Performance of diagnostic centers in the classification of opportunistic screening mammograms from the Brazilian public health system (SUS)

Objective To evaluate the performance of diagnostic centers in the classification of mammography reports from an opportunistic screening undertaken by the Brazilian public health system (SUS) in the municipality of Goiânia, GO, Brazil in 2010. Materials and Methods The present ecological study analyzed data reported to the Sistema de Informação do Controle do Câncer de Mama (SISMAMA) (Breast Cancer Management Information System) by diagnostic centers involved in the mammographic screening developed by the SUS. Based on the frequency of mammograms per BI-RADS® category and on the limits established for the present study, the authors have calculated the rate of conformity for each diagnostic center. Diagnostic centers with equal rates of conformity were considered as having equal performance. Results Fifteen diagnostic centers performed mammographic studies for SUS and reported 31,198 screening mammograms. The performance of the diagnostic centers concerning BI-RADS classification has demonstrated that none of them was in conformity for all categories, one center presented conformity in five categories, two centers, in four categories, three centers, in three categories, two centers, in two categories, four centers, in one category, and three centers with no conformity. Conclusion The results of the present study demonstrate unevenness in the diagnostic centers performance in the classification of mammograms reported to SISMAMA from the opportunistic screening undertaken by SUS.

Suggestion of a national diagnostic reference level for 18F-FDG/PET scans in adult cancer patients in Brazil

Objective To suggest a national value for the diagnostic reference level (DRL) in terms of activity in MBq.kg–1, for nuclear medicine procedures with fluorodeoxyglucose (18F-FDG) in whole body positron emission tomography (PET) scans of adult patients. Materials and Methods A survey on values of 18F-FDG activity administered in Brazilian clinics was undertaken by means of a questionnaire including questions about number and manufacturer of the installed equipment, model and detector type. The suggested DRL value was based on the calculation of the third quartile of the activity values distribution reported by the clinics. Results Among the surveyed Brazilian clinics, 58% responded completely or partially the questionnaire; and the results demonstrated variation of up to 100% in the reported radiopharmaceutical activity. The suggested DRL for 18F-FDG/PET activity was 5.54 MBq.kg–1 (0.149 mCi.kg–1). Conclusion The present study has demonstrated the lack of standardization in administered radiopharmaceutical activities for PET procedures in Brazil, corroborating the necessity of an official DRL value to be adopted in the country. The suggested DLR value demonstrates that there is room for optimization of the procedures and 18F-FDG/PET activities administered in Brazilian clinics to reduce the doses delivered to patients. It is important to highlight that this value should be continually revised and optimized at least every five years.

The knowledge about diagnostic imaging methods among primary care and medical emergency physicians

Objective To evaluate the knowledge about diagnostic imaging methods among primary care and medical emergency physicians. Materials and Methods Study developed with 119 primary care and medical emergency physicians in Montes Claros, MG, Brazil, by means of a structured questionnaire about general knowledge and indications of imaging methods in common clinical settings. A rate of correct responses corresponding to ≥ 80% was considered as satisfactory. The Poisson regression (PR) model was utilized in the data analysis. Results Among the 81 individuals who responded the questionnaire, 65% (n = 53) demonstrated to have satisfactory general knowledge and 44% (n = 36) gave correct responses regarding indications of imaging methods. Respectively, 65% (n = 53) and 51% (n = 41) of the respondents consider that radiography and computed tomography do not use ionizing radiation. The prevalence of a satisfactory general knowledge about imaging methods was associated with medical residency in the respondents' work field (PR = 4.55; IC 95%: 1.18-16.67; p-value: 0.03), while the prevalence of correct responses regarding indication of imaging methods was associated with the professional practice in primary health care (PR = 1.79; IC 95%: 1.16-2.70; p-value: 0.01). Conclusion Major deficiencies were observed as regards the knowledge about imaging methods among physicians, with better results obtained by those involved in primary health care and by residents.

Approches diagnostiques des bactéries intracellulaires et des germes fastidieux [Diagnostic approach of intracellular bacteria and fastidious microorganisms].

Obligate or facultative intracellular bacteria are fastidious organisms that do not or poorly grow on conventional culture media. Some of them may be the cause of frequent and potentially severe infections, such as tuberculosis (Myco- bacterium tuberculosis), community-acquired respiratory infections (Legionella spp., Mycoplasma pneumoniae, Chlamydia pneumoniae) or blood culture-negative endocarditis (Coxiella burnetii, Bartonella spp., Tropheryma whipplei). The objective of this paper is to provide a comprehensive summary of the available and recommended diagnostic tests for the detection of these fastidious organisms in clinical practice.

Les besoins en soins de support chez les patients en phase d'un traitement ambulatoire, suivant l'annonce d'un diagnostic de cancer : étude descriptive transversale

Problématique L'incidence du cancer ne cesse d'augmenter dans les pays occidentaux et en Suisse, en constituant la deuxième cause de mortalité après les maladies cardiovasculaires. Si d'une part, les différents traitements oncologiques ont le potentiel de guérir certains cancers et d'augmenter l'espérance de vie des personnes concernées, ils sont associés à de multiples problèmes physiques et psychosociaux. De même, l'annonce de la maladie provoque une fragilité émotionnelle et sociale et la phase de traitement qui suit le diagnostic de cancer est souvent associé à des besoins psychologiques et d'information élevés. But Cette étude vise à décrire les besoins en soins de support insatisfaits chez les patients nouvellement diagnostiqués d'un cancer, au cours d'un traitement ambulatoire dans un Hôpital Cantonal de la Suisse. Elle vise également à identifier les associations entre les besoins en soins de support insatisfaits et les caractéristiques sociodémographiques et médicales. Méthode Cette étude corrélationnelle descriptive a été conduite auprès de 67 patients nouvellement atteints d'un cancer primaire ou d'une récidive, recrutés selon un échantillonnage non probabiliste par convenance consécutive. Le questionnaire auto-administré comprenait le Supportive Care Needs Survey Short Form 34 et un questionnaire sur des données sociodémographiques. Les données médicales ont été collectées par les chercheurs à travers les dossiers médicaux. Résultats Les trois besoins exprimés comme les plus insatisfaits étaient « la peur que le cancer se propage » (48,5%), « l'incertitude face à l'avenir » (45,4%) et « vos préoccupations face à l'incertitude de vos proches » (43,9%). Nous constatons une insatisfaction plus élevée des besoins psychologiques (M: 32,6 ; ET: 20,4) et des besoins d'information (M: 29,3 ; ET: 17,5) par rapport aux autres dimensions de besoins. À propos des caractéristiques associées a un plus haut niveau de besoins insatisfaits, nous trouvons qu'être plus jeune (29-56 ans) ou âgés de > 72 ans est positivement associé aux besoins insatisfaits du domaine psychologique (F = 3,50 ; p = 0,02) et de l'information/système de santé (F = 3,48 ; p = 0,02). Le jeune âge est aussi associé à plus de besoins dans le domaine sexuel (F = 2,85 ; p = 0,04). Il semble exister une association négative entre le niveau d'instruction et le degré d'insatisfaction des besoins psychologiques (F = 2,92, p = 0,06). Être retraité coïncide avec un plus grand degré d'insatisfaction dans les besoins physiques et des activités de la vie quotidienne (F = 4,64 ; p = 0,013). Finalement, avoir un moins bon état général est relié à plus de besoins physiques et de besoins issus du domaine des activités de la vie quotidienne (t = -2,85 ; p = 0,005). Conclusions Les présents résultats concordent avec les études antérieures. Cette étude a la particularité d'avoir identifié les besoins insatisfaits durant la phase de traitement qui suit l'annonce du diagnostic, sans se restreindre à une maladie cancéreuse spécifique, ce qui a été peu effectué auparavant. Les chercheurs infirmiers devraient poursuivre, en collaboration avec d'autres professionnels de la santé, les recherches visant le développement d'approches efficaces pour réduire les besoins insatisfaits chez des personnes atteintes de maladies cancéreuses.

Abdominal tuberculosis: a radiological review with emphasis on computed tomography and magnetic resonance imaging findings

AbstractTuberculosis is a disease whose incidence has increased principally as a consequence of HIV infection and use of immunosuppressive drugs. The abdomen is the most common site of extrapulmonary tuberculosis. It may be confused with several different conditions such as inflammatory bowel disease, cancer and other infectious diseases. Delay in the diagnosis may result in significantly increased morbidity, and therefore an early recognition of the condition is essential for proper treatment. In the present essay, cases with confirmed diagnosis of abdominal tuberculosis were assessed by means of computed tomography and magnetic resonance imaging, demonstrating the involvement of different organs and systems, and presentations which frequently lead radiologists to a diagnostic dilemma. A brief literature review was focused on imaging findings and their respective prevalence.

IRM dans le diagnostic des spondyloarthrites axiales: utilité et pièges diagnostiques [MRI of axial spondyloarthritis: diagnostic role and pitfalls].

MRI has become a major tool for the diagnosis of axial spondyloarthritis and provides objective signs based on which therapy can be initiated. In clinical practice, ASAS classification criteria are often applied for the diagnosis of spondyloarthritis at a pre-radiographic stage. However, MRI signs of spondyloarthritis as stated in ASAS criteria lack specificity, and can be encountered in a wide array of diagnoses, in particular degenerative and mechanical conditions. In this article, we will review the role of MRI in the diagnosis and classification of spondyloarthritis, general technical considerations, the elementary MRI signs of axial spondyloarthritis, as well as diagnostic pitfalls. We also provide a practical approach on how to avoid overdiagnosis of spondyloarthritis and to improve the diagnostic value of MRI.

Proton pump inhibitor-responsive oesophageal eosinophilia: an entity challenging current diagnostic criteria for eosinophilic oesophagitis.

Consensus diagnostic recommendations to distinguish GORD from eosinophilic oesophagitis (EoE) by response to a trial of proton pump inhibitors (PPIs) unexpectedly uncovered an entity called 'PPI-responsive oesophageal eosinophilia' (PPI-REE). PPI-REE refers to patients with clinical and histological features of EoE that remit with PPI treatment. Recent and evolving evidence, mostly from adults, shows that patients with PPI-REE and patients with EoE at baseline are clinically, endoscopically and histologically indistinguishable and have a significant overlap in terms of features of Th2 immune-mediated inflammation and gene expression. Furthermore, PPI therapy restores oesophageal mucosal integrity, reduces Th2 inflammation and reverses the abnormal gene expression signature in patients with PPI-REE, similar to the effects of topical steroids in patients with EoE. Additionally, recent series have reported that patients with EoE responsive to diet/topical steroids may also achieve remission on PPI therapy. This mounting evidence supports the concept that PPI-REE represents a continuum of the same immunological mechanisms that underlie EoE. Accordingly, it seems counterintuitive to differentiate PPI-REE from EoE based on a differential response to PPI therapy when their phenotypic, molecular, mechanistic and therapeutic features cannot be reliably distinguished. For patients with symptoms and histological features of EoE, it is reasonable to consider PPI therapy not as a diagnostic test, but as a therapeutic agent. Due to its safety profile, ease of administration and high response rates (up to 50%), PPI can be considered a first-line treatment before diet and topical steroids. The reasons why some patients with EoE respond to PPI, while others do not, remain to be elucidated.

Diagnostic underestimation of atypical ductal hyperplasia and ductal carcinoma in situ at percutaneous core needle and vacuum-assisted biopsies of the breast in a Brazilian reference institution

Abstract Objective: To determine the rates of diagnostic underestimation at stereotactic percutaneous core needle biopsies (CNB) and vacuum-assisted biopsies (VABB) of nonpalpable breast lesions, with histopathological results of atypical ductal hyperplasia (ADH) or ductal carcinoma in situ (DCIS) subsequently submitted to surgical excision. As a secondary objective, the frequency of ADH and DCIS was determined for the cases submitted to biopsy. Materials and Methods: Retrospective review of 40 cases with diagnosis of ADH or DCIS on the basis of biopsies performed between February 2011 and July 2013, subsequently submitted to surgery, whose histopathological reports were available in the internal information system. Biopsy results were compared with those observed at surgery and the underestimation rate was calculated by means of specific mathematical equations. Results: The underestimation rate at CNB was 50% for ADH and 28.57% for DCIS, and at VABB it was 25% for ADH and 14.28% for DCIS. ADH represented 10.25% of all cases undergoing biopsy, whereas DCIS accounted for 23.91%. Conclusion: The diagnostic underestimation rate at CNB is two times the rate at VABB. Certainty that the target has been achieved is not the sole determining factor for a reliable diagnosis. Removal of more than 50% of the target lesion should further reduce the risk of underestimation.

Diagnostic performance of 3D TSE MRI versus 2D TSE MRI of the knee at 1.5 T, with prompt arthroscopic correlation, in the detection of meniscal and cruciate ligament tears

Abstract Objective: To compare the diagnostic performance of the three-dimensional turbo spin-echo (3D TSE) magnetic resonance imaging (MRI) technique with the performance of the standard two-dimensional turbo spin-echo (2D TSE) protocol at 1.5 T, in the detection of meniscal and ligament tears. Materials and Methods: Thirty-eight patients were imaged twice, first with a standard multiplanar 2D TSE MR technique, and then with a 3D TSE technique, both in the same 1.5 T MRI scanner. The patients underwent knee arthroscopy within the first three days after the MRI. Using arthroscopy as the reference standard, we determined the diagnostic performance and agreement. Results: For detecting anterior cruciate ligament tears, the 3D TSE and routine 2D TSE techniques showed similar values for sensitivity (93% and 93%, respectively) and specificity (80% and 85%, respectively). For detecting medial meniscal tears, the two techniques also had similar sensitivity (85% and 83%, respectively) and specificity (68% and 71%, respectively). In addition, for detecting lateral meniscal tears, the two techniques had similar sensitivity (58% and 54%, respectively) and specificity (82% and 92%, respectively). There was a substantial to almost perfect intraobserver and interobserver agreement when comparing the readings for both techniques. Conclusion: The 3D TSE technique has a diagnostic performance similar to that of the routine 2D TSE protocol for detecting meniscal and anterior cruciate ligament tears at 1.5 T, with the advantage of faster acquisition.

Mycobacterium tuberculosis Infection in Young Children: Analyzing the Performance of the Diagnostic Tests

This study evaluated the performance of the Tuberculin Skin Test (TST) and Quantiferon-TB Gold in-Tube (QFT) and the possible association of factors which may modify their results in young children (0-6 years) with recent contact with an index tuberculosis case. Materials and Methods: A cross-sectional study including 135 children was conducted in Manaus, Amazonas-Brazil. The TST and QFT were performed and the tests results were analyzed in relation to the personal characteristics of the children studied and their relationship with the index case. Results: The rates of positivity were 34.8% (TST) and 26.7% (QFT), with 14.1% of indeterminations by the QFT. Concordance between tests was fair (Kappa = 0.35 P<0.001). Both the TST and QFT were associated with the intensity of exposure (Linear OR = 1.286, P = 0.005; Linear OR = 1.161, P = 0.035 respectively) with only the TST being associated with the time of exposure (Linear OR = 1.149, P = 0.009). The presence of intestinal helminths in the TST+ group was associated with negative QFT results (OR = 0.064, P = 0.049). In the TST- group lower levels of ferritin were associated with QFT+ results (Linear OR = 0.956, P = 0.036). Conclusions: Concordance between the TST and QFT was lower than expected. The factors associated with the discordant results were intestinal helminths, ferritin levels and exposure time to the index tuberculosis case. In TST+ group, helminths were associated with negative QFT results suggesting impaired cell-mediated immunity. The TST-&QFT+ group had a shorter exposure time and lower ferritin levels, suggesting that QFT is faster and ferritin may be a potential biomarker of early stages of tuberculosis infection.

A Diagnostic view of the Genetics of CASADIL

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL, OMIM #125310) is an inherited vascular disease. The main symptoms include migraineous headache, recurrent strokes and progressive cognitive impairment. CADASIL is caused by mutations in the NOTCH3 gene which result in degeneration of vascular smooth muscle cells, arteriolar stenosis and impaired cerebral blood flow. The aims of this study were assessment of the genetic background of Finnish and Swedish CADASIL patients, analysis of genetic and environmental factors that may influence the phenotype, and identification of the optimal diagnostic strategy. The majority of Finnish CADASIL patients carry the p.Arg133Cys mutation. Haplotype analysis of 18 families revealed a region of linkage disequilibrium around the NOTCH3 locus, which is evidence for a founder effect and a common ancestral mutation. Despite the same mutational background, the clinical course of CADASIL is highly variable between and even within families. The association of several genetic factors with the phenotypic variation was investigated in 120 CADASIL patients. Apolipoprotein E allele 4 was associated with earlier occurrence of strokes, especially in younger patients. Study of a pair of monozygotic twins with CADASIL revealed environmental factors which may influence the phenotype, i.e. smoking, statin medication and physical activity. Knowledge of these factors is useful, since life-style choices may influence the disease progression. The clinical CADASIL diagnosis can be confirmed by detection of either the NOTCH3 mutation or granular osmiophilic material by electron microscopy in skin biopsy, although the sensitivity estimates have been contradictory. Comparison of these two methods in a group of 131 diagnostic cases from Finland, Sweden and France demonstrated that both methods are highly sensitive and reliable.

Osteoclastic tartrate-resistant acid phosphatase 5b. Diagnostic use and biological significance in bone physiology

The skeleton undergoes continuous turnover throughout life. In women, an increase in bone turnover is pronounced during childhood and puberty and after menopause. Bone turnover can be monitored by measuring biochemical markers of bone resorption and bone formation. Tartrate-resistant acid phosphatase (TRACP) is an enzyme secreted by osteoclasts, macrophages and dendritic cells. The secreted enzyme can be detected from the blood circulation by recently developed immunoassays. In blood circulation, the enzyme exists as two isoforms, TRACP 5a with an intact polypeptide chain and TRACP 5b in which the polypeptide chain consists of two subunits. The 5b form is predominantly secreted by osteoclasts and is thus associated with bone turnover. The secretion of TRACP 5b is not directly related to bone resorption; instead, the levels are shown to be proportional to the number of osteoclasts. Therefore, the combination of TRACP 5b and a marker reflecting bone degradation, such as C-terminal cross-linked telopeptides of type I collagen (CTX), enables a more profound analysis of the changes in bone turnover. In this study, recombinant TRACP 5a-like protein was proteolytically processed into TRACP 5b-like two subunit form. The 5b-like form was more active both as an acid phosphatase and in producing reactive oxygen species, suggesting a possible function for TRACP 5b in osteoclastic bone resorption. Even though both TRACP 5a and 5b were detected in osteoclasts, serum TRACP 5a levels demonstrated no change in response to alendronate treatment of postmenopausal women. However, TRACP 5b levels decreased substantially, demonstrating that alendronate decreases the number of osteoclasts. This was confirmed in human osteoclast cultures, showing that alendronate decreased the number of osteoclats by inducing osteoclast apoptosis, and TRACP 5b was not secreted as an active enzyme from the apoptotic osteoclasts. In peripubertal girls, the highest levels of TRACP 5b and other bone turnover markers were observed at the time of menarche, whereas at the same time the ratio of CTX to TRACP 5b was lowest, indicating the presence of a high number of osteoclasts with decreased resorptive activity. These results support the earlier findings that TRACP 5b is the predominant form of TRACP secreted by osteoclasts. The major source of circulating TRACP 5a remains to be established, but is most likely other cells of the macrophage-monocyte system. The results also suggest that bone turnover can be differentially affected by both osteoclast number and their resorptive activity, and provide further support for the possible clinical use of TRACP 5b as a marker of osteoclast number.