[Quality aspects in internal medicine--from anamnesis to meta-analysis]. / Qualitätsaspekte in Innerer Medizin--von der Anamnese bis zur Meta-Analyse.

Quality aspects get more important in internal medicine due to novel technical developments and economic constraints. In spite of an extensive research activity in clinical medicine some research aspects of quality control are new. Among these are investigations about symptoms and complaints as well as risk factors. Too much evidence might also blur the view when the necessary data might already be available from existing studies but conclusions have not been drawn to improve quality of patient care. An instrument to this end is metaanalysis compounding the results of single studies to a more meaningful result. Thus further unnecessary trials can be avoided. Finally quality control is characterized by readiness to self-criticism. Its aim is to avoid mistakes and intends to optimize medical actions whenever possible.

Accuracy and 'range of uncertainty' of oscillometric blood pressure monitors around the upper arm and the wrist.

BACKGROUND: Although they have been marketed widely, few data about the diagnostic accuracy of blood pressure monitors are available. METHODS: Repeated measurements of blood pressures in 85 patients were performed in random sequence with two oscillometric blood pressure monitors around the upper arm (Visomat OZ2) and the wrist (Omron R3( and with a standard sphygmomanometer. The oscillometric blood pressure monitors were validated according to protocols of the British Hypertension Society (BHS) and the American Association for the Advancement of Medical Instrumentation (AAMI). Subsequently, sensitivity and specificity of these monitors for the diagnosis of hypertension or exclusion of the possibility of its presence in a general medical outpatient population were calculated. RESULTS: Sphygmomanometric readings exceeded oscillometric blood pressure measurements by 3.7+/-7.5/4.8+/-5.6 mmHg (systolic/diastolic) for the upper arm and 5.7+/-6.2/6.8+/-6.8 mmHg for the wrist. Deviations occurred in both directions and were higher for blood pressures in the hypertensive range. Oscillometric blood pressure measurements at the upper arm, but not at the wrist, satisfied validation criteria of BHS and AAMI protocols. Optimal sensitivity and specificity for the diagnosis of hypertension, defined as blood pressure > 140/90 mmHg with a standard sphygmomanometer, was achieved with blood pressure limits of 133/82 mmHg for the Visomat OZ and 131/80 mmHg for the Omron R3. CONCLUSIONS: Average sphygmomanometer values exceed oscillometrically measured blood pressure values but individual disagreements cannot be predicted. Measurements at the upper arm are more accurate than are those at the wrist according to the validation protocols of the BHS and AAMI. Additional appraisal of sensitivities and specificities and of a 'range of uncertainty' for the diagnosis of hypertension may allow better judgement of accuracy of individual oscillometric blood pressure measurements.

First clinical judgment by primary care physicians distinguishes well between nonorganic and organic causes of abdominal or chest pain.

OBJECTIVE: To evaluate the accuracy of a preliminary diagnosis based solely on patient history and physical examination in medical outpatients with abdominal or chest pain. DESIGN: Prospective observational study. SETTING: General medical outpatient clinic in a university teaching hospital. PARTICIPANTS: One hundred ninety new, consecutive patients with a mean age of 44 years (SD = 14 years, range 30-58 years) with a main complaint of abdominal or chest pain. MEASUREMENTS AND MAIN RESULTS: The preliminary diagnosis, established on the basis of patient history and physical examination, was compared with a final diagnosis, obtained after workup at completion of the chart. A nonorganic cause was established in 66 (59%) of 112 patients with abdominal pain and in 65 (83%) of 78 with chest pain. The preliminary diagnosis of "nonorganic" versus "organic" causes was correct in 79% of patients with abdominal pain and in 88% of patients with chest pain. An "undoubted" preliminary diagnosis predicted a correct assessment in all patients with abdominal pain and in all but one patient with chest pain. Overall, only 4 patients (3%) were initially incorrectly diagnosed as having a nonorganic cause of pain rather than an organic cause. In addition, final nonorganic diagnosis (n = 131) was compared with long-term follow-up by obtaining information from patients and, if necessary, from treating physicians. Follow-up information, obtained for 71% of these patients after a mean of 29 months (range 18-56 months) identified three other patients that had been misdiagnosed as having abdominal pain of nonorganic causes. Compared with follow-up, the diagnostic accuracy for nonorganic abdominal and chest pain at chart completion was 93% and 98%, respectively. CONCLUSIONS: A preliminary diagnosis of nonorganic versus organic abdominal or chest pain based on patient history and physical examination proved remarkably reliable. Accuracy was almost complete in patients with an "undoubted" preliminary diagnosis, suggesting that watchful waiting can be recommended in such cases.