Clavicle and acromioclavicular joint injuries: a review of imaging,treatment, and complications

Fractures of the clavicle account for 2.6–5% of all fractures. Clavicular fractures have traditionally been treated conservatively, however, there has recently been increased interest in surgical repair of displaced clavicular fractures, with resultant lower rates of nonunion and malunion. Treatment of acromioclavicular (AC) separation has traditionally been conservative, with surgery reserved for patients with chronic pain or significant dislocation and acute soft tissue injury. It is important for the radiologist to become familiar with the surgical techniques used to fixate these fractures as well as the post-operative appearance and potential complications.     

Three-year postoperative ultrasensitive prostate-specific antigen following open radical retropubic prostatectomy is a predictor for delayed biochemical recurrence

Background

Prostate-specific antigen (PSA) is the only independent predictor of biochemical recurrence (BCR) following radical prostatectomy (RP) subject to change over time.

Objective

To determine whether an ultrasensitive PSA measured at 3 yr following RP is a predictor of subsequent BCR.

Design, setting, and participants

There were 1197 consecutive men with clinically localized prostate cancer who underwent an open radical retropubic prostatectomy (ORRP) at a tertiary referral academic medical center. Exclusions included 107 men (8.9%) who developed a PSA level ≥0.2 ng/ml or underwent hormone therapy or radiation therapy (RT) within the first 3 r after surgery, 191 men (16%) who did not undergo a 3-yr ultrasensitive PSA assay, and 98 men (8.2%) who had PSA levels ≥0.1 and <0.2 at 3 yr. The remaining 801 men were stratified into two groups based on their ultrasensitive PSA level at 3 yr postoperatively: group 1, which consisted of patients whose PSA was ≤0.04 (n = 765), and group 2, which consisted of patients whose PSA was >0.04 and <0.10 (n = 36).

Measurements

Delayed BCR was the primary end point and represented those men in this cohort who developed a PSA level ≥0.2 or underwent salvage RT for a persistently rising PSA level after 3 yr of follow-up.

Results and limitations

The 7-yr cumulative BCR-free survival rate for groups 1 and 2 was 0.957 (95% confidence interval [CI], 0.920-0.978) and 0.654 (95% CI, 0.318-0.855), respectively. In multivariable Cox proportional hazards models, ultrasensitive PSA level at 3 yr remained the only significant predictor of delayed BCR (likelihood ratio χ² for full model: 27.03; df = 1; p < 0.001). A limitation of the study is that no uniform PSA assay was obtained.

Conclusions

Our findings provide compelling evidence that an ultrasensitive PSA at 3 yr following RP provides useful insights into delayed BCR and is a source of reassurance for the overwhelming majority of men being followed for delayed recurrences.     

Guided ordering: Clinician interactions with complex order-sets

BackgroundElectronic order-sets increasingly ask clinicians to answer questions or follow algorithms. Cooperation with such requests has not been studied.SettingInternal Medicine service of an academic medical center.ObjectiveWe studied the accuracy of clinician responses to questions embedded in electronic admission and discharge order-sets. Embedded questions asked whether any of three “core” diagnoses was present; a response was required to submit orders. Endorsement of any diagnosis made available best-practice ordering screens for that diagnosis.DesignThree reviewers examined 180 electronic records (8% of discharges), drawn equally (for each core diagnosis) from possible combinations of Yes/No responses on admission and discharge. In addition to noting responses, we identified whether the core diagnosis was coded, determined from notes whether the admitting clinician believed that diagnosis present, and sought clinical evidence of disease on admission. We also surveyed participating clinicians anonymously about practices in answering embedded questions.MeasurementsWe measured occurrence of six admission and five discharge scenarios relating medical record evidence of disease to clinician responses about its presence.ResultsThe commonest discordant pattern between response and evidence was a negative response to disease presence on admission despite both early clinical evidence and documentation.Survey of study clinicians found that 75% endorsed some intentional inaccuracy; the commonest reason given was that questions were sometimes irrelevant to the clinical situation at the point asked.ConclusionThrough faults in order-set design, limitations of software, and/or because of an inherent tendency to resist directed behavior, clinicians may often ignore questions embedded in order-sets.     

Preoperative status and risk of complications in patients with hip fracture

BACKGROUND: Limited information is available on preoperative status and risks for complications for older patients having surgery for hip fracture. Our objective was to identify potentially modifiable clinical findings that should be considered in decisions about the timing of surgery. METHODS: We conducted a prospective cohort study with data obtained from medical records and through structured interviews with patients. A total of 571 adults with hip fracture who were admitted to 4 metropolitan hospitals were included. RESULTS: Multiple logistic regression was used to identify risk factors (including 11 categories of physical and laboratory findings, classified as mild and severe abnormalities) for in-hospital complications. The presence of more than 1 (odds ratio [OR] 9.7, 95% confidence interval [CI] 2.8 to 33.0) major abnormality before surgery or the presence of major abnormalities on admission that were not corrected prior to surgery (OR 2.8, 95% CI 1.2 to 6.4) was independently associated with the development of postoperative complications. We also found that minor abnormalities, while warranting correction, did not increase risk (OR 0.70, 95% CI 0.28 to 1.73). CONCLUSIONS: In this study of older adults undergoing urgent surgery, potentially reversible abnormalities in laboratory and physical examination occurred frequently and significantly increased the risk of postoperative complications. Major clinical abnormalities should be corrected prior to surgery, but patients with minor abnormalities may proceed to surgery with attention to these medical problems perioperatively.