Validity Of Clinical Diagnosis Research Articles

Patient characteristics, validity of clinical diagnoses and Outcomes Associated with Suicidality in Inpatients with Symptoms of Depression (OASIS-D): design, procedures and outcomes

BackgroundSuicidality, ranging from passive suicidal thoughts to suicide attempt, is common in major depressive disorder (MDD). However, relatively little is known about patient, illness and treatment characteristics in those with co-occurring MDD and suicidality, including the timing of and factors associated with the offset, continuation or reemergence of suicidality. Here, we present the background, rationale, design and hypotheses of the Patient Characteristics, Validity of Clinical Diagnoses and Outcomes Associated with Suicidality in Inpatients with Symptoms of Depression (OASIS-D) study, an investigator-initiated, observational study, funded by Janssen-Cilag GmbH.Methods/ResultsOASIS-D is an eight-site, six-month, cohort study of patients aged 18-75 hospitalized with MDD. Divided into three sub-studies and patient populations (PPs), OASIS-D will (i) systematically characterize approximately 4500 consecutively hospitalized patients with any form of unipolar depressive episode (PP1), (ii) evaluate the validity of the clinical diagnosis of moderate or severe unipolar depressive episode with the Mini-International Neuropsychiatric Interview (M.I.N.I.) and present suicidality (at least passive suicidal thoughts) present ≥ 48 h after admission with the Sheehan-Suicide Tracking Scale (S-STS), assessing also predictors of the diagnostic concordance/discordance of MDD in around 500 inpatients (PP2), and (iii) characterize and prospectively follow for 6 months 315 inpatients with a research-verified moderate or severe unipolar depressive episode and at least passive suicidal thoughts ≥ 48 h after admission, evaluating treatment and illness/response patterns at baseline, hospital discharge, 3 and 6 months. Exploratory objectives will describe the association between the number of days with suicidality and utilization of outpatient and inpatient care services, and structured assessments of factors influencing the risk of self-injurious behavior without suicidal intent, and of continuous, intermittent or remitted suicidality during the 6-month observation period.ConclusionDespite their frequency and clinical relevance, relatively little is known about patient and treatment characteristics of individuals with MDD and suicidality, including factors moderating and mediating the outcome of both MDD and suicidality. Results of the OASIS-D study are hoped to improve the understanding of the frequency, correlates and 6-month naturalistic treatment and outcome trajectories of different levels of suicidality in hospitalized adults with MDD and suicidality.Trial registrationNCT04404309 [ClinicalTrials.gov]

Characteristics of Adults Hospitalized for a Major Depressive Disorder: Results from the Multicenter OASIS-D Study

IntroductionMajor Depressive Disorder (MDD) is one of the most common mental illnesses worldwide and is strongly associated with suicidality. Commonly used treatments for MDD with suicidality include crisis intervention, oral antidepressants (although risk of suicidal behavior is high among non-responders and during the first 10-14 days of the treatment) benzodiazepines and lithium. Although several interventions addressing suicidality exist, only few studies have characterized in detail patients with MDD and suicidality, including treatment, clinical course and outcomes. Patient Characteristics, Validity of Clinical Diagnoses and Outcomes Associated with Suicidality in Inpatients with Symptoms of Depression (OASIS-D)-study is an investigator-initiated trial funded by Janssen-Cilag GmbH.ObjectivesFor population 1 out of 3 OASIS-D populations, to assess the sub-population of patients with suicidality and its correlates in hospitalized individuals with MDD.MethodsThe ongoing OASIS-D study consecutively examines hospitalized patients at 8 German psychiatric university hospitals treated as part of routine clinical care. A sub-group of patients with persistent suicidality after >48 hours post-hospitalization are assessed in detail and a sub-group of those are followed for 6 months to assess course and treatment of suicidality associated with MDD. The present analysis focuses on a preplanned interim analysis of the overall hospitalized population with MDD.ResultsOf 2,049 inpatients (age=42.5±15.9 years, females=53.2%), 68.0% had severe MDD without psychosis and 21.2% had moderately severe MDD, with 16.7% having treatment-resistant MDD. Most inpatients referred themselves (49.4%), followed by referrals by outpatient care providers (14.6%), inpatient care providers (9.0%), family/friends (8.5%), and ambulance (6.8%). Of these admissions, 43.1% represented a psychiatric emergency, with suicidality being the reason in 35.9%. Altogether, 72.4% had at least current passive suicidal ideation (SI, lifetime=87.2%), including passive SI (25.1%), active SI without plan (15.5%), active SI with plan (14.2%), and active SI with plan+intent (14.1%), while 11.5% had attempted suicide ≤2 weeks before admission (lifetime=28.7%). Drug-induced mental and behavioral disorders (19.6%) were the most frequent comorbid disorders, followed by personality disorders (8.2%). Upon admission, 64.5% were receiving psychiatric medications, including antidepressants (46.7%), second-generation antipsychotics (23.0%), anxiolytics (11.4%) antiepileptics (6.0%), and lithium (2.8%). Altogether, 9.8% reported nonadherence to medications within 6 months of admission.ConclusionsIn adults admitted for MDD, suicidality was common, representing a psychiatric emergency in 35.9% of patients. Usual-care treatments and outcomes of suicidality in hospitalized adults with MDD require further study.Disclosure of InterestNone Declared

Diagnostic stability among patients readmitted with serious mental illnesses in a referral psychiatric university hospital in Tabriz, Iran,in 2016

Introduction: Regarding mental disorders, one of the important factors in the validity of clinical diagnosis is its consistency in consecutive evaluations. This varies from 29% in personality disorders to 70% in schizophrenia. This survey was conducted to study clinical diagnosis stability among readmitted patients in referral psychiatric university hospital. Methods: In this study, 1000 records were evaluated retrospectively. Data were gathered by educated clinical psychologist with a prepared checklist. The checklist consisted of demographic data, clinical interview data, primary and final diagnosis, and process of care. The collected data were analyzed using SPSS software and presented as descriptive and proportion measures. Results: The mean age of patients in the first hospitalization was 31.23 years. Since the first admission, 26.6% of patients’ life time was spent in hospitals. The clinical diagnosis of cases at discharge was bipolar mood disorder I (BMD I) and schizophrenia in 49.5 and 40.4 percent of cases, respectively. Generally, concordance between admission and discharge diagnosis was 94.9 and 84.4 percent among the women and men, respectively. 66.0% of patients with BMD I and 71.4% of patients schizophrenia received the same diagnosis in at least 75% of their next hospital admissions. Furthermore, the prospective consistency was 80 and 60 percent in schizophrenia and BMD I, respectively. Conclusion: The findings of the present study showed that in psychiatric studies, clinical diagnosis can be challenging especially in short term evaluations.

Application of Bayes' Theorem in Valuating Depression Tests Performance.

The validity of clinical diagnoses is a fundamental topic in clinical psychology, because now there are some political administrations, as the IOM or the U.K. government, which are focusing on best evidence-based practice in clinical psychology. The most problematic issue in clinical psychology is to avoid wrong diagnoses which can have negative consequences on individual life and on the utility of clinical treatments. In the case of diagnoses based on self-report tests, the diagnostic decision about individual health is based on the comparison between its score and the cutoff, according to the frequentist approach to probability. However, the frequentist approach underestimates the possible risks of incorrect diagnoses based on cutoffs only. The Bayesian approach is a valid alternative to make diagnoses on the basis of the scores from psychological tests. The Bayes' theorem estimates the posterior probability of the presence of a pathology on the basis of the knowledge about the diffusion of this pathology (prior probability) and of the knowledge of sensitivity and specificity values of the test. With all this information, it is possible to estimate the diagnostic accuracy of some self-report tests used for assessing depression. We analyzed the diagnostic accuracy of the most used psychological tests of depression (Zung's Self-Rating Depression Scale, Hamilton Rating Scale for Depression, Center for Epidemiological Studies for Depression and the Beck Depression Inventory), together with a new scale (Teate Depression Inventory) developed with the IRT procedure, by analyzing the published works in which data about sensitivity and specificity of these scales are reported. Except the TDI, none of these scales can reach a satisfactory level of diagnostic accuracy, probably for the absence of an optimal procedure to select test items and subjects with clearly defined pathological symptoms which could allow the reduction of false positives in test scoring.

監察剖検所見からみた院外心肺停止死因臨床診断の課題(Difficulty making a clinical diagnosis of cardiopulmonary arrest based on postmortem medical examination findings)

【背景及び目的】院外心肺停止（Cardiopulmonary arrest以下CPA）症例は臨床経過が不明な場合が多く，たとえ目撃があっても不十分な病歴しか得られない。蘇生行為中の限られた検査所見により臨床的死因推定が行われているのが現状であり，死因不明症例が数多く存在する。当院の位置する神戸市は監察医制度の対象地域であり，CPA症例の解剖実施率は高い。臨床的死因推定と監察医の解剖所見の相違は散見され，救急医が行う死因推定の妥当性は明らかでない。今回我々は自験例から，臨床的死因推定と死因不明症例の検証を行った。【対象と方法】2010年4月から2011年3月までの12か月間を対象期間とし，同期間に当院へ搬送された連続223症例のCPAについて臨床的死因推定と兵庫県監察医務室での解剖所見を後方視的に比較検討した。【結果】223症例中151症例が監察医務室で検案され，うち100症例で行政解剖が行われた。解剖が実施された100症例中，臨床的に死因が推定できなかったものは36％，心原性が20％であった。この臨床的死因推定不能症例の解剖結果では，43％が心原性疾患と最多であり，外因性25％，大動脈疾患11％，消化器疾患7％，呼吸器疾患4％，肺塞栓症3％，脳血管障害2％，不明1％，その他4％であった。臨床的死因推定と解剖所見との不一致例は17％存在した。【考察】臨床的死因推定がなされた場合の解剖所見との一致率は83％であり，その妥当性は高かった。死因が臨床的に推定できない場合の解剖結果は非心原性が57％を占め，臨床経過が似る大動脈解離や肺塞栓の割合も少なくない。臨床的死因不明症例においては解剖を実施せずに正確な死因特定を行うことは困難である。【結語】臨床的死因推定の妥当性は高いが，臨床的死因不明症例では解剖によるさらなる死因究明が望ましい。 Background: The clinical history of a patient with cardiopulmonary arrest (CPA) who is transported to the emergency department is commonly unknown. Even if a witness is present, the patient’s available clinical history is usually limited. Clinicians presume the cause of death from results of limited tests performed during active resuscitation, which leaves many causes undetermined. Kobe city has a medical examiation system in which, autopsies are performed at a high rate. However, because of many differences between clinical and autopsy diagnoses, the validity of clinical diagnosis is currently unclear. In this study, we evaluated the clinical diagnosis of CPA against autopsy findings and investigated cases of unknown cause of death. Patients and Method: We reviewed the records of patients with CPA who were transported to our hospital between April 2010 and March 2011 and compared the differences between clinical and autopsy diagnoses in the Medical Examiner’s Office of Hyogo Prefecture. Results: Over the study period, 151 subjects underwent postmortem examination or autopsy; of them, postmortem examination alone was performed in 51, while postmortem examination plus autopsy was performed in 100. A total of 36% of the autopsy cases had an unknown cause of death. Causes of death confirmed by autopsy included cardiogenic disease in 43%, exogenous factors in 25%, aortic disease in 11%, digestive disorder in 7%, respiratory disease in 4%, pulmonary embolism in 3%, cerebrovascular disease in 2%, unknown in 1%, and other in 4%. Of those subjects with a clinical diagnosis, 17% had a different autopsy diagnosis. Discussion: The rate of agreement between clinical diagnosis and autopsy diagnosis was 83%, which demonstrates that clinical diagnoses are generally reliable. Moreover, considering the possibility of preceding endogenous disease in drowning or asphyxiation cases, led to even greater accuracy. When the clinical diagnosis was unknown, non–cardiac CPA was diagnosed at a rate of 57%. Because aortic dissection and pulmonary embolism are commonly clinically similar to cardiogenic CPA, it is difficult to identify an individual’s cause of death without an autopsy. Conclusion: Findings in this study show that clinical diagnosis has high validity. If an individual’s clinical diagnosis is unknown, an autopsy is recommended. 院外心肺停止（Cardiopulmonary arrest以下CPA）症例は基礎疾患や臨床経過が不明な場合が多く，たとえ目撃があるCPA症例であっても不十分な病歴しか得られない。不十分な病歴や蘇生行為中の限られた身体所見・検査所見により臨床的死因推定が行われているのが現状であり，臨床的に死因が推定困難な症例も多く存在する。 神戸市は総人口が約150万人の都市であり，その大部分が監察医制度の対象地域となっている。年間死亡数は約1万4千人であり，そのうち救急搬送されるCPA患者は約900～1,000人／年である。2010年の兵庫県監察医務室による検案数は1,685件であり，解剖数は1,130件であった 1。 当院は神戸市の中核病院として年間約250人のCPA症例を受け入れている。我々は当院に搬送され監察医制度により検案・行政解剖が行われた症例について監察医と救急医による合同カンファレンスを定期的に開催し，臨床所見と解剖所見のすり合わせを行ってきた。実際には臨床的に心原性と判断した症例が脳神経疾患や感染症であったなど，臨床的な死因推定と解剖所見の相違点が散見される。 一方，院外CPA症例の記録集約としてウツタイン様式 2が世界的にも使用されている。ウツタイン様式では死因は心原性と非心原性に大別され，原因不明の場合は除外診断として心原性に分類することになる。しかし，除外診断によって心原性に分類することへの妥当性は不明である。 本研究の目的は，原因不明のCPA患者の多くを解剖している当院の症例を用い，臨床的死因不明患者の死因究明と臨床的死因推定の妥当性を検討することである。 2010年4月から2011年3月の12か月間に当院へ搬送されたCPA患者連続223症例を対象とし，カルテレビューにより臨床的死因推定と解剖所見を比較検討した。 死因分類については，心原性疾患・脳血管障害・消化器疾患・呼吸器疾患・大動脈疾患・肺塞栓症・外因性・その他・不明に分類すると定義した。臨床的死因推定は，診療した救急医により病歴・蘇生中の検査（血液検査：血算・一般生化学 トロポニンT 胸部レントゲン 超音波検査）により総合的に判断されたものであり，死亡時画像診断Autopsy imaging（以下Ai）は原則として実施していない。 臨床的に死因が推定されるが特定には至っていない症例，もしくは臨床的に死因が不明な症例は監察医制度にのっとり監察医により検案が行われた。当院かかりつけ患者であり既知の疾患による死亡と判断した症例，もしくはかかりつけ医と連絡がとれて既知の疾患による死亡と判断できる症例，明らかに死因が特定できる症例は死亡診断書を作成している。 期間内対象患者223症例の内訳は，男性134例（平均年齢65.6〈2～96〉歳），女性89例（平均年齢69.0〈0～99〉歳）であった。223症例中，監察医制度にのっとり検案・解剖された症例は151症例（検案のみ51症例・解剖あり100症例：解剖実施率66％）であった（Fig. 1）。 Description of databases. Cases framed by a bold line represent the number of data in this study. CPA; cardiopulmonary arrest. 解剖が実施されず検案のみとなるのは，縊頸・多発外傷など明らかな外因死の症例，家族の同意が得られない症例などである。解剖未実施の症例は，監察医務室にて病歴・検査所見などの臨床情報や検案所見に基づいて死体検案書が作成された。検案のみの51症例中，明らかな外因死は28症例（55％），死体検案書に家族の不承諾が解剖未実施の理由と明記されているものが12症例（24％），明らかな外因死でないが解剖未実施理由の明記がないものが11症例（21％）であった。 検案のみの51症例の臨床的死因推定の結果内訳は，外因性31症例（61％），消化器疾患3症例（6％），大動脈疾患2症例（4％），心原性疾患2症例（4％），呼吸器疾患1症例（2％），その他1症例（2％），不明11症例（21％）。検案結果は外因性30症例（59％），心原性疾患8症例（17％），消化器疾患4症例（8％），大動脈疾患1症例（2％），その他2症例（4％），不詳5症例（10％）であった。 解剖が実施された100症例の臨床的死因推定は，不明が36症例（36％）と最多であり，外因性25症例（25％），心原性疾患20症例（20％），消化器疾患7症例（7％），大動脈疾患5症例（5％），脳血管障害2症例（2％），呼吸器疾患2症例（2％），肺塞栓症1症例（1％），その他2症例（2％）であった（Table 1）。 一方，実際の解剖所見では43症例（43％）が心原性疾患と最多であり，外因性が25症例（25％），大動脈疾患11症例（11％），消化器疾患7症例（7％），呼吸器疾患4症例（4％），肺塞栓症3症例（3％），脳血管障害2症例（2％），不明1症例（1％），その他4症例（4％）であった（Table 1）。 臨床的死因が推定できなかった36症例での解剖結果の内訳は，心原性疾患16症例（44％），大動脈疾患5症例（14％），外因性3症例（8％），呼吸器疾患2症例（5.5％），脳血管障害2症例（5.5％），消化器疾患2症例（5.5％），肺塞栓症2症例（5.5％），不明1症例（3％），その他3症例（8％）であった（Table 2）。 非心原性疾患か心原性疾患について，臨床的死因推定と解剖所見の不一致症例は11症例（17％）であった。 臨床的死因推定が非心原性疾患であった44症例のうち解剖所見で心原性疾患であったのは9症例（20％）あり，内訳は脳血管障害2症例（症例1～2），感染症2症例（症例3～4），消化器疾患（症例5～6），外因性（症例7～9）であった（Table 3）。 症例1では鼾をかいて入眠している状態からCPAに至っているため，症例2では歩行中の突然死であったがトロポニンTが陰性であったため，脳血管障害が疑われた。症例3では発見時に34度の低体温とレントゲンにて肺炎像を認めたため，症例4ではCPAに至る前に悪寒を訴えておりレントゲンにて肺炎像を認めたため，感染症が疑われた。症例5ではCPA直前に黒色水様便を認めていたため，症例6では下腹部痛を訴えてからCPAに至っておりレントゲンにて腸管拡張を認めたため，消化器疾患が疑われた。症例7～9では，いずれも浴槽内で顔が水面に浸かった状態で発見されたCPAであり，蘇生行為中の胸部レントゲン所見・エコー所見からは死因を示唆する所見は認めなかったため溺水・窒息と判断された。 臨床的死因推定が心原性疾患であった20症例のうち解剖所見で非心原性疾患であったのは10％（2症例）であり，内訳は大動脈疾患と消化器疾患がそれぞれ1症例であった（Table 1）。 症例10では車内にてCPAの状態で発見され，PEA時の心電図モニター波形でST上昇を認めるがFAST陰性とレントゲンでの縦隔拡大を認めないことから心原性が疑われたが大動脈解離であった。症例11では，蘇生中のレントゲンにて肺水腫を認めたことから心原性が疑われたが，肝硬変が死因であった。 監察医制度がある地域は東京23区内・横浜市・名古屋市・大阪市・神戸市の5都市のみであり，それ以外の地域での院外CPA症例に対する承諾解剖実施率は多くの地域で1％以下 3である。ほとんどの場合は臨床的要因から死因推定しているのが現状だが，この推定の妥当性は不明である。解剖が行われた院外CPA症例での臨床所見と解剖所見の相違についての報告は散見され，山下ら 4は解剖結果により58症例中25例（43％）で新たな所見が得られたと報告している。また，石田ら 5は解剖が行われた院外CPA症例で，20症例中7症例（45％）において解剖結果で直接死因が判明したと報告している。滝ら 6は解剖が行われた院外CPA症例において，24症例中17症例（71％）で死因が明確になった，もしくは訂正されたと報告した。しかしこれらの報告 4, 5, 6での解剖実施率は13％～20％程度と多くの院外CPA症例が存在するなかで解剖が実施された少数であり，解剖が実施された背景など選択バイアスが存在し全体を反映しているとはいえない。 本研究の意義は監察医制度による高い解剖実施率（66％）にある。さらに，確定診断に至る決定的な証拠がないかぎり，臨床的な死因推定が行われている症例も監察医制度にて検案・行政解剖が実施されることである。 その結果，決定的な確定診断に至る証拠がない院外CPA症例は全て検案・行政解剖が実施されており，一般的な院外CPA症例の実態を反映していると考えられる。 本研究での臨床的死因推定ができた64症例での解剖所見との一致率は，心原性か非心原性かで判断した場合は83％（診断一致症例：53症例/臨床的死因推定可能症例：64症例）であり比較的高かった。臨床的には非心原性を疑ったが解剖所見では心原性と判断した症例は9％存在するが，その3分の１は入浴中の溺水や窒息症例であった。臨床的に外因死が疑われる状況であっても，内因性疾患が先行した可能性は考慮すべきである。臨床的には心原性が疑われたが解剖所見では非心原性と判断された症例は2％のみであった。以上のことから，死因推定可能であった場合の臨床的死因推定の妥当性は比較的高く，入浴中の溺水や窒息症例において先行する内因性疾患に留意することで，さらなる精度の向上が期待できる。 ウツタイン様式では臨床的死因不明患者は除外診断として心原性に分類されるが，本研究結果では臨床的死因不明患者のうち非心原性が56％であった。特に，心原性と同様に病歴では急性発症や突然死となりうる大動脈疾患や肺塞栓症が多いことは注目に値する。中尾ら 7の報告でも，監察医制度で解剖が実施されたうち10％が大動脈疾患・2％が肺塞栓であったことからも，これらの疾患は一定の頻度で存在していると推察される。ウツタイン様式に従い除外診断で心原性疾患とすると，心原性疾患20％に不明症例36％が追加されるため，結果的に56％が心原性疾患に分類される。しかし，解剖結果では臨床的死因不明の56％（非心原性疾患20症例/臨床的死因不明36症例）が非心原性疾患であり，解剖結果全体では心原性疾患が43％となるためウツタイン様式での統計結果と大きな差を認めた。ウツタイン様式による心原性分類の23％が実際には非心原性であったことは死因統計としても無視できない数字である。このことからも臨床的に死因推定困難な場合は積極的に解剖を行うことが必要であろう。 本研究の限界として非解剖症例の存在による最終確定診断の妥当性の問題と，Aiを実施した場合の臨床診断率の向上が考慮されていない点が挙げられる。 解剖実施率は66％であったが，解剖実施されなかった理由は家族の同意が得られないほかは，多発外傷や縊頸など明らかな外因死が大多数を占めていた。このため非解剖症例で，臨床的にも死因が不明な患者は22％と少ない。検案のみの症例の検案結果は臨床情報に大きく影響され，診断根拠が臨床情報であることが大多数である。そのため，解剖を行って診断を得た場合には臨床診断との不一致を認めた可能性がある。しかし，非解剖症例での内因性症例の割合は38％と少なく，解剖が実施されたとしても本研究の結果への影響は少ないと考える。 また，当院ではAiは原則として実施しておらずこれを行った場合の影響は不明である。CTを用いたAiによって診断が可能な割合は3割にとどまるといわれており，特に大動脈解離や肺塞栓といった血管病変では単純CTでは評価困難である 8。造影剤を注入後に胸骨圧迫を行い造影CTを撮影することで血管病変を指摘する試みがなされているが，現時点では発展途上の技術である 8。 今後，Aiの普及・発展により臨床的死因推定の精度がより改善し，解剖を行わなくとも確定診断に至る症例も増加すると期待できるが，Aiと解剖の適応は今後の課題である。 臨床的死因推定が不明の場合は非心原性も多いため解剖を積極的に考慮すべきである。臨床的に死因推定された場合は精度も高く信頼にたりうる。 本論文の要旨は第16回日本臨床救急医学会総会（2012年6月熊本）にて発表した。 なお本論文における利益相反はない。

Dementia diagnostic criteria in Down syndrome.

Dementia is a common clinical presentation among older adults with Down syndrome. The presentation of dementia in Down syndrome differs compared with typical Alzheimer's disease. The performance of manualised dementia criteria in the International Classification of Diseases (ICD)-10 and Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR) is uncertain in this population.We aimed to determine the concurrent validity and reliability of clinicians' diagnoses of dementia against ICD-10 and DSM-IV-TR diagnoses. Validity of clinical diagnoses were also explored by establishing the stability of diagnoses over time. We used clinical data from memory assessments of 85 people with Down syndrome, of whom 64 (75.3%) had a diagnosis of dementia. The cases of dementia were presented to expert raters who rated the case as dementia or no dementia using ICD-10 and DSM-IV-TR criteria and their own clinical judgement. We found that clinician's judgement corresponded best with clinically diagnosed cases of dementia, identifying 84.4% cases of clinically diagnosed dementia at the time of diagnosis. ICD-10 criteria identified 70.3% cases, and DSM-IV-TR criteria identified 56.3% cases at the time of clinically diagnosed dementia. Over time, the proportion of cases meeting ICD-10 or DSM-IV-TR diagnoses increased, suggesting that experienced clinicians used their clinical knowledge of dementia presentation in Down syndrome to diagnose the disorder at an earlier stage than would have been possible had they relied on the classic description contained in the diagnostic systems. Clinical diagnosis of dementia in Down syndrome is valid and reliable and can be used as the standard against which new criteria such as the DSM-5 are measured.

Do the clinical diagnostic skills of dermatologists correlate with the histopathological gold standard?

While numerous studies have evaluated the diagnostic accuracy of dermatologists and non-dermatologists in the clinical diagnosis of dermatologic diseases, they lack comprehensive evaluation of the validity of clinical diagnosis in dermatology or an analysis of the accuracy of multiple wide-ranging diagnoses. An extensive literature review was performed for all articles assessing the validity of clinical dermatologic diagnoses compared to histopathological gold standards. This commentary will discuss [...]

Demise of medical autopsy

The term “autopsy” is derived from a Greek word “autopsia” meaning act of seeing with one’s own eyes. An autopsy involves dissection and examination of a dead body to determine the cause of death and learn about disease processes. In the early 20 th century, autopsy is considered to play a fundamental role in medical education guided by the Osterian philosophy. [1] The medical autopsy continue to have a multifactorial role in the delivery of modern medical education. It is the most reliable method to evaluate the validity of clinical diagnoses. [2] Over the years especially during the latter part of the 20 th century, a decline in the rate of autopsies performed occurred world-wide. [3-6] The demise of the educational role of medical autopsy has followed its decline in-hospital practice. [7] Decline in the autopsy rates has occurred world-wide over the past 40 years especially in New Zealand, the United Kingdom [8] and the United States. [9] Usefulness of medical autopsy may be divided into various categories. 1. Educational role: Hill and Anderson highlighted the core areas of knowledge learnt effectively by the medical students that includes clinicopathological correlation, pathophysiology, anatomy and observational skills. [10] Autopsy also increases the awareness of patients with multiple conditions and the level of uncertainty in medical science. Moreover, autopsy brings about the opportunity to discuss ethical and legal aspects of death and death certification. [11] Many undergraduate and postgraduate students find autopsy to be very useful although some find it distasteful. [11,12] 2. Clinical role: Various studies highlighted discrepancies between clinical diagnosis and autopsy findings. [13,14] The autopsy thus plays a vital clinical role in auditing medical care despite the advancement in diagnostic techniques. [7] 3. P athologist’s perspective: Many pathologists describe autopsy as the ultimate medical consultation [13] and the ultimate audit. [14]

Clinical and Laboratory Signs as Dengue Markers During an Outbreak in Rio de Janeiro

One of the main challenges for clinical research in dengue is the low validity of clinical diagnosis. To analyze clinical and laboratory data as predicitve factors of dengue diagnosis at Evandro Chagas Clinical Research Institute, Oswaldo Cruz Foundation, during the 2001-2002 dengue outbreak in Rio de Janeiro. Cross sectional study comparing clinical laboratory data collected from the National Information System for Compulsory Notification Diseases (SINAN) in two serologically confirmed groups: dengue D (N = 453) and non-dengue ND (N = 80). Fever, exanthema, itching, mean platelet count < 150,000, WBC count < 4,000 and absence of vomiting and of abdominal pain help to distinguish D from ND groups. When considered individually, these signs and symptoms enhance diagnostic sensitivity and, when used in combination, improve specificity. A combination of symptoms not necessarily considered indicative of dengue diagnosis could improve surveillance and medical decision-making in simple clinical settings.

Validity of clinical diagnosis in isolated laryngomalaciain infants with congenital stridor

Validity of clinical diagnosis in isolated laryngomalaciain infants with congenital stridor

An assessment of care provided by a public sector STD clinic in Cape Town.

A study was undertaken in a Cape Town public sector STD clinic to evaluate the content and quality of care provided since it has been recognized that appropriate improvements in the management of conventional sexually transmitted diseases (STDs), including provision of correct therapy, health education, condom promotion and partner notification, could result in a reduced incidence of HIV infection. Our objectives were to assess patients' needs for health education and to assess the quality of STD management in terms of health education, condom promotion, partner notification, the validity of the clinical diagnoses and the adequacy of the treatments prescribed. The study subjects were sampled systematically, according to their gender. Patients included in the study were given a standardized interview and their clinical records reviewed. Specimens were collected for laboratory investigations. For each STD detected, the treatment was defined as adequate if drugs currently known to be active against that infection were prescribed. One hundred and seventy men and 161 women were included in the study (median age: females 22 years, males 26 years). While almost all patients believed their STD may have been caused by unprotected sexual intercourse, many also believed it may have been caused by other factors, such as bewitchment with traditional medicine. Only 21% of male and 37% of female patients received any education about STD transmission during the clinic visit, and only 25% of male and 36% of female patients received education about condom use. As a result of the low sensitivity of the clinicians' diagnoses, 16% of men and 61% of women left the clinic with at least one infection inadequately treated. The majority of patients were not receiving education for the prevention of STDs including HIV. Many were not receiving adequate treatment for their infections. The introduction of a syndromic management protocol in this setting would substantially reduce the proportion of inadequately-treated patients. However, syndromic protocols, and the means by which they are implemented, need to take into account problems with the clinical detection of genital ulcerative disease and candidiasis in women.

Validity of clinical diagnosis in age-associated dementia

With neuropathological diagnosis as the point of reference, the validity of clinical diagnosis was studied in 50 patients who had met DSM-III-R criteria for dementia. Clinical diagnosis of ATD (dementia of Alzheimer type) was made in 14 cases, of VD (vascular dementia) in 14 cases, of others in 5 cases and of undefined in 16 cases. At necropsy, 16 cases fulfilled the histological criteria for ATD, while 15 cases were VD, 3 cases were mixed dementia and 14 cases were other CNS disorders. In 2 other cases, the neuropathological picture was considered to be nondiagnostic. The accuracy of clinical diagnosis of VD was higher than that of ATD. Clinical diagnostic sensitivity was 81.8% for ATD and 91.7% for VD; corresponding specificity was 78.3% and 86.4%. With our clinical criteria, slowly evolving VD with no clinical evidence of stroke would not be identified as VD. On the other hand, AD patients who happened to have a stroke would be diagnosed as VD. These results suggest that further investigations as to VD (its clinical course, findings of computed tomographic scan and magnetic resonance imaging) are needed for more appropriate clinical criteria.

Early Clinical Diagnosis of Stroke Subtype

We assessed the validity of clinical diagnosis of topography (CDT) and etiology (CDE) in 100 consecutive patients who were examined within 12 h of stroke onset by a stroke team (1 neurologist with int

Registration of Alzheimer patients in an autopsy program: Who does it and why?

Registration of Alzheimer patients with an autopsy program is essential for research, for post-mortem validation of clinical diagnosis, and for genetic counseling of relatives. Although the number of Alzheimer patients is increasing, those undergoing autopsy constitute a minority because their relatives may be unaware of the benefits of autopsy or may be uncomfortable with autopsy as a sensitive issue. To learn about what motivates the families of Alzheimer patients to register them in an autopsy program, we surveyed the demographic characteristics and attitudes toward brain autopsy of next of kin to 250 consecutive registrants of the St. Louis University Medical Center I Alzheimer', Association Brain Bank. Mean age of respondents at registration of the patient was 56.9 ± 12.06. One-third of the respondents were registrants' spouses -and three out of five respondents had a parent with Alzheimer's disease. All respondents but three were white, and two-thirds of them were women. Forty percent of the respondents were at first either opposed or undecided about autopsy. Main objections to autopsy were uncertainty about the benefits of autopsy, concerns about disfigurement of body, and concern about delay of the funeral. Support organizations, such as the Alzheimer's Association played a more important role in informing family members about the benefits of brain autopsy than patients' physicians or nursing home staff. The most common reason for wanting an autopsy was concern about a possible hereditary component of Alzheimer's disease. Twenty-eight percent of the respondents had another relative with dementia

Validity of clinical diagnosis in dementia: a prospective clinicopathological study.

With neuropathological diagnosis as the point of reference, the accuracy of clinical diagnosis was studied in a series of 58 demented patients. Alzheimer's disease and multi-infarct dementia were recognised with sensitivities and specificities exceeding 70%, whereas combined dementia as a separate group was relatively unreliably diagnosed. The value of Hachinski's Ischaemic Score in differentiating between Alzheimer's disease and vascular dementias was demonstrated. Its performance was to some extent improved by assigning new weights to the items. In a logistic regression model, fluctuating course, nocturnal confusion, and focal neurological symptoms emerged as features with the best discriminating value, and helped to diagnose correctly 89% of the Alzheimer and 71% of the vascular dementia patients.