Topical treatments for head lice.
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Animals↗
Biomedical subjects
G R Bergus
Publications and source records attributed to G R Bergus.
An approach to diagnostic imaging of suspected pulmonary embolism.
Risk factors for pulmonary embolism include immobilization, trauma and surgery, particularly for hip fracture. Patients may present with acute respiratory symptoms, including tachypnea, tachycardia and rales. Chest radiographs and clinical and laboratory findings alone cannot provide a firm diagnosis. A completely normal chest radiograph may be seen in up to 40 percent of patients with pulmonary embolism, and as many as 30 percent of persons with pulmonary embolism and no prior cardiopulmonary disease will have a PaO2 greater than 80 mm Hg. The ventilation/perfusion (V/Q) lung scan is central to guiding clinical decisions. V/Q scans interpreted as either normal, near normal or high probability are reasonably diagnostic. A low probability V/Q scan can exclude the diagnosis of pulmonary embolism only if the patient has a clinically low probability of pulmonary embolism. Intermediate V/Q scans are not diagnostic and call for further evaluation. Compression ultrasonography is sensitive in detecting symptomatic deep venous thrombosis in the thigh. When clinical suspicion remains high and noninvasive imaging studies are uncertain, pulmonary angiography is likely to be diagnostic.
Algorithms↗
Risk assessment after acute upper GI hemorrhage.
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Acute Disease↗
Diagnostic imaging to identify the cause of jaundice.
Imaging studies can be helpful in identifying the etiology of conjugated (direct) hyper-bilirubinemia. An elevated direct bilirubin level suggests obstructive jaundice, and ultrasound or computed tomographic (CT) imaging may identify the responsible structural lesion. Imaging can also be used to guide percutaneous biopsy. A cost-effective strategy for determining the cause of direct hyperbilirubinemia rests on ultrasound as the primary modality. Endoscopic retrograde cholangiopancreatography and CT are performed as follow-up studies only when necessary. Magnetic resonance imaging is rarely useful.
Adult↗
Abortion training in family practice residency programs.
BACKGROUND: Despite a relatively fixed demand for services, access to abortion services has become increasingly limited, in part due to fewer training opportunities for OB-GYN residents. The recommended core educational guidelines for family practice residents include voluntary interruption of pregnancy up to 10 weeks gestation, but the availability of and interest in such training have not been reported. METHODS: A survey questionnaire assessing availability of abortion training, percentage of residents participating, program demographics, and resident interest in training was sent to all US family practice residency program directors and randomly selected third-year residents during the 1993-1994 academic year: A total of 301 of 399 (75%) program directors and 253 of 399 (63%) third-year residents completed the questionnaire. RESULTS: Twelve percent of programs nationwide offered abortion training during 1993-1994. Western programs were more likely to offer training (18 of 50 or 36%) than Northeastern (7 of 55 or 12%), Midwestern (6 of 98 or 6%), or Southern programs (4 of 98 or 4%). When available, 45% of trainees chose to participate. Training was primarily in suction curettage up to 12 weeks gestational age. The median duration of training was 4 weeks. Training was provided in both freestanding clinics and hospitals. Religious hospitals were less likely to offer training. CONCLUSIONS: About one of eight family practice residency programs nationwide offer training in abortion. When offered, nearly half of family practice residents choose to participate in this training. Interested family practice residents could be trained to fill an increasing need for physicians willing and able to perform first-trimester abortions.
Abortion, Induced↗
Diagnosing left lower lobe pneumonia: usefulness of the 'spine sign' on lateral chest radiographs.
BACKGROUND: Left lower lobe pneumonia may be obscured by the heart on the postero-anterior (PA) chest radiograph. In such cases, the lateral projection may be helpful, especially if it exhibits the "spine sign", which is an interruption in the progressive increase in lucency of the vertebral bodies from superior to inferior. We investigated whether the spine sign would help family physicians diagnose left lower lobe pneumonia on chest radiographs. METHODS: We selected the chest radiographs of all patients with left lower lobe pneumonia who were seen between 1983 and 1995 at a family practice training program (N = 78) and an equal number of chest radiographs of patients without pneumonia. Six family physicians read these radiographs under two viewing conditions: PA only vs PA and lateral. We used receiver operating characteristic (ROC) curve methodology to compare the two viewing conditions. RESULTS: There was no significant difference in performance between the two viewing conditions. The lateral view was helpful in some patients but misleading in others. Among patients with pneumonia, the lateral view was helpful when the spine sign was present, but it was misleading when the spine sign was absent. CONCLUSIONS: In this study of family physicians, the lateral chest radiograph did not improve overall diagnostic accuracy in patients with left lower lobe pneumonia. Among pneumonia patients with the spine sign, however, the lateral view was often helpful.
Adolescent↗
Added value of radiologist consultation to family practitioners in the outpatient setting.
PURPOSE: To measure the added value of a radiologist's consultation to the interpretation of radiographs previously read by a family practitioner. MATERIALS AND METHODS: The authors reviewed 1,674 chest and extremity radiographs previously read by a family practitioner and consulting radiologist. The 196 radiographs in which there was a discrepancy between the family practitioner's and radiologist's report were evaluated by a radiologist and family physician not involved in and blinded to the original interpretations. The overall accuracy of the participants was determined and differences statistically quantified. RESULTS: The overall sensitivity of the radiologists was greater than that of the family practitioners (92% vs 86%); specificity was not significantly different. For extremity examinations, there were no significant differences in accuracy of the radiologists and family practitioners; the sensitivity of radiologists for chest studies was considerably greater (89% vs 80%). Radiologic consultation was of particular value in the detection of pneumonia and masses. CONCLUSION: At a family practice center, the radiologist's role for extremity radiographs might be limited to individual consultation, with review of all chest radiographs.
Ambulatory Care↗
Teleradiology for rural hospitals: analysis of a field study.
We compared the accuracy of a low-cost teleradiology system with plain film at a small rural hospital. The comparison was a case-control, paired-comparison study. In total 377 consecutive cases were read prospectively by teleradiology and later by independent interpretation of the plain films. 'Truth' was determined in discrepant cases by further investigation of available records and images. Sensitivity and specificity were determined for each modality, and agreement using the kappa statistic. There was 90% agreement between teleradiology and plain film, with no significant differences. Sensitivities (0.88, 0.89) and specificities (0.98, 0.98) of the two methods were almost identical. McNemar's test indicated no significant differences in the accuracy of the two modalities. We conclude that inexpensive teleradiology for small rural hospitals is equivalent to plain film for radiologists' interpretation.
Case-Control Studies↗
Radiologic interpretation by family physicians in an office practice setting.
BACKGROUND: Radiology is an integral part of the office practice of many family physicians. Nevertheless, data are sparse on the performance of family physicians in this endeavor. This study investigated the performance of family physicians at interpreting radiographs ordered in a free-standing family practice office. METHODS: A consecutive series of radiographic studies performed at a family practice office during a 3-year period was surveyed. All radiographic studies included in this analysis (N = 1674) were separately interpreted by the family physician ordering the study and an overreading radiologist. If the interpretations agreed, the studies were accepted as having been correctly interpreted. Cases in which the interpretations disagreed were reexamined. RESULTS: Family physicians correctly interpreted 92.4% of the radiographic studies (95% confidence interval, 91.0 to 93.6). Their accuracy with extremity films (96.0%) was significantly higher than their accuracy with chest films (89.3%, P < .001). Family physicians were more likely to correctly interpret normal films (95.2%) than abnormal ones (85.9%, P < .001). Thirty-five percent of the cases in which there were differences between family physician and radiologist interpretations were correctly interpreted by family physicians. CONCLUSIONS: Family physicians showed a high degree of accuracy in radiologic interpretation in an office setting. Chest films were inherently more difficult to interpret than extremity films. Because correct interpretation depends on body part examined and the prevalence of disease, the performance of family physicians will probably vary in different practice settings.
Ambulatory Care↗
Clinical practice. How physicians make medical decisions and why medical decision making can help.
Medical decision making (MDM) contains tools that can contribute to the skill and expertise of physicians. MDM is especially useful for primary care physicians. Practicing in this clinical world is practicing in a world of great uncertainty--the world in which many of these tools were designed to be useful.
Algorithms↗
Using data from epidemiologic studies to revise probabilities.
Information about the relationship between risk factors and the probability of disease is often reported by an odds ratio, although its use for revising the probability of disease in a clinical setting is not intuitive and requires complex computations. A somewhat better approach is Bayesian probability revision. The authors present a method where likelihood ratios can be obtained from odds ratios, and they present simple computational methods for implementing all of the techniques described.
Epidemiologic Methods↗
A glossary of medical decision-making terms.
Many of the terms used in medical decision making are foreign to clinicians. This problem creates a barrier that can prevent physicians from acquiring these new clinical tools. This glossary contains definitions of the most common terms as well as examples of their usage by using Down syndrome as the illustrative condition.
Decision Support Techniques↗
Clinical reasoning about new symptoms despite preexisting disease: sources of error and order effects.
BACKGROUND: Previous work that studied the evaluation of new, atypical symptoms in patients with preexisting diseases indicated that physicians largely ignored the past medical history and therefore erred in their diagnoses, when compared to a Bayesian analysis. Other studies have shown that the order in which information is presented to a decision maker can affect the inferences drawn, again contrary to a Bayesian standard. OBJECTIVES: The aim of the study was to investigate the source of disparity between clinical judgment and Bayesian analysis and to investigate the effect of alternative orders of presenting information on diagnostic conclusions. METHODS: Two groups of family physicians received a written clinical scenario. One group was given the past medical history before the history of present illness, the physical exam, and the laboratory data. The second group learned about the past medical history after all other clinical information had been presented. Judgments of test accuracy and probably diagnosis were collected at several points to identify the source of any diagnostic error. RESULTS: For both groups, the major source of error was in estimating the prior probability of disease, not in estimating the accuracy of a diagnostic test or updating opinions following receipt of test results. Although both groups of physicians received the same information, they came to markedly different conclusions about the most likely diagnosis. The group given the past medical history at the beginning of the scenario considered this information much less significant than did the group who received it at the end. CONCLUSIONS: Family physicians deviate from a Bayesian standard of reasoning by wrongly specifying prior probabilities and by being influenced by the order in which clinical information is presented.
Bayes Theorem↗
Use of the periodic health evaluation by family physicians.
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Adult↗
Superficial tinea infections.
Dermatophytes commonly cause superficial dermatoses, especially in children, but these infections are frequently misdiagnosed as nonfungal disease. Superficial tinea infections can vary widely in appearance, ranging from a single, small, circular lesion with mild erythema and a scaling active border to multiple large areas of marked inflammation with vesicle formation. Therefore, laboratory tests, particularly the potassium hydroxide slide preparation, are often necessary to establish the diagnosis. The culture becomes particularly important if the smear is negative but a superficial dermatosis is strongly suspected. Tinea capitis is frequently diagnosed only by culture. Since many agents are available to treat superficial dermatoses, cost should be an important consideration in the selection of a topical antifungal agent. Oral agents are recommended for scalp and nail infections, as well as extensive body infections. Griseofulvin is the oral agent of choice because of its efficacy and low toxicity.
Humans↗
Staving off acute otitis media. When is prophylaxis with antibiotics desirable?
Acute otitis media affects most young children and is the condition for which children are most frequently treated with antibiotics. A pattern of recurrent acute ear infections develops in some children and is a source of frustration for parents and physicians. Recurrent episodes can exacerbate asthma or other underlying medical problems, and long-term effects can include chronic otitis media with permanent middle-ear injury and, possibly, delay in psychomotor and language development. Antibiotic prophylaxis can reduce the number of episodes of acute otitis media in children at high risk for recurrent infection. There is no perfect antibiotic to prevent acute otitis media. However, the risks associated with the drugs described in this article are low. Prophylaxis with antibiotics does not prevent all episodes of acute otitis media but can reduce the number of episodes by 50%.
Acute Disease↗