Variation In Diagnosis Research Articles

Enhancing oral health diagnosis and treatment with artificial intelligence in dentistry

This study aims to explore the potential of artificial intelligence (AI) in enhancing oral health diagnosis and treatment in the field of dentistry. With a sample size of 100 individuals from the population of Lahore, this research investigates the efficacy of AI technologies in revolutionizing oral healthcare practices. The traditional approach to oral health diagnosis and treatment heavily relies on subjective human judgment, leading to variations in diagnoses and treatment plans. By leveraging AI algorithms, this study demonstrates how machine learning and deep learning techniques can assist dentists in making accurate and efficient diagnoses, resulting in improved treatment outcomes. The research involves the development of an AI model trained on a dataset comprising dental records and associated clinical information. Through the analysis of this dataset, the AI model learns to recognize patterns, identify abnormalities, and predict potential oral health issues. By integrating this model into dental practices, dentists can make informed decisions based on data-driven insights, ultimately leading to enhanced patient care. Furthermore, this study evaluates the potential challenges and ethical considerations associated with implementing AI in dentistry.

A bird's-eye view of pathologist over diagnostic confusion of oral cavity lesions.

Oral cavity can be host to multitude of neoplastic, premalignant or non neoplastic pathological lesions. Diagnosis of lesions of oral cavity is always of interest to clinician and pathologist and rely on clinical appearance of lesions. There can be variation in diagnosis of clinical lesion with histopathology. Many oral carcinomas arise within the sites that previously had premalignant lesion. Incidence of oral cancers in population has increased among younger generations related to habits and lifestyle. These lesions during clinical presentation are misleading and create diagnostic dilemma owing to age, sex and distribution of lesions. Understanding distribution of oral mucosal lesions helps to diagnose lesions of oral cavity. Purpose of this study is to observe the variation in clinical diagnosis with histopathological diagnosis in patients with inflammatory, premalignant, benign and malignant lesions of oral cavity and oropharynx and also clinical distribution of lesions of oral cavity and oropharynx lesions by histopathology. Out of total 105 lesions, ulcer in oral cavity seen in 58 (55.23%) of patients, followed by swelling or feeling of lump in oral cavity in 36 (34.29%) of patients and foreign body sensation in 23 (21.90%) of patients with tongue as most frequent site for most of lesions of oral cavity accounting in 33 (31.43%) of cases, and less frequently lesions were seen in retro molar trigone area in 2 (1.90%) patients. Histopathological diagnosis of premalignant, non neoplastic and inflammatory lesions was made in 24 (22.85%) cases, benign tumours were diagnosed in 14 (13.33%) cases and rest of 67 (63.81%) lesions were malignant. Mucocoel were seen in five (4.76%) cases, radicular cyst was seen in one (0.95%) case of female patient and four cases of Leukoplakia with one case showing mild dysplasia. Among benign tumours 11 (10.47%) patients presented with gingivitis turned out to be squamous papillomas were seen in five (4.76%) cases, fibroma was diagnosed in four (3.80%) cases, pyogenic granuloma was diagnosed in four (3.80%) cases most commonly seen over gingiva and myoepithelioma of minor salivary gland was observed in one (0.95%) case over soft palate. Out of 67 cases of malignant lesions squamous cell carcinomas were seen in 59 (88.05%) cases followed by verrucous carcinoma in 3 (4.47%) cases, 2 (2.99%) cases were basaloid squamous cell carcinomas, mucoepidermoid carcinoma was seen in 2 (2.99%) cases and 1 (1.49%) case of adenoid cystic carcinoma was seen. Majority of squamous cell carcinomas cases in study were well differentiated in 49 (73.13%) cases followed by moderately differentiated in 16 (23.88%) cases and poorly differentiated in 2 (2.99%) cases. Malignant transformation of tonsil tissue post operatively was observed in 1 (0.95%) patients on histopathology. One (2.5%) case of myoepithelioma was seen in 60 years male over soft palate. Of all oral biopsies reported in study, increasing trend of malignancies in lower age groups of population making it an emerging threat to community and highlighting need to take effective measures to increase public awareness about risk factors and consequences of this condition. Screening programmes targeted to population over 25 years are recommended to overcome this.

Survey of Diagnostic and Management Practices in Small Bowel Obstruction: Individual and Generational Variation Despite Practice Guidelines.

Background: Small bowel obstruction (SBO) is a common disorder managed by surgeons. Despite extensive publications and management guidelines, there is no universally accepted approach to its diagnosis and management. We conducted a survey of acute care surgeons to elucidate their SBO practice patterns.Methods: A self-report survey of SBO diagnosis and management practices was designed and distributed by email to AAST surgeons who cared for adult SBO patients. Responses were analyzed with descriptive statistics and Chi-square test of independence at α = .05.Results: There were 201 useable surveys: 53% ≥ 50years, 77% male, 77% at level I trauma centers. Only 35.8% reported formal hospital SBO management guidelines. Computed tomography (CT) scan was the only diagnostic exam listed as "essential" by the majority of respondents (82.6%). Following NG decompression, 153 (76.1%) would "always/frequently" administer a water-soluble contrast challenge (GC). There were notable age differences in approach. Compared to those ≥50years, younger surgeons were less likely to deem plain abdominal films as "essential" (16.0% vs 40.2%; P < .01) but more likely to require CT scan (88.3% vs 77.6%; P = .045) for diagnosis and to "always/frequently" administer GC (84.0% vs 69.2%; P < .01). Younger surgeons used laparoscopy "frequently" more often than older surgeons (34.0% vs 21.5%, P = .05).Discussion: There is significant variation in diagnosis and management of SBO among respondents in this convenience sample, despite existing PMGs. Novel age differences in responses were observed, which prompts further evaluation. Additional research is needed to determine whether variation in practice patterns is widespread and affects outcomes.

Variation in diagnosis of urinary incontinence in women by provider and patient demographic factors.

Urinary incontinence (UI) among women is under-recognized in primary care setting. We hypothesized that UI is, therefore, more commonly diagnosed by specialists. Our aim was to determine the rate of UI diagnosis by provider and patient demographics, and whether these factors affect the likelihood of UI diagnosis. Retrospective study using electronic medical records from 2010 to 2019. Ambulatory patient encounters by adult females were identified. Encounters with new diagnosis of UI (stress, urgency, mixed, or unspecified) were identified using ICD 9 and 10 codes. The following data were extracted: diagnosing provider specialty and sex, patient age, BMI, race, estimated household income, insurance coverage and type, and primary care provider (PCP). Rate of UI diagnosis was calculated using proportions. Univariable comparison and multivariable logistic regression were performed. 576,110 patient encounters were captured. 14,378 patient encounters had UI diagnosis (2.5%). UI population had the following characteristics: Mean age of 60.1 ± 15.5years, 65.6% identified as white, 75.7% had a PCP, and 87.9% had insurance. UI diagnosis rate was < 1% for PCPs. Multivariable logistic regression showed that urogynecologists and female providers were more likely to diagnose UI; patient demographics associated with UI diagnosis included older age, elevated BMI, white race, commercial insurance, and having a PCP. Estimated household income did not have a significant effect. Diagnosis of UI is seldom made by PCPs. Race, insurance, and having a PCP may affect the likelihood of receiving UI diagnosis. Continued efforts to promote equity in recognizing UI may be warranted.

Calendar month variation in the diagnosis and severity of pulmonary embolism.

Pulmonary embolism (PE) is the third-leading cause of cardiovascular death in the United States, and several studies suggest PE shows seasonal variation. Variation in monthly PE diagnosis may be due to pathophysiologic factors or confounding/bias. However, severe PE may be less prone to diagnostic bias. To address this gap, we analyzed two registries from 1/2013-12/2018 with the aim of describing temporal trends in PE diagnosis and severity. We performed a retrospective analysis of two existing databases containing: (1) consecutive patients diagnosed with PE in the emergency departments (EDs) of two large, urban teaching hospitals, and (2) severe PEs requiring PE Response Team (PERT) activation at one of the above hospitals. The primary outcome was to assess variation in PE diagnosis and severity by calendar month. Separate analysis of these two databases sought to control for workup bias by trainee experience across the academic year. One-way ANOVA and Poisson regression were performed to assess for cyclical variation across calendar months, using Stata v16.1. The PE diagnosis database contained 1324 patients over 36months. One-way ANOVA did not reveal a statistically significant (p = 0.713) association between calendar month and PE number. The PERT activation database contained 1082 patients over 72months. One-way ANOVA revealed a statistically significant (p = 0.024) association between calendar month and activations, repeated year-on-year. Our results indicate correlation between calendar month and PERT activation; however, this pattern was not observed for PE diagnoses. This finding warrants further investigation into the causes of calendar month variation of PERT activations.

Provider- and Facility-Level Variation in Precancerous Cervical Biopsy Diagnoses.

Reproducibility of cervical biopsy diagnoses is low and may vary based on where the diagnostic test is performed and by whom. Our objective was to measure multilevel variation in diagnoses across colposcopists, pathologists, and laboratory facilities. We cross-sectionally examined variation in cervical biopsy diagnoses within the 5 sites of the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR I) consortium within levels defined by colposcopists, pathologists, and laboratory facilities. Patients aged 18 to 65 years with a colposcopy with biopsy performed were included, with diagnoses categorized as normal, cervical intraepithelial neoplasia grade 1 (CIN1), grade 2 (CIN2), and grade 3 (CIN3). Using Markov Chain Monte-Carlo methods, we fit mixed-effects logistic regression models for biopsy diagnoses and presented median odds ratios (MORs), which reflect the variability within each level. Median odds ratios can be interpreted as the average increased odds a patient would have for a given outcome (e.g., CIN2 or CIN3 vs normal or CIN1) when switching to a provider with higher odds of diagnosing that outcome. The MOR is always 1 or greater, and a value of 1 indicates no variation in outcome for that level, with higher values indicating greater variation. A total of 130,110 patients were included who received care across 82 laboratory facilities, 2,620 colposcopists, and 489 pathologists. Substantial variation in biopsy diagnoses was found at each level, with the most occurring between laboratory facilities, followed by pathologists and colposcopists. Substantial variation in biopsy diagnoses of CIN2 or CIN3 (vs normal or CIN1) was present between laboratory facilities (MOR: 1.26; 95% credible interval = 1.19-1.36). Improving consistency in cervical biopsy diagnoses is needed to reduce underdiagnosis, overdiagnosis, and unnecessary treatment resulting from variation in cervical biopsy diagnoses.

Large Variation in Diagnosis and Treatment of Chyle Leak after Pancreatic Surgery: A Nationwide Insight

Background: In the current literature different diagnosis and treatment strategies for chyle leak after pancreatic surgery are described. In 2017, the International Study Group for Pancreatic Surgery defined a consensus-based definition for diagnosis. However, consensus on the optimal treatment strategy is lacking. Aim: The aim of this multicenter study is to investigate the current treatment and diagnosis of chyle leak after pancreatic surgery in clinical practice in the Netherlands to gain insight into practical applications of chyle leak. Methods: A nationwide survey about the diagnosis and treatment of chyle leak was sent to specialized dieticians and pancreatic surgeons from all 16 pancreatic centers collaborating in the Dutch Pancreatic Cancer Group. Data was quantitative processed according to thematic content analysis and by using descriptive analysis. Results: In total, 16 dieticians from 16 centers and 20 surgeons from 12 centers completed the questionnaire. Analysis showed that the International Study Group for Pancreatic Surgery-definition for chyle leak was used in clinical practice by 31% (n=11) of the respondents. The results show also large nationwide variation in treatment of chyle leak after pancreatic surgery, as well between as within centers. The most common treatment was a step-up approach of nutritional therapies (44% (n=16)), which starts with an enteral fat restricted diet enriched with medium chain fatty acids followed by total parenteral nutrition. Conclusion This study shows that the current diagnosis and treatment strategies for chyle leak after pancreatic surgery in clinical practice on a nationwide scale are different. More comparable studies are needed to define the optimal treatment strategy for chyle leak. There is need for an international multidisciplinary (sub)working group to reach consensus on the treatment strategy of chyle leak and to discuss implementation strategies for clinical practice.

Variation of diagnosis and treatment of catheter-associated urinary tract infections: an online survey among caretakers involved.

The diagnosis of a clinically significant catheter-associated urinary tract infection (CAUTI) in patients performing clean intermittent catheterization (CIC) or with an indwelling catheter (IC) can be challenging. To get an insight into the variation of the used definition, diagnosis and management of CAUTIs by relevant healthcare workers in the Netherlands. An online clinical scenario-based survey. The survey was built in Limesurvey and distributed to healthcare workers from randomly selected urology departments, rehabilitation departments/centres and general practice offices between January and May 2022. Questions regarding their field of experience, management strategies, used guidelines and two hypothetical cases with clinical scenarios of a possible CAUTI were included. A total of 172 individuals participated, of which 112 completed the survey. In all, 32 individuals who completed the survey partially were also included. Participants consisted of 68 [44 urologists, 22 rehabilitation doctors (RDs) and 2 general practitioners (GPs)] doctors, 60 nurses (46 from the urology department and 14 from rehabilitation centres/departments) and 16 medical assistants (13 from urology department and 3 from GP offices). The majority consulted patients with an IC or on CIC on a daily/weekly or monthly basis. In all, 35 urologists (79.5%), 9 RDs (40.9%), 21 (45.7%) nurses in the urology department and 6 (42.9%) nurses from a rehabilitation department/centre indicated bladder irrigation as a treatment option for prevention/treatment of CAUTIs, treatment of symptoms or treatment of blockage of the catheter. In the clinical scenarios presented, treatment discrepancies were seen between subspecialties and healthcare workers. Various guidelines were named for the definition of CAUTIs. A considerable variation in diagnoses and management of CAUTIs between the healthcare workers involved was seen. Uniformity in diagnosing and managing CAUTIs, to prevent overtreatment and possible resistance to antibiotics, is advised. Suitable multidisciplinary guidelines are preferred.

Variation in diagnosis and management of allergic reactions among emergency medicine and allergy immunology providers

Background: Children with anaphylaxis often emergently present for treatment. Providers' adherence to the principles of optimal management according to the most recent national guidelines is unknown. Objective: To assess the variation in management approaches for allergic reactions and anaphylaxis between allergy/immunology (AI) and emergency medicine (EM) providers. Methods: This was a cross-sectional survey study of AI and EM providers in the University of Colorado affiliated hospitals and Colorado Asthma and Allergy Society. The survey consisted of six cases of patients with allergic reactions, with four cases that represented patients with anaphylaxis that resolved by the time of discharge. For each vignette, the participants were asked about preferred initial therapy, adjunctive therapies, monitoring, outpatient prescription medications, and discharge instructions provided. Survey derivation and validation was accomplished by a multidisciplinary team of experts by using a modified Delphi process. Results: A total of 413 clinicians were contacted, of whom 194, (47%) responded, including 69 pediatric EM, 50 general EM, and 49 AI providers, and 26 did not identify a provider type. There were no statistically significant differences in correct recognition of anaphylaxis between the AI and EM providers. For each case, statistically significant differences were noted in the use of corticosteroids during and after resolution of anaphylaxis: AI providers reported giving fewer prescriptions than did the EM providers for corticosteroids in all cases of anaphylaxis (p < 0.001). The AI providers were less likely to prescribe scheduled antihistamines than were the EM providers in half of the cases (p < 0.02). Conclusion: Across the specialties, there were high rates of recognition of epinephrine as first-line treatment for anaphylaxis. The majority of the EM providers prescribed scheduled corticosteroids and antihistamines after resolution of anaphylaxis, whereas most of the AI providers did not prescribe scheduled corticosteroids. Analysis of the current data suggests against the routine use of corticosteroids in the management of anaphylaxis, particularly continued use after resolution of symptoms. AI involvement in the creation of EM and hospital protocols for allergic reactions could improve overall care.

Variation in attitudes toward diagnosis and medication of ADHD: a survey among clinicians in the Norwegian child and adolescent mental health services

Prevalence and medication rates of ADHD vary geographically, both between and within countries. No absolute cutoff exists between ADHD and normal behavior, making clinician attitudes (leading to local practice cultures) a potential explanation for the observed variation in diagnosis and medication rates. The objective of this study was to describe variation in attitudes toward diagnosis and medication of ADHD among clinicians working in child and adolescent mental health services (CAMHS). We hypothesized that attitudes would vary along a spectrum from “restrictive” to “liberal”. We also explored whether differences in attitudes between clinicians were related to professional background and workplace (clinic). A survey in the form of a web-based questionnaire was developed. All CAMHS outpatient clinics in Norway were invited. Potential respondents were all clinicians involved in diagnosing and treating children and adolescents with ADHD. To investigate the existence of attitudes toward diagnosis and medication as latent constructs, we applied confirmatory factor analysis (CFA). We further examined how much of variance in attitudes could be ascribed to profession and clinics by estimating intraclass correlation coefficients. In total, 674 respondents representing 77 (88%) of the clinics participated. We confirmed variation in attitudes with average responses leaning toward the “restrictive” end of the spectrum. CFA supported “attitude toward diagnosis” and “attitude toward medication” as separate, and moderately correlated (r = 0.4) latent variables, representing a scale from restrictive to liberal. Professional background and workplace explained only a small part of variance in these attitudes.

Seasonal variation in diagnosis of cutaneous invasive melanoma and cutaneous squamous cell carcinoma: A nationwide study in the Netherlands

BackgroundCurrently, there is no study that has reported on the seasonal trends of skin cancer in the Netherlands. This study aimed to investigate seasonal variation in diagnosis of cutaneous melanoma (CM) and cutaneous squamous cell carcinoma (cSCC) focusing on different subgroups. MethodsCM diagnosed from 2001 till 2019 and cSCCs from 2001 till 2015 were selected from the Netherlands Cancer Registry. The monthly distribution of CM and cSCC diagnoses were evaluated. Summer-to-winter ratios (SWRs) were calculated overall and stratified by patient and tumour characteristics. ResultsSignificant increases in melanoma incidence were noted over the summer months (SWR 1.39 (CI 1.37–1.40)). This increase was less apparent for cSCCs, as higher incidence rates were observed in the months September-November (SWR 1.13 (CI 1.12–1.14)). The seasonal variation of CM was greater in women and younger people, in superficial spreading melanoma and lentigo maligna melanoma, for the extremities, in thinner lesions, and for stage I at diagnosis. The seasonal variation of cSCC was similar for both sexes, most marked in patients 45‐69 and ≥ 70, and for the extremities. ConclusionsOur findings showed a pronounced seasonal variation in the diagnosis of CM with a peak in the summer months. For cSCC, no evident peak was observed, but an increase in diagnosis was noted in fall. Both CM and cSCC showed strong seasonal effects for the extremities.

Routine Pathological Examination of Clinically Presumed Dupuytren Disease: Does It Add Value?

In surgery for Dupuytren disease (DD), palmar fascia specimens are routinely submitted for pathological evaluation. The purpose of this study was to determine the rate of discordant diagnosis and the value of, and costs associated with, routine pathological analysis of palmar fascia tissue extracted in surgery for clinically diagnosed DD. All pathology reports for in-house palmar fascia specimens obtained in surgery for clinically diagnosed DD (time period: January 2001 to December 2020) were retrieved from one academic institution. All specimens were classified by a hierarchical free-text string matching algorithm (HFTSMA) and searched for evidence of malignancy. The primary outcome was percentage of concordant, discrepant, and discordant diagnoses. Secondary outcomes included anatomical location and costs. The HFTSMA was used to capture the anatomical location. Costs included professional, laboratory processing, and ancillary fees based on the Ontario Schedule of Benefits. The search retrieved 1323 pathology reports, with 1480 palmar fascia specimens, from 1078 individual patients. By diagnosis, 96.1% of specimens (1422/1480) were concordant (fibromatosis), 3.9% (58/1480) were discrepant (scarring/fibrosis, benign fascia/connective tissue, or other benign findings), and 0% (0/1480) were discordant. The most common location was ring finger (n = 381, 48.7%). Ancillary testing was minimal. The cost per palmar fascia specimen was estimated to be CAD $34.57. The institutional costs were approximately CAD $2558.18/year. Routine pathological examination of specimens in cases of clinically diagnosed DD does not yield additional clinically important findings and may not warrant their costs.

Physician Practice Style and Healthcare Costs: Evidence from Emergency Departments

We study healthcare operations of emergency departments (EDs) by examining the practice styles and skills of ED physicians. Our data include all residents of Montreal, Canada, with an initial ED visit in Montreal during a nine-month period. For each visit, our data record the initial treating hospital, ED physician, ED billed expenditures, and all interactions with the health system within the subsequent 90 days. Physicians in Montreal rotate across shifts between simple and difficult cases, implying a quasi-random assignment of patients to physicians within an ED. We consider three medical conditions that present frequently in the ED and for which mistreatment may have dramatic consequences—angina, appendicitis, and transient ischemic attacks—jointly examining diagnostic and disposition skills. To control for variation in diagnosis, our sample for each condition consists of patients with a broader set of symptoms and signs potentially indicative of the condition. Separately by condition, we regress healthcare usage and cost measures on indicators for physicians to estimate the skill and practice style of each physician. We then evaluate the variation across physicians in their practice style and skills and the correlations between different measures of skill and practice style. We find significant variation across physicians in their practice styles and skills. We also find that physicians with costly practice styles often have worse outcomes in terms of more ED revisits and more hospitalizations. Finally, the practice styles and skills of physicians correlate positively across the three conditions that we consider. This paper was accepted by Jayashankar Swaminathan, operations management. Funding: Gowrisankaran acknowledges funding from the Center for Management Innovations in Healthcare at the University of Arizona. Supplemental Material: The online appendix and data are available at https://doi.org/10.1287/mnsc.2022.4544 .

Developmental disability among Aboriginal children in Western Australia (WA).

BackgroundWhile Aboriginal Australians are known to be disproportionately affected by intellectual disabilities (ID) and/or autism spectrum disorders (developmental disabilities), true prevalences among Aboriginal children are unclear, with evidence of delayed and missed diagnoses and barriers to services. This study estimated these prevalences and disability service use among WA Aboriginal children. ApproachTwo cohorts and data sources were used. Firstly, a state-based health and disability data linkage for all WA Aboriginal children born 2000-2013, including hospital, public outpatient mental health, birth and death data and state registries of birth defects, cerebral palsy and ID. The cumulative incidence of diagnosis by age 18 was estimated. Secondly, prevalence of service access was estimated from all National Disability Insurance Scheme (NDIS) WA Aboriginal and non-Aboriginal participants aged 0-17 on 30/6/2021 with a primary diagnosis of ID (with or without fetal alcohol spectrum disorder (FASD)) or autism. Census population counts were denominators. ResultsUsing the data linkage, 3.3% of Aboriginal children born 2000-2013 were diagnosed with developmental disability by 18 years. The most common diagnosis (2.5%) was ID without FASD. Using NDIS data, 3.1% of Aboriginal children were NDIS participants with development disability in 2021, but only 0.7% of children with ID without FASD. Instead, autism was most common diagnosis. Aboriginal children were more likely than non-Aboriginal children to be NDIS participants with autism (prevalence ratio (PR): 1.16, 95% confidence interval (CI): 1.06-1.26), ID without FASD (PR: 2.06, 95% CI: 1.80-2.35) and ID with FASD (PR: 40.5, 95%CI: 29.9-57.1). For both data sources, prevalences differed by region. Aboriginal NDIS participants with ID had an older age distribution than non-Aboriginal participants. ConclusionFor both cohorts, the prevalence of developmental disability was &gt;3%, though the contributions of ID and autism differed in the two data sources. Variation in diagnoses by region and Aboriginal status may indicate differential diagnosis and variation in age suggests delayed diagnoses or access to services for Aboriginal children.

EP-370 Contemporary clinical management strategies in lower gastrointestinal bleeding: A single-centre retrospective observational study

Abstract Aim Significant heterogeneity exists in the recommendations for the diagnosis and management of acute lower gastrointestinal bleeding (LGIB). This study aims to demonstrate the contemporary management strategies adopted by a busy tertiary hospital. Methods We conducted a single-centre retrospective review of adults presenting to our institution with LGIB between January and March 2021. Demographic data, observations, laboratory results, endoscopy and radiology reports, operation notes and discharge summaries were collected for each patient via a retrospectively maintained registry. Results 23 patients were included. Mean age was 66.6 years with a mean initial haemoglobin of 10.9 g/dL (Range 4.1–15.5g/dL). 17% of patients were in circulatory shock on presentation. 70% of patients presented with haematochezia. 47.8% of patients were on either an anticoagulant or anti-platelet agent at presentation. The transfusion index in this cohort was 30%. 26.1% of patients had a re-bleed during their admission. The diagnostic yield of cross-sectional imaging amongst 11 patients was 27.3% with no correlation with haemodynamic status or active bleeding. 47.8% of patients underwent endoscopy and 27% of patients who underwent an endoscopic procedure required endoscopic haemostasis. Flexible sigmoidoscopy was the commonest endoscopic modality (55%), followed by gastroscopy (27%) and colonoscopy (18%). No patients required surgical or radiological intervention. No cause of bleeding was identified in 26% of patients. Conclusion This study confirms the variation in diagnosis and management of LGIB. Despite access to onsite interventional radiology, endoscopy remained the predominant diagnostic and therapeutic modality. Routine cross-sectional imaging may not be justified given its suboptimal diagnostic yield.

Utility of Routine Pathologic Examination for Fasciectomy for Dupuytren Contracture

The objective of this study was to examine the routine pathologic examination of surgical specimens obtained during fasciectomy for Dupuytren contracture. A total of 376 consecutive patients who underwent surgical limited fasciectomy with the excised tissue sent for histopathologic evaluation were identified. Patients were excluded for miscoded procedures, cases where no tissue was sent for pathologic review, and excisions of nodules only. Repeat surgeries in the same patient during the study period were excluded. The rates of concordant, discrepant, and discordant diagnoses were reported. Discrepant diagnoses were defined as different clinical diagnosis and pathologic diagnosis that did not change clinical management. Discordant diagnoses were defined as a different clinical diagnosis and a pathologic diagnosis that altered the treatment plan. The reference standard for final clinical decision-making was the pathologic diagnosis. The prevalence of concordant diagnoses was 97.1% (365 of 376), of discrepant diagnoses was 2.9% (11 of 376), and there were no discordant diagnoses. Of 376 patients, 43 underwent previous surgical fasciectomy before the study surgery, and pathologic examination was obtained in 10 of these patients. All 10 patients had concordant diagnoses. Our results suggest that routine pathologic examination did not alter the future treatment plan for patients who underwent limited fasciectomy. Discrepant diagnoses were encountered infrequently, and rarely in the setting of revision fasciectomy. Discordant diagnoses did not occur. Given the cost associated with pathologic evaluation, this raises the question of whether routine pathologic evaluation is necessary for Dupuytren surgery, where the capability of the treating surgeon to make a clinical diagnosis accurately may render confirmatory pathologic assessment redundant. Diagnostic II.

Practice Variations in the Management of Infants With Non-IgE-Mediated Cow's Milk Protein Allergy.

Infants with non-IgE-mediated food allergies are often referred to gastroenterologists or immunologists. We hypothesized that there are practice variations between these disciplines in the diagnosis and management of such infants. A computerized questionnaire was distributed between pediatric gastroenterologists and immunologists. The questions addressed diagnosis, management, and follow-up in 3 scenarios of infants with concern for food protein-induced allergic proctocolitis (FPIAP) due to non-IgE-mediated responses to cow's milk. Three cases of infants with suspected FPIAP were presented: milk-based formula-fed (case 1) or breast-fed (case 2) infants that are well appearing and thriving, and a breast-fed infant who is not growing appropriately along with a personal and family history of atopy (case 3). Fifty-eight pediatric gastroenterologists and 32 immunologists completed the questionnaire. Significant differences between gastroenterologists and immunologists were noted regarding the recommended dietary changes in these scenarios. Moreover, despite available guidelines generated by both societies, most physicians confirm the diagnosis based on resolution of symptoms after the dietary change, without re-exposure to the the suspected trigger. In addition, time for recommended re-exposure in infants with FPIAP was also different; most gastroenterologists recommended waiting until 12 months of age, while immunologists suggested reintroduction earlier, up to 6 months of age. We identified significant practice variations in diagnosis and management of FPIAP between pediatric gastroenterologists and immunologists, with lack of adherence to society guidelines. Joint task forces of primary care pediatricians, gastroenterologists, and immunologists should provide uniform guidelines to standardize care.

Analysis of Variation Between Diagnosis at Admission vs Discharge and Clinical Outcomes Among Adults With Possible Bacteremia

Misdiagnosis of infection is among the most commonly made diagnostic errors and is associated with increased morbidity and mortality. Little is known about how often misdiagnosed site of infection occurs and its association with clinical outcomes. To evaluate the discrepancy between admission and discharge site of infection diagnoses among patients with suspected bacteremia, to explore factors associated with discrepant diagnoses, and to evaluate the association with clinical outcomes. This cohort study used electronic records of 1477 adult patients who were admitted to the hospital for suspected bacteremia from April 1, 2019, to May 31, 2020, and who had blood cultures taken at the emergency department at Haga Teaching Hospital, The Hague, the Netherlands. Suspected infection sites were classified into 8 categories at admission and discharge. Misdiagnosed site was defined as a discrepancy between the suspected site of infection at admission and at discharge. Clinical outcomes were 30-day mortality, intensive care unit admission, length of hospital stay, and antibiotic use, analyzed with logistic and linear regression. Risk factors for misdiagnosed site were determined using regression analysis. A total of 1477 patients (820 [55.5%] male; median [IQR] age, 68 [56-78] years) were analyzed. The rate of misdiagnosed site of infection was 11.6% (171 of 1477); 3.1% of all patients (46 of 1477) ultimately had no infection. No association was found between misdiagnosis and 30-day mortality (adjusted odds ratio [aOR], 0.8; 95% CI, 0.3-1.9; P = .60), intensive care unit admission (aOR, 1.3; 95% CI, 0.6-3.0; P = .54), and hospital length of stay (adjusted increase of stay, 15.5%; 95% CI, -3.1% to 37.7%; P = .11). Misdiagnosed site was associated with receiving broad-spectrum antibiotics (aOR, 4.0; 95% CI, 1.8-8.8; P < .001). Older age, dementia, a positive urine sediment test result without urinary symptoms, and suspicion of an intravascular, central nervous system, or bone and joint infection were risk factors for misdiagnosed site of infection. In this cohort study, misdiagnosed site of infection occurred in 1 of 9 patients and was not associated with worse short-term clinical outcomes. Clinicians should be aware of risk factors associated with misdiagnosed site of infection and potential inappropriate antibiotic use.

Functional gastrointestinal disorders frequency by Rome IV criteria

IntroductionFunctional gastrointestinal disorders (FGIDs) are a very common pediatric disease, with strong implications for children and their families. We aimed to determine their frequency in our environment (per Rome IV criteria) and to establish if there is seasonal variability in diagnosis. MethodsDescriptive, prospective study. For 12 months, children under 16 years of age with suspected FGIDs who had a first pediatric gastroenterology consultation were included and classified according to Rome IV criteria. Statistical analysis was done with SPSS v22. Results574 children received consultations, 67% were >4 years of age. FGIDs were suspected in 44.6% of the patients, 32.4% were diagnosed according to Rome IV criteria (16.4% <4 years, 40.3% >4 years). 51.1% were female, average age of 8.4 ± 4.2 years and mean of 7 months of symptoms until diagnosis (range 3–150). In patients <4 years, the most common disorders were functional constipation (48.4%), regurgitation (22.5%) and functional diarrhea (16.1%); in patients >4 years of age, functional abdominal pain (29%), functional dyspepsia (28.4%) and functional constipation (16.8%) were most frequent. We didn’t discern seasonal variations in diagnosis in the global study population (p = 0.96) or by age group (<4 p = 0.51; >4 p = 0.57). ConclusionsFGIDs account for one third of our patients’ consultations. While the Rome IV criteria are more inclusive than before, almost 30% of patients with suspected FGIDs don’t meet said criteria. Although a seasonal difference regarding diagnosis was observed, it wasn’t statistically significant either in the sample group as a whole or by age group.

Mycobacterium tuberculosis transmission in Birmingham, UK, 2009-19: An observational study.

SummaryBackgroundOver 10-years of whole-genome sequencing (WGS) of Mycobacterium tuberculosis in Birmingham presents an opportunity to explore epidemiological trends and risk factors for transmission in new detail.MethodsBetween 1st January 2009 and 15th June 2019, we obtained the first WGS isolate from every patient resident in a postcode district covered by Birmingham's centralised tuberculosis service. Data on patients’ sex, country of birth, social risk-factors, anatomical locus of disease, and strain lineage were collected. Poisson harmonic regression was used to assess seasonal variation in case load and a mixed-effects multivariable Cox proportionate hazards model was used to assess risk factors for a future case arising in clusters defined by a 5 single nucleotide polymorphism (SNP) threshold, and by 12 SNPs in a sensitivity analysis.Findings511/1653 (31%) patients were genomically clustered with another. A seasonal variation in diagnoses was observed, peaking in spring, but only among clustered cases. Risk-factors for a future clustered case included UK-birth (aHR=2·03 (95%CI 1·35–3·04), p < 0·001), infectious (pulmonary/laryngeal/miliary) tuberculosis (aHR=3·08 (95%CI 1·98-4·78), p < 0·001), and M. tuberculosis lineage 3 (aHR=1·91 (95%CI 1·03–3·56), p = 0·041) and 4 (aHR=2·27 (95%CI 1·21–4·26), p = 0·011), vs. lineage 1. Similar results pertained to 12 SNP clusters, for which social risk-factors were also significant (aHR 1·72 (95%CI 1·02–2·93), p = 0·044). There was marked heterogeneity in transmission patterns between postcode districts.InterpretationThere is seasonal variation in the diagnosis of genomically clustered, but not non-clustered, cases. Risk factors for clustering include UK-birth, infectious forms of tuberculosis, and infection with lineage 3 or 4.FundingWellcome Trust, MRC, UKHSA