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Does Digital Rectal Examination Reduce Subsequent Hospitalizations and Endoscopies or Vice Versa?

      To the Editor:
      Shrestha et al
      • Shrestha M.P.
      • Borgstrom M.
      • Trowers E.
      Digital rectal examination reduces hospital admissions, endoscopies, and medical therapy in patients with acute gastrointestinal bleeding.
      present robust data linking the performance of a digital rectal examination to advantageous outcomes, but conclusions that attribute causal relationships to these observational data are of uncertain validity. The authors conclude, as stated in the title of their manuscript, that the performance of a digital rectal examination reduces hospital admissions and endoscopies. Rather, perhaps the outcome of hospital admission and endoscopy reduces the performance of a rectal examination in the emergency department. If the presenting clinical scenario provided some accuracy in predicting the outcome of future hospitalization or endoscopy, as is likely the case, then it would be reasonable to think that the emergency department provider might be less motivated to complete a digital rectal examination when expecting this outcome. Such an examination might be perceived to be either superfluous or potentially repetitive with that performed by the admitting physician or consulting specialist. The authors did not ask the emergency department providers why they chose to do or not do a rectal examination, but lacking randomized, controlled data, a discussion with the providers might be a simple approach to obtain insight into the explanation for this association.

      Reference

        • Shrestha M.P.
        • Borgstrom M.
        • Trowers E.
        Digital rectal examination reduces hospital admissions, endoscopies, and medical therapy in patients with acute gastrointestinal bleeding.
        Am J Med. 2017; 130: 819-825

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      • The Reply
        The American Journal of MedicineVol. 131Issue 1
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          We thank Dr. Charilaou and colleagues for their interest in our work. The authors point out the exclusion of the variable “bright red blood per rectum” from our multivariate logistic regression analysis and the need for including it in the multivariate analysis.1 The variable “bright red blood per rectum” was dropped from the multivariate analysis due to collinearity with another explanatory variable, hematemesis. The area under the receiver operating characteristic curve for predicting hospital admission was 0.85, indicating excellent discriminative property of the predictive model.
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