Missed Diagnosis Rate Research Articles

Evaluate the Methods of the screening of cervical cancer and precancerous lesions in risk factor women

Objectve To evaluate the methods of the screening of cervical cancer and precancer-ous lesions in risk factor women.Methods 100 women with risk factor were given TCT,100 women with risk factor were givenTCT and HPV-DNA,all women were given cytology exam inations.Pathology was golden standard for the diagnoses of different methods.Results TCT examed the rate of missed diagnosis is 25%,TCT and HPV-DNA examed the rate of miss diagnosis is 5%,between two methods were signifi-cant(P<0.01).Conclusion TCT and HPV-DNA exam could improve detective rate in the screening of cervieal cancer and precancerous lesions. Key words: TCT; HPV; Precancerous cervical diseases

Clinicopathologic study of von Hippel-Lindau syndrome-related and sporadic hemangioblastomas of central nervous system

To study clinicopathologic features, diagnosis, treatment and prognosis of von Hippel-Lindau (VHL) syndrome-related and sporadic hemangioblastomas of the central nervous system (CNS-HB). Histopathological, ultrastructural, immunohistochemical (EnVision method) and clinical features of 21 VHL syndrome and 63 sporadic CNS-HB cases were studied with correlation of the available follow-up information. Twenty-one VHL patients accompanied with a total of 87 CNS-HBs, including one patient of developing 12 HBs within 13 years. There were 10 patients presenting other lesions related to VHL, including 6 retinal HBs, 4 pancreatic tumors (endocrine tumor and microcystic cystadenoma), 1 clear renal cell carcinoma, 4 renal cysts and 1 endolymphatic sac tumor. One patient developed 5 different tumors related to VHL within a period of 4 years. In the 63 cases of sporadic CNS-HB (34 male and 29 female), the mean age was 43.0 years. Among the 18 VHL syndrome patients with available follow-up information, 14 were still alive and within them, 4 became disabled and 11 had developed new lesions. The other 4 patients died. Among the 42 patients of sporadic HB with follow-up information, 39 were alive including 3 disabled cases, and the other 3 died. Histologically, the tumors showed large and vacuolated stromal cells. Some tumors showed atypical nuclei. Involvement of the brain tissue was seen in 32 cases, among which, 21 patients with available follow-up information were learnt to be alive. Tumor cells of HB stained positive for vimentin, EGFR, Inhibin alpha and D2-40, but negative for CD34 and CD68. In 3 cases of HB, some stromal cells were positive for GFAP. All cases showed a low expression for Ki-67, except 2 cases with 2% and 1 case with 5% Ki-67 indices. VHL syndrome is a multisystem disorder with a poor prognosis and a high rate of missed diagnosis. The syndrome is characterized by development of various benign and malignant tumors. The most common tumor is CNS-HB, which occurs predominantly in the cerebellum. Patients with VHL syndrome tend to present at a younger age than patients with sporadic CNS-HBs, and VHL related HB occurs more predominantly in the brain stem and spinal cord. Prognosis of CNS-HB patients is not correlated with the nuclear atypicality, expression for Ki-67 and involvement of the brain tissue. Because new lesions may develop during the patient's lifetime. So that, regular clinical inspection is recommended in order to check up the development of any new lesions.

Influence of maternal BMI on genetic sonography in the FaSTER trial

We sought to evaluate the influence of maternal body mass index (BMI) on sonographic detection employing data from the FaSTER trial. Unselected singleton pregnancies underwent detailed genetic sonogram to evaluate for structural fetal anomalies and soft markers for aneuploidy. BMI (kg/m(2)) were calculated from reported initial visit values. Sensitivity, specificity, false positive and false negative rates (FPR and FNR), likelihood ratio, detection rates, and a missed diagnosis rate (MDR: FNR + marker recorded as 'missing'/N) were calculated. Eight thousand five hundred and fifty-five patients with complete BMI information had detailed genetic sonography. A lower sensitivity with an elevated FNR and MDR was observed in obese women for multiple aneuploid markers (e.g. > or =2 markers 32% sensitivity with 68% FNR among BMI <25 vs 22% and 78% among BMI >30). Similarly, the detection rate for cardiac anomalies among women at BMI <25 was higher (21.6%) at a significantly lower FPR (78.4%; 95% CI 77.3-79.5%) in comparison to obese women (8.3% with FPR 91.7%; 95% CI 90.1-93.2%). In a logistic regression model, maternal obesity significantly decreased the likelihood of sonographic detection of common anomalies (adjusted OR 0.7; 95% CI 0.6-0.9; p = 0.001). The performance of second trimester genetic sonography is influenced by obesity, with a significantly higher MDR for multiple minor markers and lower likelihood for detecting common anomalies.

Clinical and coronary angiographic analysis of elderly patients with type 2 diabetes mellitus combined with coronary heart disease

Objective:To analyze the association of type 2 diabetes mellitus(DM) with the clinical and coronary angiographic features of coronary heart disease(CHD) in patients aged over 70 years old.Methods: A total of 310 elderly patients with coronary angiograph-confirmed coronary diseases,who were treated in Changhai Hospital during Apr.2006 to Jul.2008,were retrospectively analyzed.The patients were further divided into 2 subgroups according to the presence of DM: DM-CHD group(n=155) and non-DM-CHD group(n=155).The age,gender,blood pressure,blood lipid,ejection fraction(EF),the angiographic outcomes,etc.were analyzed and compared between the two groups.Results: The incidence of hypertension was significantly higher in the DM-CHD group than in the non-DM-CHD group(P0.05).The fasting blood glucose(FBG),triglyceride(TG),low density lipoprotein cholesterol(LDL-C),and fibrinogen(FIB) were significantly higher than those in the other group(P0.01),and the high density lipoprotein cholesterol(HDL-C) was lower than that in the other group(P0.05).The EF value in the DM-CHD group was significantly lower than that in the non-DM-CHD group(P0.01).Among the 35(22%) patients preliminarily diagnosed as having DM,14(40%) would be misdiagnosed if the diagnosis depends solely on FBG without oral glucose tolerance test(OGTT).The prevalence of diffusive coronary lesions in the DM-CHD group was significantly higher than that in the non-DM group(P0.01).DM-CHD group also had significantly higher coronary stenosis index(P0.01) and more occlusive vessels than non-DM-CHD group.Conclusion: The missed diagnosis rate of DM is high in CHD patients.Compared with non-DM-CHD patients,DM-CHD patients are at higher risks for coronary disease and have more severe coronary lesions.

Analysis of discrepancies between clinical and autopsy diagnoses in 188 cases

To analyze the discrepancies between clinical and autopsy diagnoses in hospitals of different grades and with respect to duration of hospitalization. A total of 188 autopsy cases collected from hospitals of different grades were retrospectively reviewed and the discrepancies between clinical and autopsy diagnoses were analyzed. The overall rate of misdiagnosis was 48.9% (92/188). The misdiagnosis rate in grade I hospitals (75.8%, 25/33) was significantly higher than that in grade III (39.6%, 38/96; chi(2) = 12.861, P = 0.000) and grade II hospitals (49.2%, 29/59; chi(2) = 6.179, P = 0.016 ). The misdiagnosis rate of patients beyond 24 hours of admission was lower than that admitted within 24 hours (chi(2) = 20.991, P = 0.000). The overall rate of missed diagnosis was 34.6% (65/188). The rate of missed diagnosis in grade I hospitals was remarkably higher than that of the grade III hospitals (chi(2) = 8.241, P = 0.006). There was no difference between grades I and III hospitals on the rate of missed diagnosis within 24 hours of admission, however, this rate was lower in grade III hospitals in comparing with that of grade I hospitals in patients admitted beyond 24 hours (chi(2) = 5.181, P = 0.047). The distribution of disease entities commonly encountered in patients of both misdiagnosis and missed diagnosis were heart problems, infections, arterial diseases and pulmonary embolism. The rate of discrepancies between clinical and autopsy diagnoses is relatively high. The misdiagnosis and missed diagnosis rate in grade I hospitals was significantly higher than that in grade III hospitals and was closely related with the duration of hospitalization. Autopsy study thus still remains an important measure in clinical audit.

Value of waist circumference, body mass index and hyperinsulinaemia in identifying metabolic syndrome

To investigate the significance of waist circumference (WC), body mass index (BMI) and hyperinsulinaemia A (HIns) in evaluating metabolic syndrome (MS). Clinical data from middle-aged and senile individuals (middle-senile group) who received glucose tolerance test after diabetes mellitus screening and a group of subjects who received annual oral glucose tolerance test (OGTT) for diabetes mellitus screening (adult group) were collected. Data were collected by use of special messengers, input into a computer data base and analyzed using SAS 5.0 software by expert staff. Abnormal WC and BMI were determined according to International Diabetes Federation (IDF) and Chinese Diabetes Society (CDS) criteria. HIns was ascertained if fasting insulin (FIns) ⩾ 15 mU/L, and/or 2-hour insulin after a glucose challenge was (2hPIns) ⩾ 80 mU/L. Abnormalities in WC, BMI and HIns were all found to be risk factors for abnormal glucose metabolism, hypertension and dyslipidemia. In the middle-senile group, the abnormality rate of WC and HIns as well as the overall insulin level were significantly higher than those in the adult group. The abnormality rate of BMI was higher in the adult group, and HIns was mostly seen in impaired glucose test (IGT) and normal glucose test (NGT). The concordance rate of WC and BMI diagnostic criteria for evaluating obesity in the middle-senile and adult groups were 77.5% and 74.3%, respectively. When only the WC criterion was used for evaluating the existence of insulin resistance, there was a 28.2%missed diagnosis rate for MS patients. WC, BMI and HIns were all risk factors for abnormal glucose metabolism, hypertension and dyslipidemia. There was differing prevalence in the different populations. The combination of WC, BMI and HIns might be more helpful in identifying MS at early stage.

The CT characteristics of orbital blowout fracture and its medicolegal expertise

To explore the CT characteristics of orbital blowout fracture, we reviewed 76 cases with orbital blowout fracture and analyzed their clinical forensic characteristics. The missed diagnosis rate of cranial CT was 26.3%, and plain X-ray was 47.4%. The orbital CT examination has advantages in diagnosing orbital blowout fracture. In 42 cases fractures were simple medial orbital wall fracture, 30 cases were inferior orbital fractures. Loss of clinical signs included local haematoma, bone continuity, and displacement of bone fragments were mostly seen in CT image. Clinical signs and symptoms included local haematoma, whilst diplopia as the most common clinical symptom. Visual acuity was rarely affected after fracture. It is concluded that orbital blowout fracture may be misdiagnosed if only cranial CT and plain X-ray are used. Diagnose the orbital blowout fracture only by craniocerebral CT and head X-ray. Orbital CT should be done if the clinical signs are suggestive of orbital blowout fracture Visual acuity was affected and diplopia may be present.

Diagnosis and treatment of abdominal injuries after the Wenchuan earthquake

After analyzing the clinical data of 5 injured persons diagnosed with delayed spleen or liver rupture combined with fractures after the Wenchuan earthquake, we found that the abdominal injuries in earthquake were rare but usually very severe. Since almost all the injured persons had multiple injuries, mortality was extremely high. First aid service should be applied in the first 6 to 8 hours. Orderly physical examination and peritoneocentesis in multiple sites are in favor of diagnosis. Reducing the missed diagnosis rate of abdominal injuries is important in raising the rate of successful treatment. Therapy for earthquake injuries should be focused on the most deadly injuries after a thorough examination, besides this, precise employment of control surgery, swift transportation of the injured persons, and prevention and dealing with complications are also important. Key words: Wenchuan earthquake; Abdominal injury

Clinical epidemiological analysis of adult spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture

To investigate the clinical epidemiological features of adult spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture, a special kind of fracture. The clinical data of 1685 cases of adult tibial and fibular shaft fracture were analyzed retrospectively. The cause and mechanism of spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture were studied in detail. The male and female ratio in adult tibial and fibular shaft fracture was 4.52:1. Most of adult tibial and fibular shaft fracture occurred in the persons aged 31 - 40 (26.0%) and type A fracture accounted for 57.7% of the cases. The male and female ratio in adult spiral tibial fracture was 2.95:1. Most of the adult spiral tibial fracture occurred in those aged 41 - 50 (32.6%). With a male and female ratio of 6:1 (24:4) and mostly occurring in the persons aged 41 - 50, spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture composed 9.7% (28/288) of total tibial fractures and 1.7% (28/1685) of total spiral tibial and fibular fractures. Missed diagnosis rate of spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture was 67.9% (19/28) in the Department of Radiology and 53.6% in the Department of Orthopedics. With a high incidence, spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture was caused by a low energy but not an iatrogenic damage. With a high rate of missed diagnosis, the spiral tibial shaft fracture associated with ipsilateral posterior malleolar fracture should be paid more attention to clinically.

An unusual presentation of tuberculosis in pregnancy

TB accounts for 9% of deaths worldwide among women aged 15-44 years. In the United States one-fifth of diagnosed new cases of TB have extrapulmonary presentation of the disease. In a report from New York City covering the period of 1985-1992 TB among pregnant inner-city women was shown to be increasingly prevalent. TB was diagnosed in five among 40 388 births (12.4/100 000) at the involved hospitals during 1985-1990 and in 11 among 11 595 births (94.8/100 000) during 1991-1992. Ten of the 16 women had pulmonary TB six had extrapulmonary TB. Pregnancy has no adverse effect on TB if the diagnosis is not delayed. However unfortunately the diagnosis of TB during pregnancy is usually delayed (for 2-30 weeks) because of its non-specific symptoms and protean manifestation. Up to 20% of pregnant women with TB are asymptomatic or have only atypical symptoms. A report from China has shown a missed diagnosis rate of 53.2% (25/47) for pulmonary TB. In addition unavailability of biopsies and appropriateimaging during pregnancy make the diagnosis more difficult. (excerpt)

OP02.04: Ultrasound examinations for detecting congenital defects in diabetic pregnancies

Objective: To establish the accuracy of prenatal diagnosis by comparing diagnoses made in Fetal Medicine compared to those made after birth until hospital discharge. Methods: All cases seen in Fetal Medicine between 01/06/04 and 01/12/05 were collected and sorted according to diagnosis. Relevant outcome data on all these pregnancies were obtained from electronic and written sources. Women still not delivered were excluded from this initial analysis (195 cases), but will be available by the time of presentation. Otherwise follow-up is 100% complete. Results: 678 women were seen in the Fetal Medicine Unit, which involved 1256 visits, and 382 procedures. 483 (71.2%) had delivered by the time of this analysis. Of these, 282 were found to have no abnormality, 40 had minor abnormality, and 161 had major abnormality prenatally. Those cases with major abnormalities had a livebirth rate of 55.3% versus 94.5% in those with no abnormalities. With regard to accuracy of diagnosis, 398 livebirths were studied. The prenatal diagnosis was confirmed in 91.2%, while abnormalities that resolved accounted for 8%. Missed extra diagnosis which led to a significant clinical effect accounted for 0.8% cases. Conclusion: The accuracy of prenatal diagnosis in a tertiary Fetal Medicine Unit is very high, which is an important standard, clinicians and patients should expect. The missed diagnosis rate of 0.8% can be explained by present limitations in the diagnosis of cleft palate, esophageal and anal atresia, and other dysmorphic features, which are notoriously difficult to diagnose prenatally. This limitation in prenatal diagnosis should be explained to parents.

OP02.03: Audit of outcome and accuracy of prenatal diagnosis in a tertiary fetal medicine unit

To establish the accuracy of prenatal diagnosis by comparing diagnoses made in Fetal Medicine compared to those made after birth until hospital discharge. All cases seen in Fetal Medicine between 01/06/04 and 01/12/05 were collected and sorted according to diagnosis. Relevant outcome data on all these pregnancies were obtained from electronic and written sources. Women still not delivered were excluded from this initial analysis (195 cases), but will be available by the time of presentation. Otherwise follow-up is 100% complete. 678 women were seen in the Fetal Medicine Unit, which involved 1256 visits, and 382 procedures. 483 (71.2%) had delivered by the time of this analysis. Of these, 282 were found to have no abnormality, 40 had minor abnormality, and 161 had major abnormality prenatally. Those cases with major abnormalities had a livebirth rate of 55.3% versus 94.5% in those with no abnormalities. With regard to accuracy of diagnosis, 398 livebirths were studied. The prenatal diagnosis was confirmed in 91.2%, while abnormalities that resolved accounted for 8%. Missed extra diagnosis which led to a significant clinical effect accounted for 0.8% cases. The accuracy of prenatal diagnosis in a tertiary Fetal Medicine Unit is very high, which is an important standard, clinicians and patients should expect. The missed diagnosis rate of 0.8% can be explained by present limitations in the diagnosis of cleft palate, esophageal and anal atresia, and other dysmorphic features, which are notoriously difficult to diagnose prenatally. This limitation in prenatal diagnosis should be explained to parents.

The epidemiology of stroke in sickle cell patients in Yaounde, Cameroon

Background and purpose Stroke, a severe and recurrent but preventable complication of sickle cell disease (SCD), has not been well studied in Cameroon. To obtain baseline data towards the development of a national stroke prevention programme in SCD, we studied a sample of sickle cell patients with the aim of determining stroke prevalence, clinical presentation and management practices. Patients and methods Homozygous sickle cell patients in two centres in Yaounde were screened for stroke, in a cross-sectional study. Stroke was diagnosed clinically and confirmed where possible with brain computerized tomography. The National Institutes of Health Stroke Score (NIHSS) and modified Rankin scale (mRS) were used to assess stroke severity. Management practices were noted from patient charts. Results One hundred and twenty patients aged 7 months to 35 years (mean age 13.49 ± 8.79 years) were included. Eight cases of stroke (mean age 16.6 ± 11.2 years) were identified, giving a stroke prevalence of 6.67%. Cerebral infarction was thrice as common as cerebral hemorrhage and clinical presentation was classical. Cerebral infarction was more frequent in patients aged below 20 years and hemorrhage in those above 20 ( p = 0.11). The annual recurrence rate was 25%. Missed diagnosis rate by attending physician was 25%. The NIHSS and mRS showed high stroke severity. Stroke management practices were insufficient and no patient received any form of stroke prophylaxis. Conclusion Stroke prevalence and presentation in sickle cell patients in Yaounde is similar to that observed in developed countries, but the wide management gap calls for rapid action. Our situation is ideal for the study of the natural history of stroke in sickle cell disease.

The accuracy of diagnosing cervical intraepithelial neoplasia with colposcopically directed biopsy

To evaluate the accuracy of colposcopically directed biopsy in the diagnosis of cervical intraepithelial neoplasia (CIN). The clinical data of 153 patients with CIN diagnosed by colposcopically directed biopsy and treated with cervical loop electrosurgical procedure (LEEP) shortly after were retrospectively studied. The consistency of pathological examination between colposcopically directed biopsy and LEEP was evaluated. The factors of missed diagnosis of cervical invasive carcinoma were analyzed. The diagnosis of 106 out of the 153 patients by colposcopically directed biopsy was consistent with that by LEEP as confirmed by pathologic diagnosis with a consistence rate of 69.3%, however, the diagnoses of 47 of the 153 patients by colposcopically directed biopsy were not consistent with those by LEEP, with an inconsistent rate of 30.7%, including 22 cases of overdiagnosis (14.4%, 22/153) and 25 cases of underdiagnosis (16.3%, 25/153). Eighteen patients were confirmed as with cervical invasive carcinoma by LEEP/hysterectomy at last with a missed diagnosis rate of 11.8%. The missed diagnosis rate of invasive carcinoma by colposcopically directed biopsy was significantly higher in the patients with cytologic diagnosis of with > or = HSIL than in the patients cytologically diagnosed as with < HSIL (chi(2) = 8.208, P < 0.05). The accuracy of diagnosing CIN with colposcopically directed biopsy is still unsatisfying. Attention should be paid on the patients with cytological diagnosis of > or = HSIL so as to avoid missed diagnosis of cervical carcinoma.

To Adjust the Uut-off Point Reasonably and Lower the Rate of missed diagnosis of Congenital Hypothyroidism

目的 了解佛山市初生人口中先天性甲状腺功能低下症(congenital hypothyroidi sm,CH)的发生率,探讨适当调整初筛实验中召回复查的筛查切值(阳性切割点),以降低先天性甲状腺功能低下症的漏诊率.方法对81439例新生儿于出生72h后采集足跟血滤纸标本,荧光酶免疫分析法检测血中促甲状腺素(TSH)浓度,TSH初筛结果≥8mIU/L即召回复查;确诊以电化学发光法测定血清总三碘甲状腺原氨酸(TT3)、甲状腺素(TT4)、血清游离T3(FT3)、血清游离T4(FT4)及TSH浓度,并结合骨龄检查及甲状腺核素扫描以确诊.结果以8mIU/L为筛查切值诊断CH,灵敏度达100%,、特异度91.24%;检出52例CH,发生率63.85/10万(1:1566).结论本组筛查结果显示佛山市初生人口中先天性甲状腺功能低下症的发生率高于国内主要城市报道.原因考虑与适当调整筛查切值,提高检测的敏感性,发现异常及时复查,充分利用本市新生儿疾病筛查工作三级管理网络对初筛结果异常者召回复查率达100%,减少漏诊有关。

MISSED INJURIES IN THE MULTIPLY TRAUMATIZED

The delayed diagnosis of injuries in traumatized patients is a recognized problem. A retrospective review of trauma patients admitted to a major teaching hospital has been performed. The records of all patients admitted to the intensive care unit (ICU) have been checked to determine the incidence of late diagnosed injuries. The notes written by the staff of the emergency department and the ICU, and the attending surgical registrars have been used as the criteria of initial diagnosis. Comparing them to the injuries listed in the progress notes, investigation reports, discharge summary and follow-up outpatient notes led to the discovery of a number of missed injures (19 of 50 patients had one or more). In 4 cases the management involved further surgery due to new diagnoses. This is consistent with overseas literature. A review of the literature is presented and methods to improve the missed diagnosis rate are discussed.

Diagnosis of Diabetic Eye Disease-Reply

In Reply.— Dr Kutner suggested the possibility of a study to be performed under usual rather than optimal clinical conditions. Since under ideal conditions the nonophthalmologists missed 50% of treatable eye disease, there is every reason to believe that under usual clinical conditions, the missed diagnosis rate would increase even more. We appreciate Dr Fier's comments.