Accuracy of Clinical Tests in Detecting Disk Herniation and Nerve Root Compression in Subjects With Lumbar Radicular Symptoms

Objectives

To investigate the accuracy of 3 commonly used neurodynamic tests (slump test, straight-leg raise [SLR] test, femoral neurodynamic test) and 2 clinical assessments to determine radiculopathy (radiculopathy I, 1 neurologic sign; radiculopathy II, 2 neurologic signs corresponding to 1 specific nerve root) in detecting magnetic resonance imaging (MRI) findings (extrusion, subarticular nerve root compression, and foraminal nerve root compression).

Integration of lung ultrasound in the diagnostic reasoning in acute dyspneic patients: A prospective randomized study

Introduction

Misdiagnosis in acute dyspneic patients (ADP) has consequences on their outcome. Lung ultrasound (LUS) is an accurate tool to improve diagnostic performance. The main goal of this study was to assess the determinants of increased diagnostic accuracy using LUS.

External validation of a biomarker and clinical prediction model for hospital mortality in acute respiratory distress syndrome

Purpose

Mortality prediction in ARDS is important for prognostication and risk stratification. However, no prediction models have been independently validated. A combination of two biomarkers with age and APACHE III was superior in predicting mortality in the NHLBI ARDSNet ALVEOLI trial. We validated this prediction tool in two clinical trials and an observational cohort.

Methods

The validation cohorts included 849 patients from the NHLBI ARDSNet Fluid and Catheter Treatment Trial (FACTT), 144 patients from a clinical trial of sivelestat for ARDS (STRIVE), and 545 ARDS patients from the VALID observational cohort study. To evaluate the performance of the prediction model, the area under the receiver operating characteristic curve (AUC), model discrimination, and calibration were assessed, and recalibration methods were applied.

Results

The biomarker/clinical prediction model performed well in all cohorts. Performance was better in the clinical trials with an AUC of 0.74 (95% CI 0.70–0.79) in FACTT, compared to 0.72 (95% CI 0.67–0.77) in VALID, a more heterogeneous observational cohort. The AUC was 0.73 (95% CI 0.70–0.76) when FACTT and VALID were combined.

Conclusion

We validated a mortality prediction model for ARDS that includes age, APACHE III, surfactant protein D, and interleukin-8 in a variety of clinical settings. Although the model performance as measured by AUC was lower than in the original model derivation cohort, the biomarker/clinical model still performed well and may be useful for risk assessment for clinical trial enrollment, an issue of increasing importance as ARDS mortality declines, and better methods are needed for selection of the most severely ill patients for inclusion.

     

Predictive value of circulating interleukin-6 and heart-type fatty acid binding protein for three months clinical outcome in acute cerebral infarction: multiple blood markers profiling study

Introduction

There is no single blood marker for predicting the prognosis in ischemic stroke. A combination of multiple blood markers may enhance the ability to predict long-term outcome following ischemic stroke.

Methods

Blood concentrations of neuronal markers (neuron-specific enolase, visinin-like protein 1, heart type fatty acid binding protein (hFABP) and neuroglobin), astroglial markers (S100B and glial fibrillary acidic protein), inflammatory markers (IL-6, TNF-α, and C-reactive protein), blood-brain barrier marker (matrix metalloproteinase 9), and haemostatic markers (D-dimer and PAI-1) were measured within 24 hours after stroke onset. The discrimination and reclassification for favorable and poor outcome were compared after adding individual or a combination of blood markers to the clinical model of stroke outcome.

Results

In multivariate analysis, natural log-transformed (_log) IL-6 (odds ratio (OR): 1.75, 95% CI: 1.25 to 2.25, P = 0.001) and _loghFABP (OR: 3.23, 95% CI: 1.44 to 7.27, P = 0.005) were independently associated with poor outcome. The addition of a single blood marker to the clinical model did not improve the discriminating ability of the clinical model of stroke outcome. However, the addition of the combination of _logIL-6 and _loghFABP to the clinical model showed improved discrimination (area under receiver operating characteristic (AUROC) curve: 0.939 versus 0.910, P = 0.03) and reclassification performance (net reclassification improvement index: 0.18, P = 0.005).

Conclusions

A combination of circulating IL-6 and hFABP level has an additive clinical value for the prediction of stroke outcome.     

Clinical Tests Have Limited Predictive Value for Chronic Ankle Instability When Conducted in the Acute Phase of a First-Time Lateral Ankle Sprain Injury

Objective

To evaluate whether a battery of clinical assessments for acute lateral ankle sprain (LAS) can be used to predict long-term recovery.

Stress perfusion magnetic resonance imaging to detect coronary artery lesions in children

Background

Stress perfusion cardiovascular magnetic resonance (CMR) is used widely in adult ischemic heart disease, but data in children is limited. We sought to evaluate feasibility, accuracy and prognostic value of stress CMR in children with suspected coronary artery disease (CAD).

Methods

Stress CMR was reviewed from two pediatric centers over 5 years using a standard pharmacologic protocol. Wall motion abnormalities, perfusion deficits and late enhancement were correlated with coronary angiogram (CAG) when available, and clinical status at 1 year follow-up for major adverse cardiovascular events (MACE; coronary revascularization, non-fatal myocardial infarction and death due to CAD) was recorded.

Results

Sixty-four stress perfusion CMR studies in 48 children (10.9?±?4.8 years) using adenosine; 59 (92%) and dipyridamole; 5 (8%), were reviewed. Indications were Kawasaki disease (39%), post arterial switch operation (12.5%), post heart transplantation (12.5%), post anomalous coronary artery repair (11%), chest pain (11%), suspected myocarditis or CAD (3%), post coronary revascularization (3%), and others (8%). Twenty-six studies were performed under sedation. Of all studies performed, 66% showed no evidence of ischemia or infarction, 28% had perfusion deficits and 6% had late gadolinium enhancement (LGE) without perfusion deficit. Compared to CAG, the positive predictive value (PPV) of stress CMR was 80% with negative predictive value (NPV) of 88%. At 1 year clinical follow-up, the PPV and NPV of stress CMR to predict MACE were 78 and 98%.

Conclusion

Stress-perfusion CMR, in combination with LGE and wall motion-analysis is a feasible and an accurate method of diagnosing CAD in children. In difficult cases, it also helps guide clinical intervention by complementing conventional CAG with functional information.

     

The Effects of an 8-Week Stabilization Exercise Program on Lumbar Multifidus Muscle Thickness and Activation as Measured With Ultrasound Imaging in Patients With Low Back Pain: An Exploratory Study

Background

Lumbar stabilization exercise programs (LSEP) produce positive effects on clinical outcomes, but the underlying mechanisms remain relatively unexplored. Psychological and neuromuscular mechanisms can be involved, such as a better activation of the lumbar multifidus, which represents one possibility.

A High-Intensity Multicomponent Agility Intervention Improves Parkinson Patients’ Clinical and Motor Symptoms

Objective

To determine the effects of a high-intensity exercise therapy using sensorimotor and visual stimuli on nondemented Parkinson disease (PD) patients’ clinical symptoms, mobility, and standing balance.

Pseudomonas aeruginosa serotypes in nosocomial pneumonia: prevalence and clinical outcomes

Introduction

Pseudomonas aeruginosa frequently causes nosocomial pneumonia and is associated with poor outcome. The purpose of this study was to assess the prevalence and clinical outcome of nosocomial pneumonia caused by serotype-specific P. aeruginosa in critically ill patients under appropriate antimicrobial therapy management.

Methods

A retrospective, non-interventional epidemiological multicenter cohort study involving 143 patients with confirmed nosocomial pneumonia caused by P. aeruginosa. Patients were analyzed for a period of 30 days from time of nosocomial pneumonia onset. Fourteen patients fulfilling the same criteria from a phase IIa studyconducted at the same time/centers were included in the prevalence calculations but not in the clinical outcome analysis.

Results

The prevalence of serotypes was: O6 (29%), O11 (23%), O10 (10%), O2 (9%), and O1 (8%). Serotypes with a prevalence of less than 5% were found in 13% of patients, 8% were classified as not typeable. Across all serotypes, 19% mortality, 70% clinical resolution, 11% clinical continuation, and 5% clinical recurrence were recorded. Age and higher APACHE II (Acute Physiology and Chronic Health Evaluation II) were predictive risk factors associated with probability of death and lower clinical resolution for P. aeruginosa nosocomial pneumonia. Mortality tends to be higher with O1 (40%) and lower with O2 (0%); clinical resolution tends to be better with O2 (82%) compared to other serotypes. Persisting pneumonia with O6 and O11 was, respectively, 8% and 21%; clinical resolution with O6 and O11 was, respectively, 75% and 57%.

Conclusions

In P. aeruginosa nosocomial pneumonia, the most prevalent serotypes were O6 and O11. Further studies including larger group sizes are needed to correlate clinical outcome with virulence factors of P. aeruginosa in patients with nosocomial pneumonia caused by various serotypes; and to compare O6 and O11, the two serotypes most frequently encountered in critically ill patients.     

Diagnostic accuracy of lipopolysaccharide-binding protein for predicting bacteremia/clinical sepsis in children with febrile neutropenia: comparison with interleukin-6, procalcitonin, and C-reactive protein

Purpose

In febrile neutropenia (FN), no reliable marker has been identified to discriminate between severe infection and other causes of fever early in the clinical course. Since lipopolysaccharide-binding protein (LBP) has proven to be an accurate biomarker of bacteremia/clinical sepsis in critically ill non-immunocompromised infants and children, we performed a prospective study to determine the diagnostic accuracy of LBP in children with FN.

Methods

Concentrations of LBP, procalcitonin (PCT), interleukin-6 (IL-6), and C-reactive protein (CRP) were prospectively measured on two consecutive days in 90 FN episodes experienced by 47 children. Receiver operating characteristic curve analysis was performed for each biomarker to predict bacteremia/clinical sepsis and severe sepsis.

Results

Eighteen of the 90 episodes were classified as bacteremia/clinical sepsis. On both days 1 and 2, all biomarkers had a low to intermediate diagnostic accuracy for sepsis, and no significant differences were found between them (area under the curve (AUC) for LBP, 0.648 and 0.714; for PCT, 0.665 and 0.744; for IL-6, 0.775 and 0.775; and for CRP, 0.695 and 0.828). Comparison of their AUCs to the AUC of maximum body temperature on admission (AUC?=?0.668) also failed to show any significant differences. In severe sepsis, however, the best diagnostic accuracies were found for IL-6 and PCT (AUC 0.892 and 0.752, respectively), and these were significantly higher than those for LBP (AUC 0.566) on admission.

Conclusions

On admission and 24 h later, the LBP concentration is less accurate for predicting bacteremia/clinical sepsis compared to IL-6, PCT, and CRP.     

Do family physicians request ultrasound scans appropriately?

Objective

To review family physicians’ requests for abdominal, thyroid, pelvic, soft tissue, and carotid ultrasound (US) scans, and to determine whether 5% or more of these tests were not clearly indicated based on the clinical history provided.

Design

Analysis of 620 randomly chosen requests for US scans.

Setting

The Radiology Department at the Capital District Health Authority in Halifax, NS, between October 1, 2008, and June 30, 2009.

Participants

Two radiologists and 2 family physicians with clinical expertise and familiarity with the Canadian Association of Radiologists’ 2005 guidelines.

Main outcome measures

Whether US requests were “indicated,” “not clearly indicated,” or “not legible” according to the Canadian Association of Radiologists’ 2005 guidelines. Those that were illegible were discarded and replaced.

Results

More than 5% of requests for abdominal, thyroid, or carotid US scans were not clearly indicated. The percentages of requests for pelvic and soft tissue scans that were not clearly indicated were not significant. The reviewers found only 5 illegible request forms. Percentages of abdominal, thyroid, and carotid US scans not clearly indicated were 12.1%, 18.8%, and 25.2%, respectively. Reasons for inappropriate US requests included the following: wrong tests (3.2%), vague clinical questions (4.8%), and unfocused examinations (4.8%) for abdominal scans; wrong tests (3.2%), vague clinical questions (3.2%), unnecessary investigations (5.6%), and unnecessary follow-up examinations (5.6%) for thyroid scans; and unnecessary tests (10.5%), vague clinical questions (5.6%), and unnecessary tests for “dizziness” (10.5%) for carotid scans.

Conclusion

More than 5% of the abdominal, thyroid, and carotid US scans requested by family physicians were not clearly indicated based on the clinical history provided. Common trends in requesting these examinations reinforce the need to improve guidelines for requesting scans and for managing many presenting complaints in family practice.     

Clinical Specialists and Advanced Practitioners in Physical Therapy: A Survey of Physical Therapists and Employers of Physical Therapists in Ontario, Canada

Purpose:

Opportunities to expand the role of physical therapists (PTs) have evolved to include clinical specialists and advanced practitioners, although the literature on these roles is limited. We examined perceptions of PTs and PT employers in Ontario regarding clinical specialization and advanced practice.

Methods:

Using a modified Dillman approach, a cross-sectional survey was conducted with 500 PTs and 500 PT employers in Ontario. Questionnaires were tailored to address specific issues related to each cohort.

Results:

Sixty percent of PTs and 53% of PT employers responded to the survey. Thirty-three percent of PT respondents already considered themselves “clinical specialists” (CS), and 8% considered themselves “advanced practitioners” (AP), although neither role is yet formally recognized in Canada. Both groups had substantial interest in pursuing formal recognition of CS and AP status. Respondents indicated that their primary motivation to pursue such roles was to enhance clinical reasoning skills with the goal of improving client outcomes (82% for the role of CS, 71% for the role of AP). Respondents supported the involvement of academic institutions in the process (60% for CS, 70% for AP).

Conclusion:

PTs and PT employers are supportive of the roles of the CS and AP within the profession, even though there is currently no formal recognition of either role in Canada.     

Reference values and reliability for lumbopelvic strength and endurance in asymptomatic subjects

Background

Assessing the lumbopelvic region is useful for detecting many musculoskeletal dysfunctions and also performance deficits. Several clinical tests are used to assess this region, however, reference values and results related to method, reliability and error measurements of these tests have not been reported.