Undifferentiated Symptoms Research Articles

Factors Associated With Potentially Missed Diagnosis of Appendicitis in the Emergency Department

Appendicitis may be missed during initial emergency department (ED) presentation. To compare patients with a potentially missed diagnosis of appendicitis (ie, patients with symptoms associated with appendicitis, including abdominal pain, constipation, nausea and/or vomiting, fever, and diarrhea diagnosed within 1-30 days after initial ED presentation) with patients diagnosed with appendicitis on the same day of ED presentation to identify factors associated with potentially missed appendicitis. In this cohort study, a retrospective analysis of commercially insured claims data was conducted from January 1 to December 15, 2019. Patients who presented to the ED with undifferentiated symptoms associated with appendicitis between January 1, 2010, and December 31, 2017, were identified using the Clinformatics Data Mart administrative database (Optum Insights). The study sample comprised eligible adults (aged ≥18 years) and children (aged <18 years) who had previous ED visits within 30 days of an appendicitis diagnosis. Potentially missed diagnosis of appendicitis. Adjusted odds ratios (AORs) for abdominal pain and its combinations with other symptoms associated with appendicitis were compared between patients with a same-day diagnosis of appendicitis and patients with a potentially missed diagnosis of appendicitis. Of 187 461 patients with a diagnosis of appendicitis, a total of 123 711 (66%; 101 375 adults [81.9%] and 22 336 children [18.1%]) were eligible for analysis. Among adults, 51 923 (51.2%) were women, with a mean (SD) age of 44.3 (18.2) years; among children, 9631 (43.1%) were girls, with a mean (SD) age of 12.2 (18.2) years. The frequency of potentially missed appendicitis was 6060 of 101 375 adults (6.0%) and 973 of 22 336 children (4.4%). Patients with isolated abdominal pain (adults, AOR, 0.65; 95% CI, 0.62-0.69; P < .001; children, AOR, 0.79; 95% CI, 0.69-0.90; P < .001) or with abdominal pain and nausea and/or vomiting (adults, AOR, 0.90; 95% CI, 0.84-0.97; P = .003; children, AOR, 0.84; 95% CI, 0.71-0.98; P = .03) were less likely to have missed appendicitis. Patients with abdominal pain and constipation (adults, AOR, 1.51; 95% CI, 1.31-1.75; P < .001; children, AOR, 2.43; 95% CI, 1.86-3.17; P < .001) were more likely to have missed appendicitis. Stratified by the presence of undifferentiated symptoms, women (abdominal pain, AOR, 1.68; 95% CI, 1.58-1.78; nausea and/or vomiting, AOR, 1.68; 95% CI, 1.52-1.85; fever, AOR, 1.32; 95% CI, 1.10-1.59; diarrhea, AOR, 1.19; 95% CI, 1.01-1.40; and constipation, AOR, 1.50; 95% CI, 1.24-1.82) and girls (abdominal pain, AOR, 1.64; 95% CI, 1.43-1.88; nausea and/or vomiting, AOR, 1.74; 95% CI, 1.42-2.13; fever, AOR, 1.55; 95% CI, 1.14-2.11; diarrhea, AOR, 1.80; 95% CI, 1.19-2.74; and constipation, AOR, 1.25; 95% CI, 0.88-1.78) as well as patients with a comorbidity index of 2 or greater (adults, abdominal pain, AOR, 3.33; 95% CI, 3.09-3.60; nausea and/or vomiting, AOR, 3.66; 95% CI, 3.23-4.14; fever, AOR, 5.00; 95% CI, 3.79-6.60; diarrhea, AOR, 4.27; 95% CI, 3.39-5.38; and constipation, AOR, 4.17; 95% CI, 3.08-5.65; children, abdominal pain, AOR, 2.42; 95% CI, 1.93-3.05; nausea and/or vomiting, AOR, 2.55; 95% CI, 1.89-3.45; fever, AOR, 4.12; 95% CI, 2.71-6.25; diarrhea, AOR, 2.17; 95% CI, 1.18-3.97; and constipation, AOR, 2.19; 95% CI, 1.30-3.70) were more likely to have missed appendicitis. Adult patients who received computed tomographic scans at the initial ED visit (abdominal pain, AOR, 0.58; 95% CI, 0.52-0.65; nausea and/or vomiting, AOR, 0.63; 95% CI, 0.52-0.75; fever, AOR, 0.41; 95% CI, 0.29-0.58; diarrhea, AOR, 0.83; 95% CI, 0.58-1.20; and constipation, AOR, 0.60; 95% CI, 0.39-0.94) were less likely to have missed appendicitis. Regardless of age, a missed diagnosis of appendicitis was more likely to occur in women, patients with comorbidities, and patients who experienced abdominal pain accompanied by constipation. Population-based estimates of the rates of potentially missed appendicitis reveal opportunities for improvement and identify factors that may mitigate the risk of a missed diagnosis.

2719 A Rare Cause of Chronic Diarrhea: Gastrocolic Fistula

INTRODUCTION: Gastro-colic fistula is a pathological fistulous tract usually between the stomach and the transverse colon. It is a rare presentation of both benign and malignant diseases of the GI tract. Most cases in the modern world are related to adenocarcinomas of the colon. Benign fistulas are a rarer occurrence due to advancements in the medical management of peptic ulcer disease. Here we present a case report of a benign gastro-colic fistula occurring in the setting of a prior Whipple’s surgery. CASE DESCRIPTION/METHODS: A 61-year-old male presented with chronic diarrhea associated with a 50-pound weight loss, fatigue, and weakness. His past surgical history was notable of a Whipple’s procedure done 10 years ago. A trial of lactose-free diet and a course of antibiotics did not improve his symptoms. Upon further investigations, it was revealed that patient had anemia, hypokalemia and a low albumin level. Workup was negative for celiac disease, carcinoid syndrome, gastrinomas, and therefore the patient had an endoscopy which revealed a benign gastro-colic fistula in the setting of an anastomotic pyloric ulcer eroding into the transverse colon. He was then referred for surgery following optimization of his nutritional status. DISCUSSION: A majority of cases are due to malignancy, specifically gastric cancer or transverse colon cancer, although fistulas due to benign causes have also been described. In addition, cases of gastrocolic fistula have been observed in the setting of prior gastric surgeries but the interval duration of development has been reported to be around 8 to 9 months. Patients generally present with undifferentiated symptoms like diarrhea, weight loss, abdominal pain, nausea and vomiting making the diagnosis difficult. Radiologic imaging studies such as barium enema (most sensitive test) and barium meals are the mainstay of diagnosis. Endoscopy is usually not recommended as a diagnostic tool. Endoscopy with biopsy is primarily done as part of the workup to rule out malignancy. Definitive treatment includes surgical resection. Conservative medical management such as proton pump inhibitors should be considered when surgery is contraindicated or in cases that occur in the setting of peptic ulcer disease.

P.046 Flow cytometry in cerebrospinal fluid: utility in the diagnosis of central nervous system lymphoma

Background: Flow cytometry in the cerebrospinal fluid (CSF) is used as an adjunct to cytology to increase the sensitivity of detecting central nervous system (CNS) lymphoma. We aim to evaluate CSF flow cytometry as a diagnostic tool for lymphoma in patients presenting with undifferentiated neurologic symptoms. Methods: We retrospectively reviewed all CSF flow cytometry samples sent in the Calgary region from 2012-2015. Clinical data, laboratory investigations, radiologic imaging studies, and pathological data were analyzed. Clinical review extended to 2 years post CSF flow cytometric testing. Results: The number of samples of CSF flow cytometry that were positive for a hematological malignancy was 43/763 (5.6%). The overall sensitivity of the test was 72.9%. A positive result was more likely to occur in patients with a prior history of a hematological malignancy or abnormal enhancement on MRI (p&lt;0.0001). In fact, CSF flow cytometry was negative in all patients who did not have a previous hematological malignancy or abnormal enhancement on MRI (n = 247). Conclusions: CSF flow cytometry has very limited role in the screening for primary CNS lymphoma, unless a strictly endorsed testing algorithm is applied. It is, however, an invaluable tool in assessing CNS involvement in patients with previous diagnosis of hematolymphoid malignancy.

Managing diagnostic uncertainty in primary care: a systematic critical review

BackgroundDiagnostic uncertainty is one of the largest contributory factors to the occurrence of diagnostic errors across most specialties in medicine and arguably uncertainty is greatest in primary care due to the undifferentiated symptoms primary care physicians are often presented with. Physicians can respond to diagnostic uncertainty in various ways through the interplay of a series of cognitive, emotional and ethical reactions. The consequences of such uncertainty however can impact negatively upon the primary care practitioner, their patients and the wider healthcare system. Understanding the nature of the existing empirical literature in relation to managing diagnostic uncertainty in primary medical care is a logical and necessary first step in order to understand what solutions are already available and/or to aid the development of any training or feedback aimed at better managing this uncertainty. This review is the first to characterize the existing empirical literature on managing diagnostic uncertainty in primary care.MethodsSixteen databases were systematically searched from inception to present with no restrictions. Hand searches of relevant websites and reference lists of included studies were also conducted. Two authors conducted abstract/article screening and data extraction. PRISMA guidelines were adhered to.ResultsTen studies met the inclusion criteria. A narrative and conceptual synthesis was undertaken under the premises of critical reviews. Results suggest that studies have focused on internal factors (traits, skills and strategies) associated with managing diagnostic uncertainty with only one external intervention identified. Cognitive factors ranged from the influences of epistemological viewpoints to practical approaches such as greater knowledge of the patient, utilizing resources to hand and using appropriate safety netting techniques. Emotional aspects of uncertainty management included clinicians embracing uncertainty and working with provisional diagnoses. Ethical aspects of uncertainty management centered on communicating diagnostic uncertainties with patients. Personality traits and characteristics influenced each of the three domains.ConclusionsThere is little empirical evidence on how uncertainty is managed in general practice. However we highlight how the extant literature can be conceptualised into cognitive, emotional and ethical aspects of uncertainty which may help clinicians be more aware of their own biases as well as provide a platform for future research.Trial registrationPROSPERO registration: CRD42015027555

Prevalence and alternative explanations influence cancer diagnosis: An experimental study with physicians.

Cancer causes death to millions of people worldwide. Early detection of cancer in primary care may enhance patients' chances of survival. However, physicians often miss early cancers, which tend to present with undifferentiated symptoms. Within a theoretical framework of the hypothesis generation (HyGene) model, together with psychological literature, we studied how 2 factors-cancer prevalence and an alternative explanation for the patient's symptoms-impede early cancer detection, as well as prompt patient management. Three hundred family physicians diagnosed and managed 2 patient cases, where cancer was a possible diagnosis (one colorectal cancer, the other lung cancer). We employed a 2 (cancer prevalence: low vs. high) × 2 (alternative explanation: present vs. absent) between-subjects design. Cancer prevalence was manipulated by changing either patient age or sex; the alternative explanation for the symptoms was manipulated by adding or removing a relevant clinical history. Each patient consulted twice. In a series of random-intercept logistic models, both higher prevalence (OR = 1.92, 95% confidence interval [CI 1.27, 2.92]) and absence of an alternative explanation (OR = 1.70, 95% CI [1.11, 2.59]) increased the likelihood of a cancer diagnosis, which, in turn, increased the likelihood of prompt referral (OR = 22.84, 95% CI [16.14, 32.32]). These findings confirm the probabilistic nature of the diagnosis generation process and validate the application of the HyGene model to early cancer detection. Increasing the salience of cancer-such as listing cancer as a diagnostic possibility-during the initial hypothesis generation phase may improve early cancer detection. (PsycINFO Database Record

Diagnostic protocols-A consultation tool still to be discovered.

RationaleExperienced primary care physicians handle most illnesses to everyone's satisfaction despite limited resources of time and means. However, cases can be multifaceted in that harmless‐presenting symptoms may also be warning signals or an indicator of a health disorder that too infrequently presents in family practice to be diagnosed correctly. On the basis of these observations, RN Braun developed 82 diagnostic protocols for a structured recording of various complaints.MethodAll consultations during the years 2001 to 2014, in which 1 author (WF) had used diagnostic protocols in her single‐handed practice, were analyzed retrospectively regarding reasons for encounter, diagnostic classification, and long‐term outcome.ResultsDuring the period, a diagnostic protocol was used 1686 times. It was applied at a rate of approximately 5% of 2500 new complaints annually, most often (1366 times) for febrile conditions. In 320 consultations for other complaints, 43 different diagnostic protocols were applied. Among them, the “tabula diagnostica” for various undifferentiated symptoms was used most frequently (n = 54), followed by diagnostic protocols for headache (n = 45), dizziness (n = 36), precordial pain (n = 20), nonspecific abdominal pain (n = 15), low back pain (n = 14), hypertension (n = 12), diarrhea > 1 week (n = 12), epigastralgia (n = 11), depression (n = 10), polyarthralgia (n = 8), cough, and lower abdominal pain (each n = 7). A final diagnosis was established in less than 20% of cases.ConclusionsThis observational study from routine practice gives an insight how diagnostic protocols helped to manage complex patient presentations. A broader use of diagnostic protocols could investigate the potential of this consultation tool to handle the complexity of primary health care. The use of a standardized diagnostic approach could stimulate research, in particular on managing common complaints/undifferentiated illness and their inherent diagnostic uncertainty.

Systemic lupus erythematosus: an update.

Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease predominantly affecting women of childbearing age. New classification criteria for SLE have greater sensitivity and therefore improve the diagnostic certainty for some patients, especially those who may previously have been labelled as having undifferentiated symptoms. Uncontrolled disease activity leads to irreversible end-organ damage, which in turn increases the risk of premature death; early and sustained control of disease activity can usually be achieved by conventional immunosuppressant therapy. The development of biological therapy lags behind that for other rheumatic diseases, with belimumab being the only targeted therapy approved by the Therapeutic Goods Administration. "Treat-to-target" concepts are changing trial design and clinical practice, with evidence-based definition of response criteria in the form of remission and low disease activity now on the horizon. While new therapies are awaited, research should also focus on optimising the use of current therapy and improving the quality of care of patients with SLE.

P134 Point of care ultrasound accurately distinguishes inflammatory from non inflammatory disease in patients presenting with abdominal pain and diarrhea

Background: There is a considerable overlap between symptoms of irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). It is important to have access to non-invasive, safe, low cost diagnostic tools to differentiate IBD from functional abdominal symptoms such as IBS, and avoid unnecessary invasive investigations including endoscopy. Point of care ultrasound (POCUS) of the bowel is not widely accessible in North America, but is routinely used in Europe. The aim of this study was to evaluate the accuracy of POCUS in the detection of luminal inflammation compared to gold standard ileocolonscopy in patients presenting with undifferentiated lower gastrointestinal symptoms. Methods: A prospective, single- center study of consecutive patients presenting to the GI clinic with symptoms high risk for IBD were evaluated to differentiate IBD from IBS. POCUS was performed, clinical data recorded and C-reactive protein measured prior to ileocolonoscopy, which served as the gold standard. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for POCUS. Results: Eighty-six patients with undifferentiated symptoms of diarrhea (76.7%), abdominal pain (62.8%) and weight loss (18.6%) were evaluated. Nocturnal symptoms (15.1%) and incontinence (11.6%) were infrequent (Table 1). Ileocolonoscopy was negative in 72 patients confirming IBS, 2 patients had diverticulosis, while 12 revealed findings of active endoscopic disease consistent with IBD, confirmed on pathology, 11 with CD and 1 with UC, as well as microscopic colitis (N=8), diverticulosis (N=1), ischemic colitis (N=2) and one solitary rectal ulcer. The overall sensitivity, specificity, PPV and NPV of POCUS were 83.0%, 100%, 100%, and 97.37%, respectively. In cases where POCUS was positive, POCUS predicted the severity of inflammation as seen on ileocolonscopy accurately with correlate findings of 90% (9/10 cases accurately predicted severity). The accuracy of POCUS for predicting IBD was much better than CRP, as the sensitivity of CRP was only 37.5%, specificity 76.2%. Wait time for endoscopy for patients with a positive POCUS was shorter with a median of 3.5 weeks, compared to 4 weeks for those with a negative POCUS. Table 1. Demographics Table 2. Sensitivity, specificity, accuracy, PPV and NPV of POCUS relative to ileocolonoscopy Conclusions: Bedside POCUS is a useful triage tool, better than CRP in disease prediction, helpful to accurately detect the presence and severity of inflammation in the bowel and thus differentiate IBD from IBS. The detection of ileal disease was more accurate compared to colonic disease and future studies should be completed with addition of fecal calprotectin to optimize detection rates and overall accuracy.

Understanding the body-mind in primary care.

Patients' experience of symptoms does not follow the body-mind divide that characterizes the classification of disease in the health care system. Therefore, understanding patients in their entirety rather than in parts demands a different theoretical approach. Attempts have been made to formulate such approaches but many of these, such as the biopsychosocial model, are still basically dualistic or methodologically reductionist. In primary care, patients often present with diffuse symptoms, making primary care the ideal environment for understanding patients' undifferentiated symptoms and disease patterns which could readily fit both bodily and mental categories. In this article we discuss theoretical models that have attempted to overcome this challenge: The psychosomatic approach could be called holistic in the sense of taking an anti-dualistic stance. Primary care theorists have formulated integrative views but these have not gained a foothold in primary care medicine. McWhinney introduced a new metaphor, 'the body-mind', and Rudebeck advocated cultivating 'bodily empathy'. These views have much in common with both phenomenological thinking and mentalization, a psychological concept for understanding others. In the process of understanding patients there is a need for the physician to enter an intersubjectivity that aims at understanding the patient's experiences and sensations without initially jumping to diagnostic conclusions or into a division into mental and physical phenomena. Mentalization theory could form the basis of an approach to a more comprehensive understanding of patients. The success of such an approach is, however, dependent upon structural and organizational conditions that do not counteract it.

Strain Echocardiography in Acute Cardiovascular Diseases.

Echocardiography has become a critical tool in the evaluation of patients presenting to the emergency department (ED) with acute cardiovascular diseases and undifferentiated cardiopulmonary symptoms. New technological advances allow clinicians to accurately measure left ventricular (LV) strain, a superior marker of LV systolic function compared to traditional measures such as ejection fraction, but most emergency physicians (EPs) are unfamiliar with this method of echocardiographic assessment.This article discusses the application of LV longitudinal strain in the ED and reviews how it has been used in various disease states including acute heart failure, acute coronary syndromes (ACS) and pulmonary embolism.It is important for EPs to understand the utility of technological and software advances in ultrasound and how new methods can build on traditional two-dimensional and Doppler techniques of standard echocardiography. The next step in competency development for EP-performed focused echocardiography is to adopt novel approaches such as strain using speckle-tracking software in the management of patients with acute cardiovascular disease. With the advent of speckle tracking, strain image acquisition and interpretation has become semi-automated making it something that could be routinely added to the sonographic evaluation of patients presenting to the ED with cardiovascular disease. Once strain imaging is adopted by skilled EPs, focused echocardiography can be expanded and more direct, phenotype-driven care may be achievable for ED patients with a variety of conditions including heart failure, ACS and shock.

The Cognitive Psychology of Diagnostic Errors

Health care involves complex decision making, often under uncertain, ambiguous, and time-sensitive conditions. Clinicians typically face the greatest uncertainty when making diagnostic decisions; common, undifferentiated symptoms paired with increasing prevalence of complex comorbidities, continuously and rapidly evolving scientific evidence, and often fragmented information systems are just a few of the hurdles clinicians must navigate as part of daily diagnostic decision making. In this review, the current state of the science concerning the cognitive psychology of diagnostic errors is discussed, including models of diagnostic reasoning, common errors: heuristics and biases, and practical implications and interventions. Figures show a conceptual model for diagnostic errors; diagnostic and therapeutic cycles; relationships among heuristics, biases, premature closure, and diagnostic errors; Reason’s (2000) Swiss cheese model; and tradeoffs versus improvements in diagnostic performance as illustrated by the receiver operating characteristic curve. Tables list important reasons for understanding the foundational cognitive models of diagnostic reasoning; a glossary of key diagnostic error–related definitions; three models of cognitive decision making; a summary of clinical reasoning models; steps of diagnostic decision making; examples of diagnostic errors resulting from representativeness, availability, and anchoring and adjustment; categories of countermeasures for error reduction interventions; examples of cognitively, systems-, and patient-focused countermeasures for selected biases; a summary of cognitively focused countermeasures to cognitive bias; key problem “classes” where problem- or context-specific solutions might be applied; types of system-focused countermeasures; and patient-focused countermeasures to avoid diagnostic error. This review contains 5 highly rendered figures, 12 tables, and 120 references.

A longitudinal examination of the moderating effects of symptoms on the relationship between functional competence and real world functional performance in Schizophrenia

BackgroundMany individuals with schizophrenia experience remission of prominent positive symptoms but continue to experience impairments in real world functioning. Residual negative and depressive symptoms may have a direct impact on functioning and impair patients' ability to use the cognitive and functional skills that they possess (competence) in the real world (functional performance). MethodsOne hundred thirty-six individuals (100 men, 36 women) with schizophrenia were classified as having primarily positive symptoms, primarily negative symptoms, primarily depressive symptoms, or undifferentiated symptom profiles. Performance based measures of cognition and adaptive and interpersonal functional competence were used, along with ratings of real world behavior by high contact clinicians. Assessments were performed at baseline and at an 18-month follow-up. ResultsThe relationships between neurocognition and capacity/performance were not moderated by symptom group ps>.091; neurocognition predicted capacity and performance for all groups ps<.001. The relationship between adaptive competence and adaptive performance was moderated by symptom group, ps<.01, such that baseline competence only predicted future performance ratings for participants with primarily positive or undifferentiated symptoms, and not for individuals with primarily negative or depressive symptoms. This same moderation effect was found on the relationship between interpersonal competence and interpersonal performance, ps<.002. ConclusionsResidual negative and depressive symptoms are distinct constructs that impede the use of functional skills in the real world. Depressive symptoms are often overlooked in schizophrenia but appear to be an important factor that limits the use of functional ability in real world environments.

Novel biomarkers in diagnosing cardiac ischemia in the emergency department: A systematic review

BackgroundNovel biomarkers of myocardial ischemia and inflammatory processes have the potential to improve diagnostic accuracy of acute coronary syndrome (ACS) within a shorter time interval after symptom onset. ObjectiveThe objective was to review the recent literature and evaluate the evidence for use of novel biomarkers in diagnosing ACS in patients presenting with chest pain or symptoms suggestive of cardiac ischemia to the emergency department or chest pain unit. MethodsA literature search was performed in MEDLINE, EMBASE, Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, and NHSEED for studies from 2004 to 2010. We used the inclusion criteria: (1) human subjects, (2) peer-reviewed articles, (3) enrolled patients with ACS, acute myocardial infarction or undifferentiated signs and symptoms suggestive of ACS, and (4) English language or translated manuscripts. Two reviewers conducted a hierarchical selection and assessment using a scale developed by the International Liaison Committee on Resuscitation. ResultsOut of a total 3194 citations, 58 articles evaluating 37 novel biomarkers were included for final review. Forty-one studies did not support the use of their respective biomarkers. Seventeen studies supported the use of 5 biomarkers, particularly when combined with cardiac-specific troponin: heart fatty acid-binding protein, ischemia-modified albumin, B-type natriuretic peptide, copeptin, and matrix metalloproteinase-9. ConclusionIn patients presenting to the emergency department with chest pain or symptoms suggestive of cardiac ischemia, there is inadequate evidence to suggest the routine testing of novel biomarkers in isolation. However, several novel biomarkers have the potential to improve the sensitivity of diagnosing ACS when combined with cardiac-specific troponin.

Cost-Effectiveness of Strategies for Diagnosing Pulmonary Embolism Among Emergency Department Patients Presenting With Undifferentiated Symptoms

Symptoms associated with pulmonary embolism can be nonspecific and similar to many competing diagnoses, leading to excessive costly testing and treatment, as well as missed diagnoses. Objective studies are essential for diagnosis. This study evaluates the cost-effectiveness of different diagnostic strategies in an emergency department (ED) for patients presenting with undifferentiated symptoms suggestive of pulmonary embolism. Using a probabilistic decision model, we evaluated the incremental costs and effectiveness (quality-adjusted life-years gained) of 60 testing strategies for 5 patient pretest categories (distinguished by Wells score [high, moderate, or low] and whether deep venous thrombosis is clinically suspected). We performed deterministic and probabilistic sensitivity analyses. In the base case, for all patient pretest categories, the most cost-effective diagnostic strategy is to use an initial enzyme-linked immunosorbent assay D-dimer test, followed by compression ultrasonography of the lower extremities if the D-dimer is above a specified cutoff. The level of the preferred cutoff varies with the Wells pretest category and whether a deep venous thrombosis is clinically suspected. D-dimer cutoffs higher than the current recommended cutoff were often preferred for patients with even moderate and high Wells categories. Compression ultrasonography accuracy had to decrease below commonly cited levels in the literature before it was not part of a preferred strategy. When pulmonary embolism is suspected in the ED, use of an enzyme-linked immunosorbent assay D-dimer assay, often at cutoffs higher than those currently in use (for patients in whom deep venous thrombosis is not clinically suspected), followed by compression ultrasonography as appropriate, can reduce costs and improve outcomes.

Unique Characteristics of Emergency Care Research: Scope, Populations, and Infrastructure

The National Institutes of Health (NIH) Clinical and Translational Science Awards (CTSA) program and the 2006 Institute of Medicine (IOM) Report on the future of emergency care highlight the need for coordinated emergency care research (ECR) to improve the outcomes of acutely ill or injured patients. In response, the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP) sponsored the Emergency Care Research Network (ECRN) Conference in Washington, DC, on May 28, 2008. The conference objectives were to identify the unique nature of ECR and the infrastructure needed to support ECR networks and to understand the optimal role of emergency medicine (EM) and other acute care specialties in research networks. Prior to the conference, participants responded to questions addressing the relevant issues that would form the basis of breakout session discussions; two of these breakout questions are summarized in this report: 1) what makes EM research unique? and 2) what are the critical components needed to establish and maintain networked ECR? Emergency care research was defined as "the systematic examination of patient care that is expected to be continuously available to diverse populations presenting with undifferentiated symptoms of acute illness, or acutely decompensated chronic illness, and whose outcomes depend on timely diagnosis and treatment." The chain of ECR may extend beyond the physical emergency department (ED) in both place and time and integrate prehospital care, as well as short- and long-term outcome determination. ECR may extend beyond individual patients and have as the focus of investigation the actual system of emergency care delivery itself and its effects on the community with respect to access to care, use of resources, and cost. Infrastructure determinants of research network success identified by conference participants included multidisciplinary collaboration, accurate long-term outcome determination, novel information technology, intellectual infrastructure, and wider network relationships that extend beyond the ED.

Time to revisit Dr Finlay's casebook? The unique potential of the general practice case report

Time to revisit Dr Finlay's casebook? The unique potential of the general practice case report

General practitioners’ central role in management of asthma and allergic rhinitis

General practitioners’ central role in management of asthma and allergic rhinitis

Evidence-Based Perspectives on Pay for Performance and Quality of Patient Care and Outcomes in Emergency Medicine

Pay for performance is gaining momentum as a means to improve the quality of clinical care. Recently, the Centers for Medicare & Medicaid Services has expanded pay for performance initiatives to incorporate 9 emergency care metrics, including indicators for cardiac, pneumonia, and stroke care. The American College of Cardiology and American Heart Association (ACC/AHA) have published methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care. The purpose of this study is to grade each of the 9 Physician Quality Reporting Initiative emergency medicine process measures according to the ACC/AHA criteria related to clinical evidence (yes, no, indeterminate). Five of the 9 recently selected metrics in emergency medicine do not appear to meet all of the ACC/AHA criteria for measurement selection. Several of the metrics, including aspirin for acute myocardial infarction (mean hospital adherence 94.7%; SD 6.7%) and pulse oximetry for community-acquired pneumonia (mean 99.4%; SD 2.0%), already have high levels of performance nationally, which raises uncertainty about the overall cost-effectiveness of quality improvement interventions for these measures. Formal methodology needs to be established for future selection of performance measures for quality improvement programs in emergency care. These performance measures should focus on unique aspects of emergency and acute care, including recognition and treatment of time-sensitive life-threatening conditions, assessment of patients with undifferentiated signs and symptoms, and care of all-inclusive geographically based patient populations. In key emergency therapeutic areas, the evidence linking treatment and improved patient outcomes will require additional study before inclusion in pay for performance programs. New research initiatives are needed to assess the effect of timely administration of emergency department interventions on patient outcomes.

Upper gastrointestinal endoscopy or not, and in whom?

Despite progress in knowledge and effective therapies for acid-sensitive problems the indications for gastroscopy seem even more confusing than before. The primary care physician, faced with the patient with undifferentiated symptoms, is now less sure when to seek an endoscopy which is actively discouraged in many health care settings. Management guidelines, based essentially on maximizing the yield from endoscopy, may define the direction of travel but do not sit comfortably in the consultation setting.

Caring for Body and Soul: The Importance of Recognizing and Managing Psychological Distress in Persons with Multimorbidity

Primary care providers routinely encounter patients with interacting physical and psychological conditions that present as undifferentiated symptoms and feelings. Caring for the whole patient requires a good understanding of the interconnection between physical, psychological and social dimensions that may affect patients' well-being. In this article, we review the relationship between psychological distress and multimorbidity through the presentation of clinical vignettes from the real world of primary care, and discuss a team-based approach to managing care for this complex patient population.