Differential Diagnosis Assessment in Ambulatory Care With an Automated Medical History-Taking Device: Pilot Randomized Controlled Trial.

BACKGROUND: Automated medical history-taking devices (AMHTDs) are emerging tools with the potential to increase the quality of medical consultations by providing physicians with an exhaustive, high-quality, standardized anamnesis and differential diagnosis. OBJECTIVE: This study aimed to assess the effectiveness of an AMHTD to obtain an accurate differential diagnosis in an outpatient service. METHODS: We conducted a pilot randomized controlled trial involving 59 patients presenting to an emergency outpatient unit and suffering from various conditions affecting the limbs, the back, and the chest wall. Resident physicians were randomized into 2 groups, one assisted by the AMHTD and one without access to the device. For each patient, physicians were asked to establish an exhaustive differential diagnosis based on the anamnesis and clinical examination. In the intervention group, residents read the AMHTD report before performing the anamnesis. In both the groups, a senior physician had to establish a differential diagnosis, considered as the gold standard, independent of the resident's opinion and AMHTD report. RESULTS: A total of 29 patients were included in the intervention group and 30 in the control group. Differential diagnosis accuracy was higher in the intervention group (mean 75%, SD 26%) than in the control group (mean 59%, SD 31%; P=.01). Subgroup analysis showed a between-group difference of 3% (83% [17/21]-80% [14/17]) for low complexity cases (1-2 differential diagnoses possible) in favor of the AMHTD (P=.76), 31% (87% [13/15]-56% [18/33]) for intermediate complexity (3 differential diagnoses; P=.02), and 24% (63% [34/54]-39% [14/35]) for high complexity (4-5 differential diagnoses; P=.08). Physicians in the intervention group (mean 4.3, SD 2) had more years of clinical practice compared with the control group (mean 5.5, SD 2; P=.03). Differential diagnosis accuracy was negatively correlated to case complexity (r=0.41; P=.001) and the residents' years of practice (r=0.04; P=.72). The AMHTD was able to determine 73% (SD 30%) of correct differential diagnoses. Patient satisfaction was good (4.3/5), and 26 of 29 patients (90%) considered that they were able to accurately describe their symptomatology. In 8 of 29 cases (28%), residents considered that the AMHTD helped to establish the differential diagnosis. CONCLUSIONS: The AMHTD allowed physicians to make more accurate differential diagnoses, particularly in complex cases. This could be explained not only by the ability of the AMHTD to make the right diagnoses, but also by the exhaustive anamnesis provided.

[The acute management of muscle injuries in 2018]. / Prise en charge des lésions musculaires aiguës en 2018.

Acute muscle lesions are frequent conditions in sports traumato-logy. Intrinsic traumatic mechanism (excessive stretch) is more prevalent that extrinsic mechanism (direct shock or lacerations). The diagnosis is generally based on the injury mechanism description together with the clinical examination. The ultrasonography is helpful in order to evaluate the severity of the lesion and the time to sports resumption. The initial management is based on the POLICE acronym: Protection, Optimal loading, Ice, Compression, and Elevation. For high grade muscle lesions, patients might benefit from either ultrasound-guided hematoma evacuation or surgical repair. Non-steroid anti-inflammatory drugs should be avoided within the first days. The rehabilitation should begin 48h after the trauma, whatever the severity of the lesion.

Les lésions musculaires sont fréquentes en traumatologie sportive. Le mécanisme traumatique est plus fréquemment intrinsèque (par élongation) qu'extrinsèque (par choc direct ou lacération). Le diagnostic se fait sur la base de la description du mécanisme lésionnel et de l'examen clinique. L'estimation de la gravité et des délais de reprise est aidée par les examens d'imagerie, comme l'échographie. La prise en charge immédiate se base sur le protocole POLICE (Protection, Optimal loading, Ice, Compression, Elevation). Les anti-inflammatoires non stéroïdiens sont à proscrire. Les lésions de haut grade peuvent bénéficier d'une ponction-évacuation d'hématome, voire d'une réparation chirurgicale. Il est recommandé de débuter une rééducation adaptée dès 48 heures après le traumatisme, quelle que soit la sévérité de la lésion initiale.

Subscapularis- and deltoid-sparing vs traditional deltopectoral approach in reverse shoulder arthroplasty: a prospective case-control study.

BACKGROUND: With the growth of reverse shoulder arthroplasty (RSA), it is becoming increasingly necessary to establish the most cost-effective methods for the procedure. The surgical approach is one factor that may influence the cost and outcome of RSA. The purpose of this study was to compare the clinical results of a subscapularis- and deltoid-sparing (SSCS) approach to a traditional deltopectoral (TDP) approach for RSA. The hypothesis was that the SSCS approach would be associated with decreased length of stay (LOS), equal complication rate, and better short-term outcomes compared to the TDP approach. METHODS: A prospective evaluation was performed on patients undergoing RSA over a 2-year period. A deltopectoral incision was used followed by either an SSCS approach or a traditional tenotomy of the subscapularis (TDP). LOS, adverse events, physical therapy utilization, and patient satisfaction were collected in the 12 months following RSA. RESULTS: LOS was shorter with the SSCS approach compared to the TDP approach (from 8.2 ± 6.4 days to 15.2 ± 11.9 days; P = 0.04). At 3 months postoperative, the single assessment numeric evaluation score (80 ± 11% vs 70 ± 6%; P = 0.04) and active elevation (130 ± 22° vs 109 ± 24°; P = 0.01) were higher in the SSCS group. The SSCS approach resulted in a net cost savings of $5900 per patient. Postoperative physical therapy, pain levels, and patient satisfaction were comparable in both groups. No immediate intraoperative complications were noted. CONCLUSION: Using a SSCS approach is an option for patients requiring RSA. Overall LOS is minimized compared to a TDP approach with subscapularis tenotomy. The SSCS approach may provide substantial healthcare cost savings, without increasing complication rate or decreasing patient satisfaction.

Supraspinatus Intramuscular Calcified Hematoma or Necrosis Associated with Tendon Tear.

Introduction. Rotator cuff intramuscular calcification is a rare condition usually caused by heterotopic ossification and myositis ossificans. Case Presentation. We describe a patient with voluminous calcified mass entrapped in supraspinatus muscle associated with corresponding tendon tear. Histological examination corresponded to a calcified hematoma or necrosis. Patient was surgically managed with open excision of the calcified hematoma and rotator cuff arthroscopic repair. At 6 months, supraspinatus muscle was healed, and functional outcome was good. Discussion and Conclusion. We hypothesized that supraspinatus intramuscular calcified hematoma was responsible for mechanical stress on the tendon. This association has never been described.