I assessed the accuracy of two clinical prediction rules, the d-dimer blood test and point of care ultrasound for diagnosing lower limb deep vein thrombosis. Emergency physicians were trained in ultrasound and prospectively scanned emergency department patients with suspected deep vein thrombosis. Accuracy of the Wells and AMUSE rules and the ultrasound result was compared to radiology-performed ultrasound and a 90-day clinical outcome. Univariate and multivariate analyses were performed assessing which factors were associated with the outcome. The sensitivity and specificity of the Wells score for the clinical outcome was 85.7% and 68.5%; the AMUSE score 85.7% and 54.4%. Ultrasound had a sensitivity of 91.7% and specificity of 91.7% for radiology-diagnosed thrombus and 78.6% and 95.0% for clinical outcome. The odds ratio of a positive outcome with a positive ultrasound was 65.1. After receiving the ultrasound training program, emergency physicians were unable to demonstrate sufficient accuracy to replace current diagnostic strategies.

A prevalência de diabetes mellitus (DM) está aumentando constantemente em todo o mundo a uma taxa alarmante. Devido às suas complicações que causam uma maior morbidade, invalidez e mortalidade, o DM representa um enorme problema para a saúde pública. Com isso, ações, tanto em diagnóstico como em tratamento, são necessárias para desacelerar a tendência atual e prevenir o desenvolvimento das complicações do DM. Recentemente, a hemoglobina glicada (HbA1c) foi introduzida nos critérios diagnósticos de DM. Os resultados de HbA1c são igualmente apropriados para o diagnóstico, apesar de não necessariamente detectarem DM nos mesmos indivíduos detectados pelos critérios de glicemia. No entanto, os níveis de HbA1c podem ser influenciados por qualquer condição que altere a vida útil dos eritrócitos e metabolismo da hemoglobina, independentemente da glicemia, resultando em erro diagnóstico neste grupo da população com estas condições. Além disso, estudos epidemiológicos revelaram que a glicemia pós-prandial tem um maior risco de causar complicações cardiovasculares em relação à hiperglicemia persistente e pode ser acessada com precisão usando a albumina glicada (AG) e não a HbA1c. Nesse contexto, estudos recentes têm evidenciado que a AG pode ser um marcador para diagnóstico do DM e também ser utilizado como um marcador alternativo à HbA1c para o controle glicêmico. No entanto, esses estudos, foram realizados apenas na população asiática e podem não ser aplicáveis a outros grupos étnicos. Por isso, mais investigações para a validação do desempenho diagnóstico da AG na predição do DM em diferentes grupos etnicos são necessárias. Neste estudo avaliamos o desempenho da AG no diagnóstico do DM em 242 indivíduos brasileiros com idade média de 54,4 anos (+ 13,0). Baseando-se nos valores de glicose plasmática durante o teste oral de tolerância à glicose (TOTG), o DM foi detectado em 31,8%. AG ≥16,8% apresentou acurácia similar para a detecção de DM conforme definido por HbA1c >6,5%. O uso da razão glicemia de 2h pós-sobrecarga de 75g de glicose (2hPG) e AG (2hPG/AG) melhora a sensibilidade, reduz o número de diagnósticos incorretos por AG ou HbA1c >6,5% e possui um acurácia comparável ao TOTG, indicando que o uso de uma estratégia aplicando a razão da glicemia pós-prandial (GPP) real e AG (GPP/AG) pode ser mais conveniente para pacientes e aumentar o desempenho diagnóstico do teste. Estudos para validar esta estratégia são necessários. / The prevalence of diabetes mellitus (DM) is constantly increasing worldwide at an alarming rate. Due to its complications that cause greater morbidity, disability and mortality, DM represents a heavy burden on public health. Therefore, actions in both, diagnosis and treatment, are necessary to slow down the current tendency and avoid the development of DM complications. Recently, the glycated hemoglobin test (HbA1c) was introduced in the diagnostic criteria for DM. The HbA1c results are equally appropriate for diagnostic testing, though not necessarily detect DM in the same subjects detected by plasma glucose criteria. However, blood HbA1c levels may be influenced by any condition that changes the lifespan of erythrocytes and hemoglobin metabolism regardless of glycemia, resulting in the misdiagnosis of this population group. In addition, epidemiological studies have shown that postprandial glycemia has a higher risk of causing cardiovascular complications than chronic hyperglycemia and can be accurately assessed using the glycated albumin (GA) test rather than HbA1c. In this context, recent studies have shown that GA may be a marker for the diagnosis of DM and also be used as an alternative marker to HbA1c on many occasions. However, these studies have been conducted only in the Asian population and may not be applicable to other ethnic groups. Therefore, further investigations to validate the diagnostic performance of GA in the prediction of DM in different ethnic groups are necessary. In this study, we evaluated the GA performance in the diagnosis of DM in 242 Brazilian individuals with a mean age of 54.4 years (+ 13.0). Based on plasma glucose values during oral glucose tolerance test (OGTT), DM was detected in 31.8%. AG ≥16.8% presented similar accuracy for detecting DM as defined by a HbA1c >6.5%. The use of the 2-h plasma glucose after a 75-g OGTT and GA (2hPG/GA) ratio improves sensitivity, reduces the number of incorrect diagnoses by GA or HbA1c >6.5% and has an accuracy comparable to OGTT, indicating that the use of approach applying the postprandial glucose (PPG) and GA (PPG/GA) may be more convenient for patients and increase the diagnostic performance of the test. Studies to validate this approach are needed.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第21662号 / 医博第4468号 / 新制||医||1035(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 溝脇 尚志, 教授 上本 伸二, 教授 増永 慎一郎 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第21667号 / 医博第4473号 / 新制||医||1035(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 小柳 義夫, 教授 中川 一路, 教授 長船 健二 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Title: Clinical Decision Making in Paramedicine Author(s) & affiliation(s): Michael Eby – McMaster University, Hamilton, ON, Canada Sandra Monteiro – McMaster University, Hamilton, ON, Canada Geoffrey Norman – McMaster University, Hamilton, ON, Canada Walter Tavares – McMaster University, Hamilton, ON, Canada Background: Paramedics are frequently required to make rapid decisions in an uncontrolled, dynamic environment, often with limited diagnostic information. In Ontario, paramedic practice is based on a set of provincial medical directives that provide diagnostic and treatment criteria. Unsupervised deviation from these directives is classified as a form of error and highly discouraged. To date, there is little known about how years of clinical experience or level of certification affect the way these medical directives are used. The purpose of this study was to examine the relationship between paramedic experience, training and accuracy of treatment decisions when faced with patients who meet and fall outside of the existing medical directives. Methods: Thirty-one participants (16 experienced / 15 novice) were recruited from two paramedic services in Ontario. “Experienced” was defined as in-practice for 5 years or more. Participants were presented with 9 scenarios; in 6 scenarios, the patient presentation fit within the existing directives, while in 3 scenarios, the patient presentation fell outside the medical directives. Multiple-choice responses were used to capture participants’ decisions to treat or not treat the patients. Responses were scored and submitted to a mixed-factorial ANOVA to evaluate differences in accuracy between case types, years of experience and level of training. Results: There was a significant effect of case type (p < 0.004). Accuracy was lower when the patient presentation did not meet the criteria of the medical directive (76.34% (CI = 67.15% to 85.53%) vs. 98.35% (CI = 96.55% to 100%) when they did. There was no effect of years of clinical practice or level of certification. Conclusion: The results suggest both novice and experienced paramedics are able to accurately apply medical directives, however, there is a significant decrease in accuracy when the patient presentation does not fit one. This variation in practice may have a significant impact on patient safety, and further research is required to determine what factors may be causing this decreased accuracy. / Thesis / Master of Science (MSc) / Paramedics work in a fast-paced, dynamic environment. The types of patients, and the situations paramedics encounter are different every day. Paramedic practice is based on a series of provincial medical directives that outline the different proceedures, medications and types of patients that can be treated. While these directives cover many of the cases paramedics encounter, there will always be cases that don’t “fit”. The purose of this study is to see if paramedics approach those types of cases in a different way, and if their years of experience or level of training change how good they are at idenfiying what patients require treatment. As there is very little paramedic specific research on this topic, this study will serve as a starting point for future research and hopefully stimulate discussion about paramedic practice, and how to support paramedics getting better at their jobs.

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Submitted by Luciana Ferreira (lucgeral@gmail.com) on 2015-11-12T11:15:03Z No. of bitstreams: 2 Dissertação - Vivaldo Gomes da Costa - 2015.pdf: 2069412 bytes, checksum: 8451333c0969ae734748f50c7e57e0f3 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2015-11-12T11:16:34Z (GMT) No. of bitstreams: 2 Dissertação - Vivaldo Gomes da Costa - 2015.pdf: 2069412 bytes, checksum: 8451333c0969ae734748f50c7e57e0f3 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-11-12T11:16:34Z (GMT). No. of bitstreams: 2 Dissertação - Vivaldo Gomes da Costa - 2015.pdf: 2069412 bytes, checksum: 8451333c0969ae734748f50c7e57e0f3 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2015-01-12 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / The diagnosis of dengue virus (DENV) infection still remains a challenge, due to cross-reactivity between serological tests and to traditional methods that capture IgM, which is a late marker of infection. However, NS1 antigen is an early marker. Accordingly, several studies have evaluated the performance of tests that utilize NS1 capture, but the results of individual studies may be limited due to the restricted sample size of the patients recruited. Therefore, our objective was to perform a meta-analysis of the diagnostic accuracy of two commercial NS1 ELISAs (Panbio® and Platelia™). Methods and Results: Studies of interest were found in PubMed, Embase and Google Scholar databases using defined inclusion/exclusion criteria. A total of 30 studies containing 12.105 total enrolled patients were included. The overall estimated sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio were as follows: 66% (95% confidence interval (CI) 61-71), 99% (95% CI 96 -100), 98 (95% CI 20-464) 0.3 (95% CI 0.2-0.4) and 289 (95% CI 59-1412), respectively, for Panbio®, and 74% (95% CI 63-82 ), 99% (95% CI 97-100), 175 (95% CI 28-1099), 0.3 (95% CI 0.2-0.4) and 663 (95% CI 98-4478), respectively, for Platelia™. The lowest sensitivity values were for secondary infections (57% [95% CI 47-67] and 66% [95% CI 53-77] for Panbio® and Platelia™, respectively) and for the detection of DENV4. Regarding clinical manifestations, the sensitivity of Platelia™ was 69% (95% CI 43-86) and 60% (95% CI 48-70) for fever and dengue hemorrhagic fever, respectively. In addition, the sensitivity of both tests was slightly lower for samples from Southeast Asia and Oceania. Conclusion: DENV1 samples gave higher sensitivity results for both tests. We observed that factors negatively influencing the tests, such as the type of infection and viral serotype, require further investigation to optimize the diagnostic accuracy. / O diagnóstico das infecções pelo dengue vírus (DENV) continua um desafio, principalmente devido a ocorrência de reações cruzadas entre os testes sorológicos e devido aos tradicionais métodos para captura de IgM constituírem marcadores tardio da infecção. Todavia, o antígeno NS1 é um marcador precoce. Nesse contexto vários estudos tem avaliado a performance dos testes para a captura do NS1, porém os resultados dos estudos individuais podem ser limitados, por causa do restrito tamanho amostral dos pacientes recrutados. Portanto, nosso objetivo foi realizar uma meta-análise da acurácia diagnóstica de dois ensaios comerciais ELISA NS1 (Panbio® e Platelia™). Métodos e Resultados: Os estudos de interesse foram extraídos das bases de dados PubMed, Embase e Google Acadêmico, com definidos critérios de inclusão e exclusão. Um total de 30 estudos, perfazendo 12.105 pacientes recrutados, foram incluídos na análise estatística. A estimativa global da sensibilidade, especificidade, razão de verossimilhança positiva e negativa, razão de chance diagnóstica foram: 66% (95% intervalo de confiança (CI) 61-71), 99% (95% CI 96-100), 98 (95% CI 20-464), 0.3 (95% CI 0.2-0.4) e 289 (95% CI 59-1412), respectivamente para o kit da Panbio®. Enquanto para o kit da Platelia™, os resultados obtidos foram, respectivamente: 74% (95% CI 63-82), 99% (95% CI 97-100), 175 (95% CI 28-1099), 0.3 (95% CI 0.2-0.4) e 663 (95% CI 98-4478). A menor performance dos testes ocorreram nas infecções secundárias e na detecção do DENV4. Quanto às formas clínicas da dengue, a sensibilidade do Platelia™ foi de 69% (95% CI 43-86) e 60% (95% CI 48-70), para a febre da dengue e febre hemorrágica, respetivamente. A sensibilidade de ambos os testes foram discretamente menores para as amostras provenientes da Ásia e Oceania. Conclusão: As amostras de DENV1 forneceram maior sensibilidade para ambos os testes. Observamos que os fatores influenciando negativamente os testes, tais como o tipo de infecção e o sorotipo viral necessitam de maiores investigações no intuito de melhor aperfeiçoamento da acurácia diagnóstica

Objective: 1) Systematic review on the accuracy of Chronic Rhinosinusitis (CRS) identification in administrative databases; 2) Develop an administrative data algorithm to identify CRS patients who have endoscopic sinus surgery (ESS). Methods: A chart review was performed for all ESS surgical encounters at The Ottawa Hospital from 2011-12. Cases were defined as encounters in which ESS for performed for Otolaryngologist-diagnosed CRS. An algorithm to identify patients who underwent ESS for CRS was developed using diagnostic and procedural codes within health administrative data. This algorithm was internally validated. Results: Only three studies meeting inclusion criteria were identified in the systematic review and showed inaccurate CRS identification. The final algorithm using administrative and chart review data found that encounters having at least one CRS diagnostic code and one ESS procedural code had excellent accuracy for identifying ESS: sensitivity 96.0% sensitivity, specificity 100%, and positive predictive value 95.4%. Internal validation showed similar accuracy. Conclusion: Most published AD studies examining CRS do not consider the accuracy of case identification. We identified a simple algorithm based on administrative database codes accurately identified ESS-CRS encounters.

Aims: Noninvasive fractional flow reserve (FFR) measurement with computed tomography (FFRCT) is a newly described method for assessing functional significance of coronary disease. The objective of this metaanalysis is to determine the diagnostic performance of FFRCTin the assessment of hemodynamically significant coronary artery stenosis. Methods: PubMed and the Cochrane Center Register of Controlled Trials were searched from January 2000 through February 2015. Six original studies were found comparing FFRCTto invasive FFR in evaluating hemodynamic significance of coronary lesions (1354 vessels; 812 patients). Lesions were considered hemodynamically significant if invasive FFR was 0.80 or less. FFRCTused the same cutoff as invasive FFR to be considered as a positive test. Sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were calculated. Results: One-third of the lesions (n=443) were hemodynamically significant. The pooled per-vessel analysis showed that the sensitivity, specificity, negative and positive likelihood ratios, and diagnostic odds ratio of FFRCTto diagnose hemodynamically significant coronary disease were 0.84 [95% confidence interval (CI):0.80-0.87], 0.76 (95% CI: 0.73-0.79), 0.22 (95% CI: 0.17-0.29), 3.48 (95% CI: 2.21-5.47), and 16.82 (95% CI: 8.20-34.49), respectively. Conclusion: The results of this meta-analysis demonstrate that FFRCTresults correlate closely with invasive coronary angiography and FFR measurement. It is a feasible noninvasive method to assess hemodynamic significance of coronary lesions in patients with stable coronary artery disease.