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Le AH, Licurse A, Catanzano TM. Interpretation of head CT scans in the emergency department by fellows versus general staff non-neuroradiologists: a closer look at the effectiveness of a quality control program. Emerg Radiol 2007; 14:311-6. [PMID: 17605056 DOI: 10.1007/s10140-007-0645-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Accepted: 06/05/2007] [Indexed: 11/29/2022]
Abstract
Prior studies have evaluated discordance rates among radiology residents in interpretation of head computed tomograms (CTs). To our knowledge, there has been no study to compare performance among first-year fellows and more experienced general staff radiologists. This study will compare performances of these groups and evaluate the effect of a redundant system as part of a quality control program. Retrospective review of 3,886 consecutive head CTs in the Emergency Department from 7/01/04 to 6/30/2005 was performed. Fellows interpreted 2,150 and general staff radiologists 1,736 cases. Staff radiologist mean experience was 4 years (2-10 years). All primary interpretations were over-read by staff neuroradiologists (>10 years experience) as quality control. Discrepancies were divided into "major discordance" and "minor discordance." Major discordance is defined as a misread occurred that potentially delayed clinical management and thus may have incurred in mortality or disability. Minor discordance is defined as if there was no change in clinical management or impact on the patient's outcome. The patient electronic medical records were obtained and retrospectively reviewed to identify if there was an acute change in clinical management. Overall discordance rate of both groups was 2.7% (103/3,886), 0.3% major false negative (10/3,886), 1.7% minor false negative (65/3,886), 0.4% false positive (15/3,886). Fellows overall discordance rate was 2.6% (55/2,150) with major false negatives 4/2,150 (0.2%) and 2.8% (48/1,736) for general staff radiologists with 6/1736 (0.3%) major false negatives, p values 0.69 and 0.14, respectively. Three out of ten major false negatives were confirmed with the quality assurance interpretation on follow-up studies; four cases were in agreement with initial interpretation. Performance among first-year fellows and general staff radiologists in interpretation of head CTs was highly accurate (97.3%) without statistically significant difference between the groups. The overall relatively low discrepant rate between fellowship trainees and generalist staffs, as well as the negligible change in clinical management, suggests little utility in over-reads of head CT scans by the neuroradiology service as part of a year-round quality control program. However, because of a relative high discrepant rate in the early months of fellowship training (>5%) in our study, it may be wise to implement a quality assurance program in the first few months to improve patient care. Increasing over-reading rate may reduce false negative rate, as the overall false positive rate is relatively low (<0.5%).
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Affiliation(s)
- Alexander H Le
- Yale School of Medicine, Yale-New Haven Hospital, 20 York Street, New Haven, CT 06520, USA.
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Arikawa-Hirasawa E, Le AH, Nishino I, Nonaka I, Ho NC, Francomano CA, Govindraj P, Hassell JR, Devaney JM, Spranger J, Stevenson RE, Iannaccone S, Dalakas MC, Yamada Y. Structural and functional mutations of the perlecan gene cause Schwartz-Jampel syndrome, with myotonic myopathy and chondrodysplasia. Am J Hum Genet 2002; 70:1368-75. [PMID: 11941538 PMCID: PMC447613 DOI: 10.1086/340390] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2001] [Accepted: 02/22/2002] [Indexed: 11/03/2022] Open
Abstract
Perlecan, a large heparan sulfate proteoglycan, is a component of the basement membrane and other extracellular matrices and has been implicated in multiple biological functions. Mutations in the perlecan gene (HSPG2) cause two classes of skeletal disorders: the relatively mild Schwartz-Jampel syndrome (SJS) and severe neonatal lethal dyssegmental dysplasia, Silverman-Handmaker type (DDSH). SJS is an autosomal recessive skeletal dysplasia characterized by varying degrees of myotonia and chondrodysplasia, and patients with SJS survive. The molecular mechanism underlying the chondrodystrophic myotonia phenotype of SJS is unknown. In the present report, we identify five different mutations that resulted in various forms of perlecan in three unrelated patients with SJS. Heterozygous mutations in two patients with SJS either produced truncated perlecan that lacked domain V or significantly reduced levels of wild-type perlecan. The third patient had a homozygous 7-kb deletion that resulted in reduced amounts of nearly full-length perlecan. Unlike DDSH, the SJS mutations result in different forms of perlecan in reduced levels that are secreted to the extracellular matrix and are likely partially functional. These findings suggest that perlecan has an important role in neuromuscular function and cartilage formation, and they define the molecular basis involved in the difference in the phenotypic severity between DDSH and SJS.
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Affiliation(s)
- Eri Arikawa-Hirasawa
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - Alexander H. Le
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - Ichizo Nishino
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - Ikuya Nonaka
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - Nicola C. Ho
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - Clair A. Francomano
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - Prasanthi Govindraj
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - John R. Hassell
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - Joseph M. Devaney
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - Jürgen Spranger
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - Roger E. Stevenson
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - Susan Iannaccone
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - Marinos C. Dalakas
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
| | - Yoshihiko Yamada
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, and National Institute of Neuronal Disorders and Strokes, Bethesda; Department of Ultrastructural Research, National Institute of Neuroscience, Tokyo; Laboratory of Genetics, National Institute on Aging, and Johns Hopkins Bayview Medical Center, Baltimore; Shriners Hospital for Children, Tampa; Children's National Medical Center, Washington; Greenwood Genetic Center, Greenwood, SC; and Texas Scottish Rite Hospital, Dallas
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Arikawa-Hirasawa E, Wilcox WR, Le AH, Silverman N, Govindraj P, Hassell JR, Yamada Y. Dyssegmental dysplasia, Silverman-Handmaker type, is caused by functional null mutations of the perlecan gene. Nat Genet 2001; 27:431-4. [PMID: 11279527 DOI: 10.1038/86941] [Citation(s) in RCA: 182] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Perlecan is a large heparan sulfate (HS) proteoglycan present in all basement membranes and in some other tissues such as cartilage, and is implicated in cell growth and differentiation. Mice lacking the perlecan gene (Hspg2) have a severe chondrodysplasia with dyssegmental ossification of the spine and show radiographic, clinical and chondro-osseous morphology similar to a lethal autosomal recessive disorder in humans termed dyssegmental dysplasia, Silverman-Handmaker type (DDSH; MIM 224410). Here we report a homozygous, 89-bp duplication in exon 34 of HSPG2 in a pair of siblings with DDSH born to consanguineous parents, and heterozygous point mutations in the 5' donor site of intron 52 and in the middle of exon 73 in a third, unrelated patient, causing skipping of the entire exons 52 and 73 of the HSPG2 transcript, respectively. These mutations are predicted to cause a frameshift, resulting in a truncated protein core. The cartilage matrix from these patients stained poorly with antibody specific for perlecan, but there was staining of intracellular inclusion bodies. Biochemically, truncated perlecan was not secreted by the patient fibroblasts, but was degraded to smaller fragments within the cells. Thus, DDSH is caused by a functional null mutation of HSPG2. Our findings demonstrate the critical role of perlecan in cartilage development.
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Affiliation(s)
- E Arikawa-Hirasawa
- Craniofacial Developmental Biology and Regeneration Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
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