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PubMed2000

Longitudinal study of the influence of life events and personality status on diagnostic change in three neurotic disorders.

It has been known for many years that diagnosis within the neurotic spectrum of disorders is temporally unstable and also that life events can be major precipitants of change in symptoms. Reasons for this instability could include inherent inadequacy of current diagnostic practice, the influence of life events as an agent of diagnostic shift, and an innate course of disorder with features dependent on the stage at which disorder presents (e.g., development of panic to agoraphobia). These possibilities were examined in a prospective study that was initially a randomised controlled trial. Two hundred ten patients recruited from primary care psychiatric clinics with DSM-III diagnosed dysthymic, generalised anxiety, and panic disorders were randomly allocated to either drug treatment (mainly antidepressants), cognitive-behaviour therapy, or self-help therapy over a 2 year period, irrespective of original diagnosis. Life events were recorded by using a standard procedure over the period 6 months before starting treatment and at five occasions over 2 years; 181 (86%) of the patients had follow-up data and 76% maintained compliance with the original treatment allocated over the 2 years; and 155 of the 181 patients (86%) had at least one diagnostic change in this period. There was no difference in the number of diagnostic changes between the three original diagnostic groups, but dysthymic disorder changed more frequently to major depressive episode than did GAD or panic disorder (20; 11; 12) (%) and panic disorder changed more frequently to agoraphobia (with or without panic) than did dysthymia or GAD (18; 8; 6) (%). There was no relationship between loss events and depressive diagnoses or between addition events and anxiety diagnoses, but greater numbers of conflict events were associated with diagnostic change. More life events were associated with the flamboyant and dependent personality disorders, reinforcing other evidence that many life events are internally generated by personality characteristics and cannot be regarded as truly independent.

Cognitive Behavioral Therapy↗
PubMed2000

Absence of thyroid stunning after diagnostic whole-body scanning with 185 MBq 131I.

UNLABELLED: There has been recent controversy regarding the optimal protocol for imaging and ablation of post-thyroidectomy patients. Several authors have suggested that a scanning dose of 185-370 MBq (5-10 mCi) (131)I may be capable of producing a stunning effect on thyroid tissue that may interfere with the uptake and efficacy of the subsequent ablation dose of radioiodine. The purpose of this study was to determine whether a 185-MBq (5 mCi) diagnostic dose of (131)I produces a visually apparent stunning effect 72 h before (131)I ablation therapy. METHODS: One hundred twenty-two consecutive post-thyroidectomy patients for differentiated thyroid carcinoma received a 185-MBq (5 mCi) diagnostic dose of (131)I followed by a whole-body diagnostic scan at 72 h. On the same day the diagnostic scan was completed, the patient was admitted to the hospital and received an (131)I ablation therapy dose of 5550 MBq (150 mCi) in most cases. A postablation, whole-body scan was obtained at 72 h and compared with the previous diagnostic scan for any visual evidence of stunning. RESULTS: No cases of visually apparent thyroid stunning were observed on any of the postablation scans with regard to the number of (131)I foci identified or the relative intensity of (131)I uptake seen. CONCLUSION: Diagnostic whole-body scanning can be performed effectively with a 185-MBq (5 mCi) dose of (131)I 72 h before radioiodine ablation without concern for thyroid stunning.

Adolescent↗
PubMed2001

Installation and experience of an automatic scheduling system for multiple diagnostic examinations: in search of maximum utilization of regional health care resources.

We installed a scheduling system that optimally schedules multiple appointments for various diagnostic examinations for a patient based on patient characteristics, disease characteristics and conditions, characteristics of diagnostic examinations, possible interactions between two successive examinations, and features and availability of diagnostic equipment. The system consists of four client terminals, 12 laboratory terminals, and one server. After the run-in period, the system started operation in July 2000. A total of 14353 examinations involving 11447 patients were managed over 7 months. On average, approximately 82 patients per day underwent approximately 103 examinations. On average, 16.1 patients a day requested 2 or more examinations in a scheduling session (approx. 2.3 examinations/patient; maximum 5 examinations for a single patient). After reading the request sheet(s) (OCR sheet(s)), suggested time/date slots of examination(s) were displayed on the client terminal within 10 seconds. The average time required for a patient to establish his or her schedule was approximately 2 minutes. Thus, the system greatly mitigated the load on health care professionals in scheduling appointments for examinations. In general, patients had a positive impression of the system. Furthermore, networking through these health care facilities and implementing this automatic scheduling system as a centralized appointment system can easily establish a "virtual diagnostic examination center" that fully utilizes the diagnostic equipment and staff available at community health care facilities. We estimate that approximately 30% of the diagnostic examinations in a health care facility can be referred to another facility in this cooperative system.

Algorithms↗
PubMedDate not supplied

Pneumothorax after diagnostic laparoscopy.

Here we want to call laparoscopist's attention to pneumothorax after diagnostic laparoscopy. Diagnostic laparoscopy has less complications, compared with laparoscopic surgery. In our experience, only one case (0.04%) developed pneumothorax during routine diagnostic laparoscopic procedure. This complication is presented in a 50-year-old female. She complained of dyspnea just after the decrease of intraabdominal pressure and deflation of intraperitoneal gas. The chest roentgenogram showed a right pneumothorax, and a right chest tube was inserted with immediate relief of tension. Pneumothorax during diagnostic laparoscopy is relatively rare but a major complication; Medline literature research showed six reported cases of pneumothorax after diagnostic laparoscopy from 1983 to 1998 including our case. The etiology was idiopathy in 5 and diaphragmatic injury in 1. Hypotension, elevation of inspiratory pressure, dyspnea, a decrease in systemic oxygen saturation, and loss of breath sounds suggest tension pneumothorax. The clinical condition of the patients improved rapidly because of the easy diffusion of the gas used in laparoscopy. Diagnostic laparoscopists should be aware of this complication and treat ventilatory problems.

Biopsy↗
PubMed2002

[Results from a general training hospital for the implementation of a diagnostic workup for pulmonary embolism according to the Dutch Institute for Health Care Improvement].

OBJECTIVE: To evaluate the active implementation of the Dutch Institute for Healthcare Improvement's guideline for the diagnostic work-up for pulmonary embolism in a general training hospital, and to analyse reasons for not following the guideline strategy. DESIGN: Partly retrospective and partly prospective. METHOD: The diagnostic strategy was analysed for all consecutive patients with clinically suspected pulmonary embolism who underwent a perfusion lung scintigraphy. The extent to which the guideline was followed was investigated in the year before (July 1999-June 2000; n = 384) and the year after (July 2000-June 2001; n = 380) its active implementation. The possible reasons for not completing the strategy in the prospective cohort of the study were also analysed. RESULTS: Following a non-high-probability perfusion-ventilation scan, the guideline was completed in 23/117 (20%) patients prior to the implementation and in 50/109 (46%) patients after the implementation of the guideline. In 27% and 60%, respectively, an additional duplex ultrasound of the legs was made to check for deep vein thrombosis, and in 65% and 70% respectively, pulmonary angiography was performed after a normal ultrasound result. The main reasons for not following the diagnostic work-up included low clinical probability (41%, without a proper alternative diagnosis), an alternative diagnosis (36%; pneumonia, heart failure, malignancy) and a reluctance to perform angiography. The mean age of the patients for whom the guideline was completed was lower (51 years) compared to patients for whom the guideline was not followed (65 years; p < 0.001). The risk of not completing the diagnostic workup in accordance with the guideline was six-fold higher for patients > or = 80 years compared with patients < 40 years of age, whereas an alternative diagnosis was not more prevalent in patients > or = 65 years. CONCLUSION: Although active implementation of the guideline-based diagnostic work-up for pulmonary embolism increased the number of adequate diagnoses, the diagnostic work-up was not completed in half of the patients with inconclusive lung scans. The main reasons for this were the advanced age of the patient, alternative diagnoses, and a reluctance to perform pulmonary angiography.

Adult↗
PubMed2003

[Diagnostic work-up of mediastinal lymph nodes by trans-oesophageal endoscopic ultrasound and fine-needle aspiration].

INTRODUCTION: Trans-oesophageal endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is a diagnostic technique allowing direct sampling of posterior mediastinum lymph nodes under continuous visual control. Main indications of this technique include the diagnostic work-up of isolated enlarged mediastinal lymph nodes or mediastinal lymph nodes associated with intrapulmonary lesions of unknown histology. METHODS: Retrospective study of a series of consecutive patients who underwent EUS with FNA for diagnostic work-up of mediastinal lymph nodes in two department of respiratory diseases in northern France. RESULTS: Nineteen patients were studied. Twenty-nine lymph nodes in the 5, 7 and 8 (ATS classification) areas were sampled. Mean mediastinal lymph node size was 24.3 mm (4-50 mm). The diagnostic yield was 68.7%. The sensitivity and specificity for malignancy were 91.7% and 100% respectively. There were no complications. CONCLUSION: Our study suggests that EUS with FNA is a safe and reliable diagnostic tool that could be incorporated into the diagnostic work-up of mediastinal lymphadenopathy.

Adult↗
PubMed2003

[Diagnostic approach in mechanical jaundice, complicated by purulent cholangitis].

Up-to-date high-informative non-invasive diagnostic methods were used in 54 patients with obstructive jaundice (OJ) complicated by purulent cholangitis (PC). Treatment-diagnostic algorithm can to improve results of diagnosis. This algorithm is the following: ultrasonic examination as a screening method; if a case of jaundice is unclear and obturation is prolonged magnetic-resonance tomography and magnetic-resonance cholangiopancreaticography are carried out; in block of a distal part of the common bile duct--spiral computed tomography with bolus amplification and duodenoscopy. Invasive diagnostic methods--endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography (PTCG) are performed in buit indications in possibility to perform lithextraction and effective endoscopic decompression or in the tumor of Vater's papilla in case of low block. PTCG is used in high block and finished by percutaneous transhepatic bile outflow. General diagnostic efficacy of the complex in OJ was 97.8%. Diagnostic algorithm permitted us to make diagnosis and to start treatment in 85% during 1-2 days after hospitalization. Bile ducts decompression as a main stage of PC treatment was performed in the first 2 days after hospitalization. Diagnostic quest was performed at the same time with therapy after detoxication and correction of hemostasis disturbances.

Cholangitis↗
PubMed2003

[Diagnostic value of heart fatty-acid binding protein in early hospitalized patients with non ST elevation acute coronary syndrome].

BACKGROUND: Heart fatty-acid-binding protein (FABP) is supposed to be the most sensitive biomarker of myocardial necrosis in patients with Q-wave myocardial infarction (MI) and non-diagnostic ECG during first hours after onset of symptoms. However, diagnostic value of FABP in patients with non-ST elevation acute coronary syndrome (NSTEACS) is not well established. AIM: To elucidate diagnostic value of FABP in patients with NSTEACS hospitalized within time interval considered to be too early for a majority of biochemical tests. MATERIAL AND METHODS: FABP levels were measured by immunofluorometry (HyTest, Finland) in 44 patients (26 men, mean age 69+/-8.9 years) at admission within 6 hours (median - 2 h) from onset of index attack of angina and in 6, 12, 24 hours after onset of pain. Cut off FABP level was 12 ng/ml. Serum cardiac troponin I was measured for diagnosis of MI on admission and twice during first 24 hours of hospital stay. Cut off TnI level was 0.4 ng/ml. RESULTS: Acute MI was diagnosed by TnI above cut off in 31 patients (70.5%). There were no new-Q-wave MIs. Average ratio of observed serum FABP level to diagnostic cut off value on admission and in 6, 12, 24 hours after onset of pain was higher in patients with MI than in patients with unstable angina (1.01, 1.53, 0.81, 0.66 and 0.78, 0.51, 0.65, 0.56, respectively). The difference was maximally significant in 6 hours after onset of pain (p=0.018). Among patients with MI admission FABP compared with admission TnI more frequently exceeded diagnostic level (in 18 vs 9 patients, respectively, p=0.009). Sensitivity and specificity of admission levels of FABP and TnI for diagnosis of MI were 58 and 85%, 29% and 100%, respectively. CONCLUSION: In patients with NSTEACS during first 6 hours after pain onset FABP compared with TnI has greater sensitivity for detection of MI and sufficient specificity. FABP can be used as additional diagnostic tool for MI detection in early admitted patients with NSTEACS.

Acute Disease↗
PubMed1992

A comparison of diagnostic criteria for neuroleptic malignant syndrome.

BACKGROUND: A variety of diagnostic criteria for neuroleptic malignant syndrome (NMS) have been used in clinical studies of this disorder, but it is not known if different criteria consistently identify NMS. This study examines agreement between three frequently used sets of diagnostic criteria in a series of possible NMS episodes. METHOD: All clinically suspected NMS episodes occurring at a large tertiary psychiatric facility during a 6-year period were evaluated by three different sets of diagnostic criteria. Agreement among these criteria was quantified statistically by means of the kappa and intraclass correlation coefficients. RESULTS: The NMS diagnostic criteria examined generally demonstrated only fair agreement with one another in the diagnosis of NMS. Agreement was best among these criteria when the "probable" category was employed. A complex interaction involving both definition and structure of individual diagnostic criteria and designation of criteria as major or minor appears to contribute to these findings. CONCLUSION: The published diagnostic criteria used in this study do not consistently identify NMS episodes and demonstrate different thresholds for assigning this diagnosis. These differences are not due solely to different definitions of individual criteria (e.g., fever). Possible implications of these findings for clinical practice and research are discussed.

Adult↗
PubMed2003

[New variants of diagnostic procedures and therapeutic methods in insect venom allergy].

Hymenoptera venom allergy (HVA) is a typical IgE-dependent allergy. Its diagnosis includes confirmation of the presence of specific IgE antibodies to venom allergens (vsIgE), and its treatment is based on developing of immunotolerance (venom immunotherapy, VIT). In most cases of sting anaphylaxis, vsIgE can be found, in some, however, the antibodies are undetectable, in spite of systemic reaction to venom, which may be due to low specificity of diagnostic methods. Diagnostic methods might be improved by the use of recombinant allergens which, being "uncontaminated" by other venom constituents, allow for a precise setup of "individual allergogram." A diagnostic novelty is the tryptase serum level assay that is capable of confirming ex-post anaphylaxis and coincidence of mastocytosis. The diagnostic procedures applied in venom allergy make possible only to prove the existence of allergy while it is impossible to estimate, on their basis, the risk of development and intensification of future reactions. New diagnostic concept that could supplement the imperfect diagnostic armamentarium is still lacking. Clinical practice has proven that VIT is a very effective method of protection of patients with IgE-dependent wasp-sting anaphylaxis, but both the effectiveness and safety of VIT in patients allergic to bee venom are not optimal. The future of VIT is the use of modified, recombinant allergens or their peptide fragments, but clinical data on their effectiveness are unavailable as yet. The safety of VIT can be increased by means of introducing premedication with antihistamines.

Animals↗
PubMedDate not supplied

[Fever of unknown origin in Romania. II. Diagnostic Procedures. Prospective multicenter study of 164 patients].

BACKGROUND: The Diagnostic workup of patients with fever of unknown origin is a challenge, due to the great number of possible etiologies. After we studied the etiologic spectrum of fever of unknown origin in Romania, we tried to evaluate the diagnostic procedures used and their efficiency. METHODS: A multicenter cohort study of two years, with another two years of follow-up was carried out on 164 consecutive patients who met the classic, modified criteria of fever of unknown origin. We used a standardised diagnostic protocol. MAIN OUTCOME MEASURED: The role of every diagnostic procedure in establishing the final diagnosis. RESULTS: The diagnosis was made by microbiology and serology in 41 cases (25%), by histopathology in 22 cases (18%), with the help of imaging techniques in 30 cases (1.3%), based on the clinical evolution and response to treatment in 54 cases (33%) and by other methods in 12 cases (7.3%). The abdomino-pelvic ultrasonography had a sensitivity of 60%, a specificity of 70%, a positive likelihood ratio of 2.02 and a negative likelihood ratio of 0.57, while the scanner had a sensitivity of 81%, a specificity of 64%, a positive likelihood ratio of 2.23 and a negative likelihood ratio of 0.29. CONCLUSIONS: Of all the diagnostic procedures used, none had a good sensitivity/specificity. The clinical evolution and the treatment response had an important role in the diagnostic workup.

Algorithms↗
PubMed2004

Diagnostic value of endobronchial ultrasound-guided transbronchial lung biopsy in peripheral lung cancers.

BACKGROUND AND PURPOSE: The diagnostic yield of flexible fiberoptic bronchoscopy for peripheral lung cancers is still limited. This study evaluated whether endobronchial ultrasound (EBUS) may help localize and improve the diagnostic yield of bronchoscopic transbronchial lung biopsy in peripheral lung cancer. METHODS: Between July 2001 and May 2002, 218 patients received transbronchial lung biopsy during bronchoscopic examinations with (n = 122) or without EBUS guidance (n = 96) and had the presence of peripheral lung cancers subsequently confirmed. These 218 patients were included in this retrospective analysis. RESULTS: The diagnostic accuracy of transbronchial lung biopsy was significantly increased under EBUS guidance for small cell carcinoma (65.6%) and for non-small cell carcinoma (42.7%) [p < 0.01]. For peripheral lung cancer either smaller than 2 cm or larger than 2 cm, the diagnostic yield of transbronchial lung biopsy with EBUS guidance was significantly higher (66.0% vs 42.3%, p < 0.002 for mass larger than 2 cm; 54.5% vs 0%, p < 0.04 for mass smaller than 2 cm). EBUS provided a better diagnostic yield (p = 0.014; odds ratio, 0.219) for lesions localized at the left upper lobe, which are generally thought to be more difficult to approach through bronchoscopy. There were no significant differences in complications between patients who underwent bronchoscopy with or without EBUS guidance. CONCLUSIONS: Under EBUS guidance, the diagnostic yield of transbronchial lung biopsy in peripheral lung cancer by bronchoscopic examination was significantly improved without difference in the complication rate.

Adult↗
PubMed2004

A closer look at diagnosis in clinical dental practice: part 1. Reliability, validity, specificity and sensitivity of diagnostic procedures.

Dentists are involved in diagnosing disease in every aspect of their clinical practice. A range of tests, systems, guides and equipment--which can be generally referred to as diagnostic procedures--are available to aid in diagnostic decision making. In this era of evidence-based dentistry, and given the increasing demand for diagnostic accuracy and properly targeted health care, it is important to assess the value of such diagnostic procedures. Doing so allows dentists to weight appropriately the information these procedures supply, to purchase new equipment if it proves more reliable than existing equipment or even to discard a commonly used procedure if it is shown to be unreliable. This article, the first in a 6-part series, defines several concepts used to express the usefulness of diagnostic procedures, including reliability and validity, and describes some of their operating characteristics (statistical measures of performance), in particular, specificity and sensitivity. Subsequent articles in the series will discuss the value of diagnostic procedures used in daily dental practice and will compare today's most innovative procedures with established methods.

Decision Support Techniques↗
PubMed2004

[Analysis of the status of diagnosis of acute pulmonary embolism and a study of further strategy to improve the diagnostic level].

OBJECTIVE: To analyze the present status of diagnosis of pulmonary embolism (PE) by analyzing the clinical data of patients admitted during last 10 years to our hospital, in order to look for a significant diagnostic strategy to improve the diagnostic level. METHODS: The data of patients diagnosed to have PE in last 10 years were analyzed. In the last 5 months, the patients suspected to have PE were diagnosed by a comprehensive approach including clinical manifestations, lung scan and/or spirals computer tomography (SCT) in our emergency department. RESULTS: The diagnostic rate, the final diagnostic rate within 3 days and the diagnostic rate by lung scan or/and SCT were all higher in the last 3 months than ever. The proportions of angiograms and the overall 3-month PE risk were 2.8% and 0. CONCLUSION: The comprehensive approach which includes clinical manifestations, lung scan and/or SCT can obviously improve the diagnostic level of PE.

Adolescent↗
PubMed2002

A web-based central diagnostic data repository.

A central repository for diagnostic information about individual patients was created as a service to diagnostic laboratories participating in the Compentence Network for Acute and Chronic Leukemias in order to support health care delivery to patients suffering from leukemia. During the diagnostic phase several specialised laboratories perform different assays on samples from the same patient. The use of these assays in the diagnostic process and during the treatment phase may be improved in terms of both rapid delivery and cost if any one laboratory is aware of preliminary or final results from the assay carried out in other laboratories. In order to support a more efficient communication of these results, a central diagnostic data repository (CDDR) was created and web-based user interface was developed. Currently, the CDDR maintains documents in the form of portable document format (PDF) files. Several other formats are accepted and converted automatically upon entry. Patient identification is accomplished by pseudonym rather than proper name and the data is held on the CDDR for a limited time interval to accommodate the stringent privacy regulations in Germany. The principle operation of a CDDR may also be applied to the diagnostic or therapeutic process of other diseases.

Acute Disease↗
PubMed2005

Prospective study on diagnostic strategies in osteochondral lesions of the talus. Is MRI superior to helical CT?

Our aim in this prospective study was to determine the best diagnostic method for discriminating between patients with and without osteochondral lesions of the talus, with special relevance to the value of MRI compared with the new technique of multidetector helical CT. We compared the diagnostic value of history, physical examination and standard radiography, a 4 cm heel-rise view, helical CT, MRI, and diagnostic arthroscopy for simultaneous detection or exclusion of osteochondral lesions of the talus. A consecutive series of 103 patients (104 ankles) with chronic ankle pain was included in this study. Of these, 29 with 35 osteochondral lesions were identified. Twenty-seven lesions were located in the talus. Our findings showed that helical CT, MRI and diagnostic arthroscopy were significantly better than history, physical examination and standard radiography for detecting or excluding an osteochondral lesion. Also, MRI and diagnostic arthroscopy performed better than a mortise view with a 4 cm heel-rise. We did not find a statistically significant difference between helical CT and MRI. Diagnostic arthroscopy did not perform better than helical CT and MRI for detecting or excluding an osteochondral lesion.

Adolescent↗
PubMed2003

Diagnostic potential of serum matrix metalloproteinase-2 and tissue inhibitor of metalloproteinase-1 as non-invasive markers of hepatic fibrosis in patients with HCV related chronic liver disease.

As chronic liver disease progresses, an imbalance occurs between synthesis and breakdown of extracellular matrix (ECM). Matrix metalloproteinases (MMPs) are involved in degrading ECM while tissue inhibitors of metalloproteinases (TIMPs) prevent their fibrolytic action. In the present study, serum levels of matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of metalloproteinase-1 (TIMP-1) were investigated as non-invasive parameters for the diagnosis of hepatic fibrosis in patients with HCV related chronic liver disease. Their diagnostic potential was evaluated in comparison to hepatic histology and standard liver function tests. A sandwich enzyme immunoassay technique was used to study circulating values of MMP-2 and TIMP-1 in forty-one patients with HCV antibodies in their sera (27 patients with biopsy ascertained chronic hepatitis C and 14 patients with histologically proven liver cirrhosis. Hepatic histology was evaluated using the hepatitis-activity-index according to Ishak et al. (1995), quantifying separately inflammatory activity and fibrosis. Ten healthy individuals were also included in the study as controls. Serum levels of MMP-2 were similar in controls and in chronic hepatitis C patients with (n = 15) and without (n = 12) fibrosis, but increased significantly in cirrhosis. TIMP-1 serum values showed a steady increase from normal controls to chronic hepatitis C without fibrosis, hepatitis C with fibrosis, and cirrhosis. The diagnostic potential of MMP-2 to detect fibrosis was low with a sensitivity of 7% and a diagnostic efficiency of 56%. The diagnostic potential of circulating MMP-2 to detect cirrhosis was higher with a sensitivity of 83% and a specificity of 96% resulting in a diagnostic efficiency of 92%. Serum TIMP-1 values detected fibrosis with a sensitivity of 67% and a specificity of 69% resulting in an efficiency rate of 70%. TIMP-1 values detected cirrhosis with 100% sensitivity but only 75% specificity. The diagnostic potential of circulating TIMP-1 was higher than that of serum ALT, AST or albumin values. In conclusion, serum values of MMP-2 and TIMP-1 are able to detect cirrhosis with a high sensitivity. Moreover, TIMP-1 values can detect fibrosis with comparable efficiency. Regular determinations of both TIMP-1 and MMP-2 in patients with chronic hepatitis C may be used as indicators of increasing fibrosis and the development of cirrhosis.

Adult↗
PubMed2005

[Signals for the initiation of structured diagnostic procedures for depression in primary health care. A practice-relevant evaluation of international guidelines].

BACKGROUND AND OBJECTIVES: Almost every tenth patient of a general practitioner (GP) suffers from depression. However, only 20-25% of these patients are correctly diagnosed during a GP consultation. How do international guidelines for depression in primary care initiate structured diagnostic procedures for depression? METHODS: We performed a systematic literature search on guidelines for the diagnosis of depression with focus on primary care. The quality of the guidelines was rated according to base of evidence, existence of pilot studies, data on implementation, presentation and specificity for primary care settings, and conflict of interest. We also screened whether and how the guidelines comment on the initiation of structured diagnostic procedures for depression. RESULTS: Of the 22 identified guidelines, only 15 address primary care. Only 3 of these were tested in pilot studies, 3 provided data on implementation, 9 were evidence-based. The best guideline (6 out of 6 criteria met) is available in Dutch and established for The Netherlands only. We ranked the guidelines from NHG, VHA and ICSI as very good in terms of methodological quality. They present 'red flags' that initiate structured diagnostic procedures by 'opportunistic screening'. This is followed by the application of a self-rating instrument and an ICD-10-based diagnostic checklist identifying up to 98% of all patients with depression in a given consultation time of 10 minutes on average. CONCLUSION: Based on these criteria a national diagnostic depression guideline should, from our point of view, explicitly include keys such as "red flags" for the initiation of structured diagnostic procedures.

Depressive Disorder↗