Diagnósticos clínicos al ingreso y al egreso de pacientes hospitalizados en Medicina Interna, Geriatría e Infecciosos / Clinical diagnoses in admission and in discharge of patients admitted to Internal Medicine, Geriatrics and Infection wards

A partir de asumir que una coincidencia entre el diagnóstico inicial al ingreso y el definitivo al egreso, refleja alta calidad en el cumplimiento de ese paso esencial del método clínico, se revisaron los resultados de dos series de pacientes hospitalizados en Medicina Interna, Geriatría e Infecciosos, para precisar factores asociados con dicha correspondencia. Se constató total coincidencia en más de las dos terceras partes de los casos, con porcentajes elevados en los más jóvenes, los que tuvieron menor estadía y los que ingresaron en el horario de las guardias. Se destacan los altos valores para enfermedades respiratorias e infecciosas y más bajos para diagnósticos menos precisos, como anemias, síntomas y signos mal definidos y para los ingresados en Geriatría. Se hacen consideraciones sobre el error diagnóstico y la trascendencia de estos resultados para los pacientes y la organización de la atención hospitalaria

The assumption that there is a coincidence between the initial diagnosis at admission and the definite at discharge reflects a high quality in fulfillment of this essential step of clinical method. Results from two series of patients admitted in Internal Medicine, Geriatrics and infectiuos diseases departments were reviewed to specify exactly the factors associated with such correspondence. Authors verified the total coincidence in more than the two third of cases with high percentages in younger, which had a minor stage and those admitted in the medical duty times. Emphasized are the higher values for the respiratory and infectious diseases and lower for fewer accurate diagnoses including anemias, ill-defined symptoms and signs and for those admitted in Geriatrics department. We took into account on the diagnostic error and the importance of these results for patients and the organization of hospital care

Challenges in neurosurgical intraoperative consultation.

BACKGROUND: Intraoperative consultation for neurosurgical specimens can be difficult at times, despite the use of both frozen section and squash preparation. Various factors influence the diagnostic accuracy of these procedures. This study was conducted to evaluate reasons for discordant case results in neurosurgical intraoperative consultations and make a comparative analysis of these two commonly used methods to identify the possible pitfalls, errors, and limitations. MATERIALS AND METHODS: All the neurosurgical cases received in the Department of Pathology for intraoperative consultation over a period of 3 years were studied retrospectively. The slides of frozen sections and squash preparation were retrieved and the diagnosis was compared with the final diagnosis given on paraffin-embedded sections. RESULTS AND OBSERVATIONS: A total of 6% of the cases were found to be discordant; these included angiomatous meningioma, Non-Hodgkins lymphoma, metastatic renal cell carcinoma, cerebellopontine angle fibrous meningioma, and craniopharyngioma. Highly vascular lesions, unavailability of squash preparation in a few cases and technical errors like thick smears, excessively crushed specimen, freezing, and cautery induced and crushing artifacts contributed to misdiagnosis. CONCLUSION: The discrepant cases need to be reviewed regularly by pathologists to familiarize themselves with the morphological changes and artifacts. The knowledge of possible errors could minimize misinterpretation and help in providing a more conclusive opinion to the operating surgeon.

Clinical diagnosis of depression in primary care: a meta-analysis.

BACKGROUND: Depression is a major burden for the health-care system worldwide. Most care for depression is delivered by general practitioners (GPs). We assessed the rate of true positives and negatives, and false positives and negatives in primary care when GPs make routine diagnoses of depression. METHODS: We undertook a meta-analysis of 118 studies that assessed the accuracy of unassisted diagnoses of depression by GPs. 41 of these studies were included because they had a robust outcome standard of a structured or semi-structured interview. FINDINGS: 50 371 patients were pooled across 41 studies and examined. GPs correctly identified depression in 47.3% (95% CI 41.7% to 53.0%) of cases and recorded depression in their notes in 33.6% (22.4% to 45.7%). 19 studies assessed both rule-in and rule-out accuracy; from these studies, the weighted sensitivity was 50.1% (41.3% to 59.0%) and specificity was 81.3% (74.5% to 87.3%). At a rate of 21.9%, the positive predictive value was 42.0% (39.6% to 44.3%) and the negative predictive value was 85.8% (84.8% to 86.7%). This finding suggests that for every 100 unselected cases seen in primary care, there are more false positives (n=15) than either missed (n=10) or identified cases (n=10). Accuracy was improved with prospective examination over an extended period (3-12 months) rather than relying on a one-off assessment or case-note records. INTERPRETATION: GPs can rule out depression in most people who are not depressed; however, the modest prevalence of depression in primary care means that misidentifications outnumber missed cases. Diagnosis could be improved by re-assessment of individuals who might have depression. FUNDING: None.

Misdiagnosis due to gastrointestinal symptoms in an adolescent with probable autonomic status epilepticus and Panayiotopoulos syndrome.

Panayiotopoulos syndrome is a common benign epilepsy affecting otherwise healthy children that present with autonomic seizures, in which nausea, retching, and vomiting are particularly common and prominent. Because of the unusual ictal symptoms and lengthy manifestations, misdiagnosis is a common major problem. We describe a young girl with intractable and lengthy vomiting attacks, several admissions to hospitals, and extensive gastroenterological workup for several years from early childhood. On all previous occasions the diagnosis varied from psychosomatic disease, to functional dyspepsia, to cyclic vomiting syndrome. The possibility of autonomic epileptic seizures and Panayiotopoulos syndrome, though likely, was not considered.

Does incorrect level needle localization during anterior cervical discectomy and fusion lead to accelerated disc degeneration?

STUDY DESIGN: Retrospective radiographic analysis. OBJECTIVE: To retrospectively review a group of patients undergoing anterior cervical discectomy and fusion (ACDF) to determine the relative risk of adjacent level disc degeneration after incorrect needle localization. SUMMARY OF BACKGROUND DATA: The needle puncture technique is a well-established method to cause disc degeneration in experimental animal studies. The risk for accelerated degeneration because of needle puncture in humans is unknown. METHODS: A retrospective radiographic analysis of 87 consecutive patients after single or 2-level ACDF with anterior plate instrumentation was performed. Perioperative and follow-up radiographs were used to grade disc degeneration according to a previously described scale. RESULTS: Eighty-seven patients were included in the study (36 underwent 1-level ACDF, and 51 underwent 2-level ACDF). Seventy-two had correct needle localization at the level of planned surgery; 15 had incorrect needle localization (1 level above the operative level). There were no differences between the 2 groups in age, sex and length of follow-up. Patients in the incorrectly marked group were statistically more likely to demonstrate progressive disc degeneration with an odds ratio of 3.2. There was no correlation between age and length of follow-up with development of disc degeneration. CONCLUSION: There is a 3-fold increase in risk of developing adjacent level disc degeneration in incorrectly marked discs after ACDF at short-term follow-up. This may indicate that either needle related trauma or unnecessary surgical dissection contributes to accelerated adjacent segment degeneration.

Analysis of factors associated with volumetric data errors in gamma knife radiosurgery.

OBJECT: Gamma knife (GK) surgery is an important part of the treatment armamentarium for benign and malignant brain tumors. In general, quantitative volumetrical analysis of the tumor on neuroimaging studies is the most reliable method of assessment of the tumor's response and is critical for accurate dose planning. This study evaluated various factors contributing to volumetric data error of tumors treated with GK radiosurgery. METHOD: Three differently shaped phantoms (spherical, rectangular, and irregular morphology) were created by immersing like shaped objects into 2% agarose gel. The volumes of phantoms were measured by laser scanning with errors <1%. MRI sequence and parameters including time of flight (TOF), T(1), T(2), different slice thickness, size of field of view (FOV), phase FOV as well as different position and axis of phantoms were retrieved and transferred to a Perfexion Gamma Knife Workstation (PGK-WS) and Picture Archiving and Communication System (PACS) for data analysis. The volumetric data errors were presented as the volume difference between those computed on the PGK-WS and actual volume measured by laser scanning divided by the actual laser scanning volume. The systemic error was defined as volume discrepancy between Perfexion and PACS over that in Perfexion. One-way ANOVA was used for evaluation of data errors between different methods as well as for factor analysis. RESULTS: The MRI-computed volume of the various phantoms approached the laser-scanned volume within 2% when the slice number was >or=30. The volumetrical data errors (10/5 slices) associated with various MRIs for phantoms were 6.94 +/- 0.04%/9.45 +/- 0.35% (spherical phantom), 12.3 +/- 0.2%/ 20.06 +/- 0.7% (rectangular phantom), and 9.29 +/- 0.078%/ 15.67 +/- 0.6% (irregular phantom) (p < 0.001 and p < 0.001), respectively. The system errors (10/5 slices) associated with various MRIs for the phantoms were 3.17 +/- 0.11%/3.9 +/- 0.13% (spherical phantom), 3.61 +/- 0.12%/4.01 +/- 0.12% (rectangular phantom), and 4.39 +/- 0.07%/4.75 +/- 0.13% (irregular phantom) (p < 0.001 and p = 0.01), respectively. The volumetric data errors were related to the number of slices and the shape of phantom, but the systemic errors were only related to the irregularity of phantom morphology. The volumetrical data errors were not related to size of the FOV, phase FOV, sequence of T(1), T(2), TOF, and position of phantom. For the rectangular phantom, the data error was related to slice orientation of imaging acquisition (p < 0.001). CONCLUSION: Volume discrepancies existed between those volumes computed by the PGK-WS and volumes determined by laser scanning. The volumetric data errors were reduced through the acquisition of more slices through the phantom and a more spherical morphology of the phantom. Relatively few system volume errors were observed between those by the PGK-WS and PACS except for a significant discrepancy for the irregular surface phantom. For the rectangular-shaped phantom, the volumetric data errors were significantly related to slice orientation of measurement. When measuring the tumor response in GK radiosurgery or follow-up, an error of as large as 20% is possible for irregularly shaped object and with MRIs using

An uncommon skin condition illustrates the need for caution when prescribing for friends.

PURPOSE: A dual-focused case study written to discuss the legal and medical hazards of informally writing prescriptions for friends or family members and to provide knowledge of early-stage mycosis fungoides (MF), its course, and treatment. DATA SOURCES: A review of the prescribing practices of clinicians, the cognitive processes needed in diagnosis and treatment, the current ethical guidelines, and a review of MF, its course, and treatments. CONCLUSIONS: Treating acquaintances and family informally places clinicians at risk for liability and patients at risk for inaccurate diagnosis and treatment. This case illustrates the potential hazard of casually treating a friend for what looks like a benign condition. Resembling atopic dermatitis in its early stages, MF is the most common of a rare group of skin lymphomas. Early diagnosis and treatment are crucial for a better prognosis. Had this clinician complied with the request of her friend, his diagnosis would have been missed and timely treatment delayed. IMPLICATIONS FOR PRACTICE: No matter what the prior relationship may have been, once a clinician treats a patient, a legally binding relationship begins, requiring the due standard of care. Nurse practitioners (NPs) need to be aware of the potential for error when treating acquaintances. Available NP standards of practice and ethical guidelines should address informal treatment situations.

Effects of misdiagnosis in input data on the identification of differential expression genes in incipient Alzheimer patients.

Gene expression profiles of 16 Alzheimer's (AD) patients, diagnosed as incipient or healthy using Mini-Mental State Examination and Neurofibrillary Tangles scores, were analyzed to validate the reclassification of 4 subjects previously identified as being misdiagnosed. Three datasets were created using original classifications (D1), new classifications, based on a misclassification algorithm (D2), and by removing questionable subjects (D3). Mixed model analysis was used to identify differentially expressed genes. Many genes related to the nervous system and AD were found to be differentially expressed in D2 and D3, while few genes, none related to NS or AD, were found using D1. Several additional relevant genes were found when using D2 versus D3, which were likely due to differences in sample size. These results suggest the 4 questionable subjects were likely misclassified in D1. The similarities between results obtained using D2 and D3 provides further evidence of the adequacy of the misclassification algorithm.

The role of treatment setting and high acuity in the overdiagnosis of schizophrenia in African Americans.

Multiple studies have shown that significant disparities exist in the diagnosis of schizophrenia between African Americans (AAs) and Whites with severe mental illness. This phenomenon has been a topic in the literature for nearly three decades, yet it remains unclear what factors contribute most conclusively to the overdiagnosis of schizophrenia in AAs. The purpose of this article was to collectively examine the contributing factors identified in the literature and to discuss the role of acuity and treatment setting in overdiagnosis as well. A variety of client-level (higher rates of use of psychotomimetic substances in AAs) and care process-level (misinterpretation of cultural mistrust as paranoia, under detection of depression, similarities in diagnostic criteria between mood and psychotic disorders, provider bias, miscommunication between patient and provider, changes in diagnostic criteria, differences in diagnostic practice between providers, and a lack of sufficient data obtained) factors emerged as influential in overdiagnosis. However, in this review, it also emerged that AAs tendency to use emergency and acute care services, a systems level factor, could be related as well. It is possible that assessment at a time when symptom acuity is severe might increase the likelihood of a schizophrenia diagnosis in AAs.

An iatrogenic enchondroma? An unusual X-ray finding.

In this unusual case, accumulation of silver nitrate used to treat over-granulation in a finger injury led to a near-misdiagnosis of a bony tumour on X-ray. This underlines the need to support X-ray results with a full clinical assessment.

Potential misdiagnosis of 3-methylcrotonyl-coenzyme A carboxylase deficiency associated with absent or trace urinary 3-methylcrotonylglycine.

We report 2 patients with isolated 3-methylcrotonyl-coenzyme A carboxylase deficiency whose urine was devoid of, or contained only trace, 3-methylcrotonylglycine, the pathognomonic marker for this disorder. The first patient, a girl with trisomy 21, was detected through newborn screening with an elevated 5 carbon hydroxycarnitine species level, and the second patient came to clinical attention at the age of 5 months because of failure to thrive and developmental delay. Investigation of urinary organic acids revealed an elevated 3-hydroxyisovaleric acid level but no demonstrable 3-methylcrotonylglycine in both patients. Enzyme studies in cultured fibroblasts confirmed isolated 3-methylcrotonyl-coenzyme A carboxylase deficiency with residual activities of 5% to 7% and 12% of the median control value, respectively. Incorporation of 14C-isovaleric acid into intact fibroblasts was essentially normal, showing that the overall pathway was at least partially functional and potentially explaining the absence of 3-methylcrotonylglycine in urine. Mutation analysis of the MCCA and MCCB genes revealed that both patients were compound heterozygous for a missense mutation, MCCB-c.1015G-->A (p.V339M), and a second mutation that leads to undetectable MCCB messenger (poly A+) RNA. Absent or trace 3-methylcrotonylglycine levels in urine raises the potential for misdiagnosis in the clinical biochemical genetics laboratory based solely on urine organic acid analysis using combined gas chromatography-mass spectrometry.

Relative performance of three methods for diagnosing bacterial vaginosis during pregnancy.

OBJECTIVE: This study measures the relative performance of three methods for diagnosing bacterial vaginosis (BV) during pregnancy and assesses the implications of measurement for clinical practice and surveillance. METHODS: A sample (n = 1,780) of English or Spanish speaking women, with a singleton intrauterine pregnancy and receiving prenatal care at a consortium of public health centers in Philadelphia were consecutively enrolled. Gram stain, clinician's diagnosis, and a commercial test were the three diagnostic methods used to assess BV. Sensitivity, specificity, and the positive and negative predictive values of clinical diagnosis and the commercial test were assessed using the gram stain/Nugent score as a gold standard. RESULTS: The prevalence of BV, measured on the same population, differed considerably depending on the diagnostic test used. The measured prevalences were 55% (Gram stain), 28.5% (clinician's diagnosis), and 12.6% (commercial test). The prevalence of BV (diagnosed by gram stain) was twice as high among African American women compared to White women. Only 69% BV-positive high-risk women were treated for BV. CONCLUSIONS: Inaccurate diagnosis of BV leads to missed cases. The identification of true cases is critical for assigning treatment and for assessing treatment effectiveness. Clinician's routine diagnosis fell short of recommended procedures and performed poorly compared to gold standard in case ascertainment. This inability to ascertain cases may have an impact on our ability to prevent preterm birth.

Tc-99m ECD neuro-SPECT and diffusion weighted MRI in the detection of the anatomical extent of subacute stroke: a cautionary note regarding reperfusion hyperemia.

We present a case of subacute middle cerebral artery infarct, which demonstrates restricted diffusion on MRI and reperfusion hyperemia in the posterior half of the lesion on angiography. Tc-99m ethyl cysteinate dimer (ECD) SPECT obtained shortly after the MRI failed to demonstrate perfusion defects in the regions demonstrating reperfusion hyperemia on angiography, underestimating the true size of the infarct. Crossed cerebellar diaschisis is, however, present. SPECT studies obtained over the following weeks demonstrated gradual enlargement of the lesion to approximate the MRI signal changes over a 19-day period. The case presented demonstrates retention of ECD in the infarcted brain. Several studies have demonstrated that Tc-99m ECD uptake is dependent on preserved brain tissue function because tracer retention requires enzymatic esterase activity, rather than the passive, nonenergy dependent trapping of Tc-99m hexamethylpropyleneamine oxime. Hence, infarcted areas undergoing reperfusion hyperemia are unlikely to demonstrate ECD uptake. This report illustrates that MRI diffusion weighted imaging may be more accurate in demonstrating the full extent of reperfused infarcts earlier than Tc-99m ECD SPECT. SPECT in this case failed to demonstrate reduced uptake in reperfused regions of the infarct. Also, crossed cerebellar diaschisis may serve as an early marker of extensive neuronal dysfunction.

2B or not 2B? Disparate discrimination of functional VWF discordance using different assay panels or methodologies may lead to success or failure in the early identification of type 2B VWD.

Laboratory proficiency in the identification of functional von Willebrand factor (VWF) discordance in type 2B von Willebrand disease (VWD) was assessed by external quality assurance surveys conducted by the RCPA Haematology QAP, and using six different type 2B VWD plasma samples (three historical and three previously unpublished) tested by up to 52 laboratories. For the three most recent samples, functional VWF discordance was either not identified in testing or by interpretation with misidentification as 'normal' or 'type 1 VWD', on average for 25.7% of test occasions when laboratories performed VWF:Ag and VWF:RCo as their primary VWF test panel, but somewhat fewer occasions (10.9%) for laboratories that incorporated VWF:CB as an additional functional VWF assay. VWF assay sub-methodologies also influenced the appropriate identification of samples as potentially type 2 VWD, and VWF functional discordance was more consistently identified when laboratories used (i) automated platelet agglutination for VWF:RCo compared to classical platelet aggregometry, (ii) inhouse VWF:CB assays compared to commercial kit methods, and (iii) automated LIA-based 'VWF:Activity' assays compared to ELISA based assays. We conclude that:(i) laboratories are generally proficient in tests for VWD but interpretative diagnostic errors do occur; (ii) correct diagnosis is more likely when test panels are more comprehensive and include the VWF:CB; (iii) sub-methodology influences the appropriate identification of VWF functional discordance. On the basis of these findings, we provide a series of recommendations to enable the appropriate laboratory identification of VWD, in particular type 2B VWD.

Reducing missed injuries at a level II trauma center.

The phenomenon of missed injury in trauma patients has been recognized for some time. Tertiary examination has been proposed as one strategy to decrease the incidence of missed injuries. The tertiary examination is a comprehensive reevaluation that includes a repeated head-to-toe examination and review of all laboratory and radiologic studies, completed within 24 hours of admission. The purpose of this study was to assess the statistical significance of missed injuries discovered through tertiary examinations at a level II trauma center. Over a period of 6 months, a tertiary examination was completed before discharge of admitted patients who met activation criteria. Of the 90 patients, 13 had a missed injury (incidence of 14%), which was significant. The 16 missed injuries represented only 2.7% of the total 589 injuries, which was not significant. The most commonly missed injuries were fractures of the extremities. We propose that tertiary examinations be adopted as a standard of care for patients admitted to level II trauma centers.

Common misdiagnosis of a common neurological disorder: how are we misdiagnosing essential tremor?

BACKGROUND: As a common neurological disorder, the diagnosis of essential tremor (ET) is considered routine. Despite this, previous work suggests that misdiagnoses may be common. Among other things, these misdiagnoses can lead to treatment errors. OBJECTIVES: To estimate how often other tremor disorders are misdiagnosed as ET and to identify factors that increase the odds of misdiagnosing ET and to precisely quantify the extent to which they do so. DESIGN: Seventy-one consecutive patients underwent an evaluation at the Neurological Institute of New York, New York, between January 1, 2000, and December 31, 2005; these patients had a pre-evaluation diagnosis of ET. The criteria for ET were adapted from the consensus statement of the Movement Disorder Society. RESULTS: Twenty-six patients (37%) were misdiagnosed as having ET ("false ET"). Their true diagnoses were Parkinson disease (11 patients [15%]), dystonia (6 patients [8%]), Parkinson disease with ET (5 patients [7%]), and other disorders (4 patients [6%]). Factors associated with misdiagnosed ET included unilateral arm tremor (odds ratio, 10.5; 95% confidence interval, 1.2-95.4; P=.02), spooning of the hands and other dystonic postures (odds ratio, 16.3; 95% confidence interval, 4.0-66.4; P<.001), and other unusual features (isolated thumb tremor, isolated leg tremor, and non-rhythmic tremor) (odds ratio, 49.4; 95% confidence interval, 2.7-895.0; P<.001). CONCLUSIONS: About 1 in 3 patients with tremor was misdiagnosed as having ET, with the most frequent false diagnoses being Parkinson disease and dystonia. Several factors that increased the odds of misdiagnosing ET were identified. These factors could be incorporated into improved diagnostic algorithms.

Delayed recognition of a pseudo-outbreak of Mycobacterium terrae.

Pseudo-outbreaks of mycobacteria are difficult to recognize because of long incubation periods for growth and species identification. We report our experience with one clinical microbiology laboratory that isolated a species of nontuberculous mycobacteria from 14 patient specimens. These specimens came from 12 patients at 2 hospitals over a 6-day period and included 6 different fluids or tissues. Because of the delay between mycobacterial specimen submission and growth in culture, the outbreak was not noted until more than a month later. Initial species determination by a reference laboratory indicated that these isolates were Mycobacterium fortuitum. One patient received treatment for presumed M fortuitum brain infection, and it was not effective in changing her clinical course. The isolates were sent to the Centers for Disease Control and Prevention (CDC) for identification and typing by pulsed-field gel electrophoresis. The CDC determined that the isolates were an identical strain of M terrae, thus confirming a pseudo-outbreak. Combining pseudo-outbreak isolates with those correctly identified initially as M terrae during the 6-day period in question, there were 22 samples from 20 patients with M terrae. Since the pseudo-outbreak, the number of cultures of M terrae in the clinical laboratory has returned to baseline levels without any specific intervention.