[Semiotics of the Currarino syndrome]

The main criteria for diagnosis of the Currarino syndrome have been defined. Roentgenologic investigation of the lumbar-sacral spine in direct projection is indicated to all the patients with anorectal developmental defects, in particular with congenital anorectal stenosis. In detection of a specific defect of the terminal vertebrae, the performance of computed tomography of the pelvic bottom and nuclear magnetic resonance tomography of the lumbar-sacral spine is necessary. This permits to assess the nature of a presacral tumour and degree of dysplasia of the external and sphincter. Timely diagnosis of the Currarino syndrome in children with the anorectal developmental defects permits to avoid severe septic and functional complications in surgical intervention.

Interstitial cystitis: women at risk for psychiatric misdiagnosis

Interstitial cystitis (IC) is a form of painful bladder disease, characterized by chronic urinary urgency, frequency, and pain without evidence of bacterial infection. Ninety percent of patients with IC are women. Somatization disorder is a psychiatric diagnosis, given most often to women who report a variety of symptoms, such as dysmenorrhea, burning in sex organs, dyspareunia, irregular menstrual periods, and painful urination. Because diagnosis of interstitial cystitis may take many years, health care providers must be alert to the risks of the overdiagnosis of psychiatric problems and the underdiagnosis of interstitial cystitis.

[Diagnosis of migraine in general practice]

195 patients with headache were examined by general practitioners and neurologists, and their diagnoses were compared. The general practitioners diagnosed migraine in 116 cases, the neurologists in 144 cases, and in 104 cases their diagnoses agreed. Thus, migraine can be difficult to diagnose, and this study indicates underdiagnosis of this common condition by general practitioners. This may result in overuse of analgesics and alternative therapies, and too little prescription of specific migraine medication. Greater familiarity with the diagnostic criteria of the International Headache Society should make it easier to arrive at a correct migraine diagnosis.

[The reasons for a late diagnosis of duodenal peptic ulcer in women at a polyclinic]

The method of retrospective analysis was used to examine 240 women with duodenal ulcer. Mean time of establishing the diagnosis was 6.3 years. The causes of belated diagnosis in out-patient conditions were inadequate knowledge of atypical course of ulcer in women by the physician; incomplete evaluation of the X-ray data; infrequent fibroscopy and underestimation of endoscopic data; rare use of intragastric pH-metry.

MIBG detection of hepatic neuroblastoma: correlation with CT, US and surgical findings

Metaiodobenzylguanidine (MIBG) imaging is used in the diagnosis, staging and follow-up of virtually every case of neuroblastoma seen at our institution. Normal sites of MIBG uptake include the liver and therefore difficulties have been predicted and encountered in the diagnosis of hepatic neuroblastoma due to inability to separate abnormally increased tracer deposition from normal hepatic activity. We reviewed every MIBG (I123 and I131) study performed at our pediatric hospital over a 4 year period encompassing 88 patients, 67 of whom had biopsy proven neuroblastoma. Hepatic findings onMIBG studies were compared with concurrent abdominal CT and US studies in all 67 patients. The clinical records of all patients with abnormal MIBG scans or abnormal CT or US studies of the liver were also reviewed. Eight patients were found to have abnormal liver findings on one or more imaging studies (MIBG, CT, or US). There were 3 true positive MIBG studies, one of which was an early study in a patient who later went on to have one of the false positive studies. Two patients had false positive MIBG scans for liver neuroblastoma. MIBG failed to detect liver involvement in 4 patients.

[Factors delaying therapy in myocardial infarct]

The timelag from onset of myocardial infarction to beginning of treatment is significantly correlated with prognosis, especially since introduction of thrombolytic therapy. Based on the last case of 967 Austrian physicians (general practitioners and internists, working in an office or in a hospital) we investigated possible factors delaying the beginning of treatment. On the average it took 111 minutes from onset of symptoms until the patient contacted physicians working in offices. The overall mean from onset of symptoms to hospital admission was 136 minutes. Within the hospital almost no delay was reported. Main factors for delay were repression or suppression and misinterpretation of symptoms. Thus, the biggest potential for an early onset of treatment lies within the patients response to onset of symptoms. Measures improving knowledge about mechanisms of the disease of known or possible coronary heart disease patients are most important. Side-effects, such as over-critical or demanding patients should be avoided. In any case they should not distract from the importance of measures improving patients response.

[The diagnosis and treatment of acute pancreatitis]

From 1986 to 1990 1,577 patients were treated for acute pancreatitis. Destructive forms were found in 585 (37.1%) patients. Clinical, laboratory, roentgenological, endoscopic, and radiation methods were employed in establishing the diagnosis. Laparoscopy was the most informative method which combined successfully diagnostic and therapeutic aspects. Operations were performed on 165 patients with complicated forms of acute pancreatitis. The remaining 1,412 patients received nonoperative treatment including laparoscopic drainage. Total mortality 2.29%, postoperative mortality 21.29%.

Diagnosis and treatment of nevomelanocytic lesions of the skin. A community-based study

BACKGROUND AND DESIGN

Nevomelanocytic lesions of the skin are frequently removed. However, little data are available concerning the diagnostic accuracy, histologic features, and methods of removal for these common lesions. We identified 2935 consecutive nevomelanocytic lesions examined at four pathology laboratories to determine the accuracy of the preoperative diagnosis, the characteristics of the patients treated, and the methods used for removal.

RESULTS

Of 2935 melanocytic lesions, 2087 (71%) were benign nevi, 684 (22%) were dysplastic nevi, 72 (3%) were blue nevi, and 76 (3%) were lentigines. Lentiginous melanocytic hyperplasias with cytologic atypia (20) and melanoma (26) each represented less than 1% of such lesions. Diagnostic accuracy varied by the pathologic diagnosis and the specialty of the treating physician. Dermatologists and plastic surgeons had the highest diagnostic accuracy. Techniques used to remove melanocytic lesions varied by physician specialty and type of lesion.

CONCLUSIONS

Despite the high frequency of removal, the methods used to remove nevomelanocytic lesions vary widely. Improving the clinician's ability to distinguish type of lesion may improve care. Studies that determine optimal means for their removal are warranted.

Subependymoma of the thoracic cord: potential pitfalls in diagnosis

Subependymomas are rare tumours, usually intracranial, which have a distinctive histological appearance and a relatively benign nature. A symptomatic case of a thoracic spinal intramedullary tumour is presented. Complete removal with neurological recovery was achieved. Increased awareness of this lesion is desirable. Histological examination of small tumour specimens may result in an erroneous tissue diagnosis of astrocytoma and inadequate treatment.

Accuracy of intraoperative frozen section diagnosis in head and neck surgery: experience at a university medical center

We performed 2,210 intraoperative frozen sections on 258 patients from the Otolaryngology-Head and Neck Surgery Service in 1990 and 1991. Surgery involved a wide variety of benign and malignant lesions. Techniques included biopsies for diagnosis, simple excision, thyroid and salivary gland surgeries, lymph node biopsies, composite resections with radical neck dissections, laryngectomies, and skull base surgeries. During the 2-year period, 1,947 (88.1%) sections were requested for evaluation of surgical margins, 258 (11.7%) for diagnosis, and five (0.2%) cases for tissue identification. There was disagreement between the frozen section and permanent section in 46 (2.1%) cases, and the deferral diagnosis rate was 0.8%. Disagreements were the result of sampling errors in 33 and interpretive errors in 13 cases. There were six (0.3%) false-negative diagnosis of malignancy and four (0.2%) false-positive diagnoses of malignancy. Three of these had an impact on patient care as discussed. We recommend careful sampling and sectioning of small biopsies and the need for vigilant communication between surgeon and pathologist.

[Methodological recommendations for the study and management of patients with abdominal aortic aneurysms]

The life of the patients having aneurysms of aorta abdominal is in danger seriously because of the strong tendency of the aneurysms to make ruptures with the expansion of the diameter. The inhibition, even the retardation of the expansion of the aneurysms is impossible and the treatment can be only a surgical one. Stating the diagnosis aneurysm of aorta abdominal in the not specialized hospitals appears possible only in 30-50% from the cases. The frequency of the faults with the symptomatic aneurysms is comparatively high and 50% of the patients are being set for operations with a diagnosis "acuta abdomen". In the cases of ruptures the number of the faults reaches up to 72%. The lethality of the planned operative treatment is 3-5%. The lethality in the cases of urgent operation with ruptures is 50-75%. In order to avoid the faults and the complications in diagnosis of the illness we have made practical recommendations for consideration and discussion of the diagnosis and the tactics with patients having abdominal aneurysms. They are recommended for use in dispensary, surgical, urological and cardiological consulting rooms and the respective departments of the hospitals without special profile.

[The ultrasonic diagnosis of choledocholithiasis]

The results of examination and treatment of 162 patients with clinically suspected choledocholithiasis were analysed. The high significance of ultrasonic examination in the diagnosis of a calculous nature of the affection of the biliary tree with a record of its echosemeiotics is shown. The wide use of ultrasonic examination yields better information. Study of the results of complex examination of 110 patients with verified choledocholithiasis confirmed the high rarefying capacity of the ultrasonic method in the detection of stones in the extrahepatic biliary tree (85.8% accuracy of the examination) both when it is applied for the first time and when it is used during the treatment. Obligatory performance of ultrasonic examination in diseases of the extrahepatic biliary ducts is suggested.

A case of long-standing classical rheumatoid arthritis complicated by serological and clinical characteristics of SLE

A patient with RA who developed anti-Sm antibodies, a false positive serological test for syphilis (FPSTS), pericardial effusion, and leukopenia, 19-year after the onset of classical RA, is described. This case indicates a possible clinical association between the development of specific autoantibodies and clinical symptoms of SLE.

Interdepartmental quality assurance using coded autopsy results

A system of reporting discrepancies between antemortem and postmortem diagnoses was devised for use in interdepartmental quality assurance at a large community medical center. Between 1988 and 1991, 213 autopsies comprising 6% of deaths were coded using the system of Battle et al. (1) and distributed to the quality assurance committees of clinical departments. A major discrepancy was found in 11.7% (95% confidence interval; 6.8 to 18.4%) of adult cases. The discrepancy rate tended to increase with increasing patient age, but there was no significant effect due to patient sex, race, hospital of origin, clinical department of origin, whether the autopsy was restricted to examination of only part of the body, or whether the patient died in or out of the hospital. The possible uses of the quality assurance system and problems encountered with its implementation are discussed.

Conservative management of bilateral massive edema of the ovary. A case report

A case of bilateral massive ovarian edema with unilateral ovarian torsion is reported. Following surgical removal of the adnexa with the torsion, the edema of the opposite ovary resolved with oral contraceptive therapy. This has not been previously reported. This case is instructive because the nodular appearance and yellow color of the ovaries and the presence of yellow ascitic fluid could lead to an erroneous diagnosis of malignancy, resulting in performance of a more radical surgical procedure than is necessary. A review of the literature and the unusual nature of this lesion indicates the need for caution in diagnosis and management.

Paederus dermatitis: an easy diagnosable but misdiagnosed eruption

Paederus dermatitis is a peculiar irritant contact dermatitis characterised by erythemato-bullous lesions of sudden onset on exposed areas of the body. The disease is provoked by an insect belonging to genus Paederus. This beetle does not bite or sting, but accidental brushing against or crushing the beetle over the skin provokes the release of its coelomic fluid which contains paederin, a potent vesicant agent. Due to the pathogenic mechanism, the morphology and location of the dermatitis change from case to case. The lesion usually resembles the accidental dropping of a caustic or hot liquid. The uncommon association of acute dermatitis with minimal or no complaints, which would be noteworthy in the case of chemical or thermal burns, facilitates diagnosis which is corroborated by the season and by the case history.

Patient-centered computing: can it curb malpractice risk?

The threat of a medical malpractice suit represents a major cause of career dissatisfaction for American physicians. Patient-centered computing may improve physician-patient communications, thereby reducing liability risk. This review describes programs that have sought to enhance patient education and involvement pertaining to 5 major categories of malpractice lawsuits: Diagnosis, medications, obstetrics, surgery, and treatment errors.

[Diagnostic and treatment planning errors in patients with combined jaw deformities and the means for their prevention]

The authors analyze errors in the treatment of 18 patients with combined deformations of the jaws. Errors in the diagnosis, surgical treatment and the postoperative care are discussed, as are irrational orthodontic measures. Principles of the prevention of combined therapy complications are presented.