First clinical judgment by primary care physicians distinguishes well between nonorganic and organic causes of abdominal or chest pain

Objective: To evaluate the accuracy of a preliminary diagnosis based solely on patient history and physical examination in medical outpatients with abdominal or chest pain. Design: Prospective observational study. Setting: General medical outpatient clinic in a university teaching hospital. Participants: One hundred ninety new, consecutive patients with a mean age of 44 years (SD=14 years, range 30-58 years) with a main complaint of abdominal or chest pain. Measurements and main results: The preliminary diagnosis, established on the basis of patient history and physical examination, was compared with a final diagnosis, obtained after workup at completion of the chart. A nonorganic cause was established in 66 (59%) of 112 patients with abdominal pain and in 65 (83%) of 78 with chest pain. The preliminary diagnosis of "nonorganic” versus "organic” causes was correct in 79% of patients with abdominal pain and in 88% of patients with chest pain. An "undoubted” preliminary diagnosis predicted a correct assessment in all patients with abdominal pain and in all but one patient with chest pain. Overall, only 4 patients (3%) were initially incorrectly diagnosed as having a nonorganic cause of pain rather than an organic cause. In addition, final nonorganic diagnosis (n=131) was compared with long-term follow-up by obtaining information from patients and, if necessary, from treating physicians. Follow-up information, obtained for 71% of these patients after a mean of 29 months (range 18-56 months) identified three other patients that had been misdiagnosed as having abdominal pain of nonorganic causes. Compared with follow-up, the diagnostic accuracy for nonorganic abdominal and chest pain at chart completion was 93% and 98%, respectively. Conclusions: A preliminary diagnosis of nonorganic versus organic abdominal or chest pain based on patient history and physical examination proved remarkably reliable. Accuracy was almost complete in patients with an "undoubted” preliminary diagnosis, suggesting that watchful waiting can be recommended in such case

Salovum Egg Yolk Containing Antisecretory Factor As an Adjunct Therapy in Severe Cholera in Adult Males: A Pilot Study

Cholera involves stimulation of intestinal secretory process in response to cholera toxin leading to profuse watery diarrhoea that might cause death due to dehydration unless timely rehydration therapy is initiated. Efforts to identify and test potential antisecretory agents are ongoing. Antisecretory factor (AF) is a naturally-occurring protein produced in the human secretory organs, including the intestine, with antisectory properties demonstrated in animal and human models of secretory diarrhoea. Salovum egg yolk powder contains proteins with antisecretory properties in a much higher (500 times) concentration than that of normal hen eggs. This is achieved by feeding hens with specially-processed cereals, capable of inducing proteins with antisecretory properties in the yolk. The aim of the study was to examine the effect of Salovum egg yolk powder containing AF in the treatment of adult cholera patients. In an open, randomized controlled trial (pilot study), 40 adult male patients with severe cholera were studied: 20 received standard treatment (oral rehydration solution, antibiotic, and usual hospital diet) plus Salovum egg yolk powder (study group) and 20 received standard treatment alone (control group). All the patients received tablet doxycycline (300 mg) once immediately after randomization. Written informed consent was obtained from each subject before enrollment. The main outcome measures were stool weight and duration of diarrhoea. The demographic and baseline clinical characteristics of the study patients were comparable between the groups. No significant differences were found in the mean stool weight, g/kg of body-weight during the first 24 hours [study vs control group, mean±standard deviation (SD), 218±119 vs 195±136], second 24 hours (mean±SD, 23±39 vs 22±34), and cumulative up to 72 hours (mean±SD, 245±152 vs 218±169). The duration (hours) of diarrhoea after admission in the hospital was also similar in both the groups (mean±SD, 33±14 vs 32±10). No adverse effect was observed. Salovum egg powder containing AF as an adjunct therapy in the treatment of severe cholera could not demonstrate any beneficial effect. Further studies with higher doses of Salovum egg yolk powder might be considered in future to establish its antisecretory effect

Quality assessment of a randomly selected sample of Swiss medical expertises : a pilot study

Background: Considerable criticism has lately been raised by the media regarding the quality of Swiss medical expertises. The present investigation was therefore undertaken to assess the professional quality of Swiss medical expertises. The study was part of a market analysis of medical expertises (MGS study). Methods: A sample of 97 anonymised expertises randomly chosen from a total of 3165, collected in the MGS study over a period of 3 months, were evaluated by an international board of medical experts and reviewers, using a stepwise developed questionnaire. Each expertise was independently evaluated by two experts. Data were then tested for plausibility (obvious errors and misunderstandings). The main outcome was the overall quality rating of the expertise that was graded from 1 (very poor) to 6 (excellent) in analogy to the Swiss school grading system. For analysis and interpretation the grades were divided into sufficient (grades >= 4) and insufficient (grades <4). Results: Overall 19.6% (95% confidence interval: 13.1%; 28.3%) of the expertises were rated to be of insufficient quality. The quality was inversely related to the number of involved medical disciplines, the time relapsed since injury and positively related to the difficulty of the expertise. In addition, expertises in the French and Italian languages were rated superior to those in German. Conclusions: Our results confirm recent criticisms that the professional quality of expertises does not suffice. This is hardly acceptable in face of the financial and personal consequences. There is an obvious need for further research using larger samples and for educational programmes on all levels

Salovum Egg Yolk Containing Antisecretory Factor As an Adjunct Therapy in Severe Cholera in Adult Males: A Pilot Study

Cholera involves stimulation of intestinal secretory process in response to cholera toxin leading to profuse watery diarrhoea that might cause death due to dehydration unless timely rehydration therapy is initiated. Efforts to identify and test potential antisecretory agents are ongoing. Antisecretory factor (AF) is a naturally-occurring protein produced in the human secretory organs, including the intestine, with antisectory properties demonstrated in animal and human models of secretory diarrhoea. Salovum egg yolk powder contains proteins with antisecretory properties in a much higher (500 times) concentration than that of normal hen eggs. This is achieved by feeding hens with specially-processed cereals, capable of inducing proteins with antisecretory properties in the yolk. The aim of the study was to examine the effect of Salovum egg yolk powder containing AF in the treatment of adult cholera patients. In an open, randomized controlled trial (pilot study), 40 adult male patients with severe cholera were studied: 20 received standard treatment (oral rehydration solution, antibiotic, and usual hospital diet) plus Salovum egg yolk powder (study group) and 20 received standard treatment alone (control group). All the patients received tablet doxycycline (300 mg) once immediately after randomization. Written informed consent was obtained from each subject before enrollment. The main outcome measures were stool weight and duration of diarrhoea. The demographic and baseline clinical characteristics of the study patients were comparable between the groups. No significant differences were found in the mean stool weight, g/kg of body-weight during the first 24 hours [study vs control group, mean\ub1standard deviation (SD), 218\ub1119 vs 195\ub1136], second 24 hours (mean\ub1SD, 23\ub139 vs 22\ub134), and cumulative up to 72 hours (mean\ub1SD, 245\ub1152 vs 218\ub1169). The duration (hours) of diarrhoea after admission in the hospital was also similar in both the groups (mean\ub1SD, 33\ub114 vs 32\ub110). No adverse effect was observed. Salovum egg powder containing AF as an adjunct therapy in the treatment of severe cholera could not demonstrate any beneficial effect. Further studies with higher doses of Salovum egg yolk powder might be considered in future to establish its antisecretory effect

Observational Follow-up Study on a Cohort of Children with Severe Pneumonia after Discharge from a Day-care Clinic in Dhaka, Bangladesh

Compliance, morbidity, mortality, and hospitalization during fortnightly follow-up were evaluated by an observational study on a cohort of children with severe and very severe pneumonia after day-care treatment at an urban clinic. The primary outcome measures were proportions of success (compliance) and failure (non-compliance) of follow-up visits at the day-care clinic. In total, 251 children were followed up, with median (IQR) age of 5.0 (3.0-9.0) months, and their compliance dropped from 92% at the first to 85% at the sixth visit. Cough (28%), fever (20%), and rapid breathing (13%) were common morbidities. Successful follow-up visits were possible in 180 (95.2%) and 56 (90.3%) of the children with severe and very severe pneumonia respectively. Eleven (4.4%) needed hospitalization, and four (1.6%) died. Majority ( 4890%) of the children could be successfully followed up; some failed to attend their scheduled follow-up visits due to hospitalization and death. The common morbidities indicate the importance of follow-up for detecting medical problems and early treatment, thus reducing risk of death

Efficacy of partially hydrolyzed guar gum (PHGG) supplemented modified oral rehydration solution in the treatment of severely malnourished children with watery diarrhoea: a randomised double-blind controlled trial

Objectives: To examine whether PHGG added ORS reduce duration of diarrhoea, stool output and enhance weight gain. Methods: In a double-blind controlled clinical trial, 126 malnourished children (weight for length/weight for age &lt; 123 Z-score with or without pedal edema), aged 6 \u2013 36 months with acute diarrhoea &lt;7 days were studied in two treatment groups; 63 received modified WHO ORS (Na 75, K 40, Cl 87, citrate 7, glucose 90 mmol/L) with PHGG 15 g/L (study group); 63 received modified WHO ORS without PHGG (control). Other treatments were similar in both groups. The study protocol was approved by Ethics Committee of icddr,b; the study was carried out at the Dhaka Hospital. Results: The mean duration of diarrhoea (h) was significantly shorter in children of the study group (Study vs. control, mean \ub1 SD, 57 \ub1 31 vs. 75 \ub1 39, p = 0.01). Although there was a trend in stool weight reduction in children receiving ORS with PHGG (study vs. control, stool weight (g), mean \ub1 SD; 1st 24 hour, 854.03 \ub1 532.15 vs. 949.11 \ub1 544.33, p = 0.32; 2nd 24 hour, 579.84 \ub1 466.01 vs. 761.26 \ub1 631.64, p = 0.069; 3rd 24 hour, 385.87 \ub1 454.09 vs. 495.73 \ub1 487.61, p = 0.196), especially in 2nd 24 h period, the difference was not statistically significant. The mean time (day) to attain weight for length 80% of NCHS median without edema was significantly shorter in the study group (study vs. control, mean \ub1 SD, 4.5 \ub1 2.6 vs. 5.7 \ub1 2.8, p = 0.027). Conclusion: PHGG added to ORS substantially reduced duration of diarrhoea. It also enhanced weight gain. Further studies might substantiate to establish its beneficial effect. Clinical trial registration number: NCT0182158

Satisfaction of staff of Swiss insurance companies with medical appraisals: a cross sectional study

<p>Abstract</p> <p>Background</p> <p>A high quality of timely delivered medical appraisals is crucial for social and other insurances to judge possible occupational reintegration measures for patients with medical conditions who are in danger to lose their job. However, little is known about the satisfaction of staff of insurance companies with medical appraisals that they have commissioned.</p> <p>Our questionnaire survey prospectively included all medical appraisals arriving at Swiss insurances from FEB to APR 2008. We assessed the satisfaction of the commissioner with medical appraisals performed by medical assessors. In addition, we evaluated the contribution of several factors to overall satisfaction. The unit of sample was the medical appraisal.</p> <p>Findings</p> <p>We analysed 3165 medical appraisals, 2444 (77%) of them from the public disability insurance, 678 (22%) from private accident, liability and loss of income insurances and 43 (1%) from other insurances. Overall satisfaction of staff of insurance companies in Switzerland was high, but satisfaction of the disability insurance with appraisals was generally lower compared to satisfaction of private insurances. The staff of the disability insurance judged time for preparation as too long in 30%. For staff of private insurance companies 20% of appraisals were not "worth its price". Well-grounded and comprehensible conclusions were the single most important factor for high overall satisfaction (OR 10.1; 95%-CI: 1.1-89.3).</p> <p>Conclusions</p> <p>From the viewpoint of staff of insurance companies, a relevant part of medical appraisals arrives too late. Medical assessors have to take the specific needs of insurances into account, to perform more appraisals with sound conclusions in due time.</p

Medizinische Gutachten in der Schweiz im Jahr 2008 : eine Querschnittstudie zur Marktsituation und Qualitätssicherung

Medizinische Gutachten haben eine wesentliche Funktion zur Beurteilung und Abwicklung von Versicherungsfällen in praktisch allen Sozialversicherungszweigen sowie in den privaten Personen- und Haftpflichtversicherungen. Durch die wachsende Zahl von Invaliditätsfällen, den zunehmenden Finanzdruck auf die Invalidenversicherung sowie die schwierige Objektivierbarkeit von bestimmten, zusehends häufiger vorkommenden Krankheitsbildern oder Unfallfolgen ist die Nachfrage nach medizinischen Gutachten in der Schweiz seit Ende der 90er Jahre stetig angestiegen. Gleichzeitig zeigen frühere Pilotstudien Qualitätsmängel der Begutachtungen auf, und entsprechend hat die öffentliche Diskussion über die Gutachtenqualität zugenommen. Als eine Folge davon ist die Gutachterausbildung in der Schweiz ausgebaut worden. Bis anhin gibt es praktisch keine wissenschaftliche Aufarbeitung, welche Aufschlüsse über Nachfrage, Preisgestaltung und insbesondere Qualitätsbeurteilung medizinischer Gutachten in der Schweiz ermöglicht. Entsprechend soll die durchgeführte Studie eine umfassende Standortbestimmung ergeben, um effiziente Handlungsempfehlungen ableiten zu können. Die vorliegende Studie liefert dazu erste Grundlagen auf der Basis von Untersuchungen für das Jahr 2008