A clinical prediction rule for the diagnosis of ureteral calculi in emergency departmentsElton, Thomas J.;Roth, Craig S.;Berquist, Thomas H.;Silverstein, D.
doi: 10.1007/BF02599984pmid: 8441076
Abstract Objective: To determine: 1) whether a simple clinical prediction rule could identify emergency department patients with ureteral calculi; 2) whether the kidney, ureter, and bladder (KUB) radiograph provides diagnostic information beyond that obtained from the history and physical examination; and 3) whether ureteral calculi can be diagnosed accurately in the emergency department without emergency excretory urography, commonly known as intravenous pyelography (IVP). Patients: Two hundred three patients who underwent emergency KUB and IVP studies for nontraumatic abdominal or flank pain (derivation group) were retrospectively identified from radiology department records; 72 patients were prospectively evaluated in the emergency department for suspected ureteral stones (validation group). Measurements: Clinical information included age, gender, characteristics of pain, associated symptoms, presence of fever, history of ureteral calculi, whether a stone was passed, and results of urinalysis and KUB and IVP studies. All KUB and IVP radiographs were independently reviewed by a radiologist blinded to the patient’s clinical information and urinalysis results. Design: Stepwise linear discriminant analysis was used to derive a four-item prediction rule from the derivation group and the validation group; the areas under the receiver operating characteristic (ROC) curves and the misclassification rates were compared. Results: The four-item rule (acute onset, flank pain, hematuria, and positive KUB radiograph) correctly classified 83% of patients in the derivation group and 90% in the validation group. The four-item rule had an ROC area of 0.86 in the derivation group and 0.89 in the validation group. The KUB radiograph significantly improved the discriminant ability of the two history items and the urinalysis result. Thirty-three percent of patients were identified to be in a subset with a 96% probability of having a stone. Conclusion: These findings, which should be confirmed in another emergency department, suggest that subsets of patients with suspected ureteral calculi may be managed without emergency IVP; this approach thereby reduces the time a patient spends in the emergency department, radiation exposure, expense, and morbidity.
Diagnosis of obstructive airways disease from the clinical examinationHolleman, Donald R.;Simel, David L.;Goldberg, Joel S.
doi: 10.1007/BF02599985pmid: 8441077
Abstract Objective: To determine the operating characteristics of history and physical examination items for pulmonary airflow obstruction. Design: Prospective observational study. Setting: Medical Preoperative Evaluation Clinic at the Durham Veterans Affairs Medical Center. Patients/participants: Consecutive patients referred for outpatient medical preoperative risk assessment. Interventions: None. Measurements and main results: Number of years the patient had smoked cigarettes, patient-reported wheezing [LR+ (likelihood ratio for finding present)=3.1; LR− (likelihood ratio for finding absent)=0.58], and auscultated wheezing (LR+=12; LR−=0.87) were independent predictors of obstructive airways disease from the history and physical examination. Forced expiratory time and peak expiratory flow rate, both measured by the clinician at the bedside, were additional independent predictors of airflow obstruction. A nomogram using patient-reported wheezing, number of years the patient had smoked, and auscultated wheezing was developed and validated (area under receiver operating characteristic curve=0.78; p=0.0001) for the bedside prediction of obstructive airways disease. Peak expiratory flow rate can be substituted for auscultated wheezing with similar predictive ability. Conclusions: The results of bedside clinical examinations predict the presence of obstructive airways disease. A nomogram based on a combination of four bedside findings predicts airflow obstruction as well as clinicians’ overall clinical impressions.
Prevalence of depressive symptoms among established vietnamese refugees in the united statesBuchwald, Dedra;Manson, Spero M.;Dinges, Norman G.;Keane, Ellen M.;Kinzie, J. David
doi: 10.1007/BF02599987pmid: 8441079
Abstract Objective: To determine the prevalence of depressive symptoms among Vietnamese refugees who have lived in the United States for at least two months. Design: A prospective and descriptive study using the Vietnamese Depression Scale (VDS). Scores of ≥ 13 on the VDS were considered indicative of depression. Setting: Ten public health clinics in four states. Patients/participants: Four hundred seventy-six consecutive adult Vietnamese refugees presenting for primary care. Interventions: The VDS, an 18-item culture-specific self-report measure, was used to screen for depressive symptoms. Measurements and main results: Twenty percent of these patients had scores of 13 or above. Although being female; being older; being divorced, separated, or widowed; and being poorly educated were significant univariate risk factors for screening positive, only the latter two were significant in a multivariate model. Physical complaints were common and induced considerable anxiety about health status, but psychological and emotional symptoms were even more prevalent. Patients scoring 13 or higher had a higher rate of endorsement for every item in the scale than did those scoring lower than 13. Conclusions: This study substantiates the feasibility and importance of screening for depressive symptoms among Vietnamese refugees, particularly in primary care settings where they are most likely to seek care for both medical and psychological problems.
The relevance to clinical practice of the certifying examination in internal medicineNorcini, John J.;Day, Susan C.;Grosso, Louis J.;Langdon, Lynn O.;Kimball, Harry R.;Popp, Richard L.;Goldfinger, Stephen E.
doi: 10.1007/BF02599989pmid: 8441080
Abstract Objective: To determine the relevance of the initial certifying examination to the practice of internal medicine and the suitability of items used in initial certification for recertification. Design: Using a matrix-sampling approach, items from the 1991 Certifying Examination were assigned to two sets of judges: directors of the American Board of Internal Medicine (ABIM) and practicing general internists. Each judge rated the relevance of items on a five-point scale. Participants: 54 current or former directors of the ABIM and 72 practicing general internists; practitioners were nominated by directors and their ratings were included if they spent > 80% of their time in direct patient care. Results: The directors’ mean rating of all 576 items was 3.98 (SD=0.62); the practitioners’ mean rating was 4.11 (SD=0.82). The directors assigned to 27 items ratings of less than 3 and the practitioners assigned to 42 items ratings of less than 3; seven of these items received low ratings from both groups. There were differences in the two groups’ ratings of the relevance of various medical content categories, but the mean rating of core items was higher than that of noncore items and the mean rating of items testing clinical judgment was higher than that of items testing knowledge or synthesis. Conclusions: These findings suggest that the initial certifying examination is relevant to clinical practice and that many of the examination items are suitable for use in recertification. Differences in perception appear to exist between practitioners and directors, and the use of practitioner ratings is likely to be a routine part of judging the suitability of items for Board examinations in the future.
NBME examination part I as a predictor of clinical and ABIM certifying examination performancesSosenko, Jay;Stekel, Karen W.;Soto, Ramon;Gelbard, Mark
doi: 10.1007/BF02599990pmid: 8441081
Abstract The authors studied the extent that National Board of Medical Examiners examination Part I (NBME Part I) performance was predictive of American Board of Internal Medicine examination (ABIME) scores and clinical skills ratings. Information was obtained for Jackson Memorial Hospital internal medicine residents who completed training from 1980 to 1988. There was a highly significant association (r=0.57, p<0.0001,n=117) between ABIME and NBME Part I scores. Clinical evaluations and NBME Part I scores were less strongly related. The data indicate that NBME Part I scores are highly predictive of ABIME outcome. NBME Part I scores also appear to be predictive of clinical performance, but to a lesser extent.
Bacteremia in the elderlyRichardson, James P.
doi: 10.1007/BF02599992pmid: 8441082
Summary Bacteremia has a high mortality rate in all elderly populations, but especially nursing home residents and the hospitalized elderly. Elderly patients with bacteremia may present in a nonspecific fashion with incontinence, with falls, or afebrile. Mortality is greater in patients whose bacteremia originates outside the genitourinary tract or who are bacteremic with gram-positive organisms. Early appropriate treatment has been found to reduce mortality in some studies, especially in patients over 85 years old or with gram-positive bacteremias. Gram-negative bacteremias are more common than those caused by gram-positive organisms in most studies.E. coli is the most common gram-negative isolate, followed in most studies by either Proteus or Klebsiella. Staphylococcus aureus is the most common gram-positive isolate; enterococcus and pneumococcus are also frequently isolated. Bacteremia in the elderly may present in a subtle fashion. Appropriate antibiotic therapy may reduce mortality and should include antibiotic coverage forS. aureus and gram-negative bacilli, as well as for anaerobes if pressure ulcers are suspected as the source. Clinicians who care for the elderly should be aware of the possible presentations of bacteremia and the appropriate treatment in all clinical settings.
FibromyalgiaPowers, Roxann
doi: 10.1007/bf02599993pmid: 8441083
ConclusionsFibromyalgia is a common syndrome characterized by widespread aching, stiffness, fatigue, poor sleep, and the presence of multiple reproducible tender points. The pathophysiology of the syndrome remains elusive, but psychological factors, an alpha-delta sleep disturbance, an abnormality at the level of the muscle, and an immunoregulatory disorder have been proposed. Few treatment modalities have been shown to have beneficial effect.Although the constellation of signs and symptoms associated with fibromyalgia has been recorded in medical writings throughout history, sound methodologic studies supporting the existence of fibromyalgia as a distinct syndrome have only recently begun to appear. The emergence of scientifically derived classification criteria may lead to increased clinical acceptance of the syndrome, but validating studies and well-designed investigations searching for etiologic factors are needed before fibromyalgia earns the scientific community’s unconditional endorsement. Nevertheless, fibromyalgia is a common syndrome of musculoskeletal pain affecting many patients who are deserving of physicians’ consideration and respect.