Two-dimensional fusion imaging of planar bone scintigraphy and radiographs in patients with clinical scaphoid fracture: an imaging study.

BACKGROUND: Although magnetic resonance imaging (MRI) is now considered the gold standard in second-line imaging of patients with suspected scaphoid fracture and negative radiographs, bone scintigraphy can be used in patients with pacemakers, metallic implants, or other contraindications to MRI. Bone scintigraphy is highly sensitive for the detection of fractures, but exact localization of scintigraphic lesions may be difficult and can negatively affect diagnostic accuracy. PURPOSE: To investigate the influence of image fusion of planar bone scintigraphy and radiographs on image interpretation in patients with suspected scaphoid fracture. MATERIAL AND METHODS: In 24 consecutive patients with suspected scaphoid fracture, a standard planar bone scintigraphy of both hands was supplemented with fusion imaging of the injured wrist. Standard and fusion images were evaluated independently by three experienced nuclear medicine physicians. In addition to the diagnosis, the degree of diagnostic confidence was scored in each case. RESULTS: The addition of fusion images changed the interpretation of each of the three observers in seven, four, and two cases, respectively, reducing the number of positive interpretations of two of the observers from 11 and nine cases to six and seven cases, respectively. The degree of diagnostic confidence increased significantly in two observers, and interobserver agreement increased in all three pairs of observers from 0.83, 0.57, and 0.73 to 0.89, 0.8, and 0.9, respectively. CONCLUSION: Image fusion of planar bone scintigrams and radiographs has a significant influence on image interpretation and increases both diagnostic confidence and interobserver agreement.

Muscle size, neuromuscular activation, and rapid force characteristics in elderly men and women: effects of unilateral long-term disuse due to hip-osteoarthritis.

Substantial evidence exists for the age-related decline in muscle strength and neural function, but the effect of long-term disuse in the elderly is largely unexplored. The present study examined the effect of unilateral long-term limb disuse on maximal voluntary quadriceps contraction (MVC), lean quadriceps muscle cross-sectional area (LCSA), contractile rate of force development (RFD, Delta force/Delta time), impulse (integral force dt), muscle activation deficit (interpolated twitch technique), maximal neuromuscular activity [electromyogram (EMG)], and antagonist muscle coactivation in elderly men (M: 60-86 yr; n = 19) and women (W: 60-86 yr; n = 20) with unilateral chronic hip-osteoarthritis. Both sides were examined to compare the effect of long-term decreased activity on the affected (AF) leg with the unaffected (UN) side. AF had a significant lower MVC (W: 20%; M: 20%), LCSA (W: 8%; M: 10%), contractile RFD (W: 17-26%; M: 15-24%), impulse (W: 10-19%, M: 19-20%), maximal EMG amplitude (W: 22-25%, M: 22-28%), and an increased muscle activation deficit (-18%) compared with UN. Furthermore, women were less strong (AF: 40%; UN: 39%), had less muscle mass (AF: 33%; UN: 34%), and had a lower RFD (AF: 38-50%; UN: 41-48%) compared with men. Similarly, maximum EMG amplitude was smaller for both agonists (AF: 51-63%; UN: 35-61%) and antagonist (AF: 49-64%; UN: 36-56%) muscles in women compared with men. However, when MVC and RFD were normalized to LCSA, there were no differences between genders. The present data demonstrate that disuse leads to a marked loss of muscle strength and muscle mass in elderly individuals. Furthermore, the data indicate that neuromuscular activation and contractile RFD are more affected by long-term disuse than maximal muscle strength, which may increase the future risk for falls.

Factors affecting postoperative mortality of patients with displaced femoral neck fracture.

Displaced femoral neck fractures are known to be associated with high rates of mortality. The purpose of the present study is to investigate pre- and postoperative factors which influence this mortality in a series of 1186 consecutive Danish patients presenting to one hospital's orthopaedic department with Garden type 3-4 fractures. Subsequent mortality data was obtained from the state population register (224 were still alive). The stepwise Cox proportional hazards model was used for multivariate analysis in order to obtain the predictors of postoperative mortality. The median survival of male subjects fell from 5.2 years in an age-matched control population to 1.6 years in the patients. In women survival time fell from 6.6 to 2.8 years. Almost all excess mortality occurred during the first 3 months following hemiarthroplasty. In order of significance, key factors negatively influencing mortality at 3 months were: cardiac complications, dementia, male sex, age, waiting time before operation, stroke and dislocation of the prosthesis and perioperative fracture. Of these, waiting time for surgery and dislocation of the prosthesis could be modified. A number of other studies have confirmed the importance of optimising these factors.

[Visits to hospital emergency departments after restricted-admission changes at the Rigshospitalet]. / Skadestuehenvendelser i H:S efter aendringen af skadestuestrukturen på Rigshospitalet.

INTRODUCTION: The aim of this study was to describe changes in the use of accident and emergency departments in the Copenhagen Hospital Co-operation after restricted admittance to the accident and emergency department at a large Danish university hospital, Rigshospitalet (admittance only for patients transported by ambulance or presenting with a referral from a doctor). MATERIAL AND METHODS: A retrospective study compared the number of patients treated in two periods, 1.7.1998 to 30.6.1999 and 1.7.1999 to 30.6.2000. Additional patient data were collected for the periods 1.7.1998 to 31.12.1998 and 1.7.1999 to 31.12.1999. RESULTS: A 4% decrease was seen in the total number of patients treated at the accident and emergency departments. The decrease in the number of patients treated at the accident and emergency department at Rigshospitalet was 69%, whereas the accident and emergency department at Bispebjerg Hospital experienced a 53% rise. DISCUSSION: The study showed good compliance in the local population after the restricted admittance to an accident and emergency department at a large university hospital. An expected total fall in the number of patients treated at the accident and emergency departments in the Copenhagen Hospital Co-operation could not be documented.

An audit on guidelines used for the initial management of patients with minor head injuries in Denmark.

The purpose of this quality assurance study was to compare the practice used in the management of patients with minor head injuries (MHI) in Denmark with guidelines recommended by Danish neurosurgeons and analyse differences between hospitals in the treatment of patients with MHI. All 68 accident and emergency departments in Denmark covering a population of 5,146,000 inhabitants and 895,000 attenders received a questionnaire containing questions about epidemiological data, the clinical practice and the use of skull x-ray. Ninety-four per cent of the hospitals responded. The number of patients admitted per 100,000 inhabitants per year was the same (mean 235) in large and small hospitals, but in the small hospitals significantly more patients per 100,000 attenders per year were admitted (p < 0.05). More than 80% of the hospitals recommended admission if the patient reported unconsciousness, significant headache, dizziness or nausea and vomiting. Symptoms found at the examination in the A & E department had high priority in the decision to admit patients in more than 90% of the hospitals. Skull x-ray was always used in only 2/64 hospitals. The compliance with guidelines give by Danish neurosurgeons was unsatisfactory as far as the symptoms in the history were concerned.

[Minor head injuries. Prognostic factors in the evaluation of patients]. / Lettere hovedtraumer. Prognostiske faktorer ved vurdering af patienter.

In order to identify signs to be used in the decision whether or not to admit patients after minor head injuries (MHI), the records of 713 females and 1163 males were reviewed. Skull X-ray was not obtained routinely, all patients were able to talk and walk when they reached medical contact. Nine patients developed an intracranial complication, three had an operation and one died. The risk of developing an ICC was 16.7% when the patient was agitated, 3.4% in the presence of impaired consciousness and 2.1% when positive neurological signs were observed at the time of examination. Based on the medical history, amnesia for more than five minutes and vomiting were associated with a risk of 3.3% and 1.2% respectively. The risk increased considerably in the presence of two of the above mentioned signs and was 60% if the patient was agitated and had amnesia for more than five minutes. Consequently, we recommend that all patients with one or more of the above symptoms or alcohol intoxication after a MHI should be admitted for observation. This policy may hold the possibility of considerable economic savings.

The role of neuroimaging in the initial management of patients with minor head injury.

STUDY OBJECTIVE: To determine whether omitting neuroimaging in the primary assessment of patients with minor head injuries in the emergency department is safe. DESIGN: Prospective cohort study. SETTING: University hospital, Copenhagen County Hospital, Glostrup, Denmark. PARTICIPANTS: The study group consisted of 2,204 patients presenting to the ED after sustaining minor head injuries. Only patients able to talk and walk were included. MEASUREMENTS AND MAIN RESULTS: The decision to admit was based exclusively on clinical guidelines in which the findings in the ED were of highest priority. Seven patients (0.3%) had a skull radiograph; computed tomography was not used in the primary evaluation. Four hundred thirty patients (19.5%) were admitted. After hospitalization, four patients developed intracranial complications. One required surgery, two required hyperventilation, and one was observed. Follow-up demonstrated that no patient with an intracranial complication had been missed. CONCLUSION: We found it safe to exclude neuroimaging in the primary assessment of patients with minor head injuries in the ED, and to rely instead on clinical criteria.

Prognostic signs in the evaluation of patients with minor head injury.

To assess signs that might be used in the decision whether or not to admit a patient with minor head injury, the records of 713 female and 1163 male patients were reviewed. Skull radiographs were not obtained routinely; all patients were able to walk and talk when they reached medical contact. Nine patients developed an intracranial complication. The risk of developing such a complication was 16.7 per cent when the patient was agitated, 3.4 per cent in the presence of impaired consciousness and 2.1 per cent when positive neurological signs were observed at the time of examination. Based on the medical history, amnesia for > 5 min and vomiting were associated with a risk of 3.3 and 1.2 per cent respectively; the risk increased considerably in the presence of both. It is recommended that all patients presenting themselves with one or more of the above symptoms or signs, or with alcohol intoxication, after a minor head injury be admitted for observation. If these guidelines had been used, all patients with an intracranial complication would have been detected, and 44.5 per cent of the bed-days used would have been saved.

Intra-articular bupivacaine plus adrenaline for arthroscopic surgery of the knee.

The purpose of the study was to evaluate three different doses of intra-articular bupivacaine plus adrenaline in relation to per- and postoperative pain relief following arthroscopy. Sixty patients were allocated to three groups of 20 patients each scheduled for arthroscopy. They were randomized prospectively to receive bupivacaine plus adrenaline 25 mg + 50 micrograms, 50 mg + 100 micrograms, 75 mg + 150 micrograms, respectively, diluted to a volume of 30 ml. Four patients were excluded because the operation could not be carried out under intra-articular analgesia, 18 patients had a diagnostic arthroscopy and 38 patients had different arthroscopic operations performed. The number of patients scoring pain in the knee as moderate or severe was less in Group 3 than in the other two groups, i.e. the highest dose had a better pain relief. No adverse effects were registered. With respect to per- or postoperative administration of analgesics, postoperative pain occurrence, and the surgeon's acceptance of the method, there were no statistically significant differences. Ninety-two percent of the patients would prefer intraarticular analgesia if they should need to have another arthroscopy performed.

Hydrolysis of substrate analogues catalysed by beta-D-glucosidase from Aspergillus niger. Part II: Deoxy and deoxyhalo derivatives of cellobiose.

The hydrolysis of sixteen mainly deoxy and deoxyhalo derivatives of celloboise catalysed by beta-D-glucosidase from Aspergillus niger has been studied by means of 1H NMR spectroscopy and progress-curve enzyme kinetics in both single-substrate and competition experiments. In the non-reducing ring of cellobiose it was found that the hydroxy groups at positions 2', 3', and 4' are essential for the enzymatic hydrolysis. The primary hydroxy group on 6' in this ring is, although important for the hydrolysis, not essential. The analogues modified at positions 3' and 4' and the 6'-bromo-6'-deoxy derivative were not inhibitors, whereas the 2'-deoxy derivative inhibited the enzymatic hydrolysis of methyl beta-cellobioside to some extent. Of the analogues modified in the reducing ring, some were hydrolysed faster (e.g. the deoxy compounds) and some slower than methyl beta-cellobioside in single-substrate experiments, but all derivatives were hydrolysed at a lower rate than this reference substrate in direct competition and displayed relatively weak inhibitory effects. The results are interpreted qualitatively with respect to changes in the free binding energies of the substrates and catalytic transition states based on the Michaelis-Menten mechanism, and some mechanistic implications of these findings are discussed.

[Minor head injuries in a Copenhagen district. 1. Epidemiology]. / Mindre hovedtraumer i et københavnsk omegnsområde. 1. Epidemiologi.

The records of 1,218 males and 743 females admitted to Copenhagen County Hospital in Glostrup between January 1 1985 and December 31 1986 were studied. The mean age was 28.2 years (SD = 20.3 years). The incidence rate was 360 per 100,000 inhabitants per year and was between 30 and 130% larger for males than females (p less than 0.001), the incidence rate was 26% higher in this study as compared to the rate in Denmark as a whole. Patients between 0 and 14 years were most frequently admitted between noon and the early evening hours and those between 15 and 64 years most frequently from late in the afternoon until the early night. The distribution was uniform throughout the week. There was a tendency towards more frequent admissions in the April and July trimesters. 74% of the patients were admitted at hours when the staff was minimal. This category comprised 4.9% of all patients admitted as emergencies to the hospital. The mean hospitalization was 1.6 days (range 1-14 days). Females were hospitalized longer than males (p less than 0.001). Furthermore, hospitalization was significantly longer, the older the patients were (p = 0.005). Patients with minor head trauma constitute a considerable work load in the hospital, especially outside normal working-hours.

[Minor head injuries in a Copenhagen district. 2. Causes, simultaneous lesions, alcohol and economic aspects]. / Mindre hovedtraumer i et københavnsk omegnsområde. 2. Arsager, konkurrerende laesioner, alkohol og økonomiske aspekter.

In order to elucidate causes, simultaneous lesions, alcohol intoxication and economic aspects of admission of patients with minor head traumas, the records of 1,961 patients admitted in 1985 and 1986 were reviewed. 35% were admitted after traffic accidents, 18% after assaults and 17% because of home accidents. In the age group 30-39 years, 40% of the males were admitted after assaults. 7% sustained fractures of the extremities, 4% facial fractures and 3% and 1% thoracic and abdominal lesions respectively. At least 28% of all patients, more than 50% of the patients admitted during evening- and night hours and 51% of the males between 14 and 65 years were clinically alcohol intoxicated. 1,876 patients were admitted solely for observation, nine developed an intracranial complication, three were operated upon and one died. The bed day expenditure was 2.7 mill. Dkr. (pounds 225,000), and for the entire nation 64.8 mill. Dkr (pounds 5,400,000). The costs for diagnosing one case of intracranial lesion in Denmark were 925.000 Dkr. (approximately pounds 80,000) and 2.1 mill. Dkr. (pounds 180,000) to find the cases requiring treatment (1985 level).

Is a skull X-ray necessary after milder head trauma?

During the 2-year period 1985-86 a total of 1,876 patients were admitted to our hospital after milder head trauma including cerebral concussion. Two hundred and eighty four patients who had a skull X-ray were not selected from guidelines. In 1,592 patients without a skull X-ray, signs of an intracranial complication developed in six cases and were verified by CT. In the 284 patients with skull X-ray a fracture was demonstrated in 25, and of these 25 patients only one patient disclosed a cerebral contusion. In the 259 patients with skull X-ray, but without demonstration of fracture, there were subsequently seen one subdural haematoma and one cerebral contusion. The incidence of intracranial complications in patients without and with skull X-ray with or without fracture does not differ significantly. In these circumstances we do not find any justification for routine skull X-ray after milder head trauma.

The natural course of radionuclide bone scanning in the evaluation of total knee replacement--a 2 year prospective study.

In order to establish the natural course of radionuclide bone scanning images after total knee replacement 41 consecutive patients were scheduled for examination 3, 7, 12 and 24 months after surgery. The mean age was 69 years (range 50-80 years); the female:male ratio was 4:1. Thirty-two patients completed the entire program. A total of 143 99Tcm medronic acid complex scintigrams was performed. No significant difference between the grades of total scintigraphic uptake at any of the four examinations nor any difference between the first and the last examinations could be demonstrated (P = 0.58, Friedman test and P = 0.20, Wilcoxon test, respectively). Twelve months after surgery one fifth of the knees still demonstrated definitely increased scintigraphic uptake and 24 months after surgery 12.5% of the knees had definitely increased uptake. We believe that the increased uptake seen for a variable length of time after surgery limits the usefulness of radionuclide bone scanning in the evaluation of total knee replacement.

Tibial plateau fractures. A comparison of conservative and surgical treatment.

We evaluated the long-term results of 109 tibial plateau fractures, 61 treated by skeletal traction and early knee movement and 48 treated by surgery, at an average follow-up of 70 months. The functional results were much the same, though meniscectomy had been performed in almost half of the surgical patients. Time in bed and duration of hospital stay were clearly shorter after surgery (p less than 0.0001). We concluded that conservative management is a valid alternative to surgery, but should probably be reserved for cases where operation is undesirable. Future studies should compare surgery without meniscectomy and conservative treatment using cast braces to reduce the time in traction.

Mediastinal and subcutaneous cervical emphysema caused by perforating sigmoid cancer. Case report.

A case of mediastinal and subcutaneous cervical emphysema due to perforation of a sigmoid cancer is presented. Sudden deterioration and development of subcutaneous and mediastinal emphysema in a chronically ill patient with equivocal abdominal signs should alert the examiner to the possibility of retroperitoneal gastrointestinal perforation.

Radionuclide scanning after total knee replacement: correlation with pain and radiolucent lines. A prospective study.

The authors examined the relationships among Tc-99m radionuclide bone scan findings, pain, and radiolucent lines in 35 postsurgical knees. Our prospective study included bone scans, as well as radiographic and clinical examination three, seven, and 12 months after knee replacement surgery in 35 patients. Twenty-seven patients had no pain 12 months after surgery and eight patients had moderate or severe pain. Prosthetic loosening was seen in one patient. Thirty-three patients exhibited a radiolucent line under the tibial part of the prosthesis. Isotope uptake was the same in the painful and nonpainful knees, and the degree of isotope uptake did not correlate with the development of radiolucent lines around the prosthetic components.

Bleeding after hip arthroplasty not increased by heparin plus dihydroergotamine.

We measured the postoperative bleeding following total hip replacement when low-dose heparin plus dihydroergotamine was used for preventing postoperative deep-venous thrombosis. The patients were allocated by random numbers to either 5,000 IU heparin and 0.5 mg dihydroergotamine injected subcutaneously twice daily or to placebo injections. The mean postoperative bleeding in the anticoagulation group of 91 patients was 583 ml and in the placebo group of 103 patients 529 ml, i.e., there was no difference between the two groups.