Impact of clinical history on fracture detection with radiography

The effect of knowledge of localizing symptoms and signs in the detection of fractures was studied. Forty radiographs of the extremities were examined twice by seven radiologists; the sessions were separated by 4 months. In 26 cases, a subtle fracture was present; 14 cases were normal. In half of the cases at each session, the precise location of pain, tenderness, or swelling was provided. The observer was asked to determine if the case was normal or abnormal (provide the exact location of the fracture) and to indicate the degree of confidence in the diagnosis. Responses were converted to a numeric scale for analysis. Analysis of receiver operator characteristic parameters indicates that clues regarding location of trauma facilitate detection of fractures. The improvement is based largely on an increased true-positive rate without an increased false-positive rate, regardless of the decision criteria of the radiologist (overall willingness to "overread" or "underread"). This has direct clinical applicability and reinforces the plea of radiologists for precise clinical information.     

Operative venodilation: a previously unsuspected factor in the cause of postoperative deep vein thrombosis

Intraoperative venodilation in veins distant from the site of operation has been shown to occur in animals and has been directly correlated with focal venous endothelial damage. This exposure of subendothelial collagen could serve as initiation sites for thrombus formation. This study tests the hypothesis that human beings (1) significant operative venodilation occurs and that it correlates with postoperative deep venous thrombosis (DVT); (2) operative venodilation can be pharmacologically controlled; and (3) this control reduces the incidence of postoperative DVT. Twenty-one patients undergoing total hip replacement had their contralateral cephalic vein continuously monitored with modified ultrasonographic instrumentation, with a continuous on-line recorder graphing venous diameter. Patients were randomly assigned to receive 0.5 mg of dihydroergotamine and 5000 U of heparin (DHE/Hep) for prophylaxis or placebo, with investigators "blinded" Postoperatively, all patients underwent ascending phlebography. Patients in whom postoperative DVT developed (11) had a mean operative venodilation of 28.9% +/- 3.93%, and those in whom DVT did not develop (10) had a mean venodilation of 11.6% +/- 1.55% (p = 0.001). Only 17% (2/12) dilating less than 20% baseline diameter had DVT compared with 100% (9/9) dilating greater than 20% of baseline diameter (p = 0.002). Patients receiving venotonic agent DHE had significantly less venodilation and DVT (p less than 0.001) compared with patients receiving the placebo. Patients who had DVT and whose veins dilated greater than 20% were older than patients who did not have DVT and whose veins minimally dilated: p = 0.04 and p = 0.07, respectively. Although there was a trend toward increased venoconstriction in patients receiving DHE/Hep (p = 0.09), there was no correlation of venoconstriction with ultimate thrombotic outcome. Maximal venodilation occurs during handling of soft tissue (muscle), and this occurs significantly sooner than maximal venoconstriction, which occurs during bone manipulation. We conclude that excessive operative venodilation is a new and important etiologic factor that leads to postoperative DVT. Operative venodilation can be pharmacologically controlled with the venotonic agent DHE. The combination DHE/Hep reduces postoperative DVT by the reduction of operative venodilation in the presence of low doses of an anticoagulant. These findings offer a new approach for predicting postoperative DVT and an object rationale for developing effective prophylaxis.     

Lymph node infarction – a rare complication associated with disseminated intra vascular coagulation in a case of dengue fever

Background  

Lymph node infarction is known to occur in association with many non-neoplastic and neoplastic conditions however its occurrence in association with DIC is not reported hitherto in the literature.     

Acute coronary syndromes

The first 150 words of the full text of this article appear below. Key points Coronary artery disease accounts for >30% ofdeaths in Western society. The diagnosis of myocardial infarctionshould be qualified by size, causation and time from occurrence. Mortalityis reduced by immediate or ‘primary’ percutaneouscoronary intervention or thrombolysis within the first 24 hof onset of ST-segment elevation myocardial infarction. Strategiesto reduce platelet activation (glycoprotein IIb/IIIa receptorantagonists, or clopidogrel) are now recommended in the treatmentof high-risk non-ST-segment myocardial infarction/unstable angina. Elevatedserum troponins may be the result of non-ischaemic myocardialdamage, especially in critical illness.