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ARDMS NewsWire: July 09, 2010‏

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ARDMS NewsWire: July 09, 2010‏

مُساهمة من طرف د.عوض محمد الخضر في السبت يوليو 10, 2010 3:40 pm

Point-of-care Ultrasound Useful for Fracture Diagnosis



Clinicians trained to use portable, point-of-care ultrasound equipment can achieve a high level of accuracy in identifying fractures in children and young adults when x-ray units are not available, according to a study published online in Injury.



Portable ultrasound potentially could be used to provide diagnostic imaging exams for injured patients in parts of the world without access to radiographic equipment. Fractures represent approximately 20% of emergency department visits by children, but treatment is often compromised because up to 75% of the world's population has no access to diagnostic imaging services, according to an estimate by the World Health Organization (WHO) (Injury).



Point-of-care ultrasound equipment is compact, portable, and less costly than x-ray systems. The modality is highly specific for identifying fractures as small as 1 mm due to the reflective acoustic properties of cortical bone. For this reason, pediatric emergency physicians at Bellevue Hospital Center in New York City conducted a study of patients younger than 25 who were admitted to the hospital's emergency department with suspected fractures. The prospective cohort study aimed to determine the accuracy of point-of-care ultrasound performed by clinicians.



Ten pediatric emergency physicians with varying levels of emergency ultrasound experience underwent one hour of point-of-care ultrasound training. The training combined the viewing of a 30-minute video with a 30-minute hands-on scanning session of normal bone anatomy and simulated fractures.



Lead author Eric Weinberg, MD, and colleagues reported that suspected fractures of the wrist and proximal foot were excluded due to the difficulty in evaluating intra-articular cortical surfaces and contours of these bones using ultrasound. Fractures were defined as cortical disruption or irregularity when scanning along the long axis of a bone, and as having a skipping or discontinuity effect when dynamically scanned along the short axis.



In all, 212 patients were enrolled in the study, of whom 67% were younger than 18 years. A typical ultrasound exam took four minutes. A single senior ultrasound technologist reviewed all of the ultrasound scans to provide quality assurance monitoring of the 348 bones that were imaged.



Bone fractures were accurately identified in 25% of the patients. Forty-three errors were made, all of which were attributable to operator technique; 37 involved ends of bones, with approximately one-third of these involving growth plates. Three false-negative sonograms were of a fractured clavicular shaft, a fractured phalanx shaft, and a fractured mandibular ramus. The two false-positive exams were of a rib and phalanx.



The authors reported an overall sensitivity of 73%, with 92% specificity. Sensitivity was 73% for long bones and 77% for nonlong bones, the latter representing 42% of the total. Specificity was 92% and 93%, respectively.



Radiographs remain the preferred diagnostic exam to identify or rule out bone fractures. However, the authors' data and the results of previously published studies suggest that point-of-care ultrasound may be an alternative for identifying fractures of the diaphyses of long bones, ribs, distal humerus, and skull, they wrote. In some cases, this might alleviate the need for radiation dose exposure where x-ray equipment is available.



In developing countries and geographically remote locations lacking x-ray equipment, point-of-care ultrasound by physicians minimally trained in its use may produce diagnostic images that can greatly benefit diagnosis. It also may be used in conjunction with satellite-delivered teleradiology for consultative interpretation, reflecting the origin of the first teleradiology services which provided clinical consultation to isolated villages in Canada and offshore drilling rigs in 1980.
View the article online
Article written by staff at auntminnie.com and adapted for the purposes of this newsletter.
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Doppler Ultrasound Can Reveal Presence of Subclinical Musculoskeletal Disease in Patients With Psoriasis

Patients with plaque-type psoriasis more frequently display pathological findings on power doppler ultrasound examination indicative for synovitis and enthesopathy compared with non-psoriatic patients, suggesting a subclinical musculoskeletal involvement in patients asymptomatic for musculoskeletal disease.

However, ultrasound findings in patients with plaque-type psoriasis without musculoskeletal clinical involvement are not well defined. Findings were presented at the 3rd International Congress on Psoriasis.

"The objective of our study was to investigate the presence of synovitis and enthesitis with power Doppler ultrasonography in patients with psoriasis without symptoms nor clinical signs of musculoskeletal diseases," said lead study author E. Dauden, MD, Dermatology, University Hospital De La Princessa, Madrid, Spain.

A total of 136 patients with plaque psoriasis and 46 age-matched controls with other skin diseases, all without musculoskeletal diseases were recruited at 14 centers. They underwent dermatological and rheumatological assessment.

For each patient a blinded power doppler ultrasound assessment was performed by the same investigator at each centre.

The results of the assessment consisted of detection of 1 synovitis with synovial PD signal in 36 joints, 1 tenosynovitis detection with tenosynovial PD signal at 22 sites, and 1enthesopathy dectetion with entheseal PD signal in 18 entheses.

The total percentage of joints with synovitis was 2.4% in patients with psoriasis and 1% in controls (P < .0005).

Entesopathy was present in 11.6% of patients with entheses and 5.3% of control entheses (P < .0005)

While no patients in the control group showed entheseal PD signal, 7.4% of patients with psoriasis did show this finding (P = .05).

Among all the clinical and demographic data, the only significantly predictive factor of pathological PDUS finding was psoriasis.

"We found synovitis and enthesopathy were significantly more frequent in psoriasis patients than in controls," said Dr. Dauden. "This finding may indicate a subclinical musculoskeletal involvement."
View the article online
Article written by staff at docguide.com and adapted for the purposes of this newsletter.
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CT Scans Pose Risks, Need More Regulation

From long-term cancer risks to radiation overdose mistakes, CT scans pose a growing danger to the American public and need more regulation to improve their safety, imaging experts write in a leading medical journal.

The articles in New England Journal of Medicine come a week after a story by The Associated Press detailed the overuse of imaging tests and how much the average American's radiation dose has grown in recent years.

CT scans are super-sharp X-rays that have transformed medicine by helping doctors quickly diagnose or rule out injuries and diseases. But they use far more radiation than ordinary X-rays, and too much radiation raises the risk of cancer over time.

The federal Food and Drug Administration and Congress are considering new measures to help prevent medical mistakes – relatively rare cases where some people are accidentally given radiation overdoses.

However, far more people face potential long-term harm from ordinary scans that are done correctly but that are overused, repeated or simply unnecessary.

Each year, 10 percent of the U.S. population gets a CT scan, and use of this imaging is growing more than 10 percent per year.

"That's really the area we should focus on," said the author of one of the articles, Dr. Rebecca Smith-Bindman. She is a radiologist at the University of California at San Francisco on temporary leave to do radiation research at the National Cancer Institute.

The FDA regulates scanning equipment, but lacks authority to say how doctors use it, or when tests are appropriate. No federal standards exist for how much radiation a CT scan should use, and a study Smith-Bindman led found a 13-fold variation in the dose that patients at four California hospitals received for the same type of scan.

"The doses are much higher and much more variable than people realize" for CT scanning, she said. "It's time to make it safer."

Industry efforts to curb overuse and lower radiation doses have had little impact, she said. "It is all voluntary," conceded Dr. John Patti, a Massachusetts General Hospital radiologist who heads the American College of Radiology's board of chancellors.

Two scientists with leadership roles in the group and extensive ties to industry and health insurers wrote in a second article in the journal that the use of high-tech imaging needs to become more selective.

Patients who pressure doctors for tests they may not need are part of the problem, write Dr. Bruce J. Hillman of the University of Virginia, and Jeff Goldsmith, president of Health Futures Inc., a Charlottesville, Va.-based health information policy and analysis company.

Fear of being sued also leads to too many tests – a problem that won't be fixed unless there are limits on malpractice awards, they wrote.

And although Medicare bars doctors from having a financial stake in care they order for their patients, "a loophole" lets them do tests on machines in their offices, Hillman and Goldsmith wrote. Some doctors have exploited this to send patients to off-site scanning facilities they own.

Congress could give the FDA authority to set doses for CT scans the way it has allowed the agency to do so for mammograms, Smith-Bindman said.

Groups that track quality-of-control measures for the federal government also should include lowering radiation dose as one of their standards, Smith-Bindman said. European countries have done this for more than a decade and doses have fallen there, she said.
View the article online
Article written by staff at huffingtonpost.com and adapted for the purposes of this newsletter.
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New Study Shows Benefits of Ultrasound-guided Anesthetic Technique

Ultrasound-guided anesthetic technique contributes to safety and effectiveness of nerve blocks. Correct placement of anesthetic greatly reduces negative outcomes like convulsions and cardiac arrest. Using ultrasound to guide the placement of peripheral nerve blocks improves the accuracy of correct anesthetic spread, leading to improved pain control, reduction in nausea and vomiting in patients and decreased negative outcomes like convulsions and cardiac arrest.

Peripheral nerve blocks refer to the injection of local anesthetic onto or near nerves for temporary control of pain. Nerve blocks relieve pain by interrupting how pain signals are sent to the brain.

Published in the July issue of Regional Anesthesia and Pain Medicine, the Sunnybrook study assessed whether 20 participants using ultrasound could accurately identify tissue spread of small volumes of local anesthetic. Recognizing local anesthetic spread as it is injected around a target structure is critically important as it provides both visual confirmation of the correct spread of local anesthetic and also provides the ability to reduce the volume of anesthetic used.

Using a gelatin model, the participants placed a nerve block needle in the model of a nerve block, with raisins acting as target structures. The accuracy of the test was found to be greater than 90 per cent in the users.

"We learned that with ultrasound it is easy to determine that local anesthetic spread is occurring in the correct place during a nerve block," said Dr. Colin McCartney, principal investigator and anesthesiologist at Sunnybrook's Holland Orthopaedic and Arthritic Centre. "This is tremendously important as failure to ensure the correct spread can lead to intravenous injection of local anesthetic with convulsions and cardiac arrest in patients."

The study may impact the training of future novice anesthesiologists before they attempt ultrasound-guided regional anesthesia in patients. "We know that hands-on training improves the performance of a skill, so this model could be a positive learning tool for the next generation of anesthesiologists," said McCartney."This study may also increase awareness around the fact that ultrasound-guided anesthetic techniques increase safety, in addition to the already demonstrated advantages of reduced nausea and faster discharge from the hospital after surgery," added McCartney.

_________________
اللهم أجعل خير عمري آخره،وخير أعمالي خواتمها،وخيرأيامي يوم ألقاك
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د.عوض محمد الخضر
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تاريخ التسجيل : 25/05/2010
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