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BACKGROUND: A study was undertaken to explore the pathway to diagnosis among a group of patients recently diagnosed with lung cancer. METHODS: A directed interview study triangulating patients' accounts with hospital and GP records was performed with 22 men and women recently diagnosed with lung cancer at two cancer centres in the south and north of England. The main outcome measures were the symptoms leading up to a diagnosis of lung cancer and patient and GP responses before diagnosis. RESULTS: Patients recalled having new symptoms for many months, typically over the year before their diagnosis, irrespective of their disease stage once diagnosed. Chest symptoms (cough, breathing changes, and pain in the chest) were common, as were systemic symptoms (fatigue/lethargy, weight loss and eating changes). Although symptoms were reported as being marked changes in health, these were not in the main (with the exception of haemoptysis) interpreted as serious by patients at the time and not acted on. Once the trigger for action occurred (the event that took patients to their GP or elsewhere in the healthcare system), events were relatively speedy and were faster for patients who presented via their GP than via other routes. Patients' beliefs about health changes that may indicate lung cancer appeared to have played a part in delay in diagnosis. CONCLUSION: Further investigation of the factors influencing the timing of diagnosis in lung cancer is warranted since it appears that patients did not readily attend GP surgeries with symptoms. Insight into patients' perspectives on their experience before diagnosis may help medical carers to recognise patients with lung cancer more easily so that they can refer them for diagnosis and treatment. Encouragement to present early with signs of lung cancer should be considered alongside other efforts to speed up diagnosis and treatment.
BACKGROUND: In general practice, making a diagnosis does not follow the same lines as in secondary care because every new diagnosis is made against 'foreknowledge' and could be coloured by it. This could explain low accordance and differences in diagnoses between primary and secondary care, in particular when mental illness such as depression is concerned. When criteria are used for diagnosis there should be no differences. AIM: To establish the accordance with the Diagnostic and Statistical Manual of mental disorders, 4th edition (DSM-IV) criteria of major depressive disorder when the diagnosis of depression has been made by general practitioners (GPs) for whom coding and using criteria for diagnosis is a daily routine (ICHPPC-2 criteria). METHOD: Ninety-nine general practice patients from four general practices belonging to the Continuous Morbidity Registry (CMR) of the University of Nijmegen in The Netherlands were interviewed using the Composite International Diagnostic Interview (auto) 12-month version (DSM-IV criteria). Thirty-three patients had a code for depression; 33 patients a code for chronic nervous functional complaints (CNFC); and 33 had no code for mental illness (the depression and CNFC codes were given in the 12 months prior to the interview). Specificity and accordance with the DSM-IV criteria of major depressive disorder (MDD) were calculated with the results from the interviews. RESULTS: Of the 33 general practice depression cases (all matching ICHPPC-2 criteria), 28 matched DSM-IV criteria: 26 for MDD and 2 for dysthymia. No cases of DSM-IV MDD were found in the control group without a code for a mental disorder, and seven out of 33 were found in the control group with the code for CNFC. CONCLUSION: The specificity of diagnosis of depression made by GPs in a continuous morbidity registry and the accordance with DSM-IV criteria are high. Using criteria for diagnosis, which is a trend, could be one of the solutions towards a better diagnosis. As far as the sensitivity is concerned, GPs should not be distracted from using criteria for the diagnosis of depression when a large variety of complaints is presented.
Asthma classification by clinical symptoms and signs (clinical diagnosis) was compared with the classification by score calculated from clinical findings and examinations (score diagnosis) in 25 patients with bronchial asthma. 1. Ten subjects classified as Ia (simple bronchoconstriction type) by clinical diagnosis were divided into 6 cases with expectoration of less than 49 ml a day and 4 cases with expectoration of between 50 and 99 ml. The level of serum IgE and number of eosinophils in BALF were significantly higher in the latter cases than in the former cases. The cases whose expectoration was from 50 to 99 ml a day were classified as Ib (bronchoconstriction with hypersecretion type) by score diagnosis. 2. The six subjects who were classified as type Ib by clinical diagnosis were also evaluated as type Ib by score diagnosis. 3. Nine of the 10 subjects classified as type II by clinical diagnosis were evaluated as type II by score diagnosis. One case, whose score was under 12 points, was evaluated as questionable type II by score diagnosis.
Fifty-six patients with laryngeal cancer were examined. The rate of correct diagnosis of clinical staging was 64.3%. Whereas the rate of correct diagnosis of staging by CT was markedly improved, 89.3%. In particular, CT facilitated correct diagnosis of T4. Supraglottic T3 cancer is diagnosed on the basis of deep infiltration or fixation of the hemi-larynx. Disappearance of the pre-epiglottic space or ulcer formation was recognized as a CT finding of deep infiltration. Disappearance of the paraglottic space and dislocation of the arytenoid cartilage were used as the standard for CT findings of laryngeal T3 cancer. CT allowed diagnosis to be made in 84.4% of cases which were pathologically determined to be T4. It can be said that CT is a very effective method for staging diagnosis in patients with laryngeal cancer. Fifty-seven patients with hypopharyngeal cancer and cancer of the cervical esophagus were also examined. When 40 post-surgical patients were compared according to pathological classification of T, the rate of correct diagnosis of clinical staging was 77.5% while that of staging diagnosis by CT was 82.5%. The rate of correct diagnosis by postoperative CT was 80.0% compared with the pathological determination of depth of invasion. The diagnosis of depth of invasion by CT on initial examination is thus an effective means for the determination of prognosis.
OBJECTIVE: To evaluate the relationship between islet cell antibodies (ICAs) and the cardiovascular risk profile 5 years after clinical diagnosis of NIDDM. RESEARCH DESIGN AND METHODS: Five years after clinical diagnosis, we evaluated blood pressure (BP) and lipids in 17 NIDDM patients with ICA at diagnosis (age 60 +/- 4 years) and 133 NIDDM patients without ICA at diagnosis (age 61 +/- 1 year). Urinary albumin excretion was evaluated in a subset of 12 NIDDM patients with ICA at diagnosis (age 60 +/- 4 years) and 82 NIDDM patients without ICA at diagnosis (age 61 +/- 1 year). RESULTS: NIDDM patients without ICA showed higher BP (140/86 +/- 2/1 mmHg vs. 128/79 +/- 3/2 mmHg; P < 0.05), total cholesterol (6.10 +/- 0.11 vs. 5.09 +/- 0.29 mmol/l; P < 0.01), LDL-to-HDL ratio (3.85 +/- 0.14 vs. 2.49 +/- 0.18; P < 0.001), and triglycerides (2.58 +/- 0.24 vs. 0.90 +/- 0.06 mmol/l; P < 0.001), lower HDL cholesterol (1.08 +/- 0.03 vs. 1.40 +/- 0.08 mmol/l; P < 0.001), and higher urinary albumin excretion (0.16 +/- 0.06 vs. 0.01 +/- 0.01 g/24 h; P < 0.05) than NIDDM patients with ICA. Among NIDDM patients without ICA, no differences concerning BP or lipids were found between obese and nonobese patients. CONCLUSIONS: ICA at diagnosis of NIDDM is a marker of more favorable cardiovascular risk profile 5 years after clinical diagnosis.
The aim of this study was to check the earliest time for the ultrasonic pregnancy diagnosis in flock management of sheep after finishing the mating season. Therefore a transcutaneous pregnancy diagnosis (5 MHz) took place on a total of 1060 German merino-mutton sheep between day 10 and 90 after mating (a.m.) and a transrectal diagnosis (5 MHz) took place on a total of 1442 German merino-mutton sheep between day 10 and 70 a.m. At the beginning of the third week a.m. the accuracy of transrectal diagnosis was over 95% and increased to 100% on day 35 a.m. At that time the accuracy of transcutaneous diagnosis was 80% and reached 100% on day 60 a.m. Considering the reached accuracies the pregnancy diagnosis should not take place before day 35 after the end of the breeding season. After day 35 a.m. it is advisable to combine the transcutaneous and the transrectal pregnancy diagnosis. That means that at first all animals are examined by transcutaneous sonography and in the second step the so-called "non-pregnant sheep" are checked by transrectal ultrasound. From the beginning of the third month a.m. a single transcutaneous pregnancy diagnosis is sufficient.
A computer system for the assistance of syndrome diagnosis in dysmorphology (EL BUSCA) was developed, and used to test the mechanics of the diagnostic process. EL BUSCA has a reference file (REF) with 200 syndromes, expressed in 175 signals. Signals have a weight value resulting from the difference between the number of syndromes including that sign and the total number of syndromes in the REF. A mean signal weight was calculated for each syndrome. The system was tested with 200 published cases (CASES), representing 82 different syndromes. Each consultation (CONS) entered up to 15 patient signals. The system then selected syndromes having three or more of those signals. 'Present' (REF+CASE), 'Absent' (REF only), and 'Additional' (CASE only) signals, as well as the score given by the sum of the weights of 'present' signals, were displayed for each suggested diagnosis. A consultation was successful (positive answer) if the correct diagnosis appeared among the first 12 ranked. EL BUSCA gave a positive answer in 82% of the 200 test consultations. Linear regression, with ranking of the correct diagnosis among the answers as the dependent variable, was used for the analysis of the following results. For the REF, no relationship was found for either the number or the mean weight of the signals with the ranking of the correct diagnosis. For the CASES, there was a linear relationship between the number of signals of each consultation and the ranking of the correct diagnosis, indicating that the larger the number of signals consulted, the lower the ranking of the correct diagnosis. No effect was seen for the mean weight of consulted signals.(ABSTRACT TRUNCATED AT 250 WORDS)
Prenatal diagnosis (chorionic villus sampling (CVS) or amniocentesis) is performed at a relatively late stage of pregnancy (11-18 weeks). Such tests have significant disadvantages including increased risk of miscarriage and delay before results are known. Earlier prenatal diagnosis (< 11 weeks) has been discontinued because of the risk of fetal abnormalities. Recently fetal cells have been recovered from the coelomic cavity at 7-12 weeks gestation (coelocentesis). This study has established that highly sensitive fluorescent polymerase chain reaction (PCR) can provide rapid (4-5 h), reliable and accurate multiple genetic diagnoses (sexing and single-gene diagnosis) from coelomic cells. As prenatal diagnosis has a significant risk of contamination, we have also shown that coelomic cells can be simultaneously DNA fingerprinted to determine that contamination has not occurred. This earlier method of prenatal diagnosis would be very valuable, as it may overcome some problems of later conventional prenatal diagnosis and allow reassurance/treatment to be undertaken at a much earlier stage. Successful application of these techniques may supersede alternative methods of prenatal diagnosis. Although these techniques appear very promising, extensive clinical trials must be undertaken to determine safety of coelocentesis, diagnostic reliability and accuracy in a clinical setting.
The use of nursing diagnosis by staff nurses in a 225-bed metropolitan hospital was examined. The sample consisted of 82 newly hired nurses who had participated in a mandated staff development program on nursing process theory and use of nursing diagnosis, with an emphasis on transfer of knowledge to practice. The data collected included demographic information, attitudes concerning nursing diagnosis, pretest and posttest scores, and percent completed on the audits of chart documentation. A cross-tabulation by clinical arena was performed on the forms used to document utilization of nursing diagnosis. Analysis of the data indicated that a greater proportion of the charts for the nurses in the maternal/child clinical arena evidenced use of nursing diagnosis as a component of practice. The nurses in the critical care arena scored slightly lower. The nurses in the medical/surgical arena had the lowest compliance of both completion and utilization of nursing diagnosis. This study demonstrated that nurses can be taught to use nursing diagnosis in the clinical setting.
This paper describes development of concepts of diagnosis and differential diagnosis between endogenous psychoses: schizophrenia and depression. It explains the most important concepts of classification founded on different assumptions. Essential factors which influence diagnosis and differential diagnosis such as prognostic, psychopathology, drug response and anatomopathology were presented. Apart from concepts presuming exact differential diagnosis between schizophrenia and depression, more current resolution of the problem was presented: differential typology instead of differential diagnosis. The conclusion is that classification which closely relates diagnosis to clinical practice (treatment) is most valuable.
BACKGROUND: The authors performed a retrospective study to estimate the incidence rate of metastatic disease at the time of diagnosis of extremity osteosarcoma (OS), to characterize its pattern of presentation, and to identify factors predictive of survival within a cohort of patients with pulmonary metastatic disease at diagnosis. METHODS: From the institutional solid tumor database, the authors identified all patients diagnosed with extremity OS since CT became available at the study institution (1977). The authors recorded patient demographics, the site of primary disease, the histologic subtype of OS, and the presence of metastases at diagnosis. In those patients with pulmonary metastases at diagnosis, the presence of calcifications, the primary tumor volume, the number of pulmonary lobes with disease, and the number of pulmonary nodules were recorded. RESULTS: Of an evaluable population of 215 patients, 32 (15%) had bone or pulmonary metastases at diagnosis, of whom original imaging from 28 patients was available for review. Osteoblastic histology correlated with lung metastases at diagnosis (P = 0.049). One of the 32 patients had a solitary bone metastasis without lung metastases. Four of 28 patients (14%) with original imaging available had calcifications within the pulmonary nodules. Both the number of nodules and the number of lobes involved were found to be significant predictors of survival (P = 0.0009 and P = 0. 04, respectively); multiple nodules were bilateral in 61% of patients. CONCLUSIONS: The rate of incidence of computed tomography detected pulmonary metastases was found to be 14% (31 of 215 patients) at diagnosis and 0.5% (1 of 215 patients) for bone metastases in patients with primary extremity OS. Pulmonary metastases usually are multiple and bilateral and infrequently calcify. The number of nodules and lobes involved are predictors of patient survival.
PURPOSE OF REVIEW: New developments in the nasal and paranasal sinus cancers are reviewed. RECENT FINDINGS: In addition to woodworking, several risk factors for nasal and paranasal sinus cancers have been identified, most notably smoking. Progress in the differential diagnosis of small round cell nasal and paranasal sinus cancers allows the precise diagnosis of esthesioneuroblastoma. Despite recent improvements, T staging for ethmoid and nasal cavity needs refinement. An association of surgery and radiation therapy remains the best treatment modality. Major developments include endoscopic resection of nasal and paranasal sinus cancers, high-precision radiotherapy techniques such as intensity-modulated radiotherapy, and proton-beam radiotherapy. There is probably no role for chemotherapy in esthesioneuroblastoma. Although chemotherapy is important for aggressive neoplasms, its generalized use for nasal and paranasal sinus cancers awaits the application/development of newer drugs. These drugs might be applied locally since the majority of recurrences remain local. SUMMARY: Progress in the treatment of nasal and paranasal sinus cancers could be achieved through better prevention and the developments of more selective treatments such as endoscopic resection, high-precision radiotherapy, and new chemotherapy drugs.
PURPOSE: Epilepsy syndromes can be identified very early in the course of a seizure disorder. It is unclear how accurate and resilient such early classifications are. We compared the classification of epilepsy syndromes made previously on the basis of information available at diagnosis with those made 2 years later in a cohort of children with newly diagnosed epilepsy. METHODS: Children (n = 613) were prospectively identified at the time of initial diagnosis by participating physicians in Connecticut between 1993 and 1997. Classification of epilepsy syndrome according to International League Against Epilepsy guidelines was made previously based on all relevant information available at diagnosis. All cases were reclassified again after 2 years of additional evidence had accumulated. The distributions of syndromes at diagnosis and at 2 years are compared and reasons for changes examined. RESULTS: After 2 years, syndromes remained the same in 86.3% of the cohort and changes occurred in 13.7% (n = 84). Evolution of the syndrome occurred in 24 children (3.9%), and rectification to the initial diagnosis occurred in 60 children (9.8%). The most common scenario for evolution of a syndrome was from West syndrome (n = 5), undetermined (n = 4), or symptomatic localization-related epilepsy (n = 3) to the Lennox-Gastaut syndrome. The most common rectification of initial classifications involved incompletely classified syndromes (cryptogenic localization-related and undetermined syndromes; n = 36). In a few instances, a fully specified syndrome was reclassified to another apparently unrelated syndrome. In these cases, initial information at diagnosis had been difficult to interpret. CONCLUSIONS: Epilepsy syndromes can, for the most part, be identified at the time of initial diagnosis. Two years later, rectifications were made in only 9.8% of cases, and most of these involved syndromes that represented incomplete classifications in the first place. Significant changes were rare. The International League Against Epilepsy classification of the epilepsies can be meaningfully applied in epidemiological studies of newly diagnosed pediatric epilepsy.
BACKGROUND: Acute appendicitis is one of the most common surgical emergencies. Its diagnosis is usually made depending on presenting history, clinical evaluation and laboratory tests. It has been estimated that the accuracy of the clinical diagnosis of acute appendicitis is lying between 76% and 92% (1). Negative appendectomies are one of the burdens facing not only the general surgeon but also the patient himself and the society as a whole, since appendectomy, as any other operation, results in socio-economic impacts in form of lost working days and declined productivity. OBJECTIVES: To determine the accuracy of c-reactive protein (CRP) in the diagnosis of acute appendicitis in comparison with the accuracy of clinical diagnosis. METHODS: This is a prospective study of all appendectomized patients during a one-year period in King Hussein Hospital in Amman/Jordan. RESULTS: A total of 98 patients were included in this study. The diagnosis of acute appendicitis was histopathologically confirmed in 89 patients (91%), while 9 normal appendixes (9%) were removed. The readings of CRP were ranging between 0 and 11.7 mg/l (mean 5.6 mg/l) in patients with normal appendixes, and between 6-93.4 mg/l (mean 36.2 mg/l) in patients with acute appendicitis. Normal CRP readings were found in 4 patients with acute appendicitis, and of the 9 cases with normal appendectomy, CRP level was elevated in only one patient, so the CRP levels were true (positively or negatively) in 93 patients and it was false positive in one patient (11%) and false negative in 4 patients (4%). On the other hand, the clinical diagnosis was correct in 89 cases (91%) and false in 9 cases (9%), the difference is statistically significant (p value = 0.009). CONCLUSIONS: We conclude that CRP is very helpful in the diagnosis of acute appendicitis, but it doesn't replace the clinical skills of general surgeons.
A comparison of 265 cases of tripel-diagnosis and 112 surgical biopsies of the female breast is reported. In 89,83% of these 265 cases the correct diagnosis was found, in 9,43% the result was doubtful, in 0,75% completely wrong. In 3,77% of these doubtful results the repetition of the tripel-diagnosis gave the correct diagnosis, in 4,15% surgical biopsy we found 2,68% wrong diagnosis. This fact shows the certainty of tripel-diagnosis. In addition the highly significant lower rate of complications, the avoidance of the risk of narcosis and scars and the lower amount of costs show the high clinical value of the so-called tripel-diagnosis.
For diagnosing myocardial infarction by myocardial scintigraphy using 201TlCl, the following two items were compared: 1) The diagnostic accuracy of visual evaluation of myocardial planar images versus that of single photon emission computed tomography (SPECT) images. 2) The diagnostic accuracy of qualitative and quantitative evaluations of SPECT images. The planar and SPECT methods were performed for 81 subjects consisting of 41 patients having myocardial infarction and 40 normal persons. Receiver operator characteristic (ROC) analysis, which is most objective in evaluation of visual diagnosis, was also used. To analyze quantitative diagnosis by ROC analysis, the normal range of circumferential profile analysis of myocardial short-axial tomography was determined by assessing five step divisions (less than 1 SD, 1-1.7 SD, 1.7-2.3 SD, 2.3-3 SD, and more than 3 SD) from 10 normal cases. Four physicians and three laboratory technicians familiar with myocardial images diagnosed the myocardial planar images and SPECT images individually. The results were analyzed and the ROC curves were constructed. The results indicated that image diagnosis by SPECT was superior to that by the visual planar method for all persons. The physicians who had more experience in diagnosing myocardial images made more accurate diagnosis. However, quantitative SPECT image diagnosis was superior to visual SPECT image diagnosis. Thus, with the input of data of the normal range of quantitative SPECT image diagnosis into the computer, the prospects of accurate computer assessments of myocardial infarctions were posed.(ABSTRACT TRUNCATED AT 250 WORDS)