Diagnosis最新文献

Over-testing, or the inappropriate use of diagnostic tests, is a highly prevalent phenomenon in modern medical practice, driven by a variety of physician, patient/disease, practice environment and system-related factors. Most of the time, physician proclivities to over-investigate fundamentally reflects a flawed clinical reasoning process under real-world practice conditions. Over the years, various educational campaigns and interventions such as the Choosing Wisely programme have been attempted to varying success, without clear evidence of a sustained reduction in the excessive/inappropriate use of diagnostic tests in clinical practice. Therefore, in this article, we hope to provide fresh perspectives on the concept of "diagnostic stewardship", which has hitherto been largely confined to the realm of infectious diseases to govern responsible clinical use of antimicrobials, by explaining its role in the delivery of patient-centered and sustainable healthcare. We further explore the underlying contributors to over-testing and how it relates to flaws in clinical reasoning in real-world settings. Lastly, we discuss multi-level educational and practice-based interventions that may help to curb the tide of profligate diagnostic testing behaviors.

Objectives: To analyze a theoretical framework that incorporates incivility among healthcare teams in relation to diagnostic safety, and to assess its potential utility for advancing research and practice.

Methods: A structured literature review was conducted across PubMed, Web of Science, and CINAHL using search terms such as "diagnostic safety," "team dynamics," "theoretical framework," "incivility," and "diagnostic framework". A theoretical framework was selected for analysis. Walker and Avant's six-step theory analysis method was applied to assess the framework's origins, meaning, logical adequacy, usefulness, generalizability, parsimony, and testability.

Results: The literature review yielded 144 articles after screening and applying inclusion criteria. Ten articles were reviewed, and the Model of Ward Team Dynamics in Diagnosis by Choi et al. was selected for analysis, as it was the only framework that explicitly addressed unacceptable behaviors (i.e., incivility) in diagnostic team settings. The Choi et al. framework uniquely integrates unacceptable behaviors as a mediating factor in diagnostic team performance, distinguishing it from other diagnostic models. The analysis found the framework to be conceptually well-grounded, with several constructs operationally defined and empirically measurable. However, gaps were identified in parsimony and the clarity of relational statements, indicating opportunities for refinement and empirical testing.

Conclusions: The framework offers a valuable theoretical foundation for studying the impact of incivility on diagnostic safety. Its integration of behavioral constructs supports its relevance for empirical research and intervention development aimed at improving team dynamics and diagnostic outcomes.

Objectives: The misdiagnosis of appendicitis remains frequent. Better understanding of its clinical evolution over time would decrease the incidence of misdiagnosis.

Case presentation: At the Society to Improve Diagnosis in medicine conference in Cleveland Ohio in October 2023, Alice Tapper and her father, CNN journalist Jake Tapper, presented her case of misdiagnosed appendicitis. Thanks to meticulous notes and a detailed timeline, the case vividly demonstrates the protean nature of appendicitis as well as the cognitive pitfalls of clinicians who treat it.

Conclusion: McBurney's point tenderness is over-emphasized as the key to the diagnosis of appendicitis.

Introduction: Carpal tunnel syndrome (CTS) involves the entrapment of the median nerve at the wrist. Despite acceptable sensitivity and specificity in diagnostics tests, errors persist, leading to unsuccessful treatments, especially when CTS is an early sign of other conditions.

Content: This review aims to identify red flags that may manifest as CTS or coexist with it, and to describe their clinical presentations.

Summary: A PubMed search (2000-2025) yielded 622 articles, with 24 included in the review. Of these, 12 articles explored CTS and amyloidosis, three with neurological pathologies, three with tumours, two with rheumatic diseases, one with Raynaud's disease, one on CTS in children, and two with other conditions.

Outlook: Many conditions can be mistaken for CTS. Given its high prevalence, healthcare professionals must distinguish these to reduce surgical failures and improve early detection of conditions like cardiac amyloidosis or multiple sclerosis.

The pursuit of medical diagnosis has long been shaped by an epistemic framework that assumes diseases have inherent, discoverable essences. This essentialist approach, deeply rooted in Aristotelian thought, has historically guided diagnostic reasoning and classification for over a century. However, the rise of artificial intelligence (AI) is catalyzing a philosophical and practical shift toward nominalism - a framework in which diagnoses are derived from dynamic, data-driven pattern recognition rather than fixed disease categories. This transition, if it occurs, would be revolutionary, exposing core limitations of essentialist thinking and reframing diagnosis as a process rather than a static conclusion. In doing so, it challenges the conventional concept of an 'endpoint diagnosis' - the idea that diseases can be definitively and completely categorized. Instead, diagnosis emerges as a contingent narrative point within broader clinical trajectories, calling for a reimagining of diagnostic reasoning in the AI era.

Diagnostic uncertainty remains a persistent challenge in improving diagnostic practice, particularly for individual physicians. This paper applies the BANI (Brittle, Anxious, Nonlinear, Incomprehensible) framework to examine the nature of uncertainty encountered by physicians. Using clinical case examples, I demonstrate how BANI manifests in the diagnostic process and propose GRACE₂, a six-element behavioral framework designed to support physicians in managing diagnostic uncertainty. GRACE₂ integrates cognitive flexibility, adaptive reasoning, and empathic communication. Together with BANI, it offers a structured and actionable approach to enhancing physicians' diagnostic decision-making, thereby contributing to the broader goal of improving diagnostic safety for patients.

Traditional approaches to improving diagnosis in medicine have focused mainly on identifying and analyzing errors using the Safety-I perspective. Yet, the vast majority of diagnostic encounters are successful, and structured reflection on these positive outcomes remains uncommon in current practice. In this article, I introduce SIDER (Specification, Ishikawa diagram, driver diagram, Engaging the patient and the team, Reflection), a practical protocol designed to embed Safety-II principles into routine diagnostic reflection by encouraging clinicians to learn from what goes right. SIDER guides clinicians through five clear phases: specifying a particularly challenging or instructive case, mapping contributing factors using an Ishikawa diagram, translating those findings into actionable strategies with a driver diagram, engaging the care team and patient to gather collective insights, and concluding with individual reflection to support ongoing calibration and learning. I describe how SIDER enables clinicians to extract broad and transferable lessons from successful but complex diagnostic cases, complementing traditional error analysis and supporting a culture of continuous improvement. By adopting this framework, healthcare teams can expand opportunities for experiential learning, strengthen adaptive expertise, and advance safer diagnostic practice. Future studies are warranted to evaluate the effectiveness of SIDER-guided reflection in enhancing diagnostic performance and improving patient outcomes.

Objectives: Diagnostic errors are a significant source of patient harm, often arising from cognitive biases and communication breakdowns. Diagnostic timeouts (DTOs) offer a structured opportunity to reassess diagnoses, but their implementation is inconsistent. This study aimed to evaluate a nurse-driven DTO framework designed to enhance interprofessional communication and diagnostic accuracy in a pediatric hospital setting.

Methods: A multidisciplinary committee developed and piloted a DTO framework on a 48-bed pediatric acute care unit. Bedside nurses received structured education on DTOs, and standardized prompts were integrated into nursing workflows to identify patients who may benefit from a DTO. Feasibility and acceptability were assessed through voluntary surveys, post-DTO documentation, and qualitative feedback.

Results: Among 90 surveyed nurses, 28 % reported that a DTO would have been beneficial for at least one patient in the eight weeks prior to the intervention period. Over six months, 13 nurse-initiated DTOs occurred, with nearly half (46 %) prompting additional workup. Two DTOs led to escalation of care. Qualitative feedback highlighted improved communication, increased psychological safety, and enhanced teamwork.

Conclusions: Pilot implementation of a formalized nurse-driven DTO framework was well-received, reinforcing its role in structured diagnostic reassessment. Future efforts will expand DTO implementation and evaluate its impact on psychological safety.

Objectives: The aim was to reduce blood loss related to laboratory blood sampling by decreasing the discard blood volume from the central venous catheter (CVC) from 10 to 3 mL, and replacing the 3 mL tube for complete blood count (CBC) with a 2 mL tube. A comparison study was performed, and after introduction of this modified protocol the decrease in withdrawn blood was calculated.

Methods: In 52 adult inpatients at the ICU 3 mL of blood was discarded from the CVC, and blood was drawn in a 5 mL serum tube and a 2 mL EDTA tube (test samples), followed by subsequent sampling for routine laboratory testing using the same blood tubes (routine samples). In paired test and routine samples, clinical chemistry testing and CBC were performed.

Results: High correlations (ρ>0.90) were obtained for the majority of parameters. Small constant difference was obtained for hemoglobin. Small significant biases were observed for hemoglobin, MCHC, albumin, ALT, calcium, chlorides, MCV and glucose, however, being below the biases of the analytical methods. No statistically significant differences between test and routine samples were found for any of the assessed tests (p>0.05). Implementation of the 3 mL discard blood volume protocol and transition to a smaller volume tube for CBC reduced the amount of withdrawn blood by almost half (46 %).

Conclusions: The 3 mL discard blood volume from the CVC can be safely used for routine hematology and clinical chemistry testing. The dual approach assessed herein can contribute to reduction of iatrogenic blood loss.

Objectives: The aim of this study is to assess the discrepancies between potassium values obtained from point-of-care testing and laboratory analyzers, and to propose a straightforward method to indirectly assess the likelihood of hemolysis in whole blood samples.

Methods: The data were collected from 409 hospitalized patients (199 males, 210 females; median age 78 years, interquartile range 55-87) in whom were simultaneously requested the blood gas profile, including electrolytes (Na, K, Cl and Ca²⁺) on the GEM Premier 5000 blood gas analyzer and K in plasma samples on the Cobas analytical system.

Results: The Wilcoxon test showed a significant difference (p<0.0001) for K measurements, with a number of positive differences between Cobas and GEM Premier 5,000 of 110 and negative differences of 293. The median value of the hemolysis index was 7 (95 % CI for the median 6 to 8). The differences between the two K measurements obtained from plasma and whole blood samples showed a lowest and highest differences of -1.7 and 4.6 mmol/L. The median difference was 0.63 (95 % CI for the median: 0.54-0.73) and the interquartile range (IQR) was 0.48-0.9. Overall, 89 samples (21 %) displayed a difference larger than the relative change value.

Conclusions: The presence of hemolysis in plasma samples should alert laboratory professionals to carefully evaluate the corresponding whole blood results. Concordant values indicate the presence of hemolysis in the whole blood sample, while discordant values suggest that hemolysis only affects one of the two samples.