The value of mammography in women with focal breast complaints in addition to initial targeted ultrasound.

PURPOSE: To determine the added value of mammography in women with focal breast complaints and the utility of initial targeted ultrasound in this setting. METHODS: Women with symptomatic breast disease who were evaluated by breast imaging (mammography/digital breast tomosynthesis and ultrasound) between January 2016 and December 2016 in the Radboud University Medical Centre were included. We retrospectively collected the following data: date of birth, indication of imaging, visibility on mammography/ultrasound, whether biopsy was taken, additional findings, BI-RADS-classification, pathology and follow-up results. RESULTS: A total of 494 women were included (mean age 46.5, range 30 to 93). In 49 women (9.9%), symptomatic breast cancer was diagnosed, all visible during targeted ultrasound. The negative predictive value of targeted ultrasound was very high (99.8%). Additional findings on mammography were significantly more often malignant when the symptomatic lesion was also malignant (3.8% vs 70%, P < 0.05). In only one patient with symptoms caused by a benign finding, an incidental malignancy was detected on mammography outside the area of complaint (detection rate 2.2/1000 examinations). CONCLUSIONS: The contribution of mammography for cancer detection in women with focal breast complaints is very low when targeted ultrasound is performed. Additional findings are most common in patients with symptomatic breast cancer. Our results suggest that initial targeted ultrasound is a more appropriate initial tool for the evaluation of focal breast complaints. Mammography could be performed on indication only.

The ONTAI study - a survey on antimicrobial dosing and the practice of therapeutic drug monitoring in German intensive care units.

PURPOSE: Optimization of antibiotic therapy is still urgently needed in critically ill patients. The aim of the ONTAI survey (online survey on the use of Therapeutic Drug Monitoring of antibiotics in intensive care units) was to evaluate which strategies intensive care physicians in Germany use to improve the quality of antibiotic therapy and what role a Therapeutic Drug Monitoring (TDM) plays. METHODS: Among the members of the German Society for Anaesthesiology and the German Society for Medical Intensive Care Medicine and Emergency Medicine, a national cross-sectional survey was conducted using an online questionnaire. RESULTS: The questionnaire was completely answered by 398 respondents. Without TDM, prolonged infusion was judged to be the most appropriate dosing regimen for beta lactams. A TDM for piperacillin, meropenem and vancomycin was performed in 17, 22 and 75% of respondents, respectively. For all beta lactams, a TDM was requested more often than it was available. There was great uncertainty as to the optimal pharmacokinetic/pharmacodynamic index for beta-lactams. 86% of the respondents who received minimal inhibitory concentrations adapted the therapy accordingly. CONCLUSION: German intensive care physicians are convinced of TDM for dose optimization. However, practical implementation, the determination of MICs and defined target values are still lacking.

[Emergency room management of severely injured patients]. / Schockraumversorgung von schwer verletzten Patienten. Analyse vermeidbarer Abweichungen vom Behandlungsalgorithmus. Analysis of avoidable deviations from the treatment algorithm.

BACKGROUND: In cases involving major trauma life-threatening situations should be immediately diagnosed and treated. Clinical algorithms can potentially decrease the rate of complications and errors. The purpose of this study was to investigate the incidence of deviations from a multislice computed tomography based trauma room algorithm. MATERIALS AND METHODS: During a primary trauma survey an independent study monitor observed the on site treatment sequence step by step. Time intervals between admission and start of each procedure were recorded. Deviations from the algorithm and delays were analyzed. RESULTS: In 57 trauma patients a total of 49 deviations were documented. Median time between admission and transfer to the adjacent MSCT room was 9 min. Of the patients 11 were bypassed to the MSCT suite without a primary survey (19.3%). In 2 cases an absence of non-invasive blood pressure monitoring was recorded (3.5%) and 3 patients with potential cervical spine trauma were not immobilized at the scene or during primary survey (5.3%). In 8 cases focused assessment with sonography for trauma (FAST) was not performed (14%). Contrary to the algorithm 10 patients received an arterial or central venous line during initial treatment (18%) resulting in a median delay of 8 min. The deviations from the algorithm resulted in no adverse effects on complications or mortality. CONCLUSION: Self-critical analysis of trauma resuscitation can increase the quality of treatment by revealing constantly recurring faults.

[Analysis of failure modes in multislice computed tomography during primary trauma survey]. / Analyse von Verzögerungen der Schockraumdiagnostik bei Einsatz der Mehrschicht-Spiral-Computertomografie.

PURPOSE: In the case of major trauma, immediate recognition and treatment of life-threatening conditions are essential. An increasing number of European trauma centers use MSCT during the primary trauma survey due to its high diagnostic precision and speed. However, there is currently little empirical data about failures in this process to practice quality assurance. The aim of this study was to evaluate this process under operating resuscitation conditions and to identify failure modes that caused delays in completion. MATERIALS AND METHODS: An independent study monitor documented the course of trauma room treatment during a 10-month period. The inclusion criteria were patients who were admitted directly from the accident scene and the study monitor was present at the time of admission. RESULTS: According to our ATLS-based trauma algorithm whole-body CT (WBCT) consists of non-contrast head CT (CCT) and contrast-enhanced trunk CT (TCT). 57 trauma patients receiving 45 WBCT. 5 single CCT and 4 single TCT studies were evaluated. After initial resuscitation, CCT was obtained within 17 min of trauma room admission (IQR 13.0 - 20.0). In 20 % (95 %CI 9 - 31 %) of the cases, a CCT delay of median 5.0 min (IQR 3.8 - 8.0) was observed caused by e. g. earings, piercings and ECG cables in the scan field or intoxicated patients. Contrast-enhanced TCT was performed after 23.0 min (IQR 19.0 - 27.0). Due to preventable errors 12 of the 49 TCT studies were delayed (25 % 95 %CI 12 - 37 %) for 5 min (IQR 3.0 - 8.0). CONCLUSION: Under "front line" conditions every fifth CCT and every fourth TCT study was completed with a median delay of 5 min. An independent process analysis revealed that unpreventable delays were due to uncooperative patients or system failure. Preventable delays were due to errors such as short intravenous lines or deviation from trauma room algorithms. Preventable delays could be avoided by addressing human and technical aspects such as revising checklists and functional architecture of the trauma bay. The failure mode and effect analysis (FMEA) method would assure quality in this process.