Diagnosis最新文献

Objectives: Diagnostic and management reasoning of neurological disorders may present unique challenges and uncertainty for clinicians, particularly in emergency department settings. This study aims to assess the level of uncertainty emergency department physicians experience when diagnosing neurological versus non-neurological conditions, and whether this uncertainty extends to the management of neurological conditions. Additionally, the study explores whether clinical experience is related to perceived diagnostic and/or management uncertainty.

Methods: Fifty-three emergency department physicians completed a survey measuring diagnostic uncertainty, management uncertainty, and associated anxiety. The survey included clinical vignettes depicting neurological and non-neurological cases, as well as items which assessed perceived diagnostic and management uncertainty across eight different specialties. Statistical analyses included paired samples t-test for comparing uncertainty between neurology and non-neurology cases and a general linear model to assess relationship between clinical experience and uncertainty.

Results: Emergency department physicians reported greater diagnostic uncertainty for neurological vignettes compared to non-neurological vignettes (Cohen's d=1.37), as well as greater management uncertainty (Cohen's d=1.41). They also reported greater anxiety when diagnosing neurological cases compared to non-neurological cases (Cohen's d=1.33), as well as greater anxiety when managing them (Cohen's d=0.69). Exploratory analyses indicated that with greater experience, management uncertainty of neurology cases decreased, while diagnostic uncertainty remained unchanged.

Conclusions: The results suggest unique diagnostic and management challenges posed by neurological cases in emergency departments, particularly for less experienced providers. Future research could focus on developing interventions to reduce diagnostic and management uncertainty in neurological conditions.

Objectives: To compare proportions of pediatric emergency department (PED) patients with missed opportunities for diagnostic excellence (MODEs) by patient race and ethnicity, defined as either White non-Hispanic/Latino (WNH), or non-WNH. In addition, to assess the thoroughness of the PED patient evaluation by patient race and ethnicity.

Methods: Electronic trigger (E-trigger) followed by manual screening identified children with unplanned admission within 10 days of an index PED or pediatric urgent care (PUC) encounter from January 2018 through July 2022. Cases with disparate diagnoses at index encounter and hospital discharge were reviewed using the Revised Safer Dx tool to determine the presence of a MODE. Patient race and ethnicity were abstracted from the electronic record. The primary outcome was proportion of MODEs by race and ethnicity, analyzed using univariate comparisons; the secondary outcome was the completeness of the diagnostic evaluation. Independent predictors of MODEs were identified following multivariable logistic regression analysis.

Results: A total of 816 patients were screened in for Revised Safer Dx review, and a total of 183 potential MODEs were identified. Non-WNH populations did not differ significantly by proportion of potential MODEs when compared to WNH patients. WNH patients received a higher median number of diagnostic tests (p=0.02), more diagnostic workup (p=0.03), and more frequently had the eventual correct diagnosis initially considered (p=0.02) than non-WNH patients. Race and ethnicity did not significantly affect the odds of a MODE.

Conclusions: While race and ethnicity did not predict higher odds of a MODE, non-WNH PED/PUC populations received disparate levels of diagnostic consideration.

Diagnostic error is a pervasive problem in healthcare with approximately one-third of adverse events in hospitals attributed to a failure in the diagnostic process. Cognitive biases are systematic, often unconscious, automatic patterns of thought that sometimes skew thinking and are considered a major contributor to diagnostic error. More than 100 different biases have been described that affect clinical decision-making, and the challenge for educators and clinicians is bringing the conceptual knowledge of cognitive bias to the bedside in an applicable and useful way to mitigate the effects of cognitive bias in diagnosis. The language that is commonly used around cognitive bias is technical in nature, often with complicated and nuanced descriptions, so developing a clear understanding of cognitive bias is a task that needs sophisticated language and memory skills as well as clinical reasoning skills. A novel language approach to learning and talking about biases in medicine is to use idioms, short phrases with a particular meaning that differs from the meaning of each word on their own, to simplify the terminology and improve recognition of cognitive bias at the frontline. We present 'The Idiom's Guide to Cognitive Bias', a Table that lists 21 common cognitive biases in the diagnostic process, and defines each, offering a healthcare example and possible explanation for why each occurs. The benefit of The Guide is its practical approach to reinforcing cognitive and medical concepts through the synergy of language and imagery and to demystify cognitive bias in the diagnostic process.

Objectives: Diagnostic errors represent the most common and costly preventable patient safety events, with historically marginalized populations disproportionately impacted due to systemic inequities in healthcare. Addressing these disparities requires embedding equity into every facet of the diagnostic process. The aim was to develop, refine, and validate a competency framework for Equity-Driven Diagnostic Excellence (DxEqEx).

Methods: A modified Delphi method was used, involving transdisciplinary diverse healthcare system participants, including patient advocates, physicians, nurses, and other healthcare professionals. Participants were guided through multiple rounds of feedback and ratings, assessing the importance, disciplinary relevance, feasibility, skill acquisition level required, granularity, and representativeness of the DxEqEx framework.

Results: Sixteen essential competencies have been identified, categorized into three domains: Intrapersonal, Team-based, and Structural. Participants rated the framework with high importance and strong relevance to their respective disciplines. However, the feasibility of implementing the framework varied, largely due to broader challenges within the healthcare system. The competencies were assessed as requiring a proficient skill level according to Dreyfus' model. The final round maintained strong ratings for granularity and representativeness, which supported the final version of the framework.

Conclusions: The DxEqEx framework holds significant potential to proactively address the needs of historically marginalized patients throughout the diagnostic process. Future research should focus on participatory, resource-efficient implementation.

Objectives: Fundoscopy can be challenging for non-ophthalmologists. For emergency physicians, non-mydriatic fundus photography is superior to other forms of ophthalmoscopy in sensitivity, specificity, and inter-examination agreement. We report on a prospective cross-sectional study evaluating the use of non-mydriatic photography as a triage and telemedicine tool for patients with vision loss in a Canadian emergency setting.

Methods: Images of both eyes were obtained by a non-ophthalmologist using a handheld, non-mydriatic fundus camera and shared with a fellowship-trained ophthalmologist without patient context. The reviewer was asked to (1) select the best photo obtained for each eye and rate image quality on a Likert scale, (2) comment on the presence or absence of fundus abnormalities and (3) provide an opinion on whether findings would have changed patient disposition if available at the time of the initial Emergency Department (ED) exam.

Results: Of 57 patients evaluated in the ED for vision loss, 22.8 % had a documented fundus examination. 86.8 % of images were deemed to have acceptable quality (Likert scale≥2). Factors limiting image quality included media opacity, pupillary miosis, photosensitivity, and eyelid/periorbital abnormalities. Of patients with relevant abnormalities, 0 % were identified by emergency physicians. In contrast, 37.5 % of patients with relevant findings were identified on review of images alone (specificity=100 %).

Conclusions: Fundoscopy is infrequently performed in the emergency setting in patients presenting with vision loss. Non-mydriatic fundus photography is a cost-effective method of fundus examination for non-expert examiners and can be reliably used as a telemedicine tool for remote ophthalmology consultation.

Introduction: Synthetic magnetic resonance imaging (SyMRI) is a non-invasive, robust MRI technique that generates multiple contrast-weighted images by acquiring a single MRI sequence within a few minutes, along with quantitative maps, automatic brain segmentation, and volumetry. Since its inception, it has undergone technical advancements and has also been tested for feasibility in various organs and pathological conditions. This scoping review comprehensively pinpoints the critical technical aspects and maps the wide range of clinical applications/benefits of SyMRI.

Content: A comprehensive search was conducted across five databases, PubMed, Scopus, Web of Science, Embase, and CINAHL Ultimate, using appropriate keywords related to SyMRI. A total of 99 studies were included after a 2-step screening process. Data related to the technical factors and clinical application was charted.

Summary: SyMRI provides quantitative maps and segmentation techniques comparable to conventional MRI and has demonstrated feasibility and applications across neuroimaging, musculoskeletal, abdominal and breast pathologies spanning the entire human lifespan, from prenatal development to advanced age. Certain drawbacks related to image quality have been encountered that can be overcome with technical advances, especially AI-based algorithms.

Outlook: SyMRI has immense potential for being incorporated into routine imaging for various pathologies due to its added advantage of providing quantitative measurements for more robust diagnostic and prognostic work-up with faster acquisitions and greater post-processing options.

Objectives: This study reported a large cohort of fetal blood analysis of various hemoglobinopathies.

Methods: A total of 371 fetal blood specimens were recruited. Complete blood count and hemoglobin (Hb) analysis using capillary electrophoresis were performed. Genotypes were defined by DNA analysis.

Results: Among 371 fetuses, 36 were non-thalassemic and 29 thalassemia genotypes were identified in the remaining 335 fetuses. Fetuses with β-thalassemia and Hb E traits, homozygous Hb E, and Hb E-β⁰-thalassemia had similar hematological parameters as those of non-thalassemic. However, the levels of Hb A in β-thalassemia and Hb E traits were approximately half of that observed in the non-thalassemic fetuses. As for Hb E, fetuses with a single copy of the β^E-globin gene in the Hb E trait and Hb E-β⁰-thalassemia had lower Hb E levels as compared to that of the homozygous Hb E. For α-thalassemia, fetuses with one or two α-globin gene defects had small changes in hematological parameters, but variable Hb Bart's levels were observed. Fetuses with Hb H and Hb H-CS diseases had moderate anemia, whereas those with homozygous Hb CS and Hb Bart's hydrops fetalis had severe anemia. Identification of the fetuses with Hb Bart's hydrops fetalis with various genetic interactions allows the exact re-location of electrophoretic mobilities of various embryonic Hbs.

Conclusions: This study confirmed the genetic heterogeneity of hemoglobinopathies among the fetuses and fetal blood analysis are useful for presumptive diagnosis of hemoglobinopathies. The results should facilitate a prevention and control program of hemoglobinopathies in the region.

Introduction: Dengue is a viral infection caused by any one of the four related dengue virus (DENV) serotypes, 1-4. DENV is a single-stranded RNA virus belonging to the genus Flavivirus. Dengue can cause a range of symptoms, from mild to severe life-threatening illness. Currently, treatment for DENV is limited to supportive care, with better outcomes achieved through early diagnosis. The WHO has suggested that dengue mortality can be reduced to nearly zero by implementing appropriate clinical management strategies, such as early laboratory diagnosis. This calls for diagnostic approaches that combine high sensitivity and specificity, while also being suitable for point-of-care testing (POCT) in remote locations with minimal staff training and low testing costs.

Content: In this paper, we outline the limitations of existing confirmatory dengue diagnostic methods, such as ELISA and RT-PCR, which are time-consuming, expensive, and require skilled personnel. We also highlight alternative strategies to overcome these challenges. Additionally, the paper emphasizes the growing clinical demand for diagnosing severe dengue to reduce the risk of death, which must be addressed by next-generation dengue diagnostic approaches.

Summary: We propose the adoption of alternative strategies, such as fluorescence immunoassay (FIA) and chemiluminescence immunoassay (CLIA), which have the potential to overcome the limitations of existing dengue diagnostic methods.

Outlook: Improvements in dengue diagnosis, with a specific focus on identifying severe dengue in POCT setting, can help achieve the goal of zero deaths from dengue.

Coronary artery disease (CAD) is the leading cause of cardiovascular events and showed high prevalence and healthcare costs in 2019. However, CAD screening for cardiovascular event prevention is invasive and expensive. This study aims to estimate the ability of a noninvasive method, pulse wave velocity (PWV), to detect the presence or absence of coronary artery disease in patients with suspected CAD. A systematic review and meta-analysis of the available evidence was conducted, comparing PWV with the gold standard diagnostic method, angiography. The literature search was systematically performed in the PubMed, Scopus and Web of Science databases from inception to August 2024. Study quality assessment was performed using the Diagnostic Accuracy Study Quality Assessment Tool (QUADAS-2). Publication bias was assessed using the method proposed by Deeks. Statistical analyses were performed with the STATA SE software, version 15. The eight included studies had a cross-sectional design, in which the presence of CAD was measured simultaneously by PWV and angiography. To assess the accuracy of the tests, the overall sensitivity and specificity were combined into a single value, the diagnostic odds ratio (dOR), which provided a value of 3.61, indicating a high probability of detecting CAD by PWV. The implementation of PWV as a screening technique in healthcare centers could bring great benefits to patients with suspected CAD and increase efficiency in the use of healthcare resources.