Structural imaging findings on non-enhanced computed tomography are severely underreported in the primary care diagnostic work-up of subjective cognitive decline

SummaryIn primary care, the physician has to decide which patients have to be referred for further diagnostic work-up. At present, only in 20% to 30% of the referred patients the diagnosis DVT is confirmed. This puts a burden on both patients and health care budgets. The question arises whether the diagnostic work-up and referral of patients suspected of DVT in primary care could be more efficient. A simple diagnostic decision rule developed in primary care is required to safely exclude the presence of DVT in patients suspected of DVT, without the need for referral. In a cross-sectional study, we investigated the data of 1295 consecutive patients consulting their primary care physician with symptoms suggestive of DVT, to develop and validate a simple diagnostic decision rule to safely exclude the presence of DVT. Independent diagnostic indicators of the presence of DVT were male gender, oral contraceptive use, presence of malignancy, recent surgery, absence of leg trauma, vein distension, calf difference and D-dimer test result. Application of this rule could reduce the number of referrals by at least 23% while only 0·7% of the patients with a DVT would not be referred. We conclude that by using eight simple diagnostic indicators from patient history, physical examination and the result of D-dimer testing, it is possible to safely rule out DVT in a large number of patients in primary care, reducing unnecessary patient burden and health care costs.

Download Full-text

On multislice computed tomography pulmonary angiography and ventilation/perfusion scanning for the diagnostic work-up of suspected pulmonary embolism

European Journal of Internal Medicine ◽

10.1016/j.ejim.2010.09.009 ◽

2011 ◽

Vol 22 (1) ◽

pp. 122-123

Author(s):

Javier Galipienzo ◽

Julio Flores ◽

Jaime García de Tena

Keyword(s):

Computed Tomography ◽

Pulmonary Embolism ◽

Multislice Computed Tomography ◽

Pulmonary Angiography ◽

Suspected Pulmonary Embolism ◽

Computed Tomography Pulmonary Angiography ◽

Diagnostic Work ◽

Work Up ◽

Diagnostic Work Up

Download Full-text

The Role of Cranial Computed Tomography in the Diagnostic Work-up of Headache

Headache The Journal of Head and Face Pain ◽

10.1046/j.1526-4610.1996.3606347.x ◽

1996 ◽

Vol 36 (6) ◽

pp. 347-348 ◽

Cited By ~ 16

Author(s):

Philippe Demaerel ◽

Ignace Boelaert ◽

Guy Wilms ◽

Albert L. Baert

Keyword(s):

Computed Tomography ◽

Cranial Computed Tomography ◽

Diagnostic Work ◽

Work Up ◽

Diagnostic Work Up

Download Full-text

PET-PANC: multicentre prospective diagnostic accuracy and health economic analysis study of the impact of combined modality 18fluorine-2-fluoro-2-deoxy-d-glucose positron emission tomography with computed tomography scanning in the diagnosis and management of pancreatic cancer

Health Technology Assessment ◽

10.3310/hta22070 ◽

2018 ◽

Vol 22 (7) ◽

pp. 1-114 ◽

Cited By ~ 31

Author(s):

Paula Ghaneh ◽

Robert Hanson ◽

Andrew Titman ◽

Gill Lancaster ◽

Catrin Plumpton ◽

...

Keyword(s):

Computed Tomography ◽

Pancreatic Cancer ◽

Chronic Pancreatitis ◽

Diagnostic Accuracy ◽

Cost Effective ◽

Diagnostic Value ◽

Pet Ct ◽

Diagnostic Work ◽

Work Up ◽

Diagnostic Work Up

Background Pancreatic cancer diagnosis and staging can be difficult in 10–20% of patients. Positron emission tomography (PET)/computed tomography (CT) adds precise anatomical localisation to functional data. The use of PET/CT may add further value to the diagnosis and staging of pancreatic cancer. Objective To determine the incremental diagnostic accuracy and impact of PET/CT in addition to standard diagnostic work-up in patients with suspected pancreatic cancer. Design A multicentre prospective diagnostic accuracy and clinical value study of PET/CT in suspected pancreatic malignancy. Participants Patients with suspected pancreatic malignancy. Interventions All patients to undergo PET/CT following standard diagnostic work-up. Main outcome measures The primary outcome was the incremental diagnostic value of PET/CT in addition to standard diagnostic work-up with multidetector computed tomography (MDCT). Secondary outcomes were (1) changes in patients’ diagnosis, staging and management as a result of PET/CT; (2) changes in the costs and effectiveness of patient management as a result of PET/CT; (3) the incremental diagnostic value of PET/CT in chronic pancreatitis; (4) the identification of groups of patients who would benefit most from PET/CT; and (5) the incremental diagnostic value of PET/CT in other pancreatic tumours. Results Between 2011 and 2013, 589 patients with suspected pancreatic cancer underwent MDCT and PET/CT, with 550 patients having complete data and in-range PET/CT. Sensitivity and specificity for the diagnosis of pancreatic cancer were 88.5% and 70.6%, respectively, for MDCT and 92.7% and 75.8%, respectively, for PET/CT. The maximum standardised uptake value (SUVmax.) for a pancreatic cancer diagnosis was 7.5. PET/CT demonstrated a significant improvement in relative sensitivity (p = 0.01) and specificity (p = 0.023) compared with MDCT. Incremental likelihood ratios demonstrated that PET/CT significantly improved diagnostic accuracy in all scenarios (p < 0.0002). PET/CT correctly changed the staging of pancreatic cancer in 56 patients (p = 0.001). PET/CT influenced management in 250 (45%) patients. PET/CT stopped resection in 58 (20%) patients who were due to have surgery. The benefit of PET/CT was limited in patients with chronic pancreatitis or other pancreatic tumours. PET/CT was associated with a gain in quality-adjusted life-years of 0.0157 (95% confidence interval –0.0101 to 0.0430). In the base-case model PET/CT was seen to dominate MDCT alone and is thus highly likely to be cost-effective for the UK NHS. PET/CT was seen to be most cost-effective for the subgroup of patients with suspected pancreatic cancer who were thought to be resectable. Conclusion PET/CT provided a significant incremental diagnostic benefit in the diagnosis of pancreatic cancer and significantly influenced the staging and management of patients. PET/CT had limited utility in chronic pancreatitis and other pancreatic tumours. PET/CT is likely to be cost-effective at current reimbursement rates for PET/CT to the UK NHS. This was not a randomised controlled trial and therefore we do not have any information from patients who would have undergone MDCT only for comparison. In addition, there were issues in estimating costs for PET/CT. Future work should evaluate the role of PET/CT in intraductal papillary mucinous neoplasm and prognosis and response to therapy in patients with pancreatic cancer. Study registration Current Controlled Trials ISRCTN73852054 and UKCRN 8166. Funding The National Institute for Health Research Health Technology Assessment programme.

Download Full-text

Workload, diagnostic work-up and treatment of urinary tract infections in adults during out-of-hours primary care: a retrospective cohort study

BMC Family Practice ◽

10.1186/s12875-020-01305-8 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Michelle Spek ◽

Jochen W. L. Cals ◽

Guy J. Oudhuis ◽

Paul H. M. Savelkoul ◽

Eefje G. P. M. de Bont

Keyword(s):

Primary Care ◽

Cohort Study ◽

Urinary Tract ◽

Urinary Tract Infections ◽

Electronic Patient Records ◽

Out Of Hours ◽

Diagnostic Work ◽

Tract Infections ◽

Work Up ◽

Diagnostic Work Up

Abstract Background Urinary tract infections (UTIs) are one of the most common infections in primary care. Previous research showed that GPs find it challenging to diagnose UTIs and frequently divert from guidelines leading to unwarranted antibiotic prescriptions and inefficient use of diagnostics such as urinary cultures. We hypothesise that management of UTIs during out-of-hours care may be extra challenging due to a higher workload and logistical issues regarding diagnostic work-up and obtaining results. We therefore aimed to study the workload, diagnostic work-up and treatment of UTIs during out-of-hours primary care. Methods We performed a retrospective observational cohort study in which we analysed a full year (2018) of electronic patient records of two large Dutch GP out-of-hours centres. All adult patients with UTI symptoms were included in this study. Descriptive statistics and multivariate regression were used to analyse diagnostics and subsequent management. Results A total of 5657 patients were included (78.9% female, mean age of 54 years), with an average of eight patients per day that contact a GP out-of-hours centre because of UTI symptoms. Urinary dipsticks were used in 87.5% of all patients visiting the out-of-hours centres with UTI symptoms. Strikingly, urinary cultures were only requested in 10.3% of patients in which urinary culture was indicated. Seventy-four percent of the patients received antibiotics. Seventy-nine percent of the patients with a negative nitrite test still received antibiotics. Remarkably, patients at risk of complications because of a UTI, such as men, received fewer antibiotic prescriptions. Conclusions In total, 74% of the patients received antibiotics. 8 out of 10 patients still received an antibiotic prescription in case of a negative nitrite test, and 9 out of 10 patients with an indication did not receive a urine culture. In conclusion, we found that correctly diagnosing UTIs and prescribing antibiotics for UTIs is a challenge that needs major improvement, especially during out-of-hours GP care.

Download Full-text

Pulmonary Artery Sling: A New Diagnostic Tool and Clinical Review

PEDIATRICS ◽

10.1542/peds.69.4.472 ◽

1982 ◽

Vol 69 (4) ◽

pp. 472-475

Author(s):

Karen S. Rheuban ◽

Nancy Ayres ◽

J. Gordon Still ◽

Bennett Alford

Keyword(s):

Computed Tomography ◽

Pulmonary Artery ◽

Diagnostic Tool ◽

Vascular Ring ◽

Vascular Anomaly ◽

Pulmonary Artery Sling ◽

Cardiovascular Malformation ◽

Diagnostic Work ◽

Work Up ◽

Diagnostic Work Up

The pulmonary artery sling is a vascular anomaly that produces severe respiratory disease in infancy. The differential diagnosis is lengthy, and the diagnostic work-up frequently includes such invasive maneuvers as bronchography, bronchoscopy, and cardiac catheterization. In this paper the use of a new noninvasive diagnostic tool, computed tomography, to aid in the diagnosis of this form of vascular ring, is discussed and a review of salient features of this cardiovascular malformation is presented.

Download Full-text