the dermatologist: a case report

Na prática clínica da dermatologia não é incomum nos depararmos com situações desafiadoras, de difícil caracterização e que podem nos induzir ao erro diagnóstico. Quadros cutâneos com apresentações semelhantes entre si estão aqui inclusas e, neste caso, é de suma importância a atuação do médico dermatologista de forma a unir as informações da anamnese, exame físico e exames complementares, a fim de excluir condições de pior prognóstico e que requerem atuação mais agressiva de outras condições benignas e/ou com menor impacto negativo. Apresentamos abaixo uma dessas situações de desafio diagnóstico em que uma lesão cutânea secundária à osteomielite crônica foi inicialmente atribuída à causa inflamatória ou neoplásica (AU)

In the clinical practice of Dermatology, it is not uncommon to encounter challenging situations that are difficult to characterize and may lead to misdiagnosis. Skin conditions with similar presentations are included here and, in this case, it is of utmost importance that the dermatologist combines information from the medical history, physical examination and complementary tests in order to exclude conditions with worse prognosis and that require more aggressive action than other benign conditions and/or with less negative impac (AU)

Mala colocación de electrodos: un desafío diagnóstico aún presente / Malposition of ECG electrodes; a continuing challenge

INTRODUCCIÓN: Se revisan los principales errores en la colocación de los electrodos para el registro del ECG. Se ilustran algunos de ellos y se comenta sobre los errores en los informes que pueden tener repercusiones en el diagnóstco clínico.

ABSTRAC: The main mistakes in the placement of electrodes during the recording of an ECG are reviewed. Some of them are illustrated and the consequences for clinical diagnosis are discussed.

Lo dilemático de un (intento de) suicidio. El que encuentra, atesora / The Dilemma of a (Attempted) Suicide

El suicidio ­o las autolesiones como su antecesor mortífero­ no suelen ser más que una pantalla a un dolor imposible de ser procesado por el sujeto que padece. Las coordenadas que lo atraviesan se amplían, convergen y torsionan en una espiral sin fin cuando ya no quedan recursos para encontrar una salida vital. El proyecto de vida pareciera impensable, en especial, cuando las múltiples versiones de lo ominoso se hacen presentes. Si además el tiempo etario donde aparecen coincide con un tiempo crucial ­adolescencia, jóvenes, adultos mayores­ suele requerirse algún modo de apuntalamiento al Yo en crisis. En este episodio de New Amsterdam vemos como el desinvestimiento subjetivo que produce la invisibilidad del sujeto para los objetos externos diferenciados madre familia (Aulagnier,2004) hacen a una joven intentar construir su identidad bajo un tiempo extremo de angustia

Suicide ­or self-harm like its deadly predecessor­ are usually nothing more than a screen for a pain impossible to be processed by the subject who suffers. The coordinates that pass through it expand, converge and twist in an endless spiral when there are no more resources left to find a vital exit. The life project seems unthinkable, especially when the multiple versions of the ominous are present. If, in addition, the age period in which they appear coincides with a crucial time ­ adolescence, youth, older adults ­ some form of propping up the Self in crisis is usually required. In this episode of New Amsterdam we see how the subjective disinvestment that produces the invisibility of the subject for the differentiated external objects mother-family (Aulagnier, 2004) makes a young woman try to build her identity under an extreme time of anguish

¿Es posible la coinfección o un diagnóstico erróneo por dengue y COVID-19? Una revisión de reporte de casos / Is dengue and COVID-19 coinfection or misdiagnosis possible? A review on reported cases

INTRODUCCIÓN: El nuevo coronavirus ha continuado propagándose por todo el mundo donde existen otras enfermedades endémicas que han sido una carga para la salud pública durante muchos años. Como cualquier infección, se habría esperado encontrar en coinfección con algunas de éstas. Específicamente, los países tropicales y subtropicales han venido manejando la carga del dengue a medida que aumentan los picos con períodos de tiempo más cortos. OBJETIVO: Resumir la evidencia que existe en la coinfección relacionada con el SARS-CoV-2 y el virus del dengue. METODOLOGÍA: Se realizó una revisión narrativa en bases de datos sobre reportes de coinfección y diagnóstico erróneo de SARS-CoV-2 y el dengue dado que la temporada de lluvias cada año aumenta la prevalencia de infecciones virales en países endémicos. Informes recientes incluso han descrito casos positivos en uno de estas infecciones que luego resultaron en falso positivo. Una prueba positiva para COVID-19 o fiebre del dengue en áreas endémicas no debe excluir la otra infección. CONCLUSIÓN: A partir de ahora, estos dos deberían ser considerados como un diagnóstico diferencial y esto debe generar preocupación de salud pública por su coinfección en países endémicos para reforzar la promoción y prevención a las comunidades y mitigar estas enfermedades.

BACKGROUND: Novel coronavirus has continued to spread throughout the world where there are other endemic diseases that have been a burden to public health for many years. As any infection, it was expected there could be coinfection between these. Tropical and subtropical countries are currently managing with dengue as peaks increase with shorter periods of time. AIM: To summarize the evidence that exists in the co-infection related to SARS-CoV-2 and the dengue virus. METHOD: We conducted a narrative review in data bases about reports of coinfection and misdiagnosis of SARS-CoV-2 and dengue virus given the fact that rainy season every year increase the prevalence of viral infections in endemic countries. Recent reports have even described positive cases in one of these infections that later resulted in false positive. A positive test for COVID-19 or dengue fever in endemic areas should not exclude the other infection. CONCLUSION: From now on, these two should be considered as a differential diagnosis and this should raise public health concern for COVID-19 and dengue coinfection in endemic countries to reinforce promotion and prevention to communities to prevent these diseases.

The consequences Sars-CoV-2 pandemic on medical education in the combat leprosy / As consequências da pandemia de Sars-CoV-2 sobre a educação médica no combate à hanseníase / Las consecuencias de la pandemia de Sars-CoV-2 en educación médica en combate à lepra

Background and objectives: Leprosy is an infectious disease in which early diagnosis is a decisive factor to prevent disability and disabilities. This study sought to analyze the panorama of leprosy between 2016 and 2021 in the state of Rio Grande do Sul and unveil the importance of medical education in the context of Neglected Tropical Diseases during the Sars-CoV-2 pandemic. Methods: Cross-sectional study using the State Center database of Health Surveillance of Rio Grande do Sul. In the data collection, were included leprosy data of individuals residents in the state of Rio Grande do Sul (RS), in the 2016 period 2021. The variables analyzed were confirmed leprosy cases, notified cases, the number of cases in terms of operational classifications of leprosy, the therapeutic scheme, and the number of cases according to the degrees of physical disability. Results: Over this period, 725 cases were confirmed as leprosy, 70% in the years 2016, 2017 and 2018. Of the total number of cases, 88% were Multibacillary form of the disease, 50% had some degree of disability at diagnosis time and 80% underwent the standard treatment regimen. Conclusion: There is a delay in leprosy diagnosis, and there is underdiagnosis of the disease in the state of Rio Grande do Sul: which highlights the need to reaffirm educational practices on mycobacteriosis.(AU)

Justificativa e objetivos: A hanseníase é uma doença infectocontagiosa na qual o diagnóstico precoce é fator decisivo para prevenir incapacidade e deficiências. O presente estudo buscou analisar o panorama da hanseníase entre os anos de 2016 e 2021 no estado do Rio Grande do Sul, desvelando a importância da educação médica no contexto das Doenças Tropicais Negligenciadas durante a pandemia da Sars-CoV-2. Métodos: Estudo transversal por meio da base de dados do Centro Estadual de Vigilância em Saúde do Rio Grande do Sul. Na coleta de dados, foram incluídos os dados de hanseníase em indivíduos residentes do estado do Rio Grande do Sul (RS), no período de 2016 a 2021. As variáveis analisadas foram os casos confirmados de hanseníase, os casos notificados, o número de casos quanto às classificações operacionais de hanseníase, o esquema terapêutico e o número de casos de acordo com os graus de incapacidade física. Resultados: No período analisado, foram confirmados 725 casos de hanseníase, sendo 70% nos anos de 2016, 2017 e 2018. Do número total de casos, 88% eram a forma multibacilar da doença, 50% apresentaram algum grau de incapacidade física no momento do diagnóstico e 80% realizaram o esquema terapêutico padrão. Conclusão: Existe atraso no diagnóstico de hanseníase e há subdiagnóstico da doença no estado do Rio Grande do Sul, o que evidencia a necessidade de reafirmação das práticas educacionais sobre a micobacteriose.(AU)

Justificación y objetivos: La lepra es una enfermedad infecciosa en la que el diagnóstico precoz es un factor decisivo para prevenir la incapacidad y las discapacidades. Este estudio buscó analizar el panorama de la lepra entre 2016 y 2021 en el estado de Rio Grande do Sul y develar la importancia de la educación médica en el contexto de las Enfermedades Tropicales Desatendidas durante la pandemia Sars-CoV-2. Métodos: Estudio transversal con datos del Centro Estatal de Vigilancia en Salud de Rio Grande do Sul. La recolección de datos incluyó datos sobre lepra en individuos residentes en el estado de Rio Grande do Sul (RS), de 2016 a 2021. Las variables analizadas fueron casos confirmados de lepra, casos notificados, el número de casos en términos de clasificaciones operativas de lepra, el esquema terapéutico y el número de casos según los grados de discapacidad física. Resultados: En el período analizado se confirmaron 725 casos de lepra, 70% en los años 2016, 2017 y 2018. Del total de casos, 88% fueron la forma multibacilar de la enfermedad, 50% tenían algún grado de discapacidad física en el momento del diagnóstico y el 80% realizó el régimen terapéutico padrón. Conclusiones: Hay un retraso en el diagnóstico de la lepra y hay un infradiagnóstico de la enfermedad en el estado de Rio Grande do Sul: lo que pone de relieve la necesidad de reafirmar las prácticas educativas sobre micobacteriosis.(AU)

Avaliação de exames histopatológicos do colo do útero diagnosticados como "outras neoplasias" no Sistema de Informação do Câncer, Brasil, 2013-2020: estudo descritivo / Evaluación de exámenes histopatológicos del cuello uterino diagnosticados como "otras neoplasias" en el Sistema de Información del Cáncer, Brasil, 2013-2020: estudio descriptivo / Evaluation of histopathological examinations of the cervix diagnosed as "other neoplasms" on the Cancer Information System, Brazil, 2013-2020: a descriptive study

Objetivo: descrever e reclassificar os diagnósticos de outras neoplasias de exames histopatológicos do colo do útero registrados no Sistema de Informação do Câncer (Siscan), Brasil, 2013-2020. Métodos: estudo descritivo dos diagnósticos compilados no campo "outras neoplasias malignas" do Siscan; os diagnósticos foram avaliados por patologista e reclassificados nas categorias existentes no formulário; foram calculadas frequências absolutas e relativas dos diagnósticos registrados incorretamente. Resultados: o diagnóstico "outras neoplasias malignas" representou 2,4% (n = 5.778) dos diagnósticos, dos quais 67,4% poderiam ser registrados em categorias existentes, 8,9% eram efetivamente outros tipos de neoplasias malignas, e 24,5% apresentavam resultados não compatíveis com outras neoplasias, como achados benignos ou fora do colo do útero, não disponíveis nos campos existentes. Conclusão: o campo "outras neoplasias malignas" é frequentemente utilizado de maneira inadequada, no Siscan; constata-se a necessidade de capacitar os profissionais para o adequado uso dos campos do sistema e incluir novas categorias diagnósticas no formulário.

Objetivo: describir y reclasificar los diagnósticos registrados en el campo "otras neoplasias malignas" de exámenes histopatológicos del cuello uterino en el Sistema de Información del Cáncer (Siscan), Brasil, 2013-2020. Métodos: estudio descriptivo del campo "otras neoplasias malignas" en Siscan; estudio descriptivo de las fichas diagnósticas recopiladas en el campo "otras neoplasias malignas" en Siscan entre 2013 y 2020. Resultados: los diagnósticos histopatológicos "otras neoplasias malignas" representaron el 2,4% (n = 5.778) del total, de los cuales el 67,4% se pudo registrar en las categorías existentes, el 8,9% fueron en realidad otros tipos de neoplasias malignas y el 24,5% fueron resultados no compatibles con otras neoplasias y que no estaban incluidas en las opciones existentes. Conclusión: el campo "otras neoplasias malignas" es frecuentemente utilizado de manera inadecuada, en Siscan; existe la necesidad de capacitar a los profesionales para que utilicen correctamente los campos del sistema e incluyan nuevas categorías de diagnóstico en el formulario.

Objective: to describe and reclassify cervical histopathology test result diagnoses recorded as other neoplasms on the Cancer Information System (SISCAN), Brazil, 2013-2020. Methods: this was a descriptive study based on diagnoses input to the "other malign neoplasms" field on the SISCAN; a pathologist assessed the diagnoses and reclassified them based on the categories existing on the standardized record form; absolute and relative frequencies of incorrectly recorded diagnoses were calculated. Results: histopathology test results registered as "other malign neoplasms" accounted for 2.4% (n = 5,778) of all records, 67.4% of which in fact fell into categories already existing on the form, 8.9% were indeed other neoplasms and 24.5% were results not compatible with other neoplasms and were not covered by the form categories, such as benign findings or findings outside the cervix. Conclusion: the "other malignant neoplasms" field is frequently misused on the SISCAN; the analysis highlighted the need to train professionals to use the system properly, as well as the need to include new categories on the form.

Identifying and understanding optical coherence tomography artifacts that may be confused with glaucoma / Identificando e compreendendo os artefatos de tomografia de coerência óptica que podem ser confundidos com o glaucoma

ABSTRACT Optical coherence tomography is often used for detection of glaucoma as well as to monitor progression. This paper reviews the most common types of artifacts on the optical coherence tomography report that may be confused with glaucomatous damage. We mainly focus on anatomy-related artifacts in which the retinal layer segmentation and thickness measurements are correct. In such cases, the probability maps (also known as deviation maps) show abnormal (red and yellow) regions, which may mislead the clinician to assume disease is present. This is due to the anatomic variability of the individual, and the normative database must be taken into account.

RESUMO A tomografia de coerência óptica é frequentemente usada para detectar glaucoma, bem como para monitorar a progressão. Este artigo analisa os tipos mais comuns de artefatos no relatório de tomografia de coerência óptica que podem ser confundidos com danos glaucomatosos. Nós nos concentramos principalmente nos artefatos relacionados à anatomia em que a segmentação da camada da retina e as medidas de espessura estão corretas. Nesses casos, os mapas de probabilidade (também conhecidos como mapas de desvio) mostram regiões anormais (vermelho e amarelo), o que pode induzir o clínico em erro ao supor que a doença está presente. Isto se deve à variabilidade anatômica do indivíduo, e o banco de dados normativo deve ser levado em conta.

Avaliação do manejo médico no atendimento de cefaleia na sala de urgência e emergência do Hospital Regional de Barbacena - MG / Evaluation of medical management in the treatment of headache in the urgency and emergency room of the Hospital Regional de Barbacena - MG

Introdução: O manejo da cefaleia nas salas de urgência e emergência deve ser baseada em uma anamnese detalhada para que o diagnóstico e tratamento sejam adequados, entretanto não é o que se encontra nos atendimentos. Objetivo: Avaliar o manejo do atendimento das cefaleias em uma sala de Urgência e Emergência. Métodos: Estudo de corte transversal retrospectivo, realizado através da análise de dados de 1317 prontuários eletrônicos de pacientes com queixa de cefaleia que procuraram o serviço de emergência do Hospital Regional de Barbacena durante o período de 01 de janeiro de 2017 a 30 de junho de 2019. Os diagnósticos relatados nos prontuários foram classificados de acordo com os critérios da Classificação Internacional das Cefaleias (ICHD-3). Os dados foram submetidos à análise estatísticas, pelo teste de qui-quadrado. Considerou-se diferenças estatisticamente significativas aquelas cujo valor p≤0,05. Resultados: Do total de prontuários, três foram excluídos, sendo analisados 1314. Entre os prontuários analisados, 73,21% apresentaram diagnósticos iniciais eram cefaleia, 16,67% migrânea e 10,12% cefaleia do tipo tensão. Já no diagnóstico final, cefaleia correspondeu a 59,67%, migrânea a 17,95% e cefaleia do tipo tensão a 8,52%. Em relação ao tratamento, foi receitado opioides para 43,99% dos pacientes e para o restante foram prescritos medicamentos não opioides. Conclusão: O trabalho sugeriu falha no manejo da cefaleia nas salas de urgência e emergência, provavelmente pela limitação do conhecimento dos profissionais de saúde acerca da dor de cabeça. O que acarretou no grande número de diagnósticos inespecíficos e inadequada abordagem terapêutica.

Introduction: Detailed clinical evaluation should be the basis for the proper management of headaches in emergency rooms, in order to allow adequate diagnosis and treatment. However, this is not usually observed on clinical rounds. Objective: To evaluate the management of headache consultations in an emergency rooms. Methods: This is a cross-section study was performed analyzing data from 1,317 electronic medical records of patients with headache complaints who sought treatment at the Barbacena City Regional Hospital's between January 1, 2017, and June 20, 2019. Medical records were classified according to the International Classification of Headache Disorders (ICHD-3). The data collected were statistically analyzed using chi-square tests. The study considered a p-value≤0.05 to define statistically significant differences. Results: Three medical records were excluded and 1,314 were analyzed. Among the medical records analyzed, 73.21% of initial diagnoses were classified as headache, 16.67% as migraine, and 10.12% as tension-type headache. Headache corresponded to 59.76% of final diagnoses, migraine to 17.95%, and tension-type headache to 8.52%. Regarding the treatment, 43.99% of patients were prescribed opioids for the remaining were prescribed nonopioid medications. Conclusion: The study suggests that the management of headaches is inadequate in emergency rooms, probably due to limited knowledge of health professionals about headache. This resulted in a large number of nonspecific diagnoses and inadequate therapeutic approaches.

Solid papillary carcinoma of the breast

Solid Papillary Carcinoma (SPC) of the breast is a rare tumor with an incidence of less than 1%, mainly affecting elderly females. It is morphologically characterized by well-defined nodules with low-grade nuclear features associated with fibrovascular cores and shows neuroendocrine differentiation. SPC can be in-situ or invasive but has a favorable prognosis. It is a morphological mimicker of some pre-malignant conditions leading to its frequent misdiagnosis. An appropriate immunohistochemical (IHC) panel workup helps in distinguishing this tumor from its various morphological mimics. In this report, we present one such case of SPC with a small focus of invasion, reviewing the literature.

The use of deliberate reflection to reduce confirmation bias among orthopedic surgery residents / O uso da reflexão deliberada para reduzir o viés de confirmação em residentes de ortopedia

Introduction: cognitive biases might affect decision-making processes such as clinical reasoning and confirmation bias is among the most important ones. The use of strategies that stimulate deliberate reflection during the diagnostic process seems to reduce availability bias, but its effect in reducing confirmation bias needs to be evaluated. Aims: to examine whether deliberate reflection reduces confirmation bias and increases the diagnostic accuracy of orthopedic residents solving written clinical cases. Methods: experimental study comparing the diagnostic accuracy of orthopedic residents in the resolution of eight written clinical cases containing a referral diagnosis. Half of the written cases had a wrong referral diagnosis. One group of residents used deliberate reflection (RG), which stimulates comparison and contrast of clinical hypotheses in a systematic manner, and a control group (CG), was asked to provide differential diagnoses with no further instruction. The study included 55 third-year orthopedic residents, 27 allocated to the RG and 28 to the CG. Results: residents on the RG had higher diagnostic scores than the CG for clinical cases with a correct referral diagnosis (62.0±20.1 vs. 49.1±21.0 respectively; p = 0.021). For clinical cases with incorrect referral diagnosis, diagnostic accuracy was similar between residents on the RG and those on the CG (39.8±24.3 vs. 44.6±26.7 respectively; p = 0.662). We observed an overall confirmation bias in 26.3% of initial diagnoses (non-analytic phase) and 19.5% of final diagnoses (analytic phase) when solving clinical cases with incorrect referral diagnosis. Residents from RG showed a reduction in confirmation of incorrect referral diagnosis when comparing the initial diagnosis given in the non-analytic phase with the one provided as the final diagnosis (25.9±17.7 vs. 17.6±18.1, respectively; Cohen d: 0.46; p = 0.003). In the CG, the reduction in the confirmation of incorrect diagnosis was not statistically significant. Conclusions:confirmation bias was present when residents solved written clinical cases with incorrect referral diagnoses, and deliberate reflection reduced such bias. Despite the reduction in confirmation bias, diagnostic accuracy of residents from the RG was similar to those from the CG when solving the set of clinical cases with a wrong referral diagnosis.

Introdução: os vieses cognitivos podem afetar tanto os processos de tomada de decisão como o raciocínio clínico e o viés de confirmação está entre os mais importantes. O uso de estratégias que estimulem a reflexão deliberada durante o processo diagnóstico parece reduzir o viés de disponibilidade, mas seu efeito na redução do viés de confirmação precisa ser avaliado. Objetivos: examinar se a reflexão deliberada reduz o viés de confirmação e aumenta a acurácia do diagnóstico de residentes de ortopedia ao resolverem casos clínicos escritos. Métodos: estudo experimental comparando a acurácia diagnóstica de residentes de ortopedia na resolução de oito casos clínicos escritos contendo um diagnóstico de encaminhamento. Metade dos casos escritos tinha um diagnóstico de encaminhamento errado. Um grupo de residentes utilizou a reflexão deliberada (GR), que estimula a comparação e o contraste de hipóteses clínicas de maneira sistemática, e um grupo controle (GC) foi solicitado a fornecer diagnósticos diferenciais sem maiores instruções. O estudo incluiu 55 residentes de ortopedia do terceiro ano, 27 alocados no GR e 28 no GC. Resultados: residentes no GR tiveram escores diagnósticos mais altos do que o GC para casos clínicos com um diagnóstico de encaminhamento correto (62,0±20,1 vs. 49,1±21,0 respectivamente; p = 0,021). Para os casos clínicos com diagnóstico de encaminhamento incorreto, a acurácia diagnóstica foi semelhante entre os residentes do GR e os do GC (39,8±24,3 vs. 44,6±26,7 respectivamente; p = 0,662). Observamos viés geral de confirmação em 26,3% dos diagnósticos iniciais (fase não analítica) e 19,5% dos diagnósticos finais (fase analítica) na resolução de casos clínicos com diagnóstico de encaminhamento incorreto. Os residentes do GR mostraram uma redução na confirmação do diagnóstico de encaminhamento incorreto ao comparar o diagnóstico inicial dado na fase não analítica com aquele fornecido como diagnóstico final (25,9±17,7 vs. 17,6±18,1, respectivamente; Cohen d: 0,46; p = 0,003). No GC, a redução na confirmação do diagnóstico incorreto não foi estatisticamente significativa. Conclusões: o viés de confirmação esteve presente quando os residentes resolveram casos clínicos escritos com diagnósticos de encaminhamento incorretos e a reflexão deliberada reduziu esse viés. Apesar da redução do viés de confirmação, a acurácia diagnóstica dos residentes do GR foi semelhante à do GC na solução do conjunto de casos clínicos com diagnóstico de encaminhamento incorreto.

Caracterização da produção científica sobre erro no trabalho em saúde / Caracterización de la producción científica sobre error en el trabajo en salud / Characterization of scientific production on errors in health work

Resumo Objetivo Caracterizar a produção científica nacional e internacional sobre erro no trabalho em saúde no período de 2000 a 2020. Métodos Trata-se de revisão integrativa de literatura, de estudos nacionais e internacionais, realizada nas bases MEDLINE, LILACS/BIREME, PubMed e SciELO. Foram encontrados 4164 estudos, sendo 148 incluídos e submetidos a análise de conteúdo temática. As buscas foram realizadas no período de janeiro a março de 2020 e abril de 2021. Os resultados foram sistematizados em três categorias temáticas. Resultados Na categoria Características dos estudos sobre erros, evidenciou-se que as categorias profissionais mais frequentes na ocorrência do erro são enfermeiras(os), médicos e farmacêuticos; quanto à Características do erro no trabalho em saúde, os tipos mais relatados são erro de medicação, de diagnóstico e na assistência de enfermagem, incluindo queda de pacientes, flebites decorrentes de cateteres venosos periféricos, ocorrência de úlceras por pressão e extubação de drenos, cateteres e sondas; e no Contexto para a ocorrência do erro, foram identificados elementos individuais e do contexto do trabalho, destacando-se este último. Conclusão Evidenciou-se que a ocorrência de erros no trabalho em saúde ocorre em um contexto de precarização do trabalho, com processos de trabalho marcados pela heterogeneidade. A partir da compreensão de que os trabalhadores da saúde erram e que a precarização do trabalho potencializa a ocorrência de erros, faz-se necessário a reorganização dos sistemas de saúde para que sejam reduzidas as oportunidades para o acontecimento de erros e que sejam promovidos os aprendizados quando estes ocorrerem.

Resumen Objetivo Caracterizar la producción científica nacional e internacional sobre el error en el trabajo en salud en el período de 2000 a 2020. Métodos Se trata de una revisión integrativa de literatura, de estudios nacionales e internacionales, realizada en las bases MEDLINE, LILACS/BIREME, PubMed y SciELO. Se encontraron 4164 estudios y 148 fueron incluidos y sometidos a un análisis temático de contenido. Las búsquedas se realizaron en el período de enero a marzo de 2020 y abril de 2021. Los resultados fueron sistematizados en tres categorías temáticas. Resultados En la categoría Características de los estudios sobre errores, se evidenció que las categorías profesionales más frecuentes en la ocurrencia del error son enfermeras(os), médicos y farmacéuticos; con relación a las Características del error en el trabajo en salud, los tipos más relatados son error de medicación, de diagnóstico y en la asistencia de enfermería, incluyendo la caída de pacientes, flebitis resultantes de catéteres venosos periféricos, y ocurrencia de úlceras por presión y extubación de drenaje, catéteres y sondas; y en el Contexto para la ocurrencia del error, se identificaron elementos individuales y del contexto del trabajo, destacándose este último. Conclusión Se evidenció que la ocurrencia de errores en el trabajo en salud se da en un contexto de precarización del trabajo, con procesos de trabajo marcados por la heterogeneidad. A partir del entendimiento de que los trabajadores de la salud cometen errores y que la precarización del trabajo potencia la ocurrencia de errores, se hace necesario reorganizar los sistemas de salud para que se reduzcan las oportunidades de que los errores ocurran y que se promuevan los aprendizajes cuando estos ocurran.

Abstract Objective To characterize the national and international scientific production on errors in health work from 2000 to 2020. Methods This is an integrative literature review of national and international studies, carried out in the MEDLINE, LILACS/BIREME, PubMed and SciELO databases. A total of 4164 studies were found, 148 of which were included and submitted to thematic content analysis. The searches were carried out from January to March 2020 and April 2021. The results were systematized into three thematic categories. Results In the category Characteristics of studies on errors, it was evidenced that the most frequent professional categories in error occurrence are nurses, physicians and pharmacists; regarding Characteristics of error in health work, the most reported types are medication, diagnosis and nursing care errors, including patient falls., phlebitis resulting from peripheral venous catheters, occurrence of pressure ulcers and extubation of drains, catheters and probes; and in Context for error occurrence, individual elements and work context were identified, highlighting the latter. Conclusion It was evident that error in health work occurs in a context of precarious work, with work processes marked by heterogeneity. From the understanding that health workers make mistakes and that the precariousness of work enhances error occurrence, it is necessary to reorganize health systems so that the opportunities for errors to occur are reduced and that learning is promoted when they occur.

A case of pseudomyogenic hemangioendothelioma misdiagnosed as low-grade malignant fibrous histiocytoma and review of literature / 中南大学学报(医学版)

Pseudomyogenic hemangioendothelioma (PHE) is a rare angiogenic tumor. Histologically, the morphological characteristics of neoplastic vessels and endothelial differentiation are not obvious, and it is easy to be confused with epithelioid sarcoma, epithelioid hemangioendothelioma and myogenic tumor. PHE usually occurs in arms and legs in young people and has a significant male predominance. The tumor has a predilection for the distal extremities and its typical manifestation is multiple center invasion of a single limb, which can involve all layers of skin and subcutaneous tissues,and is often accompanied by abvious pain. Histologically, PHE is characterized by infiltrative growth of tumor. Most tumor lesions are composed of sheets and loose fascicles of plump spindle or epithelioid cells within a background of variably prominent inflammatory infiltration, which was commonly composed of neutrophils. Some cells may resemble rhabdomyoblasts, and nuclear atypia and mitosis were rare. The tumor cells generally expressed positive cytokeratin (CK), ETS-related gene (ERG), Friend leukemia virus integration 1 (FLI1) and integrase interactor 1(INI1). In some cases, the tumor cells expressed CD31. A case of a young woman was reported in this paper, who presented with a subcutaneous mass with severe pain and was chronologically misdiagnosed with herpes zoster, low-grade malignant fibrous histiocytoma and epithelioid hemangioendothelioma. In this study, the clinical and pathological features, differential diagnosis and the latest progress in therapy of PHE were analyzed based on relevant literature.

Misdiagnosis of Acute Renal Artery Thrombosis as Acute Abdominal Disease:Report of One Case / 中国医学科学院学报

Renal artery thrombosis can cause acute occlusion of unilateral or bilateral renal arteries,and kidney failure would be induced if it is not diagnosed and treated in time.Therefore,rapid and correct treatment is especially important for renal artery thrombosis.Due to the lack of specificity of clinical manifestations,this disease in commonly misdiagnosed or missed and thus has a low early diagnosis rate.Here we report a case of acute renal artery thrombosis to improve the diagnosis and treatment.

The application of sigma metrics in the laboratory to assess quality control processes in South Africa

Objective: This study aimed to determine the sigma metrics of analytes when using different total allowable error guidelines.Methods: A retrospective analysis was performed on 19 general chemistry analytes at Charlotte Maxeke Johannesburg Academic Hospital in South Africa between January 2017 and December 2017. Sigma metrics were calculated on two identical analysers, using internal quality control data and total allowable error guidelines from the Ricos biological variation database and three alternative sources (the Royal College of Pathologists of Australasia, the Clinical Laboratory Improvements Amendment, and the European Federation of Clinical Chemistry and Laboratory Medicine). Results: The sigma performance was similar on both analysers but varied based on the guideline used, with the Clinical Laboratory Improvements Amendment guidelines resulting in the best sigma metrics (53% of analytes on one analyser and 46% on the other had acceptable sigma metrics) and the Royal College of Pathologists of Australia guidelines being the most stringent (21% and 23%). Sodium and chloride performed poorly across all guidelines (sigma < 3). There were also month-to-month variations that may result in acceptable sigma despite poor performance during certain months.Conclusion: The sigma varies greatly depending on the total allowable error, but could be a valuable tool to save time and decrease costs in high-volume laboratories. Sigma metrics calculations need to be standardised

Pertinencia de la solicitud del dímero D en pacientes de un servicio de urgencias / Pertinence of D-dimer request in patients in emergency services / Relevância da solicitação de D-dímero em pacientes de um setor de emergência

Introducción. El tromboembolismo pulmonar y la trombosis venosa profunda son urgencias cardiovasculares relativamente comunes, se han descrito diferentes predictores clínicos para la estratificación del riesgo, biomarcadores séricos y pruebas de imagenología. Dentro de los biomarcadores séricos se ha descrito el dímero D. Debido a que la enfermedad tromboembólica venosa es un reto diagnóstico para el clínico, el objetivo del presente estudio fue evaluar la pertinencia de la solicitud del dímero D, en el servicio de urgencias de un centro de tercer nivel en la ciudad de Bogotá durante los años 2018-2019. Metodología. Estudio observacional, descriptivo y transversal retrospectivo de pacientes que consultaron al servicio de urgencias, de una clínica de tercer nivel, de la ciudad de Bogotá, durante el periodo 2018-2019. Resultados. Se revisaron 583 historias clínicas, se excluyeron 107 pacientes, con un total final de 474 (57.3% mujeres y 42.6% hombres). De estos, 21 pacientes presentaron estudios positivos (angiotomografía y Doppler venoso). El dímero D presentó un valor predictivo negativo inferior al 50%. Discusión. A pesar de los resultados y de ser un estudio de un solo centro se evidencian las dificultades que tienen los médicos de los servicios de urgencias al momento de solicitar pruebas diagnósticas. Conclusiones. Este estudio evidencia la dificultad que existe en los servicios de urgencias al momento de la evaluación diagnóstica y cómo la solicitud de los paraclínicos tiene que ser un proceso estandarizado, guiado por los motivos de consulta y hallazgos al examen físico, y así no perder las características operativas de las pruebas diagnósticas y su utilidad al momento de la evaluación clínica.

Introduction. Pulmonary thromboembolisms and deep vein thromboses are relatively common cardiovascular emergencies. Various clinical predictors, serial biomarkers and imaging tests have been described for the stratification of the risk. D-dimer has been described within the serial biomarkers. Since venous thromboembolic disease is a diagnostic challenge for doctors, the objective of this study was to assess the pertinence of the D-dimer request in emergency services in a level three center in Bogotá during 2018-2019. Methodology. An observational, descriptive and cross-sectional retrospective study of patients who resorted to emergency services in a level three clinic in Bogotá during 2018-2019. Results. 583 medical records were reviewed, and 107 patients were excluded, with a final total of 474 patients (57.3% women and 42.6% men). Of these, 21 patients had positive studies (angiotomography and venous doppler ultrasound). D-dimer had a negative predictive value of less than 50%. Discussion. Despite the results and it being a study in a single clinic, the difficulties emergency service doctors experience when requesting diagnostic tests can be observed. Conclusions. This study shows the difficulties in emergency services when performing a diagnosis. The request for complementary tests has to be a standardized process guided by the reasons for the consultation and findings from the physical exam, in order not to lose the operational characteristics of the diagnostic tests and their usefulness during the clinical evaluation.

Introdução. Tromboembolismo pulmonar e trombose venosa profunda são emergências cardiovasculares relativamente comuns. Têm sido descritos diferentes preditores clínicos para estratificação de risco, biomarcadores séricos e testes de imagem. Entre os biomarcadores séricos, foi descrito o D-dímero. Considerando que a doença tromboembólica venosa é um desafio diagnóstico para o clínico, o objetivo deste estudo foi avaliar a relevância da solicitação de D-dímero no serviço de emergência de um centro de terceiro nível na cidade de Bogotá ao longo dos anos 2018-2019. Metodologia. Estudo observacional, descritivo e transversal retrospectivo de pacientes que consultaram o serviço de emergência de uma clínica de terceiro nível na cidade de Bogotá, no período de 2018-2019. Resultados. Foram revisados 583 prontuários, excluídos 107 pacientes, totalizando 474 (57.3% mulheres e 42.6% homens). Destes, 21 pacientes apresentaram estudos positivos (angiotomografia e Doppler venoso). D-dímero apresentou valor preditivo negativo inferior a 50%. Discussão. Apesar dos resultados e do fato de se tratar de um estudo só de um centro, são evidentes as dificuldades que os médicos de emergência apresentam ao solicitarem exames diagnósticos. Conclusões. Este estudo mostra a dificuldade que existe nos serviços de emergência no momento da avaliação diagnóstica e como a solicitação dos testes paraclínicos tem que ser um processo padronizado, orientado pelos motivos da consulta e pelos resultados do exame físico, e assim não perder as características operacionais dos exames diagnósticos e sua utilidade no momento da avaliação clínica.