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Comparison of three methods for demonstration of thyroid enlargement in 92 patients showed that the sensitivity of sonographic volumetrics (93%) and palpation (91%) is superior to radiography (45%). Sonography has the disadvantage of lack of quantitative demonstration of retrosternal goitre. Palpation and chest radiograph had the disadvantage of a frequency of false positive findings in 8.7 and 10.9%.
BACKGROUND: Current assessments of cardiac rejection in murine transplant models rely on subjective estimates of the force of the palpable heart beat that have limited sensitivity and precision. METHODS: We used 2-dimensional echocardiography to evaluate changes in left ventricular posterior wall thickness (PWT) in a heterotopic cardiac mouse transplant model of rejection. Nine allografts and 6 isografts were imaged daily for 6 days and harvested. Thirteen allografts were imaged daily and harvested at day 3. RESULTS: Intraobserver variability on PWT was 0.003 +/- 0.09 mm, interobserver variability 0.09 +/- 0.11 mm. Allograft PWT increased after transplantation (0.74 +/- 0.02 mm to 1.28 +/- 0.05 mm at day 5, P <.0001). For isografts, PWT remained constant (0.73 +/- 0.03 mm to 0.85 +/- 0.01 mm) after an initial increase at day 1. Palpation failed to identify rejection at day 3 whereas PWT was already increased (1.15 +/- 0.02 mm in the allografts at day 3 vs 0.85 +/- 0.02 mm in the isografts, P <.0001). There was a relation between histologic score and PWT (P <.0001). CONCLUSION: Two-dimensional echocardiography allows the noninvasive detection and follow-up of cardiac rejection after transplantation. It eliminates the subjectivity of palpation and provides quantitative and reliable indices of rejection.
OBJECTIVE: To assess the intraexaminer and interexaminer reliability of a multidimensional spinal diagnostic method commonly used by chiropractors. DESIGN: An intraexaminer and interexaminer Latin square, repeated measures reliability study. The techniques of diagnosis under investigation included visual postural analysis, pain description by the patient, plain static erect x-ray film of the lumbar spine, leg length discrepancy, neurologic tests, motion palpation, static palpation, and orthopedic tests. PARTICIPANTS: Three experienced chiropractors examined 19 patients, and 2 experienced chiropractors examined 10 and 9 patients, respectively, who were suffering from chronic mechanical low-back pain. RESULTS: Intraexaminer reliability of the decision to manipulate a certain spinal segmental level was moderate (kappa = 0.47). The interexaminer agreement pooled across all spinal joints indicated fair agreement (kappa = 0.27). Interexaminer reliability for individual examiner pairs for the L4/L5 segmental level was slight (kappa = 0.09). At the L5/S1 level, the interexaminer reliability was fair (kappa = 0.25). For the sacroiliac joints, interexaminer reliability was slight (kappa = 0.04 and 0.14). CONCLUSION: This study of commonly used chiropractic diagnostic methods in patients with chronic mechanical low-back pain to detect manipulable lesions in the lower thoracic spine, lumbar spine, and the sacroiliac joints has revealed that the measures are not reproducible. The implementation of these examination techniques alone should not be seen by practitioners to provide reliable information concerning where to direct a manipulative procedure in patients with chronic mechanical low-back pain.
The aim of this study was to investigate the impact of temporomandibular joint (TMJ) pain on daily living in patients with rheumatoid arthritis (RA) involving the TMJ. Nineteen patients (17 F, 2 M) with a median (IQR) age of 44 (23) years were included. A scale for the influence of TMJ pain/discomfort on the activities of daily living was used. TMJ resting pain and pain upon maximum mouth opening according to a visual analog scale as well as pressure pain threshold and tenderness to digital palpation of the TMJ were assessed. Blood samples were collected to measure the level of acute phase proteins. Activities of daily living were influenced in all patients at different levels. The impact on daily living by TMJ pain/discomfort was greatest on the performance of physical exercises and jaw movements, while it was smallest on the performance of hobbies and eating. Pain during maximum mouth opening and tenderness to digital palpation were correlated to difficulties with several activities such as to yawn and open the mouth wide, while pressure pain threshold was correlated with difficulties during eating, which confirms that the pain was located in the TMJ. In conclusion, this study indicates that pain/discomfort from the TMJ in patients with RA has a significant negative impact on activities of daily living.
BACKGROUND: The transepicondylar axis is often used for positioning of the femoral component in knee replacement. METHODS: We studied the reproducibility of the intra-operative palpation of the transepicondylar axis for rotational alignment of the femoral component in 20 total knee replacement (TKR) implantations with a non-image-based navigation system. 2 surgeons defined the transepicondylar axis 3 times each without changing the reference plane. RESULTS: The angle between the reference plane and the transepicondylar axis was measured by the navigation system. The mean intra-observer ranges of variation were 5 degrees and 6 degrees for both surgeons, with a maximum of 15 degrees. The mean inter-observer range of variation was 9 degrees, with a maximum of 15 degrees. Variations occurred in either internal or external rotation. Intra-observer agreement was considered good for one surgeon and poor for the other. There was no agreement between the two observers. INTERPRETATION: To define the rotational alignment of the femoral component of a TKR according to the intra-operative palpation of the transepicondylar axis may not be as reproducible as expected. However, the exact effect of this variability on the outcome after TKR should be studied.
The loss of tactile sensation is a commonly known drawback of minimally invasive surgery (MIS). Since the advent of MIS, research activities in providing tactile information to the surgeon are still ongoing, in order to improve patient safety and to extend the indications for MIS. We have designed a tactile sensor system comprising a tactile laparoscopic grasper for surgical palpation. For this purpose, we developed a novel tactile sensor technology which allows the manufacturing of an integrated sensor array within an acceptable price range. The array was integrated into the jaws of a 10mm laparoscopic grasper. The tactile data are transferred wirelessly via Bluetooth and are presented visually to the surgeon. The goal was to be able to obtain information about the shape and consistency of tissue structures by gently compressing the tissue between the jaws of the tactile instrument and thus to be able to recognize and assess anatomical or pathological structures, even if they are hidden in the tissue. With a prototype of the tactile sensor system we have conducted bench-tests as well as in-vitro and in-vivo experiments. The system proved feasibility in an experimental environment, it was easy to use, and the novel tactile sensor array was applicable for both palpation and grasping manoeuvres with forces of up to 60N. The tactile data turned out to be a useful supplement to the minimal amount of haptic feedback that is provided by current endoscopic instruments and the endoscopic image under certain conditions.
The goal of this study was to assess the prevalence of iodine deficiency (ID) in Azerbaijan after the discontinuation of an iodine prophylaxis program by assessing the prevalence of goiter, iodine intake, and thyroid function. The study included 942 schoolchildren (475 boys and 467 girls) ages 8-14 years, from 13 distinct regions. The survey included the following: (1) clinical evaluation; (2) assessment of thyroid volume both by ultrasound and by palpation; (3) determination of iodide in a morning urine specimen using the classic Sandel-Kolthoff reaction in 347 schoolchildren; (4) determinations of thyrotropin (TSH), triiodothyronine (T3), thyroxine (T4), thyroglobulin (Tg), and anti-thyroid peroxidase (TPO) in serum (n = 165) and TSH in whole blood spotted on filter paper (n = 942). The prevalence of goiter for the whole country was determined by ultrasound (US) to be 86% and by palpation 66%, reaching 100% in the mountainous regions of Caucasus. The median urinary iodine excretion (UIE) was 54 microg/L, reaching level of 26 and 39 microg/L in the Caucasus region. In conclusion, according to the World Health Organization (WHO) classification, Azerbaijan now has mild to moderate ID (median UIE, 54 microg/L) and in the mountainous regions with severe ID. The high prevalence of goiter and the low UIE emphasizes the need for urgent medical reintervention. An iodination program is now implemented by our team in the mountainous regions under the auspice of the government of Azerbaijan.
BACKGROUND: The association between subtypes of mammographic findings and histopathological tumor extension in patients with ductal carcinoma in situ has remained unclear. The purpose of this study was to investigate the relationship between tumor extension on mammography, by stratifying four subtypes, and histopathological tumor size in patients with ductal carcinoma in situ. METHODS: This study was performed on 109 breasts with ductal carcinoma in situ. They were treated by mastectomy at our Hospital between January 1990 and December 1999. Findings on mammography were categorized as microcalcification type, spiculated type, circumscribed type or fibrocystic-change type. The microcalcification type consisted of breasts with malignant microcalcifications, regardless of the presence or absence of tumor shadow. We analyzed the relationship between tumor size on mammography in each category and histopathological tumor size. In the breasts with palpable tumors, we compared palpated tumor size and histopathological tumor size according to the mammographic subtypes. RESULTS: There was no statistical difference between mammographic tumor size and histopathological tumor size for each mammographic subtype (microcalcification type, P = 0.60; spiculated type, P = 0.72; circumscribed type, P = 0.055). The size of the ductal carcinoma in situ in microcalcification and spiculated type was estimated approximately by mammography. However, mammography tended to overestimate the circumscribed type. In the cases of palpable tumor, we statistically underestimated the size of ductal carcinoma in situ by palpation in microcalcification and fibrocystic-change type (microcalcification type, P = 0.0001; fibrocystic-change type, P = 0.040). CONCLUSION: Mammographic categorization is useful for surgical planning of ductal carcinoma in situ, particularly when considering breast-conserving surgery.
A new anthropometric landmark of the face, called the maxillozygion (mz; right, left) is presented. The bilateral landmark is the most prominent point of the maxillozygomatic suture line, identified by palpation of the most anterior protruding contours on the frontal aspect of the face, located below the lateral third of the right and left bony orbits. The reliability of locating the landmark on both sides of the face by palpation is discussed. Preliminary data determining the position of the maxillozygion in the vertical, sagittal, and horizontal planes in white and Asian sample populations is presented. In general, the Asian face tends to be the same width (zygion [zy]-zy) as the white face; however, the maxillozygion is located more laterally on the Asian face compared with the white face.
OBJECTIVE: This study determined, prospectively, whether duodenotomy (DX) should be routinely performed in explorations for patients with Zollinger-Ellison syndrome (ZES). SUMMARY BACKGROUND DATA: Duodenal gastrinomas are now being found with increasing frequency in patients with Zollinger-Ellison syndrome. The surgical approach used to detect these tumors is controversial. Some recommend intraoperative endoscopy with transillumination (IOE) at surgery, while others recommend routine DX. METHODS: Beginning in 1989, the authors prospectively compared the ability of palpation, intraoperative ultrasound (IOUS), IOE, and DX (in that sequence) to detect gastrinomas in 35 consecutive patients with ZES. Each patient also underwent preoperative localization studies. RESULTS: Thirty-three of 35 patients (94%) had tumor detected and excised; duodenal gastrinomas were excised in 27 patients (77%). The average size of the duodenal tumors was 0.8 cm, significantly smaller (p < 0.005) than the pancreatic and lymph node tumors in this series. Standard palpation after a Kocher maneuver identified 19 of the 31 duodenal tumors (61%) in the 27 patients. IOUS revealed only eight duodenal tumors (26%) and no new lesions. IOE identified 20 duodenal gastrinomas (64%) and 6 new lesions. DX identified 31 duodenal tumors (100%) and 5 additional tumors. The morbidity rate was 17%. One patient had a duodenal fistula after operation (2.8%) and subsequently recovered. No patient died. CONCLUSIONS: These results demonstrate that the duodenum is the most common location for gastrinoma in patients with ZES (77%) and that DX to detect and remove duodenal gastrinomas should be routinely performed in all explorations for patients with ZES.
In exposing facial fractures for reduction and fixation with coronal, subciliary, subtarsal, and upper buccal sulcus approaches, the supraorbital and infraorbital nerves are susceptible to injury. The location of the supraorbital and infraorbital nerves can be predicted by palpating for the supraorbital notch. Significant edema as seen with facial fractures can make these prominent bony landmarks difficult to palpate, however. The purpose of this study was to determine a method to predict the location of the supraorbital and infraorbital nerves in the face of frontal and periorbital edema when the supraorbital and infraorbital nerves are not palpable. The supraorbital and infraorbital nerves were identified in 14 cadaver heads. The orbital width from the medial to lateral canthus was measured. The distance of the vertical vector of the supraorbital and infraorbital nerves from the medial canthus was measured along this horizontal vector of the orbit. The distance of the infraorbital nerve from the infraorbital rim was measured. The orbital width measured 42.2 +/- 1.6 mm from the medial to lateral canthus. The vertical vector of the supraorbital nerve measured 15.9 +/- 1.1 mm from the medial canthus along the horizontal vector of the orbit. The vertical vector of the infraorbital verve measured 16.8 +/- 1.4 mm from the medial canthus along the horizontal vector of the orbit. The infraorbital nerve measured 9.8 +/- 1.0 mm inferior to the infraorbital rim. The medial one third of the orbit measured 14.1 mm. Therefore, the supraorbital and infraorbital nerves are located approximately along the medial third of the orbit, with the upper bound of 95% confidence at 3.1 mm. The location of the supraorbital and infraorbital nerves can be predicted by the previous landmark ratio to within 3 mm.
OBJECTIVE: The objective was to assess the associations between changes in pain and grip strength and manual tests among patients with chronic tennis elbow. DESIGN: Measurements for 45 consecutive patients with unilateral tennis elbow were made before and after an exercise intervention. SETTING: The setting was a physiatric outpatient clinic. PATIENTS: The patients were 45 persons with chronic unilateral tennis elbow: 32 women and 13 men. The mean age was 44 (31-54) years; mean duration of symptoms was 35 (10-66) weeks. OUTCOME MEASURES: Manual tests, pressure pain thresholds at three cubital points, a pain questionnaire, a pain drawing, and grip strength measurements were assessed. RESULTS: Grip strength became normal during the treatment. Pressure pain thresholds reached 66% of that of the healthy arm. Lowered pain thresholds and changes in pain thresholds of the lateral epicondyle were strongly associated with the findings in the manual tests. Mills test and resisted wrist extension tests were associated with perceived pain, and resisted wrist extension tests also were associated with decreased grip strength. Pain on palpation was associated with lowered pain thresholds at the lateral epicondylus and with perceived pain under physical load. After the treatment, for 13 patients all 4 manual tests were still positive; for 17 patients, 3 were still positive; and for 5 patients, all were negative. Positive clinical tests were associated with lowered pain thresholds, decreased grip strength, and high perceived pain scores. CONCLUSIONS: Pain thresholds at the lateral epicondyles are strongly associated with pain on palpation and with a positive Mills test. Resisted wrist extension test results reflect decreased grip strength. Impaired function of the hand is associated with the number of positive clinical tests. Pain threshold evaluation is a simple, easy, inexpensive method that provides useful additional quantitative data on pain and disability among patients with chronic tennis elbow.
Thyroid scintigraphy with Tc-99m pertechnetate was performed in 249 patients who received radiation therapy for abnormalities in the head or neck in order to determine the role of this examination in the detection of abnormal nodules arising from cancer. These patients received a mean total dose of about 10.1 Gy. The mean follow-up period was 39 years. All patients underwent physical examination without prior knowledge of the scintigram. Scintigrams were evaluated without prior knowledge of the physical examination. In 158 cases, both the physical examination and scintigraphy were negative. In 64 cases, both examinations were positive. In ten patients, the physical examination was positive and scintigraphy was negative and vice versa in 17 patients. Of 249 patients, 28 ultimately underwent thyroid surgery; a total of four had carcinoma. A cost-benefit relationship as to routine scintigraphy as a screening procedure is presented. If patients are first screened by palpation, a number of abnormal nodules will be missed. In addition, a considerable number with positive palpation would probably undergo surgery unnecessarily. From a clinical and financial point of view, it is believed that scintigraphy is the examination of choice for screening for radiation-induced thyroid malignancies.
Multiple randomized clinical trials have been unsuccessful in providing evidence of efficacy of electronic fetal monitoring; thus, there is renewed interest in intermittent auscultation during labor for women with low-risk pregnancies. Auscultation must be used with palpation or external or internal electronic monitoring of uterine contractions. Auscultation and palpation require education, experience, and competency validation at regular intervals. Institutional policies and standards of care are mandatory for intermittent auscultation. Concerns exist regarding the personnel costs for auscultation; however, these costs may ultimately be shown to be offset by significant benefits in improved outcomes and patient satisfaction.
STUDY DESIGN: A controlled rabbit model of lumbar posterolateral intertransverse process arthrodesis was used to evaluate a bone graft substitute. OBJECTIVE: To determine the efficacy of demineralized bone matrix gel as an autograft extender, using different ratios of demineralized bone matrix to autograft and to determine the efficacy of demineralized bone matrix as an autogenous bone graft enhancer by adding it to the usual quantity of autograft. SUMMARY OF BACKGROUND DATA: Autogenous bone is considered the most effective bone graft material for posterolateral lumbar arthrodesis, yet nonunions occur in up to 30% of patients. In addition, donor site complications may occur in 25-30% of patients. This has prompted the search for and investigation of bone graft extenders, enhancers, and substitutes. Commercially available demineralized bone matrix gel is one possible graft extender and enhancer, which, unlike mineralized allografts, has osteoinductive properties. Although the gel is in common use, the efficacy of demineralized bone matrix when used for posterolateral spine arthrodesis has not been examined in prospective clinical studies. Furthermore, no known animal studies have tested demineralized bone matrix gel in a posterolateral arthrodesis model. METHODS: Forty-seven New Zealand white rabbits underwent bilateral posterolateral spine arthrodesis at L5-L6 using autogenous iliac crest bone graft alone or in combination with demineralized bone matrix. Four groups were formed on the basis of the ratio of autograft to demineralized bone matrix: autograft alone (3 mL), 100:0 group; autograft (3 mL) and demineralized bone matrix (1.5 mL), 100:50 group; autograft (1.5 mL) and demineralized bone matrix (1.5 mL), 50:50 group; and autograft (0.75 mL) and demineralized bone matrix (2.25 mL), 25:75 group. Rabbits were killed 6 weeks after surgery. Inspection, manual palpation, radiographic film, and histologic evaluation were used to assess fusion. RESULTS: All groups had similar fusion rates (66-73%) based on manual palpation. Rabbits implanted with demineralized bone matrix had more mature fusion masses, evidenced by the greater trabecular bone formation seen on radiographic film and histologic study. CONCLUSIONS: Demineralized bone matrix was effective as a graft extender when used in up to a 3:1 ratio with autograft in a rabbit posterolateral spine fusion model. When less than the standard volume of autograft was used, the addition of demineralized bone matrix gel lead to fusion success rates comparable to those of the standard amount of autograft alone. However, demineralized bone matrix did not increase the frequency of successful fusion when added to the standard amount of autograft.
STUDY DESIGN: Posterolateral lumbar transverse process fusion in a rabbit model was performed using two different carriers for recombinant human morphogenetic protein-2, one having a porous structure and the other being a Type I collagen sheet. OBJECTIVES: To compare the effectiveness of two different carriers for recombinant human morphogenetic protein-2 in achieving lumbar intertransverse process arthrodesis. SUMMARY OF BACKGROUND DATA: The application of osteoinductive growth factors at various anatomic sites, such as in long bones and spinal segments, has been performed experimentally by many researchers. Although many carriers of osteoinductive factors have been reported, the most effective carrier has not been established. We have reported the efficacy of sintered bovine bone, True Bone Ceramics, which is coated with Type I collagen as a carrier of recombinant human bone morphogenetic protein-2 in achieving lumbar intertransverse process arthrodesis. True Bone Ceramics is a crystallized form of bone minerals made from sintering bovine bone at high temperatures and possesses natural trabecular structure. The crystalline character of True Bone Ceramics is similar to that of artificial hydroxyapatite. In this study we focused on the structure of two different carriers to facilitate osteosynthesis in lumbar arthrodesis. METHODS: Fifty-four adult rabbits underwent bilateral lumbar intertransverse process arthrodesis at L4-L5. The animals were divided into five groups and had implants placed as follows: Group 1, autograft group, harvested autologous corticocancellous bone from the posterior iliac crest; Group 2, TBC group, True Bone Ceramics alone; Group 3, TBC-TBMP group, True Bone Ceramics coated with Type I collagen infiltrated with 100 microg of recombinant human bone morphogenetic protein-2; Group 4, collagen group, Type I collagen sheet; and Group 5, collagen-BMP group, implanted collagen sheet containing 100 microg of recombinant human bone morphogenetic protein-2. Spinal fusion was evaluated by radiographic analysis, manual palpation, biomechanical testing, and histologic examination at both 3 and 6 weeks after surgery. RESULTS: Radiographs in the TBC-TBMP group showed a continuous trabecular pattern within the intertransverse area at 3 weeks after surgery. The fusion mass in the intertransverse area was more prominent than in the other groups. At 3 weeks after surgery the TBC-TBMP group had higher fusion rates based on manual palpation, and the fusions showed significantly higher tensile strength and stiffness. The histologic findings in the TBC-TBMP group at 3 weeks after surgery showed a cortical bone rim around the edge of the fusion mass, and contiguous new bone appearing between the recipient bone and the matrix of TBC without evidence of foreign body formation. In the collagen-BMP group, less mature bone formation was present within the grafted area and the new bone was not contiguous, even at 6 weeks after surgery. CONCLUSIONS: As a carrier for recombinant human bone morphogenetic protein-2, True Bone Ceramics, possessing a bony or porous structure, was more effective than a Type I collagen sheet in achieving a faster and stronger lumbar spinal fusion in a rabbit model.
OBJECTIVES: The prevalence of temporomandibular disorders in patients with chronic whiplash-associated disorder is a controversial issue that may be influenced by the widespread pain character and psychologic distress frequently observed in patients with chronic pain. The aim of this study was to determine the prevalence of temporomandibular disorder pain, widespread pain, and psychologic distress in persons with chronic whiplash-associated disorder pain, using a controlled, single blind study design. The prevalence of temporomandibular disorder pain in the chronic whiplash-associated disorder pain group was compared with 2 control groups: a chronic neck pain group and a no neck pain group. METHODS: From 65 persons, a standardized oral history was taken, a physical examination of the neck and the masticatory system was performed, widespread pain was investigated by tender point palpation, and psychologic distress was measured with a questionnaire (SCL-90). Because the recognition of temporomandibular disorder pain and neck pain remains a matter of debate, 3 well-defined classification systems were used: one based on the oral history, a second on a combination of oral history and pain on active movements and palpation, and a third one based on a combination of oral history and function tests. RESULTS: Irrespective of the classification system used, the chronic whiplash-associated disorder pain group more often suffered from temporomandibular disorder pain (0.001<P<0.028) and widespread pain (0.001<P<0.003) than the no neck pain group. Moreover, patients with whiplash-associated disorder showed more psychologic distress (0.000<P<0.044) than the other 2 groups. DISCUSSION: The higher prevalence of widespread pain and psychologic distress in patients with chronic whiplash-associated disorder suggests that the higher prevalence of temporomandibular disorder pain in these patients is part of a more widespread chronic pain disorder.
OBJECTIVES: To examine whether generalized pain sensitivity in women with vulvar vestibulitis syndrome (VVS) is increased, suggestive of altered pain processing at the level of the central nervous system, and to investigate pain history and other pain measures in women with VVS. METHODS: Sixteen women with VVS and 16 age-matched (+/-3 years) and oral contraceptive status-matched (yes or no) control women participated in this cross-sectional study. The TP examination, typically used in the diagnosis of FMS, consists of the palpation of 9 bilateral nonvulvar areas by a blinded rheumatologist and was the main measure of generalized sensitivity. Pain intensity and unpleasantness rating (0 to 10) were recorded after each palpation. In addition, nonvulvar pain history, pain interference, catastrophizing, and anxiety were assessed via questionnaires. RESULTS: Women with VVS had significantly more painful TPs than nonaffected women; they reported significantly higher pain intensity and unpleasantness ratings and displayed more pain behaviors than controls (P<0.05). Furthermore, VVS patients reported having experienced more pain problems and associated interference, they catastrophized more in response to vulvar and nonvulvar pain, and they had higher levels of trait anxiety than controls (P<0.05). DISCUSSION: These results are consistent with recent findings of generalized sensitivity and heightened responses to pain in women with VVS. These results suggest that the mechanisms involved in VVS may include those that are genital specific in addition to those that are more generalized, and possibly centrally mediated.