Cost description of clinical examination and MRI in wrist ligament injuries

Objective: The total number and cost of wrist MRIs in the catchment area of the Västra Götaland Region in Sweden (population 1 723 000) during 1 year was analysed, together with the number and content of referrals.

Methods: Six radiology departments reported the numbers and rate of all MRI investigations intended to diagnose wrist ligament injuries (n?=?411) and other injuries to the wrist.

Results: The additional cost of the difference between MRIs and a clinical examination by a hand surgeon, plus indirect costs for patients with suspected wrist ligament injuries, was calculated as 957 000 euros.

Conclusions: It is recommended that MRI should only be used in patients in whom there are clinical difficulties in terms of diagnosing wrist ligament injuries. It is suggested that patients with suspected wrist ligament injuries should be referred directly to an experienced hand surgeon, capable of performing a standardised wrist examination and, when needed, diagnostic arthroscopy and final treatment. The proposed algorithm for the diagnosis and treatment of suspected wrist ligament injuries presented in the present study could save time for the patient and for the radiology departments, as well as reducing costs. The ability to implement the early and appropriate treatment of acute ligament injuries could be improved at the same time.     

Aortic Valve Replacement Using Local Myocardial Hypothermia

This material comprises 100 cases of aortic valve replacement. Ninety-one of the valves were replaced with the Björk—Shiley tilting disc valve prosthesis and 9 with the Smeloff—Cutter ball valve. No coronary perfusion was used during surgery. The myocardium was protected by local myocardial hypothermia, achieved by an intracoronary infusion of Bretschneider's solution (+4°C) prior to surgery. A weak and flaccid heart without coronary perfusion cannulas facilitated the surgical procedure. Myocardial function was very good and the course of the patients excellent postoperatively. Seven percent of the patients were lost within one month after operation and late mortality was 13%. A comparison between clinical and haemodynamic findings obtained 2–3 months before and one year after surgery was made in 55 patients. A marked subjective improvement was seen in all but five patients. There was a significant increase of average physical working capacity and regression of ECG-signs of left ventricular hypertrophy and strain as well as of roentgenological heart size. Angina pectoris was present in only three patients postoperatively as compared with 23 before surgery. The improvement of physical working capacity was paralleled by a significant increase of cardiac output during exercise, caused by a rise of stroke volume, heart rate on maximal load tolerated remaining unchanged. Blood pressure reactions during work were normalized in patients with both pre-operative aortic stenosis and aortic insufficiency. A significant postoperative paravalvular leakage was rare in the present material.     

Studying psychoactive substance use in injured patients: Does exclusion of late arriving patients bias the results?

BackgroundMost studies of the prevalence of psychoactive substances in injured emergency department patients have excluded those who arrive more than 6 h after injury. This may cause a selection bias. The aim of this study was: (1) to describe the characteristics of patients who arrive more than 6 h after injury, compared to patients who arrive sooner (2) to examine whether self-report can add to the assessment of alcohol use when the patient is assessed more than 6 h after injury.MethodsBlood sample analysis and self-report data were used to assess the prevalence of psychoactive substances in injured patients admitted to an emergency department within 48 h of injury (n = 1611). Discriminant function analysis was used to assess group differences.ResultsThe patients who arrived more than 6 h after injury differed significantly from those who arrived earlier in several respects. They more often screened positive for hypnotics; they were older, they were more likely to have had a fall and they were more often injured at home and at night. Self reported use of alcohol showed good consistency with blood sample screening within 6 h of injury and could therefore be used to assess alcohol use more than 6 h after injury.ConclusionsPatients who arrive more than 6 h after injury differ significantly from those who arrive earlier. Future studies on the prevalence of psychoactive substances in emergency departments could expand the inclusion window.