Clinical assessment.

A systematic review of clinical assessment for undergraduate nursing students

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessMultimodal Approach May Improve Ability to Predict Transition to PsychosisNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:17 Nov 2016https://doi.org/10.1176/appi.pn.2016.11a6AbstractThirty percent of people classified at ultra-high risk of psychosis experience a transition, but simple clinical assessments can raise the predictive value to 70 percent.Despite best efforts to identify patients at greatest risk of developing psychosis, studies suggest that some 70 percent of people identified as ultra-high risk (UHR) for psychosis never develop a psychotic disorder.A study published in September in Translational Psychiatry suggests that using a multimodal diagnostic approach that combines a person’s historical risk factors (such as family history of psychosis), clinical assessments (such as Positive and Negative Syndrome Scale), and blood biomarkers (including measures of oxidative stress and fatty acids) may be able to better predict UHR patients most likely to develop psychosis.Researchers have been searching for ways to improve their ability to identify individuals at risk of developing psychosis since UHR criteria were first introduced in the 1990s. A patient is considered to be UHR if he or she experiences one or more of the following: attenuated positive symptoms (APS); positive symptoms at full psychotic intensity for brief, limited periods known as brief intermittent psychotic symptoms (BLIPS); and a combination of genetic risk accompanied by functional decline, known as genetic risk and deterioration (GRD). “Currently, all patients in the ultra-high-risk group are considered to have a similar chance of a future psychotic episode,” said Scott Clark, Ph.D., M.B.B.S., a clinical investigator of psychiatry at the University of Adelaide in Australia.But as a meta-analysis published earlier this year in JAMA Psychiatry suggests, current UHR criteria may fail to fully capture the heterogeneity of the group and each subgroup may carry different levels of risk. The meta-analysis, which compiled 33 studies including over 4,000 individuals, found that the presence of BLIPS conferred a higher psychosis risk than the other groups, whereas GRD by itself conferred no greater risk than someone not designated UHR. “What we need is a more reliable—and flexible—method of prediction to tailor care appropriately for the people who need it most,” Clark said. Clark led a multinational team that developed a staged diagnostic tool that combines basic bedside clinical assessments with a person’s risk history and their plasma concentrations of the fatty acids omega-3 and nervonic acid (both critical for healthy brain function). In a retrospective assessment of 40 UHR individuals (who were enrolled in the placebo group of a year-long trial examining of the effect of omega-3 fatty acid supplementation on psychosis risk), this new approach demonstrated greatly improved accuracy.Of the 40 patients tested, the multimodal diagnosis identified eight of the 11 people who transitioned to psychosis within the year while also finding one false positive among the 29 patients who did not transition. This yielded a sensitivity of 73 percent, a specificity of 96 percent, and overall accuracy of about 70 percent.The model was also able to classify 77 percent of patients as low or high risk using only the historical and clinical information.“A staged approach to risk assessment would then be the most efficient, using fatty-acid markers only when the probability following history and clinical assessment is between 0.1 and 0.9, that is, 23 percent of participants in the current study,” the authors wrote. “Extending this staged approach, resource-intensive neuroimaging or electrophysiology could be reserved for cases that remain at intermediate risk based on clinical and blood biomarker assessments.”In addition, because the model was designed to be flexible, other diagnostic tools in development, such as visual tests or language processing software, could one day be incorporated to provide a more comprehensive patient stratification and increase the accuracy of the model even further. Clark said his group now plans to team up with Orygen Youth Health in Melbourne, Australia, to test this model in an independent population of at-risk individuals, and if those results are positive, he is hopeful that he and colleagues will be able to initiate a large, prospective clinical trial.Clark’s study was supported by the James and Diana Ramsay Foundation. ■“Prediction of Transition From Ultra-High Risk to First-Episode Psychosis Using a Probabilistic Model Combining History, ClinicalAssess-ment, and Fatty-Acid Biomarker” can be accessed here. ISSUES NewArchived

Often, the type of neck dissection performed in patients with head and neck malignancy is finally determined by intraoperative assessment of clinically suspect lymph nodes by frozen section. This prospective study aimed to assess the accuracy of clinical intraoperative lymph node assessment and therefore to examine validity of the underlying assumption that the surgeon can consistently identify nodes that contain metastatic tumor. We also aimed to assess whether gross morphological characteristics of the lymph nodes examined could be correlated with nodal status and therefore used to predict those nodes containing metastatic disease. A prospective study assessing the accuracy of clinical intraoperative lymph node assessment in the node-negative neck. Forty-six neck dissections from 34 patients with head and neck cancer were prospectively examined intraoperatively by a single surgeon. All obvious nodes were clinically assessed, morphologically described, and subsequently correlated with pathological findings. Sixty palpable nodes were identified in 32 neck dissections. They were clinically categorized as malignant or suspect (22) or benign (38). Pathological examination revealed a false-positive rate of 30% and a false-negative rate of 44%. The sensitivity of intraoperative lymph node assessment was 56%, and the specificity was 70%. Apart from "infiltration," morphological characteristics could not be correlated with nodal status. In the 14 neck dissections with no obviously palpable lymph nodes, 4 (29%) were positive for metastatic disease. In the node-negative neck, intraoperative assessment does not seem to improve the accuracy of staging. The only parameter of benefit and correlating with metastatic disease is clinical evidence of infiltration. The assumption that frozen section is a good determinate for selection of type of neck dissection is questionable. If selective neck dissection is not found to be therapeutic, its use leads to over-reliance on other therapeutic treatment such as postoperative radiotherapy, depriving the patient of a potential useful treatment modality in cases of locoregional recurrence.

Aims:The aim of the study was to determine the rates of trachoma in Aboriginal communities and to compare clinical assessment with photographic assessment for the presence of signs of trachoma.Methods:Five...

Early detection of critical bleeding by accurate tools can help ensure rapid delivery of blood products to improve outcomes in major trauma patients. We conducted a systematic review to evaluate the accuracy of risk tools to predict critical bleeding in patients with major trauma. PubMed, Embase, and CENTRAL were searched up to February 2021 for studies investigating risk tools to predict critical bleeding for major trauma people in prehospital and emergency department. We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis of Diagnostic Test Accuracy study guidelines. Two independent authors included studies, extracted data, appraised the quality using the Quality Assessment of Diagnostic Accuracy Studies 2 and assessed the certainty of evidence (CoE) using the Grading of Recommendations Assessment, Development and Evaluation methodology. Sensitivity, specificity, and the receiver operating characteristics curve for all selected triage tools. Eighty-nine observational studies for adults and 12 observational studies for children met our inclusion criteria. In adults, we found 23 externally validated and 28 unvalidated tools; in children, 3 externally validated tools and 5 unvalidated. In the externally validated tools, we identified those including clinical, laboratory, and ultrasound assessments. Among tools including only a clinical assessment, the Shock Index showed high sensitivity and specificity with the CoE ranging from very low to moderate in adults, as well as Shock Index Pediatric Age adjusted with a moderate CoE. We found that tools using clinical, laboratory, and ultrasound assessments were overall more accurate than those tools without all three components. Clinicians should consider risk tools to predict critical bleeding in a time-sensitive setting like major life-threatening trauma. The Shock Index and Shock Index Pediatric Age adjusted are easy and handy tools to predict critical bleeding in the prehospital setting. In the emergency department, however, many other tools can be used, which include laboratory and ultrasound assessments, depending on staff experience and resources. Systematic Review and Meta-Analysis; Level III.

BackgroundInformal family care partners are crucial in dementia care, serving as primary advocates and caregivers. A caregivers’ perception of their care recipient's dementia severity, whether they overestimate or underestimate the progression, can impact care satisfaction and applicability. Overestimation may lead to unnecessary interventions or distress, while underestimation can delay critical support. Caregivers offer valuable insights extending beyond clinical scores, capturing nuances essential for effective care planning. This study investigates the agreement between caregivers’ perception of dementia severity and clinical severity assessment, and how demographic and contextual factors influence accuracy.MethodData were collected from a convenience sample of 22 dyads. Caregivers were eligible if they were 18 years or older, spoke and read English, and provided unpaid care to a family member with dementia for at least 2 months. Caregivers completed surveys ranking their perception of their care recipient's dementia severity (e.g., mild, moderate, severe, very severe), along with various demographic and contextual factors. A collapsed version of the Clinical Dementia Rating (CDR) scale, administered by certified staff, objectively measured dementia severity. Agreement between caregivers’ perceived dementia severity and CDR severity was evaluated, and additional analyses identified predictors of accuracy.ResultForty‐five percent of caregivers (age = 62.8±14.7; 82% female) overestimated their care recipients’ (age = 81±9.6; 50% female) dementia severity (i.e., 70% of mild cases; 17% of moderate; 100% of severe), and eighteen percent underestimated severity (i.e., 17% of moderate cases; 75% of very severe). There was a significant positive association between caregivers’ perceived dementia severity and CDR severity (p = 0.041), indicating that perceived severity increased as CDR severity increased (OR=2.4). There was weak agreement between perceived and CDR severity (K = 0.1; p >0.05). No demographic or contextual factors influenced perception accuracy.ConclusionWhile caregivers’ perceptions of dementia severity often diverge from clinical assessments, they reflect the lived reality. Acknowledging the tendency to overestimate, improved communication and education between dyads and providers is vital. Dynamic knowledge sharing will help align expectations and ensure sufficient support is provided based on the needs of the care recipient, not solely their clinical score.

Photodynamic therapy is an approved treatment for primary, superficial, and small nodular basal cell carcinomas with a thickness of < 2 mm located on low-risk sites. Histologically verified basal cell carcinomas clinically assessed as suited for photodynamic therapy were included. The study aimed to investigate the agreement between clinical and histological assessments of basal cell carcinoma subtypes and thickness of tumours selected for photodynamic therapy with histopathological evaluation as a reference. A total of 343 tumours were included. The agreement between clinical and histological diagnosis of basal cell carcinoma subtype was 72% (p < 0.001). Clinical assessment of subtype had a sensitivity of 93% and specificity of 55% for superficial tumours and a sensitivity of 55% and specificity of 85% for nodular tumours. The mean ± SD thickness values by clinical and histological assessments were 0.95 ± 0.53 and 0.86 ± 0.75. The difference of 0.09 mm was statistically significant (p = 0.017), but not considered to be clinically relevant, although the differences between specific subgroups could be relevant. Among basal cell carcinomas clinically diagnosed as superficial, 91% were histologically consistent with the current photodynamic therapy criteria. The main results suggest that histopathological evaluation should precede photodynamic therapy to ensure selection of suitable basal cell carcinomas. In selected cases, the clinical diagnosis alone may be adequate before proceeding with photodynamic therapy.

Clinical cognitive assessment demands a multifaceted approach. The history is key and the examiner must ascertain from the patient and/or an informant the salient symptoms leading to the presentation, as this will have useful localization—and diagnostic—value. An exploration of the affected cognitive domains should be supplemented by an effort to establish the tempo of progression of the syndrome—the relevant background history, family history, and the psychosocial milieu. Cognition can be assessed in both a qualitative and a quantitative fashion; it is important to ensure that all domains are evaluated. Other neurological or psychiatric symptoms should be noted, and the cognitive examination should be supplemented by an appropriately focused neurological examination. A thorough clinical assessment, or ‘phenotyping’ exercise, will often strongly suggest a diagnosis prior to imaging or other tests or, at the very least, guide the appropriate investigation approach for an individual patient.

Chapter 2 - Practice Implementation, Clinical Assessment, and Outcomes Measurement

General clinical cognitive assessment scales are not sensitive enough to cognitive impairment in high-functioning stroke patients. The dual-task assessment has advantages for identifying cognitive deficits in high-functioning stroke patients and has been gradually applied in clinical assessment and cognitive training. Moreover, the Stroop paradigm has higher sensitivity and specificity for attentional assessment than conventional clinical cognitive assessment scales. Therefore, this study presents the dual-task assessment based on the Stroop paradigm to identify cognitive deficits in high-functioning stroke patients. This study demonstrates a single- and dual-task evaluation based on the Stroop paradigm and confirms its feasibility through case experiments and synchronized functional near-infrared spectroscopy evaluation. The Stroop reaction time and correct rate are used as the main indicators to evaluate the cognitive level of the subjects. This study protocol aims to provide new ideas to figure out the ceiling effect in general clinical assessment failure for high-functioning stroke patients.

The development of a quantifiable and noninvasive method of monitoring disease activity and response to therapy is vital for arthritis management. The purpose of this study was to investigate the utility of quantitative dynamic contrast-enhanced MRI (DCE-MRI) based on pharmacokinetic (PK) modeling to evaluate disease activity in the knee and correlate the results with the clinical assessment in children with juvenile idiopathic arthritis (JIA). A group of 17 children with JIA underwent longitudinal clinical and laboratory assessment and DCE-MRI of the knee at enrollment, 3 months, and 12 months. A PK model was employed using MRI signal enhancement data to give three parameters, K(trans') (min(-1)), k(ep) (min(-1)), and V(p) (') and to calculate synovial volume. The PK parameters, synovial volumes, and clinical and laboratory assessments in most children were significantly decreased (P < 0.05) at 12 months when compared to the enrollment values. There was excellent correlation between the PK and synovial volume and the clinical and laboratory assessments. Differences in MR and clinical parameter values in individual subjects illustrate persistent synovitis when in clinical remission. A decrease in PK parameter values obtained from DCE-MRI in children with JIA likely reflects diminution of disease activity. This technique may be used as an objective follow-up measure of therapeutic efficacy in patients with JIA. MR imaging can detect persistent synovitis in patients considered to be in clinical remission.

Qualitative analysis of telephonic comprehensive medication review content and delivery.

Most epidemiologic studies of puberty have only 1 source of pubertal development information (maternal, self or clinical). Interpretation of results across studies requires data on reliability and validity across sources. The LEGACY Girls Study, a 5-site prospective study of girls aged 6 to 13 years (n = 1040) collected information on breast and pubic hair development from mothers (for all daughters) and daughters (if ≥10 years) according to Tanner stage (T1-5) drawings. At 2 LEGACY sites, girls (n = 282) were also examined in the clinic by trained professionals. We assessed agreement (κ) and validity (sensitivity and specificity) with the clinical assessment (gold standard) for both the mothers' and daughters' assessment in the subcohort of 282. In the entire cohort, we examined the agreement between mothers and daughters. Compared with clinical assessment, sensitivity of maternal assessment for breast development was 77.2 and specificity was 94.3. In girls aged ≥11 years, self-assessment had higher sensitivity and specificity than maternal report. Specificity for both mothers and self, but not sensitivity, was significantly lower for overweight girls. In the overall cohort, maternal and daughter agreement for breast development and pubic hair development (T2+ vs T1) were similar (0.66, [95% confidence interval 0.58-0.75] and 0.69 [95% confidence interval 0.61-0.77], respectively), but declined with age. Mothers were more likely to report a lower Tanner stage for both breast and pubic hair compared with self-assessments. These differences in validity should be considered in studies measuring pubertal changes longitudinally when they do not have access to clinical assessments.

Magnetic resonance imaging and clinical assessments for perianal Crohn's disease: Gain and limits

We evaluated the relationships between the cerebral metabolic rate of glucose (CMRglu) measured by dynamic (18)F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and the clinical and neuropsychological assessment before and after the surgical procedure in idiopathic normal pressure hydrocephalus (INPH) patients. Eleven selected INPH patients underwent clinical assessment (modified Rankin scale, Krauss scale, Larsson categorization system and Stein-Langfitt scale), cognitive evaluation (Mini-Mental State Examination, MMSE) and dynamic (18)F-FDG PET/CT scan 3 days before and 1 week after ventricular shunt placement. After shunting, the global CMRglu significantly increased (2.95 ± 0.44 vs 4.38 ± 0.68, p = 10(-7)) in all INPH patients with a mean percentage value of 48.7%. After shunting, no significant change was found in the Evans ratio whereas a significant decrease in all clinical scale scores was observed. Only a slight reduction in the MMSE was found. After shunting, a significant correlation between the global CMRglu value and clinical assessment was found (R (2) = 0.75, p = 0.024); indeed all clinical scale scores varied (decreasing) and the CMRglu value also varied (increasing) in all INPH patients. Our preliminary data show that changes in the CMRglu are promptly reversible after surgery and that there is a relationship between the early metabolic changes and clinical symptoms, independently from the simultaneous changes in the ventricular size. The remarkable and prompt improvement in the global CMRglu and in symptoms may also have important implications for the current concept of "neuronal plasticity" and for the cells' reactivity in order to recover their metabolic function.