[Minimalization and optimalization of psychiatric examinations for the purpose of diagnostic and prognostic classification (author's transl)].
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Humans↗
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Results for “diagnostic optimization”
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[Optimal parameters of reversal photic stimulation in the diagnostic use of visually evoked potentials].
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Adult↗
[Optimal and threshold values in the application of diagnostic tests].
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Diagnostic Errors↗
Non-contrast thin-section helical CT of urinary tract calculi in children.
BACKGROUND: Non-contrast thin-section helical CT has gained acceptance for the diagnosis of urinary tract calculi in adults, but experience with the technique in children is limited. PURPOSE: To evaluate the utility of non-contrast thin section helical CT for the diagnosis of urinary tract calculi in children. MATERIALS AND METHODS: Radiology databases at three pediatric institutions were searched to identify all pediatric patients evaluated by "renal stone" protocol CT scans (no oral or intravenous contrast, scans covering the entire urinary tract obtained in helical mode with narrow collimation (< 5 mm)). CT scans were reviewed for the primary finding of urinary tract calculi, for secondary signs of acute urinary tract obstruction and for evidence of alternative diagnoses. Medical records were reviewed to determine clinical presentation and to confirm the eventual diagnosis. RESULTS: One hundred thirty-seven scans of 113 children (mean age: 11.2 years) were studied. Thirty-eight of 94 examinations (40%) performed on 82 children for acute pain and/or hematuria showed ureteral calculi. Alternative diagnoses were suggested by CT on 16 scans (17%). Twenty-eight scans were performed on 10 asymptomatic children with known calculus disease confirming renal stone burden on 21 scans (75%) and persistent ureteral calculi on 6 scans (21%). Upper tract calculi were demonstrated on 10 of 15 scans (67%) performed to evaluate for calculi in patients with known non-calculus genitourinary tract abnormalities. CONCLUSIONS: Non-contrast thin section helical CT is a useful method to diagnose urinary tract calculi in children. Radiation dose in this retrospective study may exceed the lowest possible radiation dose for diagnostic accuracy. Further research is needed to optimize CT imaging parameters, while maintaining diagnostic accuracy and minimizing radiation dose.
Adolescent↗
Radiology of the central airways.
Diagnostic imaging of the central airways has evolved from being the blind spot in the chest radiograph to involving complex imaging techniques in a region of great pathologic diversity. Just as diagnostic imaging has become more sophisticated, so have the techniques now available for the surgical treatment of these disorders. Close cooperation and consultation between the clinical and diagnostic teams will remain the hallmark of optimal patient care in this sophisticated diagnostic and treatment environment.
Adult↗
Quality control assessment for the PCR diagnosis of tick-borne encephalitis virus infections.
BACKGROUND: Reverse transcriptase-polymerase chain reaction (RT-PCR) is an efficient method for the early detection of tick-borne encephalitis virus (TBEV) RNA in blood and serum samples taken prior to the appearance of antibodies. Improved diagnostics are critical for optimally detecting and managing TBE infections and quality control measures are therefore essential. OBJECTIVE: To assess the diagnostic quality of laboratories by performing an external quality assurance (EQA) programme for the molecular detection of TBE infections. STUDY DESIGN: A panel of 12 prepared human plasma samples were distributed and tested for the presence of TBEV-specific RNA. The panel comprised eight samples spiked with different TBEV strains of European, Siberian and Far Eastern subtypes, and included a 10-fold dilution series. Two specificity controls consisted of a sample with Louping ill virus (LIV) and a sample with a pool of four other flaviviruses, and two negative control samples were further included. RESULTS: Twenty-three laboratories from 16 European and 2 non-European countries participated in this EQA programme. Only two participants correctly identified all samples. Nine laboratories correctly identified 75.0-91.7% of the samples; seven laboratories correctly identified 54.5-66.7% and five laboratories correctly identified < or =50%. CONCLUSIONS: The EQA programme provides information on the quality of the RT-PCR methods used by the participating laboratories and indicates that most of these need to improve sensitivity and specificity of their molecular assays for TBEV.
Encephalitis Viruses, Tick-Borne↗
Guidelines for point-of-care testing. Improving patient outcomes.
Whole-blood biosensors and point-of-care testing created a unique paradigm in medical diagnostics in the 1980s, when liver and heart transplant centers, as well as operating rooms and other critical care areas implemented whole-blood analysis to provide rapid test results in 2 to 5 minutes. Rising expectations, patient-focused hospitals, and managed care intensify the need for immediate decisions at the point of care. The guidelines promote consensus priorities, multidisciplinary teamwork, fiscal coordination, and collaborative practice during this phase of rapid change. Four primary principles and accompanying guideline objectives are optimization (patient outcomes, medical linkages, integrated diagnostic synthesis, therapeutic turnaround time, test clusters, and critical limits), hybridization (strategic modalities, economic effectiveness, and testing --> monitoring), quality (quality improvement, clinical performance, risk reduction and academics and accreditation), and consistency (results communication and error minimization, and reference intervals and standardization). Whole-blood analysis and point-of-care testing help facilitate temporal optimization, optimize diagnostic-therapeutic processes, and improve patient outcomes in critical care.
Blood Chemical Analysis↗
[Mild cognitive impairments in the elderly: a critical review].
The aging of the population leads to increased awareness of problems associated with age-related degenerative dementias. Given that these dementias are progressive in onset, many clinicians and researchers have proposed criteria that allow for the identification of older subjects manifesting cognitive impairment, but not responding to the criteria for dementia. Our knowledge of subjects with mild cognitive impairment is limited; it is, however, established that they present a high risk of developing dementia in the future. Although it is essential to increase our comprehension of their cognitive and functional decline, the study of subjects presenting mild cognitive impairment is compromised due to the existence of numerous non-converging classifications. The goal of the present article is to conduct a critical review of the different classifications of mild cognitive impairment in the elderly in order to attempt to identify the optimal criteria, allowing for a distinction to be made between subjects with mild cognitive impairment, who remain in a stable state and those whose condition evolves to a dementia. These criteria may enable us to describe a homogenuous group of individuals presenting with different rates of dementia risk factors. We present the classifications most frequently used in clinical and research settings. After listing them according to categorial, clinical or dimensional approaches, we performed a critical analysis for each one. Depending on the diagnostic criteria applied, major variations are revealed for the prevalence of cognitive impairment and the incidence of dementia. They are explained by methodological and theoretical shortcomings that we point out and discuss (e.g., reference group, lack of diagnostic criteria or exclusion criteria, high level of subjectivity). Beyond these criticisms, we discuss the challenges to be met in order to reach the optimal identification criteria. Notably, the impact of mild cognitive impairment on daily living activities should be tested with the use of more specific questionnaires/tasks. The goal of the objective definition of cognitive impairment should be to minimize subjectivity in the diagnosis. It is also suggested that sensitive cognitive measures would be used on all aspects of cognition, while recognizing and taking into account all confounding factors (e.g., age, education level). Given the nature and consequences of mild cognitive impairment, an inter-disciplinary approach is suggested (e.g., neurobiological, psychiatric, and genetic cues). A consensus on optimal diagnostic criteria is essential to propose cognitive and pharmacological treatments for the effective prevention of ementia.
Age Factors↗
The area under the ROC curve and its competitors.
The area under the receiver operating characteristic (ROC) curve is a popular measure of the power of a (two-disease) diagnostic test, but it is shown here to be an inconsistent criterion: tests of indistinguishable clinical impacts may have different areas. A class of diagnosticity measures (DMs) of proven optimality is proposed instead. Once a regret(-like) measure of diagnostic uncertainty is agreed upon, the associated DM is uniquely defined and, indeed, calculable from the ROC curve configuration. Two scaled variants of the ROC are introduced and used to advantage in the analysis. They may also be helpful to students of medical decision making.
Decision Theory↗
A cost effective approach to the investigation of syncope: relative merit of different diagnostic strategies.
OBJECTIVE: To compare the cost effectiveness of a conventional diagnostic work-up with that of several different diagnostic cascades for the investigation of undifferentiated syncope. DESIGN: A MEDLINE search established a weighted estimate of diagnostic yield for several diagnostic investigations. 'High-end' and 'low-end' cost estimates were calculated for these investigations based on figures from four representative Canadian tertiary care centres in four different provinces. Several diagnostic models were applied to a hypothetical cohort of 100 patients with undifferentiated syncope. RESULTS: The conventional diagnostic cascade resulted in a diagnosis in 85% of patients, at a cost per diagnosis of $467 to $959. The optimal model increased the diagnostic yield to 98.9%, at a cost of $460 to $1043 per diagnosed patient. CONCLUSION: A combination of new technology and selective use of investigations has the potential to raise diagnostic yield without appreciably increasing cost per diagnosis.
Algorithms↗
Diagnosis of occlusal caries: Part I. Conventional methods.
Accurate diagnosis of the presence or absence of disease is a fundamental requirement in health care. The diagnosis of non-overt occlusal decay is challenging and can be highly subjective, and its inherent uncertainties can lead to widely differing treatment decisions. The development of more sensitive, specific and reproducible diagnostic tools for occlusal surfaces would contribute greatly to more precise planning of preventive and operative therapy. The purpose of this 2-part paper is to review current knowledge concerning conventional and new diagnostic methods for occlusal caries. Part I looks at established diagnostic methods for occlusal surfaces. Conventional visual, tactile and radiographic examinations provide less-than-ideal diagnostic sensitivity. Neither fissure discolouration (black or brown) nor the use of an explorer has been shown to improve diagnostic accuracy. However, the combination of careful visual examination with optimal radiographic examination affords better diagnostic performance. The best visual indicators involve precise features associated with the presence of disease, such as opaque fissure demineralization and the presence and extent of localized breakdown of the enamel. For best results, teeth should be clean, thoroughly dry and well illuminated. Part II will examine new and emerging technologies, including the DIAGNOdent laser fluorescence device, which are being developed for the diagnosis of occlusal decay.
Dental Caries↗
[Community-acquired pneumonia in the elderly: the peculiarities of the clinical picture, diagnosis and treatment].
The article presents the results of studying the peculiarities of the clinical picture, diagnosis and treatment for community-acquired pneumonia in the elderly in view of the interaction of combined pathology of respiratory, cardiovascular and urological systems in order to optimize medical-and-diagnostic support of the above-mentioned category of patients in conditions of the pulmonology department of versatile educational establishment. Optimization of all-round inspection of the sick with pneumonia in the advanced age at an initial stage of treatment in conditions of the pulmonology department so as to reveal the aggravation of internal bodies' combined diseases will allow making early correction of aetiotropic, pathogenetic and symptomatic combined pathology therapy available, which reduces the terms of staying at hospital without damage of diagnosis and treatment.
Adolescent↗
Priority of test locations for automated perimetry in glaucoma.
PURPOSE: Static threshold automated perimetry is a demanding test which can be tiring for some patients. The authors investigate how to optimize early stages of the test which can shorten examination time and improve performance. The effectiveness of measuring every point twice to improve diagnostic precision (proportion of eyes correctly diagnosed as normal or glaucomatous) also was evaluated. METHODS: The authors evaluated the relative contributions of individual test locations to the sensitivity and specificity of static threshold perimetry. One hundred visual fields (Octopus Program G1) of 100 patients with open-angle glaucoma and early glaucomatous defects were used to rank the most frequently defective test locations. This sequence was modified so that highly correlated points were not ranked together. The sensitivities and specificities of the defined sequence of test presentations were then measured in a separate database of 70 normal controls and 70 patients with early glaucomatous visual field defects. RESULTS: Sensitivity and specificity were, respectively, 80% and 80% after 12 locations, 89% and 89% after 26 locations, and 97% and 99% after all 59 test locations. The information obtained with the first phase alone approximates that of both phases. CONCLUSION: Staging of locations tested with automated perimetry in glaucoma may be a valuable method to reduce examination time, minimize fatigue effects, and optimize diagnostic information. Retesting every point does not improve diagnostic precision.
Glaucoma, Open-Angle↗
A cost-minimization analysis of alternative strategies in diagnosing pancreatic cancer.
BACKGROUND: Several modalities currently exist for tissue confirmation of suspected pancreatic cancer prior to therapy. Since there is a paucity of cost-minimization studies comparing these different biopsy modalities, we analyzed costs and examined effectiveness of four alternative strategies for diagnosing pancreatic cancer. METHODS: A decision analysis model of patients with suspected pancreatic cancer was constructed. We analyzed costs, failure rate, testing characteristics, and complication rates of four commonly employed diagnostic modalities: 1) computerized tomography or ultrasound-guided fine-needle aspiration (CT/US-FNA), 2) endoscopic retrograde cholangiopancreatography with brushings (ERCP-B), 3) Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA), and 4) laparoscopic surgical biopsy. If the first attempt with a particular modality failed, a different modality was employed to identify the most preferable secondary biopsy strategy. RESULTS: This analysis identifies EUS-FNA as the preferred initial modality for the diagnosis of pancreatic cancer. Resultant expected costs and strategies in decreasing optimality include: 1) EUS-FNA (1,405 dollars), 2) ERCP-B (1,432 dollars), 3) CT/US-FNA (3,682 dollars), and 4) surgery (17,711 dollars). If a patient presents with obstructive jaundice, decision analysis modeling resulted in a total expected costs of 1,970 dollars if ERCP-B is successful at the time of biliary stent placement. Additional analyses to identify the preferred follow-up modality after a failed alternative method showed that EUS-FNA is the preferred secondary modality if any of the other three modalities failed first, in both the setting of and absence of obstructive jaundice. One- and two-way sensitivity analysis of the variables shows unchanged results over an acceptable range. CONCLUSIONS: This cost-minimization study illustrates that EUS-FNA is the best initial and the preferred secondary alternative method for the diagnosis of suspected pancreatic cancer. In addition to local expertise and availability, costs and diagnostic yield should be considered when choosing an optimal diagnostic strategy.
Biopsy↗
Duplex ultrasound criteria for the identification of carotid stenosis should be laboratory specific.
BACKGROUND AND PURPOSE: Published criteria for the determination of carotid stenosis have been widely applied by vascular laboratories. We compared two vascular laboratories and their duplex ultrasound (DU) machines in terms of their overall diagnostic performance and the optimal criteria to identify patients who have a 70% to 99% stenosis of the internal carotid artery. METHODS: Measurements of stenosis by DU and angiography were compared for 123 carotid arteries (60 arteries, laboratory A; 63 arteries, laboratory B). Receiver operating characteristic (ROC) curves were created, and the areas under the ROC curves and the optimal criteria for determining a 70% to 99% stenosis were compared. Multiple regression analysis was used to measure the effect of laboratory on the relationship between angiographic stenosis and DU velocity parameters. RESULTS: Areas under the ROC curves were similar for both laboratories (0.89 to 0.90, laboratory A; 0.90 to 0.92, laboratory B). However, the optimal criterion for the identification of a 70% to 99% carotid stenosis was different for each laboratory. For most velocity parameters, based on regression analyses, the predicted percent angiographic stenosis for laboratory A was significantly greater than that for laboratory B. In addition, performance differed between the laboratories when established criteria from the literature were applied. CONCLUSIONS: Two vascular laboratories with similar diagnostic accuracy by ROC analysis have markedly different "optimal" DU criteria. For a given angiographic stenosis, velocities in one laboratory were consistently greater than those in the other laboratory. Laboratory-specific criteria rather than published criteria should be used to identify patients with internal carotid artery stenoses.
Aged↗
Colon polyps and cancer.
The superiority of colonoscopy to double-contrast barium enema in detecting neoplasia was finally demonstrated in 2000, but colonoscopic surveillance programs are still based on short-term observations and are mostly inadequate, despite the prospective design of the trials. The evaluation of the diagnostic accuracy of virtual colonoscopy is in progress, but its appropriate place in clinical gastroenterology has not yet been defined. There is now solid evidence that screening with fecal occult blood testing (FOBT) not only reduces the mortality from colorectal cancer, but also that the incidence is substantially reduced after removal of the precursor lesions. Feasibility studies for population screening are ongoing. A once-only sigmoidoscopy will probably not be an optimal method of screening, but may be added to a program with FOBT. Molecular stool screening is attractive, but still experimental. Colonoscopy is not attractive as an initial screening instrument, despite its high diagnostic accuracy, and should only be used for screening high-risk individuals. Genetic methods are playing an increasing role in defining prognostic markers for intestinal neoplasia, and it is recommended that information services should be established for the public. Chemopreventive studies have revealed that dietary fiber supplementation may not reduce the risk of adenomas; the opposite seems to be true for aspirin and non-aspirin NSAIDs, which are active in the early phase of carcinogenesis. New techniques for optimizing diagnostic and therapeutic colonoscopy have been introduced.
Colonic Neoplasms↗
[Diagnostic workup for indicating the presence of pulmonary embolism: still not optimal].
Despite numerous studies, which have documented that only 25-30% of patients presenting with suspected pulmonary embolism actually have emboli, the tendency to overdiagnose and overtreat this disease remains. Findings from the study by Kamphuisen et al. (2002:2083-7) in consecutive patients with suspected pulmonary embolism (non-diagnostic ventilation perfusion scan) in a general training hospital, confirm that with an optimal collaboration between pulmonologists, internists, radiologists and nuclear specialists, who follow a previously agreed diagnostic work-up, the proportion of patients without a proper confirmation or exclusion of pulmonary embolism can be minimized. However, a more promising solution to the problem might be the implementation of a strategy consisting of anamnestic features, measurement of the D-dimer concentration in plasma, and spiral CT.
Angiography↗
Direct access to equivocal approximal carious lesions.
Approximal carious lesions provide unique diagnostic and restorative challenges for clinicians interested in conserving tooth structure. Direct access reduces diagnostic doubt and facilitates optimal restorative management. The direct access afforded to newly erupted posterior teeth provides an incomparable window of opportunity to the proximal surfaces. Optimal management is limited to the interval between exfoliation and eruption, because access is lost once the erupting adjacent permanent teeth come into contact. Diagnostic and restorative strategies accomplished after creation of direct access to approximal lesions are discussed.
Adult↗