Reduction in inappropriate MRI knee studies after implementation of an appropriateness checklist: Experience at a tertiary care centre.

PURPOSE: To evaluate reduction in inappropriate knee MRI requests following implementation of a mandatory knee MRI appropriateness checklist. METHODS: A retrospective review was performed at a single tertiary care centre. A knee MRI appropriateness checklist was developed based on the ACR Appropriateness Criteria and adherence from referring physicians was mandatory. Reports from 200 consecutive knee MRI studies one year prior to implementation were compared to 200 consecutive knee MRI studies following implementation. The presence of moderate or greater osteoarthritis on MRI reports was used as a marker for inappropriate knee MRIs. Patient demographics, wait times, number of knee MRIs, and number of all MRIs at our centre over a six month period post-intervention and pre-intervention were recorded. Differences between pre-intervention and post-intervention presence of moderate or greater osteoarthritis, patient demographics, wait times, and number of MRIs analyzed. RESULTS: A significant decrease was found in moderate or greater grade osteoarthritis following intervention, decreasing from 36.5% to 20.5% (73 studies versus 41 studies, p = 0.023). Of these, the most profound decrease occurred in studies with severe osteoarthritis, with an 80 % decrease (35 studies versus 7 studies, p < 0.001). Post intervention, 48 % fewer knee MRIs were performed in the same time interval (652 studies pre-intervention versus 336 studies post intervention, p < 0.001). No significant differences were found in the patient demographics. CONCLUSION: Mandatory knee MRI appropriateness checklists are associated with a significant reduction in the number of inappropriate studies performed. Follow up studies will be required to assess long-term impact in a larger population.

The prevalence of wrist ganglia in an asymptomatic population: magnetic resonance evaluation.

Magnetic resonance imaging (MRI) was performed on the wrists of 103 asymptomatic volunteers. The images were evaluated independently by two musculoskeletal radiologists and one orthopaedic surgeon. Wrist ganglia were identified in 53 out of the 103 wrists. The average long and short axes measurements were 8 mm (range 3-22) and 3 mm (range 2-10), respectively. Seventy per cent of the ganglia originated from the palmar capsule in the region of the interval between the radioscaphocapitate ligament and the long radiolunate ligament. Fourteen per cent of the ganglia were dorsal and originated from the dorsal, distal fibres of the scapholunate ligament. Two ganglia had surrounding soft tissue oedema and one had an associated intraosseous component. Unlike previous surgical and pathological series, our study showed that palmar wrist ganglia are more common than dorsal wrist ganglia. The vast majority of these asymptomatic ganglia occur without associated ligamentous disruption, soft tissue oedema or intraosseous communication.

The detection of loose bodies in the elbow: the value of MRI and CT arthrography.

Our aim was to determine the clinical value of MRI and CT arthrography in predicting the presence of loose bodies in the elbow. A series of 26 patients with mechanical symptoms in the elbow had plain radiography, MRI and CT arthrography, followed by routine arthroscopy of the elbow. The location and number of loose bodies determined by MRI and CT arthrography were recorded. Pre-operative plain radiography, MRI and CT arthrography were compared with arthroscopy. Both MRI and CT arthrography had excellent sensitivity (92% to 100%) but low to moderate specificity (15% to 77%) in identifying posteriorly-based loose bodies. Neither MRI nor CT arthrography was consistently sensitive (46% to 91%) or specific (13% to 73%) in predicting the presence or absence of loose bodies anteriorly. The overall sensitivity for the detection of loose bodies in either compartment was 88% to 100% and the specificity 20% to 70%. Pre-operative radiography had a similar sensitivity and specificity of 84% and 71%, respectively. Our results suggest that neither CT arthrography nor MRI is reliable or accurate enough to be any more effective than plain radiography alone in patients presenting with mechanical symptoms in the elbow.

Percutaneous inferior vena caval approach for long-term central venous access.

PURPOSE: The authors report their experience with the translumbar inferior vena cava (IVC) approach for central venous access during a 6-year period at three teaching hospital sites. PATIENTS AND METHODS: Twenty-nine percutaneous IVC central venous access catheters were inserted in 22 patients during a 6-year period in the radiology departments of three teaching hospital sites. All patients had undergone unsuccessful attempts at conventional central venous access. Information was gathered by retrospective radiologic and hospital chart review. RESULTS: All attempted placements were successful. Catheters were in place for a total of 3,510 catheter days. The average length of catheter placement was 121 days (range, 14-536 days). Life-table analysis predicted catheter function rates of 55% and 29% at 6 and 12 months, respectively. Three procedure-related complications occurred. A lower pole branch of the right renal artery was inadvertently entered with a 22-gauge needle during attempted IVC puncture in one patient without clinical sequelae. A second patient developed a small groin hematoma at the femoral venous puncture site, which resolved spontaneously. A third patient developed a moderate retroperitoneal hematoma, which resolved without specific intervention. The sepsis rate was 2.8 infections per 1,000 catheter days with an average time to infection of 127 days (range, 10-536 days). CONCLUSION: In the authors' experience of 29 translumbar central venous catheter insertions, all attempts were successful. Percutaneous central venous access via the IVC is a safe and effective option for patients in whom more conventional access is not possible.

Wound and skin care for the PICU.

Pediatric intensive care nurses are frequently challenged by caring for critically ill patients with wounds or the potential for skin breakdown. This article summarizes wound care guidelines, discusses nutritional support, and provides a tool for assessing the pediatric patient at risk for skin breakdown.

Two-arm trajectory planning in a manipulation task.

This paper addresses the trajectory planning problem for a task which requires positioning and orienting an object firmly grasped by two hands at a visually specified goal configuration in the horizontal plane. The motor task involves three degrees of freedom (two translational and one rotational), and the motions of the arms are constrained by the physical coupling through the held object. Experimentally measured trajectories of two arms in the coordinated positioning/orienting task are presented. The hypothesis that the rotational and translational components of motions are decoupled and independently planned is tested. Two explicit mathematical models to account for the kinematic features of the two-arm motions are formulated, and the predictions of the models are compared with the experimental data. Both models extend the minimum-jerk model to the two-arm coordinated motions case. The trajectories predicted by the models were found to be in qualitative agreement with the experimental data. However, neither model could account for the observed configuration dependence of the motions, nor for some of the properties of the measured velocity components of the motions. Our findings support the idea that the rotational and translational components of two-arm motions in the positioning/orienting task are independently planned in extra-personal space, and are further combined in a hierarchical fashion to produce the observed motions. The tested models may serve as a basis for further investigations of issues pertinent to the generation of two-arm trajectories.

Soft tissue coccidioidomycosis on MRI.

OBJECTIVE: To determine the appearance of soft tissue coccidioidomycosis on MRI. MATERIALS AND METHODS: Two cases of soft coccidioidomycosis with preoperative MR imaging are presented. RESULTS: Prospectively, infection was considered unlikely both clinically and on imaging studies. In retrospect, the MR appearance was nonspecific in one case and suggestive of infection in the other. CONCLUSION: Radiologists should be prepared to entertain coccidioidal abscess as a differential consideration when soft tissue masses are seen on MRI, even when infection is not suggested clinically.

Plantaris muscle injury: evaluation with MR imaging.

PURPOSE: To determine the MR imaging appearance of injury to the plantaris muscle. MATERIALS AND METHODS: Fifteen patients with sports-related injuries to the lower leg underwent magnetic resonance (MR) imaging with T1- and T2-weighted, gradient-echo T2*-weighted, short inversion time inversion-recovery, and fast spin-echo sequences. The plantaris muscle and tendon, as well as the surrounding structures, were retrospectively examined for abnormalities. RESULTS: All 15 patients had rupture of the plantaris muscle or strain. An associated torn anterior cruciate ligament (ACL) was found in 10 of 15 patients. Five injuries were isolated or associated with partial tears of the gastrocnemius or popliteus muscle. At initial presentation, three patients had large, focal elongated fluid collections between the medial head of the gastrocnemius muscle and the soleus muscle. CONCLUSION: Rupture of the plantaris muscle may occur at the myotendinous junction with or without an associated hematoma or partial tear of the medial head of the gastrocnemius muscle. A strain of the more proximal plantaris muscle may also occur as an isolated injury or in conjunction with injury to the ACL.

Caring for children with ostomies.

Caring for children with ostomies comprehensively requires that the healthcare professional understand issues related to normal growth and development as well as more specific medical information about disease processes and ostomy care. Parents should have a working knowledge of routine ostomy care and need guidelines to assist them in recognizing ostomy complications. Complications range from mild to severe. Many patients will experience at least one ostomy-related complication during the time they have their diversion. Active support of the child and the parent is essential toward facilitating acceptance and integration of ostomy care in pediatric ostomy clients.

Posterosuperior glenoid impingement of the shoulder: findings at MR imaging and MR arthrography with arthroscopic correlation.

PURPOSE: To determine the utility of magnetic resonance (MR) imaging and MR arthrography in the evaluation of arthroscopic findings of posterosuperior glenoid impingement. MATERIALS AND METHODS: The findings at MR imaging, MR arthrography, and physical examination with the patient under anesthesia were retrospectively reviewed in eight patients with arthroscopic evidence of posterosuperior glenoid impingement. RESULTS: All patients had shoulder pain; anterior instability was found in six patients. Other than bone marrow abnormalities, findings at MR imaging were not reliable for the detection of posterosuperior glenoid impingement. MR arthrography was superior to routine MR imaging in all four cases in which it was done; positioning the shoulder in abduction and external rotation was beneficial in three of four patients. CONCLUSION: Impingement of the rotator cuff on the posterior superior glenoid labrum is a cause of posterior shoulder pain in athletes who throw. MR arthrography may allow detection of abnormalities associated with this clinical entity.

Tears of the medial collateral ligament: magnetic resonance imaging findings and associated injuries.

For 23 patients with a surgically proven tear of the medial collateral ligament the findings from magnetic resonance imaging (MRI) of the knee were evaluated retrospectively. MRI revealed the tear in all cases, although when the injury was severe, distinguishing high-grade partial tears from complete tears was difficult. Physical examination had indicated a tear in 22 (96%) of the cases. A high prevalence of associated cruciate and meniscal injuries was seen (in 23 [100%] and 12 [52%] of the cases respectively). Tears of the fibular collateral ligament occurred in 13 (57%) of the patients and at least one bony infraction in 22 (96%); most of the infractions were in the lateral compartment. Infractions of the lateral femoral condyle were frequently geographic (in 14 [70%] of the 20 cases) or impacted (in 5 [25%]). The spectrum of injuries associated with tears of the medial collateral ligament was consistent with the findings of previous studies focusing on cruciate and meniscal abnormalities; the minor variations were likely due to the severity of valgus stress in this sample.

Resident training in breast imaging in Canada: current status.

The authors evaluated the current status of resident training in breast imaging in Canada to provide baseline data for guidelines on the amount and the nature of training necessary. Information was obtained, by means of a questionnaire or a telephone interview, from the directors of all 16 radiology residency programs and the 58 radiology residents in their final year at the time of the study. All programs offer training in breast imaging; the training is mandatory in 11 (69%) and elective in 5 (31%). Of the 58 residents, 52 had had some training in breast imaging at the time of the study. Of these, 24 (46%) had spent a period averaging 3.9 weeks exclusively on breast imaging. Forty-one percent of residents felt that the duration of their breast imaging training was too short, and 35% felt that they could not practise mammography independently after their rotation. The authors found that training in breast imaging across the country is highly variable. Although this training is being upgraded in many programs, deficiencies remain. Guidelines are needed to ensure a minimum standard for training in breast imaging.

Wound healing in pediatrics.

Wound repair is an outcome of biologic and behavioral characteristics. Each patient must be evaluated individually for phenomena that might alter the reparative process. Nursing intervention acts as an accompaniment to the healing process and must be based on scientific inquiry.

[Malacoplakia associated with adenocarcinoma of the rectum: clinico-pathologic and ultrastructural study]. / Malacoplaquia asociada con adenocarcinoma rectal: estudio clínico-patológico y ultraestructural.

A case of malacoplakia associated with rectal adenocarcinoma is reported. Optical and electron microscopic study disclosed a histiocytic infiltrate adjacent to the adenocarcinoma containing spherical and concentric inclusions designated as Michaelis-Gutmann bodies. The pathogenesis is discussed and the literature is reviewed.

Preventing delivery of enteral formula via parenteral route.

A potentially life-threatening complication of nursing care delivered to a patient receiving concurrent enteral and parenteral support is identified, which has not previously been reported in the literature. Strategies for minimizing the risk of accidental administration of enteral formula via the parenteral route are presented.

Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers. The role of gastric colonization.

Gram-negative nosocomial pneumonia may result from retrograde colonization of the pharynx from the stomach, and this may be more likely when the gastric pH is relatively high. We studied the rate of nosocomial pneumonia among 130 patients given mechanical ventilation in an intensive care unit who were receiving as prophylaxis for stress ulcer either sucralfate (n = 61), which does not raise gastric pH, or conventional treatment with antacids, histamine type 2 (H2) blockers, or both (n = 69). At the time of randomization to treatment, the two groups were similar in age, underlying diseases, and severity of acute illness. Patients in the sucralfate group had a higher proportion of gastric aspirates with a pH less than or equal to 4 (P less than 0.001) and significantly lower concentrations of gram-negative bacilli (P less than 0.05) in gastric aspirates, pharyngeal swabs, and tracheal aspirates than did patients in the antacid-H2-blocker group. The rate of pneumonia was twice as high in the antacid-H2 group as in the sucralfate group (95 percent confidence interval, 0.89 to 4.58; P = 0.11). Gram-negative bacilli were isolated more frequently from the tracheal aspirates of patients with pneumonia who were receiving antacids or H2 blockers. Mortality rates were 1.6 times higher in the antacid-H2 group than in the sucralfate group (95 percent confidence interval, 0.99 to 2.50; P = 0.07). Although our results fell just short of statistical significance when they were analyzed according to intention to treat, they suggest that agents that elevate gastric pH increase the risk of nosocomial pneumonia in patients receiving ventilation by favoring gastric colonization with gram-negative bacilli. We conclude that in patients receiving mechanical ventilation, the use of a prophylactic agent against stress-ulcer bleeding that preserves the natural gastric acid barrier against bacterial overgrowth may be preferable to antacids and H2 blockers.