Simple Clinical Assessment Research Articles

The Timed Up and Go Test is Related to Quantitative Ultrasound Parameters of Bone Strength in Japanese Community-Dwelling Elderly Women

[Purpose] The timed up and go test (TUGT) requires no special equipment or training, and it is a simple clinical assessment tool. The aim of this study was to investigate the relationship between a quantitative ultrasound (QUS) parameter of bone strength and TUGT in Japanese community-dwelling elderly women. [Methods] Ninety-nine community-dwelling elderly women participated (mean age, 74.4 ± 5.7 years) in the present study. The speed of sound (SOS) in the right calcaneus was measured using a QUS device to assess bone strength. Physical function examinations included grip strength, single leg stance time, TUGT, and gait speed. The Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC) was used to assess each subject's functioning, and each subject's age, height, and weight were also collected. [Results] In multiple linear regression analysis controlling for age, of the physical function parameters, only TUGT was significantly related to SOS in all subjects. Furthermore, the relationship between SOS and TUGT was significant for those with high TMIG-IC scores, but SOS was not associated with any physical function parameters (including TUGT) for those with low TMIG-IC scores. [Conclusion] TUGT may contribute to the development of a simple clinical assessment tool that could be used to screen for hip fracture risk.

Preoperative assessment of basal cell carcinoma using conventional fluorescence diagnosis

Fluorescence diagnosis (FD) seems to be a promising method for the non-invasive detection of tumour boundaries. We aimed to investigate the diagnostic performance of conventional FD of basal cell carcinoma (BCC). Patients were included in this study when they had a skin lesion on the head which was clinically consistent with the diagnosis of BCC. FD was performed using a 20% 5-aminolaevulinic acid (ALA) cream. The FD tumour area was determined 3.5 h after the ALA application using the naked eye and a Wood lamp. The tumour margins were marked on the basis of FD. The lesions were then excised according to the FD-defined tumour margin. On histology, the tumour margins were checked whether the lesion was completely excised in accordance with FD. Twenty-eight BCCs were finally included into the statistical analysis. In six BCCs, the FD-defined BCC margin did not correlate with the histopathologically assessed tumour borders. Four of these lesions were incompletely excised; two tumours were excised in toto indicating that the tumour was beyond the FD-defined margin but not at the excision margin. Hence, the rate of incompletely excised BCCs was 14.3% (4/28). The sensitivity and specificity rates of FD were 79 and 100%, respectively. FD is pretty sensitive and highly specific in regard to the demarcation of BCC margins. When compared to clinically based BCC excision, however, FD does not appear to be substantially superior to simple clinical assessment of tumour margins.

Assessment of clinical response after two cycles of primary chemotherapy in breast cancer

Complete clinical (cCR) and pathological (pCR) response to neoadjuvant chemotherapy in breast cancer is associated with improved survival. Various imaging and immunological techniques have been tested as predictors of response early in the course of chemotherapy, but their predictive value has not been compared with that of a simple early clinical assessment. Two hundred breast cancer patients (T2-4, N0-1) were treated with neoadjuvant chemotherapy. Clinical response after two cycles of treatment was compared with final clinical and pathological response. The likelihood of achieving cCR or pCR was compared by response after two cycles. Overall final clinical response rate was 79% (30.5% cCR and 11.9% pCR). After two cycles of chemotherapy, clinical response rate was 54.5%. For responders after two cycles, final cCR = 51.3% and pCR = 21.5%. For non-responders after two cycles, cCR = 5.5% and pCR = 1.2%. Response after two cycles predicts for pCR (P = 0.003; sensitivity 95.2%, specificity 52.9%). Clinical response after two cycles of chemotherapy predicts for pCR and is a valid early endpoint that could be incorporated into the design of future neoadjuvant trials.

Hip Muscle Activity is Altered in Patellofemoral Pain

PURPOSE: It is commonly accepted that the aetiology of patellofemoral pain is mutifactorial. While many individuals have altered muscle function locally at the tibiofemoral or patellofemoral joints, it has been recognized by clinicians that hip muscle function (strength or co-ordination) may be impaired in individuals with patellofemoral pain. This study aimed to investigate whether individuals with patellofemoral pain have altered hip muscle function compared with their healthy counterparts. A further aim was to establish whether a simple clinical assessment of the single leg squat could identify individuals with altered hip muscle function METHODS: Fifteen individuals with and without patellofemoral pain were recruited for this project. The electromyographic (EMG) of the gluteus medius muscles were collected during a stair stepping visual choice reaction time task. Anterior gluteus medius (AGM) was collected using surface electrodes, while posterior gluteus medius (PGM) was collected using fine wire electrodes. The onset of EMG activity of the gluteal muscles was assessed. Trunk side bend, hip external rotation and abduction torque were collected using a hand-held Nicholas Manual Muscle tester (model). The single leg squat performance was assessed by a panel of four experienced physical therapists. These clinicians reviewed a digital video recording of the participant performing five consecutive single leg squats. After reviewing the participants independently, the clinicians reached consensus on whether the participant could be graded as “good” or “poor”. Those participants who were classified as neither good nor poor were excluded from this analysis RESULTS: Individuals with patellofemoral pain exhibited a later onset of both hip muscles (AGM and PGM) (p <0.05) than the healthy individuals. Interestingly, this alteration in the temporal control of the hip muscles was not associated with a deficit in hip muscle strength (p >0.05). Furthermore, individuals with poor performance on the clinical assessment of the single leg squat exhibited a delayed onset of the AGM and PGM. CONCLUSIONS: Onsets of the AGM and PGM EMG is delayed in many individuals with patellofemoral pain. Furthermore, a simple clinical assessment tool is able to identify which individuals exhibit these temporal disruptions in hip muscle activity. In such individuals, clinicians should consider including an appropriate rehabilitation strategy

Functional Bowel Disorders

Employing a consensus approach, our working team critically considered the available evidence and multinational expert criticism, revised the Rome II diagnostic criteria for the functional bowel disorders, and updated diagnosis and treatment recommendations. Diagnosis of a functional bowel disorder (FBD) requires characteristic symptoms during the last 3 months and onset > or =6 months ago. Alarm symptoms suggest the possibility of structural disease, but do not necessarily negate a diagnosis of an FBD. Irritable bowel syndrome (IBS), functional bloating, functional constipation, and functional diarrhea are best identified by symptom-based approaches. Subtyping of IBS is controversial, and we suggest it be based on stool form, which can be aided by use of the Bristol Stool Form Scale. Diagnostic testing should be guided by the patient's age, primary symptom characteristics, and other clinical and laboratory features. Treatment of FBDs is based on an individualized evaluation, explanation, and reassurance. Alterations in diet, drug treatment aimed at predominant symptoms, and psychotherapy may be beneficial.

Where Does Fitness Fit In?

Cardiorespiratory fitness, as measured by a number of relatively simple and inexpensive clinical maneuvers, provides strong and independent prognostic information about the overall risk of illness and death, especially that from cardiovascular causes. This relationship extends to men, women, and adolescents. It is valid in apparently healthy persons; in patients with a broad range of maladies, including several types of cancer and cardiovascular disease; and in at-risk patients with diabetes mellitus, the metabolic syndrome, and hypertension.1–3 However, despite the profoundly important prognostic information provided by simple clinical assessments of fitness, they are rarely used in the clinical setting and . . .

Oral Fluid Human Immunodeficiency Virus Tests

Perinatal exposure of infants in low resource settings generates the bulk of pediatric human immunodeficiency virus (HIV) disease globally. The HIV status of these infants is established by testing serum for anti-HIV antibodies at 12 months of age in Prevention of Mother to Child Transmission (PMTCT) programs because polymerase chain reaction testing is unavailable. The diagnostic accuracy of 2 oral fluid (OF) HIV tests has not been previously evaluated in children. A serum and 2 OF HIV tests were performed at 12 months of age in a cohort of 321 vertically exposed children in a prospective, longitudinal study at a secondary level hospital in Johannesburg, South Africa during a 14-month period preceding October 2003. The 3 HIV tests were performed independently of each other by personnel blinded to the child's true HIV infection status, the reference standard used for comparison. HIV testing was performed at a median age of 12.1 months. The true HIV infection status of 310 of 321 (97%) children was determined. In comparison with serum testing results, OF HIV tests reduced the percentage of children requiring repeat HIV tests from 45% to 8-12%. The abilities of OF and serum to predict an HIV-uninfected status were comparable with negative predictive values >99%. Interpretation of HIV tests in conjunction with simple clinical assessment further improved the predictive value of the test. OF HIV tests perform well in children and have the potential to increase accessibility and acceptability of HIV diagnosis for infants in the context of PMTCT programs in low resource settings.

Development of a clinical assessment tool in identifying Asian men with low bone mineral density and comparison of its usefulness to quantitative bone ultrasound

Osteoporosis in men is a largely neglected condition in Asia (and elsewhere), despite the fact that one-third of hip fractures occur in men. Moreover, access to bone mineral density (BMD) measurements is limited in many areas of Asia, and inexpensive methods of targeting high risk patients for BMD measurements would be valuable. We have developed a simple clinical assessment tool to identify high risk Asian men for BMD measurements. Information on risk factors was collected from 420 community-dwelling adult Chinese men aged 50 years and above using a structured questionnaire, and the ability of these risk factors to identify subjects with femoral neck BMD T score < or = -2.5 was assessed. Multiple regression analysis and item reduction yielded a final clinical risk assessment tool based on only age and weight, similar to the Osteoporosis Self-assessment Tool for Asians (OSTA), described previously for Asian women. The OSTA values of < or = -1 had a sensitivity of 81% and specificity of 66%, and the area under the receiver operating characteristics curve was 0.83. The index was validated in another sample of 356 men with a sensitivity of 82% and specificity of 67 %, and an AUC of 0.85. The usefulness of OSTA was further compared to calcaneal quantitative bone ultrasound (QUS) in the validation sample of 356 men. The optimal cutoff T score of -1.2 for QUS yielded sensitivity and specificity values of 75 and 67%, respectively. The AUC for QUS was 0.79. Combining OSTA and QUI gave a sensitivity of 88% and specificity of 66% to identify men with low BMD at the femoral neck, and an AUC of 0.86 which was statistically not different from either OSTA or QUI alone. We conclude that OSTA is a simple and effective clinical risk assessment tool for identifying not only female but also male subjects at increased risk of osteoporosis, and its use could facilitate the appropriate and more cost-effective use of bone densitometry in developing countries.

Diseño de un índice pronóstico clínico para el manejo de la neumonía del adulto adquirida en la comunidad

Community acquired pneumonia (CAP) severity assessment is crucial. To develop a practical clinical severity assessment model for stratifying immunocompetent adult patients hospitalized with CAP into different management groups. During a 24 months period, 455 adult patients (250 male, mean age 69 +/- 19 years old) were evaluated. All the relevant clinical information recorded and they were followed during hospital stay until discharge or death. Mortality until 30 days after admission was determined. The mean hospital length of stay was 9.9 +/- 9.4 days and 76% had an underlying disease. In hospital mortality was 7.6% and 10.1% at 30 days follow up. Admission prognostic factors associated with high mortality at 30 days follow up were: advanced age, presence of comorbidity, suspicion of aspiration, duration of symptoms < or = 2 days, altered mental status, absence of cough, fever and cbills, low blood pressure, tachypnea, hypoxemia and multilobar radiographic pulmonary infiltrates. A clinical prognostic index derived from a logistic regression analysis including five independent variables associated with mortality (confuson, comorbidity, low systolic blood pressure, temperature < 37.5 degrees C and respiratory rate > 20/min), enabled patients to be stratified according to increasing risk of mortality: class 1: 0.9%, class 2: 4.9%, class 3: 14.2%, and class 4: 35.6%. A simple clinical severity assessment tool based on confusion, comorbidity, blood pressure, temperature and respiratory rate could be used to stratify patients with CAP into different risk class categories and management groups.

Subject index

The emergency department (ED) is frequently the doorway to the intensive care unit (ICU) for a significant number of critically ill patients presenting to the hospital. Hemodynamic monitoring (HDM) which is a key component in the effective management of the critically ill patient presenting to the ED, is primarily concerned with assessing the performance of the cardiovascular system and determining the correct therapeutic intervention to optimise end-organ oxygen delivery. The spectrum of hemodynamic monitoring ranges from simple clinical assessment and routine bedside monitoring to point of care ultrasonography and various invasive monitoring devices. The clinician must be aware of the range of available techniques, methods, interventions and technological advances as well as possess a sound approach to basic hemodynamic monitoring prior to selecting the optimal modality. This article comprises an in depth discussion of an approach to hemodynamic monitoring techniques and principles as well as methods of predicting fluid responsiveness as it applies to the ED clinician. We review the role, applicability and validity of various methods and techniques that include; clinical assessment, passive leg raising, blood pressure, finger based monitoring devices, the mini-fluid challenge, the end-expiratory occlusion test, central venous pressure monitoring, the pulmonary artery catheter, ultrasonography, bioreactance and other modern invasive hemodynamic monitoring devices.

An assessment tool for predicting fracture risk in postmenopausal women.

Due to the magnitude of the morbidity and mortality associated with untreated osteoporosis, it is essential that high-risk individuals be identified so that they can receive appropriate evaluation and treatment. The objective of this investigation was to develop a simple clinical assessment tool based on a small number of risk factors that could be used by women or their clinicians to assess their risk of fractures. Using data from the Study of Osteoporotic Fractures (SOF), a total of 7782 women age 65 years and older with bone mineral density (BMD) measurements and baseline risk factors were included in the analysis. A model with and without BMD T-scores was developed by identifying variables that could be easily assessed in either clinical practice or by self-administration. The assessment tool, called the FRACTURE Index, is comprised of a set of seven variables that include age; BMD T-score, fracture after age 50 years, maternal hip fracture after age 50, weight less than or equal to 125 pounds (57 kg), smoking status, and use of arms to stand up from a chair. The FRACTURE Index was shown to be predictive of hip fracture, as well as vertebral and nonvertebral fractures. In addition, this index was validated using the EPIDOS fracture study. The FRACTURE Index can be used either with or without BMD testing by older postmenopausal women or their clinicians to assess the 5-year risk of hip and other osteoporotic fractures, and could be useful in helping to determine the need for further evaluation and treatment of these women.

The Footwear Assessment Form: a reliable clinical tool to assess footwear characteristics of relevance to postural stability in older adults.

Falls in older adults are common and may result in serious injury. Inappropriate footwear has been suggested to be a contributing factor to many falls. However no studies have been undertaken to determine whether clinicians can reliably assess footwear variables thought to influence postural stability in older adults. The aim of this study was therefore to develop a simple clinical footwear assessment form and assess its reliability, both between examiners and with repeated assessments over time. Two examiners assessed seven footwear variables (shoe type, heel height, heel counter stiffness, longitudinal sole rigidity, sole flexion point, tread pattern and sole hardness) in 12 different shoes, and repeated the measurements three weeks later. The examiners were blinded to each other's and their own previous results. Analysis using the kappa (kappa) and percentage agreement statistics revealed the examiners' footwear assessments to be generally highly reliable (kappa = 0.47-1.00 for inter-tester comparisons, kappa = 0.40-1.00 for intra-tester comparisons), with the exception of inter-tester assessment of sole hardness (kappa = 0.03-0.48). The Footwear Assessment Form is a reliable clinical tool for the assessment of shoe type, heel height, heel counter stiffness, longitudinal sole rigidity and tread pattern; however, a more objective protocol may be required to improve the reliability of sole hardness evaluation. The Footwear Assessment Form can now be used with confidence in the clinical setting and in future investigations to determine the contribution of footwear characteristics to instability and falls in older adults.

Strategies for the safe and effective exclusion and diagnosis of deep vein thrombosis by the sequential use of clinical score, D-dimer testing, and compression ultrasonography.

Patients with suspected deep vein thrombosis (DVT) are subjected to leg vein compression ultrasonography (CUS) that confirms DVT in only 20 to 30% of patients. A positive CUS is consistent with DVT irrespective of clinical score. The sequential use of a simple clinical score assessment, a rapid sensitive enzyme-linked immunosorbent assay (ELISA) D-dimer test and CUS to safely exclude DVT is promising. The clinical score is a validated clinical model of complaints, signs, and symptoms, on the basis of which a pretest clinical probability for DVT can be estimated as low, moderate, and high. The safe exclusion of DVT by a rapid sensitive D-dimer test in combination with clinical score or CUS necessitates a negative predictive value of more than 99%. The negative predictive value for DVT is determined by the sensitivity of the rapid ELISA D-dimer test and the prevalence of DVT in subgroups of outpatients with suspected DVT. The prevalence of DVT in outpatients with a low, moderate, and high clinical score varies widely from 3 to 10%, 15 to 30% and more than 70%, respectively. A negative rapid ELISA D-dimer and a low clinical score (prevalence DVT 3 to 5%) will have a very high negative predictive value of more than 99.5% to exclude DVT without the need of CUS testing. A negative ELISA D-dimer test and a first-negative CUS safely exclude DVT in patients with a moderate clinical score with a negative predictive value of more than 99.5%, therefore obviating the need to repeat CUS. The use of a rapid ELISA D-dimer testing in patients with a high clinical score is not recommended. A negative CUS, a low clinical score, and a positive ELISA D-dimer, even less than 1000 ng/mL exclude DVT with a nega tive predictive value of more than 99%. Patients with a negative CUS, but a positive ELISA D-dimer, and a moderate or high clinical score have a probability of DVT of 3 to 5% and 20 to 30%, respectively, and are thus candidates for repeated CUS testing. The proposed sequential use of the clinical score assessment, a rapid ELISA D-dimer test, and CUS will be the most cost-effective diagnostic strategy for DVT because of a significant reduction of CUS examinations and gain of time for the patient and physician in charge.

Is simple clinical assessment adequate for cardiac risk stratification before elective non-cardiac surgery?

With surgical outcomes being the subject of increasing medical and non-medical scrutiny, there is pressure to identify patients at high risk of perioperative cardiac events, most importantly fatal and non-fatal myocardial infarction. Thomas Lee and colleagues1 have shown that a simple clinical assessment is the only risk-stratifying measure required for most patients being considered for major non-cardiac surgery. Their revised Cardiac Risk Index, based on the type of surgery and risk factors related to the individual (panel) is derived from multiple-regression analysis of a large cohort of patients (2893 in the derivation set, 1422 in the validation set) and represents a helpful simplification and improvement of their original scoring system developed in the 1970s.

Intravenous Fluid Therapy of Calves

Dehydration in neonatal calves with diarrhea is a common cause of death. Severely dehydrated calves that are unable to suckle need intravenous fluids for effective resuscitation. This article gives an overview of the principles of intravenous fluid therapy for dehydrated calves including the types of fluids commonly used and methods of fluid administration. Practical on-farm options for simple clinical assessment and treatment of dehydration and acidosis in calves are also discussed in this article.

Simple clinical assessment of colonic response to food.

The colonic response to food (CRF) is an integrated function of the colon that has been poorly studied in clinical practice. This study describes a new method to measure it, based on the progress of radio-opaque markers, and shows the results in healthy subjects and in patients with irritable bowel syndrome (IBS). Thirty healthy subjects and 43 patients suffering from IBS were studied. Two studies of colonic transit time (CTT), at rest and after eating a standard test meal, were performed. CRF was quantified by calculating the variation in number of markers in each zone of interest of the large bowel using X-ray films of the abdomen taken before and after eating. The results were as follows: (1) CRF is characterised by caudal propulsion of the colonic contents in the two groups. In controls, there is emptying of the cecum-ascending colon region and filling of the distal large bowel. In IBS patients, only emptying of the left transverse colon and the splenic flexure is found. (2) IBS patients have a delayed CTT because of slowing in the right and left colon, and this is both before and after a meal. The determination of the movements of markers after eating is a simple method that is useful in clinical practice to evaluate CRF.

Albendazole chemotherapy for treatment of diarrhoea in patients with AIDS in Zambia: a randomised double blind controlled trial

To determine the value of short course, high dose albendazole chemotherapy in the treatment of persistent diarrhoea related to HIV in unselected patients in urban Zambia. A randomised double blind placebo controlled trial of albendazole 800 mg twice daily for two weeks. Patients were monitored intensively for one month and followed for up to six months. Home care. AIDS services in Lusaka and Ndola. 174 HIV seropositive patients with persistent diarrhoea (defined as loose but not bloody stools three or more times a day for three weeks or longer). No investigations were undertaken except HIV testing after counselling. Proportion of time periods during which diarrhoea was experienced after completion of treatment; proportion of patients with full remission after completion of treatment; mortality. The patients taking albendazole had diarrhoea on 29% fewer days than those taking placebo (P < 0.0001) in the two weeks after treatment. The benefit of albendazole was maintained over six months. In patients with a Karnofsky score of 50 to 70 (needing help with activities of daily living and unable to work, but not needing admission to hospital) diarrhoea was reduced by 50%. Remission was obtained in 26% of all patients who received albendazole (P = 0.004 against 9% receiving placebo), and this difference was maintained over six months (log rank test, P = 0.003). Albendazole had no effect on mortality. Minimal adverse effects were noted. For HIV infected Zambians with diarrhoea of more than three weeks' duration albendazole offers substantial relief from symptoms and may be used empirically, without prior investigation.

A simple clinical assessment of attention in schizophrenia

Although attentional dysfunction is considered a predominant feature of schizophrenia, it is seldom quantitatively assessed in clinical practice. A simple paper-and-pencil test of selective attention (Ruff et al., 1986) provides a 5-min assessment with theoretical relevance for schizophrenia. Thirty schizophrenic subjects performed the 2 and 7 Selective Attention Test, which measures speed and accuracy, and compares controlled and automatic information processing. Ninety percent of the subjects displayed automatic processing. Speed was severely impaired, and accuracy was less so. Sixty-seven percent of the schizophrenic subjects performed in the normal range (± 1 SD) for accuracy, but only 23% scored in the normal range for speed. Speed and accuracy were moderately correlated. Although theories of a lateralized deficit were not supported, the results are consistent with a hypothesized frontal lobe dysfunction. The automatic processing demonstrated may represent old learning. Poor controlled processing may preclude the acquisition of automatic functioning. This selective attention test may provide a measure of severity of cognitive impairment relevant to daily life functioning.

Dissemination of Research Results regarding the Pharmacotherapy of Substance Abuse: Case Examples and Critical Review

The transfer of treatment research findings to clinical practice begins with influential dissemination. Other factors, such as availability of resources, acceptance by clinicians, and relevant (i.e., pharmaceutical) company sponsorship can ultimately determine the clinical application of a new technology. Two examples related to the pharmacotherapy of substance abuse which were experienced during our work at the Addiction Research Foundation, as well as our proposal for a dissemination model, are discussed. Alcohol withdrawal (A W) and alcoholic liver disease (ALD) are common, potentially serious clinical problems associated with alcohol abuse. Clinical trials indicated that assessment and monitoring of AW can be simplified and standardized with a valid, reliable instrument, the CIWA-A. In severe AW (CIWA-A score &gt;25), the benzodiazepine. loading dose technique was proven to be an affective, shortened, simplified pharmacotherapy. An attempt to improve treatment of AW in rural detox centers in Ontario, Canada, was thwarted by lack of resources to perform simple clinical assessments and make decisions regarding pharmacotherapy and by reluctance to change. The CIWA-A was not adopted because, according to its guidelines, most detox center patients would be diagnosed with severe AW and would require pharmacotherapy, but dedicated and accessible physicians were not available to administer it (i.e., the problem was denied). Furthermore detox center staff were not willing to change current treatment practices (supportive care) for most severe AW patients. In the other case, in a long-term (2-year) placebo-controlled clinical trial in 310 patients, mortality from ALD was reduced by 50% with propylthiouracil (PTU), an antihyperthyroid medication. Results were published in a prestigious medical journal but misconceptions about risk of hypothyroidism and other side effects (e.g., agranulocytosis), cancellation of a multicenter trial, and lack of endorsement by hospitals and pharmaceutical companies may have deterred physicians from prescribing it. Thus, due to an inadequate marketing strategy, clinical use of PTU for ALD did not extend significantly beyond the original research institute. These two examples show that scientists must collaborate with professionals trained in techniques of dissemination and marketing in order to facilitate the transfer of research results to clinical practice. To correct this situation partially the Pharmacotherapy Research Unit, Addiction Research Foundation Clinical Research and Treatment Institute, presented a model for disseminating research results. However, due to administrative changes within the Foundation, the model has not been implemented. Efforts at research dissemination at NIDA, in the United States, seem to be developing in a more secure footing because of consistent administrative support and clear objectives.

Prognostic value of noninvasive cardiac tests in the assessment of patients with peripheral vascular disease

Two hundred thirty-six patients with peripheral vascular disease were prospectively studied to assess whether noninvasive cardiac investigations could predict prognosis better than simple clinical assessment. Clinical history, examination and resting electrocardiography were considered in all patients; exercise electrocardiography, Holter monitoring, radionuclide ventriculography and dipyridamole thallium imaging were performed in a subgroup of 168 patients. Follow-up for 6 to 30 months revealed major cardiac events in 21 patients. Cox survival analysis showed that clinical evidence of prior coronary artery disease was the best variable from clinical assessment that predicted cardiac events, with no other clinical variable adding to the statistical model. When variables from noninvasive cardiac assessment were added to the model, which included clinical evidence of coronary artery disease, dipyridamole thallium heart:lung ratio and left ventricular ejection fraction added significantly and incrementally to the prediction of cardiac events. Results of exercise electrocardiography or Holter monitoring did not add significantly. It is concluded that high lung uptake of thallium during dipyridamole stress, and impaired left ventricular ejection fraction help to identify patients with peripheral vascular disease who are at high cardiac risk, and should therefore be used for selecting subsequent cardiovascular medical, surgical and anesthetic management.