Misdiagnosis of Clostridioides difficile Infections by Standard-of-Care Specimen Collection and Testing among Hospitalized Adults, Louisville, Kentucky, USA, 2019-20201.

Although Clostridioides difficile infection (CDI) incidence is high in the United States, standard-of-care (SOC) stool collection and testing practices might result in incidence overestimation or underestimation. We conducted diarrhea surveillance among inpatients >50 years of age in Louisville, Kentucky, USA, during October 14, 2019-October 13, 2020; concurrent SOC stool collection and CDI testing occurred independently. A study CDI case was nucleic acid amplification test‒/cytotoxicity neutralization assay‒positive or nucleic acid amplification test‒positive stool in a patient with pseudomembranous colitis. Study incidence was adjusted for hospitalization share and specimen collection rate and, in a sensitivity analysis, for diarrhea cases without study testing. SOC hospitalized CDI incidence was 121/100,000 population/year; study incidence was 154/100,000 population/year and, in sensitivity analysis, 202/100,000 population/year. Of 75 SOC CDI cases, 12 (16.0%) were not study diagnosed; of 109 study CDI cases, 44 (40.4%) were not SOC diagnosed. CDI incidence estimates based on SOC CDI testing are probably underestimated.

Epidemic Management via Imperfect Testing: A Multi-criterial Perspective.

Diagnostic testing may represent a key component in response to an ongoing epidemic, especially if coupled with containment measures, such as mandatory self-isolation, aimed to prevent infectious individuals from furthering onward transmission while allowing non-infected individuals to go about their lives. However, by its own nature as an imperfect binary classifier, testing can produce false negative or false positive results. Both types of misclassification are problematic: while the former may exacerbate the spread of disease, the latter may result in unnecessary isolation mandates and socioeconomic burden. As clearly shown by the COVID-19 pandemic, achieving adequate protection for both people and society is a crucial, yet highly challenging task that needs to be addressed in managing large-scale epidemic transmission. To explore the trade-offs imposed by diagnostic testing and mandatory isolation as tools for epidemic containment, here we present an extension of the classical Susceptible-Infected-Recovered model that accounts for an additional stratification of the population based on the results of diagnostic testing. We show that, under suitable epidemiological conditions, a careful assessment of testing and isolation protocols can contribute to epidemic containment, even in the presence of false negative/positive results. Also, using a multi-criterial framework, we identify simple, yet Pareto-efficient testing and isolation scenarios that can minimize case count, isolation time, or seek a trade-off solution for these often contrasting epidemic management objectives.

Reactive Arthritis

Reactive arthritis develops as a sequela of a remote infection, usually of the gastrointestinal or genitourinary tract. The presence of acute arthritis and absence of specific diagnostic test markers can lead to misdiagnosis. Prompt recognition and proper management prevent reactive arthritis from progressing to a chronic destructive arthritis. The nurse practitioner's familiarity with reactive arthritis, signs and symptoms, diagnostic criteria, and treatment regimen promote early intervention for achieving the best outcomes, including remission.

Diagnosis and treatment of spontaneous splenic rupture associated with severe acute respiratory syndrome coronavirus 2

Coronavirus disease 2019 (COVID-19) is an acute viral disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and is mainly transmitted through the respiratory tract. It not only invades the respiratory system of human body, but also damages various organs and systems. Evidence has shown that there may be a causal association between SARS-CoV-2 and spontaneous splenic rupture. This article recognizes the possibility of SARS-CoV-2-associated spontaneous splenic rupture and discusses its pathogenesis and related diagnosis and treatment regimens, so as to avoid missed diagnosis and misdiagnosis in clinical practice.

A Curious Case of New-Onset Diabetes

New-onset type 1 diabetes most frequently presents with diabetic ketoacidosis in young patients. A subset of patients with autoimmune type 1 diabetes may present with a slower progression to insulin deficiency and are frequently misdiagnosed with type 2 diabetes. Clinicians should screen for type 1 diabetes in patients who present with hyperglycemia and do not have obvious signs of insulin resistance or obesity. This case report presents an adult patient with hyperglycemia after a hospital admission for coronavirus disease 2019 and the evidence used to diagnose type 1 diabetes with atypical presentation.

Hospital dual-channel adoption decisions with telemedicine referral and misdiagnosis.

With the rapid development of telemedicine and the impact of the COVID-19 pandemic, more and more patients are now resorting to using telemedicine channels for healthcare services. However, for hospitals, there exists a lack of managerial guidance in place to help them adopt telemedicine in a practical and standardized way. This study considers a hospital operating with both telemedicine (virtual) and face-to-face (physical) medical channels, and which allocates its capacity by also taking into account the possibility of both referrals and misdiagnosis. Methodologically, we construct a game model based on a queuing framework. We first analyze equilibrium strategies for patient arrivals. Then we propose the necessary conditions for a hospital to develop a telemedicine channel and to operate both channels simultaneously. Finally, we find the optimal decisions for the service level of telemedicine, which can also be regarded as the optimal proportion of diseases treated by telemedicine, and the optimal hospital capacity allocation ratio between the two channels. We also find that hospitals in a full coverage market (e.g., for certain small-scale hospitals and community hospitals or cancer hospitals) are more difficult to adopt telemedicine than hospitals in a partial coverage market (e.g., for comprehensive large-scale hospitals with many potential patients). Small-scale hospitals are more suited to operating telemedicine as a gatekeeper to help triage patients, while large hospitals are more prone to regard telemedicine as a medical channel for providing professional medical services to patients. We also analyze the effects of the telemedicine cure rate and the cost ratio of telemedicine to the physical hospital on the overall healthcare system performance, including the physical hospital arrival rate, patients' waiting time, total profit, and social welfare. Then we compare the performance, ex ante versus ex post, the implementation of telemedicine. It is shown that when the market is partially covered, the total social welfare is always higher than it was before the implementation. However, as far as the profit goes, if the telemedicine cure rate is low and the cost ratio is high, the total hospital profit may be lower than it was prior to using telemedicine. However, the profit and social welfare of hospitals in the full coverage market are always lower than it was before the implementation. In addition, the waiting time in the hospital is always higher than that before the implementation, which means that the implementation of telemedicine will make patients who must receive treatment in the physical hospital face even worse congestion than before. More insights and results are gleaned from a series of numerical studies.

A Confusing Final Diagnosis in the Differential Diagnosis of SARS-Cov-2 Associated Multisystem Inflammatory Syndrome in Children: Salmonellosis

Multisystem Inflammatory Syndrome in Children (MIS-C) is a severe clinical condition associated with the SARS-CoV-2 infection characterized by an increased inflammatory response. MIS-C shares common features with other pediatric inflammatory and infectious conditions including bacterial infections. Salmonella infections should be kept in mind as a causative agent of bacterial gastroenteritis in the differential diagnosis of patients with suspected MIS-C to avoid misdiagnosis. In this report, a case series of pediatric patients with a final diagnosis of salmonellosis were presented, although a primarily diagnosis of MIS-C at admission was considered due to symptoms and findings together with strong laboratory or epidemiological evidence for SARS-CoV-2 infection. Copyright © 2022 Ankara Pediatric Hematology Oncology Training and Research Hospital. All rights reserved.

Misdiagnoses in the Context of Suspected Pandemic Influenza or Coronavirus Disease 2019: A Systematic Review.

There have been numerous reports of patients initially misdiagnosed in the 2009 H1N1 influenza and coronavirus disease 2019 (COVID-19) pandemics within the literature. A systematic review was undertaken to collate misdiagnoses during the H1N1 and COVID-19 pandemics and identify which cognitive biases may contribute to this. MEDLINE, Embase, Cochrane and MedRxiv databases were searched for misdiagnoses or cognitive biases resulting in misdiagnosis, occurring during the H1N1 or COVID-19 virus pandemics. Eligible studies were assessed for quality using JBI criteria; primary outcome was the final diagnosis. Sixty-nine studies involving 2551 participants were included. We identified 686 cases of misdiagnosis, categorized as viral respiratory infection, other respiratory infection, non-respiratory infection, and non-infective. Misdiagnoses are listed and relevant investigations are offered. No article described prospective assessment of decision making in the pandemic setting or debiasing diagnostic thinking. Further research is required to understand why misdiagnoses occur and harm arises and how clinicians can be assisted in their decision making in a pandemic context.

Vexas Syndrome Presenting As Long Covid-19

Objective VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a recently described systemic inflammatory syndrome caused by somatic mutations of UBA1. COVID-19 is a viral infection that was described in 2019 and spread widely and quickly all around the world. Constitutional, thrombotic and pulmonary symptoms of these two conditions are similar, which is why cases of VEXAS syndrome may be misdiagnosed as a COVID infection. Case report We introduced a case report of a 72-year-old male patient with VEXAS syndrome who had fever, fatigue, deep vein thrombosis and a cough and was thought to have a long COVID-19 infection for one year. Then we diagnosed him with VEXAS syndrome with vacuoles in myelomonocytic cells, skin lesions and a mutation of the UBA-1 gene. Conclusion VEXAS and long COVID are two new conditions with overlapping clinical presentations. Physicians must be aware of these clinical conditions because of their different treatment strategy and prognosis.

Misdiagnosis of COVID-19 infection before molecular confirmation in Sulaimaniyah City, Iraq.

BACKGROUND: During the last 2 years, in the Kurdistan Region, Northern Iraq, there were thousands of COVID-19 cases that have not been reported officially, but diagnosed and confirmed by private laboratories and private hospitals, or clinicians based on typical clinical signs, as well as few people using home self-test after appearing of some flu-like clinical symptoms. Thus, this study aims to assess the misdiagnosis and mismanagement of cases before COVID-19 confirmation. METHODS: This study enrolled 100 consecutive patients who visited an outpatient clinic of Shar Hospital that had symptoms highly suspicious of COVID-19 infection while misdiagnosed previously to have other types of disease. Detailed questionnaires were filled for all studied patients, including age, gender, main presenting symptoms, and duration of these symptoms with the following questions: who made the false diagnosis, depending on which diagnostic test the false diagnosis was made, which medication was used for the false diagnosis, who prescribed those medications, and how long those medications were used. They were investigated by RT-PCR on their nasopharyngeal swab for confirmation. RESULTS: Most of the false diagnoses were typhoid (63%), influenza (14%), pneumonia (9%), gastroenteritis (5%), common cold (4%), brucellosis (4%), and meningitis (1%). Regarding the false diagnosis of cases, 92% were made by non-physician healthcare workers, and only 8% were made by physicians. All false diagnoses with typhoid, gastroenteritis, and common cold were made by non-physician healthcare workers, together with about half of the diagnosis of pneumonia and brucellosis, with statistically significant results (P < 0.001). CONCLUSIONS: We realized that some patients had been misdiagnosed before the COVID-19 infection confirmation. Their health conditions improved drastically after correct diagnosis and treatment, and this research is considered the first research to be conducted in Iraq in this regard.

Corrigendum: Diagnostic Delay of Pulmonary Embolism in COVID-19 Patients.

[This corrects the article DOI: 10.3389/fmed.2021.637375.].

Clinical characteristics of novel coronavirus pneumonia in children in Jinan

Objective: To enhance the understanding of novel coronavirus pneumonia (NCP) in children, to provide reference for the early diagnosis and treatment and to prevent misdiagnosis.

Acute Exacerbation of Rheumatoid Arthritis Misdiagnosed as COVID-19: A Case Report.

Background: Rheumatoid arthritis (RA) is a systemic inflammatory connective tissue disease that affects 1-2% of the population worldwide. Pulmonary manifestations including interstitial lung disease (ILD), airway disease, pleural and vascular disease can be seen in up to 30-40% of patients with RA, which are recognized as the second most frequent cause of death in RA patients. The simultaneous occurrence of COVID-19 in RA patients with or without ILD, and the similarities and differences between RA-related ILD and COVID-19 lung findings have been reported in the literature. However, there was no reported case on differentiation of clinical findings of a patient with RA exacerbation causing a new diagnosis of ILD during the pandemic conditions. Case Presentation: Here, we presented a patient with RA who was misdiagnosed as COVID-19 twice due to non-specific respiratory symptoms and ground-glass opacities observed in high-resolution CT. The misdiagnosis led to a delayed diagnosis of ILD and prolonged pulmonary symptoms. Discussion: Clinicians must critically review patients throughout the diagnostic workup by thinking other diseases besides COVID-19, particularly in the absence of a confirmatory result. The link between ILD or ILD exacerbation and COVID-19 remains to be determined. While research continues in the field, it is important to consider the importance of COVID-19 in cases of ILD exacerbation, and vice versa. Conclusion: Distinguishing lung imaging findings of COVID-19 from ILD is a major concern. Even though the primary manifestation of COVID-19 consists of respiratory symptoms, clinicians should be vigilant for other common conditions having the same symptoms. Clinicians should carefully distinguish a differential diagnosis between COVID-19 and a flare of rheumatic disease.

More on the invisibility of chronic kidney disease and counting.

Lack of awareness of a diagnosis of chronic kidney disease (CKD) in patients and physicians is a major contributor to fueling the CKD pandemic by also making it invisible to researchers and health authorities. This is an urgent matter to tackle if dire predictions of future CKD burden are to be addressed. CKD is set to become the fifth-leading global cause of death by 2040 and the second-leading cause of death before the end of the century in some countries with long life expectancy. Coronavirus disease 2019 (COVID-19) illustrated this invisibility: only after the summer of 2020 did it become clear that CKD was a major driver of COVID-19 mortality, both in terms of prevalence as a risk factor and of the risk conferred for lethal COVID-19. However, by that time the damage was done: news outlets and scientific publications continued to list diabetes and hypertension, but not CKD, as major risk factors for severe COVID-19. In a shocking recent example from Sweden, CKD was found to be diagnosed in just 23% of 57 880 persons who fulfilled diagnostic criteria for CKD. In the very same large cohort, diabetes or cancer were diagnosed in 29% of persons, hypertension in 82%, cardiovascular disease in 39% and heart failure in 28%. Thus, from the point of view of physicians, patients and health authorities, CKD was the least common comorbidity in persons with CKD, ranking sixth, after other better-known conditions. One of the consequences of this lack of awareness was that nephrotoxic medications were more commonly prescribed in patients with CKD who did not have a diagnosis of CKD. Low awareness of CKD may also fuel concepts such as the high prevalence of hypertensive nephropathy when CKD is diagnosed after the better-known condition of hypertension.

Knowledge of general physicians in interpreting chest computed tomography used to examine Coronavirus Disease-2019 in Iran

BACKGROUND: Lung is the primary organ affected by the Coronavirus Disease-2019 (COVID-19) virus, which causes pneumonia, an acute respiratory distress syndrome (ARDS). Lung computed tomography (CT) is a very useful and practical modality in diagnosing COVID-19 due to its speed and high sensitivity in determining the severity. When visiting patients with suspected COVID-19 in hospitals, general practitioners are usually the first medical staff to visit these patients. Therefore, sufficient knowledge in the interpretation of the patients' lung CT scan is essential for general practitioners. CASE REPORT: A 28-year-old male patient referred to a physician at the hospital. He had only the symptoms of shortness of breath and mild chest pain during deep breathing. The general practitioner requested a CT scan of the patient;in addition, the physician diagnosed that the lungs were healthy and prescribed azithromycin and diphenhydramine syrup. Since the patient was a medical staff and was fully acquainted with CT scans, he became suspicious of the stereotype of his lung image and referred to an infectious disease specialist. Upon seeing the CT, the specialist immediately became suspicious of COVID-19 and referred the CT to a radiologist. CONCLUSION: In order to prevent misdiagnosis and spread of COVID-19 in the examinations, it is necessary to enhance the general practitioners' knowledge of the CT scan of lungs of suspected patients and patients with low lung infection, which can be difficult for general practitioners, by infectious disease specialists and radiologists.

Temperature responsive smart polymer for enabling affinity enrichment of current coronavirus (SARS-CoV-2) to improve its diagnostic sensitivity.

The current commercially available SARS-CoV-2 diagnostic approaches including nucleic acid molecular assaying using polymerase chain reaction (PCR) have many limitations and drawbacks. SARS-CoV-2 diagnostic strategies were reported to have a high false-negative rate and low sensitivity due to low viral antibodies or antigenic load in the specimens, that is why even PCR test is recommended to be repeated to overcome this problem. Thus, in anticipation of COVID-19 current wave and the upcoming waves, we should have an accurate and rapid diagnostic tool to control this pandemic. In this study, we developed a novel preanalytical strategy to be used for SARS-CoV-2 specimen enrichment to avoid misdiagnosis. This method depends on the immuno-affinity trapping of the viral target followed by in situ thermal precipitation and enrichment. We designed, synthesized, and characterized a thermal-responsive polymer poly (N-isopropylacrylamide-co-2-hydroxyisopropylacrylamide-co-strained alkyne isopropylacrylamide) followed by decoration with SARS-CoV-2 antibody. Different investigations approved the successful synthesis of the polymeric antibody conjugate. This conjugate was shown to enrich recombinant SARS-CoV-2 nucleocapsid protein samples to about 6 folds. This developed system succeeded in avoiding the misdiagnosis of low viral load specimens using the lateral flow immunoassay test. The strength of this work is that, to the best of our knowledge, this report may be the first to functionalize SARS-CoV-2 antibody to a thermo-responsive polymer for increasing its screening sensitivity during the current pandemic.

Upgrades to intensive care: The effects of COVID-19 on decision-making in the emergency department.

INTRODUCTION: The initial surge of critically ill patients in the COVID-19 pandemic severely disrupted processes at acute care hospitals. This study examines the frequency and causes for patients upgraded to intensive care unit (ICU) level care following admission from the emergency department (ED) to non-critical care units. METHODS: The number of ICU upgrades per month was determined, including the percentage of upgrades noted to have non-concordant diagnoses. Charts with non-concordant diagnoses were examined in detail as to the ED medical decision-making, clinical circumstances surrounding the upgrade, and presence of a diagnosis of COVID-19. For each case, a cognitive bias was assigned. RESULTS: The percentage of upgraded cases with non-concordant diagnoses increased from a baseline range of 14-20% to 41.3%. The majority of upgrades were due to premature closure (72.2%), anchoring (61.1%), and confirmation bias (55.6%). CONCLUSION: Consistent with the behavioral literature, this suggests that stressful ambient conditions affect cognitive reasoning processes.

Diagnostic Delay of Pulmonary Embolism in COVID-19 Patients.

Pulmonary embolism (PE) is a frequent, life-threatening COVID-19 complication, whose diagnosis can be challenging because of its non-specific symptoms. There are no studies assessing the impact of diagnostic delay on COVID-19 related PE. The aim of our exploratory study was to assess the diagnostic delay of PE in COVID-19 patients, and to identify potential associations between patient- or physician-related variables and the delay. This is a single-center observational retrospective study that included 29 consecutive COVID-19 patients admitted to the San Matteo Hospital Foundation between February and May 2020, with a diagnosis of PE, and a control population of 23 non-COVID-19 patients admitted at our hospital during the same time lapse in 2019. We calculated the patient-related delay (i.e., the time between the onset of the symptoms and the first medical examination), and the physician-related delay (i.e., the time between the first medical examination and the diagnosis of PE). The overall diagnostic delay significantly correlated with the physician-related delay (p < 0.0001), with the tendency to a worse outcome in long physician-related diagnostic delay (p = 0.04). The delay was related to the presence of fever, respiratory symptoms and high levels of lactate dehydrogenase. It is important to rule out PE as soon as possible, in order to start the right therapy, to improve patient's outcome and to shorten the hospitalization.

Managing the risks of making the wrong diagnosis: First, do no harm.

The appropriate use of diagnostics is important as misdiagnosis may have serious consequences. Confidence in a diagnostic test result depends on the test's accuracy (sensitivity and specificity) in the context of the use-case (who is tested and why) and the prevalence of the condition investigated. Here, we offer an approach to diagnostics focused on the risks and effects of making the wrong diagnosis. We propose 'fitness brackets' for a given test to define the range within which the test is fit-for-purpose, based on the use-case and risk-management principles. We use as exemplars tests for dengue pre-vaccination screening and tests for diagnosing Covid-19 in different settings.