Differential Diagnostic Evaluation Research Articles

Whole-body vibration-related health disorders in occupational medicine – an international comparison

Workers with whole-body vibration (WBV) exposure are likely to report non-specific health complaints. Health and safety providers may not recognise such occupational injuries and may be unfamiliar with appropriate exposure assessment and prevention. This is a review of clinical studies, medical evidence, differential diagnostic evaluation protocols, surveillance programmes, national and international standards, and interventions recommendations utilising PubMed and other online resources. In summary, several studies show a clear trend: with increasing duration and intensity of occupational WBV exposure, primarily musculoskeletal or neurological disorders of the spine occur. Other organ damage has also been reported. In some European Union countries, spinal injury caused by WBV is recognised as an occupational disease and may be compensable. The WBV-related injury diagnosis includes a review of the work history, exposure assessment and differential diagnostic evaluation. WBV health surveillance should assess health status of WBV-exposed workers and address preventive measures.

Differential diagnosis of Mendelian and mitochondrial disorders in patients with suspected multiple sclerosis

Several single gene disorders share clinical and radiologic characteristics with multiple sclerosis and have the potential to be overlooked in the differential diagnostic evaluation of both adult and paediatric patients with multiple sclerosis. This group includes lysosomal storage disorders, various mitochondrial diseases, other neurometabolic disorders, and several other miscellaneous disorders. Recognition of a single-gene disorder as causal for a patient's 'multiple sclerosis-like' phenotype is critically important for accurate direction of patient management, and evokes broader genetic counselling implications for affected families. Here we review single gene disorders that have the potential to mimic multiple sclerosis, provide an overview of clinical and investigational characteristics of each disorder, and present guidelines for when clinicians should suspect an underlying heritable disorder that requires diagnostic confirmation in a patient with a definite or probable diagnosis of multiple sclerosis.

Observation-centered approach to ASD assessment in Tanzania.

Abstract In many lower-income countries, there is a paucity of assessment services for autism spectrum disorders (ASD)., Guidelines will be provided for conducting cross-cultural assessments in the context of limited validated resources in Tanzania. By examining behavioral, social, and adaptive differences we were able to provide differential diagnostic evaluations aligning with best practice standards for 41 children in Tanzania age 2-21 years. We describe the utility of a flexible, behavioral observation instrument, the Childhood Autism Rating Scales, Second Edition (CARS2), to gather diagnostic information in a culturally sensitive manner. We observed that the ASD group was characterized by significantly higher scores on the CARS2, F = 21.09, p < .001, η(2) = .37, than the general delay comparison group. Additional recommendations are provided for making cultural adaptations to current assessment instruments for use in a country without normed instruments, such as Tanzania.

Small part ultrasound in childhood and adolescence

Small-part sonography refers to the display of small, near-surface structures using high-frequency linear array transducers. Traditional applications for small part ultrasound imaging include visualization and differential diagnostic evaluation in unclear superficial bodily structures with solid, liquid and mixed texture, as well as similar structures in nearly superficial organs such as the thyroid glands and the testes. Furthermore indications in the head and neck regions are the assessment of the outer CSF spaces in infants, the sonography of the orbit, the sonography of the walls of the large neck vessels, the visualization of superficially situated lymph nodes and neoplasms.Clinical evidence concludes that sonography, having of all imaging modalities the highest spatial resolution in the millimeter- and micrometer range (100–1000μm), can be considered the best suited technique for examining superficial pathological formations and near-surface organs. In addition, it delivers important information about characteristic, often pathognomonic tissue architecture in pathological processes.

Effect of Hispanic Ethnicity and Language Barriers on Appendiceal Perforation Rates and Imaging in Children

To determine the association between Hispanic ethnicity and limited English proficiency (LEP) and the rates of appendiceal perforation and advanced radiologic imaging (computed tomography and ultrasound) in children with abdominal pain. We performed a secondary analysis of a prospective, cross-sectional, multicenter study of children aged 3-18 years presenting with abdominal pain concerning for appendicitis between March 2009 and April 2010 at 10 tertiary care pediatric emergency departments in the US. Appendiceal perforation and advanced imaging rates were compared between ethnic and language proficiency groups using simple and multivariate regression models. Of 2590 patients enrolled, 1001 (38%) had appendicitis, including 36% of non-Hispanics and 44% of Hispanics. In multivariate modeling, Hispanics with LEP had a significantly greater odds of appendiceal perforation (OR, 1.44; 95% CI, 1.20-1.74). Hispanics with LEP with appendiceal perforation of moderate clinical severity were less likely to undergo advanced imaging compared with English-speaking non-Hispanics (OR, 0.64; 95% CI, 0.43-0.95). Hispanic ethnicity with LEP is an important risk factor for appendiceal perforation in pediatric patients brought to the emergency department with possible appendicitis. Among patients with moderate clinical severity, Hispanic ethnicity with LEP appears to be associated with lower imaging rates. This effect of English proficiency and Hispanic ethnicity warrants further investigation to understand and overcome barriers, which may lead to increased appendiceal perforation rates and differential diagnostic evaluation.

Developmental outcomes of children with auditory neuropathy/dyssynchrony (auditory neuropathy spectrum disorder)

Background This paper reviews current knowledge about the developmental outcomes of children with auditory neuropathy/auditory dyssynchrony (ANAD). Aim The article discusses the diverse variables that can impact developmental outcomes of this population of children with hearing loss and what is currently known in the literature. Since two-thirds of the children with ANAD have additional disabilities, this population of children is very complex. Patients The article discusses three children with very diverse developmental profiles including the differential diagnostic evaluations that supported decisions about communication approaches. Methods Three case histories of children with ANAD representing different individual characteristics and developmental trajectories are discussed. These three cases were chosen to represent the diversity of the population of children with ANAD. Results Case A is a child who received bilateral cochlear implantation and successfully developed listening and spoken language skills. Case B is a child who received bilateral cochlear implantation which did not result in successful listening and spoken language because of a breakdown at the level of the auditory cortex but is using sign language as a primary approach to learn to communicate. Case C is a child with significant co-morbidities including cerebral palsy and global developmental delays who is communicating through both spoken and signed language without the use of amplification. Conclusion Children with ANAD have significant diversity in their ability to access spoken language without amplification, with hearing aids and with cochlear implants. However, despite this diversity, when children are provided access to language through individualization and appropriate matching of both auditory and visual communication approaches, they can become successful language learners.

D.D.Pletnev about mental symptoms in the picture of purely somatic diseases: lessons of history and today

The article is dedicated to brief statement of priority scientific investigations of the distinguished domestic therapist, Professor Dmitry Dmitriyevich Pletnev, having made significant contribution into development of clinical direction of psychosomatic medicine in Russia. At the level of diagnostic and conclusive possibilities of his time in the beginning of the XXth century, the scientist has grounded those scientific positions which currently are broadly studied in the aspect of co-morbidity of cardiovascular diseases and mental disorders of anxiety-depressive spectrum. D.D.Pletnev, one of the first clinicians-therapists has paid attention to difficulties of differential-diagnostic evaluation of state of somatic patients with psycho-emotional disturbances «depressive affects and neurosis of anxiety». Many papers of the scientist dedicated to study of «mental symptoms in picture of purely somatic diseases», what in the modern medicine is interpreted as various manifestations of neurotic and affective disorders in diseases of inner organs, wrongly forgotten, remain relevant at present as well. As perspective scientific directions, questions of integrative approach to study of interrelationship of pathology of cardiovascular system, anxiety and depressive disorders of neurotic and affective level are discussed.

P-081 Detection of monocyte precursors in bone marrow biopsies for the differential diagnostic evaluation of chronic myelomonocytic leukemia by immunohistology

P-081 Detection of monocyte precursors in bone marrow biopsies for the differential diagnostic evaluation of chronic myelomonocytic leukemia by immunohistology

Differential Diagnostic Aspects Are Lacking

Acute abdomen requires emergency treatment, including emergency diagnostic evaluation. In the introduction of their review article, the authors say that “While […] around 1% of all patients with acute abdomen have AMI [acute mesenteric ischemia], AMI is the cause of acute abdomen in up to 10% of patients aged over 70”, without explaining differential diagnostic aspects. Intestinal angioedema with massive mucosal swelling presents with similar symptoms; this seems to be neither more common nor rarer than AMI. Intestinal angioedema can have allergic triggers but can also be caused by taking angiotensin converting enzyme inhibitors and angiotensin II receptor blockers (many cases have been documented in the literature) or be provoked by non-steroidal anti-inflammatory drugs. An individual case of intestinal angioedema has been described in a patient after taking a calcium antagonist (1). Hereditary angioedema (HAE, a defect in C1-INH synthesis), angioedema with normal concentrations of C1-esterase-inhibitor but functional insufficiency, and angioedema based on acquired C1-esterase-inhibitor deficiency (acquired angioedema, AA) as well as idiopathic angioedema should also be included in the differential diagnostic evaluation. While a patient’s medical history can provide an early indication of angioedema due to medication, diet, or hereditary causes and thus prevent unnecessary laparotomy, hereditary angioedema and other forms need to be confirmed using specific laboratory-based examination. In case of clinical suspicion, this should include immunological determination of C1-INH, functional determination of C1-INH, measurement of C1, C2, C4, CH50, and, if required, measurement of autoantibodies against C1-INH (2). Adding intestinal angioedema as a differential diagnosis to the well-known range of causes for acute abdomen might be worth mentioning, in order to clearly differentiate from vascular-ischemic causes.

Differenzialdiagnostik manualmedizinischer Syndrome bei unteren Rückenschmerzen unter Einbeziehung osteopathischer Verfahren

The differential diagnostic evaluation of painful functional disorders of the lumbosacral and lumbopelvic region, i. e. the so-called “low back pain” is very extensive, but is often reduced to the question of chronicity. The manual medical diagnosis can make a valuable contribution in such cases for determination of structural and functional pathology. Early application of manual medical therapies seems to be effective for peracute complaints. The mobilization of restrictions of the pelvic visceral attachments should be included. In the following review manual medical syndromes are presented that summarize the findings from the musculoskeletal and visceral system. This is intended to facilitate the primary differential diagnostic evaluation, as well as treatment planning. The combination with osteopathic methods is very profitable. A necessary specialist differential diagnosis remains essential.

A screening programme on chronic solvent-induced encephalopathy among Dutch painters

BackgroundLong-term exposure to organic solvents may lead to chronic solvent induced encephalopathy (CSE) in painters. In combination with reduction of exposure, a workers’ health surveillance programme was developed, resulting in a three-stage CSE screening procedure for early neurobehavioural changes possibly predicting chronic health effects. The screening consists of a questionnaire (Neurosymptom Screening Checklist 60, NSC-60), computerised neurobehavioural functioning testing (Neurobehavioural Evaluation System; NES2) and multidisciplinary differential diagnostic evaluation by experts (called ‘Solvent Team’). Results from the screening were compared with the results of the ‘care as usual’ (CAU), in which symptomatic patients were referred directly to the Solvent Team by occupational physicians, general practitioners or medical specialists. Parallel to the screening programme, a legal ban on indoor use of solvent-based paints resulted in lower exposure to solvents. ObjectiveTo investigate the usefulness of the NSC-60 questionnaire as a screening tool for CSE among painters and to investigate the course of the number of CSE cases over the years as a potential consequence of improved prevention and control. ResultsFrom 1998 to 2004, more than 40,000 painters were invited to participate in a health surveillance programme including a periodical occupational health examination (PHE) and 50% did participate. Four percent (N=794) of these had a positive score on the NSC-60. The Solvent Team assessed 101 of these for CSE, which resulted in 27 CSE cases diagnosed. CAU during the same period of the surveillance (1998–2004) yielded 619 painters and 75 of these had the diagnosis CSE. After 2002 the number of CSE diagnosed cases dropped considerably and in 2004 only one case of CSE could be diagnosed. The substantially lower prevalence of CSE diagnosed cases in painters after 2002 might partly be explained as a result of a successful participation in the screening procedure of most prevalent CSE cases during the years 1998–2002. A second reason for the reduction of new diagnosed cases of CSE can be the effectiveness of the ban on indoor use of solvent-based paints resulting in lower exposure levels at work. ConclusionThe screening procedure is useful to screen for CSE among people taking part in the PHE programme. Control of CSE can be achieved by an integrated preventive approach with reduction of exposure and screening on early health effects.

Competence Lies With the Emergency Physician

Emergency medical care should be included in the standard management in the prehospital phase of stroke. It is a distinct advantage if the dispatchers can optimally assess the urgency by means of standardized “filtering questions” (triage) and can then dispatch accordingly. The authors' recommendations in Table 1 do not reflect the Notarztindikationskatalog (the catalogue of indications for emergency medical management) for Bavaria. In my opinion, distinctions such as those listed in Table 1 are therefore obsolete, as they stipulate that the emergency physician should be alerted only if a patient is unconscious, and in all other cases the emergency ambulance team should decide on site about alerting the doctor. This would mean acting against the slogans “time is brain” and “competence is brain,” since all therapeutic measures listed in Table 3 constitute actions taken by physicians. Paramedics may just be able to meet the requirement for venous access in all patients with a suspected diagnosis of stroke (in accordance with the German Medical Association's statement relating to the emergency competence of paramedics and delegating medical services in the emergency medical services). However, administration of urapidil, for example, would not be covered by the emergency competence. Competence in the prehospital phase lies with the emergency physician for all measures listed by the authors—and this is not intended to diminish the professionalism of our emergency services. Paramedics cannot take a structured medical history with subsequent differential diagnostic evaluation. Even experienced emergency physicians are not able to predict the course during transport, especially if the cause of the symptoms is an intracerebral hemorrhage. Potential peracute deterioration of the patient's condition, including life threatening events, requires management by emergency physicians. And especially in rural areas, much valuable time would be lost if the emergency physician is called out afterwards.

Diagnosis of Whole-Body Vibration Related Health Problems in Occupational Medicine

Occupational whole-body vibration (WBV) exposed workers may report nonspecific health complaints or debilitating physical disorders. Health care providers and safety professionals may not recognize such occupational injuries and be unfamiliar with appropriate exposure assessment. Method: Review of peer-reviewed clinical studies and publications, medical evidence, differential diagnostic evaluation protocols, surveillance programs, national and international standards, and intervention recommendations regarding WBV. Results: There are well-designed epidemiological studies showing that prolonged and increasing exposures to WBV can primarily result in musculoskeletal or neurological disorders of the spine. Less frequent and weaker evidence exist for organ damage that include intestinal organs, vascular system and other body parts. In some countries spinal injury caused by long-term occupational WBV exposure is compensable. Many physicians and occupational safety experts seem to be unfamiliar with the wide spectrum of health complaints and the proper evaluation of WBV-exposed patients following expert reviews and international guidelines/standards. Detailed protective regulations and provisions exist primarily in highly industrialized countries with good occupational health systems. The causal diagnosis should be based on medical findings, a differential diagnostic methodology and adequate work exposure assessment and documentation of WBV. Conclusion: A proper WBV-related injury diagnosis includes a critical review of the work history, exposure data assessment and the clinical differential diagnostic evaluation. Many health care providers receive little or no training in the recognition of WBV-related injuries and case management. WBV health surveillance should assess the health status of WBV-exposed workers and address preventive measures for employers and employees.

Self-harming Behavior or Suicidal Intent

Mavrogiorgou et al (1) discussed the medical-therapeutic approach in psychiatric emergencies. However, in order to distinguish between suicidal and self-harming behavior in terms of differential diagnostic evaluation, some recent evidence should be added (2). “Self-harming behavior” refers to direct, self-inflicted harm to one’s own body without suicidal intent (3). In attempted suicide, it is understood that this act aims to end intolerable psychological suffering by one’s own death. Self-harming behavior, on the other hand, aims to reduce painful emotional states. Brown et al. (4) compared self-harming behavior and attempted suicides and found that adult patients with borderline disorders use self-harming behaviors in order to distract from problems, express anger, and trigger positive feelings. Therefore, self-harming behavior aims to provide temporary relief whereas the predominant motive of attempted suicide is “to make others better off”. Attempted suicide and self-harming behavior differ in terms of the emotions that the intended action aims to deal with. Self-harming behavior mainly aims to regulate acute and upsetting arousal affects (anger, frustration, fear). Suicide attempts, on the other hand, are favored by sustained emotions at a low level of arousal (loneliness, hopelessness). Self-harming behavior is accompanied by mild forms of injuries (cutting, hitting oneself, etc). By contrast, suicide attempts often result in severe forms of injuries (overdose, use of firearms, etc). As a rule, patients with self-harming behavior have less serious injuries and a higher number of already inflicted self-injuries than patients with suicidal intent. The crucial difference is the emotional state preceding the act (acutely occurring emotions at a high level of arousal versus sustained emotions at a low level of arousal).

Neurophysiological tests and neuroimaging procedures in non-acute headache (2nd edition)

A large number of instrumental investigations are used in patients with non-acute headache in both research and clinical fields. Although the literature has shown that most of these tools contributed greatly to increasing understanding of the pathogenesis of primary headache, they are of little or no value in the clinical setting. This paper provides an update of the 2004 EFNS guidelines and recommendations for the use of neurophysiological tools and neuroimaging procedures in non-acute headache (first edition). Even though the period since the publication of the first edition has seen an increase in the number of published papers dealing with this topic, the updated guidelines contain only minimal changes in the levels of evidence and grades of recommendation. (i) Interictal EEG is not routinely indicated in the diagnostic evaluation of patients with headache. Interictal EEG is, however, indicated if the clinical history suggests a possible diagnosis of epilepsy (differential diagnosis). Ictal EEG could be useful in certain patients suffering from hemiplegic or basilar migraine. (ii) Recording evoked potentials is not recommended for the diagnosis of headache disorders. (iii) There is no evidence warranting recommendation of reflex responses or autonomic tests for the routine clinical examination of patients with headache. (iv) Manual palpation of pericranial muscles, with standardized palpation pressure, can be recommended for subdividing patient groups but not for diagnosis. Pain threshold measurements and EMG are not recommended as clinical diagnostic tests. (v) In adult and pediatric patients with migraine, with no recent change in attack pattern, no history of seizures, and no other focal neurological symptoms or signs, the routine use of neuroimaging is not warranted. In patients with trigeminal autonomic cephalalgia, neuroimaging should be carefully considered and may necessitate additional scanning of intracranial/cervical vasculature and/or the sellar/orbital/(para)nasal region. In patients with atypical headache patterns, a history of seizures and/or focal neurological symptoms or signs, MRI may be indicated. (vi) If attacks can be fully accounted for by the standard headache classification (IHS), a PET or SPECT scan will normally be of no further diagnostic value. Nuclear medical examinations of the cerebral circulation and metabolism can be carried out in subgroups of patients with headache for the diagnosis and evaluation of complications, when patients experience unusually severe attacks or when the quality or severity of attacks has changed. (vii) Transcranial Doppler examination is not helpful in headache diagnosis. Although many of the examinations described in the present guidelines are of little or no value in the clinical setting, most of the tools, including thermal pain thresholds and transcranial magnetic stimulation, have considerable potential for differential diagnostic evaluation as well as for the further exploration of headache pathophysiology and the effects of pharmacological treatment.

Narkolepsi og andre hypersomnier

Narcolepsy is currently categorized into three groups; narcolepsy with and without emotionally triggered loss of muscle tone (cataplexy), and narcolepsy secondary to other medical conditions. Many patients with hypersomnia are diagnosed too late. The article presents a review of this field. Sources are literature identified through a non-systematic Pub-Med search and the authors' personal experience with diagnosing and treating patients with narcolepsy and other hypersomnias. Sleep attacks and emotionally triggered loss of muscle tone are the most important symptoms of narcolepsy with cataplexy. Loss of hypocretin-producing cells is considered to be the cause. Absence of the tissue antigen HLA DQB1*0602 renders narcolepsy an unlikely diagnosis. Narcolepsy without cataplexy occurs less frequently and may have another biological basis. A differential diagnostic evaluation is important to determine whether hypersomnia is associated with obstructive sleep apnea, neurological disease or psychiatric disorders. Polysomnography and multiple sleep latency tests are important diagnostic tools. Hypocretine levels in the cerebrospinal fluid should be measured in most patients. Methylphenidate and other CNS-stimulants are the most potent drugs for treatment of sleep attacks. Tricyclic antidepressive drugs and some newer drugs may be efficient in cataplexy. Narcolepsy may affect education and work-life. Medication is available. Regular general practitioners should refer patients suspected of having narcolepsy for evaluation in a sleep centre or a hospital with established routines for diagnosis of sleep disorders.

Behandlungspfad „Akutes Koronarsyndrom“

The clinical pathway "acute coronary syndrome" of the university hospital Marburg describes the guideline-conform and consented management of patients with ST-segment elevation infarct (STEMI), non-ST-segment elevation infarct (NSTEMI) and Troponin negative unstable angina. A 12-lead ECG recording is made and read in all patients within 10 minutes. All patients with STEMI undergo immediate revascularisation using primary percutanuous catheter intervention (PCI) after administration of basic medical therapy. Primary PCI is also used in all patients with NSTEMI, persistent chest pain, rhythm or hemodynamic instability. Patients with unstable angina, who became free of symptoms after application of basic medication, but who have additional risk factors undergo cardiac catheterisation within 48 hours. Acute myocardial infarction can be ruled out in patients with twofold negative cardiac troponin levels during 6-12 hours. In the absence of further symptoms, these patiens undergo differential diagnostic evaluation of cardiac and extracardiac causes of chest pain. The introduction of this clinical pathway 2 years ago, which was consented before by the hospital board and the clinical directors, has lead to a remarkable improvement in the clinical decision-making at the emergency room of the hospital and reduced the door to intervention time considerably.

C‐Reactive Protein May Be Increased in Migraine Patients Who Present With Complex Clinical Features

Stroke risk is increased in migraine, the basis of which remains to be established. C-reactive protein (CRP) is a marker of cerebrovascular disease, suggesting in part an inflammatory mechanism. Because attacks of migraine may involve repeated sterile vascular inflammation, we measured CRP in migraine patients. Retrospective review was conducted of 60 randomly sampled charts of patients with the diagnosis of migraine without aura (MwoA, n = 29) and migraine with aura (MwA, n = 31), in which CRP was recorded as part of the differential diagnostic evaluation. CRP was measured by standard commercial laboratory methods; high sensitivity CRP (hs-CRP) values above 3mg/L were considered abnormal. Elevated hs-CRP was found in 43% of all patients (26 of 60). In MwoA, of 29 subjects, abnormal hs-CRP was recorded in 16; in 10 no other conditions were found to explain the abnormality. In MwA, of 31 subjects, abnormal CRP was recorded in 10; in 5 no other condition could explain the abnormality. No associations were found between other demographic or clinical features. CRP may be abnormal in MwoA and MwA patients who present with atypical, severe, or complex clinical features that require extensive differential diagnostic investigation.

Clival chordoma manifesting as nasal bleeding. A case report

Chordoma is a rare cartilaginous tumor, for which bleeding presentation is unusual. We report a case of rare hemorrhaged clival chordoma, which was diagnosed correctly by magnetic resonance imaging. A 32-year-old man presented with nasal bleeding. The tumor was totally removed via a trans-sphenoidal approach, from which the surgical specimen confirmed chordoma. Epistaxis seemed to be caused by the spreading of the intratumoral hemorrhage into the sphenoid sinus. This case demonstrates the importance of an exact differential diagnostic evaluation, including chordoma, by use of modern imaging techniques for nasal bleeding.

Stroke and neurodegenerative disorders. 4. neurodegenerative disorders

Bryant PR, Geis CC, Moroz A, O’Neill BJ, Bogey RA. Stroke and neurodegenerative disorders. 4. Neurodegenerative disorders. 2004;85(3 Suppl 1):S21–33. This self-directed learning module highlights diagnosis, treatment, and rehabilitation issues in patients with neurodegenerative disorders, including multiple sclerosis (MS), Parkinson’s disease, and amyotrophic lateral sclerosis (ALS). It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the differential diagnosis, diagnostic evaluation, medical management, and rehabilitation issues in MS. Similarly, the differential diagnosis treatment and rehabilitation in Parkinson’s disease is discussed. Electrodiagnosis, pharmacologic treatment, and rehabilitation options for ALS are also discussed. Overall article objective To review the differential diagnosis, evaluation, medical treatment, and rehabilitation management of patients with MS, Parkinson’s disease, and ALS.