array:23 [ "pii" => "S0025775320301391" "issn" => "00257753" "doi" => "10.1016/j.medcli.2019.10.025" "estado" => "S300" "fechaPublicacion" => "2021-02-12" "aid" => "5122" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2020" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2021;156:150-1" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S0025775320301007" "issn" => "00257753" "doi" => "10.1016/j.medcli.2019.11.014" "estado" => "S300" "fechaPublicacion" => "2021-02-12" "aid" => "5084" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2021;156:151-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Cardiac dextroposition associated to Poland syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "151" "paginaFinal" => "152" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de Poland asociado a dextrocardia" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 548 "Ancho" => 1255 "Tamanyo" => 72376 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Chest X-rays demonstrated an isolated dextrocardia (*), with an asymmetric thorax but without ribs defects. Pulmonary anatomy seems to be normal, with right lobar bronchi on the right and two on the left; the gastric bubble was on the left side (arrow), and liver on the right side (+). (B) Depression of the left anterior chest wall and nipple defect (arrows).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Elena Guadalupe Corella Aznar, Ariadna Ayerza Casas, Daniel Palanca Arias, Lorenzo Jiménez Montañés" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Elena Guadalupe" "apellidos" => "Corella Aznar" ] 1 => array:2 [ "nombre" => "Ariadna" "apellidos" => "Ayerza Casas" ] 2 => array:2 [ "nombre" => "Daniel" "apellidos" => "Palanca Arias" ] 3 => array:2 [ "nombre" => "Lorenzo" "apellidos" => "Jiménez Montañés" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775320301007?idApp=UINPBA00004N" "url" => "/00257753/0000015600000003/v1_202101240617/S0025775320301007/v1_202101240617/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0025775320301640" "issn" => "00257753" "doi" => "10.1016/j.medcli.2019.10.027" "estado" => "S300" "fechaPublicacion" => "2021-02-12" "aid" => "5129" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2021;156:149-50" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>" "titulo" => "Réplica al artículo «Síndrome de Löfgren: presentación de dos casos»" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "149" "paginaFinal" => "150" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Reply to the article «Löfgren syndrome: Report of two cases»" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Javier Miguel Martín Guerra, Miguel Martín Asenjo, José María Prieto de Paula" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Javier Miguel" "apellidos" => "Martín Guerra" ] 1 => array:2 [ "nombre" => "Miguel" "apellidos" => "Martín Asenjo" ] 2 => array:2 [ "nombre" => "José María" "apellidos" => "Prieto de Paula" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020620306495" "doi" => "10.1016/j.medcle.2019.10.026" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620306495?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775320301640?idApp=UINPBA00004N" "url" => "/00257753/0000015600000003/v1_202101240617/S0025775320301640/v1_202101240617/es/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Reply to “To improve in diagnostic safety: The pending subject”" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "150" "paginaFinal" => "151" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Joao Luis Modesto Dos Santos, Beatriz Zabalza Ollo, Susana Clemos Matamoros" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Joao Luis" "apellidos" => "Modesto Dos Santos" "email" => array:1 [ 0 => "jl.modesto.dos@navarra.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Beatriz" "apellidos" => "Zabalza Ollo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Susana" "apellidos" => "Clemos Matamoros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Complejo Hospitalario de Navarra, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Análisis Clínicos, Complejo Hospitalario de Navarra, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Reina Sofia de Tudela, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "En respuesta a “Mejorar en seguridad diagnóstica: la asignatura pendiente”" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the article entitled “To improve in diagnostic safety: The pending subject”<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> from Tudela et al. In a very elegant way, this article points out some key elements to bear in mind regarding patient diagnostic safety.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A very interesting point mentioned is the change from the classic paradigm of avoiding diagnostic errors, to a personalised medicine philosophy focused in solution seeking and rational complementary examinations, with the inevitable awareness of uncertainty in the diagnostic process of any patient. In fact, other investigations have reviewed the importance of such issue and have also reinforced the necessity of a comfortable relationship with uncertainty in such process,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> as well as the need of linking diagnostic efforts to treatment and clinical suspicion, rather to net-fishing “incidentalomas”.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Nevertheless, medical community behaviour change can be a challenging process, mainly to those practitioners with longstanding routines. In this context, the “Choosing Wisely” Campaign has strengthened this effort, even though with modest results for the moment.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Therefore, we think that practical examples might help to contextualise the subject discussed and to raise some added awareness on it to clinicians. Hence, we hereby present the results of auditing the serum protein electrophoresis (SPE) requested at our hospital.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We conducted a retrospective transversal review of the SPE requested from a period of two years (May 2017–May 2019) to our laboratory at a tertiary teaching hospital in Pamplona (Spain), finding a total of 41,306 requests. The in-hospital services requesting such laboratory determination most often were Internal Medicine (9931, 24.04%), Haematology (7994, 19.35%), Rheumatology (3323, 8.04%) and Nephrology (3101, 7.51%). Focusing in the SPE requested by Internal Medicine we found a normal profile in more than half of the requests (55.02%). Also, in 27.32% an inflammatory profile was found, as well as hypergammaglobulinemia in 9.12% of the cases. On the other hand, only 4.94% (491) presented a monoclonal band.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Many scientific societies stand that the main utility of serum protein electrophoresis is screening (when not performed as a single determination) and follow up of monoclonal gammopathies.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> In this sense, when focusing on the SPE requested by the Internal Medicine service, it is surprising the low proportion of monoclonal gammopathies found, and the appearance of unspecific inflammatory profile in more than 35% of the cases. Although this audit as no intention to infer causality, the presence of such high detection of normal or inflammatory patterns (more than 90% of the cases) in contrast with the few monoclonal gammopathies found (less than 5% of the cases) could indicate this examination to be requested outside of an adequate clinical context. In fact, when enquiring the motifs of such high request we found SPE to be routinely included under the admission laboratory tests of most patients assessed by Internal Medicine. Therefore, such determinations where not necessarily guided by clinical suspicion and differential diagnosis, but rather by routine in an important proportion of cases.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The direct consequence of these findings is precisely, in a first instance, an important attributable cost without a clear justification. Far from being a matter only of health management and executive concern, it is ineludibly the role each clinician has in the global ecology of health care system. Second, the finding of irrelevant results can induce patients to be submitted to more invasive examinations, where medical complications are a not so unusual possibility. And while the benefits might outweigh the risks in some pondered examinations, routinely assessment of patients leaves, by definition, no space to such balance. Finally, although an enormous work is still to be done in diagnostic safety from the clinician point of view, it is also acknowledgeable the need for patient education on building a comfortable deal with uncertainty in regarding diagnostics.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mejorar en seguridad diagnóstica: la asignatura pendiente" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Tudela" 1 => "C. Forcada" 2 => "A. Carreres" 3 => "M. Ballester" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medcle.2019.06.012" "Revista" => array:3 [ "tituloSerie" => "Med Clin Barc" "fecha" => "2019" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7603093" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ten principles for more conservative care-full diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.D. Schiff" 1 => "S.A. Martin" 2 => "D.H. Eidelman" 3 => "L.A. Volk" 4 => "E. Ruan" 5 => "C. Cassel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.7326/M18-1468" "Revista" => array:6 [ "tituloSerie" => "Ann Intern Med" "fecha" => "2018" "volumen" => "169" "paginaInicial" => "643" "paginaFinal" => "645" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30285046" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early trends among seven recommendations from the choosing wisely campaign" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Rosenberg" 1 => "A. Agiro" 2 => "M. Gottlieb" 3 => "J. Barron" 4 => "P. Brady" 5 => "Y. Liu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamainternmed.2015.5441" "Revista" => array:6 [ "tituloSerie" => "JAMA Intern Med" "fecha" => "2015" "volumen" => "175" "paginaInicial" => "1913" "paginaFinal" => "1920" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26457643" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations for electrophoretic separation of plasma protein in the serum (2014)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Pérez Surribas" 1 => "M.C. Cárdenas Fernández" 2 => "E. Zapico Muñiz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Documentos de la S.E.Q.C." "fecha" => "2015" "volumen" => "04" "paginaInicial" => "91" "paginaFinal" => "104" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "National Collaborating Centre for Cancer. Myeloma: diagnosis and management. NICE Guideline 35, February 2016. Available from: <a target="_blank" href="https://www.nice.org.uk/guidance/NG35">https://www.nice.org.uk/guidance/NG35</a>." ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00257753/0000015600000003/v1_202101240617/S0025775320301391/v1_202101240617/en/main.assets" "Apartado" => array:4 [ "identificador" => "66430" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas al Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00257753/0000015600000003/v1_202101240617/S0025775320301391/v1_202101240617/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775320301391?idApp=UINPBA00004N" ]
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