Search PubMed⌕ Search

Biomedical subjects

J G Elmore

Publications and source records attributed to J G Elmore.

36 records · Page 2Linked to original sources
PubMed1997

The impact of clinical history on mammographic interpretations.

OBJECTIVE: To determine whether mammographic interpretations are biased by the patient's clinical history. DESIGN: On 2 occasions, separated by a 5-month wash-out period, 10 radiologists read mammograms for the same 100 women, randomly divided into 2 groups of 50. For 1 group, the clinical history was supplied for the first reading and omitted (except for age) for the second reading. This sequence was reversed in the other group. In addition, 5 cases were shown a third time with a deliberately leading sham history. PATIENTS: Selected with stratified random sampling from 3 categories of diagnostic findings (64 had mammographic abnormalities) and from the definitive designation of breast cancer or no breast cancer (18 had breast cancer). MAIN OUTCOME MEASURES: Radiologists' diagnostic accuracy and directional changes in interpretations and recommendations between the 2 readings. RESULTS: The direction suggested by the history led to small but consistent changes in the interpretations. Overall diagnostic accuracy was not altered, but recommendations were affected for appropriate further diagnostic workup: an alerting history (eg, breast symptoms or family history of breast cancer) increased the number of workups recommended in patients without cancer (P=.01); and a nonalerting history led to fewer recommended workups in the cancer patients (P=.02). The direction of the sham histories led an average of 4 of the 10 radiologists to change previous diagnoses and an average of 1 radiologist to change a previous biopsy recommendation. CONCLUSIONS: Knowledge of the clinical history may alter a radiologist's level of diagnostic suspicion without improving performance in either diagnosis or management recommendations.

Adult↗
PubMed1996

Acute meningitis with a negative Gram's stain: clinical and management outcomes in 171 episodes.

PURPOSE: To characterize the diagnostic spectrum and physician management decisions of patients presenting to an emergency department with an acute, community-acquired illness, cerebrospinal fluid (CSF) white blood cell count > 5/mm3, and a negative Gram's stain for bacteria. PATIENTS AND METHODS: In this retrospective cohort study over a 2-year period, symptoms, examination findings, paraclinical data, physician management, and clinical outcomes were assessed for each patient. RESULTS: One hundred sixty-eight patients (171 patient episodes) were evaluated. Almost half of the cohort presented in nonsummer months (48%); 20% of concurrent comorbid disease, and 15% had identified immunocompromising conditions. The reported examination findings were diverse, with diverse, with fever [49%] and neck stiffness [39%] being the most frequent findings. The majority were hospitalized (70%), with a median stay of 4 days. Approximately one half underwent computed tomography or magnetic resonance imaging (49%), and received empiric treatment with antibiotics (52%). A diagnostic cause was established in 23%, with the majority being inherently treatable diseases (including syphilis, bacteremia, Lyme disease). Variables significantly associated with a subsequent proven diagnostic cause included: age > 60 years; presence of comorbid disease (especially immunodeficiency); and presentation in winter months. CONCLUSIONS: A large proportion of patients presenting with acute meningitis and a negative CSF Gram's stain undergo hospitalization, noninvasive cranial imaging, and receive empiric antibiotic therapy. Better clinical guidelines are needed to identify the diagnostic and management decisions that benefit patient outcome.

Acute Disease↗
PubMed1996

The evolving clinical status of patients after a myocardial infarction: the importance of post-hospital data for mortality prediction.

Studies predicting mortality after myocardial infarction (MI) usually rely on in-hospital data, and combine patients admitted for the first MI with recurrent MI patients. Since treatment decisions are often made or modified at the first outpatient clinic visit, this study was designed to evaluate the importance of post-hospital data on mortality prediction after a first myocardial infarction (MI). An inception cohort of patients enrolled in the Beta-Blocker in Heart Attack Trial (n = 2830) was included. Forty-three variables (including in-hospital and post-hospital data) were evaluated using stepwise logistic regression. Ten variables were independently associated with 1-year mortality: five used in-hospital data (history of hypertension, hypercholesterolemia, congestive heart failure [CHF], ventricular tachycardia, and age); and five variables depended on post-hospital data collected at the first outpatient visit (CHF after discharge, New York Heart Association functional class, heart rate, pulmonary rates, and smoking). Two predictive systems were developed that partitioned patients into one of four classes with distinct mortality risks: a composite system using the 10 in- and post-hospital variables, and a system using only the 5 in-hospital variables. Mortality risk for the composite system classes ranged from 0.6 to 20.0% (I [n = 861], 0.6%; II [n = 1151], 2.3%; III [n =698], 4.3%; IV [n = 120], 20.0%). In contrast, the range of mortality risk using the in-hospital data only system was less (1 to 8.3%). Most importantly, a distinct gradient within each class of the in-hospital data only system was created by the addition of the post-hospital data. This study demonstrates that risk stratification after an acute first MI is improved by the addition of post-hospital data.

Adult↗
PubMed1996

Diagnostic bias in clinical decision making: an example of L-tryptophan and the diagnosis of eosinophilia-myalgia syndrome.

OBJECTIVE: Eosinophilia-myalgia syndrome (EMS) has been defined as the clinical presentation of eosinophilia, severe myalgia, and the exclusion of other infectious/malignant illnesses. Since the case definition does not require exposure to L-tryptophan (LT), diagnostic bias would occur if a physician's decision to diagnose EMS were influenced by knowledge of LT use. METHODS: A random sample of 813 physicians practising in the United States and Canada was obtained. Physicians were asked to provide diagnoses for 6 case vignettes having diverse resemblances to EMS. Six weeks later, participants were asked to provide diagnoses for a complementary series of cases described in identical text except for different data regarding LT use. RESULTS: Physicians who responded (N = 227, 28%) were more likely to diagnose EMS when LT exposure was present compared to the same case without LT use. In the most striking difference, EMS was diagnosed by 48% of physicians when the case was described in a man using LT, but by only 8% of physicians for the same case without LT use. The McNemar bias ratios, which compare responses provided by physicians completing both series, ranged from 0.65 to 1.0. CONCLUSION: These data indicate that the diagnosis of EMS may be biased by knowledge of LT. By showing the presence of diagnostic bias in clinical decision making, we suggest an important methodological problem that may arise in both clinical and research settings.

Eosinophilia-Myalgia Syndrome↗
PubMed1995

Oral cancer and mouthwash use: evaluation of the epidemiologic evidence.

BACKGROUND: An association between mouthwash use and cancer of the oropharynx has been the focus of many epidemiologic studies. PURPOSE: To critically review the methodology of studies of this association. METHODS: Studies were identified through a computerized MEDLINE search of English-language publications from 1976 to 1994. Eligible studies were independently reviewed, and specific criteria were applied to assess issues in the design, analysis, and results of the studies. Methodologic criteria were used that define a case-control study of acceptable epidemiologic quality: (1) histologic confirmation of cancer; (2) use of incident cases; (3) population-based cases; (4) equal exclusions of controls; (5) population-based controls; (6) exposure to mouthwash use before the cancer diagnosis; and (7) adjustments or restrictions for tobacco, alcohol, or both. RESULTS: Seven case-control studies were identified. The odds ratios for these studies ranged from a protective effect (0.82 for any use of mouthwash) to an elevation in risk (2.5 at the highest exposure). Two studies had significant unadjusted odds ratios for the risk of oral cancer. Of the three studies with data on women adjusted for tobacco and alcohol use, one was statistically significant, and none of the three similar studies in men was significant (although one was close). The five studies with data on female nonsmokers, nondrinkers, or both had odds ratios ranging from 1.1 to 3.16 (only one study was significant at the p = 0.05 level), and the four studies with similar data on men were not significant. Two studies met only two of the methodologic criteria, three studies met three, one met four, and one met all seven. CONCLUSIONS: Few of the available studies on mouthwash use and risk of subsequent oropharynx cancer adhere to basic methodologic principles of case-control design. Neither the data for the overall association nor the analysis in patients without other clinical risk factors support a link between mouthwash use and oral cancer.

Female↗
PubMed1995

Continuing occurrence of eosinophilia myalgia syndrome in Canada.

Eosinophilia myalgia syndrome (EMS), was defined by the Centers for Disease Control (CDC) as eosinophilia > 1000 mm3 and incapacitating myalgia without infection or neoplasm. Studies suggested that use of L-tryptophan (L-T), was a risk factor. We conducted a pharmacoepidemiological survey in Canada where access to L-T is limited. Using the active surveillance method, a 100% sample of potentially involved specialists and a 15% sample of family physicians from Ontario and Quebec were surveyed regarding treatment of patients with severe myalgia within the past year. Follow-up amplified clinical and laboratory information. Overall response rates were 61.4%. Thirty-eight per cent of respondents reported at least one patient. Of 6423 patients assessed, 19 'definite' and 25 'possible' EMS cases were identified. Information from physicians did not suggest use of L-T in patients with definite or possible EMS. It was considered that the cases found an underestimate of the incidence of EMS. Its continuing occurrence in Canada brings causal interpretations of earlier studies into question.

Adult↗
PubMed1994

Variability in radiologists' interpretations of mammograms.

BACKGROUND: Despite the proved value of mammography in screening for breast cancer, its efficacy depends on radiologists' interpretations. The variability in such interpretations is not well understood. METHODS: Using a technique of stratified random sampling, we selected 150 mammograms obtained in 1987: 27 from women with histopathologically confirmed breast cancer and 123 from women with no evidence of breast cancer after three years of follow-up examinations. Ten radiologists, who were unaware of the diagnoses and research hypothesis, each interpreted the 150 mammograms. Disagreement was analyzed within pairs of the 10 radiologists, as well as for the group of 150 women as a whole. RESULTS: The diagnostic consistency between pairs of radiologists was moderate, with a median weighted percentage of agreement of 78 percent (weighted kappa, 0.47). The frequency of the radiologists' recommendations for an immediate workup ranged from 74 to 96 percent for mammograms from the women with cancer and from 11 to 65 percent for films from the women without cancer. A substantial disagreement in management recommendations--in which one radiologist recommended routine follow-up and another recommended a biopsy for the same patient--occurred in 3 percent of the pairwise comparisons but in 25 percent of the comparisons for the group of women as a whole. When two or more radiologists recommended a biopsy for the same patient, a disagreement in the stated location (right or left breast) occurred in 2 percent of the pairwise comparisons among the radiologists but in 9 percent of comparisons for the group of women as a whole. Because some disagreement was likely, given that 10 radiologists read each film, the pairwise comparison is a more conservative estimate of disagreement. CONCLUSIONS: Although mammography is of value in screening women for breast cancer, radiologists can differ, sometimes substantially, in their interpretations of mammograms and in their recommendations for management. Efforts to improve accuracy and reduce variability in interpretation may increase the effectiveness of mammography in detecting early breast cancers.

Breast Diseases↗
PubMed1994

Joseph Goldberger: an unsung hero of American clinical epidemiology.

Pellagra, a disease rarely seen in developed countries today, was common during the first half of this century in the United States. The disease was initially believed to be infectious, and severe "pellagraphobia" left many victims and their families ostracized. This paper calls attention to Joseph Goldberger, an American physician whose remarkable research helped correct the erroneous belief in an infectious cause for pellagra and led to the elimination of pellagra epidemics in the United States.

Epidemiology↗
PubMed1993

Technology assessment in diagnostic imaging. A proposal for a phased approach to evaluating radiology research.

RATIONALE AND OBJECTIVES: The authors propose an objective basis for critical evaluation of research trends and define and analyze a sample of radiology studies according to research phase. METHODS: A random sample of 146 original diagnostic studies from two radiology journals was categorized according to phase, modality, and design by three physician reviewers, collated with a microcomputer database, and analyzed using an SAS program. RESULTS: Phase 1 studies (technical evaluation) constituted 18.5% of publications: phase 2 (standardization and tissue characterization), 10.3%; phase 3 (spectrum of appearances), 40.4%; phase 4 (diagnostic efficacy), 21.2%; and phase 5 (clinical evaluation), 9.6%. Of 48 diagnostic efficacy studies, 42% were prospective (versus 35% for the total sample), 38% were controlled (median sample size, 53 [versus 30 for the total sample]). Only 27% of the 48 diagnostic efficacy studies were externally funded. Research in magnetic resonance imaging (MRI), which comprised 45% of all publications, was oriented toward phase 1 (32%) rather than phase 5 studies (0%). Phase 5 studies were the focus of 18% and 8% of ultrasound (US) and computed tomography (CT) studies, respectively. There were more prospective, controlled efficacy studies in US than in MRI or CT. CONCLUSIONS: Analyses of research trends will be facilitated by use of a standard taxonomy which adopts a modality-based, phased approach.

Diagnostic Imaging↗
PubMed1992

Problems of comorbidity in mortality after prostatectomy.

OBJECTIVE: In recent studies of patients with benign prostatic hyperplasia (BPH), men undergoing transurethral resection of the prostate (TURP) had higher long-term mortality than men undergoing open prostatectomy. We tested the hypothesis that the higher mortality for patients undergoing TURP could have occurred if these patients were older and sicker at the time of surgery than patients undergoing open prostatectomy. DESIGN AND SETTING: Retrospective cohort study at Yale-New Haven (Conn) Hospital. PATIENTS: Two hundred fifty-two men who underwent TURP or open prostatectomy from 1979 through 1981 for the treatment of BPH. MAIN OUTCOME MEASURES: Five-year mortality adjusted for age and severity of comorbid illness at the time of surgery. RESULTS: The crude 5-year mortality rates were 17.5% (22 of 126 patients) for the TURP group and 13.5% (17 of 126 patients) for the open group. At the time of surgery, however, patients in the TURP group were sicker and older than patients in the open group. As the detail and quality of the assessment of comorbidity increased, the adjusted risk of TURP decreased. Improved classifications of comorbidity in three different forms of statistical analysis did not show an effect of type of prostatectomy on long-term mortality (Mantel-Haenszel relative risk, 1.03; 95% confidence interval, 0.57 to 1.87). CONCLUSIONS: These results suggest that TURP does not increase long-term mortality after surgery for the treatment of BPH. Inadequate accounting for severity of illness may also affect other statistical "adjustments" used in research concerned with patient outcomes.

Age Factors↗