Psychiatry Clinical Skills Evaluation: Interrater Reliability of the American Board of Psychiatry and Neurology Required Assessment.

OBJECTIVE: The American Board of Psychiatry and Neurology (ABPN) requires applicants to successfully complete at least 3 Clinical Skills Evaluations (CSE) as part of the credentialing requirements to sit for the psychiatry certification examination. The authors examined a database of CSE assessments conducted at a single site to determine the interrater and test-retest reliability of the evaluation. METHODS: The authors examined 159 CSE assessments of 51 practicing psychiatrists who completed residency prior to the implementation of CSEs, but did not previously sit for the ABPN examination and later required CSEs to do so. Of these, 36 were simultaneously observed by 2 evaluators, at least 1 of whom had extensive experience with the CSE and 8 of whom were novice evaluators. At least 3 CSEs were done on the same day by each candidate. RESULTS: The intraclass correlations for CSEs observed by 2 evaluators for the 3 clinical skills assessed (patient-physician relationship, conduct of the interview, and case presentation), were in the low-moderate "good" range for interrater reliability. Test-retest reliability for all candidates was in the moderate-high "good" range. Significant learning took place between the 1st and 3rd CSEs, with a mean improvement of 0.42-0.49 points on an 8-point scale (p < 0.01). CONCLUSIONS: These data demonstrate good interrater reliability for the CSE even when conducted by novice faculty evaluators and good test-retest reliability despite significant learning that occurred over the series of assessments. The study supports both the educational and assessment value of the CSE.

Differences in Outcomes Associated With Individual Radiologists for Emergency Department Patients With Headache Imaged With CT: A Retrospective Cohort Study of 25,596 Patients.

OBJECTIVE. The purpose of this study was to determine whether diagnostic radiologists impart variation into resource use and patient outcomes in emergency department (ED) patients undergoing CT for headache. MATERIALS AND METHODS. This was a single-institution retrospective quality assurance cohort study of 25,596 unique adult ED patients undergoing head CT for headache from January 2012 to October 2017. CT examinations were interpreted by 55 attending radiologists (25 neuroradiologists, 30 radiologists of other specialties) who each interpreted a mean of 1469.8 ± 787.9 CT examinations. Risk adjustment for variables thought to influence outcome included baseline risk (demographics, Elixhauser comorbidity score), clinical factors (vital signs, ED triage and pain scores, laboratory data, hydrocephalus, prior intracranial hemorrhage, neurosurgical consultation within last 12 months), and system factors (time of CT, physician experience, neuroradiology training). Multivariable models were built to analyze the effect of individual radiologists on subsequent outcomes. Any p value less than 0.007 was considered significant after Bonferroni correction. RESULTS. The study found 57.5% (14,718/25,596) of CT interpretations were performed by neuroradiologists, and most patients (98.1% [25,119/25,596]) had no neurosurgical history. After risk adjustment, individual radiologists were not an independent predictor of hospital admission (p = 0.49), 30-day readmission (p = 0.30), 30-day mortality (p = 0.14), or neurosurgical intervention (p = 0.04) but did predict MRI use (p < 0.001; odds ratio [OR] range among radiologists, 0.009-38.2), neurology consultation (p < 0.001; OR range, 0.4-3.2), and neurosurgical consultation (p < 0.001; OR range, 0.1-9.9). CONCLUSION. Radiologists with different skills, experience, and practice patterns appear interchangeable for major clinical outcomes when interpreting CT for headache in the ED, but their differences predict differential use of downstream health care resources. Resource use measures are potential quality indicators in this cohort.

Self-Administered Acupressure for Chronic Low Back Pain: A Randomized Controlled Pilot Trial.

Objective Chronic low back pain (CLBP) is associated with fatigue, pain, poor sleep, and disability. Acupressure is a low-risk treatment option used to manage symptoms in other groups, but its efficacy, particularly on fatigue and sleep, is unknown in CLBP. This study examined preliminary effects of two types of self-administered acupressure (relaxing and stimulating) on fatigue, pain, sleep, and reported disability. Methods A randomized pilot trial was conducted (N = 67) in which participants were randomized into six weeks of relaxing acupressure, stimulating acupressure, or usual care. Fatigue was measured by the Brief Fatigue Inventory, pain was measured by the Brief Pain Inventory, sleep was measured by the Pittsburgh Sleep Quality Index, and reported disability was measured by the Roland Morris Scale. Results Baseline characteristics were similar across groups. An intent-to-treat analysis using general linear models showed positive improvement in pain in acupressure groups compared with usual care. Pain was reduced by 35-36% in the acupressure groups. Improvement in fatigue was also found in stimulating acupressure compared with usual care. Adverse events were minimal and related to application of too much pressure. Discussion Although this was a small study, acupressure demonstrated promising preliminary support of efficacy for pain and fatigue reduction in this population.

Dual-Energy CT-Based Differentiation of Benign Posttreatment Changes From Primary or Recurrent Malignancy of the Head and Neck: Comparison of Spectral Hounsfield Units at 40 and 70 keV and Iodine Concentration.

OBJECTIVE: The goals of our study were to evaluate dual-energy CT (DECT) differences between benign posttreatment changes and primary or recurrent head and neck malignancies in terms of spectral Hounsfield units for virtual monochromatic series at 40 keV and iodine concentration and compare their utility with that of spectral Hounsfield units at 70 keV. MATERIALS AND METHODS: A retrospective review of patients with a history of head and neck malignancy evaluated with DECT of the neck from November 2012 through December 2014 revealed 16 patients with benign posttreatment changes and 24 with malignancies (17 primary tumors and seven recurrent tumors). One reader placed ROIs within benign posttreatment changes or malignant tumors in each patient to generate spectral Hounsfield units at 40 keV, iodine concentration, and spectral Hounsfield units at 70 keV, and the Wilcoxon rank sum test was used to evaluate the differences between the two cohorts. ROC curves were also generated, and AUC and partial AUC were calculated at the three following specificities: 75%, 80%, and 90%. RESULTS: Malignant tissues were significantly different from benign posttreatment changes in spectral Hounsfield units at 40 keV (p < 0.0001), iodine concentration (p < 0.0001), and spectral Hounsfield units at 70 keV (p = 0.0001). The AUCs were 0.949, 0.943, and 0.858 for spectral Hounsfield units at 40 keV, iodine concentration, and spectral Hounsfield units at 70 keV, respectively. Both spectral Hounsfield units at 40 keV and iodine concentration had statistically higher partial AUCs than spectral Hounsfield units at 70 keV at 90% specificity (p = 0.0133 and 0.0063, respectively) but were not significantly different from each other. CONCLUSION: DECT-derived spectral Hounsfield units at 40 keV and iodine concentration may be superior to spectral Hounsfield units at 70 keV, which is similar to MDCT, in differentiating benign posttreatment changes from primary or recurrent head and neck malignancies.

Quality of consumer-targeted internet guidance on home firearm and ammunition storage.

BACKGROUND AND OBJECTIVES: Four storage practices protect against unintentional and/or self-inflicted firearm injury among children and adolescents: keeping guns locked (1) and unloaded (2) and keeping ammunition locked up (3) and in a separate location from the guns (4). Our aim was to mimic common Google search strategies on firearm/ammunition storage and assess whether the resulting web pages provided recommendations consistent with those supported by the literature. METHODS: We identified 87 web pages by Google search of the 10 most commonly used search terms in the USA related to firearm/ammunition storage. Two non-blinded independent reviewers analysed web page technical quality according to a 17-item checklist derived from previous studies. A single reviewer analysed readability by US grade level assigned by Flesch-Kincaid Grade Level Index. Two separate, blinded, independent reviewers analysed deidentified web page content for accuracy and completeness describing the four accepted storage practices. Reviewers resolved disagreements by consensus. RESULTS: The web pages described, on average, less than one of four accepted storage practices (mean 0.2 (95% CL 0.1 to 0.4)). Only two web pages (2%) identified all four practices. Two web pages (2%) made assertions inconsistent with recommendations; both implied that loaded firearms could be stored safely. Flesch-Kincaid Grade Level Index averaged 8.0 (95% CL 7.3 to 8.7). The average technical quality score was 7.1 (95% CL 6.8 to 7.4) out of an available score of 17. There was a high degree of agreement between reviewers regarding completeness (weighted κ 0.78 (95% CL 0.61 to 0.97)). CONCLUSIONS: The internet currently provides incomplete information about safe firearm storage. Understanding existing deficiencies may inform future strategies for improvement.

Ultrasound shear wave speed measurements correlate with liver fibrosis in children.

BACKGROUND: Little published research has shown the relationship between noninvasive US shear wave speed (SWS) measurements and degree of liver fibrosis as established by percutaneous biopsy in children. OBJECTIVE: To assess the relationship between liver US shear wave speed (SWS) measurements and parenchymal fibrosis in children. MATERIALS AND METHODS: Sixty-two children (0-18 years old) with known or suspected liver disease underwent same-day US shear wave elastography (SWE) and clinically ordered percutaneous core needle biopsy. SWE was performed just before the liver biopsy in the area targeted for sampling, using an Acuson S3000 US system with a 9L4 transducer; six SWS measurements were acquired using Virtual Touch Quantification (VTQ) and Virtual Touch IQ (VTIQ) modes. Biopsy specimens were scored for histological fibrosis and inflammation. Bivariate relationships were assessed using Pearson correlation, while multiple linear regression analysis was used to establish the relationship between SWS and predictor variables. Receiver operating characteristic (ROC) curves were created to assess the abilities of VTQ and VTIQ to discern low vs. high liver fibrosis (histological fibrosis scores 0-2 vs. 3-6). RESULTS: There were significant positive correlations between liver histological fibrosis score and VTQ (n = 49) and VTIQ (n = 48) mean shear wave speed measurements (r = 0.68 and r = 0.73; P-values <0.0001). There also were significant positive correlations between liver histological inflammation score and VTQ and VTIQ mean shear wave speed measurements (r = 0.47 and r = 0.44, and P = 0.0006 and P = 0.0016, respectively). For VTQ, both histological fibrosis (P < 0.0001) and inflammation (P = 0.04) scores were significant predictors of shear wave speed (model adjusted R (2) = 0.49). For VTIQ, only histological fibrosis score (P < 0.0001) was a significant predictor of shear wave speed (model adjusted R (2) = 0.56). ROC areas under the curve were 0.84 and 0.86 for VTQ and VTIQ, respectively. CONCLUSION: Liver US shear wave speed measurements increase with increasing parenchymal fibrosis in children.

Model-based iterative reconstruction: effect on patient radiation dose and image quality in pediatric body CT.

PURPOSE: To retrospectively compare image quality and radiation dose between a reduced-dose computed tomographic (CT) protocol that uses model-based iterative reconstruction (MBIR) and a standard-dose CT protocol that uses 30% adaptive statistical iterative reconstruction (ASIR) with filtered back projection. MATERIALS AND METHODS: Institutional review board approval was obtained. Clinical CT images of the chest, abdomen, and pelvis obtained with a reduced-dose protocol were identified. Images were reconstructed with two algorithms: MBIR and 100% ASIR. All subjects had undergone standard-dose CT within the prior year, and the images were reconstructed with 30% ASIR. Reduced- and standard-dose images were evaluated objectively and subjectively. Reduced-dose images were evaluated for lesion detectability. Spatial resolution was assessed in a phantom. Radiation dose was estimated by using volumetric CT dose index (CTDI(vol)) and calculated size-specific dose estimates (SSDE). A combination of descriptive statistics, analysis of variance, and t tests was used for statistical analysis. RESULTS: In the 25 patients who underwent the reduced-dose protocol, mean decrease in CTDI(vol) was 46% (range, 19%-65%) and mean decrease in SSDE was 44% (range, 19%-64%). Reduced-dose MBIR images had less noise (P > .004). Spatial resolution was superior for reduced-dose MBIR images. Reduced-dose MBIR images were equivalent to standard-dose images for lungs and soft tissues (P > .05) but were inferior for bones (P = .004). Reduced-dose 100% ASIR images were inferior for soft tissues (P < .002), lungs (P < .001), and bones (P < .001). By using the same reduced-dose acquisition, lesion detectability was better (38% [32 of 84 rated lesions]) or the same (62% [52 of 84 rated lesions]) with MBIR as compared with 100% ASIR. CONCLUSION: CT performed with a reduced-dose protocol and MBIR is feasible in the pediatric population, and it maintains diagnostic quality.

Adrenal Incidentaloma triage with single-source (fast-kilovoltage switch) dual-energy CT.

OBJECTIVE: The purpose of this article is to evaluate single-source dual-energy CT (DECT) for distinguishing benign and indeterminate adrenal nodules, with attention to the effects of phase of IV contrast enhancement. MATERIALS AND METHODS: A retrospective review revealed 273 contrast-enhanced abdominal DECT examinations from November 2009 through March 2012. Fifty adrenal nodules 0.8 cm or larger were identified in 41 patients (22 women and 19 men; average age, 66 years; age range, 36-88 years). CT postprocessing and measurements were independently performed by two radiologists (readers 1 and 2) for each nodule, as follows: attenuation (in Hounsfield units) on true unenhanced images; contrast-enhanced attenuation (in Hounsfield units) on monochromatic spectral images at 40, 75, and 140 keV; and contrast-enhanced material density (in milligrams per milliliter) on virtual unenhanced images. Nodules were classified as benign (< 10 HU) and indeterminate (≥ 10 HU) according to true unenhanced images. RESULTS: Interreader agreement regarding benign and indeterminate nodules was high (κ = 0.92; 95% CI, 0.8-1.0). At 140 keV, the attenuation of benign nodules was significantly lower (reader 1, 7.0 ± 12.5 HU; reader 2, 7.8 ± 9.2 HU) than that of indeterminate nodules (reader 1, 15.7 ± 20.5 HU [p = 0.004]; reader 2, 17.5 ± 13.4 HU [p < 0.0001]). On virtual unenhanced images, benign nodules had significantly lower material density (reader 1, 992.4 ± 9.9 mg/mL; reader 2, 992.7 ± 9.6 mg/mL) than did indeterminate nodules (reader 1, 1001.1 ± 20.5 mg/mL [p = 0.038]; reader 2, 1007.6 ± 13.4 mg/mL [p < 0.0001]). CONCLUSION: DECT tools can mathematically subtract iodine or minimize its effects in high-energy reconstructions, approximating unenhanced imaging and potentially reducing the need for additional studies to triage adrenal nodules detected on contrast-enhanced DECT examinations.

Ultrasound shear wave elastography helps discriminate low-grade from high-grade bowel wall fibrosis in ex vivo human intestinal specimens.

OBJECTIVES: To determine whether bowel wall fibrosis can be detected in freshly resected human intestinal specimens based on ultrasound-derived shear wave speed. METHODS: Seventeen intact (>3-cm) bowel segments (15 small and 2 large intestine) from 12 patients with known or suspected inflammatory bowel disease were procured immediately after surgical resection. Ultrasound shear wave elastography of the bowel wall was performed by two methods (Virtual Touch Quantification [VTQ] and Virtual Touch-IQ [VT-IQ]; Siemens Medical Solutions USA, Inc, Mountain View, CA). Eighteen short-axis shear wave speed measurements were acquired from each specimen: 3 from the 9-, 12-, and 3-o'clock locations for each method. Imaging was performed in two areas for specimens greater than 10 cm in length (separated by ≥5 cm). A gastrointestinal pathologist scored correlative histologic slides for inflammation and fibrosis. Differences in mean shear wave speed between bowel segments with low and high inflammation/fibrosis scores were assessed by a Student t test. Receiver operating characteristic curve analysis was performed. RESULTS: High-fibrosis score (n = 11) bowel segments had a significantly greater mean shear wave speed than low-fibrosis score (n = 6) bowel segments (mean ± SD: VTQ, 1.59 ± 0.37 versus 1.18 ± 0.08 m/s; P= .004; VT-IQ, 1.87 ± 0.44 versus 1.50 ± 0.26 m/s; P= .049). There was no significant difference in mean shear wave speed between high-and low-inflammation score bowel segments (P > .05 for both VTQ and VT-IQ). Receiver operating characteristic curves showed areas under the curve of 0.91 (95% confidence interval, 0.67-0.99) for VTQ and 0.77 (95% confidence interval, 0.51-0.94) for VT-IQ in distinguishing low-from high-fibrosis score bowel segments. CONCLUSIONS: Ex vivo bowel wall shear wave speed measurements increase when transmural intestinal fibrosis is present.

Efficacy of a cartoon and photograph montage storybook in preparing children for voiding cystourethrogram.

BACKGROUND: Undergoing voiding cystourethrogram (VCUG) can be distressing for children. OBJECTIVE: To assess the efficacy of a cartoon and photograph montage storybook in preparing children for VCUG. MATERIALS AND METHODS: Outpatient children (ages 2-14 years) who had VCUGs between December 2011 and June 2012 were randomly assigned to two groups; one group received the storybook a week before the procedure. Parents and guardians were asked to complete an anonymous survey rating their child's tolerance of the exam from 1 to 5, worst to best, immediately after VCUG. The VCUG technologist also rated the child's tolerance. RESULTS: Children prepared for VCUG with the storybook had less distress than those without. Results were analyzed by Cochran-Mantel-Haenszel and Cochran-Armitage Trend exact tests, a P value of both tests of 0.0092 indicating a statistically significant difference between the tolerance scores of children prepared with the storybook and those without. Effects of gender and history of VCUG were not statistically significant. Two-thirds of all children had no other source of information. CONCLUSION: The cartoon and photograph montage storybook format of preparing children for VCUG was effective in increasing their tolerance for the procedure. The storybook should be mailed out in advance because the majority of families did not pursue information on preparing their children for VCUG.

Is venous foot pump effective in prevention of thromboembolic disease after joint arthroplasty: a meta-analysis.

The goal of this meta-analysis was to evaluate the efficacy of venous foot pumps in prevention of venous thromboembolism following joint arthroplasty. Using different databases, we found 13 prospective clinical trials published meeting our inclusion criteria. In total, 1514 patients were included in the final analysis. Venous foot pump devices are effective in prevention of venous thromboembolic disease after total hip and knee arthroplasty compared to chemoprophylaxis. This was especially significant in prevention of major deep vein thrombosis and pulmonary emboli rate. The use of mechanical devices like venous calf or foot pump, either alone or in combination with less potent chemical prophylaxis, on the other hand can reduce the rate of venous thromboembolism and complications of potent chemoprophylaxis like wound hematoma.

Ethical Perspectives of Chinese and United States Physicians at Initiation of a Research Collaborative.

Variances in perceived standards regarding research integrity appear to exist between China and the U.S. An established joint institute for translational and clinical research between one Chinese and one U.S. health system provides a valuable venue in which to evaluate these perceptions better. We therefore undertook a survey of 209 physicians at the two institutions in 2013-14. The vast majority of physicians from both institutions understood the necessity of obtaining informed consent from research participants, the need to provide a description of the risks of participation, and the voluntary nature of research participation. However, there were differences in responses between the two sites in willingness to report plagiarism (U.S. 95.65% vs. Chinese 40.21%; p < .0001) and data falsification (U.S. 100% vs. Chinese 81.25%; p < .0001) and in willingness to attend biomedical industry-funded promotional events (U.S. 11.0% vs. Chinese 74.0%; p < .0001). When planning to conduct collaborative clinical research across cultures, particularly when uncertainty regarding the similarity of research cultures exists, exploration of cultural and ethical norms in research may be informative regarding educational needs and the risks of research and academic misconduct.

Radiographic stool quantification: an equivalence study of 484 symptomatic and asymptomatic subjects.

PURPOSE: To determine if symptomatic patients referred for radiographic stool quantification have equivalent stool burden to asymptomatic patients. METHOD: This was an IRB-approved HIPAA-compliant retrospective equivalence cohort study. An a priori equivalence power calculation was performed. Consecutive abdominal radiographs performed in adult outpatients with bloating, constipation, diarrhea, or abdominal pain to assess "fecal loading" [n = 242 (fecal cohort)] were compared to those performed in asymptomatic adult outpatients to assess "renal stones" [n = 242 (renal cohort)]. Radiographs were randomized and reviewed by two blinded independent abdominal radiologists. Exclusion criteria, designed to avoid unblinding, included urinary tract calculi ≥ 0.5 cm, multiple urinary tract calculi, and ureteral stent(s). Readers scored all radiographs (n = 484) for stool burden using validated Leech criteria [scale: 0 (none) to 15 (extreme diffuse)]. Mean Leech scores and 95% confidence intervals were calculated. Multivariable generalized linear modeling was performed to adjust for baseline medication use, age, and gender. The adjusted parameter estimate was used to test for equivalence in the mean difference between cohorts using Schuirmann's method of two one-sided t-tests. Inter-reader agreement was assessed with intraclass correlation coefficients. RESULTS: Overall mean Leech scores for fecal [6.9 (95% CI 6.7, 7.2)] and renal [7.3 (95% CI 7.1, 7.5)] cohorts were equivalent within a margin of 0.75 (adjusted mean difference: - 0.4 [90% CI - 0.7, - 0.04]; p value = 0.02). Inter-reader agreement was good [ICC: 0.62 (95% CI 0.56, 0.68)]. CONCLUSION: Radiographic stool quantification produces equivalent results in symptomatic and asymptomatic adults and is of uncertain value.

Diagnostic accuracy of MDCT in differentiating gallbladder cancer from acute and xanthogranulomatous cholecystitis.

OBJECTIVE: To determine the diagnostic accuracy of multi-detector CT (MDCT) for differentiating gallbladder cancer from acute and xanthogranulomatous cholecystitis using previously described imaging features. METHODS: In this IRB approved HIPAA-compliant retrospective cohort study, contrast-enhanced MDCT of histologically confirmed acute cholecystitis (n = 17), xanthogranulomatous cholecystitis (n = 25), and gallbladder cancer (n = 18) were reviewed independently by three abdominal radiologists blinded to outcome. The primary outcome was the diagnostic accuracy of MDCT for the differentiation of gallbladder cancer from cholecystitis (acute and xanthogranulomatous) using various imaging parameters. Kappa (κ) statistics and two-way mixed-model single-measure intra-class correlation statistics (ICC) were calculated for each imaging feature and the final radiologic diagnosis. RESULTS: Inter-rater agreement was moderate to substantial (κ = 0.43-0.70), sensitivity 0.67-0.78, specificity 0.22-0.33 and the positive likelihood ratio was 4.28-8.56 for the differentiation of gallbladder cancer from benign gallbladder pathology. Only three imaging findings: disrupted gallbladder mucosa (κ = 0.68), intraluminal gallstones (κ = 0.66), and gallbladder wall thickness (ICC = 0.63) had substantial inter-rater agreement. The following had slight or no agreement: intramural hypoattenuating nodules (κ = 0.17), transient hepatic attenuation differences (κ = 0.14), gallbladder wall calcification (κ = -0.01), gallbladder wall enhancement (κ = 0.18), and omental or mesenteric invasion (κ = 0.08). In the final multivariate model, the following were significant predictors useful in making or excluding diagnosis of gallbladder cancer: focal gallbladder wall thickening (p = 0.003, OR: 13.09 [95% CI: 2.40-71.48]), pericholecystic "fat stranding" (p = 0.018, OR: 0.10 [95% CI: 0.01-0.66]), and maximum short axis lymph node diameter (p = 0.043, OR: 1.18 [95% CI: 1.00-1.38]). CONCLUSION: MDCT has moderate sensitivity, poor specificity, and moderate-to-substantial inter-rater repeatability for the differentiation of gallbladder cancer from acute and xanthogranulomatous cholecystitis.

Academic institution pilot study shows far fewer diagnoses of sinusitis than reported nationally.

OBJECTIVE: To compare the prevalence of acute sinusitis (AS) and chronic sinusitis (CS) diagnosed by primary care and emergency medicine physicians in our academic institution to national data. STUDY DESIGN: Cross-sectional pilot study of institutional census data and a population-based national sample. The setting was primary care and emergency departments at an academic healthcare institution and community healthcare practices nationally. MATERIALS AND METHODS: We determined the proportion of adults visits at our institution for AS and CS from January 1, 2005, to December 31, 2010. We used the same parameters with the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. As a control comparison, we determined the proportion of visits for epistaxis. RESULTS: The sinusitis prevalence was considerably lower at our academic institution: all sinusitis (AS and CS combined) ranged from 0.8% to 1.0% at our institution compared to 3.1% to 3.7% nationally. There were very small differences between AS rates at the academic institution (0.7%-0.8%) and nationally (0.8%-1.4%, P < 0.001) but very large differences between CS rates at the academic institution (0.1%) and national data (1.7%-2.9%, P < 0.001). Epistaxis rates were nearly identical in both datasets (0.1%-0.2%, P = 0.98-0.99). CONCLUSION: The prevalence of CS is much lower at our academic institution, but the prevalence of AS and epistaxis are similar to national data. This suggests CS is over-diagnosed by primary care and emergency medicine providers and that CS diagnosed outside of an academic institution or a specialty clinic may not hold up to diagnostic scrutiny. For this reason, diagnostic and treatment protocols for CS that have been developed in academic specialty clinics should not be extrapolated to patients diagnosed with CS in the community setting. The most appropriate intervention for the majority of patients diagnosed with CS in primary care and emergency medicine may be education of providers and patients about conditions that may be misdiagnosed as CS.

A diagnostic dilemma: chronic sinusitis diagnosed by non-otolaryngologists.

BACKGROUND: Ambulatory care visits for chronic sinusitis outnumber visits for acute sinusitis. The majority of these visits are with non-otolaryngologists. In order to better understand patients diagnosed with chronic sinusitis by non-otolaryngologists, we sought to determine if incident cases of chronic sinusitis diagnosed by primary care (PC) or emergency medicine (EM) providers meet diagnostic criteria. METHODS: This was a retrospective cohort study. Patients were identified using administrative data from 2005 to 2006. The dataset was then clinically annotated based on chart review. We excluded prevalent cases. RESULTS: We identified 114 patients with newly diagnosed chronic sinusitis in EM (75) or PC settings (39). Rhinorrhea (EM 61%, PC 59%) and nasal obstruction (EM 67%, PC 64%) were common in both settings but facial fullness (EM 80%, PC 39%) and pain (EM 40%, PC 18%) were more common in the EM setting. Few patients reported symptoms of 90 days or longer (EM 6.0%, PC 24%) and no patient had evidence of inflammation on physical examination. A minority of patients received a sinus computed tomography (CT) scan (22.8%) or nasal endoscopy (1.8%). In total, only 1 patient diagnosed with chronic sinusitis met the diagnostic criteria. CONCLUSION: Most patients diagnosed with chronic sinusitis by non-otolaryngologists do not have the condition. Caution should be used in studying chronic sinusitis using administrative data from non-otolaryngology providers because a large proportion of the patients may not actually have the disease.

Diagnosis and treatment of acute sinusitis in the primary care setting: A retrospective cohort.

OBJECTIVES AND HYPOTHESIS: Our objectives were to characterize the quality of acute sinusitis care and to identify nonclinical factors associated with antibiotic use for acute sinusitis. We hypothesized that we would identify provider-level factors associated with antibiotic use. STUDY DESIGN: Retrospective cohort at a single academic institution. METHODS: We developed and clinically annotated an administrative dataset of adult patients diagnosed with acute sinusitis between January 1, 2005, and December 31, 2006. We used identify factors associated with receipt of antibiotics. RESULTS: We find that 66.0% of patients with mild symptoms of short duration are given antibiotics, and that nonclinical factors, including the individual provider, the provider's specialty, and the presence of a medical trainee, significantly influence antibiotic use. Relative to internal medicine providers, family medicine providers use fewer antibiotics, and emergency medicine providers use more antibiotics for acute sinusitis. CONCLUSIONS: Antibiotics continue to be overused for patients with mild acute sinusitis of short duration. Nonclinical characteristics, including the individual provider, the provider's specialty, and the presence of a medical trainee, significantly influence use of antibiotics for acute sinusitis. LEVEL OF EVIDENCE: 4.

Cell count and differential of aspirated fluid in the diagnosis of infection at the site of total knee arthroplasty.

BACKGROUND: Although there is no absolute diagnostic test for periprosthetic infection, the synovial fluid leukocyte count and neutrophil percentage have been reported to have high sensitivity and specificity. However, the cutoff values for these tests are not agreed upon. We sought to identify definite cutoff values for both the fluid leukocyte count and the neutrophil percentage that may help to diagnose infection at the site of a prosthetic joint. METHODS: We analyzed synovial fluid that had been aspirated preoperatively from 429 knees that had undergone revision arthroplasty at three different academic institutions; 161 knees were found to be infected, and 268 knees were not. Using receiver operating characteristic curves, we determined cutoff values for the fluid leukocyte count and neutrophil differential with an optimal balance of sensitivity and specificity for the diagnosis of periprosthetic infection. The sensitivity, specificity, and predictive values were calculated for those cutoff values. The erythrocyte sedimentation rate and C-reactive protein level cutoff values of 30 mm/hr and 10 mg/L, respectively, were combined with the cutoff values for the fluid leukocyte count and neutrophil percentage. RESULTS: The cutoff values for optimal accuracy in the diagnosis of infection were >1100 cells/10(-3)cm(3) for the fluid leukocyte count and >64% for the neutrophil differential. When both tests yielded results below their cutoff values, the negative predictive value of the combination increased to 98.2% (95% confidence interval, 95.5% to 99.5%), whereas when both tests yielded results greater than their cutoff values, infection was confirmed in 98.6% (95% confidence interval, 94.9% to 99.8%) of the cases in our cohort. Similarly, when both the neutrophil percentage and the C-reactive protein level were less than the cutoff values of 64% and 10 mg/L, respectively, the presence of periprosthetic infection was very unlikely. CONCLUSIONS: The synovial fluid leukocyte count and differential are useful adjuncts to the erythrocyte sedimentation rate and the C-reactive protein level in the preoperative workup of infection at the site of a total knee arthroplasty. The present study identified cutoff values for the leukocyte count (>1100 cells/10(-3)cm(3)) and neutrophil percentage (>64%) that can be used to diagnose infection. Combining the peripheral blood tests with the synovial fluid cell count and differential can improve their diagnostic value.

Revision total hip arthroplasty in octogenarians. A case-control study.

BACKGROUND: Revision total hip arthroplasty in the very elderly is believed to be associated with a high complication rate. We evaluated the early outcomes and prevalence of complications following revision total hip arthroplasty in patients older than eighty years of age and compared them with those in a younger patient population. METHODS: We retrospectively reviewed the results of 170 revision total hip arthroplasties that had been performed in 159 octogenarians in our institute between 1992 and 1999. The mean patient age at the time of surgery was 83.8 years, and the mean follow-up time was 6.8 years. We then compared these results with those of 170 revision total hip arthroplasties, done with the same surgical technique and prosthesis, in 162 patients who were seventy years old or younger and followed for a mean of six years. The functional outcome and the quality of life following the arthroplasties were assessed with use of the Harris hip score and the Short Form-36 (SF-36), respectively. Risk factors for complications and mortality were identified, and Kaplan-Meier analysis was used to determine survivorship. RESULTS: The octogenarians had a significant improvement in the mean Harris hip score, from 47 points preoperatively to 85 points at the time of the latest follow-up. In the control group, the Harris hip score also improved significantly, from a preoperative mean of 44.3 points to a mean of 87.9 points at the time of the latest follow-up. There was no significant difference between the two groups in the magnitude of improvement of the Harris hip score. There were 100 deaths (a rate of 58.8%) at a mean of 5.3 years postoperatively in the octogenarian group compared with twelve deaths (7.1%) in the control group (p < 0.0001). There were no intraoperative deaths in either group. Of the 100 octogenarian patients who died, 94% had a well-functioning hip at the time of death. Perioperative medical complications developed in thirty patients (thirty-eight hips [22.4%]) in the octogenarian group and in twenty-five patients (twenty-six hips [15.3%]) in the control group (p > 0.05). There were thirteen repeat revisions and four other types of reoperations in the octogenarian group and twenty-three repeat revisions and six other types of reoperations in the control group (p = 0.08). A dislocation was sustained by four patients in the octogenarian group and sixteen patients in the control group (p = 0.01). CONCLUSIONS: Revision total hip arthroplasty can provide substantial clinical benefit to patients over eighty years of age. The medical complication rate for octogenarians may not differ significantly from that for patients seventy years of age or younger, and the prevalence of technical complications and dislocations can be expected to be lower than that for younger patients.