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PubMed1999

[The diagnostic and therapeutic procedures in pulmonary embolism: a survey in the Veneto Region].

BACKGROUND: Pulmonary embolism is one of the most frequent cardiopulmonary diseases, but it is often under- or misdiagnosed. In order to address this issue and to identify flow charts that are commonly used in pulmonary embolism diagnosis and treatment, 191 clinical wards of internal medicine, cardiology, geriatrics, pneumology and intensive care units, located in the Veneto Region, were surveyed. METHODS: An anonymous questionnaire was mailed to each ward in order to collect clinical diagnostic information on all pulmonary embolisms which occurred during 1993. Among the returned questionnaires, 114 (59.6%) had usable information for the analysis. RESULTS: The vast majority of participating centers reported in 1993 less than 10 pulmonary embolism events. No significant differences were observed between internal medicine, geriatrics, pneumology wards and intensive care units. The reported events, however, were slightly higher in the divisions of cardiology with an annual average of 12 events per center. First level diagnostic procedures, such as ECG, chest X-ray and arterial blood gas analysis were chosen and performed in all patients. Interestingly, Doppler echocardiography, which is often not included in official guidelines for pulmonary embolism diagnosis, was performed in 56% of the participating centers. On the contrary, ventilation-perfusion lung scanning, which is considered highly predictive in many diagnostic algorithms, was underutilized (35% perfusion scan, 20% ventilation scan). This underuse was probably due to technical and organizational difficulties. Pulmonary angiography, the most accurate procedure for the diagnosis of pulmonary embolism, was performed in 28% of the patients. During the acute phase, intravenous heparin was commonly used; 91% of patients received the infusion continuously, 4% intermittently. Thrombolysis was performed in 25% of the patients. The preferred drugs were recombinant tissue-plasminogen activator (67%), followed by urokinase (20%) and streptokinase (13%). To start thrombolytic therapy, 20% of the interviewed clinicians considered sufficient the evidence of clinical manifestations of pulmonary embolism confirmed by echocardiographic data. At discharge, prescription of oral anticoagulant drugs was common (78%) for at least 6 months (47%). Standardized procedures for the diagnosis and treatment of pulmonary embolism were already implemented in 13% of the participating centers. CONCLUSIONS: These data suggest a common effort to define unanimous conventional protocols in the management of pulmonary embolism. It should be underlined, however, that a particular attention to the clinical manifestations and a productive collaboration among clinicians with different expertise are required to improve the diagnosis and treatment of pulmonary embolism.

Diagnostic Imaging↗

PubMed2003

[Therapy and prevention of deep venous thrombosis and pulmonary embolism in gynecology and obstetrics].

AIM: The aim of this paper is to present the latest developments in therapy and prophylaxis of deep vein thrombosis in gynecology and obstetrics. DATA EXTRACTION: The data presented in the paper have been extracted from the Current Contents database. In the introduction, the coagulation cascade is described, and certain coagulation abnormalities caused by deficiency or decreased activity of coagulation factors are highlighted. The most prominent signs of deep vein thrombosis in pregnant women are swelling and tenderness of the affected leg, sometimes accompanied with fever and leucocytosis. In pelvic thrombosis, swelling of the leg is often absent and such a condition may be mistaken for other abdominal emergencies. The diagnostic algorithm for deep vein thrombosis starts with the clinical Wells criteria. To confirm the diagnosis it is necessary to visualize the thrombus by one of the imaging methods. The value of D-dimer is limited by its low positive predictive value, particularly in pregnant women. Low weight molecular heparin's have lately almost replaced standard heparin in the treatment of the deep vein thrombosis in pregnant women for providing advantages of subcutaneous application, no need of laboratory control of coagulation parameters, lower risk of bleeding, and lower incidence of osteoporosis and heparin-induced thrombocytopenia. We list the recommendations of the American College of Chest Physicians published in 1991, which stratify pregnant women with deep vein thrombosis according to their medical history and laboratory parameters. We have specified the proposed approach according to: history of deep vein thrombosis due to transient risk factors; previous idiopathic deep vein thrombosis without anticoagulant therapy; previous deep vein thrombosis with thrombophylia; previous idiopathic deep vein thrombosis on anticoagulant therapy; laboratory-proven thrombophilia with no history of deep vein thrombosis; and recurrent deep vein thrombosis. Pregnant women with artificial heart valves may undergo one of three proposed treatments. Long preoperative hospitalization, prolonged operative procedures, extensive injuries of blood vein vessels on radical procedures, frequently present accompanying malignant disease or previous irradiation therapy and postoperative bed-ridden period after major gynecologic procedures increase the risk of perioperative development of deep vein thrombosis. It is necessary to appraise this risk, classify patients in one of the four groups, and administer appropriate measures. Patients at a low risk of developing thromboembolic incidents are those younger than 40, undergoing procedures lasting less than 30 minutes and without other risk factors. The risk is moderate in patients aged 40-60 without other risk factors, or those aged under 40 having malignancy have high risk. Patients at a very high risk are those with a history of deep vein thrombosis, thrombophilia or pelvic exenteration. In the last decade there has been a great advancement in the diagnostics and treatment of deep vein thrombosis. The discovery of genetic disorders predisposing the patient to the development of a thromboembolic incident (thrombophilia) has changed our position concerning the duration of anticoagulant therapy, and nowadays it can last from several months to a lifetime regimen, depending on the underlying mechanism causing the incident. A significant improvement in therapy has occurred with the introduction of low molecular weight heparins in clinical practice. Their therapeutic value is equal to standard heparin, and their advantages include easier dosage and less nursing time as well as in a lower incidence of side effects such as haemorrhage. For these reasons, low molecular weight heparin has almost completely replaced standard heparin in the western world.

Adult↗

PubMed1998

[False aneurysms of lower extremity arteries: noninvasive preop diagnosis with magnetic resonance angiography and Doppler ultrasonography].

The purpose of this study was to work out a diagnostic algorithm to be used in patients surgically treated because of a false aneurysm of arteries supplying the lower limb. The study includes preoperative vessel evaluation as well as treatment results assessment with MRA and US methods. Examinations included until now 16 patients with clinical false aneurysm suspicion. Most cases presented false aneurysms being complications after arterial graft implantation, in two patients, who were not previously operated, diagnosed false aneurysms were the result of injury. We performed 23 examinations (7 of which were postoperative treatment result evaluation examinations). Examinations were performed on MR equipment with a 1.5 T field induction. The 2D TOF with traveling presaturation method was used. Primary data and reconstructed (MIP) angiograms were analyzed by a radiologist having no access to clinical information and previous examination results. Ultrasound duplex doppler examinations were performed with 7 MHz linear probe. The MRA examinations visualized 7 false aneurysms of the lower Y-graft junction. Clinical verification, ultrasonography examinations and surgery confirmed the existence of 6 aneurysms of the Y-graft as well as 5 out of 6 diagnosed in the ileofemoral graft junctions area. The post-traumatic aorta aneurysm and the postarteriographic femoral aneurysm were also confirmed. Two false positive MRA diagnoses were due to dilatation of the artery below the graft junction, in one case it was a dilatation of the vessel below a stenosis. Furthermore, the MRA helped diagnosing stenoses and occlusions in femoral arteries and common iliac artery.

Adult↗

PubMed2000

Comparative multicentre study of a panel of thyroid tests using different automated immunoassay platforms and specimens at high risk of antibody interference.

The introduction of automation for immunoassays in recent years has brought about important and evident improvements in assay precision. Increasing standardization and comparability between platforms should enable the development of clinical guidelines and diagnostic algorithms for appropriate clinical decision making. A continuing source of variation between different automated immunoassay platforms is the sporadic effect of interfering antibodies or substances, thus causing aberrant results not supporting the patient's clinical status. The aim of this study was to describe current thyroid panel variation between automated immunoassay platforms including population specimens at risk of antibody interference. A multisite design with laboratories in three different countries using four different automated immunoassay platforms (Roche-Boehringer Mannheim Elecsys (Italy), Roche-Boehringer Mannheim ES300 (Wales), Bayer Immuno 1 and the Bayer ACS:180 evaluated the thyroid panel of thyrotropin (TSH), triiodothyromine (T3), free thyroxine (FT4) and free triiodothyronine (FT3). A common set of 158 randomly selected patient samples of non-thyroid and thyroid disorders, with and without treatment, was tested. Included were 62 patient samples at risk for endogenous antibody interference with high antimicrosomal antibody, anti-TSH receptor antibody and increased rheumatoid factor sub-populations. Across all controls and between platforms, precision measurements were comparable and varied between 0.7% and 12.8% for TSH, 2.8% and 13% for FT4, 1.8% and 10.5% for FT3 and 3.1% and 16% for T3 assay. Acceptable correlation and reproducibility were found between the three Bayer Immuno 1 platforms at each country's site with all four thyroid panel assays demonstrating r-values of 0.989 to 1.000 and slopes of 0.915 to 1.078. Comparisons between the different platforms showed acceptable correlation for all thyroid panel assays. Specimens containing rheumatoid factor were associated with a significantly increased variation between systems for the FT4 and FT3 assays (p < 0.01). This effect did not appear to be selective for a given platform. For specimens with raised autoimmune antibodies and therefore at risk of assay antibody interference, no variation could be observed between the platforms.

Antibodies↗

PubMed2000

Excess triiodothyronine as a risk factor of coronary events.

BACKGROUND: Abnormalities in cardiac function, eg, arrhythmias and congestive heart failure, often accompany thyrotoxicosis. A relationship between thyroid hormone excess and the cardiac complications of angina pectoris and myocardial infarction (MI) remains largely speculative. METHODS: The results of thyroid function studies on blood samples drawn from a total of 1049 patients (aged 40 years or older) immediately on emergency medical admission were related to frequencies of angina pectoris and myocardial infarction as determined according to current diagnostic algorithms. After 3 years, those patients who had initially presented with angina pectoris or acute MI were observed for subsequent coronary events; of these (n=185), 98% of the subjects (n=181) could be reevaluated. RESULTS: On hospital admission, the relative rate of angina pectoris and MI was markedly high (odds ratio, 2.6; 95% confidence interval, 1.3-5.2; P=.007) in patients with elevated serum free and total triiodothyronine (T(3)) levels. An initially elevated free T(3) level was a risk factor for subsequent coronary events during the 3-year follow-up (adjusted odds ratio, 4.8; 95% confidence interval, 1.3-17.4; P=.02). CONCLUSIONS: An elevation of serum free T(3) levels at hospital admission is associated with a 2.6-fold greater likelihood of the presence of a coronary event. Moreover, an initially elevated T(3) level is associated with a 3-fold higher risk of developing a subsequent coronary event during the next 3 years. Excess T(3) seemed to be a factor associated with the development and progression of acute myocardial ischemia.

Adult↗

PubMedDate not supplied

Overuse of transthoracic echocardiography in the diagnosis of native valve endocarditis.

BACKGROUND: Infective endocarditis (IE) is a diagnostic challenge due to its variable presentation and nonspecific clinical findings. The use of transthoracic echocardiography (TTE) has greatly improved the ability to diagnose IE early, and therefore reduce high mortality and morbidity rates. However, reliance on TTE to exclude IE may lead to overuse of this technology in patients with a low pretest probability of IE. METHODS: Prospective observational study of all patients referred for TTE to diagnose IE. Clinical factors were used to determine likelihood of IE based on the Von Reyn criteria, and the resulting diagnostic probabilities were correlated with abnormal TTE findings as well as duration of antibiotic therapy. RESULTS: One hundred eleven TTEs performed on 98 patients were included in the analysis. Over 70% of TTEs were obtained in patients in whom the diagnosis of IE was rejected by Von Reyn criteria. Therapeutic management (prolonged antibiotic administration) was associated significantly with Von Reyn categorization, and not significantly affected by TTE results. CONCLUSIONS: Most TTEs are obtained in patients with a low pretest probability of IE and do not contribute to therapeutic decision making. We propose a diagnostic algorithm to direct the use of TTE to patients with intermediate or high pretest probability of IE.

Adolescent↗

PubMed2002

Plasma D-dimers in the diagnosis of venous thromboembolism.

Clinical suspicion for venous thromboembolism (VTE) mandates objective testing to confirm or exclude the diagnosis. However, current imaging modalities are imperfect because of a small but important risk of complications with invasive techniques or limited sensitivity with noninvasive ones. A diagnostic tool for VTE is needed that is noninvasive and highly accurate, allowing immediate treatment decisions to be made in most cases. Plasma D-dimers (D-ds), specific cross-linked fibrin derivatives, partially fulfill these criteria in that they are sensitive markers for thrombosis but lack specificity. They therefore cannot be used to make a positive diagnosis of VTE; however, they generally have high negative predictive value and are useful as an exclusionary test, a potentially important role given that VTE is eventually ruled out in most patients investigated. Clinical management studies are clarifying the role of D-ds in the diagnostic paradigm of VTE: negative ultrasound and D-d findings obviate the need for serial imaging in suspected deep vein thrombosis, and anticoagulant therapy can be safely withheld in patients with non-high clinical suspicion for pulmonary embolism and non-high probability ventilation perfusion scan if D-d test results are negative. More recently, the combination of a negative SimpliRED (AGEN Biomedical Ltd, Brisbane, Australia) D-d result and low clinical suspicion derived using a formal scoring system has been shown to exclude deep vein thrombosis and pulmonary embolism and to obviate the need for imaging. Several different D-d assays are now available, and clinicians should be aware of the performance characteristics of the test used before incorporation into diagnostic algorithms as these will differ between assays, and the results of clinical management studies cannot necessarily be safely extrapolated to assays other than those specifically evaluated. If alternative assays are to be substituted, these should consistently have been shown to possess equivalent or greater sensitivity.

Biomarkers↗

PubMedDate not supplied

A rapid test for infectious and inflammatory enteritis.

BACKGROUND: Inflammatory illnesses are an indication for specific diagnostic studies and possible antimicrobial therapy. The presence of fecal leukocytes has been used as a marker of inflammatory diarrhea; however, microscopic examination of the fecal smear is unreliable if the specimen is transported, refrigerated, frozen, or collected by swab. OBJECTIVE: To evaluate a rapid, sensitive, semiquantitative test for detection of fecal leukocytes using antilactoferrin latex bead agglutination (LFLA), a test that remains sensitive even after specimens are refrigerated, frozen, or stored on swabs. METHODS: LFLA titers were determined in stool specimens from previously healthy volunteers before and after experimental infection with different enteric pathogens and from patients with nosocomial diarrhea caused by Clostridium difficile. RESULTS: Healthy controls and subjects with noninflammatory diarrhea caused by Vibrio cholerae consistently demonstrated LFLA titers less than 1:50. In contrast, subjects with inflammatory diarrhea caused by Shigella species and C difficile had markedly elevated titers. Titers for subjects with experimental shigellosis ranged from 1:50 to 1:3200, with seven (78%) of nine at 1:400 or greater. Titers for patients with C difficile enteritis ranged as high as 1:1200, with six (50%) of 12 at 1:400 or greater. Subjects with experimental enteropathogenic Escherichia coli infection also had elevated titers, ranging from 1:100 to 1:1600, with three (43%) of seven at 1:400 or greater. Titers for subjects with experimental enterotoxigenic E coli infection were moderately elevated, with nine (53%) of 17 ranging from 1:50 to 1:200 (only one [6%] of 17 was > or = 1:400), suggesting a mild inflammatory process. CONCLUSIONS: The fecal LFLA assay distinguishes inflammatory from noninflammatory diarrhea, may provide new information on mildly inflammatory processes, and may be a useful, rapid test in a diagnostic algorithm for acute, infectious diarrheal illnesses.

Communicable Diseases↗

PubMed2001

Eagle syndrome produced by a granular cell tumor.

Eagle syndrome includes elicitation of pain on swallowing, turning the head, or extending the tongue. The syndrome is thought to be caused by irritation of the glossopharyngeal nerve, most commonly caused by its impingement against an elongated styloid process. We present a rare case of a granular cell tumor presenting as Eagle syndrome. Granular cell tumors orignate from Schwann cells and are most common in the subcutaneous tissue of the head, neck, and oral cavity, especially the tongue. A granular cell tumor is typically benign and solitary, rarely malignant. The differential diagnosis, diagnostic algorithm, and treatment are presented.

Adult↗

PubMed1999

The role of transthoracic echocardiography in the diagnosis of infective endocarditis in children.

BACKGROUND: Infective endocarditis (IE) is frequently suspected but infrequently diagnosed in children. Clinicians often order echocardiograms to "rule out" IE. In an era of cost constraint, clinically efficient strategies must be developed to eliminate unnecessary tests. We hypothesized that transthoracic echocardiography (TTE) is only useful in children in whom there is a high clinical suspicion of IE based on history, physical examination, and persistently positive blood cultures. OBJECTIVE: To determine the role of TTE as a screening test for suspected IE in children. METHODS: Echocardiographic reports and medical records were reviewed retrospectively for 173 consecutive patients who underwent TTE to rule out IE from January 1993 to August 1996. RESULTS: Persistent fever was the predominant symptom leading to a suspicion of IE (120 patients [69.4%]). Fifty-seven (32.9%) of the 173 patients had congenital heart disease and 95 patients (54.9%) had indwelling venous catheters. Twenty-six patients (15.0%) were diagnosed and treated for IE. Twelve (46.2%) of these 26 patients had vegetations seen on TTE. The conditions of the remaining 14 patients were diagnosed clinically and these patients had persistently positive blood cultures. By univariate analysis, the risk factors associated with the diagnosis of IE were malaise, congestive heart failure, new or changing heart murmur, leukocytosis, hematuria, and the presence of 2 or more positive blood cultures for the same organism. The risk factors associated with positive TTE were malaise, congestive heart failure, new or changing heart murmur, leukocytosis, hematuria, and 2 or more positive blood cultures. The presence of an indwelling catheter or immunocompromised status were not predictive of vegetation or IE. CONCLUSIONS: Transthoracic echocardiography has poor sensitivity as a screening test for IE in patients with low clinical probability of the disease. A diagnostic algorithm for IE is suggested based on these data.

Adolescent↗

PubMed1984

The design of the Epidemiologic Catchment Area surveys. The control and measurement of error.

Several methods are used to minimize and measure error in the NIMH Epidemiologic Catchment Area program. Sampling methods involve the inclusion of group quarters such as prisons, nursing homes, and mental hospitals in the sample frame and the use of probability sampling throughout. Interviewing, methods include use of identical diagnostic interview protocols, centralized training of interview supervisors, standard instructions to interviewers, and reinterview of a subsample by clinicians. In the area of completion, the methods include a 75% to 80% respondent completion rate, a 95% or greater completion rate for individual questions, use of informant interviews where necessary, and statistical adjustments to correct for low completion rates in some subgroups. Analytic methods include use of a computerized diagnostic algorithm, common estimation formulas on identically formatted data files, and estimation of exact variances that take account of the multistage sample design.

Catchment Area, Health↗

PubMed2001

Computed tomography in the evaluation of penetrating neck trauma: a preliminary study.

HYPOTHESIS: Penetrating neck trauma has traditionally been evaluated by surgical exploration and/or invasive diagnostic studies. We hypothesized that computed tomography (CT), used as an early diagnostic tool to accurately determine trajectory, would direct or eliminate further studies or procedures in stable patients with penetrating neck trauma. DESIGN: Retrospective case series. SETTING: Academic, urban, level I trauma center. PATIENTS: Hemodynamically stable patients without hard signs of vascular injury or aerodigestive violation who had sustained penetrating trauma to the neck. INTERVENTIONS: Patients underwent a spiral CT as an initial diagnostic study after initial evaluation in the trauma bay. Further invasive studies were directed by CT findings. MAIN OUTCOME MEASURES: Number of invasive studies performed. RESULTS: Twenty-three patients were identified during the 30-month period. Nineteen patients sustained gunshot wounds; 3, shotgun wounds; and 1, a stab wound. One patient died of a cranial gunshot wound. Three isolated zone I, 1 isolated zone II, 9 isolated zone III, and 10 multiple neck zone trajectories were evaluated. Thirteen patients were identified by CT to have trajectories remote from vital structures and required no further evaluation. Ten patients underwent angiography. Only 2 underwent bronchoscopy and esophagoscopy. Four patients were discharged from the emergency department; 7 other patients were discharged within 24 hours. No adverse patient events occurred before, during, or after CT scan. CONCLUSIONS: Computed tomography in stable selected patients with penetrating neck trauma appears safe. Invasive studies can often be eliminated from the diagnostic algorithm when CT demonstrates trajectories remote from vital structures. As a result, efficient evaluation and early discharge from the trauma bay or emergency department can be realized. Further prospective study of CT scan after penetrating neck trauma is needed.

Adult↗

PubMed1982

The changing pattern of hemolytic streptococcal gangrene.

We reviewed nine cases in which either limg-threatening or life-threatening complications developed due to streptococcal infection. Our findings indicate important changes in the pattern of this fulminating illness since its original description in 1924. A higher mortality reflects increased longevity with a greater frequency of impaired host resistance and degenerative diseases involving vital organs. Initial symptoms and signs often mimic acute thrombophlebitis, acute arthritis, deep soft-tissue trauma, or acute vascular occlusion. The emergence of multiple organ failure and serious coagulation disorders are a challenge to current therapy. A diagnostic algorithm was developed to aid in the early diagnosis and management of this life-threatening infection.

Adult↗

PubMed1998

Does the Composite International Diagnostic Interview underdiagnose the eating disorders?

OBJECTIVE: A study was undertaken to assess the procedural validity of the Composite International Diagnostic Interview (CIDI) for the diagnosis of eating disorders. METHOD: The CIDI was administered to 44 patients consecutively admitted to an eating disorders unit. CIDI-generated diagnoses were compared with clinical diagnoses documented in patient files. Discrepancies between diagnoses were examined in detail. RESULTS: A significant level of disagreement was apparent, particularly for anorexia nervosa patients. A large number of patients with symptoms requiring inpatient treatment did not reach criteria using CIDI's diagnostic algorithm. CONCLUSION: Considerable difficulties remain in the use of standardized assessments, such as the CIDI, to diagnose eating disorders. While presenting features of the illness, for example, ego syntonic nature of the illness, secrecy, and denial, may be part of the reason, the questions used by the CIDI appear to be in need of some refinement.

Anorexia Nervosa↗

PubMed1999

Chest pain in anorexia nervosa.

OBJECTIVE: To determine the incidence and characteristics of chest pain in patients with anorexia nervosa. METHOD: A cross-sectional survey of 54 patients. A pain history according to a diagnostic algorithm that was constructed from a Medline search (1966-1996) was used. RESULTS: Eighty-seven percent of patients had experienced chest pain. The most common diagnosis was idiopathic, occurring in 38% of participants. The incidence of typical and atypical angina was 11% and 9%, respectively. Increasing age, smoking history, and a family history of chest pain were more common in those with the atypical or typical angina. CONCLUSIONS: Chest pain is a common symptom in patients with eating disorders, and the incidence of typical and atypical angina is surprisingly high. All patients with eating disorders should be screened for chest pain and other risk factors for coronary heart disease.

Adolescent↗

PubMed1986

Computerized interactive morphometry as a potentially useful tool for the classification of non-Hodgkin's lymphomas.

The use of a simple form of Computerized Interactive Morphometry (CIM) is proposed as a tool to achieve a reproducible classification of non-Hodgkin's lymphomas. This system combines a random sampling method for cells with simple size measurements and additional subjective criteria such as a shape, mitotic counts, and follicular or diffuse features. In this system, which utilizes a high resolution touch screen as interactive peripheral, the video image of the specimen is superimposed to a computer generated reference system which consists of a test area and four fixed points for random sampling of cells and a series of concentric circles to serve as internal standard for nuclear size; the computer tabulates and facilitates data processing. Forty-four lymphoid lesions have been characterized with the CIM system and specific criteria for diagnoses according to the Working Formulation of non-Hodgkin's lymphomas for clinical usage are derived. Studies of inter- and intraobserver variations in data collection are discussed, and a diagnostic algorithm that categorizes non-Hodgkin's lymphomas according to the relative proportions of various lymphoid cells and densities of mitotic counts is proposed. The potential applications of touch screen-based CIM for the study of malignant lymphomas and its practical technical advantages over other quantitative systems based on either gray-level analysis or tracings of cell contours on photographs or digitizer pads are emphasized.

Computers↗

PubMed1995

Issues in the assessment of personality disorder and substance abuse using the Millon Clinical Multiaxial Inventory (MCMI-II).

Substance abuse treatment clients often present other severe mental health problems that affect treatment outcomes. Hence, screening and assessment for psychological distress and personality disorder are an important part of effective treatment, discharge, and aftercare planning. The Millon Clinical Multiaxial Inventory-II (MCMI-II) frequently is used for this purpose. In this paper, several issues of concern to MCMI-II users are addressed. These include the extent to which MCMI-II scales correspond to DSM-III-R disorders; overdiagnosis of disorders using the MCMI-II; accuracy of MCMI-II diagnostic cut-off scores; and the clinical utility of MCMI-II diagnostic algorithms. Approaches to addressing these issues are offered.

Diagnosis, Dual (Psychiatry)↗

PubMed2000

Interventions for tubal ectopic pregnancy.

BACKGROUND: The diagnosis of ectopic pregnancy can now often be made by non-invasive methods due to sensitive pregnancy tests (in urine and serum) and high resolution transvaginal sonography, which have been integrated in diagnostic algorithms. These algorithms, in combination with the increased awareness and knowledge of risk factors among both clinicians and patients, have enabled an early and accurate diagnosis of ectopic pregnancy. As a consequence, the clinical presentation of ectopic pregnancy has changed from a life threatening disease to a more benign condition. This in turn has resulted in major changes in the options available for therapeutic management. Many treatment options are now available to the clinician in the treatment of tubal pregnancy: surgical treatment, which can be performed radically or conservatively, either laparoscopically or by an open surgical procedure; medical treatment, with a variety of drugs, that can be administered systemically and/or locally by different routes (transvaginally under sonographic guidance or under laparoscopic guidance); expectant management. The choice of a treatment modality should be based on short-term outcome measures (primary treatment success and reinterventions for clinical symptoms or persistent trophoblast) and on long-term outcome measures (tubal patency and future fertility). OBJECTIVES: In the treatment of tubal pregnancy various types of treatments are available: surgical treatment, medical treatment and expectant management. In this review the effects of various treatments are summarized in terms of treatment success, need for reinterventions, tubal patency and future fertility. SEARCH STRATEGY: The Cochrane Menstrual Disorders and Subfertility Group trials register and MEDLINE were searched. SELECTION CRITERIA: Randomized controlled trials comparing treatments in women with ectopic pregnancy. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data extracted independently by two reviewers. Differences were resolved by discussion with all reviewers. MAIN RESULTS: Laparoscopic conservative surgery is significantly less successful than the open surgical approach in the elimination of tubal pregnancy due to a higher persistent trophoblast rate of laparoscopic surgery. Long term follow-up shows similar tubal patency rates, whereas the number of subsequent intrauterine pregnancies is comparable, and the number of repeat ectopic pregnancies lower, although these differences are not statistically significant. The laparoscopic approach is less costly as a result of significantly less blood loss and analgesic requirement, and a shorter duration of operation time, hospital stay, and convalescence time. Compared to laparoscopic conservative surgery (salpingostomy) local methotrexate is not a treatment option. Injection of this drug, both under laparoscopic guidance and under ultrasound guidance, is significantly less successful in the elimination of tubal pregnancy. Systemic methotrexate in a single dose intramuscular regimen is not effective enough in eliminating the tubal pregnancy compared to laparoscopic salpingostomy. This as a result of inadequately declining serum hCG concentrations after one single dose of methotrexate necessitating additional methotrexate injections or surgical interventions. If methotrexate primarily given in a multiple dose intramuscular regimen is compared with laparoscopic salpingostomy no large differences are found in medical outcomes, both short term and long term. However, this treatment regimen is associated with a greater impairment of health related quality of life and is more expensive, due to surgical interventions for clinical signs of tubal rupture, generating additional direct costs due to prolonged hospital stay. Furthermore, indirect costs due to productivity loss are higher. Only in patients with low initial serum hCG concentrations systemic methotrexate leads to costs savings compared to laparoscopic salpingostomy.

Female↗