Negative Exam Research Articles

Colonoscope Withdrawal Times and the Presence or Abscence of Colonic Adenomas at Screening Colonoscopy

Purpose: To determine the relationship between colonoscope withdrawal time, adenoma detection, and adenoma size during screening colonoscopy in an ambulatory private practice setting. Methods: 97 consecutive patients undergoing screening colonoscopy included 46 males (47%) and 51 females (53%). No patient had undergone previous colonoscopy or colon resection surgery. Patients with first degree family members suffering from colon cancer were excluded from the study. The examination was performed with Olympus colonoscopes after either phosphosoda or PEG lavage purge. Diprovan was used for sedation and all exams were performed by one endoscopist (apk). Upon entering the cecum and identifying the ileocecal valve withdrawal timing was initiated with a stop watch. Results: The mean age of the study patients was 60.7 years. All exams were successful to the cecum. The average age of patients with no adenomas was 59.1 yrs, with adenomas 64.3 years. Adenoma Incidence: Patients with adenomas: 26 (27%) Patients with adenomas >1 cm: 13 (13%) Patients with adenomas >2 cm: 3 (3%) Colonoscope Withdrawal Times: Mean withdrawal time all patients: 12 min 37 sec Mean withdrawal time in patients with no adenomas: 10 min 59 sec Mean withdrawal time in patients with adenomas: 14 min 9 sec Mean withdrawal time in patients with adenomas >1 cm: 21 min 37sec Mean withdrawal time in patients with adenomas >2 cm: 30 min 50 sec Conclusions: The adenoma incidence rate at screening colonoscopy in this study was 27%. Withdrawal time for patients with no adenomas detected (10:59) was longer than the recently recommended 6 minute minimum time for withdrawal in negative exams. Withdrawal times for more complex adenomas (>1 cm) were substantially longer than withdrawal times for the total adenoma subset. (p < .01) 3% of patients harbored adenomas >2 cm in diameter. Screening colonoscopy in private practice should be successful to the cecum in a very high percentage of patients.

Influência da parasitemia na evolução da doença de Chagas crônica

During 13 years, 190 individuals with chagasic infection were submitted to clinical and parasitological examinations to investigate the relationship between parasitemia and the evolution of chronic chagasic infection. Fifty-six patients with positive xenodiagnosis and 134 with negative exams were compared from 1988 to 91, it was found that 22 (39.3%) and 50 (37.3%), respectively, presented disease progression. The parasitemia was stratified into high, medium and low and the relation with the disease evolution showed that 5 (62.5%), 10 (41.7%) and 57 (36.1%), respectively, presented progressive disease, though without a statistically significant difference (p>0.05). When 20 patients with persistent parasitemia in 1976/91, were compared with 59 with negative xenodiagnosis, a progressive evolution was observed in 6 (30%) and 17 (28.8%), respectively. Comparing six patients with high parasitemia and 59 with negative exams, it was verified that 3 (50%) and 17 (28.8%), respectively, showed progressive disease, but this was not statistically significant, (p>0.05). Mean age with high, medium and low parasitemia were 39.6, 45.3 and 41.5 years, respectively, (p>0.05). Mean age in patients showing progressive, unaltered and regressive evolution was 46.4, 39.8 and 32.6 years, respectively, with a statistically significant difference between progressive and regressive evolution (p<0.05). It is suggested that high parasitemia did not have an influence on the evolution of the chronic infection.

THE EFFECT OF A NEGATIVE SCREENING UPPER ENDOSCOPY ON QUALITY OF LIFE AND HEALTH-RELATED ANXIETY IN PATIENTS WITH GERD

Purpose: A large proportion of patients who undergo screening upper endoscopy (EGD) for reflux will have normal exams. Investigators have postulated that a negative upper endoscopy may have a positive psychological effect. The purpose of this study is to determine the effect of a negative screening EGD on quality of life and health-related anxiety over time in patients with GERD symptoms. Methods: Subjects ages 18–80 with classic GERD symptoms who were scheduled for screening EGD were prospectively enrolled at a university endoscopy unit and two community centers. One week prior to their EGD, subjects completed the SCL-90-R, the Spielberger State/Trait Anxiety Scale, the SF-36, the Gastrointestinal Quality of Life Index, the GERD-HRQL, and the GERD Symptom Assessment Scale. Endoscopic andpathologic reports were reviewed following the procedure. Subjects with a normal endoscopic exam were sent the same questionnaires at six and twelve weeks post-endoscopy. Paired t-tests were performed comparing the pre-procedure anxiety and quality of life levels to those six and twelve weeks post-endoscopy, to assess the extent and durability of any changes. Results: To date, 33 subjects have enrolled in the study, with 13 subjects (8 females, 5 males, mean age 46) having completed the study. Compared to the pre-procedure data, there was a transient and insignificant improvement in each of the 8 domains of the SF-36, as well as the Spielberger State Anxiety Scale (see graph). These improvements decreased by week 12, with all subjects having returned to baseline levels of quality of life and healthcare-related anxiety. [figure 1]Figure: SF-36(By Domain)Conclusions: These preliminary data suggest that positive effects of a negative EGD on quality of life or anxiety levels in GERD patients are transient and small in magnitude. Clinicians should not perform low -yield upper endoscopy for GERD expecting durable reassurance and improved quality of life for patients with a negative exam.

The Use of Negative Events to Prime Cognitive Vulnerability to Depression

This prospective study tested three hypotheses put forth to explain previous inconsistencies in research examining the hopelessness theory of depression. Ninety-three university students completed measures of attributional style for achievement and interpersonal events both before and after experiencing a negative prime. Depressed mood was assessed before the priming task, and at two time points after the students completed their most difficult midterm exam: immediately after receiving their exam grade and 4 days later. Both exam outcome and attributional style, but not their interaction, were significant predictors of change in depressed mood immediately following the receipt of exam grades. Primed depressogenic attributional styles for achievement events interacted with a negative exam outcome to predict depressive mood reactions 4 days later.

Frequency of lymphocytic meningitis associated with mumps before and after a mass campaign for mumps vaccination in children from Salvador, Northeast Brazil.

To describe the frequency of lymphocytic meningitis(LM) concomitant with mumps, before and after the mumps mass immunization campaign in 1997. Demographic, clinical and cerebrospinal fluid(CSF) information was collected from the chart of all patients aged from 2 to 59 months, whose CSF exam was performed at the CSF Lab/FJS, between 1989 and 2001. LM was defined as pleocytosis composed by lymphomononuclear cells and negative exams for bacterial or mycologic infection. Of 1,519 patients, 894(58.9%) had normal exams. LM was present in 301(19.8%) patients, out of which 22(7.3%) had concomitant mumps. The frequency of LM ranged from 15.8% in 1989 to 19.7% in 2001 and of LM with concomitant Mumps ranged from 10.5% in 1989 to 4.7% in 1995, when the last cases were registered. It is probable that the mumps vaccine campaign has influenced the absence of LM with concomitant Mumps, from 1996 to 2001.

Diagnosing appendicitis with CT and ultrasound using prospective patient stratification by body mass index

Purpose: To determine the accuracy of CT and ultrasonography (US) in diagnosing appendicitis in adults stratified to either modality on the basis of body mass index (BMI), a measure of body habitus. Methods: Seventy-two adults with suspected appendicitis and demonstrating atypical clinical features were prospectively stratified to either appendiceal CT or US based on BMI. Patients with BMI < 30 underwent US and with BMI ≥ 30 underwent CT. Outcomes were determined by surgery, the medical record, and clinical follow-up after 3 months. Results: Of the 72 patients enrolled, 30 (24 women and 6 men) underwent CT and 42 (35 women and 7 men) underwent US. The average BMI was 34 ± 4 among patients who had CT and 24 ± 3 among patients who had US. Of the patients who had CT scans, 4 had positive scans for appendicitis and all of these were proven at surgery to have appendicitis. The remaining 26 patients had negative CT scans for appendicitis. Twenty-two of these were subsequently proven either by surgery or clinical follow-up not to have appendicitis, while 4 were lost to follow-up. This corresponds to a sensitivity, specificity, positive predictive value, and negative predictive value of 100 %. Twelve ultrasound examinations were positive for appendicitis. Nine of these patients had appendicitis proven at surgery, 1 had a perforated Meckel's diverticulum, and 2 did not have appendicitis after clinical follow-up. Twenty-seven patients had negative ultrasound exams for appendicitis. However, 6 of these had appendicitis proven at surgery, 17 did not have appendicitis, and 4 were lost to follow-up. Three patients had ultrasound exams that were equivocal for appendicitis; of these, 1 had appendicitis and 2 did not. For US, this corresponds to a sensitivity of 60 %, specificity of 85 %, PPV of 75 %, and NPV of 74 %. Conclusion: This study suggests that CT is an accurate method of evaluating adults with suspected appendicitis who have BMI ≥ 30. Stratifying patients with BMI < 30 to US did not reproduce the results already reported in the literature.

Worker Monitoring Tests for Carpal Tunnel Syndrome: Results from an Industrial Longitudinal Study

This paper presents the initial findings from a study using two computer-controlled functional tests for sensory and motor deficits in carpal tunnel syndrome (CTS). The gap detection sensory test quantifies dynamic tactile inspection thresholds for areas of the hand innervated by the median nerve. The rapid pinch and release psychomotor test measures the initiation and control of specific muscles innervated by the median nerve motor branch. The purpose of this ongoing study is to evaluate industrial subjects recruited from varying high risk industrial settings, such as poultry processing, automotive manufacturing, plastics manufacturing, assembly, and newspaper publishing for longitudinal changes in test outcomes. A total of 169 subjects were tested during the first year of this study. All subjects completed a symptom survey, underwent a physical examination of the upper limbs, shoulder and neck, had a nerve conduction study (NCS), and were administered the Wisconsin Test Battery. Both hands of the subjects are examined and categorized by presence of absence of physical exam findings, self-reported symptoms, and nerve conduction study (NCS) results. The data was analyzed for differences between subjects reporting positive or negative symptoms, and positive or negative physical exam and NCS findings. In summary, the psychomotor and sensory test outcomes were related to objective NCS findings but it is interesting to note that symptoms alone were not significantly associated with functional sensory or psychomotor performance. Unlike our previous studies, where CTS patients in the electromyography (EMG) clinic seeking medical assistance were tested, all subjects were from a working population. It is likely that most of the positive exam and NCS subjects in the current study involve CTS symptoms that are less severe than our previous studies using EMG clinic subjects, many whom were preparing for surgery.

Management of patients with ultrasound negative biliary colic: The role of cholecystectomy

Background: Management of pts with biliary colic sxs (right upper quadrant abdominal pain with or without nausea)and negative ultrasound exam for gallstones can be challenging. The aim of this study was to ascertain the role of cholecystectomy in these pts. Methods: We restrospectively reviewed records of 229 pts who were evaluated at our institution between 1994 and 1999. Of 229 pts, 179 pts (78%) underwent cholecystectomy and 50 pts (22%) were managed without surgery. The two groups of pts were similar in terms of age, gender, sx duration and other clinical characteristics. All pts were evaluated by a gastroenterologist and had tests including ultrasound of the abdomen, cholecystokinin stimulated cholescintigraphy (CCK-CS), upper orX-ray or endoscopy. Pts (I 85F, 44M, avg age 45 yrs) were followed up for an avg of 26.7 mos (range 4-70 mos). Data including gallbladder motility, reproduction of biliary colic sxs during CCK-CS and gallbladder histology were abstracted. Results: Of 179 pts who were treated with cholecystectomy, 154 (86%) had resolution of biliary colic. Of 50 pts who were managed without cholecystectomy, 16 (32%) had symptom improvement (P<.OI). Of 179 pts who underwent surgery, 130 (73%) had histologic evidence of cholecystitis and 49 (27%) did not. Histologyproven cholecystitis was not a good predictor of sx resolution after surgery (114/130 vs 40/49)(P=NS). Of the 179 pts who had surgery, 122 (68%) had abnormal pre-operative gallbladder motility and 57 (32%) had normal motility. Of 50 pts who did not have surgery, 21 (42%) had abnormal motility and 29 (58%) had normal motility. Pts with abnormal gallbladder motility had a similar symptomatic outcome as pts with normal motility with or without cholecystectomy (P=NS). Of 179 pts who had surgery, 155 (87%) had biliary colic sxs reproduced following CCK challenge during CCK-CS and 24 (13%) did not. Of 50 pts who did not have surgery, 39 (78%) had biliary colic sxs reproduced following CCK challenge and II (22%) did not. Among pts who had CCK-induced sx reproduction, 137 (88%) improved following surgery, 28 (72%) failed to improve symptomatically without surgery (P<.OI). Conclusion: Cholecystectomy is effective in relieving sxs in pts with ultrasound negative biliary colic. CCK induced sx reproduction appears to be a good prognostic indicator of the clinial outcome.

Small bowel bleeding

Most patients with small bowel bleeding present with chronic, recurrent, transfusion-dependent, debilitating disease. Less commonly, an acute gastrointestinal bleeding episode with negative upper and lower endoscopic exams may be the initial presentation. Lesions responsible for small bowel bleeding, on the other hand, include arterio-venous malformations, tumors, and ulcers. The treatment options must therefore be directed to the specific cause of bleeding and its mode of presentation (acute versus chronic; intermittent). Treatment before a specific diagnosis has been reached includes blood transfusions as needed, and chronic iron supplementation. Once the diagnosis of arterio-venous malformations has been made, thermal endoscopic therapy (heater probe, bipolar electrocoagulation, argon plasma coagulation, or laser) with or without injection (epinephrine) is the mainstay treatment option. The same option is available for small bowel ulcers that show stigmata of recent bleeding, eg, a non-bleeding visible vessel or adherent clot, or are actively bleeding at the time of enteroscopy. For the patient with a small bowel tumor thought to be responsible for the bleeding, surgical excision or resection is the treatment of choice. The surgical option is also reserved for those patients with diffuse and multiple lesions, and those with lesions beyond the reach of the push enteroscope, which preclude endoscopic therapy. Invasive radiological methods via selective catheterization and vasopressin injection or embolization are reserved for patients with a demonstrable actively bleeding lesion found at the time of the diagnostic work-up, and those who may not be candidates for surgery. For those patients in whom endoscopic therapy or surgery is not amenable (ie, anatomical location, multiple lesions involving several segments of the small bowel), those who are not surgical candidates and those who have recurrent bleeding after repeat endoscopic or surgical therapies, medical therapy with continuous iron supplementation, avoidance of ulcerogenic drugs (eg, NSAIDs) and hormonal therapy (for those with arteriovenous malformations) should be considered.

BUN/creatinine ratios: aid to decision making about delayed imaging in Tc-99m red blood cell scans for gastrointestinal hemorrhage.

In patients with gastrointestinal hemorrhage, delayed or late scans with Tc-99m labeled red blood cells are readily performed and have prognostic impact when early images are negative. Nevertheless, there have been no indicators for the likelihood of detecting bleeding on such images. In a review of all gastrointestinal bleeding scans over an 8-year period, 73 patients had delayed images (> 3 hours) following early negative exams. For these patients, determinations of serum blood urea nitrogen (BUN) and creatinine (Cr) were evaluated as the BUN/Cr ratio and were compared against delayed scan findings and confirmed diagnoses. Patients with significant renal failure were excluded from analysis. There were 34 late positive (46%) and 39 late negative (54%) studies. Mean BUN/Cr was 26.5 and 20.0 in patients with late positive and late negative scans, respectively (p < 0.05). Occurrence of late positive scans was 38% (19/50) for BUN/Cr < 25.0 vs. 65% (15/23) for BUN/Cr > 25.0 (p < 0.05). Patients with early negative images and a BUN/Cr ratio of 25 or greater have a greater likelihood of a positive delayed image. Late imaging should be encouraged in patients with elevated BUN/Cr and early negative scintigraphy.

The Utility of Preoperative Screening Colonoscopy in Gynecologic Oncology

Abstract The American Cancer Society (ACS) recommends that asymptomatic women, age 50 and over, undergo sigmoidoscopy every 3 to 5 years, after two negative yearly exams. Epidemiologic evidence suggests that women with gynecologic or breast cancers have an increased risk of developing colon cancer. It is unclear whether the ACS guidelines are applicable for women with a new diagnosis of gynecologic malignancy. This retrospective study was undertaken to assess the usefulness of preoperative colonoscopy in our gynecologic oncology patient population. Patients undergoing evaluation for a major operative procedure for known or suspected gynecologic malignancies were referred for colonoscopy at the discretion of their attending surgeon. Five hundred patients' charts were reviewed to identify 212 patients in whom preoperative colonoscopy was performed (the study group). In this group, 17 cases of colonic polyps, 5 cases of synchronous colon cancer, and 2 cases of cancer metastatic to the colon were discovered, representing 11% of the study group. Whereas 23% of the patients screened were less than 50 years of age, only two cases of polyps occurred in this age group, and no cases of cancer. Patients aged 70 or greater made up 28% of the study group, but accounted for 41% of the cases of polyps and 40% of the colon cancers. Twenty-nine percent of the study group had adenocarcinoma of the endometrium, representing 7 of 17 cases of polyps, 1 of 5 colon cancers, and 1 of 2 metastatic cancers. Although this retrospective study involved colonoscopy, the locations of the observed lesions were within the theoretic reach of a flexible sigmoidscope in 75% of cases. We conclude that in the preoperative workup of gynecologic oncology patients, no colon screening is needed in the asymptomatic patient less than 50 years of age. ACS guidelines are appropriate for patients aged 50-70, but for those 70 or greater we would consider full colonoscopy.

The anatomy of missed breast cancers

Missed breast cancer continues to account for the highest percentage of medical malpractice cases in the United States. A retrospective, computer-aided study was performed to investigate the mechanisms of missed breast carcinomas, missed either by mammography or by clinical exam. In a consecutive series of 509 breast cancers found in patients registered at a University Comprehensive Breast Cancer Clinic, no tumour that was 5 mm or less in maximal diameter was clinically palpable. This subgroup consisted of seven in situ and 32 invasive carcinomas. The incidence of palpable tumours in 5 mm increments increased so that when a tumour was between 11 and 15 mm in size, 48% of the lesions were palpable, and with tumours greater than 20 mm in size, 84% were palpable. There was a good correlation between size of the tumour as judged by mammography and the eventual size determined by histologic examination. Smaller breast cancers were detected by mammography than by physical examination. In a separate analysis of 553 consecutive cases of breast cancer examined by mammography, there were 50 (9%) cases in which the cancer was not read from the mammogram. In retrospect, 10 of these mammograms were abnormal for a misinterpretation rate of 1.8%. Cancers associated with false negative mammograms occurred more often in younger women and in dense breast parenchyma than cancers detected by mammography. Cancers missed by mammography were smaller than palpable cancers detected by mammography, more often had negative nodes and presented with a lower stage of disease. Breast augmentation implants were associated more frequently with missed breast cancers, with 5 8 clinically detected breast carcinomas being undetected by mammography. An asymmetric mass was more often associated with cancers missed by mammography, accounting for the sole sign of malignancy in 3% of all cancers, but was the source of 14% of false negative exams. Architectural distortion, ill-defined or well circumscribed masses or calcifications as mammographic signs of malignancy were not associated with an increased frequency of missed cancers. Three ‘interval’ breast cancers occurred in this series and are included in the false negative mammograms. It is concluded that the threshold of clinically detected breast cancers is 6 mm and experienced clinicians do not detect the majority of breast cancers until the lesions are greater than 16 mm. Mammography has a defined misinterpretation and false negative rate. Likewise, asymmetric mammographic densities that are greater than 16 mm and are not palpable may be followed, since most breast cancers are palpable in this range.

Quality of life following a false positive mammogram

To assess how women regard having had a false positive mammogram screening exam, and the influence that this had on their quality of life, 126 such women were interviewed. Their responses were compared to those of 152 women randomly selected among screenees with a negative exam. Eighteen months after the screening the reported prevalence of anxiety about breast cancer was 29% among women with a false positive and 13% among women with a negative screening mammogram (P = 0.001). Of 30 women biopsied, 8 (27%) had pain in the breast and 10 (33%) had reduced sexual sensitivity. A false positive mammogram was described by 7 (5%) of the women as the worst thing they ever had experienced. However, most women with a false positive result regarded this experience, in retrospect, as but one of many minor stressful experiences creating a temporary decrease in quality of life. They report the same quality of life today as women with negative screening results and 98% would attend another screening. Even so, false positive results are a matter of concern, and efforts should be made to minimise this cost whenever a screening programme is conducted.