Standardized Diagnostic Algorithm Research Articles

What Else Is Back There?

t e p t m a n p p m s t m c PRESENTATION Chronic back pain is a condition often seen by the internist and rarely requires further testing. When pain is intractable, however, other rare potential causes may need to be evaluated. A 47-year-old Caucasian man with history of chronic back pain presented to our facility for evaluation of suddenonset, severe, mid-thoracic back pain that radiated around to his chest and was worsened by any movement. No trauma was associated with the pain, which had started the previous day. He had experienced a similar pain episode 3 months previously and had been evaluated by a chiropractor, who determined the cause to be musculoskeletal. The pain had resolved with physical therapy. The patient denied any constitutional symptoms, chest pain, shortness of breath, limb weakness, paresthesias, numbness, or bowel or bladder dysfunction. No other significant past medical or family history was noted. He denied any alcohol, tobacco, or illicit drug use.

Propranolol for the treatment of airway hemangiomas: A case series and treatment algorithm

Objectives (1) To present six patients with symptomatic airway hemangiomas treated with oral propranolol. (2) To review the diagnostic and treatment options for airway hemangiomas and propose a new management protocol. Study design Retrospective review. Setting Tertiary care children's hospital. Subjects and methods Pediatric patients diagnosed with obstructive airway hemangiomas treated with oral propranolol. Patients were followed for symptomatic improvement and relief of airway obstruction on imaging or laryngoscopy. Results Seven patients presenting with airway obstruction were treated with propranolol. One patient had a focal hemangioma confined to the subglottis. Four patients had airway hemangiomas that extended beyond the confines of the larynx and trachea. A sixth patient had a bulky supraglottic hemangioma. A seventh patient with an extensive maxillofacial lesion failed propranolol therapy and was found to have a pyogenic granuloma on final pathology after excision. Six patients had failed standard medical therapy and/or surgical interventions and were treated successfully with oral propranolol with improvements in airway symptoms and oral intake, requiring no further surgical intervention. Treatment was initiated as early as 1.5 months of age, and as late as 22 months. No adverse side effects of propranolol were noted. Conclusions Oral propranolol was successfully used to treat airway hemangiomas, resulting in rapid airway stabilization, obviating the need for operative intervention, and reducing the duration of systemic corticosteroid therapy while causing no obvious adverse effects. These outstanding results enable the possibility of use of a standardized diagnostic and treatment algorithm for airway hemangiomas that incorporates systemic propranolol.

Dyspnoe-Algorithmen für Praxis und Notfallstation

The evaluation of dyspnea in the Emergency Department (ED) is a critical step in the diagnostic procedure, especially when cardiopulmonary disease is suspected. Because dyspnea is a symptom in which many different afferent mechanisms are involved, a large number of underlying causes must be considered, alone or in combination. Qualitative and quantitative aspects of difficult or laboured breathing may vary extremely between patients. Therefore, especially under time pressure in emergency situations, it is important to consider a very broad differential diagnosis, and at the same time use a standardized protocol or diagnostic algorithms for the initial work-up.In this article, a standardized work-up published by family practitioners is compared to a standardized work-up proposed by our ED. While practitioners may safely use a multi-step algorithmic approach, it is important in the ED to consider all possible serious underlying conditions at the same time. Over 90 % of all emergency situations are accounted for by only 7 different disease groups. Therefore, all of these must be considered simultaneously in a protocol that is useful for emergency physicians.

Enterovirus‐Associated Encephalitis in the California Encephalitis Project, 1998–2005

Encephalitis is a relatively rare presentation of enterovirus (EV) infections. Clinical and epidemiologic characteristics of EV encephalitis (EVE) have not been well characterized. Patients with encephalitis enrolled in the California Encephalitis Project from 1998 to 2005 were tested for a range of pathogens, including EV, using a standardized diagnostic algorithm. EVE was categorized as "confirmed" (EV detected in cerebrospinal fluid [CSF] or brain tissue) or "possible" (EV found in respiratory or fecal specimens or serum EV immunoglobulin [Ig] M detected). We compared clinical and epidemiologic characteristics of EVE with those of other infectious encephalitis cases. EVE was diagnosed in 73 (4.6%) of 1571 patients (45 confirmed cases, 28 possible cases); 11.1% of cases had other infectious causes. Patients with confirmed EVE were younger, although 27% were adults, who presented with significantly less severe symptoms. Serotypes identified in EVE cases correlated with the predominant serotype for the given year reported to the National Enterovirus Surveillance System at the Centers for Disease Control and Prevention. Two of 4 fatal EVE cases were associated with EV71. EVs are an important cause of encephalitis cases requiring hospitalization, in both children and adults. Our data suggest that EVE severity varies by serotype, confirm the importance of CSF/brain tissue polymerase chain reaction, and demonstrate that serum IgM findings are of little value in diagnosing EVE.

The role of the “International Classification of Functioning, Disability and Health, ICF” in the description and classification of mental disorders

Diagnoses according to ICD-10 or DSM are conclusions derived from diagnostic algorithms, based on symptoms, but also illness course, history and consequences of the illness state. But, there is only limited consensus about the definitions of the criteria which are the basis of diagnostic algorithms. In DSM there is only a small glossary of technical terms, while ICD does not provide any respective definitions at all. When the diagnostic criteria are unreliable or invalid, then also the diagnostic conclusions must be invalid, even when they are based on strict algorithms. Therefore, standardized definitions for diagnostic criteria are as important as standardized diagnostic algorithms. The ICF, published by WHO in 2001, defines in it's first chapter mental functions which are identical with descriptions of psychopathological terms, if there is a malfunctioning. As definitions of diagnostic criteria are missing in ICD or DSM, the ICF definitions for functions, and thus disorders of functions, are at present the only glossary of illness signs and symptoms. Therefore, the ICF can serve as the basis for diagnostic algorithms in ICD or DSM. Furthermore, illness definitions are, apart from symptoms, also based on illness consequences. These are also defined in ICF as capacities (or disorders of capacity) and participation. Disorders of functions, capacity and participation together can describe targets of treatment. In summary, ICD and ICF as members of the family of WHO classification systems can together provide a common language for the description of health, illness and treatment goals.

Vaskuläre Rekanalisationstechniken: Nierenarterienstenosen

Decisive for the evaluation for radiological interventional therapy of renal artery stenosis, are the morphologic diagnostic by Duplex sonography, non-invasive cross-sectional angiography and digital subtraction angiography in addition to the anamnesis and clinical constellation. A standardized diagnostic algorithm and an evidence-based indication status contribute just as importantly to improvement of outcome as the implementation of uniform peri-interventional measures and a structured procedure for angiography, percutaneous transluminal renoangioplasty and follow-up. The aim of this article is to provide a practical introduction for the current radiological management of renal artery stenosis.

Functional Problems and Treatment Solutions After Total Hip Arthroplasty

The success of total hip arthroplasties (THA) in terms of patient satisfaction, improved function, and reduced pain has been well documented. Cases of patient dissatisfaction are often linked to complications due to comorbitities, radiographic loosening, and poor prosthesis alignment; however, a small number of patients are still reporting functional problems without any obvious causes. The purpose of this study was to elucidate some of the abnormalities that may lead to biomechanical dysfunction after THA and to assess the efficacy of physical therapeutic modalities that have been specifically customized for this patient population. Seventy-eight THA patients complained of poor functional capabilities after THA. Physical examination, videotape analysis, 3-dimensional gait studies, and isokinetic strength assessment indicated gait abnormalities associated with muscle weakness (57), muscle tightness (32), limb-length differences (11), and/or 2-dimensional biomechanical malalignment of the leg (10). All patients were placed on individualized treatment protocols that included physical therapy, electrical stimulation, shoe lifts, orthoses, intramuscular botulinum toxin A, and intra-articular corticosteroid injections. At final follow-up of 63 months (range, 24-200 months), 73 (94%) patients had good to excellent clinical outcomes. Five patients were recalcitrant to both invasive and noninvasive conservative measures and were considered clinical failures. Overall, the mean Harris hip score improved to 94 points (range, 65-100 points) and patient satisfaction averaged 8.7 out of 10 possible points (range, 2-10 points). The excellent clinical results from this study suggest that thorough clinical assessment and 3-dimensional gait studies are valuable tools in identifying biomechanical abnormalities in patients with functional problems after THA. A standardized diagnostic algorithm to understand these underlying dysfunctions in patients who demonstrate no radiographic abnormalities facilitates the development of customized rehabilitation modalities and improves clinical outcome.

Diagnosis and Characteristics of Syncope in Older Patients Referred to Geriatric Departments

To test the applicability and safety of a standardized diagnostic algorithm in geriatric departments and to define the prevalence of different causes of syncope in older patients. Multicenter cross-sectional observational study. In-hospital geriatric acute care departments and outpatient clinics. Two hundred forty-two patients (aged>or=65, mean+/-standard deviation=79+/-7, range 65-98) consecutively referred for evaluation of transient loss of consciousness to any of six clinical centers participating in the study. Of these, 11 had a syncope-like condition (5 transient ischemic attack; 6 seizures), and 231 had syncope (aged 65-74, n=71; aged>or=75, n=160). Protocol designed to define etiology and clinical characteristics of syncope derived from European Society of Cardiology Guidelines on syncope. No major complication occurred with use of the protocol. Neurally mediated was the more prevalent form of syncope in this population (66.6%). Cardiac causes accounted for 14.7% of all cases. The neuroreflex form of syncope (vasovagal, situational, and carotid sinus syndrome) was more common in younger than in older patients (62.3% vs 36.2%; P=.001), whereas orthostatic syncope was more frequent in the older than in the younger group (30.5% vs 4.2%; P<.001). In only 10.4% of cases, syncope remained of unexplained origin. After initial evaluation, a definite diagnosis was possible in 40.1% of the cases, and a suspected diagnosis was obtained in 57.9%. Syncope of suspected cardiac origin after initial evaluation was confirmed in 43.7% of cases, and neuromediated causes were confirmed in 83.5% of the cases. The protocol is applicable even beyond the age of 90 in geriatric departments. The standardized protocol is associated with a reduction in the frequency of unexplained syncope to about 10%.

Registry on the Evaluation of Syncope Assessment Strategy in the Emergency Room (Resaster Study)

Background Previous studies suggest that the management of patients (pts) with syncope admitted to the emergency room (ER) is not standardized. Aims To perform a review of all ER visits in a period of three months, searching for syncope (Sync) and presyncope (Presync) consults, determining incidence, admission rates and diagnostic yield of pts admitted to the ER. Methods Systematic review of electronic charts from 4 academic hospitals. Admission and discharge diagnosis were recorded. A simple standardized diagnostic algorithm based on clinical presentation, previous history, physical examination and ancillary diagnostic tests were blindly reviewed by 3 of the investigators and compared with the admission and discharge diagnosis. Results Sync/presync was the primary diagnosis in 438: Sync 318 (72%) and Presync 120 (28%). Mean age of pts with Sync and Presync was 56±23.5 years, and 50% were females. Structural heart disease was present in 20% (CAD 69%). 123 pts (28%) with Sync/Presync were admitted, representing 0.51% of all ER. Average length of stay was 7.4±9.8 days. Average estimated cost in admitted pts was CAN$ 4570.33±4700. Diagnosis at the ER visit, discharge and RESASTER diagnosis are summarized in the table: ![Graphic][1] Conclusions Application of a retrospective algorithmic diagnostic approach applied during ER assessment of pts with sync/presync increased diagnostic yield (15% to 77%), with vasovagal syncope accounting for more than half of the diagnosis. Simple clinical may reduce unnecessary testing, costs and hospital admissions in pts presenting with syncope to the ER. [1]: /embed/graphic-1.gif

Operationsverfahren bei primärem Hyperparathyreodismus – Einfluss präoperativer Befunde auf die Operationsplanung: minimal invasive oder konventionelle Parathyreoidektomie

BACKGROUND: Minimally invasive operative procedures to cure primary hyperparathyroidism (pHPT) are challenging the conventional bilateral exploration in localized single-gland disease. However, concomitant thyroid nodules can hamper the limited approaches. It was the aim of this study to establish and evaluate a standardized diagnostic algorithm, applicable in an endemic goiter region, directing pHPT patients to an individually adapted surgical approach. METHODS: 40 consecutive patients with pHPT were enrolled in a prospective study. According to a standardized diagnostic protocol, patients were selected for either open minimally invasive parathyroid exploration (OMIP), unilateral parathyroid exploration (UP) followed by thyroid surgery or bilateral cervical exploration (BE). PTH was monitored intraoperatively, follow-up was 2 weeks and 6 months postoperatively. RESULTS: 21 patients (52.5%) were selected for OMIP. 2 out of 21 (9.5%) procedures had to be converted to the conventional bilateral approach. 12 patients (30%) were correctly scheduled for UP and additional thyroid resection, and in 7 patients (17.5%) primary BE was necessary. All patients were normocalcemic at 6 months follow-up. CONCLUSIONS: 95% of patients could be scheduled for the appropriate surgical approach by the applied pre-therapeutic algorithm. This makes parathyroidectomy a predictable operative procedure in the routine clinical setup even in an endemic goiter region.

Verletzungen des Lisfranc-Gelenks

Tarsometatarsal injuries represent rare lesions of the midfoot. In 90% of the cases fractures or fracture dislocations are associated with ligamentous injury components. Two-thirds of these injuries are due to high energy trauma by direct axial loading of the foot during motor vehicle accidents or following a fall from substantial height. 50% of the patients are polytraumatized. One-third of the Lisfranc lesions are caused by low energy trauma with indirect loading mechanisms of a mainly plantar-flexed foot. Due to the variety of the clinical and radiographic appearances of Lisfranc joint injuries and inadequate standard radiographic examinations the rate in primarily missed lesions amounts up to 20%, in particular, in patients with multiple trauma. Neglected Lisfranc lesions generally lead to painful posttraumatic foot deformities even at a minor degree of dislocation. As such, bearing in mind the specific trauma mechanism a high degree of suspicion is necessary to detect this specific entity of midfoot lesion employing a standardized clinical and radiographic diagnostic algorithm. Correct management of the soft tissues is essential for the functional outcome as a high rate of compartment syndromes may develop. Treatment follows the general principles of joint injuries, i.e. anatomical reduction and stable retention of the Lisfranc joint components, until definite osteo-ligamentous healing has occurred. With some rare exceptions open reduction and temporary arthrodesis of the Lisfranc joint line with small-fragments transfixation screws or K-wires represents the current gold standard of surgical treatment. Adequate anatomic reduction and stable fixation are prerequisites for good functional results. In patients where posttraumatic foot deformities or painful osteoarthritis has developed, realignement arthrodeses of the corresponding Lisfranc joint segments involved are the tools for an improvement of function.

Emergency laparoscopy for abdominal stab wounds.

Management strategies for abdominal stab wounds (ASW) in initially asymptomatic patients range from mandatory explorative laparotomy (EL) to conservative approaches with observation alone. Emergency diagnostic laparoscopy (DL) may play a potential role between these two extremes-hence lowering the rate of unnecessary laparotomies and keeping the rate of missed injuries to a minimum. At our institution mandatory EL was carried out in every patient with ASW until 1992. In a retrospective study the charts of 43 patients with ASW were reviewed in terms of initial diagnostic procedures, intraabdominal injuries, and course and length of hospital stay. Between 5/1993 and 4/1995 DL was performed in a prospective study in 15 patients with suspected peritoneal penetration (PP) after ASW according to a standardized diagnostic and therapeutic algorithm. In 17 patients (40%) EL showed no PP; 15 (35%) had significant intraabdominal injuries, while 11 patients with PP didn't have lacerations of intraabdominal organs, resulting in an overall rate of nontherapeutic laparotomy of 65%. Mortality was 6% (n = 3), average hospital stay 8 days. Primary DL could exclude PP in 10 out of 15 patients (66%). The remaining five patients (33%) showed PP: In two patients with ASW to the right upper quadrant, intraabdominal injuries could be excluded by DL, and in one patient a low-grade liver injury was treated laparoscopically, thus avoiding laparotomy in a total of 87% (n = 13). In two patients with PP laparoscopy was converted to laparotomy: no pathological finding in one case, splenectomy for spleen laceration in the second patient, resulting in a rate of nontherapeutic laparotomies of 7%. All patients in this series had an uneventful course; average hospital stay was 2.4 days. DL offers an important diagnostic tool in excluding peritoneal penetration in ASW, hence lowering the rate of unnecessary laparotomies. Given experience and skills, laparoscopy may be used therapeutically in selected cases of ASW.

Inflammatory bowel disease (ulcerative colitis and Crohn's disease): diagnostic criteria and differential diagnosis.

Chronic inflammatory bowel diseases (i.e., ulcerative colitis and Crohn's disease) are syndromes in which standardized criteria are necessary in the diagnostic process. The present review is based on the diagnostic criteria used at our institution. We base the diagnosis of ulcerative colitis and Crohn's disease on combined information from the patient history, and radiological, endoscopic and histological findings after exclusion of neoplastic and infectious disease. The patient history must include precise information on the nature and duration of symptoms as well as the presence of relevant influential factors such as travel activity, drug intake and sexual habits. In immunocompromised patients extensive microbiological investigations are required to exclude infection. Typical radiological and colonoscopic findings in ulcerative colitis are mucosal inflammatory changes extending circumferentially and continuously from the rectum and proximally in the colon. In contrast, Crohn's disease is most frequently located in the small bowel and in case of colonic involvement, the rectum is often spared. The best predictors of Crohn's disease are discontinuous lesions, cobblestones and apthous ulceration. Histological changes such as abnormal mucosal architecture and lamina propria cellularity, neutrophil polymorph infiltration and epithelial cell abnormality are useful and reproducible features in the evaluation of colorectal biopsy specimens. The inflammatory bowel diseases, ulcerative colitis and Crohn's disease, continue to be etiological and diagnostic challenges. Increased use of standardized criteria and diagnostic algorithms are essential instruments to improve the overall quality of the management of patients with these diseases.

Recent trends in acute coronary heart disease--mortality, morbidity, medical care, and risk factors. The Minnesota Heart Survey Investigators.

Mortality from coronary heart disease (CHD) has declined in the United States since the late 1960s. To understand the reasons for the decline during the period form 1985 to 1990, we examined trends in mortality and morbidity due to CHD, medical care, and risk factors for CHD in a large metropolitan population. We identified all deaths from CHD in residents of the Minneapolis-St. Paul, Minnesota, metropolitan area who were 30 to 74 years old and classified the deaths according to whether they occurred in or out of the hospital. For 1985 and 1990, we obtained lists of patients in this age range who were discharged with a diagnosis of acute CHD from all area hospitals, and we selected the medical records of 50 percent of these patients for abstraction. Definite myocardial infarctions were identified with standardized diagnostic algorithm. The 1985 and 1990 cohorts of patients hospitalized for myocardial infarction were followed for at least three years to identify those who died from any cause. Trends in risk factors for CHD were investigated through surveys of 25-to-74-year-olds that were conducted in 1985 through 1987 and 1990 through 1992. Between 1985 and 1990, mortality from CHD fell by 25 percent for both men and women, and the decline in in-hospital mortality (41 percent) exceeded the decline in out-of-hospital mortality (17 percent) among men. The rates of hospitalization for acute myocardial infarction declined slightly, by 5 to 10 percent, between 1985 and 1990. Survival among patients hospitalized for acute myocardial infarction increased substantially during that period. After adjustment for age and previous myocardial infarction, the relative risk of dying within three years of hospitalization for a myocardial infarction (for the 1990 cohort as compared with the 1985 cohort) was 0.76 for men (95 percent confidence interval, 0.65 to 0.89) and 0.84 for women (95 percent confidence interval, 0.71 to 1.00). Substantial increases in the use of thrombolytic therapy, heparin, aspirin, and coronary angioplasty paralleled the survival trends. In general, the risk-factor profile of the area population with respect to CHD also improved considerably during that time. The recent decline in mortality due to CHD in the Minneapolis-St. Paul metropolitan area can be explained by both the declining incidence of myocardial infarction in the population and the improved survival of patients with myocardial infarction.