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Clinical Judgment (clinical + judgment)
Selected AbstractsClinical Judgment Versus Decision Analysis for Managing Device AdvisoriesPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 10 2008MITESH S. AMIN M.D. Introduction: Implantable cardioverter-defibrillator (ICD) and pacemaker (PM) advisories may have a significant impact on patient management. Surveys of clinical practice have shown a great deal of variability in patient management after a device advisory. We compared our management of consecutive patients in a single large university practice with device advisories to the "best" patient management strategy predicted by a decision analysis model. Methods: We performed a retrospective review of all patients who had implanted devices affected by an advisory at our medical center between March 2005 and May 2006 and compared our actual patient management strategy with that subsequently predicted by a decision analysis model. Results: Over 14 months, 11 advisories from three different manufacturers affected 436 patients. Twelve patients (2.8%) were deceased and 39 patients (8.9%) were followed at outside facilities. Management of the 385 remaining patients varied based on type of malfunction or potential malfunction, manufacturer recommendations, device dependency, and patient or physician preferences. Management consisted of the following: 57 device replacements (15.2%), 44 devices reprogrammed or magnets issued (11.7%), and 268 patients underwent more frequent follow-up (71.3%). No major complications, related to device malfunction or device replacement, occurred among any patient affected with a device advisory. Concordance between the decision analysis model and our management strategy occurred in 57.1% of cases and 25 devices were replaced when it was not the preferred treatment strategy predicted by the decision model (43.9%, 37.3% when excluding devices replaced based on patient preference). The decision analysis favored replacement for all patients with PM dependency, but only for four patients with ICDs for secondary prevention. No devices were left implanted that the decision analysis model predicted should have been replaced. Conclusions: We found that despite a fairly conservative device replacement strategy for advisories, we still replaced more devices when it was not the preferred device management strategy predicted by a decision analysis model. This study demonstrates that even when risks and benefits are being considered by experienced clinicians, a formal decision analysis can help to develop a systematic evidence based approach and potentially avoid unnecessary procedures. [source] Comparing Dementia Diagnostic Methods Used with People with Intellectual DisabilitiesJOURNAL OF POLICY AND PRACTICE IN INTELLECTUAL DISABILITIES, Issue 2 2005Diana B. Burt Abstract, Accurate detection of dementia in adults with intellectual disabilities is important for clinical care, program planning, and clinical research. This paper reports on a study that examined two major diagnostic methods that varied in the following ways: (1) the extent to which they relied on clinical judgment; (2) the statistical method used to detect declines; and (3) the sensitivity to declines in functioning. Two methods based on testing were compared with one based on clinical judgment. Data were drawn from annual sequential assessments of 168 adults with intellectual disabilities (78 with Down syndrome and 90 with other etiologies). Agreement between testing and clinical judgment methods was 72,75% depending on testing method used. Clinical judgment produced a higher rate of dementia diagnosis for adults with Down syndrome compared with testing methods, suggesting a possible bias. The authors found that diagnostic criteria were useful both for identifying dementia and for describing its characteristics. Our results suggest that clinical judgment could result in a higher number of adults with Down syndrome diagnosed with dementia than methods based on test batteries. Common results across research studies indicate that combinations of sources of information (interviews/direct testing) would be most useful for dementia diagnosis. Future collaboration across research sites is needed to promote rapid progress in this important area, with emphasis on differential diagnosis. [source] Early clinical experience with adalimumab in treatment of inflammatory bowel disease with infliximab-treated and naïve patientsALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 3 2009A. SWAMINATH Summary Background, Adalimumab, at an induction dose of 160/80 mg followed by 40 mg every other week is approved for treatment of refractory Crohn's disease (CD) and for patients with loss of response to infliximab. Aim, To evaluate the indications for adalimumab, the proportion of inflammatory bowel disease patients who require dose escalation and to identify whether this strategy is effective in inducing or maintaining remission. Methods, Patients prescribed adalimumab for CD were identified and included for analysis, if they had follow-up of at least 6 weeks. Adalimumab dose was escalated if patients had return of symptoms prior to next dose. Clinical judgment was used to determine severity of disease. A second GI physician confirmed disease severity as determined by the first physician. Results, A total of 48 out of 60 patients met inclusion criteria. Adalimumab was used to treat CD in 47/48 (98%) and ulcerative colitis in one (2%). Most patients had moderate 30/48 (63%) or severe 17/48 (35%) disease. Prior infliximab exposure was present in 42/48 (88%). Adalimumab dose escalation occurred in 14/48 (29%) within an average time of 2.2 months (s.d. 1.5 months). A majority of patients who required dose escalation, nine of 14 (64%) did not improve clinically. Steroids could be discontinued in three of 16 (18.8%). Clinical improvement was noted in 21/48 (43.8%) and one of 48 (2%) patients achieved clinical remission. Adverse drug reactions necessitated drug discontinuation in four of 48 (8%) of patients. Conclusions, This retrospective review from a single academic medical centre suggests that a minority of patients, who cannot be maintained on 40 mg every other week, of adalimumab benefit from an increased dose. This suggests the need for a treatment with an alternative mode of action in anti-TNF failures. [source] Small and Medium-Sized Congenital Nevi in Children: A Comparison of the Costs of Excision and Long-Term Follow-UpDERMATOLOGIC SURGERY, Issue 12 2009FERNANDO ALFAGEME ROLDÁN MD BACKGROUND Clinical decisions on whether to follow up or remove small and medium congenital melanocytic nevi (SMCMN) in children have cost implications that have not been studied. OBJECTIVES To compare the costs of excision of SMCMN in children with lifelong follow-up in a tertiary center. METHODS AND MATERIALS We elaborated models for the evaluation of the costs of excision and long-term follow-up. We retrospectively collected data on 113 consecutive excised SMCMN (105 single-step interventions and 8 multiple-step interventions) from the medical records of our pediatric dermatology unit from 2001 to 2007 and calculated and compared the costs (direct and indirect) of surgery and follow-up. RESULTS The mean ± standard deviation and total cohort costs for single-step interventions were ,1,504.73 ± 198.33 and 157,996.20, respectively. Median and cohort lifelong follow-up costs were similar if performed every 4 years (1,482.66 ± 34.98 and 156,679.63). For multiple-step interventions (3 or 4 steps), surgery costs were similar to those of annual lifelong follow-up. In the case of two-step surgery, costs were similar to lifelong follow-up every 2 years. CONCLUSIONS An analysis of the costs of surgery and long-term follow-up in children with SMCMN is possible. Although the clinical judgment of the dermatologist and parental opinion are the main determinants in the management of SMCMN, costs should also be taken into account. [source] I PREVENT Bacterial Resistance.DERMATOLOGIC SURGERY, Issue 10 2009An Update on the Use of Antibiotics in Dermatologic Surgery BACKGROUND AND OBJECTIVES Prophylaxis may be given to prevent a surgical wound infection, infective endocarditis (IE), or infection of a prosthetic joint, but its use before cutaneous surgery is controversial. Our aim was to review the current literature and provide a mnemonic to assist providers in appropriately prescribing prophylactic antibiotics. METHODS AND MATERIALS We reviewed the current literature, including the new guidelines provided by the American Heart Association (AHA). RESULTS The new AHA guidelines recommend prophylaxis for patients with high risk of an adverse outcome from IE instead of high risk of developing IE. The American Academy of Orthopedic Surgeons and the American Dental Association also provide guidelines. Given the paucity of conclusive studies, prophylaxis against a surgical wound infection is based more on clinical judgment. CONCLUSION The mnemonic we propose, "I PREVENT," represents: Immunosuppressed patients; patients with a Prosthetic valve; some patients with a joint Replacement; a history of infective Endocarditis; a Valvulopathy in cardiac transplant recipients; Endocrine disorders such as uncontrolled diabetes mellitus; Neonatal disorders including unrepaired cyanotic heart disorders (CHDs), repaired CHD with prosthetic material, or repaired CHD with residual defects; and the Tetrad of antibiotics: amoxicillin, cephalexin, clindamycin, and ciprofloxacin. [source] High-Risk Cutaneous Squamous Cell Carcinoma without Palpable Lymphadenopathy: Is There a Therapeutic Role for Elective Neck Dissection?DERMATOLOGIC SURGERY, Issue 4 2007JUAN-CARLOS MARTINEZ MD PURPOSE The beneficial role of elective neck dissection (END) in the management of high-risk cutaneous squamous cell carcinoma (CSCC) of the head and neck remains unproven. Some surgical specialists suggest that END may be beneficial for patients with clinically node-negative (N0) high-risk CSCC, but there are few data to support this claim. We reviewed the available literature regarding the use of END in the management of both CSCC and head and neck SCC (HNSCC). METHODOLOGY The available medical literature pertaining to END in both CSCC and HNSCC was reviewed using PubMed and Ovid Medline searches. RESULTS Many surgical specialists recommend that END be routinely performed in patients with N0 HNSCC when the risk of occult metastases is estimated to exceed 20%; however, patients who undergo END have no proven survival benefit over those who are initially staged as N0 and undergo therapeutic neck dissection (TND) after the development of apparent regional disease. There is a lack of data regarding the proper management of regional nodal basins in patients with N0 CSCC. In the absence of evidence-based data, the cutaneous surgeon must rely on clinical judgment to guide the management of patients with N0 high-risk CSCC of the head and neck. CONCLUSIONS Appropriate work-up for occult nodal disease may occasionally be warranted in patients with high-risk CSCC. END may play a role in only a very limited number of patients with high-risk CSCC. [source] Accuracy of Tissue Doppler Echocardiography in the Diagnosis of New-Onset Congestive Heart Failure in Patients with Levels of B-Type Natriuretic Peptide in the Midrange and Normal Left Ventricular Ejection FractionECHOCARDIOGRAPHY, Issue 8 2006Stephane Arques M.D. Background: Based on the hypothesis that it reflects left ventricular (LV) diastolic pressures, B-type natriuretic peptide (BNP) is largely utilized as first-line diagnostic complement in the emergency diagnosis of congestive heart failure (HF). The incremental diagnostic value of tissue Doppler echocardiography, a reliable noninvasive estimate of LV filling pressures, has been reported in patients with preserved LV ejection fraction and discrepancy between BNP levels and the clinical judgment, however, its clinical validity in such patients in the presence of BNP concentrations in the midrange, which may reflect intermediate, nondiagnostic levels of LV filling pressures, is unknown. Methods: 34 patients without history of HF, presenting with acute dyspnea at rest, BNP levels of 100,400 pg/ml and normal LV ejection fraction were prospectively enrolled (17 with congestive HF and 17 with noncardiac cause). Tissue Doppler echocardiography was performed within 3 hours after admission. Results: unlike BNP (P = 0.78), Boston criteria (P = 0.0129), radiographic pulmonary edema (P = 0.0036) and average E/Ea ratio (P = 0.0032) were predictive of congestive HF by logistic regression analysis. In this clinical setting, radiographic pulmonary edema had a positive predictive value of 80% in the diagnosis of congestive HF. In patients without evidence of radiographic pulmonary edema, average E/Ea > 10 was a powerful predictor of congestive HF (area under the ROC curve of 0.886, P < 0.001, sensitivity 100% and specificity 78.6%). Conclusion: by better reflecting LV filling pressures, bedside tissue Doppler echocardiography accurately differentiates congestive HF from noncardiac cause in dyspneic patients with intermediate, nondiagnostic BNP levels and normal LV ejection fraction. [source] Assessment of drug-induced liver injury in clinical practiceFUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 2 2008Ma Isabel Lucena Abstract Currently, pharmaceutical preparations are serious contributors to liver disease, with hepatotoxicity ranking as the most frequent cause for acute liver failure and post-marketing regulatory decisions. The diagnostic approach of drug-induced liver injury (DILI) is still rudimentary and inaccurate because of the lack of reliable markers for use in general clinical practice. To incriminate any given drug in an episode of liver dysfunction is a step-by-step process that requires a high degree of suspicion, compatible chronology, awareness of the drug's hepatotoxic potential, the exclusion of alternative causes of liver damage, and the ability to detect the presence of subtle data that favour a toxic aetiology. Clinical and laboratory data may also be assessed with algorithms or clinical scales, which may add consistency to the clinical judgment by translating the suspicion into a quantitative score. The CIOMS/RUCAM instrument is considered at present the best method for assessing causality in DILI, although it could be improved through the use of large database of bona fide DILI cases for validation criteria. [source] Preoperative assessment for and outcomes of mandibular conservation surgery,HEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 12 2001John W. Werning MD Abstract Introduction The role of marginal mandibulectomy and other conservative resective procedures for patients with early cortical mandibular invasion from squamous carcinoma of the oral cavity remains poorly defined. The purpose of this retrospective study was to evaluate the efficacy of preoperative assessment for bone invasion and the outcomes of different mandibular resective procedures that preserve mandibular continuity. Methods The charts of 222 patients treated at the University of Texas M. D. Anderson Cancer Center between 1960 and 1990 were reviewed. All patients had a biopsy-confirmed diagnosis of squamous carcinoma involving either the lower gingiva, floor of mouth, oral tongue, or retromolar trigone. All patients had a surgical resection that involved removing less than a segment of the mandible. Patient data were analyzed to determine the usefulness of preoperative assessment and outcomes of therapy. Results Clinical evaluation of mandibular bone invasion was more sensitive than radiologic evaluation, whereas radiologic assessment was more specific and had a higher reliability index. The overall local and regional recurrence and distant metastasis rates for all T stages were 14.4%, 18.0%, and 2.7%, respectively. Sixty-nine point eight percent of all patients were without evidence of disease 2 years after treatment. Conclusions Mandibular conservation surgery is oncologically safe for patients with early mandibular invasion. Accurate preoperative assessment that combines clinical examination and radiographic evaluation is better than either modality alone, but clinical judgment is still necessary for proper patient selection. © 2001 John Wiley & Sons, Inc. Head Neck 23: 1024,1030, 2001. [source] Novel Nursing Terminologies for the Rapid Response SystemINTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 2 2009Elizabeth Wong CRNA PURPOSE., Nursing terminology with implications for the rapid response system (RRS) is introduced and proposed: critical incident nursing diagnosis (CIND), defined as the recognition of an acute life-threatening event that occurs as a result of disease, surgery, treatment, or medication; critical incident nursing intervention, defined as any indirect or direct care registered nurse-initiated treatment, based upon clinical judgment and knowledge that a registered nurse performs in response to a CIND; and critical incident control, defined as a response that attempts to reverse a life-threatening condition. DATA SOURCES., The current literature, research studies, meta-analyses from a variety of disciplines, and personal clinical experience serve as the data sources for this article. DATA SYNTHESIS., The current nursing diagnoses, nursing interventions, and nursing outcomes listed in the North American Nursing Diagnosis Association International Classification, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC), respectively, are inaccurate or inadequate for describing nursing care during life-threatening situations. The lack of such standardized nursing terminology creates a barrier that may impede critical communication and patient care during life-threatening situations when activating the RRS. CONCLUSIONS., The North American Nursing Diagnosis Association International Classification, NIC, and NOC are urged to refine their classifications and include CIND, critical incident nursing intervention, and critical incident control. The RRS should incorporate standardized nursing terminology to describe patient care during life-threatening situations. IMPLICATIONS FOR NURSING PRACTICE., Refining the diagnoses, interventions, and outcomes classifications will permit nursing researchers, among others, to conduct studies on the efficacy of the proposed novel nursing terminology when providing care to patients during life-threatening situations. In addition, including the proposed novel nursing terminology in the RRS offers a means of improving care in such situations. [source] Coining and Defining Novel Nursing Terminology.INTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 1 2009Part 3: Critical Incident Control PURPOSE.,In the third of a three-part series, a novel nursing terminology is introduced and proposed for inclusion in the Nursing Outcomes Classification (NOC),Critical incident control (CIC),defined as a response that attempts to reverse a life-threatening condition. Critical incident nursing diagnosis (CIND), defined as recognition of an acute life-threatening event that occurs as a result of disease, surgery, treatment, or medication, and critical incident nursing intervention, defined as any indirect or direct care registered nurse,initiated treatment, based upon clinical judgment and knowledge that a registered nurse performs in response to a CIND, were introduced in Parts 1 and 2 of this series, respectively. DATA SOURCES.,The current literature, research studies, meta-analyses from a variety of disciplines, and personal clinical experience serve as the data sources for this article. DATA SYNTHESIS.,The current nursing outcomes in the NOC are inaccurate or inadequate for describing nursing care during life-threatening situations. The lack of standardized nursing terminology creates a barrier that may impede critical communication and patient care during life-threatening situations. CONCLUSION.,Coining and defining novel nursing terminology, CIC, for patient care during life-threatening situations is important and fills the gap in the current standardized nursing terminology. IMPLICATIONS FOR NURSING PRACTICE.,Refining the NOC will permit nursing researchers, among others, to conduct studies on nursing diagnoses in conjunction with the proposed novel nursing terminology, CIC. [source] Coining and Defining Novel Nursing Terminology.INTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 4 2008Part 2: Critical Incident Nursing Intervention PURPOSE.,In the second of a three-part series, a novel nursing terminology is introduced and proposed for inclusion in the Nursing Interventions Classification (NIC): Critical incident nursing intervention (CINI), defined as any indirect or direct care registered nurse,initiated treatment, based upon clinical judgment and knowledge that a registered nurse performs in response to a critical incident nursing diagnosis (CIND). A CIND is defined as recognition of an acute life-threatening event that occurs as a result of disease, surgery, treatment, or medication. DATA SOURCES.,The literature, research studies, meta-analyses from a variety of disciplines, and personal clinical experience serve as the data sources for this article. DATA SYNTHESIS.,The current nursing interventions in the NIC are inaccurate or inadequate for describing nursing care during life-threatening situations. The lack of standardized nursing terminology creates a barrier that may impede critical communication and patient care during life-threatening situations. CONCLUSION.,Coining and defining novel nursing terminology, CINI, for patient care during life-threatening situations is important and fills the gap in the current standardized nursing terminology. IMPLICATIONS FOR NURSING PRACTICE.,Refining the NIC will permit nursing researchers, among others, to conduct studies on nursing interventions in conjunction with the proposed novel nursing terminology, CINI. The first article in this series (Part 1) introduced the novel nursing terminology: CIND; the present article (Part 2) introduces the novel nursing terminology: CINI; and the third article in this series (Part 3) will introduce the novel nursing terminology: critical incident control. [source] Nursing Diagnoses in a Brazilian Intensive Care UnitINTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 3 2006Amália De Fátima Lucena PURPOSE.,To identify the nursing diagnoses and their most frequent related factors or risk factors in patients admitted to an intensive care unit (ICU). METHOD.,Descriptive cross-sectional study with information from 991 admissions to an ICU during a 6-month period. FINDINGS.,Sixteen nursing diagnoses resulting from hospitalization were most frequently identified; six had percentages greater than 40% with 29 related/risk factors. The resulting averages were 6.9 diagnoses per hospitalization and 1.2 related/risk factors per nursing diagnoses. CONCLUSIONS.,The nursing diagnoses identified seemed to be common to the clinical practice of nursing and their fundamental related/risk factors to precise clinical judgment, thus providing a basis for interventions for a desired outcome. PRACTICE IMPLICATIONS.,The findings have contributed to the development of the standardized nursing language usage in Brazilian nursing practices. Diagnósticos de Enfermagem em uma Unidade de Terapia Intensiva Brasileira OBJETIVO.,Identificar os diagnósticos de enfermagem e os seus fatores relacionados/risco mais freqüentemente estabelecidos aos pacientes internados numa unidade de terapia intensiva (UTI). MÉTODO.,Estudo descritivo, transversal, com informações de 991 admissões numa UTI, durante seis meses. RESULTADOS.,Dezesseis diagnósticos de enfermagem foram mais freqüentes, seis deles com percentuais acima de 40% por internação e com 29 fatores relacionados ou de risco. As médias foram de 6,9 diagnósticos de enfermagem por internação e 1,2 fatores relacionados ou de risco por diagnóstico de enfermagem. CONCLUSÕES.,Os diagnósticos de enfermagem identificados parecem ser comuns à prática clínica de enfermagem e os seus fatores relacionados ou de risco fundamentais ao julgamento clínico preciso, que subsidia à escolha da intervenção para um resultado esperado. IMPLICAÇÕES PARA A PRÁTICA.,Os resultados têm colaborado para o desenvolvimento do uso da linguagem padronizada de enfermagem no Brasil. [source] Clinical reasoning: concept analysisJOURNAL OF ADVANCED NURSING, Issue 5 2010Barbara Simmons simmons b. (2010) Clinical reasoning: concept analysis. Journal of Advanced Nursing,66(5), 1151,1158. Abstract Title.,Clinical reasoning: concept analysis. Aim., This paper is a report of a concept analysis of clinical reasoning in nursing. Background., Clinical reasoning is an ambiguous term that is often used synonymously with decision-making and clinical judgment. Clinical reasoning has not been clearly defined in the literature. Healthcare settings are increasingly filled with uncertainty, risk and complexity due to increased patient acuity, multiple comorbidities, and enhanced use of technology, all of which require clinical reasoning. Data sources., Literature for this concept analysis was retrieved from several databases, including CINAHL, PubMed, PsycINFO, ERIC and OvidMEDLINE, for the years 1980 to 2008. Review methods., Rodgers's evolutionary method of concept analysis was used because of its applicability to concepts that are still evolving. Results., Multiple terms have been used synonymously to describe the thinking skills that nurses use. Research in the past 20 years has elucidated differences among these terms and identified the cognitive processes that precede judgment and decision-making. Our concept analysis defines one of these terms, ,clinical reasoning,' as a complex process that uses cognition, metacognition, and discipline-specific knowledge to gather and analyse patient information, evaluate its significance, and weigh alternative actions. Conclusion., This concept analysis provides a middle-range descriptive theory of clinical reasoning in nursing that helps clarify meaning and gives direction for future research. Appropriate instruments to operationalize the concept need to be developed. Research is needed to identify additional variables that have an impact on clinical reasoning and what are the consequences of clinical reasoning in specific situations. [source] Decision-making for acutely ill nursing home residents: nurses in the middleJOURNAL OF ADVANCED NURSING, Issue 5 2009Ruth Palan Lopez Abstract Title.,Decision-making for acutely ill nursing home residents: nurses in the middle. Aim., This paper is a report of a study to generate a model of nursing behaviours and social processes inherent in decision-making for acutely ill nursing home residents. Background., Most research concerning clinical decision-making in nursing homes focuses on the perspectives of doctors. Much less is known about the perspectives and actions of nurses with regard to decision-making, despite the centrality of their roles in nursing homes. Method., Grounded theory was used. Data were collected in 2004 in four nursing homes in the United States of America using in-depth, semi-structured interviews, 74 hours of non-participant observation and informal conversational interviews with key nursing staff involved in decision-making. Findings., Nurses strive to create a plan of care acceptable to family members and doctors, consistent with wishes of residents and most comfortable for residents. A unifying theme of satisfying all sides emerged as representative of the negotiation strategies used by nurses to address these competing points of view. Four phases in this negotiation occurred: weighing the significance; notifying the family; feeling it out; and playing the middleman. The outcome was either a decision for life-prolongation or for palliative care. Conclusion., Decisions for nursing home residents are complex and involve weighing and balancing the interests and preferences of many concerned participants, including residents, families and doctors. This process requires skill in clinical judgment, communication and collaboration. [source] The Associations Between Basal Salivary Cortisol and Illness Symptomatology in Chronic Fatigue SyndromeJOURNAL OF APPLIED BIOBEHAVIORAL RESEARCH, Issue 3 2008Susan Torres-Harding Hypocortisolism has been reported in chronic fatigue syndrome (CFS), with the significance of this finding to disease etiology unclear. This study examined cortisol levels and their relationships with symptoms in a group of 108 individuals with CFS. CFS symptoms examined included fatigue, pain, sleep difficulties, neurocognitive functioning, and psychiatric status. Alterations in cortisol levels were examined by calculation of mean daily cortisol, and temporal variation in cortisol function was examined by means of a regression slope. Additionally, deviation from expected cortisol diurnal pattern was determined via clinical judgment. Results indicated that fatigue and pain were associated with salivary cortisol levels. In particular, variance from the expected pattern of cortisol was associated with increased levels of fatigue. The implications of these findings are discussed. [source] In defense of clinical judgment , and mechanical predictionJOURNAL OF BEHAVIORAL DECISION MAKING, Issue 5 2006Jason Dana Abstract Despite over 50 years of one-sided research favoring formal prediction rules over human judgment, the "clinical-statistical controversy," as it has come to be known, remains something of a hot-button issue. Surveying the objections to the formal approach, it seems the strongest point of disagreement is that clinical expertise can be replaced by statistics. We review and expand upon an unfortunately obscured part of Meehl's book to try to reconcile the issue. Building on Meehl, we argue that the clinician provides information that cannot be captured in, or outperformed by, mere frequency tables. However, that information is still best harnessed by a mechanical prediction rule that makes the ultimate decision. Two original studies support our arguments. The first study shows that multivariate prediction models using no data other than clinical speculations can perform well against statistical regression models. Study 2, however, showed that holistic predictions were less accurate than predictions made by mechanically combining smaller judgments without input from the judge at the combination stage. While we agree that clinical expertise cannot be replaced or neglected, we see no ethical reason to resist using explicit, mechanical rules for socially important decisions. Copyright © 2006 John Wiley & Sons, Ltd. [source] When religion and obsessive,compulsive disorder collide: Treating scrupulosity in ultra-orthodox JewsJOURNAL OF CLINICAL PSYCHOLOGY, Issue 10 2007Jonathan D. Huppert Evidence-based practice suggests that clinicians should integrate the best available research with clinical judgment and patient values. Treatment of religious patients with scrupulosity provides a paradigmatic example of such integration. The purpose of this study is to describe potential adaptations to make exposure and response prevention, the first-line treatment for obsessive,compulsive disorder, acceptable and consistent with the values of members of the Ultra-Orthodox Jewish community. We believe that understanding these challenges will enhance the clinician's ability to increase patient motivation and participation in therapy and thereby provide more effective treatment for these and other religious patients. © 2007 Wiley Periodicals, Inc. J Clin Psychol 63: 925,941, 2007. [source] Computer utilization and clinical judgment in psychological assessment reportsJOURNAL OF CLINICAL PSYCHOLOGY, Issue 1 2006Elizabeth O. Lichtenberger The process of assessment report writing is a complex one, involving both the statistical evaluation of data and clinical methods of data interpretation to appropriately answer referral questions. Today, a computer often analyzes data generated in a psychological assessment, at least in part. In this article, the author focuses on the interaction between the decision-making processes of human clinicians and the test interpretations that are computer-based. The benefits and problems with computers in assessment are highlighted and are presented alongside the research on the validity of automated assessment, as well as research comparing clinicians and computers in the decision-making process. The author concludes that clinical judgment and computer-based test interpretation each have weaknesses. However, by using certain strategies to reduce clinicians' susceptibility to errors in decision making and to ensure that only valid computer-based test interpretations are used, clinicians can optimize the accuracy of conclusions that they draw in their assessment report © 2005 Wiley Periodicals, Inc. J Clin Psychol. [source] Opioids and opiates: analgesia with cardiovascular, haemodynamic and immune implications in critical illnessJOURNAL OF INTERNAL MEDICINE, Issue 2 2006P. E. MOLINA Abstract. Traumatic injury, surgical interventions and sepsis are amongst some of the clinical conditions that result in marked activation of neuroendocrine and opiate responses aimed at restoring haemodynamic and metabolic homeostasis. The central activation of the neuroendocrine and opiate systems, known collectively as the stress response, is elicited by diverse physical stressor conditions, including ischaemia, glucopenia and inflammation. The role of the hypothalamic,pituitary,adrenal axis and sympathetic nervous system in counterregulation of haemodynamic and metabolic alterations has been studied extensively. However, that of the endogenous opiates/opioid system is still unclear. In addition to activation of the opiate receptor through the endogenous release of opioids, pharmacotherapy with opiate receptor agonists is frequently used for sedation and analgesia of injured, septic and critically ill patients. How this affects the haemodynamic, cardiovascular, metabolic and immune responses is poorly understood. The variety of opiate receptor types, their specificity and ubiquitous location both in the central nervous system and in the periphery adds additional complicating factors to the clear understanding of their contribution to the stress response to the various physical perturbations. This review aims at discussing scientific evidence gathered from preclinical studies on the role of endogenous opioids as well as those administered as pharmacological agents on the host cardiovascular, neuroendocrine, metabolic and immune response mechanisms critical for survival from injury in perspective with clinical observations that provide parallel assessment of relevant outcome measures. When possible, the clinical relevance and corresponding scenarios where this evidence can be integrated into our understanding of the clinical implications of opiate effects will be examined. Overall, the scientific basis to enhance clinical judgment and expectations when using opioid sedation and analgesia in the management of the injured, septic or postsurgical patient will be discussed. [source] Management of Multivessel Coronary Disease: Let Us Not Shortchange Drug-Eluting StentsJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 3 2008F.A.C.C., KISHORE J. HARJAI M.D. A recent observational study of coronary artery graft (CABG) versus drug-eluting stents (DES) performed in the state of New York reported that CABG was superior to DES for multivessel disease. Our comment provides rational criticism of this study, reviews the data that support a role for DES in the management of multivessel coronary disease, and emphasizes the need for ongoing prospective clinical trials in this area. Till randomized trial data become available, physicians should continue to use their clinical judgment based on existing evidence in managing their patients with multivessel coronary artery disease (CAD). [source] Comparing Dementia Diagnostic Methods Used with People with Intellectual DisabilitiesJOURNAL OF POLICY AND PRACTICE IN INTELLECTUAL DISABILITIES, Issue 2 2005Diana B. Burt Abstract, Accurate detection of dementia in adults with intellectual disabilities is important for clinical care, program planning, and clinical research. This paper reports on a study that examined two major diagnostic methods that varied in the following ways: (1) the extent to which they relied on clinical judgment; (2) the statistical method used to detect declines; and (3) the sensitivity to declines in functioning. Two methods based on testing were compared with one based on clinical judgment. Data were drawn from annual sequential assessments of 168 adults with intellectual disabilities (78 with Down syndrome and 90 with other etiologies). Agreement between testing and clinical judgment methods was 72,75% depending on testing method used. Clinical judgment produced a higher rate of dementia diagnosis for adults with Down syndrome compared with testing methods, suggesting a possible bias. The authors found that diagnostic criteria were useful both for identifying dementia and for describing its characteristics. Our results suggest that clinical judgment could result in a higher number of adults with Down syndrome diagnosed with dementia than methods based on test batteries. Common results across research studies indicate that combinations of sources of information (interviews/direct testing) would be most useful for dementia diagnosis. Future collaboration across research sites is needed to promote rapid progress in this important area, with emphasis on differential diagnosis. [source] Management studies using a combination of D-dimer test result and clinical probability to rule out venous thromboembolism: a systematic reviewJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 11 2005A. J. TEN CATE-HOEK Summary.,Background:,While the number of patients with suspected venous thromboembolism (VTE) referred to hospital emergency units increases, the proportion in whom the diagnosis can be confirmed is decreasing. A more efficient but safe diagnostic strategy is needed. Objective:,To evaluate the safety of withholding anticoagulant therapy in patients suspected of VTE based on a diagnostic work-up that combines a clinical decision rule (CDR) with a D-dimer test result without performing additional diagnostic tests. Patients/methods:,We searched Medline (January 1996,December 2004)-related articles and reference lists of studies in English for prospective clinical studies that managed consecutive patients suspected of VTE and used a D-dimer assay combined with an explicit CDR or implicit clinical judgment. Results:,We identified 11 studies in which 6837 consecutive outpatients suspected of VTE were included. In the combined management studies, the overall rate of thromboembolic events was nine out of 2056 patients (0.44 %, 95% CI 0.2%,0.83%) in whom anticoagulants were withheld based on the D-dimer result and a low clinical score. Similar results were obtained with qualitative and quantitative D-dimer tests and with different decision rules. The rate of exclusion varied between 30% and 50% and was highest with a low incidence of VTE among those referred. Conclusion:,Withholding anticoagulant treatment in patients suspected of VTE on the basis of a work-up consisting of a low clinical probability combined with either a qualitative or quantitative D-dimer test result is safe. [source] Effect of the two-wall-stitch mistake upon patency of rat femoral vein anastomosis: Preliminary observationsMICROSURGERY, Issue 4 2004Marco Pignatti M.D. Anastomotic patency is believed to be the most important factor in microvascular surgery. The two-wall stitch is a technical error commonly considered to cause thrombosis of the anastomosis, especially on the venous side. In order to demonstrate the real effect on vein patency of the two-wall stitch, the authors performed a standardized mistake after correct microanastomosis on the femoral vein of 15 rats, with one stitch passing through the whole thickness of the two walls of the vein. Traditional correct anastomoses on the contralateral side were used as controls. Patency was assessed at 5, 20, and 60 min and at 24 h by the milking test, and by direct section of the vessel at 24 h. The results showed no statistically significant difference between the two techniques. Histological examination confirmed the clinical judgment about the vessel's patency, and ultrastructural microscopy evidenced only mild signs of endothelial activation. In conclusion, this study indicates that the occasional two-wall stitch does not necessarily increase the risk of venous occlusion in anastomoses of the rat femoral vein. © 2004 Wiley-Liss, Inc. [source] Pregnant with possibilities: drawing on hermeneutic thought to reframe home-visiting programs for young mothersNURSING INQUIRY, Issue 3 2009Lee SmithBattleArticle first published online: 11 AUG 200 Although the positive outcomes achieved in home-visiting interventions targeting young, disadvantaged mothers are partly credited to therapeutic relationships, researchers rarely offer philosophical or theoretical explanations for these relationships. This omission is a conspicuous oversight as nurse,family relationships have figured prominently in public health nursing practice since its inception. In this study, I suggest that the contribution of therapeutic relationships to positive outcomes will remain theoretically undeveloped as long as clinical trials and nursing practice models follow the logic of techne. After describing how a scientific,clinical gaze misrepresents teen mothers and contributes to a rational,technical model of clinical practice, I draw on contemporary hermeneutics to describe how dialog and understanding are indispensable for clinical judgment and the judicious use of scientific knowledge. This hermeneutic corrective calls attention to the dialogical nature of truth and the relational skills that disclose meaning, preserve personhood, and support possibilities available in the life-world. Dialogical understanding also disrupts the scientific,clinical gaze by disclosing the social disparities that are implicated in early childbearing and teen mothers' long-term prospects. The implications of this thought for legitimating and supporting the flexibility and clinical know-how that ,strays' from protocol-driven care is addressed. [source] From clinical practice to guidelines: how to recognize rhinosinusitis in childrenPEDIATRIC ALLERGY AND IMMUNOLOGY, Issue 2007S. Esposito Rhinosinusitis is a common childhood respiratory infection. Children have approximately six to eight viral infections of the upper respiratory tract each year, 5,13% of which may be complicated by a secondary bacterial infection of the paranasal sinuses. The diagnosis of acute bacterial rhinosinusitis in children is established by the persistence of purulent nasal or post-nasal draining lasting at least 10 days, especially if accompanied by supporting symptoms and signs, at which point antibiotic treatment has to be recommended. Appropriate antibacterial therapy should also be recommended if the draining has been present for less time, but is concomitantly associated with significant fever and localized signs of sinus inflammation in a child who appears ill. Imaging studies are not necessary to confirm the diagnosis of clinical rhinosinusitis for the purposes of treatment, but should be reserved for cases in which the diagnosis is in doubt or a complication is suspected, and for patients with recurrent or chronic rhinosinusitis. Under these circumstances, computed tomography is the preferred evaluation. Together with their clinical judgment, these suggestions may be useful for pediatricians in diagnosing this common condition. [source] Management of hematological malignancies during pregnancy,AMERICAN JOURNAL OF HEMATOLOGY, Issue 12 2009Tina Rizack The management of hematological malignancies during pregnancy is a challenging endeavor, which not only requires technical skills and knowledge by the clinicians but also requires sound clinical judgment and compassion, keeping in mind the patient and family preferences and, ultimately, the wellbeing of the neonate. The incidence of hematological malignancies during pregnancy is rare, ranging from 1 in 1,000 to 1 in 10,000 deliveries, impeding the design and execution of large prospective studies. The purpose of this review is to evaluate the limited existing data and make useful suggestions in the management of acute and chronic leukemias, Hodgkin and non-Hodgkin lymphomas, plasma cell myeloma, and other hematological malignancies, such as myelodysplastic syndromes and hairy cell leukemia, during pregnancy. Am. J. Hematol. 2009. © 2009 Wiley-Liss, Inc. [source] Potential utility of actuarial methods for identifying specific learning disabilitiesPSYCHOLOGY IN THE SCHOOLS, Issue 6 2010Nicholas Benson This article describes how actuarial methods can supplant discrepancy models and augment problem solving and Response to Intervention (RTI) efforts by guiding the process of identifying specific learning disabilities (SLD). Actuarial methods use routinized selection and execution of formulas derived from empirically established relationships to make predictions that fall within a plausible range of possible future outcomes. In the case of SLD identification, the extent to which predictions are reasonable can be evaluated by their ability to categorize large segments of the population into subgroups that vary considerably along a spectrum of risk for academic failure. Although empirical comparisons of actuarial methods to clinical judgment reveal that actuarial methods consistently outperform clinical judgment, multidisciplinary teams charged with identifying SLD currently rely on clinical judgment. Actuarial methods provide educators with an empirically verifiable indicator of student need for special education and related services that could be used to estimate the relative effects of exclusionary criteria. This indicator would provide a defensible endpoint in the process of identifying SLD as well as a means of informing and improving the SLD identification process. © 2010 Wiley Periodicals, Inc. [source] Integration of psychological assessment approaches in school psychologyPSYCHOLOGY IN THE SCHOOLS, Issue 3 2007Cynthia A. Riccio There are multiple existing and emerging models and methods of psychological assessment derived from a variety of theoretical or empirical perspectives. Integration of information relating to personality, behavior, and social-emotional competence as part of the psychological assessment with psychoeducational data can better inform service delivery and the outcomes of the children and families served. The various models and methods of psychological assessment used by school psychologists are reviewed in this article. The advantages and complexities of integrating information using actuarial and clinical judgment are explored. Finally, a discussion and model of how psychological and psychoeducational data can be used to aid in the understanding of the child and facilitate intervention planning is provided. © 2007 Wiley Periodicals, Inc. Psychol Schs 44: 243,255, 2007. [source] What is the optimal approach for using a direct amplification test in the routine diagnosis of pulmonary tuberculosis?RESPIROLOGY, Issue 4 2002A preliminary assessment Objective: The aim of this study was to determine the most appropriate strategy for the rapid diagnosis of pulmonary tuberculosis (PTB) using a nucleic acid amplification (NAA) test. Methodology: This was a prospective study of 128 adult patients in whom respiratory secretions were tested for Mycobacterium tuberculosis by the AMPLICOR assay. The basis for starting PTB treatment was noted for each patient. The optimal approach was determined by using Bayes' theorem to compare different combinations of pretest probability, smear results with the AMPLICOR test. Results: The incidence of PTB was 15.6%. In only one patient was treatment for PTB commenced because of a positive AMPLICOR result. The rest were managed according to the conventional approach which relied upon clinical judgment and direct smear. The optimal approach was to treat patients with high or intermediate pretest risk for PTB who returned positive AMPLICOR tests. The overall accuracies of the conventional approach, AMPLICOR test and optimal approach were 89.8, 95.3 and 96.1%, respectively. Conclusion: This small study suggests that NAA testing be limited to patients with high or intermediate pretest risk of PTB. In this group, positive results demand treatment while the management of those with negative results still relies on clinical judgment. [source] | ||||||||||||||||||||||||||||||||||