Genome-first evaluation with exome sequence and clinical data uncovers underdiagnosed genetic disorders in a large healthcare system

Population-based genomic screening may help diagnose individuals with disease-risk variants. Here, we perform a genome-first evaluation for nine disorders in 29,039 participants with linked exome sequences and electronic health records (EHRs). We identify 614 individuals with 303 pathogenic/likely pathogenic or predicted loss-of-function (P/LP/LoF) variants, yielding 644 observations; 487 observations (76%) lack a corresponding clinical diagnosis in the EHR. Upon further investigation, 75 clinically undiagnosed observations (15%) have evidence of symptomatic untreated disease, including familial hypercholesterolemia (3 of 6 [50%] undiagnosed observations with disease evidence) and breast cancer (23 of 106 [22%]). These genetic findings enable targeted phenotyping that reveals new diagnoses in previously undiagnosed individuals. Disease yield is greater with variants in penetrant genes for which disease is observed in carriers in an independent cohort. The prevalence of P/LP/LoF variants exceeds that of clinical diagnoses, and some clinically undiagnosed carriers are discovered to have disease. These results highlight the potential of population-based genomic screening.

Underreporting and Misclassification of Respiratory Syncytial Virus-Coded Hospitalization Among Adults in Denmark Between 2015-2016 and 2017-2018

BACKGROUND

Low awareness and lack of routine testing for respiratory syncytial virus (RSV) infections among adults has led to underreporting in hospital records. This study aimed to assess the underreporting and misclassification of RSV infections among adults hospitalized with an respiratory tract infection (RTI)-coded hospitalization.

METHODS

This study is an observational cohort study of RSV-associated hospitalizations among Danish adults (≥18 years old) conducted, between 2015 to 2018. Data were extracted from the Danish National Patient Registry (DNPR) and the Danish Microbiology Database. We identified RSV-positive hospitalizations by linking RTI-coded hospitalizations with a positive RSV test.

RESULTS

Using hospital admission registries, we identified 440 RSV-coded hospitalizations, of whom 420 (95%) had a positive RSV test registered. By linking patients with RTI-coded hospital admissions to RSV test result, we found 570 additional episodes of RSV-positive hospitalizations without an RSV-coded diagnosis.

CONCLUSIONS

Our study of national register data showed that RSV is underreported among Danish adults. The study showed that the reliability of hospitalization data to estimate the burden of RSV among adults is questionable and are sensitive to changes in practice over time, even with complete nationwide healthcare data. Healthcare data can be useful to observe seasonality but to estimate the disease burden, prospective surveillance is recommended.

An update on asthma diagnosis

OBJECTIVE

Asthma imposes a significant health and socioeconomic burden with an average prevalence impacting 5-10% of the global population. The aim of this narrative review is to update the current literature on topics related to asthma diagnosis.

DATA SOURCES

Original research articles were identified from PubMed using the search terms "asthma diagnosis" and "asthma misdiagnosis".

STUDY SELECTIONS

Recently published articles (n = 51) detailing the diagnosis, misdiagnosis of asthma, and the updated recommendations of the European and international asthma guidelines.

RESULTS

Emerging evidence revealed that asthma might represent a rather heterogenous clinical entity with varying underlying molecular mechanisms. Attempts have been made to unravel these traits to better provide accurate diagnosis and a more efficient patient-based management approach. The lack of a gold standard test for asthma diagnosis has contributed to its over- and underdiagnosis. This is problematic, given that overdiagnosis might lead to delay of both diagnosis and prompt treatment of other diseases, while underdiagnosis might substantially impact quality of life due to progression of asthma by increased rate of exacerbations and airway remodeling. In addition to poor asthma control and potential patient harm, asthma misdiagnosis is also associated with excessive costs. As a result, current international guidelines emphasize the need for a standardized approach to diagnosis, including objective measurements prior to treatment.

CONCLUSION

Future research is warranted to define the optimal diagnostic and treatable traits approach especially for patients with severe asthma, as they may benefit from the advent of newly targeted asthma management.

Using Clinical Vignettes to Understand the Complexity of Diagnosing Type 1 Diabetes in Sub-Saharan Africa

Lack of awareness, access to insulin and diabetes care can result in high levels of morbidity and mortality for children with type 1 diabetes (T1DM) in sub-Saharan Africa (SSA). Improvements in access to insulin and diabetes management have improved outcomes in some settings. However, many people still present in diabetic ketoacidosis (DKA) in parallel to misdiagnosis of children with T1DM in contexts with high rates of communicable diseases. The aim of this study was to highlight the complexity of diagnosing pediatric T1DM in a healthcare environment dominated by infectious diseases and lack of adequate health system resources. This was done by developing clinical vignettes and recreating the hypothetico-deductive process of a clinician confronted with DKA in the absence of identification of pathognomonic elements of diabetes and with limited diagnostic tools. A non-systematic literature search for T1DM and DKA in SSA was conducted and used to construct clinical vignettes for children presenting in DKA. A broad differential diagnosis of the main conditions present in SSA was made, then used to construct a clinician's medical reasoning, and anticipate the results of different actions on the diagnostic process. An examination of the use of the digital based Integrated Management of Childhood Illness diagnostic algorithm was done, and an analysis of the software's efficiency in adequately diagnosing DKA was assessed. The main obstacles to diagnosis were low specificity of non-pathognomonic DKA symptoms and lack of tools to measure blood or urine glucose. Avenues for improvement include awareness of T1DM symptomatology in communities and health systems, and greater availability of diagnostic tests. Through this work clinical vignettes are shown to be a useful tool in analyzing the obstacles to underdiagnosis of diabetes, a technique that could be used for other pathologies in limited settings, for clinical teaching, research, and advocacy.

Idiopathic Normal Pressure Hydrocephalus: The Real Social and Economic Burden of a Possibly Enormous Underdiagnosis Problem

Normal Pressure Hydrocephalus (iNPH) typically affects the elderly and can cause cognitive decline, resulting in its differential diagnosis with other neurodegenerative conditions. Moreover, it is probably underdiagnosed; such under- and misdiagnosis prevents the patient from receiving the right treatment and significantly affects the quality of life and life expectancy. This investigation is an in-depth analysis of the actual incidence of iNPH in the population of the province served by our hospital (circa 580,000 individuals). The first phase of this study was conducted by visualizing a total of 1232 brain CT scans performed in the Emergency Departments of the four hospitals of our network on patients who were admitted for different complaints yet screened as suspicious for iNPH. Subsequently, corresponding Emergency Department medical records were investigated to understand the medical history of each patient in search of elements attributable to an alteration of CSF dynamics. The cohort of positive CT scans, according to the radiological and clinical inclusion criteria, included 192 patients. Among the reasons to require acute medical care, "Fall" was the most common. The cumulative incidence of CT scans suggestive of iNPH among the patients undergoing CT scans was as high as 15.58%, and the period prevalence calculated for the total amount of patients accessing the Emergency Departments was 1.084%. The real incidence of iNPH in the population may be underestimated, and the social burden linked to the assistance of patients suffering from such untreated conditions could be significantly relieved.

Suspected Undiagnosed ADRD Among Middle Eastern and North African Americans

ADRD underdiagnosis among minority populations is well-established and known to be more prevalent among women. Yet, it remains unclear if these patterns exist among adults of Middle Eastern and North African (MENA) descent. We estimated ADRD underdiagnosis among adults of MENA descent and other US- and foreign-born non-Hispanic Whites and compared sex-stratified results. We linked 2000-2017 National Health Interview Survey and 2001-2018 Medical Expenditure Panel Survey data (ages > = 65 years, n = 23,981). Undiagnosed ADRD was suspected if participants reported cognitive limitations without corresponding ADRD diagnosis. Undiagnosed ADRD was highest among adults of MENA descent (15.8%) compared to non-Hispanic Whites (US-born = 8.1%; foreign-born = 11.8%). Women of MENA descent had 2.52 times greater odds (95% CI = 1.31-4.84) of undiagnosed ADRD compared to US-born White women after adjusting for risk factors. This study contributes the first national estimates of undiagnosed ADRD among adults of MENA descent. Continued research is needed to facilitate policy changes that more comprehensively address health disparities and related resource allocation.

HERACLIS-HDV cohort for the factors of underdiagnosis and prevalence of hepatitis D virus infection in HBsAg-positive patients

BACKGROUND AND AIMS

Hepatitis D virus (HDV) underdiagnosis remains common. We assessed the HDV screening and prevalence rates in HBsAg-positive patients seen at tertiary liver centres throughout Greece as well as factors affecting HDV diagnosis.

METHODS

All adult HBsAg-positive patients seen within the last 5 years were included. Non-screened patients who visited or could be recalled to the clinics over a 6-month period were prospectively tested for anti-HDV.

RESULTS

Of 5079 HBsAg-positive patients, 53% had anti-HDV screening (41% before and 12% after study initiation). Pre-study (8%-88%) and total screening rates (14%-100%) varied widely among centres. Screening rates were associated with older age, known risk group, elevated ALT, centre location and size and period of first visit. Anti-HDV prevalence was 5.8% without significant difference in patients screened before (6.1%) or after study initiation (4.7%, p = 0.240). Anti-HDV positivity was associated with younger age, parenteral drug use, born abroad, advanced liver disease and centre location. Overall, HDV RNA detectability rate was 71.6% being more frequent in anti-HDV-positive patients with elevated ALT, advanced liver disease and hepatitis B therapy.

CONCLUSIONS

Anti-HDV screening rates and recall capabilities vary widely among Greek liver clinics being higher in HBsAg-positive patients of known risk group with active/advanced liver disease seen at smaller centres, while non-medical factors are also important. Anti-HDV prevalence varies throughout Greece being higher in patients born abroad with younger age, parenteral drug use and advanced liver disease. Viremia is more frequently but not exclusively detected in anti-HDV-positive patients with elevated ALT and advanced liver disease.

Prevalence, diagnosis, and treatment of chronic obstructive pulmonary disease in a hospitalized lung cancer population: a single center study

Background

Chronic obstructive pulmonary disease (COPD) often coexists with lung cancer (LC) and has a detrimental effect on the prognosis of LC patients. Presently, there is a lack of adequate assessment regarding the management of COPD in LC patients. This study assessed the screening, prevalence, diagnosis and treatment of COPD in hospitalized LC patients and compared the management practices between two departments at our hospital.

Methods

We retrospectively assessed the data of 3,578 patients diagnosed with primary LC in the Department of Respiratory and Critical Care Medicine and the Department of Thoracic Surgery from January 2019 to December 2020. We also compared the rate of spirometry, COPD diagnosis and COPD inhalation treatment between the LC patients from both departments, the proportion of patients aware of their COPD diagnosis and adhered to inhaled therapy, and analyzed factors influencing COPD diagnosis and inhalation treatment.

Results

A total of 2,762 (77.2%) LC patients underwent spirometry, and the observed spirometry-defined COPD prevalence was 25.0% (690/2,762). The proportion of spirometry performed in the Department of Thoracic Surgery was significantly higher than in the Department of Respiratory and Critical Care Medicine (90.5% vs. 62.9%; P<0.001). The overall COPD diagnosis rate recorded in the discharge diagnosis in the 690 spirometry-defined COPD patients was 46.5% (321/690), and the COPD treatment rate during hospitalization was 45.2% (312/690). In addition, physicians from the Department of Respiratory and Critical Care Medicine had a higher diagnostic rate than surgeons from the Department of Thoracic Surgery (69.1% vs. 7.5%; P<0.001), as well as a better-standardized COPD treatment rate (60.6% vs. 18.6%; P<0.001). Further, the proportion of COPD inhalation treatment was higher among LC patients with COPD recorded in discharge diagnosis (74.8% vs. 19.5%; P<0.001), and multivariate logistic regression analysis showed that COPD recorded in discharge diagnosis significantly increased the proportion of COPD awareness post-hospitalization (P<0.001).

Conclusions

This study showed that COPD could be a frequently undiagnosed and undertreated condition among LC patients, especially those hospitalized in a surgical ward. Additionally, a discharge diagnosis of COPD may increase the rate of inhalation treatment and awareness of the condition in LC patients.

The hidden borderline patient: patients with borderline personality disorder who do not engage in recurrent suicidal or self-injurious behavior

BACKGROUND

Despite the significant psychosocial morbidity associated with borderline personality disorder (BPD), its underrecognition is a significant clinical problem. BPD is likely underdiagnosed, in part, because patients with BPD usually present with chief complaints associated with mood, anxiety, and substance use disorders. When patients with BPD do not exhibit self-harm behavior, we suspect that BPD is less likely to recognized. An important question is whether the absence of this criterion, which might attenuate the likelihood of recognizing and diagnosing the disorder, identifies a subgroup of patients with BPD who are 'less borderline' than patients with BPD who do not manifest this criterion.

METHODS

Psychiatric outpatients were evaluated with a semi-structured diagnostic interview for DSM-IV BPD, 390 of whom were diagnosed with BPD. We compared the demographic and clinical characteristics of patients with BPD who do and do not engage in repeated suicidal and self-harm behavior.

RESULTS

Approximately half of the patients with BPD did not meet the suicidality/self-injury diagnostic criterion for the disorder. There were no differences between the patients who did and did not meet this criterion in occupational impairment, likelihood of receiving disability payments, impairment in social functioning, level of educational achievement, comorbid psychiatric disorders, history of childhood trauma, or severity of depression, anxiety, or anger upon presentation for treatment.

CONCLUSIONS

Repeated self-injurious and suicidal behavior is not synonymous with BPD. It is critical for clinicians to be aware that the absence of repeated self-injury and suicide threats/gestures or attempts does not rule out the diagnosis of BPD.

Underdiagnosis of cervical intraepithelial neoplasia by colposcopy and its association with thin high‑grade squamous intraepithelial lesions

The relationship between the thickness of the epithelium and the colposcopic diagnosis is controversial. The present study was conducted to determine whether colposcopic underdiagnosis of cervical intraepithelial neoplasia (CIN) is associated with thin high-grade squamous intraepithelial lesions (HSILs) of the cervix. A total of 136 cases of HSIL verified by pathological biopsy at Peking University People's Hospital between June and October 2021 were retrospectively analyzed; 79 cases were CIN2 and 57 cases were CIN3. The number and thickness of epithelial layers were analyzed using colposcopic impressions. In the low-grade colposcopic impression group, the number of epithelial layers (12.8±4.2 vs. 17.8±4.2) and epithelial thickness (105.2±41.9 µm vs. 150.3±50.0 µm) of CIN2 lesions were significantly lower compared with the high-grade colposcopic impression group; however, the differences for CIN3 were not statistically significant. CIN2 lesions had significantly fewer (12.8±4.2 vs. 17.2±5.4) and thinner (105.2±41.9 µm vs. 140.4±48.6 µm) epithelial layers than CIN3 lesions in the low-grade colposcopic impression groups. In the high-grade colposcopic impression group, however, there were no significant differences in the number or thickness of epithelial layers between CIN2 and CIN3. In 12 cases of thin HSILs, 91.6% of the colposcopic impressions were low-grade. Thin HSILs are likely associated with underdiagnosed colposcopic findings, particularly for CIN2. Thin HSILs usually present with small to minute lesions and lack the typical colposcopic appearance of classic HSIL, which may help to explain why thin HSILs are easily underestimated under colposcopy.

Prevalence of psoriatic arthritis in Chinese population with psoriasis: A multicenter study conducted by experienced rheumatologists

BACKGROUND

Reports on the prevalence of psoriatic arthritis (PsA) among Chinese patients with psoriasis are very limited. This study, conducted by rheumatologists, estimated the prevalence of PsA in a large number of Chinese patients with psoriasis.

METHODS

Consecutive patients with a confirmed diagnosis of psoriasis attending nine dermatology clinics in five hospitals were recruited. All psoriasis patients were asked to complete a questionnaire comprising 16 questions to identify possible cases of PsA. All patients with one or more positive answers to the questionnaire were evaluated by two experienced rheumatologists.

RESULTS

A total of 2434 psoriasis patients, including 1561 males and 873 females, were enrolled. Both the questionnaire and rheumatologists' examinations were completed in the dermatology clinics. The results identified 252 patients with PsA, comprising 168 males and 84 females. The overall prevalence of PsA among psoriasis patients was 10.4% (95% confidence interval [95% CI], 9.1%-11.7%). By sex, the prevalence was 10.8% (95% CI, 9.2%-12.5%) for males and 9.6% (95% CI, 7.7%-11.9%) for females and there was no significant sex difference in the prevalence of PsA (P = 0.38). Of the 252 PsA patients, 125 (49.6%, 95% CI, 41.3%-59.1%) were newly diagnosed by rheumatologists. Consequently, the prevalence of undiagnosed PsA among psoriasis patients was 5.2% (95% CI, 4.4%-6.2%).

CONCLUSION

The prevalence of PsA in the Chinese population with psoriasis is about 10.4%, which is almost double that of previous reports in the Chinese population, but lower than that in Caucasians.

Relationship between Body Mass Index and Diagnosis of Overweight or Obesity in Veterans Administration Population

Background: This paper examined the gap between obesity and its diagnosis for cohorts of patients with overweight, obesity, and morbid obesity in the Veterans Administration (VA) population. Using the risk adjustment models, it also identified factors associated with the underdiagnosis of obesity. Methods: Analysis was performed on a VA data set. We identified diagnosed patients and undiagnosed patients (identified through BMI but not diagnosed using ICD-10 codes). The groups' demographics were compared using nonparametric chi-square tests. We used logistic regression analysis to predict the likelihood of the omission of diagnosis. Results: Of the 2,900,067 veterans with excess weight, 46% were overweight, 46% had obesity, and 8% of them had morbid obesity. The overweight patients were the most underdiagnosed (96%), followed by the obese (75%) and morbidly obese cohorts (69%). Older, male, and White patients were more likely to be undiagnosed as overweight and obese; younger males were more likely to be undiagnosed as morbidly obese. (p < 0.05) Comorbidities significantly contributed to diagnosis. Conclusions: The underdiagnosis of obesity continues to be a significant problem despite its prevalence. Diagnosing obesity accurately is necessary to provide effective management and treatment.

Suspected undiagnosed ADRD among Middle Eastern and North African Americans

Background ADRD underdiagnosis among minority populations is well-established and known to be more prevalent among women. Yet, it remains unclear if these patterns exist among Middle Eastern and North African (MENA) adults. We estimated ADRD underdiagnosis among MENA and other US- and foreign-born non-Hispanic Whites and compared sex-stratified results. Methods We linked 2000-2017 National Health Interview Survey and 2001-2018 Medical Expenditure Panel Survey data (ages > = 65 years, n = 23,981). Undiagnosed ADRD was suspected if participants reported cognitive limitations without corresponding ADRD diagnosis. Results Undiagnosed ADRD was highest among MENA adults (15.8%) compared to non-Hispanic Whites (US-born = 8.1%; foreign-born = 11.8%). MENA women had 2.52 times greater odds (95% CI = 1.31-4.84) of undiagnosed ADRD compared to US-born White women after adjusting for risk factors. Discussion This study contributes the first national estimates of undiagnosed ADRD among MENA adults. Continued research is needed to facilitate policy changes that more comprehensively address health disparities and related resource allocation.

Identifying probable dementia in undiagnosed Black and White Americans using machine learning in Veterans Health Administration electronic health records

The application of machine learning (ML) tools in electronic health records (EHRs) can help reduce the underdiagnosis of dementia, but models that are not designed to reflect minority population may perpetuate that underdiagnosis. To address the underdiagnosis of dementia in both Black Americans (BAs) and white Americans (WAs), we sought to develop and validate ML models that assign race-specific risk scores. These scores were used to identify undiagnosed dementia in BA and WA Veterans in EHRs. More specifically, risk scores were generated separately for BAs (n=10K) and WAs (n=10K) in training samples of cases and controls by performing ML, equivalence mapping, topic modeling, and a support vector-machine (SVM) in structured and unstructured EHR data. Scores were validated via blinded manual chart reviews (n=1.2K) of controls from a separate sample (n=20K). AUCs and negative and positive predictive values (NPVs and PPVs) were calculated to evaluate the models. There was a strong positive relationship between SVM-generated risk scores and undiagnosed dementia. BAs were more likely than WAs to have undiagnosed dementia per chart review, both overall (15.3% vs 9.5%) and among Veterans with >90th percentile cutoff scores (25.6% vs 15.3%). With chart reviews as the reference standard and varied cutoff scores, the BA model performed slightly better than the WA model (AUC=0.86 with NPV=0.98 and PPV=0.26 at >90th percentile cutoff vs AUC=0.77 with NPV=0.98 and PPV=0.15 at >90th). The AUCs, NPVs, and PPVs suggest that race-specific ML models can assist in the identification of undiagnosed dementia, particularly in BAs. Future studies should investigate implementing EHR-based risk scores in clinics that serve both BA and WA Veterans.

Pitfalls in breast pathology

Accurate pathological diagnosis is the cornerstone of optimal clinical management for patients with breast disease. As non-operative diagnosis has now become the standard of care, histopathologists encounter the daily challenge of making definitive diagnoses on limited breast core needle biopsy (CNB) material. CNB samples are carefully evaluated using microscopic examination of haematoxylin and eosin (H&E)-stained slides and supportive immunohistochemistry (IHC), providing the necessary information to inform the next steps in the patient care pathway. Some entities may be difficult to distinguish on small tissue samples, and if there is uncertainty a diagnostic excision biopsy should be recommended. This review discusses (1) benign breast lesions that may mimic malignancy, (2) malignant conditions that may be misinterpreted as benign, (3) malignant conditions that may be incorrectly diagnosed as primary breast carcinoma, and (4) some IHC pitfalls. The aim of the review is to raise awareness of potential pitfalls in the interpretation of breast lesions that may lead to underdiagnosis, overdiagnosis, or incorrect classification of malignancy with potential adverse outcomes for individual patients.

Diagnosis of covert coarctation of the aorta in adolescents

Objectives

By reviewing the diagnostic process for adolescents with coarctation of the aorta (CoA) in our institution, we analyzed the reasons for delayed diagnosis of CoA. We also proposed a diagnostic protocol to improve the detection rate of CoA.

Methods

In this retrospective study, we included 48 patients aged 12-18 years who were diagnosed with CoA in our hospital from January 2000 to November 2022. Clinical data from involved cases in local hospitals and our institution were collected.

Results

All patients had blood pressure (BP) measurements in upper and lower extremities in our institution. They all had hypertension, 29 (60.4%) of whom had known histories of the same. BP in the upper limbs of 47 (97.9%) patients was ≥20 mmHg higher than that in the lower limbs, and BP in the upper limb of 1 (2.1%) patient was greater than 0 and less than 20 mmHg than that in the lower limb. Echocardiography (ECHO) was performed in all patients, computed tomography (CT) or magnetic resonance imaging (MRI) was performed in 44 patients (91.7%). There were 38 (79.2%) patients who visited local hospitals. Among them, a total of 20 (52.6%) patients had their right upper extremity BP measured, 18 (47.4%) only had their left upper extremity BP measured, and 16 (42.1%) had their lower extremity BP measured. ECHO was performed in 27 (56.2%) patients and CT/MRI was performed in 18 (37.5%) patients. The detection rate for CT/MRI was 100%, and those of ECHO were 72.9% and 18.5% at our institution and a local hospital, respectively. Forty-eight (100%) and 23 (60.5%) patients were detected in our institution and local hospitals (P < 0.0001).

Conclusion

We recommend measuring BP in the bilateral upper extremities. Measurement of BP in the lower extremities is recommended if hypertension is diagnosed. MRI/CT is recommended when BP in the upper extremity is greater than that in the lower extremity.

Determinants in the Underdiagnosis of COPD in Spain-CONOCEPOC Study

Factors such as seeking medical attention for respiratory symptoms and health professionals ordering spirometry come into play in the underdiagnosis of chronic obstructive pulmonary disease (COPD). The objective of this study was to analyze seeking medical attention and the use of spirometry in individuals with chronic respiratory symptoms and to compare these results with those obtained in the 2005 and 2011 surveys. Material and Methods: A cross-sectional, observational, epidemiological study was conducted via phone interview in December 2020 in Spain, with a representative sample from 17 autonomous communities. The study design was identical to that of the studies carried out in 2005 and 2011 to evaluate the changes that have occurred in seeking medical attention and performing spirometry in Spain, as well as the variability between autonomous communities. Results: From 89,601 phone contacts, a total of 6534 respondents were obtained. A total of 24.8% reported having some chronic respiratory symptom, and 17.9% reported a respiratory disease. Only 51.6% of those who had some chronic respiratory symptom had seen their doctor, which was less likely among current smokers (OR: 0.599, 95% CI: 0.467−0.769, p < 0.001) and those living in a rural setting (OR: 0.797, 95% CI: 0.651−0.975, p = 0.027). A total of 68.7% of the individuals who saw a doctor reported having undergone spirometry, most frequently males (OR: 1.535, 95% CI: 2.074−1.136, p < 0.005), former smokers (OR: 1.696, 95% CI: 2.407−1.195, p < 0.003), and those seen by a pulmonologist (OR: 6.151, 95% CI: 8.869−4.265, p < 0.001). With respect to the 2005 survey, more frequent use of spirometry has been observed (42.6 vs. 68.7%), without any change in seeking medical attention for respiratory symptoms. There is a clear variability according to the autonomous community (p < 0.05). Conclusions: Many individuals with chronic respiratory symptoms do not seek medical attention and although the use of spirometry has increased in the past 15 years, it is still an important area that needs improving in the primary care setting, especially among women. Both of these factors can be determinants in the underdiagnosis of COPD and its variability between autonomous communities.

Impact of the COVID-19 Pandemic on Primary Health Care Disease Incidence Rates: 2017 to 2020

We assessed the impact of the COVID-19 pandemic in Spain on new cases of diseases and conditions commonly seen in primary care. In 2020, there were significant reductions from 2017-2019 in the annual incidences of hypertension (40% reduction), hypercholesterolemia (36%), type 2 diabetes (39%), chronic kidney disease (43%), ischemic heart disease (48%), benign prostatic hypertrophy (38%), osteoporosis (40%), hypothyroidism (46%), chronic obstructive pulmonary disease (50%), alcohol use disorder (46%), benign colon polyps and tumors (42%), and melanomas (45%). Prioritization of COVID-19 care changed the physician-patient relationship to the detriment of face-to-face scheduled visits for chronic disease detection and monitoring, which fell by almost 41%. To return to prepandemic levels of diagnosis and management of chronic diseases, primary health care services should reorganize and carry out specific actions for groups at higher risk.VISUAL ABSTRACTAnnals "Online First" article.

Low awareness and under-diagnosis of hypothyroidism

Hypothyroidism is a common condition with a prevalence that varies according to local dietary iodine availability, gender and age. The symptoms of hypothyroidism are generally nonspecific, with considerable overlap with other conditions and with the consequences for the health of advancing age. These symptoms are not useful for diagnosing hypothyroidism and a thyroid function test is required for a firm clinical diagnosis. Lack of knowledge and understanding of hypothyroidism, and a tendency for many people to attribute the symptoms of hypothyroidism to other causes have led to substantial unawareness and often late diagnosis of hypothyroidism. Large observational studies and meta-analyses have shown that about 4-7% of community-derived populations in the USA and Europe have undiagnosed hypothyroidism. About four cases in five of these are subclinical hypothyroidism, with the remainder being overt hypothyroidism. The prevalence of undiagnosed hypothyroidism is higher in older subjects, in women, and some ethnic groups, consistent with diagnosed disease. More research is needed to quantify the clinical burden of undiagnosed hypothyroidism around the world, with educational efforts aimed at the public and healthcare professionals aimed at identifying and managing these individuals.

Underdiagnosis of cardiopulmonary involvement in patients with idiopathic inflammatory myopathies

Objectives

In the course of idiopathic inflammatory myopathies internal organs, including heart and lungs, can be involved. Cardiopulmonary complications significantly alter the course of the disease, leading to poorer prognosis. A lack of clear guidelines on the assessment of internal organ involvement in the course of myositis increases the risk of underdiagnosis. The aim of the study was to evaluate the incidence of clinical symptoms indicative of cardiovascular and pulmonary involvement in patients with myositis, and the impact of these ailments on daily living.

Material and methods

A self-designed online survey was distributed via online support groups and community forums for patients with idiopathic inflammatory myopathies. The questionnaire contained inquiries about demographical data, clinical symptoms, including symptoms indicative of cardiopulmonary involvement, as well as the standardised Health Assessment Questionnaire. Respondents were divided according to concomitant diseases into a subgroup diagnosed with cardiopulmonary diseases and a subgroup without such comorbidities. The prevalence of cardiopulmonary symptoms was compared between the subgroups. The impact of cardiopulmonary symptoms on the degree of disability and daily functioning was assessed.

Results

In total, 370 patients were included in the study group. The most commonly symptoms included dyspnoea during exercise, palpitations and ankle oedema during daily activities. Cardiopulmonary symptoms were frequent in respondents diagnosed with cardiopulmonary diseases and in patients declaring no comorbidities of the heart and lungs. Intensity of chest pain, tolerance of physical activity, and fatigue were comparable in both of the study subgroups. The degree of disability was higher in respondents with concomitant cardiovascular and/or pulmonary comorbidities, but only dry cough and ankle oedema impacted the results.

Conclusions

Clinical symptoms indicative of heart and lung involvement occur frequently in patients with idiopathic inflammatory myopathies; however, cardiopulmonary complications seem to be relatively rarely detected. Active screening for cardiopulmonary involvement is recommended.

Underdiagnosis of early cervical cancer with an invisible cervical transformation zone in an elderly patient: A case report

The treatment of cervical intraepithelial neoplasia (CIN) can result in under- or overtreatment. The current report describes a case of undertreatment of a cervical tumor. A 72-year-old woman was preoperatively diagnosed with CIN3. Following surgery, the final diagnosis of the excised specimen was keratinizing squamous cell carcinoma that measured 2.5 cm in size. The exocervical margin and deep margin were negative. The patient received adjuvant therapy with concurrent chemoradiotherapy and never had disease recurrence. In elderly patients, making an accurate preoperative diagnosis based on specimens from cervical biopsies with or without colposcopy is difficult. MRI may be an accurate preoperative indicator of early cervical tumor, although some studies have demonstrated that MRI has a limitation with respect to its diagnostic ability. Other studies have reported that it is necessary to perform conization prior to hysterectomy. Physicians must reconsider the determined preoperative diagnosis of an early cervical tumor and establish standard guidelines for deciding when to use surgical treatment in elderly patients.

Diagnostic delay in ADHD: Duration of untreated illness and its socio-demographic and clinical predictors in a sample of adult outpatients

AIM

To investigate the Duration of Untreated Illness (DUI) and its socio-demographic and clinical predictors in a sample of adult ADHD outpatients.

METHODS

The DUI of 150 adult outpatients with a confirmed diagnosis of DSM-IV ADHD was calculated. Non-parametric tests were used to evaluate differences in DUI among subgroups and to build a correlation matrix. Subsequently, a multiple linear regression model was performed.

RESULTS

The median DUI was 17 years (interquartile range [IQR] = 14). DUI was longer in employed patients, those with a family history of ADHD, those with a history of major depressive disorder and those who had predominantly inattentive ADHD in childhood. The current age, age at administration of the first proper treatment and education level were correlated with DUI. Current age (63.3% of total variance), family history of ADHD and the presence of a predominantly inattentive type in childhood (together, 2.6% of total variance) were all predictors of DUI.

CONCLUSIONS

Information programmes for caregivers and training for health care professionals should be promoted to foster the early recognition of covert inattentive symptoms and shorten DUI.

Undiagnosed Cases of Human Pneumonia Following Exposure to Chlamydia psittaci from an Infected Rosella Parrot

This report describes two cases of occupational exposure to Chlamydia psittaci following dissection of an infected Rosella (Platycercus elegans). The C. psittaci infections (with one of them resulting in diagnosed pneumonia and hospitalisation) were undiagnosed during routine medical investigations but later established due to epidemiological and clinical evidence, and molecular testing of the archived Rosella’ specimens. This case report stresses the importance of correct application and interpretation of diagnostic tests and the need to raise awareness about this zoonotic pathogen among medical practitioners and people exposed to potential animal carriers. Our findings suggest other infected individuals might be misdiagnosed and that C. psittaci (psittacosis) is likely to be underreported in Australia. This case highlights the need to operationalise the One Health concept. We call for improved communication between human and animal health service providers to allow accurate and rapid diagnosis of this zoonotic disease and raised awareness among medical practitioners. Further targeted surveys of wild birds (and other animals) should be conducted to improve assessment of risks to the general population and people working with or exposed to wild birds.

Underdiagnosis, false diagnosis and treatment of COPD in a selected population in Northern Greece

BACKGROUND

In the primary care setting, diagnosis and treatment of COPD is not always consistent with GOLD guidelines.

OBJECTIVES

To calculate the prevalence of COPD underdiagnosis, false diagnosis and treatment in the general population of northern Greece.

METHODS

Observational study in the context of an early COPD detection and smoking cessation project. Inclusion criteria: >40-year-old, current and former smokers (>10 pack-years) in five primary care centres of northern Greece from 2012 to 2019. Participation was achieved via a campaign (posters and advertisements in the mass media).

RESULTS

We examined 5,226 subjects (mean age: 58.2 ± 12.7 years, 61.5% males, current smokers: 56.2%) of whom 564 (10.8%) had symptoms and spirometrically confirmed COPD. There were 5 groups of 'interest:' a) 117/264 (44.3%) with a previous correct diagnosis COPD and correct treatment; b) 139/264 (52.7%) previous correct diagnosis COPD but overtreatment; c) 8/264 (3%) previous correct diagnosis COPD but undertreatment; d) 461 subjects (63.6% of those with previous COPD diagnosis) had previous false diagnosis of COPD (= also overtreatment); e) 300/564 (53.2%) previously not diagnosed COPD (=underdiagnosis and also undertreatment). We found that 322/461 (69.8%) of those with a previous false diagnosis have been prescribed long-acting bronchodilators plus ICS.

CONCLUSION

Among the general population subjects in northern Greece, more than 50% of patients with COPD were underdiagnosed, more than 50% of correctly diagnosed COPD patients were overtreated and most patients taking inhaled drugs were those with a false diagnosis of COPD (possibly GOLD stage 0).

Novel App-Based Portable Spirometer for the Early Detection of COPD

Chronic obstructive pulmonary disease (COPD) is preventable and treatable. However, many patients remain undiagnosed and untreated due to the underutilization or unavailability of spirometers. Accordingly, we used Spirobank Smart, an app-based spirometer, for facilitating the early detection of COPD in outpatient clinics. This prospective study recruited individuals who were at risk of COPD (i.e., with age of ≥40 years, ≥10 pack-years of smoking, and at least one respiratory symptoms) but had no previous COPD diagnosis. Eligible participants were examined with Spirobank Smart and then underwent confirmatory spirometry (performed using a diagnostic spirometer), regardless of their Spirobank Smart test results. COPD was defined and confirmed using the postbronchodilator forced expiratory volume in 1 s/forced vital capacity values of <0.70 as measured by confirmatory spirometry. A total of 767 participants were enrolled and examined using Spirobank Smart; 370 participants (94.3% men, mean age of 60.9 years and mean 42.6 pack-years of smoking) underwent confirmatory spirometry. Confirmatory spirometry identified COPD in 103 participants (27.8%). At the optimal cutoff point of 0.74 that was determined using Spirobank Smart for COPD diagnosis, the area under the receiver operating characteristic was 0.903 (95% confidence interval (CI) = 0.860-0.947). Multivariate logistic regression revealed that participants who have an FEV₁/FVC ratio of <74% that was determined using Spirobank Smart (odds ratio (OR) = 58.58, 95% CI = 27.29-125.75) and old age (OR = 3.23, 95% CI = 1.04-10.07 for 60 ≤ age < 65; OR = 5.82, 95% CI = 2.22-15.27 for age ≥ 65) had a higher risk of COPD. The Spirobank Smart is a simple and adequate tool for early COPD detection in outpatient clinics. Early diagnosis and appropriate therapy based on GOLD guidelines can positively influence respiratory symptoms and quality of life.

Coexistence of asthmatic and non-respiratory allergic symptoms in children of Batumi Region, Georgia: occurrence and association with known diagnosis of asthma

OBJECTIVES

Our recent studies showed that in children in the Batumi region, Georgia, underdiagnosis of asthma is 65%, and that not all children with known asthma had a history of allergic disorders. So, we decided to assess the association of known diagnosis of paediatric asthma with asthma-like symptoms and non-respiratory allergic symptoms and diseases using questionnaire-derived data provided by respiratory health survey.

METHODS

Subjects of the cross-sectional population-based study were 3,239 urban and 2,113 rural children aged 5-17 years whose respiratory status was assessed using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. For children with a known diagnosis of asthma, the occurrence of respiratory symptoms suggestive of asthmatic tendency and of allergic symptoms and diseases was measured and statistical association of known asthma with the respiratory and allergic symptoms was expressed as odds ratios (OR) and their 95% confidence intervals (95% CI).

RESULTS

Respiratory and all allergic symptoms and diseases, except for eczema, were statistically significantly (p < 0.05) more prevalent in children with asthma than in children without asthma. Based on the distribution of asthma vis-à-vis asthmatic tendency without or with allergic symptoms and allergic diseases the following odds ratios expressing likelihood of asthma were obtained: for asthmatic tendency: OR = 18.09 (95% CI: 11.82-27.68), for any allergic symptom: OR = 6.85 (95% CI: 4.69-10.02), for any allergic disease: OR = 10.75 (95% CI: 7.36-15.70), for asthmatic tendency with coexisting any allergic symptom: OR = 18.94 (95% CI: 12.96-27.68), for asthmatic tendency with coexisting any allergic disease: OR = 25.65 (95% CI: 17.47-37.67), and for asthmatic tendency with coexisting any allergic symptom and allergic disease: OR = 27.02 (95% CI: 18.18-40.15).

CONCLUSIONS

The findings support the view that in epidemiological setting questionnaire-based studies on asthma seems to more readily identify cases in children with more severe clinical presentation of the disease and with coexisting allergic disorders, perhaps reflecting diagnostic practices of consulting paediatricians.

Misdiagnosis and diagnostic pitfalls of chronic inflammatory demyelinating polyradiculoneuropathy

Background and purpose

The aim of this study was to determine the frequency of over‐ and underdiagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and to identify related diagnostic pitfalls.

Methods

We conducted a retrospective study in Dutch patients referred to the Erasmus University Medical Centre Rotterdam between 2011 and 2017 with either a diagnosis of CIDP or another diagnosis that was revised to CIDP. We used the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) 2010 diagnostic criteria for CIDP to classify patients into three groups: overdiagnosis, underdiagnosis, or confirmed diagnosis of CIDP. Clinical and laboratory features and treatment history were compared between groups.

Results

A referral diagnosis of CIDP was revised in 32% of patients (31/96; overdiagnosis). Of 81 patients diagnosed with CIDP, 16 (20%) were referred with another diagnosis (underdiagnosis). In the overdiagnosed patients, 20% of muscle weakness was asymmetric, 48% lacked proximal muscle weakness, 29% only had distal muscle weakness, 65% did not fulfil the electrodiagnostic criteria for CIDP, 74% had an elevated cerebrospinal fluid (CSF) protein level, and 97% had another type of neuropathy. In the underdiagnosed patients, all had proximal muscle weakness, 50% had a clinically atypical CIDP, all fulfilled the electrodiagnostic criteria for CIDP, and 25% had an increased CSF protein level.

Conclusion

Over‐ and underdiagnosis of CIDP is common. Diagnostic pitfalls include lack of attention to proximal muscle weakness as a diagnostic hallmark of CIDP, insufficient recognition of clinical atypical phenotypes, overreliance on CSF protein levels, misinterpretation of nerve conduction studies and poor adherence to electrodiagnostic criteria, and failure to exclude other causes of polyneuropathy.

Psychosocial Burden of Undiagnosed Persistent ADHD Symptoms in 12-Year-Old Children: A Population-Based Birth Cohort Study

Objective: To describe the psychosocial functioning in children with undiagnosed persistent ADHD symptoms. Method: A prospective, population-based birth cohort study was conducted among 2,945 children and their primary caregivers who lived in Tokyo, Japan, and were followed up at the age of 10 years and 12 years. Parents reported a history of ADHD diagnosis and completed the Strengths and Difficulties Questionnaire. Results: Overall, 91 participants had persistent ADHD symptoms; however, 76 (83.5%) had no history of an ADHD diagnosis. The presence of undiagnosed ADHD symptoms was significantly associated with worse psychosocial functioning for most continuous outcomes when compared with the absence of ADHD symptoms and diagnosis, including lower self-esteem (standardized mean difference [SMD] = -0.31) and higher depression (SMD = 0.36), emotional symptoms (SMD = 0.69), conduct problems (SMD = 1.26), and peer relationship problems (SMD = 0.98). Conclusion: Our findings suggest the importance of paying more attention to the possible underdiagnosis of ADHD in children.

Prevalence and associated risk factors of prenatal depression underdiagnosis: A population-based study

OBJECTIVE

To estimate prenatal depression underdiagnosis prevalence and its associated sociodemographic and obstetric risk factors among a population-based sample of Brazilian pregnant women with depression.

METHODS

We used data from the Brazilian National Survey (PNS 2013). Of the 22 445 women of reproductive age, 800 reported being pregnant. Participants answered the Patient Health Questionnaire-9 (PHQ-9) and a questionnaire with sociodemographic, obstetric, and clinical data. Classification of prenatal depression underdiagnosis was made using the comparison between results obtained from the self-referred question evaluating clinical diagnosis of depression and the results of the PHQ-9. Pregnant women with a PHQ-9 score greater than 8 and with a "No" answer in the clinical question were classified as prenatal depression underdiagnosis. Logistic regression models were performed to obtain crude and adjusted odds ratios (OR) between variables and prenatal depression underdiagnosis.

RESULTS

Prevalence of prenatal depression underdiagnosis was 82.3% (74.8%-87.8%). Pregnant women with non-white skin color and pregnant women with an elementary school degree were more likely to be underdiagnosed with prenatal depression in comparison with women with white skin color (adjusted OR 2.42, 95% confidence interval [CI] 0.99-5.91) and with women with higher education (adjusted OR 4.07, 95% CI 2.05-8.09).

CONCLUSION

Equitable mental health assistance for pregnant women should considered prenatal depression social risk factors.

Diagnostic challenges in chronic inflammatory demyelinating polyradiculoneuropathy

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) consists of a spectrum of autoimmune diseases of the peripheral nerves, causing weakness and sensory symptoms. Diagnosis often is challenging, because of the heterogeneous presentation and both mis- and underdiagnosis are common. Nerve conduction study (NCS) abnormalities suggestive of demyelination are mandatory to fulfil the diagnostic criteria. On the one hand, performance and interpretation of NCS can be difficult and none of these demyelinating findings are specific for CIDP. On the other hand, not all patients will be detected despite the relatively high sensitivity of NCS abnormalities. The electrodiagnostic criteria can be supplemented with additional diagnostic tests such as CSF examination, MRI, nerve biopsy, and somatosensory evoked potentials. However, the evidence for each of these additional diagnostic tests is limited. Studies are often small without the use of a clinically relevant control group. None of the findings are specific for CIDP, meaning that the results of the diagnostic tests should be carefully interpreted. In this update we will discuss the pitfalls in diagnosing CIDP and the value of newly introduced diagnostic tests such as nerve ultrasound and testing for autoantibodies, which are not yet part of the guidelines.

Prevalence and Characteristics of Undiagnosed COPD in Adults 40 Years and Older - Reports from the Tunisian Population-Based Burden of Obstructive Lung Disease Study

This study aimed to investigate the underdiagnosis of COPD and its determinants based on the Tunisian Burden of Obstructive Lung Disease study. We collected information on respiratory history symptoms and risk factors for COPD. Post-bronchodilator (Post-BD) FEV1/FVC < the lower limit of normal (LLN) was used to define COPD. Undiagnosed COPD was considered when participants had post-BD FEV1/FVC < LLN but were not given a diagnosis of emphysema, chronic bronchitis or COPD. 730 adults aged ⩾40 years selected from the general population were interviewed, 661 completed spirometry, 35 (5.3%) had COPD and 28 (80%) were undiagnosed with the highest prevalence in women (100%). When compared with patients with an established COPD diagnosis, undiagnosed subjects had a lower education level, milder airway obstruction (Post-BD FEV1 z-score -2.2 vs. -3.7, p < 0.001), fewer occurrence of wheezing (42.9% vs. 100%, p = 0.009), less previous lung function test (3.6% vs. 42.8%, p = 0.019) and less visits to the physician (32.1% vs. 85.7%, p = 0.020) in the past year. Multivaried analysis showed that the probability of COPD underdiagnosis was higher in subjects who had mild to moderate COPD and in those who did not visit a clinician and did not perform a spirometry in the last year. Collectively, our results highlight the need to improve the diagnosis of COPD in Tunisia. Wider use of spirometry should reduce the incidence of undiagnosed COPD. Spirometry should also predominately be performed not only in elderly male smokers but also in younger women in whom the prevalence of underdiagnosis is the highest.

Underdiagnosis of psychiatric disorders in people with intellectual disabilities: Differences between psychiatric disorders and challenging behaviour

BACKGROUND AND PURPOSE

The purpose of this study was to assess the level of mental disorders and challenging behaviour in individuals with intellectual disability (ID) supported by specialized services, but without a prior psychiatric diagnosis, and to compare the levels of different disorders depending on the severity of ID.

METHODS

This is a cross-sectional study (N = 142) of population with ID. Inclusion criteria were the following: adult patients with ID and with no previous psychiatric diagnosis prior to this survey. The Wechsler Adults Intelligence Scale-II, the Psychiatric Assessment Schedule for Adults with Developmental Disability checklist and clinical interview, the Diagnostic Assessment for the Severely Handicapped scale and the Inventory for Client and Agency Planning were the assessment tools.

RESULTS

A previously undiagnosed mental disorder was found in 29.6% of the sample. The most prevalent mental disorders were major depressive and anxiety disorders. An association between psychiatric comorbidity and challenging behaviour was found only for mild/moderate ID, especially for affective disorders.

CONCLUSIONS

The presence of a psychiatric as well as a medical comorbidity is associated with severe ID, unlike challenging behaviour. Clinical limitations of the study have been discussed.

Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives

Catatonia is a serious, common syndrome of motoric and behavioral dysfunction, which carries high morbidity and mortality. Electroconvulsive therapy (ECT) is the definitive treatment for catatonia, but access to ECT for the treatment of catatonia remains inappropriately limited. Catatonia is observable, detectable, and relevant to various medical specialties, but underdiagnosis impedes the delivery of appropriate treatment and heightens risk of serious complications including iatrogenesis. Current understanding of catatonia's pathophysiology links it to the current understanding of ECT's mechanism of action. Definitive catatonia care requires recognition of the syndrome, workup to identify and treat the underlying cause, and effective management including appropriate referral for ECT. Even when all of these conditions are met, and despite well-established data on the safety and efficacy of ECT, stigma surrounding ECT and legal restrictions for its use in catatonia are additional critical barriers. Addressing the underdiagnosis of catatonia and barriers to its treatment with ECT is vital to improving outcomes for patients. While no standardized protocols for treatment of catatonia with ECT exist, a large body of research guides evidence-based care and reveals where additional research is warranted. The authors conducted a review of the literature on ECT as a treatment for catatonia. Based on the review, the authors offer strategies and future directions for improving access to ECT for patients with catatonia, and propose an algorithm for the treatment of catatonia with ECT.

[Catatonia in clinical reality: underdiagnosed and forgotten]

BACKGROUND

Catatonia is still a poorly understood, quite common, but often overlooked clinical picture. Consequences for patients are inadequate treatment, prolonged hospital stays and more serious complications.

METHOD

In this overview, the causes for an underdiagnosis are presented and measures for their prevention named, help for the differential diagnostic classification of catatonia is offered and the treatment is briefly explained.

RESULTS AND CONCLUSIONS

Catatonia is primarily associated with schizophrenia, but is also observed in other diseases such as neuroleptic malignant syndrome (MNS), in encephalitis and also in systemic diseases. Underdiagnosis can be avoided by simple measures such as a thorough physical examination, observance of verbal and non-verbal signs of catatonia, and psychiatric consultations in general hospitals. For the treatment of acute catatonia, the high-dose administration of benzodiazepines and electroconvulsive therapy are recommended.

Poor patient awareness and frequent misdiagnosis of migraine: findings from a large transcontinental cohort

BACKGROUND AND PURPOSE

Although migraine is the second most disabling condition worldwide, there is poor awareness of it. The objective was to assess the awareness of migraine and previous diagnostic and therapeutic consultations and treatments in a large international population of migraineurs.

METHODS

This was a multicentre study conducted in 12 headache centres in seven countries. Each centre recruited up to 100 patients referred for a first visit and diagnosed with migraine. Subjects were given a structured clinical questionnaire-based interview about the perceptions of the type of headache they suffered from, its cause, previous diagnoses, investigations and treatments.

RESULTS

In all, 1161 patients completed the study. Twenty-eight per cent of participants were aware that they suffered from migraine. Sixty-four per cent called their migraine 'headache'; less commonly they used terms such as 'cervical pain' (4%), tension headache (3%) and sinusitis (1%). Eight per cent of general practitioners and 35% of specialists (of whom 51% were neurologists and/or headache specialists) consulted for migraine formulated the correct diagnosis. Before participating in the study, 50% of patients had undergone X-ray, computed tomography and/or magnetic resonance imaging of the cervical spine and 76% underwent brain and/or cervical spine imaging for migraine. Twenty-eight per cent of patients had received symptomatic migraine-specific medications and 29% at least one migraine preventive medication.

CONCLUSIONS

Although migraine is a very common disease, poor awareness of it amongst patients and physicians is still an issue in several countries. This highlights the importance of the promotion of migraine awareness to reduce its burden and limit direct and indirect costs and the risk of exposure to useless investigations.

Screening for Bipolar Disorder and Finding Borderline Personality Disorder: A Replication and Extension

The authors' group previously reported that patients who screened positive on the Mood Disorders Questionnaire (MDQ), the most frequently studied screening scale for bipolar disorder, were as likely to be diagnosed with borderline personality disorder (BPD) as with bipolar disorder. A limitation of that study was that the authors examined the performance of the MDQ in patients presenting for various psychiatric disorders, including depression. The recognition of bipolar disorder and its differential diagnosis with BPD is of greatest clinical relevance in depressed patients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, the authors attempted to replicate their initial findings in a new sample of psychiatric outpatients, and they also examined the performance of the MDQ in depressed patients. The results of the present study were consistent with the original report, thereby indicating that the MDQ is not effective in helping distinguish bipolar disorder from BPD.

Risk Factors for Underdiagnosis of Diabetes Based on the Korean National Health and Nutrition Examination Survey 2013-2015

We included 11 298 subjects aged 30 years or older without diagnosis of diabetes by doctors who had undergone A1C screening. The diagnostic criterion for diabetes was A1C ≥6.5% (48 µmol/mol). This cross-sectional study was performed by reflecting weight of the sample in Korean National Health and Nutrition Examination Survey to represent South Korea. Risk factors were age (odds ratio [OR] = 1.06, 95% confidence interval [CI] = 1.04-1.08), Medicaid beneficiary (OR = 2.77, 95% CI = 1.25-6.14), presence of family history of diabetes (OR = 1.97, 95% CI = 1.36-2.84), serum triglyceride level (OR = 1.01, 95% CI = 1.01-1.03), serum high-density lipoprotein level (OR = 0.96, 95% CI = 0.95-0.98), currently smoking (OR = 1.85, 95% CI = 1.20-2.85), and the presence of regular checkup (OR = 1.41, 95% CI = 1.01-2.00). To prevent diabetes with a healthy life, it is necessary to establish a diabetes prevention program for vulnerable people and implement health-related policies such as smoking cessation and regular checkups.

Unrecognized High Occurrence of Genetically Confirmed Hereditary Carnitine Palmitoyltransferase II Deficiency in an Austrian Family Points to the Ongoing Underdiagnosis of the Disease

Adult muscle carnitine palmitoyltransferase (CPT) II deficiency is a rare autosomal recessive disorder of long-chain fatty acid metabolism. It is typically associated with recurrent episodes of exercise-induced rhabdomyolysis and myoglobinuria, in most cases caused by a c.338C > T mutation in the CPT2 gene. Here we present the pedigree of one of the largest family studies of CPT II deficiency caused by the c.338C > T mutation, documented so far. The pedigree comprises 24 blood relatives of the index patient, a 32 year old female with genetically proven CPT II deficiency. In total, the mutation was detected in 20 family members, among them five homozygotes and 15 heterozygotes. Among all homozygotes, first symptoms of CPT II deficiency occurred during childhood. Additionally, two already deceased relatives of the index patient were carriers of at least one copy of the genetic variant, revealing a remarkably high prevalence of the c.338C > T mutation within the tested family. Beside the index patient, only one individual had been diagnosed with CPT II deficiency prior to this study and three cases of CPT II deficiency were newly detected by this family study, pointing to a general underdiagnosis of the disease. Therefore, this study emphasizes the need to raise awareness of CPT II deficiency for correct diagnosis and accurate management of the disease.

Female workers' silicosis diagnosis delayed due to gender bias

After excluding alternative explanations, a silicosis diagnosis is based on the combination of appropriate silica exposure history and compatible clinical, radiological and occasionally pathological findings. Not taking appropriate occupational history by a physician may cause a misdiagnosis or underdiagnosis of silicosis. Herein, we present a female worker in a small-scale sandblasting factory who worked as a controller. Her silicosis diagnosis was established 10 years after her first symptoms, and she underwent invasive procedures due to a lack of inquiry about her occupational history. Gender bias may be one of the reasons that her occupational history was not taken.

Prevalence, risk factors and underdiagnosis of asthma in the general population aged over 60 years

Introduction

Bronchial asthma is one of the frequent chronic diseases in elderly persons. Global data show that 6.5–17% of the elderly suffer from asthma. However, there are no Polish data available on asthma prevalence in this group.

Aim

This article is a retrospective analysis of the Polish Multicentre Study of Epidemiology of Allergic Diseases (PMSEAD) results aimed at assessing prevalence and clinical characteristics in the elderly.

Material and methods

The study was conducted in 1998–1999 in 11 research centres in Poland, including the Lodz centre. The study included randomly selected subjects of both sexes. Demographics and prevalence were assessed among adults (aged 16–80 years) based on the nationwide database and the detailed clinical analysis was based on the Lodz centre database.

Results

Nationwide data were obtained from 12 970 adults, including 1057 respondents in the Lodz Province; 20.3% of respondents in Poland and 23.6% in the Lodz Province were over 60 years of age. In both groups, elderly participants significantly more frequently suffered from asthma (asthma prevalence in this group was 6.7% for Poland and 12.0% for the Lodz Province). The multivariate analysis demonstrated that age over 60 years (OR = 2.08), residence in the city centre (OR = 3.30), and occurrence of seasonal allergic rhinitis (OR = 3.11) were significant risk factors for asthma occurrence among the residents of the Lodz Province. Among the elderly in Lodz, almost 50% of patients with asthma had not had a proper diagnosis made despite reporting clinical symptoms.

Conclusions

In Poland asthma is a common and frequently underdiagnosed disease in the elderly.

Use of echocardiograms in the Medicare population: a diagnostic tool in the fight against severe aortic stenosis

AIM

To estimate undiagnosed aortic stenosis (AS) in the Medicare population.

METHODS

Patients enrolled (2011-2014) were eligible. After criteria were applied, time zero was the first record of an echocardiogram (ECHO) for the ECHO-AS cohort and randomly assigned for the no-ECHO cohort. The ECHO-AS cohort was propensity matched to patients in the no-ECHO cohort, and survival analysis was performed.

RESULTS

Of the 854,493 (25%) patients who received an ECHO, 1 in 4 were diagnosed with AS. After propensity matching, the no-ECHO cohort who died, almost half (49%) had a record of a cardiovascular event prior to their death. The no-ECHO cohort had statistically significant (p = 0.003) higher risk of death than their ECHO-AS counterparts.

CONCLUSION

In the Medicare population, patients aged 65 years or older, with increased risk factors for and symptoms common in AS patients, should be considered for diagnostic ECHOs.

Lifestyle intervention for obesity: a call to transform the clinical care delivery system in Mexico

Obesity and its comorbidities have become the most important public health problems for Latin America. In Mexico obesity has increased dramatically to the point where the government has declared it an epidemiological emergency. The most recent national data showed overweight and obesity affects 72.5% of adults, or around 56 million Mexicans. Most Mexican adults with obesity are undiagnosed. According to data derived from a national representative survey, only 20% of adults with BMI >30 kg/m² were diagnosed with obesity by a health provider. Likewise, only 8% of individuals with obesity had received treatment for obesity. Interventions offered in the Mexican health care delivery system generally consist of traditional consultations with recommendations on diet and exercise, visits are monthly to quarterly, and validated behavior change protocols are not used. Evidence from clinical trials has shown that weight loss with this type of treatment is generally less than 1 kg per year. In contrast, intensive lifestyle interventions - protocols focusing on achieving changes in diet, physical activity, and moderate weight loss using behavioral strategies with weekly or bi-weekly sessions for the first 3 to 6 months, and a maintenance phase with trained interventionists - as implemented in the Diabetes Prevention Program and the Look AHEAD studies achieved weight loss of 7-9% at one year. Additionally, translation studies of these interventions to the community and to real-world clinical practice have achieved weight loss of around 4%. Adaptations of intensive lifestyle interventions have been implemented in the United States, both in clinical practice and in the community, and this type of intervention represents a potential model to combat obesity in Mexico and other Latin American countries. It is essential that primary care providers in Mexico implement clinical practice guidelines based on the best evidence available as discussed here to effectively treat obesity. The authors make recommendations to improve the treatment of obesity in the clinical care delivery system in Mexico using intensive lifestyle interventions.

Tourette syndrome in an elderly patient

BACKGROUND

Tourette syndrome (TS) is a neurodevelopmental motor disorder. The first diagnosis during adult life involves cases of pre-existing undiagnosed TS.

CASE DESCRIPTION

We present the case of an elderly patient with severe, non-remitted TS, misdiagnosed with "psychoneurosis". The patient was correctly labeled at the age of 82.

CONCLUSION

Despite delays in TS diagnosis, only a few patients remain undiagnosed by the age of 45. Both TS under- and misdiagnosis have an impact on patients' outcomes. HIPPOKRATIA 2019, 23(1): 47-48.

Why Is Hyperparathyroidism Underdiagnosed and Undertreated in Older Adults?

Introduction

Hyperparathyroidism significantly decreases quality of life, yet elderly patients are underdiagnosed and undertreated even though parathyroidectomy offers definitive cure with minimal morbidity. The purpose of this study is to determine why older patients with hyperparathyroidism are not appropriately diagnosed and referred for parathyroidectomy.

Methods

We reviewed charts for a random sample of 25 patients aged 75 and older who had hyperparathyroidism and were referred for surgical evaluation, and 25 who were not referred. Two reviewers independently evaluated medical records to identify reasons for delayed diagnosis of hyperparathyroidism and reasons for nonreferral for parathyroidectomy.

Results

The median age of our cohort was 84 (80-96) years, 90% were women, 60% were white, and median follow-up was 5.5 (1-17) years. In 58% of all patients, an elevated serum calcium was not acknowledged. Even when calcium and parathyroid hormone levels were both elevated, the diagnosis was missed in 28% of patients, and 16% with clear symptoms of hyperparathyroidism remained undiagnosed. For 42% of patients, a nonsurgeon informed them that surgery offered no benefit. Surgery was also rejected as a treatment for 36% of patients despite the development of new symptoms or rising calcium.

Conclusions

Substantial gaps exist in processes for diagnosis and referral of patients with hyperparathyroidism that lead to underdiagnosis and undertreatment. To improve rates of diagnosis and treatment, strategies are needed to educate nonsurgeons and patients about the benefits of surgery and to modify care processes to more efficiently diagnose and refer patients.

Prospective: Is bipolar disorder being overdiagnosed?

OBJECTIVES

Many studies indicate that bipolar disorders are underdiagnosed. Yet from 2007 to 2008, a series of publications asserted that bipolar disorders were being overdiagnosed. This review examines the methods used in the studies that reported bipolar disorders were being overdiagnosed.

METHODS

A literature search for studies with original data related to overdiagnosis of bipolar disorders was performed.

RESULTS

Four studies were found indicating bipolar disorders were being overdiagnosed. The Structured Clinical Interview of the Diagnostic and Statistical Manual of Mental Disorders (SCID) was used in the diagnostic process. The studies compared the clinical diagnosis of bipolar disorder to a single SCID interview without interviewing family or reviewing old records. The studies assumed the SCID diagnosis was correct.

CONCLUSIONS

Numerous concerns were found. The SCID frequently missed diagnosis of bipolar, the definitions of bipolar disorder are so narrow and conservative that the outcomes of the studies may have been predetermined. Ultimately, the studies compared the strength of a diagnosis made by a treating psychiatrist to a SCID diagnosis collected with virtually no information from the clinician. The assumption that the SCID diagnosis is always correct and the clinician is always wrong is unsupportable. The premise that bipolar disorders are being overdiagnosed is unsupported by reasonable science.

A Bayesian Approach to Modeling Risk of Hospital Admissions Associated With Schizophrenia Accounting for Underdiagnosis of the Disorder in Administrative Records

Schizophrenia is a debilitating serious mental illness characterized by a complex array of symptoms with varying severity and duration. Patients may seek treatment only intermittently, contributing to challenges diagnosing the disorder. A misdiagnosis may potentially bias and reduce study validity. Thus we developed a statistical model to assess the risk of 1-year hospitalization for patients diagnosed with schizophrenia, accounting for when schizophrenia is underreported in administrative databases. A retrospective study design identified patients seeking care during 2010 within an integrated health care system from the Health Maintenance Organization Research Network located in the southwestern United States. Bayesian analysis addressed the problem of underdiagnosed schizophrenia with a statistical measurement error model assuming varying rates of underreporting. Results were then compared to classical multivariable logistic regression. Assuming no underreporting, there was an 87% greater relative odds of hospitalization associated with schizophrenia, OR = 1.87, CI [1.08, 3.23]. Effect sizes and interval estimates representing the association between hospitalization and schizophrenia were reduced with the Bayesian approach accounting for underdiagnosis, suggesting that less severe patients may be underrepresented in studies of schizophrenia. The analytical approach has useful applications in other contexts where the identification of patients with a given condition may be underreported in administrative records.

Characteristics of Subjects With Undiagnosed COPD Based on Post-Bronchodilator Spirometry Data

BACKGROUND

COPD is largely underdiagnosed. Patients with undiagnosed COPD need to be diagnosed to ensure early treatment institution. It is therefore relevant to obtain a more profound understanding of the characteristics of patients with undiagnosed COPD to improve COPD case finding. This study aimed to explore the characteristics of subjects with undiagnosed COPD from the United States National Health and Nutrition Examination Survey (NHANES) dataset (2007-2012) based on post-bronchodilator spirometry.

METHODS

A multitude of statistical tests were performed to explore the potential characteristics of subjects with undiagnosed COPD. A total of 1,098 subjects with a post-bronchodilator FEV₁/FVC < 0.7 or lower limit of normal (LLN) were included in the final sample.

RESULTS

Undiagnosed subjects experienced less phlegm (P < .001), wheezing (P < .001), and chest pain (P < .001) than subjects diagnosed with COPD. They were characterized by less shortness of breath (P < .001), fewer work/school days lost to wheezing (P < .001), less sleep disturbance (P < .001), and less difficulty socializing (P < .001). The undiagnosed subjects felt less depressed (P < .001). Additionally, they were less likely to have asthma (P < .001). The annual household income was higher among the undiagnosed subjects (P < .001), and they were also characterized by higher FEV₁ (P < .001), and FVC (P < .001).

CONCLUSIONS

Subjects with undiagnosed COPD were characterized by fewer symptoms and had better lung function than their diagnosed counterparts.