Browsing by Subject "Medical History Taking"

Now showing 1 - 6 of 6
  • Thumbnail Image
    ItemOpen Access
    An international consensus on the appropriate evaluation and treatment for adults with spinal deformity.
    (European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2018-03) Berven, Sigurd H; Kamper, Steven J; Germscheid, Niccole M; Dahl, Benny; Shaffrey, Christopher I; Lenke, Lawrence G; Lewis, Stephen J; Cheung, Kenneth M; Alanay, Ahmet; Ito, Manabu; Polly, David W; Qiu, Yong; de Kleuver, Marinus; AOSpine Knowledge Forum Deformity

    Purpose

    Evaluation and surgical management for adult spinal deformity (ASD) patients varies between health care providers. The purpose of this study is to identify appropriateness of specific approaches and management strategies for the treatment of ASD.

    Methods

    From January to July 2015, the AOSpine Knowledge Deformity Forum performed a modified Delphi survey where 53 experienced deformity surgeons from 24 countries, rated the appropriateness of management strategies for multiple ASD clinical scenarios. Four rounds were performed: three surveys and a face-to-face meeting. Consensus was achieved with ≥70% agreement.

    Results

    Appropriate surgical goals are improvement of function, pain, and neural symptoms. Appropriate preoperative patient evaluation includes recording information on history and comorbidities, and radiographic workup, including long standing films and MRI for all patients. Preoperative pulmonary and cardiac testing and DEXA scan is appropriate for at-risk patients. Intraoperatively, appropriate surgical strategies include long fusions with deformity correction for patients with large deformity and sagittal imbalance, and pelvic fixation for multilevel fusions with large curves, sagittal imbalance, and osteoporosis. Decompression alone is inappropriate in patients with large curves, sagittal imbalance, and progressive deformity. It is inappropriate to fuse to L5 in patients with symptomatic disk degeneration at L5-S1.

    Conclusions

    These results provide guidance for informed decision-making in the evaluation and management of ASD. Appropriate care for ASD, a very diverse spectrum of disease, must be responsive to patient preference and values, and considerations of the care provider, and the healthcare system. A monolithic approach to care should be avoided.
  • Thumbnail Image
    ItemOpen Access
    Cost-effectiveness analysis of the diagnosis of meniscus tears.
    (Am J Sports Med, 2015-01) Mather, Richard C; Garrett, William E; Cole, Brian J; Hussey, Kristen; Bolognesi, Michael P; Lassiter, Tally; Orlando, Lori A
    BACKGROUND: Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy. PURPOSE: To identify the most efficient strategy for the diagnosis of meniscus tears. STUDY DESIGN: Economic and decision analysis; Level of evidence, 1. METHODS: A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER). RESULTS: In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively. CONCLUSION: For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test. CLINICAL RELEVANCE: Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures.
  • Thumbnail Image
    ItemOpen Access
    f-treeGC: a questionnaire-based family tree-creation software for genetic counseling and genome cohort studies.
    (BMC medical genetics, 2017-07-14) Tokutomi, Tomoharu; Fukushima, Akimune; Yamamoto, Kayono; Bansho, Yasushi; Hachiya, Tsuyoshi; Shimizu, Atsushi
    The Tohoku Medical Megabank project aims to create a next-generation personalized healthcare system by conducting large-scale genome-cohort studies involving three generations of local residents in the areas affected by the Great East Japan Earthquake. We collected medical and genomic information for developing a biobank to be used for this healthcare system. We designed a questionnaire-based pedigree-creation software program named "f-treeGC," which enables even less experienced medical practitioners to accurately and rapidly collect family health history and create pedigree charts.f-treeGC may be run on Adobe AIR. Pedigree charts are created in the following manner: 1) At system startup, the client is prompted to provide required information on the presence or absence of children; f-treeGC is capable of creating a pedigree up to three generations. 2) An interviewer fills out a multiple-choice questionnaire on genealogical information. 3) The information requested includes name, age, gender, general status, infertility status, pregnancy status, fetal status, and physical features or health conditions of individuals over three generations. In addition, information regarding the client and the proband, and birth order information, including multiple gestation, custody, multiple individuals, donor or surrogate, adoption, and consanguinity may be included. 4) f-treeGC shows only marriages between first cousins via the overlay function. 5) f-treeGC automatically creates a pedigree chart, and the chart-creation process is visible for inspection on the screen in real time. 6) The genealogical data may be saved as a file in the original format. The created/modified date and time may be changed as required, and the file may be password-protected and/or saved in read-only format. To enable sorting or searching from the database, the file name automatically contains the terms typed into the entry fields, including physical features or health conditions, by default. 7) Alternatively, family histories are collected using a completed foldable interview paper sheet named "f-sheet", which is identical to the questionnaire in f-treeGC.We developed a questionnaire-based family tree-creation software, named f-treeGC, which is fully compliant with international recommendations for standardized human pedigree nomenclature. The present software simplifies the process of collecting family histories and pedigrees, and has a variety of uses, from genome cohort studies or primary care to genetic counseling.
  • Thumbnail Image
    ItemOpen Access
    Protocol for implementation of family health history collection and decision support into primary care using a computerized family health history system.
    (BMC Health Serv Res, 2011-10-11) Orlando, Lori A; Hauser, Elizabeth R; Christianson, Carol; Powell, Karen P; Buchanan, Adam H; Chesnut, Blair; Agbaje, Astrid B; Henrich, Vincent C; Ginsburg, Geoffrey
    BACKGROUND: The CDC's Family History Public Health Initiative encourages adoption and increase awareness of family health history. To meet these goals and develop a personalized medicine implementation science research agenda, the Genomedical Connection is using an implementation research (T3 research) framework to develop and integrate a self-administered computerized family history system with built-in decision support into 2 primary care clinics in North Carolina. METHODS/DESIGN: The family health history system collects a three generation family history on 48 conditions and provides decision support (pedigree and tabular family history, provider recommendation report and patient summary report) for 4 pilot conditions: breast cancer, ovarian cancer, colon cancer, and thrombosis. All adult English-speaking, non-adopted, patients scheduled for well-visits are invited to complete the family health system prior to their appointment. Decision support documents are entered into the medical record and available to provider's prior to the appointment. In order to optimize integration, components were piloted by stakeholders prior to and during implementation. Primary outcomes are change in appropriate testing for hereditary thrombophilia and screening for breast cancer, colon cancer, and ovarian cancer one year after study enrollment. Secondary outcomes include implementation measures related to the benefits and burdens of the family health system and its impact on clinic workflow, patients' risk perception, and intention to change health related behaviors. Outcomes are assessed through chart review, patient surveys at baseline and follow-up, and provider surveys. Clinical validity of the decision support is calculated by comparing its recommendations to those made by a genetic counselor reviewing the same pedigree; and clinical utility is demonstrated through reclassification rates and changes in appropriate screening (the primary outcome). DISCUSSION: This study integrates a computerized family health history system within the context of a routine well-visit appointment to overcome many of the existing barriers to collection and use of family history information by primary care providers. Results of the implementation process, its acceptability to patients and providers, modifications necessary to optimize the system, and impact on clinical care can serve to guide future implementation projects for both family history and other tools of personalized medicine, such as health risk assessments.
  • Thumbnail Image
    ItemOpen Access
    The ABC (age, biomarkers, clinical history) stroke risk score: a biomarker-based risk score for predicting stroke in atrial fibrillation.
    (European heart journal, 2016-05) Hijazi, Ziad; Lindbäck, Johan; Alexander, John H; Hanna, Michael; Held, Claes; Hylek, Elaine M; Lopes, Renato D; Oldgren, Jonas; Siegbahn, Agneta; Stewart, Ralph AH; White, Harvey D; Granger, Christopher B; Wallentin, Lars; ARISTOTLE and STABILITY Investigators

    Aims

    Atrial fibrillation (AF) is associated with an increased risk of stroke, which is currently estimated by clinical characteristics. The cardiac biomarkers N-terminal fragment B-type natriuretic peptide (NT-proBNP) and cardiac troponin high-sensitivity (cTn-hs) are independently associated with risk of stroke in AF. Our objective was to develop and validate a new biomarker-based risk score to improve prognostication of stroke in patients with AF.

    Methods and results

    A new risk score was developed and internally validated in 14 701 patients with AF and biomarkers levels determined at baseline, median follow-up of 1.9 years. Biomarkers and clinical variables significantly contributing to predicting stroke or systemic embolism were assessed by Cox-regression and each variable obtained a weight proportional to the model coefficients. External validation was performed in 1400 patients with AF, median follow-up of 3.4 years. The most important predictors were prior stroke/transient ischaemic attack, NT-proBNP, cTn-hs, and age, which were included in the ABC (Age, Biomarkers, Clinical history) stroke risk score. The ABC-stroke score was well calibrated and yielded higher c-indices than the widely used CHA2DS2-VASc score in both the derivation cohort (0.68 vs. 0.62, P < 0.001) and the external validation cohort (0.66 vs. 0.58, P < 0.001). Moreover, the ABC-stroke score consistently provided higher c-indices in several important subgroups.

    Conclusion

    A novel biomarker-based risk score for predicting stroke in AF was successfully developed and internally validated in a large cohort of patients with AF and further externally validated in an independent AF cohort. The ABC-stroke score performed better than the presently used clinically based risk score and may provide improved decision support in AF.

    Clinicaltrials gov identifier

    NCT00412984, NCT00799903.
  • Thumbnail Image
    ItemOpen Access
    The clinical value of a cluster of patient history and observational findings as a diagnostic support tool for lumbar spine stenosis.
    (Physiotherapy research international : the journal for researchers and clinicians in physical therapy, 2011-09) Cook, Chad; Brown, Christopher; Michael, Keith; Isaacs, Robert; Howes, Cameron; Richardson, William; Roman, Matthew; Hegedus, Eric

    Objective

    The study aims to create a diagnostic support tool to indicate the likelihood of the presence of lumbar spinal stenosis (LSS) using a cluster of elements from the patient history and observational findings.

    Design

    The study is case based and case controlled.

    Setting

    The study was performed in the tertiary care of a medical center.

    Subjects

    There were a total of 1,448 patients who presented with a primary complaint of back pain with or without leg pain.

    Methods

    All patients underwent a standardized clinical examination. The diagnosis of LSS was made by one of two experienced orthopaedic surgeons based on clinical findings and imaging. Data from the patient history and observational findings were then statistically analysed using bivariate analysis and contingency tables.

    Results

    The most diagnostic combination included a cluster of: 1) bilateral symptoms; 2) leg pain more than back pain; 3) pain during walking/standing; 4) pain relief upon sitting; and 5) age>48 years. Failure to meet the condition of any one of five positive examination findings demonstrated a high sensitivity of 0.96 (95% CI=0.94-0.97) and a low negative likelihood ratio (LR-) of 0.19 (95% CI=0.12-0.29). Meeting the condition of four of five examination findings yielded a LR+ of 4.6 (95% CI=2.4-8.9) and a post-test probability of 76%.

    Conclusion

    The high sensitivity of the diagnostic support tool provides the potential to reduce the incidence of unnecessary imaging when the diagnosis of LSS is statistically unlikely. In patients where the condition of four of the five findings was present, the post-test probability of 76% suggests that imaging and further workup are indicated. This is an inexpensive but powerful tool, with a potential to increase diagnostic efficiency and reduce cost by narrowing the indications for imaging.