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#1
28.03.2006, 21:48
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Ультразвуковая диагностика заболеваний околоносовых пазух
Уважаемые коллеги! Прошу вас поделиться своим мнением об ультразвуковой диагностике заболеваний околоносовых пазух. Отвергаете ли вы такой метод напрочь? Может ли он являться альтернативным методом рентгенологическому? Использовали ли вы это в своей практике? Буду рада любому мнению.
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#2
28.03.2006, 22:38
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Цитата:
Интерпретация даже рентгеновских снимков не всегда бывает проста, и в большинстве случаев имеет место гипердиагностика. Фантазии же узистов общеизвестны, применение этого не стандартизированного для этой патологии метода может привести лишь еще большему количеству псевдогайморитов, и как следствие необоснованному назначению антибиотиков и ненужных вмешательств. На сегодняшний день GOLD STANDART для этого вида патологии является CT.
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#3
28.03.2006, 22:50
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Спасибо, что ответили. Я понимаю что все мы стремимся к золотым стандартам. А в эксвизитных ситуациях - беременные, дети, и если до рентгенкабинета 2 недели на собаках (оленях и т.д.) добираться?
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#4
28.03.2006, 23:04
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Цитата:
2-Не"стремиться ", а работать по стандартам.Не завтра, а сегодня. 3-Что Вы ответите в суде по иску поданному на Вас пациентом, которому по Вашему назначенному узи придаточных пазух носа, описали ....и Вы, на основании этого...выполнили что-то совершенно не показанное. Не знаю как Вам, а моя лицензия на врачебную деятельность мне дорога. 4-Вам, думается, работая в частной клинике, использование нестандартизированных методик также не к лицу. 5-Людям, проживающим в удаленных от специализированной медицинской помощи местах,ведь не делают операцию кухонным ножом при отсутствии освещения. Система оказания мед. помощи такой части населения должна быть предусмотрена ГОСУДАРСТВОМ.И они вправе получать ее в полном объеме наравне со всеми ПО СТАНДАРТАМ,принятымв медицине СЕГОДНЯ.
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#5
28.03.2006, 23:23
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Я с целью уточнения. В основном к коллеге Полонскому - если есть "золотой стандарт", значит есть и какой-то другой? Т.е. получается "двойные (минимум) стандарты?
 Ну а если серьёзно - к примеру моя больница и через 100 лет не будет иметь КТ. Есть только рентген и УЗИ (правда ещё никто не пробовал такой метод) - пациент в праве подавать в суд за "не стандартное" исследование? Или всё же хоть рентген прописан в хоть каком-то "стандарте"?
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#6
28.03.2006, 23:35
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Цитата:
В суд пациент подаст за причиненный вред здоровью.И в ходе разбирательства будет доказано,что назначенное лечение или выполненное вмешательство было назначено/выполнено на основании применения нестандартного метода.
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#7
28.03.2006, 23:41
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Цитата:
 разрешено ли это Минздравом как достоверный метод диагностики?
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#8
29.03.2006, 01:33
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Цитата:
PEDIATRICS Vol. 108 No. 3 September 2001, pp. 798-808 AMERICAN ACADEMY OF PEDIATRICS: Clinical Practice Guideline: Management of Sinusitis Recommendation 2a Imaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children < 6 years of age (strong recommendation based on limited scientific evidence and strong consensus of the panel). In 1981, children between the ages of 2 and 16 years presenting with either persistent or severe symptoms were evaluated with sinus radiographs.21,22 When children with persistent or severe symptoms were found to have abnormal sinus radiographs (complete opacification, mucosal thickening of at least 4 mm, or an air-fluid level), an aspiration of the maxillary sinus was performed. Bacteria in high density (104 colony-forming units/mL) were recovered in 70% to 75% of the children. This proportion of positive cultures (75%) is similar to the likelihood that a tympanocentesis will yield middle ear fluid with a positive culture for bacteria in children with otoscopic evidence of acute otitis media.30 In children with persistent symptoms, the history of protracted respiratory symptoms (>10 but <30 days without evidence of improvement) predicted significantly abnormal radiographs (complete opacification, mucosal thickening of at least 4 mm, or an air-fluid level) in 80% of children.31 For children 6 years of age or younger, the history predicted abnormal sinus radiographs in 88% of children. For children older than 6 years, the history of persistent symptoms predicted abnormal sinus radiographs in 70%. The peak age for acute bacterial sinusitis is in children 6 years of age or younger. Accordingly, in this age group, because a positive history predicts the finding of abnormal sinus radiographs so frequently (and because history plus abnormal radiographs results in a positive sinus aspirate in 75% of cases), radiographs can be safely omitted and a diagnosis of acute bacterial sinusitis can be made on clinical criteria alone. Approximately 60% of children with symptoms of sinusitis (persistent or severe) will have bacteria recovered from an aspirate of the maxillary sinus. In contrast to the general agreement that radiographs are not necessary in children 6 years of age or younger with persistent symptoms, the need for radiographs as a confirmatory test of acute sinusitis in children older than 6 years with persistent symptoms and for all children (regardless of age) with severe symptoms is controversial.32,33 Some practitioners may elect to perform sinus radiographs with the expectation or suspicion that the study may be normal. A normal radiograph is powerful evidence that bacterial sinusitis is not the cause of the clinical syndrome.34 However, the American College of Radiology has taken the position that the diagnosis of acute uncomplicated sinusitis should be made on clinical grounds alone.35 They support this position by noting that plain radiographs of the paranasal sinuses are technically difficult to perform, particularly in very young children. Correct positioning may be difficult to achieve and therefore the radiographic images may overestimate and underestimate the presence of abnormalities within the paranasal sinuses.36,37 The college would reserve the use of images for situations in which the patient does not recover or worsens during the course of appropriate antimicrobial therapy. Similarly, a recent set of guidelines generated by the Sinus and Allergy Health Partnership (representing numerous constituencies) does not recommend either radiographs or computed tomography (CT) or magnetic resonance imaging scans to diagnose uncomplicated cases of acute bacterial sinusitis in any age group.1 It is essential to recognize that abnormal images of the sinuses (either radiographs, CT, or magnetic resonance imaging) cannot stand alone as diagnostic evidence of acute bacterial sinusitis under any circumstances. Images can serve only as confirmatory measures of sinus disease in patients whose clinical histories are supportive of the diagnosis. Numerous investigations have demonstrated the high frequency of abnormal images in the paranasal sinuses of children undergoing imaging for indications other than suspected sinusitis.38-40 In a study by Glasier et al,39 almost 100% of young children who were undergoing CT examination for reasons other than sinus disease and who had an upper respiratory tract infection in the previous 2 weeks demonstrated soft tissue changes in their sinuses. A study by Gwaltney et al in 19943 found that abnormalities of the paranasal sinuses on CT scan are extremely common in young adults with acute (<72 hours) uncomplicated viral upper respiratory infections. This study and others serve to underscore that when abnormalities of the mucosa are present on images they indicate the presence of inflammation but do not disclose whether the inflammatory process is caused by viral infection, bacterial infection, allergy, or chemical irritation (eg, chlorine exposure in the swimmer). Recommendation 2b CT scans of the paranasal sinuses should be reserved for patients in whom surgery is being considered as a management strategy (strong recommendation based on good evidence and strong panel consensus). Despite the limitations of CT scans,338-40 they offer a detailed image of sinus anatomy and, when taken in conjunction with clinical findings, remain a useful adjunct to guide surgical treatment. Computed tomography scans are indicated in children who present with complications of acute bacterial sinus infection or those who have very persistent or recurrent infections that are not responsive to medical management.33 In these instances, the image, preferably a complete CT scan of the paranasal sinuses, is essential to provide precise anatomic information to the clinician. These are instances in which the physician may be contemplating surgical intervention, including aspiration of the paranasal sinuses. [Ссылки доступны только зарегистрированным пользователям ]
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#10
29.03.2006, 22:15
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Цитата:
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#12
29.03.2006, 23:02
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Цитата:
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#13
29.03.2006, 23:13
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Do imaging studies aid diagnosis of acute sinusitis?
EVIDENCE-BASED ANSWER Lau and colleagues (5, 10) reviewed 14 studies that compared various imaging studies with clinical evaluation or sinus puncture and aspiration with culture or both. A positive aspirate for bacterial pathogens was defined as the gold standard for diagnosis of sinusitis (Table). X-ray vs sinus puncture. Depending on the criteria used to define a diagnosis of sinusitis on plain radiograph, estimates of sensitivity in these studies ranged from 0.41 to 0.90, and specificity estimates ranged from 0.61 to 0.85. Imaging studies that included "mucous membrane thickening" as a criterion for sinusitis were more sensitive but less specific than studies defining positive radiographs as "opacification of sinus." CT scan, MRI, ultrasound. While a CT scan is more sensitive than plain x-ray film, (11) and MRI is more sensitive than a CT scan, (12, 13) the specificity of these studies is unclear. For example, in children and adults without symptoms of sinusitis, the prevalence of sinusitis signs on CT and MRI is 45% and 42%, respectively. (6, 7, 14) In light of such findings, these imaging methodologies are better reserved for patients in whom surgery is being contemplated, or for whom chronic sinusitis is a concern. In the 1980s and 1990s, ultrasound was studied enthusiastically. Variability in test performance is great. (6) Since the cost of this procedure is similar to that of a sinus CT, ultrasound is not indicated in the diagnostic evaluation of the sinuses. The American Academy of Allergy, Asthma and Immunology15 guideline makes the following recommendations regarding imaging: The use of imaging may be appropriate when there are vague symptoms, or poor response to initial management Standard radiographs are insensitive, but may be used for diagnosis of acute sinus disease CT is preferred for preoperative evaluation of the nose and paranasal sinuses MRI is very sensitive for diagnosis of soft tissue disease in the frontal, maxillary, and sphenoid sinuses Ultrasonography has limited utility but may be applicable in pregnant women and for determining the amount of retained secretions. [Ссылки доступны только зарегистрированным пользователям ]
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#14
29.03.2006, 23:18
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[Ссылки доступны только зарегистрированным пользователям ]
Comparison of ultrasound, radiography, and clinical examination in the diagnosis of acute maxillary sinusitis: a systematic review. Varonen H, Makela M, Savolainen S, Laara E, Hilden J. Department of Services and Quality, Stakes, National Research and Development Centre for Welfare and Health, P.O. Box 220, 00531, Helsinki, Finland. [Ссылки доступны только зарегистрированным пользователям ] The objective of this study was to assess the discriminative properties of the methods for diagnosing acute maxillary sinusitis (AMS) in unselected patients. The study design was a systematic review of evaluation studies identified by using Medline, by searching reference lists, by hand searches, and by contacting investigators. Evaluation studies were conducted anywhere in the world. Subjects were adults with suspected AMS. Main outcome measures were: sensitivity, specificity, positive and negative likelihood ratios of the primary studies, weighted means of these parameters in each comparison (clinical examination, radiography, and ultrasound compared to a reference standard in diagnosing AMS), and summary ROC curves and their Q* points where sensitivity equals specificity. For the years from 1962 to present, 49 study reports were found; 11 articles on studies that included a total of 1144 patients were eligible. Compared to sinus puncture, radiography was the most accurate method for diagnosing AMS: the Q* point on the summary ROC curve was 0.82 (95% confidence interval, CI, 0.78-0.85). Ultrasound was slightly less accurate than radiography compared to sinus puncture (Q* 0.80, 95% CI 0.76-0.83). Only two articles reported clinical examination compared to sinus puncture and the Q* for them was 0.75 (95% 0.58-0.86). Clinical examination is a rather unreliable method for diagnosing AMS, even in the hands of experienced specialists. Using radiography or ultrasound improves the accuracy of diagnosis. The diagnosis of AMS is rarely studied in primary care settings. Future comparative trials should preferably combine diagnosis and treatment, evaluating the two aspects of clinical management as unit.
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#15
29.03.2006, 23:21
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Цитата:
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Линейный вид
