Impact of 24-hour specialist coverage and an on-site CT scanner on the timely diagnosis of acute aortic dissection.

INTRODUCTION: Acute aortic dissection (AAD) is a rare and potentially fatal condition that has been known to be missed in diagnoses. Our primary objective was to determine if the availability of 24-hour emergency department (ED) specialist coverage and an on-site computed tomography (CT) scanner reduced the rate of missed diagnoses of AAD. METHODS: We selected records of patients diagnosed with dissection of the aorta from a hospital's discharge database and death register in the period of January 1998 to December 2014. AAD was defined as missed if imaging to diagnose AAD or a cardiology/cardiothoracic surgical consultation was not obtained in the ED. We compared the rates of missed diagnosis before and after the availability of 24-hour ED specialist coverage and an on-site CT scanner in the ED. RESULTS: Among 145 patients, 42 (29.0%) had a missed diagnosis. The proportion of missed AAD was lower in the post-implementation period compared to the pre-implementation period (20.0% vs. 37.3%, odds ratio [OR] 0.42, 95% confidence interval [CI] 0.20‒0.89; p = 0.023). After adjusting for confounders, the difference remained significant (OR 0.31, 95% CI 0.14‒0.70; p = 0.005). In the post-implementation period, concurrent signs of congestive cardiac failure (OR 33.51, 95% CI 1.42‒789.20; p = 0.024) and absence of a widened mediastinum on chest radiography (OR 11.52, 95% CI 1.37‒96.80; p = 0.029) were independent predictors of missed diagnoses. CONCLUSION: The availability of 24-hour ED specialist coverage and an on-site CT scanner improved the diagnosis of AAD in our study.

Computed tomography of the head for adult patients with minor head injury: are clinical decision rules a necessary evil?

INTRODUCTION: This study aimed to evaluate compliance with and performance of the Canadian Computed Tomography Head Rule (CCHR), and its applicability to the Singapore adult population with minor head injury. METHODS: We conducted a retrospective study over six months of consecutive patients who presented to the adult emergency department (ED) with minor head injury. Data on predictor variables indicated in the CCHR was collected and compliance with the CCHR was assessed by comparing the recommendations for head computed tomography (CT) to its actual usage. RESULTS: In total, 349 patients satisfied the inclusion criteria. Common mechanisms of injury were falls (59.3%), motor vehicle crashes (16.9%) and assault (12.0%). 249 (71.3%) patients underwent head CT, yielding 42 (12.0%) clinically significant findings. 1 (0.3%) patient required neurosurgical intervention. According to the CCHR, head CT was recommended for 209 (59.9%) patients. Compliance with the CCHR was 71.3%. Among the noncompliant group, head CT was overperformed for 20.1% and underperformed for 8.6% of patients. Multivariate logistic regression analysis revealed that absence of retrograde amnesia (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.8-9.7) was associated with noncompliance to the CCHR. Factors associated with underperformance were absence of motor vehicle crashes as a mechanism of injury (OR 6.6, 95% CI 1.2-36.3) and absence of headache (OR 10.8, 95% CI 1.3-87.4). CONCLUSION: Compliance with the CCHR for adult patients with minor head injury remains low in the ED. A qualitative review of physicians' practices and patients' preferences may be carried out to evaluate reasons for noncompliance.

Accuracy of magnetic resonance imaging in diagnosing lateral ankle ligament injuries: A comparative study with surgical findings and timings of scans.

OBJECTIVE: This study aimed to evaluate the accuracy of magnetic resonance imaging (MRI) in diagnosing lateral ankle ligament injuries and the effect of differences in time duration from injury to MRI. METHODS: Data were collected prospectively from 82 patients who underwent MRI and lateral ligament reconstruction, and were divided into either acute (≤3 months) or chronic (>3 months) group based on injury interval. Findings were classified as normal, partial, or complete tears of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). MRI results were compared with intraoperative findings and their accuracies were assessed using descriptive statistics. RESULTS: The accuracy of MRI for partial and complete tears of the ATFL was 74% and 79%, respectively, with sensitivity and specificity of 64% and 86% for partial tears, and 78% and 80% for complete tears, respectively. The accuracy of MRI was 66% and 88% for partial and complete tears of the CFL with a sensitivity and specificity of 41% and 87% for partial tears, and 61% and 95% for complete tears, respectively. A decrease in the MRI accuracy was observed in the chronic group. CONCLUSION: MRI is accurate in diagnosing ATFL injuries. It is specific but not sensitive for CFL tears. The accuracy is higher in the acute setting of 3 months or less from time of injury to MRI.

Body Mass Changes Across a Variety of Running Race Distances in the Tropics.

BACKGROUND: Current literature evaluating body mass (BM) changes across a variety of running race distances is limited. The primary objective of this study was to profile the range of BM changes across race distances. The secondary objective was to evaluate the prevalence of exercise-associated hyponatremia (EAH) in runners admitted to the on-site medical tent following participation of race events of different distances. METHODS: A total of 1934 runners across seven footrace categories (10-, 21-, 25-, 42-, 50-, 84-, and 100-km) were included in the study. One thousand eight hundred eighty-seven runners had their BM measured before and after each race. Blood sodium concentrations were measured from the remaining 47 symptomatic runners admitted to the on-site medical tents and did not complete the race. RESULTS: In terms of hydration status, 106 (6 %) were overhydrated, 1377 (73 %) were euhydrated, and 404 (21 %) were dehydrated. All race distances exhibited similar percentage of overhydrated runners (5 % in 10 km, 3 % in 21 km, 5 % in 25 km, 6 % in 42 km, 8 % in 50 km, 7 % in 84 km, and 6 % in 100 km). Forty-seven runners were admitted to the medical tents. Eight (17 %) were diagnosed with EAH (4 from 42 km, 2 from 84 km, 2 from 100 km), 38 (81 %) were normonatremic, and 1 (2 %) was hypernatremic. The % ΔBM across all races ranged from -8.0 to 4.1 % with a greater decrement noted in the 42-, 50-, 84-, and 100-km categories. CONCLUSIONS: Approximately 3-8 % runners had increased post-race BM, suggesting overhydration regardless of race distance. Symptomatic EAH was seen at race distances at or above 42 km, where BM changes demonstrated the widest range of values.