Expensive Diagnostic Procedures Research Articles

Choosing Wisely in oncology: are guidelines effective at preventing unnecessary diagnostics? The example of surveillance positron emission tomography for patients with localised colorectal cancer

ObjectiveHealthcare overuse is a major challenge for healthcare systems and patients worldwide. Professional guidelines such as the ‘Choosing Wisely’ guidelines have attempted to reduce specific examples of overuse. We examined...

Multimodal imaging and electrophysiological study in the differential diagnosis of rest tremor

IntroductionDistinguishing tremor-dominant Parkinson's disease (tPD) from essential tremor with rest tremor (rET) can be challenging and often requires dopamine imaging. This study aimed to differentiate between these two diseases through a machine learning (ML) approach based on rest tremor (RT) electrophysiological features and structural MRI data.MethodsWe enrolled 72 patients including 40 tPD patients and 32 rET patients, and 45 control subjects (HC). RT electrophysiological features (frequency, amplitude, and phase) were calculated using surface electromyography (sEMG). Several MRI morphometric variables (cortical thickness, surface area, cortical/subcortical volumes, roughness, and mean curvature) were extracted using Freesurfer. ML models based on a tree-based classification algorithm termed XGBoost using MRI and/or electrophysiological data were tested in distinguishing tPD from rET patients.ResultsBoth structural MRI and sEMG data showed acceptable performance in distinguishing the two patient groups. Models based on electrophysiological data performed slightly better than those based on MRI data only (mean AUC: 0.92 and 0.87, respectively; p = 0.0071). The top-performing model used a combination of sEMG features (amplitude and phase) and MRI data (cortical volumes, surface area, and mean curvature), reaching AUC: 0.97 ± 0.03 and outperforming models using separately either MRI (p = 0.0001) or EMG data (p = 0.0231). In the best model, the most important feature was the RT phase.ConclusionMachine learning models combining electrophysiological and MRI data showed great potential in distinguishing between tPD and rET patients and may serve as biomarkers to support clinicians in the differential diagnosis of rest tremor syndromes in the absence of expensive and invasive diagnostic procedures such as dopamine imaging.

Transabdominal bowel ultrasound as a method of primary diagnosis in acute bowel pathology: literature review and demonstration of clinical cases

Currently, transabdominal ultrasound of the bowel is rarely used in daily routine practice to assess bowel condition due to the difficulty of its visualization, lack of awareness of specialists, and also due to the limited number of specialists who know the technique of bowel examination. Patients with acute bowel pathology seek emergency care in more than one third of cases. Gastrointestinal ultrasound is often used as the first imaging modality with good diagnostic accuracy in the setting of acute abdomen and may be the optimal diagnostic strategy in young women because of the radiation burden associated with X-ray and computer tomography scan. The clinician can examine the gastrointestinal tract in the area of greatest pain using ultrasound, thus obtaining more information and pathology data than standard physical examination. Intestinal ultrasound is mainly used for the diagnosis and monitoring of patients with inflammatory bowel disease, which helps to avoid the frequent use of invasive and expensive diagnostic procedures and leads to the early implementation of suitable treatment. This method can also serve to detect other pathological conditions present in the gastrointestinal tract. It is a promising method with high sensitivity and specificity, which has the advantage of being easily accessible, non-invasive, safe, due to the absence of ionising radiation and the need to use contrast agents. In addition, the advantage of this method is the reduction of diagnostic search, which allows the doctor to establish the diagnosis in a shorter time, as well as to reduce the patient’s expenses for expensive examinations.

Serum CRP biomarker detection by using carbon nanotube field-effect transistor (CNT-FET) immunosensor

C-reactive protein (CRP) is produced by the liver in response to systemic inflammation caused by bacterial infection, trauma and internal organ failures. CRP serves as a potential biomarker in the precise diagnosis of cardiovascular risk, type-2 diabetes, metabolic syndrome, hypertension and various types of cancers. The pathogenic conditions indicated above are diagnosed by an elevated CRP level in the serum. In this study, we successfully fabricated a highly sensitive and selective carbon nanotube field-effect transistor (CNT-FET) immunosensor for the detection of CRP. The CNTs were deposited on the Si/SiO2 surface, between source-drain electrodes, afterwards modified with well-known linker PBASE and then anti-CRP was immobilized. This anti-CRP functionalized CNT-FET immunosensor exhibits a wide dynamic detection range (0.01–1000 μg/mL) CRP detection, rapid response time (2–3 min) and low variation (<3 %) which can be delivered as a low-cost and rapid clinical detection technology for the early diagnosis of coronary heart disease (CHD). For the clinical applications, our sensor was tested using CRP fortified serum samples and sensing performance was validated using enzyme-linked immune-sorbent assay (ELISA). This CNT-FET immunosensor will be helpful in taking over the complex laboratory-based expensive traditional CRP diagnostic procedures practiced in the hospitals.

Kosten und Erlöse der spezialisierten Palliativversorgung im ambulanten und stationären Bereich

If the question of whether specialized palliative care pays off is understood in such way that the effort and costs are well proportioned to the benefits to those affected and to society, the answer to this question is clearly yes. The clear focus on the needs of those affected, which also includes relatives, and which often goes hand in hand with the omission of useless, unwanted, and often expensive diagnostic procedures and therapies, makes palliative care a highly economic form of care. In our healthcare system, which has been increasingly economized for decades, the question of whether something “pays off” is usually understood as whether the proceeds are favorable in relation to the costs by which profit can be made. However, especially in the German hospital system, it is easier to achieve surpluses with cost-intensive interventions than with a type of care in which the costs for staff account for the largest share. Therefore, the “problem” for business people is not that palliative medicine is too expensive, but rather that it is too cheap in certain areas. In general, no universal statement can be made about how lucrative specialized palliative care is. In particular, the outpatient and inpatient areas must be considered differently due to the different systems. Only in the case of multiprofessional palliative services in hospitals can it be stated that this increasingly important area is currently not regularly reimbursed to cover costs. On the other hand, palliative care units can be designed to cover costs and still ensure a high level of quality, especially if “secondary profits” are taken into account.

Solitary focal lung lesions: modern views on the diagnosis and medical tactics of their management. Literature review

A review of the literature is devoted to highlighting of the main points relating to the modern actual multidisciplinary problem — single or solitary lung nodules with incidental detection. The main terms that are used in the study of such lesions or the more common term — nodules, as well as their definition are given. Known pathology causes for the development of solitary pulmonary nodules are also presented. The morphological characteristics of such nodules are described by X-ray or tomogram. The main problem if such nodules are detected is to establish their nature and, above all, their malignant or benign nature. Since the further medical tactic of their management are exactly different. Now the main attention is paid to malignant tumors, since they require the fastest most reliable identification and appropriate medical actions.It has been established that accurate determination of nodules etiology by the main indicators of their radiological images is impossible. Although certain dependences of the malignancy risk of nodules on their size, contours and features of optical density have been identified. And only a morphological study allows us to establish the true nature of the nodules. It is believed that over diagnostics of malignancy of pulmonary nodules leads to excessive use of expensive invasive diagnostic procedures, and to some extent harms the patient in cases of benign nodules. The review ends with a list of possible options for medical management when solitary lung nodules of unknown origin are detected. Their disadvantages and advantages are briefly presented.

Sensing Soluble Immune Checkpoint Molecules and Disease-Relevant Cytokines in Cancer: A Novel Paradigm in Disease Diagnosis and Monitoring

Conventional detection of cancer involves highly invasive and expensive diagnostic procedures, often leading to non-compliance from patients. Therefore, there is a strong requirement for the development of non-invasive techniques that can facilitate rapid and timely diagnosis of the disease. The tumor-immune interaction often leads to anomalous expression of different soluble immune signaling molecules like cytokines and chemokines, thus making them promising candidates for sensing disease development and progression. Furthermore, differential expression of soluble isoforms of several immune-checkpoint molecules like PD-L1, CTLA-4 etc., has been found to have strong correlation with tissue-specific tumor development, disease progression and in many cases, disease prognosis. Therefore, development of biosensors, to rapidly detect and analyze the levels of these soluble immune molecules in different body fluids, requiring minimal sample volume, has the potential to be a game-changer in the field of cancer diagnosis. In addition, real time monitoring of these soluble immune checkpoint molecules in patient-derived biofluids may serve as decision support tools for patient selection for immunotherapeutic interventions. Majority of the biosensors designed to detect the soluble immune biomarkers, have used a two-antibody based sandwich system to capture the target analyte. However, new technologies using bioreceptors like the aptamers or nano-yeast scFv antibody fragments have made possible multiplexed detection of several analytes simultaneously. The use of gold nanoparticles or carbon nanotubes on the electrode surface serves to increase the sensitivity of detection, due to their high electrical conductivity. Further, fabrication of the biosensors on microfluidic platforms enable the detection of these analytes at ultra-low levels. This review discusses the recent advances made in the development of biosensors for specific and selective detection of these immune-markers that can be successfully translated to the clinics as a new paradigm in disease diagnosis and monitoring.

Clinico-pathological study of cervical lymph nodes in children using ultrasound scan and FNAC: a hospital-based study

Background: Cervical lymphadenopathy is one of the commonest clinical diagnostic dilemmas in children. The diagnosis plays key role in the management of cervical lymphadenopathy. Various methods of diagnosis include non-invasive and invasive procedures. Ultrasonography is a non-invasive readily available investigation for evaluation of cervical lymph nodes. One of the most reliable, less expensive diagnostic procedure is fine needle aspiration cytology (FNAC).Methods: A prospective study was conducted on 150 children in SVS Medical College Hospital, Mahabubnagar between January 2017 and January 2020. Ultrasonography followed by FNAC of lymph node was done in all children. Microsoft office excel software used for the data analysis. Sample size was calculated with 85% confidence level and 5% margin of error.Results: Out of 150 patients 79 were non-specific reactive lymphadenitis. 54 were granulomatous lymphadenitis.15 were lymphomas. 2 were malignant.Conclusions: Both ultrasonography and FNAC are very useful tools in the evaluation of cervical lymphadenopathy in children.

Assessment of the usefulness of macroenzyme determination in the situation of increased plasma enzyme activity in the absence of clinical symptoms

Introduction: The increased activity of serum enzymes is usually a reason of multiple, often expensive and invasive diagnostic procedures. However, there are situations in which abnormal enzyme activity persists for many months or years, and detailed studies do not confirm the existence of anatomic disease. Such is the case when enzymes form complexes with immunoglobulins on the basis of the immune antigen-antibody reaction. This phenomenon is usually benign condition, is transient and does not require treatment. Aim of study: Detection of the macroenzymes in patients with elevated serum enzyme activity. Evaluation of the relationship between the presence of macroenzymes and the age of patients, body mass index, lipid profile, chronic and autoimmune diseases. Material and methods: Macroenzymes were examined by polyethylene glycol precipitation (PEG) in 121 patients with elevated values of liver or pancreatic enzymes. Results: In the study group, a statistically significant difference was found comparing the BMI of men and women. BMI was significantly higher in men with macroenzymes (p = 0.006). It was shown that the BMI of people with serum macroenzymes is significantly higher (p = 0.049) than those without macroenzymes. A statistically significant correlation was observed between the presence of macroamylase and body weight, r = 0.33, p = 0.039. A positive correlation of triglycerides and macrogenzofacts in the serum was found. Macroamylase was observed the most frequently in the healthy group and those suffering from chronic diseases (45.83% and 42.86%). In the group of autoimmune diseases (autos) the most common was macro-GGTP (42.86%). In patients with inflammatory bowel disease, 80% of the confirmed macroenzymes in serum were macro-CK.

PGI22 ESTIMATING DIAGNOSTIC COSTS ASSOCIATED WITH A SECOND-GENERATION BLOOD TEST FOR ANTI-VINCULIN AND ANTI-CYTOLETHAL DISTENDING TOXIN B (CDTB) BIOMARKERS IN COMPARISON TO THE STANDARD EXCLUSIONARY APPROACH FOR IRRITABLE BOWEL SYNDROME WITH A DIARRHEAL COMPONENT (IBS-D/M)

IBS-D/M is typically diagnosed via clinical presentation and testing that excludes other conditions. A novel second-generation blood test quantifies anti-vinculin and anti-CdtB biomarkers to rule-in a diagnosis of IBS-D/M. This study seeks to estimate the economic impact associated with the second-generation blood test compared to the standard exclusionary approach for diagnosing IBS-D/M. A cost-minimization decision tree was constructed in TreeAge Pro 2019. Six gastroenterology providers were surveyed to understand the typical diagnostic framework for IBS-D/M, including utilization probabilities of tests and procedures and the probability of treatment as a function of test results. For the second-generation blood test arm, sensitivity, specificity, and likelihood ratios determined how patients advanced to treatment. Patients negative for the second-generation blood test subsequently moved down the standard exclusionary arm. Input costs were drawn from the 2019 MDsave weighted national average. Probabilistic sensitivity analysis (PSA) was performed to determine 95% confidence intervals for costs. Decision tree results informed a budget impact model with 1M covered lives. Survey results indicated 15 tests or procedures that may be used to exclude other conditions when diagnosing IBS-D/M. The decision tree model revealed a mean diagnostic cost per patient of $1129 for the second-generation blood test arm compared to $2049 for the standard exclusionary arm. The PSA produced 95% confidence intervals for cost of $997 - $1275 for the second-generation blood test arm and $1528 - $2443 for the standard exclusionary arm. The budget impact model determined savings of $0.52 per-member-per-month when 50% of patients with possible IBS-D/M take the second-generation blood test. This model demonstrates potential savings of $253 - $1446 per patient for the second-generation blood test compared to exclusionary diagnosis of IBS-D/M by reducing the need for expensive diagnostic procedures, with annual aggregate plan savings of $6.2M possible when 50% of potential IBS-D/M patients utilize the second-generation blood test.

Ultrasound guided fine-needle aspiration biopsy of metastases in nonpalpable supraclavicular lymph nodes in lung cancer patients

&#x0D; &#x0D; &#x0D; Background and objectives: To assess frequency and signifi- cance of enlarged nonpalpable supraclavicular lymph nodes with routine ultrasound (US) evaluation and US-guided fine- needle aspiration biopsy (FNAB) for the diagnosis and staging of patients with lung cancer.&#x0D; Materials and methods: 106 consecutive patients with lung cancer and nonpalpable supraclavicular lymph nodes were evaluated with cervical US for the presence of pathological lymph nodes. FNAB was performed in patients with nodes with short-axis &gt; 5 mm, rounded shape and missing echogenic hilum.&#x0D; Results: 27 (25.5%) patients had enlarged supraclavicular lymph nodes on US. Fourteen patients (13.2%) had cytologically proven lymph node involvement. Supraclavicular lymph node metastasis was more frequent in patients with medi- astinal invasion (p = 0.0001) and patients with enlarged lymph nodes on upper paratracheal stations on thorax CT (p = 0.0001). No relation was found between supraclavicular lymph node involvement and T stage (p = 0.27), distant metastasis (p = 0.50) or histological type (p = 0.80). Three patients were upstaged from IIIA to IIIB status. US-guided FNAB was the only diagnostic method in 2 patients.&#x0D; Conclusion: US-guided FNAB is a simple and safe procedure which can document N3 stage of disease in lung cancer patients. Thereby more invasive and expensive diagnostic procedures can be avoided in selected lung cancer patients.&#x0D; &#x0D; &#x0D;

Nondestructive Raman Spectroscopy as a Tool for Early Detection and Discrimination of the Infection of Tomato Plants by Two Economically Important Viruses

Global population forecasts dictate a rapid adoption of multifaceted approaches to fulfill increasing food requirements, ameliorate food dietary value and security using sustainable and economically feasible agricultural processes. Plant pathogens induce up to 25% losses in vegetable crops and their early detection would contribute to limit their spread and economic impact. As an alternative to time-consuming, destructive, and expensive diagnostic procedures, such as immunological assays and nucleic acid-based techniques, Raman spectroscopy (RS) is a nondestructive rapid technique that generates a chemical fingerprinting of a sample, at low operating costs. Here, we assessed the suitability of RS combined to chemometric analysis to monitor the infection of an important vegetable crop plant, tomato, by two dangerous and peculiarly different viral pathogens, Tomato yellow leaf curl Sardinia virus (TYLCSV) and Tomato spotted wilt virus (TSWV). Experimentally inoculated plants were monitored over 28 days for symptom occurrence and subjected to RS analysis, alongside with measuring the virus amount by quantitative real-time PCR. RS allowed to discriminate mock inoculated (healthy) from virus-infected specimens, reaching an accuracy of >70% after only 14 days after inoculation for TYLCSV and >85% only after 8 days for TSWV, demonstrating its suitability for early detection of virus infection. Importantly, RS also highlighted spectral differences induced by the two viruses, providing specific information on the infecting agent.

A Rare Case of Pachydermodactyly in 25 years Old Male

Pachydermodactyly is a rare digital fibromatosis that can be misdiagnosed with inflammatory rheumatic diseases. So far in the literature only about 150 cases of PDD have been reported. A prompt clinical diagnosis of the disease would prevent inappropriate treatment and unnecessary expensive diagnostic procedures such as biopsy or magnetic resonance imaging. Gold standard therapy for pachydermodactyly is not established yet.A rare case of a 25 years-old male patient with pachydermodactyly is reported. He complained swelling and thhickening around joints in both hands since 7 months ago. He denied having any pain or morning stiffness of the joints and was also free other symptomatic symptomps. Family history was not significant. Dermatological state showed skin colouredhyperkeratotic patches. Laboratory showed no abnormalities. Radiology results shows no bone and joint abnormalities. Dermoscopy examination on lesion shows whitish scaling and cobblestone appearance. Diagnosis of pachydermodactyly is based on anamnesis, physical examination, laboratory findings, and plain radiograph. Early and correct diagnosis is important to prevent unnececessary, expensive, and invasive diagnostic procedure

The role of intestinal ultrasound in diagnostics of bowel diseases.

Intestinal ultrasound is a safe and inexpensive method that allows visualisation of the gastrointestinal tract and detection of abnormalities. This examination involves the use of two different ultrasound transducers: a low-frequency convex probe and high-frequency linear probe. When needed, the performance of these methods can be enhanced by the use of contrast media or Doppler techniques. Intestinal ultrasound is mostly utilised for the diagnosis and follow-up of patients with inflammatory bowel diseases, helping to avoid frequent use of invasive and expensive diagnostic procedures and leading to early implementation of suitable treatment. This technique can also serve to detect other pathologic conditions that are present in the gastrointestinal tract. It is a promising method with high sensitivity and specificity, which has gained popularity in recent years and has the potential to become the method of choice in the diagnostics of many intestinal disorders.

Phantom tumor of the lung in heart failure patient

In heart failure localized interlober pleural effusion is rare but well-known finding. But there is not enough case reports in the literature. This radiological finding seems like a mass and undergoes resolution quickly, It is also known as vanishing tumor, pseudotumor or phantom tumor. It is difficult to estimate the incidence due to the small number of reported cases. Determination of the mass appearance in chest X-ray should be reminded the phantom tumor especially in heart failure patient. This diagnosis would prevent unnecessary expensive diagnostic procedures, wrong diagnosis and treatment.

A Clinico-Pathological Study of Cervical Lymph Nodes.

Cervical lymphadenopathy is one of the commonest presenting complaint of patient in ENT OPD Fine Needle Aspiration Cytology (FNAC) is one of the most reliable, less expensive, and basic diagnostic procedure for the definitive and conclusive diagnosis for the immune system which reciprocates in the form of enlarged lymph nodes. A study was conducted in ENT Department of Santosh Medical College, Ghazibad from August 2015 to May 2016 on 64 patients with enlarged cervical lymph nodes. FNAC was done to make the diagnosis. Out of 64 patients (51.5%) was reactive non-specific, 28% tubercular, 3.1% lymphoma and 17% were malignant. FNAC is one of the most dependable diagnostic tools in case of cervical lymphadenopathy for early diagnosis and detection for the better management.

Iron Deficiency Anemia Associated with Extracorporeal Photophoresis: A Retrospective Analysis

▪Since its emergence as a novel therapy for cutaneous T-cell lymphoma in 1987, extracorporeal photopheresis (ECP) has gained popularity in the fields of solid organ and stem cell transplantation (Perotti et al Transfus Apher Sci 2015). Though ECP is thought to be associated with few adverse effects, we have anecdotally noted that some patients treated with ECP develop iron deficiency anemia. Anemia has been reported in ECP literature at an incidence of anywhere from 0% to 24.5%, however, the etiology of the anemia has not been described (Quaglino et al Int J Dermatol 2013, Flowers et al Blood 2008, Jaksch et al J Heart Lung Transpl 2012, Dignan et al Bone Marrow Transpl 2014). We performed a retrospective chart review to further investigate the magnitude of this potential adverse effect.Adult patients receiving ECP for any indication at Mayo Clinic Hospital-Rochester were eligible for inclusion. Patients with pre-existing iron deficiency anemia (IDA) or physiologic and/or pharmacologic reasons for altered iron homeostasis were excluded from analysis. The primary endpoint was to describe the cumulative incidence of IDA at one year of ECP therapy, utilizing Kaplan-Meier methodology. We defined IDA as a hemoglobin < 12 g/dL (females) or < 14 g/dL (males), plus any of the following: MCV < 80 fL, ferritin < 11 mcg/L, iron < 35 mcg/dL (females) or < 50 mcg/dL (males), total iron binding capacity > 400 mcg/dL, or percent saturation <14%. Secondarily, we aimed to describe the proportion of patients who underwent further diagnostic evaluation of IDA and those that were initiated on iron supplementation for IDA. Patients were followed for the primary endpoint until diagnosis of IDA, death, or date of last ECP session; those who did not develop IDA were censored at the date of last follow-up.Between January 1, 2006 and July 1, 2015, a total of 120 adult patients were treated with ECP at Mayo Clinic in Rochester, MN; 80 patients met inclusion criteria. For the remaining 40 patients, patients were excluded for recent history of transfusions and/or phlebotomy (n=27), incomplete documentation (n=7), IDA at baseline (n=3), or potentially confounding past medical histories (n=3). Treatment of graft-versus-host disease (GVHD) was the foremost ECP indication in our cohort, accounting for 63.8% of our patients. Patients also received ECP for treatment of cutaneous T-cell lymphoma, treatment of solid organ transplant rejection, and other indications (25%, 7.5%, and 3.8%, respectively). Mean age was 55.6 years, 38.7% were female, and the median duration of ECP therapy was 344 days (IQR 130 - 755 days).At 1 year from the start of ECP therapy, the cumulative incidence of IDA in our cohort was 21.1% (95% CI 9% - 31.6%; Figure 1). At 4 years from the start of ECP therapy, the cumulative incidence of IDA was 49.1% (95% CI 26.4% - 64.8%). Of those that developed an IDA at any time during ECP therapy, 6/20 (30%) underwent invasive diagnostic procedures (colonoscopy and/or upper endoscopy) to evaluate the etiology of the IDA. Iron supplementation was initiated in 18/20 (90%) patients; hemoglobin returned to normal in 8 patients (44.4%) based on available follow-up. These data indicate that a substantial number of patients develop IDA while receiving ECP therapy; a finding which may lead to more prompt recognition and treatment of IDA in patients receiving ECP, and perhaps spare expensive diagnostic procedures. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Changing prevalence of Helicobacter pylori infection and peptic ulcer among dyspeptic patients.

SIMI 2015 Dyspeptic syndrome defines a series of symptoms involving the upper GI tract. The syndrome affects about 25 % of the adult population, and is one of the most common GI problems in primary care or in gastroenterology practice [1]. In approximately 75 % of patients, dyspeptic symptoms are functional, meaning without an underlying cause on diagnostic evaluation. Authorities in the field stratify functional dyspepsia into three subgroups on the basis of the symptoms pattern: dyspepsia motility like, including symptoms such as bloating, predominant nausea, epigastric fullness, early satiety and anorexia; dyspepsia ulcer like, characterized by burning, epigastric hunger pain mitigated by antacid, antisecretory drugs and by food; finally unspecified dyspepsia [1]. The approach to and management of a patient with dyspepsia is based on the presence or absence of alarm features such as age older than 55 years, family history of upper GI cancer, weight loss with a regular diet, GI bleeding, dysphagia, jaundice, anemia, persistent vomiting and palpable mass or lymphadenopathy [1]. Because several disorders can be responsible for these symptoms including esophageal, gastroduodenal, pancreatic, and hepatobiliary diseases, for these patients, the goal will be to avoid invasive and expensive diagnostic procedures to arrive at a definitive diagnosis [1, 2]. Upper endoscopy is the gold standard for establishing a specific cause in patients with epigastric pain; however, it should be reserved only for patients with alarm features. For this reason, a detailed anamnesis and physical examination are fundamental to identify patients with gastroesophageal reflux disease, nonsteroidal anti-inflammatory drug (NSAID)-induced dyspepsia, as well as alarm features. The age cut-off also may be different among countries, depending upon the prevalence of gastroesophageal malignancy. In Europe, endoscopy is recommended in adults older than 45 years old [3]. The majority of investigated dyspeptic patients with a defined diagnosis of peptic ulcers have complained of epigastric pain, and we know that the most common causes of gastric and duodenal ulcers include Helicobacter pylori infection and NSAIDs use. Less common causes are: Zollinger‐Ellison tumors, Crohn’s disease, Curling ulcers (from stress due to serious

Cinnamon-induced Oral Mucosal Contact Reaction.

Contact stomatitis associated with consumption of cinnamon flavoring agents is a relatively uncommon disorder. Of relevance, both clinical features and the histopathologic findings of this condition are nonspecific, and, more importantly, may resemble some other inflammatory oral mucosa disorders, eventually making diagnosis difficult. Usually a patient exhibits a combination of white and erythematous patches of abrupt onset, accompanied by a burning sensation. To shed some light on this subject, a case of a 64-year-old woman with hypersensitivity contact reaction on the oral mucosa due to cinnamon mints is presented, with emphasis on differential diagnosis and the process for confirmation of the diagnosis. The treatment consists of discontinuing the use of cinnamon products. Clinicians will be able to recognize this disorder following a careful clinical examination and detailed history. This recognition is important in order to avoid invasive and expensive diagnostic procedures.

Access to CD4 Testing for Rural HIV Patients: Findings from a Cohort Study in Zimbabwe.

BackgroundCD4 cell count measurement remains an important diagnostic tool for HIV care in developing countries. Insufficient laboratory capacity in rural Sub-Saharan Africa is frequently mentioned but data on the impact at an individual patient level are lacking. Urban-rural discrepancies in CD4 testing have not been quantified to date. Such evidence is crucial for public health planning and to justify new yet more expensive diagnostic procedures that could circumvent access constraints in rural areas.ObjectiveTo compare CD4 testing among rural and urban HIV patients during the first year of treatment.MethodsRecords from 2,145 HIV positive adult patients from a Médecins sans Frontières (Doctors without Borders) HIV project in Beitbridge, Zimbabwe, during 2011 and 2012 were used for a retrospective cohort analysis. Covariate-adjusted risk ratios were calculated to estimate the effects of area of residence on CD4 testing at treatment initiation, six and 12 months among rural and urban patients.FindingsWhile the proportion of HIV patients returning for medical consultations at six and 12 months decreased at a similar rate in both patient groups, CD4 testing during consultations dropped to 21% and 8% for urban, and 2% and 1% for rural patients at six and 12 months, respectively. Risk ratios for missing CD4 testing were 0.8 (95% CI 0.7-0.9), 9.2 (95% CI 5.5-15.3), and 7.6 (95% 3.7-17.1) comparing rural versus urban patients at treatment initiation, six and 12 months, respectively.ConclusionsCD4 testing was low overall, and particularly poor in rural patients. Difficulties with specimen transportation were probably a major factor underlying this difference and requires new diagnostic approaches. Our findings point to severe health system constraints in providing CD4 testing overall that need to be addressed if effective monitoring of HIV patients is to be achieved, whether by alternative CD4 diagnostics or newly-recommended routine viral load testing.