General practitioners' reasoning when considering the diagnosis heart failure: a think-aloud study

BACKGROUND: Diagnosing chronic heart failure is difficult, especially in mild cases or early in the course of the disease, and guidelines are not easily implemented in everyday practice. The aim of this study was to investigate general practitioners' diagnostic reasoning about patients with suspected chronic heart failure in comparison with recommendations in European guidelines. METHODS: Think-aloud technique was used. Fifteen general practitioners reasoned about six case vignettes, representing authentic patients with suspected chronic heart failure. Information about each case was added successively in five steps. The general practitioners said their thoughts aloud while reasoning about the probability of the patient having chronic heart failure, and tried to decide about the diagnosis. Arguments for and against chronic heart failure were analysed and compared to recommendations in guidelines. RESULTS: Information about ejection fraction was the most frequent diagnostic argument, followed by information about cardiac enlargement or pulmonary congestion on chest X-ray. However, in a third of the judgement situations, no information about echocardiography was utilized in the general practitioners' diagnostic reasoning. Only three of the 15 doctors used information about a normal electrocardiography as an argument against chronic heart failure. Information about other cardio-vascular diseases was frequently used as a diagnostic argument. CONCLUSIONS: The clinical information was not utilized to the extent recommended in guidelines. Some implications of our study are that 1) general practitioners need more information about how to utilize echocardiography when diagnosing chronic heart failure, 2) guidelines ought to give more importance to information about other cardio-vascular diseases in the diagnostic reasoning, and 3) guidelines ought to treat the topic of diastolic heart failure in a clearer way

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ARTIKLAR Ragnar Bring: Tro, kyrka och stat G. O. Rosenqvist: Det nytestamentliga budskapets »avmytologisering» och förkunnelsen L. G. Rignell: Den s. k. andra Ebed-Jahvesången. Jes. 49, 1–(7) 13 TEOLOGISK LITTERATUR Henning Lindström: Om människovärdet. Bidrag till en kristen antropologi. Anm. av Rudolf Johannesson Emil Brunner: Das Missverständnis der Kirche. Anm. av Krister Stendahl Gunnar Rosendal: Den apostoliska tron. Betraktelser över den apostoliska trosbekännelsen. Anm. av Benkt-Erik Benktson David Lerch: Isaaks Opferung christlich gedeutet. Eine auslegungsgeschichtliche Untersuchung. Anm. av Bengt Hägglund Das Menschenbild im Lichte des Evangeliums. Festschrift zum 60. Geburtstag von Prof. Dr. Emil Brunner. Anm. av Bengt Hägglund Herrade Mehl-Koehnlein: Lʼhomme selon lʼapôtre Paul. Anm. av Evald Lövestam Joachim Bieneck: Sohn Gottes als Christushezeichnung der Synoptiker. Anm. av Erik Beijer Pierre Bonnard: L’épître de Saint Paul aux Philippiens. Charles Masson : L ’épître de Saint Paul aux Colossiens. Olaf Moe: Til medarbeidere for evangeliet. En tolkning av Paulus’s Brev om gleden (Filipperbrevet). 2. uppl. Anm. av Henrik Ljungman Morton Smith: Tannaitic Parallels to the Gospels. Anm. av Henrik Ljungman Helene Stokar: Sonntagsgesetzgebung. Ein Überblick bis in die Gegenwart. Anm. av Bror Jansson Alfred Müller-Armack: Diagnose unserer Gegenwart. Zur Bestimmung unseres geistesgeschichtlichen Standorts. Anm. av Gotthard Nygren FRÅN DEN TEOLOGISKA SAMTIDEN Leonard Hodgson: »Faith and Order». Lausanne, Edinburgh och Lund Hans Ording dö

Arctic terrestrial hydrology : A synthesis of processes, regional effects, and research challenges

Terrestrial hydrology is central to the Arctic system and its freshwater circulation. Water transport and water constituents vary, however, across a very diverse geography. In this paper, which is a component of the Arctic Freshwater Synthesis, we review the central freshwater processes in the terrestrial Arctic drainage and how they function and change across seven hydrophysiographical regions (Arctic tundra, boreal plains, shield, mountains, grasslands, glaciers/ice caps, and wetlands). We also highlight links between terrestrial hydrology and other components of the Arctic freshwater system. In terms of key processes, snow cover extent and duration is generally decreasing on a pan-Arctic scale, but snow depth is likely to increase in the Arctic tundra. Evapotranspiration will likely increase overall, but as it is coupled to shifts in landscape characteristics, regional changes are uncertain and may vary over time. Streamflow will generally increase with increasing precipitation, but high and low flows may decrease in some regions. Continued permafrost thaw will trigger hydrological change in multiple ways, particularly through increasing connectivity between groundwater and surface water and changing water storage in lakes and soils, which will influence exchange of moisture with the atmosphere. Other effects of hydrological change include increased risks to infrastructure and water resource planning, ecosystem shifts, and growing flows of water, nutrients, sediment, and carbon to the ocean. Coordinated efforts in monitoring, modeling, and processing studies at various scales are required to improve the understanding of change, in particular at the interfaces between hydrology, atmosphere, ecology, resources, and oceans