scholarly journals Diagnosis of dysphagia in Primary Care

2020 ◽  
Vol 105 (105(810)) ◽  
pp. 120-122
Author(s):  
F. Hinojosa-Fuentes ◽  
J. A. López-Díaz
Keyword(s):  
Primary Care ◽  
Elderly Patient ◽  
Malignant Disease ◽  
Barium Study ◽  
Early Appearance ◽  
Esophageal Dysphagia ◽  
Probable Diagnosis ◽  
Rule Out

In this work, we present the case of an elderly patient, who consulted for dysphagia mainly to solids, of early appearance. The anamnesis, in the context of an esophageal dysphagia, motivated the speed of the approach, in order to rule out a malignant disease. A barium study was requested that reports a probable diagnosis of achalasia. We highlight the value of the anamnesis in the course of the pathologies diagnosed in Primary Care, despite of limitation of complementary tests.

A single high-sensitivity cardiac troponin T compared to the HEART score for a rapid rule-out of acute myocardial infarction at a prehospital emergency clinic

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
T.R Johannessen ◽  
D Atar ◽  
O.M Vallersnes ◽  
A.C.K Larstorp ◽  
I Mdala ◽  
...  
Keyword(s):  
Primary Care ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
Low Risk ◽  
Symptom Duration ◽  
Funding Source ◽  
Emergency Setting ◽  
Heart Score ◽  
Rule Out

Abstract Background Patients presenting with acute chest pain outside of hospitals represent a diagnostic challenge. Purpose We aimed to validate whether a single high-sensitivity cardiac troponin T (hs-cTnT) safely can rule out acute myocardial infarction (AMI) in a primary care emergency setting. In addition, we aimed to investigate if the hs-HEART (History, Electrocardiogram (ECG), Age, Risk factors, and hs-Troponin) score would add valuable diagnostic information. Methods This is a secondary analysis from a prospective diagnostic study, including 1711 patients with acute non-specific chest pain presenting to a primary care emergency clinic from November 2016 to October 2018. The European Society of Cardiology (ESC) 0/1-hour algorithm triages patients towards direct rule-out if the 0-hour hs-cTnT is below 5 ng/L, combined with a normal ECG and a 3-hour symptom duration. The hs-HEART score (0–10 points) was calculated retrospectively, and a score ≤3 points was considered low-risk. In addition, a modified hs-HEART score, with more comparable hs-cTnT cut-off values, was applied. The primary endpoint was AMI during the index episode; the secondary the 90-day incidence of AMI (including index) and all-cause death. Results Among 1711 patients, 61 (3.6%) had an AMI, and 525 (30.7%) were assigned towards direct rule-out. With no AMIs in this group, the rule-out safety was high (negative predictive value (NPV) and sensitivity 100%). The hs-HEART score triaged more patients (n=966) as low-risk, but missed six AMIs (NPV 99.4% and sensitivity 90.2%). The modified hs-HEART score (n=707, AMI=3) increased the low-risk sensitivity to 95.1%. The 90-day incidence of AMI and all-cause death in the direct rule-out, low-risk hs-HEART, and modified hs-HEART group, were 0.0%, 0.7%, and 0.4%, respectively. Conclusions The ESC direct rule-out approach, with a single hs-cTnT below 5 ng/L, combined with a normal ECG, and a 3-hour symptom duration, is superior to the two hs-HEART scores in ruling out AMI in a primary care emergency setting. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): The Norwegian Research Fund for General Practice

scholarly journals Duct Excision is Still Necessary to Rule out Breast Cancer in Patients Presenting with Spontaneous Bloodstained Nipple Discharge

2011 ◽  
Vol 2011 ◽  
pp. 1-6 ◽  
Author(s):  
R. E. Foulkes ◽  
G. Heard ◽  
T. Boyce ◽  
R. Skyrme ◽  
P. A. Holland ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Malignant Disease ◽  
Nonoperative Management ◽  
Nipple Discharge ◽  
Breast Clinic ◽  
Exact Test ◽  
Malignant Lesions ◽  
Duct Excision ◽  
Symptomatic Breast ◽  
Rule Out

Introduction. Spontaneous nipple discharge is the third most common reason for presentation to a symptomatic breast clinic. Benign and malignant causes of spontaneous nipple discharge continue to be difficult to distinguish. We analyse our experience of duct excisions for spontaneous nipple discharge to try to identify features that raise suspicion of breast cancer and to identify features indicative of benign disease that would be suitable for nonoperative management.Methods. Details of one hundred and ninety-four patients who underwent duct excision for spontaneous nipple discharge between 1995 and 2005 were analysed.Results. Malignant disease was identified in 11 (5.7%) patients, 4 invasive and 7 insitu, which was 10.2% of those presenting with bloodstained discharge. All patients with malignant disease had bloodstained discharge. Discharge due to malignant disease was more likely to be bloodstained than that due to benign causes (Fisher's exact test, 2-tailedPvalue = 0.00134).Conclusion. Our findings do not support a policy of conservative management of spontaneous bloodstained nipple discharge. Cases of demonstrable spontaneous bloodstained nipple discharge should undergo duct excision to prevent malignant lesions being missed.

Faecal calprotectin is not necessarily required as a screen for significant bowel disease in primary care

2021 ◽  
pp. 000456322110634
Author(s):  
Matthew Malcolm Andrew Waite ◽  
Louise Langmead ◽  
Ruth M Ayling
Keyword(s):  
Primary Care ◽  
Bowel Disease ◽  
Test Performance ◽  
Faecal Calprotectin ◽  
Immunochemical Test ◽  
Inflammatory Bowel ◽  
Clinical Records ◽  
Sensitivity Specificity ◽  
Disease Specific ◽  
Rule Out

Objective NICE recommends measurement of faecal haemoglobin (f-Hb) using faecal immunochemical test (FIT) when colorectal cancer is suspected and calprotectin (f-Cal) in the context of inflammatory bowel disease, though neither is disease specific. During the COVID-19 pandemic, f-Hb has been a requirement prior to referral for endoscopy in England; f-Cal is often performed simultaneously. The aim of this study was to investigate test performance of both tests for significant bowel disease in those patients referred. Design All adult patients with simultaneous measurements of f-Hb and f-Cal between April 2019 and September 2020 were included. For those referred, outcomes were determined from clinical records. Results 650 patients with simultaneous samples for f-Hb an f-Cal were managed in Primary Care; 319 patients were referred to hospital; SBD was found in 32 (10.0%) (CRC 5, high risk adenomas 5, IBD 22). At a cut-off of 10 μg/g for f-Hb and 200 μg/g for f-Cal, the sensitivity, specificity and negative predictive value for diagnosis of SBD were 84.4%, 58.2% and 96.7% and 68.8%, 89.6% and 95.7%, respectively. Performance of both tests would have enabled diagnosis of two more cases of significant, but non-malignant, bowel disease but required over 4% more referrals for investigation. Conclusion Use of FIT has become established to assist prioritisation of patients for referral from Primary Care. Whilst introduced specifically for CRC, FIT performs well as a rule out for IBD in Primary Care and the use of f-Cal is not required.

scholarly journals Diagnosis and treatment of community-acquired pneumonia in patients with acute cough: a quantitative study of decision thresholds in primary care

2018 ◽  
Vol 68 (676) ◽  
pp. e765-e774 ◽  
Author(s):  
Mark H Ebell ◽  
Isabella Locatelli ◽  
Yolanda Mueller ◽  
Nicolas Senn ◽  
Kathryn Morgan
Keyword(s):  
Primary Care ◽  
Primary Care Physicians ◽  
Signs And Symptoms ◽  
Clinical Decision ◽  
Community Acquired Pneumonia ◽  
Multivariate Model ◽  
Clinical Decisions ◽  
Acute Cough ◽  
Treatment Thresholds ◽  
Rule Out

BackgroundTest and treatment thresholds have not yet been described for decision-making regarding the likelihood of pneumonia in patients with acute cough.AimTo determine decision thresholds in the management of patients with acute cough.Design and settingSet among primary care physicians attending meetings in the US and Switzerland, using data from a prospective cohort of primary care patients.MethodClinical vignettes were used to study the clinical decisions of physicians regarding eight patients with cough that varied by six signs and symptoms. The probability of community-acquired pneumonia (CAP) was determined for each vignette based on a multivariate model. A previously published approach based on logistic regression was used to determine test and treatment thresholds.ResultsIn total, 256 physicians made 764 clinical decisions. Initial physician estimates systematically overestimated the likelihood of CAP; 75% estimating a higher probability than that predicted by the multivariate model. Given the probability of CAP from a multivariate model, 16.7% (125 of 749) changed their decision from ‘treat’ to ‘test’ or ‘test’ to ‘rule out’, whereas only 3.5% (26/749) changed their decision from ‘rule out’ to ‘test’ or ‘test’ to ‘treat’. Test and treatment thresholds were 9.5% (95% confidence interval (CI) = 8.7 to 10.5) and 43.1% (95% CI = 40.1 to 46.4) and were updated to 12.7% (95% CI = 11.7 to 13.8) and 51.3% (95% CI = 48.3 to 54.9) once the true probability of CAP was given. Test thresholds were consistent between subgroups. Treatment thresholds were higher if radiography was available, for Swiss physicians, and for non-primary care physicians.ConclusionTest and treatment thresholds for CAP in patients with acute cough were 9.5% and 43.1%, respectively. Physicians tended to overestimate the likelihood of CAP, and providing information from a clinical decision rule (CDR) changed about 1 in 6 clinical decisions.

Immunoradiometric method and electrophoretic system compared for quantifying bone alkaline phosphatase in serum

1995 ◽  
Vol 41 (6) ◽  
pp. 853-857 ◽  
Author(s):  
V O Van Hoof ◽  
M Martin ◽  
P Blockx ◽  
A Prove ◽  
A Van Oosterom ◽  
...  
Keyword(s):  
Alkaline Phosphatase ◽  
Malignant Disease ◽  
Screening Method ◽  
Bone Alkaline Phosphatase ◽  
Cross Reactivity ◽  
Osteoblastic Activity ◽  
Alp Activity ◽  
Agarose Electrophoresis ◽  
End Stage ◽  
Rule Out

Abstract Agarose electrophoresis (Isopal, Beckman) and an immunoradiometric assay (IRMA) involving specific monoclonal antibodies (Ostase, Hybritech), two methods for the quantification of serum bone alkaline phosphatase (ALP, EC 3.1.3.1), a marker of osteoblastic activity, were compared in 293 patients: 79 with end-stage renal failure treated with hemodialysis and 214 with malignant disease. Overall correlation between the two methods was good (r = 0.92), except (a) for low values of bone ALP and (b) in some samples with high total liver ALP activity--both due to considerable cross-reactivity of the anti-bone ALP antibodies of the Ostase kit with liver ALP. This interference was not constant and was not evenly distributed across all concentrations of bone ALP. Low bone ALP determined with the IRMA (< or = 5 micrograms/L) was confirmed by electrophoresis (< or = 21 U/L), but bone ALP activity determined by electrophoresis to be low (< or = 21 U/L) was not correlated with the IRMA results. After standardizing our results by computing z-values for bone ALP, delta z (= zOstase - zIsopal) was significantly correlated with liver ALP activity (r = 0.73, P < 0.0001). We conclude that the IRMA for quantifying bone ALP is acceptable as a screening method. However, when high values for bone ALP are found with the Ostase method, confirmation by electrophoresis remains mandatory to rule out cross-reactivity with high amounts of liver ALP. For detecting low bone ALP activities, electrophoresis remains the method of choice.

Faster and better: Improving the diagnostic phase of lung cancer at a system level.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 115-115
Author(s):  
Melissa Kaan ◽  
Claire Holloway ◽  
Julie Gilbert ◽  
Vicky Simanovski ◽  
Garth Matheson
Keyword(s):  
Lung Cancer ◽  
Primary Care ◽  
Patient Experience ◽  
Cancer Care ◽  
Primary Care Providers ◽  
Diagnostic Process ◽  
Care Providers ◽  
The Past ◽  
Rule Out

115 Background: For many patients going through diagnostic testing for cancer, the time from suspicion to diagnosis or rule-out, can be a confusing and anxious time. In 2007, Cancer Care Ontario began investing in the implementation of diagnostic assessment programs (DAPs) across Ontario, Canada to improve the quality of care during the diagnostic phase of lung cancer. DAPs consist of multidisciplinary healthcare teams that manage and coordinate a patient’s diagnostic care from testing to a definitive diagnosis. The objectives of the DAPs are to: 1) decrease time from suspicion to diagnosis or resolution; 2) optimize the patient’s experience during the diagnostic process; 3) optimize satisfaction and experience among primary care providers and specialists; and 4) provide a sustainable solution by offering good value for money. Today over 35,000 patients have been diagnosed in one of the 18 lung DAPs that exist across the province. Methods: The implementation of DAPs featured the introduction of a patient navigator to act as the primary point of contact for patients, improve the patient experience and ensure their patients were progressing through any required diagnostic imaging and consultations in a timely manner. Cancer Care Ontario also engaged with primary care providers to refer patients with findings suspicious for lung cancer to DAPs as early as possible to ensure they benefited from organized assessment. Cancer Care Ontario has collected patient level data to measure wait times and implemented a patient survey to assess patient experience. Results: In the past five years, the median wait time from referral to a lung DAP to diagnosis or rule out has decreased by 19% to 24 days and the 90th %tile has decreased by 28% to 51 days. The large majority of patients have had a positive experience with their DAPs, with 95% of patients scoring their experience in the diagnostic process as “good” or “excellent”. Conclusions: The implementation of DAPs across the province is seen as a valuable component of quality of care by improving the diagnostic phase of cancer. The sustainability of the DAP model is demonstrated by the continued improvements in access and maintained patient experience in spite of growing volumes (91% increase in the past five years).

scholarly journals A decision aid to rule out pneumonia and reduce unnecessary prescriptions of antibiotics in primary care patients with cough and fever

BMC Medicine ◽  
2011 ◽  
Vol 9 (1) ◽  
Author(s):  
Johann Steurer ◽  
Ulrike Held ◽  
Anne Spaar ◽  
Birke Bausch ◽  
Marco Zoller ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Aid ◽  
Primary Care Patients ◽  
Rule Out

The Content of Physician and Elderly Patient Interaction in the Medical Primary Care Encounter

1992 ◽  
Vol 19 (3) ◽  
pp. 370-380 ◽  
Author(s):  
RONALD D. ADELMAN ◽  
MICHELE G. GREENE ◽  
RITA CHARON ◽  
ERIKA FRIEDMANN
Keyword(s):  
Primary Care ◽  
Elderly Patient ◽  
Patient Interaction

Telephone Triage by Primary Care Physicians

PEDIATRICS ◽  
1992 ◽  
Vol 89 (4) ◽  
pp. 701-706 ◽  
Author(s):  
Susan Zelitch Yanovski ◽  
Richard L. Brown ◽  
Donald J. Balaban ◽  
Jack A. Yanovski ◽  
James D. Malley
Keyword(s):  
Primary Care ◽  
Primary Care Physicians ◽  
Pediatric Patients ◽  
Telephone Interview ◽  
First Year ◽  
Telephone Triage ◽  
Private Practitioners ◽  
Sick Children ◽  
Better Than ◽  
Rule Out

To determine if experienced primary care physicians are more likely to reach correct decisions on the telephone than their less experienced colleagues, we asked 31 first-year and 29 third-year residents, 21 faculty, and 36 private practitioners in pediatrics and family practice to evaluate three pediatric patients via a telephone interview with a simulated mother and to decide whether each patient needed to be seen that evening. Compared with first-year residents, the third-year residents, faculty and private practitioners decided less frequently to see children who were not severely ill (P < .05) or injured (P < .01); however, less than half obtained histories considered adequate to rule out potential serious illnesses. Faculty did better than either residents or private practitioners in managing a severely dehydrated child; 100% of the faculty, but less than 60% of the residents or private practitioners, chose to see the patient promptly (P < .001). More than one third of all residents and private practitioners reached inappropriate management decisions despite obtaining information that should have altered their decisions. In these simulations, experience in private practice was not associated with improved telephone management of very sick children. Faculty physicians appeared to be better able to identify severely ill children without inappropriately evaluating those who were less ill. In all three simulations, attainment of the correct decision appeared to be determined not by the number or type of questions asked, but rather by the physician's interpretation of the information collected.

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