Intensa retención de 99mTc-MIBI en la fase tardía como causa de error diagnóstico en la gammagrafía combinada paratiroides-tiroides / High retention of 99mTc-MIBI in delayed phase as a pitfall in the combined parathyroid-thyroid scintigraphy

La gammagrafía de paratiroides con 99mTc-sestaMIBI es muy sensible en el diagnóstico y localización del adenoma de paratiroides. Sin embargo, se pueden producir errores diagnósticos debido a la coexistencia de lesiones tiroideas captantes de MIBI o en pacientes con cirugía tiroidea previa. Para intentar detectar dichas alteraciones tiroideas se realiza una gammagrafía con 99mTc-pertecnetato comparativa el mismo día. Ocasionalmente, como en nuestro caso, la lesión paratiroidea puede presentar una captación inicial y retención tardía de MIBI lo suficientemente importantes como para ser visualizadas en la gammagrafía tiroidea realizada a continuación, dando la falsa apariencia de una lesión captante también de pertecnetato. Este hecho ha sido llamado «shine through». Para evitarlo se pueden realizar las gammagrafías paratiroidea y tiroidea en días distintos. A nosotros nos resultó también de gran utilidad la comparación con ecografía y la PAAF de la lesión con determinación de PTH y tiroglobulina en el líquido aspirado(AU)

Dual phase parathyroid scintigraphy with 99mTc-sestaMIBI is a very sensitive technique in the preoperative localization and diagnosis of parathyroid adenoma. However, pitfalls have been reported in patients with thyroid nodules with MIBI uptake or with previous thyroid surgery. To solve this problem, a thyroid scintigraphy with 99mTc-pertechnetate is usually performed following the parathyroid study. Occasionally, as in our patient the parathyroid lesion may show high MIBI uptake and delayed washout that interfere with the subsequent thyroid scintigraphy giving the false appearance of a pertechnetate avid lesion. This has been called the «shine through» effect. To avoid it, the parathyroid and thyroid scintigraphies can be performed on separate days. We have also found it useful to compare our results with that of ultrasound and fine needle aspiration puncture with measurement of the parathyroid hormone (PTH) and thyroglobulin in the aspirated material(AU)

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

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(AU)

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(AU)

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.

Errores de diagnóstico y estabilidad temporal en el trastorno bipolar / Diagnostic errors and temporal stability in bipolar disorder

Introducción. El diagnóstico de trastorno bipolar se modifica con frecuencia a lo largo de la evolución de la enfermedad. Material y métodos. Se describen los cambios de diagnóstico y error asociado de 1.153 pacientes mayores de 18 años diagnosticados de trastorno bipolar y con un seguimiento mínimo de 10 visitas en base a un registro clínico de atención ambulatoria especializada en psiquiatría y hospitalizaciones psiquiátricas de 25.152 pacientes representativos de un área urbana de 240.000 habitantes. Se usó como criterio de estabilidad diagnóstica mantener el diagnóstico de trastorno bipolar en al menos el 75% de las visitas. Resultados. De los 342 pacientes diagnosticados de trastorno bipolar en la primera consulta, el 46,1% mantuvieron el diagnóstico estable. Se cometió un error inicial de infradiagnóstico con 108 pacientes estables no diagnosticados en la primera visita. Ciento ochenta y cuatro de los 342 pacientes diagnosticados en la primera visita obtuvieron posteriormente al menos un 25% de diagnósticos diferentes de bipolar y podrían ser considerados como sobre diagnóstico inicial. Doscientos nueve de 443 pacientes diagnosticados como bipolares en la última visita no mantuvieron criterios de estabilidad en su evolución y podrían, por tanto, considerarse como sobre diagnóstico final. Treinta y dos pacientes estables no diagnosticados en la última visita constituirían el error final de infradiagnóstico. Diagnósticos del espectro de la esquizofrenia (F2) aparecen casi en una de cada cuatro visitas al psiquiatra de los pacientes del estudio. Otras tres categorías presentan solapamiento: los trastornos de ansiedad (F4), los trastornos de personalidad (F6) y los trastornos por consumo de sustancias. Conclusión. El trastorno bipolar es un trastorno de difícil diagnóstico en su evolución inicial (AU)

Introduction. The diagnosis of bipolar disorder is frequently modified during the course of the illness. Material and methods. Diagnostic changes and associated errors are described for 1,153 patients diagnosed as bipolar disorder, aged over 18 years and with at least ten follow-up visits. Data was extracted from a clinical registry of out-patient care specialized in Psychiatry and psychiatric hospitalizations of 25,152 patients representative of an urban area of 240,000 in habitants. Limit for diagnostic stability was established as the maintenance of the bipolar disorder diagnosis in at least 75% of the visits. Results. A total of 158 (46.1 %) out of 342 patients diagnosed as having a bipolar disorders in the first visit kept this diagnostic constant in subsequent evaluations. Infradiagnostic initial error was committed with 108 stable patients who were not diagnosed in the first visit. 184 patients diagnosed in the first visit with bipolar disorder had less than 75 % concordant diagnosis along the follow-up and could be considered as initial over diagnosis. Two hundred and nine out of the 443 patients who were diagnosed as bipolar disorder in their last visit did not keep stability criteria in their follow-up and could be considered therefore as final over diagnosis. Thirty two stable patients not diagnosed in their last visit could be considered as infradiagnosis final error. Diagnosis from schizophrenia spectrum (F2) appears in one of every four psychiatric visits of the patients included in this study. Overlap was seen in three other categories: anxiety disorders (F4), personality disorders (F6) and substance abuse disorders. Conclusion. Initial course of bipolar disorder causes difficulties in the diagnosis (AU)

Características y manejo de las crisis epilépticas en urgencias y su correlación diagnóstica tras el ingreso / Characteristics and management of epileptic seizures in emergency department and diagnostic correlation at discharge

Introducción: las crisis convulsivas suponen un porcentaje elevado de las consultas en los servicios de urgencias, pero poco es conocido en relación al manejo y derivación de estos enfermos. El objetivo fue conocer el perfil de los pacientes que acuden a urgencias con crisis epilépticas, las medidas diagnósticas y terapéuticas, destino de los pacientes tras su valoración, así como la concordancia entre el diagnóstico inicial y definitivo de estos pacientes. Material y métodos: registramos prospectivamente todos los pacientes que acudieron al Servicio de Urgencias del Hospital Clínico de Zaragoza durante el periodo comprendido entre el 1 de noviembre del 2004 y 30 de abril del 2005 y que fueron diagnosticados de crisis comicial. Posteriormente se revisaron las historias clínicas de aquellos pacientes ingresados para determinar el diagnóstico definitivo. Resultados: de los 54.022 pacientes atendidos a urgencias, 137 (0,25%) fueron diagnosticados de crisis convulsiva, requiriendo ingreso hospitalario 61 (44%). Las crisis de novo representaron el 60% de los pacientes ingresados. Un 12% fueron secundarios a alteraciones analíticas y un 48% de los pacientes presentaron hallazgos patológicos en la neuroimagen; la falta de cumplimiento terapéutico con bajos niveles plasmáticos de fármacos fue el principal factor precipitante en los epilépticos conocidos. Los falsos positivos representaron el 33% de los diagnósticosde urgencias. Conclusiones: encontramos un tercio de errores respecto al diagnóstico de urgencias, siendo la causa más frecuente de error los síncopes y los ictus. Elevado porcentaje de diagnóstico etiológico por neuroimagen así como la escasez en la realización de electroencefalogramas y estudios toxicológicos

Background: Patients with seizures are common in the emergency department (ED), yet little is known regarding the management of these patients. This study was performed to define the demographic characteristics of patients with seizure disorders in the ED patient population and to determine final disposition, diagnostic and therapeutic activities, and to evaluate the concordance between provisional and definitive diagnosis. Material and methods: We recorded prospectively all patients which were diagnosed of seizure in ED of Hospital Clínico of Zaragoza between November 1th and April 30 th. Chart review was used to gather definitive diagnosis regarding these patients. Results: Of the 54,022 patients who presented to the ED during the study period, 137 (0.36%) had complains related to seizures. Sixty one(44%) of these patients were admitted to the hospital. New-onset seizures were thought to be present in 60% of patients. Blood work was abnormal in 12% of patients and 48% of patients had pathological findings in neuroimaging study. False positive diagnosis was present in 33% ofpatients. The most important trigger of seizures in epileptic patients was tapped suddenly the antiepileptic drug treatment. Conclusions: We found a false positive diagnosis in 33% of patients,and the most important confounding pathology was sincope and stroke.High percentaje of pathological findings in neuroimaging studies werefound. Electroencefalographic and toxicological studies were performed less than is recommended

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.