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Reproductive performance in high producing dairy cows treated with recombinant bovine somatotropin.

The reproductive performance of 156 cows treated with recombinant bST for two consecutive lactations was assessed as part of a target animal safety study conducted in the San Joaquín Valley of central California. Daily intramuscular administration of 17.2, 51.6, and 86 mg of bST per cow started at d 70 postpartum and ended at dry-off or 305 d postpartum. The AI did not begin until d 70 postpartum. During the first lactation study, multiparous cows treated with bST had significantly decreased pregnancy rates, increased behavioral anestrus, and increased anestrus confirmed by palpation. Treated primiparous cows in first lactation had shorter mean days to first standing estrus. In the second lactation study, cows treated with bST had an increased rate of delayed uterine involution, cystic ovarian condition, behavioral anestrus, and anestrus confirmed by palpation. Progeny from the first lactation cows were evaluated for rates of growth, morbidity, mortality, and for reproductive performance; no difference was detected between the progeny from different groups.

Analysis of Variance↗

The false fontanel.

In the neonate, palpation of the anterior fontanel is recognized as a simple and reliable means for estimating intracranial pressure. With closure of the fontanel this aspect of the clinical examination is lost. The authors report a series of 15 shunted infants and children in whom a false fontanel was created by making a 2-cm craniectomy in the right parietal region and excising the underlying internal pericranium. This produces a cranial opening which, like the anterior fontanel, can be used for palpation and real-time ultrasound imaging of the brain. By removing the internal pericranium, reossification of the defect is delayed by more than 12 months. Sparing the dura propria avoids the risks of cerebrospinal fluid leak or brain herniation into the cranial window. This procedure is reported to be simple, reliable, and of value in assessing shunt function in hydrocephalic infants and young children. An illustrative case report is presented.

Cerebrospinal Fluid Shunts↗

Titanium miniplates or stainless steel wire for cranial fixation: a prospective randomized comparison.

OBJECT: The authors designed a study to compare low-profile titanium miniplate fixation to that in which stainless steel wire is used. METHODS: Before undergoing craniotomy, 40 patients gave informed consent and were randomized to receive either wire or miniplate fixation. After dural closure, bone flap fixation was timed. The bone flap was measured for inward or outward offset and mobility to manual pressure on its margin. Three months postoperatively the bone flap margins were graded for appearance or palpation of an offset and for the presence of burr hole depressions. Twenty-four patients were randomized to receive miniplate fixation and 16 to receive stainless steel wire fixation. The time required for wire fixation was approximately 40% longer than that for miniplates (11.8 +/- 5.1 minutes compared with 8.3 +/- 5 minutes, p = 0.02). The offset of bone flaps after wire fixation was significantly greater than that with miniplates (1.6 +/- 1 mm compared with 0.3 +/- 0.6 mm, p < 0.001), as was the mobility of the bone flap on digital pressure (1.2 +/- 0.9 mm compared with 0.2 +/- 0.5 mm, p < 0.001). At the 3-month follow-up review, two of 12 patients had suboptimal results after wire fixation, whereas none of 14 patients had suboptimal results after miniplate fixation. When dichotomized for excellent or less-than-excellent postoperative results, the data were significantly better for patients who underwent miniplate fixation (p < 0.05). CONCLUSIONS: Titanium miniplate cranial fixation provides more accurate and rigid reapproximation of the bone edges, with results that are significantly better on close inspection or palpation. The additional cost of miniplate fixation may thus be justified in many cases.

Adult↗

Pseudolabor: A New Conversion Disorder Subtype? A Case Presentation and Literature Review.

Pseudolabor is not a recognized conversion disorder subtype. The diagnosis of conversion disorder is suspected when a patient presents with symptoms under voluntary control that mimic a neurologic or medical condition. The term pseudolabor was first used in 1994 to describe a patient who presented at 27 weeks' gestation with monitored contraction activity and no palpable uterine contractions. A second case is presented herein. Both patients were initially managed as though they had preterm labor or uterine irritability with minimal cervical changes. The diagnosis was suspected only after each patient failed to respond to aggressive tocolysis. On external tocodynamometry, contractions were abrupt in onset and abrupt in descent. Only after palpating abdominal contractions and not uterine contractions did the attending physicians make the correct diagnosis. The development of pseudolabor in a patient with previously diagnosed pseudoseizures suggests that the condition was conversion disorder. The prevalence of pseudolabor is unknown and may be underestimated: electronic fetal monitoring has minimized the need to palpate uterine contractions in the laboring patient. The diagnosis of pseudolabor as a subtype of conversion disorder should be considered in any patient who presents with recurrent preterm uterine contractions, no (or minimal) cervical changes, and an atypical contraction pattern.

Journal Article↗

Diagnostic use of ultrasonography in patients with nodular thyroid disease.

OBJECTIVE: To review the published reports pertaining to the diagnostic utility of ultrasonography for evaluation of thyroid nodules. METHODS: Various roles for diagnostic thyroid ultrasonography and screening ultrasound studies of the thyroid are discussed, and ultrasound characteristics of thyroid nodules and their association with malignant potential are described. RESULTS: In two studies that correlated ultrasound findings with physical examination findings in patients with a solitary thyroid nodule detected by palpation, 16% of such patients had no corresponding nodule evident on ultrasonography, and 45% of such patients had an additional nodule detected by ultrasonography. Similarly, approximately 18% of patients with a palpable multinodular thyroid had no nodules larger than 1 cm in diameter on ultrasound studies. Thyroid nodules larger than 1 cm have been found by ultrasonography to be present in from 2 to almost 5% of the population with normal findings on examination of the thyroid. Use of screening ultrasound study of the thyroid has been suggested for patients with a history of childhood irradiation to the head and neck or a family history of thyroid cancer. Numerous investigations that have evaluated ultrasound features of thyroid nodules have suggested five characteristics as suggestive of malignant potential--hypoechogenicity, microcalcifications, irregular or microlobulated border, absent or irregular thick halo, and increased intranodular vascularity. CONCLUSION: Correlation of ultrasound and palpation findings will provide a comprehensive evaluation of nodular thyroid disease. Moreover, real-time ultrasonography facilitates characterization of features associated with an increased risk of a malignant lesion. High-resolution thyroid ultrasonography is a dynamic tool for endocrinologists.

Humans↗

Ultrasonographical investigations of onchocerciasis in Liberia.

The efficiency of ultrasonography (US) for the diagnosis and clinical characterization of onchocerciasis was evaluated. US was performed on 120 probands in Liberia. Ninety-two patients had generalized onchocerciasis, 21 patients suffered from the chronic hyperreactive form of onchocerciasis (sowda), and 7 probands served as controls. Patients were examined by US with linear (7.5 MHz and 5 MHz) and sector (3.5 MHz) scanners. US results were evaluated by examination of extirpated nodules. The US structure of nodules revealed a typical pattern consisting of a homogeneous echogenicity with small echodense particles and a lateral acoustic shadow, and differentiation from lymph nodes, lipoma, or fibroma was achieved. Within the onchocercomata, calcifications or fluid were identified. Regarding the estimation of the worm burden, it is important to note that in 24 patients, additional nodules not previously palpated were found by US. Also, the number of worm centers in palpable conglomerate nodules were determined more exactly by US than by palpation. In 4 of 16 sowda patients, impalpable nodules were found by US. In 13 patients with positive microfilaria counts, no nodules could be detected. The highly characteristic ultrasonographical pattern of onchocercomata may serve as a basis for further US investigations in onchocerciasis.

Adolescent↗

Intussusception in children seen at Muhimbili National Hospital, Dar es Salaam.

OBJECTIVE: To review infants and children with intussusception and assess its magnitude of concern and any seasonal variation in our environment. DESIGN: A retrospective study. SETTING: Muhimbili National Hospital general paediatric and surgical wards from January 2000 to February 2004. METHODOLOGY: The charts of all infants and children up to the age of 10 years diagnosed to have intussusception were reviewed. Demographic factors evaluated included age, incidence in up to one-year olds, sex, month of presentation to assess seasonal variation, clinical features, methods of diagnosis and management, aetiology and any recurrence. RESULTS: Twenty eight children were diagnosed to have intussusception. Sixteen were males and 12 females (M:F=l .3:1). Of these, 21(75%) were infants (up to the age of one year), nine were boys and 12 were girls( M.F=l:1.3). Incidence rate in this age group was approximately 1: 7557. Most cases presented in January-March(39.3%) and July to September(39.3%). No case was seen in the month of April during the 4-year period. Except in 2002, there has been a male preponderance. The aetiology was mainly idiopathic (85.7%), there were three cases suspected to be due to mesenteric adenitis and one case of intraluminal haemangioma. There were two recurrent cases, one was within a week with no known aetiology. All patients presented with vomiting and abdominal pain/distension. Preceding gastro-enteritis was common. The majority of the cases, 17(60.7%) presented with the classic triad of vomiting, rectal bleeding and abdominal pain/distension. Abdominal mass was often difficult to palpate due to gross or tense abdomen and was only palpated in four cases(14.3%). Air or barium reduction is not done at our institution due to apart from lack of facilities, majority of the children present late, >48 hours from the onset of symptoms and diagnosis was mainly based on clinical symptoms and signs of intestinal obstruction and confirmed with presence of multiple fluid levels on a plain erect abdominal X-ray. All children were then managed by surgery, 11(39.3%) underwent bowel resection. Histopathology reports of those available did not show cause of intussusception. Seven patients died postoperatively, hospital mortality of 25%. CONCLUSION: The approximate incidence of intussusception in less than one-year olds is 1:7557 in Dar es Salaam. It is a concern in our environment causing considerable morbidity and mortality due to late presentation and efforts should be made to improve sanitation and hygiene, referring health facilities, socio-economic factors and probably look into ways of preventing the problem occurring. Seasonal variation was seen, most cases(78.6%) presenting in the dry season when there is shortage of water in the city.

Child↗

Neck strain in car occupants. The influence of crash-related factors on initial severity.

OBJECTIVE: To examine the relationship between the initial severity of neck strain in car occupants and crash-related factors, in particular, crash severity. DESIGN/PARTICIPANTS: Thirty-two individuals with neck strain after a car crash, drawn from physiotherapy and general practices in metropolitan Adelaide, were interviewed about their experience and examined by a manipulative physiotherapist. Crash severity was assessed by measurement of damage to the involved vehicles. MAIN OUTCOME MEASURES: Five measures of neck strain severity were obtained: number of body regions with symptoms, number of positive responses to palpation, cervical range of motion, subject's own rating on an analogue pain scale, and examiner's severity rating. Two measures of crash severity were used: maximum residual deformation, and velocity change of the subject's vehicle. RESULTS: Neck strain was observed in individuals who were involved in crashes of low severity. Maximum residual deformation of the vehicle was negatively associated with the subject's cervical range of motion and positively associated with the other measures of neck strain severity. For rear impacts, both measures of crash severity were associated with measures of neck strain severity. The group of subjects who were aware of the impending collision had a greater range of cervical spine movement and fewer positive responses to palpation than those who were unaware. CONCLUSIONS: Initial severity of neck strain is positively correlated with crash severity. Awareness of the impending collision may have a mitigating effect on injury severity.

Accidents, Traffic↗

Experience and attitudes of final-year medical students to digital rectal examination.

OBJECTIVE: To assess the attitudes of final-year medical students to digital rectal examination (DRE) and their experience of performing DRE during clinical training. DESIGN: Questionnaire-based survey. SETTING AND PARTICIPANTS: All students in the final year of medical school at the University of Melbourne in 2003. OUTCOME MEASURES: Agreement with statements about attitude to DRE; number of DREs performed and abnormalities palpated; and ratings of frequency of supervision and perceived barriers to performing DRE. RESULTS: 222 of 256 students (87%) responded. Almost all (97%) believed that DRE is an essential requirement for a medical practitioner, and 94% that they should have the skill before graduating, while 92% said they had been taught how to perform it. The median number of DREs performed was two, with 17% of students performing none. Sixty-three per cent had palpated a prostate, 24% a prostate cancer, 19% a rectal tumour, and 11% faecal constipation. Half the students (52%) felt they could give a reasonable or confident opinion based on their DRE findings. The most often cited reason for not performing DREs was the lack of a doctor to act as a supervisor. CONCLUSIONS: A concerted effort is needed from academics, supervising doctors and students to improve medical students' proficiency in performing DRE and confidence about their findings.

Adult↗

Patients presenting to the general practitioner with pain of dental origin.

Dentofacial pain is a common presentation in general practice, and more than 50% of cases arise from dentally related pathology. In a carious tooth, pain that is site-specific, severe and spontaneous usually denotes extension of caries into the tooth pulp. Caries does not always appear as a cavity in the tooth, but may lie beneath intact enamel or on surfaces between teeth. Examination of tooth pain should include firm percussion (eg, with a tongue depressor). Tenderness on percussion denotes progression of infection into the subdental tissue. Pain occurring 24-48 hours after a tooth extraction is commonly caused by superficial osteitis in the exposed alveolar bone. Examination will reveal the absence of a blood clot in the extraction socket and severe tenderness on local palpation. Severe pain related to impacted wisdom teeth is frequently caused by pericoronitis, an infection in the gingival tissues surrounding the tooth. The surrounding gingiva is erythematous and tender to palpation. Localised facial swellings of dental origin require immediate referral to a dentist. Progressive facial swelling requires aggressive antibiotic therapy and referral to hospital for definitive management.

Adult↗

[Management of the impalpable testis; the value of laparoscopy for subsequent treatment].

During a 5-year period between April 1984 and March 1989, we were unable to palpate 62 testes (56 child patients) at the time of diagnosis. An average of 10 months later, 51 testes (48 patients) still remained impalpable preoperatively. Of the two imaging techniques, computed tomography and ultrasonography, the former is rather superior to the latter for verifying the existence of the impalpable testis. However, careful palpation under anaesthesia results in the accurate location of the testis more often than either of those two imaging techniques. On the other hand, as an aid in management of the impalpable testis, laparoscopy offers the most useful information for use in later surgery. This is because we are able to see the spermatic vessel and the vas deferens intraabdominally, in addition to the abdominal testis. Thirty-six patients (39 testes), whose testes remained impalpable even under anaesthesia, underwent laparoscopy. In two cases, we were unable to perform laparoscopy successfully due to failed pneumoperitoneum. However, in all the other cases, the information which could be obtained was fully utilized during subsequent management. Of a total of 37 instances, 8 testes which were abdominal or just canalicular (pendulous) could be recognized. In addition, 4 more were found to have no spermatic vessel in the visual field and a further 4 had a vessel disappearing before reaching the internal ring. In the remaining 21, we were able to detect the spermatic vessel and the vas deferens. At 59 instances of exploratory surgery, a mere 11 testes, among 27 testes, could be fixed to the bottom of the scrotum, resulting in scrotal dimples lasting for several months in 2 cases. Another 14 testes were placed in the upper scrotal region, while 2 were left in the groin region subcutaneously for lack of any alternative site.

Child↗

Introduction of the blood pressure cuff into U.S. medical practice: technology and skilled practice.

The history of the sphygmomanometer, or blood pressure cuff, raises useful questions about the acceptance of new medical technologies. When the blood pressure cuff first appeared in U.S. medical practice in the first decade of the 1900s, it generated some concern and debate among physicians. Review of the medical literature, a systematic study of patient records from Massachusetts General Hospital, and consideration of events in Boston during this period suggest that physicians faced several important choices associated with the early acceptance of the cuff. The introduction of the blood pressure cuff presented physicians with several different, competing methods for assessing the force of a patient's blood flow. Physicians chose to use the cuff in a manner that preserved their exclusive use of the new tool and maintained a high level of skill for their individual practices. An early proposal to introduce the new blood pressure cuff as a simple tool for nursing use met with resistance. Many physicians initially favored a competing practice of assessing the force of blood flow by pulse palpation. Physicians eventually dropped the practice of subjectively palpating the force of blood flow and came to rely increasingly on the measurement of blood pressure using auscultation. Even after adopting the cuff into practice, however, they had little interest in completely standardizing the use of the blood pressure cuff across the practices of individual physicians.

History, 20th Century↗

Sonographically guided laparoscopy and mediastinoscopy using miniature catheter-based transducers.

Miniature ultrasound transducers (12.5 MHz) housed in 9 Fr catheters were passed through a laparoscope or mediastinoscope to image a variety of normal and abnormal structures within the peritoneal cavity and mediastinum in 20 patients. These transducers made it possible to visualize the gallbladder and bile ducts and evaluate for the presence of stones, to detect masses and provide guidance for their aspiration or biopsy, and to image the internal structures of the ovary and fallopian tube. In addition, these miniature transducers were used to locate such normal vital structures as blood vessels, thereby allowing the surgeon to decide on the best approach for dissection during mediastinoscopy. During conventional surgery, the surgeon or gynecologist can palpate an area of abnormality not directly visualized. However, during laparoscopy and mediastinoscopy direct palpation is not possible. Therefore, it is important to find another method to determine what structures lie beneath the visualized surface. These miniature ultrasound transducers appear to offer a means for making such determinations.

Adult↗

Ultrasonographically guided thyroid biopsy: a review with emphasis on technique.

We describe our technique for ultrasonographically guided fine-needle aspiration biopsy of the thyroid that achieves a high rate of diagnostic specimens. Indications for ultrasonographically guided fine-needle aspiration biopsy included a difficult-to-palpate thyroid nodule and previously unsuccessful palpation-guided fine-needle aspiration. Ultrasonographically guided fine-needle aspiration biopsy was performed on 316 thyroid nodules in 306 patients. Adequate cytologic specimens were obtained in 97.2% of the nodules in which biopsy was performed, with a 2.8% rate of inadequate cellularity. Two helpful aspects of this technique that were thought to improve the overall diagnostic yield were the use of color and power Doppler "vascular mapping" of the nodule just before biopsy and on-site cytologic control.

Biopsy, Needle↗

[Clinico-electromyographic characteristics of piriform muscle syndromes].

The report is concerned with the screening methods of lesions of the piriformis muscle in the piriformis syndrome which is more frequently connected with sacral osteochondrosis. However, this syndrome may sometimes appear in an ankylosis of the hip joint. All the diagnostical methods may be divided into 3 groups: indirect clinical method, palpation and EMG. The first method does not require special experience. A palpation of the piriformis muscle is conducted bimanually by a method proposed by the authors. EMG studies with the aid of needle electrodes permit to distinguish spasms and more crude changes in the piriform muscle.

Adult↗

Minireview: discussion about the limit between normal thyroid goiter.

Although the goitre seems to be well defined at least from clinical point of view, it is virtually impossible to find the precise definition of the opposite side of what should be the normal thyroid as concerns its size, histological structure and namely the level of growth stimulation by the external factors (such as TSH) and intrinsic tissue growth factors. Theoretically, the normal thyroid should be able to cover the requirements of the organism for the hormone in a reasonably large range without being stimulated to grow by any external or internal factors. So far, the search for normal thyroid has been conducted by several ways: 1. by post mortem thyroid weight, 2. by palpation, 3. by ultrasound. As based on post mortem thyroid weight, until the middle of this century a typical thyroid gland was considered to be about 20-25 g with the accepted upper normal size of 30 g, while more recent studies in iodine replete population have reported mean weights of about 10 g and an upper normal size 20 g. According to several classifications for thyroid palpation the unpalpable thyroid should be allotted to the Grade 0 which is defined as "normal gland", "no goiter at all", "absence of goiter" etc. The first recommendation of normal thyroid volume for children and adolescents as estimated by ultrasound has been developed by Gutekunst and Teichert (1994). However, this was later challenged by the findings of considerable number of thyroid volumes which were higher than the upper limit of that recommendation as found in the countries with satisfactory values of urinary iodine (Delange et al. 1997). Nevertheless, recently it appeared that about 10-15 percent of adolescent thyroids show increased thyroid growth rate which significantly differs from the majority and which might be related to different tuning of molecular growth mechanism presumably of genetic origin (Tajtakova et al. 1998; Langer et al., in press). From, this follows that a certain number of enlarged thyroids apparently should not be included into a normal range.

Adult↗

Severe combined immunodeficient-hu model of human prostate cancer metastasis to human bone.

Commonly used in vivo models of prostate cancer metastasis include syngeneic rodent cancers and xenografts of human cancer in immunodeficient mice. However, the occurrence of osseous metastases in these models is rare, and in xenograft models, species-specific factors may limit the ability of human cells to metastasize to rodent bones. We have modified the severe combined immunodeficient (SCID)-human model to test the ability of circulating human prostate cancer cells to home to macroscopic fragments of human bone and other organs previously implanted into SCID mice. We have also compared the growth of human prostate cancer cells in various human and mouse tissue microenvironments in vivo. Macroscopic fragments of human fetal bone, lung, or intestine (16-22 weeks gestation) or mouse bone were implanted s.c. into male CB.17 SCID mice. Four weeks later, human prostate cancer cells were injected either i.v. via the tail vein (circulating cell colonization assay) or directly into the implanted tissue fragments transdermally (end organ growth assay). Tumor growth was followed for 6 weeks by palpation and magnetic resonance imaging. After 6 weeks, tumors were enumerated in implanted human and mouse organ fragments and native mouse tissue. Tumors were characterized by histology, immunohistochemistry, and chromosomal analysis. After i.v. injection, circulating PC3 cells successfully colonized implanted human bone fragments in 5 of 19 mice. Tumors were easily followed by palpation and imaging and had an average volume of 258 mm3 at autopsy. Histological examination revealed osteolysis and a strong desmoplastic stromal response, which indicated intense stromal-epithelial interaction. Bone tumors were subcultured, and chromosomal analysis demonstrated that the tumors were derived from the parental prostate cancer cell line. Microscopic tumor colonies were also found in a few mouse lungs after i.v. injection of PC3, DU145, and LNCaP cells, however the volume of the lung nodules was less than 1 mm3 in all of the cases. No colonization of human lung or intestine implants, the mouse skeleton, or other mouse organs was detected, demonstrating a species- and tissue-specific colonization of human bone by PC3 cells. Direct injection of 10(4) prostate cancer cells into human bone implants resulted in large tumors in 75-100% of mice. PC3 and DU145 bone tumors were primarily osteolytic, whereas LNCaP bone tumors were both osteoblastic and osteolytic. PC3 and LNCaP bone tumors showed a desmoplastic stromal response, which indicated intense stromal-epithelial interaction. All three of the cell lines formed tumors in implanted human lung tissue; however, the tumors were all < or = 10 mm3 in volume and showed minimal stromal involvement. No tumors formed after either s.c. injection or injection of cells into implanted mouse bone demonstrating both species- and tissue-specific enhancement of growth of human prostate cancer cells by human bone. The severe combined immunodeficient-human model provides a useful system to study species-specific mechanisms involved in the homing of human prostate cancer cells to human bone and the growth of human prostate cancer cells in human bone.

Animals↗

[Primary testicular tumor].

OBJECTIVE: To report a case of primary germ cell testicular tumor that spontaneously remitted after metastasizing to the retroperitoneum, leaving histologically characteristic lesions of a fused tumor. The characteristic testicular ultrasound findings that permitted the diagnosis are described. METHODS/RESULTS: A 21-year-old male consulted for a retroperitoneal mass. The testes were normal on palpation. The testicular ultrasound showed a hyperechoic area with an acoustic shadow suspected as being a tumoral cicatrix. The histological analysis after orchidectomy revealed a mixed non-seminomatous germ cell tumor. CONCLUSIONS: Testicular ultrasound evaluation should be performed on all patients with retrosperitoneal germ cell tumor and normal testes on palpation. In the case described, there was good correlation between the ultrasound and the histological findings.

Adult↗