Clinics in diagnostic imaging (140). Iatrogenic sciatic nerve injury secondary to intramuscular injection

A 77-year-old Chinese female patient presented with acute onset of left lower limb paraesthesia and weakness after she received an intramuscular injection for pain relief in the gluteal region. Magnetic resonance (MR) imaging of her lumbosacral spine and sacral plexus was performed. The MR imaging findings are reviewed and discussed.     

Actinomyces turicensis infection mimicking ovarian tumour

This case report explores an unusual presentation of a commensal organism, Actinomyces, which mimicked a presentation of ovarian cancer. A 73-year-old woman presented to a tertiary level hospital with persistent left iliac fossa abdominal pain, anorexia and fever lasting over one week, with a three-month history of bright rectal bleeding. Imaging was suggestive of malignancy. Fine needle aspiration of an enlarged lymph node was non-diagnostic. Blood cultures taken at presentation became positive after two days for Gram-positive rods, which were most likely Actinomyces. The patient was treated with penicillin 1.8 g four hourly with rapid improvement. Actinomycosis is frequently misdiagnosed as malignancy initially due to its relatively indolent course. Lesions often resolve with antibiotics, without the need for surgical intervention.     

Ethical dilemmas in the care of cancer patients near the end of life

By definition, an ethical dilemma involves the need to choose from among two or more morally acceptable options or between equally unacceptable courses of action, when one choice prevents selection of the other. Advances in medicine, increasing economic stress, rise of patient self-determination and differing values between healthcare workers and patients are among the many factors contributing to the frequency and complexity of ethical issues in healthcare. In the cancer patient near the end of life, common ethical dilemmas include those dealing with artificial nutrition and hydration, truth-telling and disagreements over management plans. It would stand the clinician in good stead to be aware of these issues and have an approach toward dealing with such problems. In addition, organisations have a responsibility to ensure that systems are in place to minimise its occurrence and ensure that staff are supported through the process of resolving dilemmas and conflicts that may arise.     

Pediatric risk of malignancy index for preoperative evaluation of childhood ovarian tumors

Purpose  

This study aimed to develop and provisionally validate a novel scoring index for preoperative cancer-risk prediction in childhood ovarian tumors.     

Using demand analysis and system status management for predicting ED attendances and rostering

Introduction

It has been observed that emergency department (ED) attendances are not random events but rather have definite time patterns and trends that can be observed historically.

Objectives

To describe the time demand patterns at the ED and apply systems status management to tailor ED manpower demand.

Methods

Observational study of all patients presenting to the ED at the Singapore General Hospital during a 3-year period was conducted. We also conducted a time series analysis to determine time norms regarding physician activity for various severities of patients.

Results

The yearly ED attendances increased from 113 387 (2004) to 120 764 (2005) and to 125 773 (2006). There was a progressive increase in severity of cases, with priority 1 (most severe) increasing from 6.7% (2004) to 9.1% (2006) and priority 2 from 33.7% (2004) to 35.1% (2006). We noticed a definite time demand pattern, with seasonal peaks in June, weekly peaks on Mondays, and daily peaks at 11 to 12 am. These patterns were consistent during the period of the study. We designed a demand-based rostering tool that matched doctor-unit-hours to patient arrivals and severity. We also noted seasonal peaks corresponding to public holidays.

Conclusion

We found definite and consistent patterns of patient demand and designed a rostering tool to match ED manpower demand.     

Reliability and validity of the Edinburgh Visual Gait Score for cerebral palsy when used by inexperienced observers

The Edinburgh Visual Gait Score (EVGS) for cerebral palsy has been validated for observer reliability and validity for observers experienced in gait analysis. This study investigated the reliability and validity of the EVGS for observers inexperienced in gait analysis. Six medical students used the score to analyse videotapes from the original study by Read et al. [Read HS, Hazlewood ME, Hillman SJ, Prescott RJ, Robb JE. Edinburgh visual gait score for use in cerebral palsy. J Pediatr Orthop 2003;23:296-301]. These were viewed on two separate occasions to provide inter- and intra-observer reliability, and the results of the numerical items were compared to those from three-dimensional (3D) gait analyses for validity. Observer agreement was tested using Coefficient of Repeatability (CoR), percentage of complete agreement and the kappa statistic. The CoR for inter-observer agreement for inexperienced observers was 5.99/5.07 (Session 1/Session 2) compared to 4.60/3.95 (Session 1/Session 2) for experienced observers. The CoR for intra-observer agreement for inexperienced observers was 5.15 compared to 4.21 for experienced observers. There was complete agreement for 52% of the 10 numerical items with 3D-gait analysis data for inexperienced observers compared to 64% for experienced observers. Ranking of reliability of individual items was similar between the two groups and was generally best for events occurring at the foot and ankle. Observations of gait events by the inexperienced observers using the EVGS were reasonably reliable but not very accurate when compared to experienced observers and 3D-gait analysis.     

Validating the ABCD Score for predicting stroke risk after transient ischemic attack in the ED

Objectives

The aim of the study was to validate the use of the ABCD² score for the prediction of stroke after transient ischemic attack (TIA) in patients presenting to the emergency department (ED). The ABCD² scoring is based on 5 factors as follows: age of at least 60 years; blood pressure of at least 140/90 mm Hg; clinical features such as unilateral weakness and speech impairment alone; duration of at least 60 minutes or 10 to 59 minutes; and diabetes.

Methods

The authors conducted a retrospective observational study of all patients presented to the ED for TIA, as diagnosed by the attending emergency physicians, for a 2-year period. Sensitivity, specificity, and negative predictive value (NPV) were calculated for risk of stroke at 2, 7, 30, and 90 days after presentation.

Results

From January 1, 2005, to December 31, 2006, there were 470 patients diagnosed with TIA at the ED. Mean age was 61.0 years (SD, 13.2), with 63.3% males. Age of at least 60 years, unilateral weakness, and duration of at least 60 minutes were found to be significant predictors of stroke at 2 days. An admission rule based on an ABCD² score of at least 4 showed sensitivity of 86.4% and NPV of 91.7% for stroke at 7 days. Admission based on a score of at least 3 showed sensitivity of 96.6% and NPV of 96.1%. Admission rate was 69.1% and. 83.6%, respectively.

Conclusion

The ABCD² rule showed good sensitivity and NPV for stroke at 7 days. However, NPV was not 100%, and there would still be patients being discharged from the ED and returning with a stroke if this cutoff was implemented in our setting.     

Clinical importance of antineutrophil cytoplasmic antibody positivity during propylthiouracil treatment

Background: Propylthiouracil (PTU) is the mainstay of antithyroid drug therapy. Previous studies reported antineutrophil cytoplasmic antibody (ANCA)‐positive vasculitis in patients treated for Graves’ disease. ANCA has been associated with either PTU or to the disease itself. However, this issue has not been investigated in toxic multinodular goitre (TMNG). The aim of this study was to evaluate the frequency of ANCA positivity in both TMNG and Graves’ disease patients treated with PTU, and to investigate the clinical importance of this issue. Patients and methods: We studied the presence of ANCA in 46 patients treated with PTU (30 Graves’ disease, 16 TMNG). Two years after the discontinuation of PTU, ANCA was re‐evaluated in 29 patients (18 Graves’ disease, 11 TMNG). Results: By indirect immunofluorescence, 19 of the 46 patients (41.3%) on PTU treatment were ANCA positive [13 of the 30 patients in Graves disease (43.3%), six of the 16 patients in TMNG (37.5%)]. There was no statistically significant difference between Graves’ disease and TMNG patients for ANCA positivity (p = 0.362). ANCA positivity was not related to gender, thyroid autoantibodies, alanine aminotransferase, aspartate aminotransferase, neutrophil count and PTU dose. Two years after withdrawal of PTU treatment, 10.3% of patients continued to have positive ANCA (p < 0.0001). Signs and symptoms of vasculitis could not be detected in any of the ANCA‐positive patients. Conclusion: Our study suggests that PTU but not Graves’ disease itself is the most important factor for ANCA development. The frequency of ANCA positivity is 41.3% in our country which was not different in Graves’ disease and TMNG patients. The dose of PTU and ethnic factors are not associated with ANCA positivity. After cessation of PTU, vasculitis did not develop during the 2 years of follow‐up despite positive ANCA.