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Background: This study aimed to identify predictors of inappropriate hospital days in a department of internal medicine, as a basis for quality improvement interventions.Methods: The appropriateness of 5665 hospital days contributed by 500 patients admitted to the Department of Internal Medicine, Geneva University Hospitals, Switzerland, was assessed by means of the Appropriateness Evaluation Protocol. Predictor variables included patient's age and sex, manner of admission and discharge, and characteristics of hospital days (weekend, holiday, sequence).Results: Overall, 15% of hospital admissions and 28% of hospital days were rated as inappropriate. In multivariate models, inappropriate hospital days were more frequent among patients whose admission was inappropriate (odds ratio [OR] = 5.3, 95% CI: 3.1-8.4) and among older patients (80-95 years: OR = 3.6, 95% CI: 1.7-7.0, versus <50 years). The likelihood of inappropriateness also increased with each subsequent hospital day, culminating on the day of discharge, regardless of the total length of stay.Conclusions: This study identified both the admission and the discharge processes as important sources of inappropriate hospital use in a department of internal medicine. The oldest patients were also at high risk of remaining in the hospital inappropriately. Surprisingly, long hospital stays did not generate a higher proportion of inappropriate days than short hospital stays. This information proved useful in developing interventions to improve the hospitalization process. [ABSTRACT FROM AUTHOR]

The chronic obstructive pulmonary disease or COPD is a slowly progressive disease whose course is frequently the subject of acute episodes, of variable severity, although, in general, reversible, called acute exacerbations. In the past five years (between 2008 and 2013), seven prognostic scores have been published to try to assess the short-term risk of these acute exacerbations. Their components and characteristics are analysed and commented upon. An Internet program with a detailed compilation of the main features of these scores (www.medhyg.ch/scoredoc) supplements this review.

The chronic obstructive pulmonary disease or COPD will probably be in the year 2020 the third cause of death in the world. It appears therefore appropriate to try to make available tools capable of assessing the prognosis of patients with this disease. In the first part of this series of two papers, the question of the prognosis of stable COPD over several years is addressed. Eight prognostic scores are discussed, all of them published between 2004 and 2012. Their components and characteristics are analysed and commented upon, with, in particular, emphasis on their discriminating power. An Internet program (www.medhyg. ch/scoredoc) supplements this review.

Background: Clinical experience, features of data collection process, or both, affect diagnostic accuracy, but their respective role is unclear. OBJECTIVE, DESIGN: Prospective, observational study, to determine the respective contribution of clinical experience and data collection features to diagnostic accuracy., Methods: Six Internists, 6 second year internal medicine residents, and 6 senior medical students worked up the same 7 cases with a standardized patient. Each encounter was audiotaped and immediately assessed by the subjects who indicated the reasons underlying their data collection. We analyzed the encounters according to diagnostic accuracy, information collected, organ systems explored, diagnoses evaluated, and final decisions made, and we determined predictors of diagnostic accuracy by logistic regression models., Results: Several features significantly predicted diagnostic accuracy after correction for clinical experience: early exploration of correct diagnosis (odds ratio [OR] 24.35) or of relevant diagnostic hypotheses (OR 2.22) to frame clinical data collection, larger number of diagnostic hypotheses evaluated (OR 1.08), and collection of relevant clinical data (OR 1.19)., Conclusion: Some features of data collection and interpretation are related to diagnostic accuracy beyond clinical experience and should be explicitly included in clinical training and modeled by clinical teachers. Thoroughness in data collection should not be considered a privileged way to diagnostic success.

Computer simulation of clinical encounters is increasingly used in clinical settings to train patient work-up. The aim of this prospective, controlled study was to compare the characteristics of data collection and diagnostic exploration of physicians working up cases with a standardized patient and in a computerized simulation. Six clinicians of different clinical experience in internal medicine worked up three cases with a standardized patient and through a computer simulation allowing free inquiry. After each encounter, we asked the subjects to justify the information collected and to comment on their working diagnoses. The characteristics of data collected and working diagnoses generated were assessed and compared, according to the simulation method used. In the computer simulation, physicians limited their data collection and focused earlier and more specifically on information and working diagnoses with high levels of relevance. They reached a similar diagnostic accuracy and made decisions of a similar relevance. Computer simulation with a free-inquiry approach reproduces the data collection and the diagnostic exploration observed in a standardized-patient simulation and promotes an early collection of relevant data. Its contribution to extend the competence of learners in clinical settings should be further evaluated.

Widely prescribed, bisphosphonates inhibit bone resorption. They are not metabolised and have long half-lives. Two cases of osteonecrosis of the jaws have recently been attributed to bisphosphonates at the University Hospital of Geneva. The recent literature reveals more than a hundred similar cases throughout the world. Bone exposure appears spontaneously or after dental care. Treatment of the osteonecrosis is controversial and cure very difficult. This pathology is usually seen in patients on chemotherapy, steroids and i.v. bisphosphonates, but is sometimes seen with low-dose p.o. bisphosphonates. In view of the strong association between bisphosphonate therapy and osteonecrosis of the jaw, specialists have recommended dental and oral evaluation during bisphosphonate therapy as well as for several years after drug discontinuation.

Screening of prostate cancer with PSA is a challenge for the aid to decision. Beside the rather mediocre characteristics of the screening test, there the additional problem of the peculiar biology of this cancer, with its late development and its ability to remain latent for a prolonged period. On the other hand, the treatment (surgery, irradiation) is associated with important side-effects: impotence and urinary leakage. Several studies, which appear to be a form of aid to information than aid to shared decision, have been carried out to analyse the effect of various modes of information on the behaviour of potential candidates to screening of prostate cancer, with the following results: better knowledge of the problem, lower rate of acceptance of PSA testing and trend towards watchful waiting rather than surgery in case of discovery of cancer.

The role model displayed by clinician-teachers influences learning experiences but learners may face various reasoning styles. Our goal was to describe common strategies in clinical data collection displayed by experienced clinician-teachers in internal medicine. We studied six internists heavily involved in teaching while they were working up the same seven cases portrayed by a standardized patient. Each encounter was audio-recorded and replayed to allow the subjects commenting on the purpose and diagnostic hypotheses considered for each piece of information collected. Information and hypotheses elicited by all physicians were considered key items. Although the subjects reached the same final diagnoses, they differed on several characteristics of their data collection process. They also displayed common behaviours, such as: early acquisition of key data (half of them acquired within the first 19 questions asked) through clarification of the patients' complaints and focused data collection; early generation of the final diagnosis (within the first 10 questions asked) and use of diagnostic hypotheses to frame data collection; and summarization of the information at hand during the encounter (at least twice). Whether making teachers explicitly conscious about their own reasoning processes may help them better model and explain their diagnostic approach to specific cases should be assessed in follow-up studies.

The importance of statins in secondary prevention is well established since the 4S, CARE and LIPID studies, their indications being now applied to even normocholesterolemic patients. To date, it is still unclear which statin to choose, and at what dose. A recent study entitled "PROVE IT-TIMI-22" has compared 80 mg of atorvastatin/day to 40 mg of pravastatin/day in early secondary prevention. It appears that the intensive treatment with atorvastatin has been more effective on the LDL-cholesterol levels and has had a more favourable effect on the clinical evolution based on a composite score. We herein propose a critical review of this study and recommend a somewhat cautious attitude before giving high doses of atorvastatin in the secondary prevention of all the patients with coronary heart disease.

Background: Given that there are variations in clinicians' reasoning, methods to elaborate scoring checklists for standardised patient-based assessment need to be valid. The use of data elicited by experts solving problems independently has been advocated as a method of setting performance standards., Aims: To determine the degree of concurrence and common characteristics among items independently elicited by doctors during patient encounters and to assess the number of experts needed to derive reliable performance standards., Methods: Six experienced internists worked-up the same 7 chief complaints with standardised patients (SPs). A stimulated recall of the recorded encounter was then performed. The degree of concurrence of the collected history and physical examination information and the generated diagnostic hypotheses was computed. Reliability was derived from generalisability analyses., Results: By case, experts elicited a mean of 114 information items (SD = 15) and generated 30 diagnostic hypotheses (SD = 6). A high concurrence (80-100%) was observed for a mean of 22 information items (20%; SD = 6) and 7 diagnostic hypotheses (24%; SD = 2). More than a third of the 153 highly concurrent information items were clarification questions. At least 3 doctors were needed to obtain a reliability of 0.80 or higher when deriving the scoring checklists., Conclusion: The limited concurrency in data elicited by clinicians during a patient encounter supports the use of high-fidelity methods to develop performance checklists used in SP-based assessment. It also suggests that relying only on information collected to assess clinical competence may not be sufficient. Additional criteria, such as structure and style of work-up, should be further explored.

Introduction: The objective of evidence based medicine (EBM) is to contribute to medical decision making by providing the best possible information in terms of validity and relevance. This allows evaluation in a specific manner of the benefits and risks of a decision., Methods: The limitations and hazards of this approach are discussed in relation to a clinical case where the diagnosis of pulmonary embolism was under consideration. The individual details and the limited availability of some technical procedures illustrate the need to adapt the data of EBM to the circumstances. The choice between two diagnostic tests (d-dimers and ultrasound of the legs) and their optimal timing is analysed with integration of the consequences for the patient of the treatments proposed. This allows discussion of the concept of utility and the use of sensitivity analysis., Conclusions: If EBM is the cornerstone of rational and explicit practise it should also allow for the constraints of real life. Decision analysis, which depends on the same critical demands as EBM but can also take account of the individual features of each patient and test the robustness of a decision, gives a unique opportunity reconcile rigorous reasoning with individualisation of management.

We sought to determine the prevalence of orthostatic hypotension as a cause of syncope in the emergency setting, and describe the characteristics of patients diagnosed with this condition. Blood pressure orthostatic changes were measured prospectively in a standardized fashion up to 10 minutes, or until symptoms occurred, in all consecutive patients with syncope as a chief complaint presenting in the emergency department (ED) of a primary and tertiary care hospital. Patients unable to stand-up were excluded. Hypotension was considered to be the cause of syncope when there was: (1) a decrease in systolic blood pressure (SBP) >or= 20 mm Hg with simultaneous symptoms; (2) a decrease in SBP between 10 and 20 mm Hg, but a SBP or= 20 mm Hg were found in 10% of patients with syncope attributed to other causes. Compared with patients with vasovagal disorder, those with orthostatic hypotension were older; had more comorbid conditions including hypertension, organic heart disease, and abnormal electrocardiogram; were taking more hypotensive medications; and required more frequently hospitalization (P <.01). We concluded that standardized blood pressure measurement in the ED enabled to strongly implicate orthostatic hypotension as a cause of syncope in 24% of patients with this symptom. Drug-related hypotension was the most frequent cause for this disorder., (Copyright 2002, Elsevier Science (USA).)

Objective: To study the role of echocardiography in the stepwise evaluation of syncope., Design: A prospective observational study with an 18 month follow up., Setting: University teaching hospital providing primary and tertiary care., Subjects: 650 consecutive patients with syncope and clinical suspicion of an obstructive valvar lesion, or with syncope not explained by history, physical examination, or a 12 lead ECG, who underwent bidimensional Doppler transthoracic echocardiography., Main Outcome Measures: The causes of syncope were assigned using published diagnostic criteria. Echocardiography was considered diagnostic when confirming a suspected diagnosis, or when revealing occult cardiac disease explaining the syncope., Results: A systolic murmur was identified in 61 of the 650 patients (9%). Severe aortic stenosis was suspected in 20 of these and was confirmed by echocardiography in eight. Follow up excluded further cases of aortic stenosis. In patients with unexplained syncope (n = 155), routine echocardiography showed no abnormalities that established the cause of the syncope. Echocardiography was normal or non-relevant in all patients with a negative cardiac history and a normal ECG (n = 67). In patients with a positive cardiac history or an abnormal ECG (n = 88), echocardiography showed systolic dysfunction (left ventricular ejection fraction < or = 40%) in 24 (27%) and minor non-relevant findings in the remaining 64. Arrhythmias were diagnosed in 12 of the 24 patients with systolic dysfunction (50%), and in 12 of the 64 remaining patients (19%) (p < 0.01)., Conclusions: Echocardiography was most useful for assessing the severity of the underlying cardiac disease and for risk stratification in patients with unexplained syncope but with a positive cardiac history or an abnormal ECG.

To answer the question addressed, two working groups, one made of the staff of a University clinic, the other one composed of practising general internists, have discussed the assets and weaknesses of a University service of Internal Medicine for postgraduate training. The groups agreed on a number of points: patients' characteristics (complexity and co-morbidities), quality of teaching, method acquisition for clinical reasoning, as well as absence of exposure to ambulatory patients and of follow-up. The groups differed in their views related to the lack of training in psychiatry and psychosocial problems or to hospital dysfunctions. Opening of internal medicine to primary care appears to be necessary at the same time as individual qualities among the senior staff are to be developed, such as critical analysis and self-questioning.

Purpose: To determine the diagnostic yield of a standardized sequential evaluation of patients with syncope in a primary care teaching hospital., Patients and Methods: All consecutive patients who presented to the emergency department with syncope as a chief complaint were enrolled. Their evaluation included initial and routine clinical examination, including carotid sinus massage, as well as electrocardiography and basic laboratory testing. Targeted tests, such as echocardiography, were used when a specific entity was suspected clinically. Other cardiovascular tests (24-hour Holter monitoring, ambulatory loop recorder ECG, upright tilt test, and signal-averaged electrocardiography) were performed in patients with unexplained syncope after the initial steps. Electrophysiologic studies were performed in selected patients only as clinically appropriate. Follow-up information on recurrence and mortality were obtained every 6 months for as long as 18 months for 94% (n = 611) of the patients., Results: After the initial clinical evaluation, a suspected cause of syncope was found in 69% (n = 446) of the 650 patients, including neurocardiogenic syncope (n = 234, 36%), orthostatic hypotension (n = 156, 24%), arrhythmia (n = 24, 4%), and other diseases (n = 32, 5%). Of the 67 patients who underwent targeted tests, suspected diagnoses were confirmed in 49 (73%) patients: aortic stenosis (n = 8, 1%), pulmonary embolism (n = 8, 1%), seizures/stroke (n = 30, 5%), and other diseases (n = 3). Extensive cardiovascular workups, which were performed in 122 of the 155 patients in whom syncope remained unexplained after clinical assessment, provided a suspected cause of syncope in only 30 (25%) patients, including arrhythmias in 18 (60%), all of whom had abnormal baseline ECGs. The 18-month mortality was 9% (n = 55, including 8 patients with sudden death); syncope recurred in 15% (n = 95) of the patients., Conclusion: The diagnostic yield of a standardized clinical evaluation of syncope was 76%, greater than reported previously in unselected patients. Electrocardiogram-based risk stratification was useful in guiding the use of specialized cardiovascular tests.

Objective: To develop a simple standardized clinical score to stratify emergency ward patients with clinically suspected pulmonary embolism (PE) into groups with a high, intermediate, or low probability of PE to improve and simplify the diagnostic approach., Methods: Analysis of a database of 1090 consecutive patients admitted to the emergency ward for suspected PE in whom diagnosis of PE was ruled in or out by a standard diagnostic algorithm. Logistic regression was used to predict clinical parameters associated with PE., Results: A total of 296 (27%) of 1090 patients were found to have PE. The optimal estimate of clinical probability was based on 8 variables: recent surgery, previous thromboembolic event, older age, hypocapnia, hypoxemia, tachycardia, band atelectasis, or elevation of a hemidiaphragm on chest x-ray film. A probability score was calculated by adding points assigned to these variables. A cutoff score of 4 best identified patients with low probability of PE. A total of 486 patients (49%) had a low clinical probability of PE (score /=9)., Conclusions: This clinical score, based on easily available and objective variables, provides a standardized assessment of the clinical probability of PE. Applying this score to emergency ward patients suspected of having PE could allow a more effective diagnostic process.

Reliable prediction of adverse outcomes in acute pulmonary embolism may help choose between in-hospital and ambulatory treatment. We aimed to identify predictors of adverse events in patients with pulmonary embolism and to generate a simple risk score for use in clinical settings. We prospectively followed 296 consecutive patients with pulmonary embolism admitted through the emergency ward. Logistic regression was used to predict death, recurrent thromboembolic event, or major bleeding at 3 months. Thirty patients (10.1%) had one or more adverse events during the 3-month follow-up period: 25 patients (8.4%) died, thromboembolic events recurred in 10 patients (3.4%), and major bleeding occurred in 5 patients (1.7%). Factors associated with an adverse outcome in multivariate analysis were cancer, heart failure, previous deep vein thrombosis, systolic blood pressure <100 mmHg, arterial PaO2 <8 kPa, and presence of deep vein thrombosis on ultrasound. A risk score was calculated by adding 2 points for cancer and hypotension, and 1 point each for the other predictors. A score of 2 best identified patients at risk of an adverse outcome in a receiver operating characteristic curve analysis. Of 180 low-risk patients (67.2%) (score < or =2), only 4 experienced an adverse outcome (2.2%), compared to 23 (26.1%) of 88 high-risk patients (score > or =3). A simple risk score based on easily available variables can accurately identify patients with pulmonary embolism at low risk of an adverse outcome. Such a score may be useful for selecting patients with pulmonary embolism eligible for outpatient care.

Evidence-based medicine is a methodological approach giving access to the best information derived from clinical research for an individual patient. It requires the formulation of a question, a strategy to search for the best information, the selection of the latter, its critical appraisal and its application to the patient. The qualities, but also the limitations of this approach are discussed.

Two formats of case presentation are traditionally used for teaching problem-solving skills: clinical vignette or chief complaint formats. While the first one is more commonly used, it does not completely reflect the actual problem-solving process during a real encounter, which may hamper the learners to integrate separately acquired data gathering skills into their reasoning process and affect their diagnostic performance in practice. The present study compared diagnostic accuracy when the reasoning stimulus was a case vignette containing all diagnostic information versus the patient's chief complaint only. Forty-two medical students, 53 residents and 60 general internists participated in the study. Diagnostic accuracy was significantly lower for the chief complaint format at the student, resident, and practitioner levels. Analysis of the data gathered in the chief-complaint format revealed that faulty diagnostic decisions resulted from a failure to gather critical data. The results suggest that data gathering techniques, semiology, and medical reasoning should be trained in association and that this effort should be pursued beyond medical school.