The Abrupt Expansion of Ambulatory Telemedicine: Implications for Patient Safety

The exponential growth of telemedicine in ambulatory care triggered by the COVID-19 public health emergency has undoubtedly impacted the quality of care and patient safety. In particular, the increased adoption of remote care has impacted communication, care teams, and patient engagement, which are key factors that impact patient safety in ambulatory care. In this perspective, we draw on a scoping review of the literature, our own clinical experiences, and conversations with patient safety experts to describe how changes in communication, care teams, and patient engagement have impacted two high priority areas in ambulatory safety: diagnostic errors and medication safety. We then provide recommendations for research funders, researchers, healthcare systems, policy makers, and healthcare payors for how to improve patient safety in telemedicine based on what is currently known as well as next steps for how to advance understanding of the safety implications of telemedicine utilization.

Cutaneous leishmaniasis presenting with painless ulcer on the right forearm: A case report

BACKGROUND

Leishmaniasis includes a range of chronic infections in humans and animals and can be caused by more than 20 species of Leishmania protozoa. The manifestations of leishmaniasis are diverse and dependent on the immune response capacity of the host and the type of Leishmania. In East Asia, leishmaniasis is relatively rare and prone to misdiagnosis and underdiagnosis.

CASE SUMMARY

We report a case of a 36-year-old male with cutaneous leishmaniasis. The patient had been misdiagnosed with a bacterial skin infection and was given a dressing change and oral levofloxacin, which proved ineffective. Histopathological examination revealed amastigote (Leishman-Donovan body) in the histocytes, and nucleic acid sequencing proved that the pathogen was Leishmania major. The patient was treated successfully by regional injection of sodium gluconate (600 mg) three times. The ulcer healed and did not recur at 1.5-year follow-up.

CONCLUSION

Skin ulcers caused by leishmaniasis are easily misdiagnosed in non-epidemic countries, yet it should not be overlooked.

Artificial intelligence system for identification of false-negative interpretations in chest radiographs

OBJECTIVES

To investigate the efficacy of an artificial intelligence (AI) system for the identification of false negatives in chest radiographs that were interpreted as normal by radiologists.

METHODS

We consecutively collected chest radiographs that were read as normal during 1 month (March 2020) in a single institution. A commercialized AI system was retrospectively applied to these radiographs. Radiographs with abnormal AI results were then re-interpreted by the radiologist who initially read the radiograph ("AI as the advisor" scenario). The reference standards for the true presence of relevant abnormalities in radiographs were defined by majority voting of three thoracic radiologists. The efficacy of the AI system was evaluated by detection yield (proportion of true-positive identification among the entire examination) and false-referral rate (FRR, proportion of false-positive identification among all examinations). Decision curve analyses were performed to evaluate the net benefits of applying the AI system.

RESULTS

A total of 4208 radiographs from 3778 patients (M:F = 1542:2236; median age, 56 years) were included. The AI system identified initially overlooked relevant abnormalities with a detection yield and an FRR of 2.4% and 14.0%, respectively. In the "AI as the advisor" scenario, radiologists detected initially overlooked relevant abnormalities with a detection yield and FRR of 1.2% and 0.97%, respectively. In a decision curve analysis, AI as an advisor scenario exhibited a positive net benefit when the cost-to-benefit ratio was below 1:0.8.

CONCLUSION

An AI system could identify relevant abnormalities overlooked by radiologists and could enable radiologists to correct their false-negative interpretations by providing feedback to radiologists.

KEY POINTS

• In consecutive chest radiographs with normal interpretations, an artificial intelligence system could identify relevant abnormalities that were initially overlooked by radiologists. • The artificial intelligence system could enable radiologists to correct their initial false-negative interpretations by providing feedback to radiologists when overlooked abnormalities were present.

Influence of using recommended radiological criteria on MDCT-angiography diagnosis of single isolated subsegmental pulmonary embolism

OBJECTIVES

We assessed the rate of false-positive diagnoses of MDCT-pulmonary angiography (MDCT-A) in patients with single isolated subsegmental pulmonary embolism (SISSPE).

METHODS

All patients who underwent MDCT-A between 2006 and 2017 for ruling out acute pulmonary embolism (PE) and received an initial diagnosis of SISSPE were included. The MDCT-A of these patients were reviewed retrospectively by four experienced thoracic radiologists, who applied radiological criteria recommended by the American College of Chest Physicians Antithrombotic Guidelines (ACCP 2016) for the diagnosis of SISSPE. Data extracted from medical records were history of venous thromboembolism (VTE), alternative diagnoses, other diagnostic studies for VTE, anticoagulation, bleeding complications, and VTE over the following 3 months.

RESULTS

Of 3839 patients undergoing MDCT-A, PE was found in 1021 (26.6%) and SISSPE in 59 (1.5% overall and 5.8% of all patients with PE). An alternative diagnosis to PE was made on the basis of CT in 33 (55.9%) patients. Forty-one (69.5%) patients received anticoagulants, and major life-threatening bleeding complications occurred in 2, with one death. Recurrent PE was not documented in any patient with SISSPE. In the retrospective assessment of the 59 cases of SISSPE, 21 were negative for PE, with a false-positive rate of 35.6% (21/59); so the percentage of SISSPE cases after the revision was 3.7% of all patients with PE; 11 of these 21 patients received anticoagulation.

CONCLUSIONS

Radiologists should be aware of the high rate of false-positives when making the diagnosis of SISSPE on MDCT-A without using strict diagnostic criteria. Misdiagnosis exposes patients to unnecessary anticoagulation.

KEY POINTS

• Radiologist should be aware of the high rate of false-positive diagnoses of single isolated subsegmental pulmonary embolism (SISSPE) in MDCT-pulmonary angiography (MDCT-A) performed for ruling out pulmonary embolism. • Misdiagnosis of SISSPE in MDCT-A can be reduced by using strict diagnostic radiological criteria recommended by the American College of Chest Physicians Antithrombotic Guidelines. • Unnecessary anticoagulation therapy with potential severe bleeding complications may result from misdiagnosis of SISSPE.

Evaluation of advanced practice provider related return visits to a pediatric emergency department and their outcomes

BACKGROUND

While multiple studies have evaluated physician-related return visits (RVs) to a pediatric emergency department (PED) limited data exists for Advanced Practice Provider (APP)-related RVs, hence our study aimed to evaluate APP-related RVs and their outcomes in a PED.

METHODS

We conducted a retrospective review of 72-h RVs where clinical care was independently provided by an APP during the index visit from January 2018 to December 2019. We extracted patient demographics, index and return visits' characteristics and outcomes. Reasons for RVs were categorized as progression of illness, medication-related, callbacks and others. Index visits were assessed for any diagnostic errors; impact of which to the patient was classified as none, minor or major.

RESULTS

Our APP-related RV rate was 2.1% (653/30,328). 462 eligible RVs were included in the final analysis. Majority of RVs were for medical reasons (n = 442, 95.7%); lower acuity (Emergency Severity Index ≥3, n = 426, 92.2%); due to persistence/progression of illness (n = 403; 87.2%) with viral illness being the common diagnosis (n = 159; 34.4%). 12 (2.6%) RVs were secondary to callbacks (8 radiology callbacks; 4 false positive blood cultures). Diagnostic errors were noted in 14 (3%) encounters of which 3 resulted in a major impact; radiological (7 fractures) and ophthalmological (2 corneal abrasions and 2 foreign bodies) misses constituted the majority of these.

CONCLUSIONS

APP-related RVs for low acuity medical patients remain low and are associated with good outcomes. Diagnostic errors account for a minority of these RVs. Focused interventions targeting provider errors can further decrease these RVs.

Common blind spots and interpretive errors of neck imaging

Complex anatomy and a wide spectrum of diseases in the head and neck predispose interpretation of neck imaging to cognitive pitfalls and perceptual errors. Extra attention to common blind spots in the neck and familiarity with common interpretive challenges could aid radiologists in preventing these diagnostic errors.

Impact of diagnostic errors on adverse outcomes: learning from emergency department revisits with repeat CT or MRI

Background

To investigate diagnostic errors and their association with adverse outcomes (AOs) during patient revisits with repeat imaging (RVRIs) in the emergency department (ED).

Results

Diagnostic errors stemming from index imaging studies and AOs within 30 days in 1054 RVRIs (≤ 7 days) from 2005 to 2015 were retrospectively analyzed according to revisit timing (early [≤ 72 h] or late [> 72 h to 7 days] RVRIs). Risk factors for AOs were assessed using multivariable logistic analysis. The AO rate in the diagnostic error group was significantly higher than that in the non-error group (33.3% [77 of 231] vs. 14.8% [122 of 823], p < .001). The AO rate was the highest in early revisits within 72 h if diagnostic errors occurred (36.2%, 54 of 149). The most common diseases associated with diagnostic errors were digestive diseases in the radiologic misdiagnosis category (47.5%, 28 of 59) and neurologic diseases in the delayed radiology reporting time (46.8%, 29 of 62) and clinician error (27.3%, 30 of 110) categories. In the matched set of the AO and non-AO groups, multivariable logistic regression analysis revealed that the following diagnostic errors contributed to AO occurrence: radiologic error (odds ratio [OR] 3.56; p < .001) in total RVRIs, radiologic error (OR 3.70; p = .001) and clinician error (OR 4.82; p = .03) in early RVRIs, and radiologic error (OR 3.36; p = .02) in late RVRIs.

Conclusion

Diagnostic errors in index imaging studies are strongly associated with high AO rates in RVRIs in the ED.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13244-021-01108-0.

Internal medicine inpatients' prevalence of misdiagnosed severe osteoporosis

Vertebral fractures (VF) related to osteoporosis (i.e., severe OP) increase the risk of disability and mortality, but they are often neglected. We observed a severe OP misdiagnosis in 28.9% of inpatients with previous spinal imaging positive for VFs. Diagnosing severe OP is crucial to reduce the health care costs of inpatients.

INTRODUCTION

Vertebral fractures (VFs) related to osteoporosis (OP) increase the risk of additional fractures and death. In inpatients, VFs are often neglected with consequent delay in OP treatments, prolongation of hospitalization, and reduction of life expectancy. The aim of this study was to evaluate the prevalence of a misdiagnosed severe OP (i.e., with VF) in general medicine inpatients.

METHODS

We evaluated inpatients of a Medicine Unit between January 2019 and December 2019 without severe OP diagnosis, who had spinal imaging. For each patient, we collected demographic data, previous or current OP treatment, and presence/number of VFs. Descriptive data were presented by medians (interquartile range [IQR]) for continuous data or as numbers (percentages) for categorical data. Differences between subgroups were analyzed with chi-square or Kruskal-Wallis tests as appropriate. p-values <0.05 were considered statistically significant.

RESULTS

793 subjects were admitted to inpatient's clinic: 235 (135 females and 100 males with a median age of 76.0 [64.0-83.0] years) were enrolled. One or more vertebral fractures were present in 28.9% (68/235) subjects; 47% (32/68) had two or more vertebral fractures. The majority of patients (55/68) with VFs had not previously received a severe OP diagnosis.

CONCLUSIONS

Severe OP was misdiagnosed in at least 8.6% of inpatients. The prevalence dramatically increases (about 29%) in subjects with previous spinal imaging showing one or more VFs. More attention should be given to this co-morbidity, which is known to be an additional risk factor for disability and mortality.

Vanishing bone metastasis: pictorial essay

Vanishing bone metastasis (pseudopathological vertebral body enhancement) is a pitfall in the interpretation of contrast-enhanced computed tomography (CT) scans of patients with thoracic vein obstruction, mainly in the superior vena cava and brachiocephalic veins, typically being related to thrombosis due to malignant tumors. On the basis of the CT findings, pseudopathological vertebral body enhancement can be misdiagnosed as sclerotic bone metastasis, leading to unnecessary treatment. Although not rare, pseudopathological vertebral body enhancement is usually underdiagnosed by radiologists. The aim of this study is to review the pathophysiology of this phenomenon, illustrating the most common collateral venous pathways in thoracic vein obstruction and making the correlation with the CT findings.

Oncologic Errors in Diagnostic Radiology: A 10-Year Analysis Based on Medical Malpractice Claims

PURPOSE

To retrospectively analyze the nature and extent of oncology-related errors accounting for malpractice allegations in diagnostic radiology.

METHODS

The Comparative Benchmarking System of the Controlled Risk Insurance Company, a database containing roughly 30% of medical malpractice claims in the United States, was searched retrospectively for the period 2008 to 2017. Claims naming radiology as a primary service were identified and were stratified and compared by oncologic versus nononcologic status, allegation type (diagnostic versus nondiagnostic), and imaging modality.

RESULTS

Over the 10-year period, radiology was the primary responsible service for 3.9% of all malpractice claims (2,582 of 66,061) and 12.8% of claims with diagnostic allegations (1,756 of 13,695). Oncology (neoplasms) accounted for 44.0% of radiology cases with diagnostic allegations, a larger share than any other category of medical condition. Among radiology cases with diagnostic allegations, high-severity harm occurred in 79% of oncologic but just 42% of nononcologic cases. Of all oncologic radiology cases, 97.4% had diagnostic allegations, and just 55.0% of nononcologic radiology cases had diagnostic allegations. Imaging misinterpretation was a contributing factor for a large majority (80.7% [623 of 772]) of oncologic radiology cases with diagnostic allegations. The modalities most commonly used in oncologic radiology cases with diagnostic allegations involving misinterpretation were mammography and CT.

CONCLUSION

Oncology represents the largest source of radiology malpractice cases with diagnostic allegations. Oncologic radiology malpractice cases are more likely than nononcologic radiology cases to be due to diagnostic errors. Furthermore, compared with those that are nononcologic, oncologic radiology cases with diagnostic allegations are more likely to be associated with high-severity harm. Efforts are warranted to reduce misinterpretations of oncologic imaging.

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

OBJECTIVES

The largest proportion of general practitioner (GP) magnetic resonance imaging (MRI) is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety.

METHODS

Cohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation.

RESULTS

Of 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered 'low-value' (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%-30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost-consequence or cost-utility analysis.

CONCLUSION

Unfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1-2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.

Bereavement is different: A multinational bereavement symptom model validation

Clinicians need to rule out an appropriate grief reaction when diagnosing major depression. This study identifies symptom differences by bereavement status and validates a symptom model of bereavement. Symptom features from six national cross-sectional epidemiological samples were analyzed and estimates pooled. Crying often, thinking of death, appetite loss, waking up early, trouble sleeping, and depending on others were significantly more likely in the bereaved. Symptoms of thinking of or attempting suicide, feeling one would be better off dead or wanting to die, worthlessness, social conflict, worthlessness with difficulty making decisions, being discouraged, feeling less than others, being troubled, not coping, feeling hopeless, sleeping more, being upset and history of an anxiety disorder were all significantly less likely among the bereaved. Moderate to good model discrimination effect sizes were found. Good model performance was found when narrowly defined complicated bereavement cases were excluded. On the whole the bereaved are more likely to report symptoms consistent with a normal grief reaction. As depression screening becomes the norm in primary care, normal grief that meets Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) symptom criteria for a MDE likely has a high risk of being diagnosed inappropriately as pathological depression.

Errors, discrepancies and underlying bias in radiology with case examples: a pictorial review

Interpretation differences between radiologists and diagnostic errors are significant issues in daily radiology practice. An awareness of errors and their underlying causes can potentially increase the diagnostic performance and reduce individual harm. The aim of this paper is to review both the classification of errors and the underlying biases. Case-based examples are presented and discussed for each type of error and bias to provide greater clarity and understanding.

Challenges in diagnosis of limited granulomatosis with polyangiitis

Granulomatosis with polyangiitis (GPA) is an orphan disease with multifaceted clinical presentations and delayed diagnosis. Given the risks of delayed diagnosis and treatment, improving clinicians' awareness of atypical course of this disease is critically important. The aim of this report is to analyze a case of delayed diagnosis of GPA in view of similar publications. We analyzed articles retrieved from Scopus and MEDLINE/PubMed. The following keywords were used: "granulomatosis with polyangiitis", "Wegener granulomatosis", and "diagnostic errors". All case studies that fulfilled the Chapel Hill Consensus Conference and the American College of Rheumatology GPA criteria were retrieved. We report a 71-year-old female patient with a facial defect in the nasal region, nasal congestion, and serosanguineous discharge. Her final diagnosis of GPA was reached after a series of incorrect diagnoses in the past 40 years. A deforming facial lesion developed during this period of uncertainty and absence of appropriate treatment. This patient presented with atypical features of laboratory and instrumental examinations. Anti-neutrophil cytoplasmic antibodies (ANCA) were negative, while rheumatoid factor (RF; 46.3 IU/mL) and anti-citrullinated protein antibody (ACPA; 25.6 IU/mL) were elevated. The histological analysis of the nasal mucous membrane specimen did not indicate definite signs of vasculitis. However, it revealed a granuloma with aggregation of macrophages and massive infiltration of lymphocytes, ruling out previous diagnosis of carcinoma. We analyzed delayed diagnosis of GPA in our patient in the context of 12 previously reported similar cases of limited form of GPA. We emphasize the importance of histological examination for differential diagnosis of GPA.

Using information theory to optimize a diagnostic threshold to match physician-ordering practice

OBJECTIVE

Clinicians order laboratory tests in an effort to reduce diagnostic or therapeutic uncertainty. Information theory provides the opportunity to quantify the degree to which a test result is expected to reduce diagnostic uncertainty. We sought to apply information theory toward the evaluation and optimization of a diagnostic test threshold and to determine if the results would differ from those of conventional methodologies. We used a heparin/PF4 immunoassay (PF4 ELISA) as a case study.

MATERIALS AND METHODS

The laboratory database was queried for PF4 ELISA and serotonin release assay (SRA) results during the study period, with the latter serving as the gold standard for the disease heparin-induced thrombocytopenia (HIT). The optimized diagnostic threshold of the PF4 ELISA test was compared using conventional versus information theoretic approaches under idealized (pretest probability = 50%) and realistic (pretest probability = 2.4%) testing conditions.

RESULTS

Under ideal testing conditions, both analyses yielded a similar optimized optical density (OD) threshold of OD > 0.79. Under realistic testing conditions, information theory suggested a higher threshold, OD > 1.5 versus OD > 0.6. Increasing the diagnostic threshold improved the global information value, the value of a positive test and the noise content with only a minute change in the negative test value.

DISCUSSION

Our information theoretic approach suggested that the current FDA approved cutoff (OD > 0.4) is overly permissive leading to loss of test value and injection of noise into an already complex diagnostic dilemma. Because our approach is purely statistical and takes as input data that are readily accessible in the clinical laboratory it offers a scalable and data-driven strategy for optimizing test value that may be widely applicable in the domain of laboratory medicine.

CONCLUSION

Information theory provides more meaningful measures of test value than the widely used accuracy-based metrics.

Pitfalls in the diagnosis of Gaucher disease in Iraq: A diagnostic experience from a developing country

Background and Objectives:

Gaucher disease (GD) is a rare hereditary disorder caused by deficiency of the lysosomal enzyme β-glucocerebrosidase. An early and definitive diagnosis minimizes the sequelae of misdiagnoses, and unnecessary and invasive diagnostic procedures.

Methods:

A cross-sectional descriptive study was conducted in the period from June to August, 2018, to analysing data of thirteen patients, retrospectively. They presented to the gastrointestinal and metabolic clinics in Children Welfare Teaching Hospital in Iraq, and had wrong and delayed diagnosis of GD.

Results:

Two groups of patients were identified, based on diagnosis by enzymatic assay (considering the test positive when the enzyme level is below the normal value); those who had false positive (low level of the enzyme) result and received enzyme replacement therapy for long time, and those who had false negative (normal level of the enzyme) results which caused delay in their diagnosis and treatment. Two main factors that misled the diagnosis were identified.

Conclusion:

Each patient with Gaucher disease need to be approached by taking a thorough history, a proper clinical examination, and then by being investigated, accordingly. Biomarkers and molecular genetic studies are more accurate and solid additional tools, to the enzymatic assays on dried blood sample (DBS).

The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness

BACKGROUND

Management of patients with coma of unknown etiology (CUE) is a major challenge in most emergency departments (EDs). CUE is associated with a high mortality and a wide variety of pathologies that require differential therapies. A suspected diagnosis issued by pre-hospital emergency care providers often drives the first approach to these patients. We aim to determine the accuracy and value of the initial diagnostic hypothesis in patients with CUE.

METHODS

Consecutive ED patients presenting with CUE were prospectively enrolled. We obtained the suspected diagnoses or working hypotheses from standardized reports given by prehospital emergency care providers, both paramedics and emergency physicians. Suspected and final diagnoses were classified into I) acute primary brain lesions, II) primary brain pathologies without acute lesions and III) pathologies that affected the brain secondarily. We compared suspected and final diagnosis with percent agreement and Cohen's Kappa including sub-group analyses for paramedics and physicians. Furthermore, we tested the value of suspected and final diagnoses as predictors for mortality with binary logistic regression models.

RESULTS

Overall, suspected and final diagnoses matched in 62% of 835 enrolled patients. Cohen's Kappa showed a value of κ = .415 (95% CI .361-.469, p < .005). There was no relevant difference in diagnostic accuracy between paramedics and physicians. Suspected diagnoses did not significantly interact with in-hospital mortality (e.g., suspected class I: OR .982, 95% CI .518-1.836) while final diagnoses interacted strongly (e.g., final class I: OR 5.425, 95% CI 3.409-8.633).

CONCLUSION

In cases of CUE, the suspected diagnosis is unreliable, regardless of different pre-hospital care providers' qualifications. It is not an appropriate decision-making tool as it neither sufficiently predicts the final diagnosis nor detects the especially critical comatose patient. To avoid the risk of mistriage and unnecessarily delayed therapy, we advocate for a standardized diagnostic work-up for all CUE patients that should be triggered by the emergency symptom alone and not by any suspected diagnosis.

Carcinoma Cuniculatum of Mandible Masquerading as Odontogenic Keratocyst: Challenges in the Histopathological Diagnosis

Carcinoma cuniculatum is a locally aggressive, low-grade variant of squamous cell carcinoma. Though primarily a tumour of the skin, it has also been found to be arising from various mucosal surfaces including oral mucosa. When it occurs in the mandible it starts as a mucosal lesion which progressively invades the jaw and destroys the underlying bone, often presenting as a cystic lesion. With only around 30 cases reported in the mandible, this entity remains an elusive one for the pathologist and all except a few cases reported so far, had been misdiagnosed initially. The delay in the diagnosis is a major concern as it results in further progression of the disease with extensive involvement of bone and associated soft tissue structures. The aim of this article is to discuss the histopathological challenges faced in arriving at the diagnosis of a case of carcinoma cuniculatum involving the mandible. Owing to its overlapping clinico-pathological characteristics with odontogenic keratocyst the lesion has been misdiagnosed initially resulting in inadequate management, leading to multiple recurrences and unexpected complications. As a few cases like the present one had been erroneously diagnosed as odontogenic keratocyst previously, it becomes important to identify the varied clinical presentation and unique histopathological characteristic of carcinoma cuniculatum of mandible to help us in recognizing this often-missed entity at an earlier stage, so that it can be managed effectively.

Diagnostic errors in clinical FDG-PET/CT

PURPOSE

To determine the frequency, types, and determinants of diagnostic errors in clinical FDG-PET/CT, based on addenda to the original report.

MATERIALS AND METHODS

This retrospective study included 4,099 consecutive clinical FDG-PET/CT scans with corresponding reports that were made at a tertiary care center in an 18-month period. FDG-PET/CT reports were scrutinized for the presence of an addendum enclosing a diagnostic error.

RESULTS

90 of 4,099 FDG-PET/CT reports (2.2%) contained an addendum enclosing a diagnostic error. The distribution of perceptual and cognitive errors among these 90 diagnostic errors was 54 (60.0%)/36 (40.0%). On multivariate logistic regression analysis, only low-dose FDG-PET/CT combined with concomitantly acquired and interpreted full-dose contrast-enhanced CT remained as significantly and independently associated with the presence of a diagnostic error, relative to low-dose FDG-PET/CT without concomitantly acquired and interpreted full-dose contrast-enhanced CT (odds ratio: 2.79 [95% confidence interval: 1.61-4.85], P < 0.001). Patient age, gender, hospital status, indication for FDG-PET/CT scanning, single vs. double reading (i.e. two medical imaging specialists), reader experience, and reading by a nuclear medicine physician only vs. reading by both a nuclear medicine physician and a radiologist, were not significantly and independently associated with the presence of a diagnostic error.

CONCLUSION

Diagnostic errors in clinical FDG-PET/CT based on addenda to the original report are relatively infrequent, though certainly non-negligible. Perceptual errors are slightly more frequent than cognitive errors. The availability of a concomitantly acquired and interpreted full-dose contrast-enhanced CT seems to increase diagnostic error rate. These data can be used for quality improvement and benchmarking purposes.

Adrenal lesions found incidentally: how to improve clinical and cost-effectiveness

Introduction

Adrenal incidentalomas are lesions that are incidentally identified while scanning for other conditions. While most are benign and hormonally non-functional, around 20% are malignant and/or hormonally active, requiring prompt intervention. Malignant lesions can be aggressive and life-threatening, while hormonally active tumours cause various endocrine disorders, with significant morbidity and mortality. Despite this, management of patients with adrenal incidentalomas is variable, with no robust evidence base. This project aimed to establish more effective and timely management of these patients.

Methods

We developed a web-based, electronic Adrenal Incidentaloma Management System (eAIMS), which incorporated the evidence-based and National Health Service–aligned 2016 European guidelines. The system captures key clinical, biochemical and radiological information necessary for adrenal incidentaloma patient management and generates a pre-populated outcome letter, saving clinical and administrative time while ensuring timely management plans with enhanced safety. Furthermore, we developed a prioritisation strategy, with members of the multidisciplinary team, which prioritised high-risk individuals for detailed discussion and management. Patient focus groups informed process-mapping and multidisciplinary team process re-design and patient information leaflet development. The project was partnered by University Hospital of South Manchester to maximise generalisability.

Results

Implementation of eAIMS, along with improvements in the prioritisation strategy, resulted in a 49% reduction in staff hands-on time, as well as a 78% reduction in the time from adrenal incidentaloma identification to multidisciplinary team decision. A health economic analysis identified a 28% reduction in costs.

Conclusions

The system’s in-built data validation and the automatic generation of the multidisciplinary team outcome letter improved patient safety through a reduction in transcription errors. We are currently developing the next stage of the programme to proactively identify all new adrenal incidentaloma cases.

Exploring the Risk Factors for the Misdiagnosis of Osteonecrosis of Femoral Head: A Case-Control Study

Objective

The purpose of the present study was to evaluate the present situation and risk factors for the misdiagnosis of osteonecrosis of femoral head (ONFH), providing the basis for accurate diagnosis of ONFH.

Methods

For this retrospective study, 1471 patients with ONFH were selected from the China Osteonecrosis of Femoral Head Database (CONFHD). These patients had been recruited between July 2016 and December 2018. According to whether or not they were misdiagnosed, the patients were divided into two groups, with 1168 cases (22–84 years old) included in the diagnosis group and 303 cases (21–80 years old) in the misdiagnosis group. Misdiagnosis was measured using the following criteria: (i) the patient had the same symptoms and signs, and the second diagnosis was not consistent with the initial diagnosis within 6 months; and (ii) the patient was admitted to a hospital participating in CONFHD and the previous diagnosis was inconsistent with the diagnosis given by the expert group. Comparisons of age, visual analogue scale for pain, and body mass index between the two groups were performed using a t‐test. Gender, causes of ONFH, primary diseases requiring corticosteroids, methods of corticosteroid use, corticosteroid species, type of trauma, onset side of the disease, pain side, whether symptoms are hidden, and type of imaging examination at the initial visit were compared using the χ²‐test. Years of alcohol consumption, weekly alcohol consumption, and physician title at the initial visit were compared using a Mann–Whitney U‐test. Furthermore, the statistically significant factors were evaluated using multiple regression analysis to investigate the risk factors of misdiagnosis.

Results

A total of 303 patients (20.6%) were misdiagnosed: 118 cases were misdiagnosed as lumbar disc herniation, 86 cases as hip synovitis, 48 cases as hip osteoarthritis, 32 cases as rheumatoid arthritis, 11 cases as piriformis syndrome, 5 cases as sciatica, and 3 cases as soft‐tissue injury. Whether symptoms are hidden (P = 0.038, odds ratio [OR] = 1.546, 95% confidence interval [CI] = 1.025–2.332), physician title at the initial visit (P < 0.001, OR = 3.324, 95% CI = 1.850–5.972), X‐ray examination (P < 0.001, OR = 4.742, 95% CI = 3.159–7.118), corticosteroids (P < 0.001, OR = 0.295, 95% CI = 0.163–0.534), alcohol (P < 0.001, OR = 0.305, 95% CI = 0.171–0.546), and magnetic resonance imaging (MRI) examination (P = 0.042, OR = 0.649, 95% CI = 0.427–0.985) were each found to be associated with misdiagnosis.

Conclusion

Osteonecrosis of the femoral head is easily misdiagnosed as lumbar disc herniation, hip synovitis, hip osteoarthritis, and rheumatoid arthritis. Patient history of corticosteroid use or alcohol abuse and MRI examination at the initial diagnosis may be protective factors for misdiagnosis. Hidden symptoms, physician title at the initial visit (as attending doctor or resident doctor), and only X‐ray examination at the initial diagnosis may be risk factors for misdiagnosis.

Spider bites of medical significance in the Mediterranean area: misdiagnosis, clinical features and management

Despite the disrepute spiders have had for centuries, their bite is a rare occurrence. In the Mediterranean area, only two of the numerous known species are considered of medical significance: Latrodectus tredecimguttatus and Loxosceles rufescens. Spider bites have no pathognomonic signs or symptoms, therefore most diagnoses are presumptive; a spider bite can only be diagnosed when a spider (seen at the time of the bite) is collected and identified by an expert, since most physicians and patients are unable to recognize a certain spider species or distinguish spiders from other arthropods. Skin lesions of uncertain etiology are too often attributed to spider bites. In most cases, these are actually skin and soft-tissue infections, allergic reactions, dermatoses etc. Misdiagnosing a wound as a spider bite can lead to delays in appropriate care, cause adverse or even fatal outcomes and have medical-legal implications. Concerningly, misinformation on spider bites also affects the medical literature and it appears there is lack of awareness on current therapeutic indications for verified bites.

Malignant Lesions Mimicking Endodontic Pathoses Lesion: A Systematic Review

INTRODUCTION

Malignant nonendodontic periapical lesions represent a rare diagnosis, in which few case have been reported about this condition. Due to the low occurrence and little exploration of this subject, serious errors of diagnosis are observed in the oral medicine services. In this sense, the purpose of the present review was to integrate the information on the record published on malignant lesions that mimic endodontic pathoses into a comprehensive analysis of their clinical, radiologic, and histopathologic features.

METHODS

An online search was made in March 2020 in the following databases: Pubmed, Web of Science, and Scopus. Eligibility criteria included publications having enough clinical, radiologic, and histopathologic information to confirm the diagnosis. Data were assessed descriptively.

RESULTS

Forty-nine publications from 16 countries comprising 60 cases were included. There is a nearly equal occurrence rate between males and females (male/female ratio is 49.15%/50.84%) with a mean age of 46.56 years. The lesions were more prevalent in the posterior mandibles (40.69%), and, radiographically, they were unilocular radiolucent. Histopathologic analysis showed metastasis (26.67%) as the most prevalent lesion followed by salivary gland malignant disease (25%).

CONCLUSIONS

The present systematic review revealed several histologic types of malignant periapical lesions that could be mimicking endodontic pathoses. Because these lesions usually do not show clinical or radiologic features of malignant alteration, clinicians should consider these hypotheses in their routine.

Signet-ring cell appearance of atrophic fat cells

Cells with 'signet-ring' appearance were found at post-mortem examination of a man with a history of chronic illness, weight loss and multiple regions of 'bowel thickening' during life. Due to the decedent's history, the finding raised the possibility of disseminated signet-ring adenocarcinoma. However, the vacuoles did not stain for mucin and the cells did not stain for keratin. The cells did stain for calretinin and so a diagnosis of signet ring mesothelioma was considered. However, it was suggested that the cells with a cytoplasmic vacuole displacing the nucleus to one side producing the signet-ring appearance were instead atrophic fat cells. This was subsequently proven by Oil Red O staining.