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Diagnostic Testing (diagnostic + testing)
Selected AbstractsDiagnostic Testing for Chronic Daily HeadacheHEADACHE, Issue 6 2002Randolph W. Evans MD First page of article [source] Perceptions of Deservedness of Social Aid as a Function of Prenatal Diagnostic Testing,JOURNAL OF APPLIED SOCIAL PSYCHOLOGY, Issue 1 2003Karen L. Lawson This study examined whether judgments of deservedness of social aid subsequent to the birth of a disabled child vary as a function of prenatal diagnostic testing (PDT) use as predicted by the attribution-affect-action model (Weiner, 1980). A sample of family physicians/obstetricians (n= 341) and a university employee sample (n= 281) made attribution ratings in 3 scenarios in which an at-risk pregnant woman gave birth to a disabled child. The findings indicate that women who chose not to use PDT or who chose to continue the pregnancy following a diagnosis were judged more responsible, more to blame, and less deserving of both sympathy and social aid subsequent to giving birth to a disabled child than were women to whom testing was not made available. [source] The effect of concurrent pain on the management of patients with depression: an analysis of NHS healthcare resource utilisation using the GPRD databaseINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 5 2009L. Watson Summary Introduction:, Patients with depression frequently report painful physical symptoms. However, there are scant data from the UK concerning differences in primary and secondary care resource use between depressed patients with and without pain treated in general practice. Methods:, Patients with depression codes were identified from the General Practice Research Database (GPRD) excluding those with psychoses. The observation period was 1st January 2000,31st December 2006. Patients were further categorised into three groups: (i) no painful physical symptom codes ever in the observation period (NO PAIN); (ii) patients with no other diagnostic or test codes 30 days either side of a pain code (PAIN MINUS DIAGNOSIS) and (iii) patients with pain codes and other diagnostic codes (PAIN PLUS DIAGNOSIS). Rates of general practitioner (GP) visits, antidepressant and concomitant prescribing and switching, secondary care referrals and diagnostic tests were reported per group with 95% confidence limits (CI). Results:, A total of 145,784 patients with depression aged 18,50 years were selected. Of these, 48,615 (33.3%) were classed as NO PAIN, the remaining 66.6% having pain. PAIN MINUS DIAGNOSIS patients constituted 5654 (5.8%) of those with pain. PAIN MINUS DIAGNOSIS and PAIN PLUS DIAGNOSIS had a significantly higher rate of GP visits than NO PAIN patients, 10.37 (95% CI 10.23, 10.52); 11.15 (11.11,11.20) and 7.04 (7.00, 7.08) respectively. Inter and intraclass drug switching was high with 13% of PAIN MINUS DIAGNOSIS and 14% of PAIN PLUS DIAGNOSIS patients having three or more switches compared with 7% of NO PAIN patients. Referral rates to secondary care were significantly higher in both pain groups compared with patients with no pain. Diagnostic testing was significantly greater in PAIN MINUS DIAGNOSIS and PAIN PLUS DIAGNOSIS groups than NO PAIN patients for all test types, with X-rays being the most common test; 3.85 (3.69,4.00); 2.77 (2.74,2.80); 0.91 (0.89, 0.94) respectively. Conclusion:, Patients in general practice diagnosed with depression and concurrent painful physical symptoms have higher resource use in primary and secondary care. [source] The dominantly inherited motor and sensory neuropathies: Clinical and molecular advancesMUSCLE AND NERVE, Issue 5 2006Garth A. Nicholson MB Abstract The rapid advances in the molecular genetics and cell biology of hereditary neuropathy have revealed great genetic complexity. It is a challenge for physicians and laboratories to keep pace with new discoveries. Classification of hereditary neuropathies has evolved from a simple clinical to a detailed molecular classification. However, the molecular classification is not simple to use, as different mutations of the same gene produce a range of phenotypes. The logistics of testing for multiple gene mutations are considerable. This review gives a clinical overview of molecular and clinical advances in the dominant hereditary motor and sensory neuropathies [HMSNs, Charcot,Marie,Tooth (CMT) neuropathy], which account for some 60%,70% of families with CMT. The dominant forms of CMT have cellular mechanisms different from those of recessive forms and are a separate diagnostic challenge, so they are not included in this review. Diagnostic testing requires accurate clinical information and a selective approach to gene screening until the cost of multiple gene mutation screening falls. Accurate molecular diagnosis is critical to genetic counseling. This review concentrates on how molecular information can be used clinically, on how physicians can keep pace with new developments, and on the relevance of this new knowledge to patients. Muscle Nerve, 2006 [source] Diagnostic testing in suspected fluoroquinolone hypersensitivityCLINICAL & EXPERIMENTAL ALLERGY, Issue 11 2009C. S. Seitz Summary Background Because of their broad antibacterial activity in the gram-negative and gram-positive spectrum, high oral bioavailability, and good tissue penetration, fluoroquinolone antibiotics are widely used. Besides direct drug-related side-effects, fluoroquinolones may cause hypersensitivity reactions. Objective The aim of this retrospective analysis was to present the results of diagnostic testing in cases of clinically suspected fluoroquinolone-induced immediate or delayed hypersensitivity. Methods We studied 101 patients with a history of immediate or delayed hypersensitivity symptoms in temporal relation to treatment with a fluoroquinolone antibiotic using standardized skin testing, followed by oral challenges. Patients with anaphylaxis symptoms were further evaluated with in vitro tests. Results Fluoroquinolone hypersensitivity was excluded in 71 patients by tolerated oral challenge tests. During positive challenge tests, six patients (three out of these had positive and three had negative skin prick tests) developed anaphylaxis symptoms but the presumed IgE-mediated mechanism could not be confirmed by in vitro tests. Patch testing was constantly negative; however, in two patients a rash was induced by the challenge tests. Conclusion History alone leads clearly to a considerable over-estimation of fluoroquinolone hypersensitivity. Moreover, skin or in vitro tests do not seem to be very useful in identifying hypersensitive patients. Challenge tests appear to be necessary for definitely confirming or ruling out fluoroquinolone hypersensitivity. [source] Pitfalls in the Diagnosis of Cerebellar InfarctionACADEMIC EMERGENCY MEDICINE, Issue 1 2007Sean I. Savitz MD Abstract Background Cerebellar infarctions are an important cause of neurologic disease. Failure to recognize and rapidly diagnose cerebellar infarction may lead to serious morbidity and mortality due to hydrocephalus and brain stem infarction. Objectives To identify sources of preventable medical errors, the authors obtained pilot data on cerebellar ischemic strokes that were initially misdiagnosed in the emergency department. Methods Fifteen cases of misdiagnosed cerebellar infarctions were collected, all seen, or reviewed by the authors during a five-year period. For each patient, they report the presenting symptoms, the findings on neurologic examination performed in the emergency department, specific areas of the examination not performed or documented, diagnostic testing, the follow-up course after misdiagnosis, and outcome. The different types of errors leading to misdiagnosis are categorized. Results Half of the patients were younger than 50 years and presented with headache and dizziness. All patients had either incomplete or poorly documented neurologic examinations. Almost all patients had a computed tomographic scan of the head interpreted as normal, and most of these patients underwent subsequent magnetic resonance imaging showing cerebellar infarction. The initial incorrect diagnoses included migraine, toxic encephalopathy, gastritis, meningitis, myocardial infarction, and polyneuropathy. The overall mortality in this patient cohort was 40%. Among the survivors, about 50% had disabling deficits. Pitfalls leading to misdiagnosis involved the clinical evaluation, diagnostic testing, and establishing a diagnosis and disposition. Conclusions This study demonstrates how the diagnosis of cerebellar infarction can be missed or delayed in patients presenting to the emergency department. [source] Management of new onset atrial fibrillation in previously well patients less than 60 years of ageEMERGENCY MEDICINE AUSTRALASIA, Issue 1 2005David McD Taylor Abstract Objective:, This study reviewed the ED management of new onset atrial fibrillation (AF) in previously well patients aged less than 60 years. Methods:, We undertook a retrospective review of ED patients from 1998 to 2002 inclusive. The main outcome measures were approaches to rate or rhythm control and anticoagulation, the use of echocardiography, the value of diagnostic testing and the frequency of hospital admission. Results:, Fifty-two patients were identified. In general, all patients were haemodynamically stable. One patient had mild cardiac failure and one was clinically thyrotoxic. Serum potassium was measured in 51 (98%) patients, magnesium in 23 (44%) and cardiac enzymes in 30 (58%); results were generally unhelpful. Thyroid function tests were carried out in 40 (77%) patients; results were unremarkable except for the clinically thyrotoxic patient. No patient had echocardiography in the ED; however, 6 patients (12%) were later found to have major cardiac abnormalities. Forty-four (85%) patients received a variety of medications; 37 (71%) received an anti-arrhythmic and 24 (46%) an antithrombotic. Overall, 17 (33%) patients received theoretically effective therapy for conversion to sinus rhythm. Twenty-two (42%) patients were admitted to hospital. Conclusions:, This study reveals variation in the management of acute AF in previously well, haemodynamically stable, young patients. Pathology testing was frequently carried out with a low yield. There were high rates of attempts to cardiovert, use of antithrombotics and of admission to hospital. Although cardioversion attempts appeared to be contrary to existing guidelines, decisions may have been based primarily on patient symptoms. Echocardiography should be considered prior to anti-arrhythmic therapy. [source] Increased insulin resistance and risk of incident cerebrovascular events in patients with pre-existing atherothrombotic diseaseEUROPEAN JOURNAL OF NEUROLOGY, Issue 11 2009D. Tanne Background and purpose:, Diabetes and the metabolic syndrome are known risk factors for ischaemic stroke. Our aim was to examine whether amongst patients with pre-existing atherothrombotic disease, increased insulin resistance is associated with incident cerebrovascular events. Methods:, Patients with stable coronary heart disease included in a secondary prevention trial were followed up for a mean of 6.2 years. Coronary heart disease was documented by a history of myocardial infarction ,6 months and <5 years before enrollment and/or stable angina pectoris with evidence of ischaemia confirmed by ancillary diagnostic testing. Main exclusion criteria were insulin treated diabetes, hepatic or renal failure, and disabling stroke. Baseline insulin levels were measured in 2938 patients from stored frozen plasma samples and increased insulin resistance assessed using the homeostatic model assessment of insulin resistance (HOMA-IR), categorized into tertiles or quartiles. Results:, Crude rates of incident cerebrovascular events rose from 5.0% for HOMA-IR at the bottom tertile to 5.7% at the middle tertile, and 7.0% at the top tertile (P = 0.07). HOMA-IR at the top versus bottom tertile was associated with an unadjusted hazard ratio (HR) of 1.37 (95%CI, 0.94,1.98) and a 1-unit increase in the ln HOMA-IR was associated with a HR of 1.14 (95%CI, 0.97,1.35). In further analyses adjusting for potential confounders, or categorizing baseline HOMA-IR into quartiles, or excluding diabetic patients, we did not identify an increased risk for incident cerebrovascular events conferred by the top category. Conclusions:, Increased insulin resistance did not predict incident cerebrovascular events amongst patients with pre-existing atherothrombotic disease. [source] Prospective Validation of a Modified Thrombolysis In Myocardial Infarction Risk Score in Emergency Department Patients With Chest Pain and Possible Acute Coronary SyndromeACADEMIC EMERGENCY MEDICINE, Issue 4 2010Erik P. Hess MD Abstract Objectives:, This study attempted to prospectively validate a modified Thrombolysis In Myocardial Infarction (TIMI) risk score that classifies patients with either ST-segment deviation or cardiac troponin elevation as high risk. The objectives were to determine the ability of the modified score to risk-stratify emergency department (ED) patients with chest pain and to identify patients safe for early discharge. Methods:, This was a prospective cohort study in an urban academic ED over a 9-month period. Patients over 24 years of age with a primary complaint of chest pain were enrolled. On-duty physicians completed standardized data collection forms prior to diagnostic testing. Cardiac troponin T-values of >99th percentile (,0.01 ng/mL) were considered elevated. The primary outcome was acute myocardial infarction (AMI), revascularization, or death within 30 days. The overall diagnostic accuracy of the risk scores was compared by generating receiver operating characteristic (ROC) curves and comparing the area under the curve. The performance of the risk scores at potential decision thresholds was assessed by calculating the sensitivity and specificity at each potential cut-point. Results:, The study enrolled 1,017 patients with the following characteristics: mean (±SD) age 59.3 (±13.8) years, 60.6% male, 17.9% with a history of diabetes, and 22.4% with a history of myocardial infarction. A total of 117 (11.5%) experienced a cardiac event within 30 days (6.6% AMI, 8.9% revascularization, 0.2% death of cardiac or unknown cause). The modified TIMI risk score outperformed the original with regard to overall diagnostic accuracy (area under the ROC curve = 0.83 vs. 0.79; p = 0.030; absolute difference 0.037; 95% confidence interval [CI] = 0.004 to 0.071). The specificity of the modified score was lower at all cut-points of >0. Sensitivity and specificity at potential decision thresholds were: >0 = sensitivity 96.6%, specificity 23.7%; >1 = sensitivity 91.5%, specificity 54.2%; and >2 = sensitivity 80.3%, specificity 73.4%. The lowest cut-point (TIMI/modified TIMI >0) was the only cut-point to predict cardiac events with sufficient sensitivity to consider early discharge. The sensitivity and specificity of the modified and original TIMI risk scores at this cut-point were identical. Conclusions:, The modified TIMI risk score outperformed the original with regard to overall diagnostic accuracy. However, it had lower specificity at all cut-points of >0, suggesting suboptimal risk stratification in high-risk patients. It also lacked sufficient sensitivity and specificity to safely guide patient disposition. Both scores are insufficiently sensitive and specific to recommend as the sole means of determining disposition in ED chest pain patients. ACADEMIC EMERGENCY MEDICINE,2010; 17:368,375 © 2010 by the Society for Academic Emergency Medicine [source] Pearls From an Inpatient Headache UnitHEADACHE, Issue 6 2008Joel R. Saper MD Much can be learned from treating over 15,000 headache hospitalized patients over the course of 30 years. By the very need to be admitted, these individuals are complicated, both physiologically and often psychologically. Founded in 1978, the Michigan Head Pain and Neurological Institute and its hospital unit developed a set of criteria for admission and a growing staff of professionals to serve this complex population of patients. Experience has taught us many lessons; several are considered in this review. Among the important topics discussed are: admission criteria to the hospital unit; treatment protocols and other hospital-based strategies; integration of behavioral therapy and therapists into the treatment system; diagnostic testing of patients with intractable headache; identifying the "problem patient" and "medication misuse" early in the course of therapy; approaching the headache patient with cluster B personality disorder; and the use of interventional and anesthesiological treatment for intractable headache. Outcome data and a review of recent publications are presented. [source] HAEdb: A novel interactive, locus-specific mutation database for the C1 inhibitor gene,HUMAN MUTATION, Issue 1 2005Lajos Kalmár Abstract Hereditary angioneurotic edema (HAE) is an autosomal dominant disorder characterized by episodic local subcutaneous and submucosal edema and is caused by the deficiency of the activated C1 esterase inhibitor protein (C1-INH or C1INH; approved gene symbol SERPING1). Published C1-INH mutations are represented in large universal databases (e.g., OMIM, HGMD), but these databases update their data rather infrequently, they are not interactive, and they do not allow searches according to different criteria. The HAEdb, a C1-INH gene mutation database (http://hae.biomembrane.hu) was created to contribute to the following expectations: 1) help the comprehensive collection of information on genetic alterations of the C1-INH gene; 2) create a database in which data can be searched and compared according to several flexible criteria; and 3) provide additional help in new mutation identification. The website uses MySQL, an open-source, multithreaded, relational database management system. The user-friendly graphical interface was written in the PHP web programming language. The website consists of two main parts, the freely browsable search function, and the password-protected data deposition function. Mutations of the C1-INH gene are divided in two parts: gross mutations involving DNA fragments >1 kb, and micro mutations encompassing all non-gross mutations. Several attributes (e.g., affected exon, molecular consequence, family history) are collected for each mutation in a standardized form. This database may facilitate future comprehensive analyses of C1-INH mutations and also provide regular help for molecular diagnostic testing of HAE patients in different centers. Hum Mutat 25:1,5, 2005. © 2004 Wiley-Liss, Inc. [source] Chronic urticaria , which clinical parameters are pathogenetically relevant?JOURNAL DER DEUTSCHEN DERMATOLOGISCHEN GESELLSCHAFT, Issue 1 2007A retrospective investigation of 339 patients Summary Background: Urticaria is a clinical reaction pattern triggered by many factors causing liberation of vasoactive substances such as histamine, prostaglandins and kinins. It presents as transient itching wheals which are either limited to the local stimulus area or more widespread. Urticaria is classified according to its duration into acute (duration , 6 weeks) and chronic (duration 6 weeks) forms. Various clinical investigations may be initiated to diagnose the cause. This study critically evaluates the relevance of frequently performed laboratory investigations and searches for infectious foci, as well as the results of physical provocation testing and oral provocation with food additives. Patients and Methods: The laboratory and clinical data of 339 patients who had been treated for urticaria at the Christian-Albrechts-University in Kiel over a period of four years were collected in a data entry form and statistically evaluated. Nominal values were analyzed by their relative and absolute quantities, quantitative parameters with the help of statistical data such as minimum, maximum, median and 25th and 75th percentiles. Results: Chronic recurrent urticaria was most common, accounting for 52% of cases. Women were affected 1.8 times more often than men. One-third of the patients also had angioedema. The medians of all laboratory parameters evaluated were within normal values. Only rarely were elevated antinuclear antibody titers, abnormal thyroid function tests or active infections such as hepatitis B or borreliosis detected. The search for infectious foci identified tonsillitis or sinusitis in almost 50% of analyzed patients. Positive reactions to physical testing occurred in 30% of patients and in 11% to oral provocation with various food additives. Conclusions: This study of a large patient group stresses the relevance of individually- tailored evaluations in patients affected with urticaria rather than an expensive initial broad diagnostic testing. More specific searches should be based on individual clues. [source] Spatial Effects within the Agricultural Land Market in Northern IrelandJOURNAL OF AGRICULTURAL ECONOMICS, Issue 1 2003Myles Patton The importance of dealing properly with spatial effects, such as spatial autocorrelation, in cross-sectional econometric estimation has become more widely recognised in recent years. Spatial autocorrelation is similar in many ways to serial correlation, but while the latter is ordered on a one-dimensional time axis, the former is ordered in two dimensions. The multi-directional nature of spatial dependence means that specialised techniques are needed for diagnostic testing and estimation purposes. This paper uses these specialised diagnostics to test for spatial effects within a hedonic pricing study of the agricultural land market. The tests indicate that spatial autocorrelation (in the form of spatial lag dependence) and spatially distinct sub-markets (or spatial heterogeneity) are present. Ignoring these effects in the estimation process is likely to lead to biased parameter estimates. Consequently, we re-specify the hedonic model to allow for these spatial effects. The presence of spatial lag dependence suggests that there is circularity of price setting within the agricultural land market. This means that agricultural land prices are not solely determined by the inherent characteristics of the land, but tend to reflect also the average local price per acre. [source] Paradoxical Vasodilation During Lower Body Negative Pressure in Patients with Vasodepressor Carotid Sinus SyndromeJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 6 2003Arduino A. Mangoni MD OBJECTIVES: To elucidate the pathophysiological mechanism of the vasodepressor form (VD) of carotid sinus syndrome (CSS) by maneuvers designed to induce generalized sympathetic activation after baroreceptor unloading (lower body negative pressure, LBNP) or direct peripheral adrenoreceptor stimulation via local administration of norepinephrine (NA). DESIGN: Subjects were identified with VD of CSS through diagnostic testing. SETTING: Research laboratory. PARTICIPANTS: Eleven young controls (YC) (mean age ± standard error of mean = 22.8 ± 0.7), eight elderly controls (EC) (72.6 ± 0.6), and eight elderly patients with VD (78.7 ± 1.7). MEASUREMENTS: Forearm arterial blood flow (FABF) was measured in the left and right arms by venous occlusion plethysmography. Measurements were performed during baseline conditions, LBNP (,20 mmHg), and intra-arterial NA infusion in the left brachial artery at three progressively increasing rates (60, 120, and 240 pmol/min). RESULTS: During LBNP, FABF significantly decreased in YC (baseline 3.61 ± 0.30 vs ,20 mmHg 2.96 ± 0.24 mL/100 g/min, P = .030) and EC (4.05 ± 0.74 vs 3.69 ± 0.65 mL/100 g/min, P = .033) but increased in elderly patients with VD (3.65 ± 0.60 vs 4.54 ± 0.80 mL/100 g/min, P = .020). During NA infusion, a significant forearm vasoconstriction occurred in YC (FABF left:right ratio 1.00 ± 0.05 at baseline; 0.81 ± 0.08 at 60 pmol/min, P = .034; 0.81 ± 0.05 at 120 pmol/min, P < .001; 0.72 ± 0.04 at 240 pmol/min, P < .001), whereas no significant FABF changes were observed in EC (1.04 ± 0.06; 0.96 ± 0.07, P = .655; 0.89 ± 0.10, P = .401; 0.94 ± 0.10, P = .590) or elderly patients with VD (1.04 ± 0.06; 1.16 ±0 .10, P = .117; 1.04 ± 0.08, P = .602; 1.11 ± 0.10, P = .305). CONCLUSION: VD of CSS is associated with a paradoxical vasodilatation during LBNP and an impairment of peripheral ,-adrenergic responsiveness, which may be age-related. [source] Perceptions of Deservedness of Social Aid as a Function of Prenatal Diagnostic Testing,JOURNAL OF APPLIED SOCIAL PSYCHOLOGY, Issue 1 2003Karen L. Lawson This study examined whether judgments of deservedness of social aid subsequent to the birth of a disabled child vary as a function of prenatal diagnostic testing (PDT) use as predicted by the attribution-affect-action model (Weiner, 1980). A sample of family physicians/obstetricians (n= 341) and a university employee sample (n= 281) made attribution ratings in 3 scenarios in which an at-risk pregnant woman gave birth to a disabled child. The findings indicate that women who chose not to use PDT or who chose to continue the pregnancy following a diagnosis were judged more responsible, more to blame, and less deserving of both sympathy and social aid subsequent to giving birth to a disabled child than were women to whom testing was not made available. [source] Diagnostic issues for adolescents and adults with ADHDJOURNAL OF CLINICAL PSYCHOLOGY, Issue 5 2005Jeanette WassersteinArticle first published online: 18 FEB 200 Attention deficit hyperactivity disorder (ADHD) is a common childhood neuropsychiatric syndrome once thought to disappear with maturation. Current data indicate that ADHD remains "hidden" in many of the grownups who had it as children. Adult prevalence rates range from 1% to 6% of the population. Research suggests the core childhood symptoms of hyperactivity, inattention, and impulsivity shift with development, perhaps transforming into more overt difficulties in executive functions and affect regulation. ADHD is also usually nestled with other comorbid psychiatric conditions, especially in adolescents and adults, further complicating diagnosis and treatment. This article discusses how to recognize and diagnose ADHD in older patients. Key points include core symptoms present during childhood, appropriate family history in this strongly genetic condition, management of comorbidity, and the evolving role of diagnostic testing. Other medical causes for similar symptoms are considered. © 2005 Wiley Periodicals, Inc. J Clin Psychol/In Session 61: 535,547, 2005. [source] Educational and health service needs of Australian general practitioners in managing hepatitis CJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 4 2006Leena Gupta Abstract Background:, There has been interest in recent years in the role of primary care practitioners in managing hepatitis C, but there has been minimal research to identify educational and health service needs. A national survey of Australian general practitioners (GPs) was therefore conducted to assess their needs and identify areas for service development. Methods:, A self-administered questionnaire was developed that included questions to assess caseload, confidence in patient management, educational needs and approaches to management and prevention. Questionnaires were sent to a random sample of Australian GPs. Returned questionnaires were coded, frequencies tabulated and significant associations identified. Results:, A 70% response rate was achieved from 658 eligible GPs. A total of 76% of respondents had managed one patient in the previous year with hepatitis C. While 69% reported feeling more confident about their management of hepatitis C than 5 years previously, 55% identified a high level of need for hospital-based clinics. Financial benefits for case conferences and chronic case management were not considered useful by most GPs. Topics identified for further skills development included therapeutics and diagnostic testing. Only 39% were highly likely to discuss psychosocial issues as part of initial patient management and 37% reported finding it difficult to play a central role in the medical and psychosocial care of patients with hepatitis C. Conclusion:, These results have significant implications for policy and service development, as well as identifying areas where GPs need support. The findings invite further discussion between health authorities about the source and magnitude of funding for hospital-based services and further consideration of how to provide services to address patients' psychosocial needs. [source] Evidence-based medicine: Review of guidelines and trials in the prevention of secondary stroke,JOURNAL OF HOSPITAL MEDICINE, Issue S4 2008David J. Likosky MD Abstract Transient ischemic attack (TIA) carries a substantial short-term risk for stroke, which is a leading cause of disability and death in the United States. Despite the existing evidence-based guidelines for secondary prevention of stroke, variability in the assessment, diagnostic testing, and treatment of patients with TIA in actual clinical practice remains. Identification of stroke etiology via radiological examination is of paramount importance for the appropriate treatment of patients after TIA or stroke. Management of ischemic stroke or TIA includes lifestyle modifications, reduction of modifiable risk factors (eg, hypertension, diabetes, and elevated cholesterol), and appropriate therapeutic treatments. Antiplatelet therapy is the cornerstone of secondary prevention of stroke; guidelines for its use for noncardioembolic cases have been developed from a solid evidence base. Additional therapeutic approaches include HMG-CoA reductase inhibitors (statins), antihypertensives, and anticoagulants. The results of ongoing large trials will further clarify the role of specific antiplatelet agents for the secondary prevention of stroke in patients with noncardioembolic ischemic stroke or TIA. Journal of Hospital Medicine 2008;3(4 Suppl):S6,S19. © 2008 Society of Hospital Medicine. [source] Prospective Evaluation of Real-time Use of the Pulmonary Embolism Rule-out Criteria in an Academic Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 9 2010Jeffrey A. Kline MD Abstract Objectives:, The pulmonary embolism rule-out criteria (PERC rule) is a nine-component decision rule derived to exclude pulmonary embolism (PE) without the use of formal diagnostic testing (D-dimer, computed tomography pulmonary angiography, ventilation,perfusion lung scanning, or venous ultrasonography) when all nine components are negative ("PERC negative"). This study examined whether clinicians who document PERC negative also document results of all nine components of the PERC rule. Methods:, This was a pilot study at a single-center, urban teaching emergency department (ED) with a residency program in emergency medicine. Patients were over 17 years of age with at least one of nine predefined chief complaints. Clinicians were asked three questions regarding suspicion for PE, intent to use the PERC rule, and the result. Charts were independently reviewed by two authors for fidelity of the nine PERC components. Patients were followed for PE outcome at 14 days. Results:, The study examined 526 patients cared for by 82 clinicians, who indicated suspicion for PE in 183 of 526 (35%) and intent to use the PERC rule in 115 of 526 (22%) cases, of whom 65 of 115 were documented as PERC negative. No formal test for PE was ordered in 49 of 65 (75%), and 46 of 49 had incomplete documentation to support PERC negative. The most common deficiency was omission of two risk factors for PE in the rule (prior venous thromboembolism or recent surgery). Six patients had PE diagnosed within 14 days, but none of these had been deemed PERC negative. Conclusions:, Clinicians seldom document all nine data elements of the PERC rule in patients they deem PERC negative. These data suggest the need for paper or electronic aids to support use of the PERC rule. ACADEMIC EMERGENCY MEDICINE 2010; 17:1016,1019 © 2010 by the Society for Academic Emergency Medicine [source] Radiation exposure and diagnostic imagingJOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 4 2010CRNP (Assistant Professor), Luann Richardson PhD Purpose: The purpose of this article is to increase clinician awareness of current radiation exposures of diagnostic testing, discuss current practice patterns, and suggest strategies to address issues at the systems level, institution level, and the healthcare provider level. Data sources: Evidence-based literature including interdisciplinary peer-reviewed articles in the biological and health-related fields. Conclusions: Radiation exposure related to diagnostic testing is often higher than anticipated for both the clinician and the patient. Strategies to address radiation exposure need to be implemented at many different levels in the system. Best practice initiatives are surfacing and will require a team approach for success. Implications for practice: Nurse practitioners need to be aware of the benefits and risks of diagnostic testing involving radiation exposure. Patients should also be informed of potential risks and benefits. Alternative imaging should be considered and repetitive testing should be monitored closely. [source] Travel-Associated Dengue Infections in the United States, 1996 to 2005JOURNAL OF TRAVEL MEDICINE, Issue 1 2010Hamish P. Mohammed PhD Background. As the incidence of dengue increases globally, US travelers to endemic areas may be at an increased risk of travel-associated dengue. Methods. Data from the US Centers for Disease Control and Prevention's laboratory-based Passive Dengue Surveillance System (PDSS) were used to describe trends in travel-associated dengue reported from January 1, 1996 to December 31, 2005. The PDSS relies on provider-initiated requests for diagnostic testing of serum samples via state health departments. A case of travel-associated dengue was defined as a laboratory-positive dengue infection in a resident of the 50 US states and the District of Columbia who had been in a dengue-endemic area within 14 days before symptom onset. Dengue infection was confirmed by serologic and virologic techniques. Results. One thousand one hundred and ninety-six suspected travel-associated dengue cases were reported,334 (28%) were laboratory-positive, 597 (50%) were laboratory-negative, and 265 (22%) were laboratory-indeterminate. The incidence of laboratory-positive cases varied from 1996 to 2005, but had an overall increase with no significant trend (53.5 to 121.3 per 108 US travelers, p = 0.36). The most commonly visited regions were the Caribbean, Mexico and Central America, and Asia. The median age of laboratory-positive cases was 37 years (range: <1 to 75 y) and 166 (50%) were male. Of the 334 laboratory-positive cases, 41 (12%) were hospitalized, and 2 (1%) died. Conclusions. Residents of the US traveling to dengue-endemic regions are at risk of dengue infection and need to be instructed on appropriate prevention measures prior to travel. Especially in light of the potential transmissibility of dengue virus via blood transfusion, consistent reporting of travel-associated dengue infections is essential. [source] Evaluation of acute congestive heart failure in dogs and cats: 145 cases (2007,2008)JOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE, Issue 3 2010Caroline M. Goutal DVM Abstract Objective , To characterize the clinical presentation, management, and in-hospital outcomes of dogs and cats diagnosed with acute congestive heart failure (CHF). Design , Retrospective study of animals seen between January 2007 and May 2008. Setting , Emergency service at a university teaching hospital. Animals , Ninety dogs and 55 cats with CHF. Measurements and Main Results , Patient characteristics, including age, clinical signs, clinicopathologic abnormalities, diagnostic testing, and outcome were recorded. Forty-eight of the animals already were receiving cardiac medications at the time of presentation. The most common diseases represented were chronic valvular disease and cardiomyopathies. Cats had significantly lower median body temperature at admission compared with dogs (P<0.001). The most common abnormalities were elevated lactate (64%), elevated BUN (52%), hypochloremia (31%), hyperglycemia (27%), and elevated liver enzymes (26%). Many of these became even more prevalent during hospitalization. One hundred and sixteen animals were discharged from the hospital, for a survival rate of 80%. There was no survival difference between dogs and cats (P=0.39). Dogs that developed hypokalemia during hospital stay (P=0.04) were more likely to survive compared with those without hypokalemia and initial body temperature was lower for those cats that did not survive (P=0.02). Of those that did not survive, the majority were euthanized (n=25), while 4 dogs died. Conclusions , Dogs and cats presented to the emergency service with CHF had a high survival rate. In cats, initial body temperature was lower for those cats that did not survive. Although clinicopathologic abnormalities were common in both species, only dogs with hypokalemia had improved survival to hospital discharge. [source] Immune-mediated hemolytic anemia and severe thrombocytopenia in dogs: 12 cases (2001,2008)JOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE, Issue 3 2010Elizabeth S. Orcutt DVM Abstract Objective , To identify and characterize the syndrome of immune-mediated hemolytic anemia (IMHA) with concurrent severe thrombocytopenia (,15.0 × 109 platelets/L; [15.0 × 103 platelets/,L]), and to evaluate prognostic factors, clinicopathologic findings, complications, treatment, outcome, and survival of dogs with this hematologic disorder. Design , Retrospective, observational study. Setting , Veterinary teaching hospital. Animals , Twelve client-owned dogs with IMHA and severe thrombocytopenia (,15.0 × 109 platelets/L; [15.0 × 103 platelets/,L]), without evidence of overt disseminated intravascular coagulation. Interventions , The following data were recorded and analyzed from the electronic medical record: signalment, history, concurrent diseases, clinical signs at presentation, clinicopathologic data, diagnostic testing, radiographic findings, treatment modalities, length of hospitalization, complications, and clinical outcome. All dogs were treated with immunosuppressive doses of corticosteroids. Measurements and Main Results , Twelve dogs were identified with the diagnosis of IMHA and severe thrombocytopenia; of these, 9 (75%) survived, 3 (25%) were euthanized, and none died. Dogs that survived were significantly younger than nonsurvivors (P=0.03). There were no specific clinical signs or therapies associated with survival. Conclusions , Dogs in this study had a mortality rate similar to reported rates for dogs with either disease alone. Overall, younger dogs were more likely to survive. No association between different treatment modalities and overall survival was identified. [source] Severe blunt trauma in dogs: 235 cases (1997,2003)JOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE, Issue 6 2009Stephen A. Simpson DVM Abstract Objective , To evaluate population characteristics, injuries, emergency diagnostic testing, and outcome of dogs with blunt trauma requiring intensive care in an urban hospital. Design , Retrospective study 1997,2003. Setting , All data obtained from the University of Pennsylvania , Matthew J. Ryan Veterinary Hospital. Animals , Dogs admitted to the intensive care unit for treatment following blunt trauma. Interventions , None. Measurements and Main results , Of the 235 dogs that met inclusion criteria, 206 (88%) survived and 29 (12%) did not survive. Blunt vehicular trauma accounted for 91.1% of cases. Mild hyperglycemia and hyperlactatemia was common in both survivors and nonsurvivors. The chest was the most common region traumatized and the prevalence of polytrauma was 72.3%. Initial weight, vital signs, PCV, total plasma protein, BUN, glucose, lactate, acid-base status, and electrolytes did not differ between survivors and nonsurvivors. Nonsurvivors were significantly more likely to have had head trauma (P=0.008), cranium fractures (P<0.001), recumbency at admission (P<0.001), development of hematochezia (P<0.001), clinical suspicion of acute respiratory distress syndrome (P<0.001), disseminated intravascular coagulation (P<0.001), multiorgan dysfunction syndrome (P<0.001), development of pneumonia (P<0.001), positive-pressure ventilation (P<0.001), vasopressor use (P<0.001), and cardiopulmonary arrest (P<0.001). Conclusions , Outcome of severe blunt trauma in dogs treated with intensive care is very good. Despite the high survival rate, several features associated with poor outcome were identified. Neither admission lactate nor glucose was able to predict outcome. [source] Increasing the uptake of hepatitis C virus testing among injecting drug users in specialist drug treatment and prison settings by using dried blood spots for diagnostic testing: a cluster randomized controlled trialJOURNAL OF VIRAL HEPATITIS, Issue 4 2008M. Hickman Summary., The objective of this study was to assess whether introducing dried blood spot testing can increase hepatitis C virus (HCV) diagnostic testing. A cluster randomized controlled trial was conducted. Sites were matched into pairs, with one site in each pair randomly allocated to receive the intervention (training and use of dried blood spot). Data were collected from all sites for 6 months before and 6 months after the start of the intervention. The participants were 22 specialist drug clinics and six prisons in England and Wales. The main outcome measure of this study was percentage point difference in individuals tested for HCV (the difference between the percentage of patients tested 6 months after and 6 months before the introduction of dried blood spot tests). Before the trial, 8% of patients at control and intervention sites had been tested for HCV, with 16 sites testing less than 5% of their caseload. The average percentage point difference between intervention and control sites was 14.5% (95% CI 1.3,28%, paired t -test, P = 0.03); with 13 of the 14 pairs contributing to the positive effect of the intervention (Wilcoxon matched-pairs signed-rank-test, P = 0.002). The size of the difference between intervention and control sites varied considerably. The study provides preliminary supporting evidence that dried blood spot testing may increase the uptake of HCV diagnostic testing, by increasing the opportunity for patients to be offered testing. Additional trials with a larger number of sites are justified, ideally in the context of drug and treatment policies that gave clearer priority (and targets) to infection control and testing. [source] The definition and diagnostic testing of physical and cholinergic urticarias , EAACI/GA2LEN/EDF/UNEV consensus panel recommendationsALLERGY, Issue 12 2009M. Magerl The recommendations for the definition and diagnosis presented in this position paper are the result of a panel consensus meeting held in December 2008 in Berlin. This consensus meeting was a joint initiative of EAACI (European Academy of Allergology and Clinical Immunology) Dermatology Section, the EU-funded network of excellence, GA2LEN (Global Allergy and Asthma European Network), the EDF (European Dermatology Forum) and UNEV (urticaria network e.V.). The aim of these recommendations is to improve the diagnosis and management of patients with physical urticaria or cholinergic urticaria and to promote research and a better understanding of these diseases. Our recommendations used the paper produced by a 1996 expert meeting (1) and they acknowledge the latest changes in our understanding of physical urticarias and cholinergic urticaria as well as the recent development of novel diagnostic tools. In addition, this consensus paper highlights areas of need for further research. [source] Grading quality of evidence and strength of recommendations in clinical practice guidelines: Part 2 of 3.ALLERGY, Issue 8 2009The GRADE approach to grading quality of evidence about diagnostic tests, strategies The GRADE approach to grading the quality of evidence and strength of recommendations provides a comprehensive and transparent approach for developing clinical recommendations about using diagnostic tests or diagnostic strategies. Although grading the quality of evidence and strength of recommendations about using tests shares the logic of grading recommendations for treatment, it presents unique challenges. Guideline panels and clinicians should be alert to these special challenges when using the evidence about the accuracy of tests as the basis for clinical decisions. In the GRADE system, valid diagnostic accuracy studies can provide high quality evidence of test accuracy. However, such studies often provide only low quality evidence for the development of recommendations about diagnostic testing, as test accuracy is a surrogate for patient-important outcomes at best. Inferring from data on accuracy that using a test improves outcomes that are important to patients requires availability of an effective treatment, improved patients' wellbeing through prognostic information, or , by excluding an ominous diagnosis , reduction of anxiety and the opportunity for earlier search for an alternative diagnosis for which beneficial treatment can be available. Assessing the directness of evidence supporting the use of a diagnostic test requires judgments about the relationship between test results and patient-important consequences. Well-designed and conducted studies of allergy tests in parallel with efforts to evaluate allergy treatments critically will encourage improved guideline development for allergic diseases. [source] An economic evaluation of NIOX MINO airway inflammation monitor in the United KingdomALLERGY, Issue 3 2009D. Price Background:, Fractional exhaled nitric oxide (FENO), a marker of eosinophilic airway inflammation, is easily measured by noninvasive means. The objective of this study was to determine the cost-effectiveness of FENO measurement using a hand-held monitor (NIOX MINO), at a reimbursement price of £23, for asthma diagnosis and management in the UK. Methods:, We constructed two decision trees to compare FENO measurement with standard diagnostic testing and guideline recommendations for management. For asthma diagnosis, we compared FENO measurement with lung function and reversibility testing, bronchial provocation and sputum eosinophil count. For asthma management, we evaluated the impact on asthma control, including inhaled corticosteroid use, exacerbations and hospitalizations, of monitoring with FENO measurement vs symptoms and lung function as in standard care. Resource use and health outcomes were evaluated over a 1-year time frame. Direct costs were calculated from a UK health-care payer perspective (2005 £). Results:, An asthma diagnosis using FENO measurement cost £43 less per patient as compared with standard diagnostic tests. Asthma management using FENO measurement instead of lung function testing resulted in annual cost-savings of £341 and 0.06 quality-adjusted life-years gained for patients with mild to severe asthma and cost-savings of £554 and 0.004 quality-adjusted life-years gained for those with moderate to severe asthma. Conclusions:, Asthma diagnosis based on FENO measurement with NIOX MINO alone is less costly and more accurate than standard diagnostic methods. Asthma management based on FENO measurement is less costly than asthma management based on standard guidelines and provides similar health benefits. [source] Radiofrequency Neurotomy for Low Back Pain: Evidence-Based Procedural GuidelinesPAIN MEDICINE, Issue 2 2005W. Michael Hooten MD ABSTRACT Objective., This review was undertaken to outline the procedural limitations of the randomized controlled trials (RCTs) of radiofrequency (RF) neurotomy for low back pain. Second, the literature related to patient selection, diagnostic testing, and the technique of performing lumbar spine, RF neurotomy will be critically reviewed and analyzed. Based on these analyses, diagnostic and procedural guidelines will be proposed. Design., A Medline and EMBASE search identified three RCTs and two systematic reviews of RF neurotomy for low back pain. A similar search identified pertinent literature related to the method of patient selection for a diagnostic block, the medial branch and L5 dorsal ramus comparative block, and the anatomical and technical parameters of lumbar spine RF neurotomy. Results., Substantial procedural shortcomings were identified in all three RCTs. In the systematic reviews, these procedural limitations were not accounted for by the quality assessment of study design which resulted in an inaccurate estimate of clinical effectiveness. Analysis using likelihood ratios showed that screening criteria could increase the probability of zygapophysial joint pain before performing diagnostic blocks. Similar analysis showed that comparative medial branch blocks, rather than single blocks, must be used before RF neurotomy. Anatomical studies demonstrated that the shorter distal compared with the circumferential radius of the RF lesion necessitates placement of the electrode parallel to the course of the nerve along the base of the superior articular process. Conclusions., The evidence-based procedural guidelines provide consistent criteria for multisite studies that could enroll a sufficiently large homogenous study cohort. [source] Microbiological diagnostic testing in the treatment of periodontal diseasesPERIODONTOLOGY 2000, Issue 1 2004Peter M Loomer First page of article [source] | |||||||||||||||||||||||||||||||||||||