Variation In Diagnosis Research Articles

Inter-observer variation in the diagnosis of coronal articular fracture lines in the lunate facet of the distal radius

Several studies support the use of CT for diagnosing coronal fractures of the distal radius but the inter-observer reliability of these observations is less well studied. We tested the null hypothesis that radiographs alone and the combination of radiographs and two-dimensional computed tomography scans (2DCT) have the same inter-observer variation for the diagnosis of coronal articular fracture lines in the distal radius. Using a web-based survey, 63 surgeons were randomized to evaluate 16 fractures of the distal radius on radiographs alone or radiographs and 2DCT for the presence or absence of a coronal fracture line of the lunate facet and, if present, the stability of the fracture. The kappa multirater measure was calculated to estimate agreement between observers. The inter-observer variation in diagnosis of a coronal fracture line was fair with both radiographs and 2DCT, as was the diagnosis of instability of the volar lunate facet fracture when present. Two-dimensional computed tomography does not improve observer agreement on the diagnosis of coronal plane articular fracture lines in the lunate facet of the distal radius.

Do First Opinions Affect Second Opinions?

Second medical opinions have become commonplace and even mandatory in some health-care systems, as variations in diagnosis, treatment or prognosis may emerge among physicians. To evaluate whether physicians' judgment is affected by another medical opinion given to a patient. Orthopedic surgeons and neurologists filled out questionnaires presenting eight hypothetical clinical scenarios with suggested treatments. One group of physicians (in each specialty) was told what the other physician's opinion was (study group), and the other group was not told what it was (control group). A convenience sample of 332 physicians in Israel: 172 orthopedic surgeons (45.9% of their population) and 160 neurologists (64.0% of their population). Scoring was by choice of less or more interventional treatment in the scenarios. We used χ(2) tests and repeated measures ANOVA to compare these scores between the two groups. We also fitted a cumulative ordinal regression to account for the dependence within each physician's responses. Orthopedic surgeons in the study group chose a more interventionist treatment when the other physician suggested an intervention than those in the control group [F (1, 170) =4.6, p=0.03; OR=1.437, 95% CI 1.115-1.852]. Evaluating this effect separately in each scenario showed that in four out of the eight scenarios, they chose a more interventional treatment when the other physician suggested an intervention (scenario 1, p=0.039; scenario 2, p<0.001; scenario 3, p=0.033; scenario 6, p<0.001). These effects were insignificant among the neurologists [F (1,158) =0.44, p=0.51; OR=1.087, 95% CI 0.811-1.458]. In both specialties there were no differences in responses by level of clinical experience [orthopedic surgeons: F (2, 166) =0.752, p=0.473; neurologists: F (2,154) =1.951, p=0.146]. The exploratory survey showed that in some cases physicians' judgments may be affected by other physicians' opinions, but unaffected in other cases. Weighing previous opinions may yield a more informed clinical decision, yet physicians may be unintentionally influenced by previous opinions. Second opinion has the potential to improve the clinical decision-making processes, and mechanisms are needed to reconcile discrepant opinions.

Su1139 Eosinophilic Esophagitis is More Commonly Found in Asthma Patients With an Allergic Phenotype but is Less Likely in Those on Steroid Inhalers

Background Recent literature has suggested that the incidence and prevalence of eosinophilic esophagitis (EoE) are increasing. Aim of this study was to estimate the true populationbased incidence rates of EoE by using a large national database. Methods We performed a cross-sectional study of the pathology reports describing esophageal eosinophilia from 1996 through 2010, using the Dutch nationwide registry of histopathology reports (PALGA). All histopathology reports of the Netherlands (16,615,394 inhabitants in 2010) enter this database. Cases were identified and classified according to the diagnosis made by the pathologist. Annual incidence rates of EoE were estimated and adjusted for age and sex. Results Our search yielded 8,838 pathology reports. Diagnosis of EoE was made in 674 patients, of which 501 (74.3%) were male and 173 (25.7%) female. In another 174 cases no difference was made between eosinophilia caused by reflux disease or by EoE. The incidence of EoE increased considerably with time, being 0.01 (95% CI 0-0.02) in 1996, 0.01 (95% CI 0-0.03) in 2000, 0.14 (95% CI 0.08-0.20) in 2005, and 1.31 (95% CI 1.131.48) per 100,000 persons per year in 2010. EoE was diagnosed in all age groups, but the highest incidence was seen in patients in the male 20-29 year age group in 2010, in which it was estimated to be 3.23 (95% CI 2.13-4.33) per 100,000 persons. The incidence in children was 0.73 (95% CI 0.45-1.02) per 100,000 persons in 2010. No seasonal variation in diagnosis of EoE was seen. Conclusion We found a rapidly increasing incidence of EoE in the past 15 years that did not reach a plateau yet. This augmentation could be explained on the one hand by an increased awareness of EoE by physicians and pathologists, and on the other hand by a true increase of incidence of the disease. The latter would be in line with the parallel increase in other atopic diseases.

Racial/Ethnic Variations in the Prevalence of Selected Major Birth Defects, Metropolitan Atlanta, 1994–2005

Birth defects are the leading cause of infant mortality and are responsible for substantial child and adult morbidity. Documenting the variation in prevalence of birth defects among racial/ethnic subpopulations is critical for assessing possible variations in diagnosis, case ascertainment, or risk factors among such groups. We used data from the Metropolitan Atlanta Congenital Defects Program, a population-based birth defects registry with active case ascertainment. We estimated the racial/ethnic variation in prevalence of 46 selected major birth defects among live births, stillbirths, and pregnancy terminations at >20 weeks gestation among mothers residing in the five central counties of metropolitan Atlanta between 1994 and 2005, adjusting for infant sex, maternal age, gravidity, and socioeconomic status (SES). We also explored SES as a potential effect measure modifier. Compared with births to non-Hispanic white women, births to non-Hispanic black women had a significantly higher prevalence of five birth defects and a significantly lower prevalence of 10 birth defects, while births to Hispanic women had a significantly higher prevalence of four birth defects and a significantly lower prevalence of six birth defects. The racial/ethnic disparities in the prevalence of some defects varied by SES, but no clear pattern emerged. Racial/ethnic disparities were suggested in 57% of included birth defects. Disparities in the prevalence of birth defects may result from different underlying genetic susceptibilities; exposure to risk factors; or variability in case diagnosis, ascertainment, or reporting among the subpopulations examined. Policies that improve early diagnosis of birth defects could reduce associated morbidity and mortality.

The root canal treatment in maxillary and mandibular molars with five root canals: Two case reports with two years follow up

Introduction: One of the most important steps in successful root canal treatment process is to understand the morphology of the root canal. Therefore, the clinicians should consider and release the anatomic variations in diagnosis and treatment of the mandibular and maxillary molars. Case Series: The aim of this case series is to present the successful root canal treatments completed in lower right first molar and in upper left first molar. In the first case; in right lower first molar five root canals were found, one root canal was in the mesibuccal root, one root canal was in the mesiolingual root and three root canals were in the distal root. This root canal treatment was completed in one session. In the second case, five root canals were found, two of them were in the mesibuccal root, in upper left first molar, two of them were in the distobuccal root and the fifth was in the palatinal root. The root canal treatment process was completed in three sessions. The clinical follow up performed after two years revealed that no symptoms were observed in both cases and the teeth were radiographically healthy. Conclusion: Successful endodontic treatment starts with proper clinical and radiographic examinations. It is important for clinicians to be aware of all possible anatomic variations for a good endodontic practice.

Histologic examinations of arthroplasty specimens are not cost-effective: a retrospective cohort study.

Many hospitals require all operative specimens be sent to pathologists for routine examination. Although previous studies indicate this practice increases medical cost, it remains unclear whether it alters patient management and whether it is cost-effective. We therefore (1) determined the rate of discordance between clinical and histologic examinations of routine operative specimens during elective primary arthroplasties, (2) determined the cost of routine histologic screening, and (3) estimated its cost-effectiveness in terms of cost per quality-adjusted life year gained, as compared with gross examination or no examination. We retrospectively reviewed medical records of 1247 patients who underwent 1363 routine elective primary total joint arthroplasties between January 18, 2006 and March 15, 2010. We compared preoperative, postoperative, and histologic diagnoses for each patient and categorized them into three classes: concordant (clinical and histologic diagnoses agreed), discrepant (diagnoses differed but with no resultant change in treatment), and discordant (diagnoses differed with resultant change in treatment). Medicare reimbursements were determined through the pathology department's administrative office. In 1363 cases, 1335 (97.9%) clinical and histologic diagnoses were concordant, 28 (2.1%) were discrepant, and none were discordant. Total reimbursement for routine pathological examination was $139,532, or $102.37 per specimen. The average cost to identify each discrepant case was $4983.29. Routine histologic examination did not alter patient management, and there was no direct gain in quality-adjusted life years. Our observations show routine histologic examinations of routine operative specimens during elective primary arthroplasties increase medical cost but rarely alter patient management and are not cost-effective. Level I, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.

Abstract A103: Disparities in time-to-diagnosis and time-to-treatment of breast cancer in four Appalachian states

Abstract Research Objective: Many breast cancer patients in Appalachia face unique challenges in obtaining a timely diagnosis and beginning treatment. Barriers including low socio-economic status, mountainous terrain, and fragmentation of services across cancer care providers can contribute to disparities in the receipt of needed care. As a result, a focus on maximizing efficiency and streamlining processes to minimize the time between screening, diagnosis, and treatment for breast cancer patients has become paramount. Our study aim was to examine times to diagnosis and treatment by race and state of residence for a sample of patients in the Appalachian counties of Pennsylvania, Kentucky, North Carolina, and Ohio. Study Design: Three time intervals were constructed from our data. The intervals included: (1) a time-to-diagnosis interval, consisting of the date of first breast cancer screening exam through date of confirmed diagnosis, (2) a time-to-treatment interval, consisting of the date of diagnosis through the date of first treatment, and (3) a total interval, consisting of the date of first breast cancer screening exam through the date of confirmed diagnosis. Averages for each interval were calculated to examine differences according to race and state of residence; t-tests were performed to evaluate the statistical significance of these differences. Sample: Our population is comprised of Medicare patients who were diagnosed with breast cancer in one of the Appalachian counties of PA, KY, NC, and OH from 2006–2008. Patients may have lived in counties outside Appalachia, but their diagnosis was confirmed by an organization located in an Appalachian county. Patients were then matched to cancer registry files in PA, KY, NC, and OH by a unique ID to insure the quality of the claims data. Further, we narrowed the sample to contain only patients who had definitive screening, diagnosis, and treatment dates. The final sample consisted of 6,188 patients. Results: Time-to-diagnosis interval: North Carolina (26 days) and Pennsylvania (32 days) had shorter time-to-diagnosis than did patients in Kentucky (41 days) and Ohio (43 days). No statistically significant differences were found between white (34 days) and black (37 days) patients. Time-to-treatment interval: Kentucky (17 days) experienced the shortest time-to-treatment, whereas Ohio (23 days), North Carolina (25 days), and Pennsylvania (29 days) experienced longer time from diagnosis to first treatment. Averaged over the Appalachian areas in all 4 states, black patients (31 days) had a significantly longer time-to-treatment than white (25 days) patients (p&amp;lt;.05). Total interval: North Carolina (52 days) experienced the shortest time from first screening through the beginning of treatment, while longer intervals existed for Kentucky (58 days), Pennsylvania (61 days) and Ohio (65 days). Overall, black patients (68 days) experienced longer total intervals than white patients (59 days), although this difference was not statistically significant. Conclusions: Our findings suggest that black patients in Appalachian areas of KY, NC, OH, and PA experience delays in treatment compared to white patients after receiving a diagnosis of breast cancer. Moreover, the differences in time-to-diagnosis and treatment across states suggest that states have varying strengths and weaknesses when looking across the entire continuum of care. Implications for Policy and Practice: Understanding the factors driving variation in diagnosis and treatment intervals among Appalachian residents with Medicare coverage is paramount. Health care provider shortages, scarcity of comprehensive cancer centers, and widespread economic disadvantage are likely to be contributing factors, and further research is needed to determine the roles each of these factors play and to identify effective policy interventions to reduce disparities. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A103.

Risk Factors for Progression of Low-Grade Dysplasia in Patients With Barrett's Esophagus

Data vary on the progression of low-grade dysplasia (LGD) in patients with Barrett's esophagus (BE); in patients with LGD, we investigated the incidence of high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) and compared progression in patients with different forms of LGD (prevalent vs incident and multifocal vs unifocal). We assessed the effects of consensus diagnosis of LGD on progression rates to HGD and EAC among expert pathologists. In a multicenter outcomes project, 210 patients with BE and LGD (classified as incident, prevalent, or persistent) were included. Patients were followed up for an average of 6.2 years (959.6 patient-years). Persistent LGD was defined as detection of LGD on ≥2 consecutive occasions during the follow-up period and extent as either unifocal (LGD at one level of BE segment) or multifocal (>1 level). Histology specimens were reviewed by 2 blinded pathologists. Six patients developed EAC (incidence of 0.44%/year), and 21 developed HGD (incidence of 1.6%/year). The incidence of the combination of HGD and EAC was 1.83%/year. There were no associations between presence of prevalent, incident, or persistent LGD and the extent of LGD with progression rates. Based on consensus diagnosis of 88 reviewed specimens, there was no difference in the progression of LGD to either EAC (the incidence based on analyses by the local pathologist was 0.18%/year, the incidence when there was agreement between the local and one central pathologist was 0.21%/year, and the incidence when all 3 pathologists were in agreement was 0.39%/year) or combined HGD and EAC (0.94%/year, 0.87%/year, and 0.84%/year, respectively). Overall, patients with BE and LGD have a low annual incidence of EAC, similar to nondysplastic BE. There are no risk factors for progression and there is significant interobserver variation in diagnosis, even among expert pathologists.

Canadian Provincial Trends in Antihypertensive Drug Prescriptions Between 1996 and 2006

Background Little is known regarding potential differences in antihypertensive prescribing practices at a Canadian provincial level. Our objective was to determine provincial differences in the use of antihypertensive drug therapy in Canada. Methods Using longitudinal drug data (IMS CompuScript database; IMS Health Canada), we examined the increase in number of prescriptions dispensed for all antihypertensive agents for each province over an 11-year period (1996-2006). Results Over the 11-year study period, antihypertensive prescriptions increased by 106.2% for single-drug therapy (from 35.8% in Prince Edward Island and Newfoundland to 167.2% in British Columbia) and by 112.8% (from 22.0% in New Brunswick to 216.0% in Québec) for combination-drug therapy. Among drug classifications, angiotensin receptor blockers had the largest increase for single-drug therapy and angiotensin-converting enzyme inhibitors–diuretics for combination-drug therapy. There were marked provincial differences in the increase in total antihypertensive therapy, ranging from British Columbia, with an increase of 262%, to Prince Edward Island and Newfoundland, where the increase was 134%. Conclusion Large increases in antihypertensive prescriptions occurred in all provinces of Canada, but the provinces varied substantially in the increase in total and drug-specific classes of antihypertensive drugs. The basis for provincial differences in antihypertensive prescriptions remains unknown and is likely multifactorial but may relate in part to initial provincial variations in diagnosis, treatment, and control of hypertension, as well as individual provincial drug policies.

151 Geographical variation in diagnoses of myelodysplastic syndromes: Preliminary results of a prospective multinational non-interventional registry of anaemia patients (TORS)

151 Geographical variation in diagnoses of myelodysplastic syndromes: Preliminary results of a prospective multinational non-interventional registry of anaemia patients (TORS)

Air ambulance services in the Arctic 1999-2009: a Norwegian study

Air ambulance services in the Arctic have to deal with remote locations, long distances, rough weather conditions and seasonable darkness. Despite these challenges, the people living in the area expect a high quality of specialist health care. The objective of this study was to analyse the air ambulance operations performed in the Norwegian Arctic and study variations in diagnoses and flight patterns around the year. A retrospective analysis. All air ambulance operations performed during the time 1999 - 2009 period were analysed. The subjects were patients transported and flights performed. The primary outcome measures were patients' diagnoses and task patterns around the year. A total of 345 patients were transported and 321 flights performed. Coronary heart and vascular disease, bone fractures and infections were the most common diagnoses. Most patients (85%) had NACA score 3 or 4. Half of all fractures occurred in April and August. Most patients were males (66%), and one fourth was not Norwegian. The median flying time (one way) was 3 h 33 m. Ten percent of the flights were delayed, and only 14% were performed between midnight and 8.00 AM. The period April to August was the busiest one (58% of operations). Norway has run a safe air ambulance service in the Arctic for the last 11 years. In the future more shipping and polar adventure operations may influence the need for air ambulances, especially during summer and autumn.

Variations in the epidemiology of primary, secondary and early latent syphilis, England and Wales: 1999 to 2008

ObjectiveTo investigate factors associated with variations in diagnoses of primary, secondary and early latent syphilis in England and Wales.MethodsData were derived from two sources: diagnoses made in genitourinary medicine clinics...

Global manipulation of digital images can lead to variation in cytological diagnosis

Background: With the adoption of a completely electronic workflow by several journals and the advent of telepathology, digital imaging has become an integral part of every scientific research. However, manipulating digital images is very easy, and it can lead to misinterpretations. Aim: To analyse the impact of manipulating digital images on their diagnosis. Design: Digital images were obtained from Papanicolaou-stained smears of dysplastic and normal oral epithelium. They were manipulated using GNU Image Manipulation Program (GIMP) to alter their brightness and contrast and color levels. A Power Point presentation composed of slides of these manipulated images along with the unaltered originals arranged randomly was created. The presentation was shown to five observers individually who rated the images as normal, mild, moderate or severe dysplasia. Weighted κ statistics was used to measure and assess the levels of agreement between observers. Results: Levels of agreement between manipulated images and original images varied greatly among observers. Variation in diagnosis was in the form of overdiagnosis or under-diagnosis, usually by one grade. Conclusion: Global manipulations of digital images of cytological slides can significantly affect their interpretation. Such manipulations should therefore be kept to a minimum, and avoided wherever possible.

Air ambulance services in the Arctic 1999-2009: a Norwegian study

BackgroundAir ambulance services in the Arctic have to deal with remote locations, long distances, rough weather conditions and seasonable darkness. Despite these challenges, the people living in the area expect a high quality of specialist health care.AimsThe objective of this study was to analyse the air ambulance operations performed in the Norwegian Arctic and study variations in diagnoses and flight patterns around the year.MethodsA retrospective analysis. All air ambulance operations performed during the time 1999 - 2009 period were analysed. The subjects were patients transported and flights performed. The primary outcome measures were patients' diagnoses and task patterns around the year.ResultsA total of 345 patients were transported and 321 flights performed. Coronary heart and vascular disease, bone fractures and infections were the most common diagnoses. Most patients (85%) had NACA score 3 or 4. Half of all fractures occurred in April and August. Most patients were males (66%), and one fourth was not Norwegian. The median flying time (one way) was 3 h 33 m. Ten percent of the flights were delayed, and only 14% were performed between midnight and 8.00 AM. The period April to August was the busiest one (58% of operations).ConclusionsNorway has run a safe air ambulance service in the Arctic for the last 11 years. In the future more shipping and polar adventure operations may influence the need for air ambulances, especially during summer and autumn.

Variation in Diagnosis of Apnea in Moderately Preterm Infants Predicts Length of Stay

Apnea of prematurity is one of the most common diagnoses in the NICU. Because resolution of apnea is a usual precondition for discharge from the hospital, different monitoring practices might affect length of stay for premature infants. Our objective was to compare the proportion of 33 to 34 weeks' gestational age infants diagnosed with apnea in different NICUs and to assess whether variability in length of stay would be affected by the rate of documented apnea. This was a prospective cohort study of moderately preterm infants who survived to discharge in 10 NICUs in Massachusetts and California. The study population comprised 536 infants born between 33 and 34/7 weeks of which 264 (49%) were diagnosed with apnea. The mean postmenstrual age at discharge was higher in infants diagnosed with apnea compared with those without apnea (36.4 ± 1.3 vs 35.7 ± 0.8; P < .001, analysis of variance). Significant inter-NICU variation existed in the proportion of infants diagnosed with apnea (range: 24%-76%; P < .001). Postmenstrual age at discharge also varied between NICUs (range: 35.5 ± 0.6 to 36.7 ± 1.5 weeks; P < .001). As much as 28% of the variability in postmenstrual age at discharge between NICUs could be explained by the variability in the proportion of infants diagnosed with apnea. NICUs vary in the proportion of moderately preterm infants diagnosed with apnea, which significantly affects length of stay. Standardization of monitoring practices and definition of clinically significant cardiorespiratory events could have a significant impact on reducing the length of stay in moderately preterm infants.

Variation in Diagnosis of Apnea in Moderately Preterm Infants Predicts Length of Stay

Variation in Diagnosis of Apnea in Moderately Preterm Infants Predicts Length of Stay

Idiopathic CD4 Lymphocytopenia Due to Loss of Heterozygosity of the Mutant CD2 Gene

AbstractAbstract 2774Idiopathic CD4 lymphocytopenia (ICL) is defined as persistent depression of CD4+ T cells with the absence of any known causes including HIV infection or drugs. Although sporadic case reports of ICL suggest heterogeneity of the disease, its mechanisms remain largely unknown. We experienced a case of ICL with decreased CD2 expression that was indicated to be due to loss of heterozygosity (LOH) of CD2 gene. A 40-year-old previously healthy man presented with dry cough and high fever. He was diagnosed as pneumonia which turned out to be Pneumocystis carinii infection by the PCR examination of bronchoalveolar lavage fluid. Ultrasonographic screening revealed multiple liver tumors, and fine needle aspiration biopsy of the liver led to the diagnosis of diffuse large B-cell lymphoma. He soon developed systemic lymphadenopathy and brain tumors, and histological examination of inguinal lymph node revealed Hodgkin lymphoma. In spite of the discrepant histological diagnoses of the liver and the inguinal lymph node, both lymphoma cells were shown to be positive for EBER-ISH. Flow cytometric analysis of his peripheral blood cells revealed a significant decrease in CD3+ T-cell counts (111 cells/μl) with 32 cells/μl CD4+ T cells, although he was negative for HIV infection. Of note, CD2 expression was severely diminished on both T and NK cells, and more than half of TCRαβ positive T cells were CD4/CD8 double negative. No cell clonality was detected by TCR gene rearrangement analysis, indicating that these T cells with abnormal phenotypes constitute a polyclonal population. Thus both pneumonia and EBV-associated lymphomas were considered to be opportunistic complications of T-cell immunodeficiency. He was given 2 courses of chemotherapy and whole brain irradiation, but these treatments resulted in poor response. He finally received allogeneic bone marrow transplantation from an HLA-matched unrelated donor, and his tumors gradually decreased with successful engraftment of donor cells with normal CD2 expression. CD2 is a glycoprotein that mediates adhesion of T cells to antigen presenting cells and provides a positive costimulatory signal for TCR-mediated activation of T cells. Decreased CD2 expression has previously been documented in 2 cases of ICL (J Clin Immunol 1994;14:359, Ann Allergy Asthma Immunol 2006;98:294), but its pathogenesis has not been clarified. To elucidate the immunomodulatory effect of CD2 deficiency, we performed a functional assay of the patient's native T cells by stimulating with PMA and ionomycin. They showed biased cytokine production with excessive Th2 and suppressed Th1 responses. We established an EBV-immortalized lymphoblastoid B-cell line (LCL) from a healthy volunteer and examined autologous T-cell activity against LCL with or without the presence of CD2-blocking antibody. Blocking of CD2 signaling resulted in suppressed cytotoxic activity of T cells, indicating that CD2 is crucial to the cellular immune response against EBV-infected cells. To explore the mechanism of CD2 downregulation, CD2 transcript of the patient's blood cells was examined by RT-PCR. The result barely demonstrated the CD2 transcript of normal length, suggesting that CD2 downregulation was caused by its decreased transcriptional activity and not by the production of abnormal transcript. CD2 gene is comprised of 5 exons, and the promoter regions were previously identified in 5′- and 3'-flanking regions. Although no mutation was found within the exons or known 5'- and 3'-promoter regions of CD2 gene of the patient's blood cells, 1 homozygous mutation was detected in intron 4. In addition, 2 homozygous single nucleotide polymorphisms (SNPs) were observed in exon 5 and 3'-flanking region of CD2, which suggested LOH of CD2 allele. The mutation found in intron 4 was suspected to impair an AP-1 binding motif, and luciferase reporter assay using Jurkat cell line demonstrated that this mutation led to significant decrease in transcriptional activity of the region. This is the first report that has indicated LOH of the mutant CD2 allele is one of the underlying mechanisms of ICL. Our findings suggest that some cases of unexplained immunodeficiency may be caused by genetic abnormalities of immunoregulatory genes in apparently normal, non-malignant hematological cells. Disclosures:No relevant conflicts of interest to declare.

Parent–youth agreement on symptoms and diagnosis: Assessment with a diagnostic interview in an adolescent inpatient clinical population

Diagnostic information on adolescents may be elicited from both youths and their parents, especially for depressive and suicidal symptomatology. The objective of this study was to examine the degree of agreement between parent and adolescent reports of major psychiatric disorders, at the diagnostic and at the symptom level, in a severely affected inpatient clinical population. 64 parent–adolescent pairs were interviewed separately with the semi-structured diagnostic interview Kiddie-SADS-PL. Symptomatology was also assessed with 11 self-report and parent-report scales, all translated, adapted and in most cases validated in Iceland. A total of 25 subscales were included to assess emotional dimensions such as depression or anxiety and cognitive dimensions such as attention deficit or self-concept. Good agreement was found for social phobia and fair agreement for generalized anxiety disorder. Although parent–youth agreement was poor in most cases at the symptoms level, significant correlations indicated consistency for most severity scores, except those related to depressive symptomatology, attention deficit, separation anxiety or conduct disorder. The low agreement between reports of suicidal ideation is in line with results from previous studies and suggests that parents might under- or over-estimate this symptomatology. The combination of data obtained with diagnostic interviews and rating-scales confirmed results from prior empirical work, giving greater weight to parents’ reports of observable behavior and to adolescents´ reports of subjective experiences, especially depressive symptomatology. Our findings suggest that both parent and child informants are necessary to obtain adequate assessments in adolescents. Further research should explore the correspondence between discrepant diagnoses and external criteria such as parental psychopathology or parent–child relationships and attachment. Psychoanalysis could benefit from cognitive neuroscience and use cognitive assessments as interesting tools. Thus, cognitive assessments can show discrepant results according to parents’ or adolescents’ reports and can therefore shed light on the parent–child interaction and relational dynamics. Inversely, cognitive neuroscience could benefit from psychoanalysis by taking into account, when interpretating the scores, the relational dynamics and the personal history of the rater.

Diagnosis and management of pneumonia and bronchitis in outpatient primary care practices

To understand which clinical criteria physicians use to diagnose pneumonia compared to bronchitis and upper respiratory tract infection (URTI). Retrospective chart review of adults diagnosed with pneumonia, bronchitis, or URTI. Logistic regression analysis identified rales, a temperature > 100 degrees F (37.8 degrees C), chest pain, dyspnoea, rhonchi, heart rate, respiratory rate, and rhinorrhoea, as the best explanation for the variation in diagnosis of pneumonia compared to either of the alternative diagnoses (R2 = 59.3), with rales and a temperature > 100 degrees F explaining 30% of the variation. Rales, chest pain, and a temperature > 100 degrees F best predicted the ordering of a chest x-ray (R2 = 20.0). However, 35% (59/175) of patients diagnosed with pneumonia had a negative chest x-ray. Abnormal breath sounds were the best predictors for prescribing antibiotics (R2 = 38%). A significant number of patients with acute bronchitis (93% excluding sinusitis) and URTI (42%) were given antibiotics. The presence of abnormal breath sounds and a temperature > 100 degrees F were the best predictors of a diagnosis of pneumonia.

Necessity of Routine Pathological Examination After Surgical Excision of Wrist Ganglions

The value of routine pathological evaluation of ganglion cysts is questionable considering that the pretest odds of a wrist lesion being a ganglion cyst are usually high based on physical examination and surgical findings alone. This study evaluates the necessity of routine pathological examination of specimens derived from surgical removal of wrist ganglion cysts. We identified 429 consecutive adult patients who underwent surgical excision of a wrist ganglion with routine pathological examination of the specimen between 1997 and 2008. The rates of concordant, discrepant, and discordant diagnoses were reported with 95% confidence intervals. The odds of a discrepant or discordant diagnosis were calculated. The prevalence of a concordant diagnosis was 98.6% (424 of 429; 95% confidence interval, 97.3% to 99.6%). The prevalence of a discrepant diagnosis was 1.4% (5 of 429; 95% confidence interval, 0.38% to 2.7%), and the prevalence of a discordant diagnosis was zero. The odds ratio was 0.012 for a discrepant diagnosis and zero for a discordant diagnosis. This study suggests that, in patients with the clinical diagnosis of wrist ganglion cyst, quality of care would not be compromised by abandoning the practice of routinely submitting surgical specimens for pathological examination after excision of the ganglion cyst. Discrepant diagnoses are encountered infrequently and discordant diagnoses did not occur. We recommend pathological examination only when the clear gelatinous fluid typical of a ganglion cyst is not encountered at surgery.