***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE To test the validity of a set of defined and tested rules for decisions on use of radiography for acute ankle injuries . DESIGN Prospect i ve survey . SETTING Community hospital emergency department managing 42000 visits annually . PARTICIPANTS A non-consecutive sample of 318 adults and children presenting during 1 year was evaluated by 25 family physicians in part-time emergency practice . INTERVENTIONS Participating physicians interpreted the Ottawa ankle rules for all enrolled patients and ordered radiographs in 96 % of cases . MAIN OUTCOME MEASURES Sensitivity of the Ottawa ankle rules to predict whether radiography is required for acute ankle injuries . RESULTS Of the 318 cases , 22 incomplete records were excluded , leaving 259 records of adults and 37 records of patients younger than 16 accepted for analysis . Of 34 adult patients with identified fractures , only one was predicted by the rules not to require  radiographs . Sensitivity of the rules was 0.971 ( confidence interval [ CI ] 0.914 to 1.00 ) , specificity was 0.302 ( CI 0.242 to 0.362 ) , positive predictive value was 0.174 ( CI 0.120 to 0.228 ) , and negative predictive value was 0.986 ( CI 0.971 to 1.00 ) . Radiography could have been reduced by 26.3 % had the rules been applied . Of the 37 children , seven had fractures . All were properly identified by the rules . Radiography in this group could have been reduced by 22 % . CONCLUSIONS This study vali date s the Ottawa ankle rules and supports their use . Further research on how the rules apply to children is required To help curb excessive radiography , we developed a protocol for selecting patients with injured extremities who need x-ray examination  , and we tested the protocol prospect ively in 848 patients to determine its safety and effectiveness . Strict adherence to the protocol would have reduced x-ray usage by 12 per cent for upper extremities and 19 per cent for lower extremities . The actual reductions were 5 per cent and 16 per cent , respectively , since further reductions were limited by patient 's dem and s for x-ray examinations . One fracture in 287 were missed , but the treatment was appropriate and the outcome satisfactory . By eliminating superfluous x-ray procedures , the protocol could reduce charges by $ 79 million to $ 139 million nationwide , without compromising quality of care or increasing mal practice liability . Nevertheless , even the best protocol can not eliminate all negative x-ray studies . These results should serve as a stimulus for judicious use of radiography , but also as a warning to avoid overzealous cost-containment strategies that would reduce x-ray usage to below a safe threshold In a sports medicine center , we prospect ively evaluated the Ottawa Ankle Rules over 1 year for their ability to identify clinical ly 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 clinical ly 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 clinical ly significant fractures . The Buffalo modification could improve specificity for malleolar fractures without sacrificing sensitivity and could significantly reduce the need for radiography OBJECTIVE : To assess whether accident and emergency ( A&E ) nurses using the Ottawa Ankle Rules  could detect all  ankle fractures . DESIGN : Prospect i ve observational study . SETTING : A&E department of a university teaching hospital . SUBJECTS : All patients who presented with ankle injuries who were initially assessed by a nurse taught the Ottawa Ankle Rules .  OUTCOME MEASURES : ( 1 ) The numbers of patients referred by the nurse for ankle radiography ;  ( 2 ) of these , the number with ankle fractures ; ( 3 ) of those not sent for  radiography  initially by the nurse , the number who subsequently had x rays ( ordered by the doctor ) and had a fracture ; ( 4 ) of those having no x rays , the number who reattended later . RESULTS : 324 patients were eligible ; 238 had x rays at the request of the nurse ( 73 % ) ; 48 of these ( 20 % ) were diagnosed as having a fracture . Of those 86 patients not sent for radiography by the nurse , 19 subsequently had x ray examinations at the request of a doctor and no fracture was detected . Of the 67 not sent for radiography , none returned within the subsequent eight weeks . CONCLUSIONS : Nurses can apply the Ottawa Ankle Rules safely without missing acute fractures ; that is , of those who were not sent for radiography by nurses , none subsequently reattended the A&E department or the trauma service of the Bristol Royal Infirmary during the following two months Ankle injuries are a frequent cause of attendance to accident and emergency ( A&E ) departments . Although often classed as ' minor injuries ' , the consequences of mismanagement can be debilitating for patients . In addition , it is not always easy to differentiate those injuries with bony fractures from solely ligamentous injuries , and most patients are radiographed unnecessarily . Clinical prediction rules such as the Ottawa Ankle Rules have been devised to reduce the degree of radiographic requests , thus limiting harmful radiation exposure , and reducing departmental costs . The A&E environment of our centre often includes a variety of clinicians with little pure orthopaedic training or knowledge of these clinical prediction rules , hence , providing a prime atmosphere for their assessing their effectiveness . A prospect i ve study was performed in our centre to investigate the validity of the clinician 's decision in diagnosis of a bony injury in the absence of training with the Ottawa Ankle Rules . The effectiveness of applying the rules was then determined on the same set of patients OBJECTIVE To vali date and refine previously derived clinical decision rules that aid the efficient use of radiography in acute ankle injuries . DESIGN Survey prospect ively administered in two stages : validation and refinement of the original rules ( first stage ) and validation of the refined rules ( second stage ) . SETTING Emergency departments of two university hospitals . PATIENTS Convenience sample of adults with acute ankle injuries : 1032 of 1130 eligible patients in the first stage and 453 of 530 eligible patients in the second stage . MAIN OUTCOME MEASURES Attending emergency physicians assessed each patient for st and ardized clinical variables and classified the need for  radiography  according to the original ( first stage ) and the refined ( second stage ) decision rules . The decision rules were assessed for their ability to correctly identify the criterion st and ard of fractures on ankle and foot radiographic series . The original decision rules were refined by univariate and recursive partitioning analyses . MAIN RESULTS In the first stage , the original decision rules were found to have sensitivities of 1.0 ( 95 % confidence interval [ CI ] , 0.97 to 1.0 ) for detecting 121 maleolar zone fractures , and 0.98 ( 95 % CI , 0.88 to 1.0 ) for detecting 49 midfoot zone fractures . For interpretation of the rules in 116 patients , kappa values were 0.56 for the ankle series rule and 0.69 for the foot series rule . Recursive partitioning of 20 predictor variables yielded refined decision rules for ankle and foot radiographic series . In the second stage , the refined rules proved to have sensitivities of 1.0 ( 95 % CI , 0.93 to 1.0 ) for 50 malleolar zone fractures , and 1.0 ( 95 % CI , 0.83 to 1.0 ) for 19 midfoot zone fractures . The potential reduction in radiography is estimated to be 34 % for the ankle series and 30 % for the foot series . The probability of fracture , if the corresponding decision rule were " negative , " is estimated to be 0 % ( 95 % CI , 0 % to 0.8 % ) in the ankle series , and 0 % ( 95 % CI , 0 % to 0.4 % ) in the foot series . CONCLUSION Refinement and validation have shown the Ottawa ankle rules to be 100 % sensitive for fractures , to be reliable , and to have the potential to allow physicians to safely reduce the number of radiographs ordered in patients with ankle injuries by one third . Field trials will assess the feasibility of implementing these rules into clinical practice The Ottawa ankle rules ( OAR ) have been vali date d in many Western countries . However , a recent study performed in an accident and emergency department in Singapore failed to vali date the OAR . Therefore , the implementation of the use of OAR in accident and emergency departments in Hong Kong may be treated with skepticism . This prospect i ve study was performed to vali date the ordering of radiographs using OAR in Chinese patients with foot and ankle injuries in Hong Kong . Emergency physicians trained in the use of the OAR assessed 773 eligible patients and one hundred thirty-one fractures were identified . The sensitivity and specificity of the OAR  for ankle injuries was 98 % and 40.8 % . For midfoot injuries , the sensitivity and specificity of the OAR  was 100 % and 43.8 % . We concluded that the OAR are applicable in our population with potential advantages for reducing the number of unnecessary investigations and shortening the patients ' length of stay in accident and emergency departments STUDY OBJECTIVE To vali date criteria predicting  ankle and mid-foot fractures  with 100 % sensitivity . DESIGN Prospect i ve validation study SETTING A 929-bed community teaching hospital with an annual census of 76,488 ED visits . PARTICIPANTS Convenience sample of patients older than 18 years with acute ankle or midfoot injury . INTERVENTIONS Radiography was performed in each patient received after pertinent history and physical examination findings were recorded . RESULTS Five hundred seventy radiographs were obtained in 484 patients . Four hundred twenty-one were of the ankle , and 149 were of the foot . There were 93 ankle fractures and 29 midfoot fractures , giving a fracture yield of 22.1 % for ankle films and 19.5 % for foot films . Decision rules had sensitivity of 94.6 % and specificity of 15.5 % for ankle fractures and sensitivity of 93.1 % and specificity of 11.5 % for midfoot fractures . Prospect i ve criteria failed to predict fracture in five of the ankle group and two of the midfoot group . Physicians predicting fracture solely on the basis of clinical suspicion had a sensitivity of 69 % in ankle injuries and 76 % in midfoot injuries . CONCLUSION We were unable to vali date with 100 % sensitivity the Ottawa rules predicting ankle and midfoot fractures . However , the Ottawa rules were more sensitive than clinical suspicion alone OBJECTIVE The Ottawa Ankle Rules ( OAR ) assist emergency physicians in the appropriate use of roentgenography in adults with acute ankle injuries . The OAR state that ankle roentgenograms are needed only if there is pain near the malleoli and one or more of the following exists : ( 1 ) age 55 years or older ; ( 2 ) inability to bear weight ; or ( 3 ) bone tenderness at the posterior edge or tip of either malleolus . This study assessed the utility of the OAR on pediatric patients with acute ankle injuries . DESIGN Prospect i ve , consecutive survey of pediatric patients with acute ankle injuries . SETTING Pediatric emergency department of an urban university hospital . PARTICIPANTS Seventy-one children with acute ankle injuries were enrolled from July 22 , 1993 , to December 1 , 1993 . INTERVENTIONS Twenty-four st and ardized clinical variables were assessed and recorded by physicians in the pediatric emergency department . The OAR were applied to each patient by the investigator to determine which ones would qualify for roentgenography . MAIN OUTCOME MEASURES Sensitivity and specificity of the OAR  were calculated , as was percent reduction in roentgenograms ordered . RESULTS Seventy-one of 73 eligible patients were enrolled . The two missed patients had open fractures of the tibia .  Sixty-eight of 71 patients had ankle roentgenography during the visit . Fourteen patients ( 21 % ) ( mean age , 11.8 + /- 4.0 years ) had fractures noted on the roentgenograms . Fifty-four patients ( 79 % ) ( mean age ,  
    Output:
    
Evidence supports the Ottawa ankle rules as an accurate instrument for excluding fractures of the ankle and mid-foot .