RESUMEN
IMPORTANCE: Obstructive sleep apnea is a common disease, responsible for daytime sleepiness. Prior to referring patients for definitive testing, the likelihood of obstructive sleep apnea should be established in the clinical examination. OBJECTIVE: To systematically review the clinical examination accuracy in diagnosing obstructive sleep apnea. DATA SOURCES: MEDLINE and reference lists from articles were searched from 1966 to June 2013. Titles and abstracts (n = 4449) were reviewed for eligibility and appraised for evidence levels. STUDY SELECTION: For inclusion, studies must have used full, attended nocturnal polysomnography for the reference standard (n = 42). MAIN OUTCOMES AND MEASURES: Community and referral-based prevalence of obstructive sleep apnea; accuracy of symptoms and signs for the diagnosis of obstructive sleep apnea. RESULTS: The prevalence of sleep apnea in community-screened patients is 2% to 14% (sample sizes 360-1741) and 21% to 90% (sample sizes 42-2677) for patients referred for sleep evaluation. The prevalence varies based on the apnea-hypopnea index (AHI) threshold used for the evaluation (≥5 events/h, prevalence 14%; ≥15/h, prevalence 6%) and whether the disease definition requires symptoms in addition to an abnormal AHI (≥5/h with symptoms, prevalence 2%-4%). Among patients referred for sleep evaluation, those with sleep apnea weighed more (summary body mass index, 31.4; 95% CI, 30.5-32.2) than those without sleep apnea (summary BMI, 28.3; 95% CI, 27.6-29.0; P < .001 for the comparison). The most useful observation for identifying patients with obstructive sleep apnea was nocturnal choking or gasping (summary likelihood ratio [LR], 3.3; 95% CI, 2.1-4.6) when the diagnosis was established by AHI ≥10/h). Snoring is common in sleep apnea patients but is not useful for establishing the diagnosis (summary LR, 1.1; 95% CI, 1.0-1.1). Patients with mild snoring and body mass index lower than 26 are unlikely to have moderate or severe obstructive sleep apnea (LR, 0.07; 95% CI, 0.03-0.19 at threshold of AHI ≥15/h). CONCLUSIONS AND RELEVANCE: Nocturnal gasping or choking is the most reliable indicator of obstructive sleep apnea, whereas snoring is not very specific. The clinical examination of patients with suspected obstructive sleep apnea is useful for selecting patients for more definitive testing.
Asunto(s)
Anamnesis , Apnea Obstructiva del Sueño/diagnóstico , Obstrucción de las Vías Aéreas/etiología , Índice de Masa Corporal , Humanos , Examen Físico , Polisomnografía , Prevalencia , Derivación y Consulta , Apnea Obstructiva del Sueño/complicaciones , Apnea Obstructiva del Sueño/epidemiología , Ronquido/etiologíaRESUMEN
BACKGROUND: Clinical faculty require feedback to guide their development. Although written comments submitted by residents on clinical teaching assessments (CTAs) are potentially a rich source of feedback, little is known about their information quality. METHOD: Naturalistic study involving thematic content analyses and concordancing of comments submitted in a sample of 1,601 CTAs. RESULTS: About half of the CTAs contained comments, and most were related to perceived teacher strengths. Mixed-methods analysis of comments in the "areas for improvement" field revealed that rather than offering constructive criticism, residents vocalized their perceived learning needs. Specific, behaviorally based comments were uncommon. CONCLUSIONS: In their present format, the written comments analyzed by this study seem unlikely to provide faculty with substantive feedback. Greater insight into residents' understanding of the CTA process, including motivational factors, is necessary if academic centers intend to maximize the formative value of CTAs.
Asunto(s)
Docentes Médicos , Retroalimentación Psicológica , Internado y Residencia , Medicina Interna/educaciónRESUMEN
Intravascular hemolysis is a rare but potentially life threatening cause of red urine characterized by brisk hemolysis and release of large amounts of hemoglobin into the urine. We present an unusual case of red urine in a 20-year-old male who was subsequently diagnosed with intravascular hemolysis due to an aorto-atrial fistula. Fistula formation was likely secondary to a recently implanted atrial septal occluder, which is a reported but exceedingly rare complication of the device. We discuss the diagnostic approach to hemolytic anemia and conclude with a literature review of other cases of device associated fistula formation and hemolysis.
Asunto(s)
Fístula/diagnóstico , Defectos del Tabique Interatrial/diagnóstico , Hemoglobinuria/diagnóstico , Hemólisis/fisiología , Pigmentos Biológicos/análisis , Diagnóstico Diferencial , Fístula/complicaciones , Fístula/cirugía , Defectos del Tabique Interatrial/complicaciones , Defectos del Tabique Interatrial/cirugía , Hemoglobinuria/etiología , Hemoglobinuria/cirugía , Humanos , Masculino , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Urinálisis , Adulto JovenRESUMEN
PROBLEM BEING ADDRESSED: Family physicians are often called upon to pronounce and certify the deaths of patients. Inadequate knowledge of the Coroners Act (in the province of Ontario) and of the correct process of certifying death can make physicians uncomfortable when confronted with these tasks. OBJECTIVE OF PROGRAM: To educate family physicians about how to perform the administrative tasks required of them when patients die. PROGRAM DESCRIPTION: The program included an educational video, a tutorial outlining the process of death certification, and discussion with a regional coroner about key features of the Coroners Act. In small groups, participants worked through cases of patient deaths in which they were asked to determine whether a coroner needed to be involved, to determine the manner of death, and to complete a mock death certificate for each case. CONCLUSION: All participants reported a high level of satisfaction with the workshop and thought the main objective of the program had been achieved. Results of a test given 3 months after the workshop showed substantial improvement in participants' knowledge of the coroner's role and of the process of death certification.
Asunto(s)
Certificado de Defunción , Educación Médica Continua/métodos , Medicina Familiar y Comunitaria/educación , Rol del Médico , Cuidado Terminal/métodos , Canadá , Médicos Forenses , Curriculum , Certificado de Defunción/legislación & jurisprudencia , Medicina Familiar y Comunitaria/métodos , Conocimientos, Actitudes y Práctica en Salud , Humanos , Evaluación de Necesidades , Evaluación de Programas y Proyectos de Salud , Cuidado Terminal/legislación & jurisprudenciaRESUMEN
This study was undertaken in order to determine the availability and chemical composition of potentially lead-toxic traditional eye cosmetics ("kohls") in six of the seven emirates of the United Arab Emirates (UAE). Thus of especial interest was the percentage of the purchased samples that contained the toxic element lead. A total of 53 observably different kohl samples were found to be available overall in the six emirates: Dubai, Sharjah, Ajman, Umm Al-Quwain, Ras Al-Khaimah, and Fujairah. It was found that 19 of these samples had been previously analyzed by us in studies covering Oman, Abu Dhabi (city), and Egypt (Cairo). The techniques of X-ray powder diffraction (XRPD) and scanning electron microscopy (SEM) were used to analyze the remaining 34 samples. Overall, for the 53 kohl samples, it was found that 20 (38%) contained a lead compound (galena, PbS) as the main component. The other main components were found to be one of the following: amorphous carbon, calcite/aragonite (CaCO3), goethite (FeO(OH)), hematite (Fe2O3), sassolite (H3BO3), talc (Mg3Si4O10(OH)2), or zincite (ZnO).