Testing In Patients Research Articles

Investigating the validity of muscle response testing: Blinding the patient using subliminal visual stimuli

Research objectiveTo determine if Muscle Response Testing (MRT) can be used to distinguish lies from truths using blind test patients. DesignA prospective study of diagnostic test accuracy was carried out using MRT to distinguish lies from truth. MethodsTwenty practitioners who routinely practised MRT were paired with 20 blind test patients (TPs). TPs were asked to speak simple true and false statements about visual stimuli presented subliminally (at 20 ms). In the subliminal phase, pairs performed 20 MRTs and 20 Intuitive Guesses (IG), consisting of 2 blocks of 10 statements each. In the Supraliminal Phase, the same picture-statement pairs were repeated. The order of stimuli presentation was randomly assigned so that each pair was presented with a unique series of stimuli. ResultsIn the Subliminal Phase, MRT accuracy (as percent correct) was found to be 48.5% (95% CI 42.8–54.2), which was no different from IG accuracy (47.8%; 95% CI 43.2–52.3; p = 0.68) or chance (50.0%; p = 0.59), and no different from MRT accuracy during the supraliminal phase (59.0%; 95% CI 50.4–67.6; p = 0.05). However, supraliminal MRT accuracy was significantly different from chance (p = 0.04), indicating that the pairs could perform MRT proficiently. ConclusionThe main reason for finding no effect is suspected to be due to an inadequate subliminal methodology, a process which is quite complex. Other explanations of results include: (1) MRT is not a valid test when the TP is blind, (2) Blinding TPs during MRT will produce ambiguous or unpredictable results, or (3) Nonconscious beliefs cannot be elicited using subliminal stimuli. Future research may wish to focus on exploring these possibilities. More specifically, subsequent studies may wish to use different methods to blind TPs, and establish whether MRT can be used to detect nonconscious processes, a generally held consensus among MRT practitioners.

Development of Online Integrative Medicine Research Curriculum

To determine if Muscle Response Testing (MRT) can be used to distinguish lies from truths using blind test patients.A prospective study of diagnostic test accuracy was carried out using MRT to distinguish lies from truth.Twenty practitioners who routinely practised MRT were paired with 20 blind test patients (TPs). TPs were asked to speak simple true and false statements about visual stimuli presented subliminally (at 20 ms). In the subliminal phase, pairs performed 20 MRTs and 20 Intuitive Guesses (IG), consisting of 2 blocks of 10 statements each. In the Supraliminal Phase, the same picture-statement pairs were repeated. The order of stimuli presentation was randomly assigned so that each pair was presented with a unique series of stimuli.In the Subliminal Phase, MRT accuracy (as percent correct) was found to be 48.5% (95% CI 42.8–54.2), which was no different from IG accuracy (47.8%; 95% CI 43.2–52.3; p = 0.68) or chance (50.0%; p = 0.59), and no different from MRT accuracy during the supraliminal phase (59.0%; 95% CI 50.4–67.6; p = 0.05). However, supraliminal MRT accuracy was significantly different from chance (p = 0.04), indicating that the pairs could perform MRT proficiently.The main reason for finding no effect is suspected to be due to an inadequate subliminal methodology, a process which is quite complex. Other explanations of results include: (1) MRT is not a valid test when the TP is blind, (2) Blinding TPs during MRT will produce ambiguous or unpredictable results, or (3) Nonconscious beliefs cannot be elicited using subliminal stimuli. Future research may wish to focus on exploring these possibilities. More specifically, subsequent studies may wish to use different methods to blind TPs, and establish whether MRT can be used to detect nonconscious processes, a generally held consensus among MRT practitioners.

The Impact of Using Emotionally Arousing Stimuli on Muscle Response Testing Accuracy

Introduction: Muscle response testing (MRT) is an assessment method used by 1 million practitioners worldwide, yet its usefulness remains uncertain. The aim of this study, one in a series assessing the accuracy of MRT, was to determine whether emotionally arousing stimuli influence its accuracy compared to neutral stimuli. Methods: To assess diagnostic test accuracy 20 MRT practitioners were paired with 20 test patients (TPs). Forty MRTs were performed as TPs made true and false statements about emotionally arousing and neutral pictures. Blocks of MRT alternated with blocks of intuitive guessing (IG). Results: MRT accuracy using emotionally arousing stimuli was different than when using neutral stimuli. However, MRT accuracy was found to be significantly better than IG and chance. Similar to previous studies in this series, this study failed to detect any characteristic that consistently influenced MRT accuracy. Conclusion: Using emotionally arousing stimuli had no effect on MRT accuracy compared to using neutral stimuli. This study would have been strengthened by adding personally relevant lies instead of impersonal stimuli. A limitation of this study is its lack of generalizability to other applications of MRT. This study shows that a simple yet robust methodology for assessing MRT as a diagnostic tool can be implemented effectively.

The functional communication scale for patients with neurodegenerative disease: development and validation of a French test evaluating residual communication skills.

To propose a rapid and ecological tool specifically adapted for people with cognitive disorders in advanced stages of the diseases. Two major steps were necessary, the development of the tool itself (A) and the evaluation of some of its psychometric properties (B). The first step (A) allowed the development of a tool aimed at the observation of communication skills during a situation of natural interaction and the analysis of communication according to various activities (production, recognition and comprehension of oral language acts, written and gestural, as well as figures, in different degrees of complexity). The second step (B) consisted to measure the validity of the content and the criterion of the test, as well as its fidelity between judges. The final version of the tool is composed of two grids, an examiner's guide and a patient's test sheet. The use of the tool has been standardized. At the end of the validation process, psychometric properties demonstrated good content validity and good criterion validity for the scale. Fidelity was subsequently measured and also judged to be good. After that, a pre-test with patients with neurodegenerative diseases has been carried out. This tool should address a significant clinical need to enable clinicians to rapidly describe communication skills in a patient with neurodegenerative disease and to recommend communication strategies for formal and informal caregivers.

PROGESTERONE SKIN TESTING: TWO IRRITATING SCENARIOS

Introduction Literature supports the utility of skin testing in Progesterone hypersensitivity (PH) for decision making, but we describe false-positive from reported non-irritating progesterone testing concentrations. Case Description 39-year old female presents recurrent erythema, pruritus, diaphoresis, dyspnea, palpitations, stomach cramping and presyncopal sensation prior to menstruation. Progesterone skin testing, including prick testing (SPT) and intradermal (ID) was performed. SPT was negative and ID positive on patient and two controls (table 1). Oral antihistamines twice daily controlled her premenstrual symptoms concerning for PH. 19-year old female presented two years ago with a reaction to medroxyprogesterone. A rash developed the morning after the first dose. Within hours of the second dose, the rash spread with wheezing and throat closure sensation. She was skin tested to progesterone in sesame oil with ID positive on patient and two controls (table 1). Two years later, skin testing was repeated based on using benzyl alcohol as diluent. SPT was negative; ID was positive on patient and two controls. She underwent a four-day graded challenge without reactions. Discussion Progesterone is an oil-based medication that is difficult to dilute. In the literature, benzyl alcohol and sterile olive oil have been used for dilution with 50% of patient's testing being negative. In our experience, the 0.5 mg/mL intradermal concentration is irritating with either diluent and provided false positive results. As skin testing may not elucidate sensitization and clarify PH management, patient history remains of greatest importance in diagnosis with physician-supervised drug challenge as the procedure of choice in patients with a questionable history.

Hemidiaphragmatic Paralysis Due to Cervical Spondylosis: A Case Report

Introduction C4 radiculopathy due to cervical spondylosis has rarely been reported as a cause of hemidiaphragmatic paralysis. Case Report A 70-year-old man presented with hemidiaphragmatic paralysis due to right C3-C4 foraminal stenosis. The diagnosis was made preoperatively from findings on plain chest radiographs, respiratory function tests, and electrophysiologic tests. All the patient's test results and symptoms improved immediately after surgical treatment for cervical spondylosis. Conclusions Although it may be difficult to make a correct diagnosis based only on radiological findings at the cervical spine, we should be aware of the existence of this entity and pay close attention to chest radiographs.

GW28-e0463 SAFETY OF EARLY LOADING TEST IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION WITH AND WITHOUT Q WAVE

The work was initiated to assess results of loading test in patients with acute myocardial infarction (AMI) hospitalized at the rehabilitation department. 79 male patients aged from 49.6±0.8 years recruited to be included into this 3-5-day study were hospitalized at the emergency department,

A novel de nova missense LMNA mutation in a Turkish patient with laminopathies

The laminopathies associated to the lamin A/C (LMNA) gene mutations at chromosome 1q22 region; comprise different well-characterized phenotypes. Some of the multi-systemic laminopathies are lipodystrophy, Charcot-Marie Tooth disease (CMT), Emery-Dreifuss muscular dystrophy (EDMD) and Limb Girdle muscular dystrophy 1B (LGMD1B). The LGMD1B is characterized by a symmetric proximal weakness starting from the legs, atrioventricular conduction disturbances and dysrhythmias. 17-year-old female patient had suffered from progressive muscle weakness. Patient's testing of deep-tendon reflexes were negative in neurological examination. She had positive Gower's sign and proximal muscle strength was reduced with score of 4/5. She had foot-drop gait and atrophy of lower extremities. Her feet showed a mild pescavus deformity and could not lift up by herself. Serum creatine kinase level was normal. Followed by pediatric cardiology due to first degree A–V block. Cardiac echocardiogram demonstration was normal. Nerve conduction velocity was within normal limits and electromyogram was indicative of myopathy. Muscular histology was compatible with muscular dystrophy and showed a nonspecific excess of lipid droplets. With the diagnosis of Limb Girdle muscular dystrophy 1B; LMNA gene sequence analysis including all coding exons and exon-intron boundaries was done and LMNA NM_170707.3:c.734T>C; (p.Leu245Pro) heterozygous missense mutation was detected. This mutation was first reported by from Turkish population. In silico analysis with Mutation Taster, Polyphen2, SIFT was predict this variant as a disease causing mutation. In order to show familial segregation, mother and father also were included in the study. Her parents were no carriers of the mutation. This case illustrate the necessity of correct diagnosis, evaluation, and follow up of cardiac problems due to the wide clinical spectrum and high prevalence of cardiac conduction block in patients with LGMD1B.

Correction to: 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.

In the article by Yancy et al, “2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America,” which published online May 20, 2016, and appeared in the September 27, 2016, issue of the journal ( Circulation. 2016;134:e282–e293. DOI: 10.1161/CIR.0000000000000435), several corrections were needed. 1. On page e282, …

Top of Scope Practice

![Graphic][1] Medical laboratory professionals have long recognized that accurate and precise test results are key to appropriate and timely diagnosis and treatment. The laboratory medicine team of physicians, scientists, and technicians have historically engaged other healthcare providers, including attending physicians, nurse practitioners, and physician assistants, in choosing the correct test to order in a given situation and how to interpret the information provided in a lab report. But today we have a new direct “recipient” of our printed or electronic laboratory communication (the lab report): the patient. ![Graphic][2] ![Graphic][3] On February 3, 2014, the Department of Health and Human Services announced a final rule amending the Clinical Laboratory Improvement Amendments of 1988, giving patients access to their laboratory test reports directly from the laboratory performing the analysis. Of course, patients can continue to gain access to their lab results from their physicians, and this direct access “does not supplant the treatment conversation a healthcare provider has with a patient about the patient's test results.” Explanation of the rule change in the Federal Register clarified that laboratories are not required “to interpret test reports for individuals,” but “a laboratory may also provide additional educational or explanatory materials regarding the test results if it chooses to do so.”1 Remember what we learned in our “Communications 101” course: “When crafting a message, think about how it will be understood by the receiver.” Today, we have an opportunity to engage beyond the laboratory by adding value to the lab report. By re-envisioning our role from analyst to knowledge … [1]: /embed/inline-graphic-1.gif [2]: /embed/inline-graphic-2.gif [3]: /embed/inline-graphic-3.gif

Measures of agreement between many raters for ordinal classifications.

Screening and diagnostic procedures often require a physician's subjective interpretation of a patient's test result using an ordered categorical scale to define the patient's disease severity. Because of wide variability observed between physicians' ratings, many large-scale studies have been conducted to quantify agreement between multiple experts' ordinal classifications in common diagnostic procedures such as mammography. However, very few statistical approaches are available to assess agreement in these large-scale settings. Many existing summary measures of agreement rely on extensions of Cohen's kappa. These are prone to prevalence and marginal distribution issues, become increasingly complex for more than three experts, or are not easily implemented. Here we propose a model-based approach to assess agreement in large-scale studies based upon a framework of ordinal generalized linear mixed models. A summary measure of agreement is proposed for multiple experts assessing the same sample of patients' test results according to an ordered categorical scale. This measure avoids some of the key flaws associated with Cohen's kappa and its extensions. Simulation studies are conducted to demonstrate the validity of the approach with comparison with commonly used agreement measures. The proposed methods are easily implemented using the software package R and are applied to two large-scale cancer agreement studies.

A Mobile Health Application to Predict Postpartum Depression Based on Machine Learning.

Postpartum depression (PPD) is a disorder that often goes undiagnosed. The development of a screening program requires considerable and careful effort, where evidence-based decisions have to be taken in order to obtain an effective test with a high level of sensitivity and an acceptable specificity that is quick to perform, easy to interpret, culturally sensitive, and cost-effective. The purpose of this article is twofold: first, to develop classification models for detecting the risk of PPD during the first week after childbirth, thus enabling early intervention; and second, to develop a mobile health (m-health) application (app) for the Android(®) (Google, Mountain View, CA) platform based on the model with best performance for both mothers who have just given birth and clinicians who want to monitor their patient's test. A set of predictive models for estimating the risk of PPD was trained using machine learning techniques and data about postpartum women collected from seven Spanish hospitals. An internal evaluation was carried out using a hold-out strategy. An easy flowchart and architecture for designing the graphical user interface of the m-health app was followed. Naive Bayes showed the best balance between sensitivity and specificity as a predictive model for PPD during the first week after delivery. It was integrated into the clinical decision support system for Android mobile apps. This approach can enable the early prediction and detection of PPD because it fulfills the conditions of an effective screening test with a high level of sensitivity and specificity that is quick to perform, easy to interpret, culturally sensitive, and cost-effective.

Attitudinal concordance toward uptake and disclosure of genetic testing for cancer susceptibility in patient–family member dyads

Decisions for cancer susceptibility genetic testing (CSGT) uptake and dissemination of results occur within the family context. A national survey was performed with 990 patient-family member dyads (participation rate:76.2%), with paired questionnaires examining attitudes toward CSGT uptake and disclosure of results in response to a hypothetical scenario in which a reliable CSGT was available for the specific cancer a patient was being treated. While most patients and family members responded they would uptake or recommend CSGT if available, concordance between the dyads was poor for both patient's testing (agreement rate 77.5%, weighted κ=0.09) and first-degree relatives' testing(agreement rate 78.0%, weighted κ=0.09). Most patients (93.2%) and family members (92.9%) indicated that patients should disclose positive CSGT results to family members, with dyadic agreement of 89.1% (κ=0.15). However, there were substantial disagreement regarding when disclosure should take place, who should make the disclosure (the patient or the health care professionals), and to whom the results should be disclosed. Patients and family members may hold different attitudes toward CSGT uptake of and disclosure of results within the family. Our findings reinforce the need for a family system approach to incorporate perspectives of patients as well as their family members.

종합검진 후 지방간 환자의 복부 초음파 검사와 임상화학적 검사결과의 정확성 분석

초음파 검사는 복강내 장기를 검사하는 대표적인 영상의학검사의 한 분야이며. 혈액검사는 체내 이상 징후를 임상화학적으로 검사하는 대표적인 방법이다. 지방간의 진단은 주로 복부초음파 검사와 혈액검사를 동시에 실시하여 수행하며 두 검사의 결과를 바탕으로 진단을 하게 된다. 이 경우에 실시하는 혈액검사의 기준은 TBIL, TC, AST, ALT, ALP, GGT, TG, HDL-C, GLU의 값이다. 본 연구에서는 초음파 영상에서 지방간 진단을 받은 환자의 혈액검사 정확성을 분석하여 두 종류의 검사간 정확도를 분석하고자 하였다. 2012년 1월부터 3월간 종합검진으로 복부초음파검사와 혈액검사를 동시에 받은 환자 1350명 중 초음파 검사상 지방간 판정을 받은 459명을 대상으로 초음파 검사와 혈액검사 결과가 동일한 경우는 459명 중 280명으로 약 60.8% 이며, 초음파 검사와 혈액검사의 결과가 서로 다른 경우는 179명으로 39.2%로 밝혀져 초음파 검사와 혈액검사의 진단 정확도는 60.8% 이었다. 이는 지방간의 초음파 진단시 종사자의 주관적 능력이 병변의 진단에 큰 영향을 미친 것으로 생각되어 지속적인 초음파 임상 교육이 필요할 것으로 사료된다. Ultrasonography is one of the fields on the imaging studies within intra-abdominal organs. A blood test is a typical method of clinical chemical examination on the in vivo test of clinical symptoms. Fatty liver is performed simultaneously two kinds of diagnostics methods, intra-abdominal ultrasound and blood tests. At an implementing this, the standard of blood tests value was the TBIL, TC, AST, ALT, ALP, GGT, TG, HDL-C, GLU. In this study analyzing the accuracy of the two kinds of test, ultrasonography and blood test, on patients with fatty liver. From January to March 2012, patients 459 determined fatty liver within 1350, who received health examination simultaneously on the intra-abdominal ultrasonography and blood tests. Same result of ultrasonography and blood test's patients were 459 ie, 60.8%. and different result of those examinations was 280 ie, 39.2%. Consequently diagnostic accuracy was 60.8%. It presumably caused by differences in the diagnostic performance of ultrasound professionals(Radiologist or Radiological Technologist). In order to overcome this, ongoing educational and study will be needed.

L7.1 Genomic Medical Care: Envisioning the Workflow of the Future

Genomic analysis is likely to be too intimidating and complex for practical adoption in health care in the near future. Without significant innovation in the way that data is delivered, a treating physician is unlikely to be able to make sense of genomic findings to guide disease management.We believe that the future will usher forward a new workflow. A treating physician will order a test through a genomic medicine-enabled health care institution, where cutting-edge genetic analysis products are used to deliver sequence results to trained molecular pathologists. Specially configured software applications will be used to review medical guidelines, explore available drug trials, and review the latest biomedical research to translate the patient's biological findings into insightful treatment considerations for the patient's physician. Every patient's test results, treatments, and medical outcomes will be stored in a secure, private database to be used for comparative analysis, in which prior patients’ genetic profiles (together with other relevant insights) can be used to illuminate new treatment considerations. In this manner, every patient becomes a participant in cutting-edge genomic research. Their treating physician will get a single, user-friendly report summarizing genetic findings and identifying potential treatment options to consider for their patient.In this session we will discuss a potential solution to enable this genomic medicine workflow.

P5-S7.12 STD testing in emergency department: a novel method to provide test results

BackgroundRealising the potential of broad based STD testing depends on treatment of those with positive results. Because emergency department (ED) physicians expressed reluctance to test for STD's because they had...

Clinical Usefulness of the Muscle Contracture Test: Time to Reevaluate?

Red Deer Regional Medical Center, Red Deer, Alberta, Canada. ikwetny@hotmail.comIn a recent article, Tautz et al. 1discussed the use of a muscle contracture test for diagnosis of malignant hyperthermia (MH) susceptibility. They correctly noted that there is a 2% chance that contracture testing will incorrectly mislabel an MH-susceptible individual as normal. It is difficult to believe that any of my colleagues will expose a patient to a 2% risk of severe complications by giving triggering anesthetics. In my opinion, the fact that a patient has been evaluated for MH will be a strong indication for using nontriggering anesthesia management. Tautz et al. stated that there is a consensus among experts that a person who has had contracture testing and who is labeled not susceptible can safely receive triggering anesthetics. Unfortunately, they did not provide references to any written guidelines or consensus statements on that issue.Tautz et al. mentioned another reason for using the contractility test: the fact that for certain patients (children, severe asthmatics, and patients with difficult airways) potent inhaled anesthetics are useful. Yes, they are useful. But how safe are they? Is 98% safe enough when we have 100% safe nontriggering alternatives available? Most biopsy centers do not perform these tests for children under 5 yr old.*In the very few situations in which inhalation induction is the safest approach (e.g ., acute epiglottitis or a difficult pediatric airway), the anesthesiologist should be prepared to monitor and treat a possible MH crisis regardless of the patient's test results.I recall consulting one of my own patients regarding contracture testing after an MH crisis.2According to the clinical grading scale, this patient's likelihood of MH was “almost certain.”3The patient and family were informed, and the patient was advised to wear a Medic Alert bracelet. However, I felt uneasy recommending a procedure that was very expensive ($6,000 USD), invasive (need for another anesthesia, relative disability for 3–4 days), and burdensome (3-h flight to nearest biopsy center), with no clear benefits for the patient. In their article, Tauzt et al. wrote: “We cannot fault a clinician who wishes to give a nontriggering anesthetic to a person who has had contracture testing and who is not susceptible to MH.” Thank you for not blaming me for playing it safe! But perhaps we should fault an anesthesiologist who unnecessarily canceled elective procedures because he or she was uncomfortable anesthetizing the patients before their MH status had been established by biopsy. The debate about the usefulness of the muscle contracture test has had a long history.4In our era of evidence-based medicine and cost-effective analyses, should we not also reevaluate muscle biopsy testing for MH?Red Deer Regional Medical Center, Red Deer, Alberta, Canada. ikwetny@hotmail.com

Medication therapy management and condition care services in a community-based employer setting

A program in which health-system pharmacists and pharmacy technicians provide medication therapy management (MTM), wellness, and condition care (disease management) services under contract with local businesses is described. The health-system pharmacy department's Center for Medication Management contracts directly with company benefits departments for defined services to participating employees. The services include an initial wellness and MTM session and, for certain patients identified during the initial session, ongoing condition care. The initial appointment includes a medication history, point-of-care testing for serum lipids and glucose, body composition analysis, and completion of a health risk assessment. The pharmacist conducts a structured MTM session, reviews the patient's test results and risk factors, provides health education, discusses opportunities for cost savings, and documents all activities on the patient's medication action plan. Eligibility for the condition care program is based on a diagnosis of diabetes, hypertension, asthma, heart failure, or hyperlipidemia or elevation of lipid or glucose levels. Findings are summarized for employers after the initial wellness screening and at six-month intervals. Patients receiving condition care sign a customized contract, establish goals, attend up to four MTM sessions per year, and track their information on a website; employers may offer incentives for participation. When pharmacists recommend adjustments to therapy or cost-saving changes, it is up to patients to discuss these with their physician. A survey completed by each patient after the initial wellness session has indicated high satisfaction. Direct cost savings related to medication changes have averaged $253 per patient per year. Total cost savings to companies in the first year of the program averaged $1011 per patient. For the health system, the program has been financially sustainable. Key laboratory values indicate positive clinical outcomes. A business model in which health-system pharmacists provide MTM and condition care services for company employees has demonstrated successful outcomes in terms of patient satisfaction, cost savings, and clinical benefits.

Abstract 5079: Predictive Accuracy of Cardiopulmonary Exercise Stress Testing in Subjects With Chest Pain

Cardiopulmonary exercise testing (CPET) is widely used to grade the severity of heart failure and to assess its prognosis. However, it is unknown whether CPET may identify coronary artery disease (CAD) or exclude it in patients with chest pain. We prospectively studied 1,265 consecutive patients (55±8 years, 156 women, 628 retired from work, 234 white collar, 244 blue collar) who were evaluated with ECG stress testing (TE) for chest pain. No one had a previous myocardial infarction or documented CAD. All patients performed an incremental CPET on an electronically-braked cycle ergometer (Ergometrics 800S) until volitional fatigue. ECG was recorded during the test. Cardiovascular risk factors were present in 65%. Criteria for a positive CPET were: flattening in VO2/work rate slope with an inflection point more than 1 minute earlier than peak exercise and a flattened slope from the inflection point to peak exercise (<4 ml/min/W); the time from the inflection point to peak exercise should be similar in O2pulse. These two last criteria have been recently validated by our group in 202 patients with documented CAD ( R.Belardinelli et al, Eur Heart J , 2003 ; 24 : 1285 ). Follow-up lasted 12 months. Of 1,265 patients, 73 had a positive CPET and 1,192 had a negative CPET. Cardiac events occurred in 32 patients with a positive CPET and 10 out of 1,192 (positive predictive accuracy(PPV): 76%; negative predictive accuracy (NPV): 95%). Coronary angiography was performed in 73 patients with a positive CPET and revealed a CAD in 64. As compared with ET, sensitivity, specificity, PPV and NPV were all improved (ET: 48%,55%,33%,95%; CPET: 88%, 98%, 73%,99%, respectively). Patients with a peak VO2≥91% of predicted VO2max had no CAD in 100% of cases. In conclusion, CPET shows a predictive accuracy for CAD greater than TE in patients with chest pain. Its use should be encouraged among physicians in clinical practice.

How Patients Work On Their Plans and Test Their Therapists in Psychotherapy

Relying primarily on Weiss and Sampson's control‐mastery theory (Sampson, 1976, 1991; Silberschatz, 2005; Weiss, 1986, 1993), I briefly describe how psychopathology develops and then discuss how patients1 work in psychotherapy to master their problems and conflicts. My focus is on two particular concepts: the patient's plan for therapy and the patient's testing of the therapist during psychotherapy.