Biomedical subjects

B J Boland

Publications and source records attributed to B J Boland.

8 recordsLinked to original sources

PubMed1998

Patient-physician agreement on reasons for ambulatory general medical examinations.

OBJECTIVE: To evaluate the physician's ability to identify patients' reasons for visits (RFVs) for a general medical examination (GME), to assess predictors of agreement between patient and physician on the RFV, and to determine whether agreement about the RFVs was associated with patient satisfaction with the visit. DESIGN: We conducted a prospective study involving patients scheduled for a GME and internists in a multispecialty group practice. MATERIAL AND METHODS: Patient-physician agreement on the RFV was independently assessed by two internists. Logistic regression was used to identify predictors of low agreement. RESULTS: The 458 patients reported a total of 848 RFVs for their GME. Patient-physician agreement on the patient's RFV was low in 20% of the visits. Female gender (odds ratio, 2.02; 95% confidence interval [CI], 1.11 to 3.66), multiple RFVs (odds ratio, 2.03; 95% CI, 1.06 to 3.91), and previous GME (odds ratio, 2.18; 95% CI, 1.07 to 4.44) were independent predictors of low agreement. Patient-physician agreement for RFVs was not associated with patient satisfaction with the medical visit. CONCLUSION: In this study, physicians correctly identified the patient's main RFV in a majority of the visits. Failures to identify the patient's main RFV occurred more frequently in female patients, in patients with multiple RFVs, and in patients with a previous comprehensive GME. Surprisingly, patient-physician agreement was not associated with patient satisfaction.

Aged↗

PubMed1997

Organizing pneumonia. Features and prognosis of cryptogenic, secondary, and focal variants.

BACKGROUND: Organizing pneumonia (OP) is a non-specific response to many types of lung injury. Clinicians frequently encounter pathology reports of OP in patients with no underlying condition (cryptogenic OP, also known as BOOP or bronchiolitis obliterans OP) or in association with drugs or nonpulmonary disease. The goals of this study are to describe the clinical course and outcomes in patients with 3 clinical variants of OP. METHODS: A retrospective study of patients with OP seen at the Mayo Clinic, Rochester, Minn, from January 1, 1984, through June 30, 1994, was conducted. Initial features were obtained from medical records. Chest radiographs and pathology specimens were reviewed for this study. Resolution, relapse, and survival were obtained from medical records and a follow-up patient questionnaire. RESULTS: Seventy-four patients had pathologically confirmed OP. Organizing pneumonia was classified into 3 clinical groups: symptomatic cryptogenic OP; symptomatic OP related to underlying hematologic malignant neoplasm, collagen vascular disease, or drugs (secondary OP); and asymptomatic OP presenting as a focal nodule (focal OP). Thirty-seven patients (50%) had cryptogenic OP and 27 patients (36%) had secondary OP. No difference was found between cryptogenic and secondary OP in type or severity of symptoms, signs, laboratory and pulmonary function tests, or radiologic or pathologic findings. Corticosteroids were given at a similar initial dose (prednisone, about 50 mg/d). Resolution of symptoms was more frequent in patients with cryptogenic OP than those with secondary OP. Relapse was infrequent in both of these groups. Five-year survival was higher in patients with cryptogenic OP (73%) than in secondary OP (44%), and respiratory-related deaths were more frequent in patients with secondary OP. Organizing pneumonia was an asymptomatic focal rounded opacity in 10 patients (14%), most often detected on chest radiograph and diagnosed on lung biopsy done for suspicion of lung cancer. Patients with focal OP required no treatment and had no relapse or respiratory-related deaths. CONCLUSIONS: Clinical classification of OP is useful to predict clinical course and outcome. Cryptogenic OP most often was a symptomatic bilateral lung process that had an overall favorable prognosis with prolonged corticosteroid therapy. Patients with secondary OP had a high mortality rate when the disease was associated with predisposing conditions or drugs. Patients with asymptomatic focal OP had an excellent prognosis.

Aged↗

PubMed1996

Skeletal, cardiac, and smooth muscle failure in Duchenne muscular dystrophy.

The goals of this study were to describe the clinical course of skeletal, cardiac, and gastrointestinal muscle manifestations and trends in age at diagnosis and survival of Duchenne muscular dystrophy (DMD) patients. A retrospective cohort of 33 male patients with DMD, born between 1953 and 1983 and followed at the Mayo Clinic during their second decade of life, was studied. The mean age at DMD diagnosis was 4.6 years. Skeletal muscle weakness present in all patients at diagnosis progressed to wheelchair dependency in 32 patients (97%) by the age of 13 years (median age 10 years). Cardiac muscle failure developed in 5 patients (15%) (median age 21.5 years). Smooth muscle manifestations related to the digestive and urinary tracts occurred in 7 (21%) and 2 (6%) patients (median age 15 years), respectively. The gastrointestinal dilatations were primary in 2 patients or secondary to surgery or acute respiratory illness in 5 patients. By the end of the study period, 17 deaths had occurred (median age 17 years). Over time, there was a decrease in the time to DMD diagnosis (P = .05) but no significant change in survival (P = .44). Cardiac and smooth muscle manifestations occur late in the course of DMD. Clinical gastrointestinal symptoms related to smooth muscle function most often were secondary to surgery or a respiratory illness. In recent years, the diagnosis of DMD has been made at a younger age, but survival has not changed.

Adolescent↗

PubMed1996

Yield of laboratory tests for case-finding in the ambulatory general medical examination.

PURPOSE: To examine the diagnostic and therapeutic yield of frequently obtained laboratory tests for case-finding in the comprehensive ambulatory medical examination. PATIENTS AND METHODS: A prospective cohort study was conducted in four Mayo Clinic general internal medicine divisions that provide care to community, regional, and geographically distant patients. The main outcome measurements were the diagnostic yield and therapeutic yield of the complete blood count, chemistry panel, lipid profile, thyroid tests, and urinalysis ordered for case-finding. RESULTS: Overall, 1,508 laboratory tests consisting of 7,008 individual components were obtained for case-finding in the 531 patients (mean age 63 +/- 14 years; 57% female). Thirty-six percent (544 of 1508) of the tests were abnormal, of which 6% (33 of 544) were repeated and 9% (47 of 544) led to further investigations. The 1,508 case-finding tests had a diagnostic yield of 4.8% (73 new diagnoses) and a therapeutic yield of 4.0% (60 new therapies). The therapeutic yield of each test ordered for case-finding was as follows: lipid profile (16.5%), chemistry panel (2.8%), complete blood count (0.9%), urinalysis (0.8%), and thyroid tests (0.7%). Therapeutic yield was not associated with patient's age, gender, or referral distance but was approximately twice as high in new patients compared with established patients. CONCLUSIONS: The majority of treatments for conditions identified by case-finding laboratory tests resulted from the lipid profile. The therapeutic yield of the chemistry panel was low, and the therapeutic yield of the complete blood count, thyroid tests, and urinalysis were all less than 1%. The low therapeutic yield of many routine laboratory tests ordered for case-finding should be provided to patients, physicians, and managed care organizations to set priorities for case-finding and screening.

Aged↗

PubMed1996

Patient-physician agreement about medical diagnoses and cardiovascular risk factors in the ambulatory general medical examination.

OBJECTIVE: To describe the spectrum of medical diagnoses and cardiovascular risk factors identified by physicians during the comprehensive medical examination in ambulatory patients, to assess how accurately patients report the health problems identified by their physicians, and to determine the characteristics associated with patient and physician agreement. MATERIAL AND METHODS: We conducted a prospective study of ambulatory patients at Mayo Clinic Rochester. All 64 internists in the general internal medicine divisions who perform comprehensive medical examinations were invited to enroll 10 adult patients each; 57 physicians and 566 eligible patients participated. Complete physician and patient information on diagnosed health problems was available for 458 patient visits (81%). Diagnosed health problems were collected from both the patients and the physicians by questionnaire after the examination and classified into medical diagnoses and cardiovascular risk factors. RESULTS: Of the diagnosed health problems, 63% involved four organ system categories: (1) nutritional, endocrine, or metabolic (20%); (2) cardiovascular (18%); (3) musculoskeletal (13%); and (4) digestive (12%). Patients failed to report 68% of all health problems and 54% of the most important health problems diagnosed by the physician. Major health problems, new diagnoses, and distant residence were associated with the highest level of patient-physician agreement for diagnosed health problems. CONCLUSION: Because patients failed to report more than half of their most important health problems identified by their physicians, practitioners might consider giving problem lists or summary letters to patients to improve and reinforce communication and management of health problems.

Ambulatory Care↗

PubMed1995

Review of systems, physical examination, and routine tests for case-finding in ambulatory patients.

The screening value of the comprehensive review of systems and the complete physical examination in detecting unsuspected diseases for which therapeutic interventions are initiated has not been formally studied in ambulatory patients. The medical records of 100 randomly selected adult patients who had an ambulatory general medical evaluation at the Mayo Clinic in 1990-1991 were surveyed to compare review of systems and physical examination with routine laboratory tests, chest radiography, and electrocardiography as case-finding maneuvers. The main outcome measure was the therapeutic yield of each case-finding maneuver, defined as the proportion of maneuvers leading to a new therapy for a new clinically important diagnosis. The utilization rate of routine tests in the 100 patients (mean age: 59 +/- 16 years; 58% women) was high, ranging from 77 to 98%. Overall, the case-finding maneuvers led to 36 unsuspected clinically important diagnoses and resulted in 25 new therapeutic interventions. Higher therapeutic yield was observed for review of systems (7%), physical examination (5%), and lipid screening (9.2%) than for chemistry group (2.2%), complete blood count (1.8%), thyroid tests (1.5%), urinalysis (1.1%), electrocardiography (0%), or chest radiography (0%). The number of therapeutic interventions was not associated with patient's age (P = 0.55), sex (P = 0.88), comorbidity (P = 0.30) or with the time interval since the last general medical evaluation (P = 0.12). Based on therapeutic yield, these data suggest that review of systems and physical examination are valuable case-finding maneuvers in the periodic medical evaluation of ambulatory patients.

Adult↗

PubMed1994

Conceptual framework for evaluating laboratory tests: case-finding in ambulatory patients.

In response to concerns about inappropriate testing and healthcare costs, clinicians and laboratorians should work together to evaluate laboratory tests. Studies of routine laboratory tests ordered for screening and case-finding in the preoperative setting, at hospital admission, and in the ambulatory setting have not provided sufficient evidence of the benefits of case-finding when evaluated against commonly used criteria for screening procedures. We adapt a conceptual framework developed from radiology for evaluating imaging technologies to evaluate laboratory tests. The framework addresses diagnostic efficacy (whether the test correctly identifies abnormalities), diagnostic effectiveness (whether the test changes the physician's diagnoses), therapeutic efficacy (whether the test changes patient management), and therapeutic effectiveness (whether the test changes patients' outcomes). We propose that clinicians and laboratorians use this framework to evaluate the diagnostic efficacy, diagnostic effectiveness, therapeutic efficacy, and therapeutic effectiveness of laboratory tests in the ambulatory setting and in other settings.

Clinical Laboratory Techniques↗

PubMed1983

Aortoiliac arteriovenous fistula simulating iliac vein thrombosis following intervertebral disc surgery.

This report describes an unusual presentation of arteriovenous fistula secondary to intervertebral disc surgery. A 61-year-old obese woman underwent operation for a herniated intervertebral disc. One month later she was readmitted with painful swelling of the left calf. The condition progressed to include pigmentation of the whole extremity with varicosities and ulcerations. The femoral vein was found to be occluded and there were multiple collateral vessels in the thigh. Initially, phlebitis was diagnosed, then iliac vein thrombosis. Her symptoms improved slightly with rest and anticoagulant therapy. Finally, after 2 years, an arteriovenous fistula was suspected because of a bruit in the presacral region and oxygen saturation of venous blood in the thigh. The diagnosis was confirmed by aortography. The fistula was transected and the artery and vein individually sutured, producing immediate improvement. The patient was symptom-free 3 years later. When chronic venous obstruction, unusual distribution of collateral circulation and pigmentation of a lower extremity are found after disc surgery, an arteriovenous fistula should be suspected. The diagnostic procedures should include auscultation of the abdomen and back, venography, measurement of blood oxygen levels in the collateral venous circulation and aortography.

Aortic Diseases↗