A butterfly vertebra or a wedge fracture?

Two patients, who had injuries to the dorsal spine with vertebral wedging, are described. In both a compression wedge fracture was diagnosed, but a careful study of the anteroposterior radiographs showed that the presumed injury was a butterfly vertebra. This rare congenital anomaly, which is usually without clinical significance, may be mistaken for a wedge fracture unless the anteroposterior view is correctly assessed.

Errors in the assessment of tympanic membrane perforations

It is commonly stated that operative closure of large perforations of the tympanic membrane is less successful than closure of small perforations. Few authors mention the exact size of the perforations studied, and fewer still give their method of measuring perforations. We describe a photographic method of assessing the size of perforations relative to the total drumhead, measuring them with a computerized digitizing pad. Thirteen temporal bones were selected at random. Perforations of different sizes, shapes and at different sites were fashioned in the tympanic membranes. These were assessed by clinicians of all grades, who were asked to draw the perforations and give estimates of the perforation size as a percentage of the total drumhead. Visual estimates and drawings were compared with a photographic objective method. Gross errors (some in excess of 100%) were apparent in both estimates and drawings. There was a highly significant statistical difference between the objective method and visual estimates and drawings (P < 0.001). Greater clinical experience was not correlated with better performance in estimating the size of perforations.

Evaluation of the PACE 2 Neisseria gonorrhoeae assay by three public health laboratories

The Gen-Probe PACE 2 DNA probe assay for Neisseria gonorrhoeae was compared with conventional culture techniques in three Florida public health laboratories with 436 patients (271 females and 165 males). The prevalence rates based on culture were 19.9, 55.8, and 33.5% for females, for males, and overall, respectively. Twenty-seven probe-positive specimens gave negative culture results. Twenty of these specimens were resolved as true positives after retesting with a probe competition assay. The resolved sensitivity, specificity, positive predictive value, and negative predictive value were 99.4, 99.6, 99.4, and 99.6%, respectively.

Pertussis in Missouri: evaluation of nasopharyngeal culture, direct fluorescent antibody testing, and clinical case definitions in the diagnosis of pertussis

No diagnostic test for pertussis in routine use in the United States has both high sensitivity and high specificity. During a statewide increase in the incidence of pertussis in Missouri, we studied the clinical features of 153 patients with suspected pertussis in the Greater St. Louis area from whom a specimen for pertussis culture had been taken between 15 May and 19 September 1989. In this cross-sectional study, nasopharyngeal cultures were more likely to be positive for persons whose specimens were collected < 21 days after cough onset (adjusted rate ratio [RRa] and 95% confidence interval = 3.4; 1.5-8.0) and who were not receiving erythromycin/sulfamethoxazole prior to the culture [RRa = 5.8; 0.8-40.6], who had received fewer than three prior doses of pertussis vaccine [RRa = 1.8; 0.8-4.2], and whose specimen was in transit to the laboratory for < 4 days [RRa = 2.0; 0.8-5.5]. Among children < 5 years of age, spasmodic cough plus a lymphocytosis of > 10,000/mm3 was the acute symptom complex associated with the highest predictive value for a positive culture result (67%). Cough for > or = 14 days plus whoop was sensitive (81%) and specific (58%) for identifying children with culture-confirmed pertussis. Direct fluorescent antibody staining performed well as a screening test for pertussis but requires substantial commitment of personnel and resources. In the absence of a positive culture result, clinical case definitions should be used for decision making (e.g., initiation of antimicrobial therapy and routine case reporting).

[Study on quality of diagnosis in patients with sputum negative pulmonary tuberculosis in rural area]

1194 cases (3.9%) were randomly selected from all newly registered patients with sputum negative pulmonary tuberculosis (PTB) of Jiangsu Province in 1991. After reevaluation by specialists, final diagnosis was made. 94 cases (7.9%) were excluded because of insufficient information, the diagnosis of PTB for 107 patients (9.7%) of the remained 1100 cases were not correct. Results indicate that one of the causes for the low sputum positive rate of newly registered patients with PTB was probably due to the comparatively large proportion of misdiagnosed sputum negative patients.

Missed appendicitis in a pediatric emergency department

Appendicitis is the most common cause of abdominal pain requiring surgery in children. Missed appendicitis is also a frequent cause of professional liability in an emergency department (ED). A retrospective review of all patients with appendicitis diagnosed in the ED was undertaken to identify: 1) how many patients required more than one visit to diagnose appendicitis and 2) the clinical characteristics that distinguished the patients who visited twice from patients who were diagnosed on the first visit. A total of 87 patients with appendicitis were seen by pediatricians in the ED from 1987 to 1989. The patients included 43 girls and 44 boys (mean age, 8.9 years). Six patients (7%) were seen twice before the diagnosis of appendicitis was made. They returned to the ED on average 29 hours after the first visit. The ED discharge diagnosis of the six "missed" patients included: probable Campylobacter (n = 1), viral urinary tract infection (n = 1), gastroenteritis (n = 2), and abdominal pain (n = 2). The six missed patients were different from the other patients with appendicitis. They were more likely to have a normal appetite, to have diarrhea, and to be afebrile. All the patients had at least two of the four following signs and symptoms: vomiting, tenderness, guarding, and right lower quadrant (RLQ) pain. At the time of surgery, 23/81 (28%) of the one-visit group had a ruptured appendix, whereas 3/6 (50%) of the missed patients had a ruptured appendix.

CONCLUSIONS

1) Seven percent of the patients were seen twice in our ED before the diagnosis of appendicitis was made.(ABSTRACT TRUNCATED AT 250 WORDS)

Stepwise development of a clinical expert system in rheumatology

The evaluation of computer expert systems, a promising diagnostic tool for future application in clinical medicine, is of great importance. We present here the evaluation of our expert system, "RHEUMA". It is stressed, that repeated retrospective testing and updating of an expert system and its subsequent repeated assessment in clinical use and surroundings is mandatory. This increases the diagnostic accuracy of the system. For our system this is demonstrated under three separate conditions. In the first study the information available for the computer system (mainframe) came from medical histories only. Here an error rate of about 25%--similar to that of physicians themselves using the same information--was observed in 358 outpatients, compared to the final diagnoses of physicians also relying solely on information from medical histories. In a second step a completely new system on a personal computer was developed with all relevant diagnostic information. The error rate of this system (0.4%) was much too optimistic because the knowledge base was changed during the study, affecting about 30% of the 282 prospectively recruited outpatients. In a third step the efficacy of the expert system was tested in an additional hospital without the diagnostic involvement of the first testing clinic. The error rate of the system without changing the knowledge base reached 11% in 51 outpatients in this rheumatology clinic. This result reflects the diagnostic accuracy of the system today. Its ability to specify the same diagnoses which clinical experts reached approached 90%. Considerable time is needed for such prospective testing, with repeated updating of the knowledge base--in our case for both the two systems and field studies of 2 years each.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and pathologic factors associated with delayed diagnosis in solitary rectal ulcer syndrome

Solitary rectal ulcer syndrome (SRUS) often goes unrecognized or is misdiagnosed. Of 98 patients with a final clinicopathologic diagnosis of SRUS, an initially incorrect diagnosis had been made in 25 patients (26 percent). In these 25 patients with a misdiagnosis, the median age was 43 years and the female-to-male ratio was 3.2:1. The median duration of incorrect diagnosis was five years (range, three months to 30 years), and seven patients received prednisone (> 30 mg/day) for a mistaken diagnosis of inflammatory bowel disease. The main clinical symptoms were rectal bleeding (84 percent) and a disturbance of bowel function (56 percent). Rectal prolapse was present in 13 patients. Original rectal biopsy specimens from 23 patients were reviewed; inadequate specimens and failure to recognize diagnostic features of SRUS contributed to delayed diagnosis in 13 and 10 patients, respectively. The most common clinicopathologic misdiagnoses in SRUS patients with rectal ulcers or mucosal hyperemia were Crohn's disease and mucosal ulcerative colitis. In patients with "polypoid" SRUS, diagnostic confusion was usually with a neoplastic polyp. Persistent bowel symptoms and rectal lesions led to review of the presentations and repeat biopsy directed toward the edge of the rectal ulcers or from within the polypoid or hyperemic rectal lesions, finally establishing the diagnosis of SRUS. Intractable symptoms led to surgery in 15 patients (60 percent), with symptomatic improvement in over two-thirds.

Basilar artery migraine or cerebral vascular accident?

There are no reports of misdiagnosis of postmanipulative stroke in the literature. This report discusses a case of basilar artery migraine that was misdiagnosed as such. The main diagnostic features of this rare condition are highlighted, as are the relevant differential diagnoses.

Complications of missed arterial injuries

PURPOSE

The natural history of untreated major injuries is not well known, although serious complications are seen. The follow-up of patients who have trauma is often incomplete, and this study was undertaken to evaluate the nature of these wounds.

METHODS

Thirty-one patients with missed major arterial wounds were examined and treated according to the pathologic condition encountered. All had been seen at other hospitals, some on more than one occasion, and then sought assistance for continued problems.

RESULTS

There were 16 aneurysms in 31 patients: 4 arteriovenous fistulas, 4 dissections, 3 thromboemboli, and 1 stenosis. The arteries included the following: carotid 12, aorta 5, femoropopliteal 8, subclavian 2, axillary 1, innominate 1, iliac 1, and tibial 1. Three patients had a stroke, one had a transient ischemic attack, two had leg ischemia, and one had a gangrenous foot. Operation was required in 27 patients; there were no deaths.

CONCLUSIONS

Transmural traumatic arterial wounds of major vessels can result in serious delayed complications, months or even years after the injury. False aneurysms, dissections, occlusions, and fistulas in the extremities may not be lethal, but they cause significant disability. Such lesions in the neck or trunk are more dangerous. Despite the inconvenience and expense, patients with injuries of major arteries are best served by early repair of the wound.

Autopsy findings and clinical diagnoses: a review of 1,000 cases

The protocols of 1,000 consecutive adult patients autopsied during the period June 1983 to December 1988 were retrospectively analyzed and the findings were compared with clinical diagnoses. The autopsy rates during this period ranged between 23% and 27% of hospital deaths. Eighty-seven percent of the autopsied patients were between 15 and 59 years of age. Major discrepancies between the autopsy reports and the clinical diagnoses were present in 31.7% of all autopsy reports reviewed. Infectious diseases were the most common cause of death (46.8%), followed by cardiovascular diseases (17.1%) and neoplastic diseases (14.3%). Infections were clinically recognized in 66.7% of cases and were missed or found to be incorrect in 33.3% of cases. Tuberculosis comprised 33.8% of the major bacterial infections and was clinically diagnosed in 82% of cases. Eighty-nine percent of the major fungal infections were not suspected clinically. Rheumatic heart disease (43.8%) was the most common cardiovascular disorder and was clinically diagnosed in 93.3% of cases. Pulmonary vascular episodes were the least common cause of death and were not suspected clinically in 62.9% of cases. Malignancies were incorrectly diagnosed in 25.8% of cases. We conclude from this study that routine autopsies revealed major unexpected findings that are of clinical importance, and that a continued emphasis on autopsy evaluation is necessary for the improvement of the quality of patient care.

Cryptosporidiosis: multiattribute evaluation of six diagnostic methods

Six diagnostic methods (Giemsa staining, Ziehl-Neelsen staining, auramine-rhodamine staining, Sheather's sugar flotation, an indirect immunofluorescence procedure, and a modified concentration-sugar flotation method) for the detection of Cryptosporidium spp. in stool specimens were compared on the following attributes: diagnostic yield, cost to perform each test, ease of handling, and ability to process large numbers of specimens for screening purposes by batching. A rank ordering from least desirable to most desirable was then established for each method by using the study attributes. The process of decision analysis with respect to the laboratory diagnosis of cryptosporidiosis is discussed through the application of multiattribute utility theory to the rank ordering of the study criteria. Within a specific health care setting, a diagnostic facility will be able to calculate its own utility scores for our study attributes. Multiattribute evaluation and analysis are potentially powerful tools in the allocation of resources in the laboratory.

Melanoma in childhood and adolescence: clinical and pathological features of 48 cases

Forty-eight cases of melanoma occurring in patients under 20 years of age were reviewed from a 23-year period at a single center. Fourteen of the patients were preadolescent children and 44 were Caucasian. Histological review of 44 available primary tumors showed only superficial spreading and nodular types. Thickness ranged from 0.23 mm to 8.50 mm, with a median of 1.03 mm. Ulceration was present in 7%, necrosis in 35%, evidence of regression in 16%, and antecedent nevus in 49% of the cases. The overall 5-year survival is 77%, with a median follow-up of 48 months. There is no detectable survival difference between preadolescent children and adolescents. Several treatment failures occurred after improper biopsy and/or inaccurate original diagnosis of Spitz's nevus. Of 38 stage I and II patients given definitive surgical treatment by the authors, the 5-year survival is 90%. Although histological confusion with Spitz's nevi occasionally occurs, melanoma in this age group can be treated with good results.

Bronchiolo-alveolar cell carcinoma with apparent response to chemotherapy to anti-tuberculosis

This report describes a case of bronchiolo-alveolar cell carcinoma of the lungs presenting with severe respiratory distress and miliary shadowing on chest radiograms. The patient showed an apparent response to anti-tuberculous chemotherapy, which was probably related to the neuropsychiatric properties of isoniazid. The case illustrates that not all "miliary" chest radiograms in Africa are tuberculous and a chemotherapeutic trial is not always diagnostic in individual cases of tuberculosis.

Extrarenal Wilms' tumor. Unusual presentation in the lumbosacral region

True extrarenal Wilms' tumor is a rare malignant neoplasm most frequently presenting in the retroperitoneal or inguinal regions. We report an unusual subcutaneous lumbosacral (LS) region extrarenal Wilms' tumor without associated teratomatous tumor elements or associated neural tube defect in a 2 1/2-year-old girl. Pathologic review revealed features of true extrarenal Wilms' tumor, and the patient remains in complete remission following surgery and combination chemotherapy. This report illustrates the importance of early surgical intervention and pathologic examination of similar soft tissue masses in children.

[Possibilities of error in the sonographic diagnosis of the kidneys]

In renal sonography pitfalls and differential diagnoses are very common. Typical pitfalls are presented in a pictorial essay and are discussed.

[Errors in the measurement and interpretation of pulmonary artery pressure values evaluated by the Swan-Ganz method]

The data collected by way of the catheter has for goal to give a better therapeutic treatment and is therefore directly related to the quality of the analysis of the signal. The fidelity of the measurements depend on the performance of the material used and also to other distortions linked to their utilization. In intensive care and in perioperative resuscitation, the interpretation must also take into account the possible interference from physiopathologic mechanisms which are sometimes very complex and can modify results in a number of situations both clinical and therapeutic and in particular when they are accompanied by vascular and respiratory perturbations.