Biomedical subjects
Publications and source records attributed to H A Freed.
The polyglandular autoimmune syndromes are a rare, inherited constellation of disorders characterized by multiple endocrine end-organ failures. Since these individuals have more than one endocrine failure, it is important to recognize these syndromes in clinical practice and be alert to the possibility of a second major endocrine organ failure after one has been diagnosed.
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Today we have discussed an interesting patient with an atypical presentation of pulmonary embolism. We have outlined a suggested algorithm to aid in the diagnosis and management of this disease. References 8 through 24 in the reference section are suggested readings that offer further insight into the diagnosis and management of this entity.
Interpretations of 122 musculoskeletal radiographs were compared with interpretations of their digital counterparts at a resolution of 1,024 X 840 X 12 bits. Images were evaluated by four readers and included subtle and nonsubtle abnormalities and normal findings. Joint receiver operating characteristic (ROC) analysis results were averaged over all readers and demonstrated no statistically significant difference between the two imaging methods. High interobserver variability limited identifiable differences. Review of cases with subtle findings on the digital system at a resolution of 2,048 X 1,680 X 12 bits (2.5 line pairs per millimeter) revealed adequate visualization of the abnormality in every case. It is concluded that a resolution of 1,024 X 840 X 12 bits is adequate for the interpretation of many musculoskeletal abnormalities but that a resolution of 2,048 X 1,680 X 12 bits is needed for visualization of some subtle abnormalities.
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The value of skull radiography in identifying intracranial injury has not yet been satisfactorily defined. A multidisciplinary panel of medical experts was assembled to review the issue of skull radiography for head trauma. The panel identified two main groups of patients--those at high risk of intracranial injury and those at low risk of such injury--and developed a management strategy for imaging in the two groups. The high-risk group consists primarily of patients with severe open or closed-head injuries who have a constellation of findings that are usually clinically obvious. These patients are candidates for emergency CT scanning, neurosurgical consultation, or both. The low-risk group includes patients who are asymptomatic or who have one or more of the following: headache, dizziness, scalp hematoma, laceration, contusion, or abrasion. Radiographic imaging is not recommended for the low-risk group and should be omitted. An intermediate moderate-risk group is less well defined, and skull radiography in this group may sometimes be appropriate. A prospective study of 7035 patients with head trauma at 31 hospital emergency rooms was conducted to validate the management strategy. No intracranial injuries were discovered in any of the low-risk patients. Therefore, no intracranial injury would have been missed by excluding skull radiography for low-risk patients, according to the protocol. We conclude that use of the management strategy is safe and that it would result in a large decrease in the use of skull radiography, with concomitant reductions in unnecessary exposure to radiation and savings of millions of dollars annually.
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An effort has been under way for years to make the ordering of skull films in trauma more medically rational. Because the vast majority of skull films have no significant impact on patient management, effort had centered on increasing the yield by limiting radiographs to those who have one or more "high-yield criteria." The publically promulgated high-yield criteria, however, were insufficiently sensitive to pick up some rare occult injuries. Emphasis recently has shifted to low-yield findings (scalp laceration, scalp hematoma, dizziness, headache, and asymptomatic). Although by common practice the presence of one or more of these low-yield findings often results in a skull film, omitting them appears to be extremely safe provided that the patient has no other clinically suspicious findings. Additionally, skull films are no longer the procedure of choice in patients with a neurosurgical emergency. A patient management strategy reflecting recent research is soon to be released with the FDA Skull Panel's final report.
A retrospective review was made of fractures for which radiographic manifestations were missed by various physicians working in the ED. It revealed that fractures of three anatomic sites were being missed disproportionately often--fractures of the navicular, elbow, and calcaneus. Fractures of these sites were the most likely to be missed when present. This effect was so pronounced that elbow fractures were missed as often as phalanx fractures, even though phalanx fractures were seen in the ED more than three times as frequently. The sites with the most missed fractures in gross numbers were ribs, elbow, and the periarticular region of the phalanges, with these three sites accounting for 38% of all missed fractures seen. The elbow was the only site occurring both on the list of fractures missed disproportionately often and on the list of fractures missed most frequently. Some common fractures were not missed at all (Colle's fracture), and others were missed infrequently (hip fracture, midshaft long bone fracture). Knowledge of those fractures that are most likely to be missed makes possible a more directed educational effort.
Some skull fractures may be overlooked if the current FDA-endorsed criteria for ordering roentgenograms of the skull are followed strictly. Such cases raise the issues of the applicability of the criteria to children, the omission from the criteria of factors that are associated with skull fracture, and the fact that the criteria as currently written seem to miss certain types of occult open and depressed fractures. Modifications of two of the criteria are suggested.
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A 44-year-old patient with known, stable, long-standing quadriplegia sustained a midshaft left femur fracture in a motor vehicle accident. He presented to the emergency department (ED) two days after the accident with a chief complaint of a swollen left thigh. Management in the ED included x-ray studies and some incidental manipulation during the process of examination and splinting. While awaiting discharge, the patient, although asymptomatic, was observed to be very profusely diaphoretic above the level of his cord lesion. Blood pressure was then noted to be 230/110, far above his admission blood pressure of 110/70. A diagnosis of autonomic dysreflexia was made and the patient admitted for treatment. Fracture manipulation in the ED is herein reported to be one of the many types of acute traumatic and atraumatic somatic stresses that can cause this serious and occasionally lethal syndrome. Signs and symptoms that need to be watched for are discussed.
Puncture wounds to the foot are common presenting problems in most busy emergency departments. Although seemingly benign, the sequelae after simple puncture wounds to the foot can include cellulitis, retained foreign bodies, or even osteomyelitis. Inadequate scientific research on this topic has left only anecdotal or retrospective reports for review in the medical literature. Antibiotics, radiographs, or surgical exploration in the management of puncture wounds to the foot all lack clinical studies to support their use. This review summarizes the literature and points to the inconsistencies in the management of puncture wounds to the foot.