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Background Older patients are at risk of drug related problems (DRPs), potentially leading to emergency department (ED) visits. Identifying DRPs with medication reviews is typically evaluated in restrictive clinical studies and not in a ‘real-world’ setting with organizational challenges and time-pressure. This study aims to assess the number of DRPs at the ED in older patients living with frailty, and to determine the acceptance rate of medication recommendations among physicians and the general practitioner. Additionally, practical recommendations are provided for implementing a medication review program. Methods A retrospective observational study was performed in patients ≥ 70 years living with frailty who visited the ED at Tergooi Medical Center. Medication reviews were conducted to identify and classify DRPs as part of a larger geriatric assessment. Also, the acceptance rate of given recommendations was assessed. Results A total of 356 ED visits were included. The mean age of patients was 83 years. About 76% of patients had at least one DRP. In total, 548 DRPs were identified with a mean of 1.5 DRP per patient. The acceptance rate of medication recommendations in admitted patients was 55%, and 32% among general practitioners/elderly care specialists in discharged patients. Conclusions Our results show that medication reviews lead to better assessment of DRPs at the ED. The acceptance rate was substantially higher in admitted patients compared to discharged patients. Results of our study reflect the real-life setting of conducting medication reviews at the ED for older patients living with frailty.

Purpose Cervical spine injury after blunt trauma in children is rare but can have severe consequences. Clear protocols for diagnostic workup are, therefore, needed, but currently not available. As a step in developing such a protocol, we determined the incidence of cervical spine injury and the degree of protocol adherence at our level 2 trauma centre. Methods We analysed data from all patients aged Results We included 170 children in the first study period and 83 in the second. One patient was diagnosed with cervical spine injury. Protocol adherence regarding the indication for imaging was > 80% in both periods. Adherence regarding the imaging type decreased over time, with 45.8% of the patients receiving a primary CT scan in the second study period versus 2.9% in the first. Conclusion Radiographic imaging is frequently performed when clearing the paediatric cervical spine, although cervical spine injury is rare. Particularly CT scan usage has wrongly been emerging over time. Stricter adherence to current protocols could limit overuse of radiographic imaging, but ultimately there is a need for an accurate rule predicting which children really are at risk of injury.

The original version of this article unfortunately contained mistakes.

Emergency Departments (EDs) are increasingly seeing more seriously unwell older people living with frailty. In the context of limited resources and increasing demand it’s the ED practitioner’s challenge to unpick this constellation of physical, psychological, functional and social issues.To properly assess older people living with frailty at the ED it is crucial to use an holistic approach. This consists of triage with algorithms sensitive to the higher risk of older people living with frailty, a frailty assessment, and an assessment with the help of the principles of Comprehensive Geriatric Assessment. Multi-disciplinary care, a tailor-made treatment plan, based on what the person values most, will help the ED practitioner to deliver appropriate and valuable care during the ED stay, but also in transition from hospital to home.

A hip hemiarthroplasty is the treatment of choice for a displaced femoral neck fracture in elderly patients not eligible for total hip arthroplasty. There is continuing debate about the optimal surgical approach for this operation, with the most commonly used approaches being posterior and lateral. To compare the outcomes of the posterior and the lateral approaches in patients with a displaced femoral neck fracture treated by hemiarthroplasty. A retrospective study was carried out in two high-volume teaching hospitals in the Netherlands. Electronic patient records were searched for patient characteristics, the operative approach and adverse outcomes. A total of 1009 patients with a median age of 86 years were included. The posterior approach was used in 51.1% of patients. There were no differences in surgical site infection and periprosthetic fracture rates. There was a trend towards more dislocations in the posterior approach (2.9% vs. 1.4% with an OR of 2.1, 95% CI 0.8–5.1). An uncemented hemiprosthesis was used in 62.7% of patients. Deep surgical site infections and periprosthetic fractures occurred more often in the uncemented group (OR 2.9 and 7.4, respectively). No differences in adverse outcomes between both approaches could be shown. This study did confirm the relatively high incidence of post-operative complications in uncemented prostheses. Therefore, the cemented prosthesis should be the treatment of choice, with the approach dependent on surgeon preference and experience.

Author(s): Evans, Sam Weiss; Beal, Jacob; Berger, Kavita; Bleijs, Diederik A; Cagnetti, Alessia; Ceroni, Francesca; Epstein, Gerald L; Garcia-Reyero, Natalia; Gillum, David R; Harkess, Graeme; Hillson, Nathan J; Hogervorst, Petra AM; Jordan, Jacob L; Lacroix, Genevieve; Moritz, Rebecca; OhEigeartaigh, Sean S; Palmer, Megan J; van Passel, Mark WJ

In MS, B cells survive peripheral tolerance checkpoints to mediate local inflammation, but the underlying molecular mechanisms are relatively underexplored. In mice, the MIF pathway controls B‐cell development and the induction of EAE. Here, we found that MIF and MIF receptor CD74 are downregulated, while MIF receptor CXCR4 is upregulated in B cells from early onset MS patients. B cells were identified as the main immune subset in blood expressing MIF. Blocking of MIF and CD74 signaling in B cells triggered CXCR4 expression, and vice versa, with separate effects on their proinflammatory activity, proliferation, and sensitivity to Fas‐mediated apoptosis. This study reveals a new reciprocal negative regulation loop between CD74 and CXCR4 in human B cells. The disturbance of this loop during MS onset provides further insights into how pathogenic B cells survive peripheral tolerance checkpoints to mediate disease activity in MS.

Background:Calcinosis cutis is a major daily challenge to patients with longstanding systemic sclerosis (SSc), negatively affecting their quality of life. Unfortunately, treatment options are very limited due to lack of understanding of the pathogenetic process. Currently, calcinosis cutis is only detected at its irreversible end-stage. Early detection of calcinosis cutis could putatively allow early disease-modifying interventions and monitor treatment effects.Objectives:The aim of the current study is to assess the feasibility of visualising “active” micro-calcifications with 18-F Sodium Fluoride (NaF) PET scanning, compared to low-dose CT in patients with clinically overt calcinosis cutis.Methods:This was a cross-sectional, observational, pilot study. All patients met 2013 ACR/EULAR criteria for SSc. Patients underwent a whole body NaF PET/low-dose CT scan, scanned 90 minutes post-injection. (Sub)cutaneous calcifications were described and assessed on NaF PET, which was compared to CT images by two independent investigators.Results:A total of 10 female patients with limited cutaneous SSc [median age 56 years (IQR 52-66), median disease duration 17 years (8-19), PAH 10%, ILD 20%] were included, and compared to 10 controls [70 years (65-73)]. NaF uptake showed normal distribution throughout the skeletal bones, arterial tree, and visceral organs, which was comparable between patients and controls. Additionally, NaF uptake was visible in the skin of all SSc patients, but in none of the controls. Cutaneous NaF uptake largely correlated with clinical calcifications. Most common sites of cutaneous NaF uptake were fingers (6 patients) and knees (7 patients). Only 5% of the NaF positive lesions were not accompanied by visible calcifications on CT. Furthermore, of all calcified lesions seen on CT, 51% showed uptake on NaF PET. Small lesions (Conclusion:Imaging of “active” calcinosis cutis in limited cutaneous systemic sclerosis is feasible using NaF PET scanning. Most clinically overt calcifications and half of those seen on CT were positive for NaF uptake. Whether these “active” calcifications behave differently in terms of faster progression, clinical complaints, and infection risk, and whether these are potentially suitable for disease modifying interventions is subject to future study.Disclosure of Interests:None declared

Positive psychology has added a new element to the growing body of scientificknowledge in the field of clinical psychology. It has already shown the value ofjoy and creativity in stress and coping. Nevertheless, until recently it was unclearwhether and how positive interventions work. In this article, a new integrativestress model is explained and tested that includes positive emotions andsavouring. Savouring is viewed as the opposite of rumination: it is “dwelling inthe positive”. Our study also tested a specific positive psychological intervention,namely positive writing. We have tried to test this intervention by replicating aseminal study about the enhancing effects of positive writing on wellbeingpublished by Seligman et al. (2005). We used two control conditions for the act ofwriting and the emotional valence of the writing topic. Participants have writtendown their experiences for one week and were followed for a month afterwards.Although we were unable to replicate the findings of Seligman et al. (2005), wedid find out that positive writing increased savouring and reduced rumination.Specifically, we found that the positive writing worked better than negativewriting or writing about the past. Our findings suggest that the positive valence ofthe intervention is the most effective part of the treatment. Our study alsosuggests that the questionnaire used to measure wellbeing, the AuthenticHappiness Index might not function well, and might need to be optimized.

Purpose: The practice of prehospital immobilization is coming under increasing scrutiny. Unravelling the historical sequence of prehospital immobilization might shed more light on this matter and help resolve the situation. Main purpose of this review is to provide an overview of the development and reasoning behind the implementation of prehospital spine immobilization. Methods: An extensive search throughout historical literature and recent evidence based studies was conducted. Results: The history of treating spinal injuries dates back to prehistoric times. Descriptions of prehospital spinal immobilization are more recent and span two distinct periods. First documentation of its use comes from the early 19th century, when prehospital trauma care was introduced on the battlefields of the Napoleonic wars. The advent of radiology gradually helped to clarify the underlying pathology. In recent decades, adoption of advanced trauma life support has elevated in-hospital trauma-care to an high standard. Practice of in-hospital spine immobilization in case of suspected injury has also been implemented as standard-care in prehospital setting. Evidence for and against prehospital immobilization is equally divided in recent evidence-based studies. In addition, recent studies have shown negative side-effects of immobilisation in penetrating injuries. Conclusion: Although widely implementation of spinal immobilization to prevent spinal cord injury in both penetrating and blunt injury, it cannot be explained historically. Furthermore, there is no high-level scientific evidence to support or reject immobilisation in blunt injury. Since evidence in favour and against prehospital immobilization is equally divided, the present situation appears to have reached something of a deadlock. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.].

Background Current guidelines state that trauma patients at risk of spine injury should undergo prehospital spine immobilization to reduce the risk of neurological deterioration. Although this approach has been accepted and implemented as a standard for decades, there is little scientific evidence to support it. Furthermore, the potential dangers and sequelae of spine immobilization have been extensively reported. The role of the paramedic in this process has not yet been examined. The aim of this study was to evaluate the accuracy of prehospital evaluations for the presence of spine fractures made by paramedics. Methods All patients who presented with prehospital spine immobilization at our level II trauma center between January 2013 and January 2014 were prospectively included in a database. Prior to the diagnosis, paramedics recorded the probability of a spine fracture after a prehospital examination. These predictions were compared with patient outcomes. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. Results One hundred and thirty-nine patients were included that positive predictive value was 22%, negative predictive value was 95%, sensitivity was 92%, specificity was 30%, and accuracy was 41%. Conclusions The results of this study suggest that paramedics cannot accurately predict spinal fractures.

Background. Early prediction of academic performance is important for student selection and support. We explored, in a multivariate approach, whether pre-entry data (e.g., expectations, capabilities, motivation, attitude) could predict university students’ first year academic performance. Methods. Pre-registered applicants for a bachelor’s program filled out the Leiden Intake Questionnaire (LIQ) before study-entry (N=739). Outcome data (first-year GPA, course credits, attrition) were obtained one year later. Results. Students who performed better in preparatory education, and students who followed a conventional educational path before entering performed better during their first year at university. Non-Dutch students were less successful than Dutch students, and students who expected to spend more time on a study organization were more successful. Conclusions. The LIQ may be used for identifying upfront who may need additional support, but is not suitable for student selection. Future work on academic performance should include cross-validation to determine how well the findings may generalize.

Study objective : To determine time trends of emergency department (ED) visits, hospitalization rates, spinal cord lesions and characteristics of patients with spinal fractures in the Netherlands. Methods: In an observational database study we used the Dutch Injury Surveillance System to analyse spinal fracture-related ED visits, hospitalization rates and spinal cord lesions between 1997 and 2012. Results: The total number of ED visits associated with spinal fractures increased from 4,507 in 1997 to 9,690 in 2012 (115% increase). The increase in the total number of fractures occurred in all age groups independently of gender. However, incidence rates increased more strongly with age and were higher in young males and ageing females. The hospitalization rate of diagnosed spinal fractures remained stable between 62 and 67%. The incidence of spinal cord lesions varied between 13.8 and 20.3 per million of the population over a period of 15 years. Conclusion: Spinal fracture-related ED visits are increasing in the Dutch population, independently of age or gender. The hospitalization rate and the absolute numbers of spinal cord lesions have remained stable over a period of 15 years. These findings are relevant for public health decision-making and resource allocation.

Background The low prevalence of true fractures amongst suspected fractures magnifies the shortcomings of the diagnostic tests used to triage suspected scaphoid fractures. Purpose The objective was to develop a clinical prediction rule that would yield a subset of patients who were more likely to have a scaphoid fracture than others who lacked the subset criteria. Methods Seventy-eight consecutive patients diagnosed with a suspected scaphoid fracture were included. Standardised patient history, physical examination, range of motion (ROM) and strength measurements were studied. The reference standard for a true fracture was based on the results of magnetic resonance imaging, bone scintigraphy, follow-up radiographs and examination. Results Analysis revealed three significant independent predictors: extension Conclusion Clinical prediction rules have the potential to increase the prevalence of true fractures amongst patients with suspected scaphoid fractures, which can increase the diagnostic performance characteristics of radiological diagnostic tests used for triage.

1. Insecticidal proteins can be excreted in the honeydew when sap sucking insects feed on insect resistant transgenic plants. Honeydew can be an important source of carbohydrates thus potentially exposing a broad range of honeydew feeding insects to transgene products. 2. Snowdrop lectin ( Galanthus nivalis agglutinin; GNA) dissolved in a 2 m sucrose solution had no antifeedant effect on female aphid parasitoids (Aphidius ervi) but had a direct negative effect on their longevity. 3. When feeding on honeydew from Rhopalosiphum padi feeding on a GNA containing artificial diet Aphidius ervi suffered a longevity reduction that was more pronounced than was to be expected based on the detected GNA concentration in the honeydew. 4. Analysis of carbohydrate and amino acid composition revealed that a change in honeydew composition caused by a GNA effect on the aphids could be a possible explanation for the additional reduction in parasitoid longevity. 5. When comparing the effect of honeydew from Sitobion avenae and R. padi feeding on GNA expressing or nontransformed wheat plants on A. ervi longevity aphid species was found to have a significant effect whereas the wheat variety had no effect. The latter result was probably due to low GNA expression levels in the plants. Differences in nutritional suitability between honeydew from R. padi and S. avenae could be explained by differences in carbohydrate and amino acid composition. 6. This is the first study to demonstrate that GNA ingested by aphids and transported into the honeydew can negatively affect the parasitoids consuming this honeydew. 7. We recommend that honeydew should be considered as a route of exposure to transgene products in future risk assessment studies.

The aim of this study was to evaluate prospectively the observer variation in the detection of pathology on MRI for suspected acute scaphoid fracture. 79 consecutive MR scans were included to calculate the inter-observer variation. All patients were suspected of having a scaphoid fracture but had no fracture on radiographs. 38 randomly chosen MR scans were used to calculate the intra-observer variation. Four observers, with varying levels of expertise, blinded scored three items: (i) scaphoid fracture, (ii) localization of a scaphoid fracture, and (iii) another fracture. The observer variation was analysed using the kappa statistic. The inter-observer variation for a scaphoid fracture showed substantial agreement. For the localization of a scaphoid fracture and another fracture, there was a moderate and substantial agreement, respectively. The intra-observer variation for a scaphoid fracture had an almost perfect agreement. For the localization of a scaphoid fracture and another fracture, there was an almost perfect and substantial agreement, respectively. In conclusion, the observer variation in MRI of suspected scaphoid fractures was low. The influence of expertise with MRI in daily practice should be taken into consideration. Observers with little experience of MRI will identify all scaphoid fractures but are likely to over-diagnose injuries. Based on these results, it is recommended that all scans are reviewed by an experienced radiologist.

Larvae of the common green lacewing Chrysoperla carnea are predacious and feed on a wide range of small, soft-bodied arthropods. In addition to their feeding on prey arthropods to cover their nutritional requirements for growth and development, the consumption of non-prey foods such as honeydew has been reported. It is commonly believed that these food supplements are primarily exploited by the larvae when prey is scarce or of low nutritional quality. Here, we assess whether C. carnea larvae also use honeydew when high-quality aphid prey are readily available. In a choice experiment, the feeding behaviour of C. carnea larvae was observed in the presence of both aphids and honeydew. The larvae were starved, aphid-fed, or honeydew-fed prior to the experiment. The time spent feeding on honeydew compared with feeding on aphids was highest for starved larvae and lowest for honeydew-fed larvae. Among the three treatments, the aphid-fed larvae spent the most time resting and the least time searching. In an additional experiment food intake was assessed in terms of weight change when larvae were provided with an ad libitum supply of either aphids or honeydew. Larvae yielded a significant lower relative weight increase on honeydew compared with aphids. The reduced weight increase on honeydew was compensated when larvae were subsequently provided with aphids, but not when honeydew was provided again. This study showed that (i) prior honeydew feeding reduces overall aphid consumption, and (ii) larvae do consume honeydew even after they have been given ad libitum access to aphids. The fact that larvae of C. carnea still use honeydew as a food source in the presence of suitable prey underlines the importance of carbohydrates as foods.

1. During the adult stage many arthropod species, including aphid predators and parasitoids, depend on nectar and honeydew as a source of carbohydrates. Despite the importance of sugar feeding for these organisms, we know little about their energy and nutrient provision under field conditions. 2. Here we assessed the nutritional state of adult parasitoids, hoverflies and lacewings in a Swiss winter wheat (WW) and a spring wheat (SW) field and studied the contribution of honeydew to the diet of these aphidophagous insects. The total sugar level and the glucose-fructose ratio were used as indicators for nutritional state and sugar feeding. 3. Over 76% of the collected individuals from each of the three insect groups in both fields had recently consumed carbohydrates. The average nutritional state was significantly higher in the SW field for Chrysoperla carnea and Aphidius spp. 4. Honeydew consumption by insects is commonly investigated by analyzing target insects for the presence of honeydew 'signature' sugars, such as melezitose and erlose. However, our laboratory studies show that adults of the three insect orders investigated synthesize these 'honeydew-specific' sugars after sucrose feeding. 5. As the erlose-melezitose ratio of sucrose-fed Aphidius spp. and the hoverfly Episyrphus balteatus differed clearly from the honeydew sugar profiles of wheat infesting aphids, this ratio could be used as an alternative indicator of honeydew feeding. However, this method could not be used for the lacewing C. carnea. 6. Our data show that 55% (WW) and 59% (SW) of field-collected Aphidius spp. which showed evidence of sugar feeding could be classified as having consumed honeydew within the 24–48 h before collection. Evidence of honeydew feeding by hoverflies, on the other hand, was found to be much more variable, ranging from 0% in the WW field to 44% in the SW field. 7. This study shows that the detection of honeydew consumption in field-collected insects based on honeydew oligosaccharides can be feasible even when insects synthesize these oligosaccharides themselves.

Feeding on sugar-rich foods such as nectar and honeydew is important for survival of many adult parasitoids. Especially in agricultural systems, honeydew is often the most prevalent carbohydrate source. However, relative to plant nectar, honeydew may be relatively unsuitable, as a result of an unfavourable sugar composition or the presence of secondary plant compounds. We studied survival of the aphid parasitoid Aphidius ervi Haliday (Hymenoptera: Braconidae) on honeydew collected from various aphid species feeding on potato (Solanum tuberosum L., cv. Desiree) (Solanaceae), wheat (Triticum aestivum L., cv. Bobwhite) (Poaceae), or artificial diet, as well as the sugar composition of the different honeydews. Honeydews from the tested aphid species on potato, wheat, or artificial diet were found to be relatively suitable food sources for adult A. ervi, although not always as suitable as a 2 M sucrose solution. There were differences in honeydew sugar composition among the diffe! rent aphid species on the various host plants. Multivariate statistics showed that the factor 'aphid species' had a significant influence on the sugar composition of the honeydew, explaining 27% of the variation in the potato system and 89% in the wheat system. When exploring the relationship between carbohydrate composition of the honeydews from aphids on potato and wheat plants, and their nutritional value for A. ervi, data revealed that differences in parasitoid longevity can to some extent be explained by carbohydrate composition. Furthermore, our results confirm that sucrose and its hexose components glucose and fructose are very suitable carbohydrate sources for hymenopteran parasitoids and show that parasitoid survival on an equimolar solution of the two monosaccharides glucose and fructose does not exceed performance on the disaccharide sucrose.

Since 1999, the Dutch trauma care has been regionalized into ten trauma systems. This study is the first to review such a trauma system. The aim was to examine the sensitivity of prehospital triage criteria [triage revised trauma score (T-RTS)] in identifying major trauma patients and to evaluate the current level of trauma care of a regionalized Dutch trauma system for major trauma patients. Major trauma patients (n=511) (June 2001–December 2003) were selected from a regional trauma registry database. The prehospital T-RTS was computed and standardized W scores (Ws) were generated to compare observed vs expected survival based on contemporary US- and UK-norm databases. The T-RTS showed low sensitivity for the prehospital identification of major trauma patients [34.1% (T-RTS≤10)]. Nevertheless, 78.0% of all major trauma patients were directly managed by the trauma center. These patients were more severely injured than their counterparts at non-trauma-center hospitals (p

Summary Undisplaced scaphoid fractures are easily missed on conventional scaphoid radiographs, but these occult fractures may seriously impair hand function. Routine bone scintigraphy (BS) is often advocated if there are clinical signs of a scaphoid fracture without radiological evidence. However, the results require careful therapeutic management. Objective: To determine the diagnostic value of BS in daily practice for clinically suspected scaphoid fractures. Methods: We evaluated our protocol of routine BS in suspected scaphoid fractures. Subjects: In a retrospective study, we analysed 111 consecutive cases with signs of a scaphoid fracture on physical examination. Radiographs revealed 55 fractures, the remaining 56 patients all underwent BS. Main results: On average, the BS was performed after 4 days. It showed a fracture in 38/56 of the patients. The distribution of fractures was: scaphoid bone 15, distal radius 11, other carpal bones 9 and metacarpal bones 3. Conclusion: If there is a strong clinical suspicion of a scaphoid fracture, which cannot be confirmed by conventional radiology, BS is a valuable diagnostic tool.

Bone scintigraphy will identify up to 25% of occult scaphoid bone fractures after negative scaphoid X-rays. Consequently, it deserves a place in the diagnostic process of suspected scaphoid fractures. However, the role of bone scintigraphy is less clear if scaphoid X-rays show other fractures in the carpal region. We analysed 111 consecutive patients with a suspected scaphoid fracture on physical examination. Scaphoid X-rays revealed 61 fractures. Fifty-five patients had scaphoid fractures only and six patients had other fractures in the carpal region but no scaphoid fracture. In 50 cases, no bone injury was seen on these X-rays. In three out of the six patients with other fractures in the carpal region, bone scintigraphy revealed four occult concomitant fractures: one scaphoid, one scaphoid and trapezial and one capitate fracture. In conclusion, bone scintigraphy is required when scaphoid X-rays do not confirm a suspected scaphoid fracture, even in the presence of other fractures in the carpal region.

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The low prevalence of true fractures amongst suspected fractures magnifies the shortcomings of the diagnostic tests used to triage suspected scaphoid fractures.The objective was to develop a clinical prediction rule that would yield a subset of patients who were more likely to have a scaphoid fracture than others who lacked the subset criteria.Seventy-eight consecutive patients diagnosed with a suspected scaphoid fracture were included. Standardised patient history, physical examination, range of motion (ROM) and strength measurements were studied. The reference standard for a true fracture was based on the results of magnetic resonance imaging, bone scintigraphy, follow-up radiographs and examination.Analysis revealed three significant independent predictors: extension50%, supination strength ≤ 10% and the presence of a previous fracture.Clinical prediction rules have the potential to increase the prevalence of true fractures amongst patients with suspected scaphoid fractures, which can increase the diagnostic performance characteristics of radiological diagnostic tests used for triage.

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Heat-shock proteins as antigens in autoimmunity Willem van Eden,* Els J. M. Hogervorst,* Marca H. M. Wauben,* Ruurd van der Zee,t and Claire, J. P. Boog* *Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, University of Utrecht, Yalelaan I, 8508 TD Utrecht, The Netherlands and +Department of Bacteriology, National Institute for Public Health and Environmental Hygiene, P.O. Box I, Bilthoven, The Netherlands 171

Purpose: To examine the observer variation for bone scintigraphy in the detection of occult scaphoid fractures in daily practice, using only the early bone scanning images. Methods: One hundred bone scans of patients with a suspected scaphoid fracture but negative initial radiographs were prospectively included to calculate the inter- and intraobserver variation. Three nuclear medicine physicians independently evaluated all bone scans at 2 different points in time with a 3-month interval. The observers filled out a blinded scoring sheet for each patient. They scored if a scaphoid fracture was present or not. In addition, they scored the presence or absence of another fracture. The inter- and intraobserver variation was analyzed using the κ statistic. Results: The interobserver variation showed substantial agreement for a scaphoid fracture and almost perfect agreement for another fracture. The intraobserver variation showed almost perfect agreement for both a scaphoid fracture and another fracture. Conclusions: In the present study, early static images of bone scintigraphy for suspected scaphoid fractures showed very little inter- and intraobserver variation. In addition, expertise does not seem to have a negative influence on the results. This enhances the possibility of using bone scintigraphy in daily practice.

The distal tibiofibular syndesmosis is important for stability of the ankle mortise and thus for weight transmission and walking. Syndesmotic injuries are most commonly associated with fibular fractures, but they can also occur in isolation or with damage to the lateral ankle ligament after traumatic supination. The need for trans-syndesmotic fixation of the distal tibiofibular joint has been controversial. The goat of this review was to collect evidence on the technical aspects of performing an osteosynthesis using a syndesmotic screw and to formulate some recommendations for clinical practice. (C) 2007 Elsevier Ltd. All rights reserved

One of the new treatment options for proximal humeral fractures is the minimally invasive intramedullary nail. In this study, we reviewed the early clinical results after 1 year.35 patients with proximal humeral fractures were treated using the Polarus nail. In 14 cases the initial treatment was operative; the other 21 patients were initially treated nonoperatively. 19 patients had a 2-part fracture, 5 had a 3-part fracture and 2 had a 4-part fracture. In 9 patients the fracture extended metaphyseally. The functional outcome was assessed by the Constant score.28 patients were available for 1-year followup. 17 patients showed excellent functional outcome (with an average Constant score of 81%). 6 patients required revision surgery, 1 because of nonunion and 1 because of an avascular necrosis. 4 others were reoperated because of inadequate position of the osteosynthesis or migration of the screws.The Polarus nail is of value for (displaced) 2-, 3-, and even 4-part proximal humeral fractures and enables early postoperative mobilization with a limited amount of pain.

Syndesmotic ruptures associated with ankle fractures are most commonly caused by external rotation of the foot, eversion of the talus within the ankle mortise, and excessive dorsiflexion. The distal tibiofibular syndesmosis consists of the anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, and interosseous ligament, and it is essential for stability of the ankle mortise. Despite the numerous biomechanical and clinical studies pertaining to ankle fractures, there are no uniform recommendations regarding the use of the syndesmotic screw for specific injury patterns and fracture types. The objective of this review was to formulate recommendations for clinical practice related to the use of syndesmotic screw placement.

Summary Early diagnosis and treatment of scaphoid fractures limits the number of delayed and non-unions. Bone scintigraphy proved to be a sensitive diagnostic tool for the detection of occult scaphoid fractures. However, the results have to be interpreted with care. Objective To prospectively correlate the results of bone scintigraphy with clinical outcome. Methods In a prospective study, we analysed 50 consecutive patients with signs of a scaphoid fracture at physical examination but no evidence of a scaphoid fracture on scaphoid radiographs. All patients had a protocolised follow up at fixed intervals. The clinical outcome was defined according to a standardised algorithm. Main results Bone scintigraphy revealed 32% (16/50) occult scaphoid fractures and 40% (20/50) occult other fractures. Clinical outcome proved that bone scintigraphy was false positive in five patients and in one case false negative for a scaphoid fracture. Conclusion Bone scintigraphy in combination with protocolised physical examination is the gold standard for patients with signs of a scaphoid fracture that cannot be proven on scaphoid radiographs.