Diagnostic Re-evaluation Research Articles

Clinical utility of computed tomography-guided core needle biopsy in the diagnostic re-evaluation of patients with lymphoproliferative disorders and suspected disease progression

BackgroundHistological transformation is a common clinical event in patients with lymphoproliferative diseases, often requiring a modification in therapy. Minimally invasive biopsy techniques have been used for initial diagnosis of these disorders but their role has not been systematically evaluated in disease progression. The purpose of this study was to evaluate the yield of computed tomography (CT)-guided core needle biopsy in patients with lymphoproliferative disorders and suspected disease progression. Patients and methodsWe performed a retrospective analysis of the records of patients with known lymphoproliferative disorders who underwent CT-guided core needle biopsy during the course of their disease, between 1990 and 2002. ResultsA total of 130 patients with lymphoproliferative disorders (91 patients with non-Hodgkin’s lymphoma, 21 with Hodgkin’s disease, 10 with chronic lymphocytic leukemia, six with combined malignancies and two with Castleman’s disease) underwent CT-guided core needle biopsy 4.7±5.1 (standard deviation) (range 0–40) years after initial diagnosis. The procedure was diagnostic in 98 cases (75.4%). In 22 patients (17%) a subsequent open biopsy was performed, and in 10 (7.6%) the final diagnosis remained unconfirmed. Histological transformation was found in 20 cases (15.4%), of which 19 were suspected clinically. A new diagnosis (malignant and non-malignant) was apparent in 18 cases (13.9%) and relapsed or ongoing evidence of the original disease was found in 82 (63%). ConclusionsCT-guided core needle biopsy is a reliable procedure in patients with suspected histological transformation of lymphoproliferative disorders, and should be used as the initial tool for pathological re-evaluation.

Lack of SYT-SSX Fusion Transcripts in Malignant Peripheral Nerve Sheath Tumors on RT-PCR Analysis of 34 Archival Cases

The translocation t(X;18) is currently regarded as a specific molecular marker of synovial sarcoma (SS). Recently, however, it has been reported that malignant peripheral nerve sheath tumors expressed this marker in 75% of the cases. To test independently this iconoclastic claim, a molecular analysis for the detection of the SYT-SSX fusion genes was carried out using archival material of 34 consecutive cases diagnosed as malignant peripheral nerve sheath tumors and treated in our Institute from 1998 to 2000. In four of these cases, the molecular analysis on fixed tissues was supplemented with an analysis on fresh frozen tissue. RNA extracted from formalin-fixed paraffin-embedded tissue blocks was evaluated for the presence of SYT-SSX1 and SYT-SSX2 fusion transcripts by RT-PCR. This analysis was extended to a wide variety of normal tissues simultaneously extracted and equally processed. Only two of the cases studied harbored SYT-SSX1 and SYT-SSX2 fusion transcripts, respectively. The diagnostic reevaluation of these two cases in light of the molecular data disclosed that one had the features of a monophasic SS and the other was compatible with that entity. Both of these tumors were strongly immunoreactive for bcl-2, confirming the diagnostic utility of this marker in this instance. Our results reaffirm the specificity of SYT-SSX for SS and suggest that an opposite claim made in a recent study may have been due to a faulty interpretation of the molecular results caused by a contamination of the samples.

Postoperative multichannel magnetoencephalography in patients with recurrent seizures after epilepsy surgery.

Assessment of usefulness of magnetoencephalography (MEG) as a novel non-invasive technique in the diagnostic evaluation of patients with recurrent seizures after unsuccessful epilepsy surgery. Seventeen patients in whom epilepsy surgery had failed underwent reevaluation by means of MEG in addition to standard presurgical investigations (EEG, MRI, SPECT, and neuropsychologic testing). Source analysis of interictal epileptic MEG discharges revealed dipole localizations immediately adjacent to the borders of previous resection in 10 of 17 patients. Standard non-invasive presurgical evaluation suggested epileptogenicity over the general area of previous resection in all patients, but did not provide any detailed spatial localizing data. Invasive EEG recordings confirmed the MEG focus localization in all of 5 patients who were selected for reoperation. Second operation at the site of previous resection achieved complete seizure control in 3 and cessation of tonic-clonic seizures in 1 of these patients. MEG may provide useful information in the diagnostic reevaluation of postoperative epileptic patients in whom skull and dura defects produce a "breach effect" which alters non-invasive and invasive EEG.

Relapse prevention : Jan M. van Ree and Mirjam A.F.M. Gerrits. Rudolf Magnus Institute for Neurosciences, Department of Medical Pharmacology, Utrecht University, Utrecht, The Netherlands

Schizoaffective disorder is a common diagnosis in clinical practice but its nosological status has been subject to debate ever since it was conceptualized. Although it is key that diagnostic reliability is sufficient, schizoaffective disorder has been reported to have low interrater reliability. Evidence based on systematic review and meta-analysis methods, however, is lacking. Using a highly sensitive literature search in Medline, Embase, and PsycInfo we identified studies measuring the interrater reliability of schizoaffective disorder in comparison to schizophrenia, bipolar disorder, and unipolar disorder. Out of 4126 records screened we included 25 studies reporting on 7912 patients diagnosed by different raters. The interrater reliability of schizoaffective disorder was moderate (meta-analytic estimate of Cohen's kappa 0.57 [95% CI: 0.41–0.73]), and substantially lower than that of its main differential diagnoses (difference in kappa between 0.22 and 0.19). Although there was considerable heterogeneity, analyses revealed that the interrater reliability of schizoaffective disorder was consistently lower in the overwhelming majority of studies. The results remained robust in subgroup and sensitivity analyses (e.g., diagnostic manual used) as well as in meta-regressions (e.g., publication year) and analyses of publication bias. Clinically, the results highlight the particular importance of diagnostic re-evaluation in patients diagnosed with schizoaffective disorder. They also quantify a widely held clinical impression of lower interrater reliability and agree with earlier meta-analysis reporting low test-retest reliability.

Patient Characteristics, MRI Examination, and Dopaminergic Drug Response in Clinical Possible Parkinson's Disease

Patients with parkinsonism can be classified as clinical definite, probable, possible, or unlikely Parkinson's disease (PD). Possible PD includes patients with PD according to conventional diagnostic criteria and with at least a moderate response to dopamine agonists. However, these patients have clinical features that may reduce the probability for idiopathic PD. The objective of this study was to clinically characterize patients with possible disease in a prevalence study of PD and to indicate the frequency of idiopathic PD in this group of patients. The diagnostic re-evaluation was based on detailed MRI examinations and investigations of dopaminergic drug response after several years of treatment. In a community-based prevalence study in Norway, comprising 245 PD patients, we found 36 patients (15%) with clinical possible PD. The patients with possible disease had significant and clinically important differences in demographic and disease characteristics compared to patients with definite and probable PD. Possible PD patients were older at disease onset, more disabled, and had more neurobehavioral disorders. MRI examinations of 14 of the 36 patients with possible PD in the prevalence study revealed significant group effects compared to an age-matched control group, with reduced pars compacta width and increased cortical atrophy. In individual patients, signal attenuation consistent with vascular lesions of the basal ganglia contributed to diagnostic reclassification. Dopaminergic drug withdrawal revealed no response in 4 of 12 examined patients. Two of the remaining eight patients had a clear short-duration drug response. Six patients had only a varying degree of long-duration response. The re-evaluation of diagnosis indicates that probably less than half of the patients with clinical possible PD have idiopathic disease. Patients with atypical features and diagnosed as possible PD should thus be excluded from studies with a presumed high specificity for idiopathic PD.

Back pain: medical evaluation and therapy.

Most patients with acute low back pain or sciatica improve with appropriate conservative therapy, and most require no immediate diagnostic studies beyond a careful history and examination. In patients with "red flags" for visceral, malignant, or infectious causes or possible cauda equina syndrome, a more aggressive evaluation is mandatory. In patients whose pain does not respond to initial management or who have chronic symptoms, diagnostic re-evaluation is appropriate.

Reevaluation of the ambulatory pediatric patient whose blood culture is positive for Haemophilus influenzae type b

We conducted a retrospective review of 60 patients with Haemophilus influenzae type b bacteremia initially treated as outpatients, to test the hypothesis that a subgroup of these patients is at low risk of continuing invasive infection and thus requires a less comprehensive reevaluation. These patients were 6% of the 975 patients with invasive H. influenzae type b infection identified by active surveillance in Dallas County, Texas, during a 6 1/2-year period. The clinical assessment of "ill" appearance and persistent fever (greater than or equal to 38.0 degrees C) on the return visit were the two most useful variables in identifying patients at risk of continuing infection. Among 25 (42%) patients who were considered "ill" (febrile or afebrile), 20 (80%) had continuing invasive infection and 14 (56%) had a subsequent culture that was positive for H. influenzae type b. Among 8 patients who were considered "well" but who remained febrile, 3 (38%) had continuing infection, including 1 (13%) patient with a second culture that was positive. By contrast, among 27 (45%) patients who were considered "well" and who were afebrile, continuing invasive infection was identified in only 2 (7%) patients, and all repeat cultures were negative. These results suggest that when patients return for reevaluation of H. influenzae type b bacteremia, clinical assessment by an experienced physician, together with the febrile status of the patient, can identify those at high versus low risk of continuing invasive infection and thus guide the extent of diagnostic reevaluation.

脊椎・脊髄疾患に対するＭＲＩの臨床応用

Eighty three patients with the spine and spinal cord disorders were examined by magnetic resonance imaging (MRI). The results were as follows:1) At present time, myelography and CT myelography have some advantages over MRI in a mode of representation of disorders on the spine and spinal cord.2) But MRI was excellent in the detection of intraspinal cord lesions such as syringomyelia and hematomyelia, and lesions at craniocervical junction.3) MRI can be used routinely for clinical screening evaluation, from its noninvasive and simple property.In conclusion, MRI can be accepted as a beneficial diagnostic device and reevaluation must be done on various methods of imaging including MRI.

Canine Chronic Bronchitis

The diagnosis and management of the chronic bronchitis patient can be a challenging, but rewarding, task for the veterinarian. The normal respiratory defense mechanisms and the pathophysiologic responses to the pathologic changes are of dramatic importance in understanding the choices of therapy. The keys to successful management of the patient lie in correct assessment of the clinical features and diagnostic procedures and periodic reevaluation of the patient's response to therapy and age/environment-related progression of pathology. Lastly, the clinician must create a realistic attitude for the owner regarding chronically diseased patients.

Chymopapain chemonucleolysis: CT changes after treatment.

Chymopapain chemonucleolysis is now used extensively in this country to treat lumbar disk herniation. Despite increasing experience in patient selection, there continue to be patients who do not respond to treatment and require diagnostic reevaluation. Interpretation of postchemonucleolysis computed tomographic (CT) scans in these patients requires a knowledge of the CT changes that normally occur after treatment with chemonucleolysis. To define these temporal changes, a prospective CT evaluation was performed of 29 treated interspaces in 26 patients who returned for routine postchemonucleolysis follow-up. Despite a successful clinical response in 17 of 21 patients, changes in the size, location, shape, homogeneity, and density of the disk herniation were uncommon at the 6 week follow-up. In 24 treated interspaces, the most common changes at 6 week CT follow-up were the development of vacuum phenomenon in three (12.5%) and a slight decrease in the size of two (8.3%) disk herniations. A successful response was noted in 17 of 21 patients scanned at 6 month follow-up, with five (22.7%) of 22 injected interspaces exhibiting vacuum phenomenon and 13 (59.1%) interspaces showing an observable decrease in the size of the disk herniation. Early improvement of sciatica after chemonucleolysis often occurs without a change in the size of the disk herniation and may be mediated by chymopapain-induced disk-space narrowing. Continued improvement may be accompanied by both a decrease in the disk height and a reduction in the size of the disk protrusion.

Diagnostic and therapeutic reevaluation of patients with intractable epilepsy.

Intensive monitoring techniques were used to improve seizure diagnosis and control in 23 patients with intractable epilepsy: (1) Video recording of clinical seizures and the ictal EEG, (2) long-term telemetered EEG recordings, and (3) frequent determination of plasma antiepileptic drug concentrations. Patients were monitored in the hospital for an average of 8 weeks and after discharge were followed for an average of 8 months. At follow-up, 70 percent of the patients continued to have improved seizure control as compared with baseline studies, 83 percent had decreased toxicity, and about half had made gains in social adjustment. Use of the techniques described can make a significant contribution to patients previously considered intractable to therapy.

A Diagnostic Re-evaluation of Electric Skin Resistance, Skin Temperature and Deeper Tenderness in Patients with Abdominal Pain

Diagnostic re-evaluation of measurement of electric skin resistance (ESR), skin temperature (ST) and deeper tenderness (DT) was performed in patients with abdominal pain due to pancreatitis, cholecystopathy and duodenal ulcer. These determinations were conducted when the pain was complained of and after the pain ceased by paravertebral anesthesia. ESR was decreased on the opposite tender points of the abdominal walls as compared with those values of the healthy abdominal walls. On the contrary, ESR was increased on the suffered body areas in patients with active myelitis. ESR was decreased on the abdominal walls where visceral pain was induced by inflation of a balloon attached to the apex of a Miller-Abbott double lumen tube. DT tended to show decrease, while ST a slight increase, when the pain was evoked. However, in these pain induced experiments, ST changes were not so remarkable as those of ESR. A viscero-cutaneous reflex machanism and the predominance of sympathetic nerve control might be possible causes to produce these changes. Several important factors influencing the determination of the ESR were also discussed.

Borderline patients in a chronic ward.

The borderline syndrome was reexamined recently in a new comprehensive way. We present a diagnostic reevaluation of chronic ward patients who were formerly diagnosed and treated as chronic schizophrenics. A new, meticulous clinical assessment, as well as psychological testing, suggested the borderline-syndrome diagnosis. These patients represent a special category of borderline patients not hitherto described and a characteristic etiological background was found in their familial constellation. A causal and descriptive differentiation between these patients and schizophrenics is mandatory: careful investigation of backward populations in hospitals might reveal numerous similar cases (borderlines in this special category). They call for a different, definite line of treatment.