Computer-Assisted Diagnosis of Abdominal Pain using “Estimates” Provided by Clinicians

This paper reports a comparison between two modes of computer-aided diagnosis in a real-time prospective trial involving 472 patients with acute abdominal pain. In the first mode the computer-aided system analysed each of the 472 patients by referring to data previously collated from a large series of 600 real-life patients. In the second mode the system used as a basis for its analysis “estimates” of probability provided by a group of six clinicians. The accuracy and reliability of both modes were compared with the performance of unaided clinicians.Using “real-life” data the computer system was significantly more effective than the unaided clinician. By contrast, when using the clinicians'' own estimates the computer-aided system was often less effective than the unaided clinician—especially when diagnosing less common disorders. It seems, firstly, that future systems for computer-aided diagnosis should employ data from real-life and not clinicians'' estimates, and, secondly, that clinicians themselves cannot analyse cases in a probabilistic fashion, since often they have little idea of what the “true” probabilities are.     

TREPONEMAL SEROLOGIC TESTS—Experiences of the Bacteriology Laboratory,California State Department of Public Health

In a study of the relationship of clinical impression regarding syphilis and age, sex and pregnancy status to treponemal serologic test reactivity, it was noted that in diagnostic “problem cases” the standard lipid serologic test titers did not differentiate between syphilitic and biologic false positive reactors. Preliminary data indicated that heroin addiction may be a source of biologic false reactions and that pregnant women with standard serologic test reactivity have a lower treponemal reactivity rate than other women with lipid serologic reactivity.     

Tuberculosis: A Challenge to the General Practitioner

Of 157 patients dying of tuberculosis in Ontario (1960) 132 (87.4%) suffered from the pulmonary form of the disease (incidence 2.6 per 100,000). In the same year, 1632 of 1847, or 88.3%, active new cases reported had the pulmonary type and 183 additional cases were reported without details as to type of disease. Thus, in 1960, a total of 2030 new cases of tuberculosis were reported in Ontario.Of 1367 patients with pulmonary tuberculosis (reinfection type), 357 (26.1%) had “far advanced” disease and 613 (44.8%) had “moderately advanced” disease.This high percentage of patients with “moderately advanced” to “far advanced” disease at the time of diagnosis constitutes the real challenge to physicians in private practice, who made the diagnosis in 45% of cases.Emergence of resistant strains of bacteria increases the urgency of prompt diagnosis and treatment. The most vulnerable population segment is the 15-30 year age-group, many of whom are negative intracutaneous reactors. A high index of suspicion is necessary, particularly in certain segments of the population with a high incidence of infection, combined with a careful history, meticulous physical examination, intracutaneous tests, chest and other radiographs, and appropriate bacteriological studies.     

“Capillary Permeability” in Patients with Collagen Vascular Diseases

“Capillary permeability” to serum albumin has been measured in patients with collagen vascular diseases by a method which compares the dilution of intravenously injected ¹³¹I-human serum albumin and ⁵¹Cr-R.B.C.s. The results indicate an increased capillary permeability comparable to that which occurs in patients with extensive inflammatory skin disease. We suggest that this increased capillary permeability may be the cause of the episodes of oedema which occur in patients with collagen vascular diseases such as disseminated lupus erythematosus, systemic sclerosis, dermatomyositis, polyarteritis nodosa, and rheumatoid arthritis. “Spontaneous periodic oedema” may be the presenting feature of collagen vascular disease and is due to increased capillary permeability.     

A report of six cases

Six cases of gonococcal arthritis are described. Three presented during the initial “bacteremic stage” with polyarthralgia, fever, skin lesions and sterile synovial fluid. Two presented during the “septic joint stage” with positive synovial culture, and one presented during the “stage of residual deformity”. Transient electrocardiographic changes were noted in two of the six cases. All responded to antibiotic therapy. One required additional surgical intervention.The condition is common, coinciding with the rising incidence of symptomatic and asymptomatic gonorrhea. Gonococcal infection must be considered in the differential diagnosis of migratory polyarthralgia, tenosynovitis, oligoarthritis, fever or unusual skin lesions. Criteria for diagnosis, lines of treatment and relevant literature are reviewed.     

A comparison of descending aortic and “arterialized” capillary blood in the sick newborn

Comparison was made of 53 “arterialized” capillary (heel prick) samples with descending aortic blood in 26 babies, of whom 24 were less than one week old and 18 had R.D.S.“Arterialized” capillary blood is an accurate and practical means of assessing aortic blood pH and Pco₂ over a range of 6.69 to 7.54 and 18 to 94 mm. Hg respectively.“Arterialized” capillary sampling is a reliable means of assessing descending aortic Po₂ when the “arterialized” capillary value is less than 60 mm. Hg.When higher than 60 mm. Hg the “arterialized” capillary oxygen tension may be considerably less than that of the blood in the descending aorta, hence the “arterialized” capillary blood oxygen tension method is unreliable in estimating systemic oxygenation when the descending aortic oxygen tension is more than 60 mm. Hg.     

Subclinical Infection in Leprosy

Lymphocyte transformation has been used to study the immune response to Mycobacterium leprae among contacts and non-contacts of leprosy patients. Of 26 subjects living in a leprosy endemic area for less than two months none responded to M. leprae; 24% of subjects who had lived in an endemic area for more than a year gave a positive response to M. leprae; more than 50% of individuals with occupational contact of leprosy for more than a year responded; and about 50% of contacts of tuberculoid and treated lepromatous patients responded to M. leprae, while only 22% (4/18) of contacts of lepromatous patients treated for less than six months responded.It seems that leprosy is more highly infectious than is indicated by the prevalence of the disease and that a subclinical infection commonly follows exposure to M. leprae. The relatively low response found in contacts of active lepromatous patients suggests that in these contacts “superexposure” to M. leprae can bring about a decrease in host resistance.     

Bubble Stability Test Compared with Lecithin Assay in Prediction of Respiratory Distress Syndrome

A simple test for surfactant, utilizing bubble stability in ethanol, was performed in 106 samples of amniotic fluid obtained from 94 patients. Of these patients 80 delivered within 48 hours of the collection of the sample. The results were compared with the lecithin concentration in the same amniotic fluid samples and with the quality of respiration in the neonate. The test was “positive,” indicating fetal pulmonary maturity, in 37 cases and none of these infants developed respiratory distress syndrome (R.D.S.). In only one of these cases, however, was gestation less than 37 weeks. The test was “intermediate” or “negative” in 43 cases but in 35 of these infants respiration at birth was perfectly normal.Performed by the method described by its originators, this simple test gives too many false negative results to be of value in routine clinical practice, although a positive result is helpful. The concept of the test is ingenious, however, and further developments may be expected.     

The Metabolism of the Volatile Amines: VII. The Clinical Significance of Two Components of the Blood Ammonia Level

Blood ammonia levels consist of two components: ammonia present in blood at the time of shedding, termed “free” ammonia, and ammonia produced by the deamidating action of the alkali reagents. Blood of healthy people contained little or no “free” ammonia while blood of patients with chronic liver disease occasionally showed levels up to 1.2 μg./ml. Patients with hepatic encephalopathy had significantly elevated levels which usually fell to zero following therapy. Levels of “free” ammonia above 0.6 μg./ml. were diagnostic of hepatic encephalopathy in patients suffering from unexplained neurological disorders.The rate of formation of ammonia by the alkali reagents was increased in patients with hepatic necrosis and was depressed in those with chronic hepatitis. The ammonia appeared to arise from the deamidation of glutamine and asparagine, present in blood in both the free and peptide forms.     

Validity of Antibodies in Lymphocyte Supernatant in Diagnosing Tuberculosis in Severely Malnourished Children Presenting with Pneumonia

BackgroundThe diagnosis of tuberculosis (TB) in young children can be challenging, especially in severely malnourished children. There is a critical need for improved diagnostics for children. Thus, we sought to evaluate the performance of a technique that measures antibodies in lymphocyte supernatant (ALS) for the diagnosis of TB in severely malnourished children presenting with suspected pneumonia.MethodsChildren less than 5 years with severe acute malnutrition and radiological features of pneumonia admitted to the Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh, were enrolled consecutively following informed written consent. In addition to clinical and radiological assessment, samples taken for TB diagnosis included gastric lavage fluid and induced sputum for microbiological confirmation. ALS was measured from venous blood, and results were evaluated in children classified as “confirmed”, “non-confirmed TB” or “not TB”.ResultsAmong 224 children who had ALS analysis, 12 (5.4%) children had microbiologically “confirmed TB”, a further 41 (18%) had clinically diagnosed “non-confirmed TB” and the remaining 168 (75%) were considered not to have TB. ALS was positive in 89 (40%) and negative in 85 (39%) of children, with a large number (47 or 21%) reported as “borderline”. These proportions were similar between the three diagnostic groups. The sensitivity and specificity of ALS when comparing “Confirmed TB” to “Not TB” was only 67% (95% CI: 31–91%) and 51% (95% CI: 42–60%), respectively.

Conclusions and Significance

Our data suggest that ALS is not sufficiently accurate to improve the diagnosis of TB in children with severe malnutrition.     

Chronic Bronchitis: Method of Cigarette Smoking

Male volunteers for mass radiography examination, aged 40 or more, were questioned about their sputum production, smoking habits, and, when applicable, their method of smoking cigarettes.Of 5,438 cigarette smokers 460 (8·4%) smoked their cigarettes without removing the cigarette from the mouth between puffs (“drooping” cigarette smokers) whereas the rest smoked in the normal manner.Persons who admitted to producing sputum from their chests on most days of the year or on most days for at least three months of the year for a minimum of two years were classified as chronic bronchitics in the absence of other causative disease.The rate of chronic bronchitis among the “drooping” cigarette smokers (41·5%) was considerably greater than that among those smoking cigarettes in the normal manner (33·6%). The same pattern was maintained when age and cigarette consumption were standardized, though “drooping” cigarette smokers had a slight bias towards plain as distinct from filter cigarettes and towards a lower social class this was not sufficient to account for the excess of chronic bronchitis among those using this method of smoking.     

Leprosy in a prison population: A new active search strategy and a prospective clinical analysis

BackgroundThis study evaluates an active search strategy for leprosy diagnosis based on responses to a Leprosy Suspicion Questionnaire (LSQ), and analyzing the clinical, immunoepidemiological and follow-up aspects for individuals living in a prison population.MethodsA cross-sectional study based on a questionnaire posing 14 questions about leprosy symptoms and signs that was distributed to 1,400 prisoners. This was followed by dermatoneurological examination, anti-PGL-I serology and RLEP-PCR. Those without leprosy were placed in the Non-leprosy Group (NLG, n = 1,216) and those diagnosed with clinical symptoms of leprosy were placed in the Leprosy Group (LG, n = 34).FindingsIn total, 896 LSQ were returned (64%), and 187 (20.9%) of the responses were deemed as positive for signs/symptoms, answering 2.7 questions on average. Clinically, 1,250 (89.3%) of the prisoners were evaluated resulting in the diagnosis of 34 new cases (LG), based on well-accepted clinical signs and symptoms, a new case detection rate of 2.7% within this population, while the NLG were comprised of 1,216 individuals. The confinement time medians were 39 months in the LG while it was 36 months in the NLG (p>0.05). The 31 leprosy cases who responded to the questionnaire (LSQ+) had an average of 1.5 responses. The symptoms “anesthetized skin area” and “pain in nerves” were most commonly mentioned in the LG while “tingling, numbness in the hands/feet”, “sensation of pricks and needles”, “pain in nerves” and “spots on the skin” responses were found in more than 30% of questionnaires in the NLG. Clinically, 88.2% had dysesthetic macular skin lesions and 97.1% presented some peripheral nerve impairment, 71.9% with some degree of disability. All cases were multibacillary, confirming a late diagnosis. Anti-PGL-I results in the LG were higher than in the NLG (p<0.0001), while the RLEP-PCR was positive in 11.8% of the patients.InterpretationOur findings within the penitentiary demonstrated a hidden prevalence of leprosy, although the individuals diagnosed were likely infected while living in their former communities and not as a result of exposure in the prison. The LSQ proved to be an important screening tool to help identify leprosy cases in prisons.     

Characteristics of Attempted Suicide by Patients with Schizophrenia Compared with Those with Mood Disorders: A Case-Controlled Study in Northern Japan

Recent reports suggest a lifetime suicide risk for schizophrenia patients of approximately 5%. This figure is significantly higher than the general population suicide risk consequently, detection of those at risk is clinically important. This study was undertaken to define the characteristics of suicide attempts by schizophrenia patients compared with attempts by patients with mood disorders. All patients were diagnosed using the ICD-10 criteria. The study population comprised 65 patients with F2 disorders (schizophrenia, schizotypal and delusional disorders), i.e., “the F2 group”, and 94 patients with F3 disorders (mood disorders), i.e., “the F3 group”, who presented in the clinical setting of consultation-liaison psychiatry. The F2 group had a significantly younger mean age and significantly higher ratios of ‘past/present psychiatric treatment’ and ‘more than 3 months interruption of psychiatric treatment’. In contrast, the ratios of ‘physical disorder comorbidity’, ‘alcohol intake at suicide attempt’ and ‘suicide note left behind’ were significantly higher in the F3 group. The F2 group attempted suicide by significantly more serious methods. Furthermore, ‘hallucination-delusion’ was the most prevalent motive in the F2 group and was the only factor that showed a significant association with the seriousness of the method of suicide attempt (OR = 3.36, 95% CI: 1.05–11.33).     

A NEW CORTICOID FOR TOPICAL THERAPY—Fluocinolone Acetonide

Sixty-seven patients with chronic and subacute cutaneous lesions of varying long duration that had previously been resistant to topical use of corticosteroid compounds were treated with a cream containing fluocinolone acetonide. To avoid subjective bias, only two classifications were used in appraising results: “complete clearing of treated lesions” and “not effective.”Forty-eight patients had complete clearing of the treated area. Results were best in atopic dermatitis, chronic eczematous dermatitis and nummular dermatitis. Granuloma annulare, dyshidrotic dermatitis of the palms and psoriasis were not affected.In some cases in which there were multiple lesions some of the lesions were treated with fluocinolone acetonide cream and some were treated concurrently with other corticoid ointments or with noncorticoid compounds, either bland or with active ingredients. Fluocinolone was effective in more than twice as many cases as the other agents.In some of the patients with chronic disease it was possible to greatly reduce or discontinue systemic steroid therapy after fluocinolone acetonide became available.No untoward effects were observed.     

The Histological Components of the Phoniatrical Body-Cover Model in Minipigs of Different Ages

Pigs are models in human phoniatry. However, features of maturation and ageing have not been considered with regard to the so-called body-cover model in this species. Therefore, the glottis of “young” (2–3 months; n = 6) and “old” (4–7 years; n = 6) minipigs was investigated. Their cranial (CraF) and caudal (CauF) vocal folds were histomorphometrically and stratigraphically analysed with emphasis on their amounts of collagen structures and elastic fibres. A dense subepithelial layer (SEL) was a distinct feature of CraF and CauF of both age groups; it was spread upon the underlying loose, flexible “cover” like a fibro-elastic membrane. The “cover” was characterised by the so-called superficial layer (SL), which was distinctly loose in the “young” minipigs, but had a much denser texture in the “old” minipigs. Here, the SL was dominated by elastic fibres in the CraF, but was of mixed qualities (collagenous and elastic) in the CauF. The structural requirements for the SL’s function as a loose “cover” were thus met only in the “young” animals. A clearly demarcated intermediate layer (IL)—characterised by high amounts of elastic fibres (as in humans)—was only found in the CraF of the “young” animals. In the “old” animals, it had lost its demarcation. In the depth of the CraF of the “old” animals, many thick collagen fibre bundles were detected in a location equivalent to that of the vocal muscle in the CauF. The development of their large diameters was interpreted as part of the maturation process, thereby supporting the hypothesis of their functional importance as a component of the “body.” In the CauF, the amounts of collagen structures increased throughout the entire lamina propria, resulting in a loss of demarcated stratigraphical subdivisions in the “old” minipigs. This situation resembled that described in the vocal fold of geriatric humans.     

Respiratory syncytial virus infections in children in Montreal: a retrospective study

Seventy-seven hospitalized children from whom respiratory syncytial virus was subsequently isolated were studied in retrospect. This demonstrated the association of host invasion by this agent with an acute respiratory disease requiring hospitalization for approximately one week.Boys considerably outnumbered girls, the average age was 7.5 months, and in 56% the admission diagnosis was “bronchiolitis”. Cough and difficulty in breathing were the most common presenting complaints and “pneumonia” the most common radiological diagnosis. Nearly half the patients also harboured accepted disease-causing bacterial pathogens. All the patients recovered and have remained well.The appearance of the virus in Montreal was seasonal, beginning in late autumn and terminating in early spring.     

Quality along the Continuum: A Health Facility Assessment of Intrapartum and Postnatal Care in Ghana

Objective

To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate “effective coverage” of skilled attendance in Brong Ahafo, Ghana.

Methods

We conducted an assessment of all 86 health facilities in seven districts in Brong Ahafo. Using performance of key signal functions and the availability of relevant drugs, equipment and trained health professionals, we created composite quality categories in four dimensions: routine delivery care, emergency obstetric care (EmOC), emergency newborn care (EmNC) and non-medical quality. Linking the health facility assessment to surveillance data we estimated “effective coverage” of skilled attendance as the proportion of births in facilities of high quality.

Findings

Delivery care was offered in 64/86 facilities; only 3-13% fulfilled our requirements for the highest quality category in any dimension. Quality was lowest in the emergency care dimensions, with 63% and 58% of facilities categorized as “low” or “substandard” for EmOC and EmNC, respectively. This implies performing less than four EmOC or three EmNC signal functions, and/or employing less than two skilled health professionals, and/or that no health professionals were present during our visit. Routine delivery care was “low” or “substandard” in 39% of facilities, meaning 25/64 facilities performed less than six routine signal functions and/or had less than two skilled health professionals and/or less than one midwife. While 68% of births were in health facilities, only 18% were in facilities with “high” or “highest” quality in all dimensions.

Conclusion

Our comprehensive facility assessment showed that quality of routine and emergency intrapartum and postnatal care was generally low in the study region. While coverage with facility delivery was 68%, we estimated “effective coverage” of skilled attendance at 18%, thus revealing a large “quality gap.” Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.     

Pneumocystis Carinii Pneumonia—Problems in Diagnosis and Therapy in 24 Cases

Twenty-four instances of Pneumocystis carinii pneumonia were recognized in 23 patients at the Stanford University Hospitals between 1962 and 1970. The affected persons could be broadly characterized as “compromised” hosts. All but one were receiving immunosuppressive drug therapy for such underlying disease as hematopoietic malignant disease, collagen vascular disorder, and organ transplant rejection. The one patient not receiving immunosuppressant medication had congenital dysgammaglobulinemia and suffered two discrete bouts of pneumocystis pneumonia. Most of the patients were concomitantly infected with other “opportunistic” pathogens.Open lung biopsy remained the most reliable method of antemortem diagnosis of pneumocystis infection during this eight-year period. It resulted in little morbidity. Unfortunately, direct examination of appropriately stained sputum specimens for cysts was almost uniformly nonproductive.The majority of patients received specific antipneumocystis drug treatment (pentamidine isethionate or pyrimethamine and sulfadiazine). “Cure” was achieved when institution of therapy was prompt and duration of therapy approached the empirically recommended two-week course.The fact that pneumocystis pneumonia can be controlled if recognized early is compelling reason to pursue diagnosis of pneumocystosis in an appropriate clinical setting, namely, in patients with impaired host defenses who have pulmonary infection unresponsive to conventional therapy. There is hope that a noninvasive (serological) technique will be developed shortly to simplify identification of this not uncommon cause of diffuse interstitial pneumonitis.     

The Risks of Sleeping “Too Much”. Survey of a National Representative Sample of 24671 Adults (INPES Health Barometer)

Background

A significant U-shaped association between sleep duration and several morbidity (obesity, diabetes or cardiovascular disease) and mortality risks has been regularly reported. However, although the physiological pathways and risks associated with “too short sleep” (<5 hours/day) have been well demonstrated, little is known about “too much sleeping”.

Purpose

To explore socio-demographic characteristics and comorbidities of “long sleepers” (over 10 hours/day) from a nationally representative sample of adults.

Methods

A cross-sectional nationally representative sample of 24,671 subjects from 15 to 85-year-old. An estimated total sleep time (TST) on non-leisure days was calculated based on a specifically designed sleep log which allows to distinguish “long sleepers” from “short sleepers” (<5 hours/day). Insomnia was assessed according to the International classification of sleep disorders (ICSD-2).

Results

The average TST was 7 hours and 13 minutes (+/− 17 minutes). Six hundred and twelve subjects were “long sleepers” (2.7%) and 1969 “short sleepers” (7.5%). Compared to the whole group, “long sleepers” were more often female, younger (15–25 year-old) or older (above 65 year-old), with no academic degree, mostly clerks and blue collar workers. “Long sleepers” were significantly more likely to have psychiatric diseases and a greater body mass index (BMI). However, long sleep was not significantly associated with the presence of any other chronic medical disease assessed. Conversely, short sleep duration was significantly associated with almost all the other chronic diseases assessed.

Conclusions

In the general population, sleeping too much was associated with psychiatric diseases and higher BMI, but not with other chronic medical diseases.     

Patients Are Paying Too Much for Tuberculosis: A Direct Cost-Burden Evaluation in Burkina Faso

Background

Paying for health care may exclude poor people. Burkina Faso adopted the DOTS strategy implementing “free care” for Tuberculosis (TB) diagnosis and treatment. This should increase universal health coverage and help to overcome social and economic barriers to health access.

Methods

Straddling 2007 and 2008, in-depth interviews were conducted over a year among smear-positive pulmonary tuberculosis patients in six rural districts of Burkina Faso. Out-of-pocket expenses (direct costs) associated with TB were collected according to the different stages of their healthcare pathway.

Results

Median direct cost associated with TB was US$101 (n = 229) (i.e. 2.8 months of household income). Respectively 72% of patients incurred direct costs during the pre-diagnosis stage (i.e. self-medication, travel, traditional healers'' services), 95% during the diagnosis process (i.e. user fees, travel costs to various providers, extra sputum smears microscopy and chest radiology), 68% during the intensive treatment (i.e. medical and travel costs) and 50% during the continuation treatment (i.e. medical and travel costs). For the diagnosis stage, median direct costs already amounted to 35% of overall direct costs.

Conclusions

The patient care pathway analysis in rural Burkina Faso showed substantial direct costs and healthcare system delay within a “free care” policy for TB diagnosis and treatment. Whether in terms of redefining the free TB package or rationalizing the care pathway, serious efforts must be undertaken to make “free” health care more affordable for the patients. Locally relevant for TB, this case-study in Burkina Faso has a real potential to document how health programs'' weaknesses can be identified and solved.