Checklists to prevent diagnostic errors: a pilot randomized controlled trial Bias due to selective inclusion and reporting of outcomes and analyses in systematic reviews of randomised trials of healthcare interventions. Distinguishing patients with chronic fatigue from those with chronic fatigue syndrome: a diagnostic study in UK primary care. Dyspepsia Management in Primary Care in The Netherlands: To What Extent Is Helicobacter pylori Diagnosis and Treatment Incorporated? Characteristics and predictors of frequent utilization of emergency services. How to write an evidence-based clinical review article. The Effectiveness of Psychosocial Interventions as Adjuncts to Orthopaedic Surgery: A Systematic Review Protocol Self-reported psychosocial needs and health-related quality of life of colorectal cancer survivors. Evaluating the complaint of fatigue in primary care: diagnoses and outcomes. Enabling the diagnosis of occult psychiatric illness in the emergency department: a randomized, controlled trial of the computerized, self-administered PRIME-MD diagnostic system. Chief complaint of fatigue: a prospective study. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society
Abstract Background : Many diagnostic errors are caused by premature closure of the diagnostic process . To help prevent premature closure , we developed checklists that prompt physicians to consider all reasonable diagnoses for symptoms that commonly present in primary care . Methods : We enrolled 14 primary care physicians and 100 patients in a r and omized clinical trial . The study took place in an emergency department ( 5 physicians ) and a same-day access clinic ( 9 physicians ) . The physicians were r and omized to usual care vs. diagnostic checklist . After completing the history and physical exam , checklist physicians read aloud a differential diagnosis checklist for the chief complaint . The primary outcome was diagnostic error , which was defined as a discrepancy between the diagnosis documented at the acute visit and the diagnosis based on a 1-month follow-up phone call and record review . Results : There were 17 diagnostic errors . The mean error rate among the seven checklist physicians was not significantly different from the rate among the seven usual-care physicians ( 11.2 % vs. 17.8 % ; p=0.46 ) . In a post-hoc subgroup analysis , emergency physicians in the checklist group had a lower mean error rate than emergency physicians in the usual-care group ( 19.1 % vs. 45.0 % ; p=0.04 ) . Checklist physicians considered more diagnoses than usual-care physicians during the patient encounters ( 6.5 diagnoses [ SD 4.2 ] vs. 3.4 diagnoses [ SD 2.0 ] , p<0.001 ) . Conclusions : Checklists did not improve the diagnostic error rate in this study . However further development and testing of checklists in larger studies may be warranted BACKGROUND Systematic review s may be compromised by selective inclusion and reporting of outcomes and analyses . Selective inclusion occurs when there are multiple effect estimates in a trial report that could be included in a particular meta- analysis ( e.g. from multiple measurement scales and time points ) and the choice of effect estimate to include in the meta- analysis is based on the results ( e.g. statistical significance , magnitude or direction of effect ) . Selective reporting occurs when the reporting of a subset of outcomes and analyses in the systematic review is based on the results ( e.g. a protocol -defined outcome is omitted from the published systematic review ) . OBJECTIVES To summarise the characteristics and synthesis e the results of empirical studies that have investigated the prevalence of selective inclusion or reporting in systematic review s of r and omised controlled trials ( RCTs ) , investigated the factors ( e.g. statistical significance or direction of effect ) associated with the prevalence and quantified the bias . SEARCH METHODS We search ed the Cochrane Methodology Register ( to July 2012 ) , Ovid MEDLINE , Ovid EMBASE , Ovid PsycINFO and ISI Web of Science ( each up to May 2013 ) , and the US Agency for Healthcare Research and Quality ( AHRQ ) Effective Healthcare Program 's Scientific Re source Center ( SRC ) Methods Library ( to June 2013 ) . We also search ed the abstract books of the 2011 and 2012 Cochrane Colloquia and the article alerts for method ological work in research synthesis published from 2009 to 2011 and compiled in Research Synthesis Methods . SELECTION CRITERIA We included both published and unpublished empirical studies that investigated the prevalence and factors associated with selective inclusion or reporting , or both , in systematic review s of RCTs of healthcare interventions . We included empirical studies assessing any type of selective inclusion or reporting , such as investigations of how frequently RCT outcome data is selectively included in systematic review s based on the results , outcomes and analyses are discrepant between protocol and published review or non-significant outcomes are partially reported in the full text or summary within systematic review s. DATA COLLECTION AND ANALYSIS Two review authors independently selected empirical studies for inclusion , extracted the data and performed a risk of bias assessment . A third review author resolved any disagreements about inclusion or exclusion of empirical studies , data extraction and risk of bias . We contacted authors of included studies for additional unpublished data . Primary outcomes included overall prevalence of selective inclusion or reporting , association between selective inclusion or reporting and the statistical significance of the effect estimate , and association between selective inclusion or reporting and the direction of the effect estimate . We combined prevalence estimates and risk ratios ( RRs ) using a r and om-effects meta- analysis model . MAIN RESULTS Seven studies met the inclusion criteria . No studies had investigated selective inclusion of results in systematic review s , or discrepancies in outcomes and analyses between systematic review registry entries and published systematic review s. Based on a meta- analysis of four studies ( including 485 Cochrane Review s ) , 38 % ( 95 % confidence interval ( CI ) 23 % to 54 % ) of systematic review s added , omitted , up grade d or down grade d at least one outcome between the protocol and published systematic review . The association between statistical significance and discrepant outcome reporting between protocol and published systematic review was uncertain . The meta-analytic estimate suggested an increased risk of adding or upgrading ( i.e. changing a secondary outcome to primary ) when the outcome was statistically significant , although the 95 % CI included no association and a decreased risk as plausible estimates ( RR 1.43 , 95 % CI 0.71 to 2.85 ; two studies , n = 552 meta-analyses ) . Also , the meta-analytic estimate suggested an increased risk of downgrading ( i.e. changing a primary outcome to secondary ) when the outcome was statistically significant , although the 95 % CI included no association and a decreased risk as plausible estimates ( RR 1.26 , 95 % CI 0.60 to 2.62 ; two studies , n = 484 meta-analyses ) . None of the included studies had investigated whether the association between statistical significance and adding , upgrading or downgrading of outcomes was modified by the type of comparison , direction of effect or type of outcome ; or whether there is an association between direction of the effect estimate and discrepant outcome reporting . Several secondary outcomes were reported in the included studies . Two studies found that reasons for discrepant outcome reporting were infrequently reported in published systematic review s ( 6 % in one study and 22 % in the other ) . One study ( including 62 Cochrane Review s ) found that 32 % ( 95 % CI 21 % to 45 % ) of systematic review s did not report all primary outcomes in the abstract . Another study ( including 64 Cochrane and 118 non-Cochrane review s ) found that statistically significant primary outcomes were more likely to be completely reported in the systematic review abstract than non-significant primary outcomes ( RR 2.66 , 95 % CI 1.81 to 3.90 ) . None of the studies included systematic review s published after 2009 when reporting st and ards for systematic review s ( Preferred Reporting Items for Systematic review s and Meta-Analyses ( PRISMA ) Statement , and Method ological Expectations of Cochrane Intervention Review s ( MECIR ) ) were disseminated , so the results might not be generalisable to more recent systematic review s. AUTHORS ' CONCLUSIONS Discrepant outcome reporting between the protocol and published systematic review is fairly common , although the association between statistical significance and discrepant outcome reporting is uncertain . Complete reporting of outcomes in systematic review abstract s is associated with statistical significance of the results for those outcomes . Systematic review outcomes and analysis plans should be specified prior to seeing the results of included studies to minimise post-hoc decisions that may be based on the observed results . Modifications that occur once the review has commenced , along with their justification , should be clearly reported . Effect estimates and CIs should be reported for all systematic review outcomes regardless of the results . The lack of research on selective inclusion of results in systematic review s needs to be addressed and studies that avoid the method ological weaknesses of existing research are also needed BACKGROUND Chronic fatigue syndrome ( CFS ) has been defined , but many more patients consult in primary care with chronic fatigue that does not meet the criteria for CFS . General practitioners ( GPs ) do not generally use the CFS diagnosis , and have some doubt about the validity of CFS as an illness . AIM To describe the proportion of patients consulting their GP for fatigue that met the criteria for CFS , and to describe the social , psychological , and physical differences between patients with CFS and those with non-CFS chronic fatigue in primary care . DESIGN OF STUDY Baseline data from a trial of complex interventions for fatigue in primary care . SETTING Twenty-two general practice s located in London and the South Thames region of the United Kingdom recruited patients to the study between 1999 and 2001 . METHOD One hundred and forty-one patients who presented to their GP with unexplained fatigue lasting six months or more as a main symptom were recruited , and the Centers for Disease Control ( CDC ) case definition was applied to classify CFS . RESULTS Approximately two-thirds ( 69 % ) of patients had chronic fatigue  and not CFS . The duration of fatigue ( 32 months ) and perceived control over fatigue were similar between groups ; however , fatigue , functioning , associated symptoms , and psychological distress were more severe in the patients in the CFS group , who also consulted their GP significantly more frequently , were twice as likely to be depressed , and more than twice as likely to be unemployed . About half ( CFS = 50 % ; chronic fatigue = 55 % ) in each group attributed their fatigue to mainly psychological causes . CONCLUSIONS In primary care , CFS is a more severe illness than chronic fatigue , but non-CFS chronic fatigue is associated with significant fatigue and is reported at least twice as often . That half of patients , irrespective of CFS status , attribute their fatigue to psychological causes , more than is observed in secondary care , indicates an openness to the psychological therapies provided in that setting . More evidence on the natural history of chronic fatigue and CFS in primary care is required , as are trials of complex interventions . The results may help determine the usefulness of differentiating between chronic fatigue and CFS Background : Many guidelines on the management of Helicobacter pylori (HP)-related dyspepsia have been launched over the past decade . The suggested policies in these guidelines are often more consensus- than evidence -based ( test- and -treat policy , test and endoscope ) , which may cause confusion among primary -care physicians . Aim : To determine the current management of HP-related dyspepsia by Dutch general practitioners ( GPs ) . Methods : A r and om sample of 5 % of all Dutch GPs ( n = 355 ) were sent a question naire on the diagnosis and treatment of HP infections in dyspepsia management . Results : The response rate was 66.2 % ( n = 235 ) . Almost 80 % of the responding GPs stated they had conducted HP testing ( via endoscopy or serology ) during the previous 12 months . In the same time period , more than 94 % had actually prescribed a HP eradication therapy . A total of 70 % of the GPs stated that they used  endoscopy  to  test for HP infection  , 54 % used  serology ( ELISA ) ; whole-blood tests and carbon urea breath tests  were not used . Patients with a history of peptic ulcer disease , those on chronic acid-suppressive drugs and patients with recurrent ulcer-like complaints were most frequently tested for HP infection . Conclusions : Given the frequency of consultations for dyspepsia in primary care in the Netherl and s ( 150 new dyspeptic patients per average practice per year ) , and the reported average number of HP tests perfomed ( 1–5 per GP per year ) , HP diagnosis plays a modest role in the management of dyspepsia in Dutch general practice s. Neither the ‘ test- and -treat ’ policy recommended in the Maastricht guidelines , nor its advice regarding the choice of diagnostic tests ( carbon urea breath test or serology ) , is being followed . The majority of GPs uses endoscopy for the detection of HP infection INTRODUCTION Although frequent ED users account for a small percentage of ED visits , these patients can drain the system , contributing to overcrowding and lowered quality of care . METHODS This retrospective descriptive correlational study explored characteristics of  frequent ED users at a large Midwestern urban hospital and factors predictive of high ED utilization . The sample included adult patients with at least 6 visits in 2005 - 2006 ( N = 201 ) . For each , 6 visits were r and omly chosen for chart review ( N = 1200 visits ) of demographic , health history , and clinical factors such as chief complaints . RESULTS Frequent users were commonly female , 35 years old , white , single , unemployed , living alone , with private insurance/Medicaid and a primary care physician . Top chief complaints were abdominal pain , headache , chest pain , low back pain , and lower extremity pain . However , a Poisson regression found that the following characteristics were associated with a higher number of ED visits : male , non-Black race , part-time employment , retired/unemployed , having Medicare , and having a chief complaint of upper respiratory infection . Headache approached significance as an independent predictor of more visits . DISCUSSION Almost 95 % had fewer than 10 ED visits per year , with pain the overall top chief complaint . Seventy percent of frequent visits occurred during either the evening or night shift , perhaps indicating access issues to primary physicians or urgent care clinics . The rate of frequent users was comparable with other investigations , yet few similarities in patient characteristics and predictors of high ED utilization were found , partly because of the retrospective design , but certainly reinforcing limited generalizability of ED utilization patterns across centers in different metropolitan and geographic regions Traditional clinical review articles , also known as up date s , differ from systematic review s and meta-analyses . Up date s selectively review the medical literature while discussing a topic broadly . Non-quantitative systematic review s comprehensively examine the medical literature , seeking to identify and synthesize all relevant information to formulate the best approach to diagnosis or treatment . Meta-analyses ( quantitative systematic review s ) seek to answer a focused clinical question , using rigorous statistical analysis of pooled research studies . This article presents guidelines for writing an evidence -based clinical review article for American Family Physician . First , the topic should be of common interest and relevance to family practice . Include a table of the continuing medical education objectives of the review . State how the literature search was done and include several sources of evidence -based review s , such as the Cochrane Collaboration , BMJ 's Clinical Evidence , or the InfoRetriever Web site . Where possible , use evidence based on clinical outcomes relating to morbidity , mortality , or quality of life , and studies of primary care population s. In articles su bmi tted to American Family Physician , rate the level of evidence for key recommendations according to the following scale : level A ( r and omized controlled trial [ RCT ] , meta- analysis ) ; level B ( other evidence ) ; level C ( consensus/expert opinion ) . Finally , provide a table of key summary points AIMS Pain and anxiety are commonly reported among those undergoing orthopaedic surgery . Improvement in anxiety and pain control might be achieved by supplementing st and ard care with psychological interventions . However , the effectiveness of adjunctive psychosocial interventions in anxiety and pain control have not been addressed sufficiently by previous systematic review s in orthopaedic surgeries . The present study aim ed to assess the effectiveness of adjunctive psychosocial techniques to improve perioperative clinical care in orthopaedic surgery , to identify the most effective intervention types and to evaluate potential moderators . METHODS We will perform a systematic review and meta- analysis to address the study aims . PubMed , PsycINFO , CINAHL and ProQuest Dissertations & Theses will be search ed between 1980 and 2015 . Prospect i ve controlled clinical trials completed in adults , contrasting st and ard care and st and ard care supplemented with psychosocial methods  , will be eligible for inclusion . Effectiveness will be assessed through the outcomes of postoperative pain intensity , analgesic requirement , perioperative anxiety , quality of life and postoperative recovery . The results of a r and om-effect meta- analysis will be reported . To aid implementation of best practice , moderating effects of the type and timing of psychosocial intervention , type of surgical intervention and type of anaesthesia will be evaluated through meta-regression . Sensitivity analyses and subgroup contrasts will follow as necessary . DISCUSSION Recommendations will be made to improve medical care in orthopaedic procedures . The quality of evidence will be rated using GRADE criteria . Copyright © 2016 John Wiley & Sons , PURPOSE OF THE RESEARCH To investigate the prevalence and nature of unmet needs among colorectal cancer ( CRC ) survivors and the relationship between needs and quality of life ( QoL ) . METHODS AND SAMPLE Using the Northern Irel and Cancer Registry ( NICR ) as a sampling frame and working in collaboration with primary care physicians or GPs , the Cancer Survivors Unmet Needs ( CaSUN ) question naire and the Quality of Life in Adult Cancer Survivors Scale ( QLACS ) were posted to a r and omly selected sample of 600 CRC survivors . KEY RESULTS Approximately 69 % ( 413/600 ) met eligibility criteria for participating in the study ; and 30 % ( 124/413 ) responded to the survey . A comparative analysis of NICR data between respondents and non-respondents did not indicate any systematic bias except that respondents appeared to be younger ( 65 years vs. 67 years ) . Approximately 60 % of respondents reported having no unmet needs , with 40 % reporting one or more unmet health and social care needs such as fear of recurrence , information needs , difficulty obtaining travel insurance and car parking problems . QoL was significantly lower for CRC survivors who reported an unmet need . Highest scores ( poorer QoL ) were reported for fatigue , welfare benefits and distress recurrence . CONCLUSIONS Overall , the majority of CRC survivors who had care needs appeared to have needs that were mainly psychosocial in nature and these unmet needs were related to poorer PURPOSE This case series describes associated diagnoses and prognoses of persistent fatigue in a community-based , primary care population . PATIENTS AND METHODS All patients presenting to a private practice internist with a chief complaint of fatigue of more than 1 month 's duration were prospect ively evaluated with clinical ly directed examination and diagnostic testing .  Patients were excluded if they had a previously diagnosed illness associated with fatigue . Fatigue was attributed to newly established diagnoses or medication use based on explicit criteria . Change in the state of each patient 's fatigue was measured 6 months after entry . RESULTS Fifty-two consecutive patients entered the study . The diagnoses associated with fatigue were a medical disorder in 25 patients , depression in 10 patients , and no definitive diagnosis in 18 patients . The mean cost of diagnostic testing was $ 131 . At 6 months , 37 of 52 patients ( 72 % ) reported improvement in or resolution of their fatigue . CONCLUSION In a primary care setting , many patients presenting with persistent fatigue have an associated , treatable disease that can be determined using a cost-effective , clinical ly directed approach . Most will experience an improvement in their fatigue STUDY OBJECTIVE Undiagnosed mental illness is highly prevalent and produces needless morbidity . Emergency department patients with vague or longst and ing complaints are at risk for occult mental illness , but are seldom diagnosed . We conducted this study to determine whether a previously vali date d , self-administered , computerized psychiatric interview ( Primary Care Evaluation of Mental Disorders [ PRIME-MD ] ) could increase the detection of occult psychiatric illness in the ED . METHODS This was a r and omized , controlled trial of consecutive patients enrolled during convenient times at a university teaching hospital ED with an annual census of 38,000 . ED house staff and attending physicians participated . Patients were those with nonspecific complaints potentially associated with occult psychiatric illness ( eg , long-st and ing headache , abdominal or back pain ) . Exclusion criteria were known psychiatric illness , complaint , or medication ; and straightforward reason for the ED visit . Consenting subjects completed the PRIME-MD question naire in the waiting room , and were r and omly assigned to either the " report " ( report results given to physician ) or " no-report " groups . PRIME-MD results were clipped to the front of the chart of report group patients . There was no other intervention . The main outcome measures were the percentage of all patients and percentage of patients with a PRIME-MD diagnosis who received a psychiatric diagnosis , consultation , or referral from the emergency physician . RESULTS A total of 339 ( 5.1 % ) of all patients were approached ; 230 consented to participate in the study , and 218 completed the PRIME-MD session and were r and omly assigned to study groups . Ninety-two patients in the report group and 98 cases in the no-report group were analyzed . Patients were omitted for the following reasons : left without being seen ( 8) , mistakenly enrolled ( 10 ) , or unretrievable medical records ( 10 ) . Seventy-nine ( 42 % ) patients received a psychiatric diagnosis from PRIME-MD and 9 ( 5 % ) from the physician . The frequencies of physician psychiatric diagnosis and referral did not differ between groups ( diagnosis : report 9 % , no report 9 % , Delta 0 % , 95 % confidence interval [ CI ] -13 , 14 ; referral : report 9 % , no report 7 % , Delta 2 % , 95 % CI -11 , 16 ) . CONCLUSION ED patients willingly completed the PRIME-MD question naire ( in a median time of 7 minutes ) , which frequently diagnosed psychiatric conditions . Despite this , physicians rarely diagnosed or treated these conditions regardless of whether they were provided with the PRIME-MD diagnoses The Dartmouth COOP Project , a primary care research network , conducted a prospect i ve study of patients presenting to 28 primary care practice s with a chief complaint of fatigue . Data were gathered on fatigue status , associated systems , health status , and origin of fatigue .  Fatigue patients were demographically similar to nonfatigue patients but had significantly worse physical and mental health at study intake . Sixty-three percent of physicians and 52 % of patients rated fatigue origin as primarily physical ( gamma = 0.48 , P less than .05 ) , but in 41 % of cases , physicians indicated there was substantial interaction between physical and psychological factors . Only two factors -- depression and anxiety -- separated fatigue of physical origin from fatigue of psychological origin . Clinicians must thoughtfully evaluate fatigue 's often multiple causes and communicate their underst and ing of those causes to the patient to gain support for a reasonable treatment regimen Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . However , up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode , and 1 in 5 report substantial limitations in activity ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . Children or adolescents with low back pain ; pregnant women ; and patients with low back pain from sources outside the back ( nonspinal low back pain ) , fibromyalgia or other myofascial pain syndromes , and thoracic or cervical back pain are not included . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain Recommendation 1 : Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy or spinal stenosis , or back pain potentially associated with another specific spinal cause . The history should include assessment of psychosocial risk factors , which predict risk for chronic disabling back pain ( strong recommendation , moderate- quality evidence ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied
Pooling was not appropriate for CFS.In studies with control groups of patients without the symptom of tiredness , prevalence of somatic disease was identical to those complaining of tiredness .
Depression , however , was more frequent among those with tiredness .
Conclusions Serious somatic disease is rare in patients complaining of tiredness .
Since prevalence is similar in patients without tiredness , the association may not be causal .
Background Tiredness is one of the most frequent complaints in primary care .
Although often self-limiting and frequently associated with psychosocial stress , patients but also their physicians are often uncertain regarding a serious cause and appropriate diagnostic work-up .
We conducted a systematic review and meta- analysis of studies reporting on differential diagnosis of fatigue in primary care .