Diagnostic Recognition Research Articles

Multi-comparative systems biology analysis reveals time-course biosignatures of in vivo bovine pathway responses to B. melitensis, S. enterica Typhimurium and M. avium paratuberculosis

BackgroundTo decipher the complexity and improve the understanding of host-pathogen interactions, biologists must adopt new system level approaches in which the hierarchy of biological interactions and dynamics can be studied. This paper presents the application of systems biology for the cross-comparative analysis and interactome modeling of three different infectious agents, leading to the identification of novel, unique and common molecular host responses (biosignatures).MethodsA computational systems biology method was utilized to create interactome models of the host responses to Brucella melitensis (BMEL), Salmonella enterica Typhimurium (STM) and Mycobacterium avium paratuberculosis (MAP). A bovine ligated ileal loop biological model was employed to capture the host gene expression response at four time points post infection. New methods based on Dynamic Bayesian Network (DBN) machine learning were employed to conduct a systematic comparative analysis of pathway and Gene Ontology category perturbations.ResultsA cross-comparative assessment of 219 pathways and 1620 gene ontology (GO) categories was performed on each pathogen-host condition. Both unique and common pathway and GO perturbations indicated remarkable temporal differences in pathogen-host response profiles. Highly discriminatory pathways were selected from each pathogen condition to create a common system level interactome model comprised of 622 genes. This model was trained with data from each pathogen condition to capture unique and common gene expression features and relationships leading to the identification of candidate host-pathogen points of interactions and discriminatory biosignatures.ConclusionsOur results provide deeper understanding of the overall complexity of host defensive and pathogen invasion processes as well as the identification of novel host-pathogen interactions. The application of advanced computational methods for developing interactome models based on DBN has proven to be instrumental in conducting multi-conditional cross-comparative analyses. Further, this approach generates a fully simulateable model with capabilities for predictive analysis as well as for diagnostic pattern recognition. The resulting biosignatures may represent future targets for identification of emerging pathogens as well as for development of antimicrobial drugs, immunotherapeutics, or vaccines for prevention and treatment of diseases caused by known, emerging/re-emerging infectious agents.

Poster Presentations

Background : Recently, a tentative model of Stress-Induced Depression (STR-I-D) was proposed. The aetiology and development of STRI-D is suggested to be mediated by four neurobiological mechanisms: monoamine dysfunction, hypothalamo-pituitary adrenocortical axis dysfunction, neurogenesis dysfunction and neuroinfl ammation. While exercise is an effective adjunct or standalone therapy in the treatment and prevention of depressive disorders, its neurobiological basis is poorly understood and warrants further investigation. Objectives : To review the literature on the neurobiological mechanisms involved in the aetiology and development of STR-I-D and to review the infl uence of exercise on these neurobiological mechanisms and how it may be useful to prevent or attenuate STR-I-D. Methods : The author systematically reviewed the scientific literature on the subject over the last 30 years, searching PubMed, OvidSP and ScienceDirect databases. Main search terms included: neurotrophin, neuroinflammation, monoamine, hypothesis, psychological stress, murine, human and translational. Findings : Chronic psychological stress has a multitude of effects on the central nervous system which are known to contribute to the development of depression. These include a reduction in serotonin levels, hypercortisolaemia, reduced brain-derived neurotrophic factor and elevated proinfl ammatory cytokines (i.e. tumour necrosis factor alpha and interleukin-6). Findings are consistent across murine-based models and human studies. Preliminary data suggests exercise has beneficial effects on these same neurobiological processes, which take part in the development of depression. Conclusions : Current literature suggests an association between the four neurobiological mechanisms, STR-I-D and exercise. Further research into these mechanisms is needed to improve diagnostic recognition, predict treatment response and to provide a basis for efficient, individualised therapies.

The archaic distinction between functioning and nonfunctioning neuroendocrine neoplasms is no longer clinically relevant

Neuroendocrine neoplasms (NENs) are increasing in incidence and prevalence. This reflects greater clinical awareness, effective imaging, and increasing pathological diagnostic recognition. Although the identification and treatment of clinical neuroendocrine syndromes are established, there is confusion when a NEN has no discernible clinical symptoms. Nonfunctional tumors are usually diagnosed incidentally and at a later stage largely because either they do not secrete a bioactive product or do so, but in a form that is either inactive or in quantities that have no discernible effect. Nevertheless, the histopathology is indistinguishable from functional NENs, and tumors exhibit somatostatin receptor expression, and positive immunohistochemistry for neuroendocrine cell markers (CgA, NSE/synaptophysin). Similarly, their rates of growth and metastatic behavior are, like other NENs, predictably based on staging and grading (mitotic rate and Ki67 expression). Both types are diagnosed biochemically (CgA) and by imaging in an identical fashion with computed tomography, magnetic resonance imaging, somatostatin receptor scintigraphy, and endoscopic ultrasound. NENs, irrespective of function or bioactive secretory profile, respond with equal efficacy to the same regimen of surgery or antitumor drugs (e.g., somatostatin analogs with or without tyrosine kinase inhibitors/antiangiogenics or cytotoxics) depending on grade. Given the efficacy of somatostatin analogs in increasing progression free survival, nonfunctional NENs should be managed identically to symptomatic NENs. The consideration of NENs as functional or nonfunctional is an archaic clinical concept that should be discarded since the tumors are indistinguishable at a cellular, biological, and morphological level. All current evidences indicate that their diagnosis and treatment should follow the same common principles.

IgG4 plasma cells in inflammatory myofibroblastic tumor: inflammatory marker or pathogenic link?

Inflammatory myofibroblastic tumor is a rare mesenchymal neoplasm that harbors an anaplastic lymphoma kinase (ALK) gene rearrangement in the majority of cases. It is composed of fibroblastic–myofibroblastic cells with a characteristic inflammatory infiltrate that consists predominantly of plasma cells. In contrast, IgG4-related sclerosing disease is a recently described multisystem disorder with a histological appearance similar to inflammatory myofibroblastic tumor. The plasma cell infiltrate is characteristic in IgG4-related sclerosing disease and has been studied as a tool to render this diagnosis. Histologically, the two disorders overlap, although there are significant clinical differences. This study analyzes the histological appearance of 36 inflammatory myofibroblastic tumors, compares them with IgG4-related sclerosing disease, and assesses the plasma cell profile using immunohistochemistry to determine the range and proportion of IgG4 plasma cells. The majority of patients were children and young adults, mainly with solitary masses and no clinical manifestations of IgG4-related sclerosing disease. ALK-1 positivity was present in 23 cases (64%). None showed obliterative phlebitis or prominent lymphoid aggregates. Of 36 inflammatory myofibroblastic tumors, 15 cases showed an IgG4/IgG ratio ≥0.10, a cutoff described in the literature as supportive of IgG4-related sclerosing disease and up to 33 IgG4-positive plasma cells per high-power field indicating a mild-to-moderate increase as compared with IgG4-related sclerosing disease. Currently, the diagnostic recognition of inflammatory myofibroblastic tumor is based on clinicopathological features and diagnostic adjuncts, such as ALK-1 reactivity and genetic tests. Although inflammatory myofibroblastic tumor and IgG4-related sclerosing disease are distinct entities, a subset of inflammatory myofibroblastic tumors exhibit an IgG4/IgG ratio that is within the range for IgG4-related sclerosing disease. Therefore, the ratio alone cannot be used as a reliable discriminator between these two entities and other clinical and pathologic features must always be taken into account.

The Efficacy of a Targeted Remediation Process for Students Who Fail Standardized Patient Examinations

Background: Current remediation strategies for students failing standardized patient examinations represent poorly targeted approaches since the specific nature of clinical performance weaknesses has not been defined. Purpose: The purpose is to determine the impact of a specifically targeted clinical performance course required of students who failed a clinical performance examination. Methods: A month-long clinical performance course, targeted to treat specific types of clinical performance deficiencies, was designed to remediate students failing standardized patient examinations in 2007 (n = 8) and 2008 (n = 5). Participating students were assessed on pre- and postperformance measures, including multiple-choice tests that measured diagnostic pattern recognition and clinical data interpretation and clinical performance measures using standardized clinical encounters. Comparisons between average pre- and postintervention performance scores were computed using paired sample t tests. Results were adjusted for regression toward the mean. Results: In both 2007 and 2008, the mean preintervention clinical data interpretation and standardized patient examination scores were below the criterion referenced passing standard set for the clinical competency exam. In both years the mean postintervention scores for the participants were above the passing standard for these two examinations. Pre- and postintervention differences were statistically significant in both cases. Conclusions: This study provides insight into the reasons that students fail clinical performance examinations and elucidates one method by which such students may be successfully remediated.

The Influence of Color Information on the Recognition of Color Diagnostic and Noncolor Diagnostic Objects

ABSTRACT In the present study, the authors explore in detail the level of visual object recognition at which perceptual color information improves the recognition of color diagnostic and noncolor diagnostic objects. To address this issue, 3 object recognition tasks with different cognitive demands were designed: (a) an object verification task; (b) a category verification task; and (c) a name verification task. The authors found that perceptual color information improved color diagnostic object recognition mainly in tasks for which access to the semantic knowledge about the object was necessary to perform the task; that is, in category and name verification. In contrast, the authors found that perceptual color information facilitates noncolor diagnostic object recognition when access to the object's structural description from long-term memory was necessary—that is, object verification. In summary, the present study shows that the role of perceptual color information in object recognition is dependent on color diagnosticity.

Semantic Sparse Representation of Disease Patterns

Semantic Sparse Representation of Disease PatternsSparse data representation is discussed in a context of useful fundamentals led to semantic content description and extraction of information. Disease patterns as semantic information extracted from medical images were underlined because of discussed application of computer-aided diagnosis. Compressive sensing rules were adjusted to the requirements of diagnostic pattern recognition. Proposed methodology of sparse disease patterns considers accuracy of sparse representation to estimate target content for detailed analysis. Semantics of sparse representation were modeled by morphological content analysis. Subtle or hidden components were extracted and displayed to increase information completeness. Usefulness of sparsity was verified for computer-aided diagnosis of stroke based on brain CT scans. Implemented method was based on selective and sparse representation of subtle hypodensity to improve diagnosis. Visual expression of disease signatures was fixed to radiologist requirements, domain knowledge and experimental analysis issues. Diagnosis assistance suitability was proven by experimental subjective rating and automatic recognition.

STRUCTURE AND DISTRIBUTION OF LEADING ZOONOSES IN VOJVODINA IN 2000-2009 PERIOD

The data show that from more than 1.400 today known microorganisms, that cause infections in human population, 61% is of animal origin. The list of known zoonoses is enlarged every day, new diseases are recognized and discovered. Because of this, zoonoses are significant health and economical problem in the world. The participation of these diseases in national pathology of the inhabitants of certain area depends on the presence and number of foci, type of reservoir species, application and efficency of prophylactic measures. The goal of this paper is to analyze the structure and distribution of leading zoonoses in the population of AP Vojvodina. The analysis is made according to the data from the register of infectious diseases - Center for Disease Control and Prevention, Institute for Public Health of Vojvodina. The period included in this study is from 2000 to 2009. From 70 infectious diseases, which are to be declared according to national legislative, half of them are zoonotic diseases. In this analysis we treat only zoonotic diseases and vector borne zoonotic diseases registered in past 10 years. In the period included in this study 15 zoonotic diseases and vector borne zoonoses have been registered in AP Vojvodina. The highest level of incidence is for lyme disease, with the average 9,91/100.000 and trichinellosis with the average 6.40/t 100.000 (Table 1). Toxoplasmosis, Q fever, leptospirosis and echinococcosis have been registered in Vojvodina regularly, and the average incidence is below 1/100.000. The range from minimal to maximal registered incidence shows that there was not a significant difference in epidemiological situation of these diseases. Other zoonoses have been registered rarely and occasionally, as autochthonous or imported diseases (leishmaniasis). In this group of diseases 41 deaths have been registered. Most of it was caused by tetanus and leptospirosis. The lethality rate of tetanus was 54.55% and the patients were of the oldest age. Lethality rate from leptospirosis was 12.0%, and unlike tetanus, the patients belonged in the middle age group. The registered incidences of zoonoses in human population do not present the real situation because of the diagnostic and rapid recognition of symptoms. Some vector borne zoonotic diseases, like for example tick born meningoencephalitis and West Nile Virus fever, which regularly occur in Europe and surrounding countries, have not yet been registered in our region and Serbia. However, the risk from the infections and a possibility of occurrence is not eliminated.

Diagnostic Recognition of Facial Changes Associated With Chronic Conditions: Use of an E‐Learning Tool to Enhance Medical Student Education

Facial characteristics serve as reliable indicators of numerous diseases, and their recognition can assist junior medical students in making an accurate diagnosis. At present, however, there is little data to support the incorporation of physiognomy in medical education. This pilot study involved the design, implementation and evaluation of e‐learning tutorials as a means of teaching students to appreciate how careful observation of facial characteristics can enhance diagnosis.

Disparities between rural and urban areas for osteoporosis management in the province of Quebec following the Canadian 2002 guidelines publication

Clinical guidelines have been seen as a tool for improving management of osteoporosis in order to prevent fragility fractures. However, the impact of guidelines on clinical management of osteoporosis has not been measured. We examined medical investigation and treatment before and after the 2002 Canadian guidelines publication and examined if practice changes were different between rural and urban areas. We conducted a retrospective population-based observational study using secondary data analysis. Two studied populations were selected; one before, the other after the publication of Canadian practice guidelines. The studied populations consisted of all individuals 65 years or older from Quebec (Canada) for whom a physician claimed a consultation or have been hospitalized for fragility fracture between the two predefined periods. There was no significant difference in the rate of bone mineral density testing for women before and after guidelines publication. For men a statistically significant increase was observed but remained very low. A significant increase in bisphosphonates prescribing, but no increased in the reporting of a diagnosis of osteoporosis were observed. A significant reduction of hormonal replacement therapy was seen during the year following guidelines publication. The strongest significant increases were mostly seen in urban regions compared to rural areas. Very small changes were observed for diagnostic recognition by physicians, diagnostic testing and some recommended drugs prescribing following guidelines publication. This suggests low guidelines impact on medical practice for osteoporosis in patients suffering fragility fractures.

Key visual features for rapid categorization of animals in natural scenes.

In speeded categorization tasks, decisions could be based on diagnostic target features or they may need the activation of complete representations of the object. Depending on task requirements, the priming of feature detectors through top–down expectation might lower the threshold of selective units or speed up the rate of information accumulation. In the present paper, 40 subjects performed a rapid go/no-go animal/non-animal categorization task with 400 briefly flashed natural scenes to study how performance depends on physical scene characteristics, target configuration, and the presence or absence of diagnostic animal features. Performance was evaluated both in terms of accuracy and speed and d′ curves were plotted as a function of reaction time (RT). Such d′ curves give an estimation of the processing dynamics for studied features and characteristics over the entire subject population. Global image characteristics such as color and brightness do not critically influence categorization speed, although they slightly influence accuracy. Global critical factors include the presence of a canonical animal posture and animal/background size ratio suggesting the role of coarse global form. Performance was best for both accuracy and speed, when the animal was in a typical posture and when it occupied about 20–30% of the image. The presence of diagnostic animal features was another critical factor. Performance was significantly impaired both in accuracy (drop 3.3–7.5%) and speed (median RT increase 7–16 ms) when diagnostic animal parts (eyes, mouth, and limbs) were missing. Such animal features were shown to influence performance very early when only 15–25% of the response had been produced. In agreement with other experimental and modeling studies, our results support fast diagnostic recognition of animals based on key intermediate features and priming based on the subject's expertise.

Immuno‐MALDI‐TOF MS: New perspectives for clinical applications of mass spectrometry

The discovery of novel biomarkers by means of advanced detection tools based on proteomic analysis technologies necessitates the development of improved diagnostic methods for application in clinical routine. On the basis of three different application examples, this review presents the limitations of conventional routine diagnostic assays and illustrates the advantages of immunoaffinity enrichment combined with MALDI-TOF MS. Applying this approach increases the specificity of the analysis supporting a better diagnostic recognition, sensitivity, and differentiation of certain diseases. The use of MALDI-TOF MS as detection method facilitates the identification of modified peptides and proteins providing additional information. Further, employing respective internal standard peptides allows for relative and absolute quantitation which is mandatory in the clinical context. Although MALDI-TOF MS is not yet established for clinical routine diagnostics this technology has a high potential for improvement of clinical diagnostics and monitoring therapeutic efficacy.

Generalized Anxiety Disorder in Older Medical Patients: Diagnostic Recognition, Mental Health Management and Service Utilization

Primary care physicians often treat older adults with Generalized Anxiety Disorder. Objective To estimate physician diagnosis and recognition of anxiety and compare health service use among older adults with GAD with two comparison samples with and without other DSM diagnoses. Participants were 60+ patients of a multi-specialty medical organization. Administrative database and medical records were reviewed for a year. Differences in frequency of health service use were analyzed with logistic regression and between-subjects analysis of covariance. Physician diagnosis of GAD was 1.5% and any anxiety was 9%, and recognition of anxiety symptoms was 34% in older adults with GAD. After controlling for medical comorbidity, radiology appointments were increased in the GAD group relative to those with and without other psychiatric diagnoses, chi(2) (2, N = 225) = 4.75, p < .05. Most patients with anxiety do not have anxiety or symptoms documented in their medical records.

Late life depression and dementia: a mental health literacy survey of Australian general practitioners

Whilst previous surveys of mental health literacy of general practitioners (GPs) have shown high rates of recognition of common mental disorders, few studies have been carried out into GPs' understanding of presentations in late life. This study aims to determine GPs' recognition of mental disorders in older people, their intentions regarding investigation, specialist referral and treatment, and their beliefs about prognosis. Australian GPs who attended an educational seminar were administered questions based on clinical vignettes describing older people with depression, dementia and coronary heart disease. There was a high rate of recognition of all disorders amongst the 436 respondents. GPs demonstrated a high level of consistency about screening questionnaires, investigations and specialist referral in the dementia vignette. In contrast, less than half of GPs endorsed using a screening questionnaire or neuroimaging, and considered referral to a variety of medical specialties in the depression vignette. For both the depression and dementia vignettes, self-help treatments like walking, dietary advice or alcohol reduction were endorsed more frequently than an antidepressant or cholinesterase inhibitor respectively. Dementia tended to be viewed as having a poor prognosis, and late-life depression a moderate prognosis. Actual or intended rates of diagnostic recognition, specialist referral and benzodiazepine prescription found in this study may not translate into clinical practice for a number of reasons. Non-specific treatments without a clear evidence base were considered as often as those with a stronger evidence base. There is a need to improve the knowledge of GPs with regard to screening and investigating late life depression and managing dementia.

Substâncias húmicas como suporte à classificação de solos brasileiros

As substâncias húmicas que compõem a matéria orgânica do solo participam de forma ativa dos processos pedogenéticos do solo, em especial dos horizontes diagnósticos O e H hístico, A chernozêmico, A húmico e B espódico. Este trabalho teve como objetivo determinar o teor de C orgânico das substâncias húmicas e avaliar sua influência na separação de horizontes diagnósticos. Foram utilizados 56 horizontes diagnósticos de diferentes regiões do Brasil, 52 superficiais (H hístico, A chernozêmico, A proeminente, A húmico e A moderado) e quatro subsuperficiais (B espódico). Nesses solos, foram feitas a caracterização química e física, e também de C orgânico, da fração ácidos fúlvicos (C-FAF), fração ácidos húmicos (C-FAH) e humina (C-HUM), as relações C-FAH/C-FAF e C-EA/C-HUM (C-EA = C-FAF + C-FAH) e a percentagem das frações em relação ao C orgânico total (COT), sendo as variáveis submetidas à avaliação por análises multivariadas. Nos horizontes orgânicos, o H hístico apresentou maiores valores e equilíbrio entre o C-HUM e o C-FAH. Na maioria dos horizontes minerais, observou-se predomínio do C-HUM, seguido pelo C-FAH nos horizontes A chernozêmico e A húmico e pelo C-FAF nos horizontes A proeminente e A moderado. Nos horizontes B espódico, foi observado predomínio variável de C-FAF e C-FAH. Com a análise de variáveis canônicas, identificaram-se as variáveis que poderiam ser utilizadas para a separação dos tipos de horizontes diagnósticos. Usando a análise de agrupamento, separaram-se os tipos de horizontes com menor influência da matéria orgânica. Pela análise discriminante, obtiveram-se resultados satisfatórios na classificação dos horizontes diagnósticos com base nas variáveis das substâncias húmicas, quando comparados à classificação original. Os resultados das análises multivariadas indicam que a distribuição do C das substâncias húmicas pode ser utilizada para separar os tipos de horizontes diagnósticos ricos em C orgânico.

Epidemiology of myelodysplastic syndromes and chronic myeloproliferative disorders in the United States, 2001-2004, using data from the NAACCR and SEER programs

AbstractReporting of myelodysplastic syndromes (MDSs) and chronic myeloproliferative disorders (CMDs) to population-based cancer registries in the United States was initiated in 2001. In this first analysis of data from the North American Association of Central Cancer Registries (NAACCR), encompassing 82% of the US population, we evaluated trends in MDS and CMD incidence, estimated case numbers for the entire United States, and assessed trends in diagnostic recognition and reporting. Based on more than 40 000 observations, average annual age-adjusted incidence rates of MDS and CMD for 2001 through 2003 were 3.3 and 2.1 per 100 000, respectively. Incidence rates increased with age for both MDS and CMD (P < .05) and were highest among whites and non-Hispanics. Based on follow-up data through 2004 from the Surveillance, Epidemiology, and End Results (SEER) Program, overall relative 3-year survival rates for MDS and CMD were 45% and 80%, respectively, with males experiencing poorer survival than females. Applying the observed age-specific incidence rates to US Census population estimates, approximately 9700 patients with MDS and 6300 patients with CMD were estimated for the entire United States in 2004. MDS incidence rates significantly increased with calendar year in 2001 through 2004, and only 4% of patients were reported to registries by physicians’ offices. Thus, MDS disease burden in the United States may be underestimated.

Synthetic Informational Mineral Resource Prediction: Case Study in Chifeng Region, Inner Mongolia, China

The Chifeng region is located in the southeastern part of Inner Mongolia, North China. It spans both the metallogenic belts of the Greater Xing'an Mountain and the Yin Mountain. Because of the unique metallogenic background, the Chifeng is a region of high nonferrous metal mineral potential in China. In this article, multisource data sets including geological, geochemical, gravity, airborne magnetics, and Landsat ETM+ data were integrated for mineral potential mapping by using GIS technology. Under the guidance of regional metallogenic regularities and the application of the geoanomaly ore forming theory, nine diagnostic deposit recognition criteria layers were extracted from those sets. Furthermore, these deposit recognition criteria layers were combined in the weight of evidence (WolE) model, which used the spatial correlations between the evidence layers and the known mineral occurrences, to calculate the posterior probability and indentify the delineated prospective area. The results showed that there were three NE-SW trending prospective belts in the north of Chifeng, and one NW-SE striking favorable ore-forming belt in the south of this region. Eighty-six percent of the known mineral occurrences containing 95% of the mount metal resources fell in these four belts. The authors carried out further research study and provided references for resource prediction and assessment study in this area. The results offered scientific evidence of resource exploration in the Chifeng region.

Diffuse follicle centre lymphoma presents with high frequency of extranodal disease

19511 Background: Follicular lymphoma (FL) comprises about one third of non Hodgkins Lymphomas in adults. The WHO now recognizes Diffuse Follicle Center Lymphoma (DFCL) as an uncommon variant of follicular lymphoma. DFCL is characterized by distinct lack of follicle formation, and is composed of a diffuse proliferation of neoplastic, small cleaved follicular center cells and variable number of admixed centroblasts. Immunophenotypic data show that DFCL and FL are of identical phenotype, and are positive for follicular center cell markers CD10, BCL6 and BCL2. Little is described about the clinical presentation of this FL variant. In this study, we describe the clinical characteristics and presentation of DFCL, in light of an increase in the diagnostic recognition of this unusual entity. Methods: Patient data was compiled through medical record review of all newly diagnosed FL patients seen at University of Iowa Holden Comprehensive Cancer Center and The University of Rochester Wilmot Cancer Center between M...

Medical Student Acquisition of Clinical Working Knowledge

Background: Working knowledge of physicians manifests as a combination of diagnostic pattern recognition and clinical data interpretation (analytic fact checking). Purpose: The purpose was to study medical student acquisition of these abilities as a function of years of medical training/experience. Methods: A cross-sectional study involving students who had completed 0, 1, 2, and 3 years of medical school. All students at all levels of training took the same tests of diagnostic pattern recognition and clinical data interpretation. Percent correct scores were calculated and used to estimate learning curves. A cohort of family physicians also took the test to provide a benchmark. Results: Student diagnostic pattern recognition and clinical data interpretation ability demonstrated a steady upward growth curve but leveled off in Year 3. Diagnostic pattern recognition performance was consistently higher than clinical data interpretation performance. The rate of diagnostic performance gain with training and experience was also higher. Conclusions: Medical students acquired diagnostic pattern recognition ability and all years of medical training contributed. The rate of clinical data interpretation performance improvement was slower, and the absolute performance level was lower. What was surprising was the lower rate of improvement in diagnostic pattern recognition and clinical data interpretation performance for students during their 1st year of clinical training. Students' understanding of findings and their relationships to disease processes may be affected by their limited patient experience.

Expert therapists use specific clinical reasoning processes in the assessment and management of patients with shoulder pain: a qualitative study

What are the key items in the clinical reasoning process which expert clinicians identify as being relevant to the assessment and management of patients with shoulder pain? Qualitative study using a three-round Delphi procedure. Twenty-six experts in the UK consented to be involved and were contactable, of whom 20 contributed, with 12, 15, and 15 contributing to the different rounds. Clinical reasoning was mostly about diagnostic reasoning, but also involved narrative reasoning. Diagnostic reasoning involved both pattern recognition and hypothetico-deductive reasoning. Diagnostic reasoning emphasised general history items, a constellation of signs and symptoms to identify specific diagnostic categories, and standard physical examination procedures. Narrative reasoning was highlighted by the communication involved in expert history taking, seeing patients in their functional and psychological context, and collaborative reasoning with the patient regarding management. These expert clinicians demonstrated the use of diagnostic pattern recognition, and hypothetico-deductive and narrative clinical reasoning processes. The emphasis was on the history and basic physical examination procedures to make clinical decisions.