Underdiagnosis Rate Research Articles

The simplified depth-predicting score outperforms the depth-predicting score for predicting the depth of invasion in differentiated early gastric cancer patients among nonexpert endoscopists

AimEndoscopists utilize depth-predicting score (DPS) and simplified depth-predicting score (S-DPS) to predict the invasion depth of early gastric cancer based on conventional white-light endoscopic features. The effectiveness of these scores has not been fully elucidated among nonexpert endoscopists. This study aimed to compare the ability of DPS and S-DPS to predict invasion depth of differentiated early gastric cancers by nonexpert endoscopists. Participants and methodsWe collected subitem scores of DPS and S-DPS from 19 nonexpert endoscopists for early gastric cancer conventional white-light endoscopy images in the test dataset to predict the invasion depth of the early gastric cancer conventional white-light endoscopy images. Accuracy, specificity, overdiagnosis rate, and underdiagnosis rate were subsequently calculated using the histological invasion depth as the gold standard. ResultsUsing 3 as the cutoff line, the overall S-DPS diagnostic accuracy for invasion depth was significantly greater than that of DPS [73.86% (69.32%, 75.00%) vs. 67.05% (62.50%, 71.59%), p=0.005]. The overall S-DPS overdiagnosis rate was significantly lower than that of DPS [7.58% (3.03%, 13.64%) vs. 28.79% (18.18%, 37.88%), p=0.000]. The overall S-DPS under-diagnosed rate was significantly higher than that of DPS [86.36% (68.18%, 90.91%) vs. 45.45% (31.82%, 59.09%), p=0.000]. The specificity of the S-DPS was significantly greater than that of DPS [92.42% (86.36%, 96.97%) vs. 71.21% (62.12%, 81.82%), p=0.000]. ConclusionThe diagnostic accuracy of the S-DPS was greater than that of the DPS among nonexpert endoscopists. Furthermore, S-DPS is simpler than other methods, making it more conducive to clinical application for nonexpert endoscopists.

Characteristics and Clinical Features of Patients with Lipedema in Saudi Arabia: A Cross-sectional Comprehensive Assessment.

Lower limb swelling presents a diagnostic challenge with diverse causes, including well-known issues like venous insufficiency and lymphedema, and less-understood conditions like lipedema. Lipedema, involving abnormal fat accumulation in the lower extremities, is frequently misdiagnosed, posing challenges for affected individuals. This research aimed to report and analyze the clinical features of patients presenting with the complaint of lipedema. A retrospective cross-sectional study was conducted in Saudi Arabia from April to November 2023, involving adult patients from a specialized clinic in lipedema and lymphedema management. Data were collected through clinical evaluation and a comprehensive data collection sheet. In a cohort of 115 female patients (mean age: 38.58), the most common age for disease onset was around 20-29 years. Physical examinations revealed symmetric enlargement (88%), collar sign (43%), orthostatic nonpitting edema (49%), and telangiectasia (64%). Varicose veins were present in 36%, Stemmer signs in 2%, and foot edema in 13%. Clinical diagnosis with lipedema occurred in 71%, with grade 2 (31%) as the most common severity and type 3 (47%) as the prevalent disease type. The current study, the first of its kind in the Middle East and specifically in Saudi Arabia, emphasizes the urgency of increased awareness and intervention due to a high underdiagnosis rate in lipedema. The observed complexity in symptoms and correlations between severity, lymphatic impairment, and body mass index underscore lipedema's multifaceted nature. Future research should explore regional and cultural influences and conduct larger studies to validate and recognize various lipedema features.

Reinvestigating the performance of artificial intelligence classification algorithms on COVID-19 X-Ray and CT images

There are concerns that artificial intelligence (AI) algorithms may create underdiagnosis bias by mislabeling patient individuals with certain attributes (e.g., female and young) as healthy. Addressing this bias is crucial given the urgent need for AI diagnostics facing rapidly spreading infectious diseases like COVID-19. We find the prevalent AI diagnostic models show an underdiagnosis rate among specific patient populations, and the underdiagnosis rate is higher in some intersectional specific patient populations (for example, females aged 20-40 years). Additionally, we find training AI models on heterogeneous datasets (positive and negative samples from different datasets) may lead to poor model generalization. The model's classification performance varies significantly across test sets, with the accuracy of the better performance being over 40% higher than that of the poor performance. In conclusion, we developed an AI bias analysis pipeline to help researchers recognize and address biases that impact medical equality and ethics.

A unique circular RNA expression pattern in the peripheral blood of myalgic encephalomyelitis/chronic fatigue syndrome patients

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a debilitating disease with obscure aetiology. The underdiagnosis rate of ME/CFS is high due to the lack of diagnostic criteria based on objective markers. In recent years, circRNAs have emerged as potential genetic biomarkers for neurological diseases, including Parkinson’s disease and Alzheimer’s disease, making them likely to have the same prospect of being biomarkers in ME/CFS. However, despite the extensive amount of research that has been performed on the transcriptomes of ME/CFS patients, all of them are solely focused on linear RNAs, and the profiling of circRNAs in ME/CFS has been completely omitted. In this study, we investigated the expression profiles of circRNAs, comparing ME/CFS patients and controls before and after two sessions of cardiopulmonary exercise longitudinally.In patients with ME/CFS, the number of detected circRNAs was higher compared to healthy controls, indicating potential differences in circRNA expression associated with the disease. Additionally, healthy controls showed an increase in the number of circRNAs following exercise testing, while no similar pattern was evident in ME/CFS patients, further highlighting physiological differences between the two groups. A lack of correlation was observed between differentially expressed circRNAs and their corresponding coding genes in terms of expression and function, suggesting the potential of circRNAs as independent biomarkers in ME/CFS. Specifically, 14 circRNAs were highly expressed in ME/CFS patients but absent in controls throughout the exercise study, indicating a unique molecular signature specific to ME/CFS patients and providing potential diagnostic biomarkers for the disease. Significant enrichment of protein and gene regulative pathways were detected in relation to five of these 14 circRNAs based on their predicted miRNA target genes. Overall, this is the first study to describe the circRNA expression profile in peripheral blood of ME/CFS patients, providing valuable insights into the molecular mechanisms underlying the disease.

Endoscopic surveillance with systematic random biopsy for the early diagnosis of hereditary diffuse gastric cancer: a prospective 16-year longitudinal cohort study

Hereditary diffuse gastric cancer, generally caused by germline pathogenic variants in CDH1, presents with early-onset signet ring cell carcinoma. Prophylactic total gastrectomy is the definitive treatment. Endoscopic surveillance can inform the timing of prophylactic total gastrectomy through detection of microscopic signet ring cell carcinoma foci. However, evidence is scarce about the optimal endoscopic sampling technique and characterisation of signet ring cell carcinoma foci in hereditary diffuse gastric cancer. We aimed to formally assess the diagnostic yield of different sampling strategies and to identify criteria for the characterisation of endoscopic lesions. For this prospective longitudinal cohort study, we included individuals aged 18 years or older at the Cambridge University Hospitals National Health Service (NHS) Foundation Trust who fulfilled testing criteria for hereditary diffuse gastric cancer between June 1, 2005, and July 31, 2021. The primary outcome was detection of intramucosal signet ring cell carcinoma foci. We assessed the detection rate and anatomical location of signet ring cell carcinoma in random biopsy samples taken according to a systematic protocol compared with biopsies targeted to endoscopic findings. Endoscopic lesions were examined with white-light and narrow band imaging with magnification to assess the likelihood of cancerous foci. 145 individuals were included, of whom 68 (47%) were male and 92 (63%) carried the CDH1 pathogenic variant. 58 (40%) patients were diagnosed with invasive signet ring cell carcinoma over a median follow-up time of 51 months (IQR 18-80). The first diagnosis of signet ring cell carcinoma was most commonly made from random biopsies (29 [50%] of 58 patients), rather than targeted biopsies (15 [26%] patients). The anatomical distribution of signet ring cell carcinoma foci detected by random biopsies more accurately reflected those identified in prophylactic total gastrectomy specimens than did targeted biopsies. Omitting random biopsies in our cohort would have led to an under-diagnosis rate of 42%. Using a novel panel of endoscopic criteria, gastric lesions containing signet ring cell carcinoma were predicted with a sensitivity of 67·3% and a specificity of 90·2%. Random biopsies enhance the early detection of signet ring cell carcinoma and are complementary to targeted biopsies in surveillance of hereditary diffuse gastric cancer. This sampling method should be the standard of care when performing all surveillance endoscopies for individuals with hereditary diffuse gastric cancer. UK Medical Research Council.

Reliability Analysis of a Functional Diagnostic Test for Primary Hyperaldosteronism Based on Data Analysis.

Primary aldosteronism (PA) is one of the most common causes of secondary hypertension, with a prevalence of 12–20% in the hypertensive population. To determine the characteristic function of a fuzzy concept based on the epidemiological data, clinical manifestations, and auxiliary examinations of PA, the essence is to select a suitable domain and determine the affiliation of each element in the domain. The aldosterone/renin ratio was proposed to increase the detection rate of PA, which has the shortcoming of a high underdiagnosis rate when relying only on clinical manifestations. However, there is no unified standard for the diagnostic cut point, and there are differences in testing methods and diagnostic cut point values for different populations, which require different laboratories to establish appropriate cut points according to different regional populations to improve the diagnostic accuracy. In this article, we analyzed the reliability of functional diagnostic tests for PA based on data analysis and compared the sensitivity and specificity of different plasma aldosterone cut points for the diagnosis of PA in the 40 mg kibbutz test. The results showed that when post-saline PAC and post-cato PAC were used to confirm the diagnosis of proaldosterone, respectively, there was a similar subject working area under the curve between SSST and CCT, 0.89 and 0.78, respectively, with no significant difference in the area under the curve between the two (p=0.546). Therefore, blood sodium and blood potassium have higher specificity and sensitivity than SUSPUP, but both are lower than ARR, and data analysis can be used as an auxiliary indicator for screening.

COVID-19 Underreporting in Brazil among Patients with Severe Acute Respiratory Syndrome during the Pandemic: An Ecological Study.

Underreporting of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is a global problem and might hamper Coronavirus Disease (COVID-19) epidemiological control. Taking this into consideration, we estimated possible SARS-CoV-2 infection underreporting in Brazil among patients with severe acute respiratory syndrome (SARS). An ecological study using a descriptive analysis of the SARS report was carried out based on data supplied by the Influenza Epidemiological Surveillance Information (SIVEP)-Flu (in Brazilian Portuguese, Sistema de Vigilância Epidemiológica da Gripe) in the period between January 2015 and March 2021. The number of SARS cases and related deaths after infection by SARS-CoV-2 or Influenzae was described. The estimation of underreporting was evaluated considering the relative increase in the number of cases with undefined etiological agent comparing 2020 to 2015–2019; and descriptive analysis was carried out including data from January–March/2021. In our data, SARS-CoV-2 infection and the presence of SARS with undefined etiological agent were associated with the higher number of cases and deaths from SARS in 2020/2021. SARS upsurge was six times over that expected in 2020, according to SARS seasonality in previous years (2015–2019). The lowest possible underdiagnosis rate was observed in the age group < 2 y.o. and individuals over 30 y.o., with ~50%; while in the age groups 10–19 and 20–29 y.o., the rates were 200–250% and 100%, respectively. For the remaining age groups (2–5 and 5–9 y.o.) underreporting was over 550%, except for female individuals in the age group 2–5 y.o., in which a ~500% rate was found. Our study described that the SARS-CoV-2 infection underreporting rate in Brazil in SARS patients is alarming and presents different indices, mainly associated with the patients’ age groups. Our results, mainly the underreporting index according to sex and age, should be evaluated with caution.

Underdiagnosis bias of artificial intelligence algorithms applied to chest radiographs in under-served patient populations

Artificial intelligence (AI) systems have increasingly achieved expert-level performance in medical imaging applications. However, there is growing concern that such AI systems may reflect and amplify human bias, and reduce the quality of their performance in historically under-served populations such as female patients, Black patients, or patients of low socioeconomic status. Such biases are especially troubling in the context of underdiagnosis, whereby the AI algorithm would inaccurately label an individual with a disease as healthy, potentially delaying access to care. Here, we examine algorithmic underdiagnosis in chest X-ray pathology classification across three large chest X-ray datasets, as well as one multi-source dataset. We find that classifiers produced using state-of-the-art computer vision techniques consistently and selectively underdiagnosed under-served patient populations and that the underdiagnosis rate was higher for intersectional under-served subpopulations, for example, Hispanic female patients. Deployment of AI systems using medical imaging for disease diagnosis with such biases risks exacerbation of existing care biases and can potentially lead to unequal access to medical treatment, thereby raising ethical concerns for the use of these models in the clinic.

Evaluation of diagnostic accuracy of the automatic system for the analysis of digital lung X-ray for detection of spherical masses

Rationale: Most data on the effectiveness of systems for the analysis of digital X-ray images have been provided by their developers and require a high-quality validation in databases prepared independently of the developer.Aim: To analyze the information content of automatic identification of spherical lung masses with digital X-ray imaging using one of the widely available diagnostic algorithms on publicly unaccessible reference datasets.Materials and methods: The study was based on the recognition and analysis of digital X-ray images from two publicly inaccessible reference datasets that have the state registration (Russian Federation) with one of the publicly available diagnostic algorithms (FutureMed Analyzer). The study was performed using two models of X-ray screening as examples: Model 1 consisted of 100 X-ray images of the lungs with a normal: abnormal ratio of 94%: 6%; Model 2 consisted of 5150 chest X-ray images with a normal: abnormal ratio of 97%: 3%.Results: According to the results of the analysis of the X-ray images with the diagnostic system, 98% of the images were correctly interpreted with Model 1 and 95% of the images, with Model 2. 83% of the cases from Model 1 and 69% from Model 2% were interpreted as images with lung abnormalities. The percentage of correct answers for differentiation of the chest X-ray images into two categories (normal vs. abnormal) for Model 1 and Model 2 was 95% and 98%, respectively. The sensitivity for detection of abnormal masses ranged from 69% to 83%. The specificity was 99% for the Model 1 chest X-ray images and 96% for the Model 2 chest X-ray images. The underdiagnosis rate was quite low ranging for Model 1 – 17%, and for Model 2 – 31%. The area under the curve for Model 1 was 0.91 and for Model 2 0.85.Conclusion: The diagnostic efficiency of the automatic image analysis based on the convolutional neuronal networks approaches that of the radiologists. This system of automatic identification of abnormalities was unable to solve the most complex problems of detecting low density spherical masses (like "ground glass" area on computed tomography) and that of shadow summation for abnormalities located in such difficult to interpret zones as lung apices, clavicles, ribs, etc. To select a suitable system, medical institutions need to conduct preliminary testing in their own models equivalent to the studies performed in a given institution (parameters for radiography, nature and frequency of abnormalities).

High-Resolution Estimates and the Burden of Undetected and Untreated Chagas Disease Cases in Spain

Introduction: Spain is the non-endemic country with the highest burden of Chagas disease outside the Americas, and it represents a model for non-endemic countries concerning health policies to control the disease. This study generates high-resolution estimates of the burden of undetected and untreated T.cruzi infection cases in Spain and compare them with the actual number of cases reported by official sources. Methods: A study using aggregate data collected from the literature and official sources (Spanish National Statistics Institute; Spanish Agency of Medicines and Medical Devices) was undertaken, from 2010 to 2018, to estimate the number of Chagas disease cases and the underdiagnosis and undertreatment rates. Results: We estimated a total of 55,367 migrants living with Chagas disease in Spain in 2018, out of them 613 (1%) were children under 15 years of age. Bolivian migrants represented 54% of the total estimated cases. Underdiagnosis and undertreatment rates were heterogeneous among the different Spanish autonomous regions, being the estimated global underdiagnosis rate of around 71%. The global rate of undertreatment in Spain was estimated to be 82·5% among patients older than 14 years. Conclusion: The burden of Chagas disease in Spain remains high, with both considerable underdiagnosis and undertreatment rates, particularly notorious in childbearing age women despite being a priority group; but much improved in children, suggesting the efficacy of antenatal screening programmes implemented in the country. Funding: None to declare Declaration of Interest: All authors declare not competing interest

Prevalence of people at risk of developing type 2 diabetes mellitus and the involvement of community pharmacies in a national screening campaign: a pioneer action in Brazil

BackgroundBrazil is one of top 10 countries with the highest number of people with diabetes mellitus (DM), affecting 16.8 million peoples. It is estimated that 7.7 million people (20–79 years) in the country have not yet been diagnosed, representing an under-diagnosis rate of 46.0%. Herein we aimed to screen people for high blood glucose or risk for developing type 2 DM (T2DM) through community pharmacies in Brazil.MethodsA cross-sectional study was carried out in November 2018, involving 977 pharmacists from 345 municipalities in Brazil. The study evaluated people between 20 and 79 years old without a previous diagnosis of DM. Glycemia was considered high when its value was ≥ 100 mg/dL fasting and ≥ 140 mg/dL in a casual feeding state. The FINDRISC (Finnish Diabetes Risk Score) was used to estimate the risk for developing T2DM. The prevalence of high blood glucose was estimated and the associated factors were obtained using Poisson's multivariate analysis with robust variance.ResultsDuring the national screening campaign, 17,580 people were tested with the majority of the consultations (78.2%) being carried out in private pharmacies. The population was composed mainly of women (59.5%) and people aged between 20 and 45 years (47.9%). The frequency of participants with high blood glucose was 18.4% (95% CI 17.9–19.0). Considering the FINDRISC, 22.7% of people had a high or very high risk for T2DM. The risk factors associated with high blood glucose were: Body Mass Index > 25 kg/m2, abdominal circumference > 94 cm for men and > 80 cm for women; education level below 15 years of study, no daily intake of vegetables and fruits; previous diagnosis of arterial hypertension; history of high blood glucose and family history of DM.ConclusionsThis is the largest screening study that evaluated the frequency of high blood glucose and its associated factors in a population without a previous diagnosis ever performed in community pharmacies in Brazil. These results may help to improve public health policies and reinforce the role of pharmacists in screening and education actions aimed at this undiagnosed population in a continent-size country such as Brazil.

Opinions, Attitudes, and Perceptions in Relation to Erectile Dysfunction and Premature Ejaculation in the Undiagnosed Spanish Male Population. Results of the PANDORA Project

BackgroundApproximately 43% of Spanish men report experiencing premature ejaculation (PE) at some point in their lives and 12.1% suffer from erectile dysfunction (ED), of whom only 16.5% have seen a doctor. Despite this, ED and PE remain undiagnosed among a supposedly healthy segment of the population. AimTo assess the general knowledge of a representative population of healthy Spanish males of the symptoms, treatment, and expectations related to ED and PE. MethodsThis was a descriptive study based on an online questionnaire in which 2,515 males aged 25–75 years with no history of ED and/or PE presented their perception of aspects related to symptoms, diagnosis, treatment, and expectations in ED and PE. Main Outcome MeasuresThe study provided an evaluation of the knowledge, attitude, and underdiagnosis of ED and/or PE in healthy males and the approach taken by urology specialists and other disciplines. ResultsThe survey was completed by 2,515 healthy males, including over 80% of those who had completed secondary or higher education. 60% of the sample had never seen a urologist and 59% and 62% of the participating men responded correctly to the statements about PE and ED, respectively. Their lack of knowledge of the therapeutic alternatives was clear (74% and 76% of the panel were unaware of the existence of effective treatments for ED and PE, respectively). Despite the initiative shown by some participants in seeking information about each condition (10.3% for ED; 16.7% for PE), only 4.7% of them had been questioned about ED by a medical practitioner (1.9% for PE). The underdiagnosis rate stood at 3.5% for ED (5.6% participants >65 years) and at about 10% for PE. Clinical ImplicationsThese results will represent a point of departure for establishing some recommendations to improve the detection and treatment of these disorders. Strengths & LimitationsThis is the first study of its kind in Spain to analyze the underdiagnosis of ED and/or PE inferred from data reported by a population of healthy males. Screening for ED was performed with a validated questionnaire. However, the rest of the research was conducted using adaptations of validated questionnaires or a self-designed questionnaire based on and in consultation with a group of experienced andrologists. ConclusionPeople need to have greater knowledge of both the conditions and the related false myths to make sure that they are familiar with the existence of drug treatments and socio-sanitary interventions. Primary care physicians and urologists should also be more proactive in routine visits in order to achieve better management of ED and PE.Prieto-Castro R, Puigvert-Martínez AM, Artigas-Feliu R, et al. Opinions, Attitudes, and Perceptions in Relation to Erectile Dysfunction and Premature Ejaculation in the Undiagnosed Spanish Male Population. Results of the PANDORA Project. J Sex Med 2020;17:1495–1508.

Effect of tumor size on the accuracy of frozen section in the evaluation of mucinous borderline ovarian tumors

ObjectiveThis study aims to evaluate the accuracy of frozen section (FS) in mucinous borderline ovarian tumors (BOTs) and to examine the factors associated with misdiagnosis. MethodsIn this retrospective study, cases diagnosed as mucinous BOTs by FS or final pathologic (FP) results were studied. The results of FS and FP were compared, and the factors associated with misdiagnosis were analyzed. ResultsSeventy-nine cases were examined. The median tumor diameter was 16 (6–50) cm, and 89.9 % of cases had tumors ≥10 cm. The overall agreement ratio between FS and FP was 79.7 %. Over-diagnosis and under-diagnosis rates were 3.8 % and 16.5 %, respectively. The sensitivity and positive predictive values were both 88.7 %. None of the underdiagnosed patients (13 cases) had recurrence during the 100-month median follow-up (9–222). Misdiagnosis was more common in tumors <10 cm (p = 0.025). The under-diagnosis rate for tumors <10 cm was 30.8 %. Tumor size <10 cm was significantly associated with misdiagnosis in univariate and multivariate analyses (Odds ratio {OR} 4.92, 95 % Confidence Interval {CI} (1.08–22.45) p = 0.040; OR 5.17, 95 % CI (1.07–25.05) p = 0.041, respectively). Laterality and preoperative CA 125 levels were not associated with misdiagnosis. ConclusionTumor size <10 cm is associated with misdiagnosis in mucinous BOTs. Laterality and CA 125 levels do not affect diagnostic accuracy. The evaluation of FS by gynecologic pathologists can help to increase the accuracy of FS.

Accuracy of colposcopic findings in detecting vaginal intraepithelial neoplasia: a retrospective study.

Malignancies of the vagina are rare, but colposcopy-directed biopsies play a major role in detecting vaginal intraepithelial lesions. Data of accuracy in detecting neoplasia of the vagina are very rare compared to accuracy in detecting cervical neoplasia. The aim of this study was to evaluate the accuracy of colposcopy-directed biopsy in comparison with clinical findings of the examiner. The accuracy of colposcopy-directed biopsy was compared with the clinical finding in relation to the patient's age and the examiner's level of training. This was done in combination with PAP-smear, HPV-test results, and the history of other malignancies of the lower genital tract. The data were collected between January 2014 and February 2018 at the certified Dysplasia Unit of the University Hospital Erlangen. In total, 253 biopsies from 253 women from the vagina were obtained. The overall accuracy of biopsy in comparison with clinical finding was 52.17% for all entities-benign lesions, low-grade squamous intraepithelial lesions (LSILs), high-grade squamous intraepithelial lesions (HSILs), and vaginal carcinoma. The accuracy for detecting HSIL was 82.46% (47/57), with an underdiagnosis rate of 15.79% and an overdiagnosis rate of 1.79%. With a sensitivity of over 80%, colposcopy-directed biopsy plays an important role in detecting vaginal-HSIL. A highly experienced practitioner is increasing the sensitivity in detecting vaginal-HSIL. Careful examination is required in women with a history of HSIL of the lower genital tract or with simultaneous neoplasia because they are of greater risk of developing vaginal malignancies. The combination of careful clinical work up, PAP-smear, HPV-testing, and colposcopy-guided biopsy is crucial in detecting vaginal-HSIL.

A Community-Based Intervention for the Detection of Chagas Disease in Barcelona, Spain

Chagas disease (CHD) has become a challenge in Spain due to the high prevalence of immigrants coming from endemic areas. One of the main difficulties for its control and elimination is its underdiagnosis. The identification and integral treatment of CHD are key to increasing rates of diagnosis, overcoming psycho-social barriers and avoiding CHD progression. Community interventions with in situ screening have proven to be a useful tool in detecting CHD among those with difficulties accessing health services. To determine the underdiagnosis rate of the population most susceptible to CHD among those attending two different Bolivian cultural events celebrated in Barcelona; to describe the sociodemographic characteristics of the people screened; and to analyse the results of the screening. The community interventions were carried out at two Bolivian cultural events held in Barcelona in 2017. Participants were recruited through community health agents. A questionnaire was given to determine the participants' prior knowledge of CHD. In situ screening was offered to those who had not previously been screened. Those who did not wish to be screened were asked for the reason behind their decision. Results were gathered in a database and statistical analyses were performed using STATA v14. 635 interviews were carried out. 95% of the subjects reported prior knowledge of CHD. 271 subjects were screened: 71.2% women and 28.8% men, of whom 87.8% were of Bolivian origin. The prevalence of CHD was 8.9%. Community health interventions with in situ screening are essential to facilitating access to diagnosis.

Accuracy of frozen section at early clinical stage of endometrioid endometrial cancer: a retrospective analysis in Germany.

The aim of this study was to estimate the accuracy of intra-operative frozen section (FS) diagnosis during hysterectomy for early-stage endometrial cancer (EC). At the Department of Obstetrics and Gynecology, University of Luebeck, between 2009 and 2014, the intra-operative FS pathology of 164 patients with pre-operative endometrial curettage, showing G1 or G2 endometrioid EC at an early clinical stage (FIGO I-II), was compared retrospectively with the final paraffin section reports. The accuracy of myometrial invasion (MI) in all patients and separately in stage FIGO I patients was calculated and the under- or overtreatment of the patients was analyzed. A subgroup analysis was performed focusing on the percentage of inadequate staging by FS with clinical consequences. Concordance of FS and final pathology results in terms of FIGO stage was 85.2%, with an under-diagnosis rate of 14% and an over-diagnosis rate of 0.8%. The subgroup analysis rate of patients who were inappropriately operated using FS was 6.6%, while 3.3% underwent a secondary operation. The overall accuracy of FS in predicting MI was 93.3% and in patients with stage FIGO I, 92.7%. Sensitivity, specificity, PPV and NPV were 98.25%, 89.06%, 88.89% and 98.28%, respectively, and in stage FIGO I, 98.25%, 84.62%, 90.32% and 97.06%, respectively. The authors consider that intra-operative FS is a reliable diagnostic method to identify the clinical stage of EC and especially MI, to determine the necessity of lymphadenectomy. Further development of diagnostic techniques is essential to maximize diagnostic accuracy.

Perioperative Evaluation of Obstructive Sleep Apnea in Bariatric Surgery Population

Objective To evaluate the prevalence and clinical characteristics of obstructive sleep apnea (OSA) in bariatric surgery population.Methods Consecutive patients undergoing preoperative evaluation for bariatric surgery and referred for sleep monitoring in Peking Union Medical College Hospital from January 2009 to December 2015 were retrospectively analyzed. Age,gender,symptoms of snoring,fatigue,apnea and somnolence,apnea hyponea index (AHI),arterial blood gas,pulmonary function,sleep respiratory monitoring,positive airway therapy of OSA,and postoperative complications were recorded. The clinical characteristics of OSA groups at different severity were compared using AHI≥5 events/hour and AHI≥15 events/hour as cut-off values. Correlation analysis was applied to identify the clinical factors associated with AHI.Results Of 42 patients with complete sleeping monitoring data before bariatric surgery,30(71.4%) were diagnosed as OSA,14 (33.3%) were moderate or severe and 11 (26.2%) were severe. Also,OSA was not detected before the bariatric surgery in 25 cases (83.3%). Compared with patients with AHI<5 events/hour,patients with AHI≥5 events/hour had significantly older age (t=2.869,P=0.007),higher proportion of observed apnea (P=0.035),higher AHI (z=-4.592,P=0.000),higher proportion of night pulse oxygen saturation(SpO2) below 90% (z=-2.746,P=0.006),lower mean SpO2 (t=-2.071,P=0.046) and lower lowest SpO2 (t=-3.914,P=0.000). Compared with AHI<15 events/hour group,the AHI≥15 events/hour group had significantly higher BMI (t=2.281,P=0.043),male ratio (P=0.005),incidence of hypertension (P=0.011),proportion of observed apnea (P=0.001),percentage of smoking history (P=0.017),partial pressure of carbon dioxide(PaCO2)(t=3.478,P=0.002),AHI (z=-4.592,P=0.000),and proportion of night SpO2 below 90% (z=-4.530,P=0.000); in addition,the forced expiratory volume in one second(FEV1)% predicted (t=-3.377,P=0.002),forced vital capacity(FVC)% predicted (t=-2.342,P=0.026),night time mean SpO2 (t=-3.392,P=0.007),lowest SpO2 (t=-5.535,P=0.000) were significantly decreased. Correlation analysis showed that,in populations with normal PaCO2 (n=36),AHI was positively correlated with age (r=0.450,P=0.006) and BMI (r=0.384,P=0.021) and negatively correlated with FEV1% predicted (r=-0.457,P=0.008) and FVC% predicted (r=-0.432,P=0.013). Partial correlation analysis showed that,after age and BMI were adjusted,AHI was not correlated with FEV1% predicted(r=-0.287,P=0.125)and FVC%predicted(r=-0.241,P=0.200).Conclusion The incidence and underdiagnosis rate of OSA are high in bariatric surgery population. OSA should be routinely screened in bariatric population to reduce the postoperative complication.

Accuracy of colposcopy-directed biopsy in detecting early cervical neoplasia: a retrospective study.

Colposcopy-directed biopsy is a cornerstone method for diagnosing cervical intraepithelial neoplasia. The aim of this study was to evaluate the accuracy of colposcopy-directed biopsy in comparison with definitive surgery. The accuracy of colposcopy-directed biopsy was compared with the final histology in relation to different types of transformation zone (TZ), the patient's age, and the examiner's level of training. The overall accuracy of biopsy in comparison with definitive surgery was 71.9% for all entities-benign lesions, low-grade squamous intraepithelial lesions, high-grade squamous intraepithelial lesions (HSILs), and cervical carcinoma-with an underdiagnosis rate of 11.8% and an overdiagnosis rate of 16.5%. The accuracy for detecting HSIL was 88% (401/455), with an underdiagnosis rate of 10.5% and overdiagnosis rate of 1.3%. The accuracy rates for detecting HSIL in women with TZ1, TZ2, or TZ3 were 92.2, 90.5, and 76.5%, respectively. The accuracy rates for detecting HSIL in the different age groups were 93.1% (age 0-34), 83.6% (age 34-55), and 80% (age 55 or older). A combination of the colposcopic findings, cytology, human papillomavirus testing, and colposcopy-directed biopsy is necessary for the correct diagnosis of HSIL. The accuracy rate depends on the TZ and the patient's age. The examiner's level of training does not have any substantial influence on the accuracy.

Misdiagnosis of Chikungunya Virus Infection: Comparison of Old and Younger Adults

To assess the frequency of diagnostic errors in older adults presenting to the emergency department (ED) with symptoms suggestive of Chikungunya virus infection (CVI) and to compare the rates of misdiagnosis of older and younger adults. Cross-sectional study performed in the University Hospitals of Martinique from retrospective cases. Emergency department. Individuals aged 65 and older who attended the ED and underwent reverse transcription polymerase chain reaction (RT-PCR) testing for CVI between January and December 2014 (n=333, mean age 80±8) were considered eligible and were compared with a randomly selected sample of younger adults (< 65) (n=143, mean age 45±13). Misdiagnosis rates. The rate of misdiagnosis of CVI in the ED was 30.6% in individuals aged 65 and older and 6.3% in those younger than 65 (p<.001). The overdiagnosis rate was 9.0% in individuals aged 65 and older and 3.5% in those younger than 65 (p=.04). The underdiagnosis rate was significantly higher (p<.001) in individuals aged 65 and older (21.6%) than in those younger than 65 (2.8%). Misdiagnosis of CVI during an epidemic is statistically more frequent in older than younger adults because clinical presentation is often atypical in older adults. Specific diagnostic tools for older adults and better awareness of ED physicians of different presentations in different age groups could help to reduce the rate of misdiagnosis of CVI in the ED.

Chronic Obstructive Pulmonary Disease in Lung Cancer Patients: Prevalence, Underdiagnosis, and Clinical Characterization

Background: Lung cancer (LC) and chronic obstructive pulmonary disease (COPD) are associated with increased morbidity and mortality. The differential clinical and functional features among LC patients with or without COPD have not been defined. Objectives: The aims of this study were to examine the prevalence and underdiagnosis rate of COPD in LC patients and to compare the clinical and functional features of LC patients with and without COPD. Methods: We designed a multicenter hospital-based study including all LC cases diagnosed from January 2014 to August 2016. We assessed epidemiological, clinical, radiological, functional, and histological variables in all cases. Results: We recruited 602 patients with LC, most of them men (77.9%), with a median age of 67 ± 15 years. The COPD prevalence among LC patients was 51.5%, with a underdiagnosis rate of 71.6%. The LC+COPD patients were older and the proportion of men was higher compared with the LC-only patients. The LC+COPD patients had more pack-years, more squamous LC, a lower monoxide transfer coefficient (KCO), and higher Charlson index scores than patients with LC only. The median survival of LC-only patients was 37% longer than that of LC+COPD patients (22 vs. 16 months), but this difference was not statistically significant. Conclusions: Among LC patients, COPD is prevalent and underdiagnosed. Patients with LC+COPD more often have squamous LC, have greater comorbidities, and have a lower KCO. More effort should be made for an early diagnosis of COPD to select patients at higher risk of developing LC.