Hypersensitivity pneumonitis: application of a new diagnostic algorithm to a time series of the disease.

BACKGROUND: The diagnostic criteria for Hypersensitivity pneumonitis (HP) have changed over time. Our aim is to apply a recent diagnostic algorithm to a historical series of patients diagnosed with HP to assess its distribution according to current diagnostic criteria and the diagnostic confidence achieved. RESEARCH DESIGN AND METHODS: Application to each patient the algorithm criteria. The diagnosis was HP (≥90%), provisional high (70-89%) or low confidence (51-69%) or non-HP (unlikely) (≤50%); or HP, provisional or non-HP, if they had lung biopsy. RESULTS: 129 patients [mean age 64 ± 12 years; 79 (61.2%) women] were included of which 16 (12.4%) were diagnosed on the basis of high clinical suspicion. After applying the algorithm, 106 patients (82.2%) could be evaluated and 83 (78.3%) had a diagnosis of HP or high confidence. Lung biopsy was able to establish a diagnosis of certainty in another 21 patients and a provisional diagnosis in 9 more [total, 113 (87.6%)]. The 16 patients without strict diagnostic criteria for HP had a low confidence diagnosis. A total of 56 lung biopsies (64.4%) could have been avoided according to the new guidelines. CONCLUSIONS: The application of this algorithm achieves a high diagnostic yield in HP, significantly reducing the number of lung biopsies required.

Degree of Uncertainty in Reporting Imaging Findings for Necrotizing Enterocolitis: A Secondary Analysis from a Pilot Randomized Diagnostic Trial.

Diagnosis of necrotizing enterocolitis (NEC) relies heavily on imaging, but uncertainty in the language used in imaging reports can result in ambiguity, miscommunication, and potential diagnostic errors. To determine the degree of uncertainty in reporting imaging findings for NEC, we conducted a secondary analysis of the data from a previously completed pilot diagnostic randomized controlled trial (2019-2020). The study population comprised sixteen preterm infants with suspected NEC randomized to abdominal radiographs (AXRs) or AXR + bowel ultrasound (BUS). The level of uncertainty was determined using a four-point Likert scale. Overall, we reviewed radiology reports of 113 AXR and 24 BUS from sixteen preterm infants with NEC concern. The BUS reports showed less uncertainty for reporting pneumatosis, portal venous gas, and free air compared to AXR reports (pneumatosis: 1 [1-1.75) vs. 3 [2-3], p < 0.0001; portal venous gas: 1 [1-1] vs. 1 [1-1], p = 0.02; free air: 1 [1-1] vs. 2 [1-3], p < 0.0001). In conclusion, we found that BUS reports have a lower degree of uncertainty in reporting imaging findings of NEC compared to AXR reports. Whether the lower degree of uncertainty of BUS reports positively impacts clinical decision making in infants with possible NEC remains unknown.

Improved Diagnostic Confidence Imparted by Radiologists in Radiology Reports After Educational Interventions on Reporting Styles.

Background Radiology reports are important medico-legal documents facilitating communication between radiologists and referring doctors. Language clarity and precision are crucial for effective communication in these reports. Radiology reporting has changed with the evolution of imaging technology, prompting the adoption of precise terminology. Diagnostic certainty phrases (DCPs) play an important role in communicating diagnostic confidence in radiology reports. Objective The aim of this study was to evaluate the use of DCPs in radiology reports, before and after targeted educational interventions. Materials and methods The study was approved by the Aga Khan University Hospital's Ethical Review Committee and includes cross-sectional radiology reports. It involved three cycles of retrospective evaluation, with educational interventions in between to improve the use of DCPs. Results The study found a dynamic shift in the use of DCPs during the three cycles. Initially, intermediate-certainty phrases prevailed, followed by an increase in high-certainty phrases and a drop in low-certainty phrases. Later cycles showed a significant decline in DCPs and an increase in the use of definitive language. Across all subspecialties, there was a consistent decrease in intermediate- and low-certainty DCPs. Conclusion The study validates the transformative impact of educational interventions on the use of DCPs in radiology reports. The radiology reports frequently used DCPs with intermediate to low diagnostic certainty with improvement in the subsequent cycles of the study after educational interventions. It emphasizes the significance of continuing education to ensure the use of precise nomenclature.

Classification of Diagnostic Certainty in Radiology Reports with Deep Learning.

A radiology report is prepared for communicating clinical information about observed abnormal structures and clinically important findings with referring clinicians. However, such observations and findings are often accompanied by ambiguous expressions, which can prevent clinicians from accurately interpreting the content of reports. To systematically assess the degree of diagnostic certainty for each observation and finding in a report, we defined an ordinal scale comprising five classes: definite, likely, may represent, unlikely, and denial. Furthermore, we applied a deep learning classification model to determine its applicability to in-house radiology reports. We trained and evaluated the model using 540 in-house chest computed tomography reports. The deep learning model achieved a micro F1-score of 97.61%, which indicated that our ordinal scale was suitable for measuring the diagnostic certainty of observations and findings in a report.

Expert Clinician Certainty in Diagnosing Autism Spectrum Disorder in 16-30-Month-Olds: A Multi-site Trial Secondary Analysis.

Differential diagnosis of young children with suspected autism spectrum disorder (ASD) is challenging, and clinician uncertainty about a child's diagnosis may contribute to misdiagnosis and subsequent delays in access to early treatment. The current study was designed to replicate and expand a recent report in this Journal (McDonnell et al. in J Autism Dev Disord 49:1391-1401, https://doi.org/10.1080/15374416.2020.1823850 , 2019), in which only 60% of diagnoses were made with complete certainty by clinicians evaluating 478 toddlers and preschool children referred for possible ASD to specialized clinics. In this study, secondary analyses were performed on diagnostic, demographic and clinical data for 496 16-30-month-old children who were consecutive referrals to a 6-site clinical trial executed by specialized centers with experienced clinicians following best-practice procedures for the diagnosis of ASD. Overall, 70.2% of diagnoses were made with complete certainty. The most important factor associated with clinician uncertainty was mid-level autism-related symptomatology. Mid-level verbal age equivalents were also associated with clinician uncertainty, but measures of symptomatology were stronger predictors. None of the socio-demographic variables, including sex of the child, was significantly associated with clinician certainty. Close to one third of early diagnoses of ASD are made with a degree of uncertainty. The delineation of specific ranges on the ADOS-2 most likely to result in clinician uncertainty identified in this study may provide an opportunity to reduce random subjectivity in diagnostic decision-making via calibration of young-child diagnostic thresholds based on later-age longitudinal diagnostic outcome data, and via standardization of decision-making in regard to clinical scenarios frequently encountered by clinicians.

Clinical manifestations and long-term outcome of early Lyme neuroborreliosis according to the European Federation of Neurological Societies diagnostic criteria (definite versus possible) in central Europe. A retrospective cohort study.

BACKGROUND AND PURPOSE: The characteristics and long-term outcome of Lyme neuroborreliosis (LNB) according to diagnostic certainty (definite vs. possible) are incompletely understood. METHODS: In this retrospective cohort study of adults with definite or possible LNB, clinical and microbiological characteristics and long-term outcome over 12 months were evaluated at a single medical center. Severity of acute disease and long-term outcome were assessed using a composite clinical score encompassing clinical findings and symptoms and by the probability of incomplete recovery. RESULTS: Amongst 311 adult patients enrolled from 2008 to 2017, 139 (44.7%) had definite LNB and 172 (55.3%) had possible LNB. The most frequent LNB manifestation was cranial neuropathy with or without meningitis (53.4%). Patients with definite LNB more often had Bannwarth syndrome (53.2% vs. 18.6%), more severe disease (6 points vs. 4 points), longer pre-treatment duration (median 21 days vs. 13.5 days), higher cerebrospinal fluid pleocytosis (median 139 × 106 /L vs. 11 × 106 /L) and higher rate of Borrelia seropositivity (84.2% vs. 68.6%) than those with possible LNB. Ceftriaxone was prescribed more often than oral doxycycline in definite LNB than in possible LNB (96.4% vs. 65.7%). Unfavorable outcomes decreased during follow-up, being higher in patients with more severe disease at enrollment and in those with possible LNB, but were not associated with antibiotic therapy. CONCLUSIONS: Early LNB, most often presenting as cranial neuropathy, was definitively diagnosed in less than half of cases. A better diagnostic approach is needed to confirm borrelial etiology. Ceftriaxone was not superior to doxycycline in the treatment of early LNB, regardless of diagnostic certainty. In this retrospective cohort study of 311 adults with Lyme neuroborreliosis (LNB), allocated according to diagnostic certainty, early LNB was definitively diagnosed in less than half of cases and the most frequent LNB manifestation was cranial neuropathy with or without meningitis. Patients with definite LNB more often had Bannwarth syndrome, more severe disease, longer pre-treatment duration, higher cerebrospinal fluid pleocytosis and higher rate of Borrelia seropositivity than those with possible LNB. A better diagnostic approach is needed to confirm borrelial etiology. Ceftriaxone was not superior to doxycycline in the treatment of early LNB, regardless of diagnostic certainty.

Radiologist Reporting and Operational Management for Patients With Suspected COVID-19.

PURPOSE: The aim of this study was to evaluate the adoption and outcomes of locally designed reporting guidelines for patients with possible coronavirus disease 2019 (COVID-19). METHODS: A departmental guideline was developed for radiologists that specified reporting terminology and required communication for patients with imaging findings suggestive of COVID-19, on the basis of patient test status and imaging indication. In this retrospective study, radiology reports completed from March 1, 2020, to May 3, 2020, that mentioned COVID-19 were reviewed. Reports were divided into patients with known COVID-19, patients with "suspected" COVID-19 (having an order indication of respiratory or infectious signs or symptoms), and "unsuspected patients" (other order indications, eg, trauma or non-chest pain). The primary outcome was the percentage of COVID-19 reports using recommended terminology; the secondary outcome was percentages of suspected and unsuspected patients diagnosed with COVID-19. Relationships between categorical variables were assessed using the Fisher exact test. RESULTS: Among 77,400 total reports, 1,083 suggested COVID-19 on the basis of imaging findings; 774 of COVID-19 reports (71%) used recommended terminology. Of 574 patients without known COVID-19 at the time of interpretation, 345 (60%) were eventually diagnosed with COVID-19, including 61% (315 of 516) of suspected and 52% (30 of 58) of unsuspected patients. Nearly all unsuspected patients (46 of 58) were identified on CT. CONCLUSIONS: Radiologists rapidly adopted recommended reporting terminology for patients with suspected COVID-19. The majority of patients for whom radiologists raised concern for COVID-19 were subsequently diagnosed with the disease, including the majority of clinically unsuspected patients. Using unambiguous terminology and timely notification about previously unsuspected patients will become increasingly critical to facilitate COVID-19 testing and contact tracing as states begin to lift restrictions.

Early Adoption of a Certainty Scale to Improve Diagnostic Certainty Communication.

OBJECTIVE: Assess the early voluntary adoption of a certainty scale to improve communicating diagnostic certainty in radiology reports. METHODS: This institutional review board-approved study was part of a multifaceted initiative to improve radiology report quality at a tertiary academic hospital. A committee comprised of radiology subspecialty division representatives worked to develop recommendations for communicating varying degrees of diagnostic certainty in radiology reports in the form of a certainty scale, made publicly available online, which specified the terms recommended and the terms to be avoided in radiology reports. Twelve radiologists voluntarily piloted the scale; use was not mandatory. We assessed proportion of recommended terms among all diagnostic certainty terms in the Impression section (primary outcome) of all reports generated by the radiologists. Certainty terms were extracted via natural language processing over a 22-week postintervention period (31,399 reports) and compared with the same 22 calendar weeks 1 year pre-intervention (24,244 reports) using Fisher's exact test and statistical process control charts. RESULTS: Overall, the proportion of recommended terms significantly increased from 8,498 of 10,650 (80.0%) pre-intervention to 9,646 of 11,239 (85.8%) postintervention (P < .0001 and by statistical process control). The proportion of recommended terms significantly increased for 8 of 12 radiologists (P < .0005 each), increased insignificantly for 3 radiologists (P > .05), and decreased without significance for 1 radiologist. CONCLUSION: Designing and implementing a certainty scale was associated with increased voluntary use of recommended certainty terms in a small radiologist cohort. Larger-scale interventions will be needed for adoption of the scale across a broad range of radiologists.

[Diagnostics of polyneuropathies]. / Diagnostik bei Polyneuropathien.

The diagnosis of polyneuropathy (PNP) is based on the anamnesis and description of complaints of the patient and clinical findings. The type of distribution as well as known diseases and drug toxic factors can provide indications. Electromyography and electroneurography can be used to differentiate between axonal and demyelinating PNP. The laboratory examinations are initially directed towards frequent and treatable causes. These are then expanded depending on the suspected diagnosis. Analysis of cerebrospinal fluid (CSF) is facultative and should be carried out when there is a suspicion of a certain form of PNP with CSF findings indicative of the diagnosis. Nerve biopsy is indicated when the etiology of a severe or progressive PNP cannot be clarified by less invasive means and can have consequences for the treatment. A genetic investigation can be meaningful with a positive family anamnesis or with typical signs of hereditary PNP. Depending on the neuropathy and context, the diagnostic approach is structured differently. The special diagnostics for small fiber neuropathy and amyloid neuropathy as well as for diabetes and alcohol abuse are dealt with in detail in this article. Numerous cases of polyneuropathy remain unexplained and regularly have a favourable prognosis.

Levels of diagnostic certainty for nonepileptic attack disorder in the neuropsychiatry setting.

Nonepileptic attack disorder (NEAD) is a medical condition commonly seen in neuropsychiatry services, often as a differential diagnosis of other neuropsychiatric conditions. Recommendations by the International League Against Epilepsy (ILAE) Nonepileptic Seizures Task Force propose a four-level hierarchical approach to the diagnosis of NEAD, based on history, witnessed event, and electroencephalographic (EEG) investigation. We set out to provide the first description of the diagnostic levels of patients with NEAD at a specialist neuropsychiatry clinic. Comprehensive clinical data from 148 consecutive patients with NEAD attending the specialist Neuropsychiatry Clinic run by a single Consultant in Behavioral Neurology were retrospectively reviewed. Patients with NEAD were primarily referred to neuropsychiatry by Consultant Neurologists (n = 94; 63.5%). The majority of patients were female (n = 108; 73.0%), with a disease duration of 7.9 years (standard deviation: 10.4). Anxiety was the most common comorbidity (n = 43; 26.7%). Categorization of patients according to the ILAE Nonepileptic Seizures Task Force criteria was mainly based on clinical features and EEG findings, as only 7 (4.7%) patients had attacks witnessed by a specialist. The largest diagnostic categories were 'possible' (n = 54; 36.5%) and 'clinically established' (n = 40; 27.0%), followed by 'documented' (n = 12; 8.1%) and 'probable' (n = 5; 3.4%). In 125 patients (84.4%), EEGs were performed. Selective serotonin reuptake inhibitors were the most frequently prescribed psychotropic medications (n = 48; 32.4%); 89 patients (60.1%) received behavioral therapy. There were no differences in pharmacological or behavioral management strategies across the patients categorized under different diagnostic levels. Patients with NEAD seen within neuropsychiatry settings are mainly assigned 'possible' and 'clinically established' levels of diagnostic certainty. Difficulty in capturing typical clinical events witnessed by an experienced clinician while on video-EEG can limit the clinical application of the 'documented' diagnostic level. If appropriate, active interventions can be implemented irrespective of diagnostic levels to minimize delays in the neuropsychiatric care pathways.

Educational Case: Developmental Neck Masses and Other Neck Tumors.

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.1.

Immunization in pregnancy safety surveillance in low and middle-income countries- field performance and validation of novel case definitions.

BACKGROUND: A globally standardized approach in high and low and middle-income countries (LMIC) to actively monitor the safety of vaccines for pregnant women during development and implementation phases is critical. Brighton Collaboration's (BC) Global Alignment of Immunization Safety Assessment in Pregnancy (GAIA) project has developed globally standardized case definitions (CDs) of key obstetric and neonatal terms for the assessment of safety of vaccines in pregnancy. CDs are categorized into levels of diagnostic certainty, facilitating their use in varied settings. This study evaluates the field performance of CDs in LMIC. METHODS: Data from pregnant participants of RCTs for trivalent inactivated influenza vaccine conducted at Chris Hani Baragwanath Academic Hospital, South Africa (SA) between 2011 and 2013 were reviewed retrospectively for preterm birth, stillbirth and hypertension CDs and the Gestational age assessment (GA) algorithm. Data from an ongoing pneumococcal vaccine trial (conducted at MRC Unit, The Gambia) were collected prospectively for GA. RESULTS: For GA, 600 mother-infant dyads from Gambia and 155 mother-infant dyads from SA were reviewed. Level 2B (unsure LMP and US in 2nd trimester) was the most common level seen in Gambia (63%) and level 3B1 (unsure LMP with physical examination) in SA (43%). Preterm deliveries had similar results in SA. The pregnancy-induced hypertension definition performed well, with 96% (54/56) of cases fulfilling 'level 1' for 'preeclampsia with severe features'. 24 stillbirths were identified and 21 records were reviewed; 73.3% (11/15) of the stillbirths classified as antepartum by attending physicians and 83.3% (5/6) of the intrapartum stillbirths did not fulfil the criteria for any level of certainty. CONCLUSION: BC CDs for neonatal and maternal outcomes (preterm and hypertension) and GA were sensitive, reliable and feasible to use in RCTs in SA and Gambia. Modifications to the stillbirth CD are required to improve its usefulness in varied settings.

When Are We Sure? Predictors of Clinician Certainty in the Diagnosis of Autism Spectrum Disorder.

Differential diagnosis of autism spectrum disorder (ASD) is challenging, and uncertainty regarding a child's diagnosis may result in under-identification or prolonged diagnostic pathways. The current study examined diagnostic certainty, or how sure clinicians were that their diagnosis was accurate, among 478 toddler and preschool-aged children referred for possible ASD to academic medical specialty clinics. Overall, 60 percent of diagnoses were made with complete certainty. Clinicians were more certain when positively identifying ASD than ruling it out. Children presenting with a moderate (vs high or low) level of observable ASD symptoms were less likely to have a certain diagnosis. Further, clinicians rated less diagnostic certainty for older children, those with public insurance, and those with higher IQ and adaptive behavior abilities.

Radiologist Preferences, Agreement, and Variability in Phrases Used to Convey Diagnostic Certainty in Radiology Reports.

PURPOSE: To understand radiologists' preference and variability in phrases for expressing diagnostic certainty in radiology reports. MATERIALS AND METHODS: This institutional review board-approved study was part of a quality improvement initiative to improve the quality of radiology reports at a tertiary academic hospital. Sixteen phrases commonly used in radiology reports to convey diagnostic certainty were extracted from prior publications. The degree of diagnostic certainty was divided into six arbitrary categories by an expert panel. We used an anonymous online survey to query 239 radiologists at our institution regarding their preferred phrase for each category. We evaluated the distribution of preferred phrases, performed cluster analysis to find groups of phrases used to describe specific diagnostic certainty categories, and calculated Krippendorff's α to evaluate how reliably radiologists use various phrases to express diagnostic certainty. FINDINGS: In all, 59.4% (142 of 239) of radiologists completed the survey. The most commonly preferred phrases were "consistent with" (45.1%; 64 of 142) for 100% confident, "highly suggestive of" (46.5%; 66 of 142) for very high likelihood, "most likely" (31.0%; 44 of 142) for high likelihood, "may represent" (50.7%; 72 of 142) for intermediate likelihood, "unlikely" (47.2%; 67 of 142) for low likelihood, and "very unlikely" (40.1%; 57 of 142) for very low likelihood. Cluster analysis identified six groups of phrases used to indicate a similar level of diagnostic certainty; however, Krippendorff's α was 0.217, indicating radiologists do not consistently use the same phrases for similar degrees of confidence. CONCLUSION: Wide variability persists among radiologists' preferences for phrases used to convey diagnostic certainty. Interventions to improve consistency of use of these phrases may help reduce ambiguity and improve quality of radiology reports.

Educational Case: Medullary Thyroid Carcinoma.

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.

Optimizing self-regulation of performance: is mental effort a cue?

Accurate self-regulation of performance is important for trainees. Trainees rely on cues to make monitoring judgments to self-regulate their performance. Ideally, cues and monitoring judgements accurately reflect performance, as measured by cue diagnosticity (the ability of a cue to predict performance) and monitoring accuracy (the ability of a monitoring judgement to predict performance). However, this process is far from perfect, emphasizing the need for more accurate cues and monitoring judgements. Perhaps the mental effort of a task could be a cue used to inform certainty judgements. The purpose of this study is to measure cue utilization and cue diagnosticity of mental effort and monitoring accuracy of certainty for self-regulation of performance. Focused on the task of ECG interpretation, 22 PGY 1-3 Internal Medicine residents at McMaster University provided a diagnosis for 10 ECGs, rating their level of certainty (0-100%) and mental effort (Paas scale, 1-9). 220 ECGs completed by 22 participants were analyzed using path analysis. There was a negative moderate path coefficient between certainty and mental effort (ß = - 0.370, p < 0.001), reflecting cue utilization. Regarding cue diagnosticity of mental effort, this was reflected in a small negative path coefficient between mental effort and diagnostic accuracy (ß = - 0.170, p = 0.013). Regarding monitoring accuracy, a moderate path coefficient was observed between certainty and diagnostic accuracy (ß = 0.343, p < 0.001). Our results support mental effort as a cue and certainty as a monitoring judgement for self-regulated performance. Yet, reported correlations are not very high. Future research is needed to identify additional cues.

Evaluation of the "non-epileptic" patient in a tertiary center epilepsy clinic.

PURPOSE: The epilepsy clinic at the Montreal Neurological Institute receives a high volume of referrals. Despite most patients assessed in the clinic eventually being diagnosed with epilepsy, other disorders causing alteration of consciousness or paroxystic symptoms that could be misdiagnosed as seizures are seen frequently. The incidence and clinical characteristics of such patients have not yet been determined. We aimed to determine the proportion and clinical characteristics of patients referred to our epilepsy clinic who had a final diagnosis other than epilepsy. METHODS: We performed a retrospective chart analysis of consecutive patient referrals to the epilepsy clinic from January 2013 to January 2015, inclusively. RESULTS: Four hundred four patient referrals were evaluated, 106 (or 26%) had a final diagnosis other than epilepsy. Referrals came primarily from general practitioners and nonneurology specialists. Although most patients had a normal routine electroencephalography (EEG) prior to the clinic visit, sleep-deprived EEG and cardiac investigations were rarely performed. Patients received a final diagnosis other than epilepsy after 1 to 2 visits in 92% of cases and with minimal paraclinical investigations. Prolonged video-EEG recording was required in 27% of patients. The most common diagnoses were syncope (33%), psychiatric symptoms (20%), followed by migraine (10%), and psychogenic nonepileptic seizures (9%). CONCLUSIONS: A significant proportion of patients seen in our tertiary care epilepsy clinic is in fact, not patients with epilepsy. Enhanced knowledge of these differential diagnosis and important anamnesis components to rule out seizures will help improve guidelines for referral to Epilepsy clinic and cost-effectively optimize the use of paraclinical investigations.

Diagnosing psychogenic nonepileptic seizures: Video-EEG monitoring, suggestive seizure induction and diagnostic certainty.

Psychogenic nonepileptic seizures (PNES) can remain undiagnosed for many years, leading to unnecessary medication and delayed treatment. A recent report by the International League Against Epilepsy Nonepileptic Seizures Task Force recommends a staged approach to the diagnosis of PNES (LaFrance, et al., 2013). We aimed to investigate its practical utility, and to apply the proposed classification to evaluate the role of long-term video-EEG monitoring (VEEG) and suggestive seizure induction (SSI) in PNES workup. Using electronic medical records, 122 inpatients (mean age 36.0±12.9years; 68% women) who received the diagnosis of PNES at our epilepsy center during a 4.3-year time period were included. There was an 82.8% agreement between diagnostic certainty documented at discharge and that assigned retroactively using the Task Force recommendations. In a minority of cases, having used the Task Force criteria could have encouraged the clinicians to give more certain diagnoses, exemplifying the Task Force report's utility. Both VEEG and SSI were effective at supporting high level diagnostic certainty. Interestingly, about one in four patients (26.2%) had a non-diagnostic ("negative") VEEG but a positive SSI. On average, this subgroup did not have significantly shorter mean VEEG recording times than VEEG-positive patients. However, VEEG-negative/SSI-positive patients had a significantly lower habitual seizure frequency than their counterparts. This finding emphasizes the utility of SSI in ascertaining the diagnosis of PNES in patients who do not have a spontaneous habitual event during VEEG due to, for example, low seizure frequency.

How Sure Are You, Doctor? A Standardized Lexicon to Describe the Radiologist's Level of Certainty.

OBJECTIVE: A standardized lexicon to specify the radiologist's level of certainty in a radiologic diagnosis can decrease the confusingly large number of words and phrases currently used for that purpose. Such a lexicon furthermore can minimize ambiguity and facilitate clearer communication among radiologists, referring physicians, and patients. CONCLUSION: We would like to share our experience with the lexicon that we developed in 2009. For ease of communication, the lexicon itself is included in each radiology report.

Value of a standardized lexicon for reporting levels of diagnostic certainty in prostate MRI.

OBJECTIVE: The purpose of this study was to evaluate the usefulness and diagnostic performance of a 5-point standardized diagnostic certainty lexicon for reporting the likelihood of extracapsular extension (ECE) of prostate cancer on routine staging prostate MRI. MATERIALS AND METHODS: This study was a retrospective analysis of routine clinical prostate MRI reports before (254 patients) and after (211 patients) the implementation of a 5-point diagnostic certainty lexicon. Whole-mount step-section pathology of the radical prostatectomy specimens served as the reference standard. The terms used to express diagnostic certainty regarding ECE on standard-of-care MRI and the presence of ECE on pathology were compared between the two periods. ROC analysis was used to evaluate the diagnostic accuracy of the 5-point certainty lexicon for detecting ECE. RESULTS: Before the implementation of the certainty lexicon, radiologists used 38 different terms to express the levels of certainty regarding the presence of ECE on MRI. Afterward, they adhered to the lexicon's predefined 5-point terminology in 85.3% of cases. The 5-point certainty lexicon used on MRI reports had an AUC of 0.852 for diagnosing ECE. CONCLUSION: The implementation of a lexicon of diagnostic certainty dramatically reduced the number of expressions used by radiologists to indicate their levels of diagnostic certainty. The accuracy of the certainty lexicon for diagnosing ECE on standard-of-care prostate MRI is similar to previously reported accuracy values for the diagnosis of ECE by MRI. Thus, the use of such a lexicon might prevent miscommunication and help referring clinicians reliably incorporate radiologists' assessments into clinical decision making.