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1.
Lakartidningen ; 1162019 Nov 19.
Article in Swedish | MEDLINE | ID: mdl-31742654

ABSTRACT

Seventeen cases of infections in spinal structures were reported 2010-2017 to the Swedish Health and Social Care Inspectorate (IVO), a government agency responsible for supervising health care, for missed or delayed diagnosis. All patient records were scrutinized in order to find underlying causes and common factors. The delayed diagnoses were equally found among men and women and most frequent in in the age-group 65 to 79 years of age. The diagnostic delay most probably in many cases led to patient harm and avoidable sequelae, many with severe impairment for daily life. Several of the patients had a locus minoris resistentiae in the spine and in several cases the entry port of infections were cutaneous wounds, for example leg ulcers. The most important finding was that in the majority of cases the clinical investigation was inadequate and the clinical follow-up - while in hospital! - was inferior, without documentation of muscular weakness and sensory loss. In several cases a too passive management was found, when the losses eventually had become apparent, delaying surgical interventions.


Subject(s)
Spinal Diseases , Aged , Cauda Equina Syndrome/complications , Cauda Equina Syndrome/diagnosis , Cauda Equina Syndrome/etiology , Cauda Equina Syndrome/therapy , Delayed Diagnosis , Diagnostic Errors , Discitis/complications , Discitis/diagnosis , Discitis/etiology , Discitis/therapy , Emergency Treatment , Female , Humans , Male , Osteomyelitis/complications , Osteomyelitis/diagnosis , Osteomyelitis/etiology , Osteomyelitis/therapy , Quality of Health Care/standards , Spinal Diseases/complications , Spinal Diseases/diagnosis , Spinal Diseases/etiology , Spinal Diseases/therapy , Spinal Stenosis/complications , Spinal Stenosis/diagnosis , Spinal Stenosis/etiology , Spinal Stenosis/therapy , Spondylitis/complications , Spondylitis/diagnosis , Spondylitis/etiology , Spondylitis/therapy , Thoracic Vertebrae , Time-to-Treatment
2.
Lakartidningen ; 1142017 05 23.
Article in Swedish | MEDLINE | ID: mdl-28535025

ABSTRACT

We audited forty-six patients with a rupture of the Achilles tendon notified to the Swedish regulatory authority (the Health and Social Care Inspectorate) due to suspicion of malpractice. The patients' history and clinical presentation differed from those with a more classical acute rupture. The diagnostic errors were often found in patients older than 60 years, they were just as common in women as in men and the symptoms often had a subacute start. In most patients, the diagnostic errors were due to an incomplete clinical examination. More than one fourth of the patients were on medication with statins or quinolones.


Subject(s)
Achilles Tendon/injuries , Diagnostic Errors , Rupture/diagnosis , Achilles Tendon/drug effects , Adult , Age Distribution , Aged , Aged, 80 and over , Female , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/adverse effects , Male , Medical Audit , Middle Aged , Physical Examination , Primary Health Care , Quinolones/adverse effects , Rupture/etiology , Sweden
3.
Lakartidningen ; 1142017 03 14.
Article in Swedish | MEDLINE | ID: mdl-28291278

ABSTRACT

Systematic analysis of diagnostic errors in patients with myocardial infarction handled by the Swedish Health and Social Care Inspectorate​ Diagnostic errors in 51 patients with myocardial infarction handled by the Swedish Health and Social Care Inspectorate​ were analyzed. In more than half of the cases, the diagnostic errors occurred in health-care outside of hospitals. Diagnostic errors were more common when patients presented atypical symptoms, but atypical symptoms were equally common in male and female patients. Insufficient initial investigation, including lack of ECG registration, preceded a majority of the diagnostic errors. Wider indications for ECG and measurement of troponins in combination with increased awareness of atypical symptoms could possibly be remedies.


Subject(s)
Diagnostic Errors , Myocardial Infarction/diagnosis , Cohort Studies , Electrocardiography/statistics & numerical data , Emergency Service, Hospital , Fatal Outcome , Female , Humans , Male , Medical History Taking , Middle Aged , Myocardial Infarction/blood , Primary Health Care , Remote Consultation , Retrospective Studies , Sweden
4.
Lakartidningen ; 1142017 03 14.
Article in Swedish | MEDLINE | ID: mdl-28291281

ABSTRACT

Failing primary clinical investigation is common in missed hip fractures Diagnostic errors in 43 patients with hip fracture handled by the Swedish Health and Social Care Inspectorate were analyzed. Diagnostic errors were most likely a consequence of insufficient initial history, examination and/or radiologic examination. The most common isolated cause was delayed examination by a physician outside of a hospital setting. A substantial number of diagnostic errors were related to the radiological examination itself. Atypical symptoms were a minor cause of diagnostic errors. Since mortality in hip fracture is dependent on early surgery, preferably performed within 24 hours, diagnostic delay could prove disastrous to the patient.


Subject(s)
Diagnostic Errors , Hip Fractures/diagnosis , Medical History Taking/standards , Physical Examination/standards , Radiography/standards , Aged , Cohort Studies , Delayed Diagnosis , Humans , Male , Nurses/standards , Physicians/standards , Retrospective Studies , Sweden
5.
Lakartidningen ; 1142017 03 14.
Article in Swedish | MEDLINE | ID: mdl-28291280

ABSTRACT

Diagnostic errors in 49 patients with appendicitis handled by the Swedish Health and Social Care Inspectorate were analyzed. Diagnostic errors were more common in young or old patients, and among patients with atypical symptoms. Adjunct diagnostic tools, such as computerized tomography and/or ultrasound examination, also have limitations as regards diagnostic precision, and should therefore not be seen as golden standard. Increased individual knowledge, and not systems factors or safety culture, appears to be a suitable remedy against diagnostic errors.


Subject(s)
Appendicitis , Diagnostic Errors , Abdominal Pain/diagnosis , Adolescent , Adult , Age Distribution , Aged , Aged, 80 and over , Appendicitis/diagnosis , Appendicitis/diagnostic imaging , Appendicitis/epidemiology , Child , Cohort Studies , Constipation/diagnosis , Diagnosis, Differential , Diagnostic Errors/legislation & jurisprudence , Diagnostic Errors/prevention & control , Diagnostic Errors/statistics & numerical data , Female , Gastroenteritis/diagnosis , Humans , Male , Retrospective Studies , Urinary Tract Infections/diagnosis , Young Adult
6.
Lakartidningen ; 1142017 11 14.
Article in Swedish | MEDLINE | ID: mdl-29292917

ABSTRACT

Lumbar spine radiography - unreliable diagnostic accuracy and negligible value for the patients In 2016 140 000 lumbar spine radiographies were performed in Sweden (14 000 per million inhabitants) to a cost of about 85 million SEK (≈8.5 million Euro) and a negligible value for the patients with low back pain. In the work-up of low back pain, when imaging is indicated, lumbar spine radiography should be replaced by limited magnetic resonance imaging including a whole lower body coronal STIR sequence or computed tomography with radiation dose adapted to indication and patient age. Indication for imaging should be restricted to 1) low back pain with more than 3-4 weeks duration in combination with at least one ¼red flag«, 2) radicular pain without improvement on conservative treatment, or 3) low back pain with more than 8 weeks duration in combination with ¼yellow flags«.


Subject(s)
Lumbar Vertebrae/diagnostic imaging , Radiography/statistics & numerical data , Unnecessary Procedures , Humans , Low Back Pain/diagnostic imaging , Magnetic Resonance Imaging/economics , Magnetic Resonance Imaging/standards , Male , Middle Aged , Radiography/economics , Radiography/standards , Time Factors , Tomography, X-Ray Computed/economics , Tomography, X-Ray Computed/standards
7.
Dig Surg ; 33(4): 329-34, 2016.
Article in English | MEDLINE | ID: mdl-27215746

ABSTRACT

An elective total pancreatectomy (TP) was first performed by Eugene Rockey of Portland, Oregon, in 1942. In the 1960s and 1970s, TP was the routine resection for pancreatic cancer in many centers because of fear of a leaking pancreatojejunostomy and multicentricity of the disease but the result used to be dreadful (in today's perspective). However, more recently, postoperative mortality and morbidity after pancreatic resections have improved due to better anastomotic technique and pre-, peri- and postoperative care. Today, TP - despite being a more extensive operation - can be offered with about the same operation risk as that of a Whipple procedure. Also, major improvements in the control of diabetes have been seen and there is actually an ongoing discussion on the actual severity of the diabetic state after TP. Also, the development of modern pancreatic enzyme preparations with sufficient control of endocrine and exocrine pancreatic insufficiency provides options for overcoming the postoperative problems following TP. Due to the improved results, there are today different - and more specific - indications than before for TP: malignant tumors growing from the pancreatic head into the left pancreas, pancreatic head cancer where it is not possible to secure a tumor-free resection margin with extended resection or with dubious changes in the pancreatic main duct at frozen section, recurrent malignancy in the pancreatic remnant, at cancer surgery with resection of the celiac trunk, rescue pancreatectomy after a leaking pancreatojejunostomy with sepsis or bleeding after a Whipple-type first resection, multifocal intraductal papillary mucinous neoplasm with potentially malignant foci present in all parts of the gland, multiple metastases of renal cell carcinoma and melanoma without any residual tumor outside the pancreatic gland (possibly also other specified but uncommon metastatic tumors with a potential for cure by pancreatectomy), multifocal neuroendocrine tumors including multiple endocrine neoplasia and hereditary pancreatic cancer with a high grade of cancer penetration risk for the bearers.


Subject(s)
Pancreatectomy/adverse effects , Pancreatectomy/methods , Pancreatic Neoplasms/surgery , Patient Selection , Diabetes Mellitus/etiology , Humans , Malabsorption Syndromes/etiology , Organ Sparing Treatments , Pancreatic Neoplasms/pathology , Pylorus/surgery , Spleen/surgery , Stomach/surgery
8.
Lakartidningen ; 1132016 03 07.
Article in Swedish | MEDLINE | ID: mdl-26954926

ABSTRACT

Exocrine pancreatic insufficiency may result in urgency and foul smelling steatorrhea that is difficult to flush. The simplest way of diagnosis is by observing the response to therapy with high dose pancreatic enzymes. We here describe two different cases of exocrine insufficiency in elderly patients who earlier had some form of pancreatic surgery. These cases illustrate the varying presentations of exocrine pancreatic insufficiency and how proper history taking can help to cure this debilitating condition.


Subject(s)
Exocrine Pancreatic Insufficiency/etiology , Pancreatectomy/adverse effects , Aged , Exocrine Pancreatic Insufficiency/drug therapy , Female , Humans , Steatorrhea/etiology , Time Factors
9.
PLoS One ; 11(3): e0151262, 2016.
Article in English | MEDLINE | ID: mdl-26959234

ABSTRACT

BACKGROUND: Removal of the appendix might induce physiological changes in the gastrointestinal tract, and subsequently play a role in carcinogenesis. Therefore, we conducted a nationwide register-based cohort study in Sweden to investigate whether appendectomy is associated with altered risks of gastrointestinal cancers. METHODS: A population-based cohort study was conducted using the Swedish national registries, including 480,382 eligible patients followed during the period of 1970-2009 for the occurrence of site-specific gastrointestinal cancer (esophageal/gastric/colon/rectal cancer). Outcome and censoring information was collected by linkage to health and demography registers. We examined the incidence of appendectomy in Sweden using data from 1987-2009. We also calculated standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) to estimate the relative gastrointestinal cancer risk through comparison to the general population. RESULTS: We noted an overall decrease in the age-standardized incidence of appendectomy among the entire Swedish population from 189.3 to 105.6 per 100,000 individuals between 1987 and 2009. Grouped by different discharge diagnosis, acute appendicitis, incidental appendectomy, and entirely negative appendectomy continuously decreased over the study period, while the perforation ratio (18%-23%) stayed relatively constant. Compared to the general population, no excess cancer risk was observed for gastrointestinal cancers under study with the exception of a marginally elevated risk for esophageal adenocarcinoma (SIR 1.32, 95% CI 1.09-1.58). CONCLUSIONS: In Sweden, the incidence of appendectomy and acute appendicitis has decreased during 1987-2009. No excess gastrointestinal cancer risks were observed among these appendectomized patients, with the possible exception of esophageal adenocarcinoma.


Subject(s)
Appendectomy/adverse effects , Gastrointestinal Neoplasms/etiology , Adolescent , Adult , Appendicitis/surgery , Child , Child, Preschool , Cohort Studies , Female , Gastrointestinal Neoplasms/epidemiology , Humans , Infant , Infant, Newborn , Male , Middle Aged , Sweden , Young Adult
12.
Hepatobiliary Surg Nutr ; 4(5): 325-35, 2015 Oct.
Article in English | MEDLINE | ID: mdl-26605280

ABSTRACT

The connection between pancreatic cancer and venous thrombosis has been discussed for almost 150 years. The exact pathophysiological mechanisms are still partly understood, but it is known that pancreatic cancer induces a prothrombotic and hypercoagulable state and genetic events involved in neoplastic transformation (e.g., KRAS, c-MET, p53), procoagulant factors [e.g., tissue factor (TF), platelet factor 4 (PF4), plasminogen activator inhibitor type 1 (PAI-1)], mucin production (e.g., through activation of P- and L-selectin) and pro-inflammatory factors [e.g., cytokines, cyclooxygenase-2 (COX-2)] may be implicated. Also pancreatitis, both acute and chronic, is associated with increased risk of venous thrombosis, but in this circumstance a direct inflammatory process may be more important. This article discusses the incidence, treatment and outcome of venous thromboembolism (VTE) complicating pancreatic disease, with special emphasis on new knowledge obtained during the last fifteen years.

16.
BMC Surg ; 15: 69, 2015 Jun 02.
Article in English | MEDLINE | ID: mdl-26032861

ABSTRACT

BACKGROUND: Acute appendicitis is one of the most common acute abdominal conditions. Among other parameters, the decision to perform surgical exploration in suspected appendicitis involves diagnostic accuracy, patient age and co-morbidity, patient's own wishes, the surgeon's core medical values, expected natural course of non-operative treatment and priority considerations regarding the use of limited resources. Do objective clinical findings, such as radiology and laboratory results, have greater impact on decision-making than "soft" clinical variables? In this study we investigate the parameters that surgeons consider significant in decision-making in cases of suspected appendicitis; specifically we describe the process leading to surgical intervention in real settings. The purpose of the study was to explore the process behind the decision to undertake surgery on a patient with suspected appendicitis as a model for decision-making in surgery. METHODS: All appendectomy procedures (n = 201) at the Department of Surgery at Karolinska University Hospital performed in 2009 were retrospectively evaluated. Every two consecutive patients seeking for abdominal pain after each case undergoing surgery were included as controls. Signs and symptoms documented in the medical records were registered according to a standardized protocol. The outcome of this retrospective review formed the basis of a prospective registration of patients undergoing appendectomy. During a three- month period in 2011, the surgeons who made the decision to perform acute appendectomy on 117 consecutive appendectomized patients at the Karolinska University Hospital, Huddinge, and Södersjukhuset, were asked to answer a questionnaire about symptoms, signs and diagnostic measures considered in their treatment decision. They were also asked which three symptoms, signs and diagnostic measures had the greatest impact on their decision to perform appendectomy. RESULTS: In the retrospective review, tenderness in the right fossa had the greatest impact (OR 76) on treatment decision. In the prospective registration, the most frequent symptom present at treatment decision was pain in the right fossa (94 %). Tenderness in the right fossa (69 %) was also most important for the decision to perform surgery. Apart from local status, image diagnostics and blood sample results had the greatest impact. CONCLUSION: Local tenderness in the right fossa, lab results and the results of radiological investigations had the greatest impact on treatment decision.


Subject(s)
Appendectomy , Appendicitis/diagnosis , Clinical Decision-Making/methods , Practice Patterns, Physicians'/statistics & numerical data , Abdominal Pain/etiology , Acute Disease , Adult , Aged , Appendicitis/complications , Appendicitis/surgery , Diagnosis, Differential , Female , Humans , Male , Middle Aged , Retrospective Studies , Sweden
17.
JAMA Surg ; 150(6): 512-8, 2015 Jun.
Article in English | MEDLINE | ID: mdl-25853369

ABSTRACT

IMPORTANCE: Pancreatic cancer is the fourth leading cause of cancer-related death in Western countries. In approximately 10% of all patients with pancreatic cancer, it is possible to define a positive family history for pancreatic cancer or for one of the other related genetic syndromes. A screening program for individuals at risk is recommended; however, surveillance modalities have not been defined yet. OBJECTIVE: To analyze the short-term results of a prospective clinical surveillance program for individuals at risk for pancreatic cancer using a noninvasive magnetic resonance imaging (MRI)-based screening protocol. DESIGN, SETTING AND PARTICIPANTS: A prospective observational study of all patients with a genetic risk for developing pancreatic cancer who were referred to Karolinska University Hospital between January 1, 2010, and January 31, 2013, using an MRI-based surveillance program. All patients were investigated for the most common genetic mutations associated with pancreatic cancer. EXPOSURE: A noninvasive MRI-based screening protocol. MAIN OUTCOMES AND MEASURES: The ability of MRI to identify potential precancerous or early cancers in individuals at risk for pancreatic cancer. RESULTS: Forty patients (24 women and 16 men) were enrolled. The mean age was 49.9 years. The mean length of follow-up was 12.9 months. The numbers of relatives affected by pancreatic cancer were 5 in 2 patients (5%), 4 in 5 patients (12.5%), 3 in 17 patients (42.5%), 2 in 14 patients (35%), and 1 in 2 patients (5%). In 4 patients (10%), a p16 mutation was found; in 3, a BRCA2 mutation (7.5%); and in 1, a BRCA1 mutation (2.5%). In 16 patients (40%), MRI revealed a pancreatic lesion: intraductal papillary mucinous neoplasia (14 patients, 35%) and pancreatic ductal adenocarcinoma (2 patients, 5%). One patient had a synchronous intraductal papillary mucinous neoplasia and pancreatic ductal adenocarcinoma. Five patients (12.5%) required surgery (3 for pancreatic ductal adenocarcinoma and 2 for intraductal papillary mucinous neoplasia), while the remaining 35 are under continued surveillance. CONCLUSIONS AND RELEVANCE: During a median follow-up of approximately 1 year, pancreatic lesions were detected in 40% of the patients, of whom 5 underwent surgery. Although the study time was relatively short, the surveillance program in individuals at risk seems to be effective.


Subject(s)
Early Detection of Cancer/statistics & numerical data , Mass Screening/methods , Pancreatic Neoplasms/prevention & control , Adult , Aged , Bacteriocins , Carcinoma, Pancreatic Ductal/genetics , Carcinoma, Pancreatic Ductal/prevention & control , Early Detection of Cancer/methods , Female , Genes, BRCA1/physiology , Genes, BRCA2/physiology , Genetic Predisposition to Disease , Humans , Magnetic Resonance Imaging , Male , Middle Aged , Pancreatectomy , Pancreatic Neoplasms/genetics , Pancreatic Neoplasms/surgery , Peptides , Precancerous Conditions/diagnosis , Prospective Studies , Sweden
20.
Surgery ; 156(3): 591-600, 2014 Sep.
Article in English | MEDLINE | ID: mdl-25061003

ABSTRACT

BACKGROUND: The lymph node (Ln) status of patients with resectable pancreatic ductal adenocarcinoma is an important predictor of survival. The survival benefit of extended lymphadenectomy during pancreatectomy is, however, disputed, and there is no true definition of the optimal extent of the lymphadenectomy. The aim of this study was to formulate a definition for standard lymphadenectomy during pancreatectomy. METHODS: During a consensus meeting of the International Study Group on Pancreatic Surgery, pancreatic surgeons formulated a consensus statement based on available literature and their experience. RESULTS: The nomenclature of the Japanese Pancreas Society was accepted by all participants. Extended lymphadenectomy during pancreatoduodenectomy with resection of Ln's along the left side of the superior mesenteric artery (SMA) and around the celiac trunk, splenic artery, or left gastric artery showed no survival benefit compared with a standard lymphadenectomy. No level I evidence was available on prognostic impact of positive para-aortic Ln's. Consensus was reached on selectively removing suspected Ln's outside the resection area for frozen section. No consensus was reached on continuing or terminating resection in cases where these nodes were positive. CONCLUSION: Extended lymphadenectomy cannot be recommended. Standard lymphadenectomy for pancreatoduodenectomy should strive to resect Ln stations no. 5, 6, 8a, 12b1, 12b2, 12c, 13a, 13b, 14a, 14b, 17a, and 17b. For cancers of the body and tail of the pancreas, removal of stations 10, 11, and 18 is standard. Furthermore, lymphadenectomy is important for adequate nodal staging. Both pancreatic resection in relatively fit patients or nonresectional palliative treatment were accepted as acceptable treatment in cases of positive Ln's outside the resection plane. This consensus statement could serve as a guide for surgeons and researchers in future directives and new clinical studies.


Subject(s)
Carcinoma, Pancreatic Ductal/surgery , Lymph Node Excision/standards , Pancreatectomy/standards , Pancreatic Neoplasms/surgery , Humans , Lymph Node Excision/methods , Pancreatectomy/methods , Pancreaticoduodenectomy/methods , Pancreaticoduodenectomy/standards
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