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Diagnostic strategy
Published in Caroline J Rodgers, Richard Harrington, Helping Hands: An Introduction to Diagnostic Strategy and Clinical Reasoning, 2019
Caroline J Rodgers, Richard Harrington
Some clinical prediction rules are used widely in clinical practice. One example is the modified Wells score. Investigations are used alongside history and examination and not in place of them. Knowing when to request a test (and why) is a skill. The modified Wells scores for DVT and pulmonary embolism (PE) help to give an indication of the pretest probability that a patient has those conditions by assigning a score to the presence of certain risk factors and to whether there is an alternative diagnosis that is as or more likely. The patient is then categorised as either low, moderate or high probability of having a DVT or PE. A knowledge of this pretest probability is valuable since, as the pretest probability increases, a positive test result on investigation is more likely to be a true positive test result.12 Hence in patients with a low probability of DVT/PE, we can avoid unnecessary (and, in the case of a CT pulmonary angiogram, potentially harmful) investigations.
Carpal fractures and dislocations
Published in Charles M Court-Brown, Margaret M McQueen, Marc F Swiontkowski, David Ring, Susan M Friedman, Andrew D Duckworth, Musculoskeletal Trauma in the Elderly, 2016
A proposed solution to this is the use of clinical prediction rules, which have been documented to effectively guide patient management throughout medicine.101,102 The development and use of such rules for the suspected scaphoid fracture, including a combination of demographic and clinical risk factors, could potentially increase the prevalence of true fractures among suspected fractures.103,104 This would result in the use of advanced secondary imaging in higher risk patients, which may improve the diagnostic performance characteristics currently reported. The substantial influence of clinical prediction rules on the probability of a suspected scaphoid fracture has been already demonstrated in studies from Holland79 and Edinburgh.80 The second issue is the lack of a consensus reference standard for confirming a fracture,105,106 which means that an alternative method for calculating diagnostic performance characteristics (latent class analysis) is required.78,107
Prognosis: Studies of disease course and outcomes
Published in Milos Jenicek, Foundations of Evidence-Based Medicine, 2019
Clinical prediction rules (syn. clinical decision rules) are tools that assist practitioners by estimating the probability either of a diagnostic outcome or of a prognostic outcome.78 A clinical prediction rule is defined as a ‘decision-making tool for clinicians that includes three or more variables obtained from the history, physical examination, or simple diagnostic tests and that either provided the probability of an outcome or suggested a diagnostic or therapeutic course of action’.79 Clinical prediction tools belong therefore to both diagnosis and prognosis.80 For example the Ottawa Ankle Rules81 is a prediction tool that should help clinicians decide if a patient with an ankle injury evaluated in an emergency department needs ankle x-ray series or not: ‘An ankle x-ray series is required only if there is any pain in the malleolar zone and any of these findings:Bone tenderness at the posterior edge or tip of the lateral malleolus,orBone tenderness at the posterior edge or tip of medial malleolus,orInability to bear weight both immediately and in emergency department’.80,81
A systematic review and meta-analysis of diagnostic delay in pulmonary embolism
Published in European Journal of General Practice, 2022
R. van Maanen, E. M. Trinks-Roerdink, F. H. Rutten, G. J. Geersing
Pulmonary embolism (PE) is the most serious condition within the spectrum of venous thromboembolic (VTE) conditions, given its associated high mortality rate, as well as its related morbidity and frequent hospitalisation [1,2]. Prompt and early recognition of PE is thus paramount. Clinical prediction rules – such as the Wells criteria, Geneva rule or YEARS algorithm – can assist physicians in diagnosing PE in suspected patients [3–5]. However, these rules are useful only when the physician has a clinical suspicion of PE. It can be extremely challenging to diagnose PE on time because symptoms of PE can differ widely in severity, and are often non-specific [6,7]. In some patients ultimately diagnosed with PE, the suspicion either never arose or occurred only after multiple consultations. For example, the so-called ‘classical’ PE-triad of chest pain, dyspnoea, and haemoptysis occurs in less than 10% of patients [8].
Manual therapists’ beliefs and use of spinal thrust joint manipulation
Published in European Journal of Physiotherapy, 2022
Hendrikus Antonius (Rik) Kranenburg, Maarten A. Schmitt, Emilio J. Puentedura, Cees P. van der Schans, Nicola R. Heneghan, Nathan Hutting
Thrust Joint Manipulation (TJM) is an intervention widely used by manual therapists, chiropractors and osteopaths, ideally within a multimodal biopsychosocial approach to manage spinal complaints. TJM techniques are characterised as involving a specific high-velocity low-amplitude thrust with the aim of achieving joint cavitation [1]. Evidence, including clinical practice guidelines, supports TJM for all spinal regions for improving patient-reported and performance-based outcomes [2–7]. Although recommended, TJM techniques have been linked with side-effects and, in rare cases, serious adverse events [8–14]. Serious adverse events are mostly reported for the cervical spine (CS) and may precede spinal cord injury or stroke, especially related to TJM in the CS [14,15], and may contribute to clinicians limiting or even abandoning their use of TJM [1,16]. Clinical prediction rules are algorithms that can help predict the probability of a therapeutic outcome or clinical effectiveness of a technique. Knowledge of clinical prediction rules for spinal treatment indications may play a role in using or performing TJM techniques. Although algorithms have been developed to help guide practitioners, they are not a substitute for clinical reasoning.
Predictors of return to work after stroke: a prospective, observational cohort study with 6 months follow-up
Published in Disability and Rehabilitation, 2021
Lucas R. Nascimento, Aline A. Scianni, Louise Ada, Marcela O. Fantauzzi, Tânia L. Hirochi, Luci F. Teixeira-Salmela
Logistic regression was used to identify multivariate predictors of return to work with the level of significance set at p < 0.05. A clinical prediction rule was derived and the predictive accuracy was calculated using positive and negative likelihood ratios (LR+, LR−).