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OBJECTIVE: To assess the validity of diagnostic tools available at the primary care setting [medical history (MH), I-PSS questionnaire, digital rectal examination (DRE) and prostate specific antigen (PSA) evaluation] for the diagnosis of benign prostatic hyperplasia (BPH). SUBJECTS AND METHODS: 363 patients with suspected prostatic disease referred to urology outpatient clinics were included. For every subject initial BPH diagnosis was collected at each of the following sequential procedures: 1) MH; 2) I-PSS; 3) DRE; and 4) PSA. Each of these diagnostic decisions were compared to a final diagnosis (gold standard) reached after the addition of urinary sediment analysis, ultrasonographic assessment of residual volume and prostatic volume, and peak urinary flow measurement. A descriptive analysis was undertaken: validity and concordance between each diagnostic step and the gold standard was calculated. RESULTS: Sensitivity, specificity, positive predictive value, and negative predictive value of diagnosis based on MH+I-PSS+DRE+PSA with respect to the gold standard were 91%, 65%, 95% and 50%, respectively. The percentage of agreement and kappa index between both diagnostic strategies were 87.9% and 0.5, respectively. CONCLUSIONS: Concordance between BPH initial diagnosis based on MH+I-PSS+DRE+PSA and diagnosis based on a full range of tests was high, thus allowing recommending the use of this group of initial diagnostic procedures, which are available to the primary care physician, not only as a first diagnostic step in patients with suspected BPH, but also as a valid strategy to prevent unnecessary delay in its initial management and to facilitate appropriate referral from primary to specialized care.
The purpose of this investigation was to assess the relative risks of antithrombotic treatment following pulmonary angiography vs no angiography in patients with acute pulmonary embolism (PE). Comparisons of risks of diagnosis and therapy were made among patients treated on the basis of a pulmonary angiographic diagnosis vs patients treated on the basis of a ventilation/perfusion (V/Q) scan combined with clinical assessment in the presence of a single negative test for deep venous thrombosis. Calculations of risks assumed major complications of pulmonary angiography equal to 1.3 percent, major bleeding with heparin equal to 4.9 percent (1.1 percent among patients with a low risk of bleeding and 10.8 percent among patients with a high risk of bleeding), and major bleeding with warfarin (international normalized ratio 2 to 3) equal to 1.7 percent. Among patients with a risk of major bleeding from heparin followed by warfarin of 6.6 percent, if the estimated probability of PE was greater than about 80 percent, fewer major complications of diagnosis and treatment would occur if treatment was initiated on the basis of the V/Q scan. If the probability of PE in such patients was less than 80 percent, fewer major complications of diagnosis and treatment would occur if the diagnosis was established by pulmonary angiography. Among patients with a high (12.5 percent) risk of major bleeding, it was shown to be safer to treat on the basis of an angiographic diagnosis if the estimated probability of PE was less than 90 percent. If the patients, however, were at low (2.8 percent) risk of major bleeding, fewer major complications would occur if angiography was reserved for patients with an estimated risk of PE less than about 50 percent. Serial studies of the leg veins may eliminate the need for angiography in such patients.
OBJECTIVE: Our purpose was to determine whether abdominal CT can detect pancreatic cancer before its clinical diagnosis. SUBJECTS AND METHODS: Two radiologists interpreted in a blinded manner 62 CT scans in 28 pancreatic cancer patients that were obtained before histologic diagnosis and 89 CT scans in 89 control subjects and noted specific CT findings. The presence of pancreatic cancer was characterized as definite, suspicious, low probability, or normal. The scans of the pancreatic cancer patients were divided into four groups on the basis of the time interval preceding cancer diagnosis (0-2, 2-6, 6-18, or > 18 months), and one scan (closest to 18 months) was selected per patient per time interval. Sensitivity and specificity for pancreatic cancer and interobserver agreement for CT findings were calculated. RESULTS: Radiologists agreed that CT findings definite or suspicious for pancreatic cancer were present in 50% of the scans obtained 2-6 and 6-18 months before the diagnosis of pancreatic cancer (3/6 and 4/8 scans, respectively), but they noted such CT findings in only 7% (1/15) of the scans obtained more than 18 months before diagnosis. Pancreatic duct dilatation and cutoff were early CT findings identified by both radiologists and were associated with near-perfect and substantial interobserver agreement (kappa = 0.84 and 0.76, respectively). Ninety-five percent confidence intervals of specificity for tumor absence ranged from 92% to 100%. CONCLUSION: CT can detect a significant proportion of asymptomatic incident pancreatic cancers before the clinical diagnosis of pancreatic cancer. CT should be considered in screening at-risk patient populations. Pancreatic duct dilatation and cutoff are early findings associated with the development of pancreatic cancer and can be detected on CT with a high degree of reproducibility.
Microfilms were prepared from the case histories of 357 consecutive patients submitted to liver biopsy for the first time so that all information after the time of the liver biopsy was erased. The microfilms were assessed by four clinicians, and the pre-biopsy diagnostic proposals were graded according to the degree of certainty and were compared with the results of the liver biopsies. Out of 357 patients, 200 had a history of alcoholism, of whom 172 had alcohol-induced changes in the liver biopsies: 80 cases of alcoholic cirrhosis, 84 cases of steatosis, and 8 cases of alcoholic hepatitis without cirrhosis. In 65 of the 80 patients with biopsy-verified alcoholic cirrhosis the clinical pre-biopsy diagnosis was in agreement with the histological findings. In 51 cases in which the clinical diagnosis of alcoholic cirrhosis was given as moderately certain or very certain, 4 clinically incorrect diagnoses occurred. No incorrect diagnoses occurred in the 35 cases in which the clinicians claimed the greatest diagnostic accuracy. In the 84 patients with steatosis in the liver biopsies the clinicians felt uncertain or moderately certain about all but 2 patients, and 14 incorrect diagnoses occurred. In none of the 8 patients with histological alcoholic hepatitis without cirrhosis was a correct clinical diagnosis made. The clinical pre-biopsy diagnosis of acute hepatitis was in agreement with the results of the liver biopsies in 52 out of 57 patients. In 51 cases in which the clinical diagnosis of acute hepatitis was given as moderately certain or very certain, 1 clinically incorrect diagnosis occurred.(ABSTRACT TRUNCATED AT 250 WORDS)
In malaria endemic areas treating every fever episode as a malaria onset would result in overdiagnosis with a margin of the error varying in function of epidemiological factors. When further compounded by overestimation related to errors in parasitologic diagnosis, clinical misdiagnosis leads to unwarranted hospitalization and inappropriate treatment. In a company setting this would mean unnecessary loss of employee work time. False positive diagnosis causes overestimation of chemoresistance, overconsumption of antimalarial drugs and underestimation of other infectious diseases. Judging from these high costs, it can be assumed that improving the reliability of parasitologic diagnosis would have a positive impact on the quality of clinical management, efficiency of antimalarial use and accuracy of epidemiological surveys. This assumption was confirmed by analysis of data following start-up of a parasitologic laboratory for malaria diagnosis in the health care clinic at Sonamet's fabrication yard in Lobito, Angola. Laboratory personnel receives expert training and audit findings demonstrate consistently reliable diagnosis. This experience underscores the need for reliable parasitologic diagnosis as a prerequisite for any large-scale malaria control program.
The literature on whole genome amplification (WGA) techniques and their application to preimplantation genetic diagnosis (PGD) and prenatal diagnosis is reviewed. General polymerase chain reaction (PCR) fails to provide adequate information from limited cells in PGD and non-invasive prenatal diagnosis. Therefore several WGA techniques, such as primer extension preamplification (PEP) and degenerate oligonucleotide primed PCR (DOP-PCR), have been developed and successfully applied to clinical work during the past decade, especially in PGD and prenatal diagnosis. These techniques can provide ample amplification of genetic sequences from single cells for a series of subsequent PCR analyses such as restriction fragment length polymorphisms (RFLP) and comparative genomic hybridization (CGH), thus opening up a new area for prenatal diagnosis. However, several problems have been reported in the application of these techniques. The ideal WGA technique should have high yield, faithful representation of the original template, complete coverage of the genome, and simply performed procedure. In order to make good use of these techniques in future research and clinical work, it is undoubtedly necessary for an extensive understanding of the merits and pitfalls of these recently developed techniques.
The incidence of hepatocellular carcinoma (HCC) will continue to increase for the next decade due to a latency of about 30 years due to cirrhosis caused by chronic hepatitis C. The diagnosis of an underlying cirrhosis is of diagnostic importance. According to WHO guidelines, HCC encompasses the following: trabecular, pseudoglandular, acinar, compact, scirrhous and fibrolamellar subtypes. Cytological appearance includes hepatocellular pleomorphic, clear cell and sarcomatous subtypes. Tumor cells in hepatocellular carcinoma may display intracytoplasmic inclusions that are helpful for establishing the diagnosis. Differential diagnosis has to be considered for such hepatic tumors as adenoma and precancerous lesions such as dysplastic nodules or mesenchymal tumors. Metastases in the liver may be difficult to differentiate, especially for primary tumors from the gastrointestinal tract which may be similar to glandular or scirrhous type of HCC. The existence of underlying cirrhosis is helpful for the diagnosis and an ample spectrum of antibodies against liver antigens and adenocarcinomas are commercially available to confirm the correct diagnosis.
WHO MONICA Project has suggested diagnostic criteria for acute myocardial infarction (AMI) for monitoring the trends of coronary heart disease (CHD). The aim of our study was to compare the diagnosis of AMI by the MONICA diagnostic criteria and by the modified criteria developed within the FINMONICA study with hospital discharge (clinical) diagnosis. In a series of 1565 suspected acute CHD events treated at Kuopio University Hospital in 1987-1990, a diagnosis of definite AMI was made clinically in 566 events and by the MONICA (and FINMONICA) criteria in 551 events. The comparability between clinical and MONICA (and FINMONICA) classifications was good (kappa 0.81, Ppos 0.88, Pneg 0.93). A diagnosis of definite or possible AMI was made clinically in 734 events, in 1249 events by the MONICA criteria (kappa 0.25, Ppos 0.69, Pneg 0.47) and in 934 events by the FINMONICA criteria (kappa 0.60, Ppos 0.81, Pneg 0.77). Of the 383 events classified as possible AMI by the FINMONICA criteria the clinical diagnosis was "prolonged angina pectoris attack" or "unstable angina" in 39%. The FINMONICA diagnostic criteria for AMI are closer to clinical diagnostic classification and offer a possibility for a more detailed classification of acute CHD events than the original MONICA criteria.
PURPOSE: We have compared the sensitivities of MRI, US and radiography which are some of the radiologic modalities used in the early diagnosis of acute osteomyelitis. MATERIALS AND METHODS: After 1 week care and research on 20 New Zealand rabbits (average weight: 2.5 kg) in animal laboratory, study was begun. Six rabbits died after anesthesia and surgical procedure. There were 14 rabbits remaining and 10 of them formed the study group. Four of them were used as the control group. Fresh mouse feces was inoculated into the bone marrow of 20 tibia under general anesthesia and during the following 15 days, MRI, US and radiographic researches were made everyday. RESULTS: According to the results that we got at the end of the 15-day period, MRI was found as the most sensitive method in describing early diagnosis of infection in the bone marrow and also in showing the extension of the infection to the soft tissue. Although US showed the findings later than MRI, it was determined that its sensitivity was less than but near MRI's in detecting subperiosteal fluid in short term period. Radiographic research gives acute osteomyelitis diagnosis latest, so it was determined as the modality that has the lowest sensitivity. CONCLUSION: MRI which is one of the radiologic modalities among other diagnostic radiologic modalities that can be used in early diagnosis of acute osteomyelitis, has the highest sensitivity. Ultrasonography is the second most sensitive modality. Radiographic analysis has the least sensitivity among other modalities. As a result, first MRI then US and after that plain radiography should be used for the early diagnosis of acute osteomyelitis.
PURPOSE: The purpose of this study was to characterize gliomatosis cerebri on magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS), and to analyze the value of these two techniques in diagnosis and differential diagnosis of gliomatosis cerebri. MATERIALS AND METHODS: MR images of 14 patients with gliomatosis cerebri were reviewed retrospectively; seven of the patients also underwent MRS (single-voxel point-resolved spectroscopy, and chemical-shift imaging point-resolved spectroscopy). Tumorous were confirmed by surgery and biopsy. The distribution, extension and signal features of lesions were assessed, and the MR spectroscopy results were analyzed. RESULTS: Tumors involved at least two lobes of the brain in all patients. Widespread invasion with isointensity or hypointensity on T1-weighted MR images and hyperintensity on T2-weighted images were found while no prominent necrosis, hemorrhage or contrast enhancement was found. All patients who underwent MRS showed elevated Cho/Cr and Cho/NAA levels as well as decreased NAA/Cr ratios in the abnormal areas on T2-weighted images, three of which showed a lactate doublet. Anaplastic lesions had higher Cho/NAA levels in three cases. Abnormality of metabolism was also seen in the margin of the lesion that was normal on T2-weighted images. CONCLUSION: MRI and MRS are valuable techniques for diagnosis and differential diagnosis of gliomatosis cerebri. Combining clinical information and MRI findings, as well as MRS, is crucial for making a definitive diagnosis.
BACKGROUND: Accurate diagnosis of acute rheumatic fever (ARF) remains problematic in high-incidence settings and especially in the Aboriginal population of Australia's Northern Territory. Previous investigators have demonstrated that strict application of the 1992 Updated Jones Criteria results in under-diagnosis. This study's objectives were to review use of the Jones Criteria (1992 Update) in diagnosing ARF in Australian Aboriginal patients presenting with suspected rheumatic fever, and formulate a locally relevant algorithm to improve diagnosis. METHODS: Patients presenting to Royal Darwin Hospital with suspected ARF were prospectively assessed during a 15-month period. Demographic information, clinical history, examination, laboratory and echocardiographic findings were documented in order to determine whether the Jones Criteria were fulfilled, and to identify alternative diagnoses. The hospital discharge diagnosis was recorded and patients were followed up 18-33 months later. RESULTS: Out of 35 patients with suspected ARF, all were Aboriginal Australians, 17 (49%) had a discharge diagnosis of definite ARF, 7 (20%) had definite non-rheumatic fever diagnoses (disseminated gonococcal infection, systemic lupus erythematosis, buttock abscess and other febrile illnesses in children with cardiac murmur due to previously undiagnosed RHD). The remaining 11 (31%) posed diagnostic difficulties because of mild symptoms that failed to fulfil Jones Criteria (attracting diagnoses such as 'unexplained arthralgia') or atypical features such as older age. Two patients whose illness initially failed to fulfil the Jones Criteria, who were neither diagnosed with ARF nor commenced on secondary benzathine penicillin prophylaxis, were found on follow-up to have definite and probable ARF, respectively. At least 29% (8/28) of patients without prior recognised ARF/RHD had echocardiographic evidence of established RHD, indicating that previous episodes were missed. CONCLUSIONS: Individual mild episodes of ARF may be overlooked, with patients missing out on the timely institution of secondary prophylaxis. The Jones Criteria should be supplemented by active exclusion of differential diagnoses and vigilant follow-up including echocardiography. 'Probable' and 'possible ARF' should be recognised as diagnostic categories applying to patients not fulfilling the Jones Criteria but who nevertheless should be offered prophylactic penicillin at least until further follow-up. A set of diagnostic guidelines is proposed.