Referral and diagnosis of common rheumatic diseases by primary care physicians

OBJECTIVE: To describe primary care patterns of referral and diagnoses of patients with rheumatic diseases referred to rheumatologists. METHODS: The medical records of all consecutive patients referred in 1994 by >300 primary care physicians to two rheumatologists at an academic centre were reviewed. The referring physician diagnosis was compared with the rheumatologist's diagnosis. Sensitivity, specificity and predictive values of primary care diagnoses were estimated using the rheumatologist diagnosis as the 'gold standard'. SETTING: University-based rheumatology out-patient clinic. RESULTS: Over half of the patients referred had a rheumatologist diagnosis of soft-tissue rheumatism or a spinal pain syndrome. Three hundred and forty-seven patients (49%) had a primary care diagnosis of a defined rheumatic disease. Of these, 142 (41%) of the primary care diagnoses were subsequently modified by the rheumatologist. The highest agreement between primary care physician and rheumatologist was observed for crystal-induced arthritis (kappa = 0.86), and the lowest agreement for polymyalgia rheumatica (kappa = 0.39) and systemic lupus (kappa = 0.46). Sensitivity was lowest for a primary care diagnosis of fibromyalgia (48%) and highest for ankylosing spondylitis (94%). Positive predictive values were generally low, in particular for systemic lupus erythematosus (33%) and polymyalgia rheumatica (30%). CONCLUSION: Most patients referred to an academic rheumatology centre had soft-tissue rheumatism or other pain syndromes. In general, diagnostic agreement between rheumatologists and primary care physicians was low. Increased emphasis on musculoskeletal disorders should be encouraged in medical education to increase the efficiency of rheumatology referrals.     

Pseudotumor forms of demyelinating diseases. Report of three cases and review of the literature

INTRODUCTION AND CLINICAL CASES: We present three patients with unusual clinical findings studied in our hospital, after a period of follow-up of at least two years from the time of diagnosis of their demyelinating condition. We discuss the clinical onset, CT and magnetic resonance findings, neuropathological studies and posterior clinical course. Anatomopathological studies were done in two of the cases, since the diagnoses were not clear and the other paraclinical investigations did not clarify things. DISCUSSION: The presence of large space-occupying lesions or ring-like outlines in myelinating disorders may make it difficult to make a differential diagnosis from other conditions such as neoplasias and abscesses. This may lead to an erroneous initial diagnosis and even to the use of unsuitable, aggressive treatments. CONCLUSIONS: In young patients in whom radiological imaging suggests space-occupying lesions (single or multiple) one should consider the possibility of a primary demyelinating disease of the central nervous system with the appearance of a pseudo-tumour. In certain cases, stereotaxic biopsy should be considered if the diagnosis remains in doubt, rather than begin unsuitable treatment. The fundamental reason for the presentation of our cases is to emphasize that these pseudo-tumoral forms of demyelinating diseases should be considered in diagnosis.     

Radiotherapeutic management of osseous metastases: a survey of current patterns of care

BACKGROUND: No convincing explanation has been forthcoming for the variation in best threshold to adopt for the GHQ in different settings. METHODS: Data dealing with the GHQ and the CIDI in 15 cities from a recent WHO study was subjected to further analysis. RESULTS: The mean number of CIDI symptoms for those with single diagnoses, or those with multiple diagnoses, does not vary between cities. However, the best threshold is found to be related to the prevalence both of single and of multiple diagnoses in a centre. Variations in the diagnoses to be included in the 'gold standard' did not account for the variation observed. There was a strong relationship between area under the ROC curve (as a measure of the discriminatory power of the GHQ) and the best threshold, with higher thresholds being associated with superior performance of the GHQ. The items on the GHQ-12 that provided most discrimination between cases and non-cases varied from one centre to another. CONCLUSIONS: The GHQ threshold is partly determined by the prevalence of multiple diagnoses, with higher thresholds being associated by higher rates of both single and multiple diagnosis. The mean GHQ score for the whole population of respondents provides a rough guide to the best threshold. In those centres where the discriminatory power of the GHQ is lowest, it is necessary to use a low threshold as a way of ensuring that sensitivity is protected, but the positive predictive value of the GHQ is then lower. Some of the variation between centres is due to variation in the discriminatory power of different items.     

Primary systemic amyloidosis with delayed progression to multiple myeloma

BACKGROUND: Primary systemic amyloidosis (AL) and multiple myeloma both are clonal plasma cell proliferative disorders. Although 10-15% of patients with myeloma have coexisting primary amyloidosis, it is unusual for patients with primary amyloidosis to progress to myeloma at a later date. The authors describe a case series of six patients in whom such progression occurred. METHODS: A computerized search was done of the medical records of all patients seen at the Mayo Clinic between January 1, 1960 and December 31, 1994 with a diagnosis of AL. Of 1596 patients with AL, 6 patients (age range, 60-74 years; median age, 68 years) with biopsy-proven AL were reviewed in whom delayed (at least 6 months after the diagnosis of AL) progression to multiple myeloma occurred. RESULTS: At the time of the diagnosis of AL, none of the six patients had evidence of multiple myeloma. The dominant manifestation of AL was peripheral neuropathy in three patients and cutaneous AL, renal AL, and amyloid arthropathy in one patient each. The diagnosis of multiple myeloma was made 10-81 months after the diagnosis of AL, based on the demonstration of multiple osteolytic lesions (4 patients) or marked bone marrow infiltration (> or = 50%) by plasma cells (5 patients). Two patients had received chemotherapy (melphalan and prednisone) for AL. Five patients received chemotherapy (four patients) or high dose methylprednisolone (one patient) after the diagnosis of multiple myeloma. Five patients died, and the median actuarial survival after the diagnosis of multiple myeloma was 20 months. Multiple myeloma was the cause of death in four patients; one patient died of systemic amyloidosis. In 2 patients death occurred within 3 months. CONCLUSIONS: AL occasionally progresses to overt multiple myeloma. These cases usually occur in patients without significant cardiac or hepatic AL who live long enough to develop multiple myeloma.     

The influence of patient diagnosis and self-image on clinicians' feelings

This paper presents an analysis of the relations between the patients' psychiatric diagnoses, their self-image, and the staffs feelings toward the patients. At 17 treatment units for severely disturbed psychiatric patients, the staff rated their feelings toward the patients on a feeling checklist twice a year for 5 years. The patients were diagnosed on DSM-III-R (axis I and II) and rated their self-image on a self-rating instrument, the Structural Analysis of Social Behavior. First, comparisons between reactions toward patients with different axis I diagnoses, toward patients with different axis II diagnoses, and toward patients with either axis I or axis II diagnoses were made with one-way ANOVAs. No significant differences were found in any of these comparisons. The amount of variance in feelings explained by these groupings was between 2% and 4% (mean = 3%) for axis I, between 3% and 14% (mean = 8%) for axis II, and between 4% and 17% (mean = 9%) for the combined comparison. Differences between axis II diagnoses had the largest influence on the staffs feeling reactions. Second, comparisons between the influence of the patients' diagnoses and of their self-image on the therapists' feelings were made by way of blockwise multiple regression analyses. The results showed that the patient's self-image was more important in influencing the staffs feelings than the diagnosis but that diagnosis and self-image were virtually independent in this respect.     

The need for accurate target and dose specifications in conventional and conformal radiation therapy--an introduction

Back pain in children has long been considered a serious condition with an organic cause. The staff of the Shriner's Hospital had been informally noting that diagnoses among children with back pain had been changing. We conducted a retrospective study of 648 patients with spinal disorders treated at the Shriner's Hospital for Crippled Children, Spokane Unit, between January 1991 and June 1993. The patients were divided into two groups: those with pain and those without pain. It was found that back pain with no organic cause was the primary diagnosis in 57% of the group having pain. Only one child had a diagnosis of malignancy, and there were no cases of active infection. In the group with pain, three interesting associations were found concerning psychosocial problems, disability, and litigation. It was found that the diagnoses in children with back pain treated at this referral center during the study period parallel those in the adult population with back pain.     

Primary intraosseous meningiomas of the skull

The plain film, computed tomography (CT) and angiographic findings in 10 patients with primary intraosseous meningioma were reviewed and the differential diagnosis considered. In nine patients with benign primary intraosseous meningioma, the radiological findings revealed intraosseous expansile growth. In one patient with the malignant form of the tumour, osteolytic growth was evident on plain film and CT. In eight patients, the tumour tissue was hyperdense (65-85 HU) on the unenhanced CT images and striking enhancement was shown in seven. In five patients angiography showed that the external carotid artery fed the tumour, while in one the vasculature was normal. Benign primary intraosseous meningioma showed expansile growth and malignant tumour showed osteolytic growth. If a combination of the plain film, angiogram and CT findings is considered, a diagnosis of the benign tumour can be made and a diagnosis of benign meningioma can be suggested.     

Coronary reserve of high- and low-flow regions in the dog heart left ventricle

OBJECTIVE: To examine the relationship between psychopathology and health care utilization beginning in the preschool (ages 2 to 5) years. METHOD: Five hundred ten preschool children were enrolled through 68 primary care physicians. The test battery used for diagnoses included the Child Behavior Checklist, a developmental evaluation, the Rochester Adaptive Behavior Inventory, and a videotaped play session. Consensus DSM-III-R diagnoses were assigned using best-estimate procedures. Frequency of primary care visits was established through 1-year retrospective record review; mothers estimated total visits and emergency department (ED) use. RESULTS: Logistic regression models showed that a DSM-III-R diagnosis was related to increased ED use but not primary care or total visits. Greater functional impairment was associated with fewer primary care visits and more ED visits. Total, internalizing, and externalizing behavior problem scores were associated with increased primary care and total visits; ED visits were associated with increased total and internalizing problems. Child's health status consistently correlated with utilization. CONCLUSION: There is a consistent relationship between health care use and child psychopathology beginning in the preschool years.     

Accuracy of the clinical diagnoses of Lewy body disease, Parkinson disease, and dementia with Lewy bodies: a clinicopathologic study

BACKGROUND: Whether Parkinson disease (PD) and dementia with Lewy bodies (DLB) represent 2 distinct nosologic entities or are diverse phenotypes of Lewy body disease is subject to debate. OBJECTIVES: To determine the accuracy of the diagnoses of Lewy body disease, PD, and DLB by validating the clinical diagnoses of 6 neurologists with the neuropathologic findings and to identify early predictors of the diagnoses. METHODS: Six raters who were unaware of the neuropathologic diagnoses analyzed 105 clinical vignettes corresponding to 29 cases of Lewy body disease (post hoc analysis of 15 patients with PD and 14 with DLB) and 76 patients without PD or DLB whose cases were confirmed through autopsy findings. MAIN OUTCOME MEASURES: Sensitivity and positive predictive value (PPV) were chosen as validity measures and the K statistic as a reliability measure. RESULTS: Interrater reliability for the diagnoses of Lewy body disease and PD was moderate for the first visit and substantial for the last, whereas agreement for diagnosis of DLB was fair for the first visit and slight for the last. Median sensitivity for diagnosis of Lewy body disease was 56.9% for the first visit and 67.2% for the last; median PPV was 60.0% and 77.4%, respectively. Median sensitivity for the diagnosis of PD was 73.3% for the first visit and 80.0% for the last; median PPV was 45.9% and 64.1%, respectively. Median sensitivity for the diagnosis of DLB was 17.8% for the first visit and 28.6% for the last; median PPV was 75.0% for the first visit and 55.8% for the last. The raters' results were similar to those of the primary neurologists. Several features differentiated PD from DLB, predicted each disorder, and could be used as clinical pointers. CONCLUSIONS: The low PPV with relatively high sensitivity for the diagnosis of PD suggests overdiagnosis. Conversely, the extremely low sensitivity for the diagnosis of DLB suggests underdiagnosis. Although the case mix included in the study may not reflect the frequency of these disorders in practice, limiting the clinical applicability of the validity measures, the raters' results were similar to those of the primary neurologists who were not exposed to such limitations. Overall, our study confirms features suggested to predict these disorders, except for the early presence of postural imbalance, which is not indicative of either disorder.     

Combined esophageal atresia and duodenal stenosis in polyhydramnios. Ante-, peri- and postpartum management]

Three-dimensional sonography of the mamma with a Voluson annular array transducer (10 MHz) (Kretztechnik, Austria) is a new method applicable in differential diagnosis of mamma foci. 50 patients (19 of them with breast cancer) were thus pre-surgically examined. Both sectional and stereoscopic representations were made use of. The suspected diagnoses and their correspondences with post-surgical findings were compared to the correspondences obtained through 2D-sonography. 3D-sonography produced 4 cases of the incorrectly positive diagnosis breast cancer, 2D-sonography 2 cases of incorrectly negative diagnoses. Other advantages of 3D-sonography over 2D-sonography include: better judgement of the conditional of focal environs (infiltration), existence and form of intracystic structures and of multifocal disease, short duration of examination, possible re-diagnosing of stored data.     

Difficult diagnosis of Crohn's disease

It is often difficult to diagnose Crohn's disease because of the numerous clinical symptoms. In a retrospective study from 1963-1975 the initial diagnosis was examined in 101 patients with Crohn's disease. In 22% of the patients the initial diagnosis was correct, in 78% one or more wrong diagnoses were made. The most regular wrong diagnosis was colitis ulcerosa (30%). 41 patients were unnecessarily treated surgically before the correct diagnosis was established. The mean time from the on-set of the symptoms until the correct diagnosis was 3.6 years, the mean time from the first wrong diagnosis to the correct diagnosis, 2.9 years. In the later few years a decrease in wrong diagnoses, an increase in initially correct diagnoses and a shortening of the interval between beginning of symptoms until final diagnosis are recognizable. The possible reasons are discussed.     

Eliminating the hindsight bias.

Those who consider the likelihood of an event after it has occurred exaggerate their likelihood of having been able to predict that event in advance. We attempted to eliminate this hindsight bias among 194 neuropsychologists. Foresight subjects read a case history and were asked to estimate the probability of three different diagnoses. Subjects in each of the three hindsight groups were told that one of the three diagnoses was correct and were asked to state what probability they would have assigned to each diagnosis if they were making the original diagnosis. Foresight-reasons and hindsight-reasons subjects performed the same task as their foresight and hindsight counterparts, except they had to list one reason why each of the possible diagnoses might be correct. The frequency of subjects succumbing to the hindsight bias was lower in the hindsight-reasons groups than in the hindsight groups not asked to list reasons χ–2(1, N?=?140)?=?4.12, p     

Whole-body [18F]FDG PET in the management of metastatic brain tumours

BACKGROUND: To determine its roles in the diagnosis and the systemic evaluation of metastatic brain tumours, whole-body positron emission tomography (PET) using [18F]FDG was performed in 20 consecutive patients. METHODS: All patients were thought to be suffering or needing to be differentiated from metastatic brain tumours. Nine patients had multiple brain lesions; six were older and showed a rim-enhancing lesion with surrounding oedema; seven had homogeneously enhancing periventricular lesion(s) on computed tomography (CT) and/or magnetic resonance (MR) imaging, thought to be central nervous system lymphomas. Two patients had skull mass(es) and two patients had a solid mass suspected to be, respectively, a haemorrhagic metastasis and a metastatic malignant melanoma. All of them received whole-body [18F]FDG PET and conventional systemic work-up for metastasis in order to compare the results of the two methods. RESULTS: Metastatic brain tumours were diagnosed on whole-body [18F]FDG PET in eleven patients who had extracranial and intracranial hypermetabolic lesions. In nine of these, a conventional work-up also detected primary lesions which on whole-body [18F]FDG PET were seen to be hypermetabolic foci. Systemic lymph node metastases were detected by whole-body [18F]FDG PET only in two patients and histological diagnosis was possible by biopsy of lymph nodes rather than of brain lesions. In the remaining nine patients who had only intracranial hypermetabolic foci, histological diagnosis was made by craniotomy or stereotactic biopsy. It was confirmed that seven of nine patients were suffering from a primary brain tumour and two from metastatic carcinoma. None of the nine showed evidence of systemic cancer on conventional work-up. Histological diagnoses of the primary brain tumours were four cases of primary central nervous system lymphoma and one each of multifocal glioblastoma, Ewing's sarcoma, and cavernous angioma. Patients felt no discomfort during the whole-body [18F]FDG PET procedure and there were no complications. The false negative rate in [18F]FDG PET and in conventional work-up was 15.4% and 30.7% respectively. There were no false positives on either [18F]FDG PET or conventional work-up. CONCLUSION: It is suggested that whole-body [18F]FDG PET is a safe, reliable, and convenient method for the diagnosis and systemic evaluation of patients thought to be suffering or needing to be differentiated from a metastatic brain tumour.     

Effects of experience and training on diagnostic accuracy.

In this reexamination of a previously published report (R. Brammer, 1997), psychologists and psychology students (N = 138) were provided an artificial intelligence program that simulated a clinical interview. The "client" provided paragraph-length answers to the questions participants chose to ask. At the end of their interview, the participants provided a brief diagnosis for the client. A path analysis revealed that clinical experience is a strong predictor of the ability to form an accurate diagnosis and that an individual's level of training, mediated by the number of diagnostic questions asked, also helps to derive accurate diagnoses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Primary biliary cirrhosis: an electronic diagnostic tool trial based on symptoms, (past) history and signs only, using the European database euricterus. The Euricterus PMG

BACKGROUND/AIMS: Primary Biliary Cirrhosis (PBC) is a relatively rare chronic progressive disease in which a working diagnosis of PBC easily leads to a final diagnosis by testing for anti-mitochondrial antibodies. Liver transplantation is the only effective treatment. The aim of this study was to test an electronic diagnostic tool (tool) for it's ability to include PBC in the working differential diagnosis. METHODOLOGY: In the European Union Euricterus project a large number of (sub)icteric patients in 17 discrete disease categories, PBC being one of them, were gathered prospectively. A tool was developed-using Bayes (B) and Trial Algorithm (TA) pattern-recognition and based on items related to the history, symptoms and signs of all Euricterus patients. We have tested the diagnostic tool on 143 PBC Euricterus patients. RESULTS: PBC was mentioned by the tool in 86% (B) and 91% (TA) of the 143 patients. These figures were higher for patients under 60 and (TA only) females. Females under 60 (n = 89) scored 92% B and 96% TA. A sole diagnosis of PBC was made in 31% (B) and 66% (TA). In the other patients with a PBC probability, 7 other (first) diagnoses were presented by the tool of which non-alcoholic active liver disease and pancreatic or biliary carcinoma were the leaders. These 7 diseases appeared evenly distributed along the percentual probabilities of PBC given by the tool (B) and also along Pugh and Mayo scores (B and TA). PBC was mentioned by the tool in all patients with a Pugh score 10 or higher (advanced disease, class C). In the patients in whom the tool did not mention PBC, the primary diagnoses came from 9 other disease categories. CONCLUSION: This electronic tool has been able to identify PBC as one of the differential diagnostic modalities in the large majority of a present population of PBC patients.     

A contrast of the three more common illnesses with the ten less common in a study and 18-month follow-up of 314 psychiatric emergency room patients. II. Characteristics of patients with the three more common illnesses

The three more common illnesses diagnosed in the sample of 314 emergency room patients were (in order of frequency) affective disorder (N = 135), alcoholism (N = 112), and antisocial personality (N = 57). This study describes the occurrence and frequency of affective disorders and evaluates the relative usefulness of three separate sets of diagnostic criteria for the depressive phase of the illness, which are considered in three self-evident, mutually exclusive groups, the definition of which depends on chronology of onset in relation to other diagnoses. Findings show a 3:2 ratio of primary affective disorder to secondary affective disorder. The 112 diagnoses of alcoholism were based on defined criteria that separated "definite" (N = 102) from probable (N = 10) alcoholism. A high incidence of secondary affective disorder (38%) in patients with a first diagnosis of alcoholism is noted. The third most common diagnosis, antisocial personality, was based on defined criteria requiring a specified number of manifestations both before and after age 15 years. Only 11% of the antisocial personality patients received a single diagnosis of antisocial personality. An additional diagnosis of alcoholism occurred in 61%. Besides antisocial symptoms, the 57 patients reported 74 different nonantisocial symptoms, supporting the conclusion that antisocial personality patients may be as susceptible to neurotic and psychotic symptoms as other patients.     

Osteoarthritis and synovitis as major pathoses of the temporomandibular joint: comparison of clinical diagnosis with arthroscopic morphology

PURPOSE: The purposes of this investigation were to determine how common osteoarthritis and synovitis are in patients with severe, recalcitrant temporomandibular joint (TMJ) symptoms using clinical diagnostic criteria as well as arthroscopic examination, and to compare the accuracy of the clinical and arthroscopic diagnoses with respect to specificity and sensitivity. PATIENTS AND METHODS: Clinical and arthroscopic diagnoses were established in 126 joints of 84 patients with severe TMJ symptoms recalcitrant to conservative therapy. All joints were classified as having osteoarthritis (OA) or no osteoarthritis (non-OA) and synovitis (syn) or no synovitis (non-syn) using clinical and arthroscopic criteria. Chi-squared analysis was used to determine whether there was a relationship between the clinical and arthroscopic diagnoses. Preoperative clinical diagnoses were compared with arthroscopic morphologic diagnoses to determine the specificity and sensitivity of the clinical diagnostic criteria for synovitis and osteoarthritis. RESULTS: A preoperative clinical diagnosis of OA was established in 59 of 126 joints (47%) compared with an arthroscopic diagnoses of OA in 82 of 126 joints (65%). Chi-squared analysis showed a significant relationship between the clinical and arthroscopic diagnosis of OA. A clinical diagnosis of OA was associated with a high specificity (.977); however, there were 23 of 82 (.293) false-negative findings and a sensitivity of only .707. A preoperative clinical diagnosis of synovitis was established in 114 of 126 joints (90%), compared with an arthroscopic diagnosis of synovitis in 112 of 126 (89%). Chi-squared analysis did not show a significant relationship between the clinical and arthroscopic diagnosis of synovitis. A clinical diagnosis of synovitis was associated with a high sensitivity (.920); however, there were 11 of 14 false-positive findings (.786) associated with a low specificity (.214). CONCLUSIONS: Although there was high specificity for the clinical diagnosis of OA, the sensitivity was very low. (Comparison of clinical and arthroscopic diagnoses showed that osteoarthritis frequently escapes clinical detection. The clinical diagnosis of synovitis showed that low specificity and symptoms may be caused by other pathoses.     

African American client skin tone and clinical judgments of African American and European American psychologists.

After reviewing a photograph and case materials depicting an African American female client, African American and European American psychologists were randomly assigned to one of three skin tone versions of a photograph (light, medium, or dark) and completed a questionnaire. No relationships were found between client skin tone or psychologist sex and either primary diagnosis or treatment recommendation. However, African American psychologists rated the client more physically attractive and likely to benefit from therapy, and they expressed more positive feelings about the client and about working with the client, than did European American psychologists, who more strongly endorsed severe mental disorder diagnoses for the client. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Revisiting Anna O.: A case of chemical dependence.

The famous clinical case of Anna O./Bertha Pappenheim, who was treated by Breuer from 1880 to 1882 and whose pathology was discussed by him and Freud in an 1895 article (J. Breuer & S. Freud, 1895/1955), is reviewed based on biographical information regarding the patient, which appeared from 1953 onward. The objective of this article is to show that, in order to better understand the case, the diagnosis of chloral hydrate and morphine dependence, as well as that of mood disorder (primary or drug induced), has to be taken into account. The method used is a careful literature review. The conclusion is that, based on all available data disclosed in recent years, these 3 diagnoses should be considered in this case, which is the most studied one in the history of psychoanalysis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Syndrome comorbidity in patients diagnosed with a DSM-III—R anxiety disorder.

One hundred thirty patients presenting at an anxiety disorders research clinic were administered a structured interview (i.e., Anxiety Disorders Interview Schedule—Revised). Diagnoses were made in accordance with Diagnostic and Statistical Manual of Mental Disorders-III—Revised (DSM-III—R) criteria. Seventy percent of patients received at least one additional but secondary Axis I diagnosis. The most common additional diagnoses were simple and social phobia, which were assigned to nearly one third of all patients. In addition, 33% of anxiety disorder patients received an additional diagnosis of a depressive mood disorder (i.e., dysthymia or major depression). The distribution of specific additional diagnoses are presented for each principal anxiety disorder category. The scientific and clinical implications of comorbidity are discussed while considering the relatively high patterns of syndrome comorbidity found in the present study, which is consistent with several earlier studies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)