Evaluation of a functional medicine approach to treating fatigue, stress, and digestive issues in women.

Fatigue, stress, and digestive disorders are common among adults, especially women. We conducted a 28-week pilot study to assess the efficacy of a functional medicine approach to improving stress, energy, fatigue, digestive issues, and quality of life in middle-aged women. Findings showed significant improvements in many stress, fatigue, and quality-of-life measures. The treatment program increased mean salivary dehydroepiandrosterone levels and the cortisol-dehydroepiandrosterone ratio. Stool sample analyses suggested that these treatments reduced Helicobacter pylori infections. This study suggests that functional medicine may be an effective approach to managing stress and gastrointestinal symptoms.

Rapid resolution of intense suicidal ideation after treatment of severe obstructive sleep apnea.

Patients with insomnia may develop suicidal ideation; however, we know of no reports of suicidal ideation associated with obstructive sleep apnea. We report on a 74-year-old man who presented to his primary care physician with excessive daytime sleepiness, poor quality nocturnal sleep, depressed mood, and suicidal ideation with active suicide plans. An emergency outpatient psychiatry consultation was arranged. The patient declined psychiatric hospitalization. He agreed to a trial of continuous positive airway pressure, using a self-titrating machine, followed by an urgent sleep study. Polysomnography revealed an apnea hypopneaindex of 64, arousal index of 91 and minimum oxygen saturation of 65%. The patient's sleep and excessive daytime sleepiness responded to nCPAP. The patient declined antidepressant medication but had excellent adherence to nCPAP. Suicidal ideation and depression resolved promptly and at 4-month followup were in remission. Further studies examining the relationship among untreated obstructive sleep apnea, depression, and suicidal ideation are warranted.

Who makes the diagnosis? The role of clinical skills and diagnostic test results.

RATIONALE, AIMS AND OBJECTIVES: Advances in medicine have led to a multitude of diagnostic tests. The contribution of the clinical skills of the general internist in the context of all these advances is unknown. Our objective was to assess the relative contributions of clinical skills and diagnostic test results in arriving at a final diagnosis. METHODS: Records were retrospectively reviewed from 248 consecutive patients admitted to a general internal medicine hospital service during a 3-month period in 2000. All diagnostic evaluations that yielded the final diagnosis were recorded along with the date and time they were performed. Diagnostic credit was given to the evaluation that yielded the diagnosis at the earliest point in time. RESULTS: All cases had a firm diagnosis by 3 months after hospitalization. Of the 248 patients, 246 received a final diagnosis during hospitalization. The diagnoses were made by use of the clinical judgement of the general internist in 50.4% of the cases, a radiologic study in 31.7%, a blood test or culture result in 9.4%, biopsy findings in 3.3% and various other diagnostic studies (endoscopy, echocardiography, electromyography and electroencephalography) in 5.2%. Clinicians provided the correct diagnosis significantly more often than radiologic studies (P = 0.0015), which was the next most useful type of diagnostic evaluation. CONCLUSION: Although technology has become increasingly available in clinical practice, clinical expertise and skills are still important factors with respect to making correct, timely diagnoses in hospitalized patients.

A controlled trial of automated classification of negation from clinical notes.

BACKGROUND: Identification of negation in electronic health records is essential if we are to understand the computable meaning of the records: Our objective is to compare the accuracy of an automated mechanism for assignment of Negation to clinical concepts within a compositional expression with Human Assigned Negation. Also to perform a failure analysis to identify the causes of poorly identified negation (i.e. Missed Conceptual Representation, Inaccurate Conceptual Representation, Missed Negation, Inaccurate identification of Negation). METHODS: 41 Clinical Documents (Medical Evaluations; sometimes outside of Mayo these are referred to as History and Physical Examinations) were parsed using the Mayo Vocabulary Server Parsing Engine. SNOMED-C was used to provide concept coverage for the clinical concepts in the record. These records resulted in identification of Concepts and textual clues to Negation. These records were reviewed by an independent medical terminologist, and the results were tallied in a spreadsheet. Where questions on the review arose Internal Medicine Faculty were employed to make a final determination. RESULTS: SNOMED-CT was used to provide concept coverage of the 14,792 Concepts in 41 Health Records from John's Hopkins University. Of these, 1,823 Concepts were identified as negative by Human review. The sensitivity (Recall) of the assignment of negation was 97.2% (p < 0.001, Pearson Chi-Square test; when compared to a coin flip). The specificity of assignment of negation was 98.8%. The positive likelihood ratio of the negation was 81. The positive predictive value (Precision) was 91.2% CONCLUSION: Automated assignment of negation to concepts identified in health records based on review of the text is feasible and practical. Lexical assignment of negation is a good test of true Negativity as judged by the high sensitivity, specificity and positive likelihood ratio of the test. SNOMED-CT had overall coverage of 88.7% of the concepts being negated.