Diagnostic Orientation Research Articles

Adecuación y calidad de las ecografías abdominales solicitadas por los profesionales de medicina

ObjectiveTo evaluate the acceptability/quality of abdominal ultrasound studies requested by primary care physicians in Barcelona; to develop ultrasound guidelines and assess their impact on acceptability. MethodsDesign: 2-phase study, one retrospective, descriptive phase evaluating the acceptability/quality of requests (pre-intervention phase) and another to assess the impact of guidelines on acceptability/quality (post-intervention phase). Subjects: Requests for ultrasound studies from January-June 2010 from 10 primary care centers and the same number of requests from the same centers after the intervention. Variables. Pre-intervention phase: reason for consultation and request; presence of diagnostic orientation; results of ultrasound; acceptability/quality of the request. Intervention: design guidelines using the nominal group technique, dissemination of guidelines in the same centers. Post-intervention phase: three months after dissemination analyze the same number of requests assessing the same variables included in the pre-intervention phase. ResultsPre-intervention phase: 1,063 requests, 52.4% women, mean age 52±16years (range 11-94). Post-intervention phase: 1,060 requests, 57.6% women, mean age 54±17years (range 6-91). Main reasons for requests: abdominal pain/discomfort 38.3% (pre-intervention) and 43.1% (post-intervention). Diagnostic orientation in 14.5% (pre-intervention) and 40.8% (post-intervention). Normal ultrasound results in 46.0% (pre-intervention) and 42.3% (post-intervention). Good quality of requests in 42.7% (pre-intervention) and 46.5% (post-intervention). Acceptability of ultrasound: 70.5% (pre-intervention) and 94.1% (post-intervention). The better the quality of the request, the better the acceptability of the studies and the greater the number of pathological conditions identified. ConclusionsGuidelines for ultrasound improve the quality of requests, diagnostic orientation and acceptability of the studies.

Epidemiologic profile of uveitis: about 105 cases

La difficulté du diagnostic des uvéites réside dans la multiplicité des étiologies. La détermination des facteurs épidémiologiques des uvéites permettent une meilleure orientation diagnostique et facilitent leur prise en charge thérapeutique. C'une étude rétrospective s’étalant sur 4 ans de janvier 2012 à décembre 2015. Nous avons colligé 105 dossiers d'uvéite et étudié les aspects épidémiologiques, cliniques et étiologiques. L’âge moyen était de 42 ans, la tranche d’âge la plus touchée était de 40-50ans. Les hommes étaient plus atteints (57,14%) que les femmes (42,86%). L'uvéite était unilatérale dans 60,95% des cas. Nous avons noté une uvéite antérieure dans 35,24%, une uvéite intermédiaire dans 5,71%, une uvéite postérieure dans 10,48% et une panuvéite dans 48,57%. Les étiologies étaient dominées par la maladie de Behçet, la sarcoïdose, et la maladie de Vogt-Koyanagi-Harada. L'origine restait indéterminée dans 43,81% des cas. L’évolution était variable. Les uvéites sont des inflammations intraoculaires qui peuvent représenter une réelle menace pour la vision. La démarche permettant de découvrir la cause doit être codifiée et repose sur plusieurs étapes. Nos résultats sont relativement proches de ceux de la littérature. Les uvéites constituent une entité clinique où ophtalmologie et médecine interne se rejoignent. Le champ des causes et des investigations permettant le diagnostic est vaste voire illimité. Cette étude a permis de mettre en évidence les difficultés cliniques et de souligner les limites de notre formation sanitaire dans la prise en charge des uvéites.

Questionnaire for Investigating Therapeutic Alliance in Forensic Setting (FTBF): Results of a Pilot Study

The relation between patient and therapist has a substantial effect on the success of psychotherapy. So far, in German-speaking regions questionnaires translated from English have been used, particularly for studying outpatients. Studies investigating and concerned with specialised features of hospitalised forensic psychiatry patients are sparse. The preliminary results of this study evaluating a recently developed questionnaire aimed to investigate the quality of the therapeutic relationship in forensic psychiatry ("Fragebogen zur therapeutischen Beziehung in der Forensik, FTBF") are reported. The data were collected both in general and forensic psychiatry departments. Factor analyses yielded two essential factors, namely "positive emotional aspects" (12 items, main features trust, respect, helpfulness, harmony, and sympathy; Cronbach's α = .933) and "negative emotional aspects" (4items, main features power divide and punishment; Cronbach's α = .805). Forensic patients experienced power divide and punishment tendencies more intensively than general psychiatry patients (p < 0.001). Our questionnaire therefore demonstrates not only excellent reliabilities but also differential validity, enabling a differentiation between general and forensic psychiatry patients. Studies with larger samples would enable conclusions about the impact of the therapists' perspective, specific diagnostic subgroups and different psychotherapeutic orientations, on the patient-therapist relationship in forensic psychiatry.

Neoplasms of the disseminated neuroendocrine cell system of the gastrointestinal tract

The classification of neuroendocrine neoplasms (NEN) of the gastrointestinal tract and also the pancreas is based on the World Health Organization (WHO) classification from 2010, the site-related TNM stage classification and the clinicopathological characterization. This allows a classification of NEN that is adapted to the individual patient, is of high prognostic relevance and serves the needs of an adequate treatment. This article summarizes the current knowledge on the clinical pathology of gastrointestinal NEN, in order to enable a rapid diagnostic orientation.

METHODOLOGICAL BASES FOR DIAGNOSIS OF INNOVATION OPPORTUNITIES TOURISM ORGANIZATION

The major problems affecting the innovative processes in the tourist organization are grouped in the article. The tourist activity is so diverse that in some cases the restriction of the study does not lead to the formulation of representative findings. Considering diagnosing as the element of the preventive failure in the innovative process, the author of the article offered the possible types of model diagnostic of innovative potential and structuring of the diagnostic techniques of innovative tourist organization. It is proposed to distinguish three diagnostic orientation: a study of real innovation potential tourist organizations, the construction and study of models innovative potentials tourist organizations and the study of diagnostic systems and their links with the innovative potential. Noted that the essential point of preparing diagnosis is the selection informative signs for description of the innovation potential and the establishment of temporary and financial parameters of its holding.

Automated reticulocyte parameters for hereditary spherocytosis screening.

The laboratory diagnosis of hereditary spherocytosis (HS) is based on several screening and confirmatory tests; our algorithm includes clinical features, red blood cell morphology analysis and cryohaemolysis test, and, in case of positive screening, sodium dodecyl sulphate polyacrylamide gel electrophoresis as a diagnostic test. Using the UniCel DxH800 (Beckman Coulter) haematology analyser, we investigated automated reticulocyte parameters as HS screening tool, i.e. mean reticulocyte volume (MRV), immature reticulocyte fraction (IRF) and mean sphered cell volume (MSCV). A total of 410 samples were screened. Gel electrophoresis was applied to 159 samples that were positive for the screening tests. A total of 48 patients were diagnosed as HS, and seven were diagnosed as acquired autoimmune haemolytic anaemia (AIHA). Some other 31 anaemic conditions were also studied. From the receiver operating characteristic (ROC) curve analysis, both delta (mean cell volume (MCV)-MSCV) and MRV presented an area under the curve (AUC) of 0.98. At the diagnostic cut-off of 100 % sensitivity, MRV showed the best specificity of 88 % and a positive likelihood ratio of 8.7. The parameters IRF, MRV and MSCV discriminated HS not only from controls and other tested pathologies but also from AIHA contrary to the cryohaemolysis test. In conclusion, automated reticulocyte parameters might be helpful for haemolytic anaemia diagnostic orientation even for general laboratories. In combination with cryohaemolysis, they ensure an effective and time-saving screening for HS for more specialised laboratories.

Malaises graves d’origine allergique chez le nourrisson

The analysis of an apparent life-threatening event is mainly based on the clinical approach. When the event occurs after a meal, the diagnosis of acid gastroesophageal reflux complicated by esophagitis is suspected first. Cow's milk protein allergy is suspected when the event occurs during weaning from breastfeeding or when it is accompanied by urticaria or relapses when cow's milk is reintroduced. We report on two cases of an apparent life-threatening event associated with cow's milk protein allergy, whose symptoms and first diagnostic approach initially delayed diagnosis. Clinical manifestations of food allergy need to be known in order to avoid errors in diagnostic orientation and therapy, which may be responsible for more severe recurrences.

Diagnostic orientation and risk stratification in syncope

Syncope represents an important health issue due to the number of emergency room presentations as well as the costs associated either to patient evaluation, or to therapeutic means in certain situations. Despite recent endeavors to optimize the approach to a patient with syncope, this is still heterogeneous in day to day practice and inconsistencies with the current guidelines recommendations are still found. We use a case presentation of a cardiac syncope as a starting point in order to outline the initial evaluation and the serious adverse events risk stratification methods of a patient with syncope.

Right orbital tumor: Which diagnostic orientation? What therapeutic approach to adopt? What definitive diagnosis?

European Annals of Otorhinolaryngology, Head and Neck Diseases - Vol. 131 - N° 1 - p. 75-78

Long Term Follow-Up in Small Bowel Transplant Recipients: Ebv Infections and Post Transplant Lymphopfoliferative Disease Surveillance

Background: Control of complications is still one of the most important clinical challenge in small bowel transplantation. Early diagnosis and fast treatment can avoid negative outcomes, so obviously reliable monitoring protocols are capital: the aim of this study was to evaluate endoscopic and histological diagnostic value on a long term follow-up in case of EBV infection and PTLD occurrence. Patients and methods: We evaluated endoscopies performed during last six years on 18 recipients submitted to small bowel transplant between the year 2000 and 2006: follow-up endoscopies and biopsies after 5 years from transplant were routinely scheduled once every 6 months, otherwise more often in case of clinical indications. At transplant, recipients underwent preemptive antiviral therapy and subsequently serial monitoring of Epstein-Barr-Viral load was performed. In case of intestinal EBV infection with negative blood viral load the patients were treated only with low immunosuppression regimen. Patients with EBV infection found both on intestinal specimen and on blood samples, were treated reducing immunosuppression regimen and with i.v. Gancyclovir administration (5mg/Kg 2 times/day) for 2 weeks; patients with PTLD diagnosis were treated with low immunosuppression regimen and with Rituximab administration (375 mg/m2, once/week for 4 weeks). Results: In our series we were able to diagnose EBV infections (both in blood and intestinal mucosa), and consequently to make an early diagnose of PTLD when occurring thanks to close follow-up: endoscopy with biopsies and EBV monitoring on specimen and blood every month, PET scan every 6 month in case of positive blood EBV infection. During the considered follow-up period, with at least 5 years from transplant, we diagnosed 12 cases of EBV intestinal infections, 5 of them with positive blood viral load. Among these five cases, even if they were all treated with Gancyclovir administration, 3 patients developed PTLD occurrence and they were all treated with four weeks Rituximab schedule: we registered negative outcome in one case (the patient died due to post-operative complications after intestinal resection of obstructive intestinal PTLD); other two patients appear now free from disease, with complete PET healing on latest follow-up, even if one of them still has EBV positive intestinal biopsies and blood samples and he is under antiviral therapy up to now. Conclusion: EBV infection is one of the most common complication after intestinal transplantation, with an incidence of 67% in our series. After a median follow-up of 36 months (12-60 months) the overall survival is 88,8 %. Therefore, concerning EBV infections and PTLD surveillance during long term follow-up, endoscopy and histological analysis are good tools to provide faster diagnostic orientation, to plan appropriate treatment earlier, and to achieve positive outcomes.

Capacidad predictiva de los parámetros clínico de bacteriemia en pacientes hemodializados

Background: No clinical events to differentiate bacteteremia from other pathologies in hemodialysis patients therefore the physicians makes diagnosis and treatment decisions based on clinical evidence an local epidemiology Objective: the aim of this work was to study the frequency of microorganism isolated from blood culture of hemodialysis patients with suspected bacteraemia and evaluate Sensitivity (S) and Specificity (E) of medical diagnostic orientation in this cases of suspected Materials and methods: we performed an observational and prospective study for one year in hemodialysis patient with suspected bacteremia. We evaluated blood pressure, temperature (Tº), altered conscious state (AEC), respiratory frequency (FR), chills (ESC),diarrhea (DIARR), blood culture results and microbiological identification. We work with the mean ± standar desviation for continuous variables and frequencies for categorical variables We analyzed S, E, negative predictive value (VPN), positive predictive value (VPP) Resultados: a total of 87 events with suspected bacteremia 34 (39%) were confirmed with positive blood culture the most common microorganisms were cocci Gram positive (CGP) 65%,Most relevant clinical variables were PCP ? 2 (VPN 81%), Tº ? 38 (VPN 76%) and AEC (E 98% y VPP 80%). Conclusions: CGP were the most prevalent microorganisms None of the clinical variables shows high S and E indicating low usefulness as a predictive tool of bacteremia Excepting AEC with E98% and VPP 80% but it would be necessary to evaluate this variable with a more number patient. Results justify to routine HC use like diagnostic tool.

¿Qué necesitan saber los cirujanos ortopédicos del radiólogo?

The diagnosis of tumors and pseudotumors depends on three pillars: the clinician, the radiologist, and the pathologist. The first two can establish a presumptive diagnosis on the basis of the clinical presentation and findings on complementary tests, whereas the pathologist will have to reach the definitive diagnosis after analyzing the biopsy specimens. Obviously, the clinician and radiologist should reach a consensus regarding the diagnostic orientation; however, for this to happen there must be a relationship between the two professionals and they must work together for the benefit of the patient. Orthopedic surgeons, like any other group of specialists, would like to have radiologists working in their own center who are dedicated to the organ/system they treat, in this case the locomotor apparatus, and who can provide them with their opinion about the different images obtained. This point is very important and especially so for tumors, because this type of disease is uncommon and few specialists are dedicated to it. For this reason, when faced with a lesion that has the characteristics of a tumor, orthopedic surgeons would like radiologists to give the most accurate description of the images as possible, defining the characteristics of benignity or malignancy of the process as well as indicating the risk of fracture in a metastatic lesion. On the other hand, orthopedic surgeons would ask for a clear and comprehensible description of the images obtained in complementary tests, because orthopedic surgeons have less experience in this type of images and they are often difficult to interpret. Another aspect that is often mentioned in discussions among orthopedic surgeons is the importance of having a radiology department that performs interventional procedures. Radiologists that perform interventional procedures can facilitate our work very much, both in the diagnosis and in the treatment of certain bone tumors.Finally, we would like to stress the importance of having a radiologist who collaborates with us and is interested in our work, supporting us without being overly critical. This is also important for our relations with patients; radiologists, like all professionals, must know their responsibilities and limitations in aspects related to intervention and in elaborating the corresponding reports.

Nodule thyroïdien bénin fixant le 99mTc-MIBI

ObjectivesTo illustrate a case of intense uptake of 99mTc-MIBI on benign thyroid nodule and to recall the mechanisms of this uptake. Case presentationA patient of 25years old had a parathyroid scintigraphy for suspected right lower parathyroid adenoma. The exam showed intense uptake of 99mTc-MIBI at the infero-lateral region of the right thyroid lobe. Low levels of PTH prompted to perform a thyroid scintigraphy for better diagnostic orientation. The scan revealed a large cold right basilobar thyroid nodule. The patient underwent a right loboisthmectomy. The histological analysis found a 3cm diameter vesicular adenoma with oncocytic cells of the lower pole of right thyroid lobe. Discussion/conclusion99mTc-MIBI is used in the imaging of hyperparathyroidism. Radiotracer uptake is correlated to the parathyroid adenoma content in oxyphil cells. These cells are rich in mitochondria and retain the 99mTc-MIBI. This radiotracer can bind also on thyroid nodules. The specificity of this uptake for the diagnosis of malignancy is low. It is relevant to the nodule's wealth in oncocytic cells. These cells possess numerous mitochondria and can sequester 99mTc-MIBI like parathyroid oxyphil cells.

Anaemia in the elderly: An aetiologic profile of a prospective cohort of 95 hospitalised patients

Background and objectivesAnaemia is a significant problem in the elderly, and the cause of anaemia in approximately one third of the general population is unidentified. To date, only a few studies have focused on hospitalised patients. Patients and methodsWe prospectively included anaemic patients (according to OMS criteria) aged 65years and older who were hospitalised in the internal medicine department. The typical clinical data were collected, and a standardised set of biological tests, including cupraemia was performed. ResultsOf 360 total patients, 191 (53%) patients were anaemic; however, 96 patients were excluded because their data were incomplete. Of the remaining 95 patients that were included, 45 were men (47.4%) and 50 were women (52.6%); the mean patient age was 79.7years (66–101years). At least one cause of anaemia was diagnosed in 87 of the 95 (91.6%) patients, and anaemia was multifactorial in 44 of the 95 (46.3%) cases. The five most prominent causes of anaemia were inflammation (62.1%), iron deficiency (30.5%), folic acid deficiency (21%), chronic renal failure (17.9%) and cobalamin deficiency (11.6%). Microcytosis was present in only 27.5% of the patients who had an iron deficiency, and macrocytosis was present in only 7.4% of the patients who had a folic acid and/or cobalamin deficiency. The cause of anaemia could not be identified for 8 of the patients. The cupraemia was normal in all the patients. ConclusionA predefined protocol for older hospitalised patients was ability to identify the aetiology of anaemia in 91.6% of the cases; strikingly, anaemia was frequently caused by more than one factor (43.5%). Diagnostic orientation based on the mean corpuscular volume does not appear to correlate with mean cellular volume profile. Finally, anaemia caused by an unknown aetiology is rare and copper deficiency was not documented in any case.

Quoi de neuf en dermatologie clinique?

This year more than 3000 medical articles referenced in PubMed concerned dermatology. Our critical analysis covers different fields of dermatology: including epidemiology, clinical, diagnostic and prognostic factors. AIDS is 30 years old and the national HIV/AIDS plan for 2010-2014 recommends generalized screening facilitated by the introduction of rapid tests for diagnostic orientation. In infectious diseases, novelties concern polyomavirus, HTLV-1, leprosy, staphylococcus infections, resistance to antibiotics and scabies. Diseases of the scalp consecutive to practices of black women hairstyles were the subject of important articles. There were two important developments in acne: first, a simplified and more operational classification, secondly a suicidal risk associated with severe forms. Lymphocyte Th-17 immunity is involved in clinical phenomena either by excess (genetic or drug) or default (genetic causes). Allergology: in several studies, false negative patch tests have been published. The natural history of nevi is specified by three important articles. Serological tests to practice in cases of dermatomyositis and bullous pemphigoid are specified.

Reliability and validity of the SPAID-G checklist for detecting psychiatric disorders in adults with intellectual disability

SPAID (Psychiatric Instrument for the Intellectually Disabled Adult) is the first Italian tool-package for carrying out psychiatric diagnosis in adults with Intellectual Disabilities (ID). It includes the "G" form, for general diagnostic orientation, and specific checklists for all groups of syndromes stated by the available classification systems. SPAID was established to provide an easy and quick tool for daily practice of the personnel working with ID. The present study was aimed at evaluating psychometric and psychodiagnostic characteristics of the SPAID-G and at supplying new data on the prevalence rate of psychiatric disorders in a multicentric Italian sample of people with ID living in different settings. The SPAID-G was randomly applied to 304 participants with ID attending residential facilities or assessment services across Italy. A part of the sample was also consecutively assessed through the use of DASH, PDD-MRS and by the clinical application of the DSM-IV TR criteria. The correlation between SPAID-G scores and those provided by other evaluation tools was over 60%. Additionally, the internal consistency and inter-rater reliability resulted to be good. Psychopathological symptoms were detected in approximately 40% of the sample. Respectively, autistic spectrum disorders, impulse control disorders, mood disorders, and dramatic personality disorders were the diagnostic orientations providing the most prevalent over-threshold scores. SPAID-G seems to be a valid diagnostic tool, quick and easy to use in psychiatric disorders assessment within the Italian population with ID.

Introduction of a management system in Intensive Care Medicine based on the safety of the seriously ill patient during the entire hospitalization process: Extended Intensive Care Medicine

The clinical care of hospitalized seriously ill patients must be suitably proportionate independently of the functional unit to which they have been admitted. Most of these patients are admitted to the Intensive Care Unit (ICU), where uninterrupted management is provided, with important technological and care resources. However, hospitalization of the seriously ill patient must be understood as a continuum starting and ending beyond hospital stay. Anticipating critical worsening requiring admission to the ICU would be of benefit to the patient, avoiding greater clinical worsening, and also would be of benefit to the hospital, by allowing improved resource management.Intensivists are the professionals best suited for this purpose, since they are trained to recognize the seriousness of an always dynamic clinical situation. Addressing this task implies a change in the traditional way of working of the ICU, since a critical patient is not only a patient already admitted to the Unit but also any other patient admitted to hospital whose clinical situation is becoming destabilized. In this context, our ICU has established two strategic lines. One consists of the identification of patients at risk outside the Unit and is based on the recognition, diagnostic orientation and early treatment of the seriously ill patient, in collaboration with other clinical specialties and independently of the hospital area to which the patient has been admitted. The second line in turn comprises clinical care within the actual Unit, and is based on the promotion of safety and the vigilance of nosocomial infections.

Implantación de un sistema de gestión en Medicina Intensiva basado en la seguridad del paciente gravemente enfermo durante todo el proceso de hospitalización: servicio extendido de Medicina Intensiva

The clinical care of hospitalized seriously ill patients must be suitably proportionate independently of the functional unit to which they have been admitted. Most of these patients are admitted to the Intensive Care Unit (ICU), where uninterrupted management is provided, with important technological and care resources. However, hospitalization of the seriously ill patient must be understood as a continuum starting and ending beyond hospital stay. Anticipating critical worsening requiring admission to the ICU would be of benefit to the patient, avoiding greater clinical worsening, and also would be of benefit to the hospital, by allowing improved resource management. Intensivists are the professionals best suited for this purpose, since they are trained to recognize the seriousness of an always dynamic clinical situation. Addressing this task implies a change in the traditional way of working of the ICU, since a critical patient is not only a patient already admitted to the Unit but also any other patient admitted to hospital whose clinical situation is becoming destabilized. In this context, our ICU has established two strategic lines. One consists of the identification of patients at risk outside the Unit and is based on the recognition, diagnostic orientation and early treatment of the seriously ill patient, in collaboration with other clinical specialties and independently of the hospital area to which the patient has been admitted. The second line in turn comprises clinical care within the actual Unit, and is based on the promotion of safety and the vigilance of nosocomial infections.

Management of Demented Patients in Emergency Department

The hospitalization of the elderly with acute illness is one of the most discussed in the organization of health services, it is not yet clear whether the hospital is really the best response to the needs of the elderly, especially those with cognitive impairment. Despite evidence of possible adverse effects of hospitalization (immobilization, acute confusional state resulting in sedation, risk of falls, intestinal sub-ileus), there has been an increasing use of the hospital, particularly to specialist services. Regardless of the benefits from the shelter (instrumental diagnosis and prompt treatment of acute somatic disease), in people with dementia it needs to identify the characteristics of the person (cognitive impairment, functional status, somatic comorbidity, social and familial status), the personal needs and, therefore, diagnostic and therapeutic targets which must be assumed for that sick person during hospitalization. To this end, it is fundamental the role of assessment and diagnostic orientation that takes place in the Department of Emergency and Acceptance (DEA), which mainly receives patients at the hospital. Even before the hospital recovery it is therefore essential to check how many elderly patients with cognitive impairment that belong to the DEA, and what are their needs.

Hematological Reference Values for Healthy Adults in Togo

The hematological reference values are very important for diagnostic orientation and treatment decision. The aim of this study was to establish hematological reference values for healthy adults in Togo. A total of 2571 voluntary blood donors participated to this study. Only 1349 subjects negative for HIV, HBV, HCV, malaria, and without hemoglobin abnormalities in electrophoresis and hypochromia on blood smear, were definitively retained for the study. Median hemoglobin level was higher in males than females (15.1 g/dL versus 13.0 g/dL, p = 0.000). Median total WBC (4.2×109/L) and absolute neutrophil counts (1.6×109/L) were similar by gender. The median lymphocyte counts in males and females were, respectively, 2.1×109/L and 2.2×109/L (p = 0.11). The median platelet count was lower in males than females (236×109/L versus 247×109/L, p = 0.004). Our median values for RBC parameters differ from those of African countries probably because of our inclusion criteria which eliminate most cases with iron deficiency and/or thalassemia.