Normal metaphyseal radiologic variants not to be confused with findings of infant abuse

Postmortem high-detail skeletal radiography of 78 infants who died of the sudden infant death syndrome was performed during a 3-year period. Review of the studies reveals a variety of distinct radiologic variants that should not be confused with the metaphyseal injuries caused by infant abuse.     

For debate: consensus injury definitions in team sports should focus on missed playing time.

OBJECTIVE: To compare the most commonly used and proposed injury definitions for surveillance systems in team sports and attempt to assess their suitability for consensus definitions in terms of reliability and functionality. DATA SOURCES: The PubMed and SportDiscus databases were searched for papers on team sports that discussed consensus definitions or compared various definitions of injury. DATA SYNTHESIS: A continuum between the most broad "tissue damage" definition and the most narrow "match time loss only" definition was developed. RESULTS: A "match time loss only" injury definition can be reliably and accurately applied but only captures a small percentage of the total pool of all "tissue damage" injuries. There are some inherent biases in using a match time loss only definition (late season matches, matches with unequal breaks between games), but these are clearly visible. All other definitions improve the volume of data captured but suffer serious theoretical and/or practical flaws with respect to accuracy and reliability. No study using a broad definition has demonstrated good reliability to date (eg, using 2 independent recorders at the same team). CONCLUSION: A "match time loss only" injury definition is the most accurate and reliable of those commonly used in team sports. Other injury definitions are broader and may be more appropriate for individual team and specific injury studies. However, a match time loss definition is the most accurate and reliable tool for comparing injury rates at different teams and between different seasons within teams. Hence, we recommend this as the basis for the injury definition in a consensus statement.     

Effective dose: a flawed concept that could and should be replaced

The effective dose is designed to provide a single number proportional to the radiobiological "detriment" from a particular, often inhomogeneous, radiation exposure, with detriment representing a balance between carcinogenesis, life shortening and hereditary effects. It is commonly used to allow a comparison of the risks associated with different spatial dose distributions produced by different imaging techniques. The effective dose represents questionable science: two of the most important reasons for this are that the tissue-specific weighting factors used to calculate effective dose are a subjective mix of different endpoints, and that the marked and differing age dependencies for different endpoints are not taken into account. Importantly, the effective dose is prone to misuse, with widespread confusion between effective dose, equivalent dose and absorbed dose. It is suggested here that effective dose could and should be replaced by a new quantity that does not have these problems. An appropriate new quantity could be "effective risk", which, like effective dose, is a weighted sum of equivalent doses to different tissues; unlike effective dose, where the tissue-dependent weighting factors are a set of subjective committee-defined numbers, the weighting factors for effective risk would simply be evaluated tissue-specific lifetime cancer risks per unit equivalent dose. The resulting quantity would perform the same comparative role as effective dose; it would have the potential to be age- and, if desired, gender-specific, just as easy to estimate, less prone to misuse, more directly interpretable, and based on more defensible science.     

老年创伤救治与康复不容忽视

伴随社会的老龄化,创伤人群也呈现老龄化的趋势,老年创伤患者发病率和比例逐渐增加,老年创伤正在形成对公众健康的潜在危机。伤情评估、分类、早期救治对高危老年创伤患者的预后有极大影响,正确认识理解年龄相关生理变化有助于指导治疗。本文着重回顾国外老年创伤医学的发展,强调建立中国老年创伤患者的流行病学数据和国家创伤数据库的重要性。探讨老年创伤后分类、评估系统建立以及创伤并发症的预防对预后的影响,建议重症监护、营养护理、后期康复及随访管理不可或缺。同时,应注重老年医学为特点的创伤后疾病发生转归机制的基础研究,并加强向临床应用的转化。     

Indeterminate findings on imaging-guided biopsy: should additional intervention be pursued?

OBJECTIVE: Our purpose was to determine the outcome of patients in whom the results of imaging-guided biopsies were indeterminate and to examine factors that may affect outcome. MATERIALS AND METHODS: During a 25-month period, 619 consecutive imaging-guided biopsies (CT, n = 268 [43%]; sonography, n = 351 [57%]) were performed on abdominal lesions. Of these biopsies, findings from 454 biopsies (73%) were positive for malignancy, findings from 21 biopsies (3%) yielded a benign diagnosis, and findings from 15 biopsies (2%) were nondiagnostic. Findings from the remaining 129 biopsies (21%) were considered indeterminate because the pathologic diagnosis revealed benign tissue, inflammation, stromal elements, or atypical cells. The frequency of malignancy in lesions of patients in this indeterminate group was determined. RESULTS: Thirty-eight of the 129 patients were lost to follow-up. Of the remaining 91 patients, 55 (60%) had true-negative (benign) results, and 36 (40%) had false-negative (malignant) results. A history of malignancy had no significant effect on the true- or false-negative rate (p = .799). However, the guidance technique had a statistically significant effect: CT and sonographic guidance yielded 25 (49%) and 11 (28%) false-negative results, respectively (p = .037). The number of needle passes, needle type and gauge, and biopsy site did not have a statistically significant correlation with the false-negative rate. The presence of atypical cells in the cytologic aspirate was highly predictive, with a 71% false-negative rate (p = .008). CONCLUSION: We found a high incidence of malignancy (40%) in lesions deemed indeterminate at the time of biopsy. Thus, close follow-up or additional intervention should be pursued in such cases. Sonographic guidance resulted in a statistically significant decrease in the false-negative rate when compared with CT guidance; however, a history of malignancy, the biopsy site, the needle gauge and type, and the number of passes did not have a significant effect on the false-negative rate.     

Skin manifestations of athletes competing in the summer olympics: what a sports medicine physician should know

Olympic athletes are vulnerable to traumatic, environmental and infectious skin manifestations. Although dermatological complaints are frequent among Olympians, there is a scarcity of literature that reviews sports-related dermatoses among Olympic athletes. A comprehensive review of PREMEDLINE and MEDLINE searches of all available literature through to January 2011 was conducted, focusing on sports-related dermatological presentations as well as the key words 'Olympic athletes' and 'skin diseases'. Common skin conditions can be harmful and even prohibitive for competition. Common aetiologies of dermatological conditions related to sports include: skin infections with dermatophytes such as tinea pedis and tinea corporis, bacteria such as pitted keratolysis, and folliculitis and viruses such as herpes gladiatorum. Frictional dermatoses occur commonly and include athlete's nodules, jogger's itch, frictional blisters, callosities and talon noir. Trauma can cause haematomas such as auricular haematomas. Due to long training hours in the sun, many endurance athletes experience high levels of UV radiation and a higher risk for both melanoma and non-melanoma skin cancer. Pre-existing dermatoses can also be aggravated with practice and competition; in particular, atopic eczema and physical urticarias. Infrequent dermatoses are susceptible to misdiagnosis, delay in treatment and needless biopsies. This review highlights the diagnosis and management of sports-related dermatoses by the following general categories of Olympic sport: endurance, resistance, team sport, and performing arts.     

Non-participation in sports injury research: why football players choose not to be involved

OBJECTIVE: To ascertain the reasons behind players not participating in a sports safety research project. METHODS: During the preseason, 10 Australian football clubs volunteered 23 teams to participate in a protective equipment randomised controlled trial, the Australian Football Injury Prevention Project (AFIPP). All players from these teams were invited to participate. Players who did not agree to participate in AFIPP were surveyed about their reasons for non-involvement. RESULTS: 110 football players (response rate 63.6%) completed the non-responder survey and cited the two main reasons behind non-involvement in the project as "I did not know about the project" (39.4%) and "I was not at training when the research team visited" (36.5%). CONCLUSIONS: and implications: Preseason may not be the best time for maximal player recruitment in community based sports safety research. Enhanced communication between researchers and players at community level football clubs during the recruitment phase is likely to improve response rates.     

p-Values should not be used for evaluating the strength of DNA evidence

Recently, p-values have been suggested to explain the strength of a likelihood ratio that evaluates DNA evidence. It has been argued that likelihood ratios would be difficult to explain in court and that p-values would offer an alternative that is easily explained. In this article, we argue that p-values should not be used in this context. p-Values do not directly relate to the strength of the evidence. The likelihood ratio measures the strength of the evidence, while the p-value measures how rare it is to find evidence that is equally strong or stronger, which is something fundamentally different. In addition, a p-value is not always unambiguous. To illustrate our arguments, we present several examples from forensic genetics.     

Electrocardiographic findings in pulmonary thromboembolism--comparison with lung perfusion scan and echocardiographic findings

This study investigated the usefulness of electrocardiography (ECG) in pulmonary thromboembolism (PTE), compared with lung perfusion scan and echocardigraphic findings on evaluation of the severity. We checked ECG findings associated with PTE at hospital admission, with the seven abnormal findings described by Sreeram N, et al. On Lung perfusion scan, severity of perfusion defect was assessed total defect score (TDS), calculated as the sum of the scores for all 18 segment of lung. On echocardiography, severity of right ventricular overload was assessed. The number of the seven ECG abnormal findings and TDS were larger in patients with the right ventricular overload (p < 0.01). The number of the ECG findings was positively correlated with TDS (r = 0.75). The number of abnormal ECG findings in PTE is associated with the severity evaluated by lung perfusion scan and echocardiography.     

Eminence-based medicine versus evidence-based medicine: level v evidence in sports medicine

Through extensive survey analysis, we investigated expert opinion in sports medicine. The study had 3 purposes: to provide clinical guidance for cases in which the correct action is not necessarily apparent, to examine expert opinion itself, and to delineate areas of future study. A total of 500 members of the American Medical Society for Sports Medicine and the American Orthopaedic Society for Sports Medicine evaluated a set of 25 statements on unresolved issues in sports medicine. The following 10 statements were deemed false: "It's okay for 12-year-old pitchers to throw curve balls; it's the pitch count that matters"; "Resistance training ('weight lifting') should be avoided until physeal closure"; "Jogging during pregnancy is to be avoided"; "At an athletic event, if sideline coverage is offered by an emergency medical technician and athletic trainer, there is little additional benefit from having a physician present"; "Contact sport athletes who sustain a second concussion should be excluded from contact sports permanently"; "The utility of pre-season medical screening is derived from the history; as such, student-athletes should complete a questionnaire, with physical examination reserved for only those with a positive relevant history"; "Femoroacetabular impingement is a myth-the designation of anatomic variation as disease"; "An AC (acromioclavicular) separation in a contact athlete should not be treated surgically if the athlete won't give up the sport; it will fail"; "Ankle taping induces weakness and atrophy of the dynamic stabilizers of the ankle"; "Only autografts should be used in ACL (anterior cruciate ligament) surgery, as allografts have an unnecessary high failure rate in clinical practice." One statement was accepted as true: "Surgery to treat anterior (patello-femoral) knee pain in a patient with normal patellar mechanics and stability is contraindicated." In short, expert opinion may be a helpful adjunct to clinical practice. Expert opinion cannot replace individual judgment and certainly does not trump the primary medical literature. Yet when better evidence is lacking, expert opinion is valuable for even the staunchest practitioner of evidence-based medicine.