CODEX Digest 09.10.26

Annual wellness visits may provide opportunities for earlier dementia recognition, but diagnosis depends on what follows the encounter. This US observational study examines associations between wellness visits, subsequent healthcare decisions, and early mild cognitive impairment or dementia diagnoses. The analysis highlights the importance of annual wellness visits, specialist referral, and imaging rather than assuming that the preventive visit itself produces earlier diagnosis.

Diagnostic error is particularly consequential in critically ill patients, where rapidly changing physiology and complex workflows amplify uncertainty. This commentary applies the Systems Engineering Initiative for Patient Safety (SEIPS) framework to examine diagnostic-error contributors across the diagnostic process. The authors summarize cognitive biases that affect ICU care and expand their analysis beyond individual actions to advocate for system-level interventions addressing workflow, communication, and organizational conditions.

Diagnostic education often lacks exposure to rare, subtle, or easily confused imaging findings. This UK experimental educational study evaluates AI-generated counterfactual chest X-rays—real patient images digitally transformed to depict alternative conditions while preserving anatomy. Among 42 medical students and physicians, counterfactual comparisons improved learning and confidence calibration, although real images produced higher raw diagnostic accuracy. The findings support cautious exploration of AI as an educational supplement, not a replacement for authentic cases.

Initial rectal cancer symptoms can vary, which makes timely diagnosis challenging. This retrospective cohort study of 205 patients undergoing rectal cancer resection explores factors contributing to diagnostic delay. The results show that younger age and mild symptoms were associated with delayed presentation. Patients initially seen in primary care were more likely to experience diagnostic delays than those initially assessed at emergency departments, highlighting access pathways and referral processes as potential diagnostic-safety targets.

Missed liver malignancies remain a diagnostic challenge in high-volume imaging practice. This large, Chinese, multicenter study evaluates the proprietary AI system LiON using contrast-enhanced CT in a real-world setting. The AI-system, in collaboration with human review built into routine clinical workflow, identified 51 previously overlooked lesions and prompted report assessment. Despite these results, the authors call for comparative prospective studies across diverse healthcare systems before establishing the clinical benefit of the technology.

Diagnosis is increasingly recognized as a team activity, yet nursing contributions remain poorly defined. This commentary argues that nurses contribute to diagnosis through assessment, surveillance, escalation, communication, and clinical judgment, but ambiguous language and role boundaries can limit participation. The authors call for clearer professional expectations, stronger diagnostic education, and organizational cultures that recognize nurses as essential members of the diagnostic team.

Immediate release of test results following the 21st Century Cures Act Final Rule reshapes the diagnostic communication process. This research letter examines a cross-sectional effort exploring which patients view their results early and how well they understand them. Older adults, women, higher-income and digitally literate patients, and frequent social media users were more likely to view early results first. Lower comprehension was associated with medical-care discrimination, whereas stronger patient-centered communication and digital literacy were protective—highlighting a diagnostic safety gap beyond simply providing access.

Reliable physical examination remains fundamental to diagnostic reasoning. This educational assessment study evaluates pulmonary physical examination skills among internal medicine interns at two academic medical centers using a real patient with lung disease. Performance varied across examination techniques, recognition of physical signs, differential diagnosis, clinical judgment, and patient welfare, highlighting the persistent need to strengthen foundational diagnostic skills.

AI-assisted reporting may alter how radiologists detect, interpret, and communicate clinically important findings. This commentary examines implications of AI integration into radiology reporting, emphasizing that automation can introduce new failure modes alongside potential benefits. The authors highlight the need for human oversight, transparent responsibility, appropriate workflow design, and monitoring for errors rather than assuming that AI-generated or AI-supported reports inherently improve diagnostic safety.

Scaling AI-supported screening requires consideration of systemic factors to enable success. This UK implementation report describes the NHS England Lung Cancer Screening Programme, where more than one million imaging studies have been interpreted through a national specialist radiologist network. Vendor-agnostic AI was used to support post-deployment monitoring for algorithm drift and population bias. The discussion emphasizes infrastructure, workforce, accountability, and monitoring alongside technology.

Inadequate representation of skin of color in medical education can contribute to diagnostic inequity. This systematic review synthesizes eight educational studies involving an international set of 667 trainees. The identified interventions generally improved knowledge or confidence, but evidence was limited by small samples, single-session designs, and reliance on self-reported outcomes. Persistent challenges, particularly melanoma recognition in patients of color, underscore the need for longitudinal competency-based education to address these gaps.

False-negative cancer diagnoses can impose substantial downstream harm. This prospective, German registry study follows 9,063 melanoma patients over 28 years to identify false-negative diagnoses in 2.3% of the patients. Median time to correct diagnosis was 24 months; affected patients had markedly worse recurrence-free and melanoma-specific survival. Each false-negative diagnosis was associated with an average 8.2 years of life lost, quantifying the consequences of diagnostic delay.