Very low probability interpretation of V/Q lung scans in combination with low probability objective clinical assessment reliably excludes pulmonary embolism: data from PIOPED II.

Use of a very low probability interpretation of ventilation/perfusion (V/Q) lung scans, if verified by prospective evaluation to have a low positive predictive value (PPV), will reduce the number of nondiagnostic interpretations of V/Q scans and may be particularly useful in patients with a relative contraindication to CT. The purpose of this investigation was to test the hypothesis that a very low probability interpretation of the V/Q scan has a PPV of <10%. METHODS: Data are from PIOPED II (Prospective Investigation of Pulmonary Embolism Diagnosis II). Very low probability criteria are (a) nonsegmental perfusion abnormalities, (b) perfusion defect smaller than corresponding radiographic lesion, (c) > or =2 matched V/Q defects with regionally normal chest radiograph, (d) 1-3 small segmental perfusion defects (<25% of a segment), (e) solitary triple matched defect in middle or upper lung zones, (f) stripe sign around the perfusion defect(s), and (g) perfusion defect from pleural effusion equal to one third or more of the pleural cavity with no other perfusion defect. RESULTS: A very low probability consensus interpretation of the V/Q scan was made in 56% of patients. The PPV of a very low probability interpretation of the V/Q scans was 36 of 440 patients (8.2%). Among patients with suspected pulmonary embolism who had a low clinical probability objective clinical assessment and a very low probability V/Q scan, the PPV was 8 of 259 patients (3.1%). Among women < or =40 y, the PPV of the very low probability V/Q with a low objective clinical assessment was 1 of 50 (2%). CONCLUSION: The very low probability V/Q scan together with a low probability clinical assessment reliably excludes pulmonary embolism.     

Determining aspects of ethnicity amongst persons of South Asian origin: the use of a surname-classification programme (Nam Pehchan)

OBJECTIVE: Name-based classification systems are potentially useful in identifying study samples based on probable ethnic minority group. The aim of the current study was to assess the validity of the Nam Pehchan name classification programme of religion and language against subject self-report. STUDY DESIGN AND SETTING: A population-based cross-sectional survey conducted in areas of the North-West and West Midland regions of England with a relatively high density of South Asian ethnic minority groups. The sampling frame was age-sex registers of selected general practices and subjects were classified according to language and religion using the Nam Pehchan programme. These were compared with responses by subjects on a self-complete postal questionnaire. RESULTS: One thousand nine hundred and forty-nine subjects who participated, classified themselves as South Asian. Sensitivity in identifying religion was high amongst Muslims (92%) and Sikhs (86%), and somewhat lower in Hindus (62%). Specificity exceeded 95% for all ethnic groups. The vast majority of subjects assigned Punjabi or Gujarati as their main South Asian language indicated that they did in fact speak these languages (97% and 94%, respectively). Subjects assigned Urdu or Bengali, however, were less likely to do so (61% and 35%, respectively). CONCLUSIONS: The name-based classification system Nam Pehchan has demonstrated high levels of accuracy in some sub-groups of the South Asian population in determining subjects likely language spoken and religion-and is likely to be a useful additional tool when information on ethnicity is not already available.     

Impaired Functional Status and Echocardiographic Abnormalities Signifying Global Dysfunction Enhance the Prognostic Significance of Previously Unrecognized Myocardial Infarction Detected by Electrocardiography

Background: The relationship between electrocardiographic unrecognized myocardial infarction (UMI), abnormal functional status, echocardiographic abnormalities, and mortality has not been evaluated. Methods: A population‐based random sample of 2042 Olmsted County residents, age ≥45 years, was studied by self‐administered questionnaire, chart review, ECG and echocardiogram, and 5 year follow‐up for all‐cause mortality. UMI (n = 81) was diagnosed if ECG‐MI criteria were met without previous documented myocardial infarction. Functional Status was assessed by the Goldman Specific Activity Scale. Results: UMI subjects had an increased prevalence of abnormal functional status compared to no MI controls (22% vs 11%, P < 0.05). This association was independent of sex, obesity, smoking, diabetes, and pulmonary disease. It became insignificant after stratifying for echocardiographic abnormalities. Compared to no MI controls, UMI subjects with impaired functional status had a higher mortality hazard ratio (HR 7.2; P<0.0001) than those without impaired functional status (HR 2.7; P = 0.02). In UMI subjects with impaired functional status and any echocardiographic abnormality signifying global ventricular dysfunction (systolic or diastolic dysfunction, left atrial or left ventricular enlargement), the mortality risk was even higher (HR 9.5; P<0.001) and persisted in multivariate analyses. This increased mortality risk was unaffected by adjustment for regional wall motion abnormalities. Conclusions: The assessment of impaired functional status and echocardiographic abnormalities improves the prognostic significance of UMI. Even in the absence of regional wall motion abnormalities, structural abnormalities of global dysfunction may play a role in mediating the increased mortality associated with UMI.     

Surgical management of contiguous multilevel thoracolumbar tuberculous spondylitis

Introduction

Tuberculous spondylitis (TBS) is the most common form of extra-pulmonary tuberculosis. The mainstay of TBS management is anti-tuberculous chemotherapy. Most of the patients with TBS are treated conservatively; however in some patients surgery is indicated. Most common indications for surgery include neurological deficit, deformity, instability, large abscesses and necrotic tissue mass or inadequate response to anti-tuberculous chemotherapy. The most common form of TBS involves a single motion segment of spine (two adjoining vertebrae and their intervening disc). Sometimes TBS involves more than two adjoining vertebrae, when it is called multilevel TBS. Indications for correct surgical management of multilevel TBS is not clear from literature.

Materials and methods

We have retrospectively reviewed 87 patients operated in 10 years for multilevel TBS involving the thoracolumbar spine at our spine unit. Two types of surgeries were performed on these patients. In 57 patients, modified Hong Kong operation was performed with radical debridement, strut grafting and anterior instrumentation. In 30 patients this operation was combined with pedicle screw fixation with or without correction of kyphosis by osteotomy. Patients were followed up for correction of kyphosis, improvement in neurological deficit, pain and function. Complications were noted. On long-term follow-up (average 64 months), there was 9.34 % improvement in kyphosis angle in the modified Hong Kong group and 47.58 % improvement in the group with pedicle screw fixation and osteotomy in addition to anterior surgery (p < 0.001). Seven patients had implant failures and revision surgeries in the modified Hong Kong group. Neurological improvement, pain relief and functional outcome were the same in both groups.

Conclusion

We conclude that pedicle screw fixation with or without a correcting osteotomy should be added in all patients with multilevel thoracolumbar tuberculous spondylitis undergoing radical debridement and anterior column reconstruction.

     

Accuracy of diagnosis and relationship with quality of emergency medicine training program

An indicator for emergency room performance is the ability to establish the correct diagnosis within the emergency room over the years. The authors chose to examine the non-congruence of Emergency Room diagnoses to that established after hospital stay for three selected years. A total of 8488 records were reviewed and all disparate diagnosis were recorded and categorized. Retrospective chart reviews were done from July 2008 to February 2009 at the Aga Khan University Hospital, Karachi. A substantial reduction in the percentage of disparate diagnoses was seen over the years from 41% in the initial year to 14% in the last year evaluated. It was concluded that over the years there has been an improvement in the reliability of Emergency Room diagnoses at the Aga Khan University Hospital, Karachi.