A systematic review of radiographic definitions of foot osteoarthritis in population-based studies

OBJECTIVE

To identify the methods used in population-based epidemiological studies to diagnose radiographic foot osteoarthritis (OA) and to estimate the population prevalence of radiographic foot OA.

METHOD

Electronic databases searched included Medline, Embase, CINAHL and Ageline (inception to May 2009). The search strategy combined search terms for radiography, OA, foot, and specific foot joints. Predetermined selection criteria were applied. Data extracted from each paper included: sample population, radiographic views taken, foot joints examined, scoring system used, definition of OA applied, reliability of radiographic scoring and prevalence of radiographic OA in the foot.

RESULTS

Titles and abstracts of 1035 papers were reviewed and full-texts of 21 papers were obtained. Fifteen papers met inclusion criteria and a further 12 papers were included after screening references. Radiographic views were frequently not specified (NS) but a combination of antero-posterior (AP) and lateral (Lat) views was most commonly reported. The first metatarsophalangeal (MTP) joint was the most commonly examined joint (n=20, 74%). Nineteen studies (70%) used the Kellgren and Lawrence (K&L) grading system, 95% of which defined OA as K&L grade> or =2. Estimates of the prevalence of radiographic first MTP joint OA (defined as K&L> or =2) in middle-aged to older adults ranged from 6.3 to 39%. Significant statistical heterogeneity prevented pooling of prevalence estimates.

CONCLUSION

There are comparatively few studies examining radiographic foot OA. Existing studies mainly focus on the first MTP joint and use the K&L grading system. Future studies are needed to quantify the prevalence of radiographic OA at the different joint complexes within the foot.

Influence of acetabular and femoral version on fractures of the femoral neck

BACKGROUND

Fractures through the proximal femur are broadly grouped into intertrochanteric fractures and intracapsular fractures. It is not clear why a patient may sustain an intertrochanteric fracture as compared with an intracapsular fracture. There is an established relationship between relative hip retroversion and the development of osteoarthritis. We postulate retroversion also may be a risk factor for having intracapsular fractures develop.

QUESTIONS/PURPOSES

We looked specifically at the geometry of the hip to analyze the possibility of a relationship between acetabular version, femoral version, and Mckibbin's instability index and fracture type.

PATIENTS AND METHODS

We recruited 40 patients with fractures of the femoral neck for the study. There were 15 men and 25 women with a mean age of 80 years (range, 57-92 years). There were 14 intertrochanteric fractures and 26 intracapsular fractures. After treating their fracture, the contralateral hip was scanned in a CT scanner and assessed by two independent observers to establish the acetabular and femoral version.

RESULTS

We found no correlation between proximal femoral fracture type and the contralateral femoral version, femoral neck length, acetabular version, or Mckibbin's instability index or between fracture type and age or gender.

CONCLUSIONS

There appears to be no correlation between proximal femoral fracture type and acetabular or femoral version.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Nonparametric methods

This paper by John Belcher aims to give a non-technical illustration of the applications of non-parametric tests and to list the types of medical data that can arise. (In a second paper on pages 26-40, the author presents an overview of time series analysis).

An overview of time series analysis

In this paper John Belcher provides an introduction to some basic ideas in the analysis of time series data.

Delays in orthopaedic trauma treatment: setting standards for the time interval between admission and operation

Delay in operating on trauma patients leads to increased morbidity, mortality, length of hospital stay and overall cost. The urgency of operative intervention depends on the injury sustained. There are no published guidelines on what constitutes a reasonable delay between admission and operation. As part of the clinical governance in our unit, an audit was undertaken to examine the structure and process of trauma operating. Patients were allocated to groups defined by the Bath Orthopaedic Department, according to urgency of need for surgery. Group A: patients (for example, open fractures and dislocations) should have definitive treatment within 6 h of admission. Group B: patients (for example, hip fractures, long bone injuries and ankle fractures) should have operations on the day that they are presented to the consultant trauma meeting, or on the day that they are declared fit/ready for theatre. Group C: patients (for example, tendon injuries, simple hand fractures) should have operations within 5 days of presentation to the trauma meeting. Over 3 months, there were 401 acute orthopaedic admissions requiring surgery (61 group A, 277 group B, 63 group C). 78% of group A patients, 58% of group B patients and 86% of group C patients were operated on within the target times. In total, 137 out of 401 operations (34%) missed the targets set. 119 of these (87%) were delayed due to lack of available operating time. This was despite the fact that 59 operations (15% of total) were done on lists normally used for elective operating. Most of the other delays were due to the need for an appropriately experienced surgeon to be available. If these targets are to be achieved for the majority of patients, the trauma theatre must become more efficient, or more flexible time must be made available during evenings or weekends to clear the backlog of trauma operations.

Effects of anti-rheumatic gold salts on NF-kappa B mobilization and tumour necrosis factor-alpha (TNF-alpha)-induced neutrophil-dependent cytotoxicity for human endothelial cells

We have previously shown that the gold-containing disease-modifying anti-rheumatic drugs, auranofin (AF) and gold sodium aurothiomalate (GSTM) reduce human umbilical vein endothelial cell (HUVEC) adhesion molecule expression and neutrophil (PMN) adherence. AF diminishes E-selectin and intercellular adhesion molecule-1 (ICAM-1) on cytokine-activated HUVEC, while GSTM decreases only E-selectin. Since tight adhesion is critical for PMN to damage EC, we tested whether these drugs modulated human PMN-mediated injury to TNF-alpha-activated HUVEC in vitro (as measured by 51Cr release). Here we show that TNF-alpha caused a prominent PMN-mediated cytotoxicity that was dose-dependently reduced when AF and GSTM were added to the assay system. We also found that a potent inhibitor of NF-kappaB, pyrrolidine dithiocarbamate (PDTC) in a dose-dependent manner impaired TNF-alpha-induced cytotoxicity, indicating a role of NF-kappaB activation in cytokine-induced endothelial injury. To examine the effects of AF and GSTM on TNF-alpha-induced NF-kappaB activation this was measured in HUVEC nuclear extracts by an electrophoretic mobility shift assay. AF, but not GSTM, decreased TNF-alpha-induced NF-kappaB activation in HUVEC. Thus, in this in vitro model of vasculitis, AF and GSTM dose dependently reduced TNF-alpha-mediated neutrophil-dependent cytotoxicity for HUVEC, and AF, but not GSTM, inhibited NF-kappaB mobilization, thereby providing possible mechanisms for effects of AF and GSTM.

Development of an expert system for the interpretation of serial peak expiratory flow measurements in the diagnosis of occupational asthma. Midlands Thoracic Society Research Group

If asthma is due to work exposures there must be a relation between these exposures and the asthma. Asthma causes airway hyperresponsiveness and obstruction; the obstruction can be measured with portable meters, which usually measure peak expiratory flow, or sometimes forced expiratory volume in 1 second (FEV1). These can be measured serially (for instance 2 hourly) over several weeks at and away from work. Once occupational asthma develops, the asthma will be induced by many non-specific triggers common to non-occupational asthma. The challenge is to identify changes in peak expiratory flow due to work among other non-occupational causes. Standard statistical tests have been found to be insensitive or non-specific, principally because of the variable period for deterioration to occur after exposure, and the sometimes prolonged time for recovery to occur, such that days away from work may initially have lower measurements than days at work. A computer assisted diagnostic aid (Oasys) has been developed to separate occupational from non-occupational causes of airflow obstruction. Oasys-2 is based on a discriminant analysis, and achieved a sensitivity of 75% and a specificity of at least 94%; therefore peak expiratory flow monitoring combined with Oasys-2 analysis is better to confirm than to exclude occupational asthma. A neural network version in development has improved on this. Both have been based on expert interpretation of peak flow measurements plotted as daily maximum, mean, and minimum, with the first reading at work taken as the first reading of the day. Oasys has been evaluated with independent criteria against measurements made in a wide range of occupational situations. Oasys is sufficiently developed to be the initial method for the confirmation, although less so for exclusion of occupational asthma.

The effect of patient technique and training on the accuracy of self-recorded peak expiratory flow

The aim of the study was to investigate the difference between encouraged self-recorded peak expiratory flow (PEF) with unobserved readings and to investigate any long-term changes in PEF self-recording. Patients were trained in the PEF technique and asked to keep 2-hourly PEF records until the next clinic visit. The patients PEF were then rechecked at the second clinic visit by a series of two unobserved, an observed and an encouraged PEF measurement. A subgroup of patients were reassessed at a third clinic visit. Forty-one patients produced serial PEF readings. Significant differences between unobserved and encouraged PEF readings were detected; there was a mean decrement of 21 L x min(-1) and limits of agreements suggested that the decrement could be as high as 60 L x min(-1). Visual and statistical analysis of the serial PEF provided showed a consistent deterioration in PEF over the record in 54% and 39% of cases, respectively. No significant differences were found in the subgroup who attended a third clinic visit. The results suggest that significant inaccuracies in unobserved peak expiratory flow readings can occur between clinic visits and this can be reflected as a consistent deterioration in some. This should be kept in mind when interpreting self-recorded peak expiratory flow measurements. Re-evaluation at the third visit following the retraining effect of the second visit on peak expiratory flow technique appears to reduce inaccuracies. It is believed that peak expiratory flow technique should be reevaluated at each clinic visit.

Comparative clinical and physiological features of Maori, Pacific Islanders and Europeans with sleep related breathing disorders

Recent studies have suggested that there is a familial association of sleep apnoea syndrome and that this is not entirely explained by inheritance of known risk factors. Maori (M) and Pacific Islanders (PI) have many of the body habitus features associated with sleep apnoea and therefore might be expected to exhibit more severe disease than Europeans (E).

OBJECTIVE

To compare the clinical and physiological characteristics of the different ethnic groups and to determine if race was an independent predictor of severity of sleep apnoea.

METHODOLOGY

A prospective evaluation of patients attending the Sleep Disordered Breathing Clinic which serves the whole of Auckland (population 1.1 million), New Zealand was conducted for the period July 1994 to August 1995. The evaluation included history including a 26 question questionnaire, Epworth sleepiness score, examination, and where indicated, full polysomnography.

RESULTS

A total of 233 patients (154 E, 48 M and 33 PI), underwent full polysomnography. Forty-one (85%) of the M and 31 (94%) of PI had obstructive or mixed sleep apnoea compared with only 74 (49%) of the E (P < 0.0001; chi 2). There were few racial differences in the responses to the sleep questionnaire. M and PI were shown to have much greater neck and waist circumference and body mass indices. Severity parameters (apnoea-hypopnoea index, wake and minimum oxygen saturation, and apnoea duration) were greater for both M and PI compared with E (P < 0.001; Mann-Whitney U-test). Stepwise regression identified neck size, body mass index and age as independent predictors of severity.

CONCLUSION

When other factors were controlled for, race was not an important independent predictor of severity of sleep apnoea.

A randomized controlled trial of strict glycemic control and tertiary level obstetric care versus routine obstetric care in the management of gestational diabetes: a pilot study

OBJECTIVES

The purpose of this study was to determine whether strict maternal glycemic control for the treatment of gestational diabetes lessened the risk of fetal macrosomia, birth trauma, neonatal hypoglycemia, and operative delivery. The aim of the pilot study was to prepare for a multicenter trial by assessing patient acceptance of the study, by determining realistic accrual rates, and by detecting any major adverse outcomes in the control group that received routine obstetric care.

STUDY DESIGN

The study was a prospective randomized controlled trial comparing fetal-neonatal and maternal outcomes in 300 women with gestational diabetes. Women randomized to the treatment arm were managed by strict glycemic control and tertiary level obstetric care, and women in the control arm received routine obstetric care.

RESULTS

Three hundred women with gestational diabetes mellitus were studied. There was no difference in maternal age, weight, or length of gestation between groups. The treatment mean birth weight was 3437 +/- 575 gm compared with 3544 +/- 601 gm in the control group, a difference of 107 gm (not significant). Macrosomia rates were similar. There was no birth trauma in either group. The frequency of neonatal hypoglycemia and other metabolic complications was the same. The mode of delivery also showed similar patterns. The treatment group had significantly lower preprandial and postprandial glucose levels by 32 weeks' gestation, which continued to term.

CONCLUSION

This pilot study suggests that intensive treatment of gestational diabetes mellitus may have little effect on birth weight, birth trauma, operative delivery, or neonatal metabolic disorders. It has demonstrated the safety of proceeding to a multicenter trial of sufficient sample size to confirm these findings.

Rural elderly present need for nursing continuity

Over 25% of the elderly reside in rural areas. Elders residing in rural areas have incomes that are approximately 20% less than their urban counterparts. One year of data on the 1,972 admissions of Medicare patients to a 150-bed rural hospital was studied to seek the commonalties marking four LOS categories of patients, including their 17+ day LOS outliers. Sixteen percent of all the Medicare admissions who tended to be older, have chronic illnesses and needed multiple services, fell into the 17+ day LOS group where reimbursement covered only one-third of the actual cost of care provided. ICD-9 codes associated with the cardiac diagnostic category dominated, with 21.5% of those included in this resource-intensive group. In preparing for capitated reimbursement, all efforts to develop systems to decrease ED visits and hospital stays, while enhancing quality of life for the chronically ill, must be implemented.

The descriptive assessment for psychiatric art. A new way of quantifying paintings by psychiatric patients

This pilot study reports the development of a coding system for quantitative analysis of paintings produced by psychiatric patients. Color, color intensity, quality of line, space covered, and subjectively judged emotional tone as characteristics of paintings were recorded in each section of a grid superimposed over the picture. A sample of 39 psychiatric patients were classified into 4 groups using ICD-10 criteria: depression, psychosis, brain injury, and drug abuse. Six independent raters achieved excellent reliability across all scales on each of eight pictures. Analysis of variance results show that each diagnostic group differed on 4 of 13 variables: yellow, orange, color intensity, and line (p < .02). The prospects for further research are discussed.

Development of OASYS-2: a system for the analysis of serial measurement of peak expiratory flow in workers with suspected occupational asthma

BACKGROUND

Serial peak expiratory flow (PEF) measurement is usually the most appropriate first step in the confirmation of occupational asthma. Visual assessment of the plotted record is more sensitive and specific than statistical methods so far reported. The use of visual analysis is limited by lack of widespread expertise in the methods. A computer assisted diagnostic aid (OASYS-2) has been developed which is based on a scoring system developed from visual analysis. This removes the requirement for an experienced interpreter and should lead to the more widespread use of the technique.

METHODS

PEF records were collected from workers attending an occupational lung disease clinic for investigation of suspected occupational asthma and from workers participating in a study of respiratory symptoms in a postal sorting office. PEF records were divided into two development sets and two gold standard sets. The latter consisted of records from workers in which a final diagnosis had been reached by a method other than PEF recording. An experienced observer scored individual work and rest periods for the two development set PEF records; linear discriminant analysis was used to compare measurements taken from development set 1 records with visual scores. Two equations were produced which allowed prediction of scores for individual work or rest periods. The development set 2 was used to determine how these scores should be used to produce a whole record score. The first gold standard set was used to determine the whole record score which best separated those with and without occupational asthma. The second set determined the sensitivity and specificity of the chosen score.

RESULTS

Two hundred and sixty eight PEF records were collected from 169 workers and divided into two development sets (81 and 60 records) and two gold standard sets (60 and 67 records). Linear discriminant analysis produced equations predicting the score for work periods incorporating five indices of PEF change and one for rest periods using seven indices. These equations correctly predicted the score for development set 1 work and rest periods on 61% of occasions (kappa = 0.47). The whole record score for development set 2 records, after weighting for definite or definitely no occupational effect, correlated with the visual score (correlation coefficient 0.86). Comparison with gold standard set 1 identified a cut off which proved to have a sensitivity of 75% and a specificity of 94% for an independent diagnosis of occupational asthma when applied to gold standard set 2.

CONCLUSIONS

These results suggest that the sensitivity and specificity of analysing PEF records for occupational asthma using OASYS-2 approaches that of visual analysis, but it should be absolutely reproducible. The performance of OASYS-2 is more specific and approaches the sensitivity of other statistical methods of analysis. The evaluation of a large number of PEF records from workers exposed to different sensitising agents suggests that these results should be robust and should be repeatable in clinical practice.

Can one induce premenstrual symptomatology in women with prior hysterectomy and bilateral oophorectomy?

Nine women who had undergone hysterectomy and oophorectomy and who previously suffered from severe premenstrual syndrome (PMS) were given estrogen and progesterone in a naturalistic single-blind paradigm. The 13-item Beck Depression Inventory, Spielberger State Anxiety Inventory, Menstrual Distress Questionnaire and the Daily Ratings Form of the Premenstrual Assessment Form were all given daily. Estradiol and progesterone concentrations were estimated. When results from all subjects were considered together, these measures were not correlated with hormonal status. However, individual subjects showed correlations between some symptom scores and serum progesterone concentrations. We conclude that women diagnosed as having PMS do not respond in a uniform fashion to ovarian hormones. Further quantitative studies are needed to relate these individual differences to the syndrome of PMS.

Serologic evidence of Chlamydia trachomatis infection and risk of preterm birth

OBJECTIVE

To determine whether serologic evidence of Chlamydia trachomatis during pregnancy is a risk factor for preterm delivery (before 37 weeks' gestation).

DESIGN

Chart review.

SETTING

Antenatal clinics associated with a teaching hospital.

PATIENTS

A group of 103 unselected consecutive patients presenting for routine prenatal care.

OUTCOME MEASURES

Pregnancy outcome and C. trachomatis serologic status.

RESULTS

A total of 21 women (20%) were found to be seropositive for IgG antibodies to C. trachomatis. They were similar to the seronegative women with respect to maternal age, parity, history of preterm birth, obstetric or medical problems, smoking status, history of drug abuse, educational status and psychosocial stressors. The seropositive women were significantly more likely than the seronegative women to have a preterm birth (24% [5/21] v. 7% [6/82]i p = 0.029, odds ratio 3.96, 95% confidence interval 1.08 to 14.57), an infant with a lower mean gestational age at birth (262 [standard deviation (SD) 19] days v. 273 [SD 15] days; p = 0.0052) and an infant with a lower mean birth weight (3125 [SD 692] g v. 3473 [SD 696] g; p = 0.0434). The positive predictive value of a seropositive result for preterm birth was 31% (5/16); the negative predictive value of a seronegative result for preterm birth was 8% (6/76).

CONCLUSION

Women with serologic evidence of C. trachomatis may be at risk for preterm birth. Further study is required to determine whether serologic testing for C. trachomatis should be a routine part of prenatal care.

Predicting mental health problems in general practitioners

A total of 704 general practitioners completed questionnaires enquiring about mental health problems (response rate = 82.0%). Excessive anxiety was reported by 31.1%, troublesome depression by 13.4%, exhaustion or stress (on three or more weekdays) by 60.7%, and sleep difficulties by 47.6%. General practitioners aged 40-49 years old were most likely to report anxiety, exhaustion or stress, sexual and sleep difficulties. Retired doctors reported mental health problems markedly less often. Predictive factors for anxiety were depression, one or more nights on-call per week, and exhaustion or stress; predictive factors for depression were anxiety, and exhaustion or stress; predictive factors for exhaustion or stress were anxiety, depression, no hobbies, paperwork on three or more evenings per week, and sleep difficulties. Gender, country of origin, being single-handed, excessive alcohol consumption, and having no coping methods were not predictive factors for mental health problems.