Interobserver variation in reporting CT arthrograms of the shoulder.

Computed tomography (CT) arthrography of the shoulder is an imaging modality of great diagnostic accuracy with regard to glenohumeral instability and in particular labral lesions. Interpretation of the scans is made difficult by the frequent occurrence of normal anatomic variants and the complexity of injuries to the bone and soft tissues. We selected a continuous sample of 50 CT arthrograms of the shoulder and they were reported by two consultant musculoskeletal radiologists. The results were collated and analysed for the level of agreement. Hill-Sachs showed Kappa (K) statistic to be 0.37 (fair agreement), soft tissue Bankart 0.32 (fair agreement), bony Bankart 0.61 (substantial agreement), anterior capsular laxity 0.41 (moderate agreement) and glenohumeral osteoarthritis 0.20 (slight agreement). All the results were significant with a p value of <0.05. Nine (18%) of the 50 scans were in complete agreement. The results demonstrate that there can be considerable interobserver variation (IOV) in the reports of a CT arthrogram of a shoulder. They highlight the potential difficulties in reporting such images and suggests ways in which the report could be more focussed to provide a clinically reliable report and one which matches the surgical findings accurately.

The complete genomes of Staphylococcus aureus bacteriophages 80 and 80α--implications for the specificity of SaPI mobilization.

Staphylococcus aureus pathogenicity islands (SaPIs) are mobile elements that are induced by a helper bacteriophage to excise and replicate and to be encapsidated in phage-like particles smaller than those of the helper, leading to high-frequency transfer. SaPI mobilization is helper phage specific; only certain SaPIs can be mobilized by a particular helper phage. Staphylococcal phage 80α can mobilize every SaPI tested thus far, including SaPI1, SaPI2 and SaPIbov1. Phage 80, on the other hand, cannot mobilize SaPI1, and ϕ11 mobilizes only SaPIbov1. In order to better understand the relationship between SaPIs and their helper phages, the genomes of phages 80 and 80α were sequenced, compared with other staphylococcal phage genomes, and analyzed for unique features that may be involved in SaPI mobilization.

Radiographers and radiologists reporting plain radiograph requests from accident and emergency and general practice.

AIM: To assess selectively trained radiographers and consultant radiologists reporting plain radiographs for the Accident and Emergency Department (A&E) and general practitioners (GPs) within a typical hospital setting. METHODS: Two radiographers, a group of eight consultant radiologists, and a reference standard radiologist independently reported under controlled conditions a retrospectively selected, random, stratified sample of 400 A&E and 400 GP plain radiographs. An independent consultant radiologist judged whether the radiographer and radiologist reports agreed with the reference standard report. Clinicians then assessed whether radiographer and radiologist incorrect reports affected confidence in their diagnosis and treatment plans, and patient outcome. RESULTS: For A&E and GP plain radiographs, respectively, there was a 1% (95% confidence interval (CI) -2 to 5) and 4% (95% CI -1 to 8) difference in reporting accuracy between the two professional groups. For both A&E and GP cases there was an 8% difference in the clinicians' confidence in their diagnosis based on radiographer or radiologist incorrect reports. For A&E and GP cases, respectively, there was a 2% and 8% difference in the clinicians' confidence in their management plans based on radiographer or radiologist incorrect reports. For A&E and GP cases, respectively, there was a 1% and 11% difference in effect on patient outcome of radiographer or radiologist incorrect reports. CONCLUSION: There is the potential to extend the reporting role of selectively trained radiographers to include plain radiographs for all A&E and GP patients. Further research conducted during clinical practice at a number of sites is recommended.

The costs and effects of introducing selectively trained radiographers to an A&E reporting service: a retrospective controlled before and after study.

The costs and effects of introducing selectively trained radiographers reporting accident and emergency (A&E) radiographs of the appendicular skeleton in a district general hospital were assessed using a retrospective controlled before and after design. Reference standard reports were compared with a random stratified sample of 200 A&E and 200 general practitioner (GP) reports before and after the intervention. GP reports were used as a non-intervention, non-equivalent control group. An A&E specialist registrar judged whether incorrect A&E reports might have a clinically important effect on patient management. The effect of incorrect A&E reports on outcome was assessed by patient re-attendance to the hospital because of missed abnormalities. The annual, average and incremental costs of radiographers and radiologists reporting A&E radiographs were calculated and a sensitivity analysis was undertaken. The introduction of the radiographers resulted in a 1% (95% CI -7.9 to 5.9) fall in A&E radiograph reporting accuracy and 11% (95% CI -33.7 to 11.3) reduction of cases in which incorrect A&E reports might have a clinically important effect on patient management. Only two A&E reports (one before and one after the intervention) affected patient outcome in that a fracture missed at the first visit resulted in patient re-attendance to the X-ray Department. There was a saving of 361 pounds per annum to the X-ray Department. In conclusion this study provides further evidence that selectively trained radiographers can accurately report A&E plain radiographs and at no additional cost.

Accident and emergency and general practitioner plain radiograph reporting by radiographers and radiologists: a quasi-randomized controlled trial.

Two specially trained radiographers at York District Hospital have been reporting appendicular plain radiograph X-ray examinations for Accident and Emergency (A&E) patients since February 1995. This study explores the potential for further expanding their reporting role. This was achieved by assessing the two radiographers' and a group of consultant radiologists' ability to report on a retrospectively selected random stratified sample of 400 A&E and General Practitioner (GP) plain radiograph X-ray examinations for all body areas. Using receiver operating characteristic (ROC) curve analyses there was no statistically significant difference at the 5% level between the area under the ROC curves for the radiographers and consultant radiologists when reporting A&E or GP plain radiographs. It may be feasible to expand the reporting role of suitably trained radiographers to include plain radiograph X-ray examinations for all A&E patients and for GP patients, with no detriment to the quality of reports.

Dynamically heterogenous partitions and phylogenetic inference: an evaluation of analytical strategies with cytochrome b and ND6 gene sequences in cranes.

ki ctes over whether molecular sequence data should be partitioned for phylogenetic analysis often confound two types of heterogeneity among partitions. We distinguish historical heterogeneity (i.e., different partitions have different evolutionary relationships) from dynamic heterogeneity (i.e., different partitions show different patterns of sequence evolution) and explore the impact of the latter on phylogenetic accuracy and precision with a two-gene, mitochondrial data set for cranes. The well-established phylogeny of cranes allows us to contrast tree-based estimates of relevant parameter values with estimates based on pairwise comparisons and to ascertain the effects of incorporating different amounts of process information into phylogenetic estimates. We show that codon positions in the cytochrome b and NADH dehydrogenase subunit 6 genes are dynamically heterogenous under both Poisson and invariable-sites + gamma-rates versions of the F84 model and that heterogeneity includes variation in base composition and transition bias as well as substitution rate. Estimates of transition-bias and relative-rate parameters from pairwise sequence comparisons were comparable to those obtained as tree-based maximum likelihood estimates. Neither rate-category nor mixed-model partitioning strategies resulted in a loss of phylogenetic precision relative to unpartitioned analyses. We suggest that weighted-average distances provide a computationally feasible alternative to direct maximum likelihood estimates of phylogeny for mixed-model analyses of large, dynamically heterogenous data sets.

Formalin instillation for refractory radiation-induced hemorrhagic proctitis. Report of 16 patients.

PURPOSE: Our goal was to evaluate use of topical (4 percent) formalin in management of radiation-induced hemorrhagic proctitis, refractory to other methods of treatment. Specifically, we wished to determine its safety, ability to stop bleeding, and complications associated with therapy. METHODS: Sixteen patients with radiation-induced hemorrhagic proctitis were treated with topical (4 percent) formalin. All had been previously treated with conservative regimens such as cautery, topical steroids, or laser, but these had failed. Five-hundred milliliters (ml) of a 4 percent formalin solution was instilled into the rectum in 50-ml aliquots. Each aliquot was kept in contact with rectal mucosa for approximately 30 seconds. Treatments were performed under local anesthesia in nine patients, sedation only in four, spinal in two, and general in one patient. RESULTS: In 12 patients, bleeding stopped after a single formalin instillation; in 3, bleeding was considerably reduced but continued sporadically. One patient required three treatments before bleeding stopped. Four patients developed postoperative anal pain, of which one also had significant tenesmus and reduced capacity. Of these four patients, only two had significant anal pain and fissures that lasted longer than one month. CONCLUSIONS: Topical (4 percent) formalin is safe and effective in treatment of radiation-induced hemorrhagic proctitis. A single treatment will stop bleeding in 75 percent of patients.

Molecular divergence and phylogeny: rates and patterns of cytochrome b evolution in cranes.

Analyses of complete cytochrome b sequences from all species of cranes (Aves: Gruidae) reveal aspects of sequence evolution in the early stages of divergence. These DNA sequences are > or = 89% identical, but expected departures from random substitution are evident. Silent, third-position pyrimidine transitions are the dominant substitution type, with transversion comprising only a small fraction of sequence differences. Substitution patterns are not clearly manifested until divergence has reached a moderate level (> 3%), as expected for a stochastic process. Variation in the frequency of mismatch types among lineages decreases at larger divergences, but the level of bias does not decay. Divergence varies up to fivefold among gene regions but is not correlated with structural domain. All protein structural domains except extramembrane 4 display < 20% variable residues. Regions corresponding to putative functional domains show the excepted conservation of amino acids, although the C-terminal portion of the Q0 reaction center displays several nonconservative replacements. Phylogenetic analyses incorporating substitution asymmetries produced mixed results. Distances estimated with multiple parameters (transition, codon-position, composition, and pyrimidine-transition biases) yielded identical additive tree topologies with comparable bootstrap values, all consistent with uncontroversial species relationships. Maximum likelihood analysis incorporating these biases, as well as equally weighted parsimony analysis, produced similar results. Static, differential weighting for parsimony did not improve the phylogenetic signal but produced unusual trees with low bootstraps. The overall rate of nucleotide substitution varies slightly but significantly among cranes, and calibration of distances against fossil dates suggests divergence rates of 0.7%-1.7% per million years.

Magnetic resonance imaging of juxta-articular myxoma.

We have described the MRI features of a juxta-articular myxoma. The imaging features are similar to those of intramuscular myxoma. The lesions are differentiated by their location.

Methods and materials for porcelain veneers.

Porcelain veneers are an esthetic, relatively conservative restoration used to cover the facial surface of the teeth. Following proper guidelines, the practitioner can achieve successful results as a matter of routine. This article reviews the most current literature published on this subject to bring practitioners up to date on clinical methods and materials used for porcelain veneers.

Reproducibility of bone ages when performed by radiology registrars: an audit of Tanner and Whitehouse II versus Greulich and Pyle methods.

This audit analysed the Tanner and Whitehouse II twenty bone (TW2) method of bone age assessment which was used in our department, and compared it with the Greulich and Pyle (GP) method. 50 previous bone ages were independently re-calculated by each of three registrars using both techniques, with the time taken to perform each assessment being recorded. For each method the interobserver variation was analysed in terms of the spread of results. The intraobserver variation in TW2 was determined by comparing the bone age originally reported with that subsequently calculated on the same film by the same registrar. The average spread of results was 0.74 years for TW2 method, and 0.96 years for the GP method and this difference is not statistically significant at the 5% level. The average intraobserver variation to TW2 was 0.33 years, but with 95% confidence limits of -0.87 to +1.53 years. The average time taken was 7.9 min for TW2 and 1.4 min for GP assessments. It was concluded that the GP method gave similar reproducibility and was faster than the TW2 method. Following clinical discussion the routine departmental bone age assessment method was changed from the TW2 to the GP method.

Interdisciplinary perceptions of the dietitian's legal responsibility for lethal dietary prescription errors for patients with end-stage renal disease.

OBJECTIVE: To determine intergroup and intragroup consensus for interdisciplinary perceptions of dietitians' legal responsibility for lethal dietary prescription errors. DESIGN: Survey research was conducted by a mail questionnaire containing four hypothetical cases in which the dietitian provides a lethal amount of dietary potassium for an anephric patient. SETTING: Of the 90 New York State end-stage renal disease facilities contacted, 64 returned one or more questionnaires. SUBJECTS/SAMPLES: Usable questionnaires were tabulated from 51 registered dietitians, 39 registered head nurses, and 43 physician-medical directors. MEASURES: Consensus was recognized when 60% or more of the responses occurred in one extreme collapsed and dichotomized category of "yes" or "no" regarding the dietitian's legal responsibility. STATISTICAL ANALYSES PERFORMED: Intergroup and intragroup consensus levels were compared by frequency, mean, standard deviation, and Scheffe test of differences. RESULTS: The triad groups met varying levels of consensus on all four scenarios, with dissenting opinions by nurses on two scenarios. The dietitians and the physician-medical directors had mirror-image perceptions that the dietitian was not legally accountable for two cases of following foreseeably lethal dietary prescriptions "as written." Eight dietitians viewed the dietitian as legally nonculpable for causing a patient's death because of the dietitian's sole incompetence or carelessness in making a serious calculation error. Nurses met the highest levels of agreement and perceived the dietitian to be legally accountable for all four cases. The nurses, in contrast to the dietitians and physician-medical directors, held opinions of dietitian legal responsibility as consistent with the standard of care expectations of prudent health care professionals defined by professional malpractice jurisprudence. APPLICATIONS/CONCLUSIONS: The data indicate that to protect both the patient and the professional, there is a notable need for greater understanding dietetics jurisprudence.

Combined exfoliation and pigment dispersion syndrome.

Both exfoliation syndrome and pigmentary dispersion syndrome can lead to secondary glaucoma. We treated five patients who had pigmentary dispersion and who subsequently developed exfoliation. In one patient who had bilateral pigment dispersion syndrome, the presence of exfoliation increased the difficulty of controlling intraocular pressure in the affected eye. In a monocular patient, exfoliation and pigmentary dispersion were concurrently present with characteristic defects of both pigmentary dispersion and exfoliation as seen by transillumination defects of the iris. A third patient had bilateral pigmentary dispersion and uncontrollable intraocular pressure in an eye with exfoliation. Despite argon laser trabeculoplasty, the pressure remained uncontrolled. Another patient had a filtering operation in the left eye, with gradually increasing intraocular pressure in the right eye. Exfoliation material complicated the pressure control in the unoperated on eye. Another patient had an eight-year history of glaucoma in the left eye for which filtering surgery was performed. Exfoliation was present in both eyes with controlled pressure in the filtered eye but uncontrolled pressure in the nonfiltered eye.

Serpiginous choroidopathy associated with elevated factor VIII-von Willebrand factor antigen.

Elevated Factor VIII-von Willebrand factor antigen levels are associated with vascular endothelial injury in several disorders, including scleroderma, Raynaud's phenomenon, polymyalgia rheumatica, and temporal arteritis. Eight patients with serpiginous choroidopathy were evaluated with the use of quantitative immunoelectrophoresis for Factor VIII-von Willebrand factor antigen. The serpiginous choroidopathy patients had a mean Factor VIII-von Willebrand factor activity of 226 +/- 47.3%, whereas a disease-free, age- and sex-matched control group had a mean activity of 107 +/- 28%. These findings are statistically significant (P greater than 0.005) and suggest that in some patients, serpiginous choroidopathy represents an occlusive vascular phenomenon that involves the choroidal circulation.

Religion and health relationships: A review.

This review examines various studies showing the relation between religiosity (religious beliefs and/or practices) and health. It also includes church attendance and its relation to drug use. The role of the church in health promotion is discussed, with examples of church intervention model programs. Several attempts have been made to measure religiosity and religious commitment, but as yet little has been done to identify specific dimensions of religion as they relate to health behaviors. Even though the literature indicates that religion is generally associated with health behaviors, health status, and longevity, further research on the specifics of this relationship is needed.