Knowledge Of Clinical History Research Articles

PATIENTS WITH NON-ISCHEMIC CARDIOMYOPATHY AND MID-WALL STRIAE HAVE SIMILAR OUTCOMES AS PATIENTS WITH ISCHEMIC CARDIOMYOPATHY: A PROPENSITY-MATCHED ANALYSIS

PATIENTS WITH NON-ISCHEMIC CARDIOMYOPATHY AND MID-WALL STRIAE HAVE SIMILAR OUTCOMES AS PATIENTS WITH ISCHEMIC CARDIOMYOPATHY: A PROPENSITY-MATCHED ANALYSIS

Upper Gastrointestinal Tract Involvement in Inflammatory Bowel Diseases: Histologic Clues and Pitfalls.

The upper gastrointestinal (UGI) manifestations of inflammatory bowel diseases (IBDs) are frequently obscured by classic ileal and colonic symptoms and are reported to involve only 0.5% to 4% of adult patients. However, because of the improvement of endoscopic techniques and the growing use of esophagogastroduodenososcopy with biopsy, both asymptomatic and clinically significant esophageal, gastric, and duodenal manifestations are increasingly recognized. The UGI involvement in IBD was historically synonymous with Crohn’s disease (CD), but the doctrine of ulcerative colitis (UC) being limited to the colon has been challenged, and UC-related gastroduodenal lesions have been reported. The diagnosis of UGI IBD should ideally rely on a combination of the clinical history, endoscopic picture, and histologic features. Although endoscopic changes such as aphthoid or longitudinal ulcers and bamboo-joint-like pattern are suggestive of CD, histologic evaluation increases the sensitivity of the IBD diagnosis since histologic alterations may be present in endoscopically unremarkable mucosa. Conversely, in many cases, the histologic findings are nonspecific, and the knowledge of clinical history is vital for reaching an accurate diagnosis. The presence of epithelioid granuloma is highly suggestive of CD but is present in a minority of CD cases; thus, pathologists should be aware of how to diagnose UGI IBD in the absence of granulomata. This article reviews the most important clinical, endoscopic, and histologic features of IBD-associated esophagitis, gastritis, and duodenitis, as well as the IBD-related manifestations in the biliary tract and the postcolectomy setting.

Onion-bulb patterns predict acquired or inherited demyelinating polyneuropathy.

Onion-bulbs (OB) are concentrically layered Schwann-cell processes, surrounding nerve fibers, occurring in both inherited and acquired demyelinating polyneuropathies. We investigated whether OB patterns (generalized, mixed, or focal) correlate with acquired or inherited neuropathies. One hundred thirty-one OB-rich nerve biopsies were graded for OB pattern and inflammation without knowledge of clinical history. We classified inherited (n = 49) or acquired (n = 82) neuropathies based solely on clinical history. Fifty-one biopsies had generalized (34 inherited vs. 17 acquired, P < 0.001), 54 mixed (48 acquired vs. 6 inherited, P < 0.001), and 26 focal/multifocal (inherited [n = 9], acquired [n = 17]) OB. Inflammation occurred more frequently in acquired (n = 54) than inherited (n = 14) neuropathy (P = 0.004). Generalized OB correlates with inherited neuropathy; mixed OB with acquired. Inflammation occurs more in acquired neuropathy cases. OB patterns are best explained by ubiquitous Schwann-cell involvement in inherited and multifocal Schwann-cell involvement in acquired neuropathies and predict the electrophysiology of uniform demyelination in inherited and unequal demyelination in acquired neuropathies. Muscle Nerve 59:665-670, 2019.

Fine-needle aspiration biopsy of secondary neoplasms of the thyroid gland: a multi-institutional study of 62 cases.

Secondary neoplasms of the thyroid gland (SNTGs) are uncommon, and it is important to recognize them in thyroid fine-needle aspiration biopsy (FNAB). The authors report a cohort of 62 SNTGs from 7 institutions in the United States and Europe. Patients were identified retrospectively by searching through medical records of the respective institutions. All initial diagnoses were rendered by FNAB. SNTGs represented 0.16% of all thyroid FNABs and were more frequent among women (ratio of women to men, 1.2:1.0). The mean patient age was of 59 years (range, 7-84 years), the mean tumor size was 3 cm (range, 0.9-7 cm), and the mean interval from diagnosis of the primary tumor was 45 months (range, 0-156 months). Eighty-seven percent of SNTGs were diagnosed as malignant by FNAB, and there was a specific SNTG diagnosis in 93% of patients. Immunocytochemistry and flow cytometry, which were used in 30% of patients, were useful ancillary studies. Adenocarcinomas (n = 23; 37%) and squamous cell carcinomas (SCCs) (n = 22; 35.5%) represented the majority of SNTGs, followed by lymphoma (n = 5; 8%), melanoma (n = 5; 8%), adenoid cystic carcinoma (n = 3; 5%), and various sarcomas (n = 3; 5%). Adenocarcinomas originated from the kidney (n = 9; 39%), lung (n = 6; 26%), breast (n = 5; 22%), and colon (n = 3; 13%). SCCs originated mostly from the head and neck (n = 13; 59%), followed by lung (n = 3; 13%), esophagus (n = 3; 14%), and unknown primary sites (n = 3; 14%). Adenocarcinomas from the kidney, lung, breast, and colon along with SCCs represent the majority of SNTGs. The current results indicate that FNAB is a sensitive and accurate method for diagnosing SNTG; however, diagnostic difficulties can occur. Knowledge of clinical history and the judicious application of ancillary studies can increase the sensitivity and accuracy of FNAB for detecting SNTGs.

A comparison of cervical histopathology variability using whole slide digitized images versus glass slides: experience with a statewide registry

Whole slide imaging is increasingly used for primary and consultative diagnoses, teaching, telepathology, slide sharing, and archiving. We compared pathologist evaluations of glass slides and corresponding digitized images within the context of a statewide surveillance effort. Cervical specimens collected by the New Mexico HPV Pap Registry research program targeted cases diagnosed between 2006 and 2010. Two samples of 250 slides each were digitized with the ScanScope XT (Aperio, Vista, CA) microscope and reviewed with Aperio ImageScope reader. (1) A "random set" had a distribution of community diagnoses: 70% from cases of cervical intraepithelial neoplasia grade 2 or higher, 20% from cases of cervical intraepithelial neoplasia grade 1 and 10% from negative cases. (2) A "discrepant set" was represented by difficult cases where 2 study pathologists initially disagreed. Within the regular workflow of the New Mexico HPV Pap Registry, 3 pathologists read the slides 2 to 3 times each without knowledge of clinical history, previous readings or sampling scheme. Pathologists also read each corresponding image twice. For within- and between-reader comparisons we calculated unweighted κ statistics and asymmetry χ(2) tests. Across all comparisons, slides and images yielded similar results. For the random set, almost all within-reader and between-reader Kappa values ranged between 0.7 and 0.8 and 0.6 and 0.7, respectively. For the discrepant set, most within- and between-reader κ values were 0.4 to 0.6. As cervical intraepithelial neoplasia diagnostic terminology changes, pathologists may need to re-read histopathology slides to compare disease trends over time, eg, before/after introduction of human papillomavirus vaccination. Diagnosis of cervical intraepithelial neoplasia differed little between slides and corresponding digitized images.

Bone Marrow Edema Patterns in the Ankle and Hindfoot: Distinguishing MRI Features

Many disorders produce similar or overlapping patterns of bone marrow edema in the ankle. Bone marrow edema may present in a few hindfoot bones simultaneously or in a single bone. The purpose of this pictorial essay is to provide guidelines based on clinical history and specific MRI patterns and locations to accurately identify the cause of ankle bone marrow edema. We will first focus on bone marrow edema in general disease categories involving multiple bones, such as reactive processes, trauma, neuroarthropathy, and arthritides. A discussion of bone marrow edema in individual bones of the ankle and hindfoot including the tibia, fibula, talus, and calcaneus will follow. Helpful hints for arriving at the correct diagnosis will be provided in each section. After review of this article, radiologists should be able to use their knowledge of clinical history and specific MRI patterns and locations to accurately distinguish between the various causes of bone marrow edema in the ankle and hindfoot.

The biasing effect of clinical history on physical examination diagnostic accuracy

Literature on diagnostic test interpretation has shown that access to clinical history can both enhance diagnostic accuracy and increase diagnostic error. Knowledge of clinical history has also been shown to enhance the more complex cognitive task of physical examination diagnosis, possibly by enabling early hypothesis generation. However, it is unclear whether clinicians adhere to these early hypotheses in the face of unexpected physical findings, thus resulting in diagnostic error. A sample of 180 internal medicine residents received a short clinical history and conducted a cardiac physical examination on a high-fidelity simulator. Resident Doctors (Residents) were randomised to three groups based on the physical findings in the simulator. The concordant group received physical examination findings consistent with the diagnosis that was most probable based on the clinical history. Discordant groups received findings associated with plausible alternative diagnoses which either lacked expected findings (indistinct discordant) or contained unexpected findings (distinct discordant). Physical examination diagnostic accuracy and physical examination findings were analysed. Physical examination diagnostic accuracy varied significantly among groups (75 ± 44%, 2 ± 13% and 31 ± 47% in the concordant, indistinct discordant and distinct discordant groups, respectively (F(2,177) = 53, p < 0.0001). Of the 115 Residents who were diagnostically unsuccessful, 33% adhered to their original incorrect hypotheses. Residents verbalised an average of 12 findings (interquartile range: 10-14); 58 ± 17% were correct and the percentage of correct findings was similar in all three groups (p = 0.44). Residents showed substantially decreased diagnostic accuracy when faced with discordant physical findings. The majority of trainees given discordant physical findings rejected their initial hypotheses, but were still diagnostically unsuccessful. These results suggest that overcoming the bias induced by a misleading clinical history may involve two independent steps: rejection of the incorrect initial hypothesis, and selection of the correct diagnosis. Educational strategies focused solely on prompting clinicians to re-examine their hypotheses may be insufficient to reduce diagnostic error.

Design and Validation of the Biliary Atresia Research Consortium Histologic Assessment System for Cholestasis in Infancy

Pathologists participating in the National Institutes of Health-sponsored Biliary Atresia Research Consortium (BARC) developed and then evaluated a standardized system for histologic reporting of liver biopsies from infants with cholestasis. A set of 97 anonymous liver biopsy samples was sent to 10 pathologists at BARC centers. A semiquantitative scoring system that had 16 histologic features was developed and then used by the pathologists, who had no knowledge of clinical history, imaging results, or laboratory data. Interobserver agreement was evaluated statistically. Agreement on scoring of each feature and on the pathologists' diagnosis, compared with the final clinical diagnosis, was evaluated by using weighted kappa statistics. There was moderate to substantial interobserver agreement in identification of bile plugs in ducts, giant-cell transformation, extramedullary hematopoiesis, and bile duct proliferation. The pathologists' diagnosis of obstruction in clinically proven cases of biliary atresia (BA) ranged from 79%-98%, with a positive predictive value of 90.7%. Histologic features that best predicted BA, on the basis of logistic regression, included bile duct proliferation, portal fibrosis, and absence of sinusoidal fibrosis (each P<.0001). The BARC histologic assessment system identified features of liver biopsies from cholestatic infants, with good interobserver agreement, that might be used in diagnosis and determination of prognosis. The system diagnosed BA with a high level of sensitivity and identified infants with biliary obstruction with reasonable interobserver agreement. However, distinguishing between BA and disorders such as total parenteral nutrition-associated liver disease and alpha(1)-antitrypsin deficiency is not possible without adequate clinical information.

Tomografia computadorizada das patologias acometendo o compartimento iliopsoas

Este trabalho tem como objetivo revisar as patologias que acometem o compartimento iliopsoas. Foi realizada análise retrospectiva de casos com acometimento do compartimento iliopsoas avaliados por tomografia computadorizada (TC), no Departamento de Radiologia da Faculdade de Ciências Médicas da Universidade Estadual de Campinas, nos últimos dez anos, confirmados por biópsia cirúrgica ou percutânea. Os principais diagnósticos encontrados foram neoplasias, abscessos e hematomas. Os achados tomográficos baseiam-se na extensão do acometimento iliopsoas, no grau de atenuação, margens da lesão, presença de gás e/ou calcificações, destruição óssea, infiltração da gordura e acometimento de estruturas abdominais adjacentes. A TC é o método de escolha na avaliação do compartimento iliopsoas, podendo ser utilizada para orientar biópsias percutâneas, cirúrgicas ou drenagem. Porém, os achados isolados do estudo por TC, sem o conhecimento da história clínica, não são específicos para permitir a diferenciação das diversas patologias que acometem o compartimento iliopsoas.

Benign versus malignant solid breast masses: US differentiation.

To investigate the general applicability and interobserver variability of ultrasonographic (US) features in differentiating benign from malignant solid breast masses. One hundred sixty-two consecutive solid masses with a tissue diagnosis were reviewed. Three radiologists reviewed the masses without knowledge of clinical history or histologic examination results. US features that most reliably characterize masses as benign were a round or oval shape (67 of 71 [94%] were benign), circumscribed margins (95 of 104 [91%] were benign), and a width-to-anteroposterior (AP) dimension ratio greater than 1.4 (82 of 92 [89%] were benign). Features that characterize masses as malignant included irregular shape (19 of 31 [61%] were malignant), microlobulated (four of six [67%] were malignant) or spiculated (two of three [67%] were malignant) margins, and width-to-AP dimension ratio of 1.4 or less (28 of 70 [40%] were malignant). If the three most reliable criteria had been strictly applied by each radiologist, the overall cancer biopsy yield would have increased (from 23% to 39%) by 16%. When US images and mammograms were available, the increase in biopsy yield contributed by US was not statistically significant (2%, P = .73). However, in independent reviews, one to three reviewers interpreted four carcinomas as benign at US. The data confirm that certain US features can help differentiate benign from malignant masses. However, practice and interpreter variability should be further explored before these criteria are generally applied to defer biopsy of solid masses.

Diagnostic accuracy in fine-needle aspiration of soft tissue and bone lesions. Influence of clinical history and experience.

Interpretation of soft tissue and bone lesions with fine-needle aspiration (FNA) is difficult. We determined whether clinical history or experience improves diagnostic accuracy of FNA interpretation of these lesions. Four cytopathologists with varying degrees of experience retrospectively reviewed 89 soft tissue and bone lesions, initially without knowledge of clinical history and subsequently with knowledge of clinical history. Each time, the pathologist rendered a precise diagnosis (histogenetic classification, e.g., angiosarcoma, lipoma) for each case and classified the lesion into one of 4 categories: benign, probably benign, probably malignant, or malignant. The proportion of correct precise diagnoses was calculated. Also, the numbers of correct and incorrect classifications of malignancy were used in standard relative operating characteristic (ROC) curve analysis. The area under the ROC curve was estimated to give an indicator of diagnostic accuracy. Knowledge of clinical history increased the proportion of correct diagnoses and the accuracy of the classification for all observers. Experienced observers more accurately classified lesions, and knowledge of clinical history particularly improved the diagnostic accuracy of less experienced observers.

Clinician agreement on physical findings in child sexual abuse cases.

To measure agreement among experienced clinicians regarding the interpretation of physical findings in child sexual abuse cases and to determine whether knowledge of clinical history affects the interpretation of the physical findings. Experienced clinicians rated colposcopic photographs on a scale of 1 to 5 with 1 being normal and 5 being clear evidence of penetrating injury. To answer an additional study question of whether clinical history affected interpretation, 4 clinicians rated 69 cases in which they were blinded to the patients' histories and 70 cases in which the patients' histories were available. The other 3 clinicians then rated the same cases with the presence or absence of history reversed. All clinicians involved perform child sexual abuse examinations at tertiary care centers. A total of 139 girls with Tanner stage 1 or 2 genitalia who were referred to a general pediatric clinic at an academic medical center for examination of possible sexual abuse. Half of the photographs were interpreted as indicating little or no evidence of abuse. Of those photographic sets that both readers could interpret, 39% were in perfect agreement and 77% disagreed by 1 category or less. Perfect agreement across all possible pairs of readers was 34.5%. Agreement was better when the patient's clinical history was unknown (29.3% vs 38.9%, P = .005). The kappa, a measure of interrater reliability, indicated poor agreement among clinicians. The combined kappa for the first group of clinicians was 0.22 without knowledge of clinical history and 0.11 with knowledge of clinical history. For the second group of clinicians, the kappa was 0.31 without knowledge of clinical history and 0.15 with knowledge of clinical history. The overall kappa across all 7 clinicians disregarding clinical history was 0.20. Agreement was best for categories 1 (normal, kappa = 0.28) and 5 (clear evidence of a penetrating injury, kappa = 0.39). Clinicians educated and experienced in assessing child sexual abuse do not agree perfectly on the interpretation of photographs of genital findings in girls with Tanner stage 1 or 2 genitalia. Clinicians agree less when a patient's clinical history is available. Efforts should be directed at standardizing physical findings and avoiding overemphasis on physical findings in child sexual abuse cases.

Mitochondrial abnormalities in human immunodeficiency virus-associated myopathy.

There is controversy as to whether zidovudine (ZDV) induces a mitochondrial myopathy that is distinguishable from human immunodeficiency virus (HIV)-associated myopathy in ZDV-naive patients. Mitochondrial abnormalities were evaluated in skeletal muscle obtained from 18 HIV-positive, ZDV-exposed patients, and 9 who were drug naive. All patients had clinical myopathy, and underwent neuromuscular evaluation with information recorded on timing and dosage of ZDV. All underwent muscle biopsies and samples were examined without knowledge of clinical history or ZDV status. Biopsy samples were evaluated by light and electron microscopy. Mitochondrial abnormalities were seen in ZDV-treated and -naive groups, and did not correlate with ZDV exposure or cumulative ZDV dosage. Mitochondrial abnormalities displayed significant correlation with the presence and severity of myofiber degeneration on biopsy, regardless of ZDV status. As mitochondrial abnormalities reflect myofiber degeneration, present in both patient groups, they may not be used as evidence of primary mitochondrial dysfunction. The etiology of myofiber degeneration in patients with HIV infection, whether ZDV-exposed or -naive, remains unclear.

Knowledge of clinical history and the accuracy of interpretation of chest radiographs.

Knowledge of clinical history and the accuracy of interpretation of chest radiographs.W C Black and A J DwyerAudio Available | Share

Ultrasound in the diagnosis of a palpable abdominal mass. A prospective study of 107 patients.

In 107 consecutive patients referred to the ultrasound laboratory for investigation of a palpable abdominal mass, the examination was performed without knowledge of clinical history, laboratory findings, or the results of other examinations. In 101 of the patients the correct diagnosis was subsequently verified, and 29 different ultrasonic diagnoses were reached. In 98 (97%) of the patients the ultrasonic diagnoses were correct. Two uterine leiomyomas were erroneously diagnosed as ovarian in origin, and a massive adrenal carcinoma was misdiagnosed as a hepatic tumor. It is suggested that ultrasonic scanning is the method of choice in evaluating patients with a palpable abdominal mass.

The effect of clinical bias on the interpretation of myelography and spinal computed tomography.

Spinal computed tomograms and myelograms of 107 patients with sciatica or low back pain were interpreted with and without knowledge of clinical history. A significant number of interpretations was changed by knowledge of the clinical history. More studies were interpreted correctly without the clinical history than with it. Knowledge of the clinical history increased the number of false-positive and decreased the number of false-negative diagnoses. This study suggests a tendency of observers to interpret questionable myelographic or computed tomographic findings as positive when they correlate with clinical findings.