Interrater Variability among Anaesthesiologists Using American Society of Anesthesiologists Physical Status Classification System.

BACKGROUND: The American Society of Anaesthesiologists Physical Status classification is deployed by the anaesthesiologists worldwide to classify operative surgical patients. Many studies have found moderate degree of interrater variability among anaesthesiologists. The general objective of the study was to find out interrater variability among Nepalese anesthesiologists using this classification system in Nepal. The specific objectives of the study were to find out the correctness of assignment and inter-rater variability among anaesthesiologists based on their experience. METHODS: Ten clinical cases were distributed among 130 registered anaesthesiologist practitioners of Nepal after validation with the experts. Respondents were asked to assign each of ten cases to a specific physical status class. Anaesthesiologists were classified to two classes based on clinical experience as having more or less than five years of experience. RESULTS: We found substantial agreement among < 5 year's (0.66) and > 5 year's experience group (0.753) and among all raters (0.736). The mean score of the group with less than 5 years of experience was more. There was no significant difference between the mean score (p = 0.595). Overall mean score for the both groups was 5.66 with SD 1.66. There was no significant difference between the groups. CONCLUSIONS: The study shows that there is very less variation among registered practising anaesthesiologists of Nepal using American Society of Anesthesiologists Physical Status classification system.

The most common classification in the mechanical diagnosis and therapy for patients with a primary complaint of non-acute knee pain was Spinal Derangement: a retrospective chart review.

Objectives: To preliminarily investigate in patients with a primary complaint of non-acute knee pain for ≥ 1 month: 1) the proportion of patients with non-acute knee pain classified by Mechanical Diagnosis and Therapy (MDT) as Spinal Derangements, 2) the number of sessions taken to identify the concluding classification, and 3) the ability of MDT classifications, demographics, and symptomatic baselines to predict pain reduction at 1-month follow-up.Methods: This study reviewed data from outpatients managed with MDT. For modeling knee pain reduction at the 1-month follow-up, 3 MDT provisional or concluding classifications (Spinal Derangement, Knee Derangement, and Non-Derangement) and the following variables were included: 1) gender, 2) symptom duration, 3) presence of low back pain (LBP), 4) the Japanese Knee Osteoarthritis Measure, 5) average pain intensity at the initial session using a 0-10 numerical rating scale, and 6) the Kellgren-Lawrence grade.Results: Data from 101 patients were extracted. The percentage of patients with the concluding classification of Spinal Derangement was 44.6%. This was greater in those patient's reporting concomitant LBP (p = .002) and without radiographic findings of knee osteoarthritis (p < .001). A concluding classification was determined by the fourth session in 80% of patients. Multiple regression modeling demonstrated that only the concluding classification significantly predicted the knee pain reduction at the 1-month follow-up.Discussion: These findings suggest the importance of careful screening assessments of the lumbar spine and the importance of detecting Derangements throughout the follow-up sessions for patients with a primary complaint of knee pain.

Classifications of temporomandibular disorders and patients' examination protocols - comparative analysis by the convenience of their daily use in clinical practice.

OBJECTIVE: Introduction:The problem of temporomandibular disorders (TMD) is relevant in today's world and is considered one of the most common pathologies causing nonodontogenic pain syndromes of maxillofacial region. The morbidity of temporomandibular disorders is 27 to 76% among patients who seek dental care. There is now a significant number of classifications of TMD, however, clinically convenient, morphologically and pathogenetically substantiated classification of temporomandibular joint's (TMJ) conditions has not yet been developed. Therefore, the patient's examination protocols differ substantially. The aim: To analyze and assess the quality of classifications and examination protocols for the patients with suspected TMD. PATIENTS AND METHODS: Materials and methods: A comparative analysis of 5 TMD classifications and 3 protocols for the examination of patients with suspected TMDs were performed. RESULTS: Review: A comparative analysis of following TMD classifications was conducted: American Academy of Orofacial Pain, Research Diagnostic Criteria for TMD, by B.W.Neville, D.D.Damm, C.M.Allen, J.E.Bouquot, by Christian Köneke, international classification of diseases ICD-10. The analysis of the following protocols for the examination of patients with suspected TMDs was conducted: M. Helkimo index, Hamburg protocol, M. Kleinrok protocol. CONCLUSION: Conclusions: Difficulties in interpreting diagnoses by dentists are caused by ambiguities in classifications, a considerable number of clinical entities and their construction principles. Organ principle of structure has proved to be the most convenient for clinical application. The evaluation protocols are cumbersome and duplicate each other. Owing to the lack of a common opinion about the origin and development of TMD, use of the evaluation protocols is based on the experience of dental practitioners.

Agreement between novice and experienced trachoma graders improves after a single day of didactic training.

BACKGROUND/AIMS: Prevalence estimates and treatment decisions for trachoma are based entirely on ocular clinical examination. The aim of the current study is to demonstrate that ophthalmic assistants can be trained and certified to provide trachoma grading within a single day. METHODS: Conjunctival photographs from an area with endemic trachoma were randomised into two sets of 60 cases. Photographs were graded for trachomatous inflammation-follicular (TF) and trachomatous inflammation-intense (TI) by three experienced graders. Inter-rater reliability of eight ophthalmic assistants and three experienced graders were compared before and after training. RESULTS: The mean κ agreement between the ophthalmic assistants and the consensus grades of the experienced graders for TF was 0.38 (95% CI 0.18 to 0.58) before training, and increased to 0.60 (95% CI 0.42 to 0.78) after training (p=0.07). The mean κ agreement for TI was 0.16 (95% CI 0.02 to 0.30) before training, and increased to 0.39 (95% CI 0.20 to 0.58) after training (p=0.02). CONCLUSION: A single day of training improves agreement between prospective and experienced trachoma graders, and provides the basis for certification of workers who are able to accurately grade trachoma and generate reliable prevalence estimates.

Extraction of Vital Signs from Clinical Notes.

Assessment of vital signs is an essential part of surveillance of critically ill patients to detect condition changes and clinical deterioration. While most modern electronic medical records allow for vitals to be recorded in a structured format, the frequency and quality of what is electronically stored may differ from how often these measures are actually recorded. We created a tool that extracts blood pressure, heart rate, temperature, respiratory rate, blood oxygen saturation, and pain level from nursing and other clinical notes recorded in the course of inpatient care to supplement structured vital sign data.

Inter-Rater Agreement between Trachoma Graders: Comparison of Grades Given in Field Conditions versus Grades from Photographic Review.

PURPOSE: Trachoma surveillance is most commonly performed by direct observation, usually by non-ophthalmologists using the World Health Organization (WHO) simplified grading system. However, conjunctival photographs may offer several benefits over direct clinical observation, including the potential for greater inter-rater agreement. This study assesses whether inter-rater agreement of trachoma grading differs when trained graders review conjunctival photographs compared to when they perform conjunctival examinations in the field. METHODS: Three trained trachoma graders each performed an independent examination of the everted right tarsal conjunctiva of 269 children aged 0-9 years, and then reviewed photographs of these same conjunctivae in a random order. For each eye, the grader documented the presence or absence of follicular trachoma (TF) and intense trachomatous inflammation (TI) according to the WHO simplified grading system. RESULTS: Inter-rater agreement for the grade of TF was significantly higher in the field (kappa coefficient, κ, 0.73, 95% confidence interval, CI 0.67-0.80) than by photographic review (κ = 0.55, 95% CI 0.49-0.63; difference in κ between field grading and photo grading 0.18, 95% CI 0.09-0.26). When field and photographic grades were each assessed as the consensus grade from the three graders, agreement between in-field and photographic graders was high for TF (κ = 0.75, 95% CI 0.68-0.84). CONCLUSIONS: In an area with hyperendemic trachoma, inter-rater agreement was lower for photographic assessment of trachoma than for in-field assessment. However, the trachoma grade reached by a consensus of photographic graders agreed well with the grade given by a consensus of in-field graders.

Developing an acute-physical-examination template for a Tegional EHR system aimed at improving inexperienced physician's documentation.

It is well-established that to increase acceptance of electronic clinical documentation tools, such as electronic health record (EHR) systems, it is important to have a strong relationship between those who document the clinical encounters and those who reaps the benefit of digitalized and more structured documentation. [1] Therefore, templates for EHR systems benefit from being closely related to clinical practice with a strong focus on primarily solving clinical problems. Clinical use as a driver for structured documentation has been the focus of the acute-physical-examination template (APET) development in the North Denmark Region. The template was developed through a participatory design where precision and clarity of documentation was prioritized as well as fast registration. The resulting template has approximately 700 easy accessible input possibilities and will be evaluated in clinical practice in the first quarter of 2013.

Semiología renal y genitourinaria en pediatría: primera parte / Nephrologoy and urology semiology in children: first part

A pesar de los avances tecnológicos, la historia clínica y el examen físico continúan y continuarán siendo la base de un buen enfoque y aproximación diagnóstica correcta, por ésto, la semiología sigue siendo un área muy importante en la medicina. En ésta revisión se plantea una guía sistemática e integral para la evaluación del sistema nefro-urológico en el niño desde las herramienta básicas y fundamentales como la historia clínica, el examen físico con sus componentessemiológicos en lo normal y lo patológico, integrando además los métodos diagnósticos de laboratorio e imagen disponibles en la actualidad, para lograr un buen enfoque y aproximación diagnóstica en niños con enfermedad renal.

Despite technological advances, medical history and physical examination remain the foundation of a good approach and correct diagnosis; semiology remains a very important area in medicine. In this review a systematic and comprehensive guide for the evaluation of nephron urological system in children is presented, with emphasis in medical history, physical examination and semiotic aspects, in normal and pathological conditions; additionally laboratory and imaging studies available to achieve a good diagnostic approach in children with renal disease are presented.

Hepatimetria: correlação entre o método clínico e ultra-sonográfico / Liver size: correlation between clinical method and ultrasonography

Introdução: O método clínico é amplamente utilizado para avaliação da hepatimetria, utilizando-se a associaçãodas técnicas de percussão e palpação. Alterações encontradas no exame físico determinam investigações posteriores com exames complementares. Objetivo: Avaliar a correlação da hepatimetria obtida pela semiotécnica de percussão e palpação, com a hepatimetria obtida através da ultra-sonografia. Métodos: Foi realizado um estudo transversal, onde a amostra foi formada por quarenta acadêmicos do Curso de Medicina da Unisul – Tubarão - SC. Os participantes foram submetidos ao exame clínico e ultra-sonográficoabdominal. Resultados: Dos 40 participantes, 20 de cada gênero,a idade média foi de 22,98 (± 2,75) anos. A média final da hepatimetria clínica foi de 9,14 (± 1,99) cm. A diferença das medidas entre os examinadores não foi estatisticamente significativa (p=0,28). A média dahepatimetria obtida através do ultra-som foi de 10,33 (± 2,89) cm. Não foram estatisticamente significativas asdiferenças da hepatimetria entre os gêneros (p=0,11) e entre os biótipos (p=0,082). Para os indivíduos com pesoabaixo de 70Kg o coeficiente de correlação de Pearson foi de 0,75 (IC 95%: 0,23 a 0,78). Para os indivíduoscom peso superior a 70 Kg o coeficiente de correlação de Pearson foi de 0,45 (IC 95%: -0,27 a 0,66). Conclusão: A hepatimetria obtida pelo método clínicoapresenta boa correlação com o método ultrasonográfico, embora subestime o tamanho real do fígado em adultos jovens. A influência das habilidades doexaminador mostram-se nítidas, assim como as características dos pacientes.

Introduction: The clinical method widely is used for evaluation of the liver size.Objectives: To evaluate the correlation of the liver size gotten for the technique semiologic of percussion and palpation, with the liver size obtained byultrasonography. Methods: A transversal study was carried through between-observator, sample was formed by fortyacademics of the Course of Medicine of the Unisul – Tubarão - SC. The participants had been submitted tothe clinical examination and the abdominal ultrasonography. Results: 20 participants had been of each gender,average age were of 22,98 (± 2,75) years. The final average of the clinical liver size was of 9,14 (± 1,99) cm.The difference of the measures between the examiners was not statistically significant (p=0,28). The average ofthe liver size obtained by trasonography was of 10,33 (± 2,89) cm had not been statistically significant the differences of the liver size between genders (p=0,11) and the biotypes (p=0,082). For people which weightbelow of 70Kg we find the following correlation: r = 0,75 (IC 95%: 0,23 0,78). For people which weight above70 kg we find the following correlation r = 0,45 (IC 95%: -0,27 0,66).Conclusion: The liver size obtained by the clinical method presents good correlation with the ultrasonography method, even so underestimate the realsize of the liver in young adults. The influence of the abilities of the examiner reveals clear, as well as thecharacteristics of the patients.

Accuracy of clinical examination findings in the diagnosis of COPD.

OBJECTIVE: Simple diagnostic methods can facilitate the diagnosis of COPD, which is a major public health problem. The objective of this study was to investigate the accuracy of clinical variables in the diagnosis of COPD. METHODS: Patients with COPD and control subjects were prospectively evaluated by two investigators regarding nine clinical variables. The likelihood ratio for the diagnosis of COPD was determined using a logistic regression model. RESULTS: The study comprised 98 patients with COPD (mean age, 62.3+/- 12.3 years; mean FEV1, 48.3 +/- 21.6%) and 102 controls. The likelihood ratios (95% CIs) for the diagnosis of COPD were as follows: 4.75 (2.29-9.82; p < 0.0001) for accessory muscle recruitment; 5.05 (2.72-9.39; p < 0.0001) for pursed-lip breathing; 2.58 (1.45-4.57; p < 0.001) for barrel chest; 3.65 (2.01-6.62; p < 0.0001) for decreased chest expansion; 7.17 (3.75-13.73; p < 0.0001) for reduced breath sounds; 2.17 (1.01-4.67; p < 0.05) for a thoracic index > or = 0.9; 2.36 (1.22-4.58; p < 0.05) for laryngeal height < or = 5.5 cm; 3.44 (1.92-6.16; p < 0.0001) for forced expiratory time > or = 4 s; and 4.78 (2.13-10.70; p < 0.0001) for lower liver edge > or = 4 cm from lower costal edge. Inter-rater reliability for those same variables was, respectively, 0.57, 0.45, 0.62, 0.32, 0.53, 0.32, 0.59, 0.52 and 0.44 (p < 0.0001 for all). CONCLUSIONS: Various clinical examination findings could be used as diagnostic tests for COPD.

Acurácia do exame clínico no diagnóstico da DPOC / Accuracy of clinical examination findings in the diagnosis of COPD

Objetivo: A DPOC é um problema de saúde pública, e métodos diagnósticos simples podem ser úteis para facilitar o diagnóstico desta doença. O objetivo deste estudo foi avaliar a acurácia de variáveis clínicas para o diagnóstico de DPOC. Métodos: Pacientes com DPOC e controles foram prospectivamente avaliados por dois examinadores quanto a nove variáveis clínicas. A razão de verossimilhança para o diagnóstico de DPOC foi determinada utilizando-se o modelo de regressão logística. Resultados: Foram incluídos 98 pacientes com DPOC (idade média, 62,3 ± 12,3 anos; VEF1 médio, 48,3 ± 21,6%) e 102 controles. A razão de verossimilhança e IC95% para o diagnóstico de DPOC foram: 4,75 (2,29-9,82; p < 0,0001) para uso da musculatura acessória; 5,05 (2,72-9,39; p < 0,0001) para respiração com os lábios semicerrados; 2,58 (1,45-4,57; p < 0,001) para tórax em barril; 3,65 (2,01-6,62; p < 0,0001) para redução da expansibilidade torácica; 7,17 (3,75-13,73; p < 0,0001) para redução do murmúrio vesicular; 2,17 (1,01‑4,67; p < 0,05) para índice torácico ≥ 0,9; 2,36 (1,22-4,58; p < 0,05) para comprimento laríngeo ≤ 5,5 cm; 3,44 (1,92‑6,16; p < 0,0001) para tempo expiratório forçado ≥ 4 s; e 4,78 (2,13-10,70; p < 0.0001) para limite inferior do fígado ≥ 4 cm abaixo do rebordo costal. A concordância entre observadores para as mesmas variáveis foi, respectivamente, 0,57, 0,45, 0,62, 0,32, 0,53, 0,32, 0,59, 0,52 e 0,44 (p < 0,0001 para todas). Conclusões: Vários achados do exame clínico podem ser utilizados como testes diagnósticos para DPOC.

Objective: Simple diagnostic methods can facilitate the diagnosis of COPD, which is a major public health problem. The objective of this study was to investigate the accuracy of clinical variables in the diagnosis of COPD. Methods: Patients with COPD and control subjects were prospectively evaluated by two investigators regarding nine clinical variables. The likelihood ratio for the diagnosis of COPD was determined using a logisticregression model. Results: The study comprised 98 patients with COPD (mean age, 62.3± 12.3 years; mean FEV1, 48.3 ± 21.6%) and 102 controls. The likelihood ratios (95% CIs) for the diagnosis of COPD were as follows: 4.75 (2.29-9.82; p < 0.0001) for accessory muscle recruitment; 5.05 (2.72-9.39; p < 0.0001) for pursed-lipbreathing; 2.58 (1.45‑4.57; p < 0.001) for barrel chest; 3.65 (2.01-6.62; p < 0.0001) for decreased chest expansion;7.17 (3.75-13.73; p < 0.0001) for reduced breath sounds; 2.17 (1.01- .67; p < 0.05) for a thoracic index ≥ 0.9; 2.36 (1.22-4.58; p < 0.05) for laryngeal height ≤ 5.5 cm; 3.44 (1.92-6.16; p < 0.0001) for forced expiratory time ≥ 4 s; and 4.78 (2.13-10.70; p < 0.0001) for lower liver edge ≥ 4 cm from lower costal edge. Inter-rater reliability for those same variables was, respectively, 0.57, 0.45, 0.62, 0.32, 0.53, 0.32, 0.59, 0.52 and 0.44 (p < 0.0001 for all). Conclusions: Various clinical examination findings could be used as diagnostic tests for COPD.

Abusive head trauma.

Child physical abuse that results in injury to the head or brain has been described using many terms, including battered child syndrome, whiplash injuries, shaken infant or shaken impact syndrome, and nonmechanistic terms such as abusive head trauma or nonaccidental trauma. These injuries sustained by child abuse victims are discussed in detail in this article, including information about diagnosis, management and outcomes. The use of forensics, the use imaging studies, and associated injuries are also detailed.

Automatic classification of foot examination findings using clinical notes and machine learning.

We examine the feasibility of a machine learning approach to identification of foot examination (FE) findings from the unstructured text of clinical reports. A Support Vector Machine (SVM) based system was constructed to process the text of physical examination sections of in- and out-patient clinical notes to identify if the findings of structural, neurological, and vascular components of a FE revealed normal or abnormal findings or were not assessed. The system was tested on 145 randomly selected patients for each FE component using 10-fold cross validation. The accuracy was 80%, 87% and 88% for structural, neurological, and vascular component classifiers, respectively. Our results indicate that using machine learning to identify FE findings from clinical reports is a viable alternative to manual review and warrants further investigation. This application may improve quality and safety by providing inexpensive and scalable methodology for quality and risk factor assessments at the point of care.

An Apgar score for surgery.

BACKGROUND: Surgical teams have not had a routine, reliable measure of patient condition at the end of an operation. We aimed to develop an Apgar score for the field of surgery, an outcomes score that teams could calculate at the end of any general or vascular surgical procedure to accurately grade a patient's condition and chances of major complications or death. STUDY DESIGN: We derived our surgical score in a retrospective analysis of data from medical records and the National Surgical Quality Improvement Program for 303 randomly selected patients undergoing colectomy at Brigham and Women's Hospital, Boston. The primary outcomes measure was incidence of major complication or death within 30 days of operation. We validated the score in two prospective, randomly selected cohorts: 102 colectomy patients and 767 patients undergoing general or vascular operations at the same institution. RESULTS: A 10-point score based on a patient's estimated amount of blood loss, lowest heart rate, and lowest mean arterial pressure during general or vascular operations was significantly associated with major complications or death within 30 days (p < 0.0001; c-index = 0.72). Of 767 general and vascular surgery patients, 29 (3.8%) had a surgical score

Classification systems for osteonecrosis: an overview.

Currently a number of classification systems for osteonecrosis are in use. The use of different systems often leads to confusion and makes it difficult to compare the results of different methods of treatment. Because the management of osteonecrosis is determined in large part by the stage of the disease, it is important to use an effective and reliable method of staging and classification. This article provides an overview of the systems most commonly used so the reader can better understand and compare the outcome of studies that report their results using different methods of classification. The essential features of the ideal system are outlined to enable the reader to decide which of the available classification systems best meets these goals.