Can a normal range of elbow movement predict a normal elbow x ray?

Background

Elbow injuries account for approximately 2–3% of presentations to the emergency department. This is associated not only with a very high rate of x rays but also with a very high rate of “missed fractures”This study examines which components of elbow examination have the best correlation with a normal radiograph.

Design setting

A district general hospital''s emergency department seeing 83 000 new attendances per annum (pa) (approximately 1600 elbow injuries pa).

Methods

After estimating the power before data collection, all patients presenting with elbow injuries were considered for inclusion, and were excluded only if they were unable to follow instructions owing to either reduced conscious levels or mental conditions. A proforma was completed after patient examination, indicating the features of clinical examination, and the results of radiographs if any. The formal report of all radiographs taken was sought from the radiology department.

Results

407 patients were entered into the study, of whom 331 received a radiograph of the elbow. Full extension of the elbow had a specificity of 0.916 (95% confidence interval (CI) 0.863 to 0.969, sensitivity 0.478) for detection of a normal radiograph. An equal range of movement ROM had a specificity of 0.976 (95% CI 0.940 to 0.991, sensitivity 0.211). Subgroup analysis of patients aged <16 years showed a specificity of equal ROM of 1 (95% CI 0.941 to 1.000) for the detection of a normal x ray.Logistic regression analysis showed that best predictive values were achieved by a combination of full extension, flexion and supination.

Conclusion

A two‐tier clinical rule for management of elbow injury is proposed: (1) Those patients aged ⩽16 years with a ROM equal to the unaffected side may be safely discharged; (2) Those patients with normal extension, flexion and supination do not require emergent elbow radiographs.Elbow injuries account for a considerable proportion of attendances to any emergency department. They affect all age groups, although the exact pathology at each age varies. It is also well recognised that interpretation of the elbow x ray is difficult and that there is a marked “missed fracture” rate. A New York University Hospital¹ reported that 2–3% of their attendances were due to elbow injury. They experienced a missed fracture rate despite radiography of 10.8% of all fractures presenting the third most frequently missed fracture group.The introduction of clinical rules for joints, such as the Ottawa ankle, knee and cervical spine rules, and the Pittsburgh knee rule, have aided junior staff in the assessment of joints, and have guided the use of investigation.^2,3,4,5,6 Two groups have previously looked at the use of abnormal elbow extension as a predictor of significant injury.^7,8 Both groups noted that extension alone some fractures judged clinically significant, although not requiring active intervention.Our study prospectively assessed the ability of a normal range of movement during elbow examination to predict a normal elbow radiograph. We were especially interested in specific movements or combinations of movements that would increase the sensitivity of clinical examination to predict a normal radiograph.     

Outcomes following oesophagectomy in patients with oesophageal cancer: a secondary analysis of the ICNARC Case Mix Programme Database

Introduction

This report describes the case mix and outcomes of patients with oesophageal cancer admitted to adult critical care units following elective oesophageal surgery in England, Wales and Northern Ireland.

Methods

Admissions to critical care following elective oesophageal surgery for malignancy were identified using data from the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database. Information on admissions between December 1995 and September 2007 were extracted and the association between in-hospital mortality and patient characteristics on admission to critical care was assessed using multiple logistic regression analysis. The performance of three prognostic models (Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II and the ICNARC physiology score) was also evaluated.

Results

Between 1995 and 2007, there were 7227 admissions to 181 critical care units following oesophageal surgery for malignancy. Overall mortality in critical care was 4.4% and in-hospital mortality was 11%, although both declined steadily over time. Eight hundred and seventy-three (12.2%) patients were readmitted to critical care, most commonly for respiratory complications (49%) and surgical complications (25%). Readmitted patients had a critical care unit mortality of 24.7% and in-hospital mortality of 33.9%. Overall in-hospital mortality was associated with patient age, and various physiological measurements on admission to critical care (partial pressure of arterial oxygen (PaO₂):fraction of inspired oxygen (FiO₂) ratio, lowest arterial pH, mechanical ventilation, serum albumin, urea and creatinine). The three prognostic models evaluated performed poorly in measures of discrimination, calibration and goodness of fit.

Conclusions

Surgery for oesophageal malignancy continues to be associated with significant morbidity and mortality. Age and organ dysfunction in the early postoperative period are associated with an increased risk of death. Postoperative serum albumin is confirmed as an additional prognostic factor. More work is required to determine how this knowledge may improve clinical management.

     

The Program for Rheumatic Independent Self-Management: A Pilot Evaluation

The 'Program for Rheumatic Independent Self-Management' (PRISM) is an interdisciplinary programme that integrates group education and individualised treatment using the principles of self-management, adult learning, case management and self-efficacy enhancement. This study is a before-after evaluation of 57 individuals who attended PRISM. Outcome measures were selected to measure self-efficacy, disability, pain and ability to cope. The mean self-efficacy score increased immediately following the programme and this improvement was maintained at 6-month follow-up. Disability decreased from baseline to 6-month follow-up. There was a decrease in the mean level of pain from post-class to 6-month follow-up. All of these changes were statistically significant. These preliminary findings suggest that PRISM may be effective in enhancing self-efficacy, and reducing disability and pain.     

Evaluation of teleradiology for interpretation of intravenous urograms

The diagnostic yield of a commercial teleradiology/picture archiving and communication system (ATT-Philips Comm View T/PACS) was evaluated for 100 urograms. A single image from each examination was digitized (2048 x 1684 x 12-bit pixels) and transmitted from a satellite hospital over a T-1 line using the T/PACS system. The video display of each digitized image was reviewed independently by four radiologists. The same four radiologists reviewed the original film images at a different time without knowledge of their T/PACS interpretation. There was no statistically significant difference in the sensitivity for clinical findings between T/PACS (86%) and film (89%). The false positive rate, however, was significantly higher with T/PACS than with film (44 versus 32 false positive findings per 100 films). We conclude that T/PACS of the type studied here demonstrates sufficient sensitivity for the detection of clinically important urographic findings in the emergency setting. A final reading of the original films is still necessary, however, to assure appropriate specificity.     

Analysis of the resource-based relative value scale for Medicare reimbursements to academic and community hospital radiology departments

The authors examined a homogeneous sample of 40 radiologists from four academic centers (ACs) and four community hospitals (CHs) to assess the prevalence, accuracy, and sources of knowledge regarding the resource-based relative value scale (RBRVS) reform of Medicare. The radiologists were also asked to estimate the relative intraservice work values of 12 of the radiologic services in the original RBRVS study, using the same definitions and the same standard service. The radiologists were found to be relatively well informed and accurate regarding the RBRVS-based Medicare reform. However, the standard errors of estimated work in the sample were much greater (from 56% to over 800%) than those reported for the nationally based RBRVS. The AC and CH radiologists also appeared to differ qualitatively in their perceptions of intraservice work. These findings suggest that the RBRVS may not represent accurately the spread of perceived relative work values among radiologists, including differences between AC and CH components in terms of site-specific radiologic work.     

Use of new heterobifunctional reagent for radiometallic labeling of antibodies

A new heterobifunctional reagent, 2,6-dioxo-N-(carboxymethyl)morpholine (DCM), was synthesized, reacted with a monoclonal antibody (MAb) to human high-molecular-weight, melanoma-associated antigen, and then chelated with 111In. The same MAb also was chelated with 111In with the use of the bicyclic anhydride of pentetic acid (BADTPA), a homobifunctional reagent, for comparative studies. The labeling efficiencies were similar: an average of 79% for 111In-iminodiacetic acid-MAb and an average of 75% for 111In-DTPA-MAb. However, the loss of immunoreactivity was 32.6% and 58.7% for both radiolabeled antibodies, respectively. Analysis by sodium dodecyl sulfate-polyacrylamide gel electrophoresis demonstrated a high-molecular-weight polymer band only for the 111In-DTPA-MAb preparation. The results indicate that DCM likely causes less denaturation of antibody by eliminating the cross-linking reaction that is known to occur with homobifunctional chelating reagents.     

Differential effects of gonadal steroids on dopamine metabolism in mesolimbic and nigro-striatal pathways of male rat brain

Thirty days after castration the concentration of dopamine (DA) was significantly reduced in the septum and n. accumbens septi, but not in the caudate-putamen, of male rat brain. The concentrations of dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA), the principle metabolites of DA, also tended to be lower in septum and n. accumbens septi after castration. Chronic s.c. administration of testosterone (T), estradiol (E₂), 5α-dihydrotestosterone (DHT), or E₂ plus DHT in silastic capsules effectively reversed these effects of castration in septum and n. accumbens septi without affecting concentrations of DA, DOPAC, or HVA in caudate-putamen. The accumulation of DOPA after inhibition of aromatic amino acid decarboxylase activity, which was taken as an in vivo index of tyrosine hydroxylase activity, was not affected in these brain regions by long-term castration or by chronic administration of DHT to castrated males. Acute administration of haloperidol caused equivalent, significant increments in concentrations of DOPAC and HVA in all brain regions studied, regardless of whether castrated rats had been implanted with DHT capsules or no hormone. However, in the absence of haloperidol treatment the concentration of DOPAC in septum and n. accumbens septi, but not in caudate-putamen, was significantly higher in castrated rats implanted with DHT as opposed to no hormone. These results suggest that chronic exposure to T, or to its neural metabolites, E₂ and DHT, selectively enhances metabolic activity in mesolimbic DA neurons.