The diagnostic process: a comparison of scanning techniques.

In choosing between various scanning techniques the factors to be considered include availability, cost, the type of equipment, the expertise of the medical and technical staff, and the inherent capabilities of the system. Although it is difficult to state dogmatically which scanning technique is best for each patient and condition, one or other technique is clearly preferable in some areas of medicine. Ultrasound, for example, should be used in obstetrics, while computerized tomography has revolutionised neuroradiological diagnosis. Nevertheless, there is still no substitute for good history taking and a thorough physical examination. The most important factor determining the choice of technique is the system''s ability to answer the specific question required for the management of the patient.     

Immediate diagnosis in vaginal cytology using interference contrast microscopy (Nomarski).

Studying fresh aspiration material from the posterior fornix and cervix, by Interference Contrast Microscopy (Nomarski) is a good method of cytologic examination. It is shown how most cell types can be observed, just as they can be by the classical Papanicolaou staining. Normal and abnormal, even dysplastic and malignant cells can be recognized. This method is also very useful for identifying parasites, fungi and bacteria, by morphology and active movements. While encoraging the use of this method, it is advisable to compare the results with slides examined later by the Papanicolaou technique, for maximum safety of the patient.     

A discussion of the pediatric clinical guidelines

It is evident from both the AAO and AOA guideline position statements that a visual and eye examination is essential within the first few months of life. Thus, both groups recognize the importance of examining infants within the critical period of visual development. The adequacy of testing performed by lay screeners or primary care physicians to rule out all visual disorders is highly questionable. Photorefraction is a promising screening technique, but as yet needs to be validated by further study. The only adequate means of detecting early vision and eye disorders is through examination by an eye care professional. However, this conclusion immediately underscores the need for eye care professionals prepared to examine very young children. The primary eye care of children should not be considered the responsibility of a minority of ‘pediatric specialists’. Clinical techniques are currently available which would enable all practitioners to evaluate children in the first few months of life, a critical time for an initial evaluation. We believe it is essential for all eye care professionals to be trained in these basics of eye and vision care. The need for widespread pediatric training should be addressed when reviewing the clinical education of interns.Both guidelines yield valuable guidance and background information for the pediatric examination. The AOA guideline is more complete, and includes a useful bibliography. It is well researched, and should be particularly helpful to the newer practitioner. The AAO guideline provides less detailed guidance, and omits some newer and important examination techniques, such as preferential looking for visual acuity and spray application for administering drugs.The AOA and AAO pediatric clinical practice guidelines can serve as helpful examination tutorials for the practitioner. The guidelines do not address the decision making process of diagnosis and treatment options. The references included in the documents can help fill in the gaps, but would require a substantial commitment of time for research and study. We see the need for additional guidelines to help guide the process of difficult decision-making when the patient is ‘in the chair’. The publication of such second generation documents would serve eye care professionals in the total case management of the pediatric patient.     

The "round block" surgical technique in the management of multicentric fibroadenomas

The "round block" surgical technique in the treatment of a female patient with multiple, multicentric fibroadenomas in both breasts is presented. The advantages of this technique for patients with multicentric benign breast lesions are minimal postoperative scar and a favourable aesthetic result. Breast dimensions and the areolar diameter were measured in 203 subjects of Primorsko-Goranska county during examination in the Out-Patient Hospital for Breast Diseases, including the operated patient. Smaller breast dimensions and a larger areolar diameter provide an easier access to any part of the breast due to a smaller distance between the incision and a fibroadenoma and a larger circumference of circular periareolar incision, thus facilitating the surgery. The analysis of average, maximum and minimum values measured shows that the "round block" technique can be performed in all cases of multiple and multicentric fibroadenomas regardless of breast size, areolar diameter and the location of fibroadenoma in the breast.     

Radial artery wall shear stress evaluation in patients with arteriovenous fistula for hemodialysis access

It has been extensively documented that changes in blood flow induce vascular remodeling and this phenomenon seems to be correlated to the shear forces imposed on the vessel wall by motion of blood. Wall shear stress, the tractive force that acts on the endothelium, has been shown to influence endothelial cell function. To study changes in wall shear stress that develop on the vessel wall upon changes of blood flow, we set up a technique that allows estimation of shear stress in the radial artery of patients on chronic hemodialysis therapy. The technique is based on color-flow Doppler examination of the radial artery before and after surgical creation of radiocephalic fistula for hemodialysis. Calculation of time function wall shear stress and blood flow rate in the radial artery is performed on the basis of arterial diameter, center-line velocity waveform and blood viscosity, using a numerical method developed according to Womersley's theory for pulsatile flow in tubes. The results presented confirm that the model developed is suitable for calculation of the wall shear stress that develops in the radial artery of patients before and after surgical creation of an arteriovenous fistula for hemodialysis. This methodology was developed for characterization of wall shear stress in the radial artery but may be well applied to other vessels that can be examined by echo-Doppler technique.     

Studies on Trypanosoma vivax: comparison of parasitological diagnostic methods.

Leeflang P., Buys Janny and Blotkamp Coby. 1978. Studies on Trypanosoma vivax: comparison of parasitological diagnostic methods. International Journal for Parasitology8: 15–18. Parasitological methods for the diagnosis of Trypanosoma vivax infections in Nigerian cattle, including thin and thick blood smear and lymph gland smear examination, haematocrit centrifuge technique, hypotonie lysis test and mouse inoculation were evaluated. In 155 blood samples, thick film examination was significantly better than thin smear examination; in 126 samples, the haematocrit centrifuge technique was significantly superior over thin smear but not over thick film examination; when all six methods were applied in 52 samples, significant differences could only be demonstrated between mouse inoculation on one hand and thick film and gland smear examination, haematocrit centrifuge technique and hypotonie lysis test on the other hand, and between thin smear examination and hypotonic lysis test. It was shown that none of the tests was either satisfactory or sufficiently reliable to be used alone. The combination of either haematocrit centrifuge technique or thick film examination together with thin smear examination is recommended as most practical for the diagnosis of T. vivax infection under field conditions. The haematocrit centrifuge technique is also more advantageous because simultaneous estimation of the packed cell volume will evaluate the clinical condition of the herd. A comparison of the value of diagnostic methods for East and West African T. vivax was included in the present study.     

Cytologic diagnosis of a solitary brain metastasis from papillary carcinoma of the thyroid. A case report.

BACKGROUND: Papillary carcinoma of the thyroid metastasizes to the brain in rare instances. In published series and case reports of metastatic papillary thyroid carcinoma, diagnosis of central nervous system (CNS) metastases has been determined by histologic methods. We present a case of papillary carcinoma metastatic to brain diagnosed by cytologic methods. CASE: A 43-year-old female, initially diagnosed at age 12 with papillary carcinoma of the thyroid metastatic to regional lymph nodes and lung, presented with head aches of increasing frequency and severity. A computed tomography scan confirmed a 1-cm nodule in the right inferior frontal lobe of the brain. For clinical reasons, the patient was followed with serial imaging for five years. At age 48 there was significant progression of the CNS disease, and the patient underwent stereotactic biopsy with drainage of cyst fluid. Cytologic examination of the cyst fluid and immunocytochemical studies confirmed the typical features of papillary thyroid carcinoma, including papillary clusters of cells with finely granular chromatin, micronucleoli, nuclear grooves and an associated psammoma body. CONCLUSION: Neurocytology is a useful technique in the examination of cystic lesions of the brain and may be the sole technique for determination of diagnosis.     

The Cost-Effectiveness Analysis of Teleglaucoma Screening Device

Glaucoma is the leading cause of irreversible vision loss and costs the American economy $2.9 billion. Teleglaucoma remotely detects glaucoma improving access to ophthalmic care in rural areas. It helps manage glaucoma more efficiently to preserve vision and reduce healthcare costs. A cost-effectiveness analysis was conducted using healthcare provider or third-party payer perspective within rural Canada. The study population were patients at-risk of glaucoma which includes those with diabetes and/or hypertension, family history of glaucoma, adults older than 50 years, and concurrent ocular conditions in rural Alberta. Markov modelling was used to model glaucoma health states. Effectiveness was measured in Quality-Adjusted Life Years (QALYs) and costs were used in Canadian dollars. Using TreeAge Pro 2009, incremental cost-effectiveness ratios (ICER) were developed in dollars per QALYs. Deterministic and probabilistic sensitivity analyses were performed to assess the factors affecting cost-effectiveness. Teleglaucoma had a 20% increase in ophthalmologist-referral rate; it reduced patient travel times by 61 hours and physician wait times by 30% in comparison to in-person examination (standard of care). Teleglaucoma costs $872 per patient screened which was 80% less than in-person examination. Teleglaucoma had a greater incremental effectiveness providing an additional 0.12 QALY per patient examination. It was more sensitive (86.5%) and less specific (78.6%) than in-person examination. Teleglaucoma was more cost-effective than in-person examination with an ICER of-$27,460/QALY. This indicated that teleglaucoma will save $27, 460 for each additional QALY gained. Long term benefits showed teleglaucoma prevents 24% cases of glaucoma blindness after 30 years. Teleglaucoma demonstrated improved health outcomes, as well as, cost benefits. It increases access to ophthalmic care and improves healthcare service efficiency, specifically in rural areas. Teleglaucoma is more cost-effective than current in-person examination and can improve the quality of life in glaucoma patients.     

A Standardized Procedure for Echoencephalography and for Analyzing Echoencephalograms

Although echoencephalography is a simple, convenient and atraumatic diagnostic technique, the accuracy and reliability of this test and whether it is reproducible can be greatly influenced by the way in which the examination is performed and subsequently analyzed. Echoencephalography in 850 patients has led to the development of a standardized technique which takes into account the positioning of the patient, the application of the transducer, the identification of the midline-echo-complex, and the elimination of observer bias. Once performed the test must meet rigid standards of acceptability. If acceptable the test is analyzed according to an established format.     

Peripheral in-continuity tissue examination

When treating skin cancers, it is essential to remove the entire neoplasm if possible. Immediate reconstruction is most helpful in returning the patient to a useful and satisfactory life. The Mohs histologic technique can be time-consuming and cumbersome. Reconstruction can be delayed. A modification of Mohs technique, peripheral in-continuity tissue examination (PITE), is described in which the surgeon and the pathologist combine their talents to remove the tumor. All margins are evaluated, and the surgical defect is closed primarily. Larger and more complex tumors can be removed and defects immediately reconstructed using this efficient technique, obviating the inconvenience, pain, and expense of multiple, separate procedures.     

A case of human cryptosporidiosis in Czechoslovakia

A case of human cryptosporidiosis, the first one reported in Czechoslovakia, is described. The disease was diagnosed by the presence of Cryptosporidium oocysts in the feces. The methods used independently to identify oocysts were the fecal flotation technique employing a saturated solution of sucrose and the microscopic examination of stained fecal smears. The patient was a 4-year-old boy with watery diarrhea of 5 days' duration who was kept on a diet and treated with a suspension of Endiaron N Spofa. Excretion positivity for Cryptosporidium oocysts in the feces was detectable at 3 and 5 days after appearance of first clinical manifestations. Bacteriological examination was repeatedly negative. This finding leaves little doubt as to existence of human cryptosporidiosis in Czechoslovakia, but what remains obscure is its overall contribution to the etiology of diarrheal diseases encountered in the population.     

Comparison of Fluorescent Antibody with Cultural Technique for Isolation of Enteropathogenic Escherichia coli from Swine

In an investigation of hogs as possible reservoirs of human strains of enteropathogenic Escherichia coli (EEC), 92 six-month-old grain- and garbage-fed hogs were examined on the farm and again at the packing plant. Of the 331 specimens obtained by swabbing the rectum, cecum, and edible meat carcass of these hogs, 125 were presumptively positive for EEC when screened by the fluorescent-antibody (FA) technique. These “presumptive positive” specimens then underwent extensive bacteriological examination and complete serological typing. The FA technique proved to be an easier, simpler, and more economical procedure than culture when a large number of specimens were examined for possible EEC serogroups. It was found especially valuable for identification of multiple serogroups of EEC within a single specimen. It also appeared to be more sensitive than cultural examination, since results were not dependent on the presence of large numbers of organisms in the specimen, or even on their viability. However, the FA technique was found to be less specific than culture because of cross-reactivity with antigenically related Enterobacteriaceae when fluorescein-labeled antisera were used. Therefore, any specimen found positive on FA examination should be considered as presumptive positive until confirmed by bacteriological examination and complete serological study.     

Counter-flow gas contrast in the differential diagnosis of formation of the cardiodiaphragmatic angle

X-ray examination using counter-flow gas contrast study was performed in 30 patients for differential diagnosis of cardiodiaphragmatic angular formations. Approximately 700 ml of gas was administered in to the mediastinum, 1500 ml into the abdominal cavity, followed by x-ray examination (roentgenoscopy, roentgenography and tomography) in 30 min. It made it possible to determine an accurate site of the formation and to make correct diagnosis in 28 cases. This method is highly informative and considerably reduces the diagnostic period, decreasing radiation exposure of a patient.     

Detection of Plasmodium falciparum by indirect immunofluorescence using specific murine monoclonal antibodies

The monoclonal immunofluorescence technique described here is a sensitive method to detect very small P. falciparum antigens. It is specially usefull in very low parasitemias when the detection of infected R.B.C. is particularly difficult by conventional Giemsa's coloured smears on thick drops. This technique requires only 0.5 to 1 ml of blood to be performed. This method allows the microscopic examination of large number of blood samples in a relatively short time. It permits also a very precise localisation of parasite in R.B.C. In the same way, the chemotherapy can easily be followed up and chemo-resistance forms may be studied more precisely than when using the standard microscopic examination. Reactions are always negative in individuals who have never visited malaria endemic countries. The plasma polyclonal antibodies directed against P. falciparum do not interfere with the technique (carried out on fresh or thawed R.B.C.).     

Colonoscopy in surgical practice.

Colonoscopy is a rewarding new technique with a potential for early and more accurate diagnosis. One hundred and seventy colonoscopies carried out over the past three years showed or confirmed colonic cancer in 14 patients, and solitary or multiple colonic polyps were found in 28 cases, of which 18 were excised endoscopically. A large villous adenoma was diagnosed in one patient, and the absence of a suspected sinister lesion was shown by direct examination and biopsy in 110 cases. There were 17 examination failures, including two perforations of the bowel. Colonoscopy complements rather than supplants barium enema examination and will make diagnostic laparotomy for colonic lesions unnecessary. The use of the diathermy snare allows endoscopic removal of colonic polyps and should greatly reduce the need for formal surgery in these cases. The financial saving to the Health Service will greatly outweigh the expense of the procedure, but it should be undertaken only in well organised centres as a specialist service for selected patients. In skilled hands it is safe, but potential hazards exist for the inexperienced endoscopist.     

Application of wound closure Molndal technique after laparoscopic cholecystectomy--initial comparative study

Because of a possible delayed wound healing, critical colonization and infection of wounds present a problem for surgeons. Colonized and infected wounds are a potential source for cross-infection. Molndal technique of wound dressing has proven to be effective in prevention of infection. Also the wound heal better and faster. In our study we wanted to describe the benefits of the Molndal technique wound dressing after laparoscopic cholecistectomy compared to traditional wound dressing technique. Molndal technique consisted of wound dressing with Aquacel Ag--Hydrofiber (ConvaTec, Dublin, Ireland). Traditional technique was performed using gauze compresses and hypoallergic adhesives. We analyzed the results of 100 patients after laparoscopic cholecystectomy. 50 patients were treated by Molndal technique and 50 patients by the traditional technique of wound dressing. In the group treated by Molndal technique only 1 (2%) patient has revealed a wound infection, proven by positive microbiological examination and suppuration, mostly in the subumbilical incision. In the traditional technique group 7 (14%) patients developed wound infection also predominantly in the subumbilical incision. The difference was statistically significant (p < 0.01). Our results are clearly showing that Molndal technique is effective in preventing the infection of subumbilical incision wound and is to by recommend for regular use at designated site after laparoscopic cholecistectomy.     

Patient dose levels for seven different radiographic examination types

This study was carried out as a part of a comprehensive project to establish a national diagnostic reference level (NDRL), for the first time, in Saudi Arabia. Seven of the most common X-ray examinations (10 projections) were included. This study consisted of 200 patients who were referred for X-ray examinations at King Khalid University Hospital (KKUH). The selected X-ray examinations were skull (PA), kub (AP and LAT), ankle (AP and LAT), foot (AP/OBL and LAT/OBL), hib (AP and LAT) and sinuses paranasal (AP). Mean patient information and exposure parameters for these seven radiographic examinations were recorded at KKUH. Some of these radiographic examinations were compared with their corresponding values at other national places [Security Forces Hospital (SFH); King Abdulaziz City for Science and Technology (KACST)] in Saudi Arabia. We found that the patient mean dose values recorded at KKUH were varied from those recorded at other national places. Wide variations in patient dose arising from a specific type of X-ray examination at different national places suggests that significant reductions in patient dose would be possible without affecting image quality. Furthermore, variations in patient dose may emerge from the examination technique, clinical condition, radiologist skill, tube current, tube potential and focus to film distance. The data of this study will be useful for the formulation of NDRLs, and it is also provides local diagnostic reference levels for some diagnostic X-ray examinations at KKUH and other national places in Saudi Arabia.     

Application of wound dressing Molndal technique in clean and potentially contamined postoperative wounds--initial comparative study

Because of a possible delayed wound healing, critical colonization and infection of wounds present a problem for surgeons, particularly in patients with compromised immune system or in case where the wound is heavy contaminated or poorly perfused. Molndal technique of wound dressing has proven to be effective in prevention of infection. In our study we wanted to describe the benefits of the application of Molndal technique wound dressing compared to traditional wound dressing technique at potentially contaminated and clean postoperative wounds. We examined postoperative wound after radical excision of pilonidal sinus and after implantation of partial endoprosthesis in hip fracture. Molndal technique consisted of wound dressing with Aquacel Ag - Hydrofiber. Traditional technique was performed using gauze compresses and hypoallergic adhesives. We analyzed the results of 50 patients after radical excision of pilonidal sinus. 25 patients were treated by Molndal technique and 25 patients by the traditional technique of wound dressing. In the group treated by Molndal technique only 1 (4%) patient has revealed a wound infection, proven by positive microbiological examination and suppuration. In the traditional technique group 4 (16%) patients developed wound infection as inflammation and secretion as a sign of superficial infection. In the other group we analyzed the results of 50 patients after implantation of partial endoprosthesis after hip fracture. 20 patients were treated by Molndal technique and 30 patients by the traditional technique of wound dressing. In the group treated by Molndal technique no patient has revealed a wound infection (0%). In the traditional technique group 4 (13%) patients developed wound infection. All complication in both group were superficial incisional surgical infection (according to HPSC). There was no deep incisional surgical site infection or organ/space surgical site infection. Our results are clearly showing that Molndal technique is effective in preventing the postoperative wound infection.     

Automated quality assurance and patient dosimetry in diagnostic radiology

It has been generally considered that improved methods of quality assurance would reduce the population dose from diagnostic radiology. This paper describes the development of a computerized method of automatically monitoring tube and generator parameters to perform on-line quality assurance, whilst undertaking various patient dosimetry measurements and calculations for each exposure. The method involves interfacing a microcomputer to a microprocessor controlled X-ray generator. Details of the various interfacing methods and modifications to the X-ray unit are given. The instrument enables quality assurance to be performed for every exposure by comparing tube and generator parameters against nominal settings. The software automatically warns the operator of any deviations from accepted limiting values. When a patient is examined, details of the examination and projection are entered into a database. The exposure area product and field size are monitored for each exposure. This data, together with information on tube potential and examination/projection is used to deduce patient entrance skin dose and energy imparted. Doses to individual organs are estimated using normalized organ dose data and a knowledge of tube potential and field size.