About signs and symptoms: can semiotics expand the view of clinical medicine?

Semiotics, the theory of sign and meaning, may help physicians complement the project of interpreting signs and symptoms into diagnoses. A sign stands for something. We communicate indirectly through signs, and make sense of our world by interpreting signs into meaning. Thus, through association and inference, we transform flowers into love, Othello into jealousy, and chest pain into heart attack. Medical semiotics is part of general semiotics, which means the study of life of signs within society. With special reference to a case story, elements from general semiotics, together with two theoreticians of equal importance, the Swiss linguist Ferdinand de Saussure and the American logician Charles Sanders Peirce, are presented. Two different modes of understanding clinical medicine are contrasted to illustrate the external link between what we believe or suggest, on the one hand, and the external reality on the other hand.     

The importance of clinical symptoms and signs in the diagnosis of community-acquired pneumonia

PURPOSE: 118 Patients with suspected obstruction of the biliary tract of pancreatic duct were examined to evaluate the accuracy of MR cholangiopancreatography (MRCP) in comparison with diagnostic findings in endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Using a 0.5-Tesla MR imaging system (FLEXART, Toshiba) and a QD body-coil, a recently developed heavily T2-weighted fast acquisition spin echo sequence (FASE) was applied. In this FASE sequence two significant features are implemented. A fast spin-echo (SE) sequence allows a large number of echos and conjugate K-space filling speeds up data acquisition. Thus, the acquisition time of single-shot breath-hold images takes only 3 seconds, which makes MRCP a feasible technique even in elderly or suffering patients. There is no need for time-consuming postprocessing procedures. RESULTS: In all MRCP examinations images of satisfactory quality were obtained. In cases of obstruction of the biliary or pancreatic duct, locations and lengths of stenoses were correctly demonstrated. Gallstones within the gallbladder or in the extrahepatic bile ducts were also properly visualised in MRCP. Stenoses caused by non-depicted pancreatic carcinoma, gallbladder carcinoma, or segmental pancreatitis were reliably shown. CONCLUSION: Even if MRCP will not replace ERCP, a number of clinical applications for non-invasive MRCP examination arise: primary diagnosis in patients with obstructive jaundice, obstruction of the biliary or pancreatic duct, if ERCP is not possible due to anatomic reason and in patients scheduled for laparoscopic cholecystectomy.     

Spontaneous reduction of intussusception: verification with US

PURPOSE: To report cases of spontaneous reduction of intussusception. MATERIALS AND METHODS: The authors reviewed the clinical and imaging findings in four patients with intussusception. Patients ranged in age from 3 to 7 months and were seen over a 12-year period. RESULTS: Intussusception was diagnosed with ultrasound (US) in all four patients; however, when enema studies were performed, intussusception was not identified. Repeat US also failed to demonstrate the presence of an intussusception, and all four patients showed concomitant rapid resolution of symptoms. CONCLUSION: Spontaneous reduction of intussusception is probably more common than is generally thought, and its documentation was facilitated with US. It is likely that spontaneously reduced intussusception will be documented more frequently in the future.     

Systemic Candida infection in pediatric BM autotransplantation: clinical signs, outcome and prognosis

Of the 393 children who underwent BM autotransplantation in the pediatric oncology unit of the Institut Gustave Roussy between February 1979 and September 1991, 14 (3.56%) developed disseminated Candida infection within 3 months. This incidence was far lower than in other published series. Eleven of the 14 patients recovered from the infection, giving a far higher survival rate (78%) than among adult BM transplant recipients (usually < 30%). All 14 patients had four or more risk factors and persistent BM aplasia (median, 25 days); six had Candida tropicalis infection. Four cases of deep visceral involvement were documented, two of which were lethal. Clinical signs were relatively uniform and included secondary high-grade fever (> 40 degrees C) for 8 days; half the patients developed cardiovascular impairment, respiratory distress, neurological disturbances (altered consciousness or delirium) and severe diarrhoea, within as little as 10 days after transplantation. Blood cultures rapidly became positive after the onset of clinical signs and this permitted prompt treatment with a combination of amphotericin B and 5-fluorocytosine; in addition, central catheters were removed. Blood cultures became sterile within 4 days of treatment in 10 of the 14 cases. The generally favourable outcome in this series could be related to the young age of the patients, the absence of GVHD, the absence of total body irradiation in the conditioning regimen, and early antifungal treatment.     

Prodromal symptoms vs. early warning signs and clinical action in schizophrenia

The term "prodromal symptoms" has traditionally referred to prepsychotic changes in thought, affect, and cognition that precede the initial onset of schizophrenia. Recently, however, the term has been extended into a clinical action context to refer to the early warning signs (EWS) of impending relapse in patients already diagnosed as having schizophrenia. However, recent reports reviewed by Norman and Malla (1995, this issue) use a narrow definition of prodromal symptoms and question their use in the clinical action context. We argue that the dual use of the term "prodromal symptoms" has led to conceptual confusion and to the impression that EWS cannot be used effectively for clinical action. The ability to base clinical action on EWS is central to schizophrenia therapeutics and is the cornerstone of pharmacological strategies based on early intervention. Our review of the evidence suggests that the effective clinical use of EWS depends on (1) the inclusion of both psychotic and nonpsychotic symptoms as EWS; (2) the use of clinician judgment in combination with predefined symptom changes to define the occurrence of EWS; (3) frequent clinical visits; and (4) the use of family or caregiver informants. We therefore suggest that, in the clinical action context, the terminology "early warning signs of impending relapse" should be used instead.     

The relationship between medical and psychiatric symptoms.

The Cornell Medical Index, Taylor scale, and the Saslow Psychosomatic Inventory were administered to in-patients and out-patients in the medical and psychiatric hospitals and clinics of a medical school. The result was that "number of medical symptoms was a good predictor (correlated highly) of psychiatric symptomatology and vice versa." Females had more medical symptoms than men, but no such distinction appeared, re: psychiatric symptoms. From Psyc Abstracts 36:01:3HI55M. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Big Five dimensions and ADHD symptoms: Links between personality traits and clinical symptoms.

Attention-deficit/hyperactivity disorder (ADHD) in adulthood is conceptualized as originating in childhood. Despite considerable theoretical interest, little is known about how ADHD symptoms relate to normal personality traits in adults. In 6 studies, the Big Five personality dimensions were related to ADHD symptoms that adults both recalled from childhood and reported concurrently (total N=1,620). Substantial effects emerged that were replicated across samples. First, the ADHD symptom cluster of inattention-disorganization was substantially related to low Conscientiousness and, to a lesser extent, Neuroticism. Second, ADHD symptom clusters of hyperactivity-impulsivity and oppositional childhood and adult behaviors were associated with low Agreeableness. Results were replicated with self-reports and observer reports of personality in community and clinical samples. Findings support theoretical connections between personality traits and ADHD symptoms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The clinical diagnosis of deep venous thrombosis: integrating incidence, risk factors, and symptoms and signs

Symptoms and clinical signs suggestive of deep venous thrombosis (DVT) are common and have numerous possible causes. Studies have shown that symptoms and clinical signs in themselves are inaccurate for the diagnosis of DVT. However, clinicians have other information at hand, such as data on risk factors for DVT, that may help improve their ability to predict a diagnosis of DVT in the individual patient. Epidemiological data on DVT incidence and risk factors were reviewed, as were published data on the accuracy of clinical diagnosis of DVT, with the use of both symptoms and signs in isolation and symptoms and signs combined with other clinical information in the form of clinical prediction indexes. Symptoms and clinical signs, when combined with other patient information such as the presence or absence of known risk factors for DVT, can improve clinical prediction considerably. Further study is needed to determine whether clinical prediction indexes have a role in improving the diagnostic process in patients with suspected DVT.     

The relationship between cognitive inhibition and psychotic symptoms.

Cognitive models of schizophrenia have highlighted deficits of inhibitory attentional processes as central to the disorder. This has been investigated using "negative priming" (S. P. Tipper, 1985), with schizophrenia patients showing a reduction of negative priming in a number of studies. This study attempted to replicate these findings, but studied psychotic symptoms rather than the broad diagnostic category of schizophrenia. Psychotic individuals exhibiting positive symptoms were compared with asymptomatic psychiatric patients and with a normal control group. As predicted, the symptomatic group failed to show the usual negative priming effect, which was present in the asymptomatic and normal groups. A modest but significant correlation was found between negative priming and delusions. Neither diagnosis, nor affective or negative symptoms, nor chronicity, nor medication, was related to negative priming. These data replicate previous findings that positive symptoms are related to a reduction in cognitive inhibition, although considerable variability was observed among the psychotic patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Myotonic dystrophy: relative sensitivity of symptoms signs and abnormal investigations

Twenty-five symptoms, signs, and abnormal investigations were looked for in 20 patients with clinically-definite myotonic dystrophy. Weakness of facial muscles, neck flexors, and arm external rotators was found in all patients (sensitivity = 100%). Arm external rotation has not been reported as a frequently involved muscle in previous clinical studies on myotonic dystrophy. Careful examination of muscle strength may therefore predict which patients may or may not carry the abnormal gene for myotonic dystrophy.     

Presenting symptoms and signs after whiplash injury: the influence of accident mechanisms

OBJECTIVE: To assess the relationship between accident mechanisms and initial findings after whiplash injury. DESIGN: Cohort study. SETTING: Outpatient department, Department of Neurology, University of Berne, Switzerland. PATIENTS: A population-based sample of 137 consecutive patients referred by primary care physicians. Fractures or dislocations of the cervical spine, head trauma, and preexisting neurologic disorders were exclusion criteria. MAIN OUTCOME MEASURES: Patients were interviewed and examined within 7.2 days (SD, 3.9 days) after trauma. Analyzed accident features were position in the car, use of seat belt, head restraint and its point of head contact, damage to seat, head position and state of preparedness at the moment of impact, and type of collision. Analyzed symptoms were intensity and onset delay of post-traumatic head and neck pain; pain in the shoulders, back, and anterior neck; symptoms of neurologic dysfunction according to presumed origin--cranial nerve or brainstem, radicular or myelopathic; and a score of multiple symptoms. Analyzed signs were neck muscle tenderness and restricted neck movement, and signs of cranial nerve, brainstem, or radicular dysfunction. RESULTS: Passenger position in the car, use of seat belt, and the presence of a head restraint showed no significant relationship with findings. Rotated or inclined head position at the moment of impact was associated with a higher frequency of multiple symptoms (p = 0.045 and 0.008) with more severe symptoms and signs of musculoligamental cervical strain (p = 0.048 and 0.038) and of neural, particularly radicular (p = 0.031 and 0.019), damage. Unprepared occupants had a higher frequency of multiple symptoms (p = 0.031) and more severe headache (p = 0.046). Rear-end collision was associated with a higher frequency of multiple symptoms (p = 0.006), especially of cranial nerve or brainstem dysfunction (p = 0.00003). CONCLUSION: Three features of accident mechanisms were associated with more severe symptoms: an unprepared occupant; rear-end collision, with or without subsequent frontal impact; and rotated or inclined head position at the moment of impact.     

Prodromal signs and symptoms of schizophrenic relapse.

Six-week periods prior to 17 psychotic relapses and to 10 relapses characterized by depression and/or hostility were examined for 23 recent-onset schizophrenic outpatients. These prodromal periods were compared with periods that did not precede relapse for the same patients and for 27 schizophrenic patients who did not relapse. The Brief Psychiatric Rating Scale (BPRS) was used to assess symptomatology. Psychotic relapse was defined as an elevation to severe or extremely severe from nonpathological levels on one or more of BPRS items: Hallucinations, Unusual Thought Content, and Conceptual Disorganization. Nonpsychotic relapses were similarly defined using the Depression and Hostility items of the BPRS. Even small elevations in odd thought content, unusual perceptual experiences, depression, somatic concern, and guilt above the levels usually present for a given patient may presage psychotic relapse during the 6 to 8 weeks prior to its occurrence. When compared with nonprodromal periods of other patients, periods before relapse were found to show significantly higher levels of hostility and grandiosity in addition to higher levels of unusual thought content and perceptual abnormalities. For relapses characterized by depression and hostility, an elevation of activation was found in the prodromal period. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Underlying mechanisms in the relationship between Africentric worldview and depressive symptoms.

This study examines underlying mechanisms in the relationship between an Africentric worldview and depressive symptoms. Participants were 112 African American young adults. An Africentric worldview buffered the association between perceived stress and depressive symptoms. The relationship between an Africentric worldview and depressive symptoms was mediated by perceived stress and emotion-focused coping. These findings highlight the protective function of an Africentric worldview in the context of African Americans’ stress experiences and psychological health and offer promise for enhancing African American mental health service delivery and treatment interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Children with anogenital symptoms and signs referred for sexual abuse evaluations

Germ cell tumors (GCTs) are the most frequent cancer in men aged 15 to 34 years. These tumors are highly responsive to therapy with platinum-containing regimens, and 80% of cases so treated can be considered cured. Cytogenetically, 80% of GCTs have an i(12p) regardless of tumor site or histopathology, and those that are i(12p) negative have other manifestations of 12p amplification. GCTs occasionally arise extragonadally, and such cases can be especially difficult to distinguish from poorly differentiated somatic carcinomas, a situation that poses a diagnostic and treatment dilemma We developed a technique for two-color fluorescence in situ hybridization chromosome painting on nuclei released from paraffin-embedded sections. In four tumors for which GCT was a differential diagnosis, we examined the 12p and 12q chromosome arm distributions by this technique. By use of 12p and 12q painting probes developed by microdissection, 12p and 12q were distinguished and their relative distributions evaluated. In each of the four cases, 12p regions seemed to be rearranged and over-represented relative to 12q regions. In three of the cases, an apparent i(12p) could be identified. These results support a diagnosis of GCT or GCT origin in these four cases. In tumors for which specific cytogenetic abnormalities are known, chromosome painting by fluorescence in situ hybridization using paraffin-embedded tissue is a useful technique to aid in the diagnosis of tumors that are difficult to differentiate. The patients can then be placed on treatment regimens appropriate for their specific tumor type.     

Improving the relationship between the randomized clinical trial and real-world clinical practice.

I comment on the article by Krause (see record 2011-19228-002), which discusses a number of ways for clinical psychotherapy outcome researchers to make the results of randomized controlled trials (RCT) more useful to practicing psychotherapists primarily by making the distributions of raw data from those studies available to the public. In this way, it would be possible for psychotherapists to determine which treatment of an RCT (experimental or control) would be best for a specific patient. Problems with this proposal are discussed and an alternative model that integrates psychotherapy outcome data from group means and clinical case studies is offered. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The relationship between posttraumatic stress symptoms and sexual risk: Examining potential mechanisms.

Little is known about behavioral and psychological mechanisms that may explain relationships between posttraumatic stress and sexual risks. As rates of HIV infection among African American women remain significantly higher than for other female subgroups, research on sexual risk among African American women is needed. The present study examines the relationships of posttraumatic stress symptoms as measured by the Posttraumatic Stress Disorder Checklist-Civilian Version with sexual risk behaviors, sexual sensation-seeking, and sexual compulsivity in 30 undergraduate African American women with any reported history of sexual intercourse. Higher posttraumatic stress symptoms were associated with more sexual partners, greater frequency of vaginal sex without a condom, and endorsement of sex while under the influence of a substance. Posttraumatic stress symptoms were negatively correlated with perceived sexual control, but were not significantly correlated with sexual compulsivity or sensation-seeking. Perceived sexual control was negatively associated with frequency of unprotected sex and sex under the influence. The preliminary evidence from this small sample suggests sexual control may mediate the relationship of the posttraumatic stress symptoms with unprotected sex. These results are generally consistent with previous findings suggesting posttraumatic stress is associated with sexual risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)