气管黏液表皮样癌误诊为气管异物1例

1临床资料患儿,男,5岁,因进食后呛咳、发现气管异物4 h于2022-06-17就诊于昆明市儿童医院。患儿家属代诉患儿进食鸡蛋时不慎误吸,随后出现频繁、剧烈呛咳,伴喘息。随即于当地医院就诊,行胸部CT示气管近隆突部2.2 cm处见0.9 cm×0.8 cm稍高密度影,考虑异物(图1A)。诊断为主气管异物梗阻,未行处理,由救护车送至我院ICU。查体:一般情况欠佳,双肺呼吸音粗,可闻及少许痰鸣音,未闻及哮鸣音。入院诊断:气管内异物、呼吸道感染。患儿入ICU后为防止烦躁加重气管异物位置变化,给予舒芬太尼、右美托咪定和丙泊酚持续镇静镇痛,给予头孢唑林钠、奥美拉唑以及地奈德和吸入用盐酸氨溴索雾化。

Evaluation of a Web-based Diagnosis Reminder System for Difficult Diagnostic Reasoning

A web-based diagnosis reminder system may help physicians to perform difficult diagnostic reasoning but its performance has not been evaluated in comparison to that of expert physicians. Clinical case conference was conducted using 10 difficult cases related to internal medicine. Two experienced and expert diagnosticians were invited to comprise a team. A physician assisted with a web-based diagnosis reminder system also participated. Two groups were allowed to propose three possibilities for each case immediately obtaining information on history, physical exam and simple tests. Total scores and the number of accurate diagnoses were greater in the computer-assisted physicianthan in the expert physician team. In conclusion, A web-based diagnosis reminder system can help physicians to well perform difficult diagnostic reasoningcompared to expert physicians.

Potential Usefulness of Diagnostic Reminder as Web-based Clinical Decision Support System

Diagnostic error is prevalent and there is a need for reducing it for improving patient safety. Electronic resources may be candidates as diagnostic decision support systems to assist physicians in clinics or hospitals. A unique system has been developed by consisting of a disease knowledge database coupled with algorithms designed specifically for clinical reminders during real-time diagnostic processes. This system is currently being used as a diagnostic decision-support tool in a clinic base and its usefulness has been empirically evaluated by applying it to the case reports in the New England Journal of Medicine. Further studies are needed to prove its usefulness for reducing diagnostic errors in real clinical practice.

Ten misconceptions regarding decision-making in critical care

Diagnostic errors are prevalent in critical care practice and are associated with patient harm and costs for providers and the healthcare system.Patient complexity,illness severity,and the urgency in initiating proper treatment all contribute to decision-making errors.Clinician-related factors such as fatigue,cognitive overload,and inexperience further interfere with effective decision-making.Cognitive science has provided insight into the clinical decision-making process that can be used to reduce error.This evidence-based review discusses ten common misconceptions regarding critical care decision-making.By understanding how practitioners make clinical decisions and examining how errors occur,strategies may be developed and implemented to decrease errors in Decision-making and improve patient outcomes.

A clinicopathological analysis in unsuspected gallbladder carcinoma: A report of 23 cases

AIM： To study the clinicopathological characteristics of unsuspected gallbladder carcinoma （UGC）. METHODS： We retrospectively studied 23 cases of UGC in Tongji Hospital, and compared their clinicopathological characteristics with 33 cases of preoperatively diagnosed gallbladder carcinoma （PDGC）. RESULTS： The proportion of UGC coexisting with cholecystolithiasis was significantly higher than that of PDGC （x^2 = 13.53, P 〈 0.01）. The infection rate of hepatitis B virus was 21.74% （5/23） in UGC and 30.30% （10/33） in PDGC. Nine （39.13%） of 23 patients with UGC and 8/33 （24.24） PDGC had contact with schistosome pestilent water. The rate of multiple pregnancies was 56.52% （13/23） in the patients with UGC and 42.42% （14/33） in PDGC. The primary location of the UGC was mostly in the neck and body of the gallbladder, and that of the PDGC was often in the body and bottom. The incidence of Nevin stage I and 11 UGC was significantly higher than that of PDGC （x^2 = 4.44, P 〈 0.05 and 2 = 4.96, P 〈 0.05） while that of Nevin stage V UGC was significantly lower than that of PDGC （x^2 = 7.59, P 〈 0.01）. According to the grading of carcinoma, the incidence of well-differentiated UGC was significantly higher than that of PDGC （2 = 4.16, P 〈 0.05）, and that of poorlydifferentiated UGC was significantly lower than that of PDGC （x^2 = 4.48, P 〈 0.05）.CONCLUSION： There are different characteristics between UGC and PDGC, such as in primary location, malignant degree and incidence of coexistence with cholecystolithiasis. Cholecystolithiasis, hepatitis B, schistosome and multiple pregnancies were high risk factors for gallbladder carcinoma.

Cutaneous leishmaniasis presenting with painless ulcer on the right forearm:A case report

BACKGROUND Leishmaniasis includes a range of chronic infections in humans and animals and can be caused by more than 20 species of Leishmania protozoa.The manifestations of leishmaniasis are diverse and dependent on the immune response capacity of the host and the type of Leishmania.In East Asia,leishmaniasis is relatively rare and prone to misdiagnosis and underdiagnosis.CASE SUMMARY We report a case of a 36-year-old male with cutaneous leishmaniasis.The patient had been misdiagnosed with a bacterial skin infection and was given a dressing change and oral levofloxacin,which proved ineffective.Histopathological examination revealed amastigote(Leishman-Donovan body)in the histocytes,and nucleic acid sequencing proved that the pathogen was Leishmania major.The patient was treated successfully by regional injection of sodium gluconate(600 mg)three times.The ulcer healed and did not recur at 1.5-year follow-up.CONCLUSION Skin ulcers caused by leishmaniasis are easily misdiagnosed in non-epidemic countries,yet it should not be overlooked.

粗针穿刺活检明确误诊为甲状腺原发肿瘤的晚期食管癌1例

甲状腺肿物发病率高,随着大众健康意识的提高、体检项目的普及甲状腺和高分辨率彩超的使用,甲状腺肿物的检出率明显增高[1]。大多数基层医院仅根据甲状腺彩超结果选择定期复查或者手术治疗,导致误诊的恶性肿瘤发生进展或良性结节实施了不必要的手术,严重威胁患者的生命安全,加重了患者的经济负担[2]。而一些有条件的医院可选择穿刺活检,这是术前判断甲状腺肿物良恶性的最佳方法,目前多采用超声引导下细针穿刺活检(fine needle aspiration biopsy,FNAB)[3],近年来十堰市太和医院乳腺甲状腺血管外科开展了粗针穿刺活检(core needle biopsy,CNB),笔者诊治了1例以甲状腺肿物为首发表现,通过超声引导下CNB明确为晚期食管癌的病例现报道如下。

Misdiagnosis of Sexually Transmitted Diseases in Hong Kong Outpatient Private Healthcare

Background and objective: Early and accurate diagnosis is one of the critical requirements for successful management of all diseases. Yet, delayed diagnosis and misdiagnosis remain as vital problems, consequently impose adverse effects on patient treatment. Sexually transmitted disease (STD) is one of the most common infectious diseases, and more than one million of STD cases are acquired every day globally. Misdiagnosis of STD inevitably exists, therefore should not be overlooked. Being a medical diagnostic laboratory providing various STDs diagnosing service in Hong Kong, we aimed to determine the misdiagnosis rate of STDs and investigate the possible underlying cause. Methods: Specimens were collected for STD diagnosis from multiple clinics during 1 June 2021 to 20 October 2021 from different clinics and hospitals were included in the study. DNA extraction was performed using magnetic bead based method;then the extracted DNA was tested using the DiagCor GenoFlowTM STD Array kit to detect the existence of any targeted pathogens. Results: 1459 specimens were collected and included during the designated time period, with 643 specimens found to be positive with at least one targeted STD pathogen. 494 of these were found to be aligned with test ordered by physicians, and the remaining 149 positive cases had at least one pathogen detected but not requested to be tested by the physicians resulting in misdiagnosis. The overall misdiagnosis rate was determined to be 23.2% (149/643), with high frequency of misdiagnosis occurred to tests ordered for one to three pathogens detection. Also, Ureaplasma urealyticum and/or Ureaplasma parvum (UU/UP) was the commonest pathogen detected in this study. Conclusion: The findings suggested incorrect test selection made by physicians was one of the major reasons of STDs misdiagnosis in outpatient settings. To reduce diagnostic errors in STD diagnosis, physicians are encouraged to select and request test that allow detection of multiple pathogens, as co-infection of multiple pathogens in STD patients is commonly observed. The correct selection of test would not only benefit the patient, but also the public health.

Diagnostic significance of ultrasonography and CT for large upper abdominal mass

OBJECTIVE: To assess the effect of ultrasonography and computerized tomography (CT) in the diagnosis of large upper abdominal mass. METHODS: Data from 43 cases that were clinically and pathologically confirmed were retrospectively analyzed and the effect of their preoperative ultrasonography and CT was compared. RESULTS: Four of 10 (40 percent) cases of liver mass were diagnosed correctly using ultrasonic device, nineteen of 25 (76 percent) cases of adrenal gland mass and 2 of 4 cases of kidney mass. Two of 10 (20 percent) cases of liver mass were correctly diagnosed by CT, and so were 6 of 22 (27.2 percent) cases of adrenal gland mass. In 4 patients with spleen mass, neither ultrasonography nor CT diagnosis was correct. CONCLUSION: Because upper abdomen organs are closely connected with each other, correct imaging localization of a large mass in this region is not easy. In this study, we compared the accuracy of ultrasonography and CT in diagnosing large upper abdominal masses, and found that ultrasonography works better for adrenal rather than liver or kidney. Neither ultrasonography or CT could accurately diagnose a large mass in the spleen.

A systematic evaluation of the performance of GPT-4 and PaLM2 to diagnose comorbidities in MIMIC-IV patients

Background:Given the strikingly high diagnostic error rate in hospitals,and the recent development of Large Language Models(LLMs),we set out to measure the diagnostic sensitivity of two popular LLMs:GPT-4 and PaLM2.Small-scale studies to evaluate the diagnostic ability of LLMs have shown promising results,with GPT-4 demonstrating high accuracy in diagnosing test cases.However,larger evaluations on real electronic patient data are needed to provide more reliable estimates.Methods:To fill this gap in the literature,we used a deidentified Electronic Health Record(EHR)data set of about 300,000 patients admitted to the Beth Israel Deaconess Medical Center in Boston.This data set contained blood,imaging,microbiology and vital sign information as well as the patients'medical diagnostic codes.Based on the available EHR data,doctors curated a set of diagnoses for each patient,which we will refer to as ground truth diagnoses.We then designed carefully-written prompts to get patient diagnostic predictions from the LLMs and compared this to the ground truth diagnoses in a random sample of 1000 patients.Results:Based on the proportion of correctly predicted ground truth diagnoses,we estimated the diagnostic hit rate of GPT-4 to be 93.9%.PaLM2 achieved 84.7%on the same data set.On these 1000 randomly selected EHRs,GPT-4 correctly identified 1116 unique diagnoses.Conclusion:The results suggest that artificial intelligence(AI)has the potential when working alongside clinicians to reduce cognitive errors which lead to hundreds of thousands of misdiagnoses every year.However,human oversight of AI remains essential:LLMs cannot replace clinicians,especially when it comes to human understanding and empathy.Furthermore,a significant number of challenges in incorporating AI into health care exist,including ethical,liability and regulatory barriers.

Endoscopic characteristics in predicting prognosis of biopsy-diagnosed gastric low-grade intraepithelial neoplasia

Background: Endoscopic biopsy can underestimate gastric malignancies as low-grade intraepithelial neoplasia (LGIN). Definitively diagnosed LGIN would progress. This study aimed to evaluate predictive factors to identify malignancies misdiagnosed as LGIN by biopsy and LGIN at high risk of progression.Methods: The clinical records of patients diagnosed with gastric LGIN by endoscopic biopsy who underwent at least two endoscopies during the first year of follow-up between 2007 and 2017 were retrospectively collected. Three endoscopists reviewed photographs of the initial endoscopy, described lesion characteristics, and made endoscopic diagnoses. Logistic regression was used to analyze predictors to identify malignancies underestimated as LGIN. A receiver operating characteristic curve was used to evaluate the diagnostic accuracy of these predictors. Patient clinical outcomes of follow-up >1 year were collected. Kaplan-Meier estimates with log-rank tests and Cox proportional hazards regression were used to analyze predictors of progression.Results: Overall, 48 of 182 (26.4%) patients were proven to have malignancies. A single lesion, a large lesion size, and marked intestinal metaplasia (IM) were independent predictors of initially misdiagnosed malignancies. The area under the curve of these predictors was 0.871, with a sensitivity of 68.7% and specificity of 92.5%. Twelve of 98 patients (12.2%) progressed during the 33-month median follow-up period. A whitish appearance, irregular margins, marked IM, and histological diagnosis of LGIN more than twice within the first year were predictors for progression.Conclusions: Lesions diagnosed as LGIN by biopsy with marked IM and other predictors above should be prudently treated for high potential to be malignancies or progress. Endoscopic follow-up with repeated biopsies within the first year is recommended.

Analysis of misdiagnosis in patients with multiple trauma

Objective： To explore the features, treatment outcomes and reasons for misdiagnosis in patients with multiple trauma, so as to decrease the incidence of misdiagnosis.Methods： A total of 3 163 patients with multiple trauma who were admitted in our department from August 1997 to August 2008, were retrospectively studied to compare the features of diagnosis and treatment. There were 2 117 males （66.93%） and 1 046 females （33.07%） with the mean age of 36.46 years （range, 14-80 years）. Parameters such as general status, traumatic condition, diagnosis and treatment situation, prognosis and mortality were analyzed. The differences between misdiagnosis group and correct diagnosis group were compared in terms of severity of injury, complications and treatment outcomes to elucidate the cause and prevention of misdiagnosis.Results： The misdiagnosis rate of multiple trauma in this study was 16.19%. The major anatomic sites misdiagnosed were limbs and pelvis （299 positions, 39.50%）, abdominal region and pelvic organ （148 positions, 19.55%）,and thoracic region （109 positions, 14.40%）. In misdiagnosis group, ISS, length of hospital stay, rates of disturbance of consciousness, critical cases and shock cases were 33.78± 19.64, （23.59±7.26） days, 49.22%, 33.01% and 47.46%,respectively, which were significantly higher than those of the correct diagnosis group （P〈0.01）. And the data showed that the more serious the injury was, the higher the rate of misdiagnosis would be. The rate of primary diagnosis by trauma surgeons in correct diagnosis group was 75.78%, significantly higher than that of the misdiagnosis group （ x2=382.01,P〈0.01）. The mortality rate of the mi sdiagnosis group was 2.93%, which was significantly higher than that for all patients （ x2=5.22, P〈0.05）.Conclusions： The results indicated that patients with severe multiple trauma are at high risk of misdiagnosis in early treatment. The mortality rate of misdiagnosed patients is higher than the correctly-diagnosed patients. To prevent misdiagnosis, physicians need to take great care to conduct thorough clinical examinations and repeated evaluation.

Optional therapeutic strategies based on clinically different types of acute pulmonary embolism

OBJECTIVE: To establish a clinical classification of pulmonary embolism (PE), and to evaluate the optional treatment strategies for different types of PE. METHODS: From December 1995 to July 2001, 45 patients with acute PE were hospitalized, of which 33 received intravenous thrombolytic therapy or interventional treatment. RESULTS: Misdiagnostic rate in the 45 patients with acute PE during first visit was 62.2% and mortality rate was 28.9%. Misdiagnostic rate in acute PE patients who had undergone surgery was 82% and mortality rate was 73%. The effective rate of thrombolytic therapy was 77.7%. Clinical symptoms rapidly disappeared in massive PE patients treated with interventional therapies. CONCLUSIONS: Intravenous thrombolytic therapy is one of the most effective methods for treating acute PE. Application of interventional therapy for severe acute PE is also promising.

Chilaiditi syndrome： a case of recurrent respiratory distress

A61-year-old woman was admitted to the Department of Vasculocardiology,First Affiliated Hospital of Zhengzhou University presented with recurrent respiratory distress for 2 weeks without fever,cough,phlegm,chest pain or hemoptysis.Her symptom had generally worsened at night when she lying supine,and that could be partly alleviated when she had a seat or stand for a few minutes.Two weeks ago,the patient was admitted to the local hospital with diagnosis of ＂coronary disease;chronic hepatitis B;stage Ⅱ hypertension＂.After administered with conservative treatment,her symptoms were not significantly alleviated.The patient was then referred to our hospital in September 2012 for further evaluation and treatment.The patient had a past medical history of hypertension with regular medications of compound kendir lenves （one tablet daily） and reserpine （one tablet daily）.Her family history was negative.

Subtrochanteric osteoid osteoma： A misdiagnosed case complicated by a hip fracture

A 34-year-old man with a subtrochanteric osteoid osteoma localized to the lateral cortex of the left femur is reported. The patient presented with mild spontaneous pain of the lateral thigh and knee. He refused a radiographic examination and was treated as a greater trochanteric pa in syndrome for 9 months. He was then admitted with a transcervical fracture of the neck of the left femur after a fall from standing height. The fracture was fixed with 3 cannulated screws and healed uneventfully. His symptoms worsened after the first postoperative year. Eighteen months postoperatively the pain was dull, worsening at night, and relieved only with anti-inflammatory drugs, and he had a limp. New radiographs and tomograms were indicative of a lateral subtrochanteric osteoid osteoma with a subperiosteal localization. The lesion was treated successfully with surgical excision of a piece of reactive bone including the nidus.

Tumor in Cervical Vertebral Canal Misdiagnosed as Cervical Spondylosis: A Case Report

1 Clinical Material A female patient, 44 years old, first visited on November 7th, 2009.Chief complaints: Pain in the right shoulder and back, accompanied by pain and numbness in the right arm for 1 week, worsened with adynamia of fingers.Present history: According to her complaints,