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Biomedical subjects

D R Bordley

Publications and source records attributed to D R Bordley.

13 recordsLinked to original sources
PubMed1993

Diagnostic strategies in the management of acute upper gastrointestinal bleeding: patient and physician preferences.

BACKGROUND: Routine diagnostic endoscopy is commonly obtained for low-risk patients with acute upper gastrointestinal bleeding despite evidence from controlled trials that it does not improve patient outcome. OBJECTIVE: To determine whether endoscopy is being overutilized for these patients or whether considerations not addressed in the trials could justify its widespread use. METHODS: Twenty-five patients recovering from a recent hemorrhage and 22 primary care physicians used the analytic hierarchy process to perform an individualized analysis regarding the diagnostic management of acute upper gastrointestinal bleeding. The results were used to determine whether routine endoscopy was consistent with each subject's interpretation of relevant data and judgments regarding the relative importance of five management goals. The authors then compared the proportion of subjects in each group who preferred endoscopy over two non-endoscopy strategies (upper gastrointestinal series and no routine diagnostic test) with 85%, the current rate of endoscopy at the authors' hospital. RESULTS: Endoscopy was preferred by 92% (97.5% CI: 70%-98%) of the patients and 55% (97.5% CI: 31%-77%) of the physicians. The patients ranked identifying the cause of bleeding the second most important management goal after avoiding a poor outcome from the acute bleeding episode. CONCLUSIONS: The current rate of diagnostic endoscopy is higher than would be expected based on physicians' preferences but quite consistent with patients' preferences. Patients regard knowledge of the bleeding site as important, even if this information will not affect management or prognosis. Attempts to assess the use of diagnostic endoscopy and other diagnostic tests should take both patient preferences and the pure value of diagnostic information into account.

Adult↗
PubMed1992

Using the analytic hierarchy process (AHP) to develop and disseminate guidelines.

To be effective, practice guidelines must accommodate the unique circumstances of individual patients. This article describes how the analytic hierarchy process (AHP), a decision-making technique, could be used to create flexible guidelines by linking guideline developers and clinical decision makers as coworkers in a common decision-making process. The advantages of using this approach for guideline dissemination are discussed and compared with other methods for disseminating and implementing guidelines. The clinical feasibility of the AHP approach is also reviewed.

Barium Sulfate↗
PubMed1985

Early clinical signs identify low-risk patients with acute upper gastrointestinal hemorrhage.

Early identification of patients at low risk for poor outcome after acute upper gastrointestinal hemorrhage would allow reduction of diagnostic and therapeutic interventions. We identified six early predictors of good outcome: age less than 75 years, no unstable comorbid illness, no ascites found on physical examination, normal prothrombin time, and, within an hour after presentation, systolic blood pressure of 100 mm Hg or greater and nasogastric aspirate free of fresh blood. Presence of all six predictors defined the low-risk population. Among 162 patients in the development and retrospective validation phases of our study, all 74 low-risk patients had good outcomes. A prospective validation study of 111 patients further established the accuracy of our predictive method; only two of 52 low-risk patients had poor outcomes. Application of our method should allow more selective management of patients with acute upper gastrointestinal hemorrhage.

Acute Disease↗
PubMed1980

Osteomalacia and weakness from excessive antacid ingestion.

A 60-year-old woman was evaluated for bone pain and incapacitating weakness. Initial laboratory studies showed a serum calcium level of 10.1 mg/dL, severe hypophosphatemia (1.1 mg/dL), and an elevated alkaline phosphatase level. X-ray films showed changes consistent with osteomalacia. Further studies revealed hypercalciuria (448 mg/24 hr) but absent urinary phosphorus. These data indicated phosphate malabsorption. Excessive use of an aluminum hydroxide-containing antacid was the cause of this patient's failure to absorb dietary phosphate. The features of this syndrome are reviewed to increase physicians' awareness of this illness, which occurs particularly in the elderly and is easily treated.

Alkaline Phosphatase↗
PubMedDate not supplied

Monitoring and improving the content of medical residents' ambulatory care experience: a microcomputer-based method using diagnosis clusters.

Changing patterns of medical practice necessitate increased experience in ambulatory settings for internal medicine residents. Residency program directors must monitor the content and balance of the ambulatory care experience. Evaluation of ambulatory care educational programs requires a concise method of describing the illnesses seen in each outpatient setting and of monitoring individual resident activities. The authors present an easily applied, microcomputer-based method of analysis using diagnosis clusters that has been found to be useful in evaluating and modifying the ambulatory care curriculum at their institution. It provides a concise description of individual ambulatory settings, affords an opportunity to compare each setting with national norms, and identifies areas of inadequate exposure in each resident's experience.

Ambulatory Care↗
PubMedDate not supplied

Initial management of serious urinary tract infection: epidemiologic guidelines.

OBJECTIVE: To obtain information necessary for the development of initial antibiotic treatment guidelines for patients with serious urinary tract infections. DESIGN: Retrospective chart review. SETTING: The medical service of a 533-bed university-affiliated community hospital. PATIENTS: 253 unselected patients hospitalized between January 1985 and December 1987 given principal discharge diagnoses of urinary tract infection, pyelonephritis, or gram-negative rod bacteremia originating in the urinary tract. RESULTS: Three clinically distinct groups were identified: women under 50 years old, older women, and men. Escherichia coli was isolated from 93% of young women, 70% of older women, and 46% of men. Pseudomonas aeruginosa was isolated from 39% of men with one or more urinary tract risk factors, including recent or recurrent urinary tract infections and known genitourinary tract abnormality. The overall prevalence of Group D streptococci was only 1%. More than 20% of the patients in each group were bacteremic. In all groups, resistance to ampicillin and first-generation cephalosporins was common. Trimethoprim-sulfamethoxazole was active in 98% of young women and 85% of older women and men without urinary risk factors. CONCLUSIONS: Age and gender identify clinically important subgroups of patients with serious urinary tract infections. Pending culture results, all patients should be considered bacteremic, ampicillin alone should not be prescribed, and antibiotics effective against P. aeruginosa should be given to men, especially those with risk factors.

Adult↗
PubMedDate not supplied

An evaluation of clinicians' subjective prior probability estimates.

The degree of consensus and the accuracy of subjective prior probability estimates made by 104 clinicians were examined. The clinicians' estimates were compared with objective prior probabilities obtained from published sources and actual patient outcomes. Each clinician made seven estimates based upon written case summaries abstracted from patient records. Consensus was measured by calculating estimate ranges and standard deviations. The clinicians' estimates varied widely: the smallest range was 80 (2%-82%); four of the seven probability ranges were greater than 90. The average standard deviation was 19.5. Using these prior probabilities and Bayes' theorem, widely varying posttest probabilities would result after many common diagnostic tests. Accuracy was measured using the Brier score, which ranges from 0 to 1; a score of 0 indicates perfect accuracy. The clinicians' Brier scores ranged from 0.05 to 0.57. The objectively determined probabilities achieved a Brier score of 0.11, better than that of 96% of the clinicians. Clinical experience did not consistently affect estimate accuracy or consensus. The clinicians' subjective estimates were inaccurate measures of the prior probability of disease. There was little consensus regarding disease likelihood among the clinicians. Objective prior probabilities were more accurate and less variable.

Decision Making↗
PubMedDate not supplied

Isoniazid prophylaxis: the importance of individual values.

To provide insight into the decision whether to use isoniazid prophylaxis in uncomplicated cases of positive tuberculin tests, the authors conducted a multicriteria decision analysis using the analytic hierarchy process. If reducing the chance of developing active tuberculosis is considered at least slightly more important than avoiding isoniazid-related side effects, isoniazid prophylaxis is the better strategy for all patients. If avoiding isoniazid-related side effects is considered at least slightly more important, no prophylaxis is the better strategy for all patients. If these two considerations are judged equally important, the better strategy depends on patient age, the anticipated effectiveness of isoniazid prophylaxis, and whether or not the patient is a recent tuberculin convertor. The tradeoff between avoiding active tuberculosis and avoiding isoniazid-related side effects is the most important factor in the decision regarding the proper management of patients with positive tuberculin tests. These results emphasize the importance of taking an individualized approach to the management of these patients.

Adult↗