In the primary care setting, rotator cuff pathology is commonly encountered. Information regarding the risks of oral medications for the management of the associated pain keeps mounting. Partial-thickness rotator cuff tears remain difficult to diagnose with a single imaging modality. Musculoskeletal education in medical schools and non-orthopaedic residency and fellowship training programs continues to be an area for additional improvement. In the primary care office, the initial evaluation of shoulder pain should include a thorough musculoskeletal evaluation in order to identify the source of the pain (e.g., shoulder, cervical spine, chest wall), as well as the development of an initial treatment plan. Access to imaging modalities such as ultrasound and MRI can vary depending on the resources available in the primary care setting. The identification of patients who may benefit from early surgical referral is imperative for optimizing outcomes.
A vast majority of ED patients with persistently elevated BP did not receive BP counseling and referral for further evaluation of elevated BP, suggesting lack of adherence to American College of Emergency Physicians policy recommendations in the assessment of ED patients with asymptomatic elevated BP.
The Balance Error Scoring System (BESS) is a commonly used concussion assessment tool. Recent studies have questioned the stability and reliability of baseline BESS scores. The purpose of this longitudinal prospective cohort study is to examine differences in yearly baseline BESS scores in athletes participating on an NCAA Division-I football team. NCAA Division-I freshman football athletes were videotaped performing the BESS test at matriculation and after 1 year of participation in the football program. Twenty-three athletes were enrolled in year 1 of the study, and 25 athletes were enrolled in year 2. Those athletes enrolled in year 1 were again videotaped after year 2 of the study. The paired t-test was used to assess for change in score over time for the firm surface, foam surface, and the cumulative BESS score. Additionally, inter- and intrarater reliability values were calculated. Cumulative errors on the BESS significantly decreased from a mean of 20.3 at baseline to 16.8 after 1 year of participation. The mean number of errors following the second year of participation was 15.0. Inter-rater reliability for the cumulative score ranged from 0.65 to 0.75. Intrarater reliability was 0.81. After 1 year of participation, there is a statistically and clinically significant improvement in BESS scores in an NCAA Division-I football program. Although additional improvement in BESS scores was noted after a second year of participation, it did not reach statistical significance. Football athletes should undergo baseline BESS testing at least yearly if the BESS is to be optimally useful as a diagnostic test for concussion.
IntroductionDistal forearm fractures (DFF) account for 1.5% of emergency department (ED) visits in the United States. Clinicians frequently obtain imaging above/below the location of injury to rule out additional injuries. We sought to determine the incidence of associated proximal fractures (APF) in the setting of DFF and to evaluate the imaging practices in a nationally representative sample of EDs.MethodsWe queried the 2013 National Emergency Department Sample using International Classification of Diseases, 9th edition, diagnostic codes for DFF and APF. Current Procedural Technology codes identified associated imaging studies. We calculated national estimates using a weighted analysis of patient and hospital-level characteristics associated with APF and imaging practices. An analysis of costs estimated the financial impact of additional imaging in patients with DFF using Medicare reimbursement to approximate costs according to the 2018 Medicare Physician Fee Schedule.ResultsIn 2013, an estimated 297,755 ED visits (weighted) were associated with a DFF, of which 1.6% (4836 cases) had an APF. The incidence of APF was lower among females (odds ratio [OR] (0.76); 95% confidence interval [CI], 0.64–0.91) but higher in metropolitan teaching hospitals compared to metropolitan non-teaching hospitals (OR [2.39]; 95% CI, 1.43–3.99) and Level 1 trauma centers (OR [3.9]; 95%, 1.91–7.96) compared to non-trauma centers. Approximately 40% (n = 117,948) of those with only DFF received non-wrist radiographs and 19% (n = 55,236) underwent non-wrist/non-forearm imaging. Factors independently associated with additional imaging included gender, payer, patient and hospital rurality, hospital region, teaching status, ownership, and trauma center level. Nearly $3.6 million (2018 U.S. dollars) was spent on the aforementioned additional imaging.ConclusionDespite the frequency of proximal imaging in patients with DFF, the incidence of APF was low. Further study to identify risk factors for APF based on mechanism and physical examination factors may result in reduced imaging and decreased avoidable healthcare spending.
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