Accuracy of the Ottawa Ankle Rules applied by non-physician providers in a pediatric emergency department

CJEM ◽  
2017 ◽  
Vol 20 (5) ◽  
pp. 746-752
Author(s):  
Joe MacLellan ◽  
Teya Smith ◽  
Jason Baserman ◽  
Shawn Dowling
Keyword(s):  
Phase 1 ◽  
Clinical Decision ◽  
Pediatric Emergency ◽  
Observer Agreement ◽  
Physician Assessment ◽  
Ottawa Ankle Rules ◽  
Fractures In Children ◽  
Care Workers ◽  
Foot Injury ◽  
Clinically Significant

AbstractObjectiveThe Ottawa Ankle Rules (OAR) are a clinical decision tool used to minimize unnecessary radiographs in ankle and foot injuries. The OAR are a reliable tool to exclude fractures in children over 5 years of age when applied by physicians. Limited data support its use by other health care workers in children. Our objective was to determine the accuracy of the OAR when applied by non-physician providers (NPP).MethodsChildren aged 5 to 17 years presenting with an acute ankle or foot injury were enrolled. Phase 1 captured baseline data on x-ray use in 106 patients. NPPs were then educated on the usage of the OAR and completed an OAR learning module. In phase 2, NPPs applied the OAR to 184 included patients.ResultsThe sensitivity of the foot rule, as applied by NPP’s, was 100% (56-100% CI) and the specificity was 17% (9-29% CI) for clinically significant fractures. The sensitivity of the ankle portion of the rule, as applied by NPP’s, was 88% (47-99 CI) and the specificity was 31% (23-40% CI) for clinically significant fractures. The only clinically significant fracture missed by NPP’s was detected on physician assessment. Inter-observer agreement was κ=0.24 for the ankle rule and κ=0.49 for the foot rule.ConclusionThe sensitivity of the OAR when applied by NPP’s was very good. More training and practice using the OAR would likely improve NPP’s inter-observer reliability. Our data suggest the OAR may be a useful tool for NPP’s to apply prior to physician assessment.

Let’s Do the Twist

2020 ◽  
pp. 95-102
Author(s):  
Laurie Malia ◽  
Joni E. Rabiner
Keyword(s):  
Decision Rules ◽  
Sports Injury ◽  
Clinical Decision ◽  
Pediatric Emergency ◽  
Low Risk ◽  
Ankle Injuries ◽  
Ankle Sprains ◽  
Ottawa Ankle Rules ◽  
Fractures In Children ◽  
Salter Harris

Ankle injuries are a common presentation to the pediatric emergency department, with ankle sprains significantly more common than ankle fractures. This chapter presents a child with a swollen, painful ankle after a sports injury. Evaluation of ankle injuries is discussed, including use of clinical decision rules such as the Ottawa Ankle Rules and the Low Risk Ankle Rule, which help determine who is at low risk for ankle fracture and may not need radiographic imaging. Classification of fractures in children with open physes using the Salter-Harris nomenclature is reviewed. Management of ankle injuries, including bracing, splinting, casting, need for urgent orthopedic consultation, follow-up, and healing are also discussed.

scholarly journals P086: Accuracy of the Ottawa Ankle Rules when applied by allied health providers in a pediatric emergency department

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S107-S107
Author(s):  
J. MacLellan ◽  
T. Smith ◽  
J. Baserman ◽  
S. Dowling
Keyword(s):  
Ankle Fracture ◽  
Allied Health ◽  
Health Providers ◽  
Convenience Sample ◽  
X Ray ◽  
Physician Assessment ◽  
Ottawa Ankle Rules ◽  
Foot Injury ◽  
Foot Fracture ◽  
Clinically Significant

Introduction: The Ottawa Ankle Rules (OAR) are a clinical decision tool used to minimize unnecessary radiographs in ankle and foot injuries. The OAR has been shown to be a reliable rule to exclude fractures in children over 5 years of age. However, there is limited data to support its use by other health care workers in children. Our objective was to determine the sensitivity and specificity of the OAR, to detect clinically significant fractures, when applied by allied health providers (AHPs). Methods: Children aged 5 to 17 years presenting with an acute ankle or foot injury were enrolled. Patients assessed by a physician prior to an AHP, presenting for reassessment or >24 hours after the injury, having open, penetrating or neurovascular injury, or multiple injuries were excluded. Patients with metabolic bone disease, a previous x-ray, or the inability to communicate or ambulate before the injury were also excluded. Baseline data on x-ray use was collected in a convenience sample of 100 patients. AHPs then completed an OAR learning module. Then in phase 2, AHPs applied the OAR to a convenience sample of 186 patients. Both AHPs and physicians performed inter-observer assessments. Results: When AHP’s applied the ankle portion of the OAR, the sensitivity was 88% (95% CI 46.7-99.3) and the specificity was 32.5% (95% CI 24.5-41.6) for clinically significant fractures. When AHP’s applied the foot portion of the OAR, the sensitivity was 87.5% (95% CI 46.7-99.3) and the specificity was 15.6% (95% CI 7.0-30.1) for clinically significant fractures. In total, 2 clinically significant fractures (1 foot fracture and 1 ankle fracture) were missed by AHP’s. Inter-observer agreement was κ=0.24 for the ankle rule and κ=0.32 for the foot rule. The missed ankle fracture had a positive OAR when performed by a physician as an inter-observer assessment. The missed foot fracture was a distal metatarsal fracture that was outside of the “foot zone” as defined by the OAR. Conclusion: The sensitivity of the OAR when applied by AHP’s was very good. Both clinically significant fractures that were missed by AHP’s would likely have been picked up by a physician assessment. More training and practice using the OAR would likely improve AHP’s inter-observer reliability. Our data suggest the OAR may be a useful tool for AHP’s to apply as a screening tool prior to physician assessment.

scholarly journals Use of the Ottawa Ankle Rules in children: a survey of physicians’ practice patterns

CJEM ◽  
2011 ◽  
Vol 13 (05) ◽  
pp. 333-338 ◽  
Author(s):  
Shawn K. Dowling ◽  
Ian Wishart
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Health Care Professionals ◽  
Pediatric Emergency ◽  
Ankle Fractures ◽  
Care Providers ◽  
Emergency Physicians ◽  
Ottawa Ankle Rules ◽  
Clinically Significant

ABSTRACT: Introduction: A number of studies have assessed the diagnostic accuracy of the Ottawa Ankle Rules (OAR) in children; however, the role of the OAR in guiding physician radiograph use is unclear. Objectives: The primary purpose of this study was to determine the extent to which Canadian pediatric emergency physicians report using the OAR. Secondary goals included determining current diagnostic and management strategies for Salter-Harris 1 (SH-1) injuries of the ankle and which fractures physicians deem to be clinically significant. Methods: A self-administered piloted survey was distributed by mail to 215 Canadian pediatric emergency physicians using a modified Dillman technique. Participants were selected through Pediatric Emergency Research Canada (PERC), a national network of health care professionals with an interest in pediatric emergency medicine research. Results: Of 209 surveys, 144 were returned, for a response rate of 68.9%. Of those, 87.5% (126 of 144) reported applying the OAR in children to determine the need for radiographs in acute ankle or midfoot injuries. Of those, 65.1% reported using the OAR always or usually, and 64.5% (93 of 144) of physicians stated that they believe all ankle fractures are clinically significant. Although physicians report that they most commonly order the radiographs, 36.2% of participants indicated that radiographs were requisitioned by nurses or other health care providers at their facilities. SH-1 fractures were reported to be most commonly managed by immobilization (83.3%; 120 of 144), with most patients going on to follow-up with an orthopedic surgeon. Conclusions: The majority of Canadian pediatric emergency physicians indicate that they use the OAR when assessing children with acute ankle and midfoot injuries. Most physicians believe that all ankle fractures, including SH-1, are clinically significant and have a management preference for immobilization and orthopedic follow-up.

scholarly journals Nationwide Seroprevalence of SARS-CoV-2 IgG Antibodies among Four Groups of Primary Health-Care Workers and Their Household Contacts 6 Months after the Initiation of the COVID-19 Vaccination Campaign in France: SeroPRIM Study Protocol

Pathogens ◽  
2021 ◽  
Vol 10 (7) ◽  
pp. 911
Author(s):  
Marie Pouquet ◽  
Dorine Decarreaux ◽  
Pol Prévot-Monsacré ◽  
Corentin Hervé ◽  
Andréas Werner ◽  
...  
Keyword(s):  
Health Care ◽  
Primary Health Care ◽  
Health Care Workers ◽  
Phase 1 ◽  
Vaccination Campaign ◽  
Igg Antibodies ◽  
Household Contacts ◽  
Primary Health ◽  
Care Workers ◽  
Natural Protection

Background: The protocol study will focus on the seroprevalence of IgG antibodies to SARS-CoV-2 achieved by vaccination and/or natural protection as well as the history, symptoms, and risk factors for SARS-CoV-2 in four primary health-care workers (PHCWs) and their household contacts in metropolitan France. Methods: Here, we propose a protocol for a nationwide survey to determine the seroprevalence of IgG antibodies to SARS-CoV-2 achieved by vaccination and/or natural protection in four PHCW populations (general practitioners, pediatricians, pharmacists and assistants, and dentists and assistants) and their household contacts. Participants will be included from June to July 2021 (Phase 1) among PHCW populations located throughout metropolitan France. They will be asked to provide a range of demographic and behavioral information since the first SARS-CoV-2 wave and a self-sampled dried blood spot. Phase 1 will involve also a questionnaire and serological study of PHCWs’ household contacts. Seroprevalence will be estimated using two ELISAs designed to detect specific IgG antibodies to SARS-CoV-2 in humoral fluid, and these results will be confirmed using a virus neutralization test. This study will be repeated from November to December 2021 (Phase 2) to evaluate the evolution of immune status achieved by vaccination and/or natural protection of PHCWs and to describe the history of exposure to SARS-CoV-2.

4971Blood viscosity and its relevance to the diagnosis and management of pulmonary hypertension: a new elephant in the cathlab

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
A Kempny ◽  
K Dimopoulos ◽  
A E Fraisse ◽  
G P Diller ◽  
L C Price ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Cardiac Catheterization ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Pulmonary Vasculature ◽  
Pulmonary Vascular Disease ◽  
Significant Difference ◽  
The Difference ◽  
Clinically Significant ◽  
The Relationship

Abstract Background Pulmonary vascular resistance (PVR) is an essential parameter assessed during cardiac catheterization. It is used to confirm pulmonary vascular disease, to assess response to targeted pulmonary hypertension (PH) therapy and to determine the possibility of surgery, such as closure of intra-cardiac shunt or transplantation. While PVR is believed to mainly reflect the properties of the pulmonary vasculature, it is also related to blood viscosity (BV). Objectives We aimed to assess the relationship between measured (mPVR) and viscosity-corrected PVR (cPVR) and its impact on clinical decision-making. Methods We assessed consecutive PH patients undergoing cardiac catheterization. BV was assessed using the Hutton method. Results We included 465 patients (56.6% female, median age 63y). The difference between mPVR and cPVR was highest in patients with abnormal Hb levels (anemic patients: 5.6 [3.4–8.0] vs 7.8Wood Units (WU) [5.1–11.9], P<0.001; patients with raised Hb: 10.8 [6.9–15.4] vs. 7.6WU [4.6–10.8], P<0.001, respectively). Overall, 33.3% patients had a clinically significant (>2.0WU) difference between mPVR and cPVR, and this was more pronounced in those with anemia (52.9%) or raised Hb (77.6%). In patients in the upper quartile for this difference, mPVR and cPVR differed by 4.0WU [3.4–5.2]. Adjustment of PVR required Conclusions We report, herewith, a clinically significant difference between mPVR and cPVR in a third of contemporary patients assessed for PH. This difference is most pronounced in patients with anemia, in whom mPVR significantly underestimates PVR, whereas in most patients with raised Hb, mPVR overestimates it. Our data suggest that routine adjustment for BV is necessary.

scholarly journals PEMCRC anaphylaxis study protocol: a multicentre cohort study to derive and validate clinical decision models for the emergency department management of children with anaphylaxis

BMJ Open ◽  
2021 ◽  
Vol 11 (1) ◽  
pp. e037341
Author(s):  
Timothy E Dribin ◽  
Kenneth A Michelson ◽  
David Vyles ◽  
Mark I Neuman ◽  
David C Brousseau ◽  
...  
Keyword(s):  
Risk Factors ◽  
Emergency Department ◽  
Online Education ◽  
Prediction Models ◽  
Recursive Partitioning ◽  
Clinical Decision ◽  
Pediatric Emergency ◽  
Initial Reaction ◽  
Research Committee ◽  
Reaction Severity

IntroductionThere remain significant knowledge gaps about the management and outcomes of children with anaphylaxis. These gaps have led to practice variation regarding decisions to hospitalise children and length of observation periods following treatment with epinephrine. The objectives of this multicentre study are to (1) determine the prevalence of and risk factors for severe, persistent, refractory and biphasic anaphylaxis, as well as persistent and biphasic non-anaphylactic reactions; (2) derive and validate prediction models for emergency department (ED) discharge; and (3) determine data-driven lengths of ED and inpatient observation prior to discharge to home based on initial reaction severity.Methods and analysisThe study is being conducted through the Pediatric Emergency Medicine Collaborative Research Committee (PEMCRC). Children 6 months to less than 18 years of age presenting to 30 participating EDs for anaphylaxis from October 2015 to December 2019 will be eligible. The primary outcomes for each objective are (1) severe, persistent, refractory or biphasic anaphylaxis, as well as persistent or biphasic non-anaphylactic reactions; (2) safe ED discharge, defined as no receipt of acute anaphylaxis medications or hypotension beyond 4 hours from first administered dose of epinephrine; and (3) time from first to last administered dose of epinephrine and vasopressor cessation. Analyses for each objective include (1) descriptive statistics to estimate prevalence and generalised estimating equations that will be used to investigate risk factors for anaphylaxis outcomes, (2) least absolute shrinkage and selection operator regression and binary recursive partitioning to derive and validate prediction models of children who may be candidates for safe ED discharge, and (3) Kaplan-Meier analyses to assess timing from first to last epinephrine doses and vasopressor cessation based on initial reaction severity.Ethics and disseminationAll sites will obtain institutional review board approval; results will be published in peer-reviewed journals and disseminated via traditional and social media, blogs and online education platforms.

Prospective Evaluation of the Ottawa Ankle Rules in a University Sports Medicine Center

1998 ◽  
Vol 26 (2) ◽  
pp. 158-165 ◽  
Author(s):  
John J. Leddy ◽  
Robert J. Smolinski ◽  
James Lawrence ◽  
Jody L. Snyder ◽  
Roger L. Priore
Keyword(s):  
Sports Medicine ◽  
Ankle Injuries ◽  
Fracture Rate ◽  
Malleolar Fracture ◽  
Potential Reduction ◽  
Malleolar Fractures ◽  
Ottawa Ankle Rules ◽  
Clinically Significant ◽  
Sensitivity Specificity ◽  
Fracture Identification

In a sports medicine center, we prospectively evaluated the Ottawa Ankle Rules over 1 year for their ability to identify clinically significant ankle and midfoot fractures and to reduce the need for radiography. We also developed a modification to improve specificity for malleolar fracture identification. Patients with acute ankle injuries ( 10 days old) had the rules applied and then had radiographs taken. Sensitivity, specificity, and the potential reduction in the use of radiography were calculated for the Ottawa Ankle Rules in 132 patients and for the new “Buffalo” rule in 78 of these patients. There were 11 clinically significant fractures (fracture rate, 8.3% per year). In these 132 patients, the Ottawa Ankle Rules would have reduced the need for radiography by 34%, without any fractures being missed (sensitivity 100%, specificity 37%). In 78 patients, the specificity for malleolar fracture for the new rule was significantly greater than that of the Ottawa Ankle Rules malleolar rule (59% versus 42%), sensitivity remained 100%, and the potential reduction in the need for radiography (54%) was significantly greater. The Ottawa Ankle Rules could significantly reduce the need for radiography in patients with acute ankle and midfoot injuries in this setting without missing clinically significant fractures. The Buffalo modification could improve specificity for malleolar fractures without sacrificing sensitivity and could significantly reduce the need for radiography.

scholarly journals Updated Review of Blood Culture Contamination

2006 ◽  
Vol 19 (4) ◽  
pp. 788-802 ◽  
Author(s):  
Keri K. Hall ◽  
Jason A. Lyman
Keyword(s):  
Health Care ◽  
Decision Support ◽  
Blood Culture ◽  
Infection Control ◽  
Clinical Decision ◽  
Potential Utility ◽  
Diagnostic Uncertainty ◽  
Computer Based ◽  
Clinically Significant ◽  
Care Costs

SUMMARY Blood culture contamination represents an ongoing source of frustration for clinicians and microbiologists alike. Ambiguous culture results often lead to diagnostic uncertainty in clinical management and are associated with increased health care costs due to unnecessary treatment and testing. A variety of strategies have been investigated and employed to decrease contamination rates. In addition, numerous approaches to increase our ability to distinguish between clinically significant bacteremia and contamination have been explored. In recent years, there has been an increase in the application of computer-based tools to support infection control activities as well as provide clinical decision support related to the management of infectious diseases. Finally, new approaches for estimating bacteremia risk which have the potential to decrease unnecessary blood culture utilization have been developed and evaluated. In this review, we provide an overview of blood culture contamination and describe the potential utility of a variety of approaches to improve both detection and prevention. While it is clear that progress is being made, fundamental challenges remain.

Serial plasma and CSF cell-free tumor DNA (cf-tDNA) tracking in diffuse midline glioma patients undergoing treatment with ONC201.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 2012-2012
Author(s):  
Evan Cantor ◽  
Kyle Wierzbicki ◽  
Rohinton Tarapore ◽  
Chase Thomas ◽  
Rodrigo Cartaxo ◽  
...  
Keyword(s):  
Tumor Size ◽  
Clinical Decision Making ◽  
Phase 1 ◽  
Complete Response ◽  
Clinical Decision ◽  
Experimental Therapy ◽  
Plasma Samples ◽  
Mri Scans ◽  
Tumor Dna ◽  
Diffuse Midline Glioma

2012 Background: Diffuse midline glioma (DMG) with the H3K27M mutation is a lethal childhood brain cancer, with patients rarely surviving 2 years from diagnosis. There are few available means of monitoring the disease beyond serial MRI scans, making clinical decision making slow, difficult, and often reactive. Methods: We conducted a multi-site phase 1 trial of the imipridone ONC201 for children with H3K27M-mutant glioma (NCT03416530). Patients enrolled on Arm D of the trial (n=24) underwent serial lumbar puncture (baseline, 2 and 6 months) for cell-free tumor DNA (cf-tDNA) analysis at time of MRI. Additionally, patients on all arms of the trial at the University of Michigan underwent serial plasma collection. CSF collection was feasible in this cohort, with no procedural complications. We collected a total of 96 plasma samples and 53 CSF samples from 29 patients, including those with H3F3A (H3.3) (n=13), HIST13HB (H3.1) (n= 4), and unknown H3 status/not biopsied (n=12) [range of 0-8 CSF samples and 0-10 plasma samples]. We performed digital droplet polymerase chain reaction (ddPCR) analysis and/or amplicon-based electronic sequencing (Oxford Nanopore) of cf-tDNA samples and compared variant allele fraction (VAF) to radiographic change (maximal 2D tumor area on MRI). Results: Preliminary analysis of samples (n=58) demonstrates a correlation between changes in tumor size and H3K27M cf-tDNA VAF, when removing samples with concurrent bevacizumab. Analysis of remaining CSF and plasma samples is ongoing, including analysis of novel biomarkers of response. In multiple cases, early reduction in CSF cf-tDNA predicts long-term clinical response (>1 year) to ONC201 and does not increase in cases of later-defined pseudo-progression (radiation necrosis). For example, a now 9-year old patient with thalamic H3K27M-mutant DMG underwent treatment with ONC201 after initial radiation and developed an increase in tumor size at 4 months post-radiation (124% baseline) of unclear etiology at the time. Meanwhile, her ddPCR declined from baseline 6.76% VAF to <1%, which has persisted, with now near complete response (85% tumor reduction) at 30 months on treatment from diagnosis. Conclusions: In summary, we present the feasibility and utility of serial CSF/plasma monitoring of a promising experimental therapy for DMG.

scholarly journals Ki-67 Evaluation for Clinical Decision in Metastatic Lung Carcinoids: A Proof of Concept

2019 ◽  
Vol 12 ◽  
pp. 2632010X1982925 ◽  
Author(s):  
Giuseppe Pelosi ◽  
Federica Massa ◽  
Gaia Gatti ◽  
Luisella Righi ◽  
Marco Volante ◽  
...  
Keyword(s):  
Close Correlation ◽  
Clinical Decision ◽  
Somatostatin Analogues ◽  
Mitotic Count ◽  
Observer Agreement ◽  
Proof Of Concept ◽  
Metastatic Carcinoid ◽  
Ki 67 ◽  
Pulmonary Carcinoid ◽  
Platinum Based Chemotherapy

Accrual of metastatic pulmonary carcinoid patients for therapy is usually relied on clinical and histologic characterization, with no role for the proliferation activity as defined by Ki-67 labelling index (LI). A total of 14 carcinoid patients with tumour primaries (TP) and 19 corresponding tumour metastases (TM) were blindly reviewed by 2 different pathologists for necrosis, mitotic count, and Ki-67 LI. Ki-67 LI outperformed histologic subtyping, mitotic count, and necrosis with good to almost excellent (0.40-0.75) inter-observer agreement. About 10% cut-off Ki-67 LI predicted survival better than histology for TP and TM for both observers. The TM patients survived differently according to diverse treatments (somatostatin analogues [SSAs], analogues plus additional treatments except for platinum; platinum-based chemotherapy) in close correlation with <10%, 10% to 20%, and >20% cut-off thresholds of Ki-67 LI, respectively. There was also a trend for an increase in Ki-67 LI in TM as compared with TP. This is the first proof of concept in which a clinical potential is preliminarily suggested for Ki-67 LI to better stratify pulmonary metastatic carcinoid patients for treatment according to a criterion of histology-independent biological aggressiveness.

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