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PubMed1986

An algorithm for differential diagnosis in jaundice and its applications.

During the recent years a broad spectrum of diagnostic methods have appeared for the differentiation of obstructive and nonobstructive jaundice: ultrasound examination, CT-scan, direct cholangiography, etc. These investigations are costly and not without risks. It is therefore essential to devise an optimal diagnostic strategy for each patient. Extensive clinical and clinical chemical information was collected from 1,002 jaundiced patients. By application of Bayes' theorem and logistic discriminant analysis a diagnostic algorithm was developed based upon 21 variables of the 107 variables collected. This algorithm permitted a probabilistic classification of jaundiced patients into four diagnostic categories: acute non-obstructive, chronic non-obstructive, benign obstructive and malignant obstructive jaundice. Adopting a probability limit of 0.80, 683 patients (69 p. 100) were correctly classified, 34 patients (3.5 p. 100) were wrongly so, and 268 patients (27 p. 100) could not be classified with a probability above 0.80 (doubtful cases). The algorithm was also tested in a further series of 110 jaundiced patients and found to perform equally well: 88 patients classified, 22 patients remaining doubtful. Patients with doubtful diagnoses should be referred to a non-invasive test such as ultrasound examination, whereas patients with definite diagnoses can be referred to invasive tests (liver biopsy, direct cholangiography) as appropriate. The diagnostic algorithm seems to be a reliable tool for the primary differential diagnosis of the jaundiced patient and can be used in the planning of further diagnostic tests for the individual patient.

Algorithms↗

PubMed2003

Prostatitis revisited: new definitions, new approaches.

Prostatitis syndromes represent an important health care problem resulting in considerable morbidity and expenditure of health care resources. Comparison of the traditional and consensus classification schemes demonstrates no changes in the traditional categories of acute bacterial prostatitis and chronic bacterial prostatitis. Examining only the EPS, however, results in diagnosis of half of the patients with inflammatory CP/CPPS. An optimal diagnostic strategy required evaluation of the VB3 and SFA in addition to the traditional EPS examination. Such precision is necessary for research studies, but whether such precision is important clinically remains unproved. The new interest in optimal evaluation and characterization of patients with chronic prostatitis and related conditions has resulted in important research initiatives examining the etiology and optimal treatment for this large group of patients.

Acute Disease↗

PubMed2002

Assessment of the diagnostic accuracy of the TDx-FLM II to predict fetal lung maturity.

BACKGROUND: Because respiratory distress syndrome (RDS) affects 1% of live births, accurate and rapid assessment of markers of fetal lung maturity is critical to clinicians in deciding whether to deliver a preterm infant. Our objective was to determine the optimal diagnostic cutoff value for the TDx-FLM II assay (Abbott Laboratories) for predicting clinically significant RDS. METHODS: Amniotic fluid TDx-FLM II data were collected retrospectively over 4 years. Women were included in the study if they had delivered within 72 h of TDx-FLM II testing and both the mother and infant charts could be reviewed. Women who had been treated with steroids and delivered unaffected infants were excluded from the analysis. The diagnosis of RDS was defined as infants who either were treated with surfactant and/or were placed on a ventilator and/or required continuous positive airway pressure for >1 day. RESULTS: A total of 185 women met all entry criteria (15 RDS, 170 non-RDS). A cutoff value for a mature result of >or=45 mg/g gave a sensitivity of 100% (95% confidence interval, 82-100%) and a specificity of 90% (95% confidence interval, 78-89%). CONCLUSIONS: The TDx-FLM II appears to predict clinically significant RDS when a cutoff of >or=45 mg/g is used for mature results. Further studies will be required to confirm these findings.

Amniotic Fluid↗

PubMed1995

Normal post-race antimyosin myocardial scintigraphy in asymptomatic marathon runners with elevated serum creatine kinase MB isoenzyme and troponin T levels. Evidence against silent myocardial cell necrosis.

Recent epidemiologic studies confirm that heavy physical exertion can trigger myocardial infarction. Diagnosis of acute myocardial injury in marathon runners is complicated by elevations of serum creatine kinase MB isoenzyme activity in asymptomatic finishers with normal post-race infarct-avid myocardial scintigraphy. Such isoenzyme elevations can arise from exertional rhabdomyolysis of skeletal muscle biochemically altered by training, from silent injury to the myocardium or from a combined tissue source. To assess silent myocardial cell necrosis in marathon runners, we performed quantitative anti-myosin myocardial scintigraphy after competition with serum immunoassays for creatine kinase MB isoenzyme and troponin T. Therefore, 8 male marathon runners with a mean age of 52 years underwent quantitative antimyosin myocardial scintigraphy immediately following the 1988 and 1993 Boston Marathons. Serum immunoassays for creatine kinase MB isoenzyme by a chemiluminescent method (CLIA) and troponin T by an enzyme-linked immunosorbent assay were performed in 4 runners after the 1993 race. Quantitative antimyosin myocardial scintigraphy was normal in all runners including 3 who participated after both races 5 years apart. Post-race serum creatine kinase MB isoenzyme and/or troponin T levels were in a range otherwise diagnostic of acute myocardial infarction in 3 of 4 subjects. Normal quantitative antimyosin myocardial imaging in asymptomatic marathon runners excludes silent myocardial cell necrosis as the source of elevated serum protein markers. Such imaging may be the optimal diagnostic modality for detection of myocardial cell necrosis in symptomatic athletes when results of conventional testing are inconclusive.

Adult↗

PubMedDate not supplied

[The significance of extra-articular manifestations for the differential diagnosis of musculoskeletal diseases in children].

Musculoskeletal complaints comprise about 7% of all pediatric office visits. The differential diagnosis of these complaints is very extensive. A great diagnostic aid offer quality, distribution and temporal course of the pain of joints, bone and muscles, of an objectively detectable arthritis, and especially of the numerous manifestations of other organ systems: Constitutional signs, fever, skin, mucous membranes, eyes, nervous system, heart, vasculature, lungs, digestive system and urogenital system. Combinations of these often early manifestations are crucial to determine the disease category, which is urgent for further diagnostic measures and for therapy: Bacterial, rheumatic, collagen-vascular, traumatic, orthopedic, and neoplastic disease. They are as important for making the final diagnosis and for the early recognition of later manifestations and complications. To achieve an optimal diagnostic efficiency, laboratory investigations should be carefully selected according to the clinical findings and diagnoses. A few regular investigations are valuable for the assessment of disease activity and therapy, and others for the early detection of initially asymptomatic manifestations.

Arthritis, Juvenile↗

PubMed1995

[What are the indications for myocardial scintigraphy?].

Myocardial scintigraphy is a noninvasive technique of functional blood flow imaging whose indications are often poorly defined. The various practical modalities of the examination, as well as the tracers currently available in France are reviewed. The diagnostic value in the detection of coronary disease is then described, with emphasis on the complementarity of scintigraphy and the other techniques, particularly the stress test, and by trying to position scintigraphy in the context of the optimal diagnostic strategy. Finally, the prognostic value of scintigraphy, its value in post-infarction assessment and in the functional evaluation of known coronary stenoses are discussed.

Coronary Disease↗

PubMed1998

Bayesian modeling of muscle biopsy contracture testing for malignant hyperthermia susceptibility.

BACKGROUND: Phenotyping malignant hyperthermia (MH) by contracture testing has a low but quantifiable degree of inaccuracy, measured by its sensitivity and specificity. Quantifying the limitations inherent in diagnostic testing for MH can help resolve issues in clinical practice, such as the interpretation of a negative test and the apparent lack of complete genetic linkage to RYR1. METHODS: Bayesian models, mathematical descriptions of the outcome of diagnostic testing, were constructed. The inputs to the model include patient factors, summarized in a single number called pretest probability (PTP), and sensitivity and specificity that specify the accuracy of the entire test process. The outputs of the model include positive predictive value (PPV) and negative predictive value (NPV), which are numeric expressions of diagnostic certainty of positive and negative test results. A special case was constructed for equivocal results. RESULTS: The PPV, NPV, and efficiency of contracture testing for MH are functions of PTP, sensitivity, and specificity. The NPV is high for all clinical PTP, whereas PPV is clinically useful for moderate to high PTP. CONCLUSIONS: Diagnostic contracture testing for MH is clinically useful because of high NPV and can exclude MH with near certainty. For MH probands, the clinical grading scale for MH may guide PTP estimation, whereas for relatives of probands, PTP is a function of kinship to a known MH-susceptible relative. A sequential testing strategy optimizes diagnostic information by maximizing PTP within a pedigree. Incomplete testing of parents of an MH susceptible child can pose a significant risk of false-negative results for the untested parent. Even with optimal pedigree testing strategies, the PPV drift effect results in a considerable source of phenotypic uncertainty for genetic linkage studies.

Bayes Theorem↗

PubMed2001

The application of high-resolution CT to diagnosis in diffuse parenchymal lung disease.

High resolution computed tomography (CT) now has a central role in the evaluation of diffuse lung disease. It is of particular use in the formulation of a differential diagnosis. Whilst CT often conveys sufficient information to allow non-invasive diagnosis, it sometimes reveals atypical appearances, contributing to the continuing reclassification of diffuse lung disease and justifying histological evaluation in some patients. Thus, CT as a new technology does not always replace conventional diagnostic methods, but is best integrated with clinical assessment, other non-invasive investigations and surgical lung biopsy: this applies equally to clinical diagnosis and to the definition and reclassification of disease entities. In this article, we explore the optimal diagnostic use of CT. The limitations of CT series in simulating the clinical application of CT in the management of diffuse parenchymal lung disease highlight the need for an integrated approach to diagnosis, including corroborative data drawn from many sources. High-resolution computed tomography, when interpreted in the context of the pre-test probability, obviates invasive investigation in many cases. As descriptions of the CT appearances of individual diffuse lung diseases are refined, ongoing re-evaluation is required to establish which features can be regarded as pathognomonic, for diagnostic purposes, and how CT can be integrated into revised disease definitions so that the most clinically relevant diagnostic criteria are formulated.

Female↗

PubMedDate not supplied

[New trends in endoscopic diagnosis of tumors of the larynx].

Early detection and accurate determination of localization and extent of benign growths, particularly precancerous lesions and malignant tumors of larynx have significant therapeutic and prognostic importance. Today, laryngomicroscopy (LMS) is worldwide accepted diagnostic procedure for detection, description and biopsy of laryngeal pathology. In many cases it is a therapeutic procedure. However, detection and accurate description of laryngeal lesion can often be a difficult task, requiring great experience of ENT specialist. Because that attempts to optimize diagnostic procedure for more sensitive detection, and more accurate describing of laryngeal pathology are still challenges for otolaryngologists. Each diagnostic procedure that is able to give accurate information about nature of laryngeal lesion without devastation of tissue has important advantages over standard biopsy. Contact laryngomicroscopy is in vivo microscopic examination of laryngeal mucosa without biopsy. Procedure is performed during laryngomicroscopy by introducing contact endoscope into larynx. Autofluorescent endoscopy is based on ability of flavin mononucleotide (FMN) in normal cells to emit green fluorescence when is exposed to blue light. Neoplastic cells do not have FMN and do not emit green fluorescence. This procedure does not require any substance as a photosenzitizer. Induced fluorescence is based on selective accumulation of protoporphyrine IX (PP IX) in neoplastic tissue that can be detected as a violet fluorescence that emit PP IX. Induction of tumor tissue to fluoresce is achieved with topic or systemic application of 5-aminolevulinic acid (5-ALA). These diagnostic methods have greater sensitivity in detection of tumor than laryngomicroscopy, but have some disadvantages. Combination of laryngomicroscopy and any of these procedures gives more accurate diagnosis than laryngomicroscopy alone.

Fluorescence↗

PubMedDate not supplied

Overactive bladder--a practical approach to evaluation and management.

The overactive bladder (OAB) is a highly prevalent condition characterized by the combination of urgency and frequency with or without urge incontinence. The pathophysiology is multifactorial; the background is complicated and not yet fully understood. The basic diagnostic workup comprises symptoms assessment, targeted physical examination, urine analysis, post-void residual urine estimation which mostly allows to make a working diagnosis and to find out which patients can be treated also by the nonspecialist. The bladder diary is an optimal diagnostic instrument with a lot of information, whereas urodynamics are expensive and somewhat unverified in their value. The symptom-focused diagnosis is absolutely sufficient to start nonoperative therapy for OAB symptoms. The OAB presents a treatment challenge, as the management of OAB patients is not standardized. An algorithm should include an initial period of at least 6 weeks of conservative therapy consisting of antimuscarinic drugs in combination with behavioral therapy including pelvic floor exercises. If this combination is not successful, the primary diagnosis should be questioned and additional diagnostic tests may be required. If the therapy is successful after 8 weeks, a continuation should be considered in case the symptoms occur after stopping pharmacological therapy. Further therapy depends on the severity of the initial symptoms, the presence of side effects and the motivation of the patient. If pharmacotherapy is not successful or additional therapy desirable, electrical neuromodulation can be added for another period of 6 weeks for up to 3-6 months considering firstly non-invasive therapeutic modalities before recommending invasive sacral neuromodulation. Neuromodulation should be discussed before more invasive procedures, such as bladder augmentation, are considered. There are potentially promising new therapies on the horizon for the OAB. The use of intravesical agents, which decrease the afferent-sensory input, may herald a new therapeutic paradigm for the treatment of the OAB. Refinements in the techniques and the delivery vehicle for electrical stimulation may offer an even less invasive method of neuromodulation. Finally, ongoing research in biotechnology and tissue engineering may produce a functional, stable, compatible tissue substitute suitable for bladder augmentation. The objectives are (1) to define the overactive bladder, (2) to understand the prevalence of the overactive bladder and its impact on the quality of life, (3) to review the basic evaluation of the patient with symptoms suggestive of the overactive bladder and how to differentiate the overactive bladder from other types of urinary dysfunction, and (4) to understand the rationale for and the approach to therapy for the overactive bladder.

Cognitive Behavioral Therapy↗

PubMedDate not supplied

Comparison of SeroMP IgA with four other commercial assays for serodiagnosis of Mycoplasma pneumoniae pneumonia.

Acute phase serum samples from 23 patients with Mycoplasma pneumoniae pneumonia were examined for specific antibodies with microparticle agglutination (MAG)-assay, complement fixation (CF)-test, IgM-specific ELISA, and Immunocard-based IgM-EIA. A novel 3-h IgA-ELISA (SeroMP-IgA) was tested to assess its diagnostic value. For MAG, CF, IgM-ELISA, card-based IgM-EIA, and IgA-ELISA positive results were obtained in 87%, 87%, 91%, 87%, and 100%, respectively. Overall concordance was 78%. Specificity testing of 46 healthy blood donors revealed an optimal diagnostic cut-off range of 22-30 IgA-ELISA binding units (BU)/mL resulting in 91%-100% specificity and 100%-96% sensitivity for serologic diagnosis of acute M. pneumoniae infection.

Adolescent↗

PubMed1975

[Neurootological findings in zoster oticus (author's transl)].

Zoster oticus is an important disorder in neurootological routine diagnostics. However, the neurotoxic zoster virus is not being confined to the nerval periphery. Therefore as well typical peripheral as well as typical central as well as combined reactional patterns are to be found by neurootological functions tests. By selection and adaptation of tests optimal diagnostics can be completed in the vestibular-ocular, the vestibular-spinal and retinal-ocular sensory motory systems. Thus disorders as such can be identified and additionally localised. The peripheral zoster oticus can be differentiated from the central zoster encephalitis. These findings are demonstrated by typical case reports.

Audiometry↗

PubMed2004

[Personnel and structural requirements for the shock trauma room management of multiple trauma. A systematic review of the literature].

The aim of the study was the description of personal and structural preconditions essential for adequate diagnostic requirements and treatment in severely injured patients. Herein we give detailed information regarding both the composition and qualification of the trauma team and the activation criteria as well as instructions for the design of the emergency room and technical requirements. Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). The trauma team should consist of (trauma) surgeons, anesthesiologists, radiologists, and one to two nursing staff members of each department. The attending physician should be present within 20 min. Trauma team activation criteria are among others: high energy/velocity trauma, penetrating injuries, GCS < or =14, and intubation. The emergency room should be integrated in the emergency department with all technical equipment being permanently available for optimal diagnostic and therapeutic management. A CT scanner should be positioned nearby.Adequate management of severely injured patients requires optimal personal and structural conditions. High costs and additional personnel are justified by improved quality of treatment.

Emergency Medical Services↗

PubMed2005

[Serological and genetic markers in the diagnosis and follow-up of coeliac disease].

INTRODUCTION: Understanding of celiac disease has changed with the advent of serological markers (antigliadin IgA, anti-endomysial IgA and anti-transglutaminase IgA antibodies) and with the identification of major susceptibility genes (HLA-DQA1*05-DQB1*02). Reports of the efficacy of these diagnostic tests have varied, depending on the methodology used and the population investigated. OBJECTIVES: To determine the clinical utility of genetic and serological markers in the diagnosis of celiac disease, their relationship with histological lesions and their changes during treatment, in order to establish an optimal diagnostic algorithm in our environment. PATIENTS AND METHODS: We performed a retrospective study of 590 patients from the health area of Badajoz referred to the Immunology Laboratory for screening or follow-up of celiac disease. The results of intestinal histology, serological markers (antigliadin IgA, anti-endomysial IgA and anti-transglutaminase IgA antibodies), and genomic typing (HLA-DQA1*05-DQB1*02) were analyzed. RESULTS: The sensitivity and specificity of serological tests were greater than 90 %, with a negative predictive value of 98-100 %. HLA-DQA1*05-DQB1*02 was detected in 97 % of celiac patients, with a very high negative predictive value (99 %). On biopsy, 95 % of the patients with some grade of intestinal lesion were positive for antigliadin and/or anti-endomysial antibodies. CONCLUSION: To avoid missed diagnoses, the diagnostic algorithm of celiac disease should include at least two serological markers (antigliadin antibodies and anti-endomysial and/or anti-transglutaminase antibodies) and IgA quantification. Genomic typing should be carried out if one or more markers are positive or if the subject belongs to any of the risk groups. The physician should decide on the advisability of intestinal biopsy on the basis of the patient's clinical and immunological history.

Atrophy↗

PubMed1980

[Concept of reliable laboratory test procedures (author's transl)].

Considering the multitude of tests in clinical chemistry and hematology, their low diagnositc sensitivity and specifity, and the low incidence of the diseases in a non selected population it is not possible presently to recommend a general screening procedure based on the definition of the reference, the methodological reproducibility and the diagnostic information of a test procedure it is possible to calculate the number of requests necessary to get any desired number of pathological results. "Tell me how many pathological results you want and I'll tell you how many requests you need". In order to get an optimal diagnostic information for clinical chemistry and hematological tests, it is necessary to increase the prevalence by proper selection of the patients and then to order test procedures specific for the suspected disease.

Age Factors↗

PubMed2000

Management of kidney injuries in children with blunt abdominal trauma.

BACKGROUND/PURPOSE: The authors analyzed the incidence and the course of renal injuries encountered in a cohort of pediatric patients with blunt abdominal trauma. This review focuses on the early diagnostic and therapeutic approach rather than the long-term outcome and draws conclusions for an effective initial management. METHODS: From 1976 to 1996, the charts of 308 children with blunt abdominal trauma that were admitted to the authors' department were reviewed. The patients initially were evaluated using urinalysis, ultrasonography, and abdominal paracentesis (until 1984) and in specific cases iv-urography, computed tomography (CT), and angiography. The authors retrospectively classified the renal trauma after the widely used Organ Injury Scaling (OIS) into 5 grades and correlated the diagnostic value of various techniques as well as the diagnostic approach. RESULTS: Sixty-nine serious abdominal traumas were encountered. Thirty-six patients suffered renal lesions grade 2 (G2) or higher; 20 children were polytraumatized. There were 67 renal lesions including 28 G1, 22 G2, 8 G3, 5 G4, 1 G5, and 3 lesions of the lower urinary tract. Ultrasonography and urinalysis were found to be the optimal diagnostic methods for screening and following the course of renal injury. CT scan proved to be most reliable for detecting and exactly classifying renal lesions grade 2 or higher and superseded consecutively iv-urography. In cases in which CT scan failed to show renal excretion of contrast agent, angiography was performed. Ten patients proceeded to operative therapy. CONCLUSIONS: Ultrasonography and urinalysis proved to be the optimal initial evaluation tool for excluding renal injury both as a screening method and for further controls. Exact classification was possible by CT scan. During the reviewed time period a shift from surgical to conservative management was notable. If lesions were G4 or G5, surgical treatment with tendency toward minimally invasive therapy always was indicated.

Abdominal Injuries↗

PubMed1993

[Indications for ultrasonography in the diagnosis of surgical diseases].

Ultrasonography has established itself as an invaluable diagnostic aid in surgical diseases. In addition to the diagnosis of thoracic and abdominal disease, ultrasonography is increasing in importance in the examination of muscles, tendons and joints in small animals. In the horse, the application of the technique is being extended from tendon conditions to organ diseases. The optimal diagnostic information can only be achieved through the use of different scanner types.

Abdomen↗

PubMed2006

Diagnostic work-up and outcome of cervical metastases from an unknown primary.

CONCLUSIONS: An intensive diagnostic work-up including (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) detects many unknown primary tumours, leads to a low emergence rate of primary tumours, and selects carcinoma of unknown primary with much more favourable results after neck dissection and postoperative radiotherapy. OBJECTIVE: To investigate the optimal diagnostic approach and best treatment modality for rare head and neck cancer of unknown primary. PATIENTS AND METHODS: In a retrospective study, 69 patients admitted from 1987 to 2002 with cervical lymph node metastases without apparent primary were reviewed. Test characteristics of all diagnostic procedures were calculated. Disease-free and overall survival rates were calculated. Major prognostic factors were analysed uni-variously. RESULTS: At the primary site FDG-PET showed the best sensitivity with 69% and the highest negative predictive value with 87%. Computed tomography and magnetic resonance imaging had a better specificity with 87% and 95%, respectively. The primary tumour was detected in 23 cases (33%). Frequent primary tumour origin was the palatine tonsil (n=8, 35%), base of the tongue (n=6, 26%) and lung (n=4, 17%). All patients with unknown primary were treated by neck dissection. Adjuvant radiotherapy was performed in 26 patients (57%), concurrent radiochemotherapy was performed in 12 patients (26%). The primary emergence rate was 7%. The 5-year overall survival rate was inferior in patients with detected primary in comparison with patients with unknown primary (22% versus 52%). Significant prognostic factors in case of unknown primary were M stage, smoking, alcohol consumption and tonsillectomy. Radiotherapy but not chemotherapy with carboplatin influenced the overall survival.

Adult↗