Variance In Diagnosis Research Articles

A - 05 Insight and Anxiety Ratings as Predictors of Mild Cognitive Impairment and Dementia.

Insight has been investigated as a predictor of mood symptoms and psychosis onset. Little research has examined insight as a predictor of diagnosis, especially given possible confounding factors such as anxiety. This cross-sectional study included 223 adult patients diagnosed with Mild Cognitive Impairment (MCI) or Dementia as a result of outpatient neuropsychological evaluation. Patients completed either the Depression Anxiety Stress Scale (DASS-42) or the Beck Anxiety Inventory (BAI) and the Behavioral Dyscontrol Scale (BDS-II). Participants were divided into four groups (MCI, Dementia, MCI + Anxiety, or Dementia+Anxiety) utilizing DASS-42 anxiety scale ≥7, or BAI score ≥ 7 (clinical anxiety). Insight grouping (four categories: 0 [no insight] to 3 [intact insight]) was determined by the BDS-II clinician-based insight rating. Diagnosis and insight groups were compared using one-way ANOVAs. Predictive value of BDS-II insight scores was determined by logistic regression. The sample was 52.9% male and 87.9% non-Hispanic White, with mean age 75.54 (SD = 8.24) and education 16.1years (SD = 2.9). There was a significant difference between diagnoses and insight levels for the four conditions [F(3, 219) = 6.06, p < 0.001]. The logistic regression model was significant [χ2(9, N = 223) = 25.79, p < 0.01]. The model explained 11.9% of the variance in diagnosis and correctly identified 47.1% of the cases. Insight appears to affect the diagnostic outcomes in cases of MCI and dementia. Clinicians should consider insight ratings, along with clinical history, behavioral observations, and test findings when evaluating possible MCI and dementia. Future research should examine neurocognitive disorder subtypes to identify those most affected by reduced insight.

Distinguishing Glaucoma, Cataract, and Glaucoma Suspect Based on Visual Symptoms.

Cataract, glaucoma, and glaucoma suspect patients report differing visual symptoms. Asking patients about their visual symptoms may provide useful diagnostic information and inform decision-making in patients with comorbid conditions. To compare visual symptoms in glaucoma, glaucoma suspect (controls), and cataract patients. Glaucoma, cataract, and glaucoma suspect patients at Wilmer Eye Institute responded to a questionnaire rating the frequency and severity of 28 symptoms. Univariate and multivariable logistic regression determined the symptoms that best differentiate each disease pair. In all, 257 patients (mean age: 67.4 ± 13.4y; 57.2% female; 41.2% employed), including 79 glaucoma, 84 cataract, and 94 glaucoma suspect patients, participated. Compared with glaucoma suspects, glaucoma patients were more likely to report poor peripheral vision (OR 11.29, 95% CI: 3.73-34.16), better vision in 1 eye (OR 5.48, 95% CI: 1.33-22.64), and light sensitivity (OR 4.85, 95% CI: 1.78-13.24), explaining 40% of the variance in diagnosis (ie, glaucoma vs. glaucoma suspect). Compared with controls, cataract patients were more likely to report light sensitivity (OR 3.33, 95% CI: 1.56-7.10) and worsening vision (OR 12.20, 95% CI: 5.33-27.89), explaining 26% of the variance in diagnosis (ie, cataract vs. glaucoma suspect). Compared with cataract patients, glaucoma patients were more likely to report poor peripheral vision (OR 7.24, 95% CI: 2.53-20.72) and missing patches (OR 4.91, 95% CI: 1.52-15.84), but less likely to report worsening vision (OR 0.08, 95% CI 0.03-0.22), explaining 33% of the variance in diagnosis (ie, glaucoma vs. cataract). Visual symptoms distinguish disease state to a moderate degree in glaucoma, cataract, and glaucoma suspect patients. Asking about visual symptoms may serve as a useful diagnostic adjunct and inform decision-making, for example, in glaucoma patients considering cataract surgery.

Psychiatric and legal considerations in cases of Fetal Abduction by Maternal Evisceration.

Fifteen cases of Fetal Abduction by Maternal Evisceration (FAMAE) reported to the National Center for Missing and Exploited Children during 1987-2011 outline the findings from a review of the forensic psychiatric considerations and legal course of each of the cases. Most offenders confessed to law enforcement within a short time of being placed under arrest in statements reflecting a continued effort to manage impressions and minimize culpability. Psychiatric assessment is invariably central to the legal disposition of FAMAE cases, as the defendant's goal is to diminish the perception of culpability/criminal responsibility and mitigate sentencing. Of those sentenced in the United States, nine defendants received life without parole, two received the death penalty (one executed), and one received a minimum of 30years. Two abductors committed suicide and were not sentenced. Proffered diagnoses at trial included psychogenic amnesia, pseudocyesis, dissociative disorder, and delusional disorder; however, these rarely stood up to court scrutiny. Psychiatric experts showed the greatest variance in diagnosis over what to call the feigned pregnancy. In addition to delusional disorder and dissociative disorder, pseudocyesis, factitious disorder/pregnancy, pseudopregnancy, schizophrenia, and PTSD were among the various diagnoses proposed. A differential diagnosis for many FAMAE offenders may also include borderline personality disorder. Future research accounting for those women claiming false pregnancy who do not become homicidal will clarify whether FAMAE is the extreme endpoint of a fertility identity disorder.

1066 Effectiveness of a Nurse-Led Fibroscan Service Towards Enhanced Care in Liver Disease

INTRODUCTION: Fibroscan as a convenient, non invasive tool for classification of Liver Stiffness (KPA) and fat component (CAP) has gained popularity in the hospital as well as community health services .With burden of liver disease significantly affecting the NHS in terms of finances as well as mortality, an accurate measure of the liver parenchyma assists in delivery of safe enhanced care.We present our nurse led fibroscan service in comparison to conventional modalities in the management of liver disease. METHODS: 273 patients were referred to the Nurse led Fibroscan service from July 2017-18.The Fibroscan readings were then compared to the USS, biochemistry and liver biopsy results. British Society of Gastroenterology(BSG) guidelines were then used to manage these subjects. RESULTS: Out of 273 patients referred 30 were excluded due to difficult procedures. Out of 243 screened, 52.68% were female.An average age of 53.9 years was seen (Median 55,IQR 19).The Fibroscan results were classified based on KPA and CAP for different etiology.Mean ALT of 49.22 was seen. Fibroscan results showed , Normal 9.87% ,Fatty Liver = 50.2%,Fibrosis = 22.2%and Cirrhosis 17.69% and compared to USS. Of the 48 subjects with Normal USS, 22 showed fatty liver, 9 had fibrosis and 2 had cirrhosis on fibroscan showing a 68.75% variance in diagnosis indicating a worsening stage of liver disease. Of the 123 that had fatty liver on USS,81 had the same diagnosis on fibroscan too.There was variance in 34.14% with 3 showing a better diagnosis having Normal fibroscan and 23 and 16 subjects showing fibrosis and cirrhosis respectively, indicating a worsening diagnosis. As Per BSG guidelines, fatty liver disease and ALT of below 50 can be discharged back to the care fo GP. 51.2% of these patients were similarly discharged to the GP. 70 subjects had Cirrhosis on USS 45 had a better diagnosis indicating the variance to be 50%. The total variance in diagnosis was noted in 122 (50.2%) from USS to fibroscan, with 41% (n = 50)having a better stage and 72 (59%) showing worse stage of disease. 44 of these subjects underwent liver biopsies which correlated to the above findings in similar percentage. CONCLUSION: Nurse led fibroscan service shows effective monetary benefit in good enhanced care of liver disease. It gives a more accurate diagnosis as compared to USS and also helps in avoiding the invasive liver biopsy in majority of the cases. Utilised in a correct manner it can help in appropriate care of the liver disease patients.

Clinical and Imaging Correlates of Pediatric Mucosal Appendicitis

BackgroundMucosal appendicitis is a controversial entity that is histologically distinct from transmural appendicitis. There is mixed opinion regarding mucosal inflammation as a spectrum of appendicitis versus a negative appendectomy. The ability to distinguish these diagnoses preoperatively is of importance to prevent unnecessary surgery. We hypothesize that patients with mucosal appendicitis can be discriminated from those with transmural disease based on specific preoperative clinical and imaging findings. Materials and methodsAfter IRB approval, all patients who underwent laparoscopic appendectomy at our institution during 2015 were reviewed in the electronic medical record. Patients with mucosal appendicitis were identified and matched 2:1 to a random cohort of nonperforated transmural appendicitis cases. Demographic and clinical data were collected, including history, examination, laboratory, and imaging findings. Preoperative factors associated with mucosal appendicitis were modeled using binomial logistic regression analysis. ResultsOf 1153 appendectomies performed during 2015, 103 patients had pathologic diagnosis of mucosal appendicitis. When compared with patients with mucosal infection, leukocytosis >10,000 per microliter led to 5.9 times higher likelihood of transmural pathology (P = 0.000). Noncompressibility on ultrasound was associated with 7.3 times higher likelihood of transmural disease (P = 0.015). Echogenic changes were predictive of transmural appendicitis, conferring 3.9 times the risk (P = 0.007). Presence of free fluid led to 2.3 times the rate of transmural pathology (P = 0.007). Finally, for every millimeter decrease in appendiceal diameter, patients were half as likely to exhibit transmural disease (P = 0.000). Together, these variables can successfully predict presence of mucosal appendicitis on final pathology report at a rate of 82.1%, and explain 60% of the variance in diagnosis of mucosal versus transmural appendicitis (P = 0.000). ConclusionsMucosal appendicitis remains a controversial pathologic entity, but is not associated with greater complications compared with transmural appendicitis when treated with laparoscopic appendectomy. Transmural disease can be predicted by leukocytosis, noncompressible appendix, presence of free fluid, larger appendiceal diameter and echogenicity.

Mental disorder and disability: A cross-sectional study of disability variance in severe mental disorders

Background: Severe mental disorders are associated with long-standing functional impairment and disability. The degree of disability varies with diagnosis. However, limited evidence are available on the association of psychiatric diagnosis and disability, especially from community settings in India. Methods: We examined the association of psychiatric diagnosis and disability in 711 persons suffering from severe mental illness. The patients were recruited from 12 community psychiatry outreach clinics at Wayanad District, South India. The Indian Disability Evaluation and Assessment Scale was administered to measure disability. ANOVA was applied to examine the extent of disability variance in diagnosis. Results: Disability varied significantly with diagnosis (F = 3.866; P = 0.000). Persons with schizophrenia experienced higher disability than bipolar affective disorder and depressive disorder. However, the disability was found nonsignificant in other diagnosis groups. Conclusion: The result implies the need for illness-specific programs and rehabilitative measures for persons with disability.

Effect of changing from the National Health and Nutritional Examination Survey III spirometry reference range to that of the Global Lung Initiative 2012 at Gold Coast Hospital and Health Service.

The categorisation of lung disease into obstructive ventilatory defect (OVD) and tendency to a restrictive ventilatory defect (TRVD) patterns using spirometry is used to guide both prognostication and treatment. The effectiveness of categorisation depends upon having reference ranges that accurately represent the population they describe. The Global Lung Initiative 2012 (GLI 2012) has spirometry reference ranges drawn from the largest sample size to date. This study aimed to determine whether using spirometry reference ranges from the new GLI 2012 dataset, compared to the previously used National Health and Nutritional Examination Survey III (NHANES III) dataset, resulted in a change in diagnosis between OVD, TRVD and normal ventilatory pattern (NVP). Spirometry data were collected from 301 patients, aged 18-80 years, undergoing investigation at the Gold Coast Hospital and Health Service (GCHHS) throughout February and March 2014. OVD was defined as a forced expiratory volume in 1 second (FEV1) divided by forced vital capacity (FVC) less than lower limit of normal (LLN). TRVD was defined as FEV1/FVC ≥ LLN, FEV1 < LLN, and FVC < LLN. The LLN values were determined by equations from the GLI and NHANES datasets. Spirometry interpreted using the NHANES III equations showed: 102 individuals (33.9%) with normal spirometry, 136 (45.2%) with an OVD pattern, 52 (17.3%) with a TRVD pattern, and 11 (3.7%) with a mixed pattern. When the spirometry data were interpreted using the GLI 2012 equations 2 (0.7%) individuals changed from OVD to NVP, 2 (0.7%) changed from NVP to OVD and 14 (4.7%) changed from TRVD to NVP. Using the GLI 2012 reference range resulted in a change in diagnosis of lung disease in 5.9% of the individuals included in this study. This variance in diagnosis when changing reference ranges should be taken into account by clinicians as it may affect patient management.

Identifying Specific Clinical Symptoms of Behavioral Variant Frontotemporal Dementia Versus Differential Psychiatric Disorders in Patients Presenting With a Late-Onset Frontal Lobe Syndrome.

Early differentiation between psychiatric disorders and behavioral variant frontotemporal dementia (bvFTD) is of paramount importance in patients with the late-onset frontal lobe syndrome. As bvFTD in patients will deteriorate, psychiatric disorders are treatable. To date, misdiagnosis often occurs due to an overlap of symptoms and lack of specific biomarkers. The aim of our study was to investigate whether specific symptoms could separate bvFTD from psychiatric disorders. In a naturalistic, prospective, multicenter study, 137 patients (aged 45-75 years, 72% male) with a late-onset frontal lobe syndrome were included based on their scores on the Frontal Behavioral Inventory (FBI) and the Stereotypy Rating Inventory (SRI) from April 2011 to June 2013. In a multidisciplinary consensus meeting, diagnoses were established based on elaborate neuropsychological testing, magnetic resonance imaging, fludeoxyglucose F 18 positron emission tomography, cerebrospinal fluid biomarkers, and clinical examination by a neurologist and a psychiatrist based on the International bvFTD Criteria Consortium for bvFTD and DSM-IV-TR criteria for psychiatric disorders. Forty-four subjects (32.8%) were diagnosed with a psychiatric disorder, 10 (7.3%) with possible bvFTD, and 45 (32.8%) with probable bvFTD. A logistic regression analysis was performed with "psychiatry or bvFTD" as dependent variable and clinical variables (Montgomery-Asberg Depression Rating Scale [MADRS], SRI, FBI) and demographics as independent variables. A positive history of psychiatric illness, male gender, lower SRI scores and higher MADRS scores were predictive of psychiatric disorders, explaining 65.2% of the variance in diagnosis of psychiatry versus bvFTD (χ²₅ = 60.04, P < .001). On the FBI, symptom level verbal apraxia/aphasia and impulsivity were predictive of bvFTD, whereas irritability was predictive of psychiatric disorders. In daily clinical practice, specific subtyping of clinical symptoms in patients with late-onset frontal lobe syndrome may aid in differentiating bvFTD patients from psychiatric patients and may provide guidance in patient management.

The structure of depression, anxiety and somatic symptoms in primary care

Observed co-morbidity among the mood and anxiety disorders has led to the development of increasingly sophisticated dimensional models to represent the common and unique features of these disorders. Patients often present to primary care settings with a complex mixture of anxiety, depression and somatic symptoms. However, relatively little is known about how somatic symptoms fit into existing dimensional models. We examined the structure of 91 anxiety, depression and somatic symptoms in a sample of 5433 primary care patients drawn from 14 countries. One-, two- and three-factor lower-order models were considered; higher-order and hierarchical variants were studied for the best-fitting lower-order model. A hierarchical, bifactor model with all symptoms loading simultaneously on a general factor, along with one of three specific anxiety, depression and somatic factors, was the best-fitting model. The general factor accounted for the bulk of symptom variance and was associated with psychosocial dysfunction. Specific depression and somatic symptom factors accounted for meaningful incremental variance in diagnosis and dysfunction, whereas anxiety variance was associated primarily with the general factor. The results (a) are consistent with previous studies showing the presence and importance of a broad internalizing or distress factor linking diverse emotional disorders, and (b) extend the bounds of internalizing to include somatic complaints with non-physical etiologies.

Neuropsychological Predictors of Transition From Healthy Cognitive Aging to Mild Cognitive Impairment: The PATH Through Life Study

To identify neuropsychological predictors of transition from healthy cognitive aging to mild cognitive impairment (MCI) or any mild cognitive disorder (any-MCD) in a community-based longitudinal study of aging. Longitudinal Two thousand eighty-two individuals, aged 60–64 years and participating in a prospective epidemiologic study of mental health, and aging were assessed at two time points 4 years apart for MCI using the International Consensus Criteria, the clinical dementia rating scale (CDR, 0.5), or any of a suite of criteria sets for MCDs (any-MCD). Logistic regression was used to assess the neuropsychological predictors of conversion to diagnosis including the Mini-Mental State Examination, immediate and delayed recall (IR and DR), Digit Backward, Spot-the-Word (STW), Symbol Digits Modalities Test (SDMT), simple and choice reaction time, and reaction time variability. Of the 2,082 participants with no cognitive impairment in the first wave of data collection, 18 participants were diagnosed with MCI, 32 with CDR 0.5, and 64 participants presented with any-MCD 4 years later. The main neuropsychological predictors of conversion identified in multivariate analyses were measures of IR/DR, STW, Symbol Digit Modalities Task, and reaction time variability. Although most measures were significant predictors of conversion to MCI or any-MCD when assessed independently, four tests (IR/DR, STW, SDMT, and simple reaction time variability) accounted for the explained variance in diagnosis when all tests were assessed together. When predictive value, stability across clinical categories, and psychometric characteristics were considered together, the reaction time variability measure was the best predictor of future cognitive disorder.

The Minnesota Multiphasic Personality Inventory-2-Restructured Form in the epilepsy monitoring unit

The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) is a restructuring of the MMPI-2 that has improved the psychometric characteristics of the test. The primary aim of this study was to provide diagnostic utility data on the MMPI-2-RF in an epilepsy monitoring unit population ( N = 429). Mean comparisons revealed group differences on Validity Scales Fs and FBS-r; Restructured Clinical Scales RC1 and RC3; and Somatic Scales MLS, GIC, HPC, and NUC. Diagnostic utility data are provided for those scales with the largest effect sizes: RC1, FBS-r, and NUC. On RC1, sensitivity was 76% and specificity was 60%, similar to values found when applying published decision rules to the MMPI-2. RC1 explains unique variance in diagnosis beyond that explained by demographic or medical history risk factors. We provide likelihood ratios for scores on RC1, FBS-r, and NUC that can be used by the clinician to calculate posttest odds and probability of nonepileptic seizures using the base rate of nonepileptic seizures in his/her population.

Over‐diagnosis of high‐grade prostatic intraepithelial neoplasia: a prospective study of 251 cases

To assess the magnitude and causes of over-diagnosis of prostatic intraepithelial neoplasia (PIN), as large differences are reported in the incidence of high-grade PIN, probably because of the variance in diagnosis and interpretation. Two urological pathologists prospectively reviewed 251 consecutive patients, received in consultation and who were diagnosed and finalized by outside pathologists as having PIN. The diagnosis of PIN was confirmed in 191 patients (incidence of concordance 76.1%, true positive) and refuted in 60 (discordance 23.9%, false positive). The most common histopathological findings misinterpreted as PIN included basal cell hyperplasia, benign epithelium, low-grade PIN, reactive changes, cribriform hyperplasia, atrophy, and post-atrophic hyperplasia. There is a high rate of over-diagnosis of PIN, usually by misinterpretation of benign mimics. This significant error rate might account for some of the reported differences in the incidence of PIN and the variable predictive accuracy for cancer.

A comparison of GP and physiotherapy diagnoses

An audit compared the GP's diagnosis with the physiotherapist's, for patients with musculoskeletal conditions. Arm and leg pain was more likely to be diagnosed differently than spinal pain. Outcome of physiotherapy appeared to be affected if there was no consensus. But it was the actual conditions that influenced the outcomes and numbers of treatments, rather than the variance in diagnoses.

Differences between normal and milk allergic subjects in their immune responses after milk ingestion.

In order to understand why non-atopic people do not have adverse symptoms to food antigens which enter the circulation after eating, 8 non-atopic and 10 atopic eczema- and milk-allergic subjects were challenged with milk, and the types of circulating immune complexes formed were analysed. Although the amount of beta-lactoglobulin incorporated into complexes did not differ statistically between the groups, the type of immune complex did. Of the non-atopic individuals, 5 formed IgA and 2 IgG complexes. Of the milk-allergic group, all showed a rise in at least one type; 5 formed IgA, 7 IgG, 6 IgE, and 6 formed C1q-binding complexes. Our data suggest that serum IgA is concerned in safe food antigen handling in non-atopic people, and that the differences in the type of immune complexes formed in response to antigen challenge may underlie the systemic symptoms of food allergy.