Attitude of emergency department patients toward HIV-infected health care workers.

A telephone survey of a random sample of adult emergency department (ED) patients was conducted at a university health science center. The purpose of the study was to determine the opinion of ED patients concerning the risk of human immunodeficiency virus (HIV) transmission and their willingness to be treated by HIV-infected physicians and nurses. Surveys from 107 ED patients were compiled and available for analysis. Ninety percent of the respondents were tolerant of an HIV-infected physician or nurse (HIV + HCW)performing noninvasive procedures. Fifty percent were tolerant of an HIV + HCW performing invasive procedures. Twenty-six percent of the patients said they would leave the department rather than be treated by an HIV + HCW. Patients older than 50 years were less tolerant (P = .004) and more likely to leave the ED (P = .001).

Polyglandular autoimmune syndrome: a cause of multiple and sequential endocrine emergencies.

The polyglandular autoimmune syndromes are a rare, inherited constellation of disorders characterized by multiple endocrine end-organ failures. Since these individuals have more than one endocrine failure, it is important to recognize these syndromes in clinical practice and be alert to the possibility of a second major endocrine organ failure after one has been diagnosed.

Diagnostic efficacy of digitized images vs plain films: a study of the joints of the fingers.

Four hundred fifteen finger joints from 30 patients were evaluated for the presence of joint-space erosion, narrowing, and degenerative spurring on plain films, low-resolution digitized images (1024 x 840 bytes x 12 bit matrix), and high-resolution digitized images (2048 x 1680 bytes x 12 bit matrix). Three hundred four joints were abnormal. Low- and high-resolution digital images were displayed on a 1K x 1K monitor with the ability to change level, window, orientation, and brightness. Five radiologists interpreted images. The presence or absence of each abnormality was determined by consensus of two skeletal radiologists who did not otherwise participate in the study. Receiver-operating-characteristic analysis was used to obtain an area and a true-positive rate at a 0.10 false-positive rate for each interpreter. Randomized block analysis of variance with interpreters as blocks was used to compare areas and true-positive rates among imaging techniques for each type of abnormality; no statistically significant differences were found. In conclusion, the efficacy of display of digitized images on high- and low-resolution modes is not significantly different from that of plain films in the detection of erosions, joint-space narrowing, or degenerative spurring in small joints of the hands.

Atypical presentation of pulmonary embolism.

Today we have discussed an interesting patient with an atypical presentation of pulmonary embolism. We have outlined a suggested algorithm to aid in the diagnosis and management of this disease. References 8 through 24 in the reference section are suggested readings that offer further insight into the diagnosis and management of this entity.

Total knee replacement: radiologic findings in failure of porous-coated metal-backed patellar component.

One technique for replacing the articular surface of the patella in total knee replacement is the use of a cementless porous-coated metal-backed polyethylene component. Anteroposterior, lateral, and Merchant or skyline radiographs in 10 cases of porous-coated metal-backed components that failed were evaluated for component alignment, component displacement, radiolucencies, loose beads, and integrity of the patellar component. Component failure was documented by surgery in all 10 cases. Seven cases of failure involved the patellar pegs or junction of the pegs with the metal backing and three cases involved the polyethylene portion. In the seven cases of peg-metal backing failure, three cases showed loose beads before failure and seven cases showed displacement of the metal backing at time of failure. All three cases of polyethylene failure showed narrowing or displacement of the polyethylene portion. Our experience shows that displacement of the metal backing, displacement of the polyethylene, and disruption of patellar pegs are seen in failed porous-coated metal-backed patellar components. Loose beads may be seen before peg-metal backing failure.

Comparison of digital and conventional musculoskeletal radiography: an observer performance study.

Interpretations of 122 musculoskeletal radiographs were compared with interpretations of their digital counterparts at a resolution of 1,024 X 840 X 12 bits. Images were evaluated by four readers and included subtle and nonsubtle abnormalities and normal findings. Joint receiver operating characteristic (ROC) analysis results were averaged over all readers and demonstrated no statistically significant difference between the two imaging methods. High interobserver variability limited identifiable differences. Review of cases with subtle findings on the digital system at a resolution of 2,048 X 1,680 X 12 bits (2.5 line pairs per millimeter) revealed adequate visualization of the abnormality in every case. It is concluded that a resolution of 1,024 X 840 X 12 bits is adequate for the interpretation of many musculoskeletal abnormalities but that a resolution of 2,048 X 1,680 X 12 bits is needed for visualization of some subtle abnormalities.

Autonomic dysreflexia: a potentially fatal complication of somatic stress in quadriplegics.

A 44-year-old patient with known, stable, long-standing quadriplegia sustained a midshaft left femur fracture in a motor vehicle accident. He presented to the emergency department (ED) two days after the accident with a chief complaint of a swollen left thigh. Management in the ED included x-ray studies and some incidental manipulation during the process of examination and splinting. While awaiting discharge, the patient, although asymptomatic, was observed to be very profusely diaphoretic above the level of his cord lesion. Blood pressure was then noted to be 230/110, far above his admission blood pressure of 110/70. A diagnosis of autonomic dysreflexia was made and the patient admitted for treatment. Fracture manipulation in the ED is herein reported to be one of the many types of acute traumatic and atraumatic somatic stresses that can cause this serious and occasionally lethal syndrome. Signs and symptoms that need to be watched for are discussed.

Special diagnostic procedures in sports medicine.

In summary, there are a number of imaging procedures available to support the physician in his or her evaluation of sports injuries. Conventional radiographs remain the primary imaging examination. Specialized radiographic projections will often provide additional pertinent information. A fluoroscopic examination or conventional tomography may provide a cost-effective method of clarifying subtle post-traumatic changes. The use of the more sophisticated and costly imaging procedures should be reserved for those cases in which a diagnosis cannot be made with simpler technology. CT scanning, by virtue of its ability to image in the axial plane, has proved to be an effective method of documenting injuries particularly in complex bony anatomy such as the spine, wrist, elbow, and hips. CT arthrography provides diagnostic information about intra-articular structures. MRI is emerging as an excellent method of noninvasively imaging injuries to soft-tissue structures such as tendons, ligaments, and cartilage. The advancements in MRI technology that are projected for the future may expand the range of usefulness of this modality and decrease the current high cost of these procedures. Radionuclide scanning with Tc99m diphosphonate compounds has proved to be an efficient method of localizing subtle bone pathology and providing a "road map" for further analysis with additional imaging techniques. The cost-effective use of all of these imaging procedures is predicated on an understanding of their usefulness in the diagnosis of each clinical problem and the judicious use of each procedure to fit the needs of the individual patient.

Puncture wounds to the foot.

Puncture wounds to the foot are common presenting problems in most busy emergency departments. Although seemingly benign, the sequelae after simple puncture wounds to the foot can include cellulitis, retained foreign bodies, or even osteomyelitis. Inadequate scientific research on this topic has left only anecdotal or retrospective reports for review in the medical literature. Antibiotics, radiographs, or surgical exploration in the management of puncture wounds to the foot all lack clinical studies to support their use. This review summarizes the literature and points to the inconsistencies in the management of puncture wounds to the foot.

Skull x-ray examinations after head trauma. Recommendations by a multidisciplinary panel and validation study.

The value of skull radiography in identifying intracranial injury has not yet been satisfactorily defined. A multidisciplinary panel of medical experts was assembled to review the issue of skull radiography for head trauma. The panel identified two main groups of patients--those at high risk of intracranial injury and those at low risk of such injury--and developed a management strategy for imaging in the two groups. The high-risk group consists primarily of patients with severe open or closed-head injuries who have a constellation of findings that are usually clinically obvious. These patients are candidates for emergency CT scanning, neurosurgical consultation, or both. The low-risk group includes patients who are asymptomatic or who have one or more of the following: headache, dizziness, scalp hematoma, laceration, contusion, or abrasion. Radiographic imaging is not recommended for the low-risk group and should be omitted. An intermediate moderate-risk group is less well defined, and skull radiography in this group may sometimes be appropriate. A prospective study of 7035 patients with head trauma at 31 hospital emergency rooms was conducted to validate the management strategy. No intracranial injuries were discovered in any of the low-risk patients. Therefore, no intracranial injury would have been missed by excluding skull radiography for low-risk patients, according to the protocol. We conclude that use of the management strategy is safe and that it would result in a large decrease in the use of skull radiography, with concomitant reductions in unnecessary exposure to radiation and savings of millions of dollars annually.

Posttraumatic skull films: who needs them?

An effort has been under way for years to make the ordering of skull films in trauma more medically rational. Because the vast majority of skull films have no significant impact on patient management, effort had centered on increasing the yield by limiting radiographs to those who have one or more "high-yield criteria." The publically promulgated high-yield criteria, however, were insufficiently sensitive to pick up some rare occult injuries. Emphasis recently has shifted to low-yield findings (scalp laceration, scalp hematoma, dizziness, headache, and asymptomatic). Although by common practice the presence of one or more of these low-yield findings often results in a skull film, omitting them appears to be extremely safe provided that the patient has no other clinically suspicious findings. Additionally, skull films are no longer the procedure of choice in patients with a neurosurgical emergency. A patient management strategy reflecting recent research is soon to be released with the FDA Skull Panel's final report.

Most frequently overlooked radiographically apparent fractures in a teaching hospital emergency department.

A retrospective review was made of fractures for which radiographic manifestations were missed by various physicians working in the ED. It revealed that fractures of three anatomic sites were being missed disproportionately often--fractures of the navicular, elbow, and calcaneus. Fractures of these sites were the most likely to be missed when present. This effect was so pronounced that elbow fractures were missed as often as phalanx fractures, even though phalanx fractures were seen in the ED more than three times as frequently. The sites with the most missed fractures in gross numbers were ribs, elbow, and the periarticular region of the phalanges, with these three sites accounting for 38% of all missed fractures seen. The elbow was the only site occurring both on the list of fractures missed disproportionately often and on the list of fractures missed most frequently. Some common fractures were not missed at all (Colle's fracture), and others were missed infrequently (hip fracture, midshaft long bone fracture). Knowledge of those fractures that are most likely to be missed makes possible a more directed educational effort.

Auditory processing tests for children: normative and clinical results on the SSW test.

Staggered Spondaic Word (SSW) test results were studied in 93 normally achieving children and 97 children referred to a learning disabilities clinic. All subjects were 8-11 years of age. The SSW test was found to differentiate between the normally achieving children and those experiencing classroom learning difficulties. Further, it was found that the performance of the normally achieving group was generally better than current test norms would imply. This finding suggests the use of stricter criteria in determining when a child is at risk for central auditory processing difficulties. Results for children with classroom learning difficulties show a progression toward better performance with age, except for the Left-Competing condition. This makes it unclear whether one can or cannot expect some resolution of auditory processing difficulties by age 11.