Showing papers on "Clinical prediction rule published in 2002"

A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation.

Abstract: Study design A prospective, cohort study of patients with nonradicular low back pain referred to physical therapy. Objective Develop a clinical prediction rule for identifying patients with low back pain who improve with spinal manipulation. Summary of background data Development of clinical prediction rules for classifying patients with low back pain who are likely to respond to a particular intervention, such as manipulation, would improve clinical decision-making and research. Methods Patients with nonradicular low back pain underwent a standardized examination and then underwent a standardized spinal manipulation treatment program. Success with treatment was determined using percent change in disability scores over three sessions and served as the reference standard for determining the accuracy of examination variables. Examination variables were first analyzed for univariate accuracy in predicting success and then combined into a multivariate clinical prediction rule. Results Seventy-one patients participated. Thirty-two had success with the manipulation intervention. A clinical prediction rule with five variables (symptom duration, fear-avoidance beliefs, lumbar hypomobility, hip internal rotation range of motion, and no symptoms distal to the knee) was identified. The presence of four of five of these variables (positive likelihood ratio = 24.38) increased the probability of success with manipulation from 45% to 95%. Conclusion It appears that patients with low back pain likely to respond to manipulation can be accurately identified before treatment.

Use of a clinical decision rule in combination with D-dimer concentration in diagnostic workup of patients with suspected pulmonary embolism: a prospective management study.

Abstract: Background We designed a diagnostic strategy, based on clinical probability and D-dimer concentration, to select patients who were unlikely to have pulmonary embolism (PE), before further diagnostic workup was performed. The utility and safety of this strategy were evaluated in a prospective management study. Methods Consecutive patients with suspected PE had D-dimer testing and clinical probability assessment with a clinical decision rule. Patients with a low probability and a normal D-dimer concentration ( Results Of the 234 consecutive patients, 26% had the combination of a low probability and normal D-dimer level. During the follow-up period, none of these patients died and 3 patients had recurrent complaints of PE. In these 3 patients, PE was excluded by objective testing. The 3-month thromboembolic risk was therefore 0% (95% confidence interval, 0%-6%). The prevalence of PE in the entire population was 22%. Conclusions The combination of a low clinical probability and a normal D-dimer concentration appears to be a safe method to exclude PE, with a high clinical utility, and is readily accepted by clinicians.

Impact of a Clinical Decision Rule on Hospital Triage of Patients With Suspected Acute Cardiac Ischemia in the Emergency Department

Abstract: ContextEmergency department (ED) physicians often are uncertain about where in the hospital to triage patients with suspected acute cardiac ischemia. Many patients are triaged unnecessarily to intensive or intermediate cardiac care units.ObjectiveTo determine whether use of a clinical decision rule improves physicians' hospital triage decisions for patients with suspected acute cardiac ischemia.Design and SettingProspective before-after impact analysis conducted at a large, urban, US public hospital.ParticipantsConsecutive patients admitted from the ED with suspected acute cardiac ischemia during 2 periods: preintervention group (n = 207 patients enrolled in March 1997) and intervention group (n = 1008 patients enrolled in August-November 1999).InterventionAn adaptation of a previously validated clinical decision rule was adopted as the standard of care in the ED after a 3-month period of pilot testing and training. The rule predicts major cardiac complications within 72 hours after evaluation in the ED and stratifies patients' risk of major complications into 4 groups—high, moderate, low, and very low—according to electrocardiographic findings and presence or absence of 3 clinical predictors in the ED.Main Outcome MeasuresSafety of physicians' triage decisions, defined as the proportion of patients with major cardiac complications who were admitted to inpatient cardiac care beds (coronary care unit or inpatient telemetry unit); efficiency of decisions, defined as the proportion of patients without major complications who were triaged to an ED observation unit or an unmonitored ward.ResultsBy intention-to-treat analysis, efficiency was higher in the intervention group (36%) than the preintervention group (21%) (difference, 15%; 95% confidence interval [CI], 8%-21%; P<.001). Safety was not significantly different (94% in the intervention group vs 89%; difference, 5%; 95% CI, −11% to 39%; P = .57). Subgroup analysis of intervention-group patients showed higher efficiency when physicians actually used the decision rule (38% vs 27%; difference, 11%; 95% CI, 3%-18%; P = .01). Improved efficiency was explained solely by different triage decisions for very low-risk patients. Most surveyed physicians (16/19 [84%]) believed that the decision rule improved patient care.ConclusionsUse of the clinical decision rule had a favorable impact on physicians' hospital triage decisions. Efficiency improved without compromising safety.

The usefulness of clinical features to identify active rickets

Abstract: To develop a clinical prediction rule that could accurately identify children with active rickets in countries where nutritional rickets is common, we prospectively recorded clinical features in 736 Nigerian children aged 18 months and older presenting with leg deformities or inability to walk. We scored radiographs of the wrists and knees for active rickets of the growth plates. Sensitivities and specificities of clinical variables for radiographically active rickets were calculated and, using logistic regression, we derived a clinical prediction rule. The prediction rule was tested in a validation set of 89 children. Wrists and costochondral enlargement were the clinical signs with the best combination of sensitivity (72% and 76%, respectively) and specificity (81% and 64%, respectively) for active rickets. Age < 5 years, height-for-age Z-score < -2, leg pain during walking, wrist enlargement and costochondral enlargement were independently predictive of active rickets (p < 0.01 for each in multivariate model). In the validation set, any three of these clinical features accurately identified 87% of children with active rickets, whereas only 24% of those without active rickets had three or more features. We conclude that clinical features can be used to identify children with active rickets.

The Bleeding Risk Index: a clinical prediction rule to guide the prophylactic use of platelet transfusions in patients with lymphoma or solid tumors

Abstract: BACKGROUND The correlation between platelet count and bleeding has been well described, although no formal methods for applying this information to clinical decisions are available. The authors developed a clinical prediction rule to guide the prophylactic use of platelet transfusions among patients with lymphoma or solid tumors. METHODS The Bleeding Risk Index (BRI) was developed from logistic regression analysis of a randomly selected 750-chemotherapy cycle derivation set using data from Day 1 of cycles. The sensitivity and specificity of a BRI-based prophylaxis strategy were compared in a 512-cycle validation set with two strategies based on initiation of prophylaxis when platelet counts fell below thresholds of 20,000 per μL or 10,000 per μL. RESULTS Factors that were predictive of bleeding included any prior episode of bleeding (odds ratio [OR], 5.6; 95% confidence interval [95% CI], 2.2–14.0), treatment with a drug affecting platelet function (OR, 5.1; 95% CI, 2.0–12.6), bone marrow metastases (OR, 4.3; 95% CI, 1.7–10.8), a baseline platelet count 2 (OR, 3.4; 95% CI, 1.4–8.5), and treatment with agents that were highly toxic to the bone marrow (OR, 2.2; 95% CI, 1.0–5.4). Compared with 20,000 and 10,000 platelet threshold strategies, the BRI-based strategy provided the best trade-off between sensitivity for major bleeding episodes (80%) and specificity for any bleeding (84%). CONCLUSIONS Patients with lymphoma or solid tumors who are at high risk of bleeding can be identified reliably on Day 1 of a chemotherapy cycle. An individualized, BRI-based approach to bleeding prophylaxis provides a highly sensitive and specific alternative to traditional, nonindividualized platelet threshold strategies. Cancer 2002;94:3252–62. © 2002 American Cancer Society. DOI 10.1002/cncr.10603

Validation of a clinical prediction rule to reduce preoperative type and screen procedures

Abstract: Background We have developed a prediction rule for the occurrence of perioperative red blood cell transfusion to help to reduce the number of unnecessary preoperative type and screen procedures. We evaluated the robustness of this prediction rule in patients from another hospital. Methods The rule was retrospectively applied to 1282 consecutive patients (‘validation set') who underwent similar surgical procedures to the patients in the derivation study. The outcome was similarly defined as any allogeneic transfusion on the day of surgery or during the first postoperative day. The predictive value of the rule was assessed using a Receiver Operating Characteristic curve (ROC) and compared with the results of the derivation study. Subsequently, the number of correctly predicted transfusions was compared. Results The patient characteristics did not differ between the two sets, except for the incidence of transfusion (derivation study: 18%; present study: 8%). In the validation set, the ROC area of the prediction rule was 0.78 (95% confidence intervals [CI]: 0.73–0.82), which was within the CI of the ROC area found in the derivation study (0.75; 95% CI: 0.72–0.79). In total, 35% of the type and screen procedures could be omitted (derivation study: 50%), with 13% missed transfused patients (derivation study: 20%). Conclusions After comparing the results of this validation study with that of the derivation study, the prediction rule was robust and may work in other clinics as well.

Surveillance and screening of American cutaneous leishmaniasis by Colombian primary health care workers using a clinical prediction rule.

Abstract: Confirmed cases of American cutaneous leishmaniasis (ACL) and other dermatological diseases were evaluated in Colombia with a clinical prediction rule independently by 3 types of evaluators: community health volunteer (CHV), practical nurse (PN) and programme physician (PP). The adapted prediction rule included 6 variables based upon clinical-historical information. The screening instrument was a rotating tower of coloured squares, one colour for each variable. A score ranging from 0 to 7, and a cutoff point of > or = 4 was selected for ACL classification (sensitivity 94.3%, specificity 53.3% and efficiency 80.3%). Disease classification, total score, and variable-specific score obtained by CHVs and PNs were compared to those obtained by a PP. The impact on case detection in the study area was assessed. Both types of primary health worker had a high agreement with the PP (sensitivity) on the classification of patients with ACL by score, CHV (92.3%) and PN (93.3%). Case detection of ACL increased 3-fold over that observed one year earlier. This screening instrument and prediction rule, when incorporated into a community surveillance programme for ACL, can facilitate greater case detection and appropriate referral for more-specific diagnostic procedures.

Identifying older diabetic patients at risk of poor glycemic control

Abstract: Optimal glycemic control prevents the onset of diabetes complications. Identifying diabetic patients at risk of poor glycemic control could help promoting dedicated interventions. The purpose of this study was to identify predictors of poor short-term and long-term glycemic control in older diabetic in-patients. A total of 1354 older diabetic in-patients consecutively enrolled in a multicenter study formed the training population (retrospective arm); 264 patients consecutively admitted to a ward of general medicine formed the testing population (prospective arm). Glycated hemoglobin (HbA1c) was measured on admission and one year after the discharge in the testing population. Independent correlates of a discharge glycemia ≥ 140 mg/dl in the training population were assessed by logistic regression analysis and a clinical prediction rule was developed. The ability of the prediction rule and that of admission HbA1c to predict discharge glycemia ≥ 140 mg/dl and HbA1c > 7% one year after discharge was assessed in the testing population. Selected admission variables (diastolic arterial pressure 218 mg/dl, history of insulinic or combined hypoglycemic therapy, Charlson's index > 2) were combined to obtain a score predicting a discharge fasting glycemia ≥ 140 mg/dl in the training population. A modified score was obtained by adding 1 if admission HbA1c exceeded 7.8%. The modified score was the best predictor of both discharge glycemia ≥ 140 mg/dl (sensitivity = 79%, specificity = 63%) and 1 year HbA1c > 7% (sensitivity = 72%, specificity = 71%) in the testing population. A simple clinical prediction rule might help identify older diabetic in-patients at risk of both short and long term poor glycemic control.

Can a clinical decision rule decrease antibiotic use in viral meningitis

Abstract: revisit a prior study of children with meningeal signs who came to the emergency department at SophiaChildren’sHospital inRotterdam, theNetherlands, between 1988 and 1998. In the earlier study, the authors developed a prediction rule that identified 35% of patients with meningeal signs who did not require lumbar puncture. The study described in this issue seeks to extend that rule by incorporating cerebrospinal fluid (CSF) results with clinical findings to identify children from whom empiric antibiotic therapy can safely be withheld. It combines both a training set and a validation set from the earlier study to use as a new training set. The final rule is a clinical/blood laboratory test score detailed in the article’s “Methods” section combined with a CSF variable score best described in its footnote to Table 3; the treatment category can be found in Figure 1.