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PubMed1993

What is a reasonable orthopaedic surgical workload? An analysis of elective and trauma workloads using two different complexity scoring systems.

A 1-year prospective study of all surgical activity was undertaken by the Orthopaedic Unit using two weighting systems for operative complexity: the Intermediate Equivalent (IE) and the Operative Complexity Score (OCS). The objectives were to define the difference between caseload and workload, and to formulate a reasonable workload for an operating session and a reasonable annual workload for a consultant team. In both elective and trauma surgery the BUPA complex, major+ and major operations represented 50 per cent of the caseload but accounted for approximately 68 per cent of the workload. The BUPA minor and intermediate procedures representing the remaining 50 per cent of the caseload accounted for only 32 per cent of the workload. The number of hours required to undertake all the complex, major+ and major operations was approximately twice that required for the number of minor and intermediate procedures. Despite the marked variation in case mix, the workload achieved by the six teams in the same number of sessions was remarkably similar. On the basis of two consultant and one registrar elective lists per week, a total of 705 IEs (1795 OCS units) could be undertaken by each team in 1 year. An average of 458 IEs (1086 OCS units) of trauma surgery were undertaken by each team. Caseload is a poor performance indicator of surgical activity. This study supports the concept of 3.5-4.0 IEs as reasonable workload for an orthopaedic elective operating session, and 900 IEs (2200 OCS units) as a reasonable annual workload for an orthopaedic team.

England↗
PubMed1993

The explanatory role of events in causal and temporal reasoning in medicine.

The logic of time and the way we reason about time is intrinsically connected with the way we reason about causality. In this paper, we focus our attention on some of the less obvious ways in which reasoning about time and causality interact. It is explained why in temporal reasoning a firm distinction has to be made between the ontology, i.e., what happens, and the way we describe the ontology. Temporal events need to be redescribed in such a way that they causally explain why some of the events are followed by the others. While building a temporal/causal theory, certain events may be omitted, not because they do not play a causal role, but because they do not play an explanatory role. In doing so, it is possible to eliminate the distinction between theories representing time as dense, and theories that represent time as discrete.

Causality↗
PubMedDate not supplied

Reasons for placement, replacement, and age of gold restorations in selected practices.

A total of 745 gold restorations were surveyed concerning the reasons for their placement and replacement. Cast gold restorations (n = 480) were placed due to primary caries (23%), replacement of amalgam (39%), and composite restorations (9%), or due to failure of existing gold restorations (29%). The main reasons for replacement of cast gold restorations were fracture of tooth (36%) and secondary caries (22%). The main reasons for the placement of compacted gold restorations (n = 265) were treatment of primary caries (40%), failure of an existing compacted gold restoration (26%), removal of another type of restoration (18%), and repair of a defective margin of a casting (16%). The main reasons for replacement of compacted gold restorations were inclusion into larger restorations (29%) and secondary caries (21%). The longevity of failed gold restorations was recorded for 111 restorations. The mean age for failed cast and compacted gold restorations was about 18.5 years (range 5-41 years). The ages of 2564 gold restorations in situ, 1689 castings, and 875 compacted gold restorations were recorded. The median and mean ages for gold castings were about 15 and 16 years and for compacted gold restorations about 17 and 18 years.

Dental Restoration, Permanent↗
PubMed1995

Reasons for caregiving in African American families.

The researcher conducted in-depth focused interviews with 17 African American caregivers for older, ill relatives regarding their reasons for caregiving. Reasons for caregiving were identified and categorized as familial (duty, maintaining extended family integrity, role modeling), relational (reciprocity, affection, respect), and personal (beliefs, values, attitudes). All of the participants noted the importance of religious beliefs and the value of caring for one's own as reasons for assuming the caregiving role. The findings suggest that understanding the reasons for caregiving may influence caregiving experiences and outcomes.

Adult↗
PubMed1996

Moral reasoning and malpractice. A pilot study of orthopedic surgeons.

The relationship between moral reasoning and malpractice claims was studied in 53 orthopedic surgeons. Levels of moral reasoning were defined by the percentage of principled responses (P-score) on Rest's Defining Issues Test, while annualized rates of malpractice claims were computed on the basis of data from a regional, physician-owned, interindemnity/liability protection trust. Orthopedic surgeons with fewer than 0.20 claims per year demonstrated significantly (P = 0.04) higher levels of moral reasoning (mean P-score of 43.8) than did those with claims rates higher than 0.40 claims per year (mean P-score of 38.0). Only 1 of 13 orthopedists with P-scores over 50 was found in the higher claims group, suggesting that high levels of moral reasoning may provide a protective element against malpractice claims.

Ethics, Medical↗
PubMed1996

[Use of contraception and reasons for choosing abortion among abortion applicants].

The object of this study was to describe a group of women applying for legal abortion in relation to their use of contraception and reasons for choosing an abortion. During a period of 13 months (1991-92) a questionnaire was distributed to women applying for legal abortion at Hillerød Hospital in Denmark. Three hundred and thirty-nine women participated. Fifty-nine percent of the women had become pregnant although they had used contraception. As seen in other studies, women still state demographic factors as their most important reasons for choosing an abortion. Women with two or more children do not want to have more children. Single women do not want children without being in a stable relationship. Furthermore occupation and education were frequently stated as important reasons for having an abortion. Economy and housing were not main reasons but contributory factors. Thirty percent of the women expressed ambivalence about the choice of abortion at the time when the abort was due.

Abortion Applicants↗
PubMed1996

Patient satisfaction with a levonorgestrel-releasing contraceptive implant. Reasons for and patterns of removal.

OBJECTIVE: To investigate the experience of the users of a levonorgestrel-releasing contraceptive implant (Nor-plant) and reasons for early removal. STUDY DESIGN: Two hundred fifty-one women who had Norplant placed through the Ohio State University Department of Obstetrics and Gynecology were sent a questionnaire that included general demographic questions and questions regarding preplacement education; reasons for choosing Norplant; problems experienced due to Norplant; reasons for removal, if applicable; and overall satisfaction. RESULTS: One hundred eleven questionnaires (44%) were completed and analyzed. Twenty-four (21.6%) of patients had Norplant removed, 32 (28.8%) planned on early removal, and 55 (49.5%) desired continued use. Ninety-eight percent of women who planned continued use of Norplant had received reading material as part of their preplacement counseling and 95% felt adequately counseled. This is significantly higher than women who had Norplant removed or planned on early removal. Convenience, problems with other contraceptive methods and effectiveness were the most important reasons why patients chose Norplant. Menstrual changes were the most common side effect, experienced by 80% of all women in the study. Weight gain, headache, mood changes, mastalgia and acne were also frequently reported. Women who had Norplant removed were significantly more likely to have experienced dizziness when compared to women desiring continued use. Women planning early removal were also more likely to have experienced dizziness in addition to acne, headache, hair loss and other side effects. Menstrual irregularities, followed by mood changes and headaches, were the most important side effects associated with early Norplant removal. Overall, 68% of users were at least somewhat satisfied with Norplant. CONCLUSION: Norplant contraception was a satisfactory form of birth control for the majority of patients in the study despite the frequent occurrence of side effects. Reading material regarding benefits and side effects of Norplant is an important aspect of patient counseling and may improve long-term use of Norplant.

Adolescent↗
PubMed1996

[Frequency of utilization and reasons for exclusion from thrombolytic therapy in patients with acute myocardial infarction in Salvador-Bahia].

PURPOSE: To determine the rate of utilization and reasons for exclusion from thrombolytic therapy in acute myocardial infarction (AMI) in the setting of Intensive Care Unit (ICU) Salvador-BA. METHODS: Retrospective cohort study recording patients admitted with suspected AMI in six ICU in Salvador-BA between January/93 and December/94 were reviewed. RESULTS: Three hundred and eighty-eight of confirmed cases of AMI were analysed, 165 (42.0%) were admitted at public hospitals and 225 (58.0%) at private hospitals. Thrombolytic therapy was indicated in 143 (36.8%) patients. The thrombolysis was more frequently performed in men (PR = 1.96 IC 95% 1.39-2.77), in patients less than 60 years of age (PR = 4.46 CI 95% 2.17-9.19) and in those with Killip class I (PR = 2.62 CI 95% 1.60-4.31). The major reasons for excluding from thrombolytic therapy were late arrival, old age and lack of ST elevation. Thirty three percent of patients were excluded for more than one reasons. Multivariate analysis showed that female gender was associated with a reduced indication for thrombolytic therapy, independent of the clinical findings on admission. CONCLUSION: The frequency of the use and reasons for excluding patients from thrombolytic therapy in AMI in Salvador-BA were similar to those of other clinical studies. The recent recommendations of the Thrombolysis Brazilian Consensus will enhance the utilization of this therapy, as it expands its utilization to elderly patients and to those who arrive late to the hospital.

Age Factors↗
PubMed1997

The clinical reasoning case study: a powerful teaching tool.

This article describes the limitations of typical published case studies with respect to their congruence with actual clinical practice and their utility in teaching clinical decision making to novice or student health care providers. The authors propose a Clinical Reasoning Case Study that closely resembles an actual patient encounter, yet is also a rigorous academic exercise. In which health care providers must think aloud as the encounter unfolds. The Clinical Reasoning Case Study explicates and substantiates health care providers' thought processes underlying each decision to collect objective and subjective data. Other unique characteristics of this case study include a discussion of the working diagnosis and the provider's relative certainty about that decision; selection of the single most important objective and subjective finding that led to the diagnosis; a chronological list of diagnostic hypotheses that were generated throughout the patient encounter; and an analysis of costs, including the office visit, diagnostic tests, medications, and treatments. The Clinical Reasoning Case Study is a powerful tool for teaching and evaluating the clinical reasoning process. Two sample case studies are provided: "A Child with a Heart Murmur" and "An infant with Diaper Rash."

Clinical Competence↗
PubMedDate not supplied

[Reasons for anxiety in primary care professionals. A resident-tutor comparison].

OBJECTIVES: 1) To find the reasons for PC professionals' anxiety when going about their normal work. 2) To check whether training and experience affect the assessment of the reasons of Family Doctors for anxiety. DESIGN: A descriptive study using a questionnaire. SETTING: PC health centres with second-year family and community medicine (FCM) residents from the Murcia Teaching Unit. PARTICIPANTS: All second-year FCM residents from the Teaching Unit (28) in December 1995 and their tutors. MEASUREMENTS: Open questionnaire based on three points: Causes of anxiety in on-demand consultations; causes of anxiety in scheduled consultations; other reasons for anxiety connected with the Health Centre. RESULTS: The three most anxiety-producing causes in relation to each question were: a) on-demand consultation: residents (R)--unfinishable consultations, lack of time, clinical problems; tutors (T)--unfinishable consultations, a lot of patients waiting outside, manipulative patients. b) Scheduled consultation: R--clinical problems, consultation too long, difficulties in reaching a solution; T--consultation too long, patients without an appointment and interruptions in the middle of the consultation. c) Other reasons for anxiety: R--not being off the day after being on call, having to do research work, and emergency calls; T--emergency calls, research work and temperature problems. CONCLUSIONS: Clinical problems are the causes of anxiety with the greatest difference between tutors and residents. Regulated training in the health centre and professional experience seem to act positively on some of the causes of anxiety.

Anxiety↗
PubMed1997

[Reasons for chronic sputum culture positive tuberculosis--evaluation based on personal experience].

It is commonly believed that chronic sputum positivity in treated pulmonary tuberculosis is caused by the patients' noncompliance. We have undertaken retrospective analysis of the records of 59 patients to verify reasons of treatment failure. The group consisted of 12 women and 47 men aged between 22 to 87 (median: 47) who were sputum culture positive from 1 to 12 years (x = 3.4). According to the retrospective analysis 44 patients showed more than one reason for treatment failure. In 36 cases improper therapy was responsible for treatment failure involving insufficient number of drugs in 28 cases, untimely termination of treatment in 14 cases, inadequate drugs in 11 cases, poor control of treatment in 5 cases and insufficient doses of drugs in 1 case. The patients' noncompliance was the main reason in 33 cases, allergy and adverse reaction to drugs were the reasons of failure of the therapy in 21 cases. 18 patients (30.5%) showed primary drug resistance. The patients' records analysis revealed that the drug resistance rate was related to the duration of treatment. At the beginning every patient was resistant to 2 drugs on average while at the end of the treatment the number increased to 4. In spite of this only 31 patients (52.5%) received other than first line drugs.

Adult↗
PubMed1998

A study of reasons for an increase in acute respiratory tract infections reported by influenza sentinel practices in Germany.

The influenza sentinel and early warning system of the working group on influenza (AGI) comprises more than 600 general practitioners and paediatricians nationwide. The observations made by national influenza monitoring systems rely on parameters that differ between countries. The definition of the numerators and denominators used depends to an important extent on the national health care systems, and considerable differences between the national monitoring systems have to be expected. Consequently the validity and reliability of recorded data as well as the indicative value of certain observations have to be checked for each system. The reasons for an increase in acute respiratory infections relative to total practice contacts, as well as the number of persons who are unable to work, were investigated by telephone interviews with the reporting physicians. Reasons for such increases given by the physician included increases in morbidity in the population but to a considerable extent "organisational" reasons, not linked to an increase in morbidity were identified. Many of those "organisational" reasons seemed to be relevant in health care systems that allow the patients a free choice of the contacted physician. The telephone interview was helpful for interpretation of the data and the detection of primary local outbreaks.

Acute Disease↗
PubMed1998

Consultations at central hospitals: reasons and outcome of referrals from urban clinics in Bulawayo, Zimbabwe.

OBJECTIVE: To quantify the main reasons for referral from urban primary health care clinics to central hospitals and to assess the outcome of such referrals in Bulawayo. DESIGN: Descriptive cross sectional study. SETTING: Mpilo Central Hospital, a quaternary level hospital and referral centre for urban clinics. SUBJECTS: 914 patients referred by urban clinics who attended the hospital in April and May 1995. MAIN OUTCOME MEASURES: Frequency of referrals by referrer, reasons for referral, outcome of referrals, diagnosis of admitted referrals. RESULTS: Of 914 referrals studied, 863 (94%) were made by registered general nurses and 51 (6%) by medical officers. Four hundred and forty four (49%) referrals made by registered general nurses were for doctors to establish the diagnosis, and 341 (37%) were for treatment or operation. The other referrals were for specialists to take over management, for advice on management and referral back to the clinic, and for the hospital to carry out specific tests. Of all referrals, 844 (92%) were consulted by generalist medical officers (GMOs), and only 70 (8%) by specialists. A total of 148 (16%) patients were admitted. Of these, 84 (57%) were females and 47% of admissions were aged 15 years or more. Nine (18%) of 51 referrals made by medical officers were admitted compared to 139 (16%) of 863 by registered general nurses. The rate of admission was not different by referrer (p = 0.7). CONCLUSIONS: The main reasons for referral from urban clinics to central hospitals are for doctors to either establish the diagnosis or provide treatment. There is scope for reducing the number of referrals made primarily for these reasons if a secondary or tertiary level of care institution is availed to Bulawayo and/or if clinic operations are reorganized to make medical officers' advice more accessible to registered general nurses during working hours.

Adolescent↗
PubMed2025

Integrating expert knowledge into large language models improves performance for psychiatric reasoning and diagnosis.

BACKGROUND AND METHODS: The authors sought to evaluate the performance of common large language models (LLMs) in psychiatric diagnosis, and the impact of integrating expert-derived reasoning on their performance. Clinical case vignettes and associated diagnoses were retrieved from the DSM-5-TR Clinical Cases book. Diagnostic decision trees were retrieved from the DSM-5-TR Handbook of Differential Diagnosis and refined for LLM use. Three LLMs were prompted to provide diagnosis candidates for the vignettes either by directly prompting or using the decision trees. These candidates and diagnostic categories were compared against the correct diagnoses. The positive predictive value (PPV), sensitivity, and F1 statistic were used to measure performance. RESULTS: When directly prompted to predict diagnoses, the best LLM by F1 statistic (gpt-4o) had sensitivity of 76.7 % and PPV of 40.4 %. When making use of the refined decision trees, PPV was significantly increased (65.3 %) without a significant reduction in sensitivity (70.9 %). Across all experiments, the use of the decision trees statistically significantly increased the PPV, significantly increased the F1 statistic in 5/6 experiments, and significantly reduced sensitivity in 4/6 experiments. DISCUSSION: When used to predict psychiatric diagnoses from case vignettes, direct prompting of the LLMs yielded most true positive diagnoses but had significant overdiagnosis. Integrating expert-derived reasoning into the process using decision trees improved LLM performance (as measured by F1 statistic), primarily by suppressing overdiagnosis with a lower-magnitude negative impact on sensitivity. This suggests that the integration of clinical expert-derived reasoning could improve the performance of LLM-based tools in the behavioral health setting.

Humans↗
PubMed2005

Reasons for intentional weight loss, unintentional weight loss, and mortality in older men.

BACKGROUND: We have examined the relationship between intentional and unintentional weight loss and the reasons underlying intention to lose weight and all-cause mortality and mortality due to cardiovascular disease (CVD) and non-CVD causes in older men. METHODS: Prospective study of 4869 men aged 56 to 75 years drawn from general practices in 24 British towns, who in 1996 completed questionnaires about intentional and unintentional weight loss over the preceding 4 years and were followed up for a subsequent 7 years. RESULTS: Unintentional but not intentional weight loss was associated with a significant increase in risk of all-cause mortality compared with men who reported no weight change, even after adjustment for lifestyle characteristics and preexisting disease (adjusted relative risk [RR], 1.71; 95% confidence interval [CI], 1.33-2.19; and RR, 1.00; 95% CI, 0.91-1.10, respectively). Men who lost weight intentionally as a result of personal choice showed significant benefit in all-cause mortality (RR, 0.59; 95% CI, 0.34-1.00; P = .05), which was largely owing to a significant reduction in mortality from non-CVD causes (RR, 0.36; 95% CI, 0.15-0.87). The benefit in these men was most apparent in markedly overweight men (BMI [calculated as weight in kilograms divided by the square of height in meters] > or = 28) and in younger men (age < 65 years). Men who lost weight intentionally owing to ill health or physician's advice showed an increased risk of all-cause mortality (RR, 1.37; 95% CI, 0.96-1.94). No harm or benefit was seen for CVD mortality, irrespective of reasons for intentional weight loss. CONCLUSION: Intentional weight loss carried out for personal reasons is associated with a significant reduction in all-cause mortality in markedly overweight men, and the data suggest that the earlier the intervention, the greater the chance of benefit.

Age Factors↗
PubMed2005

Reasons for delay of surgical intervention in adult strabismus.

BACKGROUND: It has been our impression that adult patients with strabismus frequently delay surgical intervention. OBJECTIVES: To determine the length of time adult patients waited before undergoing strabismus surgery and to determine the reasons why these delays occurred. DESIGN, SETTING, AND PARTICIPANTS: Prospective survey of consecutive patients who delayed strabismus surgery for more than 1 year. INTERVENTION: Preoperative survey. MAIN OUTCOME MEASURES: The primary outcome measure was time between the onset of strabismus and surgery and the reason why surgery had not been previously sought. RESULTS: The mean age among 128 study participants was 45.7 years (age range, 18-86 years). The mean time between the onset of current strabismus and surgery was 19.9 years (range, 1-72 years). The major reasons for delay in seeking surgical treatment included the following: surgery was never offered by eye care specialist (35 patients [27%]), surgery was offered but declined by the patient (29 patients [23%]), the patient had received prior satisfactory nonsurgical care (17 patients [13%]), the patient had never sought care (14 patients [11%]), the patient had a previous poor surgical experience (8 patients [6%]), and the patient had been told by their eye specialist that nothing could be done or that surgery could make them worse (8 patients [6%]). CONCLUSIONS: Strabismus surgery is often delayed for many years in adult patients who could potentially benefit from it. Almost half of such delays could be avoided by better education of the lay public and the medical community.

Adolescent↗
PubMed1993

Immunization status and reasons for immunization delay among children using public health immunization clinics.

OBJECTIVES: To determine whether children attending our local health department clinics were being immunized in a timely manner, and to investigate the reasons for children not being immunized on schedule. DESIGN: Cross-sectional research design. SETTING: Five Salt Lake City/County Health Department immunization clinics in Utah. PARTICIPANTS: All patients presenting to the clinics for immunization from November 1990 to March 1991 when minor illness is prevalent. INTERVENTIONS: Data were gathered through interview and questionnaire. MEASUREMENTS/MAIN RESULTS: Children were mostly white; they came from two-parent households with reasonably high incomes and high parental education level. Only four children were denied vaccination, all for inappropriate timing. None were denied for illness. More than 75% had postponed bringing their children in for immunization. The most common reason given for delay was minor illness in the child. CONCLUSION: Even in this "low-risk" population, parental misperception regarding immunizations is a significant, contributing factor to low immunization rates. Public educational programs directed at increasing parental knowledge must be developed.

Child, Preschool↗
PubMed1989

The reasons for failure in parathyroid operations.

Primary hyperparathyroidism occurs in about 1 in every 700 individuals. We analyzed our experience with 81 patients with persistent or recurrent hyperparathyroidism who were treated at the University of California, San Francisco, and the Veterans Administration Medical Center, San Francisco, from January 1979 through September 1988. In the 89 reoperations performed, the following six reasons or combination of reasons were responsible for the failed initial operation: (1) in 50 patients, there were multiple abnormal glands (30 hyperplastic and 20 second adenoma); (2) in 40 patients, the tumor was located in an ectopic position (22 mediastinal, 9 deep-seated cervical, 7 intrathyroidal, and 2 undescended); (3) in 17 patients, there were supernumerary parathyroid glands; (4) in 12 patients, the abnormal parathyroid glands were found in normal locations and the tumors were missed because of surgeon inexperience; (5) in 4 patients, failure was due to metastatic parathyroid cancer; and (6) in 4 patients, failure was due to errors on frozen section examinations. Preoperative localization studies usually identified the abnormal parathyroid tumor(s) prior to reoperations and were helpful in these patients. Knowledge of the reasons for failed parathyroid operations and the usual and unusual sites where parathyroid tumors are situated as well as a complete exploration should decrease the frequency of failed parathyroid operations. Localization studies are helpful for identifying these often elusive tumors.

Choristoma↗