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Purpose: In surgery for strangulated bowel obstruction, intestinal blood flow (IBF) is usually evaluated by observing bowel colour, peristalsis, intestinal temperature and arterial pulsations in the mesentery. We investigated whether indocyanine green (ICG) fluorescence angiography (ICG-FA) is an effective alternative to palpation., Methods: Thirty-eight patients who underwent emergency surgery for strangulated bowel obstruction from January 2017 to April 2021 were divided into two groups: (i) the ICG + group, in which ICG was used during laparoscopic surgery (n = 16), and (ii) the ICG - group, in which palpation without ICG was used during open surgery (n = 22). Starting in July 2019, ICG and laparoscopic surgery were applied in all cases except emergency cases when the fluorescence laparoscope was not ready. Surgical outcomes and patient characteristics were compared., Results: Patient characteristics, the operative duration and postoperative hospitalization duration did not significantly differ between the groups. Bowel resection was performed in 4 cases (25%) among ICG + patients and 11 cases (50%) among ICG - patients. The ratios of pathological findings (ischaemia:mucosal necrosis:transmural necrosis) were 0:2:2 and 1:6:4 in the two groups, respectively. Blood loss was measured with gauze and suction tubes and was 1 (0-5) mL in the ICG + group and 12.5 (0-73) mL in the ICG - group (p = 0.002). Postoperative complications occurred in 1 case (6.3%) in the ICG + group and 9 cases (40.9%) in the ICG - group (p = 0.025)., Conclusion: Although there were few intestinal resections in the ICG + group, the rate of pathological necrosis tended to be high, and no complications due to ineligibility were noted in the intestinal preservation group. During laparoscopic surgery, ICG-FA is useful as a substitute for palpation and has the potential to improve surgical outcomes., Clinical Trial Registration: Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2019-40., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Transrectal palpation of the reproductive tract is the most common method for pregnancy determination in cattle and is considered a veterinary skill that new veterinary medicine (DVM) graduates should perform proficiently. However, using privately owned cattle to train students can be difficult because producers may believe that transrectal palpation by inexperienced students increases the risk of pregnancy wastage compared with examination by an experienced clinician. We used a randomized field trial of 1,216 healthy Holstein and Jersey cattle in 2 commercial dairy herds to estimate the effect of veterinary student transrectal palpation on early pregnancy loss. All cattle were determined to be pregnant using transrectal ultrasonography at approximately 37 d after artificial insemination. Cattle were then allocated into 2 groups based upon their ear tag number (study group = 598; control group = 618). Cattle in the study group were immediately palpated after ultrasonography by a fourth-year veterinary student, whereas control cattle were not subject to any additional pregnancy assessment. For analysis, the student palpators were divided into 2 groups: students who had previously had formal palpation training via an elective bovine palpation class (n = 30) and students who had not had palpation training (n = 134). All cattle were reevaluated using transrectal ultrasonography approximately 70 d after artificial insemination. A total of 53 (4.36%) animals lost their pregnancy between the first and second pregnancy assessments. Of the animals that lost their pregnancy, 26 (4.35%) were study group cows and 27 (4.37%) were control cows. Of the 26 cows documented to have had pregnancy loss within the study group, 20 out of 378 (5.3%) had been palpated by students who had not taken the palpation elective and 6 out of 220 (2.7%) had been palpated by students who had completed the elective. We found no difference in pregnancy loss between student-palpated and clinician-ultrasounded cattle, supporting the safety of using privately owned animals for student bovine palpation and pregnancy diagnosis training without affecting early pregnancy loss., (Copyright © 2019 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Background: Associations of alexithymia with temporomandibular pain disorders (TMD), facial pain, head pain and migraine have been described, but the role of the different dimensions of alexithymia in pain development remained incompletely understood., Objectives: We sought to investigate the associations of alexithymia and its subfactors with signs of TMD and with facial pain, head pain and migraine in the general population., Methods: A total of 1494 subjects from the general population completed the Toronto Alexithymia Scale-20 (TAS-20) and underwent a clinical functional examination with palpation of the temporomandibular joint and masticatory muscles. Facial pain, migraine and head pain were defined by questionnaire. A set of logistic regression analyses was applied with adjustment for age, sex, education, number of traumatic events, depressive symptoms and anxiety., Results: Alexithymia was associated with TMD joint pain (Odds Ratio 2.63; 95% confidence interval 1.60-4.32 for 61 TAS-20 points vs the median of the TAS-20 score) and with facial pain severity (Odds Ratio 3.22; 95% confidence interval 1.79-5.79). Differential effects of the subfactors were discovered with difficulties in identifying feelings as main predictor for joint, facial, and head pain, and externally oriented thinking (EOT) as U-shaped and strongest predictor for migraine., Conclusion: Alexithymia was moderately to strongly associated with signs and symptoms of TMD. These results should encourage dental practioners using the TAS-20 in clinical practice, to screen TMD, facial or head pain patients for alexithymia and could also help treating alexithymic TMD, facial or head pain patients., (© 2018 John Wiley & Sons Ltd.)

Objective: For health professionals, the absence of pulse checked by manual palpation is a primary indicator for initiating chest compressions in patients considered to have cardiopulmonary arrest (CA). However, using a pulse check to evaluate perfusion during CA may be associated with some risks of its own. Our objective was to compare the efficiency of cardiac ultrasonography (CUSG), Doppler ultrasonography (DUSG), and manual pulse palpation methods to check the pulse in CA patients., Material and Methods: This study was prospectively performed in 137 patients older than 16 years of age who underwent cardiopulmonary resuscitation (CPR). CUSG, DUSG, and manual pulse palpation were practiced simultaneously as suggested in the relevant guidelines. Findings of the patients were recorded at the first min, at min 15 and at the end of CPR. SPSS 18.0 was used for statistical analysis., Findings: A total of 72.3% (n = 99) of the cardiopulmonary arrest incidents occurred out-of-hospital. CUSG (4.76 ± 2.19, 4.33 ± 2.17, and 3.68 ± 2.14 s), DUSG (9.59 ± 2.37, 8.22 ± 2.86, and 7.60 ± 2.83 s), and manual pulse palpation (10.76 ± 1.03, 9.72 ± 3.01, and 9.29 ± 3.36 s) measurements of the first, second, and last inspections were detected, respectively. The false negative rates (100%, 28%, and 0%) and false positive rates (5.3%, 3.5%, and 0%) of manual pulse palpation the first, second, and last inspections were calculated, respectively, as well., Conclusion: The use of real-time CUSG during resuscitation provides a substantial contribution to the resuscitation team. CUSG will allow earlier and more accurate detection of pulse than manual pulse palpation and DUSG., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: The purposes of this study were to assess the prevalence of temporomandibular disorders symptoms and signs and the bite force in pediatric patients with idiopathic musculoskeletal pain syndrome and to compare to healthy control individuals paired by gender and age., Methods: Forty consecutive patients (32 girls) from our outpatient pediatric rheumatology pain clinic with diagnosis of idiopathic musculoskeletal pain syndrome were included in this study. Twenty healthy subjects (16 girls) were considered the control group. All individuals were interviewed according to a standardized questionnaire concerning the presence of orofacial pain and functional impairment, and were submitted to a clinical evaluation following a structured protocol. After that the bite force was measured., Results: Twelve patients met the ACR criteria for fibromyalgia, and 28 presented the diagnosis of pain amplification syndrome. The mean age of patients was 13.1 years (range, 6-18 years) and of controls was 12.8 years (range, 6-18 years) with no significant difference. Orofacial symptoms occurred in 25 patients (62.5%) and in 3 controls (15%) (p = 0.0014). Sixteen (40%) patients and four (20%) controls presented pain during mandibular function with no significant difference. Although both pain groups presented separately more frequently orofacial symptoms and pain on palpation than the controls, maximal voluntary bite force was similar between patients and controls, between both patient groups and between the two pain groups and controls., Conclusions: Our findings indicate that temporomandibular disorders symptoms were more prevalent in patients with idiopathic musculoskeletal pain syndrome than in healthy controls. However the bite force was not different among the groups.

Objective To provide evidence about the performance characteristics and consequences of bimanual ovarian palpation. Setting and methods The Prostate, Lung, Colorectal and Ovarian cancer screening trial randomized 154,900 individuals to either an intervention or control arm. Enrolled eligible participants were aged 55-74, had no history of trial cancers, and no current treatment for cancer. Intervention arm women received CA-125 tests and transvaginal ultrasound. Bimanual ovarian palpation was offered annually during the first four years of the trial. Bimanual ovarian palpation-specific sensitivity and specificity were calculated, as were rates of diagnostic procedures and resulting complications following positive bimanual ovarian palpation screens. Results A total of 20,872 women received at least one bimanual ovarian palpation, with 50,498 total bimanual ovarian palpation examinations performed. The sensitivity and specificity of bimanual ovarian palpation were 5.1% (2/39) and 99.0% (49,957/50,459), respectively; no cases were detected by bimanual ovarian palpation alone. Rates for most follow-up procedures for abnormal results in women without ovarian cancer were higher among the group with another screening test positive, except for pelvic exam, where rates were similar. No complications were reported in the bimanual ovarian palpation-only positive group. Conclusion Low sensitivity of bimanual ovarian palpation alone and in combination with other tests argue against using bimanual ovarian palpation as a screening test for ovarian cancer in asymptomatic women.

The timely diagnosis of aortic dissection is notoriously confounded by unreliable symptomatology. We present a previously unreported clinical sign: thoracic pain reproduced by abdominal palpation. Our case illustrates the dependence of traditional clinical features on the anatomical location of an aortic dissection and lends weight to the concept of aortic pain as being a dynamic product of inter-related changes in intraluminal pressure, volume, wall stress and diameter. The clinical sign we describe may be very specific of acute aortic pathology., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: A thorough clinical assessment including physical examination is crucial in a diagnostic work-up, including in patients with chronic pelvic pain syndrome (CPPS). This study investigated the prevalence of pain areas and the mechanosensitivity of peripheral nerves in patients with CPPS and compared the findings with a healthy control group., Materials and Methods: Healthy volunteers and patients diagnosed with CPPS were assessed with physical examinations and neurodynamic testing., Results: The CPPS group (n = 26) and the control group (n = 28) showed no statistical differences between males and females for age and body mass index (Mann-Whitney U test). The patients in the CPPS group were significantly older and had a significantly higher weight compared to controls. Healthy volunteers did not show any pain area or mechanosensitivity of the examined peripheral nerves of the lumbosacral plexus. Patients with CPPS showed a variety of pain from different musculoskeletal origins. Neurodynamic testing demonstrated significant mechanosensitivity in at least one nerve of the lumbosacral plexus in 88% of the patients with CPPS, suggesting minor nerve injuries. Pudendal nerve mechanosensitivity was found in 85% of patients, while 42% had multiple nerves involved. Unilateral or bilateral pudendal channel palpatory pain was present in 62% of the CPPS group and not in controls., Conclusions: This study shows musculoskeletal pain and a high prevalence of minor nerve injuries in CPPS patients, indicating the presence of abnormal impulse generation sites that can help in understanding the clinical picture in CPPS patients and guiding their treatment.

Purpose  The aim of this paper is to determine how the presence of pain during mammographic compression could be reduced. To this end, we examine its relationship with compression force, surface-area of the compressed breast, breast density (ACR) and former operations. Materials and Methods  In 199 women 765 mammograms were performed. Women were asked to rate the level of pain on a scale of 0 - 10 (0: no, 10: highest pain). The surface-area of the breast under compression captured by the mammograms was measured using planimetry. 52 of the 199 women were asked to identify the area of the upper body with the highest level of pain. Results  The thickness of the compressed breast was 65.2 % of the uncompressed breast at a force of 10 daN (57.8 % at 15 daN). When the force was increased from 10 daN to 15 daN, the average glandular dose (AGD) declined by 17 %. Tolerance of compression was associated with the size of the breast. More than 50 % of the mammograms with a small compression less than 9 daN were associated with higher level of pain. In the oblique projection, 60 % of the women specified the axilla as the area of maximum pain. Conclusion  Women with larger breasts tolerated a greater force of compression. This implies a need for individualised examination depending on the size of the breast. Women with increased pain susceptibility terminated the compression early regardless of a small compression less than 9 daN. More than 50 % of the women identified areas outside breast as especially painful. Therefore, during examination, the areas around the breast should also be taken into consideration in order to minimize unnecessary discomfort. Key Points · With increased mammographic compression force, the effectiveness of breast thickness reduction declined.. · A compression force of 15 daN enabled an additional reduction by 17 % in average glandular dose (AGD) compared to 10 daN.. · Tolerance of increased compression force was related to breast surface area.. · Women with increased susceptibility of pain terminated the compression at a low force of less than 9 daN. · Pain relating to the mammographic procedure was identified outside the breast by more than 50 % of the women.. Citation Format · Feder K, Grunert JH. Is Individualizing Breast Compression during Mammography useful? - Investigations of pain indications during mammography relating to compression force and surface area of the compressed breast. Fortschr Röntgenstr 2017; 189: 39 - 48., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Many women undergoing an assisted reproductive technology (ART) cycle will not achieve a live birth. Failure at the embryo transfer stage may be due to lack of good-quality embryo/s, lack of uterine receptivity, or the transfer technique itself. Numerous methods, including the use of ultrasound guidance for proper catheter placement in the endometrial cavity, have been suggested as more effective techniques of embryo transfer. This review evaluates the efficacy of ultrasound-guided embryo transfer (UGET) compared with 'clinical touch' (CTET), which is the traditional method of embryo transfer and relies on the clinician's tactile senses to judge when the transfer catheter is in the correct position., Objectives: To determine whether ultrasound guidance compared with clinical touch improves pregnancy outcomes in women undergoing embryo transfer during ART cycles., Search Methods: For the 2016 update of this review, we ran updated searches in the Cochrane Gynaecology and Fertility Group trials register (May 2015), the Cochrane Central Register of Controlled Trials (the Cochrane Library, May 2015), MEDLINE (2009 to May 2015), and EMBASE (2009 to May 2015). We also handsearched relevant conference proceedings: American Society for Reproductive Medicine (ASRM), European Society for Human Reproduction and Embryology (ESHRE), and International Federation of Gynecology and Obstetrics (FIGO). There were no language restrictions., Selection Criteria: We included only randomised controlled trials., Data Collection and Analysis: Two review authors independently assessed eligibility and quality of trials and extracted data from those selected. We calculated odds ratio (OR) and 95% confidence interval (CI) for dichotomous outcomes. No outcomes were reported using continuous data. We assessed the overall quality of the evidence for the main findings using the GRADE working group methods., Main Results: This systematic review now has 21 included studies (four of which we added in the 2016 update), two studies awaiting assessment, and 47 excluded studies. In total, data for meta-analyses were available in 21 trials (n = 6218 women), of which only four reported live births.UGET was associated with an increased chance of a live birth/ongoing pregnancy compared with CTET (OR 1.47, 95% CI 1.30 to 1.65; 13 trials; n = 5859 women; I(2) = 74%; low-quality evidence). Sensitivity analysis by including only trials with low risk of selection bias or by using a random-effects model did not alter the effect. We estimate that for women with a chance of a live birth/ongoing pregnancy of 23% using CTET, this would increase to between 28% and 33% using UGET. We considered the quality of the evidence using GRADE methodology to be low.UGET was associated with an increase in the chance of a clinical pregnancy (OR 1.31, 95% CI 1.17 to 1.45; 20 trials; n = 6711 women; I(2) = 42%; moderate-quality evidence). We identified no differences between groups for the incidence of adverse events including multiple pregnancy, ectopic pregnancy, or miscarriage. These events were relatively rare, and sample sizes limited the ability to detect such differences., Authors' Conclusions: The evidence suggests ultrasound guidance improves the chance of live birth/ongoing and clinical pregnancies compared with clinical touch, without increasing the chance of multiple pregnancy, ectopic pregnancy, or miscarriage. Methodological limitations included: only four studies reporting details of both computerised randomisation techniques and adequate allocation concealment, only four studies reported on the outcome of live birth, and none of the nine studies that reported on ongoing pregnancy reported on live birth, suggesting possible reporting bias. Adequate reporting of randomisation and allocation concealment will improve the quality of future studies. The primary outcome measure of future studies should be the reporting of live births per woman randomised.

Interest in the monitoring of heart rate variability (HRV) has increased recently, as it gives more detailed and immediate information about the level of stress than traditional behavioral or hypothalamus-pituitary-adrenal measures. In this study, we evaluated heart rate (HR) and parasympathetic HRV parameters to monitor cardiac stress responses to palpation per rectum (PPR) in lactating (LACT; n = 11) and nonlactating (NLACT; n = 12) dairy cows. Heart rate and HRV were recorded from 40 min before PPR until 120 min after it was completed. Heart rate, the root mean square of successive differences (RMSSD), and the high-frequency component (HF) of HRV were analyzed by examining 5-min time windows. To compare cardiac responses to PPR between groups, changes in HR and HRV parameters were calculated as area under the curve (AUC) for LACT and NLACT cows. An immediate increase in HR was detected during PPR in both LACT (+21.4 ± 2.4 beats/min) and NLACT cows (+20.6 ± 2.3 beats/min); however, no differences were found between groups on the basis of parameters of AUC. The increase in HR in both groups along with a parallel decrease in RMSSD (LACT cows: -5.2 ± 0.4 ms; NLACT cows: -5.1 ± 0.4 ms) and HF [LACT cows: -10.1 ± 0.8 nu (where nu = normalized units); NLACT cows: -16.9 ± 1.2 nu] during PPR indicate an increase in the sympathetic, and a decrease in the parasympathetic tone of the autonomic nervous system. The increase in RMSSD (LACT cows: +7.3 ± 0.7 ms; NL cows: +17.8 ± 2.2 ms) and in HF (LACT cows: +24.3 ± 2.6 nu; NLACT cows: +32.7 ± 3.5 nu) immediately after PPR indicated a rapid increase in parasympathetic activity, which decreased under the baseline values 10 min following PPR. The amplitude and the maximum RMSSD and HF values were greater in NLACT cows than in LACT animals, suggesting a higher short-term cardiac responsiveness of NLACT cows. However, the magnitude and the duration of the stress response were greater in LACT cows, as indicated by the analysis of AUC parameters (area under the HRV response curve and time to return to baseline). Cow response to the PPR was more prominent in parasympathetic HRV measures than in HR. Based on our results, the effect of PPR on the cows' cardiac stress responses may have an impact on animal welfare on dairy farms, and investigating the effect of lactation on the cardiac stress reactions could prove useful in modeling bovine stress sensitivity. Further research is needed to find out whether the differences due to lactation are physiological or management related., (Copyright © 2014 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Skeletal injury is a leading cause of chronic pain and long-term disability worldwide. While most acute skeletal pain can be effectively managed with nonsteroidal anti-inflammatory drugs and opiates, chronic skeletal pain is more difficult to control using these same therapy regimens. One possibility as to why chronic skeletal pain is more difficult to manage over time is that there may be nerve sprouting in nonhealed areas of the skeleton that normally receive little (mineralized bone) to no (articular cartilage) innervation. If such ectopic sprouting did occur, it could result in normally nonnoxious loading of the skeleton being perceived as noxious and/or the generation of a neuropathic pain state. To explore this possibility, a mouse model of skeletal pain was generated by inducing a closed fracture of the femur. Examined animals had comminuted fractures and did not fully heal even at 90+days post fracture. In all mice with nonhealed fractures, exuberant sensory and sympathetic nerve sprouting, an increase in the density of nerve fibers, and the formation of neuroma-like structures near the fracture site were observed. Additionally, all of these animals exhibited significant pain behaviors upon palpation of the nonhealed fracture site. In contrast, sprouting of sensory and sympathetic nerve fibers or significant palpation-induced pain behaviors was never observed in naïve animals. Understanding what drives this ectopic nerve sprouting and the role it plays in skeletal pain may allow a better understanding and treatment of this currently difficult-to-control pain state., (Copyright © 2014 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Background: Manual fetal manipulation has been suggested to improve the efficiency of antepartum fetal heart rate testing., Objectives: The objective of this review was to assess the merits or adverse effects of the use of manual fetal manipulation in conjunction with tests of fetal wellbeing., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013)., Selection Criteria: All published and unpublished randomised controlled trials assessing the use of fetal manipulation versus mock stimulation, no stimulation or other types of stimulation, used in conjunction with cardiotocography or other tests of fetal wellbeing., Data Collection and Analysis: Three review authors independently assessed studies for inclusion, assessed trial quality and extracted data. Data were checked for accuracy. We contacted authors of published and unpublished trials for further information., Main Results: We included four trials with a total of 1280 women with 2670 episodes of participation. No trial was at low risk of bias for all domains and only two trials were at low risk of bias for both selection and attrition bias.Fetal manual manipulation decreased the incidence of non-reactive antenatal cardiotocography test compared to mock or no stimulation. However, this was not statistically significant (average risk ratio (RR) 0.31, 95% confidence interval (CI) 0.02 to 6.20, I² = 96%; two trials, N = 2350). There was also no significant reduction in the mean testing time to achieve a reactive result (mean difference -2.29 minutes, 95% CI -9.61 minutes to 5.03 minutes, I² = 97%; two trials, N = 560).Comparing fetal manual manipulation with vibroacoustic stimulation, there was no significant difference in the incidence of non-reactive cardiotocography or the need for contraction-stress test.There were no data available on other outcomes such as perinatal mortality, fetal distress, maternal anxiety and gestation at delivery., Authors' Conclusions: There is insufficient evidence to support the use of manual fetal manipulation during cardiotocography or other tests of fetal wellbeing. More studies of manual fetal manipulation that utilises standardised protocol should be encouraged.

Objective: Palpation of brain stiffness is one of techniques that leads to successful neurosurgical procedures. In order to evaluate brain stiffness quantitatively, we studied the potential clinical applicability of a spherical indenting tactile sensor., Methods: The sensor had a spherical rigid indenter (diameter=5.0 mm; contact pressure=1.0 gf/mm2), and the indenter was rapidly pushed and pulled at a constant speed by a computer-controlled motor. The pressure-depth hysteresis curve was obtained using the sensor, and the shear elastic modulus (G) was calculated on the basis of the Hertz contact theory. We adopted the G-value at the maximum depth (G_max) as an indicator of brain stiffness., Results: First, to calibrate the sensor, we investigated the elasticity of silicone plates. The optimal settings for clinical application was an indenting speed of 1.5 mm/s and an indenting maximum depth of 2-3 mm. Next, we measured the elasticity of a decompressive site in 7 patients who had been stable for more than 21 days after undergoing decompressive craniectomy. The G_max of the decompressive site was 1.71 ± 0.75 kPa. Finally, we measured the intraoperative brain elasticity in a case of brain tumor with severe brain edema. The transdural elasticity of the edematous brain was G=4.87 kPa, and the direct elasticity of the brain surface decreased to G=4.34 kPa after dura incision., Conclusions: The spherical indentation method for measuring brain elasticity seems applicable to neurosurgical procedures.

This study aimed to measure the amount of microbial contamination caused by inspecting the lymph nodes of adult sheep carcasses for caseous lymphadenitis (CLA). Surface swabs from carcasses pre-inspection (N=296) and post-inspection (N=296) were obtained for enumeration of indicator organisms at three commercial abattoirs. At the scapular site, inspection doubled the probability of detecting E. coli (Pr before=0.35, Pr after=0.67) and increased the expected count of E. coli from 2 cfu/cm² to 13 cfu/cm². Inspection at the rump site increased the probability of detecting E. coli by 1.1 times (Pr before=0.84, Pr after=0.93) and increased the expected count from 32 cfu/cm² to 45 cfu/cm². Effects were also observed for Enterobacteriaceae and total viable count. The findings show that routine inspection of adult sheep carcasses for CLA has a detrimental impact on carcass microbiological traits., (Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.)

Background: Medial tibial stress syndrome (MTSS) is a common diagnosis. Several studies have demonstrated that excessive static navicular drop (ND) is related to the diagnosis. However, no studies have yet investigated ND and the velocity of ND during dynamic conditions. The aim of this study was to evaluate ND characteristics in patients with MTSS in dynamic and static conditions., Methods: In a case-control study, 14 patients diagnosed as having MTSS were included from an orthopedic outpatient clinic. A control group consisting of 14 healthy participants was matched regarding age, sex, and typical sporting activity. Navicular drop was evaluated during treadmill walking by a two-dimensional video analysis. Static foot posture, static ND, dynamic ND (dND), and velocity of dND were compared., Results: The two groups were comparable in relation to age, sex, height, weight, and foot size. No significant difference was found in static foot posture. Static ND showed a mean difference of 1.7 mm between the groups (P = .08). During treadmill walking, patients with MTSS had, on average, a 1.5-mm-larger dND (P =.004) and a 2.4-mm/sec-larger mean velocity of dND (P = .03)., Conclusions: Patients with MTSS display a larger ND and a higher ND velocity during treadmill walking. Increased ND velocity may be important to this condition. Future studies should include velocity of dND to investigate the mechanisms of dND in relation to overuse injuries.

Background: Many women undergoing an Assisted Reproductive Technology (ART) cycle will not achieve a live birth. Failure at the embryo transfer stage may be due to lack of good quality embryo/s, lack of uterine receptivity, or the transfer technique itself. Numerous methods, including the use of ultrasound guidance for proper catheter placement in the endometrial cavity, have been suggested as a more effective technique of embryo transfer. This review evaluates the effectiveness of ultrasound guided embryo transfer (UGET) compared with 'clinical touch' (CTET) the traditional method of embryo transfer., Objectives: To determine whether ultrasound guidance influences treatment outcomes in women undergoing embryo transfer (ET) during assisted reproductive technology (ART) cycles., Search Strategy: Electronic databases were searched in November 2009. We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched November 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2009), MEDLINE (1970-2009), EMBASE (1985-2009), BIO Extracts (1980-2009). Relevant conference proceedings were also hand searched (ASRM, ESHRE and FIGO)., Selection Criteria: Only randomised controlled trials were included., Data Collection and Analysis: Two reviewers independently assessed eligibility and quality of trials and extracted data from those selected., Main Results: This update identified 59 potential trials of which 42 were excluded. Data for analysis was available in seventeen studies. One study reported live births and personal communication resulted in data relating to this outcome being obtained in two additional studies. There is no evidence of a significant difference in the outcome of live birth (OR 1.14 (95%CI0.93 to 1.39; P=0.02) although heterogeneity was high (64%) and the results should be interpreted with caution. Seven studies reported on ongoing pregnancies. The ongoing pregnancies per woman randomised associated with UGET (441/1254) was significantly higher than for clinical touch (350/1218) OR 1.38, 95%CI 1.16 to 1.64, P<0.0003). No statistically significant differences in the incidence of adverse events were identified between the comparison groups. These events are relatively rare and sample sizes limit the ability to detect such differences., Authors' Conclusions: The studies are limited by their quality with only two studies reporting details of both computerised randomisation techniques and adequate allocation concealment. Ultrasound guidance does appear to improve the chances of live/ongoing and clinical pregnancies compared with clinical touch methods. The quality of future studies should be improved with adequate reporting of randomisation, allocation concealment, and power calculations. The primary outcome measure of future studies should be the reporting of live births per woman randomised.

This study evaluated whether reduced compression mammography to relieve breast tenderness is feasible. Women can better tolerate a compression force of approximately 90 N in mammography. The breast thickness increased approximately 3 mm when the compression force was reduced to 90 N, and although the radiation dose increased approximately 20%, the image quality was identical to that with standard compression. Many patients experience breast pain with a compression force of 120 N. Reduced compression force mammography is acceptable in women whose breasts are particularly sensitive.

Rectovaginal examination with gloves contaminated with vaginal secretions might increase the risk of human papillomavirus (HPV) inoculation of the rectum in women with genital HPV infections. Because of the high prevalence of asymptomatic genital HPV infections, and the association between HPV and colorectal malignancy, examination gloves should be changed between vaginal and rectal examinations.

Objectives: To compare transvaginal sonography for cervical length measurement and digital examination for Bishop score assessment in women undergoing labor induction at term, to assess their tolerability (in terms of pain) and ability to predict need for Cesarean delivery., Methods: A prospective study was performed on 249 women admitted for labor induction. Cervical length was measured using transvaginal ultrasound examination. A 10-point visual analog scale (VAS) for procedure-related pain was obtained. Bishop score was determined just before labor induction and another pain score was obtained. Delivery outcome was recorded. Analyses were by t-test, Fisher's exact test, receiver-operating characteristics (ROC) curves and multivariate logistic regression., Results: Transvaginal sonography was significantly less painful than digital examination for Bishop score assessment (mean difference in VAS score 3.46; P<0.001). Analyses of the ROC curves for cervical length and Bishop score indicated that both were predictors of Cesarean delivery (area under the curve 0.611 vs. 0.607; P=0.012 vs. P=0.015, respectively) with optimal cut-offs for predicting Cesarean delivery of >20 mm for cervical length and Bishop score20 mm (AOR 3.4; 95% CI, 1.4-8.1; P=0.006) were independent predictors of Cesarean delivery., Conclusions: Transvaginal sonography for cervical length measurement is better tolerated than digital examination for Bishop score assessment. Both cervical length and Bishop score are useful predictors of the need for Cesarean delivery following labor induction. A cervical length>20 mm at labor induction at term is an independent predictor of Cesarean delivery., (Copyright (c) 2007 ISUOG.)

Objective: To investigate whether a minor insult to the thyroid gland attributable to fine-needle aspiration (FNA) or external thyroid palpation can cause a release of serum thyroglobulin (Tg) into the circulation., Methods: We determined serum Tg levels before and at 60 minutes and 15 days after FNA in 25 patients with thyroid nodules. Results were compared with those obtained in 25 patients with thyroid nodules, in whom serum Tg concentrations were determined before and 60 minutes after palpation of the thyroid, and in 15 healthy subjects without thyroid disease, who had no thyroid palpation and no FNA, from whom 2 blood specimens were obtained 60 minutes apart. All participants had normal results of thyroid function tests and no detectable antithyroglobulin or thyroid peroxidase antibodies., Results: After FNA, 22 of 25 patients had significant elevation of serum Tg concentrations. The Tg levels returned to baseline values 15 days after FNA. In 4 of the 25 patients with thyroid nodules who had palpation of the thyroid, a significant increase in serum Tg levels was elicited. None of the 15 healthy subjects with normal thyroid glands (and with no FNA or thyroid palpation) had significant Tg elevations., Conclusion: FNA causes a significant increase in serum Tg concentrations, which may persist for 15 days. Therefore, Tg assay should not be scheduled prematurely after FNA.

Rectal tears are a relatively rare complication of rectal palpation, mating or dystocia, and idiopathic spontaneous occurrence of rectal perforation has also been described. Rectal tears have been classified in a three or a four-grade system. Immediate recognition of the fact that a tear has been made and prompt action will improve the horses chance of survival, and is the best defence of the veterinarian against legislation. There is no clear explanation why rectal tears sometimes occur. A questionnaire of the Netherlands Equine Veterinary Association revealed that rectal tears occurred both to inexperienced veterinarians and to very experienced colleagues, working with or without a probe for ultrasonography. In the opinion of the authors, the approach in the legislation of rectal tears should be that a rectal tear is only considered 'malpractice' if the veterinarian obviously acted carelessly. However, this would create the ridiculous situation that it seems better for the veterinarian-client relationship when the veterinarian confesses to 'careless' rectal palpation. This point needs further clarification, and perhaps an 'insurance of the horse for rectal palpation' will be the solution. Further, retrospectively over the last ten years, the problem is often not 'making a rectal tear', but 'lacking recognition of making a tear'. Whenever a rectal tear is suspected, the veterinarian must assess its severity, discuss the problem openly with the owner and apply appropriate treatment including referral.

A 6-year-old, primiparous standardbred mare was presented with a history of intestinal protrusion from the rectum shortly after parturition. A subacute grade IV rectal tear was diagnosed. The unusual nature of the tear led to speculation of a possible owner palpation accident. A grave prognosis was given and the mare was euthanized.

An epidemiological investigation of an outbreak of intestinal atresia in Israeli Holstein-Friesian newborn calves showed a linkage with rectal palpation for early pregnancy diagnosis, performed less than 42 days after insemination. The odds of an exposed calf, i.e., one born to a dam that was diagnosed by early palpation as having intestinal atresia were 119.7 times higher than one born in normal control herds (95% CI; 7.4-1946.3). A total of 682 calves-at-risk was recorded from mid-1998 to mid-2000 and a total of 47 calves (6.9%) were born with intestinal atresia during this period. Two forms of intestinal atresia were recognized at post-mortem: atresia coli and atresia ilei.

The aim of the present study was to evaluate possible injury provoked by an intensive reproductive programme based on rectal palpation in the cow. Alterations to the mesothelial surface of the peritoneum and to the oviductal mucosa were explored by scanning electron microscopy (SEM). Nine multiparous Friesian cows were selected from each of two commercial dairy herds. Cows in herd 1 were maintained on a weekly reproductive health programme, while those in herd 2 were not subjected to gynaecological exploration. Surface features of the mesothelial cells of the reproductive tract and adjacent ligaments, and the oviductal mucosa were explored by SEM observation of tissue specimens from each animal. Six cows in the intensive reproductive programme showed microscopic alterations of the peritoneal surface. Strands were observed in the oviducts and adjacent ligaments in five of these cows. These strands, composed of filaments covered with mesothelial cells, were probably adhesions. Cells with abundant vacuoles on their surface were detected in the mesothelium corresponding to three animals, two of which also showed microscopic strands. No peritoneal surface alterations were observed in the cows from herd 2. No oviductal mucosal modifications were detected in either group. These findings suggest that intensive reproductive programmes based on rectal palpation may increase the risk of peritoneal surface alterations in the cow, but effects on reproductive physiology are unlikely.

Unlabelled: The standard of care for patients following blunt trauma includes midline palpation of vertebrae to rule out fractures. Previous studies have demonstrated that spinal immobilization does cause discomfort., Objective: To determine whether spinal immobilization causes changes in physical exam findings over time., Methods: This was a single-blinded, prospective study at a tertiary care university teaching hospital. Twenty healthy volunteers without previous back pain or injuries, 13 male and seven female, were fully immobilized for one hour, with a cervical collar and strapped to a long wooden backboard. Midline palpation of vertebrae to illicit pain was performed at 10-minute intervals. In addition, the participants were asked to rate neck and back pain on a scale from 1 to 10 (1 for no pain, and 10 for unbearable pain), to see whether subjective pain from immobilization correlated with tenderness to palpation., Results: Three patients had point tenderness of cervical vertebrae within 40 minutes. Five patients developed point tenderness of vertebrae by 60 minutes. Eighteen of 20 participants complained of increasing discomfort over time. The median initial pain scale was 1 (range 1-1), in contrast to 4 (range 1-9) at 60 minutes, p < 0.05., Conclusion: This study shows that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness. In order to reduce this high false-positive rate for midline vertebral tenderness, the authors recommend that, initially on arrival to the emergency department, immediate evaluation occur of all immobilized patients. Furthermore, backboards should be modified to reduce patient discomfort to prevent the iatrogenically induced midline vertebral tenderness, thereby reducing subsequent false-positive examinations.

Objective: To investigate the influence of the traditional hands-on versus the innovative hands-poised method on the risk of perineal trauma during vaginal delivery and on neonatal outcomes., Study Design: In a prospective, randomized, multicenter study, 1,161 of 1,505 women giving birth at the Departments of Obstetrics and Gynecology of the University Hospital of Vienna and Semmelweis Women's Hospital, Vienna, between February and September 1999, were randomized into the trial. In the hands-on method, the left hand of the midwife puts pressure on the infant's head, and the right hand is placed against the perineum. In the hands-poised method, the midwife guides the parturient through the birth without touching the perineum, prepared to apply light pressure on the infant's head., Results: One hundred eighty-seven of 574 women (32.5%) in the hands-on group and 180 of 502 women (35.8%) in the hands-poised group experienced perineal tears (P = .5). Sixteen women (2.7%) treated with the hands-on method developed third-degree perineal tears as compared with five women (0.9%) treated with the hands-poised method (P < .05). In the hands-on group, 103 women (17.9%) underwent episiotomy as compared with 51 cases (10.1%) in the hands-poised group (P < .01). No significant differences in neonatal outcomes were observed between the two groups., Conclusion: Our data suggest that a policy of hands-poised care is more suitable for preserving the perineum during birth and is a safe and effective birthing alternative for women.

Background: Manual fetal manipulation has been suggested to improve the efficiency of antepartum fetal heart rate testing., Objectives: The objective of this review was to assess the merits or adverse effects of the use of manual fetal manipulation in conjunction with tests of fetal wellbeing., Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register in June 2001., Selection Criteria: All published and unpublished randomized controlled trials assessing the merits of the use of fetal manipulation in conjunction with tests of fetal wellbeing., Data Collection and Analysis: Both reviewers independently extracted data and assessed trial quality. Authors of published and unpublished trials were contacted for further information., Main Results: Only two trials with a total of 1090 women with 2110 episodes of participation were included. Manual fetal manipulation did not decrease the incidence of non-reactive antenatal cardiotocography test (odds ratio 1.28 confidence interval 0.94-1.74)., Reviewer's Conclusions: Manual fetal manipulation has not been shown to reduce the incidence of non-reactive cardiotocography. Trials of manual fetal manipulation should take into consideration that there have not been any benefits demonstrated as yet.

Objective: The purpose of this study was to examine the effects of digital cervical examination on maternal and neonatal outcomes among women with preterm rupture of membranes., Study Design: This analysis includes data from a previously reported trial of antibiotic treatment during expectant management of rupture of membranes at 24 to 32 weeks' gestation in singleton and twin gestations. Patients from both the randomized trial (n = 299 in the antibiotic group and n = 312 in the placebo group) and the observational component (n = 183) are included in this analysis. The groups were divided into those with one (n = 161) or two digital cervical examinations (n = 27) and those with no digital cervical examinations (n = 606)., Results: The gestational ages at enrollment were similar in the two groups (29 +/- 2 weeks' gestation for one or two examinations vs 29 +/- 2 weeks' gestation for no examinations; P =.85). There were no differences in chorioamnionitis (27% vs 29%; P =.69), endometritis (13% vs 11%; P =.5), or wound infection (0.5% vs 1%; P >.999) between the group with one or two examinations and the no-examination group. Infant outcomes were also similar in the two groups, including early sepsis (6% vs 5%; P =.68), respiratory distress syndrome (51% vs 45%; P =.18), intraventricular hemorrhage (7% vs 7%; P =.67), necrotizing enterocolitis (5% vs 3%; P =.19), and perinatal death (7% vs 5%; P =.45). A composite outcome made up of these neonatal outcomes was not different (56% vs 48%; P =.10) between the group with one or two examinations and the no-examination group. The time from rupture to delivery was shorter in the digital examination group (median value, 3 vs 5 days; P <. 009). Multivariable analysis to adjust for antibiotic study group, group B streptococcal culture status, race, and maternal transfer did not modify these results., Conclusion: Performance of one or two digital cervical examinations during the course of expectant management of rupture of membranes between 24 and 32 weeks' gestation was associated with shorter latency but did not appear to worsen either maternal or neonatal outcome.

We recently reviewed the Food Safety and Inspection Service's (FSIS's) inspection procedures for lambs. As a result, FSIS published a Federal Register notice informing the public of its intent to change from an inspection system that requires extensive carcass palpation to an inspection system that requires no carcass palpation for lambs. This decision was based on the following three points. (i) Extensive carcass palpation in lambs does not routinely aid in the detection of food safety hazards that result in meat-borne illnesses. (ii) Hands are capable of spreading or adding contamination to the carcasses. (iii) FSIS inspection systems must reflect science-based decisions as they pertain to meat-borne illnesses consistent with a Pathogen Reduction/Hazard Analysis and Critical Control Point environment.

The clinical evaluation of patients who present with painful anal conditions is often incomplete because of the need to avoid distress that digital examination engenders. Diagnosis is then based on the history and other findings on clinical examination. This is associated with a risk of missed and delayed diagnosis, delay in the initiation of appropriate therapy and the use of alternative investigation modalities which may not be necessary if full clinical evaluation had been done. In this communication, the experience with the use of caudal anaesthesia in the outpatient and ward setting to evaluate painful anal conditions is presented. The result shows that the technique is safe, and allows the immediate and complete evaluation of these conditions. The anaesthesia is short lasting and no morbidity was observed in this study.

Objective: To determine whether oncofetal fibronectin (fFN) assays from symptomatic women are influenced by digital examination of the cervix., Study Design: Cervicovaginal fFN specimens were obtained from women at 22-34 weeks' gestational age with symptoms of preterm labor immediately prior to a digital examination of the cervix and two hours after. Fetal fibronectin was assayed by a specific enzyme-linked immunoassay. Results were reported as positive (> or = 50 ng/mL) or negative (< 50 ng/mL). Paired initial and repeat fFN results were compared for statistical difference, and the clinical outcomes were used to assess the accuracy of the initial and repeat results., Results: Fifty symptomatic women at an average gestational age of 29.3 +/- 2.0 weeks were enrolled. Eighty-six percent of the repeat fFN results remained unchanged after a digital examination, (P = .26, beta = .2). The predictive value of a negative fFN obtained after a digital examination was 97% for the absence of spontaneous preterm delivery in < 8 or < 15 days. Two of 16 initially positive results became negative after an examination, and one patient delivered two days later. Five of 34 initially negative fFN results became positive after an examination, and 5/5 delivered more than seven days later., Conclusion: Digital examination of the cervix has an effect on fFN results. The routine use of fFN after a digital examination is not recommended.

Rebound tenderness is generally practiced in the diagnosis of acute abdominal pain. It is a test that inflicts much discomfort to the patient. Literature data derived from reports assessing the reliability of the diagnosis of acute appendicitis indicate a sensitivity of 0.78-0.91 (pooled: 0.91) and a specificity of 0.48-0.60 (pooled: 0.60) of rebound tenderness. It would appear that rebound tenderness is a test of little specificity (leading to many false positive results) and that it has very little additional value, particularly in the presence of local tenderness and/or rigidity in patients with acute abdominal pain.

Objective: To investigate the occurrence of referred pain (ReP) elicited by palpation (Pal-ReP) or by needle injection (Inj-ReP) of myofascial trigger point (MTrP), and to assess the correlated factors, including the pain intensity of an active MTrP and the occurrence of local twitch response (LTR)., Design: Correlational study., Patients: Ninety-five patients who were treated with MTrP injections., Intervention: MTrP injections., Main Outcome Measure: Pain intensity of MTrP and occurrence of Pal-ReP, Inj-ReP, and LTR., Results: Both Pal-ReP and Inj-ReP were elicited in 53.9% of MTrPs, Inj-ReP, but not Pal-ReP, was elicited in 33.7% of MTrPs. Both Pal-ReP and Inj-ReP were unobtainable in 12.3% of MTrPs. The occurrence of ReP was significantly correlated to the pain intensity of active MTrP and the occurrence of LTR., Conclusion: ReP could be elicited more frequently by needling than by palpation. The frequency of occurrence in ReP mainly depends on pain intensity of an active MTrP.

Rectal tears have important medicolegal implications, and severe tears have a poor prognosis. Prompt diagnosis, immediate application of first aid measures, early referral, use of appropriate definitive treatments, and aggressive aftercare will improve the prognosis. The grade of rectal injury will determine the definitive treatment, but there are few guidelines to determine which treatment is best in each case. Bypass procedures, such as colostomy and indwelling rectal liner, have their own advantages and disadvantages, but can facilitate healing and prevent life-threatening complications if they are used with minimum delay. Suture of the tear can be difficult, but should be attempted to hasten healing and to prevent progression of the tear to a more severe injury.

Objective: To evaluate the effect of a routine breast examination on serum PRL levels., Design: Prospective clinical study., Setting: University-based reproductive endocrinology unit., Patients: Eleven nonlactating, euprolactinemic women of reproductive age with a history of regular menstrual cycles and currently taking no medications., Interventions: Breast examination using standard technique., Main Outcome Measure: Changes in serum PRL levels after breast examination., Results: Baseline PRL levels ranged from 3.64 to 19.23 ng/mL (mean 7.17 ng/mL; conversion factor to SI unit, 1.00). There were no significant increases in PRL levels after breast examination, with mean PRL levels after 15, 30, and 45 minutes of 6.59, 6.84, and 6.45 ng/mL, respectively., Conclusion: Routine breast examination does not alter acutely serum PRL levels in normal women.

The object of the following study is a veterinary expert opinion about a llama mare. This animal was subjected to a rectal palpation for pregnancy diagnosis during which the rectum was perforated. General guide lines for rectal palpation as well as special characteristics in llamas described in the literature are discussed.

Background: Measurement of serum prostate-specific antigen (PSA) and digital rectal examination (DRE) are commonly used for prostate cancer screening. Clinicians have been advised to avoid measuring serum PSA after DRE because of the possibility of spurious elevation. However, studies in healthy volunteers have found no change. We sought to determine whether DRE performed by internists affects PSA levels in a primary care clinic population., Methods: Men older than 49 years enrolled in a Veterans Affairs internal medicine clinic were eligible for the study. For all patients, prostate size and nodularity were assessed by DRE. Blood for determination of PSA levels was drawn immediately before DRE and 30 minutes after DRE. All patients completed a questionnaire regarding voiding., Results: Two hundred two men aged 50 to 85 years (mean, 67 years) were enrolled and had complete data. The mean PSA level increased by 0.26 micrograms/L after DRE (P < .001). Six patients (2.9%; 95% confidence interval, 0.6% to 5.3%) had an increase in PSA level from less than 4 micrograms/L to more than 4 micrograms/L after DRE. There was a statistically significant but weak correlation between voiding score and PSA level (coefficient, .17; P = .02). Patients with an enlarged prostate gland had higher PSA levels than did patients with normal prostates or borderline results of examination. Nodularity did not predict an increased PSA level., Conclusions: We conclude, in an elderly veteran population, that DRE causes a statistically significant but clinically insignificant increase in serum PSA level. Additionally, we found that symptoms and physical examination results cannot be used to select a population for whom PSA screening would likely be useful.

The objective of this study was to estimate the effect on calving risk of interval from AI date until scheduled date of pregnancy examination. First AI (n = 7105) from 65 dairy herds in the United States and Canada were followed for 294 d to determine whether cows calved. Calving was modeled as a function of the number of days in the interval, herd, season, and breeding at PGF2 alpha-induced estrus by multivariate logistic regression. The main effects of herd and AI following PGF2 alpha-induced estrus were significantly associated with calving rate from first AI. The main effects of interval and season were not significantly associated with calving.

In 3 calves with irreducible umbilical swelling attributable to urachal cyst, ultrasonography was helpful in establishing a definitive diagnosis. After surgical resection of the persistent urachus, 2 calves recovered without complications. In 1 calf in which the urachus had ruptured subcutaneously during forceful diagnostic palpation, additional surgical debridement of severe skin necrosis, caused by subcutaneous accumulation of urine in the umbilical region, was required. Most irreducible masses of the umbilical area of calves can be classified as attributable to infection, hematoma, or incarcerated umbilical hernia. Urachal cyst should always be considered in the differential diagnosis of an irreducible umbilical mass. Careful palpation of the umbilicus is indicated to avoid the potential complication of iatrogenic rupture of a urachal cyst.