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The present report presents a computerized system, permitting recording of diagnostic criteria and assignment by diagnostic algorithms as proposed and intended in 7 different classification systems of depression. The potential of the procedure for comparing alternative classifications of depression is presented and discussed.
Many emergency medical service (EMS) systems are currently implementing semi-automatic external defibrillation (AED) by emergency medical technicians. Surprisingly little information is available on the possible interactions between AEDs and implanted cardiac pacemakers. Therefore, at present there are no clear guidelines for the use of AEDs on patients having a cardiac pacemaker. During resuscitation, multiple interactions between pacemakers and AEDs are possible. External defibrillation can cause damage to several functions of the pacemaker. On the other hand, the presence of pacemaker spikes during cardiac arrest might prohibit recognition of the ventricular fibrillation by the AED. We report on two resuscitation attempts in which the interaction between the ventricular fibrillation, an implanted dual chamber pacemaker and the AED was decisive for the defibrillation success. A clear understanding of these possible interactions is necessary for the further refining of diagnostic algorithms and clinical strategies of prehospital defibrillation.
The accuracy of plain films, excretory urography and ultrasound for the clinical work-up of renal colic for detecting urinary calculi was evaluated prospectively in 49 patients. Excretory urography was the most sensitive and specific test. Plain films and sonography each had a sensitivity of approximately 60%, but combined yielded a sensitivity of 80%; specificity did not improve. A diagnostic algorithm where sonography was performed first followed by an excretory urography in case of a negative sonography was highly sensitive (93%) and rather specific (79%). This algorithm appears also to have a good cost-benefit rate.
The files of 12 patients (aged 12-33 years) with an equal number of surgically proven osteoid osteomas (OOs) were reviewed in attempt to find a diagnostic algorithm in cases of unusually located OOs. Plain radiography (PR) and thin collimation computed tomography (CT) had been performed in all patients, while bone scintigraphy (BS) had been performed in eight and magnetic resonance imaging (MRI) in two. The OOs were located at juxta- or intra-articular sites, except for one located at the left neck of the L4 vertebra. The diagnosis based on the MRI examinations was synovitis. BS showed increased accumulation of the radioisotope at the site of the lesions, without the 'double density' sign. PR showed the nidus of OO in only six patients, whereas CT located the nidus in all patients. In conclusion, we believe that when an OO is clinically suspected at an unusual location, CT should be performed in all cases, even when a lesion is depicted by PR and BS, because CT will not only locate the nidus but will also provide a precise anatomy of the area around the nidus and help in therapeutic decision making and surgical planning. MRI can be misleading and must not be used in the initial assessment of a possible osteoid osteoma.
In the setting of a questionable pulmonary nodule demonstrated by conventional radiographs, the place of CT in the diagnostic algorithm is not well established. We reviewed our experience in 50 consecutive patients referred to CT for a "possible pulmonary nodule." From the chest radiographs we noted nodule location, maximum dimension, presence on one or both views, and presence on a previous radiograph (greater than 1 year old), and nodules were categorized as "likely" or "unlikely" to be real parenchymal lesions based on radiographic appearance. Of a total of 56 questionable nodules, CT demonstrated no abnormality in 21 cases, parenchymal nodules in 16, scarring, atelectasis, or infiltrate in 11, and normal structural variants in 8. True pulmonary nodules were statistically significantly more frequently categorized as "likely" lesions than normal variants or no disease, but this was not of a magnitude to be clinically useful. Based on analysis of various radiographic features of equivocal nodules and their subsequent outcomes, we suggest a radiologic approach to the equivocal pulmonary nodule.
Delayed tooth eruption (DTE) is the emergence of a tooth into the oral cavity at a time that deviates significantly from norms established for different races, ethnicities, and sexes. This article reviews the local and systemic conditions under which DTE has been reported to occur. The terminology related to disturbances in tooth eruption is also reviewed and clarified. A diagnostic algorithm is proposed to aid the clinician in the diagnosis and treatment planning of DTE. The sequential and timely eruption of teeth is critical to the timing of treatment and the selection of an orthodontic treatment modality. This review addresses the need for a more in-depth understanding of the underlying pathophysiology of DTE and gives the clinician a methodology to approach its diagnosis and treatment.
BACKGROUND: Urinary albumin excretion and left ventricular mass are related to each other and to the risk of cardiovascular events in patients with primary hypertension. We aimed to identify a lower threshold for albuminuria that might improve detection of patients with left ventricular hypertrophy (LVH) and cost-effectiveness in cardiovascular risk assessment. METHODS: Albuminuria and left ventricular mass index were assessed in 448 untreated, nondiabetic patients with primary hypertension. The impact that lower albuminuria cut-off levels might have on detecting LVH was evaluated with regard to test cost and sensitivity. This was done by a diagnostic algorithm consisting of albuminuria evaluation followed by echocardiography in the presence of normoalbuminuria. RESULTS: The area under the ROC curve of albuminuria in predicting LVH was 0.73. Using a lower albumin to creatinine ratio threshold than what is recommended by the guidelines (ie, 11.5 mg/g), the sensitivity and specificity of albuminuria in identifying patients with LVH was 39% and 92%, respectively, which translated to positive and negative predictive values of 76% and 69%, respectively. When considering only patients without electrocardiographically detected LVH, routine screening for albuminuria, followed by echocardiography in the presence of albuminuria <or = 11.5 mg/g, allowed us to decrease the number of echocardiograms by 23%. CONCLUSION: Adopting a lower threshold to define microalbuminuria could prove to be cost-effective for assessing cardiovascular risk in hypertensive patients.
BACKGROUND: Breast health has become an increasingly important issue among the veteran population. Options for the evaluation of a breast mass or a suspicious mammographic finding include open surgical biopsy at the Veterans Affairs (VA) hospital or percutaneous image-guided biopsy at an affiliated academic institution. We examined the costs and trends in the use of surgical versus percutaneous image-guided biopsy procedures in this diagnostic algorithm. METHODS: A retrospective review was performed of 62 patients who presented to the VA General Surgery Clinic with a breast mass or abnormal mammogram from 2003 to 2005. The Massachusetts Utilization Multiprogramming System and the Decision Support System software packages were used to track costs of procedures, by Current Procedure Terminology code and date of service, performed at the affiliated academic institution and at the VA hospital. These data were analyzed and described using the R statistical computing environment. RESULTS: Forty-six patients were evaluated using open biopsy techniques in the VA operating room, including 8 incisional biopsies, 21 excisional biopsies, and 17 needle-localization excisional biopsies. Sixteen patients were evaluated using minimally invasive biopsies at the affiliated academic institution, including 3 ultrasound-guided cyst aspirations, 6 ultrasound-guided core biopsies/vacuum-assisted core biopsies, 10 stereotactic breast biopsies, and 1 fine-needle aspiration. The average cost to evaluate a breast mass or abnormal mammographic finding in the operating room was 4,368.00 dollars (SD, 2,586.00 dollars), with a median cost of 3,479.00 dollars. The average cost to evaluate a breast mass or mammographic abnormality using percutaneous image-guided procedures was 1,267.00 dollars (SD, 536.00 dollars), with a median of 1,239.00 dollars. From 2003 to 2005, the proportion of percutaneous biopsies increased from 13% to 48%, whereas the proportion of open biopsies decreased from 88% to 52%. CONCLUSIONS: Over a recent 3-year period, we observed a 3.8-fold increase in the use of percutaneous image-guided techniques for the evaluation of breast lesions in the VA Tennessee Valley Healthcare System. Diagnosis by percutaneous techniques allows planning for a definitive surgery if a lesion is malignant or possible avoidance of a surgical intervention if the lesion is benign. Our data show that the costs associated with open biopsy techniques exceed those associated with percutaneous biopsies. For VA hospitals with available resources, the option of image-guided percutaneous biopsy techniques is a cost-effective alternative to open surgical biopsy.
STUDY OBJECTIVE: Pleuritic chest pain is a common presenting complaint in the emergency department (ED) and a symptom of pulmonary embolism. Patients with pleuritic chest pain would benefit from a simple and rapid way of screening for pulmonary embolism. The aim of this study is to assess the utility of Simplify D-dimer as a rule-out tool for pulmonary embolism in ED patients with pleuritic chest pain. METHODS: This was a prospective diagnostic study in a large city-center ED. Four hundred twenty-five patients with pleuritic chest pain were prospectively recruited between February 2002 and June 2003. Simplify D-dimer testing was performed on each patient in the ED. All patients followed an independent reference standard diagnostic algorithm for pulmonary embolism. Each patient was followed up clinically for 3 months. RESULTS: The calculated sensitivity of Simplify D-dimer for pulmonary embolism was 81.8% (95% confidence interval [CI] 61.4% to 92.7%), and specificity was 74.2% (95% CI 69.6% to 78.4%). The negative predictive value was 98.6% (95% CI 96.6% to 99.6%), positive predictive value 15.0% (95% CI 9.1% to 22.7%), negative likelihood ratio 0.25 (95% CI 0.10 to 0.52) and positive likelihood ratio 3.17 (95% CI 2.30 to 3.97). The study cohort pretest probability was 5.3%. A negative Simplify result reduced the posttest probability to 1.3% (95% CI 0.5% to 3.4%). CONCLUSION: The Simplify D-dimer is not sufficiently sensitive to exclude the diagnosis of pulmonary embolism in all patients presenting to the ED with pleuritic chest pain.
OBJECTIVE: Preliminary assessment of a rotary thromboelastometer (Rotem) in the haemostasis monitoring in ICU. STUDY DESIGN: Prospective, open. PATIENTS AND METHODS: The device: the Rotem is a rotary thromboelastometer, which measures continuously and retranscribes numerically viscoelastic properties of a clot after an in vitro haemostasis activation. 83 patients with various haemostasis disorders that 122 blood samples have been subjected to a double analysis: extemporaneous by Rotem and at the laboratory for conventional haemostasis tests (aPTT, PT, fibrinogen, platelets). We assessed Rotem's manipulation duration, time for the first results. We compared Rotem variables with conventional haemostasis parameters and haemostasis diagnosis with each method. RESULTS: Mean Rotem manipulation duration was measured at 2 minutes 51 seconds+/-1 minute 48 seconds and time for results at 13+/-6 minutes. Plasma fibrinogen level was strongly correlated with the kinetic of clot formation (CFT) and the maximun clot firmness (MCF) measured by Rotem (R>0.7, coefficient of Pearson). Platelets were strongly correlated with MCF. The PT and aPTT had a weak correlation with Rotem parameters (R< or =0.53). The diagnosis concordance between the two techniques was good with a pondered kappa coefficient measured at 0.68. Hypocoagulability thromboelastographic profile with Rotem was in agreement with conventional parameters diagnosis in 92 percent of cases. Hypercoagulability thromboelastographic profile was associated with a significant increase of conventional parameters (supranormal value in 78%). Normal thromboelastography profile was associated with normal conventional parameters in 49%. Different reagents used on several simultaneous tests specified the thromboelastographic diagnosis. A diagnostic algorithm showed the interest of the Rotem for the prediction of conventional test results. CONCLUSION: Rotem is an easy manipulation device whose concordant and rapid results allow its emergency use in the framework of haemorrhagic situations. It also allows an approach of hypercoagulability states so that the therapeutic implication remains to evaluate. The Rotem offers a dynamic multifactorial approach on total blood of haemostasis that is what makes it a prime aid of haemostasis monitoring, in complement of usual analytic haemostasis evaluation.
A giant coronary pseudoaneurysm of uncertain cause, arising from Vieussens' arterial ring, was preoperatively diagnosed in an oligosymptomatic female patient. Successful off-pump surgical excision without additional bypass grafting was performed. Difficulties in diagnostic algorithm, as well as possible cause and extremely rare localization were discussed.
Pathogenetically fundamental observations have identified polycythemia vera (PV) as a clonal stem cell disease with bone marrow histological and other biological features that distinctly differentiate it from other causes of 'increased' hematocrit. However, relatively little attention has been given to the effective utilization of pathology and laboratory markers of clonal myeloproliferation as diagnostic tools in PV. In contrast, the diagnostic use of red cell mass (RCM) measurement in PV stemmed from the accidental endorsement, as 'diagnostic criteria', of 'study eligibility criteria' that were formulated for clinical trials. It has since become evident that RCM measurement is a tedious procedure that is fraught with multiple-level imprecision, as well as suboptimal diagnostic accuracy. Therefore, it is reasonable to consider dispensing with RCM measurement as a diagnostic test for PV and instead utilize a diagnostic algorithm that combines clinical information with easily accessible laboratory data, including serum erythropoietin level and bone marrow histology. Recent discoveries of myeloproliferative-disease-specific molecular markers, including the JAK2 V617F tyrosine kinase mutation that is found in the majority of patients with PV, provide further support for such a measure.
It is now at least theoretically possible to prevent patients with hepatocellular carcinoma (HCC) from dying of HCC. Screening identifies small potentially curable lesions, and the diagnostic algorithm allows for efficient investigation and diagnosis. Radiofrequency ablation completely ablates more than 05% of lesions smaller than 2 cm. Second primary cancers can be dealt with in the same manner as the initial primary. If the management of HCC is so efficient and effective, liver transplantation may come to be used as a last resort, rather than the treatment of choice. This benefits patients with hepatitis C and other liver diseases because more organs become available for treatment of other liver diseases.
OBJECTIVE: Gadolinium-enhanced pulmonary magnetic resonance angiography (MRA) can be an option in patients with a history of previous adverse reaction to iodinated contrast material and renal insufficiency. Radiation is also avoided. The aim of this study is to prospectively compare the diagnostic value of MRA with that of a diagnostic strategy, taking into account catheter angiography, computed tomography angiography (CTA), and lung scintigraphy [ventilation-perfusion (VQ)]. MATERIAL AND METHODS: Magnetic resonance angiography was done in 48 patients with clinically suspected pulmonary embolism (PE) using fast gradient echo coronal acquisition with gadolinium. Interpretation was done with native coronal images and multiplanar maximum intensity projection reconstructions. Results were compared to catheter angiography (n=15), CTA (n=34), VQ (n=45), as well as 6-12 months clinical follow-ups, according to a sequenced reference tree. RESULTS: The final diagnosis of PE was retained in 11 patients (23%). There were two false negatives and no false positive results with MRA. Computed tomography angiography resulted in no false negatives or false positives. Magnetic resonance angiography had a sensitivity of 82% and a specificity of 100%. CONCLUSION: In our study, pulmonary MRA had a sensitivity of 82% and a specificity of 100% for the diagnosis of PE, with slightly less sensitivity than CTA. In the diagnostic algorithm of PE, pulmonary MRA should be considered as an alternative to CTA when iodine contrast injection or radiation is a significant matter.
To assess the validity of ADHD in children with mental retardation, we applied Robins and Guze's [Robins, E., and Guze, S.B. (1970). Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia. American Journal of Psychiatry, 126, 983-987.] criteria for determining the validity of a psychiatric disorder. We review the literature describing clinical correlates, family history, treatment response, laboratory studies, course, and outcome of children with ADHD and mental retardation. Although clearly an area in need of further research, there is preliminary evidence to suggest that ADHD is a valid psychiatric condition in children with mental retardation. Nevertheless, without knowing the base rates of ADHD symptoms in the mental retardation population, the positive predictive power and negative predictive power of ADHD symptoms in this population remain an open question. In addition to assessment of base rate symptoms, future research should consider what diagnostic algorithm may best be applied to the diagnosis of ADHD in mental retardation.
This study, based upon epidemiological survey data from the United States (U.S.) National Household Surveys on Drug Abuse (NHSDA) from 2000 to 2001, presents new estimates for the risk of developing a hallucinogen dependence syndrome within 24 months after first use of any hallucinogen (median elapsed time approximately 12 months). Subgroup variations in risk of becoming hallucinogen dependent also are explored. Estimates are derived from the NHSDA representative samples of non-institutionalized U.S. residents ages 12 and older (n=114,241). A total of 2035 respondents had used hallucinogens for the first time within 24 months prior to assessment. An estimated 2-3% of these recent-onset hallucinogen users had become dependent on hallucinogens, according to the NHSDA DSM-IV computerized diagnostic algorithm. Controlling for sociodemographic and other drug use covariates, very early first use of hallucinogens (age 10-11 years) is associated with increased risk of hallucinogen dependence (p<0.01). Excess risk of developing hallucinogen dependence was found in association with recent-onset use of mescaline; excess risk also was found for recent-onset users of ecstasy and of PCP. This study's evidence is consistent with prior evidence on a tangible but quite infrequent dependence syndrome soon after the start of hallucinogen use; it offers leads that can be confirmed or disconfirmed in future investigations.
The diagnosis of acute hypoxic hepatitis remains problematic. We describe a series of 14 patients who were initially hospitalized in an hepatic care unit with a diagnosis of fulminant hepatitis, and were subsequently found to have acute hypoxic hepatitis ('liver shock') secondary to heart failure. A diagnostic algorithm is proposed.
AIMS: To investigate regional systolic function of the left ventricle, to test the hypothesis that "pure" diastolic dysfunction (impaired global diastolic filling, with a preserved ejection fraction > or = 50%) is associated with longitudinal systolic dysfunction. METHODS AND RESULTS: One hundred thirty subjects (31 patients with asymptomatic diastolic dysfunction, 30 with diastolic heart failure, 30 with systolic heart failure; and 39 age-matched normal volunteers) were studied by conventional and tissue Doppler echocardiography. Global diastolic function was assessed using the flow propagation velocity, and by estimating left ventricular filling pressure from the ratio of transmitral E and mitral annular E(TDE) velocities (E/E(TDE)); and global systolic function by measurement of ejection fraction. Radial and longitudinal functions were assessed separately from posterior wall and mitral annular velocities. Global and radial systolic function were similar in patients with "pure" diastolic dysfunction and normal subjects, but patients with either asymptomatic diastolic dysfunction or diastolic heart failure had impaired longitudinal systolic function (mean velocities: 8.0+/-1.2 and 7.7+/-1.5 cm/s, respectively, versus 10.1+/-1.5 cm/s in controls; p<0.001). In subjects with normal ejection fraction, global diastolic function correlated with longitudinal systolic function (r=0.56 for flow propagation velocity, and r=-0.53 for E/E(TDE) ratio, both p<0.001), but not with global systolic function. CONCLUSION: Worsening global diastolic dysfunction of the left ventricle is associated with a progressive decline in longitudinal systolic function. Diastolic heart failure as conventionally diagnosed is associated with regional, subendocardial systolic dysfunction that can be revealed by tissue Doppler of long-axis shortening. Diagnostic algorithms and definitions of heart failure need to be revised.