Number Of Differential Diagnoses Research Articles

An approach to presacral mass in neonates.

Cystic masses in presacral space in a neonate have a number of differential diagnoses including type-IV sacrococcygeal teratoma (SCT), pelvic neuroblastoma, anterior meningocele, and rectal duplication cyst.[1-6] Every lesion has certain specific features that may give an insight to the preoperative diagnosis and help in individualizing the surgical approach as to the type of lesion. In case of sacrococcygeal teratoma a coccygectomy has to be added in the surgical therapy to reduce the chance of recurrence.[5]

«Crazy paving» – verrückte Pflastersteine in der thorakalen Computertomographie

The term «crazy paving» describes an unspecific pattern in thoracic computed-tomography mimicking a paving stone configuration. This pattern can be caused by a number of differential diagnosis, for example alveolar hemorrhage, alveolar proteinosis, lipoid pneumonia or adenocarcinoma in situ. The knowledge of the correlation between imaging findings, histopathological pattern and clinical presentation prepares the clinician to understand the pathophysiology and to initiate the right therapeutic processes. In the following review, we describe the most common diseases and their radiologic correlation in daily practice.

Revisión de conceptos actuales: síndrome doloroso del espacio peritrocantérico

Lateral hip pain often becomes a challenging diagnostic and therapeutic problem. As there are a number of differential diagnoses that should be taken into account, this implies that there is a group of signs and symptoms related to greater trochanteric pain, and may be more complex than a simple inflammation of the trochanteric bursae. Around 2.5% of sports injuries involve the hip, and greater trochanteric pain has been estimated at 1.8 per 1000 patients per year. This condition occurs in adults, with the highest prevalence between the fourth and sixth decades of life. The specific diagnosis of the greater trochanteric pain syndrome include trochanteric bursitis, external snapping hip (external coxa saltans), and ruptures of the tendons of the gluteus medius and lower gluteus. We present a review of the scientific literature that enables the reader to make an adequate differential diagnosis between the above-mentioned pathologies.

Continuous Heart Murmur-Two Cases of Rare Causes and Role of Imaging in Diagnosis

A continuous murmur is defined as a murmur that begins in systole, continues through the second heart sound and into part or all of diastole. Among a number of differential diagnoses, anomalous systemic arterial supply to the normal basal segments and Rupture of Sinus of Valsalva (RSOV) are two rare causes of continuous heart. These two entities, which are often overlooked clinically, may have potentially fatal complications. We herein present two cases of uncommon causes of continuous heart murmur; demonstrate the radiological features and corroborate the role of Electric Cardiogram-Gated Computed Tomography (ECG-gated CT) in diagnosis.

Comparing comorbidity measures for predicting mortality and hospitalization in three population-based cohorts

BackgroundMultiple comorbidity measures have been developed for risk-adjustment in studies using administrative data, but it is unclear which measure is optimal for specific outcomes and if the measures are equally valid in different populations. This research examined the predictive performance of five comorbidity measures in three population-based cohorts.MethodsAdministrative data from the province of Saskatchewan, Canada, were used to create the cohorts. The general population cohort included all Saskatchewan residents 20+ years, the diabetes cohort included individuals 20+ years with a diabetes diagnosis in hospital and/or physician data, and the osteoporosis cohort included individuals 50+ years with diagnosed or treated osteoporosis. Five comorbidity measures based on health services utilization, number of different diagnoses, and prescription drugs over one year were defined. Predictive performance was assessed for death and hospitalization outcomes using measures of discrimination (c-statistic) and calibration (Brier score) for multiple logistic regression models.ResultsThe comorbidity measures with optimal performance were the same in the general population (n = 662,423), diabetes (n = 41,925), and osteoporosis (n = 28,068) cohorts. For mortality, the Elixhauser index resulted in the highest c-statistic and lowest Brier score, followed by the Charlson index. For hospitalization, the number of diagnoses had the best predictive performance. Consistent results were obtained when we restricted attention to the population 65+ years in each cohort.ConclusionsThe optimal comorbidity measure depends on the health outcome and not on the disease characteristics of the study population.

Occurrence and pattern of ocular disease in children with cholestatic disorders

To describe visual function and ocular manifestations in patients with onset of cholestasis during the neonatal period. Patients with neonatal cholestasis, either transitory or chronic, who came for assessment to our tertiary referral centre were included in a cross-sectional study and underwent ophthalmological examinations including fundus photography. A total of 57 patients (24 girls and 33 boys), aged 0.4-18.0 years, were included. Of these, 28 patients had biliary atresia, 11 had Alagille's syndrome, five had progressive familiar intrahepatic cholestasis and nine had different disorders such as pituitary insufficiency, alpha-1-antitrypsin deficiency, mitochondriopathy, congenital infections or cholestasis caused by unknown reasons. Visual dysfunction and/or one or several ocular manifestations occurred in 39 out of 57 patients. Major ocular malformations occurred in five patients. Out of three patients with biliary atresia, one patient had severe visual impairment caused by microphthalmia and chorioretinal coloboma, one patient with Cat Eye syndrome had bilateral uveochorioretinal coloboma and one patient had Rieger's anomaly. Two patients, both with pituitary deficiency and transient cholestasis, had severe unilateral visual impairment caused by optic nerve hypoplasia. The majority (68%) of the patients with cholestasis had ocular manifestations. Although the severity of ocular complications varied with diagnosis, and was most apparent among patients with biliary atresia or pituitary deficiency, no conclusion can be drawn regarding the connections between these conditions from the present study. Nevertheless, ocular assessment is important for diagnostic purposes and for early intervention in patients with cholestasis.

Performance of comorbidity measures for predicting outcomes in population-based osteoporosis cohorts

The performance of five comorbidity measures, including the Charlson and Elixhauser indices, was investigated for predicting mortality, hospitalization, and fracture outcomes in two osteoporosis cohorts defined from administrative databases. The optimal comorbidity measure depended on the outcome of interest, although overall the Elixhauser index performed well. Studies that use administrative data to investigate population-based health outcomes often adopt risk-adjustment models that include comorbidities, conditions that coexist with the index disease. There has been limited research about the measurement of comorbidity in osteoporotic populations. The study purpose was to compare the performance of comorbidity measures for predicting mortality, fracture, and health service utilization outcomes in two cohorts with diagnosed or treated osteoporosis. Administrative data were from the province of Saskatchewan, Canada. Osteoporosis cohorts were identified from diagnoses in hospital and physician data and prescriptions for osteo-protective medications using case definitions with high sensitivity or high specificity. Five diagnosis- and medication-based comorbidity measures and five 1-year outcomes, including mortality, hospitalization (two measures), osteoporotic-related fracture, and hip fracture, were defined. Performance of the comorbidity measures was assessed using the c-statistic (discrimination) and Brier score (prediction error) for multiple logistic regression models. In the specific cohort (n = 9,849) for the mortality outcome, the Elixhauser index resulted in the largest improvement (8.96%) in the c-statistic and lowest Brier score compared to a model that contained demographic and socioeconomic variables, followed by the Charlson index (6.06%). For hospitalization, the number of different diagnoses resulted in the largest improvement (14.01%) in the c-statistic. The Elixhauser index resulted in significant improvements in the c-statistic for osteoporosis-related and hip fractures. Similar results were observed for the sensitive cohort (n = 28,068). Recommendations about the optimal comorbidity measure will vary with the outcome under investigation. Overall, the Elixhauser index performed well.

Dermatology Consultations in an Emergency Department Prior to Establishment of Emergency Dermatology Cover

Background and objective An increasing number of patients seek emergency treatment for dermatologic complaints. The aim of this study was to assess the characteristics of skin complaints seen in an emergency department prior to establishment of specialist dermatology cover. Materials and methods A retrospective, descriptive study was undertaken using data on urgent dermatology cases seen by nonspecialist physicians in the emergency department of Hospital General Universitario de Albacete, Spain, in 2008. Results A total of 3662 patients with skin diseases were seen (2.59% of all emergency cases; approximately 10 patients per day). The mean age was 27.73 years and there was a slight predominance of female patients. Children and adolescents accounted for 5.85% of cases. A total of 96 different conditions were diagnosed and 84% of cases corresponded to one of 21 different diagnostic entities, urticaria being the most frequent (19.27%). The 96 diagnoses were grouped into 16 categories to facilitate analysis. According to this classification, most patients had infectious diseases (47.49%), followed by urticaria and angioedema (20.13%), “nonspecific diagnosis” (11.93%), and “descriptive diagnosis” (6.49%). In 4.8% of cases, the patient was admitted, most frequently for cellulitis. Conclusions In nonspecialist emergency services, the number of different diagnoses is small in relation to the number of patients seen and the proportion of nonspecific and descriptive diagnoses is relatively large. In our opinion, an on-call dermatologist should be made available within emergency departments in order to offer a higher quality of care to patients with skin conditions.

The role of high-mobility group box-1 (HMGB-1) in the management of suspected acute appendicitis: useful diagnostic biomarker or just another blind alley?

Acute abdominal pain is one of the most frequent reasons for admitting patients to the emergency department for surgical evaluation. A wide number of differential diagnoses are available and their pre-test likelihood ratio varies according to the patients' age, gender, duration of symptoms and overall clinical context. While many patients with abdominal pain do not need to be admitted to the hospital wards and even fewer need eventual surgical intervention, the diagnosis of acute appendicitis remains one of the most frequently entertained differential in patients with abdominal pain. In fact, surgery for appendicitis is one of the most frequently performed operations in the Western world. As the authors of the current study point out, the high mobility group box-1 protein (HMGB1) has been known for many years. The study demonstrates in a small pilot that there is a difference in expression of HMGB1 between those with and those without appendicitis. However, is this difference clinically important? Clinically relevant results can only be documented through larger studies comparing its use and expression levels in both healthy subjects, subjects with abdominal pain for other reasons, patients with 'clear-cut' (histopathologically confirmed) appendicitis and in the difficult subgroup of patients with suspected appendicitis and equivocal symptoms.

Consultas dermatológicas en el Servicio de Urgencias: situación previa a la instauración de guardias de la especialidad

Background and objective an increasing number of patients seek emergency treatment for dermatologic complaints. The aim of this study was to assess the characteristics of skin complaints seen in an emergency department prior to establishment of specialist dermatology cover. Materials and methods aretrospective, descriptive study was undertaken using data on urgent dermatology cases seen by nonspecialist physicians in the emergency department of Hospital General Universitario de Albacete, Spain, in 2008. Results atotal of 3662 patients with skin diseases were seen (2.59% of all emergency cases; approximately 10 patients per day). The mean age was 27.73 years and there was a slight predominance of female patients. Children and adolescents accounted for 5.85% of cases. A total of 96 different conditions were diagnosed and 84% of cases corresponded to one of 21 different diagnostic entities, urticaria being the most frequent (19.27%). The 96 diagnoses were grouped into 16 categories to facilitate analysis. According to this classification, most patients had infectious diseases (47.49%), followed by urticaria and angioedema (20.13%), “nonspecific diagnosis” (11.93%), and “descriptive diagnosis” (6.49%). In 4.8% of cases, the patient was admitted, most frequently for cellulitis. Conclusions in nonspecialist emergency services, the number of different diagnoses is small in relation to the number of patients seen and the proportion of nonspecific and descriptive diagnoses is relatively large. In our opinion, an on-call dermatologist should be made available within emergency departments in order to offer a higher quality of care to patients with skin conditions.

Measuring the range of services clinicians are responsible for in ambulatory practice

At present, the range of services delivered in a health system is not known. Currently there are no accepted methods for defining the scope of ambulatory care. Therefore we used data from the electronic medical record and billing system of a large non-profit multi-specialty group practice to measure the number of different diagnoses that clinicians managed as well as the number of different medications, laboratory tests, imaging studies, referrals and procedures ordered. All patient encounters and clinicians in the group practice in 2008 were eligible for inclusion in the analysis. Data were analysed cumulatively for the practice and by specialty. Quantile regression models were used to adjust for differences in full-time equivalents (FTE) among physicians at the practice. In one year for this practice, with 324,229 patients who made 3,193,917 office visits to 578 physicians and 248 other clinicians, patients presented with 5638 primary and 6411 secondary diagnoses. Overall, patient management resulted in unique orders for 9481 medications, 1182 laboratory tests, 613 referrals, 284 imaging studies and 1701 procedures. After adjusting for FTE, physicians managed a median of 249 primary diagnoses and 347 secondary diagnoses. They ordered a median of 278 medications, 128 laboratory tests, 51 referrals, 29 imaging studies and 39 procedures. Physicians routinely manage a substantial variety of diagnoses, medications, and other tests and procedures. Quality improvement and health services researchers have generally focused on individual services but also must consider the wide variety and range of services delivered.

Extra scrotal spermatocele causing lower abdominal pain: a first case report

Lower quadrant abdominal pain is a common complaint evaluated in emergency departments (EDs). The number of differential diagnoses is lowered when the pain in a male patient is associated with a palpable tender mass. These diagnoses include inguinal hernia, inflamed inguinal lymph node, rectus sheath hematoma, cryptorchidism, mass derived from the spermatic cord, and polyorchidism. We report a case of extra scrotal spermatocele causing lower quadrant abdominal pain that was misdiagnosed as an inguinal hernia on several ED visits. Lower quadrant mass and pain caused by a spermatocele are unusual conditions. Upon the patient's third (ED) visit, the painful mass remained located in his right lower quadrant. The lower quadrant mass was movable on palpation and with pressure could be delivered into the superior aspect of the scrotum. The patient had an abdominal and pelvic computed tomography scan and lower quadrant ultrasound. The imaging studies revealed the mass to be a cystic structure. Surgical excision confirmed that the mass was a spermatocele. Differential diagnoses, diagnostic approaches, and treatment are discussed.

Pneumoparotitis or pneumoparotid: a differential diagnosis to consider

Childhood parotid swelling has a number of differential diagnosis mostly of inflammatory origin. Pneumoparotitis is an uncommon cause of parotid inflammation. It is caused by an excessive increase of intraoral pressure and secondary passage of air into the Stensen or Stenon duct and its glandular branches. Diagnostic clues can usually be obtained by a directed anamnesis. Ultrasonography (US) and computed tomography are essential diagnostic tools for this condition that has a benign course with spontaneous resolution in most cases. We present four cases of pneumoparotitis diagnosed by US in children 5 to 13 years of age. One of the cases occurred after the child chewed gum and made bubbles for a prolonged time-period and the other three after inflating baloons, making bubbles inside a pool and after playing the flute. All cases resolved spontaneously after two days. We suggest to consider pneumoparotitis in the differential diagnosis of parotid swelling in children.

Neumoparotiditis o neumoparótida en el niño: Un diagnóstico diferencial a considerar

Childhood parotid swelling has a number of differential diagnosis mostly of inflammatory origin. Pneumoparotitis is an uncommon cause of parotid inflammation. It is caused by an excessive increase of intraoral pressure and secondary passage of air into the Stensen or Stenon duct and its glandular branches. Diagnostic clues can usually be obtained by a directed anamnesis. Ultrasonography (US) and computed tomography are essential diagnostic tools for this condition that has a benign course with spontaneous resolution in most cases. We present four cases of pneumoparotitis diagnosed by US in children 5 to 13 years of age. One of the cases occurred after the child chewed gum and made bubbles for a prolonged time-period and the other three after inflating baloons, making bubbles inside a pool and after playing the flute. All cases resolved spontaneously after two days. We suggest to consider pneumoparotitis in the differential diagnosis of parotid swelling in children.

Pompholyx or dyshidrosis

Pompholyx is an inflammatory vesicobullous disorder of the palms and soles. Although originally thought to be related to eccrine gland pathology, the condition is now considered to be part of the eczema spectrum. Pompholyx has a number of differential diagnoses and the etiopathology of this disease is not uniform. It can develop on the basis of atopy, contact irritation and contact sensitization, mycid reaction and as a side effect of drug treatment. Pompholyx treatment is challenging: topical therapy is based on corticosteroids and calcineurin inhibitors. Topical and systemic photochemotherapy and high-dose UVA-1 irradiation have been successfully used. Systemic therapy is often necessary in advanced cases of pompholyx. Corticosteroids are commonly used, sometimes combined with immunosuppressants. Alitretinoin has efficacy in chronic hand eczema including pompholyx. Another evolving treatment seems to be the intradermal injection of botulinum toxin. In practice, patients benefit most from a combination o...

QS171. Impact of the Addition of Medical Hospitalist Service to Acute Care Surgical Service Workload

Introduction: There is a perfect storm occurring in Hospital Medicine. Primary Care physicians are increasingly sending their patients to the hospital to be managed by full-time medical hospitalists. This trend has direct impact on acute care surgical service workload. We reviewed our in-house consult experience following the institution of a medical hospitalist service. Methods: Two consecutive time periods totaling 36 months, 1/04 - 6/05 (Time Period A) and 7/05 - 1/07 (Time Period B) were reviewed for in-house surgical consultations to the acute care surgical service. Number of consults, acuity (case mix index), time to request (TTR), diagnosis (Dx), and types of insurance were compared. The full-time medical hospitalist program was instituted in May 2005. Results: There were 637 consults in Time Period A which increased to 893 consults in Time Period B (28.7% increase). The Acuity as measured by case mix index decreased from 1.12 to 1.08 (3.6%) over these time periods. The Time To Request dropped by 60% from 15 hours to 6 hours from Admission. The number of different diagnoses increased from 18 to 23 (27.7%) and the percentage of self-pay (uninsured) consults decreased by 33%, from 12% to 8%, during the 36-month study period. Conclusion: As primary care physicians abdicate the in-hospital care of their patients to full-time medical hospitalists the workload for acute care surgeons significantly increases. These patients are seen sooner in the hospital, may be less ill with a wider range of diagnoses and more likely to possess health insurance. In our experience, the capability to perform endoscopy and laparoscopy greatly enhances the utilization of the acute care surgeon for in-house consultation. Tabled 1 Time Period A Time Period B % Change Number of Consults 637 893 28.7% Acuity 1.12 1.08 3.6% TTR (hours) 15 6 60% Diagnoses 18 23 27.7% Self-Pay Insurance (%) 12 8 33% Open table in a new tab

Caffey’s disease: an unusual cause for concern

Caffey's disease or infantile cortical hyperostosis is a rare cause of irritability, bone pain, soft tissue swelling and fever in the infant. To review the presentation and diagnosis of an 8-week old infant with focal tenderness of the tibia. The symptoms, signs, laboratory work-up and radiology are reviewed. The child presented with focal bony tenderness and pyrexia. Laboratory work-up was inconclusive. The diagnosis of Caffey's disease was made following a skeletal survey to outrule non-accidental injury, which showed similar changes of cortical thickening in the mandible as well as the affected tibia. With our increasing immigrant population, an increasing number of differential diagnoses must be considered when evaluating patients presenting to our emergency rooms. Caffey's disease is an unusual cause of bone pain in the infant. Symptoms and signs are subtle and the diagnosis is generally made with plain X-rays.

ICD-10 classification in Danish child and adolescent psychiatry – Have diagnoses changed after the introduction of ICD-10?

The aim was to test this in a nationwide register study of diagnoses used in child and adolescents psychiatry in Denmark. A larger number of different diagnoses were expected to be applied after the introduction of the 10th version of the International Classification of Diseases (ICD-10). Reflecting the time trend, we particularly expected an increase in the number of neuropsychiatric diagnoses. From the Danish Psychiatric Central Register data were drawn on clinical discharge diagnoses. All patients aged 0–15 years examined at psychiatric hospitals from 1995–2002 were included; 22,469 children and adolescents with a first contact were registered. The most frequent discharge diagnoses were pervasive development disorders (PDD; 11.9%), adjustment disorders (10.6%), conduct disorder (9.5%), emotional and anxiety disorders (7.6%), hyperkinetic disorders (7.3%), and specific developmental disorders (7.3%). We found a significant increase in the number of neuropsychiatric and affective diagnoses and a significant decrease in the number of adjustment, conduct and anxiety diagnoses during the study period. Of the 22,469 diagnoses, 45% were only partly specified according to ICD-10. Thirty-four per cent had diagnoses unspecified on the four-character level (Fxx.9) and 11% had Z-diagnoses. A larger number of different diagnoses and an increase in the use of neuropsychiatric diagnoses were seen after the introduction of ICD-10. Many diagnoses were only partly specified; consequently, a more detailed specification of the ICD-10 is still required.

Pervasive Refusal Syndrome among Asylum-seeking Children

A number of asylum-seeking children in Sweden have developed a pervasive loss of function associated with profound social withdrawal. The syndrome is called Depressive Devitalization. The aim of this study was to identify possible aetiological factors, outline the similarities between Depressive Devitalization and Pervasive Refusal Syndrome and to explore possible differential diagnoses. The research was based on a literature study. Databases searched included PsychINFO, Medline, Pub med, COCHRANE and PILOTS. Possible aetiological factors identified included: Children having a perfectionist, ambitious and conscientious premorbid personality, psychiatric problems of children and parents, and traumatic events. Symptoms between the two syndromes differed only in pattern of refusal and neurological symptoms. None of the differential diagnoses explored could account for all features. The individual impact of aetiological factors requires further investigation. Children might previously have been diagnosed with a number of differential diagnoses, though none of these accounts for all symptoms seen in the syndromes. Depressive Devitalization and Pervasive Refusal Syndrome are suggested to be subgroups of the same refusal syndrome.

The development and validation of a comorbidity index for prostate cancer among Black men

Background and Objectives The purpose of this study was to develop a comorbidity index specific to Black Men with prostate cancer, because certain comorbidities and prostate cancer are particularly prevalent among this racial group. Methods This research used the Surveillance, Epidemiology, and End Results (SEER)–Medicare-linked database to develop an index of comorbidity burden based on survival, and the presence/absence of comorbid illness in 2,931 Black males diagnosed with prostate cancer. Comorbidity burden was recognized using inpatient, outpatient, and physician claims for a 2-year period prior to the diagnosis of prostate cancer. We compared five different statistical models, each with two-way, three-way, and/or four-way interactions among the comorbidities, and selected the model with only two-way interactions as the optimal choice. We demonstrated the utility of refining the simplest model, with 27 comorbidity categories only, by adjusting for the number of different diagnoses within statistically significant categories.