Diagnostic performance of chromoendoscopy and narrow band imaging for colonic neoplasms: a meta-analysis.

AIM: We conducted a meta-analysis to compare the diagnostic test performance of chromoendoscopy and narrow band imaging (NBI) for colonic neoplasms. METHOD: MEDLINE, EMBASE and the Cochrane Library were searched (1966 to March 2009). Articles were included if: (i) chromoendoscopy or NBI was used, (ii) sensitivity and specificity were reported; (iii) absolute numbers of true-positive, false-positive, true-negative and false-negative results were provided or could be calculated; and (iv) pathology was used as the reference standard. Sensitivity and specificity were pooled using random effects model. Secondary analyses were conducted by limiting the studies in which magnifying endoscopy was used alone as a diagnostic modality, and polyp size and macroscopic appearance of lesions were not considered. RESULTS: Of 1342 screened articles, 27 met the inclusion criteria. Pooled sensitivity for chromoendoscopy and NBI was 0.94 (95% CI, 0.92-0.95) and 0.94 (0.91-0.97), and specificity was 0.82 (0.77-0.88) and 0.86 (0.83-0.89), respectively. There were no differences in sensitivity (P = 0.99) or specificity (P = 0.54) between the two methods. In the secondary analysis, pooled sensitivity for choromoendoscopy and NBI was 0.93 (95% CI, 0.90-0.97) and 0.96 (0.93-0.99) and specificity was 0.80 (0.73-0.87) and 0.85 (0.78-0.92). respectively. Overall, the pooled false-negative rate was 0.057 (95% CI, 0.040-0.73) for chromoendoscopy and 0.057 (95% CI, 0.028-0.085) for NBI. CONCLUSION: Chromoendoscopy and NBI had similar diagnostic test characteristics in the assessment of colonic neoplasms; however, the false-negative rate for both methods of 5.7% is an unacceptably high rate and currently therefore, neither method is ready for general use.

The impact of oral phenylpropanolamine on blood pressure: a meta-analysis and review of the literature.

Oral phenylpropanolamine is commonly used to treat congestion and obesity. Clinicians often wonder what effect it has on blood pressure and whether they are safe in hypertensive patients. The purpose of our systematic review was to assess whether these drugs cause clinically meaningful elevations in pulse or blood pressure. English-language, randomized, placebo-controlled trials of oral phenylpropanolamine in adults with extractable data on pulse or blood pressure were studied. MEDLINE (1966-2003), Embase, the Cochrane library and reviewed article references were used as sources. Systolic (SBP) and diastolic blood pressure (DBP) and heart rate data were extracted. Additional extracted data included demographics, year, study design, study duration, drug dose and frequency, duration of washout and country. Study quality was assessed using the methods of Jadad and data were synthesized using a random effects model using weighted mean differences. In all, 33 trials reporting 48 treatment arms with 2165 patients were included. Phenylpropanolamine increased SBP 5.5 mmHg (95% CI: 3.1-8.0) and DBP 4.1 mmHg (95% CI: 2.2-6.0) with no effect on pulse. Patients with controlled hypertension were not at greater risk of blood pressure elevation. Immediate release preparations had greater effects on blood pressure than sustained release ones. Higher doses and shorter duration use also caused greater increases. Eighteen studies contained at least one treated subjects having blood pressure elevations > or =140/90 mmHg, an increase in SBP > or =15 mmHg or an increase in DBP > or =10 mmHg. In conclusion, phenylpropanolamine caused a small, but significant increase in systolic blood pressure. The effect was more pronounced with shorter-term administration, higher doses of medication and immediate release formulations.

Chronic stress enhances ibotenic acid-induced damage selectively within the hippocampal CA3 region of male, but not female rats.

The purpose of this investigation was to assess the ability of the hippocampus to withstand a metabolic challenge following chronic stress. An N-methyl-d-aspartate receptor excitotoxin (ibotenic acid, IBO) was infused into the CA3 region of the hippocampus following a period of restraint for 6 h/day/21 days. Following the end of restraint when CA3 dendritic retraction persists (3 to 4 days), rats were infused with IBO (or vehicle) into the CA3 region of the hippocampus. Stressed male rats showed significantly more CA3 damage after IBO infusion relative to controls and the saline-infused side. Moreover, IBO-exacerbation of damage in males was not observed in the CA3 region 3 to 4 days after acute stress (6 h restraint), nor in the CA1 region after chronic stress. Females were also examined and chronic stress did not exacerbate IBO damage in the CA3 region. Overall, these results demonstrate that chronic stress compromises the ability of the hippocampus to withstand a metabolic challenge days after the chronic stress regimen has subsided in male rats. Whether the conditions surrounding CA3 dendritic retraction in females represents vulnerability is less clear and warrants further investigation.

Cyclobenzaprine and back pain: a meta-analysis.

BACKGROUND: Back pain is a common problem for which cyclobenzaprine hydrochloride is frequently prescribed. OBJECTIVE: To perform a systematic review of cyclobenzaprine's effectiveness in the treatment of back pain. METHODS: We searched MEDLINE, PsycLIT, CINAHL, EMBASE, AIDSLINE, HEALTHSTAR, CANCERLIT, the Cochrane Library, Micromedex, Federal Research in Progress, and the references of reviewed articles, and contacted Merck, Sharpe and Dohme for English-language, randomized, placebo-controlled trials of cyclobenzaprine in adults with back pain. Outcomes included global improvement and 5 specific domains of back pain (local pain, muscle spasm, range of motion, tenderness to palpation, and activities of daily living). Study quality was assessed using the methods of Jadad. Summary outcomes were obtained using a random-effects model. RESULTS: Patients treated with cyclobenzaprine were nearly 5 times (odds ratio, 4.7; 95% confidence interval, 2.7-8.1) as likely to report symptom improvement by day 14 as were those treated with placebo. Slightly fewer than 3 individuals (2.7; 95% confidence interval, 2.0-4.2) needed treatment for 1 to improve. The magnitude of this improvement was modest, with an effect size of 0.38 to 0.58 in all 5 outcomes (local pain, muscle spasm, tenderness to palpation, range of motion, and activities of daily living). Treatment efficacy for these 5 outcomes was greatest early, in the first few days of treatment, declining after the first week. Patients receiving cyclobenzaprine also experienced more adverse effects, the most common being drowsiness. CONCLUSIONS: Cyclobenzaprine is more effective than placebo in the management of back pain; the effect is modest and comes at the price of greater adverse effects. The effect is greatest in the first 4 days of treatment, suggesting that shorter courses may be better. Studies comparing the relative value of acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclobenzaprine individually and in combination in the treatment of back pain are needed.

Treatment of chronic headache with antidepressants: a meta-analysis.

BACKGROUND: Although antidepressants are often used for preventing chronic headache, their effectiveness is uncertain. METHODS: We performed a meta-analysis of English-language, randomized placebo-controlled trials of antidepressants as prophylaxis for chronic headache. RESULTS: Thirty-eight trials were included. Because some compared more than one drug with placebo, 44 study arms were combined using a random effects model. Twenty-five studies focused on migraines, 12 on tension headaches, and 1 on both. Nineteen used tricyclic antidepressants, 18 serotonin antagonists, and 7 selective serotonin reuptake inhibitors. Patients receiving antidepressants were twice as likely to report headache improvement (rate ratio [RR]: 2.0; 95% confidence interval [CI]: 1.6 to 2.4). Because 31% (95% CI: 23% to 40%) more treated patients improved than those receiving placebo, clinicians would need to treat 3.2 patients for 1 patient to improve. The average amount of improvement (standardized mean difference) was 0.94 (95% CI: 0.65 to 1.2), an effect considered large. Treated patients also consumed less analgesic medication (standardized mean difference, -0.7; 95% CI: -0.5 to -0.94). There were no differences in outcomes among the three classes of agents studied or by the type of headache (migraine vs. tension), quality score, length of treatment, or percentage of patients lost to follow-up. Assessment of depression across studies was insufficient to determine if the effects were independent of depression. CONCLUSION: Antidepressants are effective in preventing chronic headaches. Whether this is independent of depression and whether there are differences in efficacy by class of agent needs further study.

The effect of unmet expectations among adults presenting with physical symptoms.

BACKGROUND: Unmet patient expectations are common and have been associated with decreased patient satisfaction. OBJECTIVE: To assess the prevalence and effect of unmet expectations in patients presenting with physical symptoms. DESIGN: Prospective cohort study. SETTING: Primary care walk-in clinic. Most patients were seeing a particular provider for the first time. PATIENTS: 750 adults whose principal reason for the clinic visit was a physical symptom. MEASUREMENTS: Patients completed previsit questionnaires that assessed symptom characteristics, the patient's expectations of the visit, functional status (Medical Outcomes Study Short Form-6), and mental disorders (Primary Care Evaluation of Mental Disorders [PRIME-MD]). Patient questionnaires given immediately after the visit and 2 weeks after the visit assessed patient satisfaction with the visit and unmet expectations; the 2-week questionnaire also assessed symptom outcome and functional status. Postvisit physician questionnaires measured encounter difficulty (Difficult Doctor Patient Relationship Questionnaire) and what the physician did in response to the patient's symptom. RESULTS: Nearly all patients (98%) had at least one previsit expectation, including a diagnosis (81%), an estimate of how long the symptom was likely to last (63%), a prescription (60%), a diagnostic test (54%), and a subspecialty referral (45%). Immediately after the visit, the most common unmet expectations were for prognostic information (51%) or diagnostic information (33%). Only 11% of patients had an unmet expectation of a diagnostic test, subspecialty referral, prescription, or sick slip. Unmet patient expectations were more common after encounters experienced as difficult by the clinician and in patients with underlying mental disorders. Patients with no unmet expectations had less worry about serious illness (54% vs. 27%; P < 0.001) and greater satisfaction (59% vs. 19%; P < 0.001), and patients who reported receiving diagnostic or prognostic information were more likely to have symptom alleviation (relative risk, 1.2 [95% CI, 1.02 to 1.3]) and functional improvement (functional status score, 25 vs. 23; P = 0.01) at 2 weeks. CONCLUSIONS: Patients who seek care for physical symptoms and do not leave the encounter with an unmet expectation are more likely to be satisfied with their care and to have less worry about serious illness. Diagnostic and prognostic information are particularly valued by patients and may be associated with greater improvement in symptoms and functional status 2 weeks after the visit.

Clinical predictors of mental disorders among medical outpatients.

BACKGROUND: Mental disorders are common among primary care patients and often not detected by primary care physicians. We report on clinical cues that may allow physicians to target patients for psychiatric screening. METHODS: Two hundred fifty consecutive adults presenting to a walk-in clinic completed previsit surveys assessing demographics, symptom characteristics, recent stress, functional status (Medical Outcomes Study Short Form-6), and mental disorders (Primary Care Evaluation of Mental Disorders [PRIME-MD]). Patients with positive findings for a mental disorder on the PRIME-MD underwent a semistructured interview. Immediately after the visit, physicians completed the Difficult Doctor Patient Relationship Questionnaire. RESULTS: Patients averaged 50.5 years of age (range, 18-92 years). Little more than half were women (53%); 43%, white; 44%, African American; 8%, Hispanic; and 6%, other. Twenty-six percent had an underlying mental disorder; 11% had more than 1 mental disorder. Sixteen percent had a depressive disorder; 6%, major depression; 11%, an anxiety disorder; 2%, panic disorder; and 9%, a somatoform disorder. Independent correlates of a mental disorder included reporting recent stress (odds ratio [OR], 6.7; 95% confidence interval [CI], 3.3-13.6), having 5 or more physical symptoms (OR, 4.0; 95% CI, 2.1-7.9), or reporting health to be less than very good (OR, 2.2; 95% CI, 1.1-4.3). There was a stepwise increase in the likelihood of having a mental disorder and number of correlates present. Among patients with no predictors, only 2% had an underlying mental disorder, compared with 72% among patients with all 3 clinical predictors. CONCLUSIONS: Patients who report recent stress, 5 or more physical symptoms, or poor health are more likely to have an underlying mental disorder. These clinical cues may allow clinicians to select patients in whom formal screening for mental disorders would be particularly fruitful.

Predictors of patient satisfaction.

Correlates of patient satisfaction at varying points in time were assessed using a survey with 2-week and 3-month follow-up in a general medicine walk-in clinic, in USA. Five hundred adults presenting with a physical symptom, seen by one of 38 participating clinicians were surveyed and the following measurements were taken into account: patient symptom characteristics, symptom-related expectations, functional status (Medical Outcomes Study Short-Form Health Survey [SF-6]), mental disorders (PRIME-MD), symptom resolution, unmet expectations, satisfaction (RAND 9-item survey), visit costs and health utilization. Physician perception of difficulty (Difficult Doctor Patient Relationship Questionnaire), and Physician Belief Scale. Immediately after the visit, 260 (52%) patients were fully satisfied with their care, increasing to 59% at 2 weeks and 63% by 3 months. Patients older than 65 and those with better functional status were more likely to be satisfied. At all time points, the presence of unmet expectations markedly decreased satisfaction: immediately post-visit (OR: 0.14, 95% CI: 0.07-0.30), 2-week (OR: 0.07, 95% CI: 0.04-0.13) and 3-month (OR: 0.05, 95% CI: 0.03-0.09). Other independent variables predicting immediate after visit satisfaction included receiving an explanation of the likely cause as well as expected duration of the presenting symptom. At 2 weeks and 3 months, experiencing symptomatic improvement increased satisfaction while additional visits (actual or anticipated) for the same symptom decreased satisfaction. A lack of unmet expectations was a powerful predictor of satisfaction at all time-points. Immediately post-visit, other predictors of satisfaction reflected aspects of patient doctor communication (receiving an explanation of the symptom cause, likely duration, lack of unmet expectations), while 2-week and 3-month satisfaction reflected aspects of symptom outcome (symptom resolution, need for repeat visits, functional status). Patient satisfaction surveys need to carefully consider the sampling time frame as well as adjust for pertinent patient characteristics.

The synaptic vesicle protein, cysteine-string protein, is associated with the plasma membrane in 3T3-L1 adipocytes and interacts with syntaxin 4.

Adipocytes and muscle cells play a major role in blood glucose homeostasis. This is dependent upon the expression of Glut4, an insulin-responsive facilitative glucose transporter. Glut4 is localised to specialised intracellular vesicles that fuse with the plasma membrane in response to insulin stimulation. The insulin-induced translocation of Glut4 to the cell surface is essential for the maintenance of optimal blood glucose levels, and defects in this system are associated with insulin resistance and type II diabetes. Therefore, a major focus of recent research has been to identify and characterise proteins that regulate Glut4 translocation. Cysteine-string protein (Csp) is a secretory vesicle protein that functions in presynaptic neurotransmission and also in regulated exocytosis from non-neuronal cells. We show that Csp1 is expressed in 3T3-L1 adipocytes and that cellular levels of this protein are increased following cell differentiation. Combined fractionation and immunofluorescence analyses reveal that Csp1 is not a component of intracellular Glut4-storage vesicles (GSVs), but is associated with the adipocyte plasma membrane. This association is stable, and not affected by either insulin stimulation or chemical depalmitoylation of Csp1. We also demonstrate that Csp1 interacts with the t-SNARE syntaxin 4. As syntaxin 4 is an important mediator of insulin-stimulated GSV fusion with the plasma membrane, this suggests that Csp1 may play a regulatory role in this process. Syntaxin 4 interacts specifically with Csp1, but not with Csp2. In contrast, syntaxin 1A binds to both Csp isoforms, and actually exhibits a higher affinity for the Csp2 protein. The results described raise a number of interesting questions concerning the intracellular targeting of Csp in different cell types, and suggest that the composition and synthesis of GSVs may be different from synaptic and other secretory vesicles. In addition, the interaction of Csp1 with syntaxin 4 suggests that this Csp isoform may play a role in insulin-stimulated fusion of GSVs with the plasma membrane.

Residential mental health assessment within Dutch criminal cases: a discussion.

In Dutch criminal cases in which doubts arise about the defendant's mental health, a forensic assessment will be requested. This is provided either by the multidisciplinary staff of residential clinics who conduct forensic evaluations for the court, or by mental health professionals contracted on a part-time basis by district courts. This article discusses the procedures applied in such cases as well as the relevant legal provisions. It focuses particularly on the clinical observation, evaluation, and reporting that is carried out over a number of weeks in the residential setting of the Pieter Baan Centrum. Specific attention is paid to procedures applied in this clinic. It is suggested that Dutch procedures for the use of mental health expertise can best be characterized by three aspects: multidisciplinary observation and reporting, the use of a sliding scale for indicating degree of responsibility, and, finally, the involvement and payment of experts by the state as such, rather than by the prosecution and/or the defense.

Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis.

BACKGROUND: Functional gastrointestinal disorders are common, accounting for up to 50% of gastroenterology referrals, and several randomized controlled trials have evaluated antidepressant therapy for their treatment. METHODS: We performed a meta-analysis of published, English-language, randomized clinical trials on the use of antidepressants for the treatment of patients with functional gastrointestinal disorders. RESULTS: Twelve randomized placebo-controlled trials of antidepressant treatment of functional gastrointestinal disorders were identified. One was excluded for using a combination of a tricyclic and neuroleptic agent. The medications included tricyclic antidepressants (amitriptyline [n = 3], clomipramine [n = 1], desipramine [n = 2], doxepin [n = 1], and trimipramine [n = 2]), and the antiserotonin agent, mianserin (n = 2). In addition, one trial compared two different antidepressants (mianserin and clomipramine) with placebo. Data were abstracted for the dichotomous outcome of symptom improvement in seven studies, and for the continuous variable of pain score in eight studies. The summary odds ratio for improvement with antidepressant therapy was 4.2 (95% confidence interval [CI]: 2.3 to 7.9), and the average standardized mean improvement in pain was equal to 0.9 SD units (95% CI: 0.6 to 1.2 SD units). On average 3.2 patients needed to be treated (95% CI: 2.1 to 6.5 patients) to improve 1 patient's symptom. CONCLUSION: Treatment of functional gastrointestinal disorders with antidepressants appears to be effective. Whether this improvement is independent of an effect of treatment on depression needs further evaluation.

Treatment of fibromyalgia with antidepressants: a meta-analysis.

BACKGROUND: Fibromyalgia is a common, poorly understood musculoskeletal pain syndrome with limited therapeutic options. OBJECTIVE: To systematically review the efficacy of antidepressants in the treatment of fibromyalgia and examine whether this effect was independent of depression. DESIGN: Meta-analysis of English-language, randomized, placebo-controlled trials. Studies were obtained from searching MEDLINE, EMBASE, and PSYCLIT (1966-1999), the Cochrane Library, unpublished literature, and bibliographies. We performed independent duplicate review of each study for both inclusion and data extraction. MAIN RESULTS: Sixteen randomized, placebo-controlled trials were identified, of which 13 were appropriate for data extraction. There were 3 classes of antidepressants evaluated: tricyclics (9 trials), selective serotonin reuptake inhibitors (3 trials), and S-adenosylmethionine (2 trials). Overall, the quality of the studies was good (mean score 5.6, scale 0-8). The odds ratio for improvement with therapy was 4.2 (95% confidence interval [95% CI], 2.6 to 6.8). The pooled risk difference for these studies was 0.25 (95% CI, 0.16 to 0.34), which calculates to 4 (95% CI, 2.9 to 6.3) individuals needing treatment for 1 patient to experience symptom improvement. When the effect on individual symptoms was combined, antidepressants improved sleep, fatigue, pain, and well-being, but not trigger points. In the 5 studies where there was adequate assessment for an effect independent of depression, only 1 study found a correlation between symptom improvement and depression scores. Outcomes were not affected by class of agent or quality score using meta-regression. CONCLUSION: Antidepressants are efficacious in treating many of the symptoms of fibromyalgia. Patients were more than 4 times as likely to report overall improvement, and reported moderate reductions in individual symptoms, particularly pain. Whether this effect is independent of depression needs further study.

Resident participation in flexible sigmoidoscopy does not affect patient satisfaction.

OBJECTIVE: We sought to assess the effect of resident involvement in flexible sigmoidoscopy on patient satisfaction and comfort. METHODS: Adults undergoing flexible sigmoidoscopy completed a previsit questionnaire on indication for procedure, GI-related history, and functional status. Immediately after the procedure, satisfaction and procedure comfort were assessed. Additional information collected included procedure duration, depth of sigmoidoscope penetration, and visualization of diverticuli or polyps. RESULTS: Among 408 endoscopies, patient characteristics and procedure indications were similar between sigmoidoscopies done by residents (n = 111) or staff. There were no differences in patient satisfaction, procedure comfort, or willingness to undergo the procedure again in the future. Sigmoidoscopies involving residents averaged 5.6 min longer, even after adjusting for preparation quality, depth of insertion, specific endoscopist, and the presence of polyps or diverticuli. CONCLUSIONS: Patient satisfaction and comfort with flexible sigmoidoscopy was not reduced by resident involvement, though the procedure duration was slightly longer.

Complications from cardiac catheterization: analysis of a military database.

BACKGROUND: Cardiac catheterization is a common procedure in the United States. Our purpose was to assess possible risk factors for complications from cardiac catheterization. METHODS: The Civilian External Peer Review Program database, which contains data on 3,494 cardiac catheterizations performed at 28 military facilities from 1987 to 1989, provided the patient population for this study. Of 360 abstracted clinical elements, 27 were selected by a panel of internists and cardiologists for evaluation as potential risk factors and were analyzed using logistic regression. Complications were analyzed within three categories: major (myocardial infarction, cerebral vascular accident, or death within 24 hours of catheterization); minor (hemorrhage requiring transfusion, pseudoaneurysm, fistula, or femoral thrombosis); and any. RESULTS: The mean age of the 3,494 patients was 56 years, and 75% of them were male; 85% were white, 10% were African-American, and 5% were other races. Complication rates were as follows: death (N = 13), 3.7/1,000; cerebral vascular accident (N = 16), 4.1/1,000; myocardial infarction (N = 22), 5.6/1,000; hemorrhage (N = 20), 5.1/1,000; fistula (N = 7), 0.3/1,000; and thrombosis (N = 15), 3.8/1,000. These were categorized as 59 major, 71 minor, or 122 any complications. Complications were more likely in patients with hypertension (odds ratio, 1.8; 95% confidence interval, 1.05-3.18), peripheral vascular disease (odds ratio, 2.9; 95% confidence interval, 1.1-8.7), age greater than 60 years (odds ratio, 2.1; 95% confidence interval, 1.2-3.8), and those undergoing angioplasty (odds ratio, 6.0; 95% confidence interval, 2.9-12.2). CONCLUSIONS: Hypertension, age greater than 60 years, peripheral vascular disease, and procedures either nonelective or involving angioplasty all independently increased the risk of complications. There was a "dose-response" relationship between risk and number of risk factors. The risk of a complication may be greater than 10% in patients with more than three risk factors.

Zinc and the common cold: a meta-analysis revisited.

The common cold has been estimated to cost the United States > $3.5 billion per year. Despite several randomized clinical trials, the effect of treating colds with zinc gluconate remains uncertain due to conflicting results. We conducted a meta-analysis of published randomized clinical trials on the use of zinc gluconate lozenges in colds using the random effects model of DerSimonians and Laird. Ten clinical trials of cold treatment with zinc gluconate were identified. After excluding two studies that used nasal inoculum of rhinovirus, eight trials were combined and analyzed. The summary odds ratio for the presence of "any cold symptoms" at 7 d was 0.52 (95% confidence interval, 0.25-1.2). We conclude that despite numerous randomized trials, the evidence for effectiveness of zinc lozenges in reducing the duration of common colds is still lacking.

Prognostic value of coronary electron-beam computed tomography for coronary heart disease events in asymptomatic populations.

The predictive ability of electron-beam computed tomography (EBCT) for coronary heart disease outcomes, particularly hard coronary outcomes (myocardial infarction or death), has been questioned in asymptomatic populations. Our objective was to synthesize data on the use of EBCT for determining cardiovascular prognosis in asymptomatic populations. Studies were identified using standard systematic review methods. The outcome of interest was relative risk for myocardial infarction or sudden death, and combined events including revascularization. Nine articles met the inclusion criteria, of which 5 were of independent studies. Using meta-analytic techniques to synthesize prognostic data, there was an increased risk (summary risk ratio 8.7, 95% confidence interval 2.7 to 28.1) of a combined outcome of nonfatal myocardial infarction or death or revascularization if the calcium score was above a median score. Similarly, there was an increased risk for hard events: myocardial infarction or death (summary risk ratio 4.2, 95% confidence interval 1.6 to 11.3). However, there was significant heterogeneity in the studies' quality and patient populations. Although EBCT appears to predict combined and hard coronary outcomes similarly in high risk, asymptomatic populations, these results should be interpreted with caution. Further study is needed on the incremental value of EBCT over conventional risk prediction before this test is used in screening asymptomatic populations.

Assessing how well three evaluation methods detect deficiencies in medical students' professionalism in two settings of an internal medicine clerkship.

PURPOSE: To compare the performances of three evaluation methods in detecting deficiencies of professionalism among third-year medical students during their ambulatory care and inpatient ward rotations of a core internal medicine clerkship. METHOD: From 1994 to 1997, 18 students at The Uniformed Services University of the Health Sciences failed to satisfactorily complete their core 12-week third-year internal medicine clerkship due to deficiencies in professionalism. Three evaluation methods had been used to assess all students' professionalism during the two rotations of their clerkship: standard checklists, written comments, and comments from formal evaluation sessions. Using qualitative methods and the information obtained by the three evaluation methods, the authors abstracted the record of each student concerning his or her clerkship behavior in terms of the six domains of professionalism used on the standard checklist. A detection index, which is the percentage of all instructors' less-than-acceptable ratings of a student across the six professionalism domains, was calculated for each evaluation method for each of the two clerkship settings. RESULTS: For each evaluation method, deficiencies in professionalism were twice as likely to be identified during the ward rotation as during the ambulatory care rotation (p < .002 for all). Formal evaluation session comments had the highest detection index in both clinical settings. Although the numbers of written and formal evaluation session comments per evaluator and per cited professionalism domain were similar, nearly a fourth of the instructors made identifying comments at the evaluation sessions only. CONCLUSION: In the clerkship studied, deficiencies in professionalism of such magnitude as to require remediation were more likely to be identified in the inpatient than in the ambulatory care setting. Of the three evaluation methods studied, the face-to-face, formal evaluation sessions significantly improved the detection of unprofessional behavior in both clerkship settings. Further efforts at such an interactive evaluation process with ambulatory care clerkship instructors may be essential for improving the identification of unprofessional behavior in that setting.

Comparison of discharge diagnoses and inpatient procedures between military and civilian health care systems.

BACKGROUND: Our goal was to compare the demographics and discharge diagnoses between civilian and military health care systems. METHODS: One year (1997) of data from the Retrospective Case Mix Adjustment System from the Military Health Services System were compared with the most recent (1994) civilian National Hospital Discharge Survey data. RESULTS: Military and civilian inpatient age (52.5 and 52.9 years), gender (54% and 59% female), and ethnic distributions (military: 71% white, 16% African American, 3% Asian American, 10% other; civilian: 65% white, 12% African American, 2.6% Asian American, 1.2% Native American, 18% unclassified) were similar. There were similar rank orderings of diagnosis-related groupings (Spearman's rank correlation = 0.72) and procedures performed during hospitalization (Spearman's rho = 0.74), although the military inpatients yielded a higher proportion associated with pregnancy and strenuous activity (traumatic joint disorders and hernias) than their civilian counterparts. CONCLUSION: The practice content of military and civilian inpatients appear to be more similar than different.

A comparison of bowel preparations for flexible sigmoidoscopy: oral magnesium citrate combined with oral bisacodyl, one hypertonic phosphate enema, or two hypertonic phosphate enemas.

OBJECTIVE: Magnesium citrate with hypertonic enemas or oral bisacodyl provides superior preparation quality for sigmoidoscopy over enemas alone. We compared three magnesium citrate sigmoidoscopy preparations in a randomized, single-blind, controlled trial. METHODS: Two hundred and ninety-one adults scheduled for routine sigmoidoscopy were randomly assigned to receive one of three preparations containing oral magnesium citrate (296 cc) taken the night before the procedure in combination with the following: 1) oral bisacodyl (10 mg), given with the magnesium citrate the night before the procedure; 2) one hypertonic phosphate enema 1 h before the procedure; or 3) two hypertonic phosphate enemas, given singly at 2 and 1 h before the procedure. Endoscopists rated preparation quality, procedure duration, and depth of endoscopic insertion. Patients assessed preparation comfort and overall satisfaction. RESULTS: Preparation quality was rated as excellent or good for 80.6% in the bisacodyl group, 88.7% in the one-enema group, and 85.1% in the two-enema group (p = 0.30). Patients reported the oral bisacodyl regimen was better tolerated (p = 0.032). Although the three regimens were comparable in most side effects, the bisacodyl preparation was associated with more diarrhea (p = 0.0003). Mean procedure duration, mean insertion depth, and prevalence of diverticula and polyps were similar in all groups. Fewer than 4% of patients required repeat procedures due to poor preparation quality. CONCLUSIONS: There was no statistical difference between the quality of the three bowel preparations. Patients considered an oral bisacodyl and magnesium citrate regimen more easily tolerated, though it was associated with more diarrhea.

A comparison of outcomes for walk-in clinic patients who see interns and those who see staff physicians.

PURPOSE: To collect pilot data on the effect of interns' involvement on patient care outcomes. METHOD: Between January 1995 and August 1998, 750 patients at a walk-in clinic completed pre-visit questionnaires on symptom-related expectations and functional status. Three follow-up surveys (immediately after the visit, at two weeks, and at three months) assessed symptom outcomes, satisfaction, illness worry, and unmet expectations. Physicians were surveyed about their perceptions of the "difficulty" of each patient encounter. RESULTS: During the study period, 195 patients (26%) were seen by interns and 555 (74%) by staff physicians. The patient groups did not differ in illness worry, unmet expectations, or satisfaction immediately after the visit, at two weeks, or at three months. Patients seen by interns were more satisfied with the time they had spent with their clinicians (p = .007). Interns were more likely to experience their patient encounters as difficult. There was no difference in visit costs, subspecialty referrals, health utilization, or hospitalization rates. CONCLUSION: Patients who are seen by interns in an ambulatory clinic are similar to those who are seen by staff physicians in terms of post-visit satisfaction, residual expectations, symptom resolution, and functional status improvement.