O fim dos nomogramas

The Nomogram Epidemic: Resurgence of a Medical Relic David A. Grimes, MD
Annals of Internal Medicine 19 August 2008 Volume 149 Issue 4 Pages 273-275
The obsolete calculators known as nomograms have become epidemic in recent medical literature. The frequency of articles in PubMed retrieved with this search term nearly doubled between 1990 to 1999 and 2000 to 2007. Popular in medicine from about 1925 to 1975, a nomogram is a crude graphical means for solving an equation by placing a straightedge across several scales. Today, most reported nomograms are inconsistent with both established definitions and half a century of clinical use. The need for nomograms disappeared with the advent of personal computing. Instead of constructing nomograms, authors should develop software, such as prediction models, that can either be downloaded to personal digital assistants or be used on the Internet. Modern computing features both accuracy and speed; nomograms offer only the latter

Angina do peito: critérios para coronariografia.

Appropriateness Criteria for Coronary Angiography in Angina: Reliability and Validity Harry Hemingway, MBBChir; Ruoling Chen, MD; Cornelia Junghans, PhD; Adam Timmis, MBBChir; Sandra Eldridge, PhD; Nick Black, MD; Paul Shekelle, MD; and Gene Feder, MD
19 August 2008 Volume 149 Issue 4 Pages 221-231
Background: Evaluated criteria for tailoring the decision to perform coronary angiography in specific clinical scenarios are lacking.
Objective: To determine the reliability and prognostic validity of patient-specific appropriateness criteria for coronary angiography among patients with suspected angina pectoris.
Design: Prospective observational study. Two independent panels of clinicians scored 2400 patient-specific indications for coronary angiography as inappropriate, uncertain, or appropriate. Using a simple computer algorithm, patients were matched to 1 of these indications.
Setting: 6 urban ambulatory care clinics in the United Kingdom.
Patients: 9356 consecutive patients with recent-onset chest pain in whom stable angina was suspected.
Measurements: Appropriateness ratings and clinical outcomes (coronary death and acute coronary syndrome events) over a median of 3 years of follow-up.
Results: 660 coronary deaths or acute coronary syndrome events occurred. Agreement between the 2 panels (reliability) on appropriateness category was moderate (weighted = 0.58; P < 0.001). Use of subsequent angiography was strongly related to appropriateness category (P for linear trend <0.001) according to scores from either panel. Among patients judged as appropriate candidates for angiography, underuse was common (57% according to panel A and 71.3% according to panel B), and not undergoing coronary angiography was associated with higher coronary event rates than was undergoing the procedure. The hazard ratio after adjustment for age, sex, exercise electrocardiography result, and secondary prevention medication was similar according to panel A (2.78 [95% CI, 1.77 to 4.37]) and panel B (2.47 [CI, 1.72 to 3.55]).
Limitation: The study was too small to assess the relationship of angiography with coronary death and did not assess the reasons why patients did not receive angiography.
Conclusion: Appropriateness scores offer prognostically valid criteria for judging which specific patients might benefit from coronary angiography. Patient-specific appropriateness scores help pinpoint areas where judgments diverge and are a promising tool for making guidelines more effective.