Although systemic corticosteroids are widely used in treating stable chronic obstructive pulmonary disease (COPD), the evidence for their efficacy is still disputed. To reappraise this evidence, the authors used a new analytic strategy in which the 14 available randomized clinical trials were evaluated according to a methodologic "review of systems" and an examination of the statistical precision of the outcome results. Although none of the trials satisfied all of the methodologic criteria for both validity and clinical pertinence, the trials finding steroids efficacious were generally better designed and more statistically precise than trials failing to show efficacy. The authors propose a set of five main methodologic guidelines that require a stable baseline state, a crossover design with suitable washout, adequate doses of corticosteroids, pragmatic designs, and comprehensive choices of outcome events. Attention to these guidelines can help improve both design and evaluation for future trials of systemic steroids for stable COPD.

Adrenal Cortex Hormones↗

PubMedDate not supplied

A new instrument for patients' ratings of physician performance in the hospital setting.

A new instrument to elicit patients' appraisals of physician performance has been developed from a previously-derived taxonomy of desired physician attitudes and behavior. The instrument allows patients to give ratings for their physicians' discrete, observable items of behavior, and also for complex, multidimensional attributes. When the instrument was administered to 131 randomly chosen medical inpatients, the results showed that technical competence and interpersonal (or humanistic) qualities were equally valued, and that physicians received high ratings for most features of performance. Except for less satisfaction in younger patients, clinical and demographic characteristics had little impact on the ratings. The performance characteristics of the instrument appear satisfactory, and its potential applications and proposals for further research are discussed.

Clinical Competence↗

PubMedDate not supplied

A rating system for prompt clinical diagnosis of ischemic stroke.

BACKGROUND: When a CT scan is not available, an early accurate clinical diagnosis of ischemic stroke is essential to initiate prompt therapy. Our objective was to construct a clinical index that is easy to use when stroke patients are first evaluated at the hospital, to identify those who probably are experiencing an acute ischemic episode. The study was conducted at a university-affiliated medical referral center and two community general hospitals in Mexico. METHODS: Clinical records were reviewed for 801 patients with sudden onset of a focal or global neurologic dysfunction, presumably of vascular origin lasting more than 24 h. Eligibility criteria for this study were admission to the hospital within the first 24 h after symptomatic onset, CT scan diagnosis between 24 and 72 h, and age >45 years. Ischemic stroke included cases of arterial brain infarction, while nonischemic stroke included subarachnoid or intraparenchymatous hemorrhage, mass lesion, venous infarction, and in cases without a CT scan evidence that could explain the clinical manifestations. Data excerpted for analysis were age, sex, history of diabetes mellitus or previous stroke/transient ischemic attack (TIA), time of onset of symptoms, presence of headache, vomiting, neck stiffness, hemiplegia, leukocytosis or atrial fibrillation, diastolic blood pressure, and Glasgow coma scale (GCS) rating. Two multivariable analyses were used: 1) step-wise multiple logistic regression (SMLR), and 2) conjunctive consolidation (CC). RESULTS: After appropriate exclusions, the study proceeded with 83 ischemic and 42 nonischemic stroke patients. With SMLR, six variables were selected as predictive for ischemic stroke, including neck stiffness, diastolic blood pressure, previous history of stroke/TIA, hemiplegia, GCS, and atrial fibrillation. An appropriate sum of weighted ratings had a positive predictive value (PPV) of 100% for ischemic stroke. With consolidated categories, the PPV was 97% when patients had the following: no neck stiffness; no atrial fibrillation but history of stroke/TIA and GCS > or =12, or no neck stiffness but atrial fibrillation. CONCLUSIONS: Among patients with acute stroke, clinical data can be used to identify a group with a high probability of ischemic stroke. There are slightly different results between both methods; while SMLR includes the four variables selected by CC, the latter included neither diastolic blood pressure nor hemiplegia/hemiparesia. However, CC results seem easier to understand and interpret than with SMLR.

Acute Disease↗

PubMedDate not supplied