Chart reviews in emergency medicine research: Where are the methods?

STUDY OBJECTIVE: Medical chart reviews are often used in emergency medicine research. However, the reliability of data abstracted by chart reviews is seldom examined critically. The objective of this investigation was to determine the proportion of emergency medicine research articles that use data from chart reviews and the proportions that report methods of case selection, abstractor training, monitoring and blinding, and interrater agreement. METHODS: Research articles published in three emergency medicine journals from January 1989 through December 1993 were identified. The articles that used chart reviews were analyzed. RESULTS: Of 986 original research articles that were identified, 244 (25%; 95% confidence interval [CI], 22% to 28%) relied on chart reviews. Inclusion criteria were described in 98% (95% CI, 96% to 99%), and 73% (95% CI, 67% to 79%) defined the variables being analyzed. Other methods were seldom mentioned: abstractor training, 18% (95% CI, 13% to 23%); standardized abstraction forms, 11% (95% CI, 7% to 15%); periodic abstractor monitoring, 4% (95% CI, 2% to 7%); and abstractor blinding to study hypotheses, 3% (95% CI, 1% to 6%). Interrater reliability was mentioned in 5% (95% CI, 3% to 9%) and tested statistically in .4% (95% CI, 0% to 2%). A 15% random sample of articles was reassessed by a second investigator; interrater agreement was high for all eight criteria. CONCLUSION: Chart review is a common method of data collection in emergency medicine research. Yet, information about the quality of the data is usually lacking. Chart reviews should be held to higher methodologic standards, or the conclusions of these studies may be in error.

Left recurrent laryngeal nerve paralysis: an unusual presentation of histoplasmosis.

A case of histoplasmosis seen as left recurrent laryngeal nerve paralysis in a 49-year-old man is described. The patient had roentgenographic findings of a solitary, noncalcified left upper lobe mass and mediastinal adenopathy. Tissue diagnosis of histoplasmosis was obtained using a thoracotomy, allowing institution of appropriate treatment.

Anorexia nervosa: adolescent starvation by choice.

Anorexia nervosa is an eating disorder which affects people of all classes and ages but in particular adolescent girls. The symptoms, characteristics, family, and modes of treatment of the typical anorectic patient are discussed.

Value of 111Indium chloride bone marrow scanning in the differential diagnosis of blood count depression in lymphoma.

In patients with Hodgkin's disease or non-Hodgkin's lymphoma, the etiology of low peripheral blood counts is often difficult to determine. Often it is based on the results of a "random" bone marrow biopsy and/or aspirate, plus evaluation of circulating peripheral blood elements. However, these tests may be misleading. The present study evaluates the usefulness of 111Indium chloride bone marrow scanning in conjunction with marrow biopsies in distinguishing intrinsic from extrinsic causes for low peripheral blood counts. Thirty consecutive patients with Hodgkin's disease or non-Hodgkin's lymphoma, presenting with low peripheral blood counts and without any form of antineoplastic treatment for at least 5 weeks, were analyzed. Scan ratings were felt to be clinically accurate in 27 of the 30 patients analyzed (90%). In 18 patients (60%), the scan provided information which was not provided by any other standard test. 111Indium chloride scanning in conjunction with a marrow biopsy appears to be a useful, accurate means of evaluating bone marrow function in patients with depressed peripheral blood counts.

Indium bone marrow scintigraphy as an aid in selecting marrow biopsy sites for the evaluation of marrow elements in patients with lymphoma.

One hundred and two previously treated lymphoma patients were studied with 111Indium bone marrow scans and bone marrow biopsies. The biopsies were considered to represent sampling errors when the cellularity of the biopsy did not reflect the general state of the marrow organ cellularity as demonstrated by the scan. In each instance the accuracy of the scan was confirmed by either another biopsy or the subsequent clinical course of the patient. Sampling errors were infrequent (1/51) in patients with normal peripheral blood counts and whose marrow had never been involved with tumor. Errors were especially likely (17/51) in patients who had had marrow involvement or those who had anemia, leukopenia, or thrombocytopenia. The 111Indium bone marrow scan allows the clinician to avoid selecting a biopsy site with a high risk for sampling error.

The accuracy of 111InCl3 as a bone marrow scanning agent.

The number of normal cellular elements present in bone marrow biopsies was compared to the extent of uptake at corresponding sites on 111InCl3 bone marrow scans in 87 patients with malignant lymphoma. Of the biopsies free of tumor, 49/54 interpreted as normocellular and 16/17 hypocellular or aplastic confirmed the scan interpretation. Of the biopsies demonstrating tumor, 10/11 of those interpreted as normocellular and 14/15 hypocellular or aplastic confirmed the scan interpretation. The 111InCl3 bone marrow scan is accurate in depicting the presence or absence of normal marrow elements, but is of value in detecting tumor only when the normal elements are extensively replaced.

Carcinoma of the oral tongue and floor of mouth: fifteen years' experience with linear acceleration therapy.

One hundred fourteen patients with carcinoma of the oral tongue and floor of mouth were treated with high-dose megavoltage radiation at Stanford University from 1956 to1970. Actuarial 5-year survival for 56 patients with oral tongue lesions was: T', 73; T', 37%; and T', 19%. Similarly, for 58 patients with lesions of the floor mouth, 5-year survival was: T', 73%; T', 37%; and T', 25%. Local control of the primary was obtained in oral tongue T' lesions 10 of 11 times; T', 5 of 8; and T', 13 of 36 times. For floor of mouth, local control was: T', 22 of 26;T', 7 of 14; andT', 3 of 15. There was an indication that better control was obtained if interstitialtherapy was a planned part of the treatment. Dose for local control when external radiation alone was utilized was usually over 1900 rets. Patients with initially clinicallynegative nodes (TXNO) who had a low radiation dose to primary echelon lymph nodes developed later cervical lymph node metastases 38% of the time. In no case did late metastatic disease appear in patients whose necks were treated prophylactically.

Irradiation of clinically uninvolved cervical lymph nodes.

Of 402 patients with cancers of the oral cavity, oropharynx, and supraglottic larynx treated at Stanford between 1957 and 1972, 164 had clinically uninvolved cervical lymph nodes prior to the initiation of radiation therapy. Lymph node metastases developed later in 38 per cent of patients with primary oral cavity carcinomas who were treated with interstitial radium implants alone. No late cervical lymph node involvement was found in those patients who received high dose external irradiation to at least the primary site and first echelon lymph nodes. Lymph node failures were ultimately noted in 20 of the 140 patients (14 per cent), who received partial or complete neck irradiation, but 18 of these occurred in patients with uncontrolled primary lesions, suggesting that re-seeding of cervical lymph nodes had taken place rather than failure of the initial irradiation to control subclinical metastases. Our present policy is to treat the primary lesion and adjacent lymph nodes with high dose megavoltage techniques, combined with interstitial irradiation if possible. Bilateral supplemental inferior neck radiation ports are added for patients with advanced primary neoplasms and for those with clinically involved cervical lymph nodes. All other patients undergoing radiation therapy for stage T1 primary lesions and clinically negative necks also receive ipsilateral low neck irradiation. In addition, cervical lymph nodes are electively irradiated when the primary lesion has been resected. When these policies are adopted, the incidence of cervical lymph node failures is extremely low in patients whose primary sites remain controlled, and morbidity from the cervical radiation fields is negligible.