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Eponyms are honorific terms ascribed to individuals who discovered a sign, test, syndrome, technique, or instrument. Despite some contentions, eponyms continue to be widely ingrained and incorporated into the medical literature and contemporary language. Physical signs are considered unreliable methods alone for detecting deep venous thrombosis (DVT). The accuracy of the majority of these signs is unknown. For those signs that have been studied, there are a number of methodological limitations hindering the ability to draw meaningful conclusions about their accuracy and validity in clinical practice. Nevertheless, some findings when present and used in conjunction with other key signs, symptoms, and aspects of the patients history may be useful in further supporting the clinical suspicion and likelihood of DVT and/or pulmonary embolism (PE) or venothromboembolism (VTE). These signs also provide the means to better recognize the relationship between clinical findings and VTE. The acquisition of historical knowledge about these signs is important as it further enhances our understanding and appreciation of the diagnostic acumen that physicians were required to employ and to diagnose VTE prior to the advent of advanced imaging methods. Described in this paper is a brief overview of thrombosis as enumerated by Rudolf Virchow, and eponymous signs described in the late eighteenth and nineteenth centuries.

Background Percussion is derived from the Latin word to hear and to touch. Percussion of the abdomen is used to detect areas of tenderness, dullness within an area of tenderness suggestive of a mass, shifting dullness representing fluid or blood, splenic, hepatic and bladder enlargement, and free air in the peritoneum. Covered are abdominal signs of percussion attributed as medical eponyms from the time-period beginning in the mid-late nineteenth century. Described is historical information behind the sign, descriptions of the sign, and implication in modern clinical practice. Data sources PubMed, Medline, online Internet word searches, textbooks, and references from other source text. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. Conclusion Percussion signs defined as medical eponyms were important discoveries adopted by physicians prior to the advent of radiographs and other imaging and diagnostic techniques. The signs perfected during this time-period provided important clinical cues as to the presence of air within the peritoneum or rupture of the spleen.

Background An eponym in clinical medicine is an honorific term ascribed to a person(s) who may have initially discovered or described a device, procedure, anatomical part, treatment, disease, symptom, syndrome, or sign found on physical examination. Signs, although often lacking sufficient sensitivity and specificity, assist in some cases to differentiate and diagnose disease. With the advent of advanced technological tools in radiological imaging and diagnostic testing, the importance of inspection, the initial steps taught during the physical examination, is often overlooked or given only cursory attention. Nevertheless, in the era of evidence-based and cost-effective medicine, it becomes compelling, and we contend that a meticulously performed history and physical examination, applying the basic tenets of inspection, remains paramount prior to obtaining appropriate diagnostic tests. Data sources PubMed, Medline, online Internet word searches and bibliographies from source text and textbooks. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. Conclusions We describe the historical aspect, clinical application, and performance of medical eponymous signs of inspection found on physical examination during the 18th to 20th centuries.

There is no recent comprehensive overview of contemporary clinical trials assessing short and long-term outcomes in patients with acute coronary syndrome (ACS). This paper reviews factors from recent clinical trials that influenced prognosis in patients with ACS. Cochrane and PubMed databases were screened systematically for clinical trials published in the English literature reporting on ACS prognosis. Two authors independently screened titles, abstracts, and full text. Studies meeting inclusion criteria evaluated the impact of modern practice on prognosis. In vitro and animal models studies, conference abstracts, imaging studies, and review articles were excluded. Disagreement in inclusion criteria was resolved by consensus. A large study of 8,859 patients showed no difference in all-cause mortality between 31 days and 2 years in patients with ST segment elevation myocardial infarction (STEMI) compared to those with non-ST segment elevation myocardial infarction (NSTEMI) or stable ischemic heart disease (SIHD). Other studies showed a significant increase in all-cause mortality in patients with STEMI within the first 30 days, with NSTEMI patients exhibiting a higher mortality rate compared to those with SIHD during the 2-year follow-up period. Our review found that women have a poorer short-term prognosis compared to men. Additionally, reports from patients receiving comprehensive and coordinated care showed longer survival rates. In view of the improved prognosis demonstrated for patients suffering from ACS, assessing prognosis in patients represents a formidable task in modern practice. Our review highlights the need for further evidence-based studies evaluating long-term outcomes on diagnostic and treatment strategies.

We read with interest the case reported by Robustell-Test et al. titled "A blinking knee: Quincke's sign as a reaction to insect bite in a chronic lymphocytic leukemia (CLL) patient".1 A variety of cutaneous lesions including plaques, bullae, dermatitis, and keratoderma have been described as causing Quincke, Quincke-like, and pseudo-Quincke signs with a blanching and/or pulsatile appearance.

Historical information about Carl Jakob Christian Adolph Gerhardt (1833–1902) has been previously discussed under the section pericarditis, where he described another sign which bears his namesake. Gerhardt found in 96 autopsies in children, thrombosis of the cerebral sinus in 7, all occurring in children less than 6 months of age. In his paper “Ueber Hirnsinusthrombosis bei Kindern” (about cerebral sinus thrombosis in children), he described in detail his observations in three of these children (Table 1, Fig. 1): Gerhardt also found that the external jugular vein on the thrombosed side is less prominent during inspiration [1]. Thus, Gerhardt sign refers to a collapsed internal jugular vein in cases of cerebral venous sinus thrombosis.

Signs of aortic and tricuspid insufficiency murmurs are covered in Chapters “ Aortic Regurgitation Murmurs” and “ Tricuspid Insufficiency Murmurs.” Herein are reviewed those remaining signs detected through auscultation, maneuvers, sphygmomanometer, or radiographic techniques. Auscultatory signs include murmurs caused by a ventricular septal defect (Roger) or sounds identified in mitral stenosis (Fraentzel). Other findings include methods used to differentiate radiating aortic murmur from those arising in carotid stenosis (Riesman), distinguishing functional from organic aortic insufficiency murmurs (Loewenberg), and determining which phase of the cardiac cycle a murmur is present (Farfel). Suzman described a maneuver to accentuate the superficial collateral veins in patients with coarctation of aorta. Goetz, through an intravenous contrast technique, radiographically visualized a patent ductus arteriosus. Some of these findings remain clinically relevant as bedside techniques. Recognized are physicians and their honorary signs as told through historical information regarding their character, contributions, and accomplishments to medicine and beyond. The signs are reported sequentially based on the date of their original publication.

Atherosclerosis is the pathological process caused by a variety of factors leading to the progressive accumulation of plaque within the arterial wall. Through observation, palpation, percussion, maneuvers, and instruments (sphygmomanometer, thermometer, and electrocardiogram), physicians identified signs, eponymously named to honor their contributions, to detect atherosclerosis and its consequences—angina pectoris and myocardial infarction. Determination of electrocardiographic patterns provides the means to assist in the diagnosis of myocardial infarction, impeding myocardial infarction involving the left anterior descending artery, and myocardial infarction in patients with preexisting left bundle branch block. Clarified are misconceptions regarding when and by whom the gestures of myocardial ischemia and infarct were described and their limited utility in clinical practice. Signs of atherosclerotic heart disease lack sufficient sensitivity to be routinely used in diagnosis. Nevertheless, they are important to understand as they provide an in-depth understanding and insight into the pathophysiology of disease. Reviewed is brief historical information of the person and original description of their sign for atherosclerosis and ischemic heart disease.

Auscultation is the most widely utilized skill employed during the physical examination in patients with acute and chronic pericarditis as physicians search to detect a pericardial friction rub, the pathognomonic sign of this disease. Auscultation is derived from the Latin word auscultare to listen or hear with attention. The word “auscultation” was coined by John Forbes (1787–1861) to describe the method of placing the ear directly against the chest wall. Although Rene Laennec (1781–1826) introduced the stethoscope in 1817 as a method of indirect auscultation, he applied this apparatus primarily in the study of lungs and breath sounds coining such terms as “crepitation, pectoriloquy, and aegophony”. Interestingly, it was Jean-Baptiste Bouillaud (1796–1881) in 1824 who is credited for using auscultation as a means for diagnosing diseases of the heart. We begin our discussion on auscultatory sounds of pericarditis by first tracing the origins of the pathognomonic sign of pericarditis, the pericardial friction rub “Skinner, The origin of medical terms. The Williams & Wilkins Company, Baltimore, 1949”.

A multitude of cardiac and peripheral phenomena, eponymously ascribed as signs, have been described in aortic regurgitation (AR) to honor physicians’ contributions to medicine. They were identified based on applying the bedside skills of observation, auscultation, palpation, maneuvers, and the sphygmomanometer. These bedside signs have diminished in use since the advent of echocardiographic and other imaging techniques of the heart. With the exception of Corrigan, Duroziez, and Hill signs, they have not been well studied and gaps remain in knowledge regarding evidence of their applicability in clinical practice. In general, for those signs which have been studied, there are a number of limitations with studies such as selection bias, inconsistent case definition and reference standard, and wide ranges of disease severities. Additionally, there is a paucity of data assessing the relationship between a sign and disease severity. Despite these shortcomings, we contend that these signs should be taught since they impart an appreciation for the keen insights applied by physicians in recognizing or eliciting them on physical examination. They also further enhance our understanding about the pathophysiology of disease and provide opportunities for further investigation. Described in this chapter is brief historical information of the person who reported the sign, its original description, and if known, its sensitivity, specificity, and validity in clinical practice. The name for the description of this pathological finding affecting the aortic valve has changed over the years and has encompassed such terms as retroversion of the valves, incompetence, insufficiency, and regurgitation. It is understood that each term is meant to describe the condition by which the aortic valves do not close tightly causing blood to flow back into the left ventricle during diastole.

Prior to the advent of advanced imaging techniques, physicians devised a variety of physical examination maneuvers, described as signs of medical eponyms, as methods to detect lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) or venothromboembolism (VTE). Eponyms are present in the medical literature because they often reflect a simpler and concise way of describing a phenomenon. They are honorific terms ascribed to individuals for their accomplishments, which may include identifying such things as a disease, structure, sign, test, procedure, syndrome, maneuver, medical device, or surgical technique. Eponyms are derived from the name of a person, but not necessarily the first, who reported, described, or significantly contributed to the clinical understanding of the occurrence. The use of eponyms remains controversial and important questions have been raised regarding their appropriateness. Although there have been instances where eponyms were abandoned, the remainder are by and large embedded within the established and contemporary medical literature making their disappearance unlikely.

Described in this section are three signs that may be found on the cardiovascular examination in patients with tuberculosis, malignancy, and in relation to anatomical changes in the right atrium. Of these signs, only the Chiari network has been the most thoroughly studied. In fact, we are unaware of any studies which evaluated the utility of Grossman or Gordon signs, which used percussion of the chest wall to detect heart size in the assessment of patients with tuberculosis or malignancy. We believe that these signs are useful to learn as they provide keen insights into how physicians identified and proposed disease pathogenesis based on key clinical findings.

A variety of signs have since been described from the time of Charcot as methods to diagnose peripheral arterial disease (PAD) or arterial injury. These signs employed the physical examination skills of observation, auscultation, palpation, or passive and active movements. Signs, also referred to in some cases as tests, were designed and described by physicians possessing keen insight and knowledge of disease pathogenesis. They were so named eponymously to honor physicians’ accomplishments. These signs are easy to perform and remain a relevant aspect of the noninvasive bedside assessment of PAD or injury. The accuracy of these signs in clinical practice is either unknown or has not been further studied but, when present, is more commonly identified in patients with more advanced disease. Understanding the historical content behind these signs provides clinicians’ background information of these physicians’ accomplishments and an appreciation of bedside methods devised in diagnosis. Knowledge of these simple bedside maneuvers enhances physicians’ diagnostic acumen, providing clues to the presence of PAD.

© The Author(s) 2020.Born in 1884 in Balıkesir, Turkey, Ömer Seyfettin was a leading figure among modern Turkish short story writers whose death in 1920 at the age of 36 led to long-term speculations about his fatal illness. In order to pay homage to his memory in the centennial of his death and to shed light on his later medical condition, this paper seeks to reexamine his last days from a medico-historical perspective. Our findings indicate that there was a notable decline in his health occurring after 1917 when he was confined to social isolation. A carbuncle was diagnosed in his posterior neck when he was 35-years of age and not satisfactorily treated. In late February 1920, he developed progressive symptoms over two weeks consisting initially of a headache, followed by fever, delirium, hallucinations, and diplopia. These clinical signs and symptoms are clinically suggestive of a septic encephalopathy presumably caused by staphylococcus aureus infection secondary to the carbuncle, or perhaps by one of the myriad causes of viral meningoencephalitis.

BACKGROUND Prior to the advent of modern imaging techniques, maneuvers were performed as part of the physical examination to further assess pathological findings or an acute abdomen and to further improve clinicians' diagnostic acumen to identify the site and cause of disease. Maneuvers such as changing the position of the patient, extremity, or displacing through pressure a particular organ or structure from its original position are typically used to exacerbate or elicit pain. Some of these techniques, also referred to as special tests, are ascribed as medical eponym signs. DATA SOURCES PubMed, Medline, online Internet word searches, textbooks and references from other source text. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. CONCLUSION These active and passive maneuvers of the abdomen, reported as medical signs, have variable performance in medical practice. The lack of diagnostic accuracy may be attributed to confounders such as the position of the organ, modification of the original technique, or lack of performance of the maneuver as originally intended.

Purpose The Healthy Work Place (HWP) study investigated methods to improve clinicians’ dissatisfaction and burnout. The purpose of this paper is to identify factors that influenced study enrollment and completion and assess effects of initial clinic site enrollment rates on clinician outcomes, including satisfaction, burnout, stress and intent to leave practice. Design/methodology/approach In total, 144 primary care clinicians (general internists, family physicians, nurse practitioners and physician assistants) at 14 primary care clinics were analyzed. Findings In total, 72 clinicians enrolled in the study and completed the first survey (50 percent enrollment rate). Of these, 10 did not complete the second survey (86 percent completion rate). Gender, type, burnout, stress and intervention did not significantly affect survey completion. Hence, widespread agreement about most moral/ethical issues (72 percent vs 22 percent; p=0.0060) and general agreement on treatment methods (81 percent vs 50 percent; p=0.0490) were reported by providers that completed both surveys as opposed to just the initial survey. Providers with high initial clinic site enrollment rates (=50 percent providers) obtained better outcomes, including improvements in or no worsening of satisfaction (odds ratio (OR)=19.16; p=0.0217) and burnout (OR=6.24; p=0.0418). Social implications More providers experiencing workplace agreement completed the initial and final surveys, and providers at sites with higher initial enrollment rates obtained better outcomes including a higher rate of improvement or no worsening of job satisfaction and burnout. Originality/value There is limited research on clinicians’ workplace and other factors that influence their participation in survey-based studies. The findings help us to understand how these factors may affect quality of data collecting and outcome. Thus, the study provides us insight for improvement of quality in primary care.

Flushing disorders with involvement of the gastrointestinal tract represent a heterogeneous group of conditions. In part 1 of this review series, neuroendocrine tumors (NET), mast cell activation disorders (MCAD), and hyperbasophilia were discussed. In this section we discuss the remaining flushing disorders which primarily or secondarily involve the gastrointestinal tract. This includes dumping syndrome, mesenteric traction syndrome, rosacea, hyperthyroidism and thyroid storm, anaphylaxis, panic disorders, paroxysmal extreme pain disorder, and food, alcohol and medications. With the exception of paroxysmal pain disorders, panic disorders and some medications, these disorders presents with dry flushing. A detailed and comprehensive family, social, medical and surgical history, as well as recognizing the presence of other systemic symptoms are important in distinguishing the different disease that cause flushing with gastrointestinal symptoms.

To determine the effectiveness of the muscarinic receptor antagonist solifenacin (VESIcare®) in the treatment of postvoid dribbling (PVD). We carried out a multicenter, 12-week, double-blind, randomized, placebo-controlled, parallel design study. Between 2012 and 2015, a total of 118 women (age 18–89 years) with PVD at least twice/weekly, were randomized to receive solifenacin (5 mg; n = 58) or placebo (n = 60) once daily. The primary outcome was the percentage reduction in PVD episodes. Secondary outcomes included the percentage of patients with ≥50% reduction in PVD episodes and changes in quality of life. There were no differences in either the primary or secondary outcome variables. Subgroup analysis, based on those with more severe disease (>10 PVD episodes/week), showed a greater and significant percentage reduction in the frequency of PVD episodes per day (60.3% vs 32.1%; p = 0.035) and a higher percentage of patients showing ≥50% reduction in the frequency of PVD episodes with solifenacin (68.1% vs 45.8%; p = 0.0476). A significant solifenacin effect occurred at week 2 and continued through week 12 for the subgroup. For solifenacin, PVD reduction was the same for the entire cohort and subgroup, whereas for placebo, it was 10% lower in the subgroup, declining from 42% to 32%. There were no differences in PVD outcomes between the solifenacin and placebo groups. Solifenacin may play a role in treating women with the most severe symptoms. Because of the powerful placebo response seen in this study, behavior-based interventions may be useful for treating PVD.

Administrative data are frequently used to identify venous thromboembolism (VTE) for research and quality reporting. However, the validity of these codes, particularly in outpatients, has not been well-established. To determine how well International Classification of Diseases, Ninth Revision (ICD-9) codes for VTE predict chart-confirmed acute VTE in inpatient and outpatients. We selected 4642 adults with an incident ICD-9 diagnosis of VTE between years 2004 and 2010 from the Cardiovascular Research Network Venous Thromboembolism cohort study. Medical charts were reviewed to determine validity of events. Positive predictive values (PPVs) of ICD-9 codes were calculated as the number of chart-validated VTE events divided by the number with specific VTE codes. Analyses were stratified by VTE type [pulmonary embolism (PE), deep venous thrombosis (DVT)], code position (primary, secondary), and setting [hospital/emergency department (ED), outpatient]. The PPV for any diagnosis of VTE was 64.6% for hospital/ED patients and 30.9% for outpatients. Primary diagnosis codes from hospital/ED patients were more likely to represent acute VTE than secondary diagnosis codes (78.9% vs. 44.4%, P

Background: Consensus for an operational definition of post-exertion malaise (PEM) and which symptoms best characterize PEM has not been established and may be due to variability within and between studies.Purpose: Determine the magnitude of the effect of maximal and submaximal physical exertion on multiple myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) symptoms that are associated with PEM and explore variability among two studies in which mood, fatigue, and pain symptoms were measured before and after exercise.Methods: Symptoms were measured before, and 48 and 72 hours after exercise in study 1 (ME/CFS = 13; Controls = 11) and before and 24 hours after exercise in study 2 (ME/CFS = 15, Controls = 15). Between-study variability was examined by comparing Hedges d effect sizes (95% CI) from studies 1 and 2. Within-patient group variability was examined via inspection of dot density plots.Results: In study 1, large increases in general fatigue (Δ = 1.05), reduced motivation (Δ = 0.93), ...

Fothergill and Carnett signs are used to distinguish intrabdominal from abdominal wall diseases. These bedside techniques may be useful in distinguishing intrabdominal from an abdominal wall cause of disease. Timely and accurate diagnosis of rectus sheath hematoma in at risk patients in the appropriate clinical setting is important because of the associated morbidity and mortality associated with this condition. Diagnosis requires an accurate and thorough history and bedside physical examination and performance of these maneuvers as originally described.

Background Studies using administrative data commonly rely on diagnosis codes to identify venous thromboembolism (VTE) events. Our objective was to assess the validity of using International Classification of Disease, 9th Revision (ICD-9) codes in identifying recurrent VTE. Materials and methods Among 5497 adults with confirmed incident VTE from four healthcare delivery systems in the Cardiovascular Research Network (CVRN), we identified all subsequent inpatient, emergency department (ED), and ambulatory clinical encounters associated with an ICD-9 code for VTE (combined with relevant radiology procedure codes for inpatient/ED VTE codes in the secondary discharge position or outpatient codes) during the follow-up period. Medical records were reviewed using standardized diagnostic criteria to assess for the presence of new, recurrent VTE. The positive predictive value (PPV) of codes was calculated as the number of valid events divided by total encounters. Results We identified 2397 encounters that were considered potential recurrent VTE by ICD-9 codes. However, only 31.1% (95%CI: 29.3–33.0%) of encounters were verified by reviewers as true recurrent VTE. Hospital or ED encounters with VTE codes in the primary position were more likely to represent valid recurrent VTE (PPV 61.3%, 95%CI: 56.7–66.3%) than codes in secondary positions (PPV 35.4%, 95%CI: 31.9–39.3%), or outpatient codes (PPV 20.3%, 95%CI: 18.3–22.5%). PPV was low for all VTE types (29.9% for pulmonary embolism, 38.3% for lower and 37.7% for upper extremity deep venous thrombosis, and 14.1% for other VTE). Conclusions ICD-9 codes do not accurately identify new VTE events in patients with a prior history of VTE.

Postpartum haemorrhage (PPH) is a serious obstetric problem that remains one of the leading causes of maternal deaths. The B‐Lynch brace suture and other uterine‐cavity‐obstructing sutures have been employed to control PPH over the last two decades. Owing to the reported high success rates (89–100%), the World Health Organization recommends this life‐saving procedure whenever indicated (Decherney et al. Current Diagnosis & Treatment Obstetrics & Gynecology, 12th edn; New York, NY: McGraw‐Hill, 2018).

Background Abdominal palpation is an important clinical skill used by physicians to detect the cause of the underlying disease. Abdominal physical signs reported as medical eponyms are sometimes helpful in supporting or confirming clinical suspicion of a diagnosis. With the advent of advanced and rapid imaging techniques physicians often know the diagnosis prior to setting their hands on patients. Nevertheless, knowledge of these signs may still remain important in settings where imaging may not be readily available and importantly provide deeper insights into the mechanism of disease. In this paper, described are medical eponyms associated with abdominal palpation from the period 1907-1926. Data sources PubMed, Medline, on-line Internet word searches, textbooks, and references from other source text were used as the data source. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. Conclusion We describe brief historical background information about the physician who reported the sign, original description of the sign, and its clinical application and implication into today's medical practice.

Few studies describe both inpatient and outpatient treatment and outcomes of patients with acute venous thromboembolism in the United States.A multi-institutional cohort of patients diagnosed with confirmed pulmonary embolism or deep venous thrombosis during the years 2004 through 2010 was established from 4 large, US-based integrated health care delivery systems. Computerized databases were accessed and medical records reviewed to collect information on patient demographics, clinical risk factors, initial antithrombotic treatment, and vital status. Multivariable Cox regression models were used to estimate the risk of death at 90 days.The cohort comprised 5497 adults with acute venous thromboembolism. Pulmonary embolism was predominantly managed in the hospital setting (95.0%), while 54.5% of patients with lower extremity thrombosis were treated as outpatients. Anticoagulant treatment differed according to thromboembolism type: 2688 patients (92.8%) with pulmonary embolism and 1625 patients (86.9%) with lower extremity thrombosis were discharged on anticoagulants, compared with 286 patients (80.1%) with upper extremity thrombosis and 69 (54.8%) patients with other thrombosis. While 4.5% of patients died during the index episode, 15.4% died within 90 days. Pulmonary embolism was associated with a higher 90-day death risk than lower extremity thrombosis (adjusted hazard ratio 1.23; 95% confidence interval, 1.04-1.47), as was not being discharged on anticoagulants (adjusted hazard ratio 5.56; 95% confidence interval, 4.76-6.67).In this multicenter, community-based study of patients with acute venous thromboembolism, anticoagulant treatment and outcomes varied by thromboembolism type. Although case fatality during the acute episode was relatively low, 15.4% of people with thromboembolism died within 90 days of the index diagnosis.

Background: Although immobility is a common risk factor for venous thromboembolism (VTE) in medical inpatients, lack of a consistent definition of this term may limit accurate assessment of VTE risk for thromboprophylaxis. Objective: To examine various definitions of immobility used in recent pharmacological thromboprophylaxis clinical trials. Data Sources: PubMed and relevant references from articles/reviews from 2008 to 2016 were searched. Randomized controlled trials (RCTs) and other clinical studies involving adult hospitalized medical patients in acute care hospital settings that used the term immobility were selected. Two investigators independently abstracted data in duplicate, and accuracy was checked by a third investigator. Results: Twenty-one clinical studies were included. There was heterogeneity among individual VTE risk factors, with respect to the definition of immobility in medical inpatients in these trials. Thirteen studies utilized objective criteria to define “immobility” including duration (12 studies) and distance or time walked (6 studies). In contrast, 7 studies focused principally on subjective definitions (ie, describing the nature of immobility rather than specifying its quantitative measurement). Three RCTs vaguely defined the level of patient’s immobility after hospitalization. Conclusion: Despite the well-known effectiveness of pharmacological thromboprophylaxis for the prevention of VTE in acutely ill medical patients, there is no current consensus on how to define immobility. The heterogeneous nature of definitions of immobility has led to uncertainty about the importance of immobility in VTE risk assessment models. Although clinical studies have incorporated varying definitions of immobility into their inclusion criteria, immobility as a specific VTE risk factor has not been clearly defined.

While primary care work conditions are associated with adverse clinician outcomes, little is known about the effect of work condition interventions on quality or safety. A cluster randomized controlled trial of 34 clinics in the upper Midwest and New York City. Primary care clinicians and their diabetic and hypertensive patients. Quality improvement projects to improve communication between providers, workflow design, and chronic disease management. Intervention clinics received brief summaries of their clinician and patient outcome data at baseline. We measured work conditions and clinician and patient outcomes both at baseline and 6–12 months post-intervention. Multilevel regression analyses assessed the impact of work condition changes on outcomes. Subgroup analyses assessed impact by intervention category. There were no significant differences in error reduction (19 % vs. 11 %, OR of improvement 1.84, 95 % CI 0.70, 4.82, p = 0.21) or quality of care improvement (19 % improved vs. 44 %, OR 0.62, 95 % CI 0.58, 1.21, p = 0.42) between intervention and control clinics. The conceptual model linking work conditions, provider outcomes, and error reduction showed significant relationships between work conditions and provider outcomes (p ≤ 0.001) and a trend toward a reduced error rate in providers with lower burnout (OR 1.44, 95 % CI 0.94, 2.23, p = 0.09). Few quality metrics, short time span, fewer clinicians recruited than anticipated. Work-life interventions improving clinician satisfaction and well-being do not necessarily reduce errors or improve quality. Longer, more focused interventions may be needed to produce meaningful improvements in patient care. Clinical trial registration number: ClinicalTrials.gov # NCT02542995.

The history of pericarditis involves the recognition of signs and symptoms detected using the physical examination skills such as inspection, palpation, percussion, and auscultation. Pericarditis is the term used to describe the spectrum of diseases that includes acute, subacute, and chronic forms. From 1761 to 1852, physicians were required to use their sense of sight, identifying abnormalities recognized as the signs of medical eponyms attributed to honor their findings. In this first part of a three-part series on pericarditis, the signs detected through inspection are described. Through inspection, physicians identified the bulging or retraction of the precordium and epigastrium in patients with pericardial effusion or adherent pericarditis. Many of these signs were detected, described, and reported in patients with advanced or chronic adherent pericarditis. It is unknown how useful these signs are in modern-day clinical practice.

Background Abdominal palpation is a difficult skill to master in the physical examination. It is through the tactile sensation of touch that abdominal tenderness is detected and expressed through pain. Its findings can be used to detect peritonitis and other acute and subtle abnormalities of the abdomen. Some techniques, recognized as signs or medical eponyms, assist clinicians in detecting disease and differentiating other conditions based on location and response to palpation. Described in this paper are medical eponyms associated with abdominal palpation from the period 1876 to 1907. Data sources PubMed, Medline, on-line Internet word searches, textbooks and references from other source text were used as the data source. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. Conclusion We present brief historical background information about the physician who reported the sign, original description of the sign, and its clinical application and implication in today's medical practice.

BACKGROUND: The relationship between worklife factors, clinician outcomes, and time pressure during office visits is unclear. OBJECTIVE: To quantify associations between time pressure, workplace characteristics ,and clinician outcomes. DESIGN: Prospective analysis of data from the Healthy Work Place randomized trial. PARTICIPANTS: 168 physicians and advanced practice clinicians in 34 primary care practices in Upper Midwest and East Coast. MAIN MEASURES AND METHODS: Time pressure was present when clinicians needed more time than allotted to provide quality care. Other metrics included work control, work pace (calm to chaotic), organizational culture and clinician satisfaction, stress, burnout, and intent to leave the practice. Hierarchical analysis assessed relationships between time pressure, organizational characteristics, and clinician outcomes. Adjusted differences between clinicians with and without time pressure were expressed as effect sizes (ESs). KEY RESULTS: Sixty-seven percent of clinicians needed more time for new patients and 53% needed additional time for follow-up appointments. Time pressure in new patient visits was more prevalent in general internists than in family physicians (74% vs 55%, p

Background Percussion and auscultation are derived from the Latin words to touch and hear respectively. Covered are abdominal percussion signs and ausculatory sign discovered from 1924 to 1980. Signs ascribed as medical eponyms pay homage to these physicians who provided new and unique insights into disease. Data sources PubMed Medline, online Internet word searches, textbooks, and references from other source text. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. Conclusion Many of these signs have been discarded because of modern imaging and diagnostic techniques. When combined with a high clinical suspicion, positive results using percussion combined with palpation is a useful bedside technique in detecting splenic enlargement. Thus some of these maneuvers remain important bedside techniques that skilled practitioners should master and along with a meaningful history provides relevant information to diagnosis. It is through learning about these techniques that we gain a sense of humility on the difficulty that physicians were faced prior to the advent of techniques which now allow us an easier way to visualize and diagnose the underlying disease processes.

Flushing is the subjective sensation of warmth accompanied by visible cutaneous erythema occurring throughout the body with a predilection for the face, neck, pinnae, and upper trunk where the skin is thinnest and cutaneous vessels are superficially located and in greatest numbers. Flushing can be present in either a wet or dry form depending upon whether neural-mediated mechanisms are involved. Activation of the sympathetic nervous system results in wet flushing, accompanied by diaphoresis, due to concomitant stimulation of eccrine sweat glands. Wet flushing is caused by certain medications, panic disorder and paroxysmal extreme pain disorder (PEPD). Vasodilator mediated flushing due to the formation and release of a variety of biogenic amines, neuropeptides and phospholipid mediators such as histamine, serotonin and prostaglandins, respectively, typically presents as dry flushing where sweating is characteristically absent. Flushing occurring with neuroendocrine tumors accompanied by gastrointestinal symptoms is generally of the dry flushing variant, which may be an important clinical clue to the differential diagnosis. A number of primary diseases of the gastrointestinal tract cause flushing, and conversely extra-intestinal conditions are associated with flushing and gastrointestinal symptoms. Gastrointestinal findings vary and include one or more of the following non-specific symptoms such as abdominal pain, nausea, vomiting, diarrhea or constipation. The purpose of this review is to provide a focused comprehensive discussion on the presentation, pathophysiology, diagnostic evaluation and management of those diseases that arise from the gastrointestinal tract or other site that may cause gastrointestinal symptoms secondarily accompanied by flushing. This review is divided into two parts given the scope of conditions that cause flushing and affect the gastrointestinal tract: Part 1 covers neuroendocrine tumors (carcinoid, pheochromocytomas, vasoactive intestinal polypeptide, medullary carcinoma of the thyroid), polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes (POEMS), and conditions involving mast cells and basophils; while Part 2 covers dumping syndrome, mesenteric traction syndrome, rosacea, hyperthyroidism and thyroid storm, anaphylaxis, panic disorders, paroxysmal extreme pain disorder, and food, alcohol and medications.

BACKGROUND Subclavian artery stenosis (SAS) is narrowing of the subclavian artery most commonly caused by atherosclerosis. It serves as a marker for cerebrovascular and myocardial ischemic events. METHODS A retrospective cohort study was conducted to determine the association of treatment via combination therapy (antiplatelet drug plus either by-pass surgery or percutaneous transluminal angioplasty (PTA) with or without stent implantation) versus antiplatelet drug therapy alone on cardiovascular events and all-cause mortality in Marshfield Clinic patients diagnosed with symptomatic SAS from January 1, 1995 to December 31, 2009. RESULTS Of the total 2153 cases, 100 patients were identified as eligible to be included in the study. Of these 100 patients that met inclusion criteria, 30 underwent combination therapy while 70 were managed only with drug treatment. A median length of follow-up was 8.45 years. Adverse cardiovascular events occurred in 5/30 (17%) of combination therapy patients compared to 28/70 (40%) of antiplatelet drug therapy only patients (p = 0.0355). Accordingly, all-cause mortality was higher (47%) in the antiplatelet drug therapy only group than the combination therapy group (13%) [hazard ratio = 3.45, p = 0.0218]. CONCLUSIONS Preliminary findings in this pilot data set suggest that combination therapy (medications plus either surgical or interventional repair) of subclavian artery stenosis is associated with less cardiovascular adverse events and higher survival rates. However, prospective randomized studies with larger number of patients are needed to validate these findings.

Hospitalized patients are at risk of venous thromboembolism (VTE) and prophylaxis is often suboptimal due to difficulty in identifying at-risk patients. Simple and validated risk-assessment models (RAMs) are available to assist clinicians in identifying patients who have a high risk for developing VTE. Despite the well-documented association of immobility with increased risk of thrombosis, immobility is not consistently defined in clinical studies. We conducted a systematic review of published VTE RAMs and used objective criteria to determine how the term immobility is defined in RAMs. We identified 17 RAMs with six being externally validated. The concept of immobility is vaguely described in different RAMs, impacting the validity of these models in clinical practice. The wide variability in defining mobility in RAMs precluded its accurate clinical application, further limiting generalization of published RAMs. Externally validated RAMs with clearly defined qualitative or quantitative terms of immobility are needed to assess VTE risk in real-time at the point-of-care.

Objective To identify risk factors associated with spontaneous recurrent epistaxis. Patients and Methods This was a retrospective cohort study assessing patients in the Marshfield Clinic system diagnosed as having epistaxis between January 1, 1991, and January 1, 2011. There were 461 cases with at least 2 episodes of spontaneous epistaxis within 3 years and 912 controls with only 1 episode in the same time frame. More than 50 potential risk factors were investigated, including demographic features, substance use, nasal anatomical abnormalities, nasal infectious and inflammatory processes, medical comorbidities, medications, and laboratory values. A Cox proportional hazards regression modeling approach was used to calculate hazard ratios of epistaxis recurrence. Results Traditional risk factors for epistaxis, including nasal perforation, nasal septum deviation, rhinitis, sinusitis, and upper respiratory tract infection, did not increase the risk of recurrence. Significant risk factors for recurrent epistaxis included congestive heart failure, diabetes mellitus, hypertension, and a history of anemia. Warfarin use increased the risk of recurrence, independent of international normalized ratio. Aspirin and clopidogrel were not found to increase the risk of recurrence. Few major adverse cardiovascular events were observed within 30 days of the first epistaxis event. Conclusion Congestive heart failure is an underappreciated risk factor for recurrent epistaxis. Hypertension and diabetes mellitus may induce atherosclerotic changes in the nasal vessels, making them friable and more at risk for bleeding. Patients with recurrent epistaxis may also be more susceptible to developing anemia. Physicians should promote antiplatelet and antithrombotic medication adherence despite an increased propensity for recurrent epistaxis to prevent major adverse cardiovascular events.