Lack of Clinical Utility of Labeled White Blood Cell Scintigraphy in Patients with Fever of Unknown Origin

Background Labeled white blood cell scintigraphy (WBCS) has been used for over 40 years to localize an infection source in patients with fever of unknown origin (FUO). It continues to be in widespread use for such patients in modern times, despite the tremendous advances in modern radiological imaging and laboratory medicine. Methods We critically evaluated the clinical contribution of WBCS performed in 132 patients with FUO at 7 hospitals from mid-2015 to the end of 2019. For each patient, all radiographic and laboratory results, and all electronic clinical notes, were carefully evaluated as many days prior to and following the scan as necessary to arrive at a final diagnosis. Results Although 50 WBCS (38%) showed positive findings, the majority of these were false positive (FP). Of the 19 true positive (TP) scans, most were already known or about to become known by tests already ordered at the time of the scan. Only 2 TP scans (1.5%) contributed to the final diagnosis, and these did so only indirectly. FP scans led to 7 unnecessary procedures. Conclusions In FUO patients for whom an infection source is not discovered following an appropriate radiographic and laboratory workup, WBCS is not a useful procedure.

Entrepreneurship and innovation in informal productive enterprises: Development of process innovation in a floral arrangement company

Purpose: reporting a process innovation in an informal productive enterprise, inserted in the field of parties, ceremonies and events décor, involving floral arrangements. Methodology: qualitative-descriptive study, with information being obtained through documentary research and case study. Originality/Relevance: this study analyzes an informal productive business, whose practice improvement was conducted based on technological resources. It is relevant because there are only few studies dedicated to technological development, and that thematize the most frequent type of productive enterprise in Brazil. Findings: the process innovation that was conducted has enabled a greater productive efficiency, as well as health, safety and hygiene in the workplace, since it has reduced costs and manufacturing time; and it has eliminated unnecessary procedures that result from the manual method. Theoretical/Methodological Implications: the innovation, developed and described heading from the theories and methodological approach used, in addition to promoting improvement in the ability of adapting to different customer demands, has added an element to the process innovation effects foreseen by Oslo Manual. Social Implications: in parallel to the operational results pointed out, the academic activity has enabled the improvement of economic enterprise that belong to settings and groups in social disadvantage.

Whirlpool No More: A Case of Misdiagnosed Malrotation with Midgut Volvulus

Introduction: Adult intestinal malrotation with midgut volvulus is rare and most often diagnosed on abdominal imaging. Once the diagnosis is made, prompt surgical intervention is necessary. A finding suggestive of malrotation with midgut volvulus on abdominal imaging is the “whirlpool” sign where the superior mesenteric vein and superior mesenteric artery twist at the root of the abdominal mesentery. This sign was once thought to be pathognomonic, but recent studies have shown that it can be seen in asymptomatic patients. Case Report: A 20-year-old female presented to our emergency department with diffuse abdominal pain. Computed tomography demonstrated the “whirlpool” sign with a concern for malrotation with midgut volvulus. Surgical consultation was obtained and the patient was rushed to the operating room for an exploratory laparotomy. Normal mesenteric attachments were seen and no significant pathology was identified during the laparotomy. The patient was eventually diagnosed with gastritis and discharged in stable condition. Conclusion: Emergency physicians and surgeons alike should be cautious in confirming malrotation with midgut volvulus solely due to the “whirlpool” sign on abdominal imaging. Premature diagnostic closure can lead to unnecessary procedures and interventions for patients as in the case we report here.

Evaluation and Management of Acute Myelopathy

Acute myelopathies are spinal cord disorders characterized by a rapidly progressive course reaching nadir within hours to a few weeks that may result in severe disability. The multitude of underlying etiologies, complexities in confirming the diagnosis, and often unforgiving nature of spinal cord damage have always represented a challenge. Moreover, certain slowly progressive myelopathies may present acutely or show abrupt worsening in specific settings and thus further complicate the diagnostic workup. Awareness of the clinical and magnetic resonance imaging characteristics of different myelopathies and the specific settings where they occur is fundamental for a correct diagnosis. Neuroimaging helps distinguish compressive etiologies that may require urgent surgery from intrinsic etiologies that generally require medical treatment. Differentiation between various myelopathies is essential to establish timely and appropriate treatment and avoid harm from unnecessary procedures. This article reviews the contemporary spectrum of acute myelopathy etiologies and provides guidance for diagnosis and management.

Predicting negative ureteroscopy for stone disease – Minimizing risk and cost

Introduction: Urolithiasis is common worldwide, with ureteric stones being a particular burden. Ureteroscopy (URS) is one of the most useful procedures in treating ureteric stones not passed spontaneously; this procedure has a complication risk of 4%. Negative URS, with described rates up to 15%, represents an avoidable patient risk and use of medical resources. Objectives: To describe rates and identify predictive factors for negative URS and to define strategies which would minimize patient and financial burden from these unnecessary procedures. Materials and methods: A retrospective cohort study analyzed patients who underwent URS in our Center to treat ureteric stones over a period of 2 years. Patient age, gender, and comorbidities, as well as laboratory and imaging findings, were analyzed. Results: 262 patients underwent URS for ureteric stones. The female population was 50.8% with a mean age of 56.89 years. A total of 78 (29.8%) URS procedures were negative. Univariate analysis showed a higher prevalence of negative URS in female patients, as well as in primary, smaller, and radiolucent stones. At multivariate analysis, a logistic regression model correctly classified 76% of patients, with smaller stone size and radiolucency being significant predictors of negative URS. Discussion and conclusions: Our Center showed a high rate of negative URS, higher than commonly described in the literature. Female patients tend to have an even higher rate, possibly due to unnoticed passage of stones. Patients with small, radiolucent stones showed the highest rates of negative URS.

A CONDUÇÃO EFICIENTE DE UM PROCESSO ADMINISTRATIVO DISCIPLINAR COMO APOIO À GESTÃO PÚBLICA

The article under the auspices of studies aims to elucidate issues pertinent to the Disciplinary Administrative Process (PAD), and an existing disparity with the Inquiry instrument, in order to conceptualize them as connected and opposing spheres. Therefore, the resolution of the project fails to comply with the search for an analysis of the effectiveness, importance and legal basis of the administrative instruments, considering the current legislation, jurisprudence and corresponding doctrines, in order to avoid formation of processes that present defects and nullities, being -the so-called unnecessary to public management. It was possible to obtain by design that the duty of managers in investigating disciplinary infractions, transcends the mere opening of the appropriate administrative procedure. This is because in addition to being associated with public management, the operator must maintain conduct in compliance with constitutional principles, in opening and judging unnecessary procedures. In a conclusive way, it appears that the Public Administration cannot, as an employer, relieve available absences practiced by its employees, even though its labor expression is of enormous quality. The resulting understanding promotes, finally, the opening of such procedures only when based on elements that make their continuity and useful completion essential, in order to satisfy Management's aspirations and desires. Thus, to encourage the study, the applied precept will be the deductive method and the dialectical hermeneutics, starting from a generalization to a particularized question, with the intention of considering the social practices, in the Administrative-Legal scope, in order to explore the means that use the Administration, to stigmatize its administrators.

Peritonsillar Abscess Size as a Predictor of Medical Therapy Success

Objective: To evaluate the success of sole medical therapy (MT) versus surgical therapy (ST) in patients with both clinically and radiographically confirmed peritonsillar abscess (PTA). To also determine treatment safety based on abscess size, and identify predictors of treatment failure. Methods: This was a retrospective cohort of 3 hospitals in a single academic health system. A total of 214 immunocompetent patients diagnosed with uncomplicated PTA underwent a contrasted CT scan of the neck. About 87 patients were treated with sole MT (intravenous antibiotics and steroids), and 127 patients were treated with ST (MT plus drainage). Results: Treatment failure occurred in 8.0% of the MT group and 7.9% of the ST group ( P = 1.00). In PTAs <2 cm, treatment failure occurred in 5.3% of the MT group and 5.0% of the ST group ( P = 1.00). In PTAs ≥2 cm, treatment failure occurred in 13.3% of the MT group and 9.0% treated with ST ( P = .53). Size ≥2 cm (OR – 3.46, P = .08) and IV clindamycin as sole IV antibiotic (OR – 2.46, P = .15) trended toward predicting treatment failure. In addition to those considered failures, 7.0% of the ST group returned to the ED with pain versus 0% of the MT group ( P = .01). Conclusion: Frequency of treatment failure was not significantly different among patients receiving MT and ST. Abscesses ≥2 cm in size were more likely to fail in both groups and ST was not statistically superior. Sole MT for uncomplicated PTA may help reduce unnecessary procedures and healthcare costs.

Acute Percheron Infarction: A Precision Learning

Background: So far, the diagnosis of acute AOP infarction is uncommon. The purpose of our study was to characterize the relationship between the imaging spectrum of acute AOP infarction and its clinical manifestations and prognosis on the basis of 23 cases.Methods: A total of 23 patients with acute AOP infarction in our institution from 2014 to 2019 were reviewed retrospectively. All cases were evaluated with computed tomography (CT), magnetic resonance imaging (MRI), detailed clinical and evaluated prognosis used a modified Rankin scale (mRs), blood studies, electrocardiogram and transthoracic echocardiography. All standard risk factors were recorded in these patients. mRs scores 90 days after discharge. Results: We identified 4 various patterns of acute AOP infarction: (1) bilateral paramedian thalamic infarction (BPTI, 52%), (2) bilateral paramedian thalamic with rostral midbrain infarction (BPTRMI, 30%), (3) bilateral paramedian and anterior thalamic infarction (BPATI, 13%), and (4) bilateral paramedian thalamic with red nuclei infarction (BPTRNI, 4%). These patients had consciousness disorder, memory dysfunctions, vertical gaze paresis, mesencephalothalamic syndrome and so on. The 65% patients with BPTI and BPATI who experienced a good functional recovery and could carry out daily life activities (mRS score ≤ 2). However, patients with BPTRMI who have an unfavorable outcome.Conclusion: Although the clinical feature of patients with AOP infarction is variable, DWI or ADC map can improve the diagnosis of acute AOP infarction patterns. Acute AOP occlusion requires immediate diagnosis and treatment initiation for a more favorable outcome and additional unnecessary procedures.

Triple diagnostic test in the evaluation of thyroid nodules

Background: Thyroid nodules are a common endocrine disease whose prevalence in India is approximately 12.2%. Although most patients with suspected nodules have benign conditions, the overestimation of malignancy leads to the performance of unnecessary procedures. No clinical, radiological and cytological parameters has singularly shown significant impact on clinical practice and post-operative histopathological examination remains the gold standard in the diagnosis of malignancy.Methods: 55 patients with thyroid nodules were evaluated and the Clinical assessment findings were recorded by McGill thyroid nodule score, ultrasonography findings using TIRADS and FNAC findings by the Bethesda system. The triple test was then used to classify them and these results were compared with the HPE of the post-operative specimen.Results: The sensitivity and specificity of TIRADS, FNAC were higher as compared to clinical score; clinical score had lowest sensitivity of 72.73%. The sensitivity, specificity, PPV, NPV and accuracy of triple test was 100%. Triple test had higher sensitivity, specificity and accuracy in differentiating thyroid nodules as compared to any of the three parameters used individually.Conclusions: Triple test has higher accuracy, sensitivity and specificity in determining the nature of thyroid nodule than each of the parameters used individually and it is especially useful in follicular lesions. On the basis of the results of this study, we conclude that the triple test can reliably be used to differentiate benign and malignant nodules preoperatively.

The Diagnosis Is in the Smear: A Case and Review of Spur Cell Anemia in Cirrhosis

The etiology of anemia in liver cirrhosis is multifactorial; one less recognized cause is hemolytic anemia due to spur cells, known as spur cell anemia. We present the case of a 57-year-old woman with alcoholic cirrhosis who presented with symptomatic macrocytic anemia with a hemoglobin level of 7.4 g/dL and signs of decompensated liver disease. Notably, she had no signs of overt bleeding. Further workup was consistent with hemolysis, with peripheral smear demonstrating spur cells. The patient was treated with both steroids and IVIG, although she eventually expired. The characteristic morphology of spur cells is due to alteration of the lipid composition of the erythrocyte membrane, changing its shape and leading to splenic sequestration and destruction. Characteristic of this disorder is an increased ratio of cholesterol to phospholipid on the membrane, as well as low levels of apolipoproteins and low- and high-density lipoproteins. The presence of spur cells is an indicator of poor prognosis and high risk of mortality. Currently, the only definitive cure is liver transplantation. There is a paucity of literature on the prevalence of this phenomenon and even less about treatment. This case highlights the importance of recognition of spur cell anemia as a cause of anemia in cirrhosis as well as the importance of the peripheral smear in the diagnostic workup. Early recognition can lead to avoidance of unnecessary procedures. Further research is needed to elucidate the true prevalence of spur cell anemia and examine further treatment options.