Does introduction of thresholds in decision aids benefit the patient?: Comparison between findings-based and threshold-based diagnostic decision aids.

PURPOSE: To assess how different diagnostic decision aids perform in terms of sensitivity, specificity, and harm. METHODS: Four diagnostic decision aids were compared, as applied to a simulated patient population: a findings-based algorithm following a linear or branched pathway, a serial threshold-based strategy, and a parallel threshold-based strategy. Headache in immune-compromised HIV patients in a developing country was used as an example. Diagnoses included cryptococcal meningitis, cerebral toxoplasmosis, tuberculous meningitis, bacterial meningitis, and malaria. Data were derived from literature and expert opinion. Diagnostic strategies' validity was assessed in terms of sensitivity, specificity, and harm related to mortality and morbidity. Sensitivity analyses and Monte Carlo simulation were performed. RESULTS: The parallel threshold-based approach led to a sensitivity of 92% and a specificity of 65%. Sensitivities of the serial threshold-based approach and the branched and linear algorithms were 47%, 47%, and 74%, respectively, and the specificities were 85%, 95%, and 96%. The parallel threshold-based approach resulted in the least harm, with the serial threshold-based approach, the branched algorithm, and the linear algorithm being associated with 1.56-, 1.44-, and 1.17-times higher harm, respectively. Findings were corroborated by sensitivity and Monte Carlo analyses. CONCLUSION: A threshold-based diagnostic approach is designed to find the optimal trade-off that minimizes expected harm, enhancing sensitivity and lowering specificity when appropriate, as in the given example of a symptom pointing to several life-threatening diseases. Findings-based algorithms, in contrast, solely consider clinical observations. A parallel workup, as opposed to a serial workup, additionally allows for all potential diseases to be reviewed, further reducing false negatives. The parallel threshold-based approach might, however, not be as good in other disease settings.

Body, Disease and Treatment in a Changing World. Latin texts and contexts in ancient and medieval medicine (Proceedings of the ninth International Conference «Ancient Latin Medical Texts», Hulme Hall, University of Manchester, 5th-8th September 2007),

This volume reflects a variegated and fruitful dialogue between classical and medieval philologists and historians of science, philosophy, literature and language as well as of medicine - the diverse range of interests that the history of medicine in the Graeco-Roman world and the medieval West continues to stimulate and draw on. A recurrent theme is the transformation of medical knowledge in different languages, literary forms and cultural milieux. Several papers concern editorial work in progress on unpublished texts, available only in manuscript or early printed editions. Ce recueil met en dialogue des spécialistes des textes médicaux latins de l'Antiquité et du Moyen Âge. Certaines analyses adoptent une approche sociolinguistique, d'autres s'intéressent à des questions de transmission et de réception, d'autres enfin livrent des études sur le lexique médical. Mais toutes concourent à éclairer une histoire culturelle de la médecine qui s'inscrit dans un monde en mutation. With a preface by D. R. Langslow, and contributions by M. Baldin, J. P. Barragán Nieto, P. P. Conde Parrado, D. Crismani, M. Cronier, C. de la Rosa Cubo, A. Ferraces Rodríguez, K.-D. Fischer, P. Gaillard-Seux, A. García González, V. Gitton-Ripoll, G. Haverling, F. Le Blay, B. Maire, G. Marasco, A. I. Martín Ferreira, I. Mazzini, F. Messina, Ph. Mudry, V. Nutton, M. Pardon-Labonnelie, R. Passarella, M. J. Pérez Ibáñez, S. Sconocchia, A. M. Urso, M. E. Vázquez Buján, and H. von Staden.

B-1 Monthly Report of Medical Services Provided under Title XIX of the Social Security Act, February 2012

B-1 Medicaid Reports -- The monthly Medicaid series of eight reports provide summaries of Medicaid eligibles, recipients served, and total payments by county, category of service, and aid category. These reports may also be known as the B-1 Reports. These reports are each available as a PDF for printing or as a CSV file for data analysis. Report Report name IAMM1800-R001--Medically Needy by County - No Spenddown and With Spenddown; IAMM1800-R002--Total Medically Needy, All Other Medicaid, and Grand Total by County; IAMM2200-R002--Monthly Expenditures by Category of Service; IAMM2200-R003--Fiscal YTD Expenditures by Category of Service; IAMM3800-R001--ICF & ICF-MR Vendor Payments by County; IAMM4400-R001--Monthly Expenditures by Eligibility Program; IAMM4400-R002--Monthly Expenditures by Category of Service by Program; IAMM4600-R002--Elderly Waiver Summary by County.

Eight years experience from a skeletal dysplasia referral center in a tertiary hospital in Southern India: A model for the diagnosis and treatment of rare diseases in a developing country.

We report on a series of 514 consecutive diagnoses of skeletal dysplasia made over an 8-year period at a tertiary hospital in Kerala, India. The most common diagnostic groups were dysostosis multiplex group (n = 73) followed by FGFR3 (n = 49) and osteogenesis imperfecta and decreased bone density group (n = 41). Molecular confirmation was obtained in 109 cases. Clinical and radiographic evaluation was obtained in close diagnostic collaboration with expert groups abroad through Internet communication for difficult cases. This has allowed for targeted biochemical and molecular studies leading to the correct identification of rare or novel conditions, which has not only helped affected families by allowing for improved genetic counseling and prenatal diagnosis but also resulted in several scientific contributions. We conclude that (1) the spectrum of genetic bone disease in Kerala, India, is similar to that of other parts of the world, but recessive entities may be more frequent because of widespread consanguinity; (2) prenatal detection of skeletal dysplasias remains relatively rare because of limited access to expert prenatal ultrasound facilities; (3) because of the low accessibility to molecular tests, precise clinical-radiographic phenotyping remains the mainstay of diagnosis and counseling and of gatekeeping to efficient laboratory testing; (4) good phenotyping allows, a significant contribution to the recognition and characterization of novel entities. We suggest that the tight collaboration between a local reference center with dedicated personnel and expert diagnostic networks may be a proficient model to bring current diagnostics to developing countries. © 2014 Wiley Periodicals, Inc.

Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule.

BACKGROUND: Chest pain can be caused by various conditions, with life-threatening cardiac disease being of greatest concern. Prediction scores to rule out coronary artery disease have been developed for use in emergency settings. We developed and validated a simple prediction rule for use in primary care. METHODS: We conducted a cross-sectional diagnostic study in 74 primary care practices in Germany. Primary care physicians recruited all consecutive patients who presented with chest pain (n = 1249) and recorded symptoms and findings for each patient (derivation cohort). An independent expert panel reviewed follow-up data obtained at six weeks and six months on symptoms, investigations, hospital admissions and medications to determine the presence or absence of coronary artery disease. Adjusted odds ratios of relevant variables were used to develop a prediction rule. We calculated measures of diagnostic accuracy for different cut-off values for the prediction scores using data derived from another prospective primary care study (validation cohort). RESULTS: The prediction rule contained five determinants (age/sex, known vascular disease, patient assumes pain is of cardiac origin, pain is worse during exercise, and pain is not reproducible by palpation), with the score ranging from 0 to 5 points. The area under the curve (receiver operating characteristic curve) was 0.87 (95% confidence interval [CI] 0.83-0.91) for the derivation cohort and 0.90 (95% CI 0.87-0.93) for the validation cohort. The best overall discrimination was with a cut-off value of 3 (positive result 3-5 points; negative result <or= 2 points), which had a sensitivity of 87.1% (95% CI 79.9%-94.2%) and a specificity of 80.8% (77.6%-83.9%). INTERPRETATION: The prediction rule for coronary artery disease in primary care proved to be robust in the validation cohort. It can help to rule out coronary artery disease in patients presenting with chest pain in primary care.

B-1 Monthly Report of Medical Services Provided under Title XIX of the Social Security Act, March 2012

B-1 Medicaid Reports -- The monthly Medicaid series of eight reports provide summaries of Medicaid eligibles, recipients served, and total payments by county, category of service, and aid category. These reports may also be known as the B-1 Reports. These reports are each available as a PDF for printing or as a CSV file for data analysis. Report Report name IAMM1800-R001--Medically Needy by County - No Spenddown and With Spenddown; IAMM1800-R002--Total Medically Needy, All Other Medicaid, and Grand Total by County; IAMM2200-R002--Monthly Expenditures by Category of Service; IAMM2200-R003--Fiscal YTD Expenditures by Category of Service; IAMM3800-R001--ICF & ICF-MR Vendor Payments by County; IAMM4400-R001--Monthly Expenditures by Eligibility Program; IAMM4400-R002--Monthly Expenditures by Category of Service by Program; IAMM4600-R002--Elderly Waiver Summary by County.

B-1 Monthly Report of Medical Services Provided under Title XIX of the Social Security Act, April 2012

B-1 Medicaid Reports -- The monthly Medicaid series of eight reports provide summaries of Medicaid eligibles, recipients served, and total payments by county, category of service, and aid category. These reports may also be known as the B-1 Reports. These reports are each available as a PDF for printing or as a CSV file for data analysis. Report Report name IAMM1800-R001--Medically Needy by County - No Spenddown and With Spenddown; IAMM1800-R002--Total Medically Needy, All Other Medicaid, and Grand Total by County; IAMM2200-R002--Monthly Expenditures by Category of Service; IAMM2200-R003--Fiscal YTD Expenditures by Category of Service; IAMM3800-R001--ICF & ICF-MR Vendor Payments by County; IAMM4400-R001--Monthly Expenditures by Eligibility Program; IAMM4400-R002--Monthly Expenditures by Category of Service by Program; IAMM4600-R002--Elderly Waiver Summary by County.

Stability of repeated student evaluations of teaching in the second preclinical year of a medical curriculum

RESUME L'étude de la médecine à la Faculté de l'Université de Lausanne est un cursus de six ans. Depuis la réforme générale du curriculum en octobre 1995, le programme de la deuxième année consacrée à l'étude de l'être humain sain a été transformé. L'enseignement intégré par système ou organe a été introduit en remplaçant l'enseignement par discipline. Parallèlement, un système d'évaluation de l'enseignement par les étudiants a été proposé. Il a été amélioré au fil des années et depuis l'année académique 1998-99, l'évaluation est devenue systémique et régulière. Notre étude présente et compare les résultats des évaluations de l'enseignement et des enseignants de neuf cours intégrés dispensés en deuxième année durant deux années académiques (1998-99 et 1999-2000). Une forte corrélation entre les résultats des deux années consécutives ainsi qu'une importante disparité des estimations à l'intérieure de chacune de deux années ont été observées. Ceci démontre un engagement sérieux des étudiants dans le processus d'évaluation, révèle la pertinence de leur analyse et leur bonne capacité de discernement. L'analyse de nos résultats montre que les évaluations effectuées par les étudiants peuvent constituer une source fiable d'informations et contribuer à l'amélioration du processus d'enseignement.

B-1 Monthly Report of Medical Services Provided under Title XIX of the Social Security Act, May 2012

B-1 Medicaid Reports -- The monthly Medicaid series of eight reports provide summaries of Medicaid eligibles, recipients served, and total payments by county, category of service, and aid category. These reports may also be known as the B-1 Reports. These reports are each available as a PDF for printing or as a CSV file for data analysis. Report Report name IAMM1800-R001--Medically Needy by County - No Spenddown and With Spenddown; IAMM1800-R002--Total Medically Needy, All Other Medicaid, and Grand Total by County; IAMM2200-R002--Monthly Expenditures by Category of Service; IAMM2200-R003--Fiscal YTD Expenditures by Category of Service; IAMM3800-R001--ICF & ICF-MR Vendor Payments by County; IAMM4400-R001--Monthly Expenditures by Eligibility Program; IAMM4400-R002--Monthly Expenditures by Category of Service by Program; IAMM4600-R002--Elderly Waiver Summary by County.

B-1 Monthly Report of Medical Services Provided under Title XIX of the Social Security Act, June 2012

B-1 Medicaid Reports -- The monthly Medicaid series of eight reports provide summaries of Medicaid eligibles, recipients served, and total payments by county, category of service, and aid category. These reports may also be known as the B-1 Reports. These reports are each available as a PDF for printing or as a CSV file for data analysis. Report Report name IAMM1800-R001--Medically Needy by County - No Spenddown and With Spenddown; IAMM1800-R002--Total Medically Needy, All Other Medicaid, and Grand Total by County; IAMM2200-R002--Monthly Expenditures by Category of Service; IAMM2200-R003--Fiscal YTD Expenditures by Category of Service; IAMM3800-R001--ICF & ICF-MR Vendor Payments by County; IAMM4400-R001--Monthly Expenditures by Eligibility Program; IAMM4400-R002--Monthly Expenditures by Category of Service by Program; IAMM4600-R002--Elderly Waiver Summary by County.

B-1 Monthly Report of Medical Services Provided under Title XIX of the Social Security Act, July 2012

B-1 Medicaid Reports -- The monthly Medicaid series of eight reports provide summaries of Medicaid eligibles, recipients served, and total payments by county, category of service, and aid category. These reports may also be known as the B-1 Reports. These reports are each available as a PDF for printing or as a CSV file for data analysis. Report Report name IAMM1800-R001--Medically Needy by County - No Spenddown and With Spenddown; IAMM1800-R002--Total Medically Needy, All Other Medicaid, and Grand Total by County; IAMM2200-R002--Monthly Expenditures by Category of Service; IAMM2200-R003--Fiscal YTD Expenditures by Category of Service; IAMM3800-R001--ICF & ICF-MR Vendor Payments by County; IAMM4400-R001--Monthly Expenditures by Eligibility Program; IAMM4400-R002--Monthly Expenditures by Category of Service by Program; IAMM4600-R002--Elderly Waiver Summary by County.

Telling the truth: medical students' progress with an ethical skill.

BACKGROUND: Truth-telling is a complex task requiring multiple skills in communication, understanding, and empathy. Its application in the context of breaking bad news (BBN) is distressing and problematic if conducted with insufficient skills. PURPOSE: We investigated the long-term influence of a simulated patient-based teaching intervention integrating the learning of communication skills within an ethical reflection on students' ethical attitudes towards truth-telling, perceived competence and comfort in BBN. METHODS: We followed two cohorts of medical students from the preclinical third year to their clinical rotations (fifth year). We analysed their ethical attitudes and level of comfort and competence in BBN before, after the intervention, and during clinical rotations. RESULTS: Students' ethical attitudes towards truth-telling remained stable. Students feeling uncomfortable or incompetent improved their level of perceived comfort or competence after the intervention, but those feeling comfortable or competent became more aware of the difficulty of the situation, and consequently decreased their level of comfort and competence. CONCLUSIONS: Confronting students with a realistic situation and integrating the practice of communication skills within an ethical reflection may be effective in maintaining ethical attitudes towards truth-telling, in developing new skills and increasing awareness about the difficulty and challenges of a BBN situation.