In-person Clinical Examinations Research Articles

Skin Cancer Diagnosis by Lesion, Physician, and Examination Type: A Systematic Review and Meta-Analysis.

Skin cancer is the most common cancer in the US; accurate detection can minimize morbidity and mortality. To assess the accuracy of skin cancer diagnosis by lesion type, physician specialty and experience, and physical examination method. PubMed, Embase, and Web of Science. Cross-sectional and case-control studies, randomized clinical trials, and nonrandomized controlled trials that used dermatologists or primary care physicians (PCPs) to examine keratinocytic and/or melanocytic skin lesions were included. Search terms, study objectives, and protocol methods were defined before study initiation. Data extraction was performed by a reviewer, with verification by a second reviewer. A mixed-effects model was used in the data analysis. Data analyses were performed from May 2022 to December 2023. Meta-analysis of diagnostic accuracy comprised sensitivity and specificity by physician type (primary care physician or dermatologist; experienced or inexperienced) and examination method (in-person clinical examination and/or clinical images vs dermoscopy and/or dermoscopic images). In all, 100 studies were included in the analysis. With experienced dermatologists using clinical examination and clinical images, the sensitivity and specificity for diagnosing keratinocytic carcinomas were 79.0% and 89.1%, respectively; using dermoscopy and dermoscopic images, sensitivity and specificity were 83.7% and 87.4%, and for PCPs, 81.4% and 80.1%. Experienced dermatologists had 2.5-fold higher odds of accurate diagnosis of keratinocytic carcinomas using in-person dermoscopy and dermoscopic images compared with in-person clinical examination and images. When examining for melanoma using clinical examination and images, sensitivity and specificity were 76.9% and 89.1% for experienced dermatologists, 78.3% and 66.2% for inexperienced dermatologists, and 37.5% and 84.6% for PCPs, respectively; whereas when using dermoscopy and dermoscopic images, sensitivity and specificity were 85.7% and 81.3%, 78.0% and 69.5%, and 49.5% and 91.3%, respectively. Experienced dermatologists had 5.7-fold higher odds of accurate diagnosis of melanoma using dermoscopy compared with clinical examination. Compared with PCPs, experienced dermatologists had 13.3-fold higher odds of accurate diagnosis of melanoma using dermoscopic images. The findings of this systematic review and meta-analysis indicate that there are significant differences in diagnostic accuracy for skin cancer when comparing physician specialty and experience, and examination methods. These summary metrics of clinician diagnostic accuracy could be useful benchmarks for clinical trials, practitioner training, and the performance of emerging technologies.

Gait video-based prediction of unified Parkinson’s disease rating scale score: a retrospective study

BackgroundThe diagnosis of Parkinson’s disease (PD) and evaluation of its symptoms require in-person clinical examination. Remote evaluation of PD symptoms is desirable, especially during a pandemic such as the coronavirus disease 2019 pandemic. One potential method to remotely evaluate PD motor impairments is video-based analysis. In this study, we aimed to assess the feasibility of predicting the Unified Parkinson’s Disease Rating Scale (UPDRS) score from gait videos using a convolutional neural network (CNN) model.MethodsWe retrospectively obtained 737 consecutive gait videos of 74 patients with PD and their corresponding neurologist-rated UPDRS scores. We utilized a CNN model for predicting the total UPDRS part III score and four subscores of axial symptoms (items 27, 28, 29, and 30), bradykinesia (items 23, 24, 25, 26, and 31), rigidity (item 22) and tremor (items 20 and 21). We trained the model on 80% of the gait videos and used 10% of the videos as a validation dataset. We evaluated the predictive performance of the trained model by comparing the model-predicted score with the neurologist-rated score for the remaining 10% of videos (test dataset). We calculated the coefficient of determination (R2) between those scores to evaluate the model’s goodness of fit.ResultsIn the test dataset, the R2 values between the model-predicted and neurologist-rated values for the total UPDRS part III score and subscores of axial symptoms, bradykinesia, rigidity, and tremor were 0.59, 0.77, 0.56, 0.46, and 0.0, respectively. The performance was relatively low for videos from patients with severe symptoms.ConclusionsDespite the low predictive performance of the model for the total UPDRS part III score, it demonstrated relatively high performance in predicting subscores of axial symptoms. The model approximately predicted the total UPDRS part III scores of patients with moderate symptoms, but the performance was low for patients with severe symptoms owing to limited data. A larger dataset is needed to improve the model’s performance in clinical settings.

Accuracy of Remote Examination for Detecting Potentially Malignant Oral Lesions: A Systematic Review and Meta-Analysis.

Objective: We aimed to investigate the accuracy of remote examination by photographs compared to in-person clinical examination for detecting potentially malignant oral lesions (PMOLs). Methods: The Reporting Guide and Guidelines for Writing Systematic Reviews (Preferred Reporting Items for Systematic Reviews and Meta-Analysis [PRISMA]) guided the reporting of findings. The search was conducted by two independent reviewers in six databases with no language restriction until November 2022. The Population, Test-Index, Reference Standard, Outcome and Study Design (PIROS) strategy guided the eligibility criteria, and studies with adult patients (P) examined remotely (I) and in-person (R) to verify the detection of PMOLs (O) were considered. The methodological quality was assessed by QUADAS-2, and the certainty of the evidence was measured by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Results: A total of 769 files were identified. After removing duplicates and reading titles and abstracts, 16 were read in full, from which 6 articles then comprised the qualitative synthesis. The oral clinical examination was the reference standard in four studies. Five studies presented high risk of bias in at least one assessment domain. A high probability of detection of PMOL by remote examination (97.37%) was observed for the three studies included in the meta-analysis, which presented high heterogeneity among them. The certainty of evidence for the outcome was considered very low. Conclusions: Remote tools for detecting PMOLs may be feasible and assertive, but new studies are required to incorporate them into clinical practice. Clinical Relevance: Remote examination for the detection of PMOLs has the potential to favoring the early diagnosis of malignant lesions.

Perspectives of Indian dental residents on novel online practical examination during COVID-19: A cross-sectional study.

This cross-sectional study aimed to assess the graduating dental residents' perspectives on the online clinical examination format. The questionnaire used to assess the perspectives was developed via a focus group discussion and was validated for face and content validity, readability testing, and pilot testing for the online version.Thisself-administered, online questionnaire integrated 15 Likert-scale-based multiple choice questions and one open-ended question. It was distributed to the residents across 16 dental schools afterthe clinical examination was completed.Theperspectives regarding examination preparation, the ability to transition to online mode, and the performance in the examination were assessed. Descriptive statistical analysis (counts and percentages) was performed. A total of 256 subjects participated in the study by returning the online survey. In the preparation phase, 70.7% (n=181) residents reported anxiety and 56.1% (n=144) reported stress. During the examinations, only 13.6% (n=35) of the participants reported difficulty with internet speed. The majority, 64.6% (n=165) of the participants reported that the absence of an external examiner face-to-face reduced anxiety.The compiled answers to the open-ended question revealed that residents expressed inconvenience in digitizing the academic logbooks and clinical work. The poor quality of sound and images affected the display of skills. The study revealed a moderate level of acceptance for the novel online practical examination method. The residents reported stress before and during the examination due to the sudden transition to an online examination. The online practical examination with modifications might be a viable alternative to the in-person clinical examination.

Adaptations in clinical examinations of medical students in response to the COVID-19 pandemic: a systematic review

IntroductionClinical examinations (assessments) are integral to ensuring that medical students can treat patients safely and effectively. The COVID-19 pandemic disrupted traditional formats of clinical examinations. This prompted Medical Schools to adapt their approaches to conducting these examinations to make them suitable for delivery in the pandemic. This systematic review aims to identify the approaches that Medical Schools, internationally, adopted in adapting their clinical examinations of medical students in response to the COVID-19 pandemic.MethodsThree databases and four key medical education journals were systematically searched up to 22 October 2021; a grey literature search was also undertaken. Two reviewers independently screened at title, abstract stage and full text stage against predefined eligibility criteria. Discrepancies were resolved by discussion and involvement of senior authors. Risk of bias assessment was performed using an adapted version of a pre-existing risk of bias assessment tool for medical education developments. Results were summarised in a narrative synthesis.ResultsA total of 36 studies were included, which documented the approaches of 48 Medical Schools in 17 countries. Approaches were categorised into in-person clinical examinations (22 studies) or online clinical examinations (14 studies). Authors of studies reporting in-person clinical examinations described deploying enhanced infection control measures along with modified patient participation. Authors of studies reporting online clinical examinations described using online software to create online examination circuits. All authors reported that adapted examinations were feasible, scores were comparable to previous years’ student cohorts, and participant feedback was positive. Risk of bias assessment highlighted heterogeneity in reporting of the clinical examinations.ConclusionsThis review identified two broad approaches to adapting clinical examinations in the pandemic: in-person and online. Authors reported it was feasible to conduct clinical examinations in the pandemic where medical educators are given sufficient time and resources to carefully plan and introduce suitable adaptations. However, the risk of bias assessment identified few studies with high reporting quality, which highlights the need for a common framework for reporting of medical education developments to enhance reproducibility across wider contexts. Our review provides medical educators with the opportunity to reflect on past practises and facilitate the design and planning of future examinations.

Parent-provided photographs as an outcome measure for childhood chalazia

To determine whether smartphone photographs of children's eyelids are reliable for diagnosing the presence of chalazia. In this prospective cross-sectional study, 60 participants, 7 months to 16.5 years of age, at four sites were enrolled; all participants had a chalazion measuring at least 2 mm on at least one eyelid based on an in-person clinical examination by a pediatric eye care professional. Smartphone photographs taken by the parent during the office visit were uploaded to the study website. A masked reader assessed each photograph for the presence or absence of chalazia; results were compared with the gold standard clinical examination results. Sensitivity and specificity for the presence of chalazion by eyelid were calculated. Photographs were available for 240 eyelids; 85 had at least one chalazion and 155 were without a chalazion based on clinical examination. The masked reader correctly classified 68 of 85 eyelids with at least one chalazion and 151 of 155 eyelids without chalazia for a sensitivity of 80% (95% CI, 72%-86%) and a specificity of 97% (95% CI, 94%-99%). Sensitivity improved to 89% for chalazia 5 mm or larger and 94% when superficially located within the eyelid. Parental smartphone photographs appear to be useful in assessing chalazia in children as an alternative to in-office follow-up examinations. These photographs may be a valuable outcome measure in future clinical trials of chalazia treatment, especially when assessing larger lesions.

Predicting Patient Loss to Follow-up in the STABILITY 1 Study: A Multicenter, International, Randomized Controlled Trial of Young, Active Patients Undergoing ACL Reconstruction.

Patients lost to follow-up (LTF) impact even the most meticulously planned randomized controlled trials. Identifying patients at high risk for becoming LTF and employing strategies to retain these patients may reduce attrition bias. A cohort of 618 young, active patients undergoing anterior cruciate ligament reconstruction in the STABILITY 1 study was analyzed. Patients completed clinical testing and 9 questionnaires at 3, 6, 12, and 24 months. Multivariable logistic regression was performed for 5 different definitions of LTF. Patient characteristics and study site were included as predictors. The LTF rate was 8.3%. Current or previous smokers (odds ratio [OR] = 2.77; 95% confidence interval [CI]: 1.20 to 5.96), those employed part-time (OR = 2.31; 95% CI: 1.04 to 5.14), and those with body mass index (BMI) of ≥25 kg/m2 had significantly greater odds of becoming LTF compared with nonsmokers, students, and those with BMI of <25 kg/m2, respectively. Those employed part-time were >8 times more likely (95% CI: 2.66 to 26.28) to become LTF compared with students within the first year. Postoperative BMI of ≥25 kg/m2 was significantly associated with 2 times greater odds of missing the in-person clinical examination at any visit or becoming LTF after the first postoperative year. The clinical site was the single largest predictor of missing data at any visit. Current or previous smoking, part-time employment, and BMI of ≥25 kg/m2 were significant predictors of becoming LTF, and part-time employment was significantly associated with early LTF. BMI of ≥25 kg/m2 was also associated with late LTF and clinical LTF. The clinical site was significantly associated with missing data at any visit. While we cannot accurately predict who will become LTF, investigators should be aware of these factors to identify high-risk patients and focus retention strategies accordingly. Understanding factors related to becoming LTF in young, active patients undergoing anterior cruciate ligament reconstruction can help investigators target retention strategies to reduce LTF in studies requiring clinical follow-up in similar populations.

Validation of self-administered tests for screening for chronic pregnancy-related pelvic girdle pain

BackgroundMany women develop pelvic girdle pain (PGP) during pregnancy and about 10% have chronic pain several years after delivery. Self-administered pain provocation tests are one way to diagnose and evaluate this pain. Their validity in post-partum women is not yet studied.The purpose of this study was to evaluate the validity of self-administered test for assessment of chronic pregnancy-related PGP several years after delivery.MethodsWomen who previously have had PGP during pregnancy and who participated in one of three RCT studies were invited to a postal follow up of symptoms including performance of self-administered tests after two, 6 or 11 years later, respectively. In total, 289 women returned the questionnaire and the test-results. Of these, a sub-group of 44 women with current PGP underwent an in-person clinical examination. Comparisons were made between test results in women with versus without PGP but also, in the sub-group, between the self-administered tests and those performed during the clinical examination.ResultsFifty-one women reported PGP affecting daily life during the last 4 weeks, and 181 reported pain when performing at least one of the tests at home. Those with chronic PGP reported more positive tests (p < 0.001). There was no significant difference between diagnosis from the self-administered tests compared to tests performed during the in-person clinical examination (p = 0.305), either for anterior or posterior PGP. There were no significant differences of the results between the tests performed self-administered vs. during the clinical examination.ConclusionA battery of self-administered tests combined with for example additional specific questions or a pain-drawing can be used as a screening tool to diagnose chronic PGP years after delivery. However, the modified SLR test has limitations which makes its use questionable.

Immediate versus delayed insertion of the IUD following medical abortion at 17–20 weeks’ gestation: Preliminary results from a randomized controlled trial

Introduction The risk-benefit ratio of immediate compared with delayed insertion of an intrauterine device (IUD) following medical abortion (MA) at 17-20 weeks gestation is largely unknown. We report preliminary findings from a randomized controlled trial on IUD use at 6 weeks after immediate compared to delayed insertion, following medical abortion at this gestation. Method This 2-arm randomized controlled trial was conducted in Cape Town, South Africa. Between August 2018 and June 2019, we consented and randomized 114 women admitted for MA. The immediate arm had an IUD inserted prior to discharge; the delayed arm was referred for insertion 3 weeks later at a primary healthcare facility. Follow-up involved in-person clinical examination and ultrasound 6 weeks after MA. Non-attendees were contacted by phone. Follow-up at 6 months is ongoing. Our main outcome was use of the original IUD at 6 weeks, defined as adequate placement without indication for removal, according to intention-to-treat (ITT). Secondary outcomes include 1) use of any IUD after the 6-week follow-up period (ITT) and 2) expulsion, intracervical and symptomatic malposition at 6 weeks after MA (per protocol [PP]). Results There were 55 women in the immediate arm and 57 in the delayed arm (ITT). At 6 weeks we followed up 98/112 women (88% in each study arm). There was adequate placement of the original IUD in 53% of women in the immediate arm versus 23% in the delayed arm. At the end of the 6-week follow-up period 73% in the immediate arm versus 40% in the delayed arm had either the original IUD, a replacement IUD, or an IUD placed for the first time at follow up. Of those who had an IUD placed, 36% (immediate) versus 14% (delayed) had complete expulsion, or removal of the IUD due to malposition (PP). Conclusions Insertion of an IUD immediately after late second trimester MA results in increased use after 6 weeks compared to delayed insertion. Expulsion rates are higher than interval insertion and higher than for immediate insertion after MA at earlier gestational ages.

Tele-Oncology: A Validation Study of Choroidal and Iris Nevi

Background/Aims: To evaluate teleophthalmological assessment of choroidal and iris nevi (tele-oncology) compared to traditional in-person clinical evaluation for detection of either axial or basal growth. Methods: This is a validation study. All 97 eyes of 99 patients were evaluated with an in-person ocular oncology visit utilizing standard testing, and subsequently had a tele-oncology evaluation with the standardized tests. The tele-oncology reviewer was blinded to the in-person examination findings. The primary study outcome was detection of nevus growth on tele-oncology compared to in-person clinical examination. Results: Patients had a mean age of 61 years and the majority had nevi located in the choroid (n = 87; 88%). The most common diagnosis was a low-risk nevus (n = 38; 44%). By tele-oncology assessment, 11 eyes showed growth. Ten of these patients had growth confirmed on in-person clinical examination. Resultantly, tele-oncology assessment of choroidal and iris nevi growth had a sensitivity of 100%, specificity of 99%, positive predictive value (PPV) of 91%, and negative predictive value (NPV) of 100%. Conclusions: The results of this study suggest that tele-oncology is a safe platform for monitoring choroidal and iris nevi for growth, with excellent sensitivity, specificity, PPV, and NPV.

The Shoulder Self-Administered Motion Evaluation Has Excellent Patient Reliability and Reproducibility on Both Physician and Repeat Follow-up Testing.

Long-term clinical evaluation is becoming more important, yet difficulties exist because there are substantial patient costs for extended follow-up. The goal of this study was to validate whether a new shoulder motion evaluation is reproducible and reliable with physician examination. Consecutive patients were administered a shoulder motion assessment during their clinic visit. Patients completed the same evaluation 2 weeks after their visit to determine test-retest reliability. Exact and approximate (within 20° or 4 spinal levels) agreements between patient and physician measurements were calculated. A total of 112 patients (224 shoulders) with an average age of 56.7 years were evaluated. The most common diagnoses were osteoarthritis (33.0%) and rotator cuff tear (32.1%). All motion questions had greater than 50% exact patient-physician agreement and greater than 70% approximate agreement. When agreement was off, patients more often underestimated their motion. There was substantial clinician-patient agreement for all questions and almost perfect agreement for forward elevation (intraclass correlation coefficient, 0.78) and internal rotation (intraclass correlation coefficient, 0.77). On test-retest reliability testing, patient-patient agreement was substantial for external rotation at the side (intraclass correlation coefficient, 0.71). There was near perfect agreement for internal rotation (intraclass correlation coefficient, 0.83) and abduction (intraclass correlation coefficient, 0.81) testing. This shoulder assessment tool had both good agreement to physician examination and substantial agreement on correlation testing. There was substantial agreement between follow-up visits, suggesting excellent reproducibility. This motion assessment shows effectiveness with most shoulder pathologies. It is recommended as a good screening tool for both clinical and research purposes requiring long-term follow-up in which in-person clinical examinations may be costly and time consuming. [Orthopedics. 2018; 41(6):e820-e826.].

Work‐Related Stress May Increase the Risk of Vascular Dementia

To examine job control, job demands, social support at work, and job strain (ratio of demands to control) in relation to risk of any dementia, Alzheimer's disease (AD), and vascular dementia (VaD). Cohort study. The population-based Study of Dementia in Swedish Twins. Two hundred fifty-seven people with dementia (167 AD, 46 VaD) and 9,849 without. Dementia diagnoses were based on telephone screening for cognitive impairment followed by in-person clinical examination. An established job exposure matrix was matched to main occupation categories to measure work characteristics. In generalized estimating equations (adjusted for the inclusion of complete twin pairs), lower job control was associated with greater risk of any dementia (odds ratio (OR)=1.17, 95% confidence interval (CI)=1.04-1.31) and VaD specifically (OR=1.39, 95% CI=1.07-1.81). Lower social support at work was associated with greater risk of dementia (OR=1.15, 95% CI=1.03-1.28), AD (OR=1.14, 95% CI=1.00-1.31), and VaD (OR=1.28, 95% CI=1.02-1.60). Greater job strain was associated with greater risk of VaD only (OR=1.28, 95% CI=1.02-1.60), especially in combination with low social support (OR=1.35, 95% CI=1.11-1.64). Age, sex, and education were controlled for. Work complexity, manual work, and vascular disease did not explain the results. No differences in work-related stress scores were observed in the 54 twin pairs discordant for dementia, although only two pairs included a twin with VaD. Work-related stress, including low job control and low social support at work, may increase the risk of dementia, particularly VaD. Modification to work environment, including attention to social context and provision of meaningful roles for employees, may contribute to efforts to promote cognitive health.

Linking clinical variables to health-related quality of life in Parkinson's disease

Objective: Identify the point-in-time relationship between Parkinson's disease (PD) signs and symptoms and measures of health-related quality of life (HRQL). Background: Clinical measures used in PD assessments traditionally emphasize physical signs and symptoms. We hypothesized that these measures would be strongly associated with the physical function dimensions of HRQL that reflect mental symptoms. Design/methods: A cross-sectional study of 193 neurology clinic PD patients employed self-administered in-clinic and take-home questionnaires and in-person clinical examinations and interviews. Results: The variance explained by PD physical signs and symptoms was substantial for physical function, but only modest for all other HRQL dimensions. Mental symptoms explained a larger proportion of variance than physical symptoms for 12 of the 14 HRQL measures. Conclusion: PD patients’ well-being, general health perceptions, health satisfaction and overall HRQL are strongly influenced by mental health symptoms and more weakly influenced by physical symptoms. Clinical evaluation of PD patients should include mental health and self-reported HRQL assessment.