Dilemma In Diagnosis Research Articles

Ductal carcinoma in situ of the breast with apocrine cytology: Definition of a borderline category

Papillary patterns of apocrine cells are frequent in benign breast biopsies and pose little diagnostic difficulty when the classic apocrine cytology is present. Dilemmas in diagnosis do occur, however, when the usual papillary patterns of hyperplastic apocrine epithelium are absent in a hyperplastic lesion, particularly if it is extensive, presents more complex patterns, and/or lacks usual nuclear features. We classified lesions with nonclassic apocrine features into diagnostic categories to separate those with malignant potential from those that are truly benign. We selected 54 such cases sent in consultation over a 2-year period (1989 to 1991). We applied two sets of criteria: nuclear patterns (usual, borderline, and as seen in ductal carcinoma in situ) and extent of lesion (<4 mm, 4 to 8 mm, and >8 mm). The cases were categorized into diagnostic groups defined by these criteria of extent of lesion and cytologic features. We believe that application of these criteria recognizing borderline features to unusual, apocrine lesions fosters reproducibility in diagnosis and thus predictability of clinical outcome. We found only 10 cases to fit into borderline categories after use of the two criteria. The clinical utility of this suggested diagnostic stratification will require follow-up studies for linkage of criteria to clinical outcomes.

Tuberculosis of peripheral joints: a dilemma in diagnosis

15 cases of peripheral joint tuberculosis presenting to a tertiary referral hospital are reviewed. The presentation is characterized by an insidious onset with a slowly progressive, painful, ankylosed or swollen monarthropathy with a mean length of history of 6.5 ± 7 years. The knee joint was involved in 7 patients, hip in 6, elbow and shoulder 1 each. Significant systemic toxicity was absent, the white count was normal (mean 7.3 ± 2.4 × 10 9/1) and the erythrocyte sedimentation rate (ESR) was only slightly elevated (mean 31 ± 23 mm/first h). Features of extra-articular pulmonary tuberculosis were present in 7 patients and periarticular findings were present (abscesses in 7 and sinuses in 4 patients). Despite a characteristic presentation, the diagnosis was initially missed in 10, leading to delay in instituting correct treatment. One patient presented with osteoarthritis and a Baker's cyst. Definitive joint arthropathy was present in all patients. The highest diagnostic yield was with a combination of synovial histology, synovial fluid culture and direct smear examination for acid fast bacilli (14 patients) and lowest if direct smear examination was used alone (2 patients). Chemotherapy with rifampicin and isoniazid alone (3 patients) or with at least 1 other drug was given for a mean of 15 ± 5 months. Apart from debridement/drainage surgery, fusion/ excision arthroplasty was performed in 6 cases and one had a total knee replacement. A heightened diagnostic acumen is needed in such cases.

Dilemmas in Caries Diagnosis. Symposium proceedings. Chicago, Illinois, March 10, 1993

Journal of Dental EducationVolume 57, Issue 6 p. 407-443 Article Dilemmas in Caries Diagnosis. Symposium proceedings. Chicago, Illinois, March 10, 1993 First published: 01 June 1993 https://doi.org/10.1002/j.0022-0337.1993.57.6.tb02765.xAbout ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume57, Issue6June 1993Pages 407-443 RelatedInformation

Dilemmas in Caries Diagnosis

New criteria and methods are needed to identify the changing expression of caries and to classify carious lesions into categories keyed to treatment strategies. Symposium speakers identified these problems and reviewed the changing philosophy of diagnosis.

Dilemmas in caries diagnosis–applications to current practice and need for research

Dilemmas in caries diagnosis–applications to current practice and need for research

Portal Hypertension as Presenting Feature of a Myeloproliferative Disorder: Diagnosis and Therapeutic Dilemmas

In some patients presenting with complications of portal hypertension, thrombosis of hepatic or portal veins is identified as the cause. Hepatic or portal vein thrombosis may be secondary to recognized etiologies like infection or malignancy. When no etiology for the thrombosis is found, it is likely that a 'latent' myeloproliferative disorder (MPD) is the underlying abnormality. We present seven patients referred to us between 1988 and 1993 with complications of portal hypertension due to hepatic or portal vein thrombosis, in whom a 'latent', and in one patient overt, MPD was identified as the underlying disorder. Problems relating to the diagnosis of (latent) MPD in this subset of patients are discussed. The importance of in vitro 'endogenous' erythroid colony formation indicating the presence of MPD is emphasized. Also, a therapeutic strategy, with special emphasis on anticoagulation therapy, is suggested.

An update on recent advances in the understanding of non-neoplastic diseases of the salivary glands

The recent advances in the understanding of the non-neoplastic disorders of salivary glands are summarised in this paper. The common infections are discussed and newer aspects of juvenile recurrent parotitis outlined. The benign lympho-epithelial lesion is reviewed in relation to Sjogren's syndrome and the salivary gland pathology seen in relation to infection with human immunodeficiency virus. A range of unusual conditions that may affect the minor salivary glands in particular, and can cause diagnosis dilemmas, is summarised.

A physical therapy model for the treatment of low back pain.

Low back pain is commonly seen in physical therapy practice, and many methods of treatment are used to reduce it. In this article, we discuss the magnitude of the low back pain problem, outline the various treatment methods, and develop a strategy to classify and standardize the treatment of the patient who has low back pain. We will develop this thought process by discussing five management considerations: (1) the dilemma of diagnosis, (2) the information gained from the assessment, (3) a patient classification system, (4) the objectives of the low back treatment process, and (5) a proposed physical therapy intervention model that matches the objectives of treatment to the classification of the patient.

Experience of an Interdisciplinary Pediatric Pain Service

This article is a report of our experience with an interdisciplinary pain service in a large tertiary care pediatric hospital. During the first 2 years of operation, we received 869 consultations and referrals from more than 19 hospital divisions. Postoperative pain was the most frequent reason for consultation (56% of patients). Patients with pain related to cancer and sickle cell disease comprised 25% of the consultations. The remaining patients had a wide variety of primary diagnoses and causes of pain. We calculated the time spent by pain service physicians in direct patient care. The majority (63%) of physician time was spent with a small number of patients (17%). Most of these patients had pain that was unrelated to surgery, cancer, or sickle cell disease, and many posed dilemmas in diagnosis and treatment. Physician time was correlated directly to the use of psychologic and physical therapies for the pain, involving multiple team members. This experience supports the demand for an interdisciplinary pain service in a tertiary care children's hospital. A significant amount of physician time is necessary to provide patient care and to maintain a team approach, however, and pediatricians and other health care professionals who aim to implement such services should be cognizant of the time required.

The dilemma of diagnosis and treatment of gestational syphilis

The dilemma of diagnosis and treatment of gestational syphilis

Acute gall bladder perforation--a dilemma in early diagnosis.

Gall bladder perforation is a rare complication of cholecystitis. A definitive diagnosis is uncommon before surgery and the morbidity and mortality associated with this condition are high. We report six patients with gall bladder perforation to show the difficulty of making an early diagnosis. The history and the clinical findings of these patients are reviewed to highlight diagnostic pitfalls.

Stage IA2 squamous carcinoma of the cervix: Difficult diagnosis and therapeutic dilemma

The International Federation of Gynecology and Obstetrics instituted a change in the classification for carcinoma of the cervix with a new substage IA2. The criteria for this substage exceed the generally accepted criteria for microinvasion. Fifty patients with early invasive squamous cell carcinoma of the cervix were treated from 1976 through 1983 with a cone biopsy followed by a radical hysterectomy and pelvic lymph node dissection. These patients were reviewed to evaluate the ability to make the histologic diagnosis and to examine the natural history of the disease with maximal treatment. Histologically positive margins were found at the time of cone biopsy in 66% (33/50) of the patients. Negative margins at the time of cone biopsy were identified in 34% (17/50) of the patients. Residual invasive disease at the time of radical hysterectomy was found in 24% (4/17) of the patients with negative margins. Two of the 50 patients had positive lymph nodes. Three patients had recurrent metastatic disease. This study demonstrates that a preoperative diagnosis of stage IA2 invasive squamous cell carcinoma of the cervix is a difficult diagnosis to establish and creates a therapeutic dilemma regarding treatment.

Flexible Ureteropyeloscopy in the Diagnosis of Benign Essential Hematuria

Benign essential hematuria is an uncommon syndrome that constitutes a dilemma in diagnosis for the urologist. We studied 32 patients with flexible ureteropyeloscopy. Previous studies included renal arteriography, computerized tomography, ultrasound and urinary cytology. The entire intrarenal collecting system was inspected in 28 of the 32 patients and discrete lesions were found in 16. The most common finding was a hemangioma on a renal papilla in 11 patients. A discrete lesion was treated in 12 patients with successful results in 11. Nonspecific abnormalities were found in 9 patients and attempts at treatment of these lesions in 4 were unsuccessful. No lesion was found in 5 patients. Flexible ureteropyeloscopy offers a minimally invasive approach for the diagnosis of unilateral gross hematuria. Treatment of solitary small discrete lesions was highly successful.

Sexual abuse in the developmentally disabled: Dilemmas of diagnosis

Evaluation of developmentally disabled persons for physical signs of sexual abuse presents many challenges to the practitioner. This group is especially vulnerable to all types of abuse. A group of 35 mentally retarded females from a residential treatment facility was examined by the child abuse medical team at Harbor/UCLA Medical Center after one inpatient was found to be pregnant. Patients ranged in age from 13 to 55 years (median, 26 years; mean, 31.3 ± 13.6 years). All of the women had some degree of disability, with 24 (69%) being categorized as profoundly retarded. No patient was able to provide a history. There were 13 (37%) patients who had genital findings we believe are consistent with prior vaginal penetration. Dilemmas which arose during evaluation included the significance of healed genital lesions in this population and the implications of the findings for the residential facility. While developmentally disabled persons need an advocate in the medical and legal systems, these patients can overwhelm the practitioner. Whenever possible, a team approach is recommended to decrease the work load and frustration and provide collegial support and affirmation of findings.

Prenatal detection of trisomy 9 mosaicism.

Chromosomal mosaicism in amniotic fluid cells poses a serious dilemma in prenatal diagnosis since the observation may represent: (1) pseudomosaicism--an inconsequential tissue culture artefact; or (2) true mosaicism--occurring in approximately 0.20 per cent of amniocenteses with a significant impact on pregnancy outcome. Mosaicism for trisomy 9 was observed in an amniotic fluid specimen obtained for advanced maternal age with two cell lines [46,XX (46 per cent)/47,XX, +9 (54 per cent)] present in each of four culture flasks. Since more than 75 per cent of newborns with trisomy 9 mosaicism have complex cardiac malformations, a fetal echocardiogram was obtained at 20 weeks' gestation and interpreted as normal. A fetal blood sample (22 weeks' gestation) disclosed only a single trisomy 9 cell among the 100 metaphases analysed. However, a second fetal echocardiogram performed at the time of blood sampling suggested a non-specific cardiac anomaly. Fetal autopsy following elective pregnancy termination revealed several malformations including severe micrognathia, persistence of the left superior vena cava, and skeletal anomalies. Cytogenetic studies of cell cultures derived from several fetal tissues demonstrated trisomy 9 ranging from 12 to 24 per cent.

The dilemma of chromosomal mosaicism in chorionic villus sampling—‘direct’ versus long‐term cultures

Chromosomal mosaicism is one of several unanswered dilemmas in first-trimester prenatal diagnosis. We report the course of a pregnancy in which a normal karyotype was detected on direct CVS preparation and fetal blood, 100 per cent trisomy 21 in one long-term CVS culture, and low-rate trisomy 21 mosaicism in a second long-term CVS culture and amniocentesis. The phenotypically normal infant had a 6 per cent mosaicism of trisomy 21. It appears that a persistent low-rate mosaicism in different tissues may be indicative of the true status of the fetus.

Bronchogenic cysts: a persistent dilemma.

Bronchogenic cysts are congenital lesions of the respiratory tract. Although usually benign, they have the potential to develop complications and can pose a dilemma in diagnosis and treatment. Twenty patients who presented to the Cardiothoracic Surgical Unit at Royal Prince Alfred Hospital over a 10 year period are reported. Symptoms were common (75%) but serious complications were rare (5%). Most cysts were excised completely at thoracotomy with minimal morbidity. The correct diagnosis was established pre-operatively in less than half of the patients. Therefore excision is recommended to confirm the diagnosis, to exclude malignancy and to minimize possible complications.

Diagnosing Organizations: Methods, Models, and Processes.

Diagnosis - Approaches and Methods Using the Open System Model Assessing Performance-Related Behavior and the Quality of Work Life Examining System Fits and Power Relations within Divisions and Organizations Diagnosing Environmental Relationships Challenges and Dilemmas of Diagnosis

The Dilemma of Pathogenesis and Diagnosis of Food Allergy

The Dilemma of Pathogenesis and Diagnosis of Food Allergy

Rocky Mountain Spotted Fever

Rocky Mountain spotted fever occurs primarily in the warm weather months of April through September in the southeastern and south central United States. It is transmitted by the bite of ticks infected with the etiologic Rickettsia. This article reviews the epidemiology, clinical manifestations, diagnosis and therapy of Rocky Mountain spotted fever. Emphasis is placed on the dilemmas of early diagnosis and the necessity of early and often empirical antibiotic treatment of suspected cases.