Sensitivity of a clinical examination to predict need for radiography in children with ankle injuries: a prospective study

BACKGROUND

Radiographs are ordered routinely for children with ankle trauma. We assessed the predictive value of a clinical examination to identify a predefined group of low-risk injuries, management of which would not be affected by absence of a radiograph. We aimed to show that no more than 1% of children with low-risk examinations (signs restricted to the distal fibula) would have high-risk fractures (all fractures except avulsion, buckle, and non-displaced Salter-Harris I and II fractures of the distal fibula), and to compare the potential reduction in radiography in children with low-risk examinations with that obtained by application of the Ottawa ankle rules (OAR).

METHODS

Standard clinical examinations and subsequent radiographs were prospectively and independently evaluated in two tertiary-care paediatric emergency departments in North America. Eligible participants were healthy children aged 3-16 years with acute ankle injuries. Sample size, negative and positive predictive values, sensitivity, and specificity were calculated. McNemar's test was used to compare differences in the potential reduction in radiographs between the low-risk examination and the OAR.

FINDINGS

607 children were enrolled; 581 (95.7%) received follow-up. None of the 381 children with low-risk examinations had a high-risk fracture (negative predictive value 100% [95% CI 99.2-100]; sensitivity 100% [93.3-100]). Radiographs could be omitted in 62.8% of children with low-risk examinations, compared with only 12.0% reduction obtained by application of the OAR (p<0.0001).

INTERPRETATION

A low-risk clinical examination in children with ankle injuries identifies 100% of high-risk diagnoses and may result in greater reduction of radiographic referrals than the OAR.

Fracture history and bone loss in patients with MS

OBJECTIVES

We have previously shown that MS patients have significantly reduced bone mass and a high prevalence of abnormal vitamin D status. The object of this study was to characterize the frequency of adulthood fractures in MS patients, prospectively determine rates of bone loss in MS, and determine whether vitamin D status is a predictor of bone loss.

METHODS

MS patients (36 women, 18 men) were compared with age- and gender-matched healthy controls (35 women, 14 men). Bone mass was performed by dual x-ray absorptiometry at baseline and at 12-month intervals over 2 years.

RESULTS

Fractures in the absence of major trauma had occurred in 2% of controls and 22% of MS patients (p < 0.002). Over the 2 years of prospective follow-up, both women and men with MS lost substantially more bone in the femoral neck than did controls (3% and 6% per year in pre- and postmenopausal women with MS versus 0.5% and 0.8% per year in controls; 7.3% per year in men with MS versus 1.6% per year in controls). Bone loss in the spine was also greater in women with MS than in controls (1.6 to 3.5% per year loss in MS patients versus no change in controls). Duration of steroid treatment beyond 5 months and ambulatory status were both predictors of bone loss. Bone loss in the spine occurred faster in MS patients with low (<20 ng/mL) 25-hydroxyvitamin D levels (1.9% per year, p < 0.04), whereas in those with normal 25-hydroxyvitamin D levels, bone loss was insignificant. At the femoral neck, bone loss was substantial in all patients, but was somewhat faster in the group with low levels of 25-hydroxyvitamin D (5.6% per year, p < 0.0001) compared with the group with high levels of 25-hydroxyvitamin D (4.3% per year, p = 0.03).

CONCLUSIONS

MS patients have more frequent fractures and lose bone mass more rapidly than do their healthy age- and gender-matched peers, in part related to insufficient vitamin D. Vitamin D repletion in MS patients who are deficient might reduce, to some extent, the rate of bone loss and decrease osteoporosis-related fractures.

Calcium potentiates the effect of estrogen and calcitonin on bone mass: review and analysis

We reviewed published clinical trials that measured bone mass of postmenopausal women from at least one skeletal site to evaluate whether calcium supplementation influenced the efficacy of estrogens and intranasal calcitonin on bone mass change. We compared results of the administration of oral estrogen or nasal calcitonin in conjuction with additional calcium intake either through diet or supplements compared with those of estrogen or calcitonin alone. Of the 31 published estrogen trials analyzed, 20 modified the diet or used a calcium supplement (total 1183 mg/d) and 11 did not (total 563 mg/d). The mean increase in bone mass of the lumbar spine when estrogen was given alone was 1.3%/y (n = 5) compared with 3.3%/y when estrogen was given in conjunction with calcium (n = 14; P = 0.01). The mean increase in bone mass of the femoral neck with estrogen alone (n = 3) was only 0.9%/y compared with 2.4%/y when calcium was given with estrogen (n = 6; P = 0.04). Similarly, forearm bone mass increased 0.4%/y with estrogen alone (n = 7) compared with 2.1%/y when estrogen was given with calcium (n = 12; P = 0.04). Similar results were found when weighted means were calculated. Of the seven published trials evaluating the effects of 200 IU nasal salmon calcitonin, six also used calcium supplements (total 1466 mg/d) whereas one used calcitonin alone (total 627 mg/d). Bone mass of the lumbar spine increased 2.1% with calcitonin plus calcium supplementation compared with -0.2%/y with calcitonin alone. These results suggest that a high calcium intake potentiates the positive effect of estrogen on bone mass at all skeletal sites and perhaps that of calcitonin on bone mass of the spine.

Assessment of the terminal 40-millisecond QRS vector in children with a history of tricyclic antidepressant ingestion

Tricyclic antidepressant (TCA) ingestions remain a serious and not uncommon overdose in children. In adults, a terminal 40 millisecond QRS vector (T40-ms) between 120 and 270 degrees has been proposed as a marker for TCA overdose; however, the normal rightward deviation and high incidence of incomplete right bundle branch block noted in the electrocardiograms (ECGs) of young children may limit the usefulness of this criterion in this population. A retrospective chart review of pediatric patients less than 11 years of age admitted to the Hospital for Sick Children with birth dates after 1971 identified by International Classification of Diseases, Ninth Edition, coding for TCA ingestion was undertaken, and data related to complications were collected and reviewed. The ECGs of 35 children presenting with TCA ingestion were examined by two blinded cardiologists and the T40-ms as well as QRS, QTc, and PR intervals were calculated and compared to those of 35 healthy age-matched controls undergoing routine ECGs. In the 35 children (aged 48 +/- 39 months [mean +/- SD]) with a history of TCA ingestion, symptoms were categorized as significant in 18 (51%), mild in 12 (34%), and none in five (14%). Seizures were present in 13 (37%), hypotension in three (9%), and arrhythmias in five (14%). The mean T40-ms axes in the TCA and control groups were 111 +/- 66 degrees and 97 +/- 71 degrees, respectively. A T40-ms between 120 and 270 degrees had a sensitivity of 38% and a specificity of 74%. A marked variability in the T40-ms was noted in both the exposed and control groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Calcium homeostasis of an elderly population upon admission to a nursing home

OBJECTIVE

To evaluate the skeletal health, calcium, and vitamin D homeostasis of patients upon their entry to a long-term-care facility. Factors that could contribute to the risk of future osteoporotic fractures were also evaluated.

DESIGN

Cross-sectional study.

PATIENTS

Two hundred eighty-seven consecutive admissions were invited to participate; 109 patients were recruited into the study.

MEASUREMENTS

A high prevalence of low to low-normal circulating levels of 25(OH)D was found in nursing home residents upon their admission to the nursing home, with 86% of the patients having circulating 25(OH)D levels of less than 50 nmol/L and 41% having levels below 25 nmol/L. Frankly elevated parathyroid hormone levels were found in 16% of the patients. Additionally, alkaline phosphatase and osteocalcin levels were elevated in 23% and 13% of the patients, respectively. Bone mineral measurements were in the osteoporotic range for 85% of the nursing home residents. Bone density results for females with a history of any classic osteoporotic fracture were significantly lower than for those with no fracture history (68.5 arbitrary units (AU) for those with no fracture history, 58.8 AU in those with history of hip fracture; P < 0.05). The bone mineral measurements were higher in women with adequate 25(OH)D compared with women with deficient or borderline 25(OH)D with and without fracture history. Levels of 25(OH)D were positively correlated with urine calcium/creatinine (r = .24; P = 0.03) and 1,25(OH)2D (r = .28; P = 0.01) and were negatively correlated with 1-84 PTH (r = -.24; P = 0.02).

CONCLUSION

Hypovitaminosis D is prevalent among elderly patients entering a nursing home with secondary hyperparathyroidism and apparently increased bone turnover present in patients with circulating 25(OH)D levels below 50 nmol/L. Bone density measurements showed that a majority of the individuals entering a nursing home are osteoporotic. There is a positive association between 25(OH)D levels and bone mass and a negative association between 25(OH)D levels and a history of fracture.