Confirmatory Imaging Research Articles

Mathematical Modeling of The Challenge to Detect Pancreatic Adenocarcinoma Early with Biomarkers

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive tumor type and is usually detected at late stage. Here, mathematical modeling is used to assess the feasibility of two-step early detection with biomarkers, followed by confirmatory imaging. A one-compartment model of biomarker concentration in blood was parameterized and analyzed. Tumor growth models were generated from two competing genomic evolution models: gradual tumor evolution and punctuated equilibrium. When a biomarker is produced by the tumor at moderate-to-high secretion rates, both evolutionary models indicate that early detection with a blood-based biomarker is feasible and can occur approximately one and a half years before the limit of detection by imaging. Early detection with a blood-based biomarker is at the borderline of clinical utility when biomarker secretion rates by the tumor are an order of magnitude lower and the fraction of biomarker entering the blood is also lower by an order of magntidue. Regardless of whether tumor evolutionary dynamics follow the gradual model or punctuated equilibrium model, the uncertainty in production and clearance rates of molecular biomarkers is a major knowledge gap, and despite significant measurement challenges, should be a priority for the field. The findings of this study provide caution regarding the feasibility of early detection of pancreatic cancer with blood-based biomarkers and challenge the community to measure biomarker production and clearance rates.

03:00 Abstract No. 13 Dose reduction using digital fluoroscopy versus digital subtraction angiography (DSA) in endovascular aneurysm repair (EVAR): single-center prospective randomized comparison

EVAR can result in high radiation dose to patients and operators. Optimal imaging is required for safe stent graft deployment. While DSA provides high quality images, radiation dose rate is increased compared to digital fluoroscopy (DF). The aim of this prospective randomized study was to assess if radiation dose in EVAR could be reduced by predominantly utilizing DF for implantation compared to the standard DSA-utilized technique. Between 2011 and 2017 patients meeting inclusion criteria for EVAR of infrarenal abdominal aortic aneurysms were prospectively enrolled. Complex repair (i.e., fenestrated EVAR, parallel stent grafts) and thoracic EVAR cases were excluded. Patients were randomized to either a standard technique in which DSA could be used freely or a DF cohort in which DF was used for implantation but ≤ 2 DSA runs were allowed for confirmatory imaging at conclusion of the case. Body mass index (BMI), technical success, dose area product (DAP), cumulative air kerma (CAK), fluoroscopy time (FT), conversion rate to DSA (when fluoroscopy was inadequate for visualization) and number of DSA runs were recorded. 43 patients met inclusion criteria; 26 were randomized to the DF group and 17 to DSA. Technical success was 43/43 (100%). 5/26 (19%) required conversion to DSA. In an intention-to-treat analysis, DAP was reduced by 24% in the DF cohort (DSA=174 Gycm2, DF=132 Gycm2[p=0.04]), with no significant difference in CAK; median DSA acquisitions respectively were 7 and 1 (range 5-10, 0-9). When accounting for 5 conversions and dividing groups by number of DSA runs such that the DF cohort had ≤2 acquisitions and the DSA cohort had ≥3 acquisitions, DAP was reduced by 41% (DSA=185 Gycm2, DF=110 Gycm2 [p<0.01]), and CAK dose was reduced by 40% (DSA=964 mGy, DF=578 mGy [p<0.01]); median DSA acquisitions respectively were 7 and 1 (range 3-10, 0-2). In 21/26 (81%) of patients, digital fluoroscopy was adequate for safe implantation during EVAR. When the number of DSA runs was ≤2, radiation dose was reduced by 41%. If image quality allows, a fluoroscopy-only or limited DSA approach to EVAR can significantly reduce radiation dose.

Is Intraoperative Fluoroscopy Necessary to Confirm Device Position for Femoral-Sided Cortical Suspensory Fixation during Anterior Cruciate Ligament Reconstruction?

Increased laxity within the graft construct system can lead to graft failure after anterior cruciate ligament (ACL) reconstruction. Suboptimal cortical device positioning could lead to increased laxity within the system, which could influence the mechanics and function of the graft reconstruction. This study evaluates the benefit of intraoperative fluoroscopy to confirm device position on the femur during ACL reconstruction using cortical suspensory fixation. One hundred consecutive patients who underwent soft tissue ACL reconstruction using a suspensory cortical device for femoral fixation were retrospectively evaluated. Patients were split into two groups: Group A utilized anteromedial portal visualization and had intraoperative fluoroscopic imaging performed at the time of ACL graft fixation to confirm femoral device placement on the lateral femoral metaphyseal cortex. Group B utilized anteromedial portal visualization alone. Both groups had radiographic X-rays performed at the first postoperative visit to evaluate device location and all images were independently evaluated by three fellowship trained orthopaedic surgeons. Device position was classified as optimal if there was complete apposition of the entire device against the femoral cortex and suboptimal if it was > 2 mm off the cortex. Fisher's exact test, analysis of variance, and 95% confidence intervals were calculated to compare the groups for statistical significance. The results showed 0/60 (0%) patients in group A had suboptimal device position at postoperative follow-up, while 4/40 (10%) patients in group B had suboptimal device position (p = 0.013). There were no graft failures in group A and one graft failure in group B. There was a significant difference in cortical device position in patients who had intraoperative fluoroscopic imaging versus patients who had no intraoperative imaging. The use of confirmatory intraoperative imaging may be beneficial to confirm appropriate device location when using a femoral cortical suspensory fixation technique for ACL reconstruction.

Abstract TP423: Risk Factors for Intracranial Hemorrhage in Cerebral Venous Thrombosis

Cerebral venous thrombosis is associated with intracranial hemorrhage. The occurrence of brain bleeding complicates management and is associated with worse outcomes. We aimed to identify clinical and imaging risk factors for intracerebral hemorrhage. We hypothesized that higher clot burden would be associated with a higher risk of intracerebral hemorrhage. Methods: We performed a retrospective analysis of an international, multicenter cohort of patients with cerebral venous thrombosis who underwent CT within 2 weeks of symptom onset and who had a subsequent confirmed diagnosis of CVT on MRV, CTV or DSA. Clinical and imaging features were compared between patients with and without intracranial hemorrhage. Clot burden was assessed by counting the number of thrombosed venous sinuses and veins on confirmatory imaging. Results: We recruited 260 patients with cerebral venous thrombosis from 10 institutions in Europe and Mexico. The mean age was 42 and 74% were female. Intracranial hemorrhage was found in 102 (39%). Intracerebral hemorrhage occurred in 64 (63%), small juxtacortical hemorrhage in 30 (29%), subarachnoid hemorrhage in 24 (24%) and subdural hemorrhage in 11 (11%). Combinations of these types of hemorrhage occurred in 23 (23%). Intraparenchymal hemorrhages in multiple locations occurred in 6 (6%). Older age, presence of hematological disease and superior sagittal thrombosis involvement were significantly associated with presence of hemorrhage. The number of thrombosed venous sinuses was not associated with intracerebral hemorrhage (average number of sinuses/veins involved with hemorrhage 2.1 versus 1.9 without hemorrhage, p=0.4). Conclusion: The high rate of intracranial hemorrhage in cerebral venous thrombosis is not explained by widespread involvement of the venous sinuses. Superior sagittal sinus involvement is associated with the presence of intracranial hemorrhage.

18F-Fluoromethylcholine-positron emission tomography/computed tomography for diagnosing bone and lymph node metastases in patients with intermediate- or high-risk prostate cancer.

BackgroundThe use of molecular imaging in staging of prostate cancer (PC) is debated. In patients with newly diagnosed PC we investigated the diagnostic value of 18F-flouromethylcholine positron emission tomography/computed tomography (18F-FCH-PET/CT) for the detection of bone and lymph node metastases compared to whole-body bone scintigraphy (WBS) with technetium-99-methylene diphosphonate (99mTc-MDP) and results of extended pelvic lymph node dissection, respectively.Materials and methodsBetween January 2013 and April 2016, 143 patients, aged 49-83, mean 69, years with newly diagnosed PC and disease characteristics necessitating WBS underwent both WBS and 18F-FCH-PET/CT using magnetic resonance imaging as standard. Eighty of these patients underwent pelvic lymph node dissection as part of radical prostatectomy or prior to external beam radiation and in these results of 18F-FCH-PET/CT were compared to histologic findings.ResultsBone metastases were detected in 8/143 patients and sensitivity and specificity of WBS were 37.5% and 85.2% versus 100.0% and 96.3% with 18F-FCH-PET/CT, P=0.63 and 0.002, respectively. Histologically confirmed metastases to regional lymph nodes were found in 25/80 patients. Suspicious choline uptake on PET/CT in pelvic lymph nodes was found in 35 patients. Sensitivity, specificity, PPV, NPV and accuracy of 18F-FCH-PET/CT in detection of lymph node metastases were 62.5%, 69.6%, 46.9%, 81.3% and 67.5%, respectively.ConclusionsFindings in this study suggested that 18F-FCH-PET/CT is a more sensitive and specific method for detection of bone metastases from PC than WBS and could potentially reduce the need for confirmatory imaging if used instead of WBS. However, 18F-FCH-PET/CT performs sub-optimally in pre-operative staging of lymph node metastases in patients undergoing extended pelvic lymph node dissection.

Submitral left ventricular aneurysm: Characteristics, diagnosis, management, and outcome

Left ventricular (LV) aneurysm (LVA) is an uncommon cardiac disorder. There is no documented report from Ethiopia. Our objective was to discuss a case of LVA we encountered and analyze the clinical characteristics, diagnosis, management modalities, and outcome of patients with LVA from published studies over the last 200 years. in addition to the case we encountered, we searched PubMed for publications on patients with LVA and analyzed those reported since 1816. We identified 369 patients with LVA. The mean age at diagnosis was 31.7 ± 21.7 years, and 52.3% of them were males. It was more frequently reported from Africa (32.0%) and Europe (31.4%). The inferior part of the left ventricle including the submitral area is the most frequently (51.8%) reported location for LVA. Diagnosis was made coincidentally in most (40.1%) of the patients. The presenting features in those symptomatic patients were dyspnea or heart failure (HF) (23.8%), rhythm disturbances (18.2%), chest pain (10.6%), syncope (8.4%), thrombus (10.8%), or embolic events (5.4%). The universally used diagnostic modality was echocardiography. Electrocardiography (61%), chest X-ray (31.2%), cardiac catheterization (42.8%), computed tomography (1.3%), and magnetic resonance imaging (1.6%) were used as confirmatory or complementary imaging tests. During the follow-up period, death from cardiac causes occurred in 13.1% of the patients, with the leading cause of the cardiac death being congestive HF (51.9%). LVA has varied clinical features with potentially deleterious outcomes. While close follow-up with echocardiography in such patients is necessary, building the local expertise in surgical management of such patients is recommended as it has implications on individual patient, proper health-care utilization, and health-care costs.

Survey of Current Management Practices for Carotid Webs.

Background: Carotid webs are thick, fibrous intimal bands that appear as intraluminal shelf-like defects at the carotid bifurcation on vascular imaging. These lesions are a potential underrecognized cause of cryptogenic ischemic stroke. Although the recognition of carotid webs has increased, no evidence-based treatment guidelines are available. We surveyed subspecialists across multiple neurologic disciplines to assess the state of current clinical practice.Methods: An 8-question multiple-choice style survey of neurologists and radiologists assessed familiarity with this disease entity, preferred imaging modalities, and management strategies for asymptomatic and symptomatic (producing stroke) carotid webs. Responses were collected through SurveyMonkey software via anonymous responses to a posted survey link on the Society of Neurointerventional Surgery website in addition to invitation emails sent to colleagues in corresponding fields.Results: Of the 74 total respondents, 64% identified as neurointerventionalists. Respondents identified computed tomography angiography as the most commonly used imaging modality to place carotid webs in the differential diagnosis (57% of respondents’ preference), while conventional digital subtraction angiogram was the preferred modality to confirm a web (54% of respondents’ preference). Respondents preferred single and dual antiplatelet therapy to manage asymptomatic and acute stroke-producing carotid webs, while invasive treatment was most commonly sought for webs producing recurrent strokes.Conclusion: Familiarity with carotid webs varied across subspecialties. We found some consensus among respondents on the imaging modality preferred to identify webs, on asymptomatic carotid web management, and on recurrently symptomatic (multiple strokes) carotid web management. Less consistency was seen regarding preferences for confirmatory imaging and management of acutely symptomatic (initial stroke) carotid webs.

Improved identification of secondary hypertension: use of a systematic protocol.

The accurate identification and diagnosis of secondary hypertension is critical, especially while atherosclerotic cardiovascular heart disease continues to be the leading cause of death in the industrialized world. Nevertheless, despite the existence of diagnostic tools, there are significant variations of the estimated prevalence of secondary hypertension, due to multiple etiologies and suboptimal recognition. This study demonstrates the results of using a systematic and protocolled approach to improve recognition of the presence of secondary hypertension. In the future, this questionnaire can be a quick and effective tool to unveil secondary hypertension in a broad array of clinical settings. A total of 28,633 consecutive patients from January 1, 2007 to January 1, 2017 were diagnosed as having primary or secondary hypertension, utilizing the International Code of Diseases. Patients were located at the Center of Hypertension, Institute of Cardiology at Austral University Hospital, Buenos Aires, Argentina and were then further classified as having TRH, or non-resistant hypertension, to which a systematic protocol was employed in search for secondary hypertension. The confirmation of secondary hypertension was subsequently confirmed by diagnostic laboratory and imaging techniques in a hospital setting. A final population of 12,284 patients with treatment resistant hypertension (TRH) and non-treatment resistant hypertension (NTRH) were included in this study, where an etiology of secondary hypertension was identified in 50.9% and 36% of patients in each treatment group, respectively. Physicians used confirmatory laboratory testing and imaging of patients who were identified as having a cause for their secondary hypertension, with no significant differences in sex, age and body mass index (BMI) among study groups. These results illustrate the prevalence and distribution of the causes of secondary hypertension using a systematic, protocolled approach, which revealed a higher percentage of secondary hypertension than previously reported. This tool may be used by healthcare providers to ensure the appropriate recognition of secondary causes of hypertension in a wider range of patients with high blood pressure beyond resistant hypertension, changing the diagnostic paradigm of this condition.

Point-of-care biliary ultrasound in the emergency department (BUSED): implications for surgical referral and emergency department wait times

BackgroundPatients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making, biliary point-of-care ultrasound (POCUS) in the emergency department has emerged as...

Bucket-Handle Tear of the Medial Meniscus in a 2-Year-Old Child.

Bucket-handle meniscal tears are extremely rare injuries in the pediatric population. Given the known sequelae of meniscal tears and the development of osteoarthritis, early diagnosis and treatment of pediatric meniscal tears are essential. The communication barrier between physicians and pediatric patients, however, creates difficulties in making the correct diagnosis of meniscal pathology. Providers should have a low threshold for obtaining further confirmatory advanced imaging if patients present with prolonged knee pain and swelling, with associated locking mechanical symptoms. Good clinical outcomes following meniscal repair have been observed, likely a result of the increased residual vascularity found within pediatric menisci. The youngest reported case of an isolated traumatic bucket-handle medial meniscal tear is examined in this article. A 2-year-old girl presented with right knee pain after a heavy object fell onto the knee several weeks earlier. On examination, the patient walked with a limp but lacked full range of active knee motion. The McMurray test elicited pain without a mechanical or palpable click. After the patient continued to exhibit limitations following conservative management, magnetic resonance imaging of the right knee was obtained, which showed a bucket-handle tear of the right medial meniscus. The patient subsequently underwent meniscal repair and, on recovery, was able to regain normal functioning of the right knee without limitations. [Orthopedics. 2018; 41(4):e580-e582.].

Age-Adjusted D-Dimer to Rule out Deep Vein Thrombosis: Findings From the PALLADIO Algorithm

D-dimer has been used as a predictor, albeit sensitive but nonspecific, for venous thromboemobolic events (VTEs). Age-adjusting has led to mixed results published in the literature. In this study, when using an age-adjusted cutoff, D-dimer shows increased specificity in patients with VTE and may lead to a reduction in the need for confirmatory imaging tests.

Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients' history elements and physical examination tests

ObjectiveTo assess the diagnostic validity of clusters combining history elements and physical examination tests to diagnose partial or complete anterior cruciate ligament (ACL) tears.DesignProspective diagnostic study.SettingsOrthopaedic clinics (n = 2), family medicine clinics (n = 2) and community-dwelling.ParticipantsConsecutive patients with a knee complaint (n = 279) and consulting one of the participating orthopaedic surgeons (n = 3) or sport medicine physicians (n = 2).InterventionsNot applicable.Main outcome measuresHistory elements and physical examination tests performed independently were compared to the reference standard: an expert physicians’ composite diagnosis including history elements, physical tests and confirmatory magnetic resonance imaging. Penalized logistic regression (LASSO) was used to identify history elements and physical examination tests associated with the diagnosis of ACL tear and recursive partitioning was used to develop diagnostic clusters. Diagnostic accuracy measures including sensitivity (Se), specificity (Sp), predictive values and positive and negative likelihood ratios (LR+/-) with associated 95% confidence intervals (CI) were calculated.ResultsForty-three individuals received a diagnosis of partial or complete ACL tear (15.4% of total cohort). The Lachman test alone was able to diagnose partial or complete ACL tears (LR+: 38.4; 95%CI: 16.0–92.5). Combining a history of trauma during a pivot with a “popping” sensation also reached a high diagnostic validity for partial or complete tears (LR+: 9.8; 95%CI: 5.6–17.3). Combining a history of trauma during a pivot, immediate effusion after trauma and a positive Lachman test was able to identify individuals with a complete ACL tear (LR+: 17.5; 95%CI: 9.8–31.5). Finally, combining a negative history of pivot or a negative popping sensation during trauma with a negative Lachman or pivot shift test was able to exclude both partial or complete ACL tears (LR-: 0.08; 95%CI: 0.03–0.24).ConclusionDiagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of ACL tears compared to various knee disorders.

Sa1288 THE INTERVAL BETWEEN UNRECOGNIZED BILIARY INJURY AND ERCP THERAPY FOR BILE DUCT LEAK PREDICTS CLINICAL OUTCOMES

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic therapy is a common, effective and safe modality to treat bile duct leak (BDL). This study evaluated whether the interval between unrecognized bile duct injury and ERCP therapy was associated with clinical outcomes. We retrospectively evaluated all patients at University of Vermont Medical Center undergoing ERCP for BDL from 2006-2015. Patient demographics, dates of surgery and biliary stenting, leak site, symptoms, intraoperative recognition, hospital interventions, and length of stay were all collected. The primary analysis was performed on patients with BDL who were unrecognized at the time of surgery. We analyzed the time from injury to therapy, injury to diagnosis and diagnosis to therapy. Diagnosis of BDL was when confirmatory imaging occurred, and therapy when biliary stenting was performed. Significance was assessed by the Independent Samples T-Test or Spearman test for correlation when appropriate. 107 patients were identified who underwent ERCP for BDL. The majority were female (64%) and were undergoing cholecystectomy (83%). Intraoperative recognition of a BDL occurred in 20%. Insertion of a plastic biliary stent for therapy occurred in 96% and a sphincterotomy was performed in 17%. For patients with BDL that were not recognized intraoperatively (N=79), the mean/median time from injury to therapy was 7.49/4.00 days respectively. Those who had a leak related to a cholecystectomy had a shorter duration to stenting than if the BDL was from a different surgery (5.48 vs 15.44 days p≤0.001). Patients who required antibiotics had a longer time from injury to therapy (10 vs 5 days, p=0.009), as did those who required placement of an IR drain (13 vs 4 days, p≤0.001). IR drain placement was associated with both significantly longer time from injury to diagnosis (14 vs 3 days, p=0.001) and longer time from diagnosis to therapy (4 vs 0.7 days, p=0.001). Patient gender, need for subsequent surgery, stent type, presence of a CBD stone, and the clinical symptom of abdominal pain were not predictive of a longer time from bile duct damage to therapy. Length of hospitalization subsequent to therapy was numerically greater for patients with a longer time to therapy, however this correlation did not reach statistical significance (p=0.093). Cholecystectomy was the most common surgical intervention resulting in BDL at our center. In surgical patients with an unrecognized BDL, those undergoing cholecystectomy had a shorter duration to therapy. Patients with a longer duration from injury to therapy were more likely to require antibiotics or an IR drain. An IR drain was associated with a longer time from injury to diagnosis and a longer time from diagnosis to therapy.

Branchial cleft cysts: a pictorial review.

Cystic masses of the neck may represent a wide variety of pathological conditions. Among these, branchial anomalies are the commonest paediatric congenital lesions of the head and neck. This article intends to review this condition under the same headings, as well as facilitate their diagnosis with the help of appropriate radiological findings of patients diagnosed with these anomalies. In order to make an accurate diagnosis, it is imperative to have an idea about the possible differentials, and the normal embryological development of the branchial arches, as well as their anomalies, in the form of sinuses, fistulae, and cysts, with their features and subtypes. The medical history of the patient and clinical manifestations helps in suspecting branchial cleft cysts; confirmatory imaging modalities include computed tomography, magnetic resonance imaging, ultrasonography, and fine-needle aspiration. The mainstay of management is usually by surgical excision. The location, clinical picture, and radiological correlation, along with a strong degree of suspicion for the condition, facilitates the diagnosis of this relatively common embryological anomaly.

Multiparametric Magnetic-Resonance to Confirm Eligibility to an Active Surveillance Program for Low-Risk Prostate Cancer: Intermediate Time Results of a Third Referral High Volume Centre Active Surveillance Protocol

Background: To evaluate the role of confirmatory multiparametric magnetic resonance imaging (mpMRI) of the prostate at the time of Active Surveillance (AS) enrollment to reduce disease misclassification. Materials: From 2012 to 2016, 383 patients with low-risk disease respecting Prostate Cancer Research International AS criteria underwent confirmatory 1.5-T mpMRI. AS was proposed to patients with Prostate Imaging and Report and Data System (PI-RADS) score ≤3 and no extraprostatic extension (EPE), whereas patients with PI-RADS score ≥4 and/or EPE were treated actively. Kaplan-Meier analyses quantified progression-free survival (PFS) in patients enrolled in the AS program. Logistic regression analyses tested the association between confirmatory mpMRI and clinically significant prostate cancer (csPCa) at radical prostatectomy (RP). Diagnostic performance of mpMRI was calculated in patients submitted to immediate RP. Results: PFS rate was 99, 90 and 86% at 1, 2 and 3 years respectively. At multivariable analysis, PI-RADS 3, PI-RADS 4, PI-RADS 5 and EPE increased the probability of having csPCa at immediate RP (PI-RADS 3 [OR] 1.2, p = 0.26; PI-RADS 4 [OR] 5.1, p = 0.02; PI-RADS 5 [OR] 6.7; p = 0.009; EPE [OR] 11.8, p < 0.001). Confirmatory mpMRI showed sensibility, specificity, positive predictive value and negative predictive value of 85, 55, 68 and 76% respectively. Conclusions: MpMRI at the time of AS enrollment reduces the misclassification rate of csPCa. We suggest to perform target biopsies in patients with PI-RADS score 3 and 4 lesions.

P081: ICD-10 coding of free text diagnoses is not reliable for the diagnosis of PE in Calgary zone emergency department patients

Introduction: Administrative data are attractive for research, policy and quality improvement initiatives as large amounts of data can often be obtained quickly and at low cost. Unfortunately, administrative data often have significant limitations owing to how they were collected and coded. In many cases, free text, often hand written, diagnoses provided by physicians are converted into ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision) codes by trained nosologists for administrative purposes. However, because of the large data sets often obtained from administrative sources, it is difficult to verify the accuracy of the data, which may lead researchers to misleading or false conclusions. The objective of this study was to evaluate the accuracy of ICD-10 codes for the diagnosis of pulmonary embolism (PE) in emergency department (ED) patients. Methods: As part of a larger study examining the effectiveness of a clinical decision support intervention on CT utilization and diagnostic yield for ED patients with suspected PE, all patients with an ICD-10 code corresponding to PE (126.0 and 126.9) on ED discharge were obtained from four adult urban EDs and one urgent care center from August 2016 to March 2017. PE diagnosis was confirmed by reviewing electronic medical records and imaging reports for all patients. Discrepancies between coded ICD-10 diagnoses and actual imaging findings were quantified. This study was REB approved. Results: Of 584 ED patients with ICD-10 codes identifying PE as a discharge diagnosis, 535 had imaging that could be reviewed. Of these, 225 (42.1%) did not have clinical diagnoses of PE, and thus were incorrectly coded, resulting in false positive ICD-10 codes. Common coding errors included physician free text diagnoses of rule out PE or query PE being coded as positive for PE. Conclusion: Administrative data are subject to errors in coding. In this study ICD-10 codes were not reliable for the diagnosis of PE, with 42.1% of PE diagnoses being false positives. Similar coding errors are likely for other diagnoses that require waits for confirmatory imaging (e.g. appendicitis). Nosologist coding of physician free text diagnoses is challenging and prone to errors. Consequently, validation of ICD-10 coding prior to analysis of administrative datasets is crucial for meaningful results.

Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain

BackgroundIdentification of sciatica may assist timely management but can be challenging in clinical practice. Diagnostic models to identify sciatica have mainly been developed in secondary care settings with conflicting reference standard selection. This study explores the challenges of reference standard selection and aims to ascertain which combination of clinical assessment items best identify sciatica in people seeking primary healthcare.MethodsData on 394 low back-related leg pain consulters were analysed. Potential sciatica indicators were seven clinical assessment items. Two reference standards were used: (i) high confidence sciatica clinical diagnosis; (ii) high confidence sciatica clinical diagnosis with confirmatory magnetic resonance imaging findings. Multivariable logistic regression models were produced for both reference standards. A tool predicting sciatica diagnosis in low back-related leg pain was derived. Latent class modelling explored the validity of the reference standard.ResultsModel (i) retained five items; model (ii) retained six items. Four items remained in both models: below knee pain, leg pain worse than back pain, positive neural tension tests and neurological deficit. Model (i) was well calibrated (p = 0.18), discrimination was area under the receiver operating characteristic curve (AUC) 0.95 (95% CI 0.93, 0.98). Model (ii) showed good discrimination (AUC 0.82; 0.78, 0.86) but poor calibration (p = 0.004). Bootstrapping revealed minimal overfitting in both models. Agreement between the two latent classes and clinical diagnosis groups defined by model (i) was substantial, and fair for model (ii).ConclusionFour clinical assessment items were common in both reference standard definitions of sciatica. A simple scoring tool for identifying sciatica was developed. These criteria could be used clinically and in research to improve accuracy of identification of this subgroup of back pain patients.

Is nonoperative management of partial distal biceps tears really successful?

The current treatment of partial distal biceps tears is a period of nonoperative management, followed by surgery, if symptoms persist. Little is known about the success rate and outcomes of nonoperative management of this illness. We identified 132 patients with partial distal biceps tears through an International Classification of Diseases, Ninth Revision code query of our institution's database. Patient records were reviewed to abstract demographic information and confirm partial tears of the distal biceps tendon based on clinical examination findings and confirmatory magnetic resonance imaging (MRI). Seventy-four patients completed an outcome survey. In our study, 55.7% of the contacted patients who tried a nonoperative course (34 of 61 patients) ultimately underwent surgery, and 13 patients underwent immediate surgery. High-need patients, as defined by occupation, were more likely to report that they recovered ideally if they underwent surgery, as compared with those who did not undergo surgery (odds ratio, 11.58; P = .0138). For low-need patients, the same analysis was not statistically significant (P = .139). There was no difference in satisfaction scores between patients who tried a nonoperative course before surgery and those who underwent immediate surgery (P = .854). An MRI-diagnosed tear of greater than 50% was a predictor of needing surgery (odds ratio, 3.0; P = .006). This study has identified clinically relevant information for the treatment of partial distal biceps tears, including the following: the failure rate of nonoperative treatment, the establishment of MRI percent tear as a predictor of failing nonoperative management, the benefit of surgery for the high-need occupational group, and the finding that nonoperative management does not negatively affect outcome if subsequent surgery is necessary.

Diagnostic Validity of Combining History Elements and Physical Examination Tests for Traumatic and Degenerative Symptomatic Meniscal Tears

BackgroundThe current approach to the clinical diagnosis of traumatic and degenerative symptomatic meniscal tears (SMTs) proposes combining history elements and physical examination tests without systematic prescription of imaging investigations, yet the evidence to support this diagnostic approach is scarce. ObjectiveTo assess the validity of diagnostic clusters combining history elements and physical examination tests to diagnose or exclude traumatic and degenerative SMT compared with other knee disorders. DesignProspective diagnostic accuracy study. SettingsPatients were recruited from 2 orthopedic clinics, 2 family medicine clinics, and from a university community. PatientsA total of 279 consecutive patients who underwent consultation for a new knee complaint. MethodsEach patient was assessed independently by 2 evaluators. History elements and standardized physical examination tests performed by a physiotherapist were compared with the reference standard: an expert physicians’ composite diagnosis including a clinical examination and confirmatory magnetic resonance imaging. Participating expert physicians were orthopedic surgeons (n = 3) or sport medicine physicians (n = 2). Penalized logistic regression (least absolute shrinkage and selection operator) was used to identify history elements and physical examination tests associated with the diagnosis of SMT and recursive partitioning was used to develop diagnostic clusters. Main Outcome MeasuresDiagnostic accuracy measures were calculated including sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (LR+/–) with associated 95% confidence intervals (CIs). ResultsEighty patients had a diagnosis of SMT (28.7%), including 35 traumatic tears and 45 degenerative tears. The combination a history of trauma during a pivot, medial knee pain location, and a positive medial joint line tenderness test was able to diagnose (LR+ = 8.9; 95% CI 6.1-13.1) or exclude (LR– = 0.10; 95% CI 0.03-0.28) a traumatic SMT. Combining a history of progressive onset of pain, medial knee pain location, pain while pivoting, absence of valgus or varus knee misalignment, or full passive knee flexion was able to moderately diagnose (LR+ = 6.4; 95% CI 4.0-10.4) or exclude (LR– = 0.10; 95% CI 0.03-0.31) a degenerative SMT. Internal validation estimates were slightly lower for all clusters but demonstrated positive LR superior to 5 and negative LR inferior to 0.2 indicating moderate shift in posttest probability. ConclusionDiagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of SMT. These results represent the initial derivation of the clusters and external validation is mandatory. Level of EvidenceI

Diagnosis and treatment of patients with prostatic abscess in the post-antibiotic era.

We reviewed the pathogenesis, clinical presentation, treatment options and outcomes of prostatic abscess in the post-antibiotic era, focusing on how patient risk factors and the emergence of multidrug-resistant organisms influence management of the condition. A MEDLINE search for "prostate abscess" or "prostatic abscess" was carried out. Prostate abscess is no longer considered a consequence of untreated urinary infection; now, men with prostatic abscess are typically debilitated or immunologically compromised, with >50% of patients having diabetes. In younger men, prostatic abscess can be the initial presentation of such chronic conditions. In older men, prostatic abscess is increasingly a complication of benign prostatic hyperplasia or prostate biopsy. Diagnosis is based on a physical examination, leukocytosis, leukocyturia and transrectal ultrasound, with magnetic resonance imaging serving as the preferred confirmatory imaging modality. Treatment of prostatic abscess is changing as a result of the emergence of atypical and drug-resistant organisms, such as extended-spectrum β-lactamase-producing enterobacteriaceae and methicillin-resistant Staphylococcus aureus. As many as 75% of infections are resistant to first-generation antibiotics, necessitating aggressive therapy with broad-spectrum parenteral antibiotics, such as third-generation cephalosporins, aztreonam or antibiotic combinations. A total of 80% of patients require early surgical drainage, frequently through a transurethral approach. In the post-antibiotic era, prostatic abscess is evolving from an uncommon complication of urinary infection to a consequence of immunodeficiency, growing antibiotic resistance and urological manipulation. This condition, primarily affecting patients with chronic medical conditions rendering them susceptible to atypical, drug-resistant organisms, requires prompt aggressive intervention with contemporary antibiotic therapy and surgical drainage.