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PubMed2000

Acceptance of voluntary HIV testing and the prevalence of HIV infection in women with cervical neoplasia in Toronto.

Over a 13-month period (1998-99), 661 adult women under the age of 50 years with a diagnosis of high grade squamous intraepithelial lesions (HSIL) or invasive cervical cancer in the previous 5 years and who were unaware of their HIV status were approached to participate in this study. After pretest counseling, patients completed a short questionnaire about risk factors for HIV infection, had blood samples drawn for HIV testing,and arranged a follow-up appointment for test results and post-test counseling. The acceptance rate for HIV testing was 73% (N = 432 with HSIL and N = 51 with invasive cervical cancer). Most women reported heterosexual intercourse as their only risk factor for HIV infection, with the majority (95.1%) reporting more than one lifetime sexual partner. Women who declined participation were significantly older (P < 0.01) than participants and nonwhites were more likely to decline (P < 0.001). None of the study participants had positive HIV test results (0/483; 95% CI, 0.00-0.009). Although HIV testing was accepted by most women following pretest counseling, there were no women who tested HIV-positive who were previously unaware of their status. Consequently we do not recommend routine HIV testing in this population.

Journal Article↗
PubMed1998

Improving primary care residents' proficiency in the diagnosis of skin cancer.

OBJECTIVE: To determine whether a brief, multicomponent intervention could improve the skin cancer diagnosis and evaluation planning performance of primary care residents to a level equivalent to that of dermatologists. PARTICIPANTS: Fifty-two primary care residents (26 in the control group and 26 in the intervention group) and 13 dermatologists completed a pretest and posttest. DESIGN: A randomized, controlled trial with pretest and posttest measurements of residents' ability to diagnose and make evaluation plans for lesions indicative of skin cancer. INTERVENTION: The intervention included face-to-face feedback sessions focusing on residents' performance deficiencies; an interactive seminar including slide presentations, case examples, and live demonstrations; and the Melanoma Prevention Kit including a booklet, magnifying tool, measuring tool, and skin color guide. MEASUREMENTS AND MAIN RESULTS: We compared the abilities of a control and an intervention group of primary care residents, and a group of dermatologists to diagnose and make evaluation plans for six categories of skin lesions including three types of skin cancer-malignant melanoma, squamous cell carcinoma, and basal cell carcinoma. At posttest, both the intervention and control group demonstrated improved performance, with the intervention group revealing significantly larger gains. The intervention group showed greater improvement than the control group across all six diagnostic categories (a gain of 13 percentage points vs 5, p < .05), and in evaluation planning for malignant melanoma (a gain of 46 percentage points vs 36, p < .05) and squamous cell carcinoma (a gain of 42 percentage points vs 21, p < .01). The intervention group performed as well as the dermatologists on five of the six skin cancer diagnosis and evaluation planning scores with the exception of the diagnosis of basal cell carcinoma. CONCLUSIONS: Primary care residents can diagnose and make evaluation plans for cancerous skin lesions, including malignant melanoma, at a level equivalent to that of dermatologists if they receive relevant, targeted education.

Clinical Competence↗
PubMed2002

Randomized double-blind parallel-group study comparing cognitive effects of a low-dose lamotrigine with valproate and placebo in healthy volunteers.

PURPOSE: This study aimed at investigating the cognitive and mood effects of lamotrigine (LTG) versus valproate (VPA) and placebo (PBO). METHODS: By studying the effects in healthy volunteers, it is possible to separate the genuine effects of LTG from the cognitive improvements, caused by better seizure control. The study used a pretest-posttest comparison of 50 mg LTG, 900 mg VPA, or PBO in a double-blind single-dummy parallel-group design with 30 healthy volunteers. Study duration was 12 days (with a last control on day 13). Outcome measures included cognitive tests (FePsy neuropsychological test battery), mood scales (ASL; mood-rating scale), and a scale for subjective complaints (ABNAS Neurotoxicity scale). Total sleep time was controlled with actigraphic recordings. The results were analyzed by comparing the change over time (pretest with posttest) for the three treatments with Student's t tests. RESULTS: COGNITIVE TESTS: significant differences between the treatments were found for measurements of cognitive activation (i.e., three of the four simple reaction-time measurements showed statistically significant differences in change between PBO and LTG in favor of LTG (p=0.03; 0.03; 0.04); two of four tests showed statistically significant differences in change between LTG and VPA, both in favor of LTG (p=0.03; 0.05). SUBJECTIVE COMPLAINTS: the ABNAS-neurotoxicity scale reveals a significant reduction of drug-related cognitive complaints for the subjects taking LTG, relative to VPA (p=0.02). MOOD RATING: significant changes were found on the scale assessing "tiredness," showing increased tiredness/sedation for VPA relative to PBO (p=0.02) and on the "timid scale" for LTG reporting "being more at ease" compared with both PBO and VPA (p=0.02; 0.02). The general direction of change for the mood scales was toward "activation" for LTG (five of six scales improved), whereas for VPA, the reverse effect was found (four of six scales showed a change in the direction of "tiredness/sedation"). CONCLUSIONS: Short-term treatment in normal volunteers with a low dose of LTG resulted in improved cognitive activation on simple reaction-time measurements, a more positive subjective report about the impact of drug treatment relative to VPA, and mood changes concurring with the activating effect demonstrated by the cognitive tests.

Adult↗
PubMed2003

Development and validation of an instrument to predict probability of home discharge from a geriatric convalescence unit in Spain.

OBJECTIVES: To develop and validate an instrument to predict probability of home discharge upon hospital admission. DESIGN: Prospective cohort study. SETTING: Geriatric convalescence unit (GCU) in Spain. PARTICIPANTS: Seven hundred eighty-one patients aged 65 and older consecutively admitted to a GCU over a 4-year period. The total sample was randomized and divided into two subgroups; the first (n = 575) was used to construct the predictive instrument (development subgroup) and the second (n = 206) for the validation process (validation subgroup). MEASUREMENTS: All patients were evaluated within the first 72 hours after admission. Age, sex, functional status before admission, diagnostic categories, functional status on admission, comorbidity, cognitive function, and social support were assessed. RESULTS: Logistic regression analysis identified three patient characteristics as independent predictors of home discharge in the development subgroup: higher scores on functional status at admission (Barthel index), normal Mini-Mental State Examination scores, and lower scores on Social Familial Evaluation Scale. A scoring system ranging from 0 to 5 was constructed using these variables to predict probability of home discharge (PHD). Different PHD scores (0-1, 2, 3, 4, and 5) identified patients with different probabilities of returning home on discharge in the validation subgroup (36.5%, 53.6%, 60.8%, 83.3%, and 100%, respectively). PHD scores of 4 and 5 demonstrated substantially higher posttest than pretest probability, with moderate and high clinical effect value. Scores of 0 or 1 demonstrated substantially lower posttest than pretest probability. CONCLUSION: A PHD instrument may be useful in identifying patients most likely to be discharged to home from the GCU. Patients with low probability of home discharge may also be identified early.

Aged↗
PubMed2002

Child safety seats: do doctors know enough?

The purpose of the study was to assess the knowledge of physicians in training about child safety seats and to test the effectiveness of a brief didactic session on improving that knowledge. Pre-post quasi experimental design was used. A 25-minute didactic session on the need for and appropriate use of child safety seats was presented. Subjects took a multiple-choice test before and immediately after the lecture. Tests were scored and baseline differences as well as differences in score improvements were analyzed by subgroup. Basic fund of knowledge was poor with a mean pretest score of 54%. Mean posttest score improved to 81.5% (P <.001). The only significant difference among groups was that pediatric residents had higher pretest scores (65%, P =.011), than their colleagues in other specialties. Medical students and residents in many specialties, including emergency medicine, have little baseline knowledge on the appropriate use of child safety seats. Knowledge can be improved with a brief didactic session.

Analysis of Variance↗
PubMed2002

Use of baseline ST-vector magnitude to identify electrocardiographic injury in patients with suspected acute myocardial infarction.

No information is currently available regarding optimal cut-off values of the ST-vector magnitude (ST-VM) for predicting acute myocardial infarction (AMI) in emergency department (ED) chest pain patients undergoing vectorcardiographic (VCG) monitoring. A prospective observational study was performed in 1,722 chest pain patients with suspected acute coronary syndrome and absence of bundle branch block (BBB) and left ventricular hypertrophy (LVH) on initial ECG who underwent continuous VCG ST-segment monitoring during the initial ED evaluation. Three cut-off values for baseline ST-VM are reported and represent the smallest values in which the positive likelihood ratio (+LR) for AMI is greater than 5, 10, and 20, respectively. AMI occurred in 158 of 1,722 patients (9.2%) without BBB or LVH on initial ECG. Optimal cut-off values at the predetermined +LR values of 5, 10, and 20, were 121 microV (sensitivity, 41.8%; specificity, 92.0%), 151 microV (sensitivity, 29.1%; specificity, 97.1%), and 175 microV (sensitivity, 25.9%; specificity, 98.7%), respectively. Combining the earlier-mentioned cut-off values with physician judgment of initial pretest probability (high, intermediate, or low, respectively) resulted in a relative increase in identification of injury of 37.5% as compared with the ED physician's interpretation of initial ECG (41.8% v 30.4%; P <.0001), and 65.2% as compared with the official ECG interpretation (41.8% v 25.3%; P <.0001). Increasing ST-VM results in increasing likelihood of AMI. Clinical studies need to be performed to determine if ST-VM cut-off values of 121, 151, and 175 microV in conjunction with physician pretest probability of AMI can be used as criterion for emergent reperfusion therapy in patients without LVH or BBB on the initial ECG.

Adult↗
PubMed2001

Training novice clinicians improves observation accuracy of the upper extremity after stroke.

OBJECTIVES: To determine whether training influenced the accuracy of observational kinematic assessment (OKA) of hemiplegic upper extremity impairment and to elucidate the contribution of knowledge of results to learning. DESIGN: Intervention study; before-after testing of OKA accuracy after training, using 2 trained groups (with knowledge of results, KR group; without, NKR group) and 1 control group with a 1-week retention test. SETTING: Tertiary teaching. PARTICIPANTS: Fifty-one first-year physical therapy student volunteers acted as observers. They were ranked on pretest accuracy and then randomized into groups. A consecutive sample of 11 stroke patients and 4 nondisabled subjects acted as performers. INTERVENTIONS: Performers were videotaped with 3 cameras and upper extremity kinematics derived using computer-assisted motion analysis. Training and test videotapes were generated. Training groups received video-based training of path indirectness accuracy on 4 occasions. The OKA accuracy of all observers' judgments of speed, jerkiness, and path indirectness were examined pretest and posttest. MAIN OUTCOME MEASURE: Accuracy reported as mean absolute error, which was calculated as difference between observers' judgments and criterion kinematic values. RESULTS: The KR and NKR groups showed reduction in mean absolute error after training of 34.8% and 6.2%, respectively. Improvements were retained after a 1-week no intervention period. Transfer to trained, but not untrained kinematic parameters occurred. The control group did not change. CONCLUSIONS: OKA accuracy is susceptible to training and knowledge of results aids learning. However, training is task specific.

Adult↗
PubMed1996

Intensive insulin therapy with insulin lispro in patients with type 1 diabetes reduces the frequency of hypoglycemic episodes.

In a randomized, open-label, controlled cross-over trial, 107 patients with type 1 diabetes were treated with either regular human insulin or insulin lispro, a rapid-acting insulin analogue. After a lead-in period of 2 to 4 weeks, the patients were randomized to receive intensified insulin treatment with one of the insulins. NPH-human insulin was used for basal substitution in both groups. The crossover took place after 3 months of treatment. Efficacy and safety of the drugs were established by the assessment of hemoglobin A1c, pretest blood glucose, 1 and 2-hour postprandial glucose excursions, number of hypoglycemic episodes, daily insulin doses, body weight, insulin antibodies, and the number and severity of adverse events. A questionnaire comprised of four primary domains was used to measure some quality of life aspects of the patients. Both treatment regimens were well tolerated. While no differences were seen in the hemoglobin A1c values, there was a trend for a decrease in the pretest blood glucose levels and significant decreases of the 1 and 2-hour postprandial glucose excursions in the patients treated with insulin lispro. The number of hypoglycemic episodes was also significantly lower in the insulin lispro treatment period. The evaluation of the quality of life questionnaire revealed an improvement in the patients treatment satisfaction for the insulin lispro group. During treatment with insulin lispro, the basal insulin doses increased slightly. However, the total daily insulin doses decreased to a greater extent with insulin lispro as compared to regular human insulin. Human insulin-specific antibody binding values at endpoint were not different for the two treatments. In conclusion, intensive insulin treatment with insulin lispro therapy results in improved postprandial glycemic control and HbA1c levels at least equal to the treatment with regular human insulin but with less hypoglycemia and more treatment satisfaction for the patient.

Adult↗
PubMed2001

[Comparison of Hannover Functional Ability Questionnaire (FFbH) and the SF-36 subscale "Physical Functioning"].

Pretesting of a questionnaire for evaluating day-patient rehabilitation, which included comparison of the "Hannover Functional Ability Questionnaire" (FFbH) and the SF-36 subscale "physical functioning" (SF-36 PF), gave rise to more extensive validity testing of the two instruments. In the framework of an expanded pretest, a questionnaire including FFbH and SF-36 PF was sent out to 520 adult former patients who had undergone inpatient orthopaedic rehabilitation following total hip or knee replacement an average 16 months ago. Return rate was 76%. Checks on plausibility showed no complaints about the Hannover Functional Ability Questionnaire while, on the SF-36 subscale, it was found that 16 of 374 patients (4.3%) had confused positive and negative ratings. Moreover, problems were found concerning the wording of several items (understanding, multidimensionality). In contrast to the FFbH, the SF-36 subscale shows weaknesses in the formulation of its items and particularly its ratings.

Adult↗
PubMed2002

[Reduction of excessive reactions after tuberculin skin test (mendel-mantoux method)].

In 2.5 % of cases excessive reaction with formation of blisters and local necrosis is seen after tuberculin skin testing with Mendel-Mantoux technique. The objective of this prospective study was to determine whether this rate can be reduced by pretesting. 426 contacts of cases with contagious pulmonary tuberculosis were examined in a public health office. A tuberculin skin test in Mendel-Mantoux technique with 1 unit purified tuberculin Behring (GT 1, bioequivalent to 0.5 units PPD-S) was applied and the results read after 3 to 7 days. Negative results were retested with 10 units (GT 10, bioequivalent to 5 units PPD-S). 422 patients completed the examination course as planned. In two cases forming of blisters was noticed. The difference between this observed rate of 0.5 % and the published rate of 2.5 % is highly significant. The alternative hypothesis that pretesting reduces the rate of excessive reactions can be assumed.

Blister↗
PubMed2003

Effects of oral creatine-pyruvate supplementation in cycling performance.

A double-blind study was performed to evaluate the effects of oral creatine-pyruvate administration on exercise performance in well-trained cyclists. Endurance and intermittent sprint performance were evaluated before (pretest) and after (posttest) one week of creatine-pyruvate intake (Cr(pyr), 2 x 3.5 g x d-1, n = 7) or placebo (PL, n = 7). Subjects first performed a 1-hour time trial during which the workload could be adjusted at 5-min intervals. Immediately they did five 10-sec sprints interspersed by 2-min rest intervals. Tests were performed on an individual race bicycle that was mounted on an ergometer. Steady-state power production on average was about 235-245 W, which corresponded to blood lactate concentrations of 4-5 mmol x l -1 and heart rate in the range of 160-170 beats x min -1. Power outputs as well as blood lactate levels and heart rates were similar between Cr(pyr) and PL at all times. Total work performed during the 1-h trial was 872 +/- 44 KJ in PL versus 891 +/- 51 KJ in CR pyr. During the intermittent sprint test power peaked at about 800-1000 watt within 2-3 sec, decreasing by 15-20 % towards the end of each sprint. Peak and mean power outputs were similar between groups at all times. Peak lactate concentrations after the final sprint were approximately 11 mmol x l -1 in both groups during both the pretest and the posttest. It is concluded that one week of creatine-pyruvate supplementation at a rate of 7 g x d -1 does not beneficially impact on either endurance capacity or intermittent sprint performance in cyclists.

Bicycling↗
PubMed2005

The role of qualitative D-dimer assays, clinical probability, and noninvasive imaging tests for the diagnosis of deep vein thrombosis and pulmonary embolism.

Recent advances in the management of patients with suspected venous thromboembolism have both improved diagnostic accuracy as well as made management algorithms safer and more accessible. It is now clear that determination of clinical probability prior to diagnostic testing will improve patient management. D-dimer testing can be employed to decrease the need for imaging tests. Patients at low risk with a negative qualitative D-dimer can avoid imaging tests. Imaging test interpretation benefits from consideration of pretest probability also as this helps clinicians determine when a test may be falsely negative or falsely positive. Diagnostic strategies should include pretest clinical probability, D-dimer assays, and noninvasive imaging tests.

Algorithms↗
PubMed1991

Piracetam in elderly motorists.

101 elderly motorists with reduced reaction capacity were examined under real traffic conditions with regard to their driving ability. They were given a daily dose of 4.8 g piracetam or placebo over a six-week period in a randomised double-blind study. The percentage of correctly solved sign-observance items, which reflects orientation and perception in real traffic conditions, increased in the placebo-treated test-group from 79.86% in the pretest to 80.07% in the retest, whereas the test subjects of the piracetam-treated group improved their performance from 77.08% to 84.16%. After being treated with piracetam for 6 weeks, the drivers showed a significantly better performance than the placebo-group. Of particular interest is the finding that the test-subjects who had scored less than 80% in the pretest improved without exception in the retest after treatment with piracetam.

Aged↗
PubMedDate not supplied

[Analysis of orthopedic specialty knowledge and comparison of 2 written test methods].

QUESTION: What about the knowledge of specific orthopaedic subjects in medical education as tested with mc-questions and open-ended questions? METHOD: 524 medical students were evaluated by a questionnaire survey to determine the state of orthopaedic knowledge in different periods of medical education. With the same questionnaire the use of two different types of written tests of knowledge (multiple choice questions and open-ended questions) has been tested and the results have been compared. The students participating in the orthopaedical practical (6th clinical semester) have been tested before and after the practical, given as pretest and posttest. RESULTS: The results show that the orthopaedic knowledge corresponds to the educational level so that during medical formation, there is a gradual knowledge gain. Comparison of the results of the pretest and the posttest reveals that the highest knowledge gain occurred during the orthopaedic practical. For all groups candidates performed better in mc-questions than in open-ended questions. Likewise in all groups, open-ended questions were found to be more difficult than the mc-questions. CONCLUSIONS: To summarize it may be concluded that there is a gradual orthopaedical knowledge gain during medical formation. It was found that students gain a considerable part of their technical knowledge during the practicals. Both mc-questions and open-ended questions are useful to measure this knowledge gain where there are hints that open-ended questions give a more accurate assessment of the actual knowledge. The pre- and posttest setting can provide both teachers and students with feedback regarding the realization and acquisition of instructional contents.

Curriculum↗
PubMed1977

Bayesian analysis of electrocardiographic exercise stress testing.

We evaluated the diagnostic accuracy of exercise-induced ST-segment depression in detecting coronary-artery disease by applying the likelihood-ratio formulation of Bayes's theorem to stress-test data, which were partitioned into half-millimeter ranges of depression. The graphic relation between the predictive value of a given test result and the pretest risk of disease in the test subjects was obtained for each of these half-millimeter intervals. This method reveals that the predictive value of testing depends on the degree of ST-segment depression, and that the pretest risk of coronary-artery disease is an important determinant of the predictive value of any test result in the individual patient. These findings suggest that the use of the terms "positive" and "negative" are inappropriate to describe most stress-test results. Instead, the results should be interpreted in terms of a continuum of risk based on the extent of ST-segment depression.

Adult↗
PubMed1979

Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease.

The diagnosis of coronary-artery disease has become increasingly complex. Many different results, obtained from tests with substantial imperfections, must be integrated into a diagnostic conclusion about the probability of disease in a given patient. To approach this problem in a practical manner, we reviewed the literature to estimate the pretest likelihood of disease (defined by age, sex and symptoms) and the sensitivity and specificity of four diagnostic tests: stress electrocardiography, cardiokymography, thallium scintigraphy and cardiac fluoroscopy. With this information, test results can be analyzed by use of Bayes' theorem of conditional probability. This approach has several advantages. It pools the diagnostic experience of many physicians ans integrates fundamental pretest clinical descriptors with many varying test results to summarize reproducibly and meaningfully the probability of angiographic coronary-artery disease. This approach also aids, but does not replace, the physician's judgment and may assit in decisions on cost effectiveness of tests.

Adult↗
PubMed1994

Absence of sex bias in the referral of patients for cardiac catheterization.

BACKGROUND: It has been suggested that women with clinical evidence of coronary artery disease are less often referred for cardiac catheterization than are men. To determine whether there is sex-related bias in referral for cardiac catheterization, we prospectively studied a cohort of 410 symptomatic outpatients (280 men and 130 women) who were being evaluated with exercise testing for possible-coronary artery disease. METHODS: Before the patients underwent exercise testing, 15 cardiologists from an academic medical center were asked to predict the probability that the patients they saw in the cardiology clinic would have angiographic evidence of any obstructive coronary disease (stenosis of 75 percent or more); the probability of severe coronary disease (three-vessel or left main coronary artery disease); the probability of left main coronary artery disease; and the probability of survival one, three, and five years after the evaluation. Similar predictions were generated by previously validated statistical models with use of data collected before exercise testing from the history, physical examination, and 12-lead electrocardiography with the patient at rest. RESULTS: Overall, women were referred for cardiac catheterization significantly less often than men (18 percent vs. 27 percent, P = 0.03). As compared with men, women had a significantly lower pretest probability of coronary disease (as estimated by their physicians) and a lower rate of positive exercise-test results. After accounting for differences in these two factors, sex was not an independent predictor of referral for catheterization. Comparing physicians' estimates of outcome with those generated by the statistical models revealed no evidence that the physicians were underestimating the risk of coronary disease in women. Furthermore, physicians' predictions did not underestimate the probability of any obstructive coronary disease in men and women who subsequently underwent catheterization. CONCLUSIONS: Academic cardiologists made appropriately lower pretest predictions of categories of disease in women with possible coronary artery disease than in men, and these assessments, along with women's lower rate of positive exercise tests, rather than bias based on sex, accounted for the lower rate of catheterization among women.

Aged↗
PubMed2002

Criteria for the safe use of D-dimer testing in emergency department patients with suspected pulmonary embolism: a multicenter US study.

STUDY OBJECTIVE: We derive a decision rule to partition emergency department patients with suspected pulmonary embolism (PE) into a small, high-risk group (>40% pretest probability) that is unsafe for D -dimer testing and a larger group that is safe to have PE ruled out with either a whole-blood D -dimer plus alveolar deadspace measurement or a quantitative D -dimer assay. METHODS: Nine hundred thirty-four patients with suspected PE were studied at 7 urban EDs in the United States. Patients were prospectively interviewed and examined for recognized symptoms, signs, and risk factors associated with PE. These data were collected before standard objective imaging for PE. Selected variables were analyzed by multivariate logistic analysis to determine factors associated with PE (P <.05). A decision rule was then constructed to categorize approximately 80% of ED patients as safe for D -dimer testing. RESULTS: Pretest prevalence of PE was 19.4% (181/934; 95% confidence interval [CI] 16.3% to 21.7%). Six variables found to be significant on multivariate analysis were used to construct the decision rule. Unsafe patients had either a shock index (heart rate/systolic blood pressure) more than 1.0 or age older than 50 years, together with any one of the following conditions: unexplained hypoxemia (SaO (2) <95%; no prior lung disease), unilateral leg swelling, recent major surgery, or hemoptysis. These criteria were met by 197 (21.0%) of 934 patients, and 83 of 197 (42.1%; 95% CI 35.3% to 49.6%) patients had PE. Exclusion of these 197 unsafe patients significantly decreased the probability of PE in the remaining 737 (79.0%) safe patients to 13.3% (95% CI 10.9% to 15.9%). CONCLUSION: Simple clinical criteria can permit safe D -dimer testing in the majority of ED patients with suspected PE. These criteria warrant prospective validation.

Adult↗