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Kharel P, Zadro JR, Wong G, Rojanabenjawong K, Traeger A, Linklater J, Maher CG. Effectiveness of implementation strategies for increasing clinicians' use of five validated imaging decision rules for musculoskeletal injuries: a systematic review. BMC Emerg Med 2024; 24:84. [PMID: 38760697 PMCID: PMC11100091 DOI: 10.1186/s12873-024-00996-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 04/29/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Strategies to enhance clinicians' adherence to validated imaging decision rules and increase the appropriateness of imaging remain unclear. OBJECTIVE To evaluate the effectiveness of various implementation strategies for increasing clinicians' use of five validated imaging decision rules (Ottawa Ankle Rules, Ottawa Knee Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study and Canadian Computed Tomography Head Rule). DESIGN Systematic review. METHODS The inclusion criteria were experimental, quasi-experimental study designs comprising randomised controlled trials (RCTs), non-randomised controlled trials, and single-arm trials (i.e. prospective observational studies) of implementation interventions in any care setting. The search encompassed electronic databases up to March 11, 2024, including MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane CENTRAL, Web of Science, and Scopus. Two reviewers assessed the risk of bias of studies independently using the Cochrane Effective Practice and Organization of Care Group (EPOC) risk of bias tool. The primary outcome was clinicians' use of decision rules. Secondary outcomes included imaging use (indicated, non-indicated and overall) and knowledge of the rules. RESULTS We included 22 studies (5-RCTs, 1-non-RCT and 16-single-arm trials), conducted in emergency care settings in six countries (USA, Canada, UK, Australia, Ireland and France). One RCT suggested that reminders may be effective at increasing clinicians' use of Ottawa Ankle Rules but may also increase the use of ankle radiography. Two RCTs that combined multiple intervention strategies showed mixed results for ankle imaging and head CT use. One combining educational meetings and materials on Ottawa Ankle Rules reduced ankle injury imaging among ED physicians, while another, with similar efforts plus clinical practice guidelines and reminders for the Canadian CT Head Rule, increased CT imaging for head injuries. For knowledge, one RCT suggested that distributing guidelines had a limited short-term impact but improved clinicians' long-term knowledge of the Ottawa Ankle Rules. CONCLUSION Interventions such as pop-up reminders, educational meetings, and posters may improve adherence to the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian CT Head Rule. Reminders may reduce non-indicated imaging for knee and ankle injuries. The uncertain quality of evidence indicates the need for well-conducted RCTs to establish effectiveness of implementation strategies.
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Affiliation(s)
- Priti Kharel
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050.
| | - Joshua R Zadro
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050
| | - Grace Wong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Adrian Traeger
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050
| | | | - Christopher G Maher
- The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050
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Kharel P, Zadro JR, Chen Z, Himbury MA, Traeger AC, Linklater J, Maher CG. Awareness and use of five imaging decision rules for musculoskeletal injuries: a systematic review. Int J Emerg Med 2023; 16:85. [PMID: 37957570 PMCID: PMC10644430 DOI: 10.1186/s12245-023-00555-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Several validated decision rules are available for clinicians to guide the appropriate use of imaging for patients with musculoskeletal injuries, including the Canadian CT Head Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study (NEXUS) guideline, Ottawa Ankle Rules and Ottawa Knee Rules. However, it is unclear to what extent clinicians are aware of the rules and are using these five rules in practice. OBJECTIVE To determine the proportion of clinicians that are aware of five imaging decision rules and the proportion that use them in practice. DESIGN Systematic review. METHODS This was a systematic review conducted in accordance with the 'Preferred reporting items for systematic reviews and meta-analyses' (PRISMA) statement. We performed searches in MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Scopus databases to identify observational and experimental studies with data on the following outcomes among clinicians related to five validated imaging decision rules: awareness, use, attitudes, knowledge, and barriers and facilitators to implementation. Where possible, we pooled data using medians to summarise these outcomes. RESULTS We included 39 studies. Studies were conducted in 15 countries (e.g. the USA, Canada, the UK, Australasia, New Zealand) and included various clinician types (e.g. emergency physicians, emergency nurses and nurse practitioners). Among the five decision rules, clinicians' awareness was highest for the Canadian C-Spine Rule (84%, n = 3 studies) and lowest for the Ottawa Knee Rules (18%, n = 2). Clinicians' use was highest for NEXUS (median percentage ranging from 7 to 77%, n = 4) followed by Canadian C-Spine Rule (56-71%, n = 7 studies) and lowest for the Ottawa Knee Rules which ranged from 18 to 58% (n = 4). CONCLUSION Our results suggest that awareness of the five imaging decision rules is low. Changing clinicians' attitudes and knowledge towards these decision rules and addressing barriers to their implementation could increase use.
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Affiliation(s)
- Priti Kharel
- Sydney Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Sydney, NSW, 2050, Australia.
| | - Joshua R Zadro
- Sydney Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Sydney, NSW, 2050, Australia
| | - Zhang Chen
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Madii A Himbury
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Adrian C Traeger
- Sydney Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Sydney, NSW, 2050, Australia
| | | | - Christopher G Maher
- Sydney Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Level 10 North, King George V Building, Missenden Road, PO Box M179, Sydney, NSW, 2050, Australia
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Zhang J, Yang K, Wang C, Gu W, Li X, Fu S, Song G, Wang J, Wu C, Zhu H, Shi Z. Risk factors for chronic ankle instability after first episode of lateral ankle sprain: A retrospective analysis of 362 cases. JOURNAL OF SPORT AND HEALTH SCIENCE 2023; 12:606-612. [PMID: 36931594 PMCID: PMC10466191 DOI: 10.1016/j.jshs.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/12/2022] [Accepted: 02/18/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Chronic ankle instability (CAI) is a common sequela following an acute lateral ankle sprain (LAS). To treat an acute LAS more effectively and efficiently, it is important to identify patients at substantial risk for developing CAI. This study identifies magnetic resonance imaging (MRI) manifestations for predicting CAI development after a first episode of LAS and explores appropriate clinical indications for ordering MRI scans for these patients. METHODS All patients with a first-episode LAS who received plain radiograph and MRI scanning within the first 2 weeks after LAS from December 1, 2017 to December 1, 2019 were identified. Data were collected using the Cumberland Ankle Instability Tool at final follow-up. Demographic and other related clinical variables, including age, sex, body mass index, and treatment were also recorded. Univariable and multivariable analyses were performed successively to identify risk factors for CAI after first-episode LAS. RESULTS A total 131 out of 362 patients with a mean follow-up of 3.0 ± 0.6 years (mean ± SD; 2.0-4.1 years) developed CAI after first-episode LAS. According to multivariable regression, development of CAI after first-episode LAS was associated with 5 prognostic factors: age (odds ratio (OR) = 0.96, 95% confidence interval (95%CI): 0.93-1.00, p = 0.032); body mass index (OR = 1.09, 95%CI: 1.02-1.17, p = 0.009); posterior talofibular ligament injury (OR = 2.17, 95%CI: 1.05-4.48, p = 0.035); large bone marrow lesion of the talus (OR = 2.69, 95%CI: 1.30-5.58, p = 0.008), and Grade 2 effusion of the tibiotalar joint (OR = 2.61, 95%CI: 1.39-4.89, p = 0.003). When patients had at least 1 positive clinical finding in the 10-m walk test, anterior drawer test, or inversion tilt test, they had a 90.2% sensitivity and 77.4% specificity in terms of detecting at least 1 prognostic factor by MRI. CONCLUSION MRI scanning is valuable in predicting CAI after first-episode LAS for those patients with at least 1 positive clinical finding in the 10-m walk test, anterior drawer test, and inversion tilt test. Further prospective and large-scale studies are necessary for validation.
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Affiliation(s)
- Jieyuan Zhang
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Kai Yang
- Department of Radiology, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Cheng Wang
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Wenqi Gu
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Xueqian Li
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Shaoling Fu
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Guoxun Song
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Jiazheng Wang
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Chenglin Wu
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Hongyi Zhu
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China; Institute of Clinical Research, National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China.
| | - Zhongmin Shi
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China.
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Akhtar H, Chaudhry SH, Bortolussi-Courval É, Hanula R, Akhtar A, Nauche B, McDonald EG. Diagnostic yield of CT head in delirium and altered mental status-A systematic review and meta-analysis. J Am Geriatr Soc 2023; 71:946-958. [PMID: 36434820 DOI: 10.1111/jgs.18134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND CT head is commonly performed in the setting of delirium and altered mental status (AMS), with variable yield. We aimed to evaluate the yield of CT head in hospitalized patients with delirium and/or AMS across a variety of clinical settings and identify factors associated with abnormal imaging. METHODS We included studies in adult hospitalized patients, admitted to the emergency department (ED) and inpatient medical unit (grouped together) or the intensive care unit (ICU). Patients had a diagnosis of delirium/AMS and underwent a CT head that was classified as abnormal or not. We searched Medline, Embase and other databases (informed by PRISMA guidelines) from inception until November 11, 2021. Studies that were exclusively performed in patients with trauma or a fall were excluded. A meta-analysis of proportions was performed; the pooled proportion of abnormal CTs was estimated using a random effects model. Heterogeneity was determined via the I2 statistic. Factors associated with an abnormal CT head were summarized qualitatively. RESULTS Forty-six studies were included for analysis. The overall yield of CT head in the inpatient/ED was 13% (95% CI: 10.2%-15.9%) and in ICU was 17.4% (95% CI: 10%-26.3%), with considerable heterogeneity (I2 96% and 98% respectively). Heterogeneity was partly explained after accounting for study region, publication year, and representativeness of the target population. Yield of CT head diminished after year 2000 (19.8% vs. 11.1%) and varied widely depending on geographical region (8.4%-25.9%). The presence of focal neurological deficits was a consistent factor that increased yield. CONCLUSION Use of CT head to diagnose the etiology of delirium and AMS varied widely and yield has declined. Guidelines and clinical decision support tools could increase the appropriate use of CT head in the diagnostic etiology of delirium/AMS.
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Affiliation(s)
- Haris Akhtar
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Shazia H Chaudhry
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Émilie Bortolussi-Courval
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Ryan Hanula
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Anas Akhtar
- Department of General Surgery, Letterkenny University Hospital, Letterkenny, Ireland
| | - Bénédicte Nauche
- McGill University Health Centre Medical Libraries, Montreal, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Canada
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[Translated article] Use of Ottawa ankle rules in a referral hospital in Peru. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022. [DOI: 10.1016/j.recot.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Palacios-Flores M, Rodríguez-Cavani J. Uso de las reglas de Ottawa para medio pie y tobillo en un hospital de referencia en Perú. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022. [DOI: 10.1016/j.recot.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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The current clinical practice of general orthopaedic surgeons in the treatment of lateral ankle sprain: a questionnaire survey in Miyazaki, Japan. BMC Musculoskelet Disord 2021; 22:636. [PMID: 34303350 PMCID: PMC8310605 DOI: 10.1186/s12891-021-04527-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 07/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lateral ankle sprain (LAS) is one of the most common musculoskeletal injuries. Numerous studies regarding LAS have been performed. However, there are few studies evaluating the current clinical practice of orthopaedic surgeons regarding LAS. The purpose of this study was to evaluate the current clinical practice of general orthopaedic surgeons in the treatment of LAS. METHODS A questionnaire survey was conducted from September 2020 to December 2020 in Miyazaki, Japan, to evaluate the clinical practice of general orthopaedic surgeons in the treatment of LAS. The survey was composed of 12 questions that were developed with consideration of the recommendations in the current clinical practice guidelines (CPGs) published by the Dutch orthopaedic society. The questions in this study were focused on the diagnosis, conservative treatment, rehabilitation, and the criteria for return to sports (RTS). RESULTS The survey response rate was 82.7% (129/156). Among the respondents, 95.3% did not consider the Ottawa Ankle Rules in the decision to perform plain radiography for patients. Rehabilitation following LAS was performed in 58.9% of patients. Eighty-five (65.9%) of the surgeons used only one factor as the criterion for RTS. The absence of pain was the most frequently used criterion (45.7%). No objective criteria were used for the RTS decision in athletes with LAS. CONCLUSIONS The present study suggested that most general orthopaedic surgeons do not provide the care for patients with LAS recommended by the current CPGs. No objective criteria for the RTS decision are used for athletes with LAS.
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Abstract
ABSTRACT The Ottawa Ankle Rules, finalized in 1995, are a clinical decision directive for the use of radiographs in patients with traumatic ankle and foot injuries. The researchers who developed the rules defined clinically insignificant ankle fractures as distal fibular or malleolar chip fractures of 3 mm or less. They concluded that at least one-third of all ankle and foot radiographs could be eliminated by using their rules, which have since been adopted as the standard of care in EDs. This article explores whether, after more than 20 years in use, the Ottawa Ankle Rules are still valid, and whether they should continue to be used or be replaced by a superior protocol.
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Affiliation(s)
- Lawrence Herman
- Lawrence Herman is president of Palantir Healthcare, LLC, in Boiling Springs, S.C., an adjunct faculty member in the Doctoral of Medical Science program, part of the School of PA Medicine at the University of Lynchburg in Lynchburg, Va., and a speaker for NOVO Nordisk in the area of obesity treatment. The author has disclosed no other potential conflicts of interest, financial or otherwise
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Canton G, Sborgia A, Maritan G, Fattori R, Roman F, Tomic M, Morandi MM, Murena L. Fibula fractures management. World J Orthop 2021; 12:254-269. [PMID: 34055584 PMCID: PMC8152440 DOI: 10.5312/wjo.v12.i5.254] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/01/2021] [Accepted: 04/05/2021] [Indexed: 02/06/2023] Open
Abstract
Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.
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Affiliation(s)
- Gianluca Canton
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Andrea Sborgia
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Guido Maritan
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Roberto Fattori
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Federico Roman
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Marko Tomic
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
| | - Massimo Max Morandi
- Department of Orthopaedic Surgery, Louisiana State University Health Science Center, Shreveport, LA 71103, United States
| | - Luigi Murena
- Department of Medical, Surgical and Life Sciences, Orthopaedics and Traumatology Unit, Trieste University, Trieste 34149, Italy
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Morais B, Branquinho A, Barreira M, Correia J, Machado M, Marques N, Ferrão A, Nóbrega J, Teixeira F, Diogo N. Validation of the Ottawa ankle rules: Strategies for increasing specificity. Injury 2021; 52:1017-1022. [PMID: 33551264 DOI: 10.1016/j.injury.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 12/31/2020] [Accepted: 01/03/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The majority of patients with ankle injuries undergo radiological examinations of the foot, ankle or both. The objective of this study was in the first place to validate the Ottawa Ankle Rules (OARs) for the population of our centre. Secondly, an attempt was made to identify parameters that contribute to improve the specificity of the method, with a view to reduce the need for patients to be exposed to radiation as well as optimizing the expenses of the Emergency Ward (EW). MATERIALS AND METHODS This was a prospective study conducted during a 9-month period. The study population included 148 patients, in 54 (36%) of the patients a fracture was present on the exams performed. Patients were submitted to a sequential protocol in the EW with a form completion, evaluation of OARs, application of the Visual Analog Pain Scale (VAS) and radiographic exams. RESULTS We found a sensitivity of OARs in ankle injuries of 100%, specificity of 26% and in midfoot injuries of 100% and 62% respectively. All patients with fractures had a VAS of 5 or more points in any of the tested sites. With the VAS criterium, we found a significant increase of global specificity (38% vs 15%), as well as when applied only to the ankle (26% to 47%) or to midfoot trauma (62% to 67%). In both, there would have been a 100% reduction of CT scans. Patients with a fracture or with fractures who required surgical treatment had a mean VAS significantly higher than patients with no fracture or fractures submitted to conservative treatment respectively. Although there was a lower percentage of fractures in the group of injuries in Work Accidents (31% vs 37% Sports Activity and 38% Leisure Activity), there was a statistically significant increase in the sum of average VAS in Accidents at Work vs Leisure Activities and vs Sports Activities. CONCLUSION We seek to confirm the usefulness of OARs for our population and we investigated strategies to further reduce the need for unnecessary radiographs. The introduction of parameters for grading pain and adapting to the context of the accident seem promising.
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Affiliation(s)
- Bruno Morais
- Department of Orthopedics Central Lisbon University Center, 8 Beneficiência Street, 1069-166 Lisbon, Portugal.
| | - André Branquinho
- Department of Orthopedics Central Lisbon University Center, 8 Beneficiência Street, 1069-166 Lisbon, Portugal
| | - Mariana Barreira
- Department of Orthopedics Central Lisbon University Center, 8 Beneficiência Street, 1069-166 Lisbon, Portugal
| | - Joana Correia
- Department of Orthopedics Central Lisbon University Center, 8 Beneficiência Street, 1069-166 Lisbon, Portugal
| | - Marino Machado
- Department of Orthopedics Central Lisbon University Center, 8 Beneficiência Street, 1069-166 Lisbon, Portugal
| | - Nuno Marques
- Department of Orthopedics Central Lisbon University Center, 8 Beneficiência Street, 1069-166 Lisbon, Portugal
| | - Ana Ferrão
- Department of Orthopedics Central Lisbon University Center, 8 Beneficiência Street, 1069-166 Lisbon, Portugal
| | - João Nóbrega
- Department of Orthopedics Central Lisbon University Center, 8 Beneficiência Street, 1069-166 Lisbon, Portugal
| | - Frederico Teixeira
- Department of Orthopedics Central Lisbon University Center, 8 Beneficiência Street, 1069-166 Lisbon, Portugal
| | - Nuno Diogo
- Department of Orthopedics Central Lisbon University Center, 8 Beneficiência Street, 1069-166 Lisbon, Portugal
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Evaluation of ankle ligaments with CT: A feasibility study. Eur J Radiol 2020; 134:109446. [PMID: 33310554 DOI: 10.1016/j.ejrad.2020.109446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 10/25/2020] [Accepted: 11/24/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE This study aims to systematically investigate if normal ankle ligaments can be assessed with CT imaging, using MRI as reference standard. METHODS 35 patients (mean age: 47 ± 15 years; female n = 19) with combined CT and MRI exams and without MR-morphologic signs of ankle ligamental injury were retrospectively identified. 3 readers independently evaluated the syndesmotic, the lateral and medial ankle ligaments in terms of visibility on a 4-point Likert scale (0-3 points) in multiplanar MDCT images in standard bone kernel reconstructions. In consensus CT-based ligament density and thickness were measured and the appearance was rated for each ligament. Results were compared and validated with corresponding MRI images. RESULTS Almost all ankle ligaments identified in MRI images could be adequately depicted in standard multiplanar bone kernel CT images with a mean visual score of 2.7/3 (± 0.2). Difficulties in CT morphological delineation of ankle ligaments occurred in cases of filiform TNL and TCL and in cases of concurrent soft tissue edema. Interreader agreement for the CT-assessment of ankle ligaments was excellent, with Fleiss Kappa values >0.8. Mean density of evaluated medial and lateral ankle ligaments was 68 ± 2.9 HU, with substantially inter- and intraindividual variations. Thickness measurements and assessment of appearance of ankle ligaments showed a good concordance between CT and MRI. CONCLUSIONS Assessment of normal ankle ligaments via standard CT in bone kernel reconstructions is feasible, with some restrictions concerning the medial collateral ligaments and in the presence of soft tissue edema.
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Jeantet QWA, Coveney EI, O'Daly BJ. Saving time in the fracture clinic: 2 weeks post-operative plain films following open reduction and internal fixation of distal radius fractures do not affect management. Ir J Med Sci 2020; 190:1041-1044. [PMID: 33140295 DOI: 10.1007/s11845-020-02420-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 10/21/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Distal radius fractures represent up to one in every sixth treated fracture. The majority of these are intra-articular and require operative management. Many recent studies advocate for the use of volar plating fixation. Following fixation, most patients attend the fracture clinic at 2 and 6 weeks post-operatively and may get repeat imaging at both visits, resulting in longer wait times and repeat exposure to radiation. Revision surgery is however rarely performed in the 2- to 6-week period, raising the question of the necessity of plain film at 2 weeks. AIM Improve patient satisfaction in the fracture clinic by reducing wait time in fracture clinic and limiting exposure to radiation. METHOD The number of distal radius open reduction and internal fixation (ORIF) over a 12-month period was retrieved using theatre logbooks. Patient details were used to check whether a plain film radiograph had been performed 2 weeks post-operatively. Subsequently, patients' records were used to determine if revision surgery was performed or planned. RESULTS In total, 123 distal radius ORIF were performed between January 2018 and January 2019. Two-week check radiographs were performed for 82 patients (67%). One patient (0.8%) underwent revision surgery following review of intra-operative imaging. No patients underwent revision ORIF following 2-week plain film. CONCLUSION Repeat imaging at 2 weeks following distal radius ORIF did not change management of distal radius fractures in this study. Therefore, our data suggests 2-week plain films should not routinely be ordered for these patients which will reduce wait time and exposure to radiation.
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Affiliation(s)
- Quentin W A Jeantet
- Department of Trauma & Orthopaedic Surgery, Tallaght University Hospital, Dublin 24, Republic of Ireland.
| | - Eamonn I Coveney
- Department of Trauma & Orthopaedic Surgery, Tallaght University Hospital, Dublin 24, Republic of Ireland
| | - Brendan J O'Daly
- Department of Trauma & Orthopaedic Surgery, Tallaght University Hospital, Dublin 24, Republic of Ireland
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Chan TM, Mercuri M, Turcotte M, Gardiner E, Sherbino J, de Wit K. Making Decisions in the Era of the Clinical Decision Rule: How Emergency Physicians Use Clinical Decision Rules. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1230-1237. [PMID: 31789846 DOI: 10.1097/acm.0000000000003098] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE Physicians are often asked to integrate clinical decision rules (CDRs) with their own cognitive processes to reach a diagnosis. Clinicians, researchers, and educators must understand these cognitive processes to evaluate and improve the diagnostic process. The authors sought to explore emergency physicians' diagnostic processes and to examine how they integrated CDRs into their reasoning using simulated cases (with chest pain or leg pain). METHOD From August 2015 to July 2016, 16 practicing emergency physicians from 3 teaching hospitals associated with McMaster University, Ontario, Canada, were interviewed via a novel "teach aloud" protocol. Six videos of simulated patients with chest pain, breathlessness, or leg discomfort were used as prompts for the physicians to demonstrate their diagnostic thinking. Using a constructivist grounded theory analysis, 3 investigators independently reviewed the interview transcripts, meeting regularly to discuss identified themes and subthemes until sufficiency was reached. RESULTS A model to describe how clinicians integrate their own decision making with CDRs was developed, showing that physicians engage in an iterative diagnostic process that repeatedly refines the differential diagnosis list. The steps in the diagnostic process were: refinement of the differential diagnosis, ordering a hierarchy of risk, the decision to test, choosing the tests, and interpreting test results. Physicians applied CDRs when they had already decided to test. CONCLUSIONS To date, CDRs assume a static, linear model of clinical decision making. Findings demonstrate that participants engaged in iterative and dynamic decision-making processes that changed throughout their patient encounter, contingent on multiple contextual features. Understanding these processes could inform future development of CDRs and educational strategies around these decision aids.
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Affiliation(s)
- Teresa M Chan
- T.M. Chan is associate professor, Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada, assistant dean, Program for Faculty Development, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada, and adjunct scientist, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada
| | - Mathew Mercuri
- M. Mercuri is assistant professor, Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada, and senior research associate, African Centre for Epistemology and Philosophy of Science, Department of Philosophy, University of Johannesburg, Johannesburg, South Africa
| | - Michelle Turcotte
- M. Turcotte is a medical student, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Emily Gardiner
- E. Gardiner is resident physician, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jonathan Sherbino
- J. Sherbino is professor, Division of Emergency Medicine, Department of Medicine, and assistant dean, McMaster Education Research, Innovation and Theory (MERIT), McMaster University, Hamilton, Ontario, Canada
| | - Kerstin de Wit
- K. de Wit is assistant professor, Division of Emergency Medicine, Department of Medicine, and associate professor, Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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CJEM Debate Series: #ChoosingWisely - The Choosing Wisely campaign will not impact physician behaviour and choices. CAN J EMERG MED 2020. [PMID: 29534784 DOI: 10.1017/cem.2017.402] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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Negus OJ, Dunn A, Ridsdill-Smith W. Lower limb acute joint injuries: when to refer for X-ray? Br J Hosp Med (Lond) 2020; 81:1-5. [PMID: 32239993 DOI: 10.12968/hmed.2020.0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article summarises the clinical decision tools available to help decide when acute lower limb joint injuries should be referred for plain film radiography. The Ottawa foot and ankle rules are a tool for deciding whether to refer a patient for X-ray or not. The rules are highly sensitive, gaining National Institute for Health and Care Excellence recommendation in the UK, although they have limited benefit in some patient groups, such as those with peripheral neuropathy. The Ottawa knee rules are highly sensitive but less specific than the Pittsburgh decision rules. Although the Pittsburgh rules are more specific, they have been less extensively investigated and, unlike the Ottawa rules, are not National Institute for Health and Care Excellence recommended. A major barrier to use of these rules in clinical practice is the concern of litigation, although National Institute for Health and Care Excellence recommendation should reassure clinicians and thus reduce the amount of unnecessary radiation exposure.
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Affiliation(s)
- Oliver J Negus
- Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Andrew Dunn
- Department of Trauma and Orthopaedics, West Suffolk Hospital, Bury St Edmunds, UK
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Quan AML, Stiell I, Perry JJ, Paradis M, Brown E, Gignac J, Wilson L, Wilson K. Mobile Clinical Decision Tools Among Emergency Department Clinicians: Web-Based Survey and Analytic Data for Evaluation of The Ottawa Rules App. JMIR Mhealth Uhealth 2020; 8:e15503. [PMID: 32012095 PMCID: PMC7016628 DOI: 10.2196/15503] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The Canadian CT Head Rule (CCHR), the Canadian Transient Ischemic Attack (TIA) Score, and the Subarachnoid Hemorrhage (SAH) Rule have all previously demonstrated the potential to significantly standardize care and improve the management of patients in emergency departments (EDs). On the basis of user feedback, we believe that the addition of these rules to the Ottawa Rules App has the potential to increase the app's usability and user acceptability. OBJECTIVE This study aimed to evaluate the perceived usefulness, acceptability, and uptake of the enhanced Ottawa Rules App (which now includes CCHR, TIA, and SAH Rules) among ED clinicians (medical students, residents, nurses, and physicians). METHODS The enhanced Ottawa Rules App was publicly released for free on iOS and Android operating systems in November 2018. This study was conducted across 2 tertiary EDs in Ottawa, Canada. Posters, direct enrollment, snowball sampling, and emails were used for study recruitment. A 24-question Web-based survey was administered to participants via email, and this was used to determine user acceptability of the app and Technology Readiness Index (TRI) scores. In-app user analytics were collected to track user behavior, such as the number of app sessions, length of app sessions, frequency of rule use, and the date app was first opened. RESULTS A total of 77 ED clinicians completed the study, including 34 nurses, 12 residents, 14 physicians, and 17 medical students completing ED rotations. The median TRI score for this group was 3.38, indicating a higher than average propensity to embrace and adopt new technologies to accomplish goals in their work or daily lives. The majority of respondents agreed or strongly agreed that the app helped participants accurately carry out the clinical rules (56/77, 73%) and that they would recommend this app to their colleagues (64/77, 83%). Feedback from study participants suggested further expansion of the app-more clinical decision rules (CDRs) and different versions of the app tailored to the clinician role. Analysis and comparison of Google Analytics data and in-app data revealed similar usage behavior among study-enrolled users and all app users globally. CONCLUSIONS This study provides evidence that using the Ottawa Rules App (version 3.0.2) to improve and guide patient care would be feasible and widely accepted. The ability to verify self-reported user data (via a Web-based survey) against server analytics data is a notable strength of this study. Participants' continued app use and request for the addition of more CDRs warrant the further development of this app and call for additional studies to evaluate its feasibility and usability in different settings as well as assessment of clinical impact.
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Affiliation(s)
- Amanda My Linh Quan
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
| | - Ian Stiell
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
- University of Ottawa, Department of Emergency Medicine, Ottawa, ON, Canada
| | - Jeffrey J Perry
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
- University of Ottawa, Department of Emergency Medicine, Ottawa, ON, Canada
| | - Michelle Paradis
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
| | - Erica Brown
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
| | - Jordan Gignac
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
| | - Lindsay Wilson
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
| | - Kumanan Wilson
- The Ottawa Hospital Research Institute, Clinical Epidemiology, Ottawa, ON, Canada
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Ma Q, Jiao Q, Wang S, Dong L, Wang Y, Chen M, Wang S, Ying H, Zhao L. Prevalence and Clinical Significance of Occult Fractures in the Extremities in Children. Front Pediatr 2020; 8:393. [PMID: 32903571 PMCID: PMC7438767 DOI: 10.3389/fped.2020.00393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 06/09/2020] [Indexed: 11/24/2022] Open
Abstract
Objective: Diagnosis of occult fractures by initial plain radiographs remains challenging in children in the emergency room. This study was to assess the prevalence and distribution of occult fracture in children with acute extremities injuries (AEI) and clinical suspicion of fracture. Methods: We conducted a retrospective study to review the medical records of all pediatric patients with AEI in the orthopedic emergency room from January 1, 2017, to December 31, 2019. For patients with concerning history and physical examination but negative initial radiographs, we conducted the following three diagnostic strategies according to the choic of children's parents: immediate MRI scanning, [2] immediate CT scanning, or [3] empiric cast immobilization with orthopedic follow-up radiographs at 2 weeks post-injury (late radiographs). Prevalence and distribution of occult fracture were recorded. Results: A total of 43,560 pediatric patients meet the inclusion criteria. A total of 4,916 fractures of the extremities were confirmed by initial plain radiographs, and 550 occult fractures were confirmed by immediate MRI, immediate CT, or late radiographs. The prevalence of occult fracture in the extremities was 10.1% (550/5,466). Supracondylar fractures were the most prevalent (2,325/5,466, 42.5%) but had the lowest rate of occult fractures (117/2,325, 5.0%). The highest rate of occult fracture was distal epiphyseal fracture of the tibia and fibula (49/145, 33.8%), but these had a relatively lower prevalence of fractures (145/5,466, 2.65%). Conclusions: We should be aware of the relative high prevalence of occult fractures in the extremities in children, especially when the injured site is in the high incidence area of occult fracture such as ankle.
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Affiliation(s)
- Qichao Ma
- Department of Orthopedics, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qin Jiao
- Department of Orthopedics, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Shiqi Wang
- Department of Orthopedics, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Liangchao Dong
- Department of Orthopedics, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yicheng Wang
- Department of Orthopedics, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Mengjie Chen
- Department of Orthopedics, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Sun Wang
- Department of Orthopedics, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hao Ying
- Department of Orthopedics, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lihua Zhao
- Department of Orthopedics, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
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18
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An Intervention to Increase Knowledge and Utilization of the Low Risk Ankle Rule Among Pediatric Emergency Department Providers. Pediatr Emerg Care 2019; 35:831-836. [PMID: 31738299 DOI: 10.1097/pec.0000000000001987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The Low Risk Ankle Rule (LRAR) can assist pediatric emergency department providers in reducing radiographs without missing significant fractures. Most providers are unaware of this tool. This study sought to educate providers about the LRAR then determine their self-reported use immediately and 2 months after education. METHODS A web-based survey was e-mailed to providers at one large pediatric emergency department. The survey assessed knowledge and use of the rule. Clinical scenarios, in which radiographs were not indicated, helped determine radiograph ordering practices. After a brief LRAR tutorial, respondents were requeried about radiograph ordering practices along with likelihood of future LRAR use. At 2 months, radiograph ordering was again assessed using the same scenarios; interim LRAR use was also determined. RESULTS Response rates on the initial and follow-up surveys were 61.4% and 96.2%, respectively. A minority (20%) had heard of the LRAR. Providers initially reported ordering radiographs on 84% of ankle injuries and 82.5% ordered radiographs in the scenario. Immediately after education, only 32% ordered a radiograph in the scenario; 85% reported that they would use the tool consistently. At 2 months, there was no significant change in radiograph ordering practices (79.5% vs 84%). In the interim, 30% reported using the rule at least once. CONCLUSIONS Most pediatric emergency department providers were unfamiliar with the LRAR. After a brief tutorial, most providers reported that planning to use the tool and self-reported radiograph ordering was significantly reduced; however, at 2 months, clinical practice was unaffected. Further work to implement the tool into practice is necessary.
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Varada S, Lacson R, Raja AS, Ip IK, Schneider L, Osterbur D, Bain P, Vetrano N, Cellini J, Mita C, Coletti M, Whelan J, Khorasani R. Characteristics of knowledge content in a curated online evidence library. J Am Med Inform Assoc 2019; 25:507-514. [PMID: 29092054 DOI: 10.1093/jamia/ocx092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/09/2017] [Indexed: 11/12/2022] Open
Abstract
Objective To describe types of recommendations represented in a curated online evidence library, report on the quality of evidence-based recommendations pertaining to diagnostic imaging exams, and assess underlying knowledge representation. Materials and Methods The evidence library is populated with clinical decision rules, professional society guidelines, and locally developed best practice guidelines. Individual recommendations were graded based on a standard methodology and compared using chi-square test. Strength of evidence ranged from grade 1 (systematic review) through grade 5 (recommendations based on expert opinion). Finally, variations in the underlying representation of these recommendations were identified. Results The library contains 546 individual imaging-related recommendations. Only 15% (16/106) of recommendations from clinical decision rules were grade 5 vs 83% (526/636) from professional society practice guidelines and local best practice guidelines that cited grade 5 studies (P < .0001). Minor head trauma, pulmonary embolism, and appendicitis were topic areas supported by the highest quality of evidence. Three main variations in underlying representations of recommendations were "single-decision," "branching," and "score-based." Discussion Most recommendations were grade 5, largely because studies to test and validate many recommendations were absent. Recommendation types vary in amount and complexity and, accordingly, the structure and syntax of statements they generate. However, they can be represented in single-decision, branching, and score-based representations. Conclusion In a curated evidence library with graded imaging-based recommendations, evidence quality varied widely, with decision rules providing the highest-quality recommendations. The library may be helpful in highlighting evidence gaps, comparing recommendations from varied sources on similar clinical topics, and prioritizing imaging recommendations to inform clinical decision support implementation.
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Affiliation(s)
- Sowmya Varada
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ronilda Lacson
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ali S Raja
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ivan K Ip
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Louise Schneider
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - David Osterbur
- Harvard Medical School, Boston, MA, USA.,Countway Library of Medicine, Boston, MA, USA
| | - Paul Bain
- Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nicole Vetrano
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jacqueline Cellini
- Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Carol Mita
- Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Margaret Coletti
- Agoos Medical Library/Knowledge Services, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Julia Whelan
- Agoos Medical Library/Knowledge Services, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ramin Khorasani
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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20
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Liu Y, Chen PHC, Krause J, Peng L. How to Read Articles That Use Machine Learning: Users' Guides to the Medical Literature. JAMA 2019; 322:1806-1816. [PMID: 31714992 DOI: 10.1001/jama.2019.16489] [Citation(s) in RCA: 278] [Impact Index Per Article: 55.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In recent years, many new clinical diagnostic tools have been developed using complicated machine learning methods. Irrespective of how a diagnostic tool is derived, it must be evaluated using a 3-step process of deriving, validating, and establishing the clinical effectiveness of the tool. Machine learning-based tools should also be assessed for the type of machine learning model used and its appropriateness for the input data type and data set size. Machine learning models also generally have additional prespecified settings called hyperparameters, which must be tuned on a data set independent of the validation set. On the validation set, the outcome against which the model is evaluated is termed the reference standard. The rigor of the reference standard must be assessed, such as against a universally accepted gold standard or expert grading.
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Affiliation(s)
- Yun Liu
- Google Health, Palo Alto, California
| | | | | | - Lily Peng
- Google Health, Palo Alto, California
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21
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Mulders MAM, Walenkamp MMJ, Sosef NL, Ouwehand F, van Velde R, Goslings CJ, Schep NWL. The Amsterdam Wrist Rules to reduce the need for radiography after a suspected distal radius fracture: an implementation study. Eur J Trauma Emerg Surg 2019; 46:573-582. [PMID: 31541258 PMCID: PMC7280343 DOI: 10.1007/s00068-019-01194-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/22/2019] [Indexed: 11/07/2022]
Abstract
Purpose While most patients with wrist trauma are routinely referred for radiography, around 50% of these radiographs show no fracture. To avoid unnecessary radiographs, the Amsterdam Wrist Rules (AWR) have previously been developed and validated. The aim of the current study was to evaluate the effect of the implementation of the AWR at the Emergency Department (ED). Methods In a before-and-after comparative prospective cohort study, all consecutive adult patients with acute wrist trauma presenting at the ED of four hospitals were included. Primary outcome was the number of wrist radiographs before and after implementation of the AWR. Secondary outcomes were the number of clinically relevant missed fractures, the overall length of stay in the ED, physician compliance regarding the AWR, and patient satisfaction and experience with the care received at the ED. Results A total of 402 patients were included. The absolute reduction in wrist radiographs after implementation was 15% (p < 0.001). One clinically irrelevant fracture was missed. Non-fracture patients without wrist radiography due to the AWR spent 34 min less time in the ED compared with non-fracture patients who had a wrist radiograph (p = 0.015). The physicians adhered to the AWR in 36% of patients. Of all patients who did not receive a radiographic examination of the wrist, 87% were satisfied. Conclusion Implementation of the AWR safely reduces the amount of wrist radiographs in selected patients and consequently reducing the length of stay in the ED. Electronic supplementary material The online version of this article (10.1007/s00068-019-01194-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marjolein A M Mulders
- Trauma Unit, Department of Surgery, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Monique M J Walenkamp
- Trauma Unit, Department of Surgery, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Nico L Sosef
- Department of Surgery, Spaarne Gasthuis, P.O. Box 770, 2130 AT, Hoofddorp, The Netherlands
| | - Frank Ouwehand
- Emergency Department, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Romuald van Velde
- Department of Surgery, Tergooi Hospitals, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands
| | - Carel J Goslings
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - Niels W L Schep
- Department of Trauma and Hand Surgery, Maasstad Hospital, P.O. Box 9100, 3007 AC, Rotterdam, The Netherlands
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Tomlinson F, Willis TA. What are medical students’ attitudes to clinical risk-scoring tools? An exploratory study. EDUCATION FOR PRIMARY CARE 2019; 30:355-360. [DOI: 10.1080/14739879.2019.1653227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
| | - Thomas A Willis
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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23
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Tay EMY, Preisz P, Day RO. Role and impact of brain computed tomography in the management of drug overdoses and guideline recommendations. Emerg Med Australas 2019; 31:1053-1058. [DOI: 10.1111/1742-6723.13316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Emma MY Tay
- Department of Clinical Pharmacology and ToxicologySt Vincent's Hospital Sydney New South Wales Australia
- Drug Health ServiceWestern Sydney Local Health District Sydney New South Wales Australia
| | - Paul Preisz
- Department of Emergency MedicineSt Vincent's Hospital Sydney New South Wales Australia
- St Vincent's Clinical School, UNSW MedicineThe University of New South Wales Sydney New South Wales Australia
| | - Richard O Day
- Department of Clinical Pharmacology and ToxicologySt Vincent's Hospital Sydney New South Wales Australia
- St Vincent's Clinical School, UNSW MedicineThe University of New South Wales Sydney New South Wales Australia
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Khalifa M, Gallego B. Grading and assessment of clinical predictive tools for paediatric head injury: a new evidence-based approach. BMC Emerg Med 2019; 19:35. [PMID: 31200643 PMCID: PMC6570950 DOI: 10.1186/s12873-019-0249-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/03/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Many clinical predictive tools have been developed to diagnose traumatic brain injury among children and guide the use of computed tomography in the emergency department. It is not always feasible to compare tools due to the diversity of their development methodologies, clinical variables, target populations, and predictive performances. The objectives of this study are to grade and assess paediatric head injury predictive tools, using a new evidence-based approach, and to provide emergency clinicians with standardised objective information on predictive tools to support their search for and selection of effective tools. METHODS Paediatric head injury predictive tools were identified through a focused review of literature. Based on the critical appraisal of published evidence about predictive performance, usability, potential effect, and post-implementation impact, tools were evaluated using a new framework for grading and assessment of predictive tools (GRASP). A comprehensive analysis was conducted to explain why certain tools were more successful. RESULTS Fourteen tools were identified and evaluated. The highest-grade tool is PECARN; the only tool evaluated in post-implementation impact studies. PECARN and CHALICE were evaluated for their potential effect on healthcare, while the remaining 12 tools were only evaluated for predictive performance. Three tools; CATCH, NEXUS II, and Palchak, were externally validated. Three tools; Haydel, Atabaki, and Buchanich, were only internally validated. The remaining six tools; Da Dalt, Greenes, Klemetti, Quayle, Dietrich, and Güzel did not show sufficient internal validity for use in clinical practice. CONCLUSIONS The GRASP framework provides clinicians with a high-level, evidence-based, comprehensive, yet simple and feasible approach to grade, compare, and select effective predictive tools. Comparing the three main tools which were assigned the highest grades; PECARN, CHALICE and CATCH, to the remaining 11, we find that the quality of tools' development studies, the experience and credibility of their authors, and the support by well-funded research programs were correlated with the tools' evidence-based assigned grades, and were more influential, than the sole high predictive performance, on the wide acceptance and successful implementation of the tools. Tools' simplicity and feasibility, in terms of resources needed, technical requirements, and training, are also crucial factors for their success.
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Affiliation(s)
- Mohamed Khalifa
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, 75 Talavera Road, North Ryde, Sydney, NSW, 2113, Australia.
| | - Blanca Gallego
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Lowy Cancer Research Centre, Level 4, Cnr High &, Botany St, Kensington, Sydney, NSW, 2052, Australia
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Keene DJ, Schlüssel MM, Thompson J, Hagan DA, Williams MA, Byrne C, Goodacre S, Cooke M, Gwilym S, Hormbrey P, Bostock J, Haywood K, Wilson D, Collins GS, Lamb SE. Prognostic models for identifying risk of poor outcome in people with acute ankle sprains: the SPRAINED development and external validation study. Health Technol Assess 2019; 22:1-112. [PMID: 30474592 DOI: 10.3310/hta22640] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Ankle sprains are very common injuries. Although recovery can occur within weeks, around one-third of patients have longer-term problems. OBJECTIVES To develop and externally validate a prognostic model for identifying people at increased risk of poor outcome after an acute ankle sprain. DESIGN Development of a prognostic model in a clinical trial cohort data set and external validation in a prospective cohort study. SETTING Emergency departments (EDs) in the UK. PARTICIPANTS Adults with an acute ankle sprain (within 7 days of injury). SAMPLE SIZE There were 584 clinical trial participants in the development data set and 682 recruited for the external validation study. PREDICTORS Candidate predictor variables were chosen based on availability in the clinical data set, clinical consensus, face validity, a systematic review of the literature, data quality and plausibility of predictiveness of the outcomes. MAIN OUTCOME MEASURES Models were developed to predict two composite outcomes representing poor outcome. Outcome 1 was the presence of at least one of the following symptoms at 9 months after injury: persistent pain, functional difficulty or lack of confidence. Outcome 2 included the same symptoms as outcome 1, with the addition of recurrence of injury. Rates of poor outcome in the external data set were lower than in the development data set, 7% versus 20% for outcome 1 and 16% versus 24% for outcome 2. ANALYSIS Multiple imputation was used to handle missing data. Logistic regression models, together with multivariable fractional polynomials, were used to select variables and identify transformations of continuous predictors that best predicted the outcome based on a nominal alpha of 0.157, chosen to minimise overfitting. Predictive accuracy was evaluated by assessing model discrimination (c-statistic) and calibration (flexible calibration plot). RESULTS (1) Performance of the prognostic models in development data set - the combined c-statistic for the outcome 1 model across the 50 imputed data sets was 0.74 [95% confidence interval (CI) 0.70 to 0.79], with good model calibration across the imputed data sets. The combined c-statistic for the outcome 2 model across the 50 imputed data sets was 0.70 (95% CI 0.65 to 0.74), with good model calibration across the imputed data sets. Updating these models, which used baseline data collected at the ED, with an additional variable at 4 weeks post injury (pain when bearing weight on the ankle) improved the discriminatory ability (c-statistic 0.77, 95% CI 0.73 to 0.82, for outcome 1 and 0.75, 95% CI 0.71 to 0.80, for outcome 2) and calibration of both models. (2) Performance of the models in the external data set - the combined c-statistic for the outcome 1 model across the 50 imputed data sets was 0.73 (95% CI 0.66 to 0.79), with a calibration plot intercept of -0.91 (95% CI -0.98 to 0.44) and slope of 1.13 (95% CI 0.76 to 1.50). The combined c-statistic for the outcome 2 model across the 50 imputed data sets was 0.63 (95% CI 0.58 to 0.69), with a calibration plot intercept of -0.25 (95% CI -0.27 to 0.11) and slope of 1.03 (95% CI 0.65 to 1.42). The updated models with the additional pain variable at 4 weeks had improved discriminatory ability over the baseline models but not better calibration. CONCLUSIONS The SPRAINED (Synthesising a clinical Prognostic Rule for Ankle Injuries in the Emergency Department) prognostic models performed reasonably well, and showed benefit compared with not using any model; therefore, the models may assist clinical decision-making when managing and advising ankle sprain patients in the ED setting. The models use predictors that are simple to obtain. LIMITATIONS The data used were from a randomised controlled trial and so were not originally intended to fulfil the aim of developing prognostic models. However, the data set was the best available, including data on the symptoms and clinical events of interest. FUTURE WORK Further model refinement, including recalibration or identifying additional predictors, may be required. The effect of implementing and using either model in clinical practice, in terms of acceptability and uptake by clinicians and on patient outcomes, should be investigated. TRIAL REGISTRATION Current Controlled Trials ISRCTN12726986. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 64. See the NIHR Journals Library website for further project information. Funding was also recieved from the NIHR Collaboration for Leadership in Applied Health Research, Care Oxford at Oxford Health NHS Foundation Trust, NIHR Biomedical Research Centre, Oxford, and the NIHR Fellowship programme.
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Affiliation(s)
- David J Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Michael M Schlüssel
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jacqueline Thompson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Daryl A Hagan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mark A Williams
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK
| | - Christopher Byrne
- Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew Cooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Stephen Gwilym
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Philip Hormbrey
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - David Wilson
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gary S Collins
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Warwick Medical School, University of Warwick, Coventry, UK
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Hayden JA, Ogilvie R, Stewart SA, French S, Campbell S, Magee K, Slipp P, Wells G, Stiell I. Development of a clinical decision support tool for diagnostic imaging use in patients with low back pain: a study protocol. Diagn Progn Res 2019; 3:1. [PMID: 31093571 PMCID: PMC6460553 DOI: 10.1186/s41512-019-0047-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 01/04/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Low back pain is one of the most common and disabling health problems in Canada and internationally. In most cases, low back pain is a benign, self-limiting condition that can be managed with little diagnostic investigation or treatment. Yet contrary to clinical practice guideline recommendations, diagnostic imaging (here meaning X-ray, MRI, CT) is commonly used in the assessment of low back pain. Diagnostic imaging is of limited value in most cases, exposing patients to unnecessary radiation and leading to increased health services use and worse patient health outcomes. The Choosing Wisely campaign has highlighted the need to reduce diagnostic imaging for low back pain; however, no clinical decision rules are available. METHODS This project will develop a clinical decision support tool for appropriate use of diagnostic imaging for patients with low back pain in the emergency department. We will conduct a prospective cohort study at five Canadian emergency departments. The study will follow recommendations for prediction model development and testing. The study population will be 4000 patients presenting to the emergency department with low back pain. We will assess potential clinical indications of emergent-cause (i.e., "red flag" items), including clinical characteristics and past history. Our outcome, emergent-cause for low back pain such as fracture, cancer, infection, or cauda equina syndrome, will be assessed at discharge and at 1-, 3-, and 12-month follow-up periods using information from self-report and health administrative data. We will construct and assess the performance of a multivariable prediction model that has strong measurement properties, presented as a clinical decision support tool acceptable to knowledge users. DISCUSSION Practice guidelines describe "red flags" for which diagnostic imaging is likely appropriate. However, recommendations across guidelines are discordant, and few studies have evaluated these criteria to determine which characteristics best predict emergent etiology that warrant diagnostic imaging. A clinical decision support tool, that recommends diagnostic imaging where appropriate, has the potential to improve clinical care and patient outcomes and reduce costs associated with managing low back pain patients.
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Affiliation(s)
- Jill A. Hayden
- 0000 0004 1936 8200grid.55602.34Department Community Health and Epidemiology, Dalhousie University, 5790 University Avenue, Halifax, NS B3H 1V7 Canada
| | - Rachel Ogilvie
- 0000 0004 1936 8200grid.55602.34Department Community Health and Epidemiology, Dalhousie University, 5790 University Avenue, Halifax, NS B3H 1V7 Canada
| | - Samuel Alan Stewart
- 0000 0004 1936 8200grid.55602.34Department Community Health and Epidemiology, Dalhousie University, 5790 University Avenue, Halifax, NS B3H 1V7 Canada
| | - Simon French
- 0000 0004 1936 8331grid.410356.5School of Rehabilitation Therapy, Queen’s University, Louise D. Acton Building, 31 George St, Kingston, ON K7L 3N6 Canada
- 0000 0001 2158 5405grid.1004.5Department of Chiropractic, Macquarie University, Sydney, NSW 2109 Australia
| | - Samuel Campbell
- 0000 0004 1936 8200grid.55602.34Department of Emergency Medicine, Dalhousie University, Emergency Medicine, Nova Scotia Health Authority, QEII Health Sciences Centre, Suite 355, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Kirk Magee
- 0000 0004 1936 8200grid.55602.34Department of Emergency Medicine, Dalhousie University, Emergency Medicine, Nova Scotia Health Authority, QEII Health Sciences Centre, Suite 355, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Patrick Slipp
- 0000 0004 0407 789Xgrid.413292.fDepartment of Radiology, Nova Scotia Health Authority, QEII Health Sciences Centre, Suite 355, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - George Wells
- 0000 0001 2182 2255grid.28046.38Epidemiology and Community Medicine, University of Ottawa, Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON K1Y 4W7 Canada
| | - Ian Stiell
- 0000 0001 2182 2255grid.28046.38Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada
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Kaniewska M, Steinbach LS, Neurauter U, Anderson SE. Lipidus migrans-a radiology imaging feature after ankle injury. Skeletal Radiol 2018; 47:1709-1715. [PMID: 29785451 DOI: 10.1007/s00256-018-2973-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/01/2018] [Accepted: 05/02/2018] [Indexed: 02/02/2023]
Abstract
We present an uncommon imaging feature with fluid fat tracking within the tendon sheath of the flexor hallucis longus (FHL) after traumatic injury to the ankle joint. We propose a coined medical term "lipidus migrans" to define the presence of floating fat in a tendon sheath. This is due to lipohemarthrosis from intra-articular fracture of the ankle with leakage of fluid fat into the tendon sheath. Communication between the FHL tendon sheath and ankle joint can occur in up to 25% of patients. Radiologists should be aware of the presence of lipidus migrans as a potential posttraumatic complication after intra-articular ankle fracture and that fat in the tendon sheath may mimic fracture fragments or even a tendon sheath tumor.
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Affiliation(s)
| | - Lynne S Steinbach
- Department of Radiology, University of California, San Francisco Medical Center, San Francisco, CA, USA
| | - Urs Neurauter
- Centre for Orthopaedic Surgery, Kantonsspital Aarau und Baden, Baden, Switzerland
| | - Suzanne E Anderson
- Institute of Radiology, Kantonsspital Baden, Baden, Switzerland.,Sydney School of Medicine, The University of Notre Dame Australia, Sydney, Australia
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Shepherd M, Louw A, Podolak J. The clinical application of pain neuroscience, graded motor imagery, and graded activity with complex regional pain syndrome-A case report. Physiother Theory Pract 2018; 36:1043-1055. [PMID: 30499359 DOI: 10.1080/09593985.2018.1548047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic Regional Pain Syndrome (CRPS) is a condition that physical therapists may encounter in an outpatient orthopedic setting. In physical therapy (PT) treatment of CRPS addresses pain and the changes observed in the brain through the use of graded motor imagery (GMI). CASE DESCRIPTION A 57-year-old female presented to an outpatient PT clinic with CRPS type 1. Complicating psychosocial factors such as kinesiophobia and catastrophization were present. The patient engaged in a treatment plan including GMI: pain neuroscience education (PNE), laterality training, motor imagery, and mirror training. As symptoms improved, graded functional exposure and functional restoration occurred. OUTCOMES The patient was seen for a total of 26 visits over a 9-month period. FAAM measures exceeded reported clinically important change that was sustained at two-year follow-up. Long term outcomes showed no functional deficits related to her foot or ankle and minimal to no catastrophizing and fear avoidance behaviors. DISCUSSION This case report showcases the use of GMI with a patient with CRPS type 1 in an outpatient orthopedic clinic. Clinicians may consider the use of GMI to progress a patient toward maximal functional gains.
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Affiliation(s)
- Mark Shepherd
- Department of Physical Therapy, South College , Knoxville, TN, USA.,Evidence in Motion Institute of Health Professions , Louisville, KY, USA
| | - Adriaan Louw
- International Spine and Pain Institute , Louisville, KY, USA
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Schlussel MM, Keene DJ, Collins GS, Bostock J, Byrne C, Goodacre S, Gwilym S, Hagan DA, Haywood K, Thompson J, Williams MA, Lamb SE. Development and prospective external validation of a tool to predict poor recovery at 9 months after acute ankle sprain in UK emergency departments: the SPRAINED prognostic model. BMJ Open 2018; 8:e022802. [PMID: 30397008 PMCID: PMC6231561 DOI: 10.1136/bmjopen-2018-022802] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To develop and externally validate a prognostic model for poor recovery after ankle sprain. SETTING AND PARTICIPANTS Model development used secondary data analysis of 584 participants from a UK multicentre randomised clinical trial. External validation used data from 682 participants recruited in 10 UK emergency departments for a prospective observational cohort. OUTCOME AND ANALYSIS Poor recovery was defined as presence of pain, functional difficulty or lack of confidence in the ankle at 9 months after injury. Twenty-three baseline candidate predictors were included together in a multivariable logistic regression model to identify the best predictors of poor recovery. Relationships between continuous variables and the outcome were modelled using fractional polynomials. Regression parameters were combined over 50 imputed data sets using Rubin's rule. To minimise overfitting, regression coefficients were multiplied by a heuristic shrinkage factor and the intercept re-estimated. Incremental value of candidate predictors assessed at 4 weeks after injury was explored using decision curve analysis and the baseline model updated. The final models included predictors selected based on the Akaike information criterion (p<0.157). Model performance was assessed by calibration and discrimination. RESULTS Outcome rate was lower in the development (6.7%) than in the external validation data set (19.9%). Mean age (29.9 and 33.6 years), body mass index (BMI; 26.3 and 27.1 kg/m2), pain when resting (37.8 and 38.5 points) or bearing weight on the ankle (75.4 and 71.3 points) were similar in both data sets. Age, BMI, pain when resting, pain bearing weight, ability to bear weight, days from injury until assessment and injury recurrence were the selected predictors. The baseline model had fair discriminatory ability (C-statistic 0.72; 95% CI 0.66 to 0.79) but poor calibration. The updated model presented better discrimination (C-statistic 0.78; 95% CI 0.72 to 0.84), but equivalent calibration. CONCLUSIONS The models include predictors easy to assess clinically and show benefit when compared with not using any model. TRIAL REGISTRATION NUMBER ISRCTN12726986; Results.
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Affiliation(s)
- Michael M Schlussel
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David J Keene
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jennifer Bostock
- Patient and Public Involvement, Quality and Outcomes of Person-Centred Care Policy Research Unit, Canterbury, UK
| | - Christopher Byrne
- Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Stephen Gwilym
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Daryl A Hagan
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jacqueline Thompson
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mark A Williams
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK
| | - Sarah E Lamb
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Al Bimani SA, Gates LS, Warner M, Ewings S, Crouch R, Bowen C. Characteristics of patients with ankle sprain presenting to an emergency department in the south of England (UK): A seven-month review. Int Emerg Nurs 2018; 41:38-44. [PMID: 29885906 DOI: 10.1016/j.ienj.2018.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 04/30/2018] [Accepted: 05/31/2018] [Indexed: 12/26/2022]
Abstract
INTRODUCTION There is lack of evidence about ankle sprain patients presenting to emergency department (ED) in the UK. The study aim was to determine prevalence, demographic and clinical characteristics of patients attending to one ED. Knowing those characteristics may help setting prevention strategies and inform effective clinical practice. METHODS A retrospective review of records from patients' database system was conducted between May and November 2015 (inclusive). RESULTS 909 new patients with ankle sprain were recorded during the study period. Patients had a median age of 27 years (IQR 20). Men aged between 14 and 37 years had higher percentage of injuries compared to women of a similar age. Overall prevalence of injury was equally distributed between men and women. Most patients were sent to radiography department for ankle/foot X-ray (89%). Over half of patients (58%) were sent home with no follow-up treatment. A subsample (n = 106) from the original sample (n = 909) showed a variety of causes of injury such as tripping (29%), non-specific injury (26.4%), sports (26%), walking (12.2%) and other accidental causes (6%). Football was the most prevalent sport (13%). CONCLUSIONS Prevention strategies, appropriate assessment tools and tailored rehabilitation programs are warranted to reduce number of patients and potential chronic symptoms.
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Affiliation(s)
- Saed A Al Bimani
- Faculty of Health Sciences, University of Southampton, Southampton, UK.
| | - Lucy S Gates
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Martin Warner
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Sean Ewings
- Statistical Sciences Research Institute, University of Southampton, Southampton, UK
| | - Robert Crouch
- Emergency Department, Southampton General Hospital, Southampton, UK
| | - Catherine Bowen
- Faculty of Health Sciences, University of Southampton, Southampton, UK
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Marincowitz C, Lecky FE, Townend W, Borakati A, Fabbri A, Sheldon TA. The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis. J Neurotrauma 2018; 35:703-718. [PMID: 29324173 PMCID: PMC5831640 DOI: 10.1089/neu.2017.5259] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.
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Affiliation(s)
- Carl Marincowitz
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Fiona E. Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - William Townend
- Emergency Department, Hull and East Yorkshire NHS Trust, Hull, United Kingdom
| | - Aditya Borakati
- Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Andrea Fabbri
- Emergency Unit, Presidio Ospedaliero Morgagni-Pierantoni, AUSL della Romagna, Forlì, Italy
| | - Trevor A. Sheldon
- Department of Health Sciences, University of York, Alcuin Research Resource Center, Heslington, York, United Kingdom
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Heyworth J, Mason SM. Emergency Medicine: great papers from the Summer of Love to 2017. Emerg Med J 2018; 35:152-155. [PMID: 29463634 DOI: 10.1136/emermed-2017-207285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 11/04/2022]
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Abstract
CONTEXT Quality improvement (QI) is a health care concept that ensures patients receive high-quality (safe, timely, effective, efficient, equitable, patient-centered) and affordable care. Despite its importance, the application of QI in athletic health care has been limited. OBJECTIVES To describe the need for and define QI in health care, to describe how to measure quality in health care, and to present a QI case in athletic training. DESCRIPTION As the athletic training profession continues to grow, a widespread engagement in QI efforts is necessary to establish the value of athletic training services for the patients that we serve. A review of the importance of QI in health care, historical perspectives of QI, tools to drive QI efforts, and examples of common QI initiatives is presented to assist clinicians in better understanding the value of QI for advancing athletic health care and the profession. Clinical and Research Advantages: By engaging clinicians in strategies to measure outcomes and improve their patient care services, QI practice can help athletic trainers provide high-quality and affordable care to patients.
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Affiliation(s)
- Andrea D Lopes Sauers
- Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa
| | - Eric L Sauers
- Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa
| | - Alison R Snyder Valier
- Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa
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Eyler Y, Sever M, Turgut A, Yalcin N, Zafer N, Suner A, Aksay E, Yesilaras M. The evaluation of the sensitivity and specificity of wrist examination findings for predicting fractures. Am J Emerg Med 2017; 36:425-429. [PMID: 28912085 DOI: 10.1016/j.ajem.2017.08.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 08/23/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the sensitivity and specificity of physical examination findings and functional tests in adult acute wrist trauma patients who presented to the emergency department (ED) and to create a reliable and practical clinical decision rule for determining the necessity of radiography in wrist trauma. METHODS This prospective observational study was conducted in a tertiary ED. Each patient was checked for 18 physical examination findings and functional tests. Patients with suspected fracture were enrolled consecutively. Antero-posterior and lateral wrist views were performed for each patient. All radiographical studies were interpreted by an orthopedic surgeon. The prevalence, sensitivity and specificity, negative and positive predictive values of each finding were calculated. A modeling for predicting fractures was created using computer. RESULTS 207 patients were evaluated and 69 patients (33.3%) had fractures. The most common encounterd fracture site was distal radius (29.5%). The most sensitive examination finding was pain in dorsiflexion (95.7%) and the most specific finding was ecchymosis (97.8%). Wrist edema, deformity and pain aggravated by pronation were found to be strong predictors of fracture. The area under the receiver operating characteristic curve at internal validation for a prediction model based on these three predictors was 0.88 (95% CI: 0.83-0,93). The overall sensitivity and specificity of this model were 94% (95% CI: 85-98%) and 51% (95% CI 43-60%) respectively. According to the model created in this study, 34% of acute blunt wrist trauma patients do not require any X-ray imaging. CONCLUSIONS This triple modeling may be used as an effective decision rule for predicting all wrist fractures in the ED and in the disaster setting.
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Affiliation(s)
- Yesim Eyler
- Department of Emergency, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Mustafa Sever
- Department of Emergency, Tepecik Training and Research Hospital, Izmir, Turkey.
| | - Ali Turgut
- Department of Orthopedics and Traumatology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Necmiye Yalcin
- Department of Emergency, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Nur Zafer
- Emergency Department, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Aslı Suner
- Department of Biostatistics and Medical Informatics, EgeUniversity, School of Medicine, Izmir, Turkey
| | - Ersin Aksay
- Department of Emergency, DokuzEylul University, School of Medicine, Izmir, Turkey
| | - Murat Yesilaras
- Department of Emergency, Tepecik Training and Research Hospital, Izmir, Turkey
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Somerville LE, Willits K, Johnson AM, Litchfield R, LeBel ME, Moro J, Bryant D. Diagnostic Validity of Patient-Reported History for Shoulder Pathology. Surg J (N Y) 2017; 3:e79-e87. [PMID: 28825026 PMCID: PMC5553515 DOI: 10.1055/s-0037-1601878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 02/28/2017] [Indexed: 12/26/2022] Open
Abstract
Objective The purpose of this article is to determine whether patient-reported history items are predictive of shoulder pathology and have the potential for use in triaging patients with shoulder pathology to orthopaedic outpatient clinics. Setting It is set at two tertiary orthopaedic clinics. Patients All new patients reporting pain and/or disability of the shoulder joint were prospectively recruited. A total of 193 patients were enrolled, 15 of whom withdrew, leaving 178 patients composing the study sample. Design Patients completed a questionnaire on the history of their pathology, then the surgeon took a thorough history indicating the most likely diagnosis. The clinician then performed appropriate physical examination. Arthroscopy was the reference standard for those undergoing surgery and magnetic resonance imaging (MRI) with arthrogram for all others. We calculated the sensitivity, specificity, and likelihood ratios (LRs) of history items alone and in combination. We used the LRs to generate a clinical decision algorithm. Main Outcome Measures Diagnosis was determined through arthroscopy or MRI arthrogram. Reporting was standardized to ensure review of all structures. Results The physical examination and history agreed in 75% of cases. Of those that did not agree, the physical examination misdirected the diagnosis in 47% of our cases. In particular, history items were strong predictors of anterior and posterior instability and subscapularis tears and were combined in a tool to be utilized for screening patients. Conclusion The patient-reported history items were effective for diagnosing shoulder pathology and should be considered for use in a triaging instrument.
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Affiliation(s)
- Lyndsay E Somerville
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Kevin Willits
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Andrew M Johnson
- School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada
| | - Robert Litchfield
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Marie-Eve LeBel
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Jaydeep Moro
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dianne Bryant
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Rijsbergen K, Blaas LS, de Jong EWM, Veldhuyzen CJH, Yuan JZ, Derksen RJ. Creating a diagnostic decision rule for shoulder injury: CASH-trial, a cross-sectional interobserver study. Am J Emerg Med 2017; 36:147-149. [PMID: 28743476 DOI: 10.1016/j.ajem.2017.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 07/03/2017] [Accepted: 07/04/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- K Rijsbergen
- Department of Surgery, Zaans Medical Center, Zaandam, The Netherlands.
| | - L S Blaas
- Department of Surgery, Zaans Medical Center, Zaandam, The Netherlands
| | - E W M de Jong
- Department of Surgery, Zaans Medical Center, Zaandam, The Netherlands
| | - C J H Veldhuyzen
- Department of Emergency Medicine, Zaans Medical Center, Zaandam, The Netherlands
| | - J Z Yuan
- Department of Surgery, Zaans Medical Center, Zaandam, The Netherlands; Department of Emergency Medicine, Zaans Medical Center, Zaandam, The Netherlands
| | - R J Derksen
- Department of Surgery, Zaans Medical Center, Zaandam, The Netherlands.
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Ban JW, Wallace E, Stevens R, Perera R. Why do authors derive new cardiovascular clinical prediction rules in the presence of existing rules? A mixed methods study. PLoS One 2017; 12:e0179102. [PMID: 28591223 PMCID: PMC5462434 DOI: 10.1371/journal.pone.0179102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/24/2017] [Indexed: 12/26/2022] Open
Abstract
Background Researchers should examine existing evidence to determine the need for a new study. It is unknown whether developers evaluate existing evidence to justify new cardiovascular clinical prediction rules (CPRs). Objective We aimed to assess whether authors of cardiovascular CPRs cited existing CPRs, why some authors did not cite existing CPRs, and why they thought existing CPRs were insufficient. Method Derivation studies of cardiovascular CPRs from the International Register of Clinical Prediction Rules for Primary Care were evaluated. We reviewed the introduction sections to determine whether existing CPRs were cited. Using thematic content analysis, the stated reasons for determining existing cardiovascular CPRs insufficient were explored. Study authors were surveyed via e-mail and post. We asked whether they were aware of any existing cardiovascular CPRs at the time of derivation, how they searched for existing CPRs, and whether they thought it was important to cite existing CPRs. Results Of 85 derivation studies included, 48 (56.5%) cited existing CPRs, 33 (38.8%) did not cite any CPR, and four (4.7%) declared there was none to cite. Content analysis identified five categories of existing CPRs insufficiency related to: (1) derivation (5 studies; 11.4% of 44), (2) construct (31 studies; 70.5%), (3) performance (10 studies; 22.7%), (4) transferability (13 studies; 29.5%), and (5) evidence (8 studies; 18.2%). Authors of 54 derivation studies (71.1% of 76 authors contacted) responded to the survey. Twenty-five authors (46.3%) reported they were aware of existing CPR at the time of derivation. Twenty-nine authors (53.7%) declared they conducted a systematic search to identify existing CPRs. Most authors (90.7%) indicated citing existing CPRs was important. Conclusion Cardiovascular CPRs are often developed without citing existing CPRs although most authors agree it is important. Common justifications for new CPRs concerned construct, including choice of predictor variables or relevance of outcomes. Developers should clearly justify why new CPRs are needed with reference to existing CPRs to avoid unnecessary duplication.
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Affiliation(s)
- Jong-Wook Ban
- Evidence-Based Health Care Programme, Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Emma Wallace
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, Medical Science Division, University of Oxford, Oxford, United Kingdom
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, Medical Science Division, University of Oxford, Oxford, United Kingdom
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Wasson JH, Soloway L, Moore LG, Labrec P, Ho L. Development of a care guidance index based on what matters to patients. Qual Life Res 2017; 27:51-58. [DOI: 10.1007/s11136-017-1573-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2017] [Indexed: 12/15/2022]
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Tajmir S, Raja AS, Ip IK, Andruchow J, Silveira P, Smith S, Khorasani R. Impact of Clinical Decision Support on Radiography for Acute Ankle Injuries: A Randomized Trial. West J Emerg Med 2017; 18:487-495. [PMID: 28435501 PMCID: PMC5391900 DOI: 10.5811/westjem.2017.1.33053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/31/2016] [Accepted: 01/16/2017] [Indexed: 12/26/2022] Open
Abstract
Introduction While only 15–20% of patients with foot and ankle injuries presenting to urgent care centers have clinically significant fractures, most undergo radiography. We examined the impact of electronic point-of-care clinical decision support (CDS) on adherence to the Ottawa Ankle Rules (OAR), as well as use and yield of foot and ankle radiographs in patients with acute ankle injury. Methods We obtained institutional review board approval for this randomized controlled study performed April 18, 2012—December 15, 2013. All ordering providers credentialed at an urgent care affiliated with a quaternary care academic hospital were randomized to either receive or not receive CDS, based on the OAR and integrated into the physician order-entry system, with feedback at the time of imaging order. If the patient met OAR low-risk criteria, providers were advised against imaging and could either cancel the order or ignore the alert. We identified patients with foot and ankle complaints via ICD-9 billing codes and electronic health records and radiology reports reviewed for those who were eligible. Chi-square was used to compare adherence to the OAR (primary outcome), radiography utilization rate and radiography yield of foot and ankle imaging (secondary outcomes) between the intervention and control groups. Results Of 14,642 patients seen at urgent care during the study period, 613 (4.2%, representing 632 visits) presented with acute ankle injury and were eligible for application of the OAR; 374 (59.2%) of these were seen by control-group providers. In the intervention group, CDS adherence was higher for both ankle (239/258=92.6% vs. 231/374=61.8%, p=0.02) and foot radiography (209/258=81.0% vs. 238/374=63.6%; p<0.01). However, ankle radiography use was higher in the intervention group (166/258=64.3% vs. 183/374=48.9%; p<0.01), while foot radiography use (141/258=54.6% vs. 202/374=54.0%; p=0.95) was not. Radiography yield was also higher in the intervention group (26/307=8.5% vs. 18/385=4.7%; p=0.04). Conclusion Clinical decision support, previously demonstrated to improve guideline adherence for high-cost imaging, can also improve guideline adherence for radiography – as demonstrated by increased OAR adherence and increased imaging yield.
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Affiliation(s)
- Shahein Tajmir
- Harvard Medical School, Boston, Massachusetts.,Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ali S Raja
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ivan K Ip
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - James Andruchow
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Patricia Silveira
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Stacy Smith
- Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ramin Khorasani
- Brigham and Women's Hospital, Center for Evidence-Based Imaging, Boston, Massachusetts.,Brigham and Women's Hospital, Department of Radiology, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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40
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Valentian M, Mewasing BI, Burggraff E, Mintandjian A, Lefranc V, Verbbrugghe R, Debost P, Ray P. Intérêt d’une demande anticipée de radiographies par l’infirmière organisatrice de l’accueil, dans les traumatismes de cheville. ANNALES FRANCAISES DE MEDECINE D URGENCE 2017. [DOI: 10.1007/s13341-017-0719-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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41
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Taylor CJ, Roalfe AK, Iles R, Hobbs FR, Barton P, Deeks J, McCahon D, Cowie MR, Sutton G, Davis RC, Mant J, McDonagh T, Tait L. Primary care REFerral for EchocaRdiogram (REFER) in heart failure: a diagnostic accuracy study. Br J Gen Pract 2017; 67:e94-e102. [PMID: 27919937 PMCID: PMC5308123 DOI: 10.3399/bjgp16x688393] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/21/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Symptoms of breathlessness, fatigue, and ankle swelling are common in general practice but deciding which patients are likely to have heart failure is challenging. AIM To evaluate the performance of a clinical decision rule (CDR), with or without N-Terminal pro-B type natriuretic peptide (NT-proBNP) assay, for identifying heart failure. DESIGN AND SETTING Prospective, observational, diagnostic validation study of patients aged >55 years, presenting with shortness of breath, lethargy, or ankle oedema, from 28 general practices in England. METHOD The outcome was test performance of the CDR and natriuretic peptide test in determining a diagnosis of heart failure. The reference standard was an expert consensus panel of three cardiologists. RESULTS Three hundred and four participants were recruited, with 104 (34.2%; 95% confidence interval [CI] = 28.9 to 39.8) having a confirmed diagnosis of heart failure. The CDR+NT-proBNP had a sensitivity of 90.4% (95% CI = 83.0 to 95.3) and specificity 45.5% (95% CI = 38.5 to 52.7). NT-proBNP level alone with a cut-off <400 pg/ml had sensitivity 76.9% (95% CI = 67.6 to 84.6) and specificity 91.5% (95% CI = 86.7 to 95.0). At the lower cut-off of NT-proBNP <125 pg/ml, sensitivity was 94.2% (95% CI = 87.9 to 97.9) and specificity 49.0% (95% CI = 41.9 to 56.1). CONCLUSION At the low threshold of NT-proBNP <125 pg/ml, natriuretic peptide testing alone was better than a validated CDR+NT-proBNP in determining which patients presenting with symptoms went on to have a diagnosis of heart failure. The higher NT-proBNP threshold of 400 pg/ml may mean more than one in five patients with heart failure are not appropriately referred. Guideline natriuretic peptide thresholds may need to be revised.
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Affiliation(s)
- Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Andrea K Roalfe
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - Rachel Iles
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - P Barton
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - D McCahon
- Institute of Applied Health Research, University of Birmingham, Birmingham
| | - M R Cowie
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London
| | - G Sutton
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London
| | - R C Davis
- Department of Cardiology, Sandwell and West Birmingham Hospitals, Lyndon, West Bromwich
| | - J Mant
- Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - T McDonagh
- Department of Cardiology, King's College Hospital, London
| | - L Tait
- School of Health Sciences, Nottingham
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Çiçekli Ö, Özdemir G, Uysal M, Biçici V, Bingöl İ. Percutaneous cannulated screw fixation for pediatric epiphyseal ankle fractures. SPRINGERPLUS 2016; 5:1925. [PMID: 27917331 PMCID: PMC5099300 DOI: 10.1186/s40064-016-3623-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 11/01/2016] [Indexed: 11/21/2022]
Abstract
Background Ankle injuries are among the most common injuries in children. The aim of this study was to compare the efficacies of two percutaneous fixation methods after closed reduction in physeal ankle fractures. Methods We reviewed the cases of 24 patients with a mean age of 12.29 years; 16 were male, and 8 were female. Only patients with fractures of Salter-Harris types 2, 3, and 4 with displacements greater than 2 mm were included in the study. Patients were treated with closed reduction manipulation and percutaneous screw fixation. For each patient, either cannulated or headless full threaded compressive screws were used for percutaneous fixation. Radiological and clinical healing time, range of motion (ROM), American Orthopaedic Foot and Ankle Society (AOFAS) score and physeal arrest were then measured. Results The mean follow-up time was 13 months. The mean time until cast removal was 3.5 weeks (range 2–5). A full ROM was achieved at an average of 5.7 weeks postoperatively (range 4–8). The radiologic healing time was 6.1 weeks (range 4–7). The patients’ clinical healing time averaged 6.8 weeks (range 5–8). Differences in radiologic healing time (p = 0.487), clinical healing time (p = 0.192), AOFAS score (p = 0.467), and complication rate (p = 0.519) between patients who received the headless compressive screw and those who received the cannulated screw for fixation were not statistically significant. Conclusions We demonstrate good clinical results with closed reduction and the percutaneous screw fixation method. Both cannulated and headless compressive screws can be used safely as a treatment method in physeal ankle fractures.
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Affiliation(s)
- Özgür Çiçekli
- Department of Orthopaedic Surgery and Traumatology, Sakarya Training and Research Hospital, Sakarya, Turkey
| | - Güzelali Özdemir
- Department of Orthopaedic Surgery and Traumatology, Numune Training and Research Hospital, Ankara, Turkey
| | - Mustafa Uysal
- Department of Orthopaedic Surgery and Traumatology, Sakarya University School of Medicine Training and Research Hospital, Sakarya, Turkey
| | - Vedat Biçici
- Department of Orthopaedic Surgery and Traumatology, Yenimahalle Training and Research Hospital, Ankara, Turkey
| | - İzzet Bingöl
- Department of Orthopaedic Surgery and Traumatology, 29 Mayıs State Hospital, Ankara, Turkey
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Munzer BW, Love J, Shipman BL, Byrne B, Cico SJ, Furlong R, Khandelwal S, Santen SA. An Analysis of the Top-cited Articles in Emergency Medicine Education Literature. West J Emerg Med 2016; 18:60-68. [PMID: 28116010 PMCID: PMC5226765 DOI: 10.5811/westjem.2016.10.31492] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/27/2016] [Indexed: 11/24/2022] Open
Abstract
Introduction Dissemination of educational research is critical to improving medical education, promotion of faculty and ultimately patient care. The objective of this study was to identify the top 25 cited education articles in the emergency medicine (EM) literature and the top 25 cited EM education articles in all journals, as well as report on the characteristics of the articles. Methods Two searches were conducted in the Web of Science in June 2016 using a list of education-related search terms. We searched 19 EM journals for education articles as well as all other literature for EM education-related articles. Articles identified were reviewed for citation count, article type, journal, authors, and publication year. Results With regards to EM journals, the greatest number of articles were classified as articles/reviews, followed by research articles on topics such as deliberate practice (cited 266 times) and cognitive errors (cited 201 times). In contrast in the non-EM journals, research articles were predominant. Both searches found several simulation and ultrasound articles to be included. The most common EM journal was Academic Emergency Medicine (n = 18), and Academic Medicine was the most common non-EM journal (n=5). A reasonable number of articles included external funding sources (6 EM articles and 13 non-EM articles.) Conclusion This study identified the most frequently cited medical education articles in the field of EM education, published in EM journals as well as all other journals indexed in Web of Science. The results identify impactful articles to medical education, providing a resource to educators while identifying trends that may be used to guide EM educational research and publishing efforts.
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Affiliation(s)
- Brendan W Munzer
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Jeffery Love
- Georgetown University Hospital/Washington Hospital Center, Department of Emergency Medicine, Washington, D.C
| | - Barbara L Shipman
- University of Michigan, Alfred Taubman Health Sciences Library, Ann Arbor, Michigan
| | - Brendan Byrne
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan; Naval Medical Center Portsmouth, Department of Emergency Medicine, Portsmouth, Virginia
| | - Stephen J Cico
- Indiana University, Department of Emergency Medicine, Indianapolis, Indiana
| | - Robert Furlong
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Sorabh Khandelwal
- Ohio State University, Department of Emergency Medicine, Columbus, Ohio
| | - Sally A Santen
- University of Michigan, Department of Learning Health Sciences, Ann Arbor, Michigan
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How Well Do You Expect to Recover, and What Does Recovery Mean, Anyway? Qualitative Study of Expectations After a Musculoskeletal Injury. Phys Ther 2016; 96:797-807. [PMID: 26586855 DOI: 10.2522/ptj.20150229] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 11/10/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Expecting to recover from a musculoskeletal injury is associated with actual recovery. Expectations are potentially modifiable, although it is not well understood how injured people formulate expectations. A better understanding of how expectations are formulated may lead to better knowledge about how interventions might be implemented, what to intervene on, and when to intervene. OBJECTIVES The objective of this study was to explore what "recovery" meant to participants, whether they expected to "recover," and how they formed these expectations. METHODS This qualitative study used interpretive phenomenological analysis. Eighteen semistructured interviews were conducted with people seeking treatment for recent musculoskeletal injuries. RESULTS Recovery was conceptualized as either (1) complete cessation of symptoms or pain-free return to function or (2) return to function despite residual symptoms. Expectations were driven by desire for a clear diagnosis, belief (or disbelief) in the clinician's prognosis, prior experiences, other people's experiences and attitudes, information from other sources such as the Internet, and a sense of self as resilient. CONCLUSIONS Expectations appear to be embedded in both hopes and fears, suggesting that clinicians should address both when negotiating realistic goals and educating patients. This approach is particularly relevant for cases of nonspecific musculoskeletal pain, where diagnoses are unclear and treatment may not completely alleviate pain.
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Wallace E, Uijen MJM, Clyne B, Zarabzadeh A, Keogh C, Galvin R, Smith SM, Fahey T. Impact analysis studies of clinical prediction rules relevant to primary care: a systematic review. BMJ Open 2016; 6:e009957. [PMID: 27008685 PMCID: PMC4800123 DOI: 10.1136/bmjopen-2015-009957] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Following appropriate validation, clinical prediction rules (CPRs) should undergo impact analysis to evaluate their effect on patient care. The aim of this systematic review is to narratively review and critically appraise CPR impact analysis studies relevant to primary care. SETTING Primary care. PARTICIPANTS Adults and children. INTERVENTION Studies that implemented the CPR compared to usual care were included. STUDY DESIGN Randomised controlled trial (RCT), controlled before-after, and interrupted time series. PRIMARY OUTCOME Physician behaviour and/or patient outcomes. RESULTS A total of 18 studies, incorporating 14 unique CPRs, were included. The main study design was RCT (n=13). Overall, 10 studies reported an improvement in primary outcome with CPR implementation. Of 6 musculoskeletal studies, 5 were effective in altering targeted physician behaviour in ordering imaging for patients presenting with ankle, knee and neck musculoskeletal injuries. Of 6 cardiovascular studies, 4 implemented cardiovascular risk scores, and 3 reported no impact on physician behaviour outcomes, such as prescribing and referral, or patient outcomes, such as reduction in serum lipid levels. 2 studies examined CPRs in decision-making for patients presenting with chest pain and reduced inappropriate admissions. Of 5 respiratory studies, 2 were effective in reducing antibiotic prescribing for sore throat following CPR implementation. Overall, study methodological quality was often unclear due to incomplete reporting. CONCLUSIONS Despite increasing interest in developing and validating CPRs relevant to primary care, relatively few have gone through impact analysis. To date, research has focused on a small number of CPRs across few clinical domains only.
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Affiliation(s)
- Emma Wallace
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Maike J M Uijen
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- Medical school, Radboud University, Nijmegen, The Netherlands
| | - Barbara Clyne
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Atieh Zarabzadeh
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Claire Keogh
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Rose Galvin
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- Department of Clinical Therapies, University of Limerick, Limerick, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Stasinopoulos D, Papadopoulos C, Lamnisos D, Stasinopoulos I. The use of Bioptron light (polarized, polychromatic, non-coherent) therapy for the treatment of acute ankle sprains. Disabil Rehabil 2016; 39:450-457. [PMID: 26939828 DOI: 10.3109/09638288.2016.1146357] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Purpose The purpose of this study was to investigate the efficacy of Bioptron light therapy for the treatment of acute ankle sprains. Method A parallel group, single-blind, controlled study was carried out in patients with grade II acute ankle sprains. Patients were randomly allocated into two treatment groups (n = 25 for each). Both groups received cryotherapy, and the test group also received Bioptron light therapy. All treatments were performed daily for 5 d. Evaluations included self-reported pain via a visual analogue scale, degree of ankle edema, and ankle range of motion via goniometry carried out before the treatment and at the end of the treatment. Results The test group showed the largest magnitude of improvement for all evaluations at treatment five, and the between-group differences observed were statistically significant (p < 0.0005 for each). Conclusions These data provide preliminary evidence of the efficacy of Bioptron light therapy supplemented with cryotherapy for the treatment of acute ankle sprains; however, larger studies are required to confirm these results. Implications for Rehabilitation Ankle sprains are common acute injuries among professional and recreational sports players but also among people in general. Cryotherapy is the first-standard treatment of acute ankle sprains. Phototherapy such as Bioptron light has been recommended supplement to cryotherapy to reduce the symptoms of ankle sprains. The results of the present trial showed that using BIOPTRON LIGHT and cryotherapy the rehabilitation period of acute ankle sprains can be reduced.
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Affiliation(s)
- Dimitrios Stasinopoulos
- a Department of Health Sciences, School of Sciences , European University of Cyprus, Physiotherapy Program , Nicosia , Cyprus
| | | | - Dimitrios Lamnisos
- a Department of Health Sciences, School of Sciences , European University of Cyprus, Physiotherapy Program , Nicosia , Cyprus
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Keene DJ, Williams MA, Segar AH, Byrne C, Lamb SE. Immobilisation versus early ankle movement for treating acute lateral ankle ligament injuries in adults. Hippokratia 2016. [DOI: 10.1002/14651858.cd012101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- David J Keene
- University of Oxford; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS); Kadoorie Centre John Radcliffe Hospital, Headley Way Oxford UK OX3 9DU
| | - Mark A Williams
- Oxford Brookes University; Department of Sport and Health Sciences; Jack Straws Lane Oxford Oxon UK OX3 0FL
| | - Anand H Segar
- University of Oxford; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS); Kadoorie Centre John Radcliffe Hospital, Headley Way Oxford UK OX3 9DU
| | - Christopher Byrne
- University of Oxford; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS); Kadoorie Centre John Radcliffe Hospital, Headley Way Oxford UK OX3 9DU
| | - Sarah E Lamb
- University of Oxford; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS); Kadoorie Centre John Radcliffe Hospital, Headley Way Oxford UK OX3 9DU
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Slaar A, Walenkamp MMJ, Bentohami A, Maas M, van Rijn RR, Steyerberg EW, Jager LC, Sosef NL, van Velde R, Ultee JM, Goslings JC, Schep NWL. A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules. Pediatr Radiol 2016; 46:50-60. [PMID: 26298555 PMCID: PMC4706582 DOI: 10.1007/s00247-015-3436-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 05/26/2015] [Accepted: 07/09/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND In most hospitals, children with acute wrist trauma are routinely referred for radiography. OBJECTIVE To develop and validate a clinical decision rule to decide whether radiography in children with wrist trauma is required. MATERIALS AND METHODS We prospectively developed and validated a clinical decision rule in two study populations. All children who presented in the emergency department of four hospitals with pain following wrist trauma were included and evaluated for 18 clinical variables. The outcome was a wrist fracture diagnosed by plain radiography. RESULTS Included in the study were 787 children. The prediction model consisted of six variables: age, swelling of the distal radius, visible deformation, distal radius tender to palpation, anatomical snuffbox tender to palpation, and painful or abnormal supination. The model showed an area under the receiver operator characteristics curve of 0.79 (95% CI: 0.76-0.83). The sensitivity and specificity were 95.9% and 37.3%, respectively. The use of this model would have resulted in a 22% absolute reduction of radiographic examinations. In a validation study, 7/170 fractures (4.1%, 95% CI: 1.7-8.3%) would have been missed using the decision model. CONCLUSION The decision model may be a valuable tool to decide whether radiography in children after wrist trauma is required.
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Affiliation(s)
- Annelie Slaar
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Monique M. J. Walenkamp
- Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Abdelali Bentohami
- Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Mario Maas
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105, AZ Amsterdam, The Netherlands
| | - Rick R. van Rijn
- Department of Radiology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105, AZ Amsterdam, The Netherlands
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus MC - University Medical Centre, Rotterdam, The Netherlands
| | - L. Cara Jager
- Emergency Department, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Nico L. Sosef
- Department of Surgery, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Romuald van Velde
- Department of Surgery, Tergooi Hospitals, Hilversum, The Netherlands
| | - Jan M. Ultee
- Department of Surgery, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands
| | - J. Carel Goslings
- Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Niels W. L. Schep
- Trauma Unit, Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands ,Department of Surgery, Maasstadziekenhuis Rotterdam, Rotterdam, The Netherlands
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Walenkamp MMJ, Bentohami A, Slaar A, Beerekamp MSH, Maas M, Jager LC, Sosef NL, van Velde R, Ultee JM, Steyerberg EW, Goslings JC, Schep NWL. The Amsterdam wrist rules: the multicenter prospective derivation and external validation of a clinical decision rule for the use of radiography in acute wrist trauma. BMC Musculoskelet Disord 2015; 16:389. [PMID: 26682537 PMCID: PMC4683697 DOI: 10.1186/s12891-015-0829-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 11/25/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although only 39 % of patients with wrist trauma have sustained a fracture, the majority of patients is routinely referred for radiography. The purpose of this study was to derive and externally validate a clinical decision rule that selects patients with acute wrist trauma in the Emergency Department (ED) for radiography. METHODS This multicenter prospective study consisted of three components: (1) derivation of a clinical prediction model for detecting wrist fractures in patients following wrist trauma; (2) external validation of this model; and (3) design of a clinical decision rule. The study was conducted in the EDs of five Dutch hospitals: one academic hospital (derivation cohort) and four regional hospitals (external validation cohort). We included all adult patients with acute wrist trauma. The main outcome was fracture of the wrist (distal radius, distal ulna or carpal bones) diagnosed on conventional X-rays. RESULTS A total of 882 patients were analyzed; 487 in the derivation cohort and 395 in the validation cohort. We derived a clinical prediction model with eight variables: age; sex, swelling of the wrist; swelling of the anatomical snuffbox, visible deformation; distal radius tender to palpation; pain on radial deviation and painful axial compression of the thumb. The Area Under the Curve at external validation of this model was 0.81 (95 % CI: 0.77-0.85). The sensitivity and specificity of the Amsterdam Wrist Rules (AWR) in the external validation cohort were 98 % (95 % CI: 95-99 %) and 21 % (95 % CI: 15 %-28). The negative predictive value was 90 % (95 % CI: 81-99 %). CONCLUSIONS The Amsterdam Wrist Rules is a clinical prediction rule with a high sensitivity and negative predictive value for fractures of the wrist. Although external validation showed low specificity and 100 % sensitivity could not be achieved, the Amsterdam Wrist Rules can provide physicians in the Emergency Department with a useful screening tool to select patients with acute wrist trauma for radiography. The upcoming implementation study will further reveal the impact of the Amsterdam Wrist Rules on the anticipated reduction of X-rays requested, missed fractures, Emergency Department waiting times and health care costs. TRIAL REGISTRATION This study was registered in the Dutch Trial Registry, reference number NTR2544 on October 1(st), 2010.
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Affiliation(s)
- Monique M J Walenkamp
- Department of Surgery, Trauma Unit, Academic Medical Center, University of Amsterdam, P.O. Box 22660, Amsterdam, 1100 DD, The Netherlands.
| | - Abdelali Bentohami
- Department of Surgery, Trauma Unit, Academic Medical Center, University of Amsterdam, P.O. Box 22660, Amsterdam, 1100 DD, The Netherlands.
| | - Annelie Slaar
- Department of Radiology, Academic Medical Center, University of Amsterdam, P.O. Box 22660, Amsterdam, 1100 DD, The Netherlands.
| | - M Suzan H Beerekamp
- Department of Surgery, Trauma Unit, Academic Medical Center, University of Amsterdam, P.O. Box 22660, Amsterdam, 1100 DD, The Netherlands.
| | - Mario Maas
- Department of Radiology, Academic Medical Center, University of Amsterdam, P.O. Box 22660, Amsterdam, 1100 DD, The Netherlands.
| | - L Cara Jager
- Emergency Department, Academic Medical Center, University of Amsterdam, P.O. Box 22660, Amsterdam, 1100 DD, The Netherlands.
| | - Nico L Sosef
- Spaarne Hospital, Department of Surgery, P.O. Box 770, Hoofddorp, 2130 AT, The Netherlands.
| | - Romuald van Velde
- Tergooi Hospitals, Department of Surgery, P.O. Box 10016, Hilversum, 1201 DA, The Netherlands.
| | - Jan M Ultee
- Sint Lucas Andreas Hospital, Department of Surgery, P.O. box 9243, Amsterdam, 1006 AE, The Netherlands.
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus Medical Center, University Medical Center Rotterdam, P.O. Box 2040, Rotterdam, 3000 CA, The Netherlands.
| | - J Carel Goslings
- Department of Surgery, Trauma Unit, Academic Medical Center, University of Amsterdam, P.O. Box 22660, Amsterdam, 1100 DD, The Netherlands.
| | - Niels W L Schep
- Maasstad Hospital, Department of Surgery, P.O. Box 9100, Rotterdam, 3007 AC, The Netherlands.
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Abstract
Current clinical concepts are reviewed regarding the epidemiology, anatomy, evaluation, and treatment of pediatric ankle fractures. Correct diagnosis and management relies on appropriate examination, imaging, and knowledge of fracture patterns specific to children. Treatment is guided by patient history, physical examination, plain film radiographs and, in some instances, computed tomography. Treatment goals are to restore acceptable limb alignment, physeal anatomy, and joint congruency. For high-risk physeal fractures, patients should be monitored for growth disturbance as needed until skeletal maturity.
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Affiliation(s)
- Alvin W Su
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA; School of Medicine, National Yang-Ming University, No. 155, Section 2, Linong Street, Beitou, Taipei, Taiwan
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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