Investigating the Use of Telemedicine by Health Care Providers to Diagnose and Manage Patients With Musculoskeletal Disorders: Systematic Review and Meta-Analysis.

BACKGROUND: Access to care is a major challenge for patients with musculoskeletal disorders (MSKDs). Telemedicine is one of the solutions to improve access to care. However, initial remote diagnosis of MSKDs involves some challenges, such as the impossibility of touching the patient during the physical examination, which makes it more complex to obtain a valid diagnosis. No meta-analysis has been performed to date to synthesize evidence regarding the initial assessment including a physical evaluation using telemedicine to diagnose patients with MSKDs. OBJECTIVE: This study aims to appraise the evidence on diagnostic and treatment plan concordance between remote assessment using synchronous or asynchronous forms of telemedicine and usual in-person assessment for the initial evaluation of various MSKDs. METHODS: An electronic search was conducted up to August 2023 using terms related to telemedicine and assessment of MSKDs. Methodological quality of studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Random-effect model meta-analyses were performed. The Grading of Recommendations, Assessment, Development, and Evaluations framework was used to synthesize the quality and certainty of the evidence. RESULTS: A total of 23 concordance studies were eligible and included adult participants (N=1493) with various MSKDs. On the basis of high certainty, pooled κ and prevalence-adjusted and bias-adjusted κ for the diagnostic concordance between remote and in-person assessments of MSKDs were 0.80 (95% CI 0.72-0.89; 7 studies, 353 patients) and 0.83 (95% CI 0.76-0.89; 6 studies, 306 patients). On the basis of moderate certainty, pooled Gwet AC1 for treatment plan concordance between remote and in-person assessments of MSKDs was 0.90 (95% CI 0.80-0.99; 2 studies, 142 patients). CONCLUSIONS: The diagnostic concordance for MSKDs is good to very good. Treatment plan concordance is probably good to excellent. Studies evaluating the accuracy to detect red and yellow flags as well as the potential increase in associated health care resources use, such as imaging tests, are needed.

Chaperone in breast examination: a comprehensive systematic review of patient and clinician perspectives, and documentation.

BACKGROUND: The General Medical Council (GMC) has made it mandatory to have a chaperone present during intimate examinations, including breast exams, highlighting the importance of medicolegal protection for both patients and clinicians. AIMS: The use of chaperones during breast examinations is logical, especially in an increasingly litigious society. This review aims to summarize current information regarding patients' and clinicians' perspectives on chaperone use in breast examination. METHODS: A PRISMA-compliant search was conducted in electronic databases from inception until April 2023 for qualitative literature on patients' and clinicians' perspectives on chaperone use in breast examination. The inclusion criteria focused on studies related to breast examinations, excluding other intimate examinations. An inductive thematic analysis was performed in three domains: physician-associated factors, patient-associated factors, and chaperone documentation. RESULTS: Ten studies were included after screening 939 articles. For breast examination, the presence of male and older surgeons, nurse availability, rural settings, and patients' psychiatric comorbidities increased the likelihood of chaperone use during consultations. Medico-legal concerns were prominent for male physicians, while female physicians highlighted the need for technical support. Logistical issues were a common hindrance. The gender of physicians was important for patients, but there was conflicting evidence regarding patient preferences for chaperones and their purpose. Poor documentation was generally observed despite quality improvement projects. CONCLUSION: This study emphasizes the vital role of chaperones in clinical practice, urging a precise definition and targeted resolution for implementation challenges. Patient preferences highlight the need for a personalized approach, and increased awareness among healthcare professionals is essential.

Assessing the severity of carpal tunnel syndrome during physical examination by measuring two-point discrimination: Post-hoc analysis of prospectively collected data.

INTRODUCTION: Carpal tunnel syndrome (CTS) commonly presents after distal radius fractures. Assessing its degree of severity is essential to therapeutic decision-making - i.e. operative vs. conservative treatment. The role of the two-point discrimination (2PD) has not yet been evaluated as a potential indicator of severity during physical examination. Therefore, in our cross-sectional study, we aimed to find a correlation between 2PD values and disease severity, based on the gold-standard electromyography and electroneurography (EMG-ENG) and ultrasonography findings. METHODS: We conducted a post-hoc analysis of prospectively assessed CTS patients for 2PD values. We analyzed the correlation between 2PD and EMG-ENG measurement results, patient characteristics, nerve ultrasonography, and relevant CTS questionnaires. CTS severity was determined by EMG-ENG results. The Pearson correlation was calculated between variables. RESULTS: The study included 81 patients. The three pre-determined EMG-ENG severity categories showed a significant correlation between both 2PD values and 2PD severity categories (r= 0.29 [0.07-0.48] and r= 0.26 [0.03-0.45]). Distal sensory latency and conduction velocity values correlated significantly with 2PD categories. However, the correlation coefficients (r= 0.25 [0.02-0.46] and r=-0.24 [-0.37-0.07]) were low. The 2PD severity categories showed no significant correlation with the severity assessed by nerve ultrasound (r=-0.07 [-0.38-0.25]). The 2PD values showed a significant correlation between the values of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire (r= 0.3 [0.06-0.51]). We concluded that the best cut-off value for differentiating severe from non-severe CTS was at the 9.5 mm 2PD cut-off value (sensitivity = 0.65 [0.45-0.81], specificity = 0.71[0.58-0.82], AUC = 0.71 [0.59-0.83]). CONCLUSION: There is a significant correlation between 2PD values and the severity of carpal tunnel syndrome as determined by EMG-ENG; however, they are not interchangeable. Based on the results of our study, we propose that measuring two-point discrimination may be a quick and easy, reliable and cost-effective screening method to assess the severity of carpal tunnel syndrome following distal radius fractures.

Automated Extraction of Physical Examination Interactions in General Practice Consultations: A Multi-Modal Using Images and Text Base Approaches.

Teleconsultation, which proliferated during the COVID-19 pandemic, is projected to keep evolving in primary care; however, virtual physical examinations continue to hinder telehealth development. This study aimed to automatically recognise physical examinations performed during in-person GP consultations by text and image-based recognition. Text-based methods used regular expressions on transcript keywords to identify physical examinations, while image-based methods utilised transfer learning (fine-tuning the Resnet-18 model) to detect physical examination interactions.

Usefulness and safety of a wearable transcutaneous electrical nerve stimulation device for promoting exercise therapy in patients with chronic knee pain: A randomized controlled trial.

OBJECTIVE: To investigate the effect of transcutaneous electrical nerve stimulation (TENS) in reducing barriers to the implementation of exercise therapy and promoting exercise therapy, focusing on physical activity. DESIGN: A single, participant-blinded, randomized controlled trial (RCT) with a pre-post design SETTING: Single-institution, orthopedic clinic PARTICIPANTS: Participants had knee pain for at least 3 months (N=63, ≥50 years of age) and were randomly assigned to the TENS (N=21), exercise (N=23), or combined (N=19) group. INTERVENTIONS: Participants were provided with 4 weeks of intervention: the TENS group using a wearable TENS device, exercise group performing designated exercises, and combined group performing activities from the TENS and exercise groups. MAIN OUTCOME MEASURES: The primary outcome measure was physical activity (PA). The secondary outcome measures were 6-minute walk test (6MWT); timed up-and-go test (TUG); stair climbing; knee pain using the visual analog scale at 6MWT, TUG, and stair climbing; and patient-reported changes in knee pain over time. RESULTS: At pre- and post-intervention, light-intensity PA time (LPA) in the TENS, exercise, and combined groups was 735.62±68.82 vs. 714.21±73.06 (p=0.061), 733.05±103.90 vs. 700.31±90.33 (p=0.057), and 710.09±62.98 vs. 685.22±58.35 (p=0.049), respectively, with a significant decrease in the combined group. Significant improvement in knee pain and stair climbing was observed in all groups pre- and post-intervention. CONCLUSIONS: The group using TENS showed improved effects of early reduction in knee pain and when combined with exercise therapy, a reduction in time spent in light-intensity activities such as sedentary behavior. Thus, the use of TENS in combination with conventional exercise therapy has the potential to reduce psychological barriers to the introduction of exercise therapy. It also promotes and ensures the safe implementation and continuation of exercise therapy.

Neck or Shoulder? Establishing Consensus for Spine Screening in Patients with Shoulder Pain: an International Modified Delphi Study.

OBJECTIVE: There is no established consensus for screening the spine in patients with shoulder pain. The aim of this study was to explore the role of the spine in shoulder pain and generate a set of recommendations for assessing the potential involvement of the spine in patients with shoulder pain. METHODS: A modified Delphi study was conducted through use of an international shoulder physical therapist's expert panel. Three domains (clinical reasoning, history, physical examination) were evaluated using a Likert scale, with consensus defined as Aiken Validity Index ≥0.7. RESULTS: Twenty-two physical therapists participated. Consensus was reached on a total of 30 items: clinical reasoning (n = 9), history (n = 13), and physical examination (n = 8). The statement that spinal and shoulder disorders can coexist, sometimes influencing each other and at other times remaining independent issues, along with the concept of radiating pain as an explanatory phenomenon for the spine contribution to shoulder pain, achieved the highest degree of consensus. CONCLUSION: International physical therapists shoulder experts reached consensus on key aspects when screening the spine in people with shoulder pain, including consideration of the distal location of symptoms relative to the shoulder, the presence or previous history of neck pain, the changes in symptoms related to neck movements, and the presence of neuropathic-like symptoms. They also acknowledged the importance of assessing active cervical or cervicothoracic movements and the usefulness of the Spurling test and symptom modification techniques applied to the spine.

First metatarsophalangeal joint dorsiflexion resistance in individuals with plantar fasciopathy.

INTRODUCTION: Plantar fasciopathy is a common foot-related musculoskeletal disorder. It has been hypothesized that this disorder could be linked to a dysfunctional windlass mechanism. However, no study to date has quantified this link to validate or refute this hypothesis. The first metatarsophalangeal joint (1st MPJ) dorsiflexion resistance test is a reliable test to evaluate the force required to initiate the windlass mechanism. Comparing the results of this test in individuals with and without plantar fasciopathy will allow for a better understanding of the relationship between plantar fasciopathy and the windlass mechanism. Thus, this study aimed to compare 1st MPJ dorsiflexion resistance in individuals with plantar fasciopathy and healthy controls. Additionally, this study aimed to explore the correlations between 1st MPJ dorsiflexion resistance and other commonly used foot orthopedic tests, specifically the supination resistance test and the Foot Posture Index. MATERIAL AND METHODS: Twenty participants with plantar fasciopathy and 20 healthy controls were recruited in this case-control study. First MPJ dorsiflexion resistance was quantified and compared between groups and between feet using a repeated measures ANOVA with one within-subject factor with two levels and one between-subject factor with two levels. It was also correlated with supination resistance and the Foot Posture Index. RESULTS: There were no significant differences in 1st MPJ dorsiflexion resistance between injured and healthy feet as well as control and plantar fasciopathy groups. There was a moderate to strong correlation (r = 0.674 to 0.891) between 1st MPJ dorsiflexion resistance and supination resistance in both groups. There was no significant correlation between 1st MPJ dorsiflexion resistance and the Foot Posture Index. CONCLUSIONS: The lack of alterations in 1st MPJ dorsiflexion resistance among individuals with plantar fasciopathy implies a potential need to reconsider the biomechanical model, proposing that a dysfunctional windlass mechanism is associated with the development of plantar fasciopathy, may need reconsideration.

Development and validation of a risk prediction model for short-term progression of carotid atherosclerosis among early middle age adults.

AIM: We aimed at creating and validating a prognostic model incorporating easily accessible clinical and laboratory parameters to forecast the likelihood of short-term progression of carotid atherosclerosis. METHODS: A prediction model was developed and validated for carotid plaque progression within 2 years in an early middle-age population in China. Progression was defined as the new appearance of carotid plaque or stenosis among participants who had normal carotid status at baseline. Leveraging data from a health check-up chain, predictors were identified using statistical methods including stepwise logistic regression, Markov Chain Monte Carlo (MCMC) simulation, random forest analysis and least absolute shrinkage selection operator (Lasso). Model performance was assessed. Bootstrap internal validation, validation on another check-up population and subgroup analysis were also conducted. RESULTS: Among 7765 participants, predictors including age, diastolic blood pressure, uric acid levels, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were identified for carotid plaque progression in 2 years. The developed prediction model demonstrated good discrimination (AUC = 0.755, 95%CI:0.736-0.774) and calibration ability (slope = 0.922 and interception = 0.007) among development data, as well as among validation data (AUC = 0.759, 95%CI:0.674-0.770; slope = 1.076 and intercept = -0.014). Internal validation using bootstrap method yielded an adjusted AUC of 0.753. The model's performance remained consistent across different subgroups. CONCLUSIONS: Our study presents a validated risk prediction model for carotid plaque progression in an early middle age population, offering a valuable tool for early identification and monitoring of cardiovascular risks. The model's robustness and applicability across different subgroups highlight its potential utility in preemptive cerebrovascular and cardiovascular disease management.

Associations between Ultrasonographically Diagnosed Lung Lesions, Clinical Parameters and Treatment Frequency in Veal Calves in an Austrian Fattening Farm.

This study evaluated the significance and predictive value of ultrasonographic and physical examination on arrival at an Austrian fattening farm. Treatment frequency and average daily weight gain (ADG) were related to physical and ultrasonographic examination results. Additionally, the effect of an intranasal vaccination in half of the examined calves was studied. The clinical and ultrasonographic health status 600 calves was recorded at the beginning and end of fattening. Half of the calves received an intranasal vaccination (Bovalto® Respi Intranasal). Overall, 44.5% showed an abnormal respiratory scoring (RS) and 56.0% showed signs of respiratory diseases in transthoracic ultrasonography (TUS) at arrival on the farm. For both RS and TUS, a categorization between ILL and HEALTHY was conducted. Results showed lower ADG in ILL calves (RS median: 0.93 kg/d; TUS median: 0.96 kg/d) compared to HEALTHY calves (RS median: 1.01 kg/d; TUS median: 1.01 kg/d). The median ADG was lower in not treated and ILL calves (RS median 0.90 kg/d; TUS: 0.93 kg/d) compared to treated and ILL calves (RS median 1.01 kg/d; TUS: 1.02 kg/d). Vaccination did not affect growth performance or occurrence of ILL, though treatment frequency was lower in VAC calves (17.0% in NVAC; 11.3% in VAC). The implementation of examination protocols for respiratory diseases may have a positive impact on production parameters (e.g., treatment frequency and ADG).

Cervical and Thoracic Spine Mobility in Rotator Cuff Related Shoulder Pain: A Comparative Analysis with Asymptomatic Controls.

Rotator cuff related shoulder pain (RCRSP) is a prevalent clinical presentation characterized by substantial diagnostic uncertainty. Some of this uncertainty relates to the involvement of the cervical and thoracic spine as a source of or contributing factor to RCRSP. Thirty-two RCRSP cases and thirty-two asymptomatic controls (AC), recruited from Hospital La Paz-Carlos III between March 2023 and September 2023, were matched for age, gender and hand dominance. Assessed variables included cervical, thoracic range of motion (ROM) and neck disability index (NDI). Independent t-tests were used to compare each of these measurements and multiple linear regression was used to examine the capacity of neck or psychosocial variables to predict the variability of the NDI. The RCRSP group had significantly reduced cervical rotation [RCRSP (111.14 ± 22.98); AC (130.23 ± 21.20), d = 0.86, p < 0.01] and flexo-extension ROM [RCRSP (112.47 ± 2.07); AC (128.5 ± 17.85), d = 0.80, p < 0.01] as well as thoracic spine flexion [RCRSP (33.02 ± 1.14); AC (34.14 ± 1.01), d = 1.04, p < 0.01], extension [RCRSP (28.63 ± 0.89); AC (27.37 ± 0.89), d = -1.40, p < 0.01], right rotation [RCRSP (40.53 ± 10.39); AC (54.45 ± 9.75), d = 1.38, p < 0.01], left rotation [RCRSP (39.00 ± 11.26); AC (54.10 ± 10.51), d = 1.39, p < 0.01] and a significantly increased NDI score [RCRSP (17.56 ± 7.25); AC (2.47 ± 3.25), d = -2.69, p < 0.01]. The variables best explaining neck disability were central sensitization index and SF-12 total score (adjusted R2 = 0.75; p < 0.01). These results suggest that clinicians should assess cervical and thoracic spine mobility in patients with RCRSP.

Comparison of the modified Mallampati classification score versus the best visible Mallampati score in the prediction of difficult tracheal intubation: a single-centre prospective observational study.

PURPOSE: The modified Mallampati classification is part of the preoperative airway risk assessment. Inconsistency in the way it is examined may contribute to heterogeneity in its diagnostic performance. The best visible Mallampati score could reduce interobserver heterogeneity but its diagnostic characteristics remain unknown. METHODS: During preoperative anesthesia consultation of adult patients with a senior anesthesiologist, we compared the modified Mallampati classification score vs the best visible Mallampati score using cervical extension, tongue in, and phonation. The primary outcome was the diagnostic characteristic of the modified Mallampati classification score vs the best visible Mallampati score as predictors of difficult orotracheal intubation (more than two direct laryngoscopies or need for an alternate device). We performed a multivariable analysis to identify independent predictors of difficult orotracheal intubation in the tested cohort. RESULTS: Difficult orotracheal intubation occurred in 77/3,243 (2.4%) patients. A best visible Mallampati score was obtained in 1,596 (49.2%) patients. Sensitivity and specificity of the modified Mallampati classification score for predicting difficult orotracheal intubation were 0.56 (95% confidence interval [CI], 0.44 to 0.66) and 0.69 (95% CI, 0.68 to 0.71), respectively. By comparison, the best visible Mallampati score was less sensitive (difference, -0.30; 95% CI, -0.19 to -0.30; P < 0.001) but more specific (difference, 0.24; 95% CI, 0.22 to -0.25; P < 0.001). In patients with difficult orotracheal intubation, 53% were incorrectly reclassified as low risk by the best visible Mallampati score. CONCLUSION: Compared with the modified Mallampati classification score, the best visible Mallampati score decreased sensitivity for predicting difficult orotracheal intubation and falsely classified half of the patients with difficult orotracheal intubation. Taking the risks associated with difficult airways into account, our findings indicate that a careful examination of the modified Mallampati classification is required during the global preoperative airway examination. STUDY REGISTRATION: ClinicalTrials.gov ( NCT02788253 ); 9 February 2016.

RéSUMé: OBJECTIF: La classification de Mallampati modifiée fait partie de l'évaluation préopératoire des risques pour les voies aériennes. La disparité dans la façon dont elle est examinée peut contribuer à l'hétérogénéité de ses performances diagnostiques. Le meilleur score de Mallampati visible pourrait réduire l'hétérogénéité inter-observateurs, mais ses caractéristiques diagnostiques restent inconnues. MéTHODE: Lors de la consultation d'anesthésie préopératoire de patient·es adultes avec un·e anesthésiologiste senior, nous avons comparé le score de classification sur l'échelle de Mallampati modifiée vs le meilleur score de Mallampati visible en utilisant l'extension cervicale, la langue rentrée, et la phonation. Le critère d'évaluation principal était la caractéristique diagnostique du score modifié de classification de Mallampati vs le meilleur score de Mallampati visible comme prédicteurs d'une intubation orotrachéale difficile (plus de deux laryngoscopies directes ou nécessité d'un autre dispositif). Nous avons réalisé une analyse multivariée pour identifier les prédicteurs indépendants d'intubation orotrachéale difficile dans la cohorte testée. RéSULTATS: Une intubation orotrachéale difficile est survenue chez 77 patient·es sur 3243 (2,4 %). Le meilleur score de Mallampati visible a été obtenu chez 1596 patient·es (49,2 %). La sensibilité et la spécificité du score de classification de Mallampati modifié pour prédire l'intubation orotrachéale difficile étaient de 0,56 (intervalle de confiance [IC] à 95 %, 0,44 à 0,66) et 0,69 (IC 95 %, 0,68 à 0,71), respectivement. À titre de comparaison, le score de Mallampati le plus visible était moins sensible (différence, −0,30; IC 95 %, −0,19 à −0,30; P < 0,001) mais plus spécifique (différence, 0,24; IC 95 %, 0,22 à −0,25; P < 0,001). Chez les patient·es présentant une intubation orotrachéale difficile, 53 % ont été reclassé·es à tort comme à faible risque par le score de Mallampati le plus visible. CONCLUSION: Par rapport au score modifié de classification de Mallampati, le score de Mallampati le mieux visible a diminué la sensibilité pour prédire l'intubation orotrachéale difficile et a faussement classé la moitié des patient·es présentant une intubation orotrachéale difficile. En tenant compte des risques associés aux voies aériennes difficiles, nos résultats indiquent qu'un examen minutieux de la classification de Mallampati modifiée est nécessaire lors de l'examen préopératoire global des voies aériennes. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov ( NCT02788253 ); 9 février 2016.

Assessing Abdominal Examination Skills in a Surgery Clerkship Standardized Patient Encounter for Curriculum Improvement.

INTRODUCTION: Standardized patient (SP) encounters allow medical students to practice physical examination skills and clinical reasoning. SP cases are used for learning and assessment, but recorded encounters can also be valuable curriculum evaluation tools. We aimed to review SP encounters to improve abdominal examination skills and the broader physical examination curriculum. METHODS: We reviewed recorded SP encounters of third-year medical students on surgery clerkship rotation. Students examined a cisgender woman presenting with acute right lower abdominal pain. We observed abdominal examinations to determine which maneuvers were attempted and completed correctly. We then used these outcomes to develop targeted clerkship training for the subsequent student cohort. Our intervention targeted abdominal examination gaps by explaining how to integrate abdominal examination findings with a focused history for surgical patients. We evaluated the intervention's impact on abdominal examination skills with third-year medical students in comparison (2021-2022, n = 119) and intervention (2022-2023, n = 132) groups. RESULTS: In both the comparison and intervention groups, nearly all students attempted at least 1 general examination maneuver like auscultation, palpation, percussion, or rebound tenderness. Only 40% of students in the comparison group attempted an advanced maneuver like the Rovsing, Psoas, or Obturator sign. After the intervention, 75% of students in the intervention group attempted an advanced maneuver (χ2(1, 251) = 31.0, p < .001). Cohorts did not gain skills over time through the clerkship. Rebound tenderness was frequently assessed incorrectly by students in both groups, with many avoiding the right lower quadrant entirely. CONCLUSIONS: This project highlights how medical students struggle to utilize abdominal examination maneuvers and integrate findings. The results also showed that students did not consistently learn advanced examination skills either before or during clerkship rotation, which may be commonly assumed by clinical faculty. Finally, this work demonstrates how SP encounters can be used to evaluate and improve surgical education curriculum.

An online training and feedback module enhances the musculoskeletal examination performance of medical interns.

BACKGROUND: Pathologies of the locomotor system are frequent and can cause disability and impact the quality of life of the people affected. In recent years, online training and feedback have emerged as learning tools in many fields of medicine. OBJECTIVE: This study aims to evaluate medical interns' musculoskeletal examination performance after completing an online training and feedback module. METHODS: This study employed a quasi-experimental design. Medical interns were invited to complete a 4-week musculoskeletal physical examination training and feedback module via an e-learning platform. The course included written and audiovisual content pertaining to medical history, physical examination, and specific tests for the diagnosis of the most common knee, spine, shoulder, ankle, and foot conditions. Before and after completing the module, their ability to perform the physical examination was evaluated using an objective structured clinical examination (OSCE) with simulated patients that took place face-to-face. A control group of experts was assessed using the OSCE, and their performance was compared to that of the interns before and after the training. At the end of the module feedback on the OSCE was provided to participants through the platform asynchronously and two evaluation questions about the user experience were conducted at the end of the study. RESULTS: A total of 35 subjects were assessed using the OSCE, including 29 interns and 6 experts. At the beginning of the training module, the group of interns obtained an average score of 50.6 ± 15.1. At the end of the module, 18 interns retook the OSCE, and their performance increased significantly to an average of 76.6 ± 12.8 (p < 0.01). Prior to the training, the experts performed significantly better than the interns (71.2 vs. 50.6; p = 0.01). After the interns received the training and feedback, there were no significant differences between the two groups (71.2 vs. 76.6; p = 0.43). Two evaluation questions were conducted at the end of the study, revealing that 93% of the participants affirm that the training module will be useful in their clinical practice, and 100% of the participants would recommend the training module to a colleague. CONCLUSION: The online training and feedback module enhances the musculoskeletal examination performance of medical interns.

A case of Burkitt Lymphoma discovered by digital rectal exam.

Burkitt Lymphoma (BL) is an aggressive B-cell lymphoma predominantly encountered in pediatrics. Sporadic type typically involves the abdomen and/or pelvis. We present an 8-year-old Caucasian male with vomiting, weight loss, fatigue, and abdominal pain. An abdominal X-ray was unremarkable without any acute findings. Pediatric gastroenterology was consulted and recommended esophagogastroduodenoscopy and colonoscopy. A digital rectal exam (DRE) was performed, and a firm lesion was palpated. The colonoscopy was normal. Subsequent magnetic resonance imaging and computed tomography scans revealed a lesion in the left lower quadrant with mass-like processes involving the porta hepatis and encasing the left distal ureter. Tissue biopsy confirmed BL. The patient completed chemotherapy and achieved remission. This case highlights DRE as a basic physical exam skill in the evaluation of patients with nonspecific gastrointestinal symptoms.

Assessing the Ability of a Large Language Model to Score Free-Text Medical Student Clinical Notes: Quantitative Study.

Background: Teaching medical students the skills required to acquire, interpret, apply, and communicate clinical information is an integral part of medical education. A crucial aspect of this process involves providing students with feedback regarding the quality of their free-text clinical notes. Objective: The goal of this study was to assess the ability of ChatGPT 3.5, a large language model, to score medical students' free-text history and physical notes. Methods: This is a single-institution, retrospective study. Standardized patients learned a prespecified clinical case and, acting as the patient, interacted with medical students. Each student wrote a free-text history and physical note of their interaction. The students' notes were scored independently by the standardized patients and ChatGPT using a prespecified scoring rubric that consisted of 85 case elements. The measure of accuracy was percent correct. Results: The study population consisted of 168 first-year medical students. There was a total of 14,280 scores. The ChatGPT incorrect scoring rate was 1.0%, and the standardized patient incorrect scoring rate was 7.2%. The ChatGPT error rate was 86%, lower than the standardized patient error rate. The ChatGPT mean incorrect scoring rate of 12 (SD 11) was significantly lower than the standardized patient mean incorrect scoring rate of 85 (SD 74; P=.002). Conclusions: ChatGPT demonstrated a significantly lower error rate compared to standardized patients. This is the first study to assess the ability of a generative pretrained transformer (GPT) program to score medical students' standardized patient-based free-text clinical notes. It is expected that, in the near future, large language models will provide real-time feedback to practicing physicians regarding their free-text notes. GPT artificial intelligence programs represent an important advance in medical education and medical practice.

Apraisal of the diagnostic value of the gag reflex in patients with neurogenic oropharyngeal dysphagia / Evaluación del valor clínico del reflejo nauseoso en la disfagia orofaríngea neurogénica.

Introduction: The gag reflex is a protection mechanism that prevents food and unwanted agents from entering the lower airways. It is usually part of the physical examination of swallowing to detect oropharyngeal dysphagia, but it is a potentially ambiguous sign. Objective: To evaluate the diagnostic value of the gag reflex in patients with neurogenic oropharyngeal dysphagia and adults without it. Materials and methods: We conducted an analytical observational study in patients with neurogenic oropharyngeal dysphagia (cases) and patients without dysphagia (controls). We evaluated the absence or presence of the reflex bilaterally, by direct visualization, and adjusted it according to sex, age, and other interaction variables. Results: We included 86 patients with neurogenic oropharyngeal dysphagia and 80 control subjects. The gag reflex on swallowing physical examination showed a positive relationship with the patients (right side: OR = 3.97; 95 % CI: 2.01-7.84; left side: OR = 4.84; 95 % CI: 2.41-9.72), but a negative association with the control group. In both groups, neither sex, nor age, nor other interaction variables modified the gag reflex. Conclusions: The gag reflex absence or presence does not confirm or exclude the existence of oropharyngeal dysphagia due to neurological and neuromuscular causes. Therefore, health professionals must not rely on this reflex. Clinicians must go beyond a simple reflex revision, even in neurological patients where it is supposed to be absent.

Introducción. El reflejo nauseoso es un mecanismo de protección que impide que alimentos y agentes no deseados penetren en la vía aérea inferior. Usualmente, hace parte del examen físico de la deglución para detectar la disfagia orofaríngea, pero es un signo potencialmente ambiguo. Objetivo. Evaluar el valor diagnóstico del reflejo nauseoso en pacientes con disfagia orofaríngea neurogénica y en pacientes sin ella. Materiales y métodos. Se trata de un estudio observacional, analítico, en pacientes con disfagia orofaríngea neurogénica (casos) y en personas sin disfagia (controles), en el cual se evaluó por visualización directa la ausencia o la presencia del reflejo nauseoso de forma bilateral. Este resultado se ajustó por sexo, edad y otras variables de interacción. Resultados. Se evaluaron 86 pacientes con disfagia orofaríngea neurogénica y 80 personas sin ella. En el examen físico de la deglución, la presencia del reflejo mostró una relación positiva con los pacientes (lado derecho: OR = 3,97; IC95%: 2,01-7,84; lado izquierdo: OR = 4,84; IC95%: 2,41-9,72), pero una asociación negativa con los controles. En ambos grupos, ni el sexo ni la edad, ni otras variables de interacción modificaron el reflejo nauseoso. Conclusiones. La ausencia o la presencia del reflejo nauseoso no confirma ni excluye la existencia de una disfagia orofaríngea por causas neurológicas o neuromusculares; por lo tanto, no es recomendable que los profesionales de la salud se fíen del resultado de este reflejo. Los médicos tratantes deben ir más allá de una simple revisión del reflejo nauseoso, incluso en pacientes neurológicos en quienes se supone que debería estar ausente.

Virtual physical examination in teleconsultation: A scoping review.

BACKGROUND: The conduct of virtual physical examination has provided significant information for the diagnosis during a teleconsultation session, especially during the COVID-19 pandemic, where in-person physical examinations have been greatly compromised. OBJECTIVE: The aim of this scoping review was to provide a comprehensive overview of the available evidence concerning virtual physical examination (VPE) in all healthcare settings during the COVID-19 pandemic. The review focuses on types of VPE, technological and non-technological approaches, patient and clinician experiences, as well as barriers and facilitators of VPE. METHODS: A literature search was conducted across three databases, namely MEDLINE, Embase, and Scopus. Only studies in the English language with primary research data collected from December 2019 to January 2023 were included. A narrative analysis, highlighting patients' and clinicians' experiences, was conducted on the included studies. This scoping review was reported using The PRISMA extension for scoping reviews (PRISMA-ScR) Checklist. RESULTS: A total of 25 articles meeting eligibility criteria were identified. Three major types of VPE included were musculoskeletal, head and neck, and chest exams. Sixteen studies involved specific technological aids, while three studies involved non-technological aids. Patients found VPE helped them to better assess their disease conditions, or aided their clinicians' understanding of their conditions. Clinicians also reported that VPE had provided enough clinically relevant information for decision-making in 2 neurological evaluations. Barriers to conducting VPE included technological challenges, efficacy concerns, confidence level of assistants, as well as patient health conditions, health literacy, safety, and privacy. CONCLUSIONS: Patients found virtual physical examination (VPE) helpful in understanding their own conditions, and clinicians found it useful for better assessing patient's conditions. From the clinicians' point of view, VPE provided sufficient clinically relevant information for decision-making in neurological evaluations. Major barriers identified for VPE included technological issues, patient's health conditions, and their health literacy.

Globally inconsistent: Countries with top health indices erratic developmental hip dysplasia screening protocols.

Purpose: Developmental hip dysplasia is a prevalent pediatric musculoskeletal condition that lacks international standardized screening. We sought to characterize developmental hip dysplasia screening practices in countries with the top global health indices. We also explored diverse definitions in reported epidemiologic rates of this condition. Methods: We performed a scoping review of developmental hip dysplasia screening protocols utilizing countries ranked in the top 25 of the Bloomberg Global Health Index using a protocolized search strategy, progressing from academic to layperson sources. A reference was eligible for inclusion if it mentioned the countries' screening program and developmental hip dysplasia was the pathology of concern. Incidence rates, when present, were also recorded. The United States Census Bureau's International Database tool provided countries' populations. We compiled the data and performed descriptive statistics and appropriate validation methods. Results: Twenty countries (80%) had searchable screening programs. Clinical screening with selective universal screening was the most commonly observed (n = 16). Four countries had universal ultrasound screening: Switzerland, Austria, Germany, and Slovenia. Five countries did not have searchable programs. No countries employed radiographic screening. Incidence rates were expressly stated in the literature for nine countries; however, the cohort of interest varied from developmental hip dysplasia versus severity of developmental hip dysplasia versus miscellaneous (e.g. requiring hospitalization). Conclusion: The findings of this investigation highlight international inconsistencies regarding developmental hip dysplasia screening and epidemiologic data. Screening variations exist despite consensus statements calling for uniformity. We agree with prior literature advocating for increasing consistency in developmental hip dysplasia management or, at a minimum, increasing transparency regarding how we manage these young patients.

Long COVID Is Not a Functional Neurologic Disorder.

Long COVID is a common sequela of SARS-CoV-2 infection. Data from numerous scientific studies indicate that long COVID involves a complex interaction between pathophysiological processes. Long COVID may involve the development of new diagnosable health conditions and exacerbation of pre-existing health conditions. However, despite this rapidly accumulating body of evidence regarding the pathobiology of long COVID, psychogenic and functional interpretations of the illness presentation continue to be endorsed by some healthcare professionals, creating confusion and inappropriate diagnostic and therapeutic pathways for people living with long COVID. The purpose of this perspective is to present a clinical and scientific rationale for why long COVID should not be considered as a functional neurologic disorder. It will begin by discussing the parallel historical development of pathobiological and psychosomatic/sociogenic diagnostic constructs arising from a common root in neurasthenia, which has resulted in the collective understandings of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and functional neurologic disorder (FND), respectively. We will also review the case definition criteria for FND and the distinguishing clinical and neuroimaging findings in FND vs. long COVID. We conclude that considering long COVID as FND is inappropriate based on differentiating pathophysiologic mechanisms and distinguishing clinical findings.