Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination?

Objective: The traditional physical examination of the heart is relatively inaccurate. There is little information regarding whether cardiac hand-carried ultrasound performed by noncardiologists adds to the accuracy of physical examinations. The purpose of this study was to determine whether hand-carried ultrasound can add to the accuracy of hospitalists' cardiac physical examinations.

The rate at which residents learn to use hand-held echocardiography at the bedside.

Purpose: Because there is little information about the training that general internists require to perform hand-carried cardiac ultrasonography (HCU), we studied the rate of learning of a group of medical residents performing HCU after minimal formal training.

Methods: Medical residents on the inpatient services at Johns Hopkins Bayview Medical Center received formal training in HCU consisting of 15-30 minutes of didactic instruction about the principles of echocardiography, followed by ongoing one-on-one instruction in performing HCU and subsequent ongoing one-on-one training from a certified echocardiography technician as they were doing scans. The residents were shown how to position the patient to obtain 2-dimensional echo images from the parasternal short and long axes and apical 4-chamber views, and how to obtain color-flow Doppler images across the mitral and aortic valves.

Validity of a vasculitis activity index for systemic necrotizing vasculitis.

Objective: To establish the validity of an index designed to measure activity in systemic necrotizing vasculitis (SNV).

Methods: The Vasculitis Activity Index (VAI) was designed to incorporate appropriately weighted clinical measurements that reflect disease activity in SNV. We performed a pilot study to guide the modification and subsequent testing of the initial design.

Dyspnea in ambulatory patients with SLE: prevalence, severity, and correlation with incremental exercise testing.

Objective: We sought to determine the prevalence and severity of dyspnea, and to correlate dyspnea with clinical features and exercise limitation in ambulatory patients with systemic lupus erythematosus (SLE).

Methods: Twenty-five consecutive patients were evaluated with a validated pulmonary questionnaire, chest radiograph, 2-dimensional echocardiography, resting pulmonary function tests, and incremental exercise testing.

Results: Dyspnea was reported by 60% (95% CI 39-79) of patients; 20% (95% CI 7-40) had severe dyspnea (inability to dress without dyspnea) and 12% (95% CI 3-31) had moderate dyspnea (dyspnea after walking 100 yards).

Methotrexate and histologic hepatic abnormalities: a meta-analysis.

Study Objective: To determine the risk of liver toxicity from the long-term administration of methotrexate in patients with rheumatoid arthritis or psoriatic arthritis.

Design: A meta-analysis of 15 studies examining the relationship between long-term, low-dose methotrexate administration and biopsy evidence of liver fibrosis.

Patients: A total of 636 patients from 15 studies.

Oral cimetidine improves the accuracy and precision of creatinine clearance in lupus nephritis.

Objective: To determine whether short-term use of oral cimetidine improves the precision of creatinine clearance (CCr) and reduces the overestimation of glomerular filtration rate (GFR) that occurs with this test in patients with lupus nephritis (because creatinine is secreted by injured renal tubular cells).

Design: Double-blind, placebo-controlled, crossover clinical trial.

Patients: Thirteen patients with lupus nephritis with mild renal insufficiency (mean serum creatinine, 230 mumol/L [2.

Serial assessment of glomerular filtration rate in lupus nephropathy.

In patients with lupus nephropathy (LN), previous studies have shown that creatinine clearance (CCr) overestimates true glomerular filtration rate as measured by inulin clearance (CIn), and that among patients the degree of overestimation is highly variable. We sought to determine whether the discrepancy between CCr and CIn remains constant over time (months, years) in each individual patient, and therefore whether serial measurements of CCr reliably reflect the direction and magnitude of change in CIn. Twenty-five patients with LN underwent simultaneous determinations of CCr and CIn performed two to four (mean 3.

Mononeuritis multiplex: the yield of evaluations for occult rheumatic diseases.

We identified 35 patients who had electrodiagnostic evidence of mononeuritis multiplex and did not have diabetes or multiple nerve compressions. Their charts were reviewed to determine the etiologies of the mononeuritis multiplex and to determine how often the laboratory examination revealed a rheumatic disease in patients whose initial history and physical examination did not suggest that a rheumatic disease was present. In 11/35 (31%; CI = 17-49) a disorder capable of causing mononeuritis multiplex was diagnosed before the symptoms of mononeuritis multiplex began.

Fatal infections in systemic lupus erythematosus: the role of opportunistic organisms.

The causes of death were examined in patients with systemic lupus erythematosus (SLE) who were cared for at the University of California, San Francisco and who died after 1969. Of the 44 deaths analyzed, 33 patients had autopsies. Infections were common and often determined to be the cause of death.

Randomized, double-blind, placebo-controlled study of the treatment of the painful shoulder.

The effect of triamcinolone subacromial bursa injection versus naproxen therapy was compared in a randomized, double-blind, placebo-controlled study of 100 patients who had painful shoulders. Outcome was compared using degree of active abduction, pain, limitation of function, and a clinical index that combined equally weighted measures of all of these. In a time-adjusted analysis, triamcinolone was superior to placebo in all clinical variables.

Antinuclear antibody, lupus anticoagulant, and anticardiolipin antibody in women with idiopathic habitual abortion. A controlled, prospective study of forty-four women.

In a controlled, prospective study of 44 consecutive women with idiopathic habitual abortion, only 5% had symptoms of rheumatic disease. Patients did not differ from control subjects in the frequency of positive results on tests for antinuclear antibody or anti-double-stranded DNA. Levels of C3 and C4 were higher in the habitual aborters.

The frequency of lupus anticoagulant in systemic lupus erythematosus. A study of sixty consecutive patients by activated partial thromboplastin time, Russell viper venom time, and anticardiolipin antibody level.

Recent reviews have suggested a higher frequency of the lupus anticoagulant or related antiphospholipid antibodies in patients with systemic lupus erythematosus (21% to 65%) than was found in earlier studies (6% to 18%). In our study of 60 consecutive patients, we found the frequency of the lupus anticoagulant by Russell viper venom time was 6.7% (95% confidence interval, 16.

Clinical response to regional intravenous guanethidine in patients with rheumatoid arthritis.

A novel therapy for rheumatoid arthritis, regional sympathetic blockade using guanethidine, was investigated in 24 patients with active disease. In a randomized double blind short-term (14 days) study, we evaluated the effect of therapy on subjective responses, change in pain, stiffness, and morning stiffness and no objective responses, change in pinch strength, grip strength, and joint tenderness. Compared to placebo, guanethidine produced a decrease in pain (p less than 0.

A computerized summary medical record system can provide more information than the standard medical record.

We assessed the ability of a computerized outpatient medical record (MR) system, the Summary Time-Oriented Record (STOR), to communicate information to clinicians in two randomized single-blind studies. In the first study, physicians were better able to predict their patients' future symptom changes and laboratory test results from outpatient visits to an arthritis clinic when STOR was added to the standard MR than when the standard MR was used alone. In a separate study, the removal of the standard MR did not result in important decrease in the physicians' ability to predict their patients' symptoms and laboratory test results if they had the option of using the full paper record when they thought they needed it.

Choosing the correct unit of analysis in Medical Care experiments.

The statistical methodology of health research experiments published in Lancet, the New England Journal of Medicine, and Medical Care between 1975 and 1980 for the presence or absence of an error of experimental design and analysis was examined. The error is the result of inappropriately using patient-related observations as the unit of analysis to form conclusions about provider behavior or outcomes determined jointly by patients and providers. The error was present in 20 of 28 (71%) health care experiments addressing an issue of health provider professional performance.

Local area networks and the hospital.

Hospital information systems are characterized by their complexity of individual functions, heterogeneity of functions, and dependence upon integration. A distributed computerized information system is well suited to meeting the needs of hospitals. A local area communications network (LACN) removes a major impediment to the use of distributed systems.

A prototype generalized network technology for hospitals: initial implementation.

A demonstration implementation of a distributed data-processing hospital information system using an intelligent local area communications network (LACN) technology is described. This system is operational at the UCSF Medical Center and integrates four heterogeneous, stand-alone minicomputers. The applications systems are PID/Registration, Outpatient Pharmacy, Clinical Laboratory, and Radiology/Medical Records.

Recognition of information in renal biopsies of patients with lupus nephritis.

To evaluate the informational value of renal biopsy in nephritis of systemic lupus erythematosus, we selected the records of 30 patients who had a renal biopsy done and also had a known clinical outcome. Detailed case histories were prepared, and three distinct randomly chosen cases were given to 197 academic rheumatologists. The rheumatologists estimated the probability of future clinical events (worsened serum creatinine, worsened urine protein, renal death, and aggressive therapy) at 3 and 12 months after the biopsy.

The information content from renal biopsy in systemic lupus erythematosus.

We analyzed data for the 12-month period after renal biopsy was done in 130 patients with systemic lupus erythematosus to examine whether renal biopsy provides useful information on the nephritis of systemic lupus erythematosus beyond that clinically available. A stepwise linear regression analysis was used to construct a linear before biopsy model that predicted the change in renal function 12 months after biopsy. The model included serum creatinine, patient age, 24-hour urine protein, a laboratory index of renal activity, antibodies to DNA, urinalysis protein, change in inverse creatinine from 6 weeks before biopsy, and urine light chain protein, and had a squared multiple correlation coefficient (R2) of 0.

Evaluation methodology for ambulatory care information systems.

The central purpose of an ambulatory care information system is to communicate information to the practitioner to facilitate clinical decision making. The clinical decision can be considered the dependent output variable in a process in which the information system, the patient, clinician characteristics and the environment are the independent input variables. Evaluation methodologies must consider there relationships.