Clinical reasoning: The relative contribution of identification, interpretation and hypothesis errors to misdiagnosis

The aim of this study was to identify and describe the types of errors in clinical reasoning that contribute to poor diagnostic performance at different levels of medical training and experience. Three cohorts of subjects, second- and fourth- (final) year medical students and a group of general practitioners, completed a set of clinical reasoning problems. The responses of those whose scores fell below the 25th centile were analysed to establish the stage of the clinical reasoning process - identification of relevant information, interpretation or hypothesis generation - at which most errors occurred and whether this was dependent on problem difficulty and level of medical experience. Results indicate that hypothesis errors decrease as expertise increases but that identification and interpretation errors increase. This may be due to inappropriate use of pattern recognition or to failure of the knowledge base. Furthermore, although hypothesis errors increased in line with problem difficulty, identification and interpretation errors decreased. A possible explanation is that as problem difficulty increases, subjects at all levels of expertise are less able to differentiate between relevant and irrelevant clinical features and so give equal consideration to all information contained within a case. It is concluded that the development of clinical reasoning in medical students throughout the course of their pre-clinical and clinical education may be enhanced by both an analysis of the clinical reasoning process and a specific focus on each of the stages at which errors commonly occur.

Erros pré-analíticos em medicina laboratorial: uma revisão sistemática

MENEZES, Patrick Lourenço. Erros pré-analíticos em medicina laboratorial: uma revisão sistemática. 2013. 98 f. Dissertação (Mestrado em Saúde, Medicina Laboratorial e Tecnologia Forense) - Instituto de Biologia Roberto Alcântara Gomes, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, 2013. A relevância evidente dos erros pré-analíticos como problema de saúde pública fica patente tanto no dano potencial aos pacientes quanto nos custos ao sistema de saúde, ambos desnecessários e evitáveis. Alguns estudos apontam que a fase pré-analítica é a mais vulnerável a erros, sendo responsável por, aproximadamente, 60 a 90% dos erros laboratoriais em consequência da falta orientação aos pacientes sobre os procedimentos que serão realizados no laboratório clínico. Objetivos: Sistematizar as evidências científicas relacionadas aos erros pré-analíticos dos exames laboratoriais de análises clínicas. Método: Uma revisão sistemática foi realizada, buscando as bases de dados do Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus(que inclui MEDLINE e Embase), ISI Web of Knowledge, SciFinder, Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs) (que inclui a Scientific Electronic Library Online SciELO) e o Índice Bibliográfico Espanhol de Ciências de Saúde (IBECS), para artigos publicados entre janeiro de 1990 e junho de 2012 sobre erros de exames laboratoriais que possam ocorrer na fase pré-analítica. Os estudos foram incluídos de acordo com os seguintes exames laboratoriais: hemograma, análise bioquímica do sangue total ou do soro, exames de coagulação sanguínea,uroanálise e exames hematológicos ou bioquímicos em outros materiais e categorizados pelo tipo de erro pré-analítico e pela frequência dos incidentes. Resultados: A busca nas bases de dados bibliográficas resultou no seguinte número de artigos recuperados: 547 na MEDLINE, 229 na Scopus, 110 na ISI, 163 na SciFinder, 228 na Lilacs e 64 na IBECS, perfazendo um total de 1.341 títulos. Ao fim da revisão sistemática, obteve-se um conjunto de 83 artigos para leitura de texto completo, dos quais 14 foram incluídos na revisão. Os estudos abrangeram diferentes tipos de laboratórios, setores técnicos e origem de erros, segundo a fase do processo laboratorial. Discussão: Sete artigos demonstraram erros de pedidos médicos, com uma alta variabilidade nos valores de incidência. Os seis artigos que estudaram erros de coleta de amostra observaram redução deste desfecho. As proporções de eventos adversos relatados e os impactos clínicos variaram, levando a consequências descritas como: erros decorrentes da flebotomia, recoleta de amostras, repetições de exames, atrasos na liberação de resultados de exames e possíveis danos ao paciente. Conclusões: O laboratório deve ter instruções por escrito para cada teste, que descreva o tipo de amostra e procedimento de coleta de amostra. Meios de identificação por código de barras, sistemas robóticos e analíticos reduzem os erros pré-analíticos. A melhoria da fase pré-analítica de testes laboratoriais permanece um desafio para muitos laboratórios clínicos.

Assessment of Tandem Mass Spectrometry and High Resolution Mass Spectrometry for the Analysis of Bupivacaine in Plasma

Triple quadrupole mass spectrometers coupled with high performance liquid chromatography are workhorses in quantitative bioanalyses. It provides substantial benefits including reproducibility, sensitivity and selectivity for trace analysis. Selected Reaction Monitoring allows targeted assay development but data sets generated contain very limited information. Data mining and analysis of non-targeted high-resolution mass spectrometry profiles of biological samples offer the opportunity to perform more exhaustive assessments, including quantitative and qualitative analysis. The objectives of this study was to test method precision and accuracy, statistically compare bupivacaine drug concentration in real study samples and verify if high resolution and accurate mass data collected in scan mode can actually permit retrospective data analysis, more specifically, extract metabolite related information. The precision and accuracy data presented using both instruments provided equivalent results. Overall, the accuracy was ranging from 106.2 to 113.2% and the precision observed was from 1.0 to 3.7%. Statistical comparisons using a linear regression between both methods reveal a coefficient of determination (R2) of 0.9996 and a slope of 1.02 demonstrating a very strong correlation between both methods. Individual sample comparison showed differences from -4.5% to 1.6% well within the accepted analytical error. Moreover, post acquisition extracted ion chromatograms at m/z 233.1648 ± 5 ppm (M-56) and m/z 305.2224 ± 5 ppm (M+16) revealed the presence of desbutyl-bupivacaine and three distinct hydroxylated bupivacaine metabolites. Post acquisition analysis allowed us to produce semiquantitative evaluations of the concentration-time profiles for bupicavaine metabolites.

Aerosols over the Arabian Sea

This paper provides an overview of dust transport pathways and concentrations over the Arabian Sea during 1995. Results indicate that the transport and input of dust to the region is complex, being affected by both temporally and spatially important processes. Highest values of dust were found off the Omani coast and in the entrance to the Gulf of Oman. Dust levels were generally lower in summer than the other seasons, although still relatively high compared to other oceanic regions. The Findlater jet, rather than acting as a source of dust from Africa, appears to block the direct transport of dust to the open Arabian Sea from desert dust source regions in the Middle East and Iran/Pakistan. Dust transport aloft, above the jet, rather than at the surface, may be more important during summer. In an opposite pattern to dust, sea salt levels were exceedingly high during the summer monsoon, presumably due to the sustained strong surface winds. The high sea salt aerosols during the summer months may be impacting on the strong aerosol reflectance and absorbance signals over the Arabian Sea that are detected by satellite each year.

Helium in solubility equilibrium with quartz and porefluids in rocks - a new approach in hydrology

Quartz crystals in sandstones at depths of 1200 m–1400 m below the surface appear to reach a solubility equilibrium with the 4He-concentration in the surrounding pore- or groundwater after some time. A rather high 4Heconcentration of 4.5x10E-3 cc STP 4He/cm3 of water measured in a groundwater sample would for instance maintain a He pressure of 0.47 atm in a related volume. This value is equal within analytical error to the pressure deduced from the measured helium content of the quartz and its internal helium-accessible volume. To determine this volume, quartz crystals of 0.1 to 1 mm were separated from sandstones and exposed to a helium gas pressure of 32 atm at a temperature of 290°C for up to 2 months. By crushing, melting or isothermal heating the helium was then extracted from the helium saturated samples. Avolume on the order of 0.1% of the crystal volume is only accessible to helium atoms but not to argon atoms or water molecules. By monitoring the diffusive loss of He from the crystals at 350°C an effective diffusion constant on the order of 10E-9 cm2/s is estimated. Extrapolation to the temperature of 70°C in the sediments at a depth of 1400 m gives a typical time of about 100 000 years to reach equilibrium between helium in porewaters and the internal He-accessible volume of quartz crystals. In a geologic situation with stagnant pore- or groundwaters in sediments it therefore appears to be possible with this new method to deduce a 4He depth profile for porewaters in impermeable rocks based on their mineral record.

Integrated Pb- and S-isotope investigation of sulphide minerals from the early Archaean of southwest Greenland

We present high-spatial resolution secondary ion mass spectrometry (SIMS) measurements of Pb and S isotopes in sulphides from early Archaean samples at two localities in southwest Greenland. Secondary pyrite from a 3.71 Ga sample of magnetite-quartz banded iron formation in the Isua Greenstone Belt, which has previously yielded unradiogenic Pb consistent with its ancient origin, contains sulphur with a mass independently fractionated (MIF) isotope signature (Delta(33)S =+3.3 parts per thousand). This reflects the secondary mineralization of remobilized sedimentary S carrying a component modified by photochemical reactions in the early Archaean atmosphere. It further represents one of the most extreme positive excursions so far known from the early Archaean rock record. Sulphides from a quartz-pyroxene rock and an ultramafic boudin from the island of Akilia, in the Godth (a) over circle bsfjord, have heterogeneous and generally radiogenic Pb isotopic compositions that we interpret to represent partial re-equilibration of Pb between the sulphides and whole rocks during tectonothermal events at 3.6, 2.7 and 1.6 Ga. Both these samples have Delta(33)S=0 (within analytical error) and therefore show no evidence for MIF sulphur. These data are consistent with previous interpretations that the rock cannot be proven to have a sedimentary origin. Our study illustrates that SIMS S-isotope measurements in ancient rocks can be used to elucidate early atmospheric parameters because of the ability to obtain combined S and Pb-isotope data, but caution must be applied when using such data to infer protolith. When information from geological context, petrography and chronology (i.e. by Pb isotopes) is combined and fully evaluated, Delta(33)S signatures from sulphides and their geological significance can be interpreted with a higher degree of confidence. (c) 2005 Elsevier B.V All rights reserved.

High-performance liquid chromatography and pharmacokinetics of some antibiotics

The principles of High Performance Liquid Chromatography (HPLC) and pharmacokinetics were applied to the use of several clinically-important drugs at the East Birmingham Hospital. Amongst these was gentamicin, which was investigated over a two-year period by a multi-disciplinary team. It was found that there was considerable intra- and inter-patient variation that had not previously been reported and the causes and consequences of such variation were considered. A detailed evaluation of available pharmacokinetic techniques was undertaken and 1- and 2-compartment models were optimised with regard to sampling procedures, analytical error and model-error. The implications for control of therapy are discussed and an improved sampling regime is proposed for routine usage. Similar techniques were applied to trimethoprim, assayed by HPLC, in patients with normal renal function and investigations were also commenced into the penetration of drug into peritoneal dialysate. Novel assay techniques were also developed for a range of drugs including 4-aminopyridine, chloramphenicol, metronidazole and a series of penicillins and cephalosporins. Stability studies on cysteamine, reaction-rate studies on creatinine-picrate and structure-activity relationships in HPLC of aminopyridines are also reported.

Ogranic geochemistry and SST reconstruction for Pliocene and Miocene Madeira Abyssal Plain turbidites

Free and "bound" long-chain alkenones (C37?2 and C37?3) in oxidized and unoxidized sections of four organic matter-rich Pliocene and Miocene Madeira Abyssal Plain turbidites (one from Ocean Drilling Program site 951B and three from site 952A) were analyzed to determine the effect of severe post depositional oxidation on the value of Uk'37. The profiles of both alkenones across the redox boundary show a preferential degradation of the C37?3 compared to the C37?2 compound. Because of the high initial Uk'37 values and the way of calculating the Uk'37 this degradation hardly influences the Uk'37 profiles. However, for lower Uk'37 values, measured selective degradation would increase Uk'37 up to 0.17 units, equivalent to 5°C. For most of the Uk'37 band-width, much smaller degradation already increases Uk'37 beyond the analytical error (0.017 units). Consequently, for interpreting the Uk'37 record in terms of past sea surface temperatures, selective degradation needs serious consideration.

Analytical and numerical solutions of the space and time fractional bloch-torrey equation

Fractional order dynamics in physics, particularly when applied to diffusion, leads to an extension of the concept of Brown-ian motion through a generalization of the Gaussian probability function to what is termed anomalous diffusion. As MRI is applied with increasing temporal and spatial resolution, the spin dynamics are being examined more closely; such examinations extend our knowledge of biological materials through a detailed analysis of relaxation time distribution and water diffusion heterogeneity. Here the dynamic models become more complex as they attempt to correlate new data with a multiplicity of tissue compartments where processes are often anisotropic. Anomalous diffusion in the human brain using fractional order calculus has been investigated. Recently, a new diffusion model was proposed by solving the Bloch-Torrey equation using fractional order calculus with respect to time and space (see R.L. Magin et al., J. Magnetic Resonance, 190 (2008) 255-270). However effective numerical methods and supporting error analyses for the fractional Bloch-Torrey equation are still limited. In this paper, the space and time fractional Bloch-Torrey equation (ST-FBTE) is considered. The time and space derivatives in the ST-FBTE are replaced by the Caputo and the sequential Riesz fractional derivatives, respectively. Firstly, we derive an analytical solution for the ST-FBTE with initial and boundary conditions on a finite domain. Secondly, we propose an implicit numerical method (INM) for the ST-FBTE, and the stability and convergence of the INM are investigated. We prove that the implicit numerical method for the ST-FBTE is unconditionally stable and convergent. Finally, we present some numerical results that support our theoretical analysis.

The analytical solution and numerical solution of the fractional diffusion-wave equation with damping

Fractional partial differential equations have been applied to many problems in physics, finance, and engineering. Numerical methods and error estimates of these equations are currently a very active area of research. In this paper we consider a fractional diffusionwave equation with damping. We derive the analytical solution for the equation using the method of separation of variables. An implicit difference approximation is constructed. Stability and convergence are proved by the energy method. Finally, two numerical examples are presented to show the effectiveness of this approximation.

Identification and elimination of a matrix-induced systematic error in LA–ICP–MS 206Pb/238U dating of zircon

Black et al. (2004) identified a systematic difference between LA–ICP–MS and TIMS measurements of 206Pb/238U in zircons, which they correlated with the incompatible trace element content of the zircon. We show that the offset between the LA–ICP–MS and TIMS measured 206Pb/238U correlates more strongly with the total radiogenic Pb than with any incompatible trace element. This suggests that the cause of the 206Pb/238U offset is related to differences in the radiation damage (alpha dose) between the reference and unknowns. We test this hypothesis in two ways. First, we show that there is a strong correlation between the difference in the LA–ICP–MS and TIMS measured 206Pb/238U and the difference in the alpha dose received by unknown and reference zircons. The LA–ICP–MS ages for the zircons we have dated can be as much as 5.1% younger than their TIMS age to 2.1% older, depending on whether the unknown or reference received the higher alpha dose. Second, we show that by annealing both reference and unknown zircons at 850 °C for 48 h in air we can eliminate the alpha-dose-induced differences in measured 206Pb/238U. This was achieved by analyzing six reference zircons a minimum of 16 times in two round robin experiments: the first consisting of unannealed zircons and the second of annealed grains. The maximum offset between the LA–ICP–MS and TIMS measured 206Pb/238U for the unannealed zircons was 2.3%, which reduced to 0.5% for the annealed grains, as predicted by within-session precision based on counting statistics. Annealing unknown zircons and references to the same state prior to analysis holds the promise of reducing the 3% external error for the measurement of 206Pb/238U of zircon by LA–ICP–MS, indicated by Klötzli et al. (2009), to better than 1%, but more analyses of annealed zircons by other laboratories are required to evaluate the true potential of the annealing method.

Digital elevation model error in terrain analysis

Digital elevation models (DEMs) have been an important topic in geography and surveying sciences for decades due to their geomorphological importance as the reference surface for gravita-tion-driven material flow, as well as the wide range of uses and applications. When DEM is used in terrain analysis, for example in automatic drainage basin delineation, errors of the model collect in the analysis results. Investigation of this phenomenon is known as error propagation analysis, which has a direct influence on the decision-making process based on interpretations and applications of terrain analysis. Additionally, it may have an indirect influence on data acquisition and the DEM generation. The focus of the thesis was on the fine toposcale DEMs, which are typically represented in a 5-50m grid and used in the application scale 1:10 000-1:50 000. The thesis presents a three-step framework for investigating error propagation in DEM-based terrain analysis. The framework includes methods for visualising the morphological gross errors of DEMs, exploring the statistical and spatial characteristics of the DEM error, making analytical and simulation-based error propagation analysis and interpreting the error propagation analysis results. The DEM error model was built using geostatistical methods. The results show that appropriate and exhaustive reporting of various aspects of fine toposcale DEM error is a complex task. This is due to the high number of outliers in the error distribution and morphological gross errors, which are detectable with presented visualisation methods. In ad-dition, the use of global characterisation of DEM error is a gross generalisation of reality due to the small extent of the areas in which the decision of stationarity is not violated. This was shown using exhaustive high-quality reference DEM based on airborne laser scanning and local semivariogram analysis. The error propagation analysis revealed that, as expected, an increase in the DEM vertical error will increase the error in surface derivatives. However, contrary to expectations, the spatial au-tocorrelation of the model appears to have varying effects on the error propagation analysis depend-ing on the application. The use of a spatially uncorrelated DEM error model has been considered as a 'worst-case scenario', but this opinion is now challenged because none of the DEM derivatives investigated in the study had maximum variation with spatially uncorrelated random error. Sig-nificant performance improvement was achieved in simulation-based error propagation analysis by applying process convolution in generating realisations of the DEM error model. In addition, typology of uncertainty in drainage basin delineations is presented.

Uniformly valid analytical solution to the problem of a decaying shock wave

An explicit representation of an analytical solution to the problem of decay of a plane shock wave of arbitrary strength is proposed. The solution satisfies the basic equations exactly. The approximation lies in the (approximate) satisfaction of two of the Rankine-Hugoniot conditions. The error incurred is shown to be very small even for strong shocks. This solution analyses the interaction of a shock of arbitrary strength with a centred simple wave overtaking it, and describes a complete history of decay with a remarkable accuracy even for strong shocks. For a weak shock, the limiting law of motion obtained from the solution is shown to be in complete agreement with the Friedrichs theory. The propagation law of the non-uniform shock wave is determined, and the equations for shock and particle paths in the (x, t)-plane are obtained. The analytic solution presented here is uniformly valid for the entire flow field behind the decaying shock wave.

Experimental validation of analytical performance models for IEEE 802.11 networks

We consider the simplest IEEE 802.11 WLAN networks for which analytical models are available and seek to provide an experimental validation of these models. Our experiments include the following cases: (i) two nodes with saturated queues, sending fixed-length UDP packets to each other, and (ii) a TCP-controlled transfer between two nodes. Our experiments are based entirely on Aruba AP-70 access points operating under Linux. We report our observations on certain non-standard behavior of the devices. In cases where the devices adhere to the standards, we find that the results from the analytical models estimate the experimental data with a mean error of 3-5%.

Bit Error Probability Analysis of SSK in DF Relaying with Threshold-Based Best Relay Selection and Selection Combining

In this letter, we analyze the end-to-end average bit error probability (ABEP) of space shift keying (SSK) in cooperative relaying with decode-and-forward (DF) protocol, considering multiple relays with a threshold based best relay selection, and selection combining of direct and relayed paths at the destination. We derive an exact analytical expression for the end-to-end ABEP in closed-form for binary SSK, where analytical results agree with simulation results. For non-binary SSK, approximate analytical and simulation results are presented.