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PubMed1999

The value of ultrasound examination in preoperative neck assessment and in early diagnosis of nodal recurrences in the follow-up of patients operated for laryngeal cancer.

The purpose of this study was to prove the superiority of ultrasound (US) examination of the neck in comparison to palpation, to reveal unpalpable nodes (pN0) before surgery, and to allow for the early detection of nodal recurrences in patients with laryngeal cancers. In all, 1,120 patients with laryngeal cancers were operated on between 1990 and 1997. All underwent palpation and neck US before surgery. In the pN0 group US revealed enlarged lymph nodes in 261/505 cases, of which 63 (24.14%) were confirmed as metastatic by histology. All 1,120 patients underwent regular postoperative US follow-up. Nearly 5,000 US examinations were performed; 136 patients who developed nodal recurrences had surgical salvage procedures. In this group 61 patients had small, nonpalpable lesions, and 46 patients discrete and slight changes in scarred necks. In this latter group of 117 patients with nonpalpable lesions, 105 cases were histologically confirmed as metastatic. In postoperative check-ups, metastases were suspected in sonographically detected subclinical nodes, but the US scans obtained were difficult to interpret. In these cases, because of the dynamics of lesion changes, US was repeated two to three times at 10- to 14-day intervals. This reappraisal enabled us to exclude malignancy in regressing nodes, as well as to obtain the stable picture of scar, and support a diagnosis while the lesion grew larger or a central area of low attenuation or hypoechogenic echos appeared in the nodal capsule. Successful radical reoperation for tumor was done on110 patients; 78 patients underwent successful salvage surgery after an early US diagnosis. The sonographic-surgical correlation was nearly 95% and the sonographic-histological correlation was 90%. The follow-up period was 1-49 months. In all preoperative assessments US was found to be a valuable tool in the staging of laryngeal cancer and planning the extent of surgery. Close follow-up with US after radiotherapy and initial operation was essential for the early detection of tumor recurrences, making surgical salvage still feasible.

Follow-Up Studies↗
PubMed2006

[Referred pain from amputation stump trigger points into the phantom limb].

OBJECTIVES: The aim of the study was to examine whether/how myofascial stump trigger points (TPs) after lower leg amputations are able to produce stump pain (SP), phantom pain (PP), and sensations (PS) in the phantom limb. METHODS: Palpation of the 5 most striking stump TPs of 30 leg amputees (12 transfemoral, 18 transtibial) was documented in a standardized manner. Patients were asked to localize SP, PP, and PS. RESULTS: Of 150 TPs, 14 produced involuntary stump movements and 10 stump fasciculations. Dorsal PP after ventral TP palpation occurred as well as PP in the toes from TPs near the hip. Of 30 patients, 20 reported PS and 8 PP; 60 of 150 TPs produced PS and 17 PP. Phantom phenomena were localized in 62.8% in the toes (1st toe 19.8%, toes 2-5 about 10% each), 17.9% midfoot, and the rest were more proximal. TPs were localized more in the lateral/dorsal stump than medial/ventral. About 70% of the TPs were found between 3 and 7 cm from the stump end, those with toe projections more distal than those with tibial projections. CONCLUSIONS: Myofascial TPs in amputation stumps are common and able to produce sensations and pain in the phantom limb. Most reported experiences were localized in the toes, as phantom pain usually is. There seems to be a "stump representation" and it seems possible that "referred TP pain" and "phantom pain" may develop from similar origin.

Humans↗
PubMed2006

Positive predictive value of breast fine needle aspiration cytology (FNAC) in combination with clinical and imaging findings: a series of 2334 subjects with abnormal cytology.

We calculate the positive predictive value (PPV) of abnormal (C3-5) FNAC, alone and in combination with clinical and imaging findings, based on a consecutive series of 2,334 subjects. The PPV of a C3, C4 or C5 report is 55.0%, 95.9% and 99.4%, respectively. C5 Cytology is highly predictive of malignancy (PPV=99.4-99.7%) except where imaging is negative or benign. When C4 cytology is associated with suspicious findings on imaging and/or palpation, its PPV increases to 98.5-98.7%. C3 is the least predictive of malignancy and even when associated with suspicious findings on imaging and/or palpation its PPV is 83.3% - C3 FNAC should therefore prompt pre-operative core biopsy. These data indicate that FNAB is still a useful test in breast diagnosis, and it may assist clinical decision-making as far as whether patients should progress to surgical management or should have further core biopsy before planning surgery.

Biopsy, Fine-Needle↗
PubMed1991

Accuracy of precordial percussion in detecting cardiomegaly.

STUDY OBJECTIVE: To assess the value of precordial percussion in detecting cardiomegaly, and to compare it with palpation of the apical impulse. DESIGN: Descriptive study. SETTING: Hospitals and clinics of a university medical center. PATIENTS: Light indirect percussion of the precordium was performed on 72 inpatients and 28 outpatients. All patients had a posteroanterior radiograph of the chest. Percussors were unaware of the clinical history and of chest roentgenogram results. MEASUREMENTS AND MAIN RESULTS: Thirty-six patients (36%) had cardiomegaly, defined as a cardiothoracic ratio of greater than 0.5 on chest roentgenogram. The cardiothoracic ratio was significantly correlated with percussion distance from the midsternal line in the left fourth (r = 0.35, p less than 0.0006), fifth (r = 0.65, p less than 0.00001), and sixth (r = 0.40, p less than 0.0001) intercostal spaces. After adjustment for clinical symptoms and systolic and diastolic blood pressures, percussion distance in the left fifth intercostal space remained a significant independent predictor of the cardiothoracic ratio. Percussion distance in the left fifth interspace discriminated cardiomegaly with a receiver-operating characteristic (ROC) area of 0.95. Percussion dullness more than 10.5 cm from the midsternal line in the left fifth interspace had a sensitivity of 94.4% (95% confidence interval [CI], 79.9% to 99.0%) and a specificity of 67.2% (CI, 54.2% to 78.1%). Distance of the apical impulse from the midsternal line discriminated with an ROC area of 0.95, but an impulse was palpated in only 40% of cases. CONCLUSIONS: Percussion in the left fifth intercostal space accurately discriminates patients with and without cardiomegaly, and adds information beyond that obtainable from the history and other parts of the physical examination.

Adolescent↗
PubMed1992

Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch.

Stroke is an especially serious complication of cardiopulmonary bypass with an incidence of 2% to 5%. This prospective study used transesophageal echocardiography (TEE) in 97 patients more than 65 years of age (mean age, 73 years) to identify those at high risk for aortic atheroemboli. The atheromatous disease of the aorta was graded by TEE: grade I = minimal intimal thickening (n = 29); II = extensive intimal thickening (n = 33); III = sessile atheroma (n = 15); IV = protruding atheroma (n = 10); V = mobile atheroma (n = 10). Clinical evaluation was also performed by intraoperative aortic palpation. Four patients who were graded as having normal aortas by palpation had intraoperative strokes. In contrast, 3 of these 4 patients were in grade V on TEE. The relationship of TEE to incidence of stroke was statistically significant (p less than 0.006), whereas there was no significant correlation between clinical grade and stroke incidence. Four of 10 TEE grade V patients were treated with hypothermic circulatory arrest and aortic arch debridement, and none suffered strokes. The other 6 patients were treated with standard techniques, and 3 had strokes. These results suggest that patients with mobile atheromatous disease are at high risk for embolic strokes that are not predicted by routine clinical evaluation. Selective use of circulatory arrest in the presence of TEE-detected mobile arch atheromas may reduce the risk of intraoperative stroke.

Aged↗
PubMed1989

Cost effectiveness of ambulatory uterine activity monitoring.

A cost analysis is presented comparing 34 patients who received uterine activity monitoring versus 33 patients who attempted to detect uterine activity by palpation. All patients were at high risk for preterm delivery and were given the same educational information and prenatal care regarding signs and symptoms of preterm labor. The results revealed an increase in newborn days (640) and cost to those patients who were in the self-palpation group ($13,364) compared to monitored parturients (268 days and $8,633). The difference was attributed to neonatal morbidity from an increased number of preterm deliveries greater than 26 weeks but less than 37 weeks (P = 0.04). The increase in NICU days was significant (P = 0.03). No difference in normal newborn costs for infants delivered after greater than 33 weeks could be detected between the two groups, but morbidity was increased among control infants delivering between 34 and 36 weeks. Uterine activity monitoring to prevent preterm birth appears to be medically effective and reduces cost.

Cost-Benefit Analysis↗
PubMed1990

Assessing clinical signs of temporomandibular disorders: reliability of clinical examiners.

Data on interrater reliability in assessing a number of clinical signs commonly evaluated in the diagnosis and treatment of temporomandibular disorders (TMD) is presented in this article. Four experienced dental hygienists who were field examiners for a large epidemiologic study of TMD and three experienced clinical TMD specialists (dentists) who are coinvestigators in the same study followed carefully detailed specifications and criteria for examination of TMD patients and pain-free controls. Excellent reliability was found for vertical range of motion measures and for summary indices measuring the overall presence of a clinical sign that could arise from several sources (for example, summary indices of muscle palpation pain). However, many clinical signs important in the differential diagnosis of subtypes of TMD were not measured with high reliability. In particular, assessment of pain in response to muscle palpation and identification of specific temporomandibular joint sounds seemed to be possible only with modest, sometimes marginal, reliability. These modest reliabilities could arise from examiner error because the clinical signs are themselves unreliable, changing spontaneously over time and making it difficult to find the same sign on successive examinations. The finding that, without calibration, experienced clinicians showed low reliability with other clinicians suggests the importance of establishing reliable clinical standards for the examination and diagnostic classification of TMD.

Adult↗
PubMed1991

Diagnostic tests used in determining the role of the occlusion in temporomandibular joint disorders.

Two diagnostic tests, positive tenderness to palpation of the inferior bellies of the lateral pterygoid muscles and a positive stress test, are helpful in determining whether the dental occlusion is a principal etiologic factor in ischemic pain in the muscles of mastication. To avoid a noxious occlusal contact, the muscles of mastication, and particularly the lateral pterygoid muscles, must increase their activity. The ability of the patient to supply the oxygen for this activity is variable. When it is inadequate, to relieve ischemic pain the muscular activity must be decreased or the oxygen supply increased. The dentist has the option of using four modalities for the treatment of these painful muscles: physiotherapy, drug therapy, psychotherapy, and occlusal therapy. When the lateral pterygoid muscles are not tender to palpation and the stress test is negative, occlusal therapy is not indicated.

Dental Occlusion, Traumatic↗
PubMed1989

Determination of prostatic volume by ultrasonography. A useful procedure in patients with prostatism?

Digital palpation is rather unreliable for estimating the volume of the prostate. Ultrasonographic measurements have been advocated as a more appropriate method. We examined 47 patients ultrasonographically. Of these, 34 underwent a transurethral resection of the prostate (TURP) (ultrasonographic volume 29 patients: prostate less than 60 cm3, 5 patients with cardiovascular problems: prostate greater than 60 cm3) and 13 an open prostatectomy according to Hryntschak (prostate greater than 60 cm3). In all patients ultrasonically determined volumes were compared with the operatively removed volume of prostatic tissue. If the size of the prostate had been estimated by digital palpation only, 12 patients would have undergone the wrong procedure (TURP instead of Hryntschack procedure). Ultrasonographic calculation of the prostatic volume demonstrated that all of these patients could be treated with less risk. After resection or abdominal prostatectomy some prostatic tissue remains. We concluded that there is no clear difference in the incidence of secondary prostatic obstruction (in need of re-TURP) either after abdominal prostatectomy or after TURP.

Adult↗
PubMed1993

Tumor promotion in a breast cancer model by exposure to a weak alternating magnetic field.

In view of the methodological problems of epidemiological studies on associations between exposures to 50/60 Hz magnetic fields (MF) and increased incidence of cancers, laboratory studies are necessary to determine if 50/60 Hz MF are cancer promoters or can progress cancers. The objective of the present study was to determine if an alternating MF of low flux density exerts tumor-promoting or co-promoting effects in a model of breast cancer in female rats. Mammary tumors were induced by the chemical carcinogen 7,12-dimethylbenz(a)anthracene (DMBA). A group of 99 rats was exposed to a homogeneous MF of 50 Hz, 100 microT (microtesla), for 24 h/day 7 day/week for a period of 91 days; another group of 99 rats was sham-exposed under the same environmental conditions as the MF-exposed rats. The exposure chambers were identical for MF-exposed and sham-exposed animals. DMBA was administered orally at a dose of 5 mg/kg at the first day of exposure and at weekly intervals thereafter up to a total dose of 20 mg per rat. The animals were palpated once weekly to assess the development of mammary tumors. In controls, DMBA induced tumors in about 40% of the animals within three months of first application. Eight weeks after DMBA application the MF-exposed rats exhibited significantly more tumors than sham-exposed animals. This difference in the rate of tumor development was observed throughout the period of exposure. At the end of the three-month period of MF exposure the tumor incidence in MF-exposed rats was 50% higher than in sham-exposed rats, the difference being statistically significant. Furthermore, the size of tumors as estimated by palpation was significantly larger in the MF-exposed compared to sham-exposed rats. The data demonstrates that long-term exposure of DMBA-treated female rats to an alternating MF of low flux density promotes the growth and increases the incidence of mammary tumors, thus strongly indicating that MF exposure exerts tumor-promoting and/or copromoting effects.

9,10-Dimethyl-1,2-benzanthracene↗
PubMed1994

Somatization and pain dispersion in chronic temporomandibular disorder pain.

We investigated the relationship between somatic and psychological symptoms and pain reported during a clinical examination for 220 patients with chronic temporomandibular disorder (TMD) pain. The clinical examination involved palpation of the muscles of the face and neck, as well as intraoral sites and non-TMD-related placebo sites. A distinction was drawn between somatization--the tendency to report numerous somatic symptoms--and psychological distress manifested by report of numerous affective and cognitive symptoms. Somatization was assessed with the Somatization scale of the SCL-90-R; cognitive/affective distress was assessed with the non-somatic items of the Anxiety and Depression scales. Heightened somatization and high-intensity pain were strong predictors of widely dispersed muscle palpation pain during the clinical examination. High-somatization patients were 3 times more likely than low-somatization subjects to report having a painful placebo site. Pain dispersion was more closely linked to report of number of somatic symptoms than to report of affective and cognitive symptoms of psychological distress.

Adolescent↗
PubMedDate not supplied

Qualitatively altered nociception in chronic myofascial pain.

The aim of the present study was to investigate the stimulus-response function for pressure versus pain in patients with myofascial pain. Forty patients with chronic tension-type headache and 40 healthy controls were examined. Tenderness in 8 pericranial muscles and tendon insertions was evaluated by manual palpation with a standardized evaluated methodology. Thereafter, a highly tender muscle and a largely normal muscle were palpated with 7 different pressure intensities using a palpometer, and the induced pain was recorded by the subjects on a visual analogue scale blinded for the observer. Pericranial myofascial tenderness was considerably higher in patients than in controls (P < 0.00001). The stimulus-response function recorded from normal muscle was well described by a power function. From highly tender muscle, the stimulus-response function was displaced towards lower pressures and, more importantly, it was linear, i.e., qualitatively different from normal muscle. Our results demonstrate for the first time that nociceptive processes are qualitatively altered in patients with chronic myofascial pain and suggest that myofascial pain may be mediated by low-threshold mechanosensitive afferents projecting to sensitized dorsal horn neurons. Further investigations of these mechanisms may lead to an increased understanding and better treatment of these common and often incapacitation pain disorders.

Adolescent↗
PubMed2005

Quasi-linear viscoelastic properties of fibrotic neck tissues obtained from ultrasound indentation tests in vivo.

BACKGROUND: Hand palpation is a conventional way to assess and document soft tissue fibrosis. But it is semi-quantitative and subjective, so there is a need to develop quantitative and objective methods for this purpose. METHODS: 105 patients with different degrees of radiation-induced fibrosis of soft tissue of the neck were assessed using an ultrasound indentation method. The force response was reconstructed from the indentation history using a quasi-linear viscoelastic model with four material parameters. The parameters which best curve-fitted the force response with respect to the experimentally measured one, were selected as the viscoelastic properties of the tested soft tissue. These parameters were compared among patient subgroups with different degrees of fibrosis as scored by hand palpation, and also compared with those of a control group of healthy, non-irradiated subjects. Their relation to the rotation range of the neck and the effective Young's modulus, were also assessed. FINDINGS: Soft tissue with a more severe degree of fibrosis was associated with a larger initial stiffness and a more rapid increase in stiffness under loading. Viscoelasticity parameters could discriminate soft tissue with different degrees of clinical fibrosis and had significant correlation with clinical parameters of fibrosis. INTERPRETATION: Change of viscoelastic properties is reflection of pathological modifications of components in fibrotic soft tissues. Measurement of viscoelasticity parameters of soft tissue provides a quantitative and objective approach for the researcher and clinician to quantify soft tissue fibrosis. RELEVANCE: Measurement of the change of viscoelastic properties of soft tissue provides a quantitative and objective approach for researchers and clinicians to quantify soft tissue fibrosis which is one of the most common late effects of radiotherapy.

Adult↗
PubMed2005

Interaction model between elastic objects for haptic feedback considering collisions of soft tissue.

The simulation of organ-organ interaction is indispensable for practical and advanced medical VR simulator such as open surgery and indirect palpation. This paper describes a method to represent real-time interaction between elastic objects for accurate force feedback in medical VR simulation. The proposed model defines boundary deformation of colliding elements based on temporary surface forces calculated by temporary deformation. The model produces accurate deformation and force feedback considering collisions of objects as well as prevents unrealistic overlap of objects. A prototype simulator of rectal palpation is constructed on general desktop PC with a haptic device, PHANToM. The system allows users to feel different stiffness of a rear elastic object located behind another elastic object. The results of experiments confirmed the method expresses organ-organ interaction in real-time and produces realistic and perceivable force feedback.

Computer Simulation↗
PubMed2005

Extracephalic tenderness and pressure pain threshold in children with headache.

BACKGROUND: Sensitisation of the pain detection system has been suggested to be involved in the pathogenesis of recurrent headache. In adults, increased sensitivity to pain has been found in patients with chronic tension type headache. Children with migraine or with unspecific headache report non-headache pains and interictal pericranial muscular tenderness more often than headache-free children. OBJECTIVE: To study if children with different types of headache report non-headache pain more often than children with no headache and if extracephalic muscular tenderness is different in children with headache in comparison to headache-free children. To find out if interval to the headache episode has influence on the extracranial muscular tenderness. DESIGN: A population-based sample of 13-year-old children with migraine (n=48), episodic tension type headache (61) or no headache (59) were interviewed for the occurrence and characteristics of headache and fulfilled a questionnaire on non-headache pain. A structured manual palpation test on muscular tenderness and a pain threshold measurement were done on seven cephalic and three extracephalic points. RESULTS: Children with migraine reported other pains, especially stomach pain and limb pain more often than children with episodic tension type or no headache. There were no significant differences in the extracephalic muscular tenderness or in the pressure pain thresholds between the three groups. CONCLUSIONS: Children with migraine experience more non-headache pains than children with episodic tension type headache and with no headache. However, neither children with migraine nor children with episodic tension type headache show increased interictal extracephalic muscular sensitivity for palpation.

Abdominal Pain↗
PubMed2006

Use of ultrasonography as a rescue technique for failed radial artery cannulation.

Radial artery cannulation may be unsuccessful in the most experienced of hands using the conventional palpation method. Repeated attempts may render the standard wrist site difficult to cannulate due to vasospasm, hematoma formation, or intimal dissection. Cannulation of other arterial sites may be difficult due to inaccessibility or more prone to adverse outcomes. The radial artery at a proximal location runs deep to the brachioradialis muscle and is difficult to palpate; however, it can be easily imaged using real-time ultrasonography. A needle-mounted cannula can then be advanced in the plane of the probe and the pulsating artery until the needle tip is within the artery. The cannula is advanced over the needle so that it lies within the arterial lumen. As the trajectory is in full view of the ultrasound probe, the technique has a very high success rate. We have used ultrasonography in over 30 cases as a rescue technique after unsuccessful attempts at radial artery cannulation. The technique is described here illustrated with 3 typical cases.

Adult↗
PubMed2006

Computed tomographic scan of the chest underestimates the number of metastatic lesions in osteosarcoma.

PURPOSE: Survival in osteosarcoma correlates with complete resection of primary and metastatic disease. The feasibility of complete pulmonary metastasectomy using thoracoscopy has been raised. Because palpation is not possible, minimally invasive techniques require preoperative radiological enumeration and localization of metastases not presenting at the lung surface. We hypothesized that computed tomographic (CT) scanning underestimated the number of pulmonary metastases in these patients. METHODS: Institutional review board approval was obtained. We determined the association between the number of lesions identified by CT scanning and the number of metastases found at thoracotomies for metastatic osteosarcoma from May 1996 to October 2004. Correlations between CT findings and pathology results were computed using the Kendall tau-b correlation coefficient. Depth, in millimeters, from the pleural surface was measured for those lesions seen on CT scan. RESULTS: We analyzed 54 consecutive thoracotomies performed in 28 patients for whom complete imaging was available. Computed tomographic scanning was performed a median of 20 days before thoracotomy (range, 1-85 days). Correlation between the number of lesions identified by CT and the number of metastases resected at surgery was poor, with a Kendall tau-b correlation coefficient of 0.45 (P < .001). In 19 (35%) of 54 thoracotomies, CT scanning underestimated the number of pathologically proven, viable and nonviable metastases found by the surgeon. Accounting for viable metastases only, correlation between the number of lesions identified by CT and the number of metastases resected at surgery was 0.50 (P < .001), and CT scanning underestimated the number of viable metastases present in 14 (26%) of 54 thoracotomies. Many lesions (32%) were pleural-based, but nearly half (47%) were 5 mm or deeper from the pleural surface of the lung. CONCLUSIONS: Even in the era of modern CT scanning, only a very rough correlation exists between CT findings and the number of lesions identified at thoracotomy. In more than one third of thoracotomies in our series, metastases would have been missed by any tactic besides manual palpation of the lung during open thoracotomy. Minimal access procedures should not be the approach of choice if the goal is resection of all pulmonary metastases in osteosarcoma.

Adolescent↗
PubMed2006

Accuracy of clinical assessment of infant heart rate in the delivery room.

Heart rate (HR) dictates intervention during neonatal resuscitation. Guidelines recommend that HR be assessed by auscultation or palpation. We compared HRs determined clinically with electrocardiography (ECG) in healthy newborns in the delivery room. Clinical assessment by 23 observers randomly allocated to assess HR by one of two methods in 26 infants, was found to be inaccurate and underestimate ECG HR. The mean difference between HR assessed by auscultation and palpation ECG and HR using methodology recommended by the Neonatal Resuscitation Programme was 14 and 22 beats per minute respectively.

Delivery Rooms↗