Assessment of validity and reliability of femoral shaft-patellar tendon angle measured on MRI.

INTRODUCTION: Clinically measured Quadriceps angle (Q-angle) has low reliability. Measurement of angle between femoral shaft and patellar tendon (FSPT angle) on routine knee MRI was described in this study to represent the lateral vector forces of quadriceps mechanism. The cross-sectional study was designed to compare this angle between subjects with objective patellofemoral instability (PFI) versus those without PFI, to assess its reliability, and to assess its validity in terms of its ability to differentiate between PFI and non-PFI subjects using the "Receiver Operating Characteristic" (ROC) curve. MATERIALS AND METHODS: MRI scans of 20 subjects with PFI and 20 without PFI were obtained. FSPT angle was measured in each MRI by three different raters. In addition, the clinical Q-angle was also measured in the control group. RESULTS: The FSPT angle was significantly higher in PFI group as compared with the non-PFI group (p < 0.001). It had substantial inter-rater reliability of 0.82 (95% CI = 0.67-0.92) in the non-PFI group and 0.89 (95% CI = 0.78-0.95) in the PFI group. Test-retest reliability was more than 0.90. The AUC for the ROC curve was 0.86 (95% CI = 0.74-0.97). The clinical Q-angle measured in non-PFI subjects had inter-rater reliability of only 0.48 (95% CI = 0.21-0.72), and showed a fair correlation of 0.58 with the MRI angle. CONCLUSION: Measurement of FSPT angle was described on MRI with substantial intra-rater and inter-rater reliability. The angle was significantly higher in PFI versus non-PFI subjects and also showed a good ability to differentiate between these two groups in the ROC curve.

Assessment and Management of Hypotension in the Elderly Patient.

INTRODUCTION: Elderly patients often present to the emergency department (ED) with nonspecific signs of infection and excessive fluid loss, with limited research into their management. The purpose of this audit was to assess the initial management of hypotensive elderly patients in the ED: observations within 15 min, fluid challenge within 1 h, time to assessment by a physician, and initial management of septic shock. SUBJECTS AND METHODS: Online patient systems were reviewed to find 40 patients >65 years old who were hypotensive (systolic blood pressure <100 mmHg or diastolic blood pressure <60 mmHg) in the ED between 1st October 2015 and 16th November 2015. This data were used to perform a retrospective audit to assess their management. RESULTS: Forty hypotensive patients were identified with an average age of 79.6, with 55% being male. Eighty-three percent had their observations recorded within 15 min of presentation, 35% had their observations repeated within 1 h, and 35% were fluid challenged within 1 h. Nearly 60% patients were reviewed within 1 h by a physician. About 33% patients were in septic shock with 41% receiving IVF within 1 h, and all 40 patient receiving antibiotics. DISCUSSION: The majority of patients had their observations performed within 15 min; however, a smaller percentage was fluid challenged within 1 h with their observations rechecked. Despite a sepsis pathway, hypotensive patients were still not receiving fluids within the hour. CONCLUSION: Developing a fast-track protocol for hypotensive elderly patients in the ED could improve initial rehydration management and ensure observations are reported in a timely manner.