Source Title:

AIR Score for suspected appendicitis

Source Type:

Peer reviewed article

Year of Primary Citation:

2015

Source Link:

Risk stratification by the Appendicitis Inflammatory Response score to guide decision-making in patients with suspected appendicitis. (2015)

Piece of Clinical Logic:

IF [AIR SCORE<5] THEN NOT [US abdomen]

Validating Clinician Name:

Ali Raja

Curator Name:

Sowmya Varada

Curator Name:

Paul Bain

Grading Dates:

Sep 5, 2015

Disclaimer:

The Appendicitis Inflammatory Response (AIR) score

• Vomiting - 1
• Right iliac fossa pain - 1
• Rebound tenderness or guarding
•   Light - 1
•   Moderate - 2
•   Strong - 3
• Temperature≥38⋅5°C - 1
• White cell count (×109/l)
•   10–14⋅9 - 1
•   ≥15 - 2
• Proportion of PMNs (%)
•   70–84 - 1
•   ≥85 - 2
• C-reactive protein (mg/l)
•   10–49 - 1
•   ≥50 - 2

PMID: 25727811 - Ultrasound performed poorly in low-risk patients. 

SYSTEMATIC LITERATURE REVIEW OF THE CLINICAL TOPIC AND RELEVANT STUDIES, AS WELL AS ASSESSMENT OF THE EVIDENCE USING A FORMAL, PUBLISHED AND WIDELY RECOGNIZED METHODOLOGY FOR GRADING EVIDENCE WAS COMPLETED BY TWO INDEPENDENT CURATORS AND A VALIDATING CLINICIAN OF THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.


CHANGES AND DIFFERENCES IN THE FORMULATION, APPLICATION OR INTERPRETATION OF APPROPRIATE USE CRITERIA, GUIDELINES OR DECISION SUPPORT RULES THAT INCORPORATE MEDICAL EVIDENCE MAY AFFECT THE UTILITY, APPLICABILITY OR VALIDITY OF THE EVIDENCE SCORING PERFORMED BY THE HARVARD LIBRARY OF EVIDENCE. THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE AND HARVARD MEDICAL SCHOOL DO NOT ASSUME ANY LIABILITY FOR ANY USE MADE BY ANY THIRD PARTY OF THE CONTENT PROVIDED THROUGH THIS WEBSITE OR OTHERWISE BY THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE. 

Source Title:

Validation and refinement of a prediction rule to identify children at low risk for acute appendicitis.

Source Type:

Peer reviewed article

Year of Primary Citation:

2012

Source Link:

http://www.ncbi.nlm.nih.gov/pubmed/22869405

Piece of Clinical Logic:

IF ([absolute neutrophil count <=6.75 x 10^3/µL] AND NOT [maximal tenderness in right lower quadrant]) THEN NOT [CT abdomen with contrast]

Validating Clinician Name:

Ali Raja

Curator Name:

David Osterbur

Curator Name:

Paul Bain

Grading Dates:

Sep 5, 2015

Disclaimer:

PMID: 22869405 -  This is a validation study. It's a single analysis based on multiple centers, rather than independent studies. This rule applies only to pediatric patients.

SYSTEMATIC LITERATURE REVIEW OF THE CLINICAL TOPIC AND RELEVANT STUDIES, AS WELL AS ASSESSMENT OF THE EVIDENCE USING A FORMAL, PUBLISHED AND WIDELY RECOGNIZED METHODOLOGY FOR GRADING EVIDENCE WAS COMPLETED BY TWO INDEPENDENT CURATORS AND A VALIDATING CLINICIAN OF THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.

CHANGES AND DIFFERENCES IN THE FORMULATION, APPLICATION OR INTERPRETATION OF APPROPRIATE USE CRITERIA, GUIDELINES OR DECISION SUPPORT RULES THAT INCORPORATE MEDICAL EVIDENCE MAY AFFECT THE UTILITY, APPLICABILITY OR VALIDITY OF THE EVIDENCE SCORING PERFORMED BY THE HARVARD LIBRARY OF EVIDENCE. THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE AND HARVARD MEDICAL SCHOOL DO NOT ASSUME ANY LIABILITY FOR ANY USE MADE BY ANY THIRD PARTY OF THE CONTENT PROVIDED THROUGH THIS WEBSITE OR OTHERWISE BY THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE. 

Source Title:

Ottawa Ankle Rule

Source Type:

Peer reviewed article

Year of Primary Citation:

1995

Source Link:

http://www.ncbi.nlm.nih.gov/pubmed/7663253

Piece of Clinical Logic:

IF [any pain in malleolar zone] AND ([Bone tenderness at the posterior edge] OR [bone tenderness at tip of lateral malleolus] OR [Bone tenderness at the posterior edge] OR [bone tenderness at tip of medial malleolus] OR [inability to bear weight both immediately & in the ED]) THEN [Xray Ankle]

Validating Clinician Name:

Ivan Ip

Curator Name:

David Osterbur

Curator Name:

Paul Bain

Grading Dates:

Mar 5, 2015

Disclaimer:

PMID: 7663253

The rules have been validated at one center by one group (emergency departments of two university hospitals within the same health system). A trial tested effectiveness at reducing radiography at multiple centers with no adverse effects. "This study has demonstrated that implementation of the Ottawa ankle rules led to significant reductions in the use of ankle and foot radiography, decreased waiting times for patients, decreased medical costs, no apparent dissatisfaction among physicians or patients, and no missed fractures." [Stiell, 1994]

SYSTEMATIC LITERATURE REVIEW OF THE CLINICAL TOPIC AND RELEVANT STUDIES, AS WELL AS ASSESSMENT OF THE EVIDENCE USING A FORMAL, PUBLISHED AND WIDELY RECOGNIZED METHODOLOGY FOR GRADING EVIDENCE WAS COMPLETED BY TWO INDEPENDENT CURATORS AND A VALIDATING CLINICIAN OF THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.
 
CHANGES AND DIFFERENCES IN THE FORMULATION, APPLICATION OR INTERPRETATION OF APPROPRIATE USE CRITERIA, GUIDELINES OR DECISION SUPPORT RULES THAT INCORPORATE MEDICAL EVIDENCE MAY AFFECT THE UTILITY, APPLICABILITY OR VALIDITY OF THE EVIDENCE SCORING PERFORMED BY THE HARVARD LIBRARY OF EVIDENCE. THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE AND HARVARD MEDICAL SCHOOL DO NOT ASSUME ANY LIABILITY FOR ANY USE MADE BY ANY THIRD PARTY OF THE CONTENT PROVIDED THROUGH THIS WEBSITE OR OTHERWISE BY THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.

Source Title:

Canadian C-spine rule

Source Type:

Peer reviewed article

Year of Primary Citation:

2011

Source Link:

http://www.ncbi.nlm.nih.gov/pubmed/21068171

Piece of Clinical Logic:

IF NOT ([age >=65] OR [fall >3 feet] OR [axial load to head] OR [motor vehicle accident >100km/hr] OR [vehicle rollover] OR [vehicle ejection] OR [usage of motorized recreational vehicle] OR [bicycle collision] OR [paresthesias in extremities]) AND [able to safely assess range of motion] AND [able to rotate neck 45 degrees left and right] THEN NOT [Xray C-spine]

Validating Clinician Name:

Ali Raja

Curator Name:

David Osterbur

Curator Name:

Paul Bain

Grading Dates:

Aug 29, 2015

Disclaimer:

PMID: 21068171 - Validating study of the Canadian C-Spine Rule in two UK hospitals.

SYSTEMATIC LITERATURE REVIEW OF THE CLINICAL TOPIC AND RELEVANT STUDIES, AS WELL AS ASSESSMENT OF THE EVIDENCE USING A FORMAL, PUBLISHED AND WIDELY RECOGNIZED METHODOLOGY FOR GRADING EVIDENCE WAS COMPLETED BY TWO INDEPENDENT CURATORS AND A VALIDATING CLINICIAN OF THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.

CHANGES AND DIFFERENCES IN THE FORMULATION, APPLICATION OR INTERPRETATION OF APPROPRIATE USE CRITERIA, GUIDELINES OR DECISION SUPPORT RULES THAT INCORPORATE MEDICAL EVIDENCE MAY AFFECT THE UTILITY, APPLICABILITY OR VALIDITY OF THE EVIDENCE SCORING PERFORMED BY THE HARVARD LIBRARY OF EVIDENCE. THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE AND HARVARD MEDICAL SCHOOL DO NOT ASSUME ANY LIABILITY FOR ANY USE MADE BY ANY THIRD PARTY OF THE CONTENT PROVIDED THROUGH THIS WEBSITE OR OTHERWISE BY THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE. 

Source Title:

NEXUS blunt trauma rule

Source Type:

Peer reviewed article

Year of Primary Citation:

2013

Source Link:

NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. (2013)

Piece of Clinical Logic:

IF NOT ([age>60] OR [fall >20 feet] OR [motor vehicle accident >40 mph] OR [chest pain] OR [intoxication] OR [abnormal mental status] OR [abnormal alertness] OR [distracting painful injury] OR [chest wall tenderness to palpation]) THEN NOT [CT Chest]

Validating Clinician Name:

Ali Raja

Curator Name:

David Osterbur

Curator Name:

Paul Bain

Grading Dates:

Sep 5, 2015

Disclaimer:

[inclusion criteria]: 
1. Decreased level of consciousness (GCS score <15 or neurologic/behavioral status not age-appropriate) in association with blunt torso trauma (but not isolated head trauma).
OR
2. Blunt traumatic event resulting in paralysis or multiple nonadjacent long bone fractures (eg, tibia fracture, ulna fracture).
OR
3. Blunt traumatic event due to motor vehicle crash >40mph, ejection, rollover, automobile vs. pedestrian, automobile (>=5 mph) vs. bicycle, fall >=20 feet, crush injury to the torso, or physical assault involving the abdomen.
OR
4. Physician concern for abdominal trauma resulting in Abdominal CT or ultrasound (FAST), Laboratory testing to screen for intra-abdominal injury, or chest or pelvic radiography. 

[exclusion criteria]: 
presenting >24 hours after injury, penetrating trauma, preexisting neurologic disorder preventing reliable examination, pregnancy, transfer from another hospital with previous abdominal CT or peritoneal lavage. 


PMID: 23925583 - Validating clinical decision rule in multiple level 1 trauma centers, rather than within one practice group.

SYSTEMATIC LITERATURE REVIEW OF THE CLINICAL TOPIC AND RELEVANT STUDIES, AS WELL AS ASSESSMENT OF THE EVIDENCE USING A FORMAL, PUBLISHED AND WIDELY RECOGNIZED METHODOLOGY FOR GRADING EVIDENCE WAS COMPLETED BY TWO INDEPENDENT CURATORS AND A VALIDATING CLINICIAN OF THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.

CHANGES AND DIFFERENCES IN THE FORMULATION, APPLICATION OR INTERPRETATION OF APPROPRIATE USE CRITERIA, GUIDELINES OR DECISION SUPPORT RULES THAT INCORPORATE MEDICAL EVIDENCE MAY AFFECT THE UTILITY, APPLICABILITY OR VALIDITY OF THE EVIDENCE SCORING PERFORMED BY THE HARVARD LIBRARY OF EVIDENCE. THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE AND HARVARD MEDICAL SCHOOL DO NOT ASSUME ANY LIABILITY FOR ANY USE MADE BY ANY THIRD PARTY OF THE CONTENT PROVIDED THROUGH THIS WEBSITE OR OTHERWISE BY THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE. 

Source Title:

Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society.

Source Type:

Peer reviewed article

Year of Primary Citation:

2005

Source Link:

http://www.ncbi.nlm.nih.gov/pubmed/16244247

Piece of Clinical Logic:

IF [pulmonary nodule on chest CT] AND [nodule size <= 4mm] AND [low risk] THEN NOT [CT Chest]

Validating Clinician Name:

Louise Schneider

Curator Name:

Sowmya Varada

Curator Name:

Fritz Dement

Grading Dates:

Jun 13, 2019

Disclaimer:

This recommendation synthesizes data and recommendations from a number of studies and guidelines.  A direct citation for this specific rule does not exist so, by definition, it must be graded as expert opinion (5-I).

[inclusion criteria]: age >=35, newly detected incidental nodule (unrelated to known underlying disease), solid nodule

[exclusion criteria]: known or suspected to have underlying malignant disease, age <35, unexplained fever

[low risk] = [minimal or absent history of smoking] OR [minimal or absent exposure to asbestos, uranium, and radon]

[high risk] = [history of smoking] OR [exposure to asbestos, uranium, or radon]

SYSTEMATIC LITERATURE REVIEW OF THE CLINICAL TOPIC AND RELEVANT STUDIES, AS WELL AS ASSESSMENT OF THE EVIDENCE USING A FORMAL, PUBLISHED AND WIDELY RECOGNIZED METHODOLOGY FOR GRADING EVIDENCE WAS COMPLETED BY TWO INDEPENDENT CURATORS AND A VALIDATING CLINICIAN OF THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.

CHANGES AND DIFFERENCES IN THE FORMULATION, APPLICATION OR INTERPRETATION OF APPROPRIATE USE CRITERIA, GUIDELINES OR DECISION SUPPORT RULES THAT INCORPORATE MEDICAL EVIDENCE MAY AFFECT THE UTILITY, APPLICABILITY OR VALIDITY OF THE EVIDENCE SCORING PERFORMED BY THE HARVARD LIBRARY OF EVIDENCE. THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE AND HARVARD MEDICAL SCHOOL DO NOT ASSUME ANY LIABILITY FOR ANY USE MADE BY ANY THIRD PARTY OF THE CONTENT PROVIDED THROUGH THIS WEBSITE OR OTHERWISE BY THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE. 

Source Title:

Lung cancer screening

Source Type:

Professional society guideline

Year of Primary Citation:

2013

Source Link:

http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lung-cancer-screening

Piece of Clinical Logic:

IF [age >=55] AND [age <=80] AND [greater than OR equal to 30 pack years] AND ([current smoker] OR [quit smoking within past 15 years]) THEN [CT lung cancer screening]

Validating Clinician Name:

Laila Cochon Coen

Curator Name:

Julia Whelan

Curator Name:

Paul Bain

Grading Dates:

May 2, 2017

Disclaimer:

This recommendation is based on an SR with significant heterogeneity but included one good quality RCT (PMID: 21714641, 23697514) with a fairly narrow confidence interval. The rule based upon this study, merits 1b.

SYSTEMATIC LITERATURE REVIEW OF THE CLINICAL TOPIC AND RELEVANT STUDIES, AS WELL AS ASSESSMENT OF THE EVIDENCE USING A FORMAL, PUBLISHED AND WIDELY RECOGNIZED METHODOLOGY FOR GRADING EVIDENCE WAS COMPLETED BY TWO INDEPENDENT CURATORS AND A VALIDATING CLINICIAN OF THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.

CHANGES AND DIFFERENCES IN THE FORMULATION, APPLICATION OR INTERPRETATION OF APPROPRIATE USE CRITERIA, GUIDELINES OR DECISION SUPPORT RULES THAT INCORPORATE MEDICAL EVIDENCE MAY AFFECT THE UTILITY, APPLICABILITY OR VALIDITY OF THE EVIDENCE SCORING PERFORMED BY THE HARVARD LIBRARY OF EVIDENCE. THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE AND HARVARD MEDICAL SCHOOL DO NOT ASSUME ANY LIABILITY FOR ANY USE MADE BY ANY THIRD PARTY OF THE CONTENT PROVIDED THROUGH THIS WEBSITE OR OTHERWISE BY THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.

Source Title:

BWH - Minor Head Trauma

Source Type:

Local best practice

Year of Primary Citation:

Source Link:

Piece of Clinical Logic:

IF ([loss of consciousness] OR [Post-Traumatic Amnesia]) AND NOT ([Focal neurologic deficit] OR [Coagulopathy] OR [Vomiting] OR [Glasgow coma score <15] OR [Severe headache] OR [Physical signs of basal skull fracture] OR [Dangerous mechanism of injury] OR [Trauma >24h ago] OR [Hemodynamically unstable]) AND [Age ≤60] THEN NOT [CT Head]

Validating Clinician Name:

Ivan Ip

Curator Name:

David Osterbur

Curator Name:

Julia Whelan

Grading Dates:

Mar 4, 2015

Disclaimer:

PMID: 21818031 

From the Brigham & Women's Hospital Clinical Decision Support system... "Performing a head CT in this patient does not meet the National Quality Forum (NQF) Imaging Efficiency Quality Measure for Appropriate Head CT Imaging in Adults with Mild Traumatic Brain Injury. This quality measure is based on the New Orleans Criteria and the Canadian CT Head Rule, each of which has been shown to detect more than 99% of intracranial injuries requiring neurosurgical intervention in multiple studies involving thousands of patients." [Harnan, 2011] 

SYSTEMATIC LITERATURE REVIEW OF THE CLINICAL TOPIC AND RELEVANT STUDIES, AS WELL AS ASSESSMENT OF THE EVIDENCE USING A FORMAL, PUBLISHED AND WIDELY RECOGNIZED METHODOLOGY FOR GRADING EVIDENCE WAS COMPLETED BY TWO INDEPENDENT CURATORS AND A VALIDATING CLINICIAN OF THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.

CHANGES AND DIFFERENCES IN THE FORMULATION, APPLICATION OR INTERPRETATION OF APPROPRIATE USE CRITERIA, GUIDELINES OR DECISION SUPPORT RULES THAT INCORPORATE MEDICAL EVIDENCE MAY AFFECT THE UTILITY, APPLICABILITY OR VALIDITY OF THE EVIDENCE SCORING PERFORMED BY THE HARVARD LIBRARY OF EVIDENCE. THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE AND HARVARD MEDICAL SCHOOL DO NOT ASSUME ANY LIABILITY FOR ANY USE MADE BY ANY THIRD PARTY OF THE CONTENT PROVIDED THROUGH THIS WEBSITE OR OTHERWISE BY THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE. 

Source Title:

ACR - Acute Shoulder Pain

Source Type:

Professional society guideline

Year of Primary Citation:

2010

Source Link:

https://acsearch.acr.org/docs/69433/Narrative/

Piece of Clinical Logic:

IF ([Normal radiograph] OR [Radiograph demonstrate coracoacromial arch osteophytes/syndesmophytes]) AND [Suspect rotator cuff tear/impingement] AND [Age >35 years] THEN [MRI shoulder without contrast]

Validating Clinician Name:

Ronilda Lacson

Curator Name:

Paul Bain

Curator Name:

Carol Mita

Grading Dates:

Mar 5, 2015

Disclaimer:

The narrative doesn't cite direct evidence for the logic. It discusses the value of different views but doesn't address the relative value of radiography or other modes.

SYSTEMATIC LITERATURE REVIEW OF THE CLINICAL TOPIC AND RELEVANT STUDIES, AS WELL AS ASSESSMENT OF THE EVIDENCE USING A FORMAL, PUBLISHED AND WIDELY RECOGNIZED METHODOLOGY FOR GRADING EVIDENCE WAS COMPLETED BY TWO INDEPENDENT CURATORS AND A VALIDATING CLINICIAN OF THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.

CHANGES AND DIFFERENCES IN THE FORMULATION, APPLICATION OR INTERPRETATION OF APPROPRIATE USE CRITERIA, GUIDELINES OR DECISION SUPPORT RULES THAT INCORPORATE MEDICAL EVIDENCE MAY AFFECT THE UTILITY, APPLICABILITY OR VALIDITY OF THE EVIDENCE SCORING PERFORMED BY THE HARVARD LIBRARY OF EVIDENCE. THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE AND HARVARD MEDICAL SCHOOL DO NOT ASSUME ANY LIABILITY FOR ANY USE MADE BY ANY THIRD PARTY OF THE CONTENT PROVIDED THROUGH THIS WEBSITE OR OTHERWISE BY THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE. 

Source Title:

Quebec decision rule for radiography in shoulder dislocation

Source Type:

Peer reviewed article

Year of Primary Citation:

2009

Source Link:

http://www.ncbi.nlm.nih.gov/pubmed/19166638

Piece of Clinical Logic:

IF [age >=18] AND [age<=39] AND ([motor vehicle collision] OR [assault] OR [sporting injury] OR [fall from greater than patient’s height]) THEN [Xray shoulder]

Validating Clinician Name:

Ali Raja

Curator Name:

Carol Mita

Curator Name:

Margo Coletti

Grading Dates:

Aug 29, 2015

Disclaimer:

PMID: 19166638 - Develpment of a clinical decision rule. A prospective derivation cohort study at four university-affiliated emergency departments.

SYSTEMATIC LITERATURE REVIEW OF THE CLINICAL TOPIC AND RELEVANT STUDIES, AS WELL AS ASSESSMENT OF THE EVIDENCE USING A FORMAL, PUBLISHED AND WIDELY RECOGNIZED METHODOLOGY FOR GRADING EVIDENCE WAS COMPLETED BY TWO INDEPENDENT CURATORS AND A VALIDATING CLINICIAN OF THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.
CHANGES AND DIFFERENCES IN THE FORMULATION, APPLICATION OR INTERPRETATION OF APPROPRIATE USE CRITERIA, GUIDELINES OR DECISION SUPPORT RULES THAT INCORPORATE MEDICAL EVIDENCE MAY AFFECT THE UTILITY, APPLICABILITY OR VALIDITY OF THE EVIDENCE SCORING PERFORMED BY THE HARVARD LIBRARY OF EVIDENCE. THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE AND HARVARD MEDICAL SCHOOL DO NOT ASSUME ANY LIABILITY FOR ANY USE MADE BY ANY THIRD PARTY OF THE CONTENT PROVIDED THROUGH THIS WEBSITE OR OTHERWISE BY THE HARVARD MEDICAL SCHOOL LIBRARY OF EVIDENCE.