Effect of different working periods on missed diagnosis of colorectal polyps in colonoscopy.

BACKGROUND: To investigate the effect of different working periods on missed diagnoses in patients with colorectal polyps in colonoscopy. METHODS: We conducted a retrospective analysis of patients who were diagnosed with colorectal polyps during colonoscopy in an outpatient department between July and December 2022. These patients were subsequently hospitalized for resection during this period. Patients with missed diagnoses were those who had newly discovered polyps in a second colonoscopy. The working periods were categorized as work, near the end of work, and delayed work, respectively, in the morning and afternoon. RESULTS: A total of 482 patients were included, and the miss rate of diagnosis was 48.1% (232/482), mainly in the transverse colon (25%), and the ascending colon (23%). Patient age was a risk factor for the miss rate of diagnosis (OR = 1.025, 95%CI: 1.009-1.042, P = 0.003) and was also associated with the number of polyps detected for the first colonoscopy (χ2 = 18.196, P = 0.001). The different working periods had no statistical effect on the missed rate of diagnosis (χ2 = 1.998, P = 0.849). However, there was an increasing trend in miss rates towards the end of work and delayed work periods, both in the morning and afternoon. The highest miss rate (60.0%) was observed during delayed work in the afternoon. Additionally, poor bowel preparation was significantly more common during delayed work in the afternoon. CONCLUSIONS: The increasing trend in miss rates towards the end of work and delayed work periods deserves clinical attention. Endoscopists cannot always stay in good condition under heavy workloads.

Kaiser score diagnosis of breast MRI lesions: Factors associated with false-negative and false-positive results.

PURPOSE: We sought factors associated with false-negative and false-positive results in the diagnosis of breast lesions using the Kaiser score (KS) on breast magnetic resonance imaging (MRI). METHODS: We retrospectively analyzed 1058 patients with 1058 breast lesions who underwent preoperative breast MRI with successful histopathologic results. Two radiologists assessed each lesion according to KS criteria, and clinicopathologic features and MRI findings were analyzed. Multivariate regression analysis was conducted to identify factors associated with false-negative and false-positive KS results. RESULTS: Of the 1058 lesions, 859 were malignant and 199 were benign. Particularly high misdiagnosis rates were observed for intraductal papilloma, inflammatory lesion, and mucinous carcinoma. For breast cancer, KS yielded 821 (95.6 %) true-positive and 38 (4.4 %) false-negative results. Multivariate analysis showed that smaller lesion size (≤1 cm) (OR, 3.698; 95 %CI, 1.430-9.567; p = 0.007), absence of ipsilateral breast hypervascularity (OR, 3.029; 95 %CI, 1.370-6.693; p = 0.006), and presence of hyperintensity on T2WI (OR, 2.405; 95 %CI, 1.121-5.162; p = 0.024) were significantly associated with false-negative breast cancer results. For benign lesions, KS yielded 141 (70.9 %) true-negative and 58 (29.1 %) false-positive results. Multivariate regression analysis revealed that non-mass enhancement lesions (OR, 4.660; 95 %CI, 2.018-10.762; p＜0.001), moderate/high background parenchymal enhancement (OR, 2.402; 95 %CI, 1.180-4.892; p = 0.016), and the presence of hyperintensity on T2WI (OR, 2.986; 95 %CI, 1.386-6.433; p = 0.005) were significantly associated with false-positive KS results. CONCLUSION: Several clinicopathologic and MRI features influence the accuracy of KS diagnosis. Understanding these factors may facilitate appropriate use of KS and guide alternative diagnostic approaches, ultimately improving diagnostic accuracy in the evaluation of breast lesions.

Underdiagnosis of umbilical hernias in CT scans in a multicenter study - the radiologically neglected pathology and its surgical implications.

PURPOSE: Umbilical hernias (UH) have a higher prevalence than previously considered. With the high workload radiologists must endure, UH can be missed when interpreting a computed tomography scan (CT). The clinical implications of its misdiagnosis are yet to be determined. Unreporting could lead to content lesions in surgical approaches and other potential complications. The aim was to determine the prevalence of UH using CT scans, and the incidence of radiological reporting. METHODS: A multicenter, cross-sectional study was performed in four tertiary-level hospitals. CT scans were reviewed for abdominal wall defects at the umbilicus, and radiological reports were examined to compare findings. In the case of UH, transversal, anteroposterior, and craniocaudal lengths were obtained. RESULTS: A total of 1557 CTs were included, from which 971 (62.4%, 95% CI 0.59-0.64) had UH. Out of those, 629 (64.8%, 95% CI 0.61-0.67) of the defects were not included in the radiological report. Smaller UH (x̄: 7.7 × 6.0 mm) were more frequently missed. Of the reported UH, 187 (54.7%) included at least one axis measurement, 289 (84.5%) content description, and 146 (42.7%) whether or not there were complication signs. CONCLUSION: There is a high prevalence of UH, and a high incidence of under-reporting. This raises the question of whether this is a population-based finding or the norm worldwide. The reason of under-reporting and the clinical implications of these must be addressed in further studies.

Paediatric-onset lymphomatoid papulosis: results of a multicentre retrospective cohort study on behalf of the EORTC Cutaneous Lymphoma Tumours Group (CLTG).

BACKGROUND: Lymphomatoid papulosis (LyP) is a rare cutaneous T-cell lymphoproliferative disorder. Comprehensive data on LyP in the paediatric population are scarce. OBJECTIVES: To characterize the epidemiological, clinical, histopathological and prognostic features of paediatric LyP. METHODS: This was a retrospective multicentre international cohort study that included 87 children and adolescents with LyP diagnosed between 1998 and 2022. Patients aged ≤ 18 years at disease onset were included. LyP diagnosis was made in each centre, based on clinicopathological correlation. RESULTS: Eighty-seven patients from 12 centres were included. Mean age at disease onset was 7.0 years (range 3 months-18 years) with a male to female ratio of 2 : 1. Mean time between the onset of the first cutaneous lesions and diagnosis was 1.3 years (range 0-14). Initial misdiagnosis concerned 26% of patients. LyP was most often misdiagnosed as pityriasis lichenoides et varioliformis acuta, insect bites or mollusca contagiosa. Erythematous papules or papulonodules were the most frequent clinical presentation. Pruritus was specifically mentioned in 21% of patients. The main histological subtype was type A in 55% of cases. When analysed, monoclonal T-cell receptor rearrangement was found in 77% of skin biopsies. The overall survival rate was 100%, with follow-up at 5 years available for 33 patients and at 15 years for 8 patients. Associated haematological malignancy (HM) occurred in 10% of cases (n = 7/73), including four patients with mycosis fungoides, one with primary cutaneous anaplastic large cell lymphoma (ALCL), one with systemic ALCL and one with acute myeloid leukaemia. If we compared incidence rates of cancer with the world population aged 0-19 years from 2001 to 2010, we estimated a significantly higher risk of associated malignancy in general, occurring before the age of 19 years (incidence rate ratio 87.49, 95% confidence interval 86.01-88.99). CONCLUSIONS: We report epidemiological data from a large international cohort of children and adolescents with LyP. Overall, the disease prognosis is good, with excellent survival rates for all patients. Owing to an increased risk of associated HM, long-term follow-up should be recommended for patients with LyP.

Lymphomatoid papulosis is a very rare skin condition caused by an abnormal increase in white blood cells (called 'lymphocytes') in the skin. The condition rarely affects children, so most of the scientific data published about this disease focuses on adults. This study involved 12 academic dermatology centres in Europe, the Middle East and North America, and gathered data from about 87 children who presented with symptoms of lymphomatoid papulosis before the age of 19 years. The aim of this study was to better describe this disease in the paediatric population and discuss its treatment options and evolution. We found that the presentation of the disease in children is roughly the same as in adults. Safe and effective treatment options exist. The disease is not life threatening, but it requires investigation by a dermatologist, both to make a careful diagnosis and to monitor it as sometimes associated cancers that originate from blood cells can occur, mostly on the skin.

Enhanced accuracy and reduced delay in diagnosing bone tumors within an expert sarcoma network: A nationwide study.

INTRODUCTION: Primary bone tumors encompass a range of rare and diverse lesions. Pathological diagnosis poses significant challenges, with histological discrepancies extensively studied in soft tissue sarcomas but lacking specific investigation in bone lesions. This study aimed to determine the rate of major diagnostic discrepancies in primary bone tumors, assessing whether initial histological analysis within an expert referral center network reduces this rate and final diagnostic delay. Additionally, we examined the impact of mandatory systematic re-reading by expert pathologists on diagnostic variation and readjustment. METHODS: Our study cohort comprised patients with primary bone tumors, drawn from the national prospective French sarcoma network database. A total of 1075 patients were included from 2018 to 2019. RESULTS: The cohort exhibited a major discrepancy rate of 24%. Within the expert referral centers network, 49 cases (7%) showed major diagnostic discrepancies in the initial analysis, compared to 207 cases (57%) outside the network (p < 0.001). Regarding the final diagnostic delay, a mean of 2.8 weeks (±4.9) was observed within the network, contrasting with 6.5 weeks (±9.1) outside the network (p < 0.001). Systematic re-reading by an expert pathologist facilitated diagnosis readjustment in 75% of the 256 cases, with 68% of all diagnostic variations occurring preoperatively. CONCLUSION: Early management within the expert network significantly reduced major diagnostic discrepancies and shortened the diagnosis delay by approximately a month. Expert pathologist systematic re-readings were responsible for diagnosis readjustments in three-quarters of cases, with two-thirds of all diagnostic variations occurring preoperatively, thereby mitigating the consequences of mistreatment.

Histopathologic evaluation of gastric intestinal metaplasia in non-neoplastic biopsy specimens: Accuracy and interobserver reliability among general pathologists and pathology residents.

OBJECTIVES: This study aimed to evaluate the accuracy and interobserver reliability of diagnosing and subtyping gastric intestinal metaplasia (IM) among general pathologists and pathology residents at a university hospital in Thailand, focusing on the challenges in the histopathologic evaluation of gastric IM for less experienced practitioners. METHODS: The study analyzed 44 non-neoplastic gastric biopsies, using a consensus diagnosis of gastrointestinal pathologists as the reference standard. Participants included 6 general pathologists and 9 pathology residents who assessed gastric IM and categorized its subtype (complete, incomplete, or mixed) on digital slides. After initial evaluations and receiving feedback, participants reviewed specific images of gastric IM, as agreed by experts. Following a one-month washout period, a reevaluation of the slides was conducted. RESULTS: Diagnostic accuracy, interobserver reliability, and time taken for diagnosis improved following training, with general pathologists showing higher accuracies than residents (median accuracy of gastric IM detection: 100 % vs. 97.7 %). Increased years of experience were associated with more IM detection accuracy (p-value<0.05). However, the overall median accuracy for diagnosing incomplete IM remained lower than for complete IM (86.4 % vs. 97.7 %). After training, diagnostic errors occurred in 6 out of 44 specimens (13.6 %), reported by over 40 % of participants. Errors involved omitting 5 slides with incomplete IM and 1 with complete IM, all showing a subtle presence of IM. CONCLUSIONS: The study highlights the diagnostic challenges in identifying incomplete gastric IM, showing notable discrepancies in accuracy and interobserver agreement. It underscores the need for better diagnostic protocols and training to enhance detection and management outcomes.

Retrospective Analysis of US Litigations Involving Dermatologists From 2011 to 2022.

BACKGROUND: Physician malpractice lawsuits are climbing, and the reasons underlying litigation against dermatologists are unclear. OBJECTIVE: To determine the reasons patients pursue litigation against dermatologists or dermatology practices. MATERIALS AND METHODS: A retrospective analysis of all state and federal cases between 2011 and 2022 was performed after a query using "Dermatology" and "dermatologist" as search terms on 2 national legal data repositories. RESULTS: The authors identified a total of 48 (37 state and 11 federal) lawsuits in which a practicing dermatologist or dermatology group practice was the defendant. The most common reason for litigation was unexpected harm (26 cases, 54.2%), followed by diagnostic error (e.g. incorrect or delayed diagnoses) (16 cases, 33.3%). Six cases resulted from the dermatologist failing to communicate important information, such as medication side effects or obtaining informed consent. Male dermatologists were sued at a rate 3.1 times higher than female dermatologists. CONCLUSION: Although lawsuits from patients against dermatologists largely involve injury from elective procedures, clinicians should practice caution regarding missed diagnoses and ensure critical information is shared with patients to safeguard against easily avoidable litigation.

Quantifying and Reducing Errors in Vascular Imaging Examination Orders Through a Multistage Quality Improvement Intervention.

PURPOSE: The aims of this study were to quantify order error rates for vascular imaging examinations and to assess the effects of a multistage quality improvement intervention on those rates. METHODS: In this prospective, institutional review board-exempt project at a large academic quaternary care hospital, the authors aimed to quantify and reduce the order error rate by 50%. The authors analyzed 844 orders for all vascular imaging examinations placed before the intervention (July 19 to August 1, 2021, and September 13 to September 26, 2021), after an intervention in the cardiac surgery department consisting of a new customized order option in the electronic health record for routine preoperative patients (postintervention 1, February 28 to March 27, 2022); and after an educational and feedback campaign (postintervention 2, May 23 to June 5, 2022). Incorrect orders were identified by a radiology trainee during protocoling if the reasons for ordered examination and imaging examination were discordant and subsequently confirmed with the ordering provider. The primary outcome, order error rate, was compared across the project periods using the χ2 test and by ordering department using the χ2 and Fisher exact tests. RESULTS: The preintervention order error rate of 16% (50 of 306) decreased by 83% to 3% (10 of 353) at postintervention 1 (P < .001) and was durable at 3% (6 of 185) by project end. Chest CT with or without contrast constituted the majority of incorrect orders (44%, 22 of 50); "Pre-Op" was the most common examination reason (32% [16 of 50]). Cardiac surgery orderers were responsible for the most incorrect orders (32% [16 of 50]). All four most common ordering departments, including cardiac surgery, reduced their order error rates after the intervention (P < .001). CONCLUSIONS: Incorrect orders for imaging examinations can be reduced through targeted quality improvement interventions combining tailored electronic health record order options with education and feedback on practice habits.

Characteristics of Disease-Specific and Generic Diagnostic Pitfalls: A Qualitative Study.

Importance: Progress in understanding and preventing diagnostic errors has been modest. New approaches are needed to help clinicians anticipate and prevent such errors. Delineating recurring diagnostic pitfalls holds potential for conceptual and practical ways for improvement. Objectives: To develop the construct and collect examples of "diagnostic pitfalls," defined as clinical situations and scenarios vulnerable to errors that may lead to missed, delayed, or wrong diagnoses. Design, Setting, and Participants: This qualitative study used data from January 1, 2004, to December 31, 2016, from retrospective analysis of diagnosis-related patient safety incident reports, closed malpractice claims, and ambulatory morbidity and mortality conferences, as well as specialty focus groups. Data analyses were conducted between January 1, 2017, and December 31, 2019. Main Outcomes and Measures: From each data source, potential diagnostic error cases were identified, and the following information was extracted: erroneous and correct diagnoses, presenting signs and symptoms, and areas of breakdowns in the diagnostic process (using Diagnosis Error Evaluation and Research and Reliable Diagnosis Challenges taxonomies). From this compilation, examples were collected of disease-specific pitfalls; this list was used to conduct a qualitative analysis of emerging themes to derive a generic taxonomy of diagnostic pitfalls. Results: A total of 836 relevant cases were identified among 4325 patient safety incident reports, 403 closed malpractice claims, 24 ambulatory morbidity and mortality conferences, and 355 focus groups responses. From these, 661 disease-specific diagnostic pitfalls were identified. A qualitative review of these disease-specific pitfalls identified 21 generic diagnostic pitfalls categories, which included mistaking one disease for another disease (eg, aortic dissection is misdiagnosed as acute myocardial infarction), failure to appreciate test result limitations, and atypical disease presentations. Conclusions and Relevance: Recurring types of pitfalls were identified and collected from diagnostic error cases. Clinicians could benefit from knowledge of both disease-specific and generic cross-cutting pitfalls. Study findings can potentially inform educational and quality improvement efforts to anticipate and prevent future errors.

Not so FAST-Chest ultrasound underdiagnoses traumatic pneumothorax.

BACKGROUND: Ultrasonography for trauma is a widely used tool in the initial evaluation of trauma patients with complete ultrasonography of trauma (CUST) demonstrating equivalence to computed tomography (CT) for detecting clinically significant abdominal hemorrhage. Initial reports demonstrated high sensitivity of CUST for the bedside diagnosis of pneumothorax. We hypothesized that the sensitivity of CUST would be greater than initial supine chest radiograph (CXR) for detecting pneumothorax. METHODS: A retrospective analysis of patients diagnosed with pneumothorax from 2018 through 2020 at a Level I trauma center was performed. Patients included had routine supine CXR and CUST performed prior to intervention as well as confirmatory CT imaging. All CUST were performed during the initial evaluation in the trauma bay by a registered sonographer. All imaging was evaluated by an attending radiologist. Subgroup analysis was performed after excluding occult pneumothorax. Immediate tube thoracostomy was defined as tube placement with confirmatory CXR within 8 hours of admission. RESULTS: There were 568 patients screened with a diagnosis of pneumothorax, identifying 362 patients with a confirmed pneumothorax in addition to CXR, CUST, and confirmatory CT imaging. The population was 83% male, had a mean age of 45 years, with 85% presenting due to blunt trauma. Sensitivity of CXR for detecting pneumothorax was 43%, while the sensitivity of CUST was 35%. After removal of occult pneumothorax (n = 171), CXR was 78% sensitive, while CUST was 65% sensitive (p < 0.01). In this subgroup, CUST had a false-negative rate of 36% (n = 62). Of those patients with a false-negative CUST, 50% (n = 31) underwent tube thoracostomy, with 85% requiring immediate placement. CONCLUSION: Complete ultrasonography of trauma performed on initial trauma evaluation had lower sensitivity than CXR for identification of pneumothorax including clinically significant pneumothorax requiring tube thoracostomy. Using CUST as the primary imaging modality in the initial evaluation of chest trauma should be considered with caution. LEVEL OF EVIDENCE: Diagnostic Test study, Level IV.

Single Shot Multibox Detector Automatic Polyp Detection Network Based on Gastrointestinal Endoscopic Images.

PURPOSE: In order to resolve the situation of high missed diagnosis rate and high misdiagnosis rate of the pathological analysis of the gastrointestinal endoscopic images by experts, we propose an automatic polyp detection algorithm based on Single Shot Multibox Detector (SSD). METHOD: In the paper, SSD is based on VGG-16, the fully connected layer is changed to a convolutional layer, and four convolutional layers with successively decreasing scales are added as a new network structure. In order to verify the practicability, it is not only compared with manual polyp detection but also with Mask R-CNN. RESULTS: Multiple experimental results show that the mean Average Precision (mAP) of the SSD network is 95.74%, which is 12.4% higher than the manual detection and 5.7% higher than the Mask R-CNN. When detecting a single frame of image, the detection speed of SSD is 8.41 times that of manual detection. CONCLUSION: Based on the traditional pattern recognition algorithm and the target detection algorithm using deep learning, we select a variety of algorithms to identify and classify polyps to achieve efficient detection results. Our research demonstrates that deep learning has a lot of room for development in the field of gastrointestinal image recognition.

A Comparison of Two Widely Used Risk Stratification Systems for Thyroid Nodule Sonographic Evaluation.

BACKGROUND: The 2015 American Thyroid Association (ATA2015) and the American College of Radiology Thyroid Imaging and Reporting Data System (ACR TI-RADS) are two widely used thyroid sonographic systems. OBJECTIVES: To compare the two systems for accuracy of cancer risk prediction. METHODS: Preoperative ultrasound images from 265 patients who underwent thyroidectomy at our hospital from January 2012 to March 2019 were retrospectively categorized by the ACR TI-RADS and ATA2015 systems. Diagnostic performances were compared. RESULTS: Of 238 nodules assessed, 115 were malignant. Malignancy risks for the five ACR TI-RADS categories were 0%, 7.5%, 11.4%, 59.6%, and 90.0%. Malignancy risks for the five ATA2015 categories were 0%, 6.8%, 17.0%, 55.5%, and 92.1%. The proportion of total nodules biopsied was higher with the ATA2015 system than the ACR TI-RADS system: 88.7% vs. 66.3%. Proportions of malignant nodules and benign nodules biopsied were higher with ATA2015 than with ACR TI-RADS: 93.3% vs. 87.8% and 84.4% vs. 46.3%, respectively. Specificity and sensitivity rates were 53.6% and 84.3%, respectively, for ACR TI-RADS, and 15.5% and 93.3%, respectively, for ATA2015. The two systems showed similarly accurate diagnostic performance (AUC > 0.88). False negative rates for ACR TI-RADS and ATA2015 were 15.6% and 6.6%, respectively. Rates of missed aggressive cancer were similar for the two systems: 3.4% and 3.7%, respectively. CONCLUSIONS: ACR TI-RADS was superior to ATA2015 in specificity and avoiding unnecessary biopsies. ATA2015 yielded better sensitivity and a lower false negative rate. Identification of aggressive cancers was identical in the two systems.

Underdiagnosis of obstructive lung disease: findings from the French CONSTANCES cohort.

BACKGROUND: The burden of undiagnosed obstructive lung disease (OLD) (mainly asthma and chronic obstructive pulmonary disease) is not fully established, and targets for corrective action are yet to be identified. We assessed the underdiagnosis of OLD and its determinants in France. METHODS: CONSTANCES is a French population-based cohort of adults aged 18-69 years at inception. We analysed data collected at inclusion in 2013-2014. Undiagnosed OLD was defined as spirometry-confirmed airflow limitation (FEV1/FVC < lower limit of normal) without prior diagnosis of asthma, chronic obstructive pulmonary disease, or bronchiectasis. Multivariate analysis was performed with weighted robust Poisson regression models to estimate the adjusted prevalence ratios (aPR) of undiagnosed OLD. RESULTS: Spirometry results were available for 19,398 participants. The prevalence of airflow limitation was 4.6%. Overall, 64.4% of adults with airflow limitation did not report a previous diagnosis of OLD. Individuals with high cumulative tobacco consumption (≥ 10 pack-years) (aPR: 1.72 [1.28-2.32]), without respiratory symptoms (aPR: 1.51 [1.28-1.78]), and with preserved lung function (aPR: 1.21 [1.04-1.41] for a 10-point increase in FEV1% predicted) had a higher risk of being undiagnosed. Half of symptomatic individuals with airflow limitation (45% of those with moderate to severe airflow limitation) were undiagnosed with OLD. CONCLUSION: Underdiagnosis of OLD is very common among French adults, even in patients with respiratory symptoms. Efforts should be made in France to raise awareness about OLD in the general population, improve the detection of respiratory symptoms, and increase the use of spirometry among primary care professionals.

Childhood Cancers Misdiagnosed as Tuberculosis in a High Tuberculosis Burden Setting.

BACKGROUND: Tuberculosis (TB) and childhood cancers have overlapping presentations and malignancies may be misdiagnosed as TB in high TB-burden settings. METHODS: This retrospective study investigated the diagnosis of TB in children with cancer registered in the Tygerberg Hospital Childhood Tumor Registry from 2008 to 2018. We studied children on anti-tuberculosis treatment (ATT) at cancer diagnosis or diagnosed with TB within 1 month of cancer diagnosis. We describe the circumstances and extent of this misdiagnosis, quantify the delay in therapy and document the outcomes of these children. RESULTS: Twenty-seven of 539 (5%) children in the registry started ATT before cancer diagnosis. Both pulmonary and extrapulmonary TB complicated the cancer diagnosis. Of the 27 patients on ATT at cancer diagnosis, 22 (81%) had contact with a TB case and in 6 of 12 children (50%) a tuberculin skin test was positive. At cancer diagnosis, 16/27 (59%) children had chest radiograph changes interpreted as TB with 11/27 (41%) regarded as suggestive of TB on expert review. The median diagnostic delay between TB and cancer diagnoses was 25 days (interquartile range 3.5-58). Of 539 children with cancer, 204 (38%) died of cancer, including 18/30 (60%) children on ATT at cancer diagnosis or diagnosed with TB within 1 month of cancer diagnosis (odds ratio 2.6; 95% confidence interval: 1.2-5.4; P = 0.012). CONCLUSIONS: The clinical and radiologic overlap of TB and cancer causes diagnostic confusion in a significant number of children with cancer and may contribute to increased mortality.

Effects of MSCT enhanced scan image diagnosis on clinical outcome of patients after radical gastrectomy and its influence on misdiagnosis rate.

PURPOSE: To explore the effect of multi-slice spiral computed tomography (MSCT) enhanced scan image diagnosis on clinical outcome of patients after radical gastrectomy and its influence on misdiagnosis rate. METHODS: A total of 62 patients diagnosed with gastric cancer and undergoing radical gastrectomy were selected. All patients were reexamined 2-6 months after operation. Conventional CT and MSCT enhanced scan were performed for image diagnosis, and the results were compared with those of gastroscopic biopsy. Finally, the misdiagnosis rate, negative predictive value, positive predictive value, sensitivity and specificity of conventional CT and MSCT enhanced scan for postoperative recurrence were analyzed. RESULTS: According to the results of gastroscopic biopsy, there were 35 cases suspected of recurrence, and 27 cases without postoperative recurrence. The specificity and sensitivity of conventional CT and MSCT enhanced scan were 85.19% vs. 92.59%, and 65.71% vs. 92.16%, respectively. Both specificity and sensitivity of MSCT enhanced scan were higher than those of conventional CT, with statistically significant differences (p<0.05). MSCT enhanced scan had a lower misdiagnosis rate for postoperative recurrence than conventional CT (5.71% vs. 22.86%) (p<0.05). Moreover, the negative predictive value and positive predictive value of conventional CT and MSCT enhanced scan were 65.71% vs. 86.21%, and 85.19% vs. 93.94%, respectively. The results showed that MSCT enhanced scan had higher negative predictive value and positive predictive value for postoperative recurrence than conventional CT, with statistically significant differences (p<0.05). CONCLUSION: MSCT enhanced scan image diagnosis is of great significance for assessing the condition of disease, determining the recurrent foci after radical gastrectomy, and developing the subsequent therapeutic regimen.

Analysis of misses in imaging of head and neck pathology by attending neuroradiologists at a single tertiary academic medical centre.

AIM: To analyse errors in head and neck (H&N) pathology made by attending neuroradiologists at a single tertiary-care centre. MATERIALS AND METHODS: A neuroradiology quality assurance (QA) database of radiological errors was searched for attending physician errors in H&N pathology from 2014-2020. Data were limited to computed tomography (CT) and magnetic resonance imaging (MRI) reports. Data were collected on missed pathologies and study types. Misses were grouped into three categories: central neck (thyroid gland, aerodigestive tract), lateral neck (salivary glands, lymph nodes, soft tissues), and face/orbits (orbits, sinuses, masticator space). RESULTS: During the study period, a total of 283,248 CT and MRI neuroradiology examinations were interpreted (all indications). Seventy-four H&N misses were identified comprising 85.1% perceptual and 14.9% interpretive errors. The distribution of errors was face/orbits (37.8%), central neck (36.5%), and lateral neck (25.7%). Clinically significant errors were found most commonly in the aerodigestive tract (21%), orbits (17.7%), masticator space, and parotid glands (14.5% each). The majority (67.6%) of the misses were detected on examinations that were not performed for a primary H&N indication; MRI brain was the most common examination (27%). Clearly malignant or potentially malignant masses accounted for 48.6% of all misses. CONCLUSION: The majority of H&N misses were perceptual and were detected on examinations not performed for a H&N indication. Clearly malignant or potentially malignant masses represented half of all misses.

Risk of missing colorectal cancer with a COVID-adapted diagnostic pathway using quantitative faecal immunochemical testing.

BACKGROUND: COVID-19 has brought an unprecedented challenge to healthcare services. The authors' COVID-adapted pathway for suspected bowel cancer combines two quantitative faecal immunochemical tests (qFITs) with a standard CT scan with oral preparation (CT mini-prep). The aim of this study was to estimate the degree of risk mitigation and residual risk of undiagnosed colorectal cancer. METHOD: Decision-tree models were developed using a combination of data from the COVID-adapted pathway (April-May 2020), a local audit of qFIT for symptomatic patients performed since 2018, relevant data (prevalence of colorectal cancer and sensitivity and specificity of diagnostic tools) obtained from literature and a local cancer data set, and expert opinion for any missing data. The considered diagnostic scenarios included: single qFIT; two qFITs; single qFIT and CT mini-prep; two qFITs and CT mini-prep (enriched pathway). These were compared to the standard diagnostic pathway (colonoscopy or CT virtual colonoscopy (CTVC)). RESULTS: The COVID-adapted pathway included 422 patients, whereas the audit of qFIT included more than 5000 patients. The risk of missing a colorectal cancer, if present, was estimated as high as 20.2 per cent with use of a single qFIT as a triage test. Using both a second qFIT and a CT mini-prep as add-on tests reduced the risk of missed cancer to 6.49 per cent. The trade-off was an increased rate of colonoscopy or CTVC, from 287 for a single qFIT to 418 for the double qFIT and CT mini-prep combination, per 1000 patients. CONCLUSION: Triage using qFIT alone could lead to a high rate of missed cancers. This may be reduced using CT mini-prep as an add-on test for triage to colonoscopy or CTVC.

Systems controls are needed to reduce mistaken tests for hemophagocytic lymphohistiocytosis, results of a prospective quality-improvement cohort study.

ABSTRACT: Medical diagnosis and therapy often rely on laboratory testing. We observed mistaken testing in evaluations for hemophagocytic lymphohistiocytosis (HLH) that led to delays and adverse outcomes. Physicians were mistakenly ordering interleukin-2 and quantitative natural killer cell flow cytometry, rather than soluble interleukin 2 receptor (sIL2R) or qualitative natural killer functional tests in the evaluation of patients suspected to have HLH.We initiated a prospective quality improvement project to reduce mistaken testing, reduce delays in correct testing due to mistaken ordering, and improve HLH evaluations. This consisted of provider education, developing an evaluation algorithm, and ultimately required systems interventions such as pop-ups and removal of the mistaken tests from the electronic ordering catalog.Active education reduced mistaken testing significantly in HLH evaluations from baseline (73.3% vs 33.3%, P = .003, relative risk reduction (RRR) 54.5%), but failed to meet the pre-specified RRR cutoff for success (70%). Education alone did not significantly reduce the proportion of HLH evaluations with delays in sIL2R testing (23.3% vs 7.4%, P = .096). Mistaken testing increased after the active intervention ended (33.3% vs 43.5%, P = .390, with RRR 40.7% from baseline. Mistaken test removal was successful: mistaken testing dropped to 0% (P < .001, RRR 100%), saved $14,235 yearly, eliminated delays in sIL2R testing from mistaken testing (23.3% vs 0%, P = .008), and expedited sIL2R testing after admission for HLH symptoms (14.6 days vs 3.8 days, P = .0012). These data show systems controls are highly effective in quality improvement while education has moderate efficacy.

Incidence and missed diagnosis risk of occult posterior malleolar fractures associated with the tibial shaft fractures: a systematic review.

BACKGROUND: Tibial shaft fractures (TSFs) combined with occult posterior malleolar fractures (PMFs) are becoming widely recognized in the field of orthopedics. The purpose of this study was to determine the clinical incidence, missed diagnosis rate, and treatment strategies of this combined injury. METHODS: PubMed, Cochrane, and MEDLINE Ovid databases were searched for articles of English language from 1988 to 2020, identifying 1549 papers. RESULTS: Twenty-one of the 1278 identified studies were eligible for inclusion. Each study reported on the incidence of this combined injury, and 12 studies documented the missed diagnosis rate. Seventeen studies reported surgical intervention strategies for PMFs. In the present review, PMFs frequently occurred in spiral TSFs (70%), especially distal third spiral TSFs (70.4%), based on CT scans or additional MRI. Based on the original X-ray detection, approximately 50% of PMFs were missed in patients with a combined injury. In addition, the treatment strategies for PMFs were inconsistent. Most studies (11/17) believe that specific surgical management needs to be developed based on the fragment size, displacement, and stability of the PMF. CONCLUSIONS: For patients with TSFs, spiral TSFs, especially distal third spiral TSFs, are closely related to PMFs and are often not sufficiently diagnosed by X-ray alone. Advanced CT and MRI examinations can significantly reduce the missed diagnosis rate of occult PMFs. According to available literature, the treatment strategy for PMFs associated with TSFs is questionable without convincing evidence of benefit.

CD56 expression in basaloid anal squamous cell carcinoma - A potential diagnostic pitfall.

Anal squamous cell carcinoma (SqCC) is a morphologically heterogeneous entity. Basaloid and non-keratinizing anal SqCC may be confused with other tumors including neuroendocrine carcinoma due to morphologic overlap, and expression of neuroendocrine markers is not well-studied in anal SqCC. Prompted by a case of anal SqCC that was initially misdiagnosed as neuroendocrine carcinoma on the basis of morphology and CD56 expression, we retrospectively examined the expression of neuroendocrine markers CD56, synaptophysin, and chromogranin in 48 cases of basaloid anal SqCC, with clinicopathologic correlation. HPV16 was identified in 46 cases, HPV33 in one case, and one case was HPV-negative. Three (6.3%) cases demonstrated CD56 expression, including two with diffuse and one with focal expression. Two CD56-positive cases demonstrated basaloid morphology with peripheral palisading and the other demonstrated adenoid cystic/cylindroma-like morphology. None of the cases showed significant synaptophysin or chromogranin expression. The three cases expressing CD56 were HPV16-positive, and one demonstrated a CTNNB1 mutation. There was no difference in clinicopathologic features including stage, outcome, or HPV status, between CD56-positive and negative groups. Our findings support that CD56 expression is infrequently expressed in anal SqCC and is not indicative of neuroendocrine differentiation in the absence of expression of more specific neuroendocrine markers such as synaptophysin and chromogranin. Pathologists should be aware that CD56 expression may occur in basaloid anal SqCC and is a diagnostic pitfall due to morphologic overlap with neuroendocrine carcinoma and other tumors including basal cell carcinoma.