Clinical Examination is Highly Sensitive for Detecting Clinically Significant Spinal Injuries after Gunshot Wounds

ABSTRACTThe evaluation of the cervical spine in the emergency department is a common and often challenging task. We report the case of a 70-year-old female who presented intoxicated with evidence of a recent fall. A 64-slice computed tomographic (CT) scan with sagittal and coronal reconstructions revealed no acute injury. The patient was reexamined when alert and had persistent neck pain. Flexionextension static views revealed severe subluxation of C5 on C6 with jumped facets, and subsequent magnetic resonance imaging confirmed significant ligamentous injury. The evidence available suggests that although CT with reconstruction is highly sensitive for clinically significant cervical injury, the possibility of severe injury remains.

Download Full-text

Comparing the clinical and economic effects of clinical examination, pulse oximetry, and echocardiography in newborn screening for congenital heart defects: A probabilistic cost-effectiveness model and value of information analysis

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462307070304 ◽

2007 ◽

Vol 23 (2) ◽

pp. 192-204 ◽

Cited By ~ 40

Author(s):

Ingolf Griebsch ◽

Rachel L. Knowles ◽

Jacqueline Brown ◽

Catherine Bull ◽

Christopher Wren ◽

...

Keyword(s):

Cost Effectiveness ◽

Newborn Screening ◽

Pulse Oximetry ◽

Clinical Examination ◽

Heart Defects ◽

False Positive Rate ◽

Research Priorities ◽

Cost Effective ◽

Positive Rate ◽

Clinically Significant

Objectives: Congenital heart defects (CHD) are an important cause of death and morbidity in early childhood, but the effectiveness of alternative newborn screening strategies in preventing the collapse or death—before diagnosis—of infants with treatable but life-threatening defects is uncertain. We assessed their effectiveness and efficiency to inform policy and research priorities.Methods: We compared the effectiveness of clinical examination alone and clinical examination with either pulse oximetry or screening echocardiography in making a timely diagnosis of life-threatening CHD or in diagnosing clinically significant CHD. We contrasted their cost-effectiveness, using a decision-analytic model based on 100,000 live births, and assessed future research priorities using value of information analysis.Results: Clinical examination alone, pulse oximetry, and screening echocardiography achieved 34.0, 70.6, and 71.3 timely diagnoses per 100,000 live births, respectively. This finding represents an additional cost per additional timely diagnosis of £4,894 and £4,496,666 for pulse oximetry and for screening echocardiography. The equivalent costs for clinically significant CHD are £1,489 and £36,013, respectively. Key determinants of cost-effectiveness are detection rates and screening test costs. The false-positive rate is very high with screening echocardiography (5.4 percent), but lower with pulse oximetry (1.3 percent) or clinical examination alone (.5 percent).Conclusions: Adding pulse oximetry to clinical examination is likely to be a cost-effective newborn screening strategy for CHD, but further research is required before this policy can be recommended. Screening echocardiography is unlikely to be cost-effective, unless the detection of all clinically significant CHD is considered beneficial and a 5 percent false-positive rate acceptable.

Download Full-text

Evaluating the Clinical Tests for Adolescent Tibial Bone Stress Injuries

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738120988691 ◽

2021 ◽

pp. 194173812098869

Author(s):

Eric D. Nussbaum ◽

Charles J. Gatt ◽

Jaynie Bjornarra ◽

Chenyun Yang

Keyword(s):

Clinical Examination ◽

Clinical Tests ◽

Stress Injury ◽

Adolescent Population ◽

Tibial Bone ◽

Bone Stress ◽

Stress Injuries ◽

Highly Sensitive ◽

History Of ◽

Grade Iii

Background: Tibial bone stress injuries are common among the athletic adolescent population. A thorough patient history and clinical examination are essential to identify the location and extent of injury. However, there has been little description or any validation of clinical tests to help guide clinicians. Consequently, a formal diagnosis is usually dependent on results from proper imaging. Hypothesis: Clinical examinations will be both highly sensitive and specific determining the incidence, grade, and location of tibial bone stress injury as compared with magnetic resonance imaging (MRI). Study Design: Case-control. Level of Evidence: Level 2. Methods: A total of 80 consecutive athletic adolescents, from various sports, with greater than 1-week history of shin pain were enrolled in this institutional review board–approved study. Exclusion criteria were age >19 years and history of traumatic injury. Patients underwent a standardized clinical examination, which included a fulcrum test (FT), tap/percussion test (TT), vibration test (VT) utilizing a 128-Hz tuning fork, weight bearing lunge test (WBLT) to determine degree of dorsiflexion range of motion (ROM), and vertical single leg hop test (VSLHT) for height, landing, and pain. Bilateral lower extremity MRI was completed on the same day as clinical evaluation and served as the injury reference. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to evaluate each clinical examination for its ability to identify a bone stress injury. Results: A total of 159 tibiae in 80 patients were evaluated. No single test or combination of tests was both highly sensitive and specific. Individual clinical tests demonstrated sensitivity ranging from 0.11 to 0.72 and specificity ranging from 0.37 to 0.93. The VSLHT noting an increase in pain was the most sensitive test (0.72; 95% CI, 0.62-0.78); however, its specificity was only 0.37 (95% CI, 0.19-0.55), with a PPV of 0.84 (95% CI, 0.78-0.91) and NPV of 0.20 (95% CI, 0.089-0.31). The WBLT demonstrated a mean ROM of 8 cm, with side-to-side differences (range 0-4 cm) not influencing incidence of injury. Combinations of tests demonstrated low sensitivity (0.03-0.40), with better specificity (0.63-1.0). When considering ability to identify higher grades of injury (grade III/IV), all tests had a high NPV indicating that if clinical tests were negative, there was a high likelihood that the patient did not have a grade III or IV injury. Conclusion: No single test or combination of tests was both highly sensitive and specific. Clinicians cannot solely rely on clinical examination for determining extent or severity of bone stress injury in the athletic adolescent population, but when combinations of tests are negative, there is likely not a high-grade bone stress injury. Clinical Relevance: Clinical tests utilized in the evaluation of adolescent tibial bone stress injury may help indicate the presence or absence of higher grade tibial bone stress injury.

Download Full-text

71. Diagnostic Stewardship of Clostridioides difficile Testing

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.273 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S153-S153

Author(s):

Zahra Qamar ◽

Lisa A Spacek ◽

Dagan Coppock ◽

Kaya Patel ◽

Nathan L’Etoile ◽

...

Keyword(s):

Retrospective Analysis ◽

Chain Reaction ◽

Clostridioides Difficile ◽

Highly Sensitive ◽

Significant Difference ◽

Before And After ◽

Bowel Movements ◽

Sensitive Polymerase Chain Reaction ◽

Polymerase Chain ◽

Clinically Significant

Abstract Background C. difficile (CD) testing is frequently ordered inappropriately. Highly sensitive polymerase chain reaction (PCR) tests can detect CD colonization leading to misdiagnosis. Providers often overlook other causes of diarrhea, notably laxatives. To improve diagnostic stewardship, our hospital introduced an electronic medical record (EMR)-based order set (OS). Methods In a 926-bed, teaching hospital, we conducted a 3-step intervention to improve CD diagnostic stewardship. (1) A retrospective analysis of CD orders before and after OS implementation was done to assess its impact on inappropriate orders. The OS included two questions: (a) Did patient have ≥ 3 loose bowel movements in past 24 hours? and (b) No laxatives in past 24 hours? An appropriate order was defined if “yes” to both questions. It was still appropriate if “no” to either question but ≥ 2 unexplained following features: fever > 100.4 F, abdominal pain, megacolon, ileus or leukocytosis > 11,000 cells/mm3 in prior day. (2) After implementation of OS, house staff compliance with OS was surveyed via email. (3) Rationale for inappropriate orders was discussed with providers. Results Of 238 patients in retrospective analysis, 44% were ≥ 65 years and 37% had other potential causes of diarrhea. Common clinical features were leukocytosis (40%) and fever (31%). There was no significant difference in inappropriate testing: pre-OS 27/99 (27%) vs post-OS 44/139 (32%) (p=0.47). Of 43 house officers who participated in the survey, 75% indicated they over rode the OS. When asked to provide rationale of inappropriate CD testing, providers acknowledged inappropriate ordering but did not want to miss a CD diagnosis and frequently overlooked other causes of diarrhea. Conclusion Appropriate CD testing relies on providers’ appreciation of a clinical picture consistent with CD infection, confirmation of clinically significant diarrhea, and consideration of other causes of diarrhea. Providers order inappropriate tests, not due to lack of knowledge, but likely fear of missing diagnosis and overlooking other causes of diarrhea. Disclosures All Authors: No reported disclosures

Download Full-text

Findings from ACGH in patient with psychomotor delay-case report

Genetics & Applications ◽

10.31383/ga.vol3iss3pp38-41 ◽

2019 ◽

Vol 3 (3) ◽

pp. 38

Author(s):

Vanja Vidović ◽

Nela Maksimović ◽

Tatjana Damnjanović ◽

Biljana Jekić ◽

Irina Milovac ◽

...

Keyword(s):

Case Report ◽

Array Cgh ◽

Karyotype Analysis ◽

Comparative Genomic ◽

Fish Analysis ◽

Mild Mental Retardation ◽

Psychomotor Delay ◽

Left Hand ◽

Highly Sensitive ◽

Clinically Significant

Initial testing of children with psychomotor delays considers karyotype analysis and metabolic tests. However, introduction of Array Comparative Genomic Hybridization (ACGH) has become the standard method of diagnostics worldwide. ACGH is a highly sensitive method which enables detection of unbalanced chromosomal aberrations and aneuploidies. In this case report, a patient is a sixteen year old girl born to unrelated parents with mild mental retardation and psychomotor delay, hyperacusis, epilepsy, silent nasal speech, clinodactyly of the V finger on left hand, as well as low set ears. Patient had a karyotype interpreted as normal using GTG band analysis. Array CGH was performed using Agilent SurePrint G3 custom CGH+SNP Microarray 8x60K (UCSC, hg19, NCBI Build 37, February,2009). Results were analyzed by CytoGenomics 3.0 Agilent software. Results of aCGH revealed clinically significant duplication of 17q25.1-q25.3 region with the size of~7.96Mb. Within the duplicated region 217 genes are present, of which 36 are described as OMIM morbid. Duplications of similar size are described in DECIPHER date base in patients with psychomotor delay, hyperactivity and neoplasm of CNS. Besides duplication, a ~755kb clinically significant deletion was detected in the 17q25.3 region. Deletion involves 18 genes of which 2 are described as OMIM morbid: TBCD (MIM604649) and ZNF750 (MIM610226). Patient with similar deletion was described in DECIPHER date base with notable psychomotor delay. Based on these results FISH analysis is recommended for both parents in order to determine the possible carrier of inversion in the region of 17qter.

Download Full-text

Etranacogene dezaparvovec (AMT-061 phase 2b): normal/near normal FIX activity and bleed cessation in hemophilia B

Blood Advances ◽

10.1182/bloodadvances.2019000811 ◽

2019 ◽

Vol 3 (21) ◽

pp. 3241-3247 ◽

Cited By ~ 8

Author(s):

Annette Von Drygalski ◽

Adam Giermasz ◽

Giancarlo Castaman ◽

Nigel S. Key ◽

Susan Lattimore ◽

...

Keyword(s):

Neutralizing Antibodies ◽

Gene Cassette ◽

Factor Ix ◽

Hemophilia B ◽

Luciferase Assay ◽

Severe Hemophilia ◽

Sustained Activity ◽

Highly Sensitive ◽

Low Levels ◽

Clinically Significant

Etranacogene dezaparvovec (AMT-061) is a recombinant AAV5 vector including a gene cassette containing the factor IX (FIX) Padua variant under the control of a liver-specific promoter. A phase 2b study was conducted to confirm that a single dose of 2 × 1013 genome copies per kilogram of etranacogene dezaparvovec will result in FIX activity ≥5% 6 weeks after dosing. Secondary end points included FIX activity at other time points, bleed frequency, FIX replacement, and safety. Etranacogene dezaparvovec was administered as a single IV infusion to 3 adults with severe to moderately severe hemophilia B. Before treatment, participants had low levels of preexisting neutralizing antibodies to AAV5. This article reports a planned 26-week interim assessment. At week 6, mean FIX activity was 31% (23.9%-37.8%), increasing to 47% (33.2%-57.0%) at 26 weeks, with 2 subjects exhibiting sustained activity >40%. Consistent with the FIX activity, etranacogene dezaparvovec was associated with a complete bleed cessation with no need for FIX replacement therapy up to 26 weeks. Etranacogene dezaparvovec was generally well tolerated. No clinically significant elevations in levels of liver enzymes or inflammatory markers were observed, and no use of corticosteroids related to treatment was required. In individuals with severe to moderately severe hemophilia B, etranacogene dezaparvovec resulted in clinically relevant increases in FIX activity, cessation of bleeds, and abrogation of the need for FIX replacement, despite the presence of preexisting anti-AAV5 neutralizing antibodies detected by using a highly sensitive luciferase assay. Consistency of results in the 3 participants supported an expanded evaluation of the safety/efficacy of etranacogene dezaparvovec in the HOPE-B (Health Outcomes With Padua Gene; Evaluation in Hemophilia-B) phase 3 trial. The current trial was registered at www.clinicaltrials.gov as #NCT03489291.

Download Full-text

Right Ventricular Infarction in Inferior Wall Myocardial Infarction

Indian Journal of Cardiovascular Disease in Women WINCARS ◽

10.1055/s-0037-1607056 ◽

2017 ◽

Vol 02 (03) ◽

pp. 029-034 ◽

Cited By ~ 1

Author(s):

Velam Vanajakshamma ◽

Kancherla Vyshnavi ◽

Kasala Latheef ◽

Rayi Ramesh ◽

Kodem DamodaraRao

Keyword(s):

Myocardial Infarction ◽

Right Ventricular ◽

Clinical Examination ◽

Inferior Wall ◽

Ventricular Ejection Fraction ◽

Right Ventricular Infarction ◽

Highly Sensitive ◽

Careful Clinical Examination ◽

St Elevation ◽

Ventricular Infarction

Background Right ventricular infarction (RVI) is common in patients with inferior wall myocardial infarction (IWMI). Right ventricular involvement increases mortality and morbidity in IWMI patients. Clinical presentation of RVI differs, and accordingly treatment and management of patients also differs. Aim To find out the frequency of RVI among patients with acute IWMI and to determine the utility of clinical examination, electrocardiography (ECG), and echocardiography (ECHO) in the diagnosis of RVI and its severity. Also o study the frequency and complications with reference to sex. Material and Methods One hundred patients with acute IWMI were recruited. Clinical examination, ECG with right precordial leads, and 2D ECHO (right ventricular end-systolic volume [RVESV] and right ventricular end-diastolic volume [RVEDV], right ventricular stroke volume [RVSV], RVESV index [RVESVI], RVEDV index [RVEDVI], RVSV index [RVSVI], and right ventricular ejection fraction [RVEF]) were done to diagnose RVI and its severity. RVI patients were divided into two groups basing on RVEF as severe RVI (EF < 35%) and mild RVI (EF > 35%). Results Forty-three (43%) patients had RVI. Thirty-one (72%) patients had mild RVI (EF > 35%) and 12 (28%) had severe RVI (EF < 35%). Clinical examination had less sensitivity (35%) and high specificity (93%) in the diagnosis of RVI whereas it was highly sensitive (100%) and specific (90%) in detecting severe RVI. Total ST elevation of ≥ 3 mm was highly sensitive (92%), and ≥ 5 mm was highly specific (94%) in detecting severe RVI. RVEF (p < 0.01), RVESVI (p < 0.01), RVEDVI (p < 0.01), RVSVI (p < 0.05), and total ST elevation (p < 0.01) were equally effective in detecting severe RVI. Case fatality rate in RVI was 7%. Proportional mortality rate in females was 67%, with higher mortality in females compared with males (p ≤ 0.05). Conclusion Right-sided leads should be taken in all cases of acute IWMI. Careful clinical examination, total ST elevation in V1, V2, V3R, V4R, ECHO RVESV, RVEDV, RVSV, RVEF, RVESVI, RVEDVI, and RVSVI are useful in detecting severe RVI. Complications were significantly associated with the severity of RVI. Mortality is high in females compared with males.

Download Full-text