We agree with Dr. Dermksian that the statement in question was imprecise and could have been more clearly written, as follows: "A recent investigation found that patients with aortic regurgitation had increased amplitude of the pulse, lower mean arterial pressure, and a greater narrowing of pulse pressure on wrist elevation than normal patients." We are grateful to him for pointing out this discrepancy and also for his kind comments about our paper as a whole.

Dr. Atkuri and colleagues question the lack of likelihood ratios in our review. It is true that likelihood ratios (which are calculated from sensitivity and specificity) can add valuable information to reports of diagnostic accuracy (1, 2). As we described at length, the vast majority of studies we found relating to the eponymous signs were of low quality and had imprecise estimates of accuracy. It was our view that reporting likelihood ratios generated by using sensitivity and specificity statistics from studies of such questionable quality would be misleading, and therefore we chose not to do so.

Dr. Atkuri and coworkers' assertion that we were "debunking" physical signs without being attentive to methodology is untenable. A major focus of our review was methodology assessment, and the overall process we followed is clearly consistent with widely accepted standards for systematic reviews (3). We also highlighted the point that the lack of evidence in the literature does not prove that these signs are without value. Indeed, we concluded by advocating for further work to clarify the role of these signs in current practice.

We are pleased to note that Dr. Atkuri and colleagues share the concerns originally expressed in our paper about the risks to medical education and practice of an inappropriate reliance on technology. Most of the eponymous signs of aortic regurgitation were identified over a century ago, when disease and treatments had a different flavor. The same can be said of many of the classical signs of physical diagnosis. We now live in an age where technology allows us to virtually dissect a patient in the hunt for disease. Unfortunately, this ability comes at a price, one that patients and society often cannot and should not have to pay. Judicious clinicians, skilled in history taking and physical examination, seek to protect their patients from unwarranted testing, procedures, and costs. Updating and enhancing the literature on bedside diagnosis can only aid their quest.