Diagnosis Care Research Articles

Mental Health in Medicine: A novel stepped care model in medical psychiatry and the implementation of measurement-based care

IntroductionIndividuals with co-occurring mental and physical health issues have worse health outcomes in both domains. Integration improves outcomes and aligns with patient preference, but health services tend to be siloed. The Mental Health in Medicine Clinic (MHiM) supports patients receiving inpatient or outpatient medical or surgical care at a tertiary academic hospital in Toronto, Canada. The predominantly virtual clinic has an interdisciplinary team offering services via stepped care, matching patient need with service intensity. Measurement-based care (MBC), the systematic evaluation of patient reported outcomes, was not initially used routinely in the clinic, but its implementation may improve treatment decision-making and may be useful in allocating patients within a stepped care model.Objectives1) To describe the stepped care model, referral patterns, diagnoses, and level of care provided since implementation of stepped care. 2) To conduct a quality improvement initiative to implement MBC in the clinic, with a goal of 50% of patients completing at the time of first assessment and prior to discharge from the clinic.MethodsWe reviewed the electronic medical record for referral source, diagnoses, and level of stepped care within the clinic. We conducted semi-structured interviews with stakeholders (clinicians, administrative staff, patients) to explore barriers to implementation of MBC. Interviews were analyzed for themes around barriers and facilitators to MBC. Plan, Do, Study, Act cycles were carried out around change concepts informed by stakeholder interviews and relevant literature.ResultsThe MHiM clinic began operations in August 2020. The clinic operated on a physician-only model until March 2022 and then shifted to a stepped care model with an interdisciplinary team. The most frequent referral sources were internal medicine, COVID19 clinics, consultation-liaison psychiatry, red blood cell disorders clinic and cardiology. Since the implementation of stepped care, 250 referrals were assessed. 58% of new referrals were assessed by the psychiatrist, 42% were managed by the NP, and 25% consulted with the social worker. Referrals consisted of trauma and stress-related disorders (32%), depression (21%) or anxiety disorders (20%). Personality, substance use, and psychotic disorders accounted for less than 10% of referrals combined. Some patients did not have any diagnosis (6%). Results from the quality improvement initiative to implement MBC will also be presented.ConclusionsThe MHiM clinic provides an integrated care pathway addressing comorbid mental and physical health conditions. We describe a novel stepped care model and the implementation of MBC. Future directions include ongoing quality improvement of MBC and its integration within the clinic to assess and re-assess service intensity.Disclosure of InterestNone Declared

актуальные аспекты диагностики шизофрении у детей и подростков

Based on current clinical approaches are revealed the challenges and increasing importance of careful diagnosis of schizophrenia in children and adolescences based on ICD-10 criteria.

Multidimensional assessment of personality disorders using different theoretical models: a comparison of the Young Schema Questionnaire, the SCID-5-AMPD structured diagnostic interview, and the PDS-ICD-11 self-report questionnaire

IntroductionThere has been a recent shift in the conceptualisation of personality disorders in diagnostic systems such as DSM-5 or ICD-11, from a categorical approach towards a dimensional approach reflecting severity in general or severity of dysfunction and related pathological traits. In addition, several psychotherapeutic approaches work with their own model of personality pathology, which similarly capture symptoms of personality disorders and their underlying processes in a more subtle way from multiple aspects, and along different constructs.ObjectivesThe aim of our study was to investigate similarities and differences between conceptualisations of personality disorder and instruments used for evaluation based on the BNO-11 Personality Disorders Severity Questionnaire (PDS-ICD-11), Module I. of the Structured Diagnostic Interview for the DSM-5 Alternative Personality Model (SCID-5-AMPD) measuring level of personality function, and the Young Schema Questionnaire assessing early maladaptive schemas.MethodsHospitalized borderline patients were assessed using the Young Schema Questionnaire, the PDS-ICD-11, and Module I. of the SCID-5-AMPD assessing personality function level. Data are analysed using correlation and linear regression models.Results Only part of the results are shown. The PDS-ICD-11 Severity Index and Self-function Index showed significant (p<0.05) and strong correlations with the Abandonment (r=0.98, r=0.94), Vulnerability to harm and illness (r=0. 92, r=0.98), Insufficient Self-Control (r=0.91, r=0.88) and Negativism/Pessimism (r=0.95, r=0.90) schemas. The mean score and all domains of the SCID-5-AMPD Module I (level of personality function) showed significant strong correlations with the Vulnerability to harm and illness schema (AMPD-Average r=0.87; AMPD-Identity r=0.86, AMPD-Objectivity r=0.81, AMPD-Empathy r=0. 77, AMPD-Intimacy r=0.80, p<0.05); moreover, a strong significant correlation was found between the Abandonment schema and AMPD-Average (r=0.81, p<0.05), AMPD-Identity (r=0.98, p<0.05), and AMPD-Intimacy domains (r=0.77, p<0.05).ConclusionsThe main indicators of measures that operationalise a dimensional approach to personality disorders show distinct patterns of strong overlap with some of the maladaptive schemas but cover only a part of the schema domains. For a careful diagnosis and psychotherapeutic plan, the combined use of these measures can provide in-depth and multifaceted information.Disclosure of InterestNone Declared

Pneumothorax revealing miliary tuberculosis: A case report

Pulmonary tuberculosis can take several clinical and radiological forms; spontaneous pneumothorax is a serious complication of tuberculosis, and tuberculous miliary is a severe form of secondary tuberculosis due to hematogenous dissemination of Mycobacterium tuberculosis. We report a case of tuberculous miliary revealed by pneumothorax. The patient was 57 years old and a farmer. He was been presented to the emergency department of Mohamed VI University Hospital in Marrakech with acute dyspnea associated with chest pain. Clinical examination and imaging revealed a spontaneous pneumothorax that complicated tuberculous miliary. Treatment consisted of a combination of anti-tuberculosis chemotherapy, chest drainage, and kinesrespiratory therapy. The outcome was favorable, with improvement in clinical and radiological signs. Pneumothorax complicating TM requires careful diagnosis and prompt management to improve prognosis.

The pattern of back pain: from spondyloarthritis to lymphoma

inflammatory back pain, which rheumatologists often deal with in their practice, has certain characteristics. However, other non-rheumatological diseases can mimic inflammatory back pain. Non-compliance with the diagnostic criteria and the presence of additional symptoms, especially from the group of "red flags", such as weight loss, fever, night sweats, etc., require careful diagnosis. The purpose of the work is to analyze a clinical case of diffuse large B-cell lymphoma in a young patient with non-specific symptoms, differential diagnosis with seronegative spondyloarthritis associated with inflammatory bowel disease. The article uses the data of objective, instrumental and laboratory examination of the patient. The work presents a clinical case of back pain in a 27-year-old patient, in which a multidisciplinary approach and specific diagnostic procedures (lymph node biopsy, histological and immunohistochemical examination) made it possible to establish the final diagnosis - diffuse large B-cell lymphoma. Based on a clinical case, a review of the literature was performed with an emphasis on the differential diagnosis between rheumatic inflammatory back pain and other causes, including paraneoplastic pain and metastatic processes. The most common causes of chronic back pain in young men are spondyloarthritis, however, in the presence of weight loss, fever, night sweats and lymphadenopathy, back pain requires careful clinical, laboratory and instrumental examination of patients. Diffuse large B-cell lymphoma can be the cause of back pain, which requires the involvement of specialists of various profiles in order to verify the final diagnosis.

Socioeconomic disparities and health literacy: Unraveling the impact on diagnostic and cancer care in Uruguay

BackgroundDisparities in the timely diagnosis and care of cancer patients, particularly concerning geographical, racial/ethnic, and economic factors, remain a global health challenge. This study explores the multifaceted interplay between socioeconomic status, health literacy, and specific patient perceptions regarding care access and treatment options that impact cancer care in Uruguay. MethodsUsing the Cancer Health Literacy Test, Spanish Version (CHLT-30-DKspa), and a highly comprehensive questionnaire, we dissected the factors influencing the pathway to diagnosis and route of cancer care. This was done to identify delays by analyzing diverse socioeconomic and sex subgroups across multiple healthcare settings. ResultsPatients with lower income took longer to get an appointment after showing symptoms (p = 0.02) and longer to get a diagnosis after having an appointment (p = 0.037). Race/ethnicity also had a significant impact on the length of time from symptoms to first appointment (p =0.019), whereas employment status had a significant impact on patients being susceptible to diagnostic delays beyond the advocated 14-day window (p = 0.02). Higher educational levels were positively associated with increased cancer health literacy scores (p = 0.043), revealing the potential to mitigate delays through health literacy-boosting initiatives. Women had significantly higher self-reported symptom duration before seeking an intervention (p = 0.022). We also found many other significant factors effecting treatment delays and cancer health literacy. ConclusionsWhile affirming the global pertinence of socioeconomic- and literacy-focused interventions in enhancing cancer care, the findings underscore a complex, gendered, and perceptually influenced healthcare navigation journey. The results highlight the urgent necessity for strategically crafted, globally relevant interventions that transcend equitable access to integrate literacy, gender sensitivity, and patient-perception alignments in pursuit of optimized global cancer care outcomes.

Education to improve timeliness of shingles diagnosis in primary care: a cluster randomised study within a trial with nested qualitative study.

Herpes zoster (shingles) is normally diagnosed clinically. Timely diagnosis is important so that antiviral treatment can be started soon after rash onset. To assess whether a practice-level educational intervention, aimed at non-clinical patient-facing staff, improves the timely assessment of patients with shingles. This was a cluster randomised study within a trial (SWAT) with nested qualitative study in general practices in England. Practices were cluster randomised 1:1, stratified by centre and minimised by practice list size and Index of Multiple Deprivation score. Intervention practices were sent educational materials, highlighting the common presenting features of shingles and what action to take if suspected. The primary and secondary outcomes were the mean proportion of patients per practice seen within 72 and 144 h of rash onset, respectively. Comparison between groups was conducted using linear regression, adjusting for randomisation variables. Semi-structured interviews with practice staff in intervention practices explored views and opinions about the intervention. In total, 67 practices were enrolled; 34 randomised to the intervention and 33 to the control. The mean difference in proportion of patients seen within 72 and 144 h was -0.132 (95% confidence interval [CI] = -0.308 to 0.043) and -0.039 (95% CI = -0.158 to 0.080), respectively. In intervention practices, 90.9% reported distributing the educational materials; however, engagement with these was suboptimal. Twelve participants were interviewed, and the poster component of the intervention was said to be easiest to implement. Our educational intervention did not improve the timely assessment of patients with shingles. This may be the result of poor intervention engagement.

Protocol: Prospective evaluation of feasibility, added value and satisfaction of remote digital self-assessment for mild cognitive impairment in routine care with the neotivCare app

IntroductionTimely diagnosis of mild cognitive impairment (MCI) in Alzheimer’s disease is crucial for early interventions, but its implementation is often challenging due to the complexity and time burden of required...

A Rare Case of Ethmoido-Maxillary Osteoblastoma: Case Report and Systematic Review

Osteoblastoma (OB) is a rare benign osteogenic tumor, primarily found in the axial skeleton and long tubular bones. It accounts for <1% of all primary bone tumors, mainly affecting young adults. Maxillofacial involvement is rare, often manifesting in the mandible. Osteoblastoma's pathogenesis is unclear, with slow growth and varied clinical presentations. Radiologically, it appears as a well-defined, osteolytic lesion with sclerotic rims. The definitive diagnosis relies on histopathology, with immunohistochemistry aiding in challenging cases. Differential diagnoses include fibrous dysplasia, osteoid osteoma, osteomas, cemento-ossifying fibroma, and low-grade osteosarcoma. Surgical excision with safety margins is the standard treatment, while radiotherapy may be considered for certain cases. Prognosis is generally good, but long-term follow-up is essential due to recurrence risks, particularly in aggressive forms. Malignant transformation can occur, emphasizing the importance of careful diagnosis and management.

Understanding autism diagnosis in primary care: Rates of diagnosis from 2004 to 2019 and child age at diagnosis.

The current demand for autism diagnostic services exceeds the ability of the workforce to assess and diagnose children in a timely manner. One solution may be to equip primary care providers (PCPs) with the tools and expertise needed to diagnose autism within their practice. PCPs are often trusted professionals who have many touchpoints with children during early development, in which they can identify early signs of autism. Recent initiatives have focused on bolstering PCPs' diagnostic capabilities; however, no studies have examined how the rates of autism diagnosis in primary care have changed over time. We aimed to evaluate whether autism diagnosis in primary care has changed over time and how diagnosis in primary care relates to a child's age at the time of diagnosis. We found that the likelihood of a child being diagnosed by a PCP decreased by about 2% with every passing year from 2004 to 2019 when accounting for demographic characteristics. In our sample, PCPs diagnosed children approximately 1 year earlier than non-PCPs (e.g., psychologists and psychiatrists). Further research is needed to understand why the proportion of children diagnosed by PCPs decreases over time. However, this decrease suggests more work is needed to get capacity-building initiatives into community primary care practice. Though we must continue to find effective ways to build community PCPs' ability to diagnose autism, the present findings support the crucial role PCPs can play in early autism diagnosis.

Medical students’ awareness of overdiagnosis and implications for preventing overdiagnosis

Overdiagnosis is a growing health issue, yet our understanding of medical students’ exposure to this concept within medical education is limited. Our aim was to explore students’ experience of diagnostic learning to identify how overdiagnosis may be understood by students. During in-person and online semi-structured interviews throughout 2021, we explored the education experience of twelve Western Sydney University medical students in years 3–5. Through inductive thematic analysis we identified four themes. These themes encompassed student commitment to learning about diagnosis, lack of certainty surrounding diagnosis and emotional factors of medical care, overdiagnosis as seen through the lens of high and low-value care during clinical placements and student-identified missed learning opportunities related to overdiagnosis. This study found that medical students develop inherent knowledge of overdiagnosis through an interplay of personal factors, medical school curriculum and the setting in which their training takes place. Our findings allow insight for future improvement of medical curriculum to produce exceptional medical graduates.

Point of care lung ultrasonographic findings in patients with clinical diagnosis of severe childhood community acquired pneumonia in the tropics

Objectives: This study aimed at defining the Lung ultrasonographic (LUS) features of severe Childhood community-acquired pneumonia (CAP) in under-5s with clinical pneumonia, as well as the correlation between clinical and ultrasonographic findings. Materials and Methods: A prospective descriptive study conducted at the Children Emergency Ward of the University College Hospital (UCH), Ibadan, Nigeria over a 1-year period. Children aged 1month to 59 months, with clinical features of severe pneumonia were recruited for the study. LUS was done at the bedside. Ethical approval was obtained for the study. Results: There were 86 children with mean age ± SD of 13.59 ± 15.55 and 50 (58.1%) males. The highest number of patients (56, 65.1%) were in the 1-12-month age group. Ultrasonographic signs of pneumonia were detected in 68 (79.1%) of the children; 55(64%) had consolidation, 29(23.3%) showed florid B-lines and 20 (23.3%) had pleural fluid. Duration of cough, and crackles on auscultation were the only features that showed significant association with the LUS diagnosis of pneumonia. Conclusion: LUS is a good point of care diagnosis of CAP in under-5 children and it can be safely done at the bedside. It is therefore recommended as a first line imaging modality in children with clinical suspicion of CAP in the Tropics.

Pertussis: management and diagnosis in primary care

Emma Rickards looks at this often distressing respiratory condition which has been on the rise this winter

Evaluating the Precision of ChatGPT Artificial Intelligence in Emergency Differential Diagnosis

Introduction: artificial intelligence (AI) is the study and development of intelligent machines that can carry out tasks that would typically require human intelligence. AI seeks to give machines the ability to think, problem-solve, sense their surroundings, and comprehend human speech. By enhancing and optimising processes, this technology is predicted to completely transform a number of industries. Artificial intelligence is tipped to be the next technological breakthrough that will shape our future. Objective: This study focused on evaluating the precision of ChatGPT artificial intelligence in emergency differential diagnosis. Methods: This was a comparison study, conducted from August to September 2023, evaluating the ability of both the Monica ChatGPT and the emergency medicine textbooks to provide differential diagnoses for frequently occurring complaints. Twelve symptoms common to adult patients were included in the list of chief complaints. To gauge the accuracy of the ChatGPT’s answers, the researcher employed ChatGPT®-4 queries. Results: The total number of differential diagnoses captured by the two resources was 431. The ChatGPT captured a total of 272 differential diagnoses; however, 59 of these were not included in the list of the chief complaints. Conclusion: The study concludes that AI can be helpful in some situations, such as primary care diagnosis and patient triage, although in most cases it is not a better diagnostic tool. Therefore, AI and human diagnosis can be used concurrently in the health sector.

Future research priorities for soft-tissue knee injuries.

To identify unanswered questions about the prevention, diagnosis, treatment, and rehabilitation and delivery of care of first-time soft-tissue knee injuries (ligament injuries, patella dislocations, meniscal injuries, and articular cartilage) in children (aged 12 years and older) and adults. The James Lind Alliance (JLA) methodology for Priority Setting Partnerships was followed. An initial survey invited patients and healthcare professionals from the UK to submit any uncertainties regarding soft-tissue knee injury prevention, diagnosis, treatment, and rehabilitation and delivery of care. Over 1,000 questions were received. From these, 74 questions (identifying common concerns) were formulated and checked against the best available evidence. An interim survey was then conducted and 27 questions were taken forward to the final workshop, held in January 2023, where they were discussed, ranked, and scored in multiple rounds of prioritization. This was conducted by healthcare professionals, patients, and carers. The top ten included questions regarding prevention, diagnosis, treatment, and rehabilitation. The number one question was, 'How urgently do soft-tissue knee injuries need to be treated for the best outcome?'. This reflects the concerns of patients, carers, and the wider multidisciplinary team. This validated process has generated ten important priorities for future soft-tissue knee injury research. These have been submitted to the National Institute for Health and Care Research. All 27 questions in the final workshop have been published on the JLA website.

Cardiogenic shock diagnosis and management in general intensive care: a nationwide survey.

the epidemiology of cardiogenic shock has evolved over the years: in the last decades an increasing prevalence of cardiogenic shock related to acute decompensated heart failure was observed. Therefore, treatment bundles should be updated according to the underlying pathophysiology. No data exist regarding the diagnostic/therapeutic strategies in general intensive care units. A 27-questions survey was spread through the GiViTi (Italian Group for the Evaluation of Interventions in Intensive Care Medicine). The results were then divided according to level of hospitals (1st-2nd versus 3rd). Sixty-nine general intensive care units replied to the survey. The shock team is present in 13% of institutions; Society for Cardiovascular Angiography and Interventions shock classification is applied only in 18.8%. Among the ICUs, 94.2% routinely use a cardiac output monitoring device (pulmonary artery catheter more frequently in 3rd level centers). The first-line adrenergic drug are vasopressors in 27.5%, inotrope in 21.7% or their combination in 50.7%; 79.7% applies fluid challenge. The first vasopressor of choice is norepinephrine (95.7%) (maximum dosage tolerated higher than 0.5 mcg/kg/min in 29%); the first line inotrope is dobutamine (52.2%), followed by epinephrine in 36.2%. The most frequently used mechanical circulatory supports are intra-aortic balloon pump (71%), Impella (34.8%) and VA-ECMO (33.3%); VA-ECMO is the first line strategy in refractory cardiogenic shock (60.8%). According to this survey, there is no standardized approach to cardiogenic shock amongst Italian general intensive care units. The application of shock severity stratification and the treatment bundles may play a key role in improving the outcome.

Abstract 2405 Reconstructed SHARP-PCR system for point of care diagnosis (POC) for plant disease

Abstract 2405 Reconstructed SHARP-PCR system for point of care diagnosis (POC) for plant disease

Resistance to thyroid hormone and nonfunctioning pituitary microadenoma in a 13-year-old boy with THRB mutation.

Resistance to thyroid hormone (RTH) is a rare syndrome characterized by elevated serum free iodothyronines levels and non-suppressed thyroid stimulating hormones (TSH). The most common cause of RTH is heterozygous pathogenic mutations in thyroid hormone receptor β gene (THRB). Because of the similarities in biochemical profiles, differential diagnosis between RTHβ and TSH-secreting pituitary adenoma (TSHoma) is important, and accurate RTHβ diagnosis is essential to prevent inappropriate treatment. A 13-year-old boy was referred to our hospital for a microadenoma and uncontrolled hyperthyroidism despite use of methimazole for more than one year. He suffered from thyrotoxic clinical features and elevated serum T3 and fT4, and normal ranges for TSH and other pituitary hormones were noted. TSH receptor antibody was undetectable, and pituitary MRI revealed a 3mm-sized microadenoma. A TRH stimulation test showed normal TSH response, and the TSH-α-subunit level was not elevated, which is consistent with RTH. The patient was diagnosed with RTHβ and coexistent non-functioning pituitary microadenoma based on identification of a heterozygous mutation, c.1021C>G (p.Leu341Val), in THRB. Methimazole treatment was stopped, and a β-adrenergic blocking agent was started, subsequently thyrotoxic symptoms were relieved. Currently, only one pediatric case diagnosed with RTH and TSHoma has been reported so far, and this case is the first to report a pediatric case of coexistence of RTH and non-functioning pituitary microadenoma. Also, this case shows that inappropriate secretion of thyroid hormones requires careful clinical diagnosis to avoid unnecessary and potentially harmful management.

Evaluating referrals of flashing lights and floaters coming into secondary care from primary care

ABSTRACT Clinical Relevance Optometrists should look to take every opportunity to expand their knowledge, understanding and skills pertaining to vitreoretinal conditions. Background Despite the existence of acute eye care schemes and the up-skilling of optometrists, many units are still noticing large numbers of poor-quality referrals with high false positive rates. The authors pondered whether these schemes are effective. Methods At two different time points, a prospective analysis of patients took place, of all the flashing lights and floaters referrals coming into secondary care at the Royal Glamorgan Hospital, Wales, UK. The following data was captured: the exact source of the primary care referral, the diagnosis being queried, the secondary care diagnoses made and the secondary care management decisions. The accuracy of retinal break and Shafer’s sign detection were also directly compared between primary care and secondary care using Cohen’s Kappa Coefficient. Results For the 2018 period, n = 51 patients were included. For the 2022–23 period n = 100 patients were included. The majority of referrals during both periods were from optometrists (>80%) via the WECS pathway. The most common diagnoses being queried were retinal breaks (~50%), followed by retinal detachments (~20%). Interestingly up to 20% of patients seen in secondary care were diagnosed as normal examinations and ~ 20%. Over 1/3 of patients were discharged after their first visit to the EEC. Statistically significant differences were found between the accuracy of retinal tear and Shafer’s identification between the primary and secondary care settings. Conclusion A high number of false positive referrals are coming into secondary care from the WECS pathway and clear training and education needs have been identified.

Monitoring of patients with cardiovascular disease

Cardiovascular disease accounts for about one-third of deaths worldwide. Not surprisingly, health administrators and insurances are interested in monitoring healthcare performance and outcomes through standardized indicators obtained from reliable data. Hospital-based registries of cardiovascular disease patients are currently considered the reference standard in documenting how patients are treated relative to best practice recommendations outside the ideal world of clinical trials. Monitoring is done by special monitors designed to observe patients’ physiological state like heart rate and rhythm, blood pressure, respiration and oxygen saturation and have become a standard device for diagnosis, observation, assessment and treatment in coronary care. Changes in vital signs frequently precede deterioration in a patient’s condition and monitors provide valuable information and increase patient safety. Cardiac monitoring is a vital component in the management of the patients with cardiovascular disease. Knowledge of the general condition, location, and extent of a myocardial infarction and effective use of continuous cardiac monitoring will aid the nurse participate in the process of diagnosis and treatment.