Christopher R. Kelly

Clearing the Air on the “Smoker’s Paradox”∗

Among behavioral risk factors for adverse health outcomes, smoking stands alone in its public health impact, accounting for nearly 500,000 (or 1 in 5) deaths in the United States annually [(1)][1]. In the aftermath of many well-chronicled legal battles with the tobacco industry, the causality

Videos in clinical medicine. Noninvasive positive-pressure ventilation.

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Can Physicians Identify Inappropriate Nuclear Stress Tests? An Examination of Inter-Rater Reliability for the 2009 Appropriate Use Criteria for Radionuclide Imaging

Background— We sought to determine inter-rater reliability of the 2009 Appropriate Use Criteria for radionuclide imaging and whether physicians at various levels of training can effectively identify nuclear stress tests with inappropriate indications. Methods and Results— Four hundred patients were randomly selected from a consecutive cohort of patients undergoing nuclear stress testing at an academic medical center. Raters with different levels of training (including cardiology attending physicians, cardiology fellows, internal medicine hospitalists, and internal medicine interns) classified individual nuclear stress tests using the 2009 Appropriate Use Criteria. Consensus classification by 2 cardiologists was considered the operational gold standard, and sensitivity and specificity of individual raters for identifying inappropriate tests were calculated. Inter-rater reliability of the Appropriate Use Criteria was assessed using Cohen &kgr; statistics for pairs of different raters. The mean age of patients was 61.5 years; 214 (54%) were female. The cardiologists rated 256 (64%) of 400 nuclear stress tests as appropriate, 68 (18%) as uncertain, 55 (14%) as inappropriate; 21 (5%) tests were unable to be classified. Inter-rater reliability for noncardiologist raters was modest (unweighted Cohen &kgr;, 0.51, 95% confidence interval, 0.45–0.55). Sensitivity of individual raters for identifying inappropriate tests ranged from 47% to 82%, while specificity ranged from 85% to 97%. Conclusions— Inter-rater reliability for the 2009 Appropriate Use Criteria for radionuclide imaging is modest, and there is considerable variation in the ability of raters at different levels of training to identify inappropriate tests.

Technique for office-based, ultrasonography-guided percutaneous biopsy of renal cortical neoplasms using a novel transducer for facilitated ultrasound targeting.

To help clarify which small renal cortical neoplasms (RCNs) require surgery by using office‐based, ultrasonography‐guided percutaneous renal biopsy.

Pulmonary-Artery Catheterization

Pulmonary-artery catheterization aids the diagnosis and management of numerous cardiovascular illnesses. This video demonstrates the insertion of a pulmonary-artery catheter.

Noninvasive Positive-Pressure Ventilation

This video demonstrates noninvasive positive-pressure ventilation. In certain conditions, this technique offers the benefits of invasive ventilation with fewer of the risks that are associated with intubation.

INTER-RATER RELIABILITY OF THE 2009 APPROPRIATE USE CRITERIA FOR CARDIAC RADIONUCLIDE IMAGING

The 2009 Appropriate Use Criteria (AUC) for Cardiac Radionuclide Imaging is used to identify nuclear stress tests of limited clinical value. However, the AUCs inter-rater reliability has not been well characterized. We randomly selected 400 nuclear stress tests performed at a single academic