Nonspecific Diagnosis Research Articles

Interpreting specific and general respiratory indicators in syndromic surveillance

ObjectiveTo improve understanding of the relative burden of differentcausative respiratory pathogens on respiratory syndromic indicatorsmonitored using syndromic surveillance systems in England.IntroductionPublic Health England (PHE) uses syndromic surveillance systemsto monitor for seasonal increases in respiratory illness. Respiratoryillnesses create a considerable burden on health care services andtherefore identifying the timing and intensity of peaks of activity isimportant for public health decision-making. Furthermore, identifyingthe incidence of specific respiratory pathogens circulating in thecommunity is essential for targeting public health interventionse.g. vaccination. Syndromic surveillance can provide early warningof increases, but cannot explicitly identify the pathogens responsiblefor such increases.PHE uses a range of general and specific respiratory syndromicindicators in their syndromic surveillance systems, e.g. “allrespiratory disease”, “influenza-like illness”, “bronchitis” and“cough”. Previous research has shown that “influenza-like illness”is associated with influenza circulating in the community1whilst“cough” and “bronchitis” syndromic indicators in children under 5are associated with respiratory syncytial virus (RSV)2, 3. However, therelative burden of other pathogens, e.g. rhinovirus and parainfluenzais less well understood. We have sought to further understand therelationship between specific pathogens and syndromic indicators andto improve estimates of disease burden. Therefore, we modelled theassociation between pathogen incidence, using laboratory reports andhealth care presentations, using syndromic data.MethodsWe used positive laboratory reports for the following pathogens as aproxy for community incidence in England: human metapneumovirus(HMPV), RSV, coronavirus, influenza strains, invasivehaemophilusinfluenzae, invasivestreptococcus pneumoniae, mycoplasmapneumoniae, parainfluenza and rhinovirus. Organisms were chosenthat were found to be important in previous work2and were availablefrom routine laboratory testing. Syndromic data included consultationswith family doctors (called General Practitioners or GPs), calls to anational telephone helpline “NHS 111” and attendances at emergencydepartments (EDs). Associations between laboratory reports andsyndromic data were examined over four winter seasons (weeks40 to 20), between 2011 and 2015. Multiple linear regression was usedto model correlations and to estimate the proportion of syndromicconsultations associated with specific pathogens. Finally, burdenestimates were used to infer the proportion of patients affected byspecific pathogens that would be diagnosed with different symptoms.ResultsInfluenza and RSV exhibited the greatest seasonal variation andwere responsible for the strongest associated burden on generalrespiratory infections. However, associations were found with theother pathogens and the burden ofstreptococcus pneumoniaewasimportant in adult age groups (25 years and over).The model estimates suggested that only a small proportion ofpatients with influenza receive a specific diagnosis that is coded toan “influenza-like illness” syndromic indicator, (6% for both GPin-hours consultations and for emergency department attendances),compared to a more general respiratory diagnosis. Also, patients withinfluenza calling NHS 111 were more likely to receive a diagnosisof fever or cough than cold/flu. Despite these findings, the specificsyndromic indicators remained more sensitive to changes in influenzaincidence than the general indicators.ConclusionsThe majority of patients affected by a seasonal respiratory pathogenare likely to receive a non-specific respiratory diagnosis. Therefore,estimates of community burden using more specific syndromicindicators such as “influenza-like illness” are likely to be a severeunderestimate. However, these specific indicators remain importantfor detecting changes in incidence and providing added intelligenceon likely causative pathogens.Specific syndromic indicators were associated with multiplepathogens and we were unable to identify indicators that were goodmarkers for pathogens other than influenza or RSV. However, futurework focusing on differences between ages and the relative levels ofa range of pathogens may be able to provide estimates for the mix ofpathogens present in the community in real-time.

Ultrasound of Neck Masses in Pediatrics

US plays an important role in the evaluation of palpable neck masses in pediatric patients. The superficially located structures are easily examined and exquisitely displayed by US using a high-frequency linear array transducer. In most of the cases, US can differentiate cystic from solid lesions. For the cystic lesions, the imaging diagnosis is based on location. The midline or paramedian location of cystic neck masses in pediatrics mostly are thyroglossal duct cyst and dermoid/epidermoid when locating between hyoid bone and thyroid gland, ranula or plunging ranula when locating in sublingual or submandibular spaces, and dermoid/epidermoid again when locating at suprasternal notch. Epiglottic cyst can also be detected in its typical location when there is no intervening air. The laterally-located cystic lesions are branchial cleft cyst, venolymphatic malformation, and phlebectasia of the jugular vein. Lymphatic malformation has its typical location in posterior triangle of the neck. Contents within cystic neck masses in many cases are not echo-free and may appear as pseudo-solid lesions on US. For the solid neck masses in pediatrics, US usually can tell whether it is an enlarged lymph node or not. Like in adult, US may depict the suspicious lymph node for biopsy. The imaging diagnosis of the solid neck masses other than enlarged lymph nodes in many cases are nonspecific and need histological diagnosis. However, there are some typical solid lesions that the diagnosis could be provided, e.g., fibromatosis colli, infantile hemangioma, ectopic thymus, and ectopic thyroid.

Une ulcération atypique de la lèvre inférieure

Cutaneous pathomimia is a self-induced disease characterized by conscious self-injury to mucocutaneous boundary or its phaneres. We report the case of a 22-year old woman, with no notable medical history, presenting with sudden onset ulceration on her lower lip evolving for 3 months in a context of preservation of patient's clinical status. The patient had previously consulted several dermatologists and had undergone two skin biopsies with non-specific histological diagnosis. Clinical examination showed painful, well-defined ulceration with clean surface and non-indurated basis, measuring 1 × 3 cm in diameter and involving the left half of the lower lip (A). Given the clinical appearance of the lesion, its chronic nature and the lack of response to local care, several diagnosis were suspected: squamous cell carcinoma, cutaneous leishmaniasis, pyoderma gangrenosum… Deep biopsy was performed showing a loss of substance revealing the chorion, without histological characters of malignancy. Syphilis and HIV tests were negative. Fifteen days after, patient's evolution was marked by the appearance of an identical lesion on the right side of the lower lip, with complete healing of the former lesion by occlusive dressing (B). The follow-up interview showed, again, manipulation with the hand as well as family conflicts. Examination by a psychiatrist compared with clinical and evolutionary data showed cutaneous pathomimia.

Ocular acne rosacea in tertiary eye center in Saudi Arabia.

To report the most common presenting signs and symptoms of ocular rosacea for timely diagnosis and management. A retrospective chart review of 23 patients with a diagnosis of acne rosacea or a non-specific diagnosis was performed at a tertiary eye hospital. Patients with lid changes such as recurrent blepharitis; meibomianitis; recurrent chalazia; facial skin change such as papules, telangiectatic blood vessels, and/or rhinophyma were included. Data were collected on patient demographics, presenting symptoms, visual acuity, dermatologic findings and treatment. There were 23 patients documented with acne rosacea with dermatologic facial findings associated with lid and/or corneal findings of peripheral thinning and vascularization. Two cases had a serious spontaneous peripheral corneal perforation. Most of the patients had no clinically significant change in visual acuity. The diagnosis of ocular acne rosacea was straightforward despite non-specific findings. Diagnostic delay can result in serious complications.

Fetal Neurosonogaphy: Ultrasound and Magnetic Resonance Imaging in Competition.

Fetal Neurosonogaphy: Ultrasound and Magnetic Resonance Imaging in Competition.

Opportunities and Challenges in Developing a Cohort of Patients with Type 2 Diabetes Mellitus Using Electronic Primary Care Data.

PurposeTo develop a cohort of patients with T2DM treated with insulin using CPRD to obtain an accurate diagnosis date. This was used to analyse time from T2DM diagnosis to first ever insulin prescription between 01/01/2000 and 30/06/2012, for patients in England and Wales.MethodsPatients aged 18 years and over at diagnosis, were included if prescribed an anti-diabetic drug and were excluded if first diagnosis-specific code was inconsistent with a T2DM diagnosis. Diagnosis codes were split into 8 categories based on whether they related to specific T2DM or non-specific diabetes codes. Patients were excluded if they had non-specific diagnosis codes and were prescribed insulin as their first-ever treatment for diabetes. Descriptive statistics for time from T2DM diagnosis to insulin initiation were calculated.ResultsTwo hundred and fifty-six codes were identified which were consistent with a first-ever diagnosis of T2DM. 7 codes were considered to clearly define a diagnosis of T2DM, which were reported for 64% of patients. The final cohort comprised 11,917 patients and the median time to first insulin prescription from the date of diagnosis was 4.4 years.ConclusionsA clear definition of cohort development is required to compare and interpret results from studies. Use of diagnosis and product codes is essential when examining use of drugs such as insulin, where competing diagnoses need to be considered separately.

Use of evidence-based assessments for childhood anxiety disorders within a regional medical system.

Anxiety disorders represent a common and serious threat to mental health in children and adolescents. To effectively treat anxiety in children, clinicians must conduct accurate assessment of patients' symptoms. However, despite the importance of assessment in the treatment of childhood anxiety disorders, the literature lacks a thorough analysis of the practices used by clinicians' when evaluating such disorders in community settings. Thus, the current study examines the quality of assessment for childhood anxiety disorders in a large regional health system. The results suggest that clinicians often provide non-specific diagnoses, infrequently document symptoms according to diagnostic criteria, and rarely administer rating scales and structured diagnostic interviews. Relatedly, diagnostic agreement across practice settings was low. Finally, the quality of assessment differed according to the setting in which the assessment was conducted and the complexity of the patient's symptomatology. These results highlight the need to develop and disseminate clinically feasible evidence-based assessment practices that can be implemented within resource-constrained service settings. (PsycINFO Database Record

Collaborative care of non‐urgent macular disease: a study of inter‐optometric referrals

PurposeDiseases involving the macula and posterior pole are leading causes of visual impairment and blindness worldwide and may require prompt ophthalmological care. However, access to eye‐care and timely patient management may be limited due to inefficient and inappropriate referrals between primary eye‐care providers and ophthalmology. Optometrists with a special interest in macular disease may be useful as a community aid to better stratify and recommend best‐practice management plans for suitable patients. This study assesses such a notion by appraising the optometric referral patterns of patients with suspected macular disease to an intermediate‐tier optometric imaging clinic.MethodsWe performed a retrospective review of patient records and referrals using patients examined at Centre for Eye Health (CFEH) for an initial or follow up macular assessment between the 1/7/2013 and 30/6/2014 (n = 291). The following data were analysed: patient demographic characteristics, primary reason for referral, diagnosed/suspected condition, CFEH diagnosis and recommended management plan.ResultsThe number of referrals stipulating a diagnosis, confirmed after evaluation at CFEH was 121 of 291 (42%). After evaluation at CFEH, the number of cases without a specific diagnosis was approximately halved (reduced from 47% to 23%), while the number of cases with no apparent defect or normal aging changes rose from 1% to 15%. Overall diagnostic congruency for specified macular conditions was high (58–94%); cases were seldom (30/291, 10%) found to have a completely different macular condition. 244 of 291 (84%) patients seen at CFEH were recommended ongoing optometric care: either with the referring optometrist or through recall to CFEH. Referral to an ophthalmologist was recommended in 47 instances (16%).ConclusionsMore widespread adoption of intermediate‐tier optometric eye‐care referral pathways in macular disease (following opportunistic primary care screening) has the potential to reduce the number of cases with non‐specific diagnoses and to increase those with a diagnosis of normal aging changes or no apparent disease. The majority of cases seen under this intermediate‐tier model required ongoing optometric care only and did not require face‐to‐face consultation with an ophthalmologist.

Splenic Abscess and Management Options: Report of Four Cases

Abscess of the spleen is a rather clinical rarity with reported mortality rate up to 47%. The timely and widespread use of imaging methods facilitates early diagnosis and guides treatment, thus improving the prognosis. Most of patients were with recognized risk factors including conditions that compromise the immune system, trauma and intravenous drug abuse in addicts. The surgical treatment by splenectomy is usually the first choice of treatment but percutaneous drainage is the valid option. Splenic abscess is an unusual and potentially life-threatening disease with a diagnostic challenge due to the non-specific clinical picture and diagnosis is confirmed based mostly on imaging studies. Splenic abscesses are very rarely encountered in surgical practice with a reported high mortality rate in neglected and untreated cases. Percutaneous drainage is a valid option and safe procedure for patients with splenic abscess. J Med Cases. 2016;7(10):432-434 doi: http://dx.doi.org/10.14740/jmc2633w

Discrete Pathophysiology is Uncommon in Patients with Nonspecific Arm Pain.

Nonspecific symptoms are common in all areas of medicine. Patients and caregivers can be frustrated when an illness cannot be reduced to a discrete pathophysiological process that corresponds with the symptoms. We therefore asked the following questions: 1) Which demographic factors and psychological comorbidities are associated with change from an initial diagnosis of nonspecific arm pain to eventual identification of discrete pathophysiology that corresponds with symptoms? 2) What is the percentage of patients eventually diagnosed with discrete pathophysiology, what are those pathologies, and do they account for the symptoms? We evaluated 634 patients with an isolated diagnosis of nonspecific upper extremity pain to see if discrete pathophysiology was diagnosed on subsequent visits to the same hand surgeon, a different hand surgeon, or any physician within our health system for the same pain. There were too few patients with discrete pathophysiology at follow-up to address the primary study question. Definite discrete pathophysiology that corresponded with the symptoms was identified in subsequent evaluations by the index surgeon in one patient (0.16% of all patients) and cured with surgery (nodular fasciitis). Subsequent doctors identified possible discrete pathophysiology in one patient and speculative pathophysiology in four patients and the index surgeon identified possible discrete pathophysiology in four patients, but the five discrete diagnoses accounted for only a fraction of the symptoms. Nonspecific diagnoses are not harmful. Prospective randomized research is merited to determine if nonspecific, descriptive diagnoses are better for patients than specific diagnoses that imply pathophysiology in the absence of discrete verifiable pathophysiology.

Diagnosis and mortality in prehospital emergency patients transported to hospital: a population-based and registry-based cohort study

ObjectiveKnowledge about patients after calling for an ambulance is limited to subgroups, such as patients with cardiac arrest, myocardial infarction, trauma and stroke, while population-based studies including all diagnoses are...

Follow-up of Women With Negative Pap Test Results and Abnormal Clinical Signs or Symptoms.

Abnormal signs or symptoms recorded on Papanicolaou (Pap) test requisitions may reflect disease not detected with Pap testing. Since 2009, these cases have been reviewed in our laboratory by a second cytotechnologist and a cytopathologist. The objective of this study was to document follow-up findings on these patients. A search for Pap test results of "Negative for intraepithelial lesion or malignancy, abnormal clinical signs or symptoms" was performed for cases from January 1, 2009, to October 10, 2013. Clinical information and follow-up findings were documented. 1,104 cases were identified. Signs and symptoms were abnormal bleeding 897 (81%), polyps 83 (8%), pelvic mass 54 (5%), visible cervical lesions 48 (4%), vaginal lesions 17 (2%) and endometrial masses 6 (0.5%). Six hundred sixty-seven (60%) had follow-up results, including 517 with histopathologic diagnoses. Two-hundred thirty-three (45%) had nonspecific benign diagnoses, 216 (42%) had benign tumor-like conditions, 28 (4%) had insufficient specimens, 16 (3%) had precancerous diagnoses and 23 (4%) had malignancies. Endometrial malignancy was identified in 14 (61%), ovarian in 6 (26%), and miscellaneous in 3 (13%). No cervical cancers were identified. We report follow-up findings from patients with abnormal clinical signs or symptoms, negative Pap test results, and follow-up recommendations highlighting reported abnormal signs or symptoms. Abnormal clinical signs and symptoms should routinely be considered in assessment and management of patients with negative cervical screening test results.

Delayed diagnosis of endobronchial mucoepidermoid carcinoma in a 29-year-old male.

Mucoepidermoid carcinoma (MEC) is an uncommon primary lung tumor. It usually involves large airways and presents clinically and radiologically with nonspecific features. Because of nonspecific presentation diagnosis is frequently delayed. We report the case of a 29-year-old male patient wherein a clinico-radiological consideration of tuberculosis (TB) led to a prolonged treatment with anti-TB medications without response. Flexible bronchoscopic biopsy confirmed the diagnosis of MEC following that the patient underwent curative surgical resection.

Implementing the K-SADS-PL as a standard diagnostic tool: Effects on clinical diagnoses

Diagnostic interviews are valuable tools for generating reliable and valid psychiatric diagnoses. However, little is known about the diagnostic effects of implementing such an interview into the standard diagnostic procedure of a child psychiatric clinic. Therefore, we reviewed discharge diagnoses of psychiatric patients (age: 8–12 years; combined sample of inpatients and day hospital patients) over two intervals before and after implementing the semi-structured diagnostic interview K-SADS-PL as a diagnostic tool during intake. Each interval was a two year period spanning from 2009–2010 (pre sample; n=177) and from 2012–2013 (post sample; n=132). The number of diagnoses per patient and the co-morbidity rate increased significantly in the post sample. Furthermore, the percentage of children with a nonspecific diagnosis “other mixed disorders of conduct and emotions” (ICD-10: F92.8) decreased significantly after using the K-SADS-PL. Regarding the main diagnostic categories, a significant increase in the number of anxiety disorders and stress-related and somatoform disorders was found in the post sample. The results suggest that implementing a semi-structured interview into the daily routine of child psychiatry may have a substantial impact on discharge diagnoses. Practical implications are discussed and ideas for future research are given.

Diffuse Large B-Cell Lymphoma of Recto-Sigmoid Colon

Primary colorectal lymphoma (PCL) is a rare malignancy accounting for 3% of all GI lymphomas and 0.1-0.5% of all colorectal malignancies. The most frequent colonic location is the cecum followed by the rectum and ascending colon. Although several cases of PCL have been reported in the literature the recto-sigmoid junction as an origin has rarely been reported. We present a rare case of diffuse large B- cell lymphoma (DLBCL) in a patient presenting with anemia, weight loss and change in bowel habits. A 79 year old male with a past medical history significant for adenocarcinoma of the prostate status post (s/p) radiation, coronary artery disease s/p CABG, chronic kidney disease admitted to Dartmouth Hitchcock Medical Center (DHMC) with complaints 30 pound weight loss, intermittent lower abdominal pain with alternating diarrhea and constipation. Of note, one month prior to admission, he underwent colonoscopy at an outside hospital due to changes in his bowel habits. Biopsies taken at the time revealed non-specific acute inflammation thought to be related to ischemic colitis. During his admission at DHMC he underwent CT scan abdomen and pelvis which revealed thickening of the recto-sigmoid colon. Subsequent colonoscopy showed a colonic mucosa characterized by circumferential ulcerations with mucopurulent exudate that extended from rectum to sigmoid colon (Figure 1). The appearance was suggestive of ischemic colitis, but rectal involvement seemed atypical. Biopsies taken were stained for hematoxylin and eosin and immunohistochemistry to reveal diffuse DLBCL of the colon.Figure 1A PET-CT scan showed hypermetabolic activity involving lung, kidney, sigmoid and rectum. This was consistent with stage IVB DLBCL with extra-nodal involvement and 4 year survival of 40-50%. The patient underwent treatment with R-CHOP (Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) however did not tolerate treatment due to worsening kidney and functional decline. He was transitioned to hospice care per family wishes and died one month later. The most common histological subtype of colorectal lymphoma is DLCBL. The etiology of DLBCL is unknown. Patient may present with variety of clinical symptoms that include abdominal pain, anorexia, weight loss, fatigue, anemia, fever, constipation and/or diarrhea. However, due to the nonspecific presentation diagnosis maybe delayed as seen in our patient. One should consider PCL in patient presenting with the above symptoms or with risk factors including HIV, organ transplant, inflammatory bowel disease and immunosuppressant agents. Endoscopists should think of a broader differential diagnosis when proctitis or colitis is seen during colonoscopy. Biopsies should be taken and reviewed by an expert GI pathologist.Figure 2

Incidence Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the U.S. Population, 2012.

Understanding skin cancer incidence is critical for planning prevention and treatment strategies and allocating medical resources. However, owing to lack of national reporting and previously nonspecific diagnosis classification, accurate measurement of the US incidence of nonmelanoma skin cancer (NMSC) has been difficult. To estimate the incidence of NMSC (keratinocyte carcinomas) in the US population in 2012 and the incidence of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) in the 2012 Medicare fee-for-service population. This study analyzes US government administrative data including the Centers for Medicare & Medicaid Services Physicians Claims databases to calculate totals of skin cancer procedures performed for Medicare beneficiaries from 2006 through 2012 and related parameters. The population-based National Ambulatory Medical Care Survey database was used to estimate NMSC-related office visits for 2012. We combined these analyses to estimate totals of new skin cancer diagnoses and affected individuals in the overall US population. Incidence of NMSC in the US population in 2012 and BCC and SCC in the 2012 Medicare fee-for-service population. The total number of procedures for skin cancer in the Medicare fee-for-service population increased by 13% from 2,048,517 in 2006 to 2,321,058 in 2012. The age-adjusted skin cancer procedure rate per 100,000 beneficiaries increased from 6075 in 2006 to 7320 in 2012. The number of procedures in Medicare beneficiaries specific for NMSC increased by 14% from 1,918,340 in 2006 to 2,191,100 in 2012. The number of persons with at least 1 procedure for NMSC increased by 14% (from 1,177,618 to 1,336,800) from 2006 through 2012. In the 2012 Medicare fee-for-service population, the age-adjusted procedure rate for BCC and SCC were 3280 and 3278 per 100,000 beneficiaries, respectively. The ratio of BCC to SCC treated in Medicare beneficiaries was 1.0. We estimate the total number of NMSCs in the US population in 2012 at 5,434,193 and the total number of persons in the United States treated for NMSC at 3,315,554. This study is a thorough nationwide estimate of the incidence of NMSC and provides evidence of continued increases in numbers of skin cancer diagnoses and affected patients in the United States. This study also demonstrates equal incidence rates for BCC and SCC in the Medicare population.

Pneumoperitoneum due to splenic abscess: A diagnostic challenge. Case Report

Abstract Background Splenic abscess is a rare clinic entity, its incidence has increased due to the rising number of clinical conditions involving immunosuppression. Endocarditis is the most frequent cause, and gram-positive aerobes are the main causal agents. Its clinical presentation is non-specific and delays diagnosis. Computed tomography scan is the method of choice, and the treatment is based on antibiotics and drainage, radiological or surgical, involving splenectomy in special cases that require it. Clinical case A 55-year-old man with abdominal pain and fever. The analysis revealed leukocytosis 14,000/mm 3 , prothrombin activity 53%, and metabolic acidosis. Computed tomography scan showed a peri-hepatic pneumoperitoneum, liquid fluid, and peri-splenic bubbles, and slight trabeculation of fat around the duodenal bulb with pneumoperitoneum in this area. Patient underwent a median laparotomy, finding a purulent peritonitis due to a ruptured abscess in the spleen, splenectomy was performed. Fluid culture showed polymorphonuclears, with no microorganisms identified. The patient progressed and was discharged on the 5th post-operative day. Conclusions Splenic abscess is an uncommon condition, in which the diagnosis is delayed and mortality, in untreated patients, is high. Its association with pneumoperitoneum may confuse the diagnosis towards viscera perforation. Thus it must be suspected in the finding of unknown cause of pneumoperitoneum by complementary examinations. The treatment of choice is splenectomy, because the capsular rupture is the norm in all of them.

Differential diagnosis "non-cardiac chest pain"

Non cardiac chest pain (NCCP) are recurrent angina pectoris like pain without evidence of coronary heart diesease in conventional diagnostic evaluation. The prevalence of NCCP is up to 70% and may be detected in this order at all levels of the medical health care system (general practitioner, emergency department, chest pain unit, coronary care). Reduction of quality of life in NCCP is comparable, partially even higher compared to cardiac chest pain. Reasons for psychological strain are symptom recurrence in app. 50%, nonspecific diagnosis with resulting uncertainty and insufficient integration of other medical disciplines in diagnostic work-up. Managing of patients with NCCP has to be interdisciplinary because non cardiac causes of chest pain may be found frequently. This are musculosceletal in app. 40%, gastrointestinal in app. 20%, psychiatric in app. 10% and pulmonary and mediastinal diseases in app. 5% of cases. Also gastroenterological expertise is required because here gastroesophageal reflux disease (GERD) in app. 60%, hypercontractile esophageal motility disorders with nutcracker, jackhammer esophagus or distal esophageal spasmus or achalasia in app. 20% and other esophageal alterations (e. g. infectious esophageal inflammation, drug-induced ulcer, rings, webs, eosinophilic esophagits) in app. 30% of cases may be detected as cause of chest pain may. This implicates that regular interdisciplinary round wards and interdisciplinary management of chest pain units are mandatory.

The Putative Role of Viruses, Bacteria, and Chronic Fungal Biotoxin Exposure in the Genesis of Intractable Fatigue Accompanied by Cognitive and Physical Disability.

Patients who present with severe intractable apparently idiopathic fatigue accompanied by profound physical and or cognitive disability present a significant therapeutic challenge. The effect of psychological counseling is limited, with significant but very slight improvements in psychometric measures of fatigue and disability but no improvement on scientific measures of physical impairment compared to controls. Similarly, exercise regimes either produce significant, but practically unimportant, benefit or provoke symptom exacerbation. Many such patients are afforded the exclusionary, non-specific diagnosis of chronic fatigue syndrome if rudimentary testing fails to discover the cause of their symptoms. More sophisticated investigations often reveal the presence of a range of pathogens capable of establishing life-long infections with sophisticated immune evasion strategies, including Parvoviruses, HHV6, variants of Epstein-Barr, Cytomegalovirus, Mycoplasma, and Borrelia burgdorferi. Other patients have a history of chronic fungal or other biotoxin exposure. Herein, we explain the epigenetic factors that may render such individuals susceptible to the chronic pathology induced by such agents, how such agents induce pathology, and, indeed, how such pathology can persist and even amplify even when infections have cleared or when biotoxin exposure has ceased. The presence of active, reactivated, or even latent Herpes virus could be a potential source of intractable fatigue accompanied by profound physical and or cognitive disability in some patients, and the same may be true of persistent Parvovirus B12 and mycoplasma infection. A history of chronic mold exposure is a feasible explanation for such symptoms, as is the presence of B. burgdorferi. The complex tropism, life cycles, genetic variability, and low titer of many of these pathogens makes their detection in blood a challenge. Examination of lymphoid tissue or CSF in such circumstances may be warranted.

Advanced Imaging of Cardiac Sarcoidosis

Sarcoidosis with cardiac involvement is underdiagnosed and can put patients at risk of morbidity including conduction defects, arrhythmias and heart failure, as well as sudden cardiac death. In addition, cardiac sarcoidosis may have no clinical manifestations or non-specific presentation and diagnosis may be difficult on clinical criteria. Investigation for cardiac sarcoidosis should be considered in those with extra-cardiac sarcoidosis and cardiac findings as well as those under the age of 60 years presenting with atrioventricular block without a clear cause. Advanced imaging modalities including cardiac magnetic resonance and positron emission tomography may help in both the diagnosis and assessment of response to treatment for cardiac sarcoidosis. This ultimately may help to minimize associated adverse outcomes from this enigmatic disease.