Clinical findings in patients presenting with sore throat. A study on inter-observer reliability

Alopecia Scoring: The Quantitative Assessment of Hair Loss in Captive Macaques

Many captive animals show forms of pelage loss that are absent in wild or free-living con-specifics, which result from grooming or plucking behaviours directed at themselves or at other individuals. For instance, dorsal hair loss in primates such as rhesus macaques ( Macaca mulatta) in research facilities, results from excessive hair-pulling or over-grooming by cage-mates. This behaviour appears to be associated with stress, and is controllable to some extent with environmental enrichment. Quantifying alopecia in primates (as in many species) is therefore potentially useful for welfare assessment. A simple system for scoring alopecia was developed and its reliability was tested. Study 1 showed high interobserver reliability between two independent scorers in assessing the state of monkeys’ coats from photographs. Study 2 showed that there were no significant differences between the scores derived from photographs and from direct observations. Thus, where hair loss due to hair pulling exists in captive primates, this scoring system provides an easy, rapid, and validated quantitative method, for use in assessing the success of attempts to reduce it via improved husbandry. In the future, such scoring systems might also prove useful for quantifying barbering in laboratory rodents.

Accuracy and interobserver variation of three clinical decision rules for the diagnosis of streptococcal pharyngitis

We evaluated the accuracy and interobserver variation of 3 clinical decision rules for streptoccocal pharyngitis diagnosis. Oropharyngeal swab culture was the reference. The Abu Reesh rule had the highest sensitivity and the World Health Organization rule showed the highest specificity. The interobserver variation of those rules indicates the need for better training of clinicians.

Limited value of physical examinations in upper respiratory illness: account of personal experience and survey of doctors' views

Medical tradition considers a physical examination (PE) an essential part of the clinical encounter. In real medical practice, however, a full PE may not be necessary when the diagnosis is clear after anamnesis and general impression. We assessed the value of PEs in 500 diagnoses of upper respiratory infection (URI) and the attitudes of 123 doctors regarding the utility of PEs in virtual cases.

METHODS

Computerized files of consecutive cases with a diagnosis of URI over 8 months in two practices were reviewed and correlation studies between the extent of PE and clinical outcomes were performed. In addition, doctors' attitudes and declarations about PEs were compared.

RESULTS

Five hundred paediatric and adult patients were included. Less than one-fifth underwent a full PE. More patients who underwent a full PE returned because they still felt unwell or their parents felt they were unwell. Fewer doctors declared actually having performed PEs than supported giving one in two virtual cases of URI. Specialized doctors were less inclined to perform PEs than doctors without a specialization.

CONCLUSIONS

Our study suggests that in many cases presenting as URI, doctors may conduct limited PEs or even omit them entirely.

Pulmonary embolism risk assessment screening tools: the interrater reliability of their criteria

BACKGROUND

Diagnostic evaluation for suspected pulmonary embolism (PE) is challenging. Dimerized plasmin fragment D (D-dimer) assays are increasingly used but have been validated only in "low-risk" patients. The accurate interpretation and application of risk assessment criteria are critical to the appropriate use of D-dimer. We sought to determine the interrater agreement of attending and third-year resident emergency medicine physicians in the specific elements of the Canadian and the Charlotte risk stratification tools and their clinical application.

METHODS

We prospectively enrolled a convenience sample of patients presenting to an urban university emergency department with suspected PE. Standardized data collection sheets were used by an attending physician and a third-year resident physician to determine the presence or absence of risk factors included in published PE prediction instruments. Each physician was blinded to the other's results and the patients' D-dimer result. Interrater agreement was measured using kappa statistics (with 95% confidence intervals).

RESULTS

Two hundred seventy-one patients were screened. The kappa scores for each risk criterion were as follows: previous deep vein thrombosis, 0.90 (95% confidence interval, 0.83-0.97); malignancy, 0.87 (0.76-0.97); deep vein thrombosis symptoms, 0.54 (0.39-0.70); immobilization, 0.41 (0.26-0.57); unexplained hypoxia, 0.58 (0.42-0.74); tachycardia, 0.94 (0.89-0.98); hemoptysis, 0.76 (0.51-1.0); and PE more likely than another diagnosis, 0.50 (0.36-0.64).

CONCLUSIONS

Interrater agreement was only fair for several important risk criteria. Small differences in determining pretest probability can lead to significant variability in risk assessment and how, or whether, the diagnosis of PE is evaluated. This study raises questions about the reliability and applicability of published PE screening criteria in clinical settings.

The interrater variation of ED abdominal examination findings in patients with acute abdominal pain

OBJECTIVE

The physical examination of the abdomen is crucial to emergency department (ED) management of patients with abdominal pain. We sought to determine the interrater variation between attending and resident physicians in detecting abdominal exam findings.

METHODS

Research enrollers surveyed attending and resident physicians on abdominal exam findings in the ED in patients with abdominal pain. Strength of agreement was calculated using the kappa statistic.

RESULTS

A convenience sample of 122 surveys was completed. Calculated kappa results are in parentheses. There was almost perfect agreement on the presence of masses and substantial agreement on the need for imaging studies. There was moderate agreement on guarding, distension, tenderness, and need for laboratory tests and surgical consultation. For 88 (72%) patients with tenderness, substantial agreement was calculated for epigastric tenderness, moderate agreement on right upper quadrant, supraumbilical, suprapubic, left lower quadrant, right lower quadrant tenderness, and fair agreement on left upper quadrant tenderness. Sixty-one (50%) patients received pain medicine in the ED. Among those, there was fair agreement on a presence of a surgical abdomen. Upper level resident physicians noted a higher level of agreement with the attending physician for tenderness than junior resident physicians.

CONCLUSIONS

There was moderate agreement between resident and attending physicians for most of the findings in patients with abdominal pain. Recognition that selected findings are more variable than others should encourage careful confirmation of resident physicians' assessments in teaching settings.