Problems Of Diseases Manifested By X-ray Local Opacity Syndrome, And Differential Diagnostic Algorithm For Its Solution

Objective: Efficiency of traditional and algorithmic diagnostics comparison; Differential Diagnostic Algorithm creation for effective X-ray differential diagnostics of diseases accompanied with local opacity. Methods: Comparative evaluation of X-ray traditional and algorithmic diagnostics has been performed by principle of other equal conditions. The first stage of independent diagnostics has reflected the results of traditional medical education. The same radiograms have been used by the same examinees in the same time for repeated diagnostics with original innovative diagnostic algorithm on the second stage.Results: X-ray diagnostic algorithm significantly decreased of errors obtained at independent diagnostics. Conclusion: Traditional X-ray diagnostics based on nosological thinking is ineffective. Syndromic algorithmic X-ray diagnostics used innovative the most effective intellectual activity, therefore, optimized results radically.Definition: Differential Diagnostic Algorithm or diagnostic algorithm is the exact comprehensible to all determination about step-by-step of elementary intellectual operations and actions in the certain sequence for establishment of a diagnosis of each of all diseases manifested by the given leading syndrome.Syndrome – is a group of symptoms/signs similar for any diseases of different organs and systems, irrespective from etiology and pathogenesis of diseases (e.g., a chest pain, heart murmurs, a fever, a local opacity on chest X-ray, etc.)Leading syndrome – is a predominant syndrome among several syndromes, which are available at the given patient.Abbreviations – DDA – Differential Diagnostic Algorithm; s/s symptoms/signs; INTRODUCTION The data presented in this article have been collected over 30 years ago at the Department of Pedagogics and Optimization of the Higher Medical Education, which the author founded in 1970 in Novosibirsk medical institute, USSR, and where for 15 years he served as the Head of the department. During this period, 3020 teachers almost from all medical institutes of the USSR were trained in our department. The author developed 15 original scientific-methodical trends, and 70 concrete methods and means of training optimization. Hundreds of students participated in different pedagogical experiments. These old data is being presented to the western reader today because the problem of effective X-ray diagnostics remains actual, and this data essentially expands literary concepts of the problem. Results received later in Israel have submitted here separately. Methodically the same comparative experiment has carried out with Israeli family doctors. They have received the western medical education, have trained with the best American textbooks, and work many years in the Israeli polyclinics. The same results have received with them, as well as in Russia. It testifies to two phenomena. The first, unsatisfactory quality of X-ray diagnosis is widely distributed that shows literature data as well 5678910. The second, various diagnostic algorithms developed by the author, are highly effective and sharply reduce number of diagnostic mistakes at the doctors who have received both Soviet, and western medical education. It defines the actuality of given article and the new diagnostic algorithm developed and tested by the author in Israel. Teachers of higher medical school, students and doctors are sure, that X-ray diagnostics is easy and simple object. Therefore, each family doctor examines roentgenograms independently, and not always reads diagnostic conclusion of radiologist. In a reality, it is one of the most complicated problems of medical professional training. However, between a standard Problems Of Diseases Manifested By X-ray Local Opacity Syndrome, And Differential Diagnostic Algorithm For Its Solution 2 of 15 opinion, official curriculums, and the reality exists the serious contradiction. This contradiction is caused by discrepancy between complexity of a subject of training, on the one hand, and method of training, on the other hand. The Novosibirsk medical institute, in which majority researches presented in given article have been executed, was one of the best in the USSR. Teachers of clinical disciplines had high medical qualification. The author has developed the new DDA for diseases manifested by local opacity, which has published in this article, recently. This DDA has been published for the first time. Medical diagnostics in general, and X-ray diagnostics, in particular, represents great clinical, methodological, economic, social, psychological problems. There are hundreds diseases of various organs manifested by various X-ray shadows on chest, and dozens diseases, manifested by local opacity on chest X-ray. Therefore, an optimizing of fast differential-diagnostic process remains actual today. Although greatest technical achievements have appears in Xray diagnostics, there is a large field in a physician’s activity that must be improve significantly. It is intellectual differential-diagnostic abilities of a doctor optimization. This article is devoted just to this problem, which has been studied insufficiently. Diagnostic and training problems have been mentioned here briefly. DIAGNOSTIC PROBLEMS There is a dramatic contradiction between the principles of diagnostic reasoning a doctor, which has taught in medical school, and the principle of diagnostic thinking, which a doctor must actually use in the clinical practice. Important significance has serious demerits of generally accepted approach to traditional medical diagnostics. It is based on the nosological intellectual system; 1. It is oriented to maximal memorization of special 2. information; It starts with disease diagnosis (disease name) and 3. goes to the etiology and pathogenesis, s/s of the disease, complications, treatment, etc; In real life, the opposite situation takes place – 4. from revealed s/s through of differential diagnostics to diagnosis, i.e. vice versa. Students, doctors and even teachers-clinicians not always can make revolutionary opposite transformations in the brain independently at constant deficiency of time; Many diseases have been manifested by the same 5. or similar s/s; Excessive amounts of medical examinations have 6. been used 12; Superfluous s/s have used frequently 3; 7. Ineffective intellectual diagnostic process of 8. diagnosis 4; Significant efforts of physicians during diagnosing 9. process 3; Relatively long time spend in determining a 10. diagnosis3; Frequent diagnostic errors, at least in the primary 11. health care setting 5678910; High cost of reliable diagnosis 1112131415; 12. A strongly marked decreasing of diagnostics 13. quality at remote medical establishments and patients, in rural sites, in particular. These problems are quite typical at X-ray diagnostics, at the local opacity syndrome particularly. Therefore, it is important to find a non-standard approach and methodology that can improve X-ray diagnostic results significantly, be widely used, and also be economical and more efficient. The best achievements in optimal diagnostics must be accessible for remote physicians and citizens. Dissatisfaction by diagnostic results and high cost of diagnosis encourages the search for non-traditional ways of improving these results. It is desirable to find a common a working tool, which could solve above-mentioned problems at the bottom steps of public health services quickly and cheaply. A DDA can become such universal tool. Our previous experience has revealed the outcomes that many times better than traditional diagnostics 1617181920. Problems Of Diseases Manifested By X-ray Local Opacity Syndrome, And Differential Diagnostic Algorithm For Its Solution 3 of 15 THEORETICAL PECULIARITIES OF CLINICAL DECISION-MAKING IN DIAGNOSTIC PROCESS The DDA creation and use is based on a new original approach to a diagnostic intellectual process optimization (a new paradigm of diagnostic decision-making) 16. Three optimal principles of diagnostic decision-making used for the most effective diagnostics. This approach essentially differs from traditional diagnostic decision-making and provides optimal diagnostic outcomes 1718. It is based on: Syndromic diagnostic decision; Minimum decisive symptoms/signs detection; Differential Diagnostics Algorithm. Only the combination of all three principles (a+b+c) provides the best results in the intellectual diagnostic process. Diagnostic decision making by syndrome is very important and promising because many various diseases with different pathologic processes have the same or very similar clinical, laboratory, X-ray, etc. s/s. Moreover, the same disease may be present with different syndromes or large s/s. Therefore, in each case it is very important to select a leading syndrome. From such leading syndrome starts a differential diagnostic process as syndromic thinking. It is possible to begin the process of syndromic diagnostics with a combination of two or more manifestations, e.g., local opacity + cough + sputum, etc. The nosological and three optimal principles are not antagonistic, but synergistic. The integrated clinical diagnostic decision-making (DDM) contains the following components for optimal diagnostics of diseases manifested by local opacity and for the DDA development. Recognition of leading manifestations (syndromic 1. based principle of DDM use); Detection of decisive s/s (principle of optimal 2. diagnostic advisability use); Differential diagnostics and final diagnosis of a 3. disease (differential diagnostics algorithm use); Confirmation of the disease diagnosis (nosological 4. approach use). The new methods directly lead to algorithmization of DDM 1920. These methods provide some elementary operations that do not require great skill from a physician and exclude superfluous examinations and tests. These features permit important and productive practical steps for making optimized diagnostic decisions. Minimum examinations and signs are necessary for precise diagnoses that decrease the costs of diagnosis significantly. These principles essentially differ from general accepted clinical thinking. These differences cause the main general and particular features and advantages of this new system of DDM in comparison with generally accepted one. Thus, diagnostic problems solution can be achieved by means of the innovative intellectual approach to medical diagnostic decision-making (DDM). PROBLEMS OF TRAINING Didactic systems and a level of training define the learning efficiency. Didactic System (DS) is a certain complex of methods and tools of the management by cognitive activity of EVERY separate learner in given learner group. There are three levels of training: I level – «knowledgeacquaintance», II level – «knowledge-copies», III level – professional training «knowledge mastering – a task the optimal professional decision making (effective professional practical activity»). Practical diagnostics demands a III level of training. Among 8 existing DS four ones no feedback, and cannot ensure of professional learning on III level in principle. Four cyclic two-ways DS could provide learning on III level. However, organizational and economical limitations do not allow using them for mass professional training. Only one the most advanced 8 DS can ensure mass professional learning practically. In general, the demerits of mass professional medical education caused, mainly, by: 1) Ineffective the 1 DS used of traditional training «one teacher – many students» without effective constant feedback to every student/doctor. It forms to EACH student only mentioned above I-II levels of training; 2) Effective intellectual diagnostic doctor's work, i.e. knowledge mastering of III level is impossible to form by Problems Of Diseases Manifested By X-ray Local Opacity Syndrome, And Differential Diagnostic Algorithm For Its Solution 4 of 15 methods of I-II study levels in principle. Therefore, diagnostic mistakes appear as the result from standard traditional training permanently. By means of 8 DS with syndromic algorithmic transformation and appropriate logic schemes, it is possible to provide a professional self-training on III level for EVERY learner. Just these combined innovative approaches and methodologies present the instrument for the major mentioned problems successful solution. Traditional generally accepted training has been conducted on the principle of «a situation – an example». Tests to check the assimilation of knowledge have been organized on the principle of «a question – an answer». These principles form and consolidates I-II levels of learning, i.e., at best, acquaintance with the subject and the repetition of its contents. A professional work requires learning at a different level «professional challenge the best decision». With regard to our case – any pathological shadow in lung – the identification of signs – effective differential diagnostics – correct diagnosis – the optimal treatment. These intellectual operations demand only III level of training – knowledge mastering. METHOD A comparative evaluation of results in traditional and algorithmic training of pulmonary X-ray diagnostics has been undertaken. Popular division of examinees into basic and control groups was unsuitable for this purpose. The problem is that professional mental abilities, which are noncomparable in different people, have been compared. Therefore, the author has developed a technique of professional work comparison at the same people with different methods of training. The principle of other equal conditions (ceteris paribus) has been observed strictly: the same examinees, the same radiograms, at the same time. The single difference was different method of training: 1) Traditional training; 2) Training by original innovative diagnostic algorithms for each X-ray syndrome. The technique of comparative experiments was performed in two stages. At the first stage, there was independent diagnostics of radiograms with diagnoses written. This stage of independent diagnostics results of traditional training has fixed. Then records with diagnoses were selected from examinees, and the second stage of experiment was started at once, with repeated diagnostics of the same radiograms utilizing the DDA. Records with new diagnoses at the second stage were selected, then results of the first independent and the second innovative stages of the experiment have been compared. In our two-stage comparative experiment between the first and second stage was a break always. Forthcoming work of examinees with the algorithm was performed for the first time in their lives. Therefore, after the selection of selfdiagnostic conclusions a detailed explanation of how to diagnose by the algorithm has been carried out. In small group the instruction was carried out with the book and the roentgenogram. My book with algorithms was before eyes of each examinee. In a big lecture hall a demonstration of the roentgenogram and algorithm was carried out simultaneously and in parallel on two big screens from two projectors. The demonstration and interpretation of each sign in consecutive movement on algorithm has been shown in details. Such demonstration of diagnostics using the algorithm has been carried out on two-three roentgenograms within 15-20 minutes. Independent diagnostics with algorithm began only after affirmative answer to a question, whether all have understood a new method of work. If even one examinee said, that he has not understood, the slow explanation with demonstration of everyone stage of the DDA and a corresponding sign on the roentgenogram repeated on another example of the same syndrome. The objects of comparison were medical students of IV-VI years, doctors in the former USSR, and Israeli family doctors. MATERIALS There are various approaches and methods of differential diagnostics at a pulmonary pathology. These are well-known clinical, instrumental and laboratory methods of examinations. Nevertheless, the most simple, fast and reliable method of recognition and differential diagnostics pulmonary diseases is X-ray diagnostics. Unfortunately, X-ray diagnostics has common faults mentioned for nosological approach to diagnostics of illnesses. Besides, the description of diseases has been separated on different classifications, e.g., pneumonias, tuberculosis, neoplasms, etc. It strongly complicates of differential diagnostics and an establishment of the diagnosis at revealing any pathological shadows on the radiological Problems Of Diseases Manifested By X-ray Local Opacity Syndrome, And Differential Diagnostic Algorithm For Its Solution 5 of 15 pulmonary image. For simplification of differential diagnostics, we have offered essentially other classi-fication of pulmonary illnesses, having grouped them on radiological syndromes 1718. It has considerably facilitated logic of intersyndromic differential diagnostics, but reliable intrasyndromic X-ray diagnostics represents a serious problem as well. This problem has been caused by a plenty of the diseases shown by the same radiological syndrome (Table 1). Therefore, intrasyndromic differential diagnostics requires the further optimization. This article is devoted just to this problem. Figure 1 Table 1: Differential diagnostics of pulmonary diseases as a syndromic problem. The number of diseases that corresponds to different radiological syndromes is approximate. E.g., one diagnosis in the DDA “pneumonia” can turn into of one from 40 diagnoses of pneumonias various etiology, as shown in the Table 2. However, these diagnoses it is impossible to detail radilogically, because here is the border of a radiological method. Numerous acute and chronic pneumonias of various etiologies frequently have an identical radiological picture. In such cases, the final diagnosis has been established by additional bacteriological, serological analyses, bronchoscopy, СT, biopsy data, etc. The DDA contains necessary recommendations in corresponding places. Presented DDA provides successful differential diagnostics of 36 diseases, manifested by local X-ray syndrome. The list of 47 extrapulmonary diseases + 40 pneumonias has been presented below as well. Figure 2 Table 2: Clinical types, forms, etiological causes of acute and chronic pneumonias manifested by a radiological local opacity syndrome (from lobar to subsegmental opacities) Besides, to the local opacity concerns 47 extrapulmonary diseases located in a chest wall, pleura, mediastinum, diaphragm (Table 3). The list of the diseases, which have caused local opacity syndrome, contains 60 illnesses, whereas the appropriate DDA provides differential diagnostics only 36 diseases. It can explain by the following cause. Quantitative discrepancy of the full list of pulmonary pathology and the reduced list of illnesses in the local opacity DDA can be illustrated on the example of extrapulmonary diseases at local opacity syndrome. The algorithm has provided 9 diagnoses of extrapulmonary diseases. But in the below-mentioned full list with 4 topographical localizations, and 63 47 diagnoses of the extrapulmonary illnesses have been listed So, the algorithm provides differential diagnostics of smaller number of illnesses, than present in the full list ones. However, the algorithm provides strategic and tactical differential diagnostics. More exact specification of the diagnosis made by means of additional examinations. Table 3: Extrapulmonary diseases manifested by local opacity syndrome (frequent diseases written by bold italic font) I. Formations located in a chest wall (21 diseases). Problems Of Diseases Manifested By X-ray Local Opacity Syndrome, And Differential Diagnostic Algorithm For Its Solution 6 of 15 1. Anomalies of development of ribs (splitting of the forward end of rib, synostosis between ribs, expansion of the forward end of a rib like a spade, etc.). 2. Diseases of ribs (a swelling of the forward ends of ribs at a rickets, an osteomyelitis or a tuberculosis, solitary cyst or giant cell tumor of bone, osteochondroma, hemangioma, a malignant tumor of a rib). 3. Damages of ribs as a result of a trauma or operations (synostoses after fractures of ribs, reclaim after a partial resection of ribs, partial thoracoplasty). 4. Diseases of a backbone (perifocal and wandering abscesses at spondylitis, the tumours which are starting with vertebrae elements, a spinal cord and its environments, from roots of spinal nerves). 5. Tumours or inflammatory infiltrates soft tissues of a chest wall and the big tumours or infiltrates in breast. 6. Foreign bodies and calcifications in soft tissues of a chest wall. II. Formations located in a pleura and a pleural cavity (12 diseases). 1. Free or encapsulated congestion of a liquid in a pleural cavity of various nature (transudation, exudation, blood, lymph, bile, contrast mass); a) Parietal (costal) effusion; b) Interlobar effusion; c) Mediastinal effusion; d) Diaphragmatic effusion; e) A combination of congestions of a liquid in different parts of a pleural cavity (parietal and interlobar, mediastinal and diaphragmatic one, etc.). Pleural stratifications and pleural thickening in various localization and origin (fibrinogenous pleurisy, adhesive pleurisy, calcifications of the pleura, combined pleural pathology). Tumors of pleura (malignant mesothelioma, metastases of malignant tumors in pleura).