Need For Additional Diagnostic Testing Research Articles

The Importance of Copy Number Variant Analysis in Patients with Monogenic Kidney Disease

IntroductionGenetic testing can reveal monogenic causes of kidney diseases, offering diagnostic, therapeutic, and prognostic benefits. While single nucleotide variants (SNVs) and copy number variants (CNVs) can result in kidney disease, CNV analysis is not always included in genetic testing. MethodsWe investigated the diagnostic value of CNV analysis in 2,432 kidney disease patients genetically tested at the University Medical Centre Utrecht between 2014 and May 2022. We combined previous diagnostic testing results, encompassing SNVs and CNVs, with newly acquired results based on retrospective CNV analysis. The reported yield considers both ACMG classification and whether the genotype actually results in disease. ResultsWe report a diagnostic yield of at least 23% for our complete diagnostic cohort. The total diagnostic yield based solely on CNVs was 2.4%. The overall contribution of CNV analysis, defined as the proportion of positive genetic tests requiring CNV analysis, was 10.5% and varied among different disease subcategories, with the highest impact seen in congenital anomalies of the kidney and urinary tract and chronic kidney disease at a young age. We highlight the efficiency of exome-based CNV calling, which reduces the need for additional diagnostic tests. Furthermore, a complex structural variant, likely a COL4A4 founder variant, was identified. Additional findings unrelated to kidney diseases were reported in a small percentage of cases. ConclusionIn summary, this study demonstrates the substantial diagnostic value of CNV analysis, providing insights into its contribution to the diagnostic yield and advocating for its routine inclusion in genetic testing of kidney disease patients.

Practical guide to the bovine necropsy

Food animal veterinarians often have the opportunity to deter­mine the cause of death of bovine patients based on grossly vis­ible pathological changes alone, without the need for additional diagnostic testing. In some production systems (e.g., feedlot, stocker, and some cow-calf operations), a field necropsy is per­formed for almost every mortality; however, for one reason or another, some veterinarians and producers are reluctant to consistently take advantage of performing this procedure. The information collected from postmortem necropsies facilitates ongoing monitoring of disease rates in populations, feeds back into various animal health protocols, and guides decisions per­taining to disease outbreaks. Developing a standardized pro­cedure and employing the appropriate equipment can usually produce a diagnosis very quickly. Furthermore, with the imple­mentation of commonly used technologies, the same principles can be utilized to assist with expanding the geographic area in which diagnoses are made.

Impaired intratumoral dendritic cell function and potential predictive value of dendritic cell markers for metastasis in malignant salivary gland tumors.

The differentiation between primary and metastatic salivary gland neoplasms (SGNs) helps in determining appropriate management strategies, including the need for additional diagnostic tests, surveillance, or aggressive treatment. The purpose of this study was to identify and quantify the immature and mature dendritic cells (DCs) in metastatic and no metastatic SGNs and determine its association with clinicopathological findings. Cross-sectional, observational, and descriptive study that includes 33 malignant salivary gland neoplasms [MSGN (6, 18.1% metastatic)], and 22 pleomorphic adenomas (PA), as a control group. Clinical and histopathological characteristics were obtained. Immunohistochemistry for human leukocyte antigen D-related (HLA-DR), CD1a, CD83, and Ki-67 proteins was done. Positive intra- and peritumoral DCs were counted. Individuals with MSGN had a lower density of intratumoral HLA-DR+ cells than those with PA (p=0.001), Ki-67 immunostaining was significantly higher in MSGN than in PA (6% vs. 1.4%, p<0.001). Metastatic MSGN showed less intratumoral CD1a+ than non-metastatic (3.2 vs. 165.1, p=0.001). No differences in intra- and peritumoral CD83+ cells were found between benign and malignant SGN. These results suggest that the immune-protective function of intratumoral DCs is compromised in MSGNs. DCs markers may represent useful prediction tools for metastases in salivary gland malignancies, with crucial implications in the implementation of appropriate disease management strategies.

The DeOrio One Finger Test: Does a Patients Ability To Localize Their Pain Lead to Different Clinical and Patient Reported Outcomes Than Those That Cannot?

Category: Other Introduction/Purpose: A basic requirement during a history and physical examination, in a foot and ankle clinic, is the ability to pinpoint where a patient experiences discomfort. Infrequently, patients are unable to localize their pain and “paint” over a non- anatomic distribution or point to multiple, independent areas across the foot. The ability to diagnose and treat a problem become significantly more difficult in these circumstances. In this study, the treatment course, clinical and patient reported outcomes(PROs) of patients who can pinpoint where they feel pain and those that “paint” over a non-anatomic area are compared. We hypothesize that patients unable to pinpoint are more likely to require advanced imaging studies, additional diagnostic modalities, and also less likely to improve in PROs at conclusion of treatment. Methods: Patients who presented in a foot and ankle clinic with foot pain between August 2021 and August 2022 were prospectively enrolled in this IRB approved study. The senior author completed a questionnaire after consultation identifying the patient as “able to pinpoint location of pain” or “unable to pinpoint location of pain.” Patients were excluded if they were &lt; 18 years old, had neuropathy, or had pain as a result of a trauma (where does a trimalleolar ankle fracture hurt for example?). In cases where patients couldn’t pinpoint, they were counseled on localizing their symptoms and seen again 6 weeks later and given another chance to pinpoint. Diabetic patients had monofilament exams during presentation to control for undiagnosed neuropathy. Patients were followed for clinical outcomes, need for advanced imaging, need for additional diagnostic testing and finally PROs. All statistical analysis was conducted using GraphPad Prism(Ver 9.0, GraphPad Software, San Diego CA USA). Results: Overall, 423 patients were included (342 patients pinpointed and 91 patients did not). Patients unable to pinpoint were more likely to smoke (odds ratio=1.46) and to be diabetic (odds ratio=3.0). Patients with rheumatoid arthritis were more likely to be able to pinpoint(odds ratio=0.82) Patients unable to pinpoint presented with lower initial PROMIS Physical Function (40.0 vs. 43.3, p&lt; 0.01) and increased Pain Interference (56.3 vs. 53.3, p&lt; 0.01) and Depression (50.4 vs. 43.3, p&lt; 0.01) then those that could localize. These patients were more likely to require advanced imaging (p=0.039) and diagnostic testing(EMG/image-guided injection) (p=0.044). Patient reported outcomes, in addition to starting out worse at presentation, did not see the same improvements at the conclusion of treatment. See the table for a summary of the key study findings. Conclusion: The ability to localize pain during a history and physical examination has direct bearing on a patients’ treatment course and outcomes in this single center study. Patients unable to pinpoint a location have lower initial and final PROs and also require more advanced imaging and diagnostic testing. Practitioners should continue to strive to better elucidate patient symptoms in hopes of more efficiently treating these patients. However, further research is needed to truly identify whether this presenting characteristic is truly indicative of patient outcomes.

Suboptimal diagnostic accuracy of ultrasound and CT for compensated cirrhosis: Evidence from prospective cohort studies.

Abdominal ultrasound (US) and CT are important tools for the initial evaluation of patients with liver disease. Our study aimed to determine the accuracy of these methods for diagnosing cirrhosis. In all, 377 participants from 4 prospective cohort studies evaluating patients with various liver diseases were included. All patients were included between 2017 and 2022 and had undergone a liver biopsy as well as US and/or CT. Using the histological assessment as the gold standard, we calculated diagnostic accuracy for US and CT. Liver biopsies were evaluated by expert histopathologists and diagnostic scans by experienced radiologists. The mean age was 54 ± 14 years and 47% were female. Most patients had NAFLD (58.3%) or alcohol-associated liver disease (25.5%). The liver biopsy showed cirrhosis in 147 patients (39.0%). Eighty-three patients with cirrhosis had Child-Pugh A (56.4% of patients with cirrhosis) and 64 had Child-Pugh B/C (43.6%). Overall, the sensitivity for diagnosing cirrhosis by US was 0.71 (95% CI 0.62-0.79) and for CT 0.74 (95% CI 0.64-0.83). The specificity was high for US (0.94, 95% CI 0.90-0.97) and for CT (0.93, 95% CI 0.83-0.98). When evaluating patients with Child-Pugh A cirrhosis, sensitivity was only 0.62 (95% CI 0.49-0.74) for US and 0.60 (95% CI 0.43-0.75) for CT. For patients with Child-Pugh B/C, sensitivity was 0.83 (95% CI 0.70-0.92) for US and 0.87 (95% CI 0.74-0.95) for CT. When limiting our analysis to NAFLD (20% with cirrhosis), the sensitivity for US was 0.45 (95% CI 0.28-0.64) and specificity was 0.97 (95% CI 0.93-0.99). US and CT show moderate sensitivity and may potentially overlook compensated cirrhosis underlining the need for additional diagnostic testing.

O-203 Unexplained infertility: diagnosis by exclusion

Abstract Study question: What is the optimal work-up to establish the diagnosis of unexplained infertility, based on the best available evidence in the literature? Summary answer: The ESHRE Guideline on Unexplained Infertility provides 35 recommendations on the diagnosis of unexplained infertility. What is known already? The diagnosis of unexplained infertility is made when no abnormalities of the female and/or male reproductive systems are clearly identified. UI is inevitably a diagnosis by exclusion, after “standard” investigations. However, a real standardization of the diagnostic work-up is still lacking. Study design, size, duration: The guideline was developed according to the structured methodology for the development of ESHRE guidelines. First, a group of experts formulated the key questions. Literature searches and assessments were then performed. Papers written in English and published up to 24 October 2022 were included in the review. Prior to publication, the guideline was reviewed by independent international reviewers. Participants/materials, setting, methods: Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholders’ review was organized after the finalization of the draft. The revised version was approved by the guideline group and the ESHRE Executive Committee. Main results and the role of chance: This guideline aims to help clinicians in delivering the optimal care for couples with unexplained infertility. Since unexplained infertility is a diagnosis of exclusion, this lecture will focus on the diagnostic procedures that couples should/could go through during the infertility work-up, and will analyse the need for additional diagnostic tests to establish the diagnosis of unexplained infertility. The guideline has been in stakeholder review and is prepared for submission in 2023. Limitations, reasons for caution: Most diagnostic tests and interventions in couples with unexplained infertility are not well studied. For a large proportion of these tests, evidence was very limited and of very low quality. Further studies are definitely needed in this field, possibly providing reliable data for revisiting the current recommendations. Wider implications of the findings: Based on the best available evidence, the guideline provides clinicians with clear advice on how to optimize the diagnostic approach to couples with unexplained infertility. In addition, a list of research recommendations is included to prompt further studies in the field. Study funding/competing interest(s) The guideline was developed and funded by ESHRE, that covered expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not

Evaluating the Utility of High Sensitivity Troponin in Blunt Cardiac Injury

IntroductionScreening for blunt cardiac injury (BCI) includes obtaining a serum troponin level and an electrocardiogram for patients diagnosed with a sternal fracture. Our institution has transitioned to the use of a high sensitivity troponin I (hsTnI). The aim of this study was to determine whether hsTnI is comparable to troponin I (TnI) in identifying clinically significant BCI. Materials and methodsTrauma patients presenting to a level I trauma center over a 24-mo period with the diagnosis of sternal fracture were screened for BCI. Any initial TnI more than 0.04 ng/mL or hsTnI more than 18 ng/L was considered positive for potential BCI. Clinically significant BCI was defined as a new-bundle branch block, ST wave change, echocardiogram change, or need for cardiac catheterization. ResultsTwo hundred sixty five patients with a sternal fracture were identified, 161 underwent screening with TnI and 104 with hsTnI. For TnI, the sensitivity and specificity for detection of clinically significant BCI was 0.80 and 0.79, respectively. For hsTnI, the sensitivity and specificity for detection of clinically significant BCI was 0.71 and 0.69, respectively. A multivariate analysis demonstrated the odds ratio for significant BCI with a positive TnI was 14.4 (95% confidence interval, 3.9-55.8, P < 0.0001) versus an odds ratio of 5.48 (95% confidence interval 1.9-15.7, P = 0.002) in the hsTnI group. ConclusionsThe sensitivity of hsTnI is comparable to TnI for detection of significant BCI. Additional investigation is needed to determine the necessity and interval for repeat testing and the need for additional diagnostic testing.

Bone Scanning Findings in a Patient with Heat Stroke–Induced Rhabdomyolysis

We present a case that caused a diagnostic dilemma on a bone scan. We also review the broad spectrum of nonmalignant findings that can impact the interpretation of a bone scan and the value of correlative imaging using SPECT/CT for exact localization and characterization of lesions. The imaging features of important benign pathologies-that is, metastatic mimics-are elaborated so that the reader can avoid misinterpretations when reporting them. We elucidate 4 uncommon benign findings on a bone scan. Rhabdomyolysis is a result of lysis of skeletal muscle with release of cell contents, such as myoglobin and muscle enzymes, and is diagnosed mostly through a combination of clinical appearance and laboratory values. Myositis ossificans is the most common form of heterotopic ossification, usually occurring within large muscles. Its importance stems largely from its ability to mimic more aggressive pathologic processes. Myositis ossificans is one of the skeletal "do not touch" lesions. Such bone lesions are defined by characteristic imaging features, the identification of which precludes the need for additional diagnostic tests or biopsies, thereby avoiding unnecessary interventions. Acute tubular necrosis is kidney injury caused by damage to the kidney tubule cells (kidney cells that reabsorb fluid and minerals from urine as it forms). Common causes are low blood flow to the kidneys, drugs that damage the kidneys, or a severe underlying infection.

Shoulder assessment by smartphone: a valid alternative for times of social distancing.

BackgroundThe delivery of orthopaedic care via telemedicine services has the potential to promote accessibility and decrease medical care expenses, while facilitating the control of infectious disease spreading. The purpose of this study was to assess agreement regarding diagnosis, recommended course of management and the perceived need for additional diagnostic testing between a video examination (VE) and a face to face (FTF) assessment of patients with shoulder disorders.MethodsForty-seven (18 females) patients presenting to a shoulder surgery clinic were assessed consecutively by VE and a FTF examination. All assessments were conducted by a shoulder specialist. Agreement regarding the established diagnosis, the recommended course of management and the need for additional diagnostic tests was assessed using percent agreement and kappa (95% CI) coefficient. Differences in the content, duration and satisfaction between the two examination modes were also assessed.ResultsPercent agreement and kappa (95% CI) coefficient for agreement regarding diagnosis were 85.1% and 0.82 (0.69–0.94), respectively. Percent agreement and kappa (95% CI) coefficient regarding the recommended course of management and the need for additional diagnostic testing were 61.7% and 0.43 (0.22–0.63), and 74.5% and 0.49 (0.25–0.74), respectively. The VE resulted in collection of less physical examination information, took longer to complete and was associated with less satisfaction by both patient and examiner.ConclusionsVideo examination of patients with shoulder disorders may present a valid alternative to FTF examination. Nevertheless, the content of the video-based physical examination may need to be modified to facilitate a clearer detection of indications for specific interventions or diagnostic tests.

Correlation Between HbA1c and Fibrocystic Breast Disease Among Polycystic Ovary Syndrome

Objective: The aim of this study is to investigate whether Hemoglobin A1c (HbA1c) levels in polycystic ovary syndrome (PCOS) can predict the risk of fibrocystic breast disease in women applied to the GynecologyO 25.7 ± 1.44). 50.6 % had the risk of fibrocystic breast disease. The mean age of menarche was 11.36 ± 0.97, and the mean level of HbA1c was 5.57 ± 0.37. FSH (p 6 in the control group. Conclusions: It was concluded that HbA1c cannot be used for assessment of the fibrocystic breast disease in the PCOS women but can predict the fibrocystic breast disease in healthy women. There may be a need for additional diagnostic tests for the PCOS women to assess the fibrocystic breast disease for early treatment.

Getting New Test Results to Patients.

We surveyed 100 patients and our clinic personnel to assess opinions regarding methods of communication in common scenarios. Response rate was 79% from patients and 75% from clinic personnel. Most patients thought letters were an appropriate way to receive normal test results (83%). They also felt medical-technician calls were appropriate for normal results (88%), medication dose changes (75%), or need for additional studies (71%). Respondents considered nurse calls acceptable in most scenarios except for new diagnoses of cancer or need for surgery; the consensus was that physicians should directly communicate to patients in these situations. Providers should take the time to discuss results with patients that lead to significant interventions, but employ support staff to disseminate information about normal results, medication dose changes, and need for additional diagnostic testing.

Patients' knowledge about the outcomes of thyroid biopsy: a patient survey.

Fine-needle aspiration biopsy of the thyroid is an increasingly common outpatient procedure. Patients are counseled about the indications and risks of this procedure and informed consent is obtained. We aimed to assess the extent to which patients acquired necessary knowledge during this process. Survey study conducted in a thyroid nodule clinic at a referral center. Adult patients who had just undergone a thyroid biopsy were asked to complete a survey, including eight questions regarding the indications and potential outcomes of thyroid biopsy. The main outcome of the study was to assess the patients' knowledge based on the response to each individual survey question. Two-hundred and ninety-seven patients were eligible, of which 196 (66%) completed the survey: most were women (76%), had adequate reading health literacy (95%) and a mean age of 58 years. Although 86% of patients correctly identified evaluation for thyroid cancer as the main indication for their biopsy, 56% were not aware of the likelihood of this diagnosis. Almost all (>90%) of respondents knew that results could be benign or malignant; fewer were aware of non-diagnostic (71%) or indeterminate (68%) outcomes, or of the need for additional diagnostic testing after the biopsy (33%). After undergoing thyroid biopsy, a high proportion of well-educated patients remained unaware of their risk for thyroid cancer, potential outcomes, and downstream consequences of their biopsy. This quality gap raises the possibility that informed consent procedures that meet legal standards may leave patients undergoing thyroid biopsy paradoxically uninformed.

Practical guide for performing a bovine necropsy

Bovine veterinarians are often afforded the opportunity to determine the cause of death based on grossly visible pathological changes alone, without the need for additional diagnostic testing. In some production systems (e.g., feedlot, Stocker, and some cow/calf operations) this opportunity is capitalized upon for almost every mortality. However, for 1 reason or another, some veterinarians are reluctant to consis¬ tently take advantage of performing this procedure. Once the appropriate equipment is employed, and a standardized pro¬ cedure is followed, practitioners will be pleasantly surprised at how efficiently and effectively a postmortem diagnosis can be determined. Furthermore, with the implementation of commonly used technologies, the same principles can be utilized to assist with expanding the geographic area in which diagnoses are made.

Rapid diagnosis of acute norovirus-associated gastroenteritis: evaluation of the Xpert Norovirus assay and its implementation as a 24/7 service in three hospitals in J\xf6nk\xf6ping County, Sweden

Noroviruses are a leading cause of epidemic and sporadic cases of acute gastroenteritis worldwide. The rapid diagnosis of norovirus infection is important for prompt infection control measures and may reduce the need for additional diagnostic testing. Here we evaluated the performance of the rapid Xpert Norovirus assay, and assessed the turn-around time (TAT) before and after the implementation of the analysis as a 24/7 service at all the three hospitals in Jönköping County, Sweden. We describe the implementation process which was performed in two steps during 2014. A total number of 276 clinical samples (stool and vomitus) from patients with symptoms of acute gastroenteritis were included in 2014–2015. The samples were analysed with the Xpert Norovirus assay and the already existing routine method: an in-house reverse transcription real-time PCR. Samples showing discrepant results with the two assays were further analysed by a third PCR method. The Xpert Norovirus assay performed well with a sensitivity of 100% and a specificity of 93% compared to the gold standard (defined as the result obtained by at least two of the three PCR methods). The median TAT decreased from 22 hours in 2013 to 2.4 hours in 2015 (p<0.001). We conclude that the performance of the Xpert Norovirus assay was excellent, and that the implementation of the analysis as a 24/7 service at all three hospitals in the county has greatly reduced the time to diagnosis which is beneficial for both patients and healthcare providers.

Data Mining to Improve Laboratory Utilization and Patient Care

![Graphic][1] Laboratory testing is an integral part of modern medicine, with results influencing diagnosis, prognosis, and therapy. A number of published studies have focused on problems with laboratory utilization (“mis-utilization”) and interventions to improve test ordering,1,2 including over-utilization (ordering too many tests), under-utilization (not ordering clinically indicated testing), and ordering incorrect testing. Inappropriate test utilization can have a variety of adverse consequences, including iatrogenic blood loss, missed diagnoses, patient anxiety, unnecessary referrals, need for additional diagnostic tests, and patient financial liability for unreimbursed test costs. With a growing focus on healthcare costs, clinical laboratories are often tasked with improving laboratory utilization, while also remaining conscious of ensuring patients receive the appropriate testing for optimal patient care. ![Graphic][2] The focus on laboratory test utilization has primarily been on two major categories of testing.1 The first is high-volume, automated tests such as complete blood count and routine chemistry tests. Common interventions to tackle over-utilization of high-volume tests include limits on repetitive ordering, providing information to providers on ordering patterns and costs, and posting price information for tests in the electronic health record (EHR). The second category of testing that is often targeted is low-volume but very high-cost orders such as panels of genetic tests. These tests may have direct costs of thousands of dollars and sometimes poor reimbursement by health insurance. Frequent strategies for managing high-priced esoteric testing include requiring pre-approval prior to ordering (by pathology or other designated group) and limitation of certain tests to specific medical specialties. Some institutions have developed “laboratory test formularies” (following a model commonly employed by pharmacies), with a formal process for placing tiered restrictions on specific tests. ![Graphic][3] Hospital EHRs and laboratory information systems (LISs) contain large amounts of data that can potentially be analyzed to improve utilization of laboratory testing. Yet, a major … [1]: /embed/inline-graphic-1.gif [2]: /embed/inline-graphic-2.gif [3]: /embed/inline-graphic-3.gif

Multicenter Evaluation of the Xpert Norovirus Assay for Detection of Norovirus Genogroups I and II in Fecal Specimens

Norovirus is the most common cause of sporadic gastroenteritis and outbreaks worldwide. The rapid identification of norovirus has important implications for infection prevention measures and may reduce the need for additional diagnostic testing. The Xpert Norovirus assay recently received FDA clearance for the detection and differentiation of norovirus genogroups I and II (GI and GII), which account for the vast majority of infections. In this study, we evaluated the performance of the Xpert Norovirus assay with both fresh, prospectively collected (n = 914) and frozen, archived (n = 489) fecal specimens. A Centers for Disease Control and Prevention (CDC) composite reference method was used as the gold standard for comparison. For both prospective and frozen specimens, the Xpert Norovirus assay showed positive percent agreement (PPA) and negative percent agreement (NPA) values of 98.3% and 98.1% for GI and of 99.4% and 98.2% for GII, respectively. Norovirus prevalence in the prospective specimens (collected from March to May of 2014) was 9.9% (n = 90), with the majority of positives caused by genogroup II (82%, n = 74). The positive predictive value (PPV) of the Xpert Norovirus assay was 75% for GI-positive specimens, whereas it was 86.5% for GII-positive specimens. The negative predictive values (NPV) for GI and GII were 100% and 99.9%, respectively.

A Data-Driven Algorithm Integrating Clinical and Laboratory Features for the Diagnosis and Prognosis of Necrotizing Enterocolitis

BackgroundNecrotizing enterocolitis (NEC) is a major source of neonatal morbidity and mortality. Since there is no specific diagnostic test or risk of progression model available for NEC, the diagnosis and outcome prediction of NEC is made on clinical grounds. The objective in this study was to develop and validate new NEC scoring systems for automated staging and prognostic forecasting.Study designA six-center consortium of university based pediatric teaching hospitals prospectively collected data on infants under suspicion of having NEC over a 7-year period. A database comprised of 520 infants was utilized to develop the NEC diagnostic and prognostic models by dividing the entire dataset into training and testing cohorts of demographically matched subjects. Developed on the training cohort and validated on the blind testing cohort, our multivariate analyses led to NEC scoring metrics integrating clinical data.ResultsMachine learning using clinical and laboratory results at the time of clinical presentation led to two NEC models: (1) an automated diagnostic classification scheme; (2) a dynamic prognostic method for risk-stratifying patients into low, intermediate and high NEC scores to determine the risk for disease progression. We submit that dynamic risk stratification of infants with NEC will assist clinicians in determining the need for additional diagnostic testing and guide potential therapies in a dynamic manner.Algorithm availability http://translationalmedicine.stanford.edu/cgi-bin/NEC/index.pl and smartphone application upon request.

The Role of Optical Coherence Tomography Raster Imaging as a Valuable Diagnostic Tool in the Differential Between Optic Disc Hemorrhage and Vitreopapillary Traction

An acute presentation of an optic disc hemorrhage can indicate true optic nerve head damage or can be a result of tractional forces on the vitreopapillary interface. An isolated optic disc hemorrhage secondary to vitreopapillary traction (VPT) can mimic the clinical presentation of a glaucomatous process or that of an underlying ocular or systemic condition. This article highlights the use of spectral domain optical coherence tomography (SD-OCT) 5 line raster (5LR) in differentiating true optic disc hemorrhages from those as a result of tractional forces. Two examples are given of patients presenting to our clinic with unilateral optic disc hemorrhages and various underlying disease processes as risk factors. With the use of SD-OCT 5LR imaging, VPT was implicated as the cause of the disc hemorrhages in both patients. Although this imaging tool alone is not enough to rule out a disease process such as glaucoma or prevent the need for additional diagnostic testing, SD-OCT 5LR is a noninvasive and valuable clinical tool in distinguishing VPT from other etiologies of an optic nerve hemorrhage.

The care of constipated children in primary care in different countries

To investigate and compare the approach to childhood constipation by primary care physicians (PCP) in three Western countries to give insight into adherence to current guidelines and in actual care. Prospective study utilizing a two-page survey regarding the approach to children suspected to have functional constipation (FC). A total of 413 of 1016 (41%) distributed surveys were returned out of which 383 were suitable for analysis. Surveys were answered anonymously. Survey responses were analysed and are reported in a descriptive way. In Italy, the Netherlands, and the USA, respectively, 75, 187 and 121 surveys were returned by PCP. The majority of PCP (62%) considered stool withholding as a result of painful defecation to be the most common cause of childhood constipation. Rectal examination was used as a standard diagnostic tool for the evaluation of FC by only 31% of PCP with significant differences among the countries (p < 0.05) and a minimum in the Netherlands (11%). Abdominal X-ray is used by 49% to diagnose FC. 63% of PCP were convinced that hard stool can be softened by drinking more water. Polyethylene glycol was the most common prescribed drug (85%). Significant differences were found among countries in the use of senna and bisacodyl suppositories (p < 0.05). Significant differences in practice exist among PCP from different countries regarding the performance of a digital rectal examination, need for additional diagnostic tests and use of laxatives in childhood constipation.

Image Quality and Radiation Exposure With a Low Tube Voltage Protocol for Coronary CT Angiography: Results of the PROTECTION II Trial

The purpose of this study was to evaluate image quality and radiation dose using a 100 kVp tube voltage scan protocol compared with standard 120 kVp for coronary computed tomography angiography (CTA). Concerns have been raised about radiation exposure during coronary CTA. The use of a 100 kVp tube voltage scan protocol effectively lowers coronary CTA radiation dose compared with standard 120 kVp, but it is unknown whether image quality is maintained. We enrolled 400 nonobese patients who underwent coronary CTA: 202 patients were randomly assigned to a 100 kVp protocol and 198 patients to a 120 kVp protocol. The primary end point was to demonstrate noninferiority in image quality with the 100 kVp protocol, which was assessed by a 4-point grading score (1 = nondiagnostic, 4 = excellent image quality). For the noninferiority analysis, a margin of -0.2 image quality score points for the difference between both scan protocols was pre-defined. Secondary end points included radiation dose and need for additional diagnostic tests during follow-up. The mean image quality scores in patients scanned with 100 kVp and 120 kVp were 3.30 ± 0.67 and 3.28 ± 0.68, respectively (p = 0.742); image quality of the 100 kVp protocol was not inferior, as demonstrated by the 97.5% confidence interval of the difference, which did not cross the pre-defined noninferiority margin of -0.2. The 100 kVp protocol was associated with a 31% relative reduction in radiation exposure (dose-length product: 868 ± 317 mGy × cm with 120 kVp vs. 599 ± 255 mGy × cm with 100 kVp; p < 0.0001). At 30-day follow-up, the need for additional diagnostic studies did not differ (13.4% vs. 19.2% for 100 kVp vs. 120 kVp, respectively; p = 0.114). A coronary CTA protocol using 100 kVp tube voltage maintained image quality, but reduced radiation exposure by 31% as compared with the standard 120 kVp protocol. Thus, 100 kVp scan protocols should be considered for nonobese patients to keep radiation exposure as low as reasonably achievable. (Prospective Randomized Trial on Radiation Dose Estimates of Cardiac CT Angiography in Patients Scanned With a 100 kVp Protocol [PROTECTION II]; NCT00611780).