Accuracy Of Clinical Evaluation Research Articles

Accuracy of Clinical Evaluation and Chest X-ray for HFpEF Diagnosis: Comparison Against Right Heart Catheterization

Accuracy of Clinical Evaluation and Chest X-ray for HFpEF Diagnosis: Comparison Against Right Heart Catheterization

Effect of simulation-based training on the accuracy of fetal head position determination in labor

ObjectivesThe objective of this study was to evaluate the effect of simulation-based training on the accuracy of fetal head position determination by junior residents during the second stage of labour. Study DesignThis prospective study was conducted in a tertiary care university hospital. During an initial period of 12 weeks, 13 junior residents were asked to routinely evaluate fetal head position by digital examination during the second stage of labour, in women with term singletons in cephalic presentation. Digital examination was followed immediately by transabdominal ultrasound to confirm fetal head position, performed by an experienced physician. Following this initial period, all participants attended a workshop where simulation-based training of fetal head position determination was provided. A second 12-week period was subsequently completed, with similar characteristics to the initial one. The accuracy of clinical evaluations was assessed by the percentage of exact evaluations, the percentage of correct evaluations within a 45° error margin, and by Cohen’s kappa coefficient of agreement. ResultsA total of 83 observations were performed in the initial period of the study and 74 observations were performed in the second period. The accuracy of fetal head position determination during the first period of the study was 59.0% (95% CI 47.7–69.7), k = 0.517 (95%CI 0.391 - 0.635), corresponding to a moderate agreement. Considering a 45° margin of error, accuracy was 71.1% (95% CI 60.1–80.5), k = 0.656 (95% CI 0.538 – 0.763), corresponding to substantial agreement. Following simulation-based training, the accuracy of fetal head position determination was 70.3% (95% CI 58.5–80.3), k = 0.651 (95% CI 0.526 - 0.785), corresponding to a substantial agreement. Considering a 45° margin of error, accuracy was 78.4% (95% CI 67.3–87.1), k = 0.745 (95% CI 0.631 – 0.854), corresponding to a substantial agreement. ConclusionsAlthough a trend towards increased accuracy in fetal head position determination was observed after simulation-based training, the difference was not statistically significant. Further studies are needed to clarify the role of simulation-based training for fetal head position determination during residency.

Measuring serum albumin levels at 0 and 24 h: Effect on the accuracy of clinical evaluations in the prediction of burn-related mortality

ObjectivesTo evaluate whether measuring serum albumin levels in clinical assessments affects the accuracy of mortality predictions in large burns and to compare patients’ serum albumin levels at hour 0(Alb0h) and hour 24(Alb24h) following their admission. MethodsThis prospective observational study was performed at an academic burn unit. Aged between 16 and 65, patients who presented with burns on more than 20% of total body surface area (%TBSA) were included. Patients with severe comorbidities, concomitant trauma or referred from other centres were excluded from the study. The main variables in the study were Alb0h, Alb24h and Abbreviated Burn Severity Index (ABSI) scores. The primary outcome was in-hospital mortality. ResultsIn a population of 105 patients, %TBSA, being female, inhalational injury, Alb0h, Alb24h and ABSI score (p<0.001) and the presence of a full thickness injury (p=0.008) were associated with mortality. In the multivariable analysis, ABSI scores and Alb24h remained in the model (OR, 2.32 and 0.06, respectively). The area under curves (AUCs) were 0.94, 0.97 and 0.97 for ABSI, ABSI+Alb0h and ABSI+Alb24h, respectively. No significant difference among the AUCs was seen, but adding Alb0h and Alb24h improved the mortality predictions of ABSI by 5 (4.7%) and 4 (3.8%) patients, respectively. Alb0h (at 3.5g/dL) and Alb24h (at 2.4g/dL) showed 84–85% and 88–85% sensitivity-specificity for mortality, respectively. ConclusionMeasuring serum albumin levels in clinical assessments slightly increases the accuracy of mortality predictions; however, different cut-off points for Alb0h and Alb24h needs to be considered to avoid interpretation errors.

Diagnostic Distinctions and Genetic Analysis of Patients Diagnosed with Moebius Syndrome

To improve diagnostic assessment in Moebius syndrome by (1) creating more selective diagnostic subgroups and (2) conducting genetic evaluation in a large patient cohort. Prospective, observational study. Attendees of 3 consecutive Moebius syndrome conferences held in the United States, with a prior diagnosis of Moebius syndrome, were invited to participate. Participants underwent standardized ophthalmologic examination for Moebius syndrome minimum diagnostic criteria (MDC) (congenital, nonprogressive facial palsy, and abduction deficit) and genetic testing for HOXA1, HOXB1, and TUBB3 mutations. The number of patients meeting MDC and the number of patients with confirmed genetic mutation. A total of 112 participants from 107 families enrolled. Nineteen percent of participants (21/112) did not meet accepted MDC for Moebius syndrome because they had abduction deficits without facial palsy or facial palsy with full ocular motility. All 5 families with 2 affected individuals had at least 1 family member in this category, including 2 siblings with comitant strabismus who harbored a HOXB1 mutation. Four unrelated participants, also not meeting MDC, had large-angle exotropia, vertical gaze deficiency, and ptosis consistent with congenital fibrosis of the extraocular muscles type 3 (CFEOM3); 1 patient harbored a novel TUBB3 mutation, and 3 patients harbored previously reported de novo TUBB3 mutations. Three percent of participants (3/112) met MDC but also had restricted vertical gaze. The remaining 88 participants (79%) met MDC and had full vertical gaze. This group had relatively homogeneous findings, and none had a family history of Moebius syndrome. Two previously undescribed phenomena were observed in this category: (1) volitional Bell's phenomenon and (2) intorsion with fixation. Although the genetic contributors to classic Moebius syndrome remain elusive, accuracy in clinical evaluation will properly subdivide patients to facilitate genetic testing as new candidate genes are identified. Failure to test ocular motility may lead to misdiagnosis of Moebius syndrome, especially in patients who have facial palsy with full ductions. Patients with exotropia, vertical gaze limitation, and ptosis do not have classic Moebius syndrome and may have TUBB3 mutations associated with CFEOM3. To optimize genetic analysis, we propose adding "full vertical motility" to the MDC for Moebius syndrome.

Comparison of empirical estimate of clinical pretest probability with the Wells score for diagnosis of deep vein thrombosis

Wells score has been validated for estimation of pretest probability in patients with suspected deep vein thrombosis (DVT). In clinical practice, many clinicians prefer to use empirical estimation rather than Wells score. However, which method is better to increase the accuracy of clinical evaluation is not well understood. Our present study compared empirical estimation of pretest probability with the Wells score to investigate the efficiency of empirical estimation in the diagnostic process of DVT. Five hundred and fifty-five patients were enrolled in this study. One hundred and fifty patients were assigned to examine the interobserver agreement for Wells score between emergency and vascular clinicians. The other 405 patients were assigned to evaluate the pretest probability of DVT on the basis of the empirical estimation and Wells score, respectively, and plasma D-dimer levels were then determined in the low-risk patients. All patients underwent venous duplex scans and had a 45-day follow up. Weighted Cohen's κ value for interobserver agreement between emergency and vascular clinicians of the Wells score was 0.836. Compared with Wells score evaluation, empirical assessment increased the sensitivity, specificity, Youden's index, positive likelihood ratio, and positive and negative predictive values, but decreased negative likelihood ratio. In addition, the appropriate D-dimer cutoff value based on Wells score was 175 μg/l and 108 patients were excluded. Empirical assessment increased the appropriate D-dimer cutoff point to 225 μg/l and 162 patients were ruled out. Our findings indicated that empirical estimation not only improves D-dimer assay efficiency for exclusion of DVT but also increases clinical judgement accuracy in the diagnosis of DVT.

Clinical evaluation and stress test have limited value in the diagnosis of in-stent restenosis

Objectives. In-stent restenosis (ISR) is the main limitation of percutaneous coronary interventions (PCI), occurring in approximately 25% of cases. Although frequently asymptomatic, many PCI patients present with recurrent symptoms of chest pain at follow-up raising a clinical suspicion of ISR. The diagnosis of ISR can be challenging in these patients and difficult to rule out without repeat coronary angiography. Design. We prospectively investigated the diagnostic accuracy of clinical evaluation and exercise stress testing to detect ISR as compared to coronary angiography, in a consecutive, unselected cohort of PCI patients. Results. We studied 91 patients with a total of 143 stents. Clinical evaluation predicted ISR to be likely in 19% of cases and the exercise test was positive in 29%. The binary restenosis rate was 21%. Clinical evaluation had a positive predictive value of 29% and accuracy of 71%, while exercise stress testing had a positive predictive value of 19% and accuracy of 65%. Conclusion. In conclusion, we found the diagnostic accuracy of clinical evaluation to be low and not significantly improved by exercise stress testing when evaluating PCI patients for ISR.

Gender Differences in Measuring Adolescent Drug Abuse and Related Psychosocial Factors

SUMMARY Although gender issues have been addressed in clinical drug abuse literature, very little research has focused on gender differences in terms of the psychometric properties of assessment instruments. If boys and girls interpret instruments differently, the accuracy of clinical evaluation, referral, and treatment decisions based on these measures may be compromised. The current study examines this issue within the context of one instrument, the Personal Experience Inventory (PEI). The PEI is a multi-scale, self-administered questionnaire that has been used in various descriptive and treatment studies of adolescent drug abusers. We examine gender-specific psychometric properties of the PEI based on a drug-abusing sample of adolescents (n of boys = 1,322; n of girls = 822). The results indicate that reliability and validity evidence, as well as factor structure data, are generally comparable for both genders. However, differences did arise in rates of elevation on the distortion scales. Limitations of the present study and future research needs are discussed.

Accuracy of Clinical Evaluation in the Determination of Brain Death

The accuracy of the clinical diagnosis of brain death has never been established. Seventy-one consecutive clinically brain dead patients were studied retrospectively. Inclusion criteria were complete cessation of brain function with profound coma of known cause, complete absence of brain stem reflexes, and apnea, all persisting for a least 6 hours. A formal apnea test with a documented Pco2 of > 60 mm Hg was required. All evaluations were done by experienced neurosurgery or neurology resident or staff physicians. The clinical diagnosis was compared with the results of radionuclide angiography and with the clinical course and final outcome. Seventy patients had no arterial blood flow on radionuclide angiography. One blood flow study was considered to have yielded a false-negative result. No patient recovered or survived. The clinical diagnosis of brain death is highly reliable when made by experienced examiners using established criteria. In this study, the accuracy was 100%.

Accuracy of Clinical Evaluation in the Determination of Brain Death

Accuracy of Clinical Evaluation in the Determination of Brain Death

Accuracy of clinical evaluation in pediatric obstructive sleep apnea

Eighty-two children underwent polysomnography (PSG) for symptoms suggestive of obstructive sleep apnea (OSA). Symptoms reported included snoring, witnessed apneic episodes, daytime somnolence, mouth breathing, and enuresis. Tonsillar size, nasal airway patency, and percentile weight were recorded. OSA was diagnosed on PSG when obstructive events were noted and apnea + hypopnea index was five or more per hour. The overall predictive accuracy of clinical suspicion of OSA was 25 (30%) of 82. Predictive accuracies (as a percentage of those with symptoms/signs who have OSA) and prevalences (as a percentage of those with OSA who have the symptom/sign), respectively, were for moderate snoring 29% (12 of 41), 48%; loud snoring 31% (11 of 35), 44%; witnessed apneas 32% (22 of 69), 88%; enuresis 46% (11 of 24), 44%; 2+ tonsillar size 37% (21 of 57), 84%; 3+ tonsillar size 33% (3 of 9), 12%; 90th percentile weight or greater 26% (7 of 27), 28%; 10th percentile weight or less 33% (5 of 15), 20%. Multiple regression analysis did not reveal a significant association between clinical parameters and the presence of OSA as defined by PSG. (Otolaryngol Head Neck Surg 1998;118:69-73.)

Prospective evaluation of ultrasonography in acute colonic diverticulitis

The clinical diagnosis of acute colonic diverticulitis (ACD) can be difficult and ultrasonography by experts is valuable in establishing the diagnosis. This prospective observational trial aimed to assess the diagnostic accuracy and clinical value of ultrasonography performed routinely by surgical residents in training. The clinical course of 187 unselected consecutive patients admitted with suspected ACD was studied prospectively. Patients who had surgery for generalized peritonitis were excluded, leaving 143 for evaluation. Ultrasonographic findings and clinical assessment on admission were correlated with the patient's clinicopathological data and discharge diagnosis respectively. Of 74 patients with proven ACD (prevalence 52 per cent) the diagnosis was made by ultrasonography in 62, with an accuracy of 88 per cent, sensitivity 84 per cent and specificity 93 per cent. Ultrasonography gave a false-negative result in 12 patients (negative predictive value (NPV) 84 per cent) and there were five false-positive findings (positive predictive value (PPV) 93 per cent). The final diagnosis in the latter five patients was colitis (two patients), caecal carcinoma (one), colonic ileus due to perforated sigmoid carcinoma (one) and suppurative pyosalpingitis with involvement of the sigmoid colon (one). The accuracy of clinical evaluation on admission was 71 per cent (sensitivity 82 per cent, specificity 55 per cent, PPV 72 per cent, NPV 68 per cent); however, in only 53 per cent of patients was the diagnosis considered clinically unequivocal. Ultrasonography is a useful and valid modality for imaging ACD and its differential diagnoses in the hands of sonographically trained surgeons. It is especially helpful when the clinical findings are equivocal.

Accuracy of Clinical Evaluation in Children for Obstructive Sleep Apnea

Accuracy of Clinical Evaluation in Children for Obstructive Sleep Apnea

Rationality and cost-effectiveness of diagnosis and treatment of group a streptococci in primary care patients with pharyngitis

Rationality and cost-effectiveness of several strategies for diagnosing and treating sore throat patients were evaluated in primary care. In an empirical material of 2016 patients, 3 different bacteriological methods (traditional culture, slide culture, and latex agglutination test) for the detection of group A beta-hemolytic streptococci (GAS) were compared. Sensitivity analyses were done for several variables, including GAS test performance, testing frequencies, medication rates, and accuracy of clinical evaluation. The amounts of unnecessary medication varied from 19 to 33%, and there were 2.2-8.9% of untreated GAS infections. Strategies based on bacteriology achieved more rational and economic results than treating no one, treating all patients, or using clinical evaluation without bacteriology. The cost-effectiveness of the latex agglutination test depended on the sensitivity of the test. The results were further sensitive to sick leave lengths, cost of antibacterials, and clinical accuracy, but not to GAS test cost. Rapid tests for GAS detection can be recommended, if the sensitivity of the test in the actual working conditions is acceptable.

Miscellaneous

A study was made by Miller in 1954 of children who were in utero and within 2,200 meters from the hypocenter at the time of the atomic bomb in Hiroshima. These earlier observations have with few exceptions been validated by this follow-up of the subjects at 20 years of age and the value and accuracy of clinical evaluation in early childhood is clearly indicated. The following conclusions are made. Both small head size (circumference minus 2 SD or more) and mental retardation are most closely related to (1) maternal exposure within 1,500 meters from the hypocenter, and (2) a gestational age of less than 15 weeks. The heads of infants with either small or normal circumferences at birth increase thereafter in circumference at the same rate and stop growing at the same age, thereby maintaining the same size relationships throughout childhood into adult life. Mortality in the mentally retarded group as a whole exceeds mortality in normal children. For the group of all subjects exposed within 1,500 meters the mortality rate is higher than for the subjects located beyond 1,500 meters.

IN UTERO EXPOSURE TO THE HIROSHIMA ATOMIC BOMB

A study was made by Miller in 1954 of children who were in utero and within 2,200 meters from the hypocenter at the time of the atomic bomb in Hiroshima. These earlier observations have with few exceptions been validated by this follow-up of the subjects at 20 years of age and the value and accuracy of clinical evaluation in early childhood is clearly indicated. The following conclusions are made. Both small head size (circumference minus 2 SD or more) and mental retardation are most closely related to (1) maternal exposure within 1,500 meters from the hypocenter, and (2) a gestational age of less than 15 weeks. The heads of infants with either small or normal circumferences at birth increase thereafter in circumference at the same rate and stop growing at the same age, thereby maintaining the same size relationships throughout childhood into adult life. Mortality in the mentally retarded group as a whole exceeds mortality in normal children. For the group of all subjects exposed within 1,500 meters the mortality rate is higher than for the subjects located beyond 1,500 meters.