Diagnosis Prognosis More Positive

By Michael A. Gips

If a victim walks into a hospital ER with symptoms from exposure to a biological agent, will anyone notice? The question has nothing to do with the chaos often associated with ER waiting rooms. It pertains to whether hospital staff will recognize symptoms that they may well have seen only in a textbook years before. Identifying symptoms quickly could mean the difference between a community having an isolated case of a disease or having a mass outbreak in the event of a bioterror attack.

Administrators and staff at the University of Iowa's Carver College of Medicine sought a solution. They found one in an update to medical software called VisualDx, by Logical Images of Rochester, New York. The program is designed to aid healthcare providers in diagnosing and treating infectious diseases, bioterror agents, adverse skin reactions to drugs, and various other medical conditions.

The software merges 7,000 images of symptoms with descriptive and explanatory text for more than 500 medical conditions. Ultimately, it helps doctors build a visual "differential diagnosis," a list of possibilities that a physician uses when diagnosing a specific disease based on a patient's symptoms, medications, medical history, and other factors.

The university originally acquired the software a few years ago to identify dermatological conditions, says Mark Graber, M.D., an associate professor of emergency medicine and family medicine at the university, as well as the research director at the school's Department of Emergency Medicine.

Within the medical center, one copy of the software is used in the Emergency Department, another is in the Family Practice unit. Logical Images added modules to later versions of the software to help identify other conditions, including adverse smallpox vaccination effects. But VisualDx could not help staff identify biological agents.

Medical staff had personal digital assistant devices containing bioterror and chemical/nuclear identification manuals that had been compiled by the U.S. military, but they lacked illustrations, a critical component of recognizing a condition. And the electronic manuals were only helpful if the doctor already knew the diagnosis; they didn't offer a search-by-symptoms function.

Then last year, Logical Images introduced a module on bioterror agents, which was added to the software package and distributed to licensed users, including the University of Iowa (at no additional cost).

In an age where bioterrorism has become a real threat, the school wanted not only to train its emergency staff in symptom recognition, but it also wanted to educate its 30-person disaster management assistance team. Graber noticed that the module had "excellent diagrams to confirm what your suspicion might be."

VisualDx, which is PC-based, is easy to use, Graber says. A doctor performs a typical workup on a patient, then chooses a category from the software that is clinically relevant to what symptoms the patient is presenting, such as acute and chronic dark skin rashes or adverse skin reactions to a medication.

The doctor enters the patient's findings, such as lesion morphology, symptoms, medical history, and travel history. The software builds and refines a pictorial differential diagnosis as each finding is entered. For example, if the doctor enters that the patient has lesions in the form of blisters, the software will call up images of possible conditions.

Further indicating that the blisters are located on symmetric extremities, such as on both forearms, narrows down the possible conditions. Adding abdominal pain as a symptom, in this case, would reduce the possibilities to three: smallpox, polyarteritis nodosa (a rare autoimmune disease characterized by spontaneous inflammation of the arteries), and vibrio vulnificus infection (infection by a bacterium that lives in warm saltwater).

Multiple images are provided for each possible diagnosis, because symptoms often vary from textbook examples. Images cover the full range of skin types and colors. The whole department uses the product, Graber says, although he is the primary user.

The software is standalone and does not involve a connection to the Internet. Although hospital staff have access to the Internet, they didn't want to worry about connectivity issues or searching for images among billions of pages on the Web. "You don't know what's going to happen in an emergency," Graber says.

Thankfully, there's been no bioterror outbreak. But the software has come in handy in helping staff to identify adverse reactions to smallpox vaccinations. "It's ID'd things that no one identified," says Graber. "More frequently, I sort of recognize something but it's a variant. They have enough pictures that you can see variants of a rash."

In addition, Graber notes, VisualDx is a particularly helpful tool at a teaching hospital. He uses it to familiarize medical students and interns with symptoms.

The program hasn't yet identified a case of infection from a biological agent, but it routinely rules out the possibility. In one case, the medical staff was baffled by the appearance of a giant hive on a patient's shin. Graber was able to match the symptoms with images from the database, ultimately identifying the condition as erythema nodosum, which is often a side effect of medications or a symptom of infections such as tuberculosis. "I wouldn't have known that's what it was," says Graber. "It only had some of the characteristics."

Graber wishes he had the product during the October 2002 anthrax scare. He recalls that many panicky patients rushed to the emergency department convinced that they had been exposed to anthrax. "Everyone who found powder in a magazine was coming over at three in the morning."

For all its value, the software could use some enhancement, Graber says. Specifically, it lacks a search by key words, though Graber notes that Logical Images is working on one.

VisualDx also has had unintended benefits. For instance, Graber, who is on the editorial board of a journal covering emergency medicine, was aided by the software when he was writing a textbook chapter on so-called B-list bioterror agents, which are considered by the U.S. government to be the second-highest-priority agents.

"Trying to pull together the information was difficult," he says, especially since photos of some conditions, such as melioidosis (which affects humans and animals such as horses), were hard to find. "I was able to refer to the software and get a better idea of what the disease would look like," he says.

(For more information: Michael S. O'Connor, president, Logical Images; phone: 800/357-7611; e-mail:

--By Michael A. Gips, a senior editor at Security Management magazine



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