Diagnostic accuracy of history taking, physical examination and imaging for phalangeal, metacarpal and carpal fractures: a systematic review update.

BACKGROUND: The standard diagnostic work-up for hand and wrist fractures consists of history taking, physical examination and imaging if needed, but the supporting evidence for this work-up is limited. The purpose of this study was to systematically examine the diagnostic accuracy of tests for hand and wrist fractures. METHODS: A systematic search for relevant studies was performed. Methodological quality was assessed and sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV) and negative predictive value (NPV) were extracted from the eligible studies. RESULTS: Of the 35 eligible studies, two described the diagnostic accuracy of history taking for hand and wrist fractures. Physical examination with or without radiological examination for diagnosing scaphoid fractures (five studies) showed Se, Sp, accuracy, PPV and NPV ranging from 15 to 100%, 13-98%, 55-73%, 14-73% and 75-100%, respectively. Physical examination with radiological examination for diagnosing other carpal bone fractures (one study) showed a Se of 100%, with the exception of the triquetrum (75%). Physical examination for diagnosing phalangeal and metacarpal fractures (one study) showed Se, Sp, accuracy, PPV and NPV ranging from 26 to 55%, 13-89%, 45-76%, 41-77% and 63-75%, respectively. Imaging modalities of scaphoid fractures showed predominantly low values for PPV and the highest values for Sp and NPV (24 studies). Magnetic Resonance Imaging (MRI), Computed Tomography (CT), Ultrasonography (US) and Bone Scintigraphy (BS) were comparable in diagnostic accuracy for diagnosing a scaphoid fracture, with an accuracy ranging from 85 to 100%, 79-100%, 49-100% and 86-97%, respectively. Imaging for metacarpal and finger fractures showed Se, Sp, accuracy, PPV and NPV ranging from 73 to 100%, 78-100%, 70-100%, 79-100% and 70-100%, respectively. CONCLUSIONS: Only two studies were found on the diagnostic accuracy of history taking for hand and wrist fractures in the current review. Physical examination was of moderate use for diagnosing a scaphoid fracture and of limited use for diagnosing phalangeal, metacarpal and remaining carpal fractures. MRI, CT and BS were found to be moderately accurate for the definitive diagnosis of clinically suspected carpal fractures

Thriving on strengths:Effects of a strengths intervention for younger and older teachers

The teaching profession is characterized by high demands and teachers who thrive are better able to navigate their demanding context than teachers who survive. Based on theories on strengths use we propose that strengths interventions which help teachers to identify, use, and develop their strengths can enhance their thriving (vitality and learning) which enables them to perform better. In addition, based on the socioemotional selective theory we propose that strengths interventions are especially beneficial for older teachers because it fits their goals and skills. We conducted a quasi-experimental study, in which 152 teachers and their team leaders participated in a strengths intervention. Longitudinal survey data indicated that the strengths intervention contributed to older teachers’ (≥ 46 years old) vitality, which in turn, contributed to their performance. No significant effects were found for younger teachers. We discuss the implications of our study for older teachers.</p

Self-Assessment of Competence and Referral Behavior for Musculoskeletal Injections among Dutch General Practitioners.

General practitioners (GPs) are qualified and trained to administer therapeutic musculoskeletal injections when indicated. However, it is unknown to what extend Dutch GPs feel competent to administer these injections in clinical practice. Reluctance among GPs to inject might lead to unnecessary and costly referral to secondary care. An online and offline questionnaire was spread among Dutch GPs, querying demographics, GPs' self-assessment of injection competence, the number of administered/referred injections and management strategy for musculoskeletal injections. A total of 355 GPs responded. In total, 81% of the GPs considered themselves competent in administering musculoskeletal injections. Self-assessed incompetent GPs performed less injections the last month than self-assessed competent GPs (1.2 ± 1.4 vs 4.8 ± 4.6 injections, P < 0.001). Additionally, they referred four times more often to a colleague GP (0.4 ± 1.0 vs 0.1 ± 0.6 injections per month, P < 0.001) and twice as often to secondary care (1.0 ± 1.3 vs 0.5 ± 0.9 injections per month, P = 0.001). Self-assessed incompetence was associated with female sex (OR [95% CI] = 4.94 [2.39, 10.21]) and part-time work (OR [95% CI] = 2.58 [1.43, 4.66]). The most frequently addressed barriers were a lack of confidence in injection skills, lack of practical training, and uncertainty about the effectiveness and diagnosis of musculoskeletal injections. Although most GPs considered themselves competent to administer musculoskeletal injections, the referral rate to secondary care for several injections was strikingly high. To decrease secondary care referrals, addressing some of the most frequently indicated barriers is highly recommended

Diagnostic accuracy of history taking, physical examination and imaging for phalangeal, metacarpal and carpal fractures: a systematic review update

BACKGROUND: The standard diagnostic work-up for hand and wrist fractures consists of history taking, physical examination and imaging if needed, but the supporting evidence for this work-up is limited. The purpose of this study was to systematically examine the diagnostic accuracy of tests for hand and wrist fractures. METHODS: A systematic search for relevant studies was performed. Methodological quality was assessed and sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV) and negative predictive value (NPV) were extracted from the eligible studies. RESULTS: Of the 35 eligible studies, two described the diagnostic accuracy of history taking for hand and wrist fractures. Physical examination with or without radiological examination for diagnosing scaphoid fractures (five studies) showed Se, Sp, accuracy, PPV and NPV ranging from 15 to 100%, 13-98%, 55-73%, 14-73% and 75-100%, respectively. Physical examination with radiological examination for diagnosing other carpal bone fractures (one study) showed a Se of 100%, with the exception of the triquetrum (75%). Physical examination for diagnosing phalangeal and metacarpal fractures (one study) showed Se, Sp, accuracy, PPV and NPV ranging from 26 to 55%, 13-89%, 45-76%, 41-77% and 63-75%, respectively. Imaging modalities of scaphoid fractures showed predominantly low values for PPV and the highest values for Sp and NPV (24 studies). Magnetic Resonance Imaging (MRI), Computed Tomography (CT), Ultrasonography (US) and Bone Scintigraphy (BS) were comparable in diagnostic accuracy for diagnosing a scaphoid fracture, with an accuracy ranging from 85 to 100%, 79-100%, 49-100% and 86-97%, respectively. Imaging for metacarpal and finger fractures showed Se, Sp, accuracy, PPV and NPV ranging from 73 to 100%, 78-100%, 70-100%, 79-100% and 70-100%, respectively. CONCLUSIONS: Only two studies were found on the diagnostic accuracy of history taking for hand and wrist fractures in the current review. Physical examination was of moderate use for diagnosing a scaphoid fracture and of limited use for diagnosing phalangeal, metacarpal and remaining carpal fractures. MRI, CT and BS were found to be moderately accurate for the definitive diagnosis of clinically suspected carpal fractures

Mogelijkheden en beperkingen van een gebiedsgerichte uitwerking van de Nitraatrichtlijn

Wordt de landbouw onevenredig hard getroffen in die gebieden in Nederland waar aan de nitraatconcentratie in het grondwater wordt voldaan? Die vraag probeerden Alterra en de Universiteit Utrecht te beantwoorden in een studie naar de mogelijkheden die de Nitraatrichtlijn biedt om de aanwijzing van nitraatuitspoelingsgevoelige gebieden (kwetsbare zones) en bijbehorende nitraatactieprogramma's te differentiëren naar de landbouw- en milieukundige omstandigheden in de verschillende regio's. Het doel hierachter is een betere aansluiting te krijgen bij de gebiedsgerichte uitwerking van de Kaderrichtlijn Water. De resultaten zijn gebaseerd op literatuurstudie, brainstormsessies, interviews en een bijeenkomst met actoren uit het veld. Een verdere differentiatie is technisch mogelijk via aanwijzing van specifieke kwetsbare zones en het uitzonderen van andere gebieden. Verwacht wordt echter dat het uit te zonderen areaal beperkt zal zijn. Meer perspectief bied een verdergaande (gebiedsgerichte) differentiatie van gebruiksnormen die van toepassing zijn op de aangewezen kwetsbare zones. Nitraatactieprogramma's zijn verder te 'harmoniseren' met stroomgebiedsplannen van de Kaderrichtlijn Water, maar dienen wel als zodanig herkenbaar in stand te blijven

A method for the deliberate and deliberative selection of policy instrument mixes for climate change adaptation

Policy instruments can help put climate adaptation plans into action. Here, we propose a method for the systematic assessment and selection of policy instruments for stimulating adaptation action. The multi-disciplinary set of six assessment criteria is derived from economics, policy, and legal studies. These criteria are specified for the purpose of climate adaptation by taking into account four challenges to the governance of climate adaptation: uncertainty, spatial diversity, controversy, and social complexity. The six criteria and four challenges are integrated into a step-wise method that enables the selection of instruments starting from a generic assessment and ending with a specific assessment of policy instrument mixes for the stimulation of a specific adaptation measure. We then apply the method to three examples of adaptation measures. The method’s merits lie in enabling deliberate choices through a holistic and comprehensive set of adaptation specific criteria, as well as deliberative choices by offering a stepwise method that structures an informed dialog on instrument selection. Although the method was created and applied by scientific experts, policy-makers can also use the method

The need of data harmonization to derive robust empirical relationships between soil conditions and vegetation.

Question: Is it possible to improve the general applicability and significance of empirical relationships between abiotic conditions and vegetation by harmonization of temporal data? Location: The Netherlands. Methods: Three datasets of vegetation, recorded after periods with different meteorological conditions, were used to analyze relationships between soil moisture regime (expressed by the mean spring groundwater level - MSLt calculated for different periods) and vegetation (expressed by the mean indicator value for moisture regime Fm). For each releve, measured groundwater levels were interpolated and extrapolated to daily values for the period 1970-2000 by means of an impulse-response model. Sigmoid regression lines between MSLt and Fm were determined for each of the three datasets and for the combined dataset. Results: A measurement period of three years resulted in significantly different relationships between Fm and MSLt for the three datasets (F-test,/? <0.05>. The three regression lines only coincided for the mean spring groundwater level computed over the period 1970-2000 (AfSLclimate) and thus provided a general applicable relationship. Precipitation surplus prior to vegetation recordings strongly affected the relationships. Conclusions: Harmonization of time series data (1) eliminates biased measurements, (2) results in generally applicable relationships between abiotic and vegetation characteristics and (3) increases the goodness of fit of these relationships. The presented harmonization procedure can be used to optimize many relationships between soil and vegetation characteristics. © IAVS; Opulus Press Uppsala

Baseline meniscal extrusion associated with incident knee osteoarthritis after 30 months in overweight and obese women

Objective: To investigate the association between baseline meniscal extrusion and the incidence of knee osteoarthritis (KOA) after 30 months in a high-risk population of overweight and obese women, free of clinical and radiological KOA at baseline. Methods: 407 middle-aged overweight women (body mass index - BMI ≥ 27 kg/m2) were evaluated at baseline and after 30 months of follow-up. Meniscal extrusion was defined as grade ≥2 on MRI according to MRI Osteoarthritis Knee Score (MOAKS). The primary outcome measure was KOA after 30 months follow-up, defined using the following criteria: either incidence of radiographic KOA (Kellgren & Lawrence grade 2 or higher), or clinical osteoarthritis (OA) according to the American College of Radiology (ACR) criteria, or medial or lateral joint space narrowing (JSN) of ≥1.0 mm. Using generalized estimating equations (GEE), we determined the association between knees with and without meniscal extrusion and both outcomes, corrected for the baseline differences. Results: 640 knees were available at baseline of which 24% (153) had meniscal extrusion. There was a significantly higher incidence of KOA according to the primary outcome measure in women with meniscal extrusion compared to those without extrusion (28.8%, odds ratio - OR 2.39, 95% CI 1.53, 3.73). A significantly higher incidence was found for the development of radiographic KOA (12.4%, OR 2.61, 95% CI 1.11, 6.13) and medial JSN (11.8%, OR 3.19, 95% CI 1.59, 6.41). Meniscal extrusion was not significantly associated with clinical KOA and lateral JSN. Conclusion: Meniscal extrusion was associated with a significantly higher incidence of KOA, providing an interesting target for early detection of individuals at risk for developing KOA

De bijdrage van m.e.r. aan besluitvorming rond infrastructuur in Nederland: Percepties vanuit het beroepsveld, Bevindingenrapport

Samenvatting In 2011 is het 25 jaar geleden dat er een wettelijke regeling voor milieueffectrapportage (m.e.r.) van kracht werd. Hier gingen bijna 10 jaar van proefnemingen met m.e.r. aan vooraf. In de loop van de tijd heeft de m.e.r.-regelgeving verschillende veranderingen ondergaan en is ook de toepassing van m.e.r. in de praktijk veranderd. In het kader van het naderende jubileum voeren de Universiteit Utrecht en de Rijksuniversiteit Groningen, in opdracht van Rijkswaterstaat, een evaluatiestudie uit naar de ervaringen met 25 jaar m.e.r. in Nederland. De nadruk ligt op het vaststellen van de mate waarin het instrument heeft bijgedragen aan een volwaardige rol van milieuwaarden in besluitvormingsproces. Doel is bouwstenen aan te dragen waarmee Rijkswaterstaat zijn positie kan bepalen ten aanzien van mogelijke knelpunten in m.e.r. en toekomstige m.e.r. ontwikkeling. Deze rapportage behandelt de belangrijkste uitkomsten van het eerste deelonderzoek, gericht op het inventariseren van ervaringen van het beroepsveld met het m.e.r.-systeem zoals dat tot 1 juli 2010 bestond en de verwachtingen ten aanzien van de ‘gemoderniseerde’ m.e.r.-regelgeving. Als methode is gekozen voor een online opiniepeiling, waaraan 441personen hebben meegewerkt. Zo’n 40% hiervan heeft (vooral) ervaring op het gebied van m.e.r. voor infrastructurele initiatieven. Op basis van de ervaringen van onze respondenten zijn onze belangrijkste conclusies: M.e.r. speelt een bescheiden rol in het bevorderen van een volwaardige rol van milieuwaarden in besluitvorming rond infrastructuur. Een mogelijke verklaring is de wijze waarop m.e.r. wordt toegepast: meer als (wettelijk verplicht) instrument om te toetsen op minimum milieunormen dan als ontwerpinstrument om milieuwaarden te optimaliseren. In andere sectoren is dat wat minder vaak het geval; De rol van m.e.r. lijkt niet te zijn overgenomen door belanghebbenden en andere actoren of door instrumenten zoals de milieuvergunning; Over het algemeen ervaren m.e.r.-professionals geen onacceptabele vertragingen in besluitvorming of lasten voor bevoegd gezag en initiatiefnemers als gevolg van m.e.r. Uitzondering zijn respondenten vanuit het bevoegd gezag; Eén van de belangrijkste wijzigingen in de m.e.r.-regelgeving – de ‘beperkte’ m.e.r.-procedure – geldt niet voor infrastructurele projecten. Dit is waarschijnlijk de reden dat niet verwacht wordt dat de ‘modernisering’ veel effect zal hebben op de bijdrage van m.e.r. aan besluitvorming of op de snelheid van besluitvorming. Wél is de afschaffing van het meest milieuvriendelijke alternatief omstreden; Het m.e.r.-systeem zou volgens de respondenten versterkt kunnen worden door standaardisatie van in te schatten milieueffecten en daarbij gehanteerde methoden, een verplicht toetsingsadvies voor alle infrastructuurinitiatieven en een verplichting tot het achteraf meten van daadwerkelijke milieueffecten. De klassieke voor- en nadelen van m.e.r. die vaak in het maatschappelijke debat naar voren worden gebracht (bijvoorbeeld: m.e.r. leidt tot milieuvriendelijker besluiten, m.e.r. werkt vertragend), worden door de meeste respondenten niet als zodanig ervaren. Dit roept de vraag op of daar nog veel aandacht moet worden besteed. Interessanter lijkt de vraag waar verbeteringen in m.e.r. mogelijk zijn. Hoe kunnen initiatiefnemers en bevoegd gezag bijvoorbeeld gestimuleerd worden om m.e.r. meer als ontwerpinstrument te gebruiken