Diagnostic accuracy of lower extremity X-ray interpretation by 'specialized' emergency nurses.

OBJECTIVES: In the quest for a cost-effective and quality-preserving solution to manage crowding in the emergency department, the possibility of deploying regular emergency nurses for the treatment of acute ankle injuries was investigated. The aim of this study is to compare the diagnostic accuracy of emergency nurses with that of senior house officers in interpreting ankle and foot radiographs. METHODS: A prospective study comparing the assessment of 60 radiographs (30 feet and 30 ankles) by 16 emergency nurses before and after an educational session was performed. Each subset of 30 radiographs contained 12 fractures, hand-picked by a radiologist to represent everyday traumatology in the emergency department. The control group consisted of eight senior house officers representing everyday expertise. The outcome of the diagnostic assessment, represented as the pooled sensitivity and specificity for both groups, was compared using Z-statistics. RESULTS: Before the training session, the specialized emergency nurse group showed a sensitivity of 0.87 (confidence interval 0.83-0.91) compared with 0.93 (confidence interval 0.88-0.96) for the control group (P = 0.05). The specificity of specialized emergency nurses was 0.87 (confidence interval 0.81-0.92) compared with 0.93 (confidence interval 0.89-0.95) for the senior house officers (P < 0.05). After the training session, specialized emergency nurse diagnostic parameters did not differ significantly from the control group, displaying a sensitivity of 0.89 (confidence interval 0.86-0.92) and specificity of 0.92 (confidence interval 0.87-0.95). CONCLUSION: Before the training session, the specialized emergency nurse group showed a significantly lower accuracy than the SHO group. After training, however, the diagnostic accuracy did not differ significantly between groups. Therefore, we conclude that emergency nurses are able to accurately interpret foot and ankle radiographs after a short educational session.     

Procainamide therapy, physical performance and energy expenditure in the Schwartz-Jampel syndrome

The effects of procainamide administration were assessed in a 5-yr-old boy with Schwartz-Jampel syndrome (chondrodystrophic myotonia). Without procainamide the resting metabolic rate was found to be significantly higher than in an age-matched control group. With a serum level of 3.8 mg l-1 procainamide a reduction of the resting metabolic rate of 22% was observed, and times needed to climb stairs and to re-open eyes after forceful contraction (blepharospasm) were significantly reduced.     

Anal dynamic plastic surgery of the gracilis muscle; a new surgical technique for the treatment of fecal incontinence]

OBJECTIVE. To study the clinical outcome of anal dynamic graciloplasty (gracilis muscle transposition and implantation of electric stimulation device) in a consecutive series of 12 patients. DESIGN. Prospective study. SETTING. Maastricht University Hospital. PATIENTS AND METHODS. Twelve patients with incapacitating faecal incontinence were treated using anal dynamic graciloplasty because they were not amenable to other medical management. The data were analysed with emphasis on the clinical outcome, anal manometry, and gracilis muscle composition before and after electric stimulation. Results were considered significant if p < or = 0.05, using the paired Student's t-test. RESULTS. Eight patients achieved complete faecal continence, one patient still has a previously constructed colostomy and in three patients no faecal incontinence could be achieved, due to infections. Median follow-up is now over 18 months (range 16 weeks-5 years). Anal manometry demonstrated an anal pressure increased from 39 mmHg (without stimulation) to 66 mmHg with electric stimulation (mean increase 27 mmHg (CI: 19-35; n = 12, p < 0.01). Gracilis muscle composition showed an increase of type I relatively fatigue-resistant fibres, capable of prolonged contractions, from 45% before stimulation to 64% afterwards (mean increase 19% (CI: 14-21; n = 8, p < 0.01). CONCLUSION. Dynamic graciloplasty is capable of replacing the function of damaged or absent anal sphincters. The construction of a colostomy in patients with incapacitating faecal incontinence can be avoided.     

Follow-up of mesh complications using the IUGA/ICS category–time–site coding classification

Introduction

The International Urogynecological Association (IUGA) and the International Continence Society (ICS) developed a complication classification to facilitate international comparison and to improve our understanding of complications. This code was applied to surgical cases for the analysis of complications after mesh insertion.

Methods

The study included patients who had undergone vaginal prolapse repair with a trocar-guided polypropylene mesh between 2006 and 2010 in a Dutch peripheral hospital. Complications were assessed at secondary follow-up and classified using category (C), timing (T), and site (S) components (CTS).

Results

Of the 107 women included, 84 returned for secondary follow-up (response rate 80 %, median time after surgery 36 months, range 12–64). In 45 patients no complications occurred. In the remaining 39 patients, 43 complication codes were established. Six of the seven categories of complications were found at all different time codes. Concerning the site of the complication codes S1, S2, and S3 were applicable. Perioperative complications (6 %) included hemorrhage and bladder perforation. Six patients were reoperated for symptomatic mesh exposure or local pain. At secondary follow-up exposure was diagnosed in another 4 patients (12 %). In 36 % mesh wrinkling or shrinkage was discovered, although without complaints in most. Eight women had daily complaints or dyspareunia. Eighty-two percent of patients indicated strong improvement after surgery. Several limitations of the classification are discussed.

Conclusions

Despite limitations, the IUGA/ICS code is demonstrated to be useful in describing mesh complications. We advise the use of the CTS code at follow-up consultations after a minimum of 2 years for improved insight into and knowledge on the occurrence of complications.     

Schwartz-Jampel syndrome: I. Clinical, electromyographic, and histologic studies

In a new, typical case of Schwartz-Jampel syndrome (SJS) the origin of the disorder was found to be purely myogenic. Concentric needle EMG showed abundant and persistent spontaneous activity, maximal at insertion, and uninfluenced by local curarization. Single-fiber EMG showed rather stable, sometimes intermittent, discharge series with occasional amplitude and/or frequency fluctuations. It could be demonstrated that this activity did not consist of complex repetitive discharges, but of independent activity of individual muscle fibers. This contrasts with findings by other investigators that have been published in this journal. Light microscopic studies of quadriceps and intercostal muscles showed no abnormalities, whereas electron-microscopic findings were in accordance with earlier studies in SJS. Endplate analysis revealed no specific changes; the postsynaptic structures gave the impression of an accelerated-maturation.     

Evaluation of effect of ankle-foot orthosis use on strength restoration of paretic dorsiflexors

OBJECTIVE: To assess whether a difference exists in restoration of strength between patients with a recent paresis of the dorsiflexors of the ankle using an ankle-foot orthosis (AFO) and patients without an AFO. DESIGN: Prospective case-control study. SETTING: Patients from regional hospitals, tested in a rehabilitation research center. PARTICIPANTS: Twenty-nine patients with a recent (6wk-1yr) peripheral paresis, alternately assigned to a group using an AFO or a control group. There was no significant difference in duration of the paresis and in torque at entering the study (T0) between the 2 groups. INTERVENTIONS: The use of an ankle-foot orthosis. MAIN OUTCOME MEASURES: Isometric torque production of ankle dorsiflexors, expressed as ratio of paretic and healthy side, in 2 measurement sessions, over a period of 6 weeks (T0-T6) with the ankle in 0 degrees and 30 degrees plantarflexion. RESULTS: Both groups had significant restoration of strength +/- standard deviation between T0 and T6 in 30 degrees flexion: non-AFO group 17% +/- 15%, AFO group 9% +/- 12%. No significant difference existed between the 2 groups (30 degrees p = .56). No significant shift in strength ratio 0 degrees :30 degrees occurred (AFO group p = .82). CONCLUSION: The use of an orthosis does not influence restoration of strength in patients with a recent peripheral paresis of the ankle dorsiflexors.     

Abnormal warm and cold sensation thresholds suggestive of small-fibre neuropathy in sarcoidosis

OBJECTIVE: A substantial number of sarcoidosis patients report apparently non-specific symptoms such as pain, for which no organic substrate has yet been found. Recently we observed symptoms suggestive of small-fibre neuropathy in a group of sarcoidosis patients. The aim of the present study was to verify this observation using various electrophysiological tests. METHODS: In 74 sarcoidosis patients complaining of symptoms suggestive of small-fibre neuropathy, thresholds for warm (WS) and cold sensation (CS) as well as for heat pain were determined at the thenar eminence and the foot dorsum. Furthermore, sympathetic skin responses (SSR), nerve conduction studies and concentric needle electromyography were performed. In 31 patients, cardiovascular autonomic testing was carried out. RESULTS: Thermal threshold testing (TTT) revealed abnormalities in 51 of the 74 patients. Abnormalities showed an asymmetrical distribution. WS was affected more often than CS and feet more often than hands. Nerve conduction studies in the legs showed slightly abnormal results in 6 patients; all of these had abnormal TTT results. The SSR was absent at the foot in 7 patients. Cardiovascular autonomic testing was abnormal in only a single patient. CONCLUSIONS: In a subgroup of sarcoidosis patients we found TTT abnormalities suggestive of small-fibre neuropathy. SSR and cardiovascular autonomic testing appeared to be of little diagnostic value. Small-fibre neuropathy may be the cause of a number of hitherto unexplained symptoms in sarcoidosis.