Volume 4, Issue 1

Focusing on the medical approach to the subjective forms of distress, this article has a three-fold argument. First, the historical starting point of diagnosing distress was neurasthenia during the last two decades of the 19th century. Second, the diagnosis of neurasthenia that initially contained more somatic than mental symptoms was gradually replaced by the more psychologically conceptualized neuroses. Such a psychiatrization of neurosis gradually separated mental and somatic syndromes into two distinct diagnostic categories, those of mental and somatic. Third, when modern “neuroses” are seen in the framework of distress rather than disease, it provides tools for new kinds of interventions, in which the principal aim is to alleviate the subjective distress with all possible and reasonable means and methods. As the social context constitutes a crucial “etiology” to medicalized forms of distress, we need new, context-based approaches to both analyze and alleviate such distress. In our historical and medical approach to these “diagnoses of distress”, we are guided by the belief that analyzing diagnostic categories can provide important insight into the mechanisms behind our changing conceptions of health and wellbeing.

Diagnostic error represents an important patient safety issue. Herein, we summarize five important things to know about this topic. (1) At least 1 in 20 adults are affected by diagnostic errors annually. (2) The root causes for diagnostic errors are typically multifactorial. (3) Cognitive errors are found in the majority of cases. (4) Most missed diagnoses involve common conditions. (5) Advancements in policy, education, and health information technologies hold promise for improving diagnostic safety.

The method of diagnosis is essentially similar to the scientific method in which a cause is suspected from clues in a situation and formulated as a hypothesis that is proven correct by the observation of its consequences. An awareness of scientific nature of diagnosis emphasizes search for clues rather than evidence for a disease when we encounter a patient with symptoms.

Background: Diagnostic error is extremely common in the USA and likely around the world. A major reason for the diagnostic error is both the overutilization and the underutilization of laboratory tests. Using a panel of two to four experts in coagulation, test selection was reviewed in clinical context and in real time, and consensus determinations were made to derive conclusions about the extent of overutilization and underutilization. Methods: Two hundred cases of patients being evaluated for bleeding or thrombotic issues were presented at each daily meeting of the diagnostic management team, and a review of each case for appropriate utilization of tests was completed. Results: Two hundred randomly selected cases revealed 77.5% diagnostic errors (155 cases). Sixteen percent were associated with overutilization of laboratory tests, 44% were associated with underutilization, and 17.5% were associated with both. The annual cost burden estimated for overutilization alone in one institution of 450 beds was on the order of $20,000. The cost burden for the delay in diagnosis or the misdiagnosis in cases with underutilization is orders of magnitude greater ($200,000 or more), but it is impossible to determine the cost of a misdiagnosis in an individual case because it can produce many different clinical outcomes. Conclusions: This was a rare opportunity for experts in a given field to review cases in real time and in clinical context and provide immediately a consensus answer about test utilization. The results of this study show errors in test selection in nearly 75% of the cases evaluated.

Background: Early-stage cerebellar hemorrhage can present with nausea or vomiting absent other neurological symptoms or signs, potentially leading to an incorrect diagnosis of gastroenteritis. We sought to determine the frequency of gastroenteritis-like presentations and delayed or missed diagnoses among patients with spontaneous cerebellar hemorrhage. Methods: This is a retrospective, case-control analysis of atraumatic, primary cerebellar hemorrhages derived from a systematic search of surgical pathology and autopsy databases at two large urban, academic medical centers from 1984 to 2006. Hospital visit and clinical symptom data were abstracted from electronic and paper medical records for included patients. Delayed or missed diagnoses were defined as those at least one previous visit for relevant clinical symptoms in the 7 days prior to the correct diagnosis being confirmed. Results: Among 254 records captured by our search filter, we identified 35 cases of pathologically proven primary cerebellar hemorrhage. Four patients (11%) were misdiagnosed initially – three with “gastroenteritis” and one with “hypertension”. In this small sample, misdiagnosed patients presented more often with normal mental state (100% vs. 35%, p=0.07) and nausea/vomiting (100% vs. 58%, p=0.22). Although patients deteriorated clinically after the initial misdiagnosis, and potentially dangerous diagnostic tests and treatment strategies were instituted as a result of misdiagnosis, none of the misdiagnosed patients died or suffered major permanent harms due to diagnostic delay. Conclusions: Our study is limited by the small number of identified cases. Nevertheless, it appears that patients with cerebellar hemorrhages can present with relatively unimpressive clinical findings without obvious neurological manifestations. Such individuals are sometimes misdiagnosed with gastroenteritis or other benign disorders initially, possibly when neurologic examination, particularly gait testing, is omitted or abridged. A careful search for subtle cerebellar signs, including dysarthria, limb ataxia, nystagmus or tandem gait instability, absent in true gastroenteritis cases, could potentially reduce misdiagnosis.

Background: Red cell distribution width (RDW) is well recognised as a marker of iron-deficient anaemia, as well as useful to the distinction between some anaemic states. A role in the prediction of patient mortality and for the laboratory diagnosis of organ dysfunction has been also investigated. RDW has recently been suggested as a marker of acute and chronic hypoxia. Methods: In this paper we use RDW kinetics to identify different patient groups and then investigate the relationship between RDW, ferritin and haemoglobin kinetics in a large cross-sectional community patient dataset. Results: A novel mathematical model of this relationship is developed that captures all aspects of variation in the data. A linear regression of RDW/log(ferritin) on days is combined with a multi-level random structure including random intercepts and slopes for each patient. Conclusions: No evidence of an age affect was found in the data. On the other hand, significant patterns in the rises and falls of log(ferritin) and haemoglobin with RDW over time are identified.

Background: One of the strongest risk factors of cardiovascular disease is a high concentration of low-density lipoprotein cholesterol (LDL-C); thus, the accurate measurement of LDL-C concentration in children is important. The aim of this study was to compare the concentration of LDL-C measured by direct method and the LDL-C concentration estimated by different formulas with the modified β-quantification method in children with type 1 diabetes. Methods: Thirty-one serum samples received from diabetic children (15/18; M/F) and 26 serum samples taken from nondiabetic children (18/14; M/F) were used in the study. LDL-C concentrations were determined by direct enzymatic method (LDL-C D ) and the modified β-quantification method (LDL-C mBQ ). The concentration of LDL-C was also calculated by different formulas. Results: The results of LDL-C mBQ and LDL-C D correlated. However, the correlation coefficient obtain in the nondiabetic samples was much higher (r=0.927; p<0.001) than the correlation coefficient for LDL-C mBQ and LDL-C D concentration obtained in the diabetic samples (r=0.691; p<0.001). Additionally, the coefficients of correlation between the LDL-C mBQ concentration and the LDL-C concentrations calculated by different formulas were lower in diabetic (range: 0.514–0.693) than in nondiabetic samples (range: 0.834–0.937). Bland-Altman plots showed much higher confidence intervals for 95% limits of agreement for the differences between LDL-C mBQ and LDL-C D as well as for the differences between LDL-C mBQ and LDL-C estimated by different formulas for samples from the diabetic samples compared with nondiabetic samples. Conclusions: The limitations of methods measurement and of each of the formulas should be taken into account when a medical decision to lower LDL-C is made in the treatment of diabetic children.

We report a novel syndrome of aseptic myonecrosis in a child occurring after intramuscular (IM) benzathine penicillin G injection for the treatment of streptococcal pharyngitis. Common side effects of IM injection, including transient injection site pain and inflammation, are common and well described. However, isolated myonecrosis following IM injection in the pediatric patient has not been previously reported. Only one similar case, following IM diclofenac injection, has been discussed in the adult literature.