Standardized Diagnostic Approach Research Articles

HIV/AIDS Patients with HIV Vasculopathy and VZV Vasculitis

Stroke is a rising cause of mortality in human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) populations. The etiology of stroke remains at the core of the decision-making process to treat and prevent recurrent events. In this population HIV vasculopathy (HIV-V) and varicella zoster virus (VZV) vasculitis are elusive causes of stroke. This study investigated radiological markers that could help identify possible etiological causes. A series of nine consecutive patients seen at a large metropolitan hospital who presented with AIDS and stroke with the suspicion of either HIV vasculopathy (HIV-V) or VZV vasculitis (VZV-V) were included. A standardized diagnostic approach was used to for HIV-V and VZV-V. Data on frequencies and typical images are reported. Of the nine patients five had VZV-V and four had HIV-V. Patients with VZV-V were generally younger than those with HIV-V; however, no other significant demographic or cardiovascular differences were found. Of the five patients with VZV-V four had small, deep, subcortical ischemic strokes and only one in this group had a large, cortical, hemispheric stroke but in the HIV-V group three patients had large, cortical hemispheric strokes and only one patient had small, subcortical ischemic strokes. In this series VZV-V seemed to present more often with deep-seated ischemic infarcts, while HIV-V appeared to be associated with large, hemispheric stroke. It seems plausible that this difference is related to the type of arteries infected by each virus. These findings are preliminary and should be confirmed with better studies.

The Spectrum of Idiopathic Pneumonia Syndrome

Noninfectious lung dysfunction is a major complication limiting the broader successful use of hematopoietic stem cell transplantation for the treatment of nonmalignant and malignant hematologic disorders, genetic disorders, and solid tumors. Until recently, clinical entities such as idiopathic pneumonia syndrome (IPS), diffuse alveolar hemorrhage, engraftment syndrome, delayed pulmonary toxicity syndrome, and bronchiolitis obliterans were considered distinct. However, evidence indicates that these entities may represent a spectrum of related lung diseases. The IPS spectrum shares similar inflammatory pathways triggered by exposure to chemoradiotherapy and alloreactive T lymphocytes. The clinical manifestations and disease course are mainly determined by the cellular type that is targeted by inflammation and injury: lung parenchyma, vascular endothelium, or airway epithelium. Other infectious and noninfectious insults and malignancies can also cause severe lung dysfunction after hematopoietic stem cell transplantation. Using a standardized aggressive diagnostic approach is essential for prompt recognition and optimal therapy. However, treatment of several diseases belonging to the IPS spectrum remains supportive, and prognosis remains poor. Identifying transplant conditions and risk factors that predispose recipients to lung dysfunction will lead to the development of techniques that are aimed at preventing IPS and IPS-related diseases. Furthermore, improved understanding of the pathogenesis of IPS will likely prove to be important in the development of novel therapies.

Standardized order sets for the treatment of severe sepsis and septic shock

Evaluation of: Thiel SW, Asghar MF, Micek ST, Reichley RM, Doherty JA, Kollef MH. Hospital-wide impact of standardized order set for the management of bacteremic severe sepsis. Crit. Care Med. 37(3), 819–824 (2009).Aggressive standardized diagnostic and therapeutic approaches to acute diseases such as acute myocardial infarction, trauma and stroke have led to improved patient survival. A standardized order set for severe sepsis and septic shock represents a similar approach. In 2001, Rivers et al., using a standardized operating procedure to treat severe sepsis and septic shock, showed a relative risk reduction of 0.34 and absolute risk reduction of 16%, with a decrease in healthcare resource consumption for patients presenting to the emergency department. Since then, similar studies have shown similar or better results. This study in particular highlights a hospital-wide initiative that further confirms that standardized order sets and operating procedures for severe sepsis and septic shock result in a significant reduction in morbidity, mortality and healthcare resource consumption. With these robust findings, future emphasis should be placed on overcoming logistical, institutional and professional barriers to the implementation of standardized order sets, which can save the life of one out of every five to six patients presenting with severe sepsis and septic shock.

Diagnosis of perinatal stroke II: mechanisms and clinical phenotypes

Here (and in an accompanying article dealing with definitions, differential diagnosis and registration), a structured sequential diagnostic flow is proposed to discern clinical phenotypes for perinatal stroke, including arterial ischaemic stroke (AIS), cerebral sinovenous thrombosis (CSVT) and haemorrhagic stroke. For neonatal AIS, the diagnostic sequence is infection, trauma, embolism, arteriopathy, other, primary thrombosis and unclassifiable; for neonatal CSVT, the sequence is infection, trauma, venopathy, other, primary thrombosis and unclassifiable. The proposed hierarchical diagnostic flows are an initial step towards a standard for registration of the causes of neonatal stroke. Such standardization should guide attempts at prevention and intervention. An extensive literature search and study of a retrospective cohort of 134 newborn infants with stroke suggest that embolism is the most common identifiable cause for stroke in general (25%), preceding trauma (10%) and infection (8%). Other causes, such as asphyxia, acute blood loss, extracorporeal membrane oxygenation, genetic disorders or prothrombotic conditions, are seen in <5% of cases. For neonatal AIS, the presence of an embolic phenotype is 33% in this cohort. The designation unclassifiable scored 34% for the entire stroke group and 25% for neonatal AIS. Complex arterial stroke with multiple arteries involved is often seen when the underlying cause is infection, cranial trauma or embolism. One important conclusion is that a means of prevention is avoidance of embolism from thrombosis outside the brain. To prevent the occurrence and recurrence of neonatal ischaemic stroke, clinicians must develop a standardized diagnostic approach that results in characterization of the clinical phenotype.

Akute Alkoholintoxikation

Despite an increasing rate of emergency admissions with acute alcohol intoxication, specific data concerning clinical risk estimation are scarce. We performed a retrospective analysis of all 857 patients admitted to the University Medical Center Mannheim with acute alcohol intoxication between 2003 and 2007. Most patients were men (76%), the mean age was 45.1 years, mean blood alcohol concentration was 2.5 %o.The majority of patients (74%) were discharged directly from the emergency department. The present data indicate a low clinical risk of alcohol intoxication and suggest that outpatient treatment is sufficient in the majority of cases. Nevertheless, a standardized diagnostic and therapeutic approach is essential in view of rare complications. Clinical monitoring should include repeated physical and especially neurological examination, toxicological blood tests, and radiological diagnostics. Discharge is possible provided that patients are awake, not disorientated and mobile. If necessary, patients should be encouraged to enter a withdrawal treatment program.

Pediatric Vaginal Trauma: Variability In Evaluation And Management Across Free-Standing Pediatric Hospitals In The United States

PURPOSE There is currently no accepted standard of care or algorithm to guide the management of pediatric vaginal trauma. Prior studies are limited to single institution case series. We evaluated a large national database to identify frequency, associated injuries, and diagnostic procedures used in the evaluation and management of children with vaginal lacerations. MATERIAL AND METHODS We queried the Pediatric Hospital Information System (PHIS) database, an administrative database of 45 free standing pediatric hospitals in the United States. Inclusion criteria were female gender, age less than 17 years, and ICD-9 diagnosis codes for vaginal laceration (non-obstetrical) over 5 years. Variables evaluated were mechanism of injury, associated injuries and surgical management. RESULTS 5,664 children with vaginal lacerations were identified. Patient characteristics: age 3-7 years (61%), Caucasian (63%), Medicaid (39%). There was no difference in management based on age, race or payer. Most common mechanisms of injury: person versus object (16%), home accidents (14%), and sexual assault (12%). 6% of patients had underlying urogynecologic anomalies. Associated injuries were rare, but when identified, included: injuries to head and face (2%), upper/lower extremity (4%), cardiothoracic (7%), abdominal (2%). When performed, diagnostic procedures included: vaginoscopy (2%), cystourethroscopy (0.5%), anoscopy or colonoscopy (0.8%). CONCLUSIONS This is the first large multi-institutional study of vaginal injuries in children. Compared to published case series, this study suggests across the nation in children's hospitals many associated injuries may be missed due to a lack of a standardized diagnostic approach to vaginal trauma.

Neonatal Seizures: Multicenter Variability in Current Treatment Practices

Standardized approaches to the treatment of neonatal seizures remain undeveloped. We assessed the type and number of anticonvulsants selected, blood levels attained, and postdischarge anticonvulsant treatment of neonatal seizures among five neonatal intensive care units in the United States between 2000-2003. Almost all of the 480 neonates (94%) with seizures were treated, initially with phenobarbital (82%), lorazepam (9%), phenytoin (2%), other anticonvulsants (1%), or a combination of the first two drugs (6%). While the majority of neonates were treated with one drug (59%), the number of anticonvulsants varied (P<0.0001), as did the peak serum phenobarbital levels (P<0.0001). The majority (75%) of survivors received anticonvulsant treatment after discharge. These neonates were more likely to have had abnormal electroencephalography or brain imaging, or to have needed a second anticonvulsant, compared with neonates whose drug therapy was discontinued. Anticonvulsant therapy is used in the majority of neonates with seizures, mostly with phenobarbital, and treatment is continued beyond discharge. The observed wide therapeutic variability may reflect a lack of standardized diagnostic and treatment approaches, particularly for seizures refractory to initial phenobarbital therapy. Trials of anticonvulsants with long-term neurodevelopmental follow-up are needed to develop evidence-based treatment guidelines.

Osteoporosis in juvenile idiopathic arthritis- a practical approach to diagnosis and therapy

In all subgroups of juvenile idiopathic arthritis, a decrease in bone mass has been described in a high percentage of children. Recently, new pathogenetic concepts have identified muscle mass as the strongest predictor of bone mass and bone is now recognized as part of the musculoskeletal system. In addition, the sophisticated use of bone densitometry in pediatrics, including new measurement techniques, has provided the tools for a reliable assessment. A standardized diagnostic approach to the musculoskeletal system, including prophylaxis and therapy, is, therefore, mandatory in all children with JIA who do not achieve rapid remission. In this review, diagnostic and therapeutic options are being described and possibilities to incorporate them into clinical practice are suggested.

P-861: On-line program for a novel individual classification of female functional androgenization (FA) using algorithmic group-specific parameter clusters

FA consists of various heterogenous entities. Therefore, a novel FA classification which defines underlying dysfunctions by a new sonographic functional ovary score (OS) (a) and a compact biochemical testing procedure has been developed (b). In order to strengthen the reproducibility, an on-line classification program, FuncAndroAid, was created using a strict algorithm. Software for a revised classification of FA patients analysed in a retrospectively controlled study. 126 patients (25.8 ± 5.3 yrs) with cutaneous androgenizing symptoms (CAS), hyperandrogenemia (HA), hyperinsulinemia (HI) and/or obesity (Ob) (b) were re-classified using an algorithm of group-specific parameter clusters. BMI, CAS, OS, LH/FSH, testosterone (T), free T/SHBG, prolactin (PRL) and lipoproteins (LPs), as well as, glucose (Gluc) and insulin (Ins) prior to (0), and 60 min after (1) an oral glucose loading were determined inter alia. FA was subdivided into 5 groups termed as: Functional Cutaneous Androgenization (FCA): cutis; Functional Androgenizing Syndrome (FAS) I to IV: ovary; adrenal gland; HA, HI and Ob; miscellaneous. Grouping was performed through a group-specific obligate 1stcategory parameter core cluster (1stCP-CC) (subgroup B) and a 1stCP-full blown cluster (1stCP-FBC) (subgroup A); e. g.: CAS and otherwise normally ranging 1stCPs conditioned subgroup A of FCA. Group′s further characterization was carried out by secondary 2ndCPs (e.g. PRL, LPs). The data of 8 volunteers (29.7 ± 4.7 yrs) served as a control (C). The web application is based on PHP language and a MySQL database. After anonymously submitting patients‘ data on the website, they were checked to see if they match a specific diagnostic group and then stored into the database for further use. Grouping is shown in Table 1. For example, FAS III revealed per defintionem significantly elevated T and OS values vs. C (P<.0001; Wilcoxon Two-Sample test) and the highest levels of BMI, FT/SHBG, Gluc 1 and Ins 0/1 vs. FCA, FAS I, FAS II and C (P<.0001-.03). Matched data showed full agreement indicating the software′s sufficient reliability. Table 1: Results of patients’ revised classificationTabled 1*Values are mean ± SD; data of FAS IV (n=18), subgroups A and B, and further 1st CPs are not shown.**Statistics of FAS III as an example: see under RESULTS. *Values are mean ± SD; data of FAS IV (n=18), subgroups A and B, and further 1st CPs are not shown. **Statistics of FAS III as an example: see under RESULTS. The revised FA classification using an exactly defined algorithm of parameter clusters served as data base for establishing the program (www.funcandroaid.com). This novel on-line program provides an indivudual, objective, standardized, reproducable and fast diagnostic approach for female FA. The software is developed modularly, including many possibilities for later extensions (e.g. therapeutic algorithm), and can be used for multi-purpose tasks. Furthermore, it could be useful for clinic and basic research. a.) Wetzka et al (2005) Hum Reprod 20, Suppl.1, i138. b.) Geisthövel et al (2005) Hum Reprod 20, Suppl.1, i174.

Osteoporosis in juvenile idiopathic arthritis

In a high percentage of patients with juvenile idiopathic arthritis (JIA) a pathologic loss of bone or the failure of bone mass to increase has been described, even with new therapeutic approaches. The decrease in bone mass correlates with the duration of active disease, and to some degree with the number of joints affected. In several studies, muscle mass has been found to be the strongest predictor of bone mass. A standardized diagnostic approach to the musculoskeletal system plus prophylactic measures and therapy are therefore mandatory in all children with JIA who do not achieve rapid remission. This review describes the options for diagnosis and treatment, and they are summarized in an algorithm.

Researchers Try to Quantify Etiology of Schizophrenia

Researchers Try to Quantify Etiology of Schizophrenia

Digestive health in the elderly: faecal incontinence in adults.

Digestive health in the elderly: faecal incontinence in adults.

The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study

Between 1 January 1993 and 1 January 1994, 204 consecutive patients with possible blunt abdominal injury were analysed retrospectively. All patients underwent a standardized diagnostic approach on admission to the emergency room. Abdominal ultrasound (AUS) was performed in all cases. If there was evidence of intra-abdominal injury on physical examination or AUS, without signs of persistent hypovolaemia after initial assessment, contrastenhanced computed tomographic scanning (CECT) of the abdomen was carried out without exception. Physical examination was equivocal in 13 and 3 per cent, respectively, of patients with ‘isolated’ abdominal trauma (N = 23) or with fractures of lower ribs 7–12 as a sole diagnosis (N = 30). In multiple injury patients (N = 95) or those with suspected ‘isolated’ head injury (N = 56), these figures reached 45 and 84 per cent, respectively. AUS (N = 204) revealed intra-abdominal injury in 20 per cent of patients, and CECT (N = 43) resulted in additional information in 49 per cent. Patients with ‘isolated’ head injury showed 9 per cent abnormalities on abdominal evaluation versus 32 per cent in multiple injury patients. In lower rib fractures (7–12) in multiple injury patients abdominal injury was diagnosed in 67 per cent of the cases. We conclude that: (1) negative findings following reliable physical examination of patients with ‘isolated’ head injury show very high values (NPV 100 per cent), but reliable physical examination is very infrequent (16 per cent); (2) NPV in lower rib fractures due to low energy impact is very high (100 per cent), with a reliable physical examination in most patients (97 per cent); (3) in patients with isolated abdominal trauma 87 per cent have a reliable physical examination with a moderately high NPV (71 per cent); (4) almost half the multiple injury patients have an unequivocal physical examination (45 per cent), with a high NPV following reliable physical examination for abdominal injury (85 per cent); (5) abdominal ultrasonography should be the first step in the radiological assessment of all patients with possible blunt abdominal injury; (6) in multiply injured patients with fractures of their lower ribs (7–12) due to high energy impact the incidence of abdominal injury is very high and CECT might be indicated even in the case of normal AUS findings.

Electrocardiographic Self‐Recording (Patient‐Activated Event Recording)

Background: Although symptoms suggestive of cardiac arrhythmias are a common event in clinical routine, a standardized diagnostic approach is not available.Methods: The diagnostic accuracy of electrocardiographic self‐recording was evaluated in 115 consecutive patients presenting with symptoms suggestive of cardiac arrhythmias.Results: In 44.3% of cases, self‐recording showed cardiac arrhythmias to be the cause of the patients' symptoms; in 35.7% cardiac arrhythmias were ruled out as the cause of the patients' symptoms. Only 6.2% of the recordings were not evaluable for technical reasons.Conclusion: ECG self‐recording is more effective in detecting arrhythmias than other methods for arrhythmia monitoring. Therefore, it should be used as a first line study in patients likely to have symptomatic arrhythmias.

Stability of the diagnosis of primary affective disorder: A four-year follow-up study

Most modern studies on depression use standardized diagnostic approaches, such as the St. Louis Criteria or the RDC. The main aim of these methods is to select reliable samples for research purposes. However, doubts have been raised as to whether the groups derived through these criteria are homogeneous. In order to investigate the stability of the diagnosis of Primary Affective Disorder (PAD), a group of 78 patients meeting the criteria for this disorder were followed up for 4 years. During this period 19.2% of patients showed important psychopathological symptoms other than affective. No particular factor, apart from bipolar illness, was found to be significantly predictive of a stable diagnosis. However, the rate of diagnoses would have been greater by taking into account family history and premorbid personality of the patients. The authors conclude that other sources of information, beyond present symptoms, ought to be taken into account in order to reach more homogeneous groupings.