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Test sequences in screening for breast cancer.

Published data of Stark and Way on the screening of 2,684 women at high risk of breast cancer are analyzed to arrive at a preferred sequence of screening tests. In the practical situation where palpation first signals a problem, the analysis suggests thermography to follow. Women with positive thermograms should then be biopsied, and those with negative thermograms should be mammographed. A positive mammogram calls for biopsy, and a negative one calls for close follow-up. For high-risk women whose breasts appear normal on palpation, a subsequent negative thermogram is not definitive enough to terminate investigation, but a negative mammogram after a negative palpation is enough evidence to waive further investigation for some time. A positive mammogram calls for immediate biopsy in any circumstance.

Breast Neoplasms↗

Most commonly used methods of detecting spinal subluxation and the preferred term for its description: a survey of chiropractors in Victoria, Australia.

PURPOSE: To determine the most commonly used diagnostic methods for detecting the spinal entity that chiropractors adjust/manipulate and the preferred term for describing this entity. DESIGN: Postal survey (self-completed questionnaire). SETTING: Victoria, Australia. PARTICIPANTS: All 554 chiropractors registered May 30, 1994, with the Chiropractors and Osteopaths Registration Board of Victoria. MAIN OUTCOME MEASURES: Frequency of use and opinion with respect to reliability of 16 specific methods, measured on a 7-point, Likert-type scale [never used (1) to always used (7) and very unreliable (1) to very reliable (7), respectively]; the respondent's preferred term for describing the spinal entity that chiropractors adjust/manipulate. RESULTS: The response rate was 85%. The most commonly used method was static palpation (mean score 6.6 +/- 1.1). Seven other methods, including pain description of the patient, orthopedic tests, motion palpation, visual posture analysis, leg length discrepancy, neurological tests and plain static X-rays had mean scores greater than 4.0. All of these methods, as well as functional X-ray views and kinesiological muscle testing, were considered reliable, with mean reliability scores greater than 4.0. Motion palpation was regarded as the most reliable method (mean reliability score 5.9 +/- 1.2). Seventy-five different terms for describing the spinal entity were named by 440 respondents. "Subluxation" was included in the preferred term of 294 respondents (67%), 46 included "dysfunction" (11%), 35 included "fixation" (8%) and 20 included "manipulable" (4.5%). CONCLUSION: Chiropractors commonly use a variety of methods to identify the spinal entity that they manipulate. There is no consensus as to the preferred term for describing this entity.

Chiropractic↗

[Ultrasonography of cervical lymphatic metastasis in patients with laryngeal neoplasms].

112 patients with larynx cancer underwent ultrasonography of neck lymph nodes to asses their metastatic involvement before surgical treatment. Evaluation of the nodes was also performed by means of simple palpation. Results of palpation and ultrasonographic examination were compared in terms of efficacy in detecting and recognition of metastatic spread within lymphatic system of neck. The final assessment was based on results of intraoperative exploration and histological examination. Results indicate that ultrasonographic evaluation is more efficient in recognition of metastases to nodes of neck then physical examination based on palpation. The authors concluded that ultrasonography as a simple and available method can be effective in detection of metastases of ca larynx to lymphatic system of neck.

Adult↗

[Clinical-epidemiological analysis of 159 children with cryptorchidism].

OBJECTIVE: To determine the epidemiological and clinical characteristics of children with Cryptorchidism in our milieu. DESIGN: Crossover study. SETTING: Specialist care. PATIENTS: 159 children referred from Primary Care for a Cryptorchidism study. MEASUREMENTS AND RESULTS: Average age of detection: 1.5-3 years. Laterality: 120 unilateral (73 right and 47 left) and 39 bilateral. Family history of Cryptorchidism in 33 cases (20.7%). 68 children (42.7%) had some anatomical malformation associated with poor testicular descent. This percentage was significantly higher in children with bilateral Cryptorchidism than with unilateral (61.5% vs 36.6%; p < 0.05). Nine children defined with multiple malformation syndromes. Location of the testes after palpation: 29.3% not able to be palpated, 22.7% high inguinal, 23.2% low inguinal, 17.1% sliding, 5% retractile and 2.5% scrotal. All cases showed normal in the hormonal study, except one case of Hypogonadotropic Hypogonadism. CONCLUSIONS: The diagnoses of Cryptorchidism were not early. Family history and associated malformations in the body himself often exist. Hormonal levels are normal. Echography is of little use in locating testes that cannot be palpated.

Abnormalities, Multiple↗

Laryngeal mobility and dysphagia.

The authors studied the utility of the physical test of laryngeal movement in swallowing disorders of the oropharyngeal region. Measurement and palpation of the larynx during deglutition were performed in the neck of 14 dysphagic patients and in two normal control groups. The normal groups were used to establish the pattern of the movement and the normal values of laryngeal elevation. Control elevation ranged from 1.80 to 2.50 cm. In eight patients laryngeal motion was defective and presented values ranging from zero to 1.50 cm. Palpation during laryngeal movement also revealed unexpected anomalous displacement such as lateral shifting and lowering of the larynx. In six patients with defective laryngeal motion, pharyngeal and upper esophageal sphincter function were also impaired. Direct measurement and palpation of laryngeal mobility during deglutition is a noninvasive method that can be used to evaluate dysphagia and the risk for aspiration. Also, it allows physical assessment of the evolution of the disorder.

Adult↗

[Functional state of the masticatory system in healthy individuals (control group) and in patients with temporomandibular joint disorders].

The functional status of the masticatory system was investigated in a sample of 68 self-defined controls without any treatment need and 82 craniomandibular disorder patients. Among the parameters investigated were measures of mandibular mobility, the presence of joint noises and palpation tenderness of 17 muscle and 3 TMJ sites. These data allowed for calculation of Fricton's Craniomandibular Index (CMI) and Helkimo's Clinical Dysfunction Index (Di). Several socalled signs of dysfunction were found in the normal control group: 38% of the joints had some kind of noise and several muscle sites were tender to palpation (splenius capitis muscle 50%, anterior masseter and temporal muscle 45%, insertion of the trapezius muscle 40%). In addition, according to Helkimo's Di. 90% of the controls would be classified as having mild to moderate dysfunction. The high prevalence of positive signs in the control sample calls for a less rigid definition of what is called a normal craniomandibular status and refutes the a priori establishment of a narrow set of criteria for normality. Some parameters showed a highly statistically significant difference among the control and patient group (p < .001): active range of motion, deviation upon opening, pain on mandibular movement, number of tender palpation points and the CMI and Di.

Adult↗

Relationship between hind limb lameness and radiographic signs of bone spavin in Icelandic horses in Sweden.

A field study was designed to estimate the prevalence of hind limb lameness in a population of Icelandic horses in Sweden. All available Icelandic horses at 11 different farms within 150 km from Uppsala were examined once during a study period of 13 months. The relationship between hind limb lameness and radiographic signs of bone spavin (RSBS) was investigated. The rate of agreement between the outcome after palpation, motion evaluation and flexion test and radiographic examination was established. A total of 379 horses including 238 geldings, 125 mares and 16 stallions, with mean age 8.1 years (range 1-19 years) were examined by palpation of the medial aspect of the tarsal joints, motion evaluation and flexion test of the hind limbs. One dorsolateral-plantaromedial oblique radiographic view was recorded from each tarsus. Palpable abnormalities were found in 118 horses (31%). Forty-three horses (12%) were lame at presentation, 94 horses (25%) were positive on flexion test and 88 horses (23%) had RSBS. There was a significant relationship between palpable abnormalities, lameness, positive flexion test and RSBS. The proportion of joints with RSBS increased with increasing severity of physical findings. The proportion of lame limbs increased with increasing radiographic changes. The presence of palpable findings or positive flexion test was not influenced by the grading of radiographic changes. Using palpation, motion evaluation, and flexion test 75% of the horses with RSBS were identified. The rate of agreement between the clinical examination and the radiographic examination was 73%.

Age Factors↗

Decreased pain detection and tolerance thresholds in chronic tension-type headache.

OBJECTIVE: To study nociceptive processing in patients with chronic tension-type headache. METHODS: Forty patients with chronic tension-type headache and 40 healthy controls were examined. Pericranial tenderness was recorded by manual palpation, pressure pain detection and tolerance thresholds were recorded with an electronic pressure algometer, and the relative (pain detection minus sensory detection) electrical pain threshold was recorded with a constant current stimulator. RESULTS: Patients were considerably more tender than controls at all the locations examined by manual palpation (P<.001). Pressure pain detection and tolerance thresholds recorded in the finger were significantly lower in patients than in controls (P<.001). A nonsignificant similar trend was observed in the temple (P < or =.12). Detection and tolerance thresholds were decreased to a similar degree in patients compared with controls, and pain thresholds recorded in the finger and in the temple were highly correlated (r=.84, P<.001). The relative electrical pain threshold recorded at the labial commissure was significantly decreased in patients compared with controls (P=.03). All of the examined pain thresholds were significantly correlated to the pericranial tenderness recorded by palpation (r=-.35 to -.53, P < or = .03). CONCLUSION: The present finding of a general hypersensitivity to pain stimuli in chronic tension-type headache indicates that central factors play an important role in the pathogenesis of this disorder.

Adult↗

Intraoperative ultrasound and preoperative localization detects all occult insulinomas; discussion 1025-6.

HYPOTHESIS: Preoperative invasive localization procedures with intraoperative ultrasound (IOUS) can result in successful surgical treatment of occult insulinomas when noninvasive imaging study results are equivocal or negative. DESIGN: Prospective study. SETTING: Tertiary care university hospital. PATIENTS: Thirty-seven consecutive patients with a biochemical diagnosis of insulinoma without multiple endocrine neoplasia (MEN). INTERVENTION: All patients underwent portal venous sampling (PVS) (n = 22) or calcium angiogram (n = 15) followed by surgery with palpation and IOUS (n = 37). MAIN OUTCOME MEASURE: Portal venous sampling, calcium angiogram, palpation, and IOUS were compared for accurate localization of insulinoma. RESULTS: All patients were cured of hypoglycemia after surgery. Portal venous sampling correctly localized tumors in 17 (77%) of 22 patients. Calcium angiogram was correct in 13 (87%) of 15 patients. Palpation identified 24 (65%) of 37 tumors, and IOUS found 35 (95%) of 37 tumors. The 2 tumors missed by IOUS were located in the tail of the pancreas and were resected based on regional localization alone. CONCLUSIONS: Intraoperative ultrasound is the single best localization study, but it will miss some tumors that regional localization can identify. Combining both modalities allowed surgical cure of all insulinomas in our study. Therefore, we recommend both IOUS and regional localization for insulinoma when preoperative imaging studies are equivocal.

Adult↗

Pancreatic insulinomas. A 15-year experience.

OBJECTIVE: To describe our experience in the management of patients with pancreatic insulinomas, emphasizing the need for preoperative localization and the outcome of surgical treatment. DESIGN: A case series. SETTING: A university hospital in Hong Kong. PATIENTS: From 1981 to 1995, 27 patients with pancreatic insulinomas were surgically treated; the mean follow-up was 25.4 months. MAIN OUTCOME MEASURES: Postoperative morbidity and euglycemia during the follow-up period. RESULTS: The accuracy of tumor localization by ultrasonography, computed tomography, and angiography was 33%, 44%, and 52%, respectively. Venous sampling for an insulin assay regionalized 90% of the tumors. In 24 patients with solitary tumors, most lesions detected or missed by preoperative localization could be either seen (n = 14) or palpated (n = 22). Intraoperative ultrasonography (n = 17) has been routinely performed since 1987; nonpalpable tumors were imaged in 2 of 15 patients with solitary tumors. Eight solitary occult tumors were detected by palpation alone or a combination of palpation and intraoperative ultrasonography. Operative mortality occurred in 1 (3.7%) of the 27 patients, while major morbidity developed in 9 (33%) of the patients. Euglycemia was achieved in 25 patients. Surgery cured all patients with benign insulinomas, whereas the cure rate for patients with malignant neoplasms was only 33%. The type of surgical treatment or correct preoperative localization did not affect the outcome of surgery. CONCLUSIONS: Pancreatic insulinomas can be readily localized intraoperatively despite failed preoperative localization studies. Surgical treatment cured benign adenomas but was associated with notable morbidity.

Adolescent↗

Method of tumor detection influences disease-free survival of women with breast carcinoma.

BACKGROUND: Screening mammography provides the primary means of reducing breast cancer mortality. Clinical breast examination (CBE) and breast self-examination (BSE) may be complementary screening modalities enabling palpation of interval cancers and detection of tumors not visualized by mammography; however, their combined contribution to improving prognosis has not been evaluated adequately. METHODS: Disease-free survival was assessed in relation to method of tumor detection among 729 consecutive patients treated by mastectomy and axillary dissection for primary breast carcinoma between 1976 and 1978. RESULTS: Disease-free survival at 10 years was significantly higher after detection by mammography (77% of 30 patients) or CBE (78% of 101 patients) compared to self-detection (64%). The hazard ratio of recurrence associated with clinical examination or mammography in contrast to self-detection was significantly reduced to 0.55 (95% CI, 0.37-0.81; P = 0.001). In addition, annual CBE, compared to less frequent clinical palpation, reduced the risk of recurrence controlling for detection modality (P = .03). In multivariate analyses, the method of detection and frequency of clinical breast examination remained statistically significant prognostic factors after controlling for number of screening mammograms, history of prior breast surgery, family history of breast cancer, and age at diagnosis. Differences in self-examination frequency were not associated with prognosis. CONCLUSIONS: Among patients diagnosed before widespread mammography screening, tumor detection by CBE was associated with a significant reduction in recurrence compared with detection by self-palpation. Improvement in the frequency and quality of CBE and BSE may enhance the contribution of these modalities to early detection, complementing the role of screening mammography in reducing breast cancer mortality rates.

Adult↗

Diagnostic value of radiological breast imaging in a non-screening population.

The aim of this study was to assess the diagnostic performance of breast imaging in the diagnosis of breast cancer in a non-screening population. In a consecutive set of patients referred for mammography in one year, the results of palpation and radiological breast imaging were scored on a 5-point grading scale and linked to pathology as gold standard after a follow up period of one year. The diagnostic performance was studied by logistic regression analysis and ROC-curves. There were 1,944 breast examinations in 1,890 patients and 3,816 breasts. Pathology results reported 118 malignancies in 115 women. With a cut-off point between benign and uncertain benign a sensitivity of 89% and a specificity of 98% was found for radiological imaging. ROC-curves showed a significant increase in diagnostic performance when radiology was added to results of palpation and age (p = 0.007). Radiological imaging tests have a large diagnostic value in the detection of breast cancer in addition to palpation and age. A sensitivity close to 100% could be reached.

Adolescent↗

Intraoperative ultrasonography in the diagnosis of hepatic metastases during surgery for colorectal cancer.

Approximately 20-25% of colorectal cancers have hepatic metastases at the time of operation and occult liver secondaries appear in 10-30% of curatively operated cases. Intraoperative liver ultrasonography has been reported to be the most accurate method for detecting colorectal metastases. A consecutive series of 119 colorectal cancer patients was studied by routine extracorporeal preoperative ultrasound (EUS), inspection and palpation of the liver at laparotomy and intraoperative liver ultrasound (IUS). 19 patients had liver metastases at the time of surgery. In eight, diagnosis was by EUS. Inspection and palpation yielded a further seven, and IUS alone a further four. Additional lesions were detected in 3 patients after preoperative ultrasound and in 6 patients following intraoperative palpation of the liver. In a further 4 cases IUS demonstrated additional metastases. Follow up for a median 38 months (12-59) was by clinical examination and six monthly liver ultrasound. During this time 8 patients, who were thought to have a clear liver, developed hepatic metastases. The mean time from surgery to the detection of occult hepatic metastases was 14.7 (8-26) months and 4 of these appeared in the second year. Intraoperative ultrasonography is a sensitive and useful method in detecting liver metastases, and may improve clinical staging and the selection of patients for further therapy. However some occult hepatic metastases will remain undetected.

Adult↗

Relative effectiveness of methods of breast self-examination.

This study investigated the effectiveness of different methods of breast self-examination (BSE) on coverage of breast area and lump detection, using a factorial design, pairing three search patterns (concentric circle, radial spoke, vertical strip) with two finger palpation techniques (small circular movements, sliding movements). Ninety-seven female undergraduates were randomly assigned to one of six BSE training conditions which were identical except in the BSE search pattern and finger palpation technique explained by the instructor. Following the 20-min, small-group training, subjects' coverage of breast area was assessed by scoring their BSE performance on a breast board. Lump detection was determined by the number of lumps correctly identified in silicone breast models. Results indicated that the vertical strip pattern was associated with significantly greater coverage of the breast area. There were no significant differences in lump detection; however, the sliding finger palpation technique resulted in significantly more false identifications of lumps.

Breast Neoplasms↗

Preoperative estimation of the size of prostatic adenomas.

In a retrospective study the postoperative weight of one hundred prostatic adenomas was compared with the preoperative estimated size, based on rectal digital palpation. As a basis for the choice between transurethral and transvesical resection the adenomas were classified by digital palpation in three weight groups: less than 20 g. 20--40 g and more than 40 g. The objective was to avoid transvesical resection in small adenomas and transurethral resection in large ones, weighing more than 40 g. No adenomas weighing less than 20 g were removed transvesically. About one fourth of the adenomas removed transurethrally weighed more than 40 g. Forty-five per cent of the adenomas were placed erroneously into the 20 g group. Rectal digital palpation is a very unreliable method of assessing prostatic size, however, very small adenomas can be identified. Urethrocystoscopy can be of aid in identifying the very large ones.

Adenoma↗

Diagnosis of liver metastases from malignant gastrointestinal neoplasms: results of pre- and intraoperative ultrasound examinations.

In this prospective study, 108 patients presenting with gastrointestinal cancer were examined for liver metastasis before and during surgery. The investigations emphasized a comparison of pre- and intraoperative ultrasound (US) examinations. The results of intraoperative liver inspection and palpation served as control parameters. In addition, an exact description and characterization of the liver metastases was attempted. Liver metastases were found in 30 of the 108 patients (28%). They could be identified in 17 subjects by preoperative US (57% sensitivity), in 21 patients by intraoperative palpation and inspection (70% sensitivity), and in 27 cases by intraoperative US (90% sensitivity). We concluded that 7%-34% of patients with liver metastases can be identified with 95% reliability using intraoperative US alone or in combination with palpation and inspection.

Colorectal Neoplasms↗

Low environmental selenium availability as an additional determinant for goiter in East Java, Indonesia?

Iodine deficiency, which is most visibly indicated by goiter, is highly prevalent in Indonesia. Since 1994, Indonesia has a decree that all salt used for human, livestock, and industry must be iodized. However, despite the increased distribution of iodized salt, pockets with significantly higher prevalence of goiter still remain. This situation may be consequence of selenium (Se) deficiency. This study aimed to assess the Se level in the environment of goiter prevalent areas. Five hundred eleven school children participated in this study. Goiter was measured using both ultrasound and palpation. Ninety-nine eggs were collected from free-living chicken in 11 villages, and the Se contents of egg yolk and egg white were determined by neutron activation analysis. In the villages studied, Se concentration in egg yolk ranged from 0.15 to 1.52 microg/g and in egg white from 0.18 to 2.97 microg/g. The prevalence of goiter measured by palpation ranged from 18.4% to 70% and by ultrasound from 0% to 100%. Because of the inconsistency of goiter rate measured by palpation and ultrasonography, the question remains whether low availability of Se in the environment might be an additional contributing factor for goiter.

Child↗

The impact of a clinical guideline on imaging children with hypertrophic pyloric stenosis.

PURPOSE: The purpose of the study was to evaluate the impact of a clinical pathway on the volume of imaging studies performed in children with suspected clinical diagnosis of hypertrophic pyloric stenosis. The pathway suggested referral to surgeons for clinical evaluation for palpation of the olive prior to ordering imaging studies. Only those children in whom the olive could not be palpated would be referred for imaging, and it was anticipated that imaging volume would be reduced following guideline implementation. MATERIALS AND METHODS: The database of the Health Policy and Clinical Effectiveness Department was used to evaluate all patients who had surgery for hypertrophic pyloric stenosis. The presence of a palpable olive and the type of imaging were evaluated both prior to and after the implementation of the clinical guideline. RESULTS: Prior to the guideline, 85 infants had surgery for pyloric stenosis, with 83 of the 85 (97%) having imaging. After the implementation of the guideline, 90 infants had surgery for pyloric stenosis with 84 of 90 patients imaged (92%). A chi-square analysis demonstrated no significant difference in the percentage of children imaged in the two groups (P = 0.104). Approximately one in five children referred for vomiting were diagnosed with hypertrophic pyloric stenosis. CONCLUSION: No significant change in imaging volume occurred following initiation of a guideline which recommended clinical evaluation for palpation of the olive prior to ordering imaging studies. Multiple factors probably contributed to the lack of demonstrated changes.

Critical Pathways↗