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PubMed1999

Can duplex ultrasound replace arteriography in screening for mesenteric ischemia?

Duplex examination of the mesenteric vasculature is not a widely performed examination, but the published literature documents the ability of this test to accurately identify chronic atherosclerotic occlusive disease. The test is a recent addition to the armamentarium of noninvasive duplex technology, with studies of adequate size for statistical analysis appearing only since 1991. Two primary sets of diagnostic threshold values for significant stenoses of the superior mesenteric artery (SMA) and the celiac artery have been published and subsequently tested for accuracy. One of these recommends use of peak systolic velocity (PSV), whereas end diastolic velocity (EDV) was found to be most accurate in the other. Both sets of criteria identify overall accuracy of greater than 90% for identification of SMA stenosis, and greater than 80% for diagnosis of celiac stenosis. Identification of celiac disease may be aided by analysis of blood flow direction in the common hepatic artery. The finding of retrograde hepatic flow is virtually diagnostic of severe celiac stenosis or complete occlusion. Duplex also has been shown capable of identifying anatomic anomalies of the mesenteric vessel origins, a situation that occurs in approximately 20% of the population. Finally, mesenteric duplex has utility in a variety of less common abdominal visceral disorders, but statistical analysis of accuracy and adequate identification of quantitative velocity thresholds have not been performed. Skilled technologists who have access to appropriate training and equipment can master this test. There is little doubt that it can replace angiography as a screening tool in the setting of suspected chronic mesenteric ischemia.

Acute Disease↗
PubMed1993

The Zurich Study. XVIII. Obsessive-compulsive disorders and syndromes in the general population.

The cross-sectional and longitudinal association between obsessive-compulsive syndrome (OCS) and other psychiatric problems and the course over 11 years was examined in a Swiss cohort of young adults. As the prevalence of obsessive-compulsive disorders, defined according to the DSM-III was very low (n = 5), we applied a lower diagnostic threshold based on obsessive-compulsive symptoms and social impairment, to define an OCS. The weighted lifetime prevalence rate for OCS at age 30 years was 5.5%. The mean age of onset was 17.1 +/- 4.9 years for males, and 19.1 +/- 5.1 year for females. OCS was associated with all subtypes of depressive disorders as well as with social phobia and agoraphobia. Although the longitudinal analysis showed no stability at the diagnostical level, there was some stability on the symptom level. Perhaps subjects with OCS learned in time to cope and to live with their symptoms without suffering.

Adaptation, Psychological↗
PubMed1997

Diagnostic tools and measurements--impact on appropriate care.

The diagnosis of primary coronal caries should be seen as a complex process, comprising both detection and measurement phases, which enables clinicians, researchers and epidemiologists to make informed decisions about the management and prognosis of the disease process. The different diagnostic thresholds employed for measurements of caries experience can be viewed as an iceberg, a metaphor which demonstrates the ambiguity of the term "caries free" and which can also represent the differing management options appropriate for the care of different types of active and inactive lesions: NAC (No Active Care). PCA (Preventive Care Advised) and OCA (Operative Care Advised). There are considerable methodological difficulties in drawing valid comparisons between studies using incompatible criteria and simulations. However, it is apparent that no caries diagnostic tool in current clinical use fulfils all of the ideal criteria for measurements needed to plan and monitor appropriate care. Systems providing reliable serial measurements with which to assess future caries risk and present caries activity are urgently required as diagnostic tasks are becoming both more difficult and more important from the standpoint of long-term oral health. Existing diagnostic tools frequently rely on subjective judgements and provide only semi-quantitative measures insensitive to smaller lesions. In the future tools are needed which are objective, quantitative and which can provide acceptable compromises between sensitivity and specificity for a wide range of applications for individual patient care as well as for research and survey use. Key problem areas with existing tools include confusion in terminology and between caries assessments made by clinicians and epidemiologists as well as the lack of valid measurements relating to the activity of primary root caries and secondary caries. Deficiencies with current tools impact on the care of individuals by allowing false negative diagnoses of hidden occlusal dentine lesions and approximal cavities on the one hand, whilst generating some false positive diagnoses on sound surfaces leading to inappropriate decisions to restore on the other. At the population level, current conventional tools significantly underestimate overall caries experience. In future the adoption of more accurate and reliable methods would facilitate more effective preventive care and promote more appropriate restorative treatment decisions. Research in this area should focus for the next five years on diagnostic technologies which: 1) inform valid prospective caries risk assessments for different age groups, 2) can help to determine present caries activity and monitor lesion behaviour over time and 3) help identify methods which can implement existing and new research knowledge about diagnostic tools into clinical and research practice.

Age Factors↗
PubMed1999

Meta-analysis of diagnostic tests with imperfect reference standards.

We present a method to estimate the summary receiver operating characteristic (SROC) curve for combining information on a diagnostic test from several different studies. Unlike previous methods that assume the reference standard to be error free, our approach allows for the possibility of errors in the reference standard, through use of a latent class model. The model provides estimates of the sensitivity and specificity of the diagnostic test and the case prevalence in each study; these parameters can then be used in a meta-analysis, for example, using the regression method proposed by Moses et al., of a measure of test discrimination on a measure of the diagnostic threshold, to fit the SROC. The method is illustrated with an example on Pap smears that shows how adjusting for imperfection in the reference standard typically reduces the scatter of data in the SROC plot, and tends to indicate better performance of the test than otherwise.

Algorithms↗
PubMed2001

The epidemiology of generalized anxiety disorder.

The literature reviewed here is consistent in showing that GAD is a common mental disorder that typically has an early age of onset, a chronic course, and a high degree of comorbidity with other anxiety and mood disorders. Comorbid GAD is often temporally primary, especially in relation to mood disorders, and is associated with an increased risk for the subsequent onset and severity of secondary disorders. The weight of evidence reviewed here argues against the view expressed by early commentators that GAD is better conceptualized as a prodrome, residual, or severity marker of other disorders than as an independent disorder. Focused studies of comorbidity between GAD and major depression, in which comorbidity is high, lead to the same conclusion. The crucial evidence for this conclusion includes the following: 1. Contrary to the findings of clinical studies, GAD in the community does not have a higher comorbidity than do most other anxiety or mood disorders. 2. The symptoms of GAD form an empiric cluster distinct from the symptoms of major depression in studies of symptom profiles. 3. Family studies show distinct aggregation of GAD and major depression. 4. Twin studies show that the environmental determinants of GAD are different from the environmental determinants of major depression. 5. The sociodemographic predictors of GAD in epidemiologic studies are different from the predictors of major depression. 6. The clinical course of GAD is less consistently related to comorbidity than is the course of other anxiety and mood disorders. 7. The impairments associated with GAD are equivalent to, or greater than, those associated with other severely impairing chronic physical and mental disorders. These findings show that the status of GAD as an independent disorder is at least as strongly supported by available evidence as is that of other anxiety or mood disorders. This article also shows that uncertainty remains regarding even the basic epidemiologic characteristics of the GAD syndrome. Lingering concerns about the independence of GAD have conspired to exacerbate this problem by promoting repeated changes in the diagnostic criteria for GAD from the DSM-III to DSM-III-R and to DSM-IV. These successive changes have made it difficult to amass consistent long-term data on the natural history of GAD. Available evidence on the empiric validity of current diagnostic thresholds for GAD raises questions about the requirements, such as whether a 6-month minimum duration and four or more additional psychophysiologic symptoms are optimal for identifying all of the people in the general population who suffer from a clinically significant GAD syndrome. An additional source of potential bias in this regard is that the DSM system requires that anxiety be excessive or unrealistic for a diagnosis of GAD. Interestingly, there is no comparable DSM requirement that dysphoria must be excessive or unrealistic to qualify as major depression. These diagnostic uncertainties make it difficult to gain a clear understanding of the true breadth and depth of the GAD syndrome in the general population. Additional research is needed, ideally from unbiased epidemiologic samples, to resolve these basic uncertainties. The strong comorbidity between GAD and major depression, the fact that most people with this type of comorbidity report that the onset of GAD occurred before the onset of depression, and the fact that temporally primary GAD significantly predicts the subsequent onset of depression and other secondary disorders raise the question of whether early intervention and treatment of primary GAD would effectively prevent the subsequent first onset of secondary anxiety and depression. Unfortunately, little is known about this possibility because, as mentioned earlier, few people with pure GAD seek treatment. Why this is true is unknown. Given the early onset of GAD and its strong effects in predicting the subsequent onset, severity, and persistence of other disorders, efforts are needed to collect epidemiologic data on the reasons for the low rate of help seeking among people with pure GAD and to develop outreach strategies that may correct this situation.

Age of Onset↗
PubMed2004

Endorectal MR imaging and MR spectroscopic imaging for locally recurrent prostate cancer after external beam radiation therapy: preliminary experience.

PURPOSE: To evaluate endorectal magnetic resonance (MR) imaging and MR spectroscopic imaging for the depiction of locally recurrent prostate cancer after external beam radiation therapy. MATERIALS AND METHODS: Endorectal MR imaging and MR spectroscopic imaging were performed in 21 patients with biochemical failure after external beam radiation therapy for prostate cancer. Two readers independently and retrospectively reviewed MR images and rated the likelihood of recurrent tumor on a five-point scale. Spectroscopic voxels were considered suspicious for malignancy if the choline level was elevated and citrate was absent. Receiver operating characteristic curve analysis was used to assess cancer detection in each side of the prostate with endorectal MR imaging and spectroscopic imaging at different thresholds based on the scores assigned by the two readers and on the number of suspicious voxels in each hemiprostate, respectively. The presence or absence of cancer at subsequent transrectal biopsy was used as the standard of reference. RESULTS: Biopsy demonstrated locally recurrent prostate cancer in nine hemiprostates in six patients. The area under the receiver operating characteristic curve for the detection of locally recurrent cancer with MR imaging was 0.49 and 0.51 for readers 1 and 2, respectively. By using the number of suspicious voxels to define different diagnostic thresholds, the area under the receiver operating characteristic curve for MR spectroscopic imaging was significantly (P < .005) higher, at 0.81. In particular, the presence of three or more suspicious voxels in a hemiprostate showed a sensitivity and specificity of 89% and 82%, respectively, for the diagnosis of local recurrence. Seven hemiprostates demonstrated complete metabolic atrophy at spectroscopic imaging and only postirradiation atrophy at biopsy. CONCLUSION: Preliminary data suggest that MR spectroscopic imaging, but not endorectal MR imaging, may be of value for the depiction of locally recurrent prostate cancer after radiation therapy.

Aged↗
PubMed1993

Comorbidity and mixed anxiety-depressive disorders: is there epidemiologic evidence?

Recent epidemiologic studies (i.e., studies conducted since 1980) have consistently demonstrated, on the basis of standardized diagnostic assessments, that there is a substantial overlap between different types of anxiety and depressive disorders. The current literature, however, discusses this issue primarily within the concept of comorbidity and there are some controversies about the existence of a separate disorder of mixed anxiety-depression (MAD). MAD can be defined by the presence of mixed symptoms of depression and anxiety that are below the diagnostic threshold for either one of these diagnoses. Since MAD has not been included in any of the current official classification systems, its prevalence, risk factors, course, and outcome have not been studied specifically in any of the recent epidemiologic studies even though MAD is thought to be very important, especially in primary care settings. This paper reviews recent epidemiologic studies and presents data from the Munich Follow-Up Study, which has found a prevalence of about 1% for MAD as defined by the ICD-10. Despite the lack of clear diagnostic criteria for MAD, there are some indications that: (1) this disorder might be frequent in primary care settings, and (2) patients with MAD frequently demonstrate subjective suffering, show impairment in personal and occupational functioning, and have high health service utilization rates. Current empirical evidence is still insufficient for deciding a suitable classificatory solution for this problem.

Anxiety↗
PubMed2005

Increased recognition of depression in primary care. Comparison between primary-care physician and ICD-10 diagnosis of depression.

BACKGROUND: Underrecognition and undertreatment of depression in primary care has been regarded as a major public health problem. In contrast, some studies found that among patients labeled as depressed by primary-care physicians (PCPs), a relevant proportion do not satisfy international diagnostic criteria for depression. The aims of this study are: (1) to assess disparity between PCP diagnosis and research diagnosis of depression; (2) to compare antidepressant treatment in concordant and discordant cases of depression. METHODS: Data are gathered from a national survey on depressive disorders in primary care, conducted with the collaboration of 191 PCPs. Three hundred and sixty-one PCP patients were evaluated, and their psychiatric diagnosis was established by the 'unaided' PCPs and by using a research interview for depression. RESULTS: PCPs recognized 79.4% of cases of depression and prescribed antidepressants to 40.9% of them. Yet, 45.0% of patients labeled as depressed by the PCPs were not cases of depression according to ICD-10 criteria; 26.9% of false-positive cases received an antidepressant. Globally, 35% of antidepressants for 'depression' were prescribed to false-positive cases. CONCLUSIONS: Underrecognition and undertreatment of depression in primary care seem to be less alarming. Conversely, PCP diagnoses of depression appear to be more inclusive than psychiatric diagnostic criteria. A possible consequence of this apparently more inclusive diagnostic threshold may be an excessive use of antidepressants. These changes require a corresponding change in research, toward efficacy and safety of the treatment of milder cases, and in education, toward the distinction between the management of mild and severe cases of depression.

Adult↗
PubMed1995

Diagnostic tests for pneumonia in ventilated patients: prospective evaluation of diagnostic accuracy using histology as a diagnostic gold standard.

The diagnostic accuracy of protected-specimen brush (PSB), bronchoalveolar lavage (BAL), and endotracheal aspirates (EA) was prospectively evaluated in a series of 28 mechanically ventilated patients (MV patients) who died within 3 d of the bronchoscopic procedure, using postmortem lung examination as the gold standard for establishing the diagnosis of pneumonia. The entire fixed lungs were carefully dissected along the bronchovascular axes and each segment was cut into 5- to 10-mm thick sections, enabling gross examination of the lung parenchyma. Two tissue blocks were taken from each segment, including grossly abnormal areas whenever present. In several cases, two peripheral (subpleural) lung-tissue blocks were also taken from each lobe prior to systematic dissection of the lungs. Quantitative cultures (QC) and direct cytologic and microbiologic examination (DE) was performed on respiratory samples obtained within 72 h before death. Values of 10(3) cfu/ml of Ringer's solution, 10(4) cfu/ml of retrieved fluid, and 10(6) cfu/ml of respiratory secretions were used as cutoff points for quantitative PSB, BAL, and EA cultures, respectively. The main findings in this study were that: (1) Pneumonia was present in 67% of the patients. (2) Histologic lesions of pneumonia were mainly bilateral and predominated in the dependent lung segments. (3) Coexistence of a variety of noninfectious processes was a common finding in patients with pneumonia. (4) In several cases pneumonia was absent from peripheral lung samples while more central areas of the same segment displayed typical foci of pneumonia. (5) The sensitivity of quantitative cultures was 55%, 57%, and 47% for EA, PSB, and BAL, respectively, and the specificity was 85%, 88%, and 100%, respectively. Reducing the diagnostic threshold of EA to 10(5) cfu/ml of respiratory secretions instead of 10(6) cfu/ml resulted in a sensitivity of 63.1% and a specificity of 75% for EA. The sensitivity of direct examination (DE) was 50%, 47%, and 47%, respectively, and the specificity was 75%, 88%, and 87%. (6) The presence of intracellular organisms (ICO) in BAL had a 36.8% sensitivity and 100% specificity in establishing the diagnosis of pneumonia regardless of their percentage. (7) Although 15 patients (53%) were not on antibiotics or were off antibiotics for more than 48 h before testing, no relationship could be established between the patients' antibiotic status and the result of any diagnostic test. By using a recommended methodology for respiratory sampling techniques together with complete postmortem lung examination as a diagnostic "gold standard," this study provides a realistic insight into the diagnostic values of EA, PSB, and BAL in MV patients with suspected pneumonia.

Biopsy↗
PubMed2005

[Anxiety disorders comorbid with unipolar depression. Clinical diagnoses versus standardized diagnostic interview].

Anxiety disorders frequently co-occur with affective disorders. It is well-known that such comorbid anxiety disorders are more frequently diagnosed with standardized interviews than during the "daily routine." In 117 consecutive inpatients with major depression we assessed the frequency of DSM-IV anxiety disorders and compared it to the routine diagnoses of the discharge letters to analyze underlying principles of such diagnostic strategies. According to SCID-I (DSM-IV) 36 patients fulfilled criteria for a comorbid anxiety disorder, while this was only true for 17 patients according to discharge letters. Logistic regression revealed that clinically recognized cases had higher anxiety levels (higher diagnostic threshold). At the same time, in patients with higher depression scores anxiety syndromes tended not to be seen as separate disorders. This strategy is in line with "classic psychopathology," where severe depression (or melancholia) "included" anxiety symptoms. The borderline between depressive disorders and anxiety disorders is not as clear-cut as DSM-IV and ICD-10 try to indicate.

Adult↗
PubMed1999

Psychometric evaluation of daytime sleepiness and nocturnal sleep onset scales in a representative community sample.

BACKGROUND: The public health importance of daytime sleepiness as a risk factor for accidents, interpersonal problems, and decreased productivity has been recognized. However, epidemiologic research on this topic has been limited by the reliance on laboratory measures (i.e., the Multiple Sleep Latency Test-MSLT). Two scales, daytime sleepiness and nocturnal sleep onset, have been identified from the self-report Sleep-Wake Activity Inventory (SWAI) in a clinic sample and validated against the MSLT. This study evaluates the replicability of the two scales in a population sample and assesses potential thresholds in scale scores that distinguish normal from pathologic levels of daytime sleepiness and difficulty falling asleep. METHODS: The sample consisted of 2181 subjects 18-45 years old in the Detroit metropolitan area. All sleep characteristic information covered the 2 weeks prior to interview. Split-half sample factor analyses were conducted to assess replicability of the results. Distribution of scale scores and their relation to construct validity variables were used to evaluate possible thresholds. RESULTS: A two-factor model appeared to best account for the variation among the 12 items from the SWAI. The two factors accounted for 50% of the variance in both split-half sample analyses. The revised eight-item daytime sleepiness and two-item nocturnal sleep onset scales showed good and fair internal consistency respectively across both split-half samples. There appeared to be a "natural break" in daytime sleepiness scale scores that was associated with a substantial and consistent change in number of hours slept. No breaks appeared in nocturnal sleep onset scores. CONCLUSIONS: This study replicated the results of the clinic-based study and suggested a potentially useful diagnostic threshold for self-report excessive daytime sleepiness. Epidemiology of sleep depends on the ability to move from the laboratory to population surveys in reliable and valid ways. Development of self-report is a step in that direction.

Adolescent↗
PubMed2006

FISH analysis for the detection of lymphoma-associated chromosomal abnormalities in routine paraffin-embedded tissue.

Over the last decade, fluorescence in situ hybridization (FISH) has become a firmly established technique in the diagnosis and assessment of lymphoid malignancies. However, this technique is not wide-ly used in the routine diagnostic evaluation of paraffin-embedded biopsies, most likely because of a perception that it is technically more demanding. There are also uncertainties regarding diagnostic thresholds and the way in which results should be interpreted. In this Review, we describe practical strategies for using FISH analysis to detect lymphoma-associated chromosomal abnormalities in routine paraffin-embedded lymphoma biopsies. Furthermore, we provide proposals on how FISH results should be interpreted (including how to calculate cutoff levels for FISH probes), recorded, and reported. An online appendix (available at http://jmd.amjpathol.org) details various simple, yet robust procedures for paraffin FISH analysis; it also provides additional information on the production of FISH probes, evaluating and reporting FISH results, sources for reagents and equipment, and troubleshooting. We hope that these suggestions will make FISH technology for the study of lymphoma biopsies more accessible to routine diagnostic and research laboratories.

Chromosome Aberrations↗
PubMed1998

Impact of diagnostic criteria on the prevalence of dental caries in Norwegian children aged 5, 12 and 18 years.

The study aimed to investigate caries prevalence in children using a severity grading diagnostic system, and to evaluate the influence of different diagnostic thresholds on the caries data. A group of 513 children, aged 5, 12 and 18 years, were examined clinically, and with available bitewing radiographs, by four calibrated examiners. The inter- and intra-examiner reliability, assessed by a weighted kappa, varied between 0.80 and 0.95. The mean dmft/DMFT values were 3.8, 5.8 and 11.0 for the three age groups respectively, and the corresponding dmfs/DMFS values were 5.4, 9.9 and 22.6. The d/D-component constituted the major part of the dmf/DMF index in all age groups, and enamel lesions accounted for 59%, 89% and 86% of the d/D-component in the three age groups respectively. It is concluded that enamel or initial caries lesions contributed substantially to the total caries prevalence, illustrating the importance of using diagnostic criteria that include all stages of clinical caries if a total picture of the caries situation is needed.

Adolescent↗
PubMed2002

Blinded review as a method for quality improvement in surgical pathology.

CONTEXT: Several studies have shown that blinded review, because it is less biased and may improve vigilance, is an excellent method for detecting errors and improving performance in gynecologic cytology. The value of blinded review in surgical pathology is not known. OBJECTIVE: To determine the value of blinded review in surgical pathology. METHODS: Five hundred ninety-two biopsy cases were reviewed without knowledge of the original diagnosis or history, and the results were compared with those of the original diagnosis. RESULTS: Complete agreement was obtained in 567 (96%) of 592 cases. The technique of blinded review of biopsy material had a sensitivity of 98%, failing to identify a lesion in 7 cases; no cases of malignancy were missed. The specificity was 100%. Differences in diagnostic threshold were the most common source of disagreement. False-negative cases were identified by the technique and were clinically significant. Power studies show that the number of cases requiring review to identify significant errors are large, but potentially achievable by blinded review. CONCLUSION: Blinded review is a sensitive and effective method for identifying areas of disagreement, including false-negative cases, and for decreasing errors in surgical pathology biopsy material.

Diagnostic Errors↗
PubMedDate not supplied

[Catatonia: resurgence of a concept. A review of the international literature].

Catatonia was first described in 1874 by Kahlbaum as being a cyclic disease mixing motor features and mood variations. Because most cases ended in dementia, Kraepelin recognized catatonia as a form of dementia praecox and Bleuler included it within his wide group of schizophrenias. This view influenced the psychiatric practice for more than 70 years. But catatonia was recently reconsidered and this because of the definition of more precise diagnosis criteria, the discovery of a striking association with mood disorders, and the emphasis on effective therapeutics. Peralta et al empirically developed a performant diagnostic instrument with the 11 most discriminant signs among catatonic features. Diagnostic threshold is three or more signs with sensitivity of 100% and specificity of 99%. These signs are: immobility/stupor (extreme passivity, marked hypokinesia); mutism (includes inaudible whisper); negativism (resistance to instructions, contrary comportment to whose asked); oppositionism, other called gegenhalten (resistance to passive movement which increases with the force exerted); posturing (patient adopts spontaneously odd postures); catalepsy (patient retains limb positions passively imposed during examination; waxy flexibility); automatic obedience (exaggerated co-operation to instructed movements); echo phenomena (movements, mimic and speech of the examiner are copied with modification and amplifications); rigidity (increased muscular tone); verbigeration (continuous and directionless repetition of single words or phrases); withdrawal/refusal to eat or drink (turning away from examiner, no eye contact, refusal to take food or drink when offered). Using this diagnostic tool, prevalence of catatonic syndrome appears to be close to 8% of psychiatric admissions. Other signs are also common but less specific: staring, ambitendance, iterations, stereotypes, mannerism, overactivity/excitement, impulsivity, combativeness. Some authors complete this description by adding an affective dimension which is considered specific. Clinical forms are differentiated according to evolution: acute, chronic and periodic forms exist; and symptomatology: excited catatonias have a best prognostic than retarded catatonias. Malignant catatonia is the most studied form because of its severity and high rate of mortality (25%); catatonic patients develop autonomic disturbances with labile blood pressure, hyperthermia, diaphoresis, etc. Malignant catatonia requires ECT intervention in emergency. While catatonias due to general medical conditions are well admitted (first concerned are neurologic etiologies) and concern 14,1% of catatonias, psychiatric comorbidity remains a problem. The documented decline in the proportion of patients with schizophrenia diagnosed as catatonic is congruent with the fact that most studies highlight the strong association between catatonia and mood disorders. However, customary clinical practice continues to over value diagnostic of schizophrenia because catatonic symptoms are recognized as schizophrenic and schizophrenia corresponds to a pharmacological target. Other authors stress that on average 20 to 40% of catatonias are idiopathic. Conceptual proximity between catatonic symptomatology and extrapyramidal syndrome could give some ways for neurobiological grasp of the trouble; mesolimbic and mesostriatal dopaminergic imbalance in a frontal lobe-basal ganglia-brainstem system is supposed to be involved. Treatment procedure could be standardized as follows: 1) Withhold neuroleptic medication. Those drugs are proven to be lethal when catatonic symptoms are developed; 2) Investigations to exclude treatable physical disorders (including standard blood laboratory tests, urinary drug screening, electroencephalogram and brain computerized tomography); 3) Trial of lorazepam. This therapeutic is safe and 80% effective. We propose to administer an initial oral 2,5 mg challenge; catatonic signs are rated after the first hours. If necessary, the patient could receive 3 mg/day with a 6-day full dose treatment and then, treatment would progressively be reduced; 4) If the patient failed to respond to lorazepam, ECT are needed; 5) Earlier use of ECT is recommended if autonomic instability or hyperthermia appears and malignant catatonia is suspected. In conclusion, catatonia has always had an unstable and blurred place in the psychiatric nosography since its first description. It has been incorporated within the group of schizophrenias and underdiagnosed for a long time, but has been predominantly associated with mood disorders for the last ten years. Psychopathological considerations, particularly on cognitive and affective status of catatonic patients, should clarify the nosologic discussion.

Benzodiazepines↗
PubMed2003

MR quantification of hepatic iron concentration.

PURPOSE: To evaluate the accuracy of magnetic resonance (MR) imaging in the quantification of hepatic iron concentration. MATERIALS AND METHODS: Between April 1999 and June 2001, 112 patients were recruited prospectively. All had undergone liver biopsy and hepatic iron concentration quantification with spectrophotometry, followed by MR imaging. MR imaging involved use of four gradient-echo sequences and one spin-echo sequence. Signal intensity (SI) was measured on images obtained with each sequence by means of regions of interest placed in the liver and paraspinal muscle to obtain the liver-to-muscle SI ratio. The relationship between hepatic iron concentration and SI ratio for each sequence was analyzed with multiple linear regression. Receiver operating characteristic analysis was performed to find the diagnostic thresholds. RESULTS: Sixty-eight patients had normal hepatic iron levels (<36 micromol/g), 23 had hemosiderosis (36-80 micromol/g), and 21 had hemochromatosis (>80 micromol/g). With all sequences, an inverse linear relationship between iron concentration and SI ratio was apparent. The authors generated a mathematic model to estimate the iron concentrations from MR imaging data (r = 0.937). For estimated concentrations of more than 85 micromol/g, the positive predictive value for hemochromatosis was 100%; for those less than 40 micromol/g, the negative predictive value for hemochromatosis was 100%. For estimated concentrations of more than 58 micromol/g, the positive predictive value for iron overload was 100%; for those less than 20 micromol/g, the negative predictive value for iron overload was 100%. CONCLUSION: MR imaging is a useful and noninvasive diagnostic tool for quantification of hepatic iron concentration.

Adult↗
PubMed1997

Doctors' attitudes towards the detection and treatment of hypertension in older people.

Within the former northern region a questionnaire was sent to a one in two random sample of general practitioners and to consultant physicians involved in the treatment of older hypertensive patients, to determine current attitudes of doctors to the management of hypertension in older people. A total of 407 general practitioners and 125 consultant physicians (including 38 consultant geriatricians) completed the questionnaire; response rates of 58% and 73% respectively. The median (range) threshold level for intervention of an otherwise well 75-year-old patient was 180 (140-240)/100 (90-120) mm Hg for general practitioners as against current recommendations of > or = 160/90 mm Hg. Geriatricians adopted significantly lower thresholds than both general practitioners and other specialists. Target blood pressure (BP) and drug therapy were in line with British Hypertension Society recommendations. The majority of general practitioners stated that they would initiate treatment for hypertension later, be less aggressive in their treatment and accept higher levels of BP than with younger patients. Approximately half perceived compliance and lifestyle changes as problematic in older people, while approximately a third were concerned about the problems created by drug treatment and uncertainty about the practicality of treating all older hypertensive patients. A quarter expressed reluctance to initiate hypertensive treatment because of side effects and to treat isolated systolic hypertension. These stated attitudes amongst general practitioners may explain the continuing conservatism in the management of hypertension. This study found considerable variation in diagnostic threshold between doctors, which suggests that current management of hypertension in older people is likely to vary significantly.

Aged↗
PubMed1993

Diagnostic efficiency of endotracheal aspirates with quantitative bacterial cultures in intubated patients with suspected pneumonia. Comparison with the protected specimen brush.

The objectives of the study were to determine the agreement between the protected specimen brush technique (PSB) with quantitative cultures and endotracheal aspirates (EA) with quantitative cultures when using increasing interpretative cutoff points and to investigate the respective operating characteristics for the diagnosis of pneumonia of PSB and EA when using quantitative cultures. Consecutive sampling of respiratory secretions using these two techniques was conducted in the respiratory intensive care units in 52 mechanically ventilated patients with clinical and radiologic suspicion of pneumonia. Quantitative bacterial cultures of PSB and EA samples were obtained. The 10(6) cfu/ml cutoff point was the most accurate diagnostic threshold for the EA technique. When using this threshold, there was a high level of agreement (84.6%) between PSB and EA results. Among the few discrepancies, the EA result was always indicative of pneumonia, whereas the PSB result was nonindicative, thus permitting us to classify correctly five patients in whom pneumonia would have been erroneously excluded on the basis of the sole result of PSB. Conversely, there was no case where the PSB result was indicative of pneumonia when the EA result (at the 10(6) cfu/ml level) was not. The operating characteristics of the PSB technique for the diagnosis of pneumonia were in accordance with previously published studies. The operating characteristics of the EA technique (when taking the 10(6) cfu/ml of respiratory secretions as the interpretative cutoff point) compared favorably with those of the PSB technique. Diagnostic accuracy rates were similar. The specificity of EA was somewhat lower (83 versus 96%), but the sensitivity was higher (82 versus 64%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗