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PubMed2002

Predicting which patients can undergo upper endoscopy comfortably without conscious sedation.

BACKGROUND: Eliminating conscious sedation for diagnostic endoscopy may be advantageous for patient safety and cost containment. The aim of this study was to identify and validate independent predictors of a comfortable, technically adequate, unsedated diagnostic upper endoscopy in Canadian patients. METHODS: Patients were consecutively enrolled in a prospective fashion. Data collected on an initial cohort of 268 patients included demographics, a validated anxiety questionnaire, use of sedatives/analgesics, upper endoscopy experience, pharyngeal sensitivity, technical adequacy, and patient assessment of comfort after the procedure. The main outcome measure was "satisfactory upper endoscopy," a composite of optimal scores for patient comfort and technical adequacy. Univariate and multivariate analyses were performed to identify the optimal predictive model of a satisfactory unsedated diagnostic upper endoscopy. Once identified, 68 additional patients were enrolled in a similar fashion from an independent prospective sample for purposes of outcome validation. Multivariate analysis was then repeated with the total cohort (N = 336). These results were then compared for concordance with those obtained from the initial cohort. RESULTS: Among the initial 268 patients (54.3% women; mean age 51 +/- 17 years), 49% were anxious, 15% regularly used sedatives and analgesics, 28% experienced increased pharyngeal sensitivity, and 41% had previously undergone upper endoscopy. Endoscopy was completed in 94.7% of patients without sedation and was technically adequate in 97%, and 80.1% were willing to repeat the procedure under similar conditions. Satisfactory upper endoscopy was achieved in only 59% of the initial cohort. The only independent and significant predictors of a satisfactory upper endoscopy were advancing age (OR 1.2: 95% CI [1.1, 1.4]) and decreased pharyngeal sensitivity (OR 0.5: 95% CI [0.27, 0.93]). Concordance of results were noted after validation with the second cohort. Satisfactory endoscopy was achieved in only 59.5% of the total cohort (n = 336); only 61% reported a comfortable procedural experience. CONCLUSIONS: The proportion of patients who can comfortably undergo technically adequate unsedated upper endoscopy is modest. Unsedated upper endoscopy is most likely to be successful under these procedural conditions in patients of advancing age with decreased pharyngeal sensitivity. The generalizability of these findings to an American population requires further study and may assist in identifying a subgroup of patients in whom it is cost-effective to perform upper endoscopy comfortably without sedation.

Adult↗
PubMed2003

Marginal zone-related neoplasms of splenic and nodal origin.

BACKGROUND: The marginal zone is an anatomically distinct B-cell compartment of lymphoid tissue with an abundant antigenic influx. Among marginal zone-derived lymphomas the WHO classification listed, in addition to extranodal marginal zone B-cell lymphoma of MALT type, two other marginal zone B-cell neoplasms: splenic marginal zone B-cell lymphoma (+/- villous lymphocytes) and nodal marginal zone B-cell lymphoma (+/- monocytoid B cells). These two entities are well characterized histologically, but specific biological markers are lacking. Treatment options are heterogeneous, including a watch-and-wait policy, surgery with or without chemotherapy, purine analogs, and interferon. No prospective studies have been conducted so far. INFORMATION SOURCES: Clinical and pathologic data were reviewed by searches of the published medical literature, including searches in PubMed , important printed publications, and abstracts presented at recent hematology and pathology meetings. STATE OF THE ART: Splenic and nodal marginal zone lymphomas are typical low-grade lymphomas with an indolent course. A subset of patients, however, presents with more aggressive disease and have a shorter survival. Clinical and biological prognostic factors identified in reported series are heterogeneous. The role played by hepatitis C virus (HCV) in marginal zone lymphomas is not fully elucidated, but there is demonstration that eradication of HCV infection in splenic lymphoma with villous lymphocytes causes regression of the lymphoma. The optimal treatment has not yet been identified. Retrospective series, however, show that splenectomy is a good option if symptoms from the presence of spleen enlargement or cytopenias need to be treated. The utility of purine analogs and of anti-CD20 immunotherapy needs to be clarified in prospective trials. PERSPECTIVES: Clinicians and pathologists should co-operate to define stringent diagnostic criteria for these indolent disorders. The optimal therapeutic approach and the role of new treatments need to be assessed in prospective clinical trials.

Humans↗
PubMed2006

Optimal design and experimental investigation of surfactant encapsulated microbubbles.

The diagnostic capabilities of ultrasound imaging can be improved with contrast-specific nonlinear imaging modalities such as harmonic and subharmonic imaging. The nonlinear response of an encapsulated microbubble in an acoustic field is strongly influenced by the shell viscoelastic properties that are determined by the shell composition and thickness. In this paper, the subharmonic performance of a surfactant encapsulated microbubble was optimized by choosing the appropriate composition of shell material with the aid of theoretical model. To study the effects of viscoelastic properties of microbubble shell materials on the nonlinear scattered response of microbubbles, a theoretical model-modified Herring equation for the oscillation of encapsulated microbubbles in the ultrasound field was employed. Based on this model, a computer aided design system was developed to optimize and analyze the acoustic properties, particularly subharmonic responses, of microbubbles under different shell parameters. Furthermore, surfactant encapsulated microbubbles with different viscoelastic properties were prepared by changing the shell composition. Their shell viscoelastic behavior was measured indirectly as dilational modulus of monolayer film formed with surfactant molecular. Moreover, in vitro quantitative acoustic properties measurements of these microbubbles were carried out to evaluate their subharmonic performance. Both of the theoretical simulation and acoustic measurement showed that the surfactant encapsulated microbubbles with good subharmonic properties could be designed and prepared by adjusting the shell material composition with the guide of the computer aided design system.

Capsules↗
PubMed1990

Quality assurance goals in surgical pathology.

The development, implementation, and evaluation of quality assurance programs for surgical pathology present special challenges, largely because of the subjective and consultative nature of the "test result" (the diagnostic report). The primary objective of quality assurance is the generation of an accurate, timely, and clinically relevant diagnostic report based on the interpretation of optimal technical preparations. This article defines the essential elements of a comprehensive quality assurance program for anatomic pathology, reviews the role of accrediting agencies in evaluating quality assurance, and describes the various contributions of professional organizations that may influence the achievement of our quality assurance goals. The major emphasis is on those activities that affect the quality of the "outcome" (completed diagnostic report) in surgical pathology and assess its contribution to patient management.

Accreditation↗
PubMed2003

Recent advances in the diagnosis and classification of inflammatory bowel disease.

The availability of an increasing number of inflammatory bowel disease (IBD)-specific serologic antibodies, the discovery of disease-susceptibility genes, the introduction of pharmacogenetic markers, and the recent application of wireless capsule enteroscopy to the evaluation of patients with IBD are providing new types of information that must be integrated with more traditional IBD paradigms. The challenge facing researchers and clinicians is to determine how to incorporate these potentially clinically relevant insights into our understanding of disease pathogenesis and to define the spectrum of potential applications to the management of patients with IBD. The ultimate diagnostic and predictive value of these tests will likely be optimized when they are applied in combination, rather than individually. As the clinical relevance of this expanding diagnostic armamentarium is defined, it is hoped that these tests will enable clinicians not only to diagnose IBD accurately but also to determine disease patterns prospectively, suggest prognoses, and allow for individualization of therapeutic regimens.

Antibodies, Antineutrophil Cytoplasmic↗
PubMedDate not supplied

Primary aldosteronism: new approaches to diagnosis and management.

Primary aldosteronism remains a diagnostic challenge. Certain immunoassay techniques, simplified diagnostic testing, and the introduction of sensitive imaging techniques have facilitated the diagnosis, but obstacles that remain include a lack of optimal screening methods, low sensitivity and specificity of current diagnostic tests, and a growing number of etiological subgroups. A rational approach to the diagnosis of primary aldosteronism is described, as is the differentiation of the surgically correctable lesion (adenoma) from the other etiological subgroups.

Adenoma↗
PubMed1977

[Comparative filmmammography and xeromammographie (author's transl)].

Under optimal conditions xeromammography and filmmammography can reach about the same diagnostic accuracy. However because of the difficulty to detect xeroradiographically tiny microcalcifications filmmammography is to be considered as the optimal mammographic method provided it is carried out with rotating molybdenum anode and industrial type film for longer processing time.

Breast Diseases↗
PubMed2005

Diagnostic open laparoscopy in the management of advanced ovarian cancer.

OBJECTIVE: Optimal primary cytoreductive surgery (OPCS) plus adjuvant chemotherapy (AC) represents the standard management for patients with advanced ovarian cancer (AOC). Recently, some authors have suggested the use of neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) in patients with unresectable AOC. This study has been started to evaluate the role of diagnostic open laparoscopy (DOL) in predicting who are the best candidates to OPCS. METHODS: All patients newly diagnosed as affected by AOC were submitted to DOL in order to establish the possibility of OPCS considered as no residual tumor left after operation. Patients considered not susceptible of OPCS were submitted to three cycles of NACT, administered every 3 weeks (Carboplatin, targeted AUC = 6, plus paclitaxel 175 mg/mq), followed by IDS and adjuvant chemotherapy. RESULTS: From January 2000 to March 2004, 87 patients with AOC underwent DOL. Fifty-three patients (61%) were judged operable and therefore submitted to primary cytoreductive surgery (Group A). Optimal debulking rate in this group of patients was 96%. Thirty-four patients were judged affected by disease not cytoriducible to absent residual tumor and therefore scheduled for NACT-IDS-AC (Group B). Twenty-five patients were judged with partial clinical response and were therefore scheduled for IDS and AC. Optimal debulking rate (no residual tumor ) in Group B patients was 80%. No major perioperative complications, due to laparoscopy, occurred. All Group B patients received the first cycle of chemotherapy the day after DOL. In 34 patients (39%), an explorative laparotomy was avoided. With a median follow-up of 22 months (range 2-49 months), the proportions surviving were 87% and 60% in Group A and Group B patients, respectively. CONCLUSION: DOL could be considered a valid diagnostic tool in evaluating the extent of disease in AOC. Our data suggest that the use of DOL leads to decrease the rate of primary cytoreductive surgery for AOC; on the other hand, a higher optimal debulking rate (no residual tumor) at primary surgery is achieved.

Adult↗
PubMed1985

[Determination of synovial fibronectin by laser nephelometry. Its diagnostic value in rheumatology].

The object of the present study was to define the optimal conditions for the quantitative determination of fibronectin in synovial fluid by laser nephelometry and to determine the diagnostic importance of this analysis in rheumatology. The results show that this technique is sensitive (threshold sensitivity is 70 mg/l if the sample is diluted 1/30 and 5 mg/l for a sample diluted to 1/2), accurate, reproducible (coefficient of variation less than 10%), specific, simple and rapid. The response is linear for dilutions from 1/30 to 1/240. Fibronectin P and fibronectin S were determined in 104 subjects who had contracted an arthropathy; 26 cases of rheumatoid polyarthritis, 43 mechanical arthropathies and 35 cases of non-rheumatoid arthritis. the plasma fibronectin does not vary significantly from one group of arthropathies to another but the mean value for the total population of arthropathies is significantly lower than that for a control group. In the synovial fluid the mean value for fibronectin in the patients with rheumatoid arthritis (583 + 76 mg/l) is very considerably higher than that in non-rheumatoid (379 + 58 mg/l) or mechanical (367 + 32 mg/l) arthritis patients. Thus, the determination of synovial fibronectin may provide useful information for the etiological diagnosis of inflammatory arthropathies.

Arthritis↗
PubMed1988

The role of aspiration cytology in the management of thyroid nodules.

In the hands of an experienced cytologist aspiration cytology is a safe and hitherto the best diagnostic tool in the evaluation of nodular thyroid lesions. In histologically verified case series 50-90% of confirmed thyroid cancers can be detected by aspiration biopsy, the sensitivity being dependent on sampling errors, microscopic misinterpretation and the variation in attitude towards indeterminate diagnosis in the decision for diagnostic surgery. The number of proven benign cases that are correctly identified as such by biopsy varies accordingly and approx. 75% (specificity). In comparison with imaging procedures, including those giving information of functional activity, the combined sensitivity and specificity rates of aspiration cytology come closest to the ideal discriminatory situation. In combination with case history and careful clinical examination, fine needle aspiration cytology is the best guidance for an optimal selection of patients for therapeutic or diagnostic surgery. Future development of sensitive markers for malignant degeneration will probably increase the selective power of this diagnostic technique.

Biopsy, Needle↗
PubMed1989

Management of diabetic ketoacidosis.

Diabetic ketoacidosis is an all too frequent and sometimes preventable complication of Type I diabetes mellitus, responsible for significant morbidity and mortality within the diabetic population. Precipitating diseases account for the majority of deaths occurring in patients admitted in diabetic ketoacidosis, but some deaths are still attributable to ketoacidosis alone, despite recent advances in therapy and management. Recognition of the ketoacidotic state is paramount to optimal therapy, and often hinges on the diagnostic acumen of the physician. Since 20 to 30% of patients presenting in diabetic ketoacidosis do so as the initial manifestation of their previously undiagnosed disease, physicians must maintain a high level of suspicion for this condition. Understanding the pathogenetic mechanisms leading to and prevailing in diabetic ketoacidosis will allow physicians to intervene in a rational manner, approaching therapy with specific end-points in mind: (a) restoration of optimal volume status; (b) reversal of acidosis; (c) reduction of serum glucose levels; (d) replacement of specific electrolytes in a timely manner; (c) institution of appropriate therapy for any precipitating cause; and, (f) careful monitoring of the patient's biochemical, physical and mental parameters to allow adjustment in therapy as necessary. The mainstay of treatment for diabetic ketoacidosis is appropriate fluid and insulin therapy. Low-dose intravenous infusion is now the accepted mode of insulin delivery for patients with this condition. Potassium replacement is almost always necessary, often requiring massive amounts of this ion due to the total body depletion seen with the development of ketoacidosis. Controversy still surrounds routine use of phosphate in diabetic ketoacidosis but replacement may be needed if serum levels fall toward the lower limits of normal values, to avoid the potential adverse effects of phosphate depletion. Administration of bicarbonate is also controversial and should be reserved for patients whose pH is less than 7.0 to 7.1 and then it should be added to intravenous fluids, not given as an intravenous bolus. Efforts toward preventing diabetic ketoacidosis should be of prime importance to physician and patient alike. Preventive measures should include patient education about diabetes mellitus, precipitating factors of diabetic ketoacidosis, signs and symptoms of early metabolic decompensation, rational insulin therapy during minor illness and appropriate timing of physician contact to help avoid this serious and sometimes fatal complication of diabetes mellitus.

Diabetic Ketoacidosis↗
PubMed2024

Development of a clinical metagenomics workflow for the diagnosis of wound infections.

BACKGROUND: Wound infections are a common complication of injuries negatively impacting the patient's recovery, causing tissue damage, delaying wound healing, and possibly leading to the spread of the infection beyond the wound site. The current gold-standard diagnostic methods based on microbiological testing are not optimal for use in austere medical treatment facilities due to the need for large equipment and the turnaround time. Clinical metagenomics (CMg) has the potential to provide an alternative to current diagnostic tests enabling rapid, untargeted identification of the causative pathogen and the provision of additional clinically relevant information using equipment with a reduced logistical and operative burden. METHODS: This study presents the development and demonstration of a CMg workflow for wound swab samples. This workflow was applied to samples prospectively collected from patients with a suspected wound infection and the results were compared to routine microbiology and real-time quantitative polymerase chain reaction (qPCR). RESULTS: Wound swab samples were prepared for nanopore-based DNA sequencing in approximately 4 h and achieved sensitivity and specificity values of 83.82% and 66.64% respectively, when compared to routine microbiology testing and species-specific qPCR. CMg also enabled the provision of additional information including the identification of fungal species, anaerobic bacteria, antimicrobial resistance (AMR) genes and microbial species diversity. CONCLUSIONS: This study demonstrates that CMg has the potential to provide an alternative diagnostic method for wound infections suitable for use in austere medical treatment facilities. Future optimisation should focus on increased method automation and an improved understanding of the interpretation of CMg outputs, including robust reporting thresholds to confirm the presence of pathogen species and AMR gene identifications.

Humans↗
PubMed1994

Mathematical model of cardiovascular mechanics for diagnostic analysis and treatment of heart failure: Part 2. Analysis of vasodilator therapy and planning of optimal drug therapy.

Using a mathematical model of cardiovascular mechanics, various complicated responses to vasodilator therapy for heart failure have been well accounted for through common logic: (i) the differential effects of various vasodilators on cardiac output; (ii) the opposite response of cardiac output to sodium nitroprusside in a normal state and heart failure state; (iii) the different responses of cardiac index, arterial pressure and left ventricular end-diastolic pressure to hydralazine in different types of heart failure. The response to combined vasodilator-inotropic agent therapy was simulated well by the model. The optimal therapeutic regimen was then formulated to simultaneously control the cardiac output, systemic and pulmonary arterial and venous pressures, and the degree of coronary ischaemia by multiple drug delivery, and the problem was solved using the model. We conclude that the model provides a useful basis for obtaining a guidance for more appropriate therapeutic regimen in heart failure.

Cardiotonic Agents↗
PubMed2005

Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom.

BACKGROUND: We review a clinical diagnostic approach to validate a redefinition of bipolar II disorder (BPII), which bypasses several conservative steps in the DSM-IV Mood Module of the Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV) to make detection of BPII more "clinician-friendly." METHOD: 563 consecutive private outpatients presenting with a DSM-IV-diagnosed major depressive episode (MDE) were included in the analyses. We used a modified SCID-CV in a semistructured way, used a duration of hypomania > or =2 days (rather than the 4-day floor cutoff recommended), did not follow the SCID-CV's stem (mood) skip-out instruction, focused more on past history of overactive behavior rather than mood change, and assessed hypomanic features both outside and during index MDE. Validation of BPII so-defined against major depressive disorder (MDD) was undertaken in the Washington University tradition. The study was conducted from June 1999 to December 2003. RESULTS: BPII occurred in 56.8% of patients. Compared with MDD, BPII had a significantly earlier index age and age at onset of first MDE and higher rates of atypical features, depressive recurrences, hypomanic symptoms during MDE, trait mood lability, and bipolar family history (p = .0000 for all variables). CONCLUSIONS: Our experience suggests that when probing history for past hypomanic episodes, behavioral activation should be inquired first, thereby facilitating the patient's subsequent recall of euphoria and/or irritability during such activated periods. Information from significant others or past records is also crucial. In light of these clinical procedures, BPII emerged as more prevalent than MDD. We submit that clinicians have the distinct advantage of intimate knowledge of their patients, which, coupled with the procedures outlined herein, can maximize the yield of BPII diagnoses.

Adult↗
PubMed2004

[The optimal combination of serum tumor markers with bioinformatics in diagnosis of colorectal carcinoma].

OBJECTIVE: To identify the optimal combination of serum tumor markers with bioinformatics in diagnosis of colorectal cancer. METHODS: The serum levels of CEA, AFP, NSE, CA199, CA242, CA724, CA211 and TPA were detected in 128 patients with colorectal carcinoma and 113 health subjects. The serum tumor markers were evaluated with the area under curves. The optimal combination of serum tumor markers was selected and the diagnostic model with artificial neural network was established. RESULTS: CEA, CA199, CA242, CA211, CA724 were selected for the optimal combination and the artificial neural network was built. The model was evaluated by a 5-cross validation approach. The model had a specificity of 95%, sensitivity of 83% and positive predictive value of 95% in diagnosis of colorectal carcinoma. CONCLUSION: The combination of optimal serum tumor markers has a high sensitivity and specificity in diagnosis of colorectal carcinoma.

Adult↗
PubMed1990

Toward a scientific psychiatric nosology. Strengths and limitations.

A consensus is emerging that psychiatric nosology should become more "scientific." The application of the scientific method to psychiatric nosology has a number of important advantages, including (1) providing a clear criterion by which to evaluate nosologic proposals, (2) preventing rapid changes due to nosologic "fashions" not supported by research findings, (3) increasing the prestige and acceptability of our nosologic system to individuals outside of psychiatry, and (4) optimizing the reliability and validity of our diagnostic constructs. However, many critical issues confronting nosologists are fundamentally nonempirical and cannot be addressed by the scientific method. Examples of such issues include (1) disagreements about the proper construct for a psychiatric disorder; (2) the interpretation of results when different validators provide opposing answers; (3) defining how different syndromes must be to be considered subtypes of the same disorder, distinct disorders within the same overall category, or entirely independent disorders; and (4) the proper balance of reliability and validity. The optimal use of the scientific method in our nosologic process requires a recognition of both its strengths and its limitations.

Humans↗
PubMed2006

Urinary tract infections in general practice patients: diagnostic tests versus bacteriological culture.

OBJECTIVES: Urinary tract infections (UTIs) are common bacterial infections encountered in general practice. For the optimal treatment the general practitioner (GP) should rely on the results of diagnostic tests and recent antimicrobial susceptibility of uropathogens. PATIENTS AND METHODS: In total 1993 female patients (11-70 years) with complaints of an acute uncomplicated UTI were included. The performance characteristics of the diagnostic tests used were determined and compared with the antibiotic prescription rate. The antibiotic therapy (agent and duration), the uropathogens and the antibiotic susceptibility of Escherichia coli were determined for each age group. RESULTS: The positive predictive value (PPV) (96%) and the specificity (94%) of the nitrite test were high for all samples. A negative nitrite with a positive leucocyte-esterase (LE) test showed a high PPV (79%) and sensitivity (82%). When both nitrite and LE tests were negative approximately 50% of the samples were culture positive. Of the patients, 94% of those with a positive nitrite test and 71% of those with a negative nitrite and positive LE test were prescribed antibiotics, mostly nitrofurantoin and trimethoprim. Nitrofurantoin prescriptions decreased and those of fluoroquinolones increased with increasing age. Nitrofurantoin was equally prescribed for 3-7 days in all patients. Trimethoprim was mostly prescribed for 3 days in patients aged 21-50 years and for 5 days in the other patients. E. coli, the uropathogen mostly isolated, decreased in frequency with increasing age. Proteus mirabilis was found more in the oldest patients and Staphylococcus saprophyticus in the younger patients. The antimicrobial susceptibility of E. coli was not age related. The lowest percentages were found for amoxicillin (67%) and trimethoprim (77%). Fluoroquinolone resistance was emerging in the older patients. CONCLUSIONS: For female patients with symptoms of an acute uncomplicated UTI a positive nitrite test or a negative nitrite test with a positive LE test confirmed UTI whereas a negative nitrite together with a negative LE test did not rule out infection. For empirical treatment GPs should take into account the changing aetiology with increasing age. Prudent use of antibiotics in general and more specifically fluoroquinolones remains recommended. As trimethoprim resistance reached 20% it might be advisable to no longer use it as therapy of first choice for acute uncomplicated UTIs in The Netherlands.

Adolescent↗
PubMed1991

[Preparation of an erythrocytic diagnostic agent based on staphylococcal proteinase].

Various methods for sheep red cell sensitization for the preparation of erythrocytic diagnostic agent from staphylococcal proteinase were under study. Sensitization with chromium chloride yielded the best results as regarded the sensitivity of the agent, optimal sensitizing dose, and sensitin consumption. The resultant erythrocytic diagnostic agent retained about 10% of the initial enzymic solution activity. The authors have demonstrated a high specificity of the erythrocytic diagnostic agent from staphylococcal proteinase, that may be used for the serologic diagnosis of staphylococcal infection and for proteinase indication in various staphylococcal preparations.

Erythrocytes↗