97% of patients told they have fibromyalgia do not meet the diagnostic criteria for this diagnosis, and have treatable disorders, such as nerve entrapments, thoracic outlet syndrome, discs which do not show on MRI, facet syndromes, etc.
Neural blockade for persistent pain after breast cancer surgery Jason Attaman
1) The review examined evidence for neural blockade as a diagnostic tool or treatment for persistent pain after breast cancer surgery.
2) Only 7 studies with a total of 135 patients were identified that used blocks targeting the stellate ganglion, paravertebral plexus, or intercostal nerves.
3) The quality of evidence from the studies was low and inconclusive about the efficacy of neural blockade for treating persistent pain after breast cancer surgery. More high-quality studies are needed to evaluate this common clinical problem.
Evaluating Chronic Pain Patients Using Methods from Johns Hopkins Hospital Ph...Nelson Hendler
This article describes the use of physiological testing, instead of anatomical testing, to evaluate chronic pain. The efficacy of this approach is documented by published outcome studies.,, Patient require surgery 50%-63% of the time to improve.
Missed Diagnoses association in Rear end collisions Nelson Hendler
There are a number of overlooked diagnoses which occur after a rear-end accident. This paper shows an attorney how to convert a misdiagnosed 'soft tissue injury case" into damaged cervical disc,TMJ, thoracic outlet syndrome,and post concussion syndrome using a diagnostic paradigm to get diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This improves patient care and increases recovery.
40%-80% of auto accident claimants have overlooked diagnoses. The most commonly overlooked are thoracic outlet syndrome, cervical disc damage mistakenly called sprain or whiplash, post-concussion syndrome, slipping rib syndrome, Tietze syndrome and Tempro-mandibular joint syndrome. This article tells readers the clinical sign and symptoms of each and the correct medical tests to use, which are employed by doctors at Johns Hopkins Hospital. It also described an on-line questionnaire at www.DiagnoseThePains.com which gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors.
This study compared patient pain scores to those assessed by emergency healthcare providers (doctors and triage nurses) in the emergency department of a large Malaysian hospital. The mean patient pain score on arrival was 6.8 out of 10, significantly higher than scores assessed by doctors (5.6) and triage nurses (4.3). Significant differences were found for 5 specific conditions: soft tissue injury, headache, abdominal pain, fracture, and abscess/cellulitis. Upon discharge or admission, nearly half of patients still reported moderate pain, suggesting undertreatment of pain in the emergency department. Accurately assessing patient-reported pain scores is important for effective pain management in emergency medicine.
The document summarizes guidelines from Canada, Germany, Israel, and Europe for the diagnosis and management of fibromyalgia (FM). Key points include:
- FM is a prevalent condition affecting approximately 2% of the population. It is characterized by chronic widespread pain, fatigue, sleep disturbances, and other symptoms.
- Diagnosis is based on a history and exam showing widespread tenderness. Basic tests can rule out other conditions.
- Optimal management begins with education and a graduated approach focusing first on lifestyle changes like exercise. Cognitive behavioral therapy and medications may also be considered.
- Guidelines agree the diagnosis is clinical. Exams and tests aim to rule out other conditions causing pain. History should include symptoms of pain, fatigue,
Management of pediatric blunt renal trauma a systematic reviewskrentz
This systematic review examines current practices in managing pediatric blunt renal trauma conservatively. 32 studies met the criteria of including cases of high-grade renal injuries in children. The literature supports applying conservative management protocols including observation, percutaneous drainage, stenting, and angioembolization to high-grade pediatric renal trauma, with short and long-term outcomes generally being favorable.
This document summarizes information from various sources on several topics:
1) It provides guidelines from Monroe Carell Jr. Children's Hospital at Vanderbilt for levels of trauma activation, including criteria for level I and level II activations.
2) It discusses the management of pediatric blunt renal trauma, highlighting guidelines that include recommendations for ICU stay, bed rest, imaging and antibiotics based on injury grade.
3) It summarizes literature on non-powder firearm injuries in pediatrics, noting they are underrecognized as dangerous and can cause injuries similar to handguns.
Neural blockade for persistent pain after breast cancer surgery Jason Attaman
1) The review examined evidence for neural blockade as a diagnostic tool or treatment for persistent pain after breast cancer surgery.
2) Only 7 studies with a total of 135 patients were identified that used blocks targeting the stellate ganglion, paravertebral plexus, or intercostal nerves.
3) The quality of evidence from the studies was low and inconclusive about the efficacy of neural blockade for treating persistent pain after breast cancer surgery. More high-quality studies are needed to evaluate this common clinical problem.
Evaluating Chronic Pain Patients Using Methods from Johns Hopkins Hospital Ph...Nelson Hendler
This article describes the use of physiological testing, instead of anatomical testing, to evaluate chronic pain. The efficacy of this approach is documented by published outcome studies.,, Patient require surgery 50%-63% of the time to improve.
Missed Diagnoses association in Rear end collisions Nelson Hendler
There are a number of overlooked diagnoses which occur after a rear-end accident. This paper shows an attorney how to convert a misdiagnosed 'soft tissue injury case" into damaged cervical disc,TMJ, thoracic outlet syndrome,and post concussion syndrome using a diagnostic paradigm to get diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This improves patient care and increases recovery.
40%-80% of auto accident claimants have overlooked diagnoses. The most commonly overlooked are thoracic outlet syndrome, cervical disc damage mistakenly called sprain or whiplash, post-concussion syndrome, slipping rib syndrome, Tietze syndrome and Tempro-mandibular joint syndrome. This article tells readers the clinical sign and symptoms of each and the correct medical tests to use, which are employed by doctors at Johns Hopkins Hospital. It also described an on-line questionnaire at www.DiagnoseThePains.com which gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors.
This study compared patient pain scores to those assessed by emergency healthcare providers (doctors and triage nurses) in the emergency department of a large Malaysian hospital. The mean patient pain score on arrival was 6.8 out of 10, significantly higher than scores assessed by doctors (5.6) and triage nurses (4.3). Significant differences were found for 5 specific conditions: soft tissue injury, headache, abdominal pain, fracture, and abscess/cellulitis. Upon discharge or admission, nearly half of patients still reported moderate pain, suggesting undertreatment of pain in the emergency department. Accurately assessing patient-reported pain scores is important for effective pain management in emergency medicine.
The document summarizes guidelines from Canada, Germany, Israel, and Europe for the diagnosis and management of fibromyalgia (FM). Key points include:
- FM is a prevalent condition affecting approximately 2% of the population. It is characterized by chronic widespread pain, fatigue, sleep disturbances, and other symptoms.
- Diagnosis is based on a history and exam showing widespread tenderness. Basic tests can rule out other conditions.
- Optimal management begins with education and a graduated approach focusing first on lifestyle changes like exercise. Cognitive behavioral therapy and medications may also be considered.
- Guidelines agree the diagnosis is clinical. Exams and tests aim to rule out other conditions causing pain. History should include symptoms of pain, fatigue,
Management of pediatric blunt renal trauma a systematic reviewskrentz
This systematic review examines current practices in managing pediatric blunt renal trauma conservatively. 32 studies met the criteria of including cases of high-grade renal injuries in children. The literature supports applying conservative management protocols including observation, percutaneous drainage, stenting, and angioembolization to high-grade pediatric renal trauma, with short and long-term outcomes generally being favorable.
This document summarizes information from various sources on several topics:
1) It provides guidelines from Monroe Carell Jr. Children's Hospital at Vanderbilt for levels of trauma activation, including criteria for level I and level II activations.
2) It discusses the management of pediatric blunt renal trauma, highlighting guidelines that include recommendations for ICU stay, bed rest, imaging and antibiotics based on injury grade.
3) It summarizes literature on non-powder firearm injuries in pediatrics, noting they are underrecognized as dangerous and can cause injuries similar to handguns.
This document provides an overview of antiseizure drugs (ASDs) used to treat epilepsy. It discusses the classification of ASDs as older first-generation drugs introduced over 40 years ago and newer second- and third-generation drugs introduced in the last 30 years. The document reviews the pharmacokinetics of ASDs, including absorption, metabolism, half-lives, and drug interactions. It also discusses guidelines for selecting ASDs based on seizure type and evaluates the efficacy and tolerability of different ASDs as initial monotherapy for treating epileptic seizures.
Depression Involved in the Chemotherapy Induced Event-based Prospective Memor...IJEAB
The aim of this study was to investigate the relationships between depression and occurrence of chemotherapy induced prospective memory impairment in patients with breast cancer (BC).The 63 BC patients before and after chemotherapy were administered with the self-rating depression scale (SDS) and a battery of cognitive neuropsychological tests including event-based and time-based prospective memory (EBPM and TBPM, respectively) tasks. The changes in their prospective memory and cognitive neuropsychological characteristics before and after chemotherapy were compared. Compared with the scores before chemotherapy, the EBPM score exhibited a statistically significant difference after chemotherapy (t = 6.069, P < 0.01), while the TBPM score showed no significant difference (t = 1.087, P > 0.05). Further, compared with the patients without depression, the patients with depression exhibited a statistically significant difference in the EBPM score (t = -4.348, P < 0.01), while the TBPM scores did not show a statistically significant difference between the two groups (t = -1.260, P > 0.05). Post-chemotherapy, EBPM and overall cognitive functions in BC patients merged with depression were found to decline, while TBPM did not show a significant change, suggesting that the combination of chemotherapy and depression might be related with the occurrence of post-chemotherapy EBPM impairment.
in this slide you will learn about
what is screening
types and uses of screening
difference between screening and diagnostic tests
criteria of screening
and
evaluation of screening tests
This study retrospectively analyzed 2399 pregnant patients who underwent neuraxial blockade (spinal, epidural, or combined spinal-epidural anesthesia) for cesarean section, vaginal delivery, or forceps delivery. The study aimed to describe the incidence of neurological complications, specifically post-dural puncture headache and nerve damage, and identify risk factors. The results found that 3% of patients developed post-dural puncture headache, 0.3% developed lower limb paresthesias, and 0.1% developed transient radicular irritation. Patients who remained in the gynecological position for over 60 minutes had an odds ratio of 1.75 for developing lower limb paresthesias, and
Trial 1 examined the effect of intensive lipid-lowering therapy to achieve an LDL cholesterol level below 70 mg/dL compared to a target range of 90-110 mg/dL in patients with atherosclerotic disease at risk for cardiovascular events. The study found that intensive therapy reduced the risk of cardiovascular events with a hazard ratio of 0.78.
Trial 2 analyzed CSF biomarkers to differentiate idiopathic normal pressure hydrocephalus (iNPH) from other cognitive and movement disorders. The study found that a profile of low levels of tau and Aβ40 and high levels of MCP-1 in CSF increased the probability of iNPH compared to other disorders such as Alzheimer's disease and Parkinson's disease. Combin
This randomized, double-blind, placebo-controlled study evaluated the efficacy and safety of rituximab for relapsing-remitting multiple sclerosis. 104 patients were randomized to receive either rituximab or placebo intravenous infusions. The primary outcome was the number of gadolinium-enhancing lesions on MRI scans from weeks 12-24. Patients receiving rituximab had significantly fewer lesions compared to placebo, indicating rituximab reduces disease activity in multiple sclerosis. Rituximab also decreased relapse rates and reduced lesion volumes on MRI. The most common adverse events were mild to moderate infusion reactions. This study provides evidence that B cell depletion with rituximab is effective and relatively safe for rel
Clinical effect and safety of pulsed radiofrequency treatment for pudendal ne...Jason Attaman
The document describes a prospective, randomized controlled clinical trial that compared the clinical effect and safety of pulsed radiofrequency (PRF) treatment combined with pudendal nerve block (NB) to NB alone for treating pudendal neuralgia. Eighty patients were randomly assigned to receive either PRF+NB or NB. Pain levels, depression scores, treatment effects, analgesic use, and adverse events were assessed over 3 months. The results showed that PRF+NB provided significantly greater pain relief and improved depression scores compared to NB alone, with no severe adverse events reported for either group.
Abstract—In the case of neurological disorders, patient autonomy is a fundamental principle which must be taken into consideration. In the case of this pathology, fluctuating mental deterioration is encountered most frequently in the case of mild forms of dementia. In the case of severe forms of dementia, the patient loses any autonomy and requires permanent medical care, as well as a permanent legal representative.
Aim of this study was to know autonomy of the patients with certain neurological disorders about ability of making decisions for their medical care.
Material and method: It is a quantitative retrospective observational study and data for which is gathered from the observation charts of 323 patients attended in either emergency or outpatient, between April to December 2006, in “Prof. Dr. Nicolae Oblu” Clinical Hospital of Emergency, Iasi, Romania. Study subjects were split into 2 groups: Group 1 (with a number of 215 cases) – a group of patients with the diagnostics of acute cerebrovascular accident, aphasia and dementia. Group 2 (with a number of 108 cases) – patients known or recently diagnosed with amyotrophic lateral sclerosis, multiple sclerosis and myasthenia gravis. Consent informed given by patient in the observation charts of above two groups was observed and number of patients who has given consent was compared in both the groups.
Results: On the cases under study, only for 13.6% of the patients of the first group there is consent informed in the observation chart, while for the patients in the second group this percentage was slightly smaller (9.3%).
Conclusions: As very few patients have given written informed consent and more sever the neurological disorder less the chances to have written informed consent by patients. So it can be concluded that medical performance brings indisputable benefits, however it should be done by a careful selection of the subjects and by following ethical principles.
The main findings of upper endoscopy in 133 patients with laryngopharyngeal reflux were:
1. Gastritis was found in 77% of patients, esophagitis in 59%, and hypofunction of the cardia in 40%.
2. Hiatal hernia was identified in 32% of patients.
3. Barrett's esophagus and neoplasms were found in 9% and 2.2% of patients respectively.
4. Only 12% of patients had a normal endoscopy.
5. Helicobacter pylori was positive in 30% of patients.
The dry needling of myofascial pain syndrome trigger points provided pain relief compared to sham needling.
Cardiology manscript from medical schoolKate Moreng
This study examined risk factor management (RFM) adherence and outcomes among 2,498 acute myocardial infarction (AMI) patients. At 1 month post-discharge, patients reported their recall of receiving RFM instructions and adherence levels, which were categorized as poor, partial, careful, or very careful. Very careful adherence was most common for medication adherence (94%). Patients reporting poor adherence were 58% more likely to report angina at 1 year compared to very careful adherence. However, RFM adherence was not associated with quality of life, physical functioning, rehospitalization, or mortality. While discharge instructions aim to improve post-AMI prognosis, greater research is needed on how adherence impacts outcomes.
Dexamethasone is a corticosteroid that has shown promise in improving outcomes for patients with bacterial meningitis. However, previous studies have found conflicting results on whether it benefits all patients or only certain subgroups. This study conducted a meta-analysis of individual patient data from 5 randomized controlled trials involving 2029 patients to identify which patients are most likely to benefit from dexamethasone treatment. The analysis found that dexamethasone did not significantly reduce death rates or neurological disability overall. It also did not provide significant benefits within any prespecified subgroups based on factors like causative organism, pre-treatment with antibiotics, HIV status, or age. The only benefit seen was a reduction in hearing loss among survivors.
Tapering Long Term Opioid Therapy in Chronic Noncancer PainAde Wijaya
1) Tapering long-term opioid therapy in patients with chronic non-cancer pain can cause withdrawal symptoms and increased pain in the short term or relapse and reduced function in the long term.
2) A slow taper of 10% reduction every 5-7 days is recommended to minimize withdrawal symptoms and improve adherence. Adjunct therapies and psychological support may help during the taper.
3) Optimized nonopioid treatment, interventional procedures, and addressing factors like depression can improve taper outcomes for patients on long-term opioid therapy for chronic non-cancer pain.
Postmastectomy and Post Thoracotomy PainJason Attaman
This document discusses postmastectomy and postthoracotomy pain. It begins by describing the various mechanisms that can cause injury during breast and chest wall surgeries, including damage to muscles, nerves, and formation of scar tissue. It then discusses two specific pain syndromes - postmastectomy pain, which 4-14% of women experience after mastectomy surgery, and postthoracotomy pain, where 26-67% of patients report long-term pain after thoracic surgery. The causes of pain in both syndromes can include tissue injury from surgery or cancer, as well as nerve injury from surgical trauma, radiation, chemotherapy, fibrosis, or cancer metastasis.
This document discusses chronic pain after surgery. It begins with introducing chronic pain as persisting more than 3 months and impacting quality of life. Surgery is recognized as a common cause of chronic pain in pain clinics. The pathophysiology involves central sensitization. Risk factors include surgical technique and nerve injury. Prevention strategies encompass regional anesthesia, preemptive analgesia, and adjuvant drugs like ketamine, gabapentin, and pregabalin. The summary reiterates that perioperative pain can lead to central sensitization and chronic postsurgical pain, while regional blocks may reduce this risk for some surgeries.
1) Plasma exchange (PE) significantly improves outcomes for patients with Guillain-Barré syndrome compared to supportive care alone based on data from multiple randomized controlled trials. PE results in greater improvement in disability and faster recovery.
2) Intravenous immunoglobulin (IVIg) is as effective as PE based on trials comparing the two treatments, with no significant differences in outcomes.
3) Combining PE and IVIg does not provide additional benefit over either treatment alone.
Tollerabilità e sicurezza delle attuali terapie biologiche per la psoriasi ne...Merqurio
This study evaluated the safety and tolerability of biological therapies for psoriasis in 103 patients in Italy over 6 years. Four biological therapies were studied: efalizumab, etanercept, infliximab, and adalimumab. Infliximab had a significantly higher rate of being discontinued due to severe adverse events compared to etanercept and efalizumab. Efalizumab and etanercept demonstrated more favorable safety profiles compared to infliximab. While more patients responded to infliximab initially, long-term tolerability was higher for efalizumab and etanercept due to their better safety profiles and compliance with therapy.
This document discusses screening for diseases from an epidemiological and public health perspective. It defines screening as identifying unrecognized diseases in apparently well people through rapid tests or exams. The objectives of screening are early disease detection to enable prompt treatment, protecting communities from diseases in screened individuals, and determining fitness for certain occupations. Screening tests should be valid, reliable, practical, efficient, and have an acceptable yield. Considerations for an effective screening program include the disease burden, available treatment, screening test qualities, and economic costs versus medical benefits. Biases like lead time bias, where screening only prolongs the time before symptoms without changing disease course, are also discussed.
A talk by Pratik Pandharipande at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All of the conference content can be found here: https://scanfoam.org/ssai2017/
Developed in collaboration between scanFOAM, SSAI and SFAI.
Diagnoses from an on-line expert system for chronic pain confirmed by intra-o...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com is an on-line expert system, which gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. To further confirm the accuracy of the Diagnostic Paradigm, a professor of neurosurgery from the University of Rome found 100% of the time, his intra-operative findings confirmed the diagnoses of the Diagnostic Paradigm. The Diagnostic Paradigm can be used to get pre-authorization for surgery from insurance companies, since it documents medical necessity
Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain ...Nelson Hendler
The Pain Validity Test can predict which patient will have abnormal medical test results with 95% accuracy, and surgical abnormalities with 94% accuracy. This on-line questionnaire takes only 5 minutes of staff time to administer, and takes only 15 minutes of patient time.Results are available immediately. This test can be used to document "medical necessity" for insurance pre-authorization for testing and surgery.
This document provides an overview of antiseizure drugs (ASDs) used to treat epilepsy. It discusses the classification of ASDs as older first-generation drugs introduced over 40 years ago and newer second- and third-generation drugs introduced in the last 30 years. The document reviews the pharmacokinetics of ASDs, including absorption, metabolism, half-lives, and drug interactions. It also discusses guidelines for selecting ASDs based on seizure type and evaluates the efficacy and tolerability of different ASDs as initial monotherapy for treating epileptic seizures.
Depression Involved in the Chemotherapy Induced Event-based Prospective Memor...IJEAB
The aim of this study was to investigate the relationships between depression and occurrence of chemotherapy induced prospective memory impairment in patients with breast cancer (BC).The 63 BC patients before and after chemotherapy were administered with the self-rating depression scale (SDS) and a battery of cognitive neuropsychological tests including event-based and time-based prospective memory (EBPM and TBPM, respectively) tasks. The changes in their prospective memory and cognitive neuropsychological characteristics before and after chemotherapy were compared. Compared with the scores before chemotherapy, the EBPM score exhibited a statistically significant difference after chemotherapy (t = 6.069, P < 0.01), while the TBPM score showed no significant difference (t = 1.087, P > 0.05). Further, compared with the patients without depression, the patients with depression exhibited a statistically significant difference in the EBPM score (t = -4.348, P < 0.01), while the TBPM scores did not show a statistically significant difference between the two groups (t = -1.260, P > 0.05). Post-chemotherapy, EBPM and overall cognitive functions in BC patients merged with depression were found to decline, while TBPM did not show a significant change, suggesting that the combination of chemotherapy and depression might be related with the occurrence of post-chemotherapy EBPM impairment.
in this slide you will learn about
what is screening
types and uses of screening
difference between screening and diagnostic tests
criteria of screening
and
evaluation of screening tests
This study retrospectively analyzed 2399 pregnant patients who underwent neuraxial blockade (spinal, epidural, or combined spinal-epidural anesthesia) for cesarean section, vaginal delivery, or forceps delivery. The study aimed to describe the incidence of neurological complications, specifically post-dural puncture headache and nerve damage, and identify risk factors. The results found that 3% of patients developed post-dural puncture headache, 0.3% developed lower limb paresthesias, and 0.1% developed transient radicular irritation. Patients who remained in the gynecological position for over 60 minutes had an odds ratio of 1.75 for developing lower limb paresthesias, and
Trial 1 examined the effect of intensive lipid-lowering therapy to achieve an LDL cholesterol level below 70 mg/dL compared to a target range of 90-110 mg/dL in patients with atherosclerotic disease at risk for cardiovascular events. The study found that intensive therapy reduced the risk of cardiovascular events with a hazard ratio of 0.78.
Trial 2 analyzed CSF biomarkers to differentiate idiopathic normal pressure hydrocephalus (iNPH) from other cognitive and movement disorders. The study found that a profile of low levels of tau and Aβ40 and high levels of MCP-1 in CSF increased the probability of iNPH compared to other disorders such as Alzheimer's disease and Parkinson's disease. Combin
This randomized, double-blind, placebo-controlled study evaluated the efficacy and safety of rituximab for relapsing-remitting multiple sclerosis. 104 patients were randomized to receive either rituximab or placebo intravenous infusions. The primary outcome was the number of gadolinium-enhancing lesions on MRI scans from weeks 12-24. Patients receiving rituximab had significantly fewer lesions compared to placebo, indicating rituximab reduces disease activity in multiple sclerosis. Rituximab also decreased relapse rates and reduced lesion volumes on MRI. The most common adverse events were mild to moderate infusion reactions. This study provides evidence that B cell depletion with rituximab is effective and relatively safe for rel
Clinical effect and safety of pulsed radiofrequency treatment for pudendal ne...Jason Attaman
The document describes a prospective, randomized controlled clinical trial that compared the clinical effect and safety of pulsed radiofrequency (PRF) treatment combined with pudendal nerve block (NB) to NB alone for treating pudendal neuralgia. Eighty patients were randomly assigned to receive either PRF+NB or NB. Pain levels, depression scores, treatment effects, analgesic use, and adverse events were assessed over 3 months. The results showed that PRF+NB provided significantly greater pain relief and improved depression scores compared to NB alone, with no severe adverse events reported for either group.
Abstract—In the case of neurological disorders, patient autonomy is a fundamental principle which must be taken into consideration. In the case of this pathology, fluctuating mental deterioration is encountered most frequently in the case of mild forms of dementia. In the case of severe forms of dementia, the patient loses any autonomy and requires permanent medical care, as well as a permanent legal representative.
Aim of this study was to know autonomy of the patients with certain neurological disorders about ability of making decisions for their medical care.
Material and method: It is a quantitative retrospective observational study and data for which is gathered from the observation charts of 323 patients attended in either emergency or outpatient, between April to December 2006, in “Prof. Dr. Nicolae Oblu” Clinical Hospital of Emergency, Iasi, Romania. Study subjects were split into 2 groups: Group 1 (with a number of 215 cases) – a group of patients with the diagnostics of acute cerebrovascular accident, aphasia and dementia. Group 2 (with a number of 108 cases) – patients known or recently diagnosed with amyotrophic lateral sclerosis, multiple sclerosis and myasthenia gravis. Consent informed given by patient in the observation charts of above two groups was observed and number of patients who has given consent was compared in both the groups.
Results: On the cases under study, only for 13.6% of the patients of the first group there is consent informed in the observation chart, while for the patients in the second group this percentage was slightly smaller (9.3%).
Conclusions: As very few patients have given written informed consent and more sever the neurological disorder less the chances to have written informed consent by patients. So it can be concluded that medical performance brings indisputable benefits, however it should be done by a careful selection of the subjects and by following ethical principles.
The main findings of upper endoscopy in 133 patients with laryngopharyngeal reflux were:
1. Gastritis was found in 77% of patients, esophagitis in 59%, and hypofunction of the cardia in 40%.
2. Hiatal hernia was identified in 32% of patients.
3. Barrett's esophagus and neoplasms were found in 9% and 2.2% of patients respectively.
4. Only 12% of patients had a normal endoscopy.
5. Helicobacter pylori was positive in 30% of patients.
The dry needling of myofascial pain syndrome trigger points provided pain relief compared to sham needling.
Cardiology manscript from medical schoolKate Moreng
This study examined risk factor management (RFM) adherence and outcomes among 2,498 acute myocardial infarction (AMI) patients. At 1 month post-discharge, patients reported their recall of receiving RFM instructions and adherence levels, which were categorized as poor, partial, careful, or very careful. Very careful adherence was most common for medication adherence (94%). Patients reporting poor adherence were 58% more likely to report angina at 1 year compared to very careful adherence. However, RFM adherence was not associated with quality of life, physical functioning, rehospitalization, or mortality. While discharge instructions aim to improve post-AMI prognosis, greater research is needed on how adherence impacts outcomes.
Dexamethasone is a corticosteroid that has shown promise in improving outcomes for patients with bacterial meningitis. However, previous studies have found conflicting results on whether it benefits all patients or only certain subgroups. This study conducted a meta-analysis of individual patient data from 5 randomized controlled trials involving 2029 patients to identify which patients are most likely to benefit from dexamethasone treatment. The analysis found that dexamethasone did not significantly reduce death rates or neurological disability overall. It also did not provide significant benefits within any prespecified subgroups based on factors like causative organism, pre-treatment with antibiotics, HIV status, or age. The only benefit seen was a reduction in hearing loss among survivors.
Tapering Long Term Opioid Therapy in Chronic Noncancer PainAde Wijaya
1) Tapering long-term opioid therapy in patients with chronic non-cancer pain can cause withdrawal symptoms and increased pain in the short term or relapse and reduced function in the long term.
2) A slow taper of 10% reduction every 5-7 days is recommended to minimize withdrawal symptoms and improve adherence. Adjunct therapies and psychological support may help during the taper.
3) Optimized nonopioid treatment, interventional procedures, and addressing factors like depression can improve taper outcomes for patients on long-term opioid therapy for chronic non-cancer pain.
Postmastectomy and Post Thoracotomy PainJason Attaman
This document discusses postmastectomy and postthoracotomy pain. It begins by describing the various mechanisms that can cause injury during breast and chest wall surgeries, including damage to muscles, nerves, and formation of scar tissue. It then discusses two specific pain syndromes - postmastectomy pain, which 4-14% of women experience after mastectomy surgery, and postthoracotomy pain, where 26-67% of patients report long-term pain after thoracic surgery. The causes of pain in both syndromes can include tissue injury from surgery or cancer, as well as nerve injury from surgical trauma, radiation, chemotherapy, fibrosis, or cancer metastasis.
This document discusses chronic pain after surgery. It begins with introducing chronic pain as persisting more than 3 months and impacting quality of life. Surgery is recognized as a common cause of chronic pain in pain clinics. The pathophysiology involves central sensitization. Risk factors include surgical technique and nerve injury. Prevention strategies encompass regional anesthesia, preemptive analgesia, and adjuvant drugs like ketamine, gabapentin, and pregabalin. The summary reiterates that perioperative pain can lead to central sensitization and chronic postsurgical pain, while regional blocks may reduce this risk for some surgeries.
1) Plasma exchange (PE) significantly improves outcomes for patients with Guillain-Barré syndrome compared to supportive care alone based on data from multiple randomized controlled trials. PE results in greater improvement in disability and faster recovery.
2) Intravenous immunoglobulin (IVIg) is as effective as PE based on trials comparing the two treatments, with no significant differences in outcomes.
3) Combining PE and IVIg does not provide additional benefit over either treatment alone.
Tollerabilità e sicurezza delle attuali terapie biologiche per la psoriasi ne...Merqurio
This study evaluated the safety and tolerability of biological therapies for psoriasis in 103 patients in Italy over 6 years. Four biological therapies were studied: efalizumab, etanercept, infliximab, and adalimumab. Infliximab had a significantly higher rate of being discontinued due to severe adverse events compared to etanercept and efalizumab. Efalizumab and etanercept demonstrated more favorable safety profiles compared to infliximab. While more patients responded to infliximab initially, long-term tolerability was higher for efalizumab and etanercept due to their better safety profiles and compliance with therapy.
This document discusses screening for diseases from an epidemiological and public health perspective. It defines screening as identifying unrecognized diseases in apparently well people through rapid tests or exams. The objectives of screening are early disease detection to enable prompt treatment, protecting communities from diseases in screened individuals, and determining fitness for certain occupations. Screening tests should be valid, reliable, practical, efficient, and have an acceptable yield. Considerations for an effective screening program include the disease burden, available treatment, screening test qualities, and economic costs versus medical benefits. Biases like lead time bias, where screening only prolongs the time before symptoms without changing disease course, are also discussed.
A talk by Pratik Pandharipande at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All of the conference content can be found here: https://scanfoam.org/ssai2017/
Developed in collaboration between scanFOAM, SSAI and SFAI.
Diagnoses from an on-line expert system for chronic pain confirmed by intra-o...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com is an on-line expert system, which gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. To further confirm the accuracy of the Diagnostic Paradigm, a professor of neurosurgery from the University of Rome found 100% of the time, his intra-operative findings confirmed the diagnoses of the Diagnostic Paradigm. The Diagnostic Paradigm can be used to get pre-authorization for surgery from insurance companies, since it documents medical necessity
Predicting Medical Test Results and Intra-Operative Findings in Chronic Pain ...Nelson Hendler
The Pain Validity Test can predict which patient will have abnormal medical test results with 95% accuracy, and surgical abnormalities with 94% accuracy. This on-line questionnaire takes only 5 minutes of staff time to administer, and takes only 15 minutes of patient time.Results are available immediately. This test can be used to document "medical necessity" for insurance pre-authorization for testing and surgery.
In 37 of 38 patients, mistakenly "diagnosed" with fibromyalgia, the authors found 133 other medical diseases, documented by objective medical testing. 97% of patients mistakenly "diagnosed" with fibromyalgia did not meet the diagnostic criteria for this disorder.Two of the authors are past presidents of the American Academy of Pain Management
Screening tests aim to identify unrecognized disease in apparently healthy individuals. They differ from diagnostic tests in that they are applied to groups rather than individuals, use a single criterion, and are less accurate. Validity refers to a test's accuracy while reliability is its precision on repeat tests. Sensitivity measures a test's ability to identify true positives, and specificity measures its ability to identify true negatives. Screening programs must consider factors like disease burden, test characteristics, and whether early detection improves outcomes.
This document summarizes and discusses several articles on physical medicine and rehabilitation (PMR) topics that were published in recent issues of various journals. The articles cover a range of topics including the treatment of 12th rib syndrome, the use of the tourniquet ischemia test to diagnose complex regional pain syndrome, physiotherapy interventions for treating spasticity, a telehealth intervention to increase fitness for those with spinal cord injuries, spinal cord involvement in COVID-19, the use of local anesthetic injections in athletes, and a comparison of video-based and text-based physical activity interventions. The document also provides an introduction and welcome from the editor as well as information about new contributors.
How to Improve the Accuracy of the Initial Evaluation, Using a System Developed By Johns Hopkins Hospital Doctors by Nelson Hendler in Examines in Physical Medicine & Rehabilitation
An Internet questionnaire to predict the presence or absence of organic patho...Nelson Hendler
The Pain Validity Test, developed by a team of physicians from Johns Hopkins Hospital, is available over the Internet, at www.MarylandClinicalDiagnostics.com. The test can predict, with 95% accuracy, which patient will have abnormalities on medical tersting, i.e. who has a valid complaint of pain. The test takes only 5 minutes to set up a patient, 15 minutes for a patient to take the test, and results are available immediately after completion. The test has been admitted as evidence in court cases in over 30 cases in 8 states.
Screening tests are used to detect disease in asymptomatic individuals. They differ from diagnostic tests in that they are applied to large groups of apparently healthy people. An ideal screening test must be inexpensive, acceptable, valid, reliable, and yield meaningful results. Sensitivity, specificity, positive predictive value, and negative predictive value are used to evaluate screening tests. Multiple criteria must be considered when choosing an appropriate screening test for a disease, including the burden of disease and availability of effective treatment. Screening programs can have benefits but also limitations such as lead time bias, length time bias, selection bias, and overdiagnosis.
This document describes a study that surveyed anesthesiologists about their treatment practices for postoperative nausea and vomiting (PONV) in ambulatory patients. The survey found that:
1) When no prophylaxis is given, 67% of anesthesiologists would treat PONV with a 5-HT3 antagonist like ondansetron.
2) 65% would also use non-pharmacological interventions like IV fluids or oxygen.
3) Treatment choices change depending on the prophylaxis given - only 5% would redose metoclopramide or 3% would redose dexamethasone, but 26% would redose a 5-HT3 antagonist.
This study compared outcomes of patients with cerebral cavernous malformations (CCMs) and new-onset seizures who received either initial surgical treatment, initial conservative treatment, or delayed surgical treatment after failed conservative treatment. Results showed that patients who received initial surgical treatment or delayed surgery had better seizure control and were more likely to discontinue antiepileptic drugs than those who received only conservative treatment. However, operative morbidity was low and comparable between surgical groups and conservative treatment. The presence of residual hemosiderin on postoperative imaging was associated with continued seizures after surgery. Overall, the study provides observational evidence that early surgical treatment may improve seizure outcomes for CCM patients with new-onset seizures compared to initial conservative management.
Comparisonof Clinical Diagnoses versus Computerized Test Diagnoses Using the ...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com was able to help the former Dean of Los Angeles Chiropractic College detect medical diagnoses which he had overlooked, and he later confirmed.
The paper lists the correct method of diagnosing chronic pain, and matching the proper medication to tissue damage without the use of narcotics or opioids.
Internal medicine or general medicine (in Commonwealth nations) is the medical specialty dealing with the prevention, diagnosis, and treatment of adult diseases. Physicians specializing in internal medicine are called internists, or physicians
This study assessed outcomes of physical therapy and surgery for 150 patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported measures. 40 patients (27%) had satisfactory improvement with a 6-week physical therapy trial, while 90 (60%) underwent surgery after physical therapy failed. Patients who underwent surgery had greater reductions in disability scores and better patient-rated outcomes compared to those who received only physical therapy. However, pre-treatment factors did not reliably predict who would benefit from each treatment. This study provides information on contemporary outcomes for physical therapy and surgery for NTOS.
This editorial discusses a study that used fMRI to identify a neural signature for physical pain. The signature was found in a distributed network of brain regions and could distinguish between painful heat, warmth, pain anticipation, recall, and social pain. However, the editorial notes that further studies are needed, as the research only examined cutaneous pain and not clinical pain conditions. The findings also have limitations as the social pain stimulus is uncertain and the spatial resolution was limited. Overall, the study provides an example of using neuroimaging to assess clinical symptoms like pain, but pain remains a private experience that can only be reported by patients.
This document summarizes a study examining medical and neurological complications in 279 patients with acute ischemic stroke. The study found that 95% of patients experienced at least one complication. The most common serious medical complication was pneumonia (5%) and the most common serious neurological complication was new or extended cerebral infarction (5%). Medical complications contributed to 51% of deaths within 3 months. Patients with serious medical complications had significantly worse outcomes on functional scales even after accounting for baseline differences.
This document summarizes a systematic review that analyzed randomized controlled drug trials for fibromyalgia syndrome (FMS) and painful diabetic peripheral neuropathy (DPN) to determine the impact of nocebo effects on adverse events reported. The review found that nocebo effects substantially accounted for adverse events in the drug groups for both conditions. Specifically, nocebo effects accounted for 72.0% of dropouts due to adverse events in the FMS drug groups and 44.9% in the DPN drug groups. The review calls for standards to better assess and report adverse events in clinical trials to more accurately determine the risks and benefits of drug therapies.
This document discusses overlapping chronic pain conditions (COPCs), where many common pain conditions frequently co-occur. It notes the high degree of overlap is often not accounted for in clinical trials. The failure to consider the heterogeneous and overlapping nature of chronic pain may result in treatments with only small effects. It presents the concept of COPCs and reviews their epidemiology, finding significant overlap between conditions like headaches, neck pain, and jaw pain in the general US population based on a national health survey. It concludes more research is needed that considers the overlapping nature of chronic pain conditions.
This document discusses overlapping chronic pain conditions (COPCs), where many common pain conditions frequently co-occur and overlap. It notes that COPCs are more prevalent in women than men. The failure to account for the heterogeneous and overlapping nature of most chronic pain conditions may result in small treatment effects when administered to general chronic pain populations. It recommends advancing the understanding of COPCs by considering their overlapping nature in clinical trials and pain condition classifications.
The document reviews diagnostic and treatment errors in trigeminal autonomic cephalalgias (TACs) and hemicrania continua (HC) based on a systematic review of 22 published studies. Some key findings include:
- The most common diagnostic errors were misdiagnosis as migraine, sinusitis, dental issues, or other disorders. Trigeminal autonomic cephalalgias and HC were frequently misdiagnosed even by neurologists and headache specialists.
- Diagnostic delays averaged several years in many studies. Invasive or unnecessary treatments were often prescribed before the correct diagnosis.
- Even after proper diagnosis, some patients continued to receive inappropriate treatments such as beta-blockers,
Similar to Fibromyalgia Over-Diagnosed 97% of the time (20)
Third Party Reporting of Patient Improvement.docxNelson Hendler
Reproting of outcome studies is often subjective. This collection of real leterrs, emails, and Facebook posting provides third party documentation and validation of the efficacy of treatment, without the subjective bias of the party doing the treatment.
Johns Hopkins Hospital doctors report that 40%-80% of chronic pain patient are misdiagnosed, and that MRIs and CTs miss pathology 56%-78% of the time, Therefore, during extensive chart reviews of current medical data will produce a classic case of GIGO-garbage in giving garbage out. The need for accurate diagnoses and testing is critical for AI to work.
Top_Down_or_The_Bottom_Up to Save Money.pdfNelson Hendler
The article describes the need for a more "granular:" assessment of workers' compensation claims, rather than the typical approach of insurance carriers which average large numbers, which causes the loss of valuable data.
The former head of HR for Burger King, British Petroleum, and Walmart, and former Assist. Prof. of Neurosurgery from Johns Hopkins Hospital describe methods to save 54% on workers' compensation using on-line "expert system" questionnaire from Johns Hopkins Hospital doctors
This paper shows how thermography can be used to disprove the misdiagnosis and over used diagnosis of "psychogenic pain." in a group of chronic pain patients.
This article outlines the differences between the anatomical and pharmacological differences between acute and chronic pain. This has significant implications for treatment, since they really are separate disorders.
This study compares the effect of benzodiazepines to narcotics on EEG, memory quotient, and WAIS testing. Valium, Librium, Dalmane and other benzodiazepines produced EEG and cognitive abnormalities in 70% of the patients, while only 30% of patients on narcotics had cognitive impairment.and EEG abnormalities.
Bi-polar patients who were having side-effects from lithium were given spironolactone to control mood swings. Five the 6 had good control for 1 year. The mechanism of membrane stabilization compared to lithium are discussed.
Emg vs. thermography to diagnose crps and radiculopthyNelson Hendler
This large clinical trial (803) patients compares the accuracy of thermography to EMG studies to see which one was a better diagnostic tool for each disorder and the degree of overlap between testing.
Valuable info for orthopedic and neurosurgeons specializing in spinal injuriesNelson Hendler
Reports from Johns Hopkins Hospital doctors document that 40%-80% of patients labeled as soft tissue injury, whiplash, sprain or strain are misdiagnosed. Use of an Internet expert system provides diagnoses with a 96% correlation with diagnoses of former Johns Hopkins Hospital doctors, resulting in a 192% increase in interventional testing, and a 50%-63% increase in surgery in previously misdiagnosed patients, 93% of whom report good to excellent improvement after surgery. .
Headache diagnostc paradigm from former Johns Hopkins Hospital staffNelson Hendler
The medical literature reports that 35%-70% of patients diagnosed with migraine headache do not have this order. The Internet based "expert system" developed by former Johns Hopkins Hospital staff, including the past president of the American Headache Society and American Academy of Pain Management provides an Internet based "expert system" which gives diagnoses with a 94% correlation with diagnosed of these doctors.
This list is all of the researchers who have published articles on the Pain Validity Test and Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com
This document lists the authors of articles on the Pain Validity Test and the Diagnostic Paradigm and Treatment Algorithm. It includes current and former physicians, researchers, and administrators from Johns Hopkins University, Helsinki University, Sapienza University of Rome, and other medical institutions. Some authors held roles like department chairs, professors, and organization presidents.
This is a simplified instruction manual, with screen shots, which will teach staff members how to administer the on-line questionnaires from www.MarylandClinicalDiagnostics.com. It will take any staff member only 15 minutes to review the handbook. Once they have reviewed the handbook, it will take only 5 minutes of staff time to set up a patient to take the tests from www.MarylandClinicalDiagnostics.com
Three Dimensional CT Imaging in post-surgical "failed back" syndromeNelson Hendler
A team of physicians from Johns Hopkins Hospital document that a regular CT misses pathology 56% of the time compared to a 3D-CT. However, if the patient has had previous surgery, the CT misses pathology 76% of the time compared to a 3D-CT. The 3D-CT can be used to combat misdiagnosis of "psychogenic pain patients."
Association between finding of provocativediscogram and vertebral endplate si...Nelson Hendler
Sandhu and his group from Cornell, found that the MRI missed disc pathology 78% of the time compared to a provocative discogram. Therefore, the MRI cannot be relied upon to provide accurate diagnoses of cervical or lumbar disc herniation or damage.
Tom Vesper, Esq. former president of New Jersey Trial Lawyer Association, describes how the Diagnostic Paradigm increased an insurance company offer of $150,000 to $500,000
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Summer is a time for fun in the sun, but the heat and humidity can also wreak havoc on your skin. From itchy rashes to unwanted pigmentation, several skin conditions become more prevalent during these warmer months.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
1. Keywords: Fibromyalgia, overdiagnosis, misdiagnosis, chronic
pain, expert system.
Introduction
No one physician can hope to understand all the complexities
of medicine. For this reason, a variety of specialists, and even
sub-specialists have emerged, to try to enhance patient care, and
provide a degree of expertise that a generalist cannot possibly hope
to achieve. This approach is laudable, because it results in better
patient diagnosis and treatment.
Certainly, the field of diagnosing and treating patients with chronic
pain is nearly as broad as medicine itself, since pain and injuries
are the symptoms that causes a patient to seek medical attention
more than others symptoms [1]. As Sir William Osler, the great
Johns Hopkins physician of the late 19th and early 20th
century
said about syphilis, “…it is almost impossible to describe its
clinical symptoms without mentioning almost every symptom of
every disease known” [2]. Residents at Johns Hopkins Hospital are
also taught that Osler was rumored to have said “ He who knows
syphilis knows medicine,” although this quote does not appear in
his textbook of medicine [3]. A number of approaches to diagnosis
and treatment of chronic patients have emerged. These have
ranged from behavioral modification, to providing nerve blocks
and epidural electrical stimulation [4]. Obvious, in a field so broad
as chronic pain, a multidisciplinary approach is the only logical
way to proceed with diagnosis and treatment [5].
Hendler has published articles indicating that 40% to 67% of
chronic pain patients involved in litigation have overlooked
diagnoses [6,7]. For certain disorders, such as Complex Regional
Pain Syndrome - Type I, (CRPS I) or as it was previously called,
reflex sympathetic dystrophy (RSD), the misdiagnosis rate may
reach 71% [8].
The diagnosis and treatment of patients who have pain at multiple
sites is even more complicated. The American College of
Rheumatology 1990 Criteria for the Classification of Fibromyalgia
are summarized in Table 1. (http://www.nfra.net/Diagnostic.htm,
National Fibromyalgia Research Association).
N = 47
AVERAGE AGE 45.3
Males 3
Females 44
"Post-traumatic Onset (auto accident, lifting, dropped object
on foot, after virus, after injection, golf, fall, throwing ball)."
32
Slow, progressive onset (over months) 15
Table 1: Demographics of patients referred with diagnosis of fibromyalgia.
*
Corresponding author
Nelson Hendler, Former Assistant Professor of Neurosurgery, Johns
Hopkins University School of Medicine, University in Baltimore,
Maryland, US, Tel: 443-277-0306; E-mail: DocNelse@aol.com
Submitted: 20 Sep 2016; Accepted: 29 Sep 2016; Published: 4 Oct 2016
Journal of Anesthesia & Pain Medicine
Volume 1 | Issue 1 | 1 of 7J Anesth Pain Med, 2016
Fibromyalgia Over-Diagnosed 97% of The Time: Chronic Pain Due To Thoracic
Outlet Syndrome, Acromo-Clavicular Joint Syndrome, Disrupted Disc, Nerve
Entrapments, Facet Syndrome and Other Disorders Mistakenly Called Fibromyalgia
Research Article
Nelson Hendler*3
and Thomas Romano2
Abstract
A review was conducted of 47 patients referred to Mensana Clinic with the diagnosis of fibromyalgia, and other
diagnoses. Of the 47 patients, 9 received only an initial evaluation, and 38 received a partial or complete diagnostic
evaluation. The diagnostic criterion for fibromyalgia was not met in 37 of 38 patients. Therefore, 97.3% of patients
were misdiagnosed by referring doctors as having fibromyalgia, when they did not meet the diagnostic criteria
(errors of commission). Additionally, referring physicians made only 7/50 diagnoses (including fibromyalgia) that
were confirmed by objective testing or diagnostic criteria, which means 86 % of the time they made diagnoses that
were not confirmed. Referring physicians also failed to diagnose 133 medical conditions that were confirmed by
objective testing at Mensana Clinic, for a failure to diagnose rate of 94.3% (errors of omission). Of the patients
misdiagnosed with fibromyalgia, i.e. told they had fibromyalgia when they did not, 94.2% of them were women.
1
Former Assistant Professor of Neurosurgery, Johns Hopkins
University School of Medicine.
2
Past president, American Academy of Pain Management.
2. Volume 1 | Issue 1 | 2 of 7J Anesth Pain Med, 2016
This study was conducted to determine how often a physician
rigorously adheres to the diagnostic criteria needed to properly
establish a diagnosis of fibromyalgia, and if there are other
documented diagnostic considerations in so called “fibromyalgia”
patients which may have been overlooked.
Subjects
Charts were reviewed of forty-seven patients who were referred
to Mensana Clinic (a multidisciplinary diagnostic and treatment
center for chronic pain) with the diagnosis of fibromyalgia during
a period from Aug. ’00 to Sept. ’03. Of the 47 patients who were
evaluated, 38 had a partial or complete evaluation at Mensana
Clinic. The demographics of the patient population are show in
Table 1. There were 3 male and 44 female patients, from 5 states.
Methods
Consecutive referrals to Mensana Clinic with the original
diagnosis of fibromyalgia were included in this study. A review
was conducted of the complete medical chart prior to referral
to Mensana Clinic, including laboratory results, and clinical
reports from treating and consulting physicians. Other diagnoses,
in addition to fibromyalgia, made by the referring or treating
physicians, were also recorded. A blind review of the charts was
conducted by one of the authors (TR), who has served as a member
of the committee of the American Rheumatologic Society, which
developed the diagnostic criteria for fibromyalgia. He determined
if the location of the patients complaints, laboratory tests, and
physical examination were compatible with the diagnosis of
fibromyalgia.
As part of the Mensana Clinic program, all patients were evaluated
by the clinical director, for at least one hour, and 38 of the 47
patients received additional diagnostic studies and laboratory
tests done at area hospitals or radiology groups. Nine of the 47
patients received only an initial evaluation, due either to the
fact they did not have adequate insurance coverage to pursue a
multidisciplinary evaluation, or they did not wish to return. They
were excluded from the study. Of the remaining 38 patients, 18/38
had only a partial evaluation, (defined as some recommended,
but not all recommended, objective testing was performed) and
20/38 had a complete multidisciplinary evaluation (defined as all
recommended objective testing was performed). Only patients
with partial or completed evaluations are included in this study.
Depending on the patient’s symptoms objective testing included
flexion extension X-rays of the spine, Doppler flow studies, MRI
of the spine, 3D-CT of the spine, bone scan, electromyography
(EMG, nerve conduction velocity studies (NCV), neurometer
studies (current perception threshold), root blocks, facet blocks,
nerve blocks, sympathetic blocks, provocative discograms, blood
studies, PET of the brain, SPECT of the brain, EEG, MRI of the
brain, and neuropsychological testing.After testing was completed,
the patients also received evaluations for their complaints, with
variousmedicalspecialists,whoareonthefacultyofJohnsHopkins
University School of Medical or University of Maryland School
of Medicine. With the exception of neurometer testing, Mensana
Clinic received no financial gain from testing nor referrals.
To evaluate the findings from the laboratory testing in a clinically
consistent manner, abnormalities were tabulated and categorized
as 1) none present, 2) mild or 3) moderate to severe (Table 2) based
on quantitative and qualitative interpretations, which follow.
Study
Number
of
Patients
Tested
None
Abnormality
Mild
Moderate/
severe
Percent
Abnormal
EMG/NCV 7 1 2 4 85%
Neurometers 28 0 8 20 100%
3D-CT 15 2 2 11 86%
Root block 4 0 0 4 100%
Facet block 3 0 0 3 100%
Doppler Flow 4 0 0 4 100%
Provocative
Discogram
6 0 0 6 100%
MRI 25 2 5 18 92%
Nerve Block 3 0 0 3 100%
Neuropsych
Testing
0 0 0 0 0
PET of Brain 2 2 0 0 0
SPECT of
Brain
2 1 0 1 50%
Bone Scan 1 0 0 1 100%
Gallium 1 0 0 1 100%
Blood Studies 20 3 0 17 85%
DEXA 1 0 1 0 100%
Total Number
of Tests
122 11 18 93 91%
Table 2: Distribution of Test Results Based on Severity ofAbnormality for
Patients Diagnosed with Fibromyalgia partial or complete evals N = 38 of
the original 47 evaluation of tests ordered, 91% of the time an abnormality
was found, that substantiated a disease other than fibromyalgia.
Laboratory results were assessed by the senior author, without the
name of the patient, or admitting diagnosis being known. Specific
criteria for inclusion in a particular category for each test were
codified, as follows: An MRI of the cervical or lumbar spine
was considered mildly abnormal if there was a small central disc
herniation, moderately abnormal if the report indicated frank disc
herniation, and severely abnormal if the report mentioned root
compression, cord compression and/or spinal stenosis. Bulging
discs, spondylosis, degenerative discs and reduced disc space
heightwerenotconsideredabnormal.Provocativediscogramswere
considered moderately abnormal only if the patient experienced
pain concordant with the anatomical distribution of pain they
normally experienced, at the time of the provocation, with a
rating of 5/10 or 6/10 for their pain. Ratings of 7/10 or greater
were considered severely abnormal. Doppler studies of the arms
were considered moderately abnormal only if there was reduction
of pulse wave amplitude of 30% to 50% with Roos maneuver or
180 degrees of abduction, and severely abnormal if the reduction
was 51% or greater. Neural foraminal stenosis was graded based
3. Volume 1 | Issue 1 | 3 of 7J Anesth Pain Med, 2016
on the radiologist’s report of mild, moderate or severe findings
on 3D-CT and/or MRI. Neurometer results were considered
abnormal based on previously published criteria for abnormality
[9]. Electromyographic (EMG) and nerve conduction velocity
(NCV) abnormalities were graded according to the reports from
the physiatrist or neurologist performing the test. Root blocks,
nerve blocks and facet blocks were graded on a comparison of
pain reduction, between pre-block and post block pain, using a
subjective 0-10 pain rating scale. The severity of abnormality of
the PET scan and/or SPECT of the brain was based severity noted
on report from the radiologist.
Diagnosesweregiventoeachpatientatfourstagesintheirtreatment:
1) Referral Diagnoses, that they had prior to being seen at Mensana
Clinic 2) Preliminary Diagnoses after the initial evaluation with
the clinical director of Mensana Clinic, 3) Intermediate Diagnoses,
made after the initiation of the diagnostic evaluation, but before
all diagnostic studies and consultations were completed, and 4)
Final Diagnoses after a complete multidisciplinary evaluation at
Mensana Clinic.
Table 3 shows the distribution of the diagnoses most commonly
used by referring physicians, and whether or not Mensana Clinic
confirmed that diagnosis after an intermediate and/or complete
diagnostic evaluation. Table 4 shows the most common diagnoses
established by Mensana Clinic, documented by abnormal objective
testing (not a clinical diagnosis), after a partial or full diagnostic
evaluation was conducted at Mensana Clinic, and indicates if this
diagnosis was mentioned by the referring physician. Thus, Table
3 represents diagnoses typically used by referring physicians,
and Table 4 represents diagnoses that are typically overlooked by
referring physicians.
N = 38 Diagnosis
Cases at
Referral*
Referral Diagnoses
Confirmed By mensana
clinic
Fibromyalgia 38 1
Sjogren's 1 1
Rheumatoid arthritis 2 1
Osteoarthritis 1 1
Lymes 1 1
Migraine 1 0
Cervical Facet Syn-
drome C2-7
1 1
Reflex sympathetic
dystrophy
4 0
Acromo-clavicular joint
impingement
1 1
Total* 50 7
Table 3: fibromyalgia and other diagnoses used by referring doctors,
Compared to diagnoses confirmed at mensana clinic.
(*some patients had multiple diagnoses), Number of diagnoses made by
referring physicians that were confirmed 7; Number of diagnoses made
by referring physicians that were not confirmed 43/50 (86%); Number of
diagnoses of fibromyalgia that were unconfirmed 37/38 (97.3%).
Number of Patients
Diagnosed by
Referring Physicians
Number of Patients
Diagnosed by
Mensana Clinic*
Diagnosis Made
by Referring
Physician
Diagnosis Missed by
Referring Physician
Made by Mensana Clinic
Fibromyalgia 38 1 37 0
Reflex Sympathetic Dystrophy (n ) 4 0 4 0
Sjogren's (m) 1 2 0 1
Rheumatoid arthritis (m) 2 1 1 0
Osteoarthritis 1 2 0 1
Lymes (m) 1 3 0 2
Lupus (m) 0 3 0 3
Diabetes (m) 0 3 0 3
Migraine 1 0 1 0
Post-mononucleosis syndrome (m) 0 1 0 1
Tietze syndrome 0 3 0 3
Rib Tip Syndrome 0 3 0 3
Post-Concussion Syndrome (a) 0 1 0 1
Pericarditis 0 1 0 1
Hypothyroidism (m) 0 2 0 2
Hyperthyroidism (m) 0 1 0 1
Hashimoto's thyroiditis (m) 0 1 0 1
Hypoparathyropidism (m) 0 2 0 2
Ankylosis Spondylitis (m) 0 2 0 2
4. Volume 1 | Issue 1 | 4 of 7J Anesth Pain Med, 2016
Thoracic Outlet Syndrome (c) 0 15 0 15
Cervical Radiculopathy (d) 0 3 0 3
Cervical Facet Syndrome C2-7 (e) 1 2 0 1
Disrupted Cervical Disc (f) 0 9 0 9
Unstable Cervical Spine (anteriolysthesis) 0 2 0 2
Temporal Mandibular Joint Syndrome (g) 0 7 0 7
Cervical Neural Foraminal Stenosis (i) 0 4 0 4
Ulnar nerve damage (j) 0 9 0 9
Median nerve damage (j) 0 2 0 2
Torn Ligament ankle (k) 0 1 0 1
Abdominal Adhesions (k) 0 1 0 1
ilio-hypogastric N entrapment (j) 0 1 0 1
Acromo-clavicular joint impingement (k) 1 13 0 12
Glenoid labral or subscapularis tear tear
(k)
0 4 0 4
Supraspinatus or bicipital tendonitis (k) 0 7 0 7
Peroneal nerve damage (j) 0 3 0 3
Tibial nerve entrapment (j) 0 1 0 1
Sciatic nerve damage (j) 0 1 0 1
Piriformis Syndrome (j) 0 1 0 1
Lateral Femoral Cutaneous nerve damage
(j)
0 1 0 1
Disrupted Lumbar Disc (f) 0 5 0 5
Lumbar Facet Syndrome L3-S1 (e) 0 6 0 6
Lumbar Neural Foraminal Stenosis (i) 0 1 0 1
Lumbar Radiculopathy (d) 0 1 0 1
Lumbar or Cervical Spinal Stenosis (l) 0 1 0 1
Vasculitis 0 1 0 1
Cerebral Palsy 0 1 0 1
spina bifida occulta 0 1 0 1
Thalamic aneurysm 0 1 0 1
Peripheral Neuropathy 0 1 0 1
Anemia 0 1 0 1
Coccydynia 0 1 0 1
TOTAL DIAGNOSES 50 140 43 133
Table 4: The most common diagnoses in patients diagnosed as fibromyalgia by the referring physicians but having other diagnoses, confirmed by
objective testing at mensana clinic. N = 38 partially completed or completed evaluations (of 47 patients seen with referral diagnoses of fibromyalgia,
and other disorders).
Tests used to confirm diagnoses:
(a) PET, SPECT and/or neuropsychological tests, (b) EEG and/or positive clinical response to anti-convulsants, (c) Dopplers and/or EMG/NCV, (d)
EMG/NCV and/or root block, (e) 3D-CT, MRI and/or facet block, (f) MRI, 3D-CT and/or provocative discogram, (g) cine MRI, (h) ENG and/or BAER,
(i) Flex-Ex X-ray, 3D-CT and/or MRI, (j) neurometer, EMG/NCV and/or nerve block, (k) MRI, (l) MRI and/or 3D-CT, (m) blood studies, (n) bone scan
and/or sympathetic blocks, (o) bone scan, sympathetic blocks, and/or nerve blocks, (p) MRI, (q) MRI, 3D-CT, and/or root block.
Number of correct diagnoses made by referring physicians was 7 (Table 3).
Incorrect diagnosis rate for fibromyalgia was 37/38 or 97.3 % (error of commission)
Overall incorrect diagnosis rate was 43/50 or 86 % (error of commission)
Overall failure to diagnosis rate was 133/140 or 95 % (error of omission)
*all 38 patients had multiple diagnoses.
5. Volume 1 | Issue 1 | 5 of 7J Anesth Pain Med, 2016
Using the criteria above, the results were biased against
abnormalities being found in this group of patients, since a) 18
of the 38 patients did not have a completed diagnostic evaluation
at the time of this article, and b) inclusion criteria for a test to be
considered abnormal were purposely narrow. Laboratory results
were interpreted as normal if there were no findings reported by
outside physicians, or if there were minimal results reported, such
as a disc bulge or spondylosis on MRI, CT or x-ray studies, without
neural foramina stenosis, lateral recess stenosis nor spinal stenosis,
minor arthritic changes on bone scan, relief less than 60% after
nerve blocks, root blocks, or facet blocks, and pain provocation
that was not concordant with the patient’s symptoms, and less than
6/10 on provocative discogram.
For the purposes of this article, a patient was considered to have a
missed diagnosis if:
• The referring physical had made a diagnosis that was
descriptive (low back pain), and not a diagnosis at all,
• The referring physician made a diagnosis of fibromyalgia that
did not meet the diagnostic criteria for this disorder.
• The referring physician made a diagnosis that was not
supported by objective anatomical or physiological testing
later done at Mensana Clinic (having a referral diagnosis of
RSD, but having negative bone scan, and no pain relief for
even one hour, after a properly performed sympathetic block).
For the purposes of this article, a patient was considered to have an
overlooked diagnosis if:
• Mensana Clinic established a diagnosis, not previously
mentioned by the referring physician, and confirmed the
diagnosis by objective testing at Mensana Clinic (such as no
mention of tibial nerve entrapment by the referring physician,
and having the diagnosis made during the Mensana Clinic
evaluation, and confirmed by EMG/nerve conduction velocity
testing and at least one hour of pain relief after a tibial nerve
block).
Results
Of the 47 patients initially evaluated, 38 patients had a partial or
complete multidisciplinary evaluation at Mensana Clinic. As the
result of the diagnoses obtained at the time of the initial evaluation,
a variety of diagnostic studies were ordered.
The results of these diagnostic studies are shown in Table 2. Of the
38 patients with partial or complete evaluations, 122 laboratory
tests were conducted. Mild abnormalities were found on testing in
18/122 tests, and moderate to severe abnormalities were found in
93/122 tests. The diagnostic criterion for fibromyalgia was not met
in 37 of 38 patients, as the result of finding an explanation for the
source of pain. Therefore, 97.3% were misdiagnosed by referring
doctors as having fibromyalgia, when they did not have it (errors
of commission). Of all 122 tests ordered for these 38 patients, 90.9
% were mildly, moderately or severely abnormal, and confirmed
the original clinical diagnosis of the clinical director of Mensana
Clinic 93 % of the time.
Table 3 shows the diagnoses used by referring physicians for their
patients diagnosed with fibromyalgia and other disorders. Of the
50 diagnoses made by referring physicians in 38 patients, only
7 were later confirmed by Mensana Clinic. In this instance, the
referring physician made unsubstantiated diagnoses 86 % of the
time (error of commission).
Table 4 lists 140 confirmed diagnoses established by Mensana
Clinic in the 38 patients originally diagnosed with fibromyalgia
and other disorders by referring physicians. Only 7 diagnoses,
made by referring physicians, were later substantiated by Mensana
Clinic. Referring physicians did not mention 133 diagnoses, which
were later confirmed by Mensana Clinic. Based on these findings,
the overlooked diagnosis rate for so called “fibromyalgia” patients
was 94.3 % (error of omission).
Several concepts can be derived from this research, and are
supported by articles in the literature. One major factor of
fibromyalgia is the pain that patients experience. Chronic pain
patients get depressed as the result of their chronic pain [10].
Depression occurs in 77% of patients with chronic pain, and 89%
of these patients had never been depressed before the onset of
their pain [11]. The severity of pain specifically associated with
fibromyalgia also produced depression [12]. The depression
may last from three to twelve years after the onset of pain [13].
This has dire consequences. Fishbain and his colleagues report
that the completed suicide rate amongst white male chronic pain
patients is two times higher than the general population, and for
white females, it is one and an half times higher than the general
population. However, more startling is the suicide rate for white
males involved in workers compensation litigation, where the
completed suicide rate jumps to 3 times higher than the general
population [14].
In addition to the psychological factors associated with pain, there
are neuropsychological issues, sociological and legal concerns as
well as financial issues, and return to work problems. The need to
increase functioning, despite the use of narcotic medication, drug
diversion, cognitive impairment from medication, the residua from
the injury or the use of medication, religious issues and others, all
make up the complex picture of a chronic pain patient [15].
Itisveryhardtoobjectivelyquantifythesymptomsoffibromyalgia,
even though there have been various attempts, using tenderness
of the pressure points, thyroid hormone, post-traumatic etiology,
hyper-mobility of joints, and neuroticism [16-22].
Moreover, there has been the realization that there is still a need
for precision in applying the diagnostic criteria for fibromyalgia,
ten years after the criteria had been established [23]. This is
further complicated by the great overlap between symptoms of
fibromyalgia and other disorders, such as Lymes disease, systemic
lupus erythematosis (SLE), and Raynaud’s phenomenon, resulting
in patients with unconfirmed symptoms of these disorders
being labeled as fibromyalgia. Additionally, other authors have
recognized the overlap in symptoms between fibromyalgia carpel
6. Volume 1 | Issue 1 | 6 of 7J Anesth Pain Med, 2016
tunnel [24-30]. These articles reported many patients mistakenly
diagnosed with fibromyalgia were correctly diagnosed with carpel
tunnel, which is compatible with the findings of this article [29-
30].
Additionally, this article show that disc disruptions occur in
a significant number of patients mistakenly diagnosed with
fibromyalgia. The mechanisms for the source of pain from internal
disc disruption, which escapes detection on MRI 78% of the time,
have been well described [31,32]. Essentially, the nucleus pulposa
herniates into the posterior portion of the annulus (disc), where pain
fibers are located [32]. However, there is no anatomical disruption
of the disc, so the disc appear normal on MRI but produces the
same clinical features of a herniated disc where the nucleus pulposa
compress the nerve root or spinal cord, with associated neck, back
or limb pain, and severe muscle contractions [31,32].
In order to assist physicians establish the correct diagnoses, and
to avoid both errors of omission and commission, a number of
so called “expert systems” have been developed. The accuracy
of any computer scored and interpreted expert systems is a major
issue. Those expert systems that seem to have the best results are
the ones that focus on a narrow and highly specialized area of
medicine. One questionnaire, consists of 60 questions, to cover
32 rheumatologic diseases, for 358 patients [33]. The correlation
rate was 74.4%, and an error rate of 25.6%, with the 44% of the
errors attributed to “information deficits of the computer using
standardized questions,”, but in a later version “RHEUMA”
was studied prospectively in 51 outpatients, and achieved a 90%
correlation with clinical experts [33,34]. Several groups have
approached the diagnosis of jaundice. ICTERUS produced a 70%
accuracy rate, while ‘Jaundice’ also had a 70% overall accuracy
rate [35,36]. An expert system for vertigo was reported, and it
generated and accuracy rate of 65% [37]. This later was reported as
OtoNeurological Expert (ONE), which generated the exact same
results reported in the earlier article [38]. A group of physicians
from Johns Hopkins Hospital developed an “expert system” which
specifically addressed 104 of the most common chronic pain
problems, including fibromyalgia. This test gives diagnoses with
a 96% correlation with diagnoses of Johns Hopkins Hospital staff
members, and can be found at www.DiagnoseMyPain.com [39].
The questionnaire is available in English, Spanish, Portuguese,
French, Italian, German, Russian, and Arabic, or in English and
Spanish at www.MarylandClinicalDiagnostics.com.
In summary, fibromyalgia may have become the “disease de jour”
for the medical community. The absence of strict adherence to the
diagnostic criteria for diagnosing fibromyalgia has led to many
missed diagnoses [23]. The data presented in this paper support the
concept that more rigorous application of the diagnostic criteria for
fibromyalgia is needed by the medical community. Moreover, there
are many medical problems which have some of the symptoms
of fibromyalgia, but each symptom may have multiple etiologies
and needs to be examined independently, to avoid overlooked or
missed diagnoses.
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