Research of the week
Emergency Med J 2007; 24: 75–7
Diagnosing septic arthritis is not always easy. Pseudogout, for example, may also present with a red hot swollen joint. The consequences of misdiagnosing infection may be devastating.
This retrospective study looked at the value of using white cell count (WCC), ESR and joint fluid WCC (jWCC) in diagnosis. Patients with a dry tap were excluded from the trial. Of the 156 patients assessed, 10 per cent had a septic arthritis.
Sensitivities and specificities were used to develop a graphical representation of the trade off between sensitivity and specificity for each of the tests. Interpretation of these suggested jWCC is the best overall test for diagnosing septic arthritis, although no test is diagnostic.
A combination of clinical history, examination and investigations are required to avoid misdiagnosis.
MRI and CT in acute stroke
Lancet 2007; 369: 293–8
It is not uncommon for a patient’s CT scan to be normal after a clinical diagnosis of a stroke. This is unsatisfactory for the patient and the clinician alike. Patients often consult their GP, curious about what their scan showed. A false negative is one possible explanation for a normal CT and begs the question whether MRI is the investigation of choice.
In this study, a head to head comparison of these two imaging methods was performed on 217 stroke patients. MRI was found to be far more sensitive than CT for acute ischaemic stroke and similar to CT for haemorrhagic events. Overall sensitivity for acute stroke was 83 per cent for MRI and 26 per cent for CT. Clearly a normal CT does not refute a diagnosis of stroke.
Emergency Med J 2007; 24: 92–5
TIA is a risk factor for further cerebral events, which can be devastating or even life threatening. The Oxford Vascular Study, in 2004, showed a 15 per cent cumulative risk of further events at 30 days.
High-risk patients may be identified using the ABCD rule (age, BP, clinical features and duration of symptoms). Age above 60, BP of >140 systolic or >90 diastolic are each worth one point. Unilateral weakness is worth two points, speech disturbance (with no weakness) is worth one, otherwise no points are awarded. If symptoms last an hour or more, two points are given and one point is given for symptoms lasting 10 – 59 minutes. A maximum of six points can be scored.
This study looked at the ability of the ABCD system to predict stroke at seven and 90 days post TIA. Researchers evaluated 90 patients in this study and 48 per cent had a high score (>5). Only patients with high scores went on to have a stroke within seven days, and six of the seven patients who had a stroke within 90 days had a score >5.
The ABCD scoring system is a useful tool to aid risk stratification and it is helpful to document the score when referring patients to secondary care.
Embolisation as a treatment for fibroids
NEJM 2007; 356: 360–70
Treatment options for fibroids include uterine artery embolisation or surgery (hysterectomy or myomectomy). This study, involving 157 patients, compared the methods. Patients undergoing embolisation had shorter hospital stays and recovery time.
Adverse events were seen in 12 per cent of the embolisation patients and 20 per cent of the surgical group (not statistically significant) in the first year. Of the embolisation patients 9 per cent required further intervention. The researchers advise discussing with patients the shorter recovery time with embolisation but the greater risk of further intervention being needed.
Depression in patients with CHD
JAMA 2007; 297: 367–79
Depression is common in patients with chronic diseases and this is recognised in the quality framework.
This trial looked at nearly 300 patients with CHD and major depression, comparing citalopram to short-term psychology. Depression was scored using the Hamilton Depression rating scale. The Beck Depression Inventory-II (BDI-II) was used as a secondary outcome.
At 12 weeks post intervention, the Canadian study found citalopram was more effective in reducing Hamilton Depression and BDI-II scores whereas psychotherapy had no advantage over weekly reviews alone. This trial may help us manage our cardiac patients more effectively.
Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, and a member of our team who regularly review the medical journal