The most useful radiographic findings were venous congestion (LR 12.0, 95% CI 6.8-21) and the presence of cardiomegaly (LR 3.3; 95% CI 2.4-4.7). The single most predictive ECG finding was atrial fibrillation (LR 3.8; 95% CI 2.7-8.8); any abnormality on ECG had an LR of 2.2 (95% CI 1.6-3.1). Serum BNP levels were not more predictive of CHF than the history or physical examination; a BNP of >250 was associated with an LR of 4.6 (95% CI 2.6-8.0).
Few findings markedly decreased the probability of CHF. Here, it is helpful to remember that an LR of 0.5 decreases the post-test probability by about 15%, and an LR of 0.2 decreases the post-test probability by about 30%. With these in mind, the absence of cardiomegaly on CXR significantly changes the post-test probability (LR 0.33; 95% CI 0.23-0.48). A serum BNP level of less than 100pg/ml strongly argues against CHF, with an LR of 0.11 (95% CI 0.07-0.16); this finding lowers the post-test probability of CHF by about 45% compared to the pre-test probability.
In summary, the most useful findings for ruling in CHF in dyspneic emergency department patients were clinical gestalt, a prior history of CHF, findings of an S3 or jugular venous distension, and radiographic findings of venous congestion or cardiomegaly. Absence of radiographic cardiomegaly and a BNP of less than 100pg/ml argue against CHF. These must be interpreted in the context of the clinical pre-test probability of CHF, as none of the findings had likelihood ratios sufficient to be diagnostic of CHF when used individually.
What Should I Wear Today?
Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005 Nov; 118(11): 1279-1286.
Background: This study addresses the prototypical everyday clinical dilemma: What should I wear to work?
Methods: Patients and visitors to an outpatient Veterans Affairs internal medicine clinic in South Carolina were shown photographs of male and female physicians in four different styles of dress:
- Professional (male physician wearing white coat with tie, female physician wearing white coat with tailored skirt or trousers);
- Business (suit and tie for male, tailored trouser or skirt for female);
- Surgical (surgical scrubs for both male and female): and
- Casual (jeans and t-shirt or short skirt).
The study was randomized so that male and female respondents viewed photographs of either male or female physicians. Respondents were asked to report how strongly they felt about the importance of their physician’s appearance, and their preference for each style of dress; specifically, respondents were asked which physician was the most trustworthy, which physician they felt most comfortable with for routine examinations and emergencies, and which physician they felt most comfortable discussing psychological, sexual, and social problems with.
Results: Respondents overwhelmingly preferred professional attire for all questions: 76.3% felt most comfortable with a professionally dressed physician for all encounters, with surgical scrubs a distant second (10.2%), ahead of business dress (8.8%). Respondents were also significantly more willing to discuss psychological, sexual, and social problems with a professionally dressed physician. Even for care in an emergency situation, respondents still expressed a significant preference for professional attire over scrubs.
In a logistic regression model, patients who were older, African-American, and had less than a high school education were significantly more likely to prefer professional attire. Interestingly, female respondents who viewed photographs of female physicians placed significantly greater emphasis on physician’s attire than did male respondents.