Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment.

BACKGROUND AND PURPOSE: Qualitative CT perfusion (CTP) assessment by using the Alberta Stroke Program Early CT Score (ASPECTS) allows rapid calculation of infarct extent for middle cerebral artery infarcts. Published thresholds exist for noncontrast CT (NCCT) ASPECTS, which may distinguish outcome/complication risk, but early ischemic signs are difficult to detect. We hypothesized that different ASPECTS thresholds exist for CTP parameters versus NCCT and that these may be superior at predicting clinical and radiologic outcome in the acute setting. MATERIALS AND METHODS: Thirty-six baseline acute stroke NCCT and CTP studies within 3 hours of symptoms were blindly reviewed by 3 neuroradiologists, and ASPECTS were assigned. Treatment response was defined as major neurologic improvement when a > or =8-point National Institutes of Health Stroke Scale improvement at 24 hours occurred. Follow-up NCCT ASPECTS and 90-day modified Rankin score (mRS) were radiologic and clinical reference standards. Receiver operating characteristic curves derived optimal thresholds for outcome. RESULTS: Cerebral blood volume and NCCT ASPECTS had similar radiologic correlations (0.6 and 0.5, respectively) and best predicted infarct size in the absence of major neurologic improvement. A NCCT ASPECT threshold of 7 and a cerebral blood volume threshold of 8 discriminated patients with poor follow-up scans (P < .0002 and P = .0001) and mRS < or =2 (P = .001 and P < .001). Only cerebral blood volume predicted major neurologic improvement (P = .02). Interobserver agreement was substantial (intraclass correlation coefficient, 0.69). Cerebral blood volume ASPECTS sensitivity, specificity, positive predictive value, and negative predictive value for clinical outcome were 60%, 100%, 100%, and 45%, respectively. No patients with cerebral blood volume ASPECTS <8 achieved good clinical outcome. CONCLUSION: Cerebral blood volume ASPECTS is equivalent to NCCT for predicting radiologic outcome but may have an additional benefit in predicting patients with major neurologic improvement.

Where do family practice patients go in case of emergency?

OBJECTIVE: To determine the annual incidence of patient-defined emergencies and patients' use of emergency services at a family medicine teaching unit. DESIGN: Cross-sectional survey. SETTING: Hospital-based family medicine teaching unit in Montreal. PARTICIPANTS: Registered patients attending a family medicine teaching unit during 11 consecutive weekdays. MAIN OUTCOME MEASURES: Annual incidence of patient-defined medical emergencies and use of emergency services at the unit. RESULTS: Eligible patients made 815 visits during the study period; 584 usable questionnaires were returned for a response rate of 71.7%. In the previous 12 months, 37% of patients reported at least one medical emergency. For their last emergency, 42% reported using at least one of the emergency services offered by the clinic. Only 19% of patients with after-hours emergencies reported using our on-call system. Although socioeconomic and clinical variables did not predict the incidence of patient-defined emergencies, multivariate analysis revealed three significant predictors for use: patients with the practice for 5 or more years were more likely to use our services, while patients 75 and older and those with emergencies after hours were less likely to use our services. CONCLUSIONS: In an urban group family practice, annual incidence of medical emergencies among registered patients was 37%. Those whose most recent emergency occurred after hours used the clinics' emergency on-call services disappointingly little.

The effect of intramedullary cement on intercalary allograft reconstruction of bone defects after tumour resection: a pilot study.

OBJECTIVE: A pilot study to evaluate the surgical and functional results of resection and reconstruction of diaphyseal bone tumours with cemented and uncemented intercalary allografts. DESIGN: A retrospective case series. SETTING: A quaternary care unit within a teaching hospital. PATIENTS: Twenty-two patients with diaphyseal bone tumours treated between 1988 and 1992, with mean follow-up of 38 months (range from 20 to 70 months). INTERVENTIONS: Diagnostic biopsy in all patients. Preoperative and postoperative chemotherapy in patients with high-grade sarcoma. En-bloc excision of all tumours. Reconstruction of the defect with cemented (15 patients) or uncemented (7 patients) intercalary allografts. MAIN OUTCOME MEASURES: Nonunion at one or both osteosynthesis sites, death from systemic disease, amputation. RESULTS: Six of the 22 patients died of systemic disease with the graft intact, and 3 subsequently had amputation for either local recurrence (2 patients) or failure of free tissue transfer (1 patient), leaving 13 patients alive with the allograft in situ at an average of 36 months (range from 24 to 64 months). There were no revision procedures to remove or replace the original allograft. Five patients had nonunion at one or more osteosynthesis sites on plain radiographs 9 months after resection. Four patients with nonunion were in the cemented group of 13 patients available for assessment at 9 months, and 1 was in the uncemented group of 5 patients available for assessment at 9 months. There were two graft fractures, both in the uncemented group. CONCLUSION: The results of this pilot study offer guarded support for the use of pressurized cement in allografts prior to reconstruction of intercalary defects.