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Background: The cricothyroid membrane (CTM) is the most important anatomic structure when performing emergency front-of-neck access (FONA) procedures. Adolescence is a period of rapid morphologic change in laryngeal structures, including the CTM. We hypothesized that the adolescent CTM would be sufficiently different from pediatric or adult anatomy to merit special consideration in FONA., Objective: The aim of the study was to define the procedurally relevant CTM anatomy in an adolescent population., Methods: This was a retrospective, multicenter cohort study composed of patients who underwent a diagnostic computed tomography scan during routine clinical care. Inclusion criteria were ages 16 to 19 years and a computed tomography of the neck with or without contrast. The primary outcome was CTM height measured in the midsagittal plane using electronic calipers., Results: One hundred thirty-four imaging studies met inclusion criteria. The average CTM height was strongly associated with age and ranged between 5.4 and 6.2 mm in male adolescents and 4.6 and 5.8 mm in female adolescents. We predicted that standard cuffed endotracheal and tracheostomy tubes recommended for FONA procedures (5.0- and 6.0-mm devices) could potentially fail for most patients in our cohort., Conclusions: The adolescent CTM is smaller than previously recognized. We recommend having a variety of equipment sizes readily available at any site where airway management in adolescents may occur., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: A low first-pass success rate of radial artery cannulation was obtained when using the conventional palpation technique (C-PT) or conventional ultrasound-guided techniques, we; therefore, evaluate the effect of a modified long-axis in-plane ultrasound technique (M-LAINUT) in guiding radial artery cannulation in adults., Methods: We conducted a prospective, randomized and controlled clinical trial of 288 patients undergoing radial artery cannulation. Patients were randomized 1:1 to M-LAINUT or C-PT group at Fujian Medical University Union Hospital between 2017 and 2018. Radial artery cannulation was performed by 3 anesthesiologists with different experience. The outcome was the first and total radial artery cannulation success rates, the number of attempts and the cannulation time, and incidence of complications., Results: Two hundred eighty-five patients were statistically analyzed. The success rate of first attempt was 91.6% in the M-LAINUT group (n = 143) and 57.7% in the C-PT group (n = 142; P < .001) (odds ratio, 7.9; 95% confidence interval, 4.0-15.7). The total success rate (≤5 minutes and ≤3 attempts) in the M-LAINUT group was 97.9%, compared to 84.5% in the palpation group (P < .001) (odds ratio, 8.5; 95% confidence interval, 2.5-29.2). The total cannulation time was shorter and the number of attempts was fewer in the M-LAINUT group than that in the C-PT group (P < .05). The incidence of hematoma in the C-PT group was 19.7%, which was significantly higher than the 2.8% in the M-LAINUT group (P < .001)., Conclusions: Modified long-axis in-plane ultrasound-guided radial artery cannulation can increase the first and total radial artery cannulation success rates, reduce the number of attempts, and shorten the total cannulation time in adults.

Introduction: There is still a need for competent breast lump detection palpation skills, especially in developing countries. Our goal is to design, develop, and establish a test to determine whether students can, by touch alone, identify and discriminate between a range of different simulated lesions at different adiposity levels., Methods: Common lesions, breast cancers, and cysts were physically simulated and hidden in a test object referred to as the "tactile landscape" (TL). Ribs, intercostal muscle, and nodularity-normal anatomical features-increased their realistic complexity. Varying depths of features simulated varying degrees of adiposity. A testing protocol was created to determine the testee's ability to identify and discriminate different commonly occurring breast masses using palpation. Five experts (four breast surgeons and one general practitioner) and 20 inexperienced medical students were recruited and tested. Results were compared., Results: The TL has been based on previously verified breast models and has softness similar to 53% of women's breasts and nodularity similar to 60% as assessed in a breast clinic by breast surgeons. The five experts indicated that the simulated lesions felt like those they might encounter in clinical practice and all of them identified the lesions and nonlesions hidden in the TL 100% correctly, thus indicating the value of the model. In contrast, only one student was able to identify all the lesions. One student identified none of them. The remaining students mean score was 65%., Conclusions: All students but one performed poorly in comparison to the experts. This indicates that the test could be useful to test students' ability to identify and discriminate breast masses. If successful, it will add previously missing capability to the mix of assessment instruments already used, thus potentially improving clinical breast examination training and assessment.

What We Already Know About This Topic: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Success of a cricothyrotomy is dependent on accurate identification of the cricothyroid membrane. The objective of this study was to compare the accuracy of ultrasonography versus external palpation in localizing the cricothyroid membrane., Methods: In total, 223 subjects with abnormal neck anatomy who were scheduled for neck computed-tomography scan at University Health Network hospitals in Toronto, Canada, were randomized into two groups: external palpation and ultrasound. The localization points of the cricothyroid membrane determined by ultrasonography or external palpation were compared to the reference midpoint (computed-tomography point) of the cricothyroid membrane by a radiologist who was blinded to group allocation. Primary outcome was the accuracy in identification of the cricothyroid membrane, which was measured by digital ruler in millimeters from the computed-tomography point to the ultrasound point or external-palpation point. Success was defined as the proportion of accurate attempts within a 5-mm distance from the computed-tomography point to the ultrasound point or external-palpation point., Results: The percentage of accurate attempts was 10-fold greater in the ultrasound than external-palpation group (81% vs. 8%; 95% CI, 63.6 to 81.3%; P < 0.0001). The mean (SD) distance measured from the external-palpation to computed-tomography point was five-fold greater than the ultrasound to the computed-tomography point (16.6 ± 7.5 vs. 3.4 ± 3.3 mm; 95% CI, 11.67 to 14.70; P < 0.0001). Analysis demonstrated that the risk ratio of inaccurate localization of the cricothyroid membrane was 9.14-fold greater with the external palpation than with the ultrasound (P < 0.0001). There were no adverse events observed., Conclusions: In subjects with poorly defined neck landmarks, ultrasonography is more accurate than external palpation in localizing the cricothyroid membrane.

Background: Ultrasonography can accurately identify the cricothyroid membrane; however, its impact on the subsequent accuracy of external palpation is not known. In this study, we tested the ability of anesthesia participants to identify the midpoint of the cricothyroid membrane using external palpation with and without ultrasound (US)-guided practice., Methods: Following institutional ethics approval and informed consent, anesthesia participants consisting of anesthesia residents, fellows, and practicing anesthesia assistants underwent didactic teaching on neck landmarks. The participants were then randomized to practice palpation of neck landmarks with US guidance (US group) or without ultrasonography (non-US [NUS] group). After the practice session, each participant identified the cricothyroid membrane using external palpation on the neck of 10 volunteers and marked the anticipated entry point for device insertion (palpation point [PT]). The midpoint of the cricothyroid membrane of each volunteer had been premarked with invisible ink using ultrasonography (US point) by a separate member of the research team. The primary outcome was the accuracy rate defined as the percentage of the attempts with the distance ≤5 mm measured from the PT to US point for the participant. The primary outcome was compared between NUS and US groups using Wilcoxon rank sum test. A mixed-effect logistic regression or mixed-effect linear model was also conducted for outcomes accounting for the clustering and adjusting for potential confounders., Results: Fifteen anesthesia participants were randomized to US (n = 8) and NUS (n = 7) groups. A total of 80 and 61 attempts were performed by the US and NUS groups, respectively. The median accuracy rate in the US group was higher than the NUS group (65% vs 30%; P = .025), and the median PT-US distance in the US group was shorter than in the NUS group (4.0 vs 8.0 mm; P = .04). The adjusted mean PT-US distance in the US group was shorter compared to the NUS group (adjusted mean [95% CI], 3.6 [2.9-4.6] vs 6.8 [5.2-8.9] mm; P < .001)., Conclusions: Anesthesia participants exposed to practice with US-guided palpation of the cricothyroid membrane location were better able to identify the cricothyroid membrane using only blind palpation than participants without US-guided practice. Practice with US-guided palpation of neck landmarks improves subsequent blind localization of the cricothyroid membrane using palpation alone.

Objective: Our objective was to describe the sonographic appearance of fluid at clinically selected interspinous spaces and see if additional interspaces could be identified as suitable and safe targets for needle insertion. We also measured the reproducibility of fluid measurements and assessed for positional differences., Methods: A prospective convenience sample of infants younger than 3 months was enrolled in the pediatric emergency department. Excluded were clinically unstable infants or those with spinal dysraphism. Infants were first held in standard lateral lumbar puncture position. Pediatric emergency medicine (PEM) physicians marked infants' backs at the level they would insert a needle using the landmark palpation technique. A PEM sonologist imaged and measured the spinal fluid in 2 orthogonal planes at this marked level in lateral then sitting positions. Fluid measurements were repeated by a second blinded PEM sonologist., Results: Forty-six infants were enrolled. Ultrasound verified the presence of fluid at the marked level as determined by the landmark palpation technique in 98% of cases. Ultrasound identified additional suitable spaces 1 space higher (82%) and 2 spaces higher (41%). Intraclass correlation coefficient of all measurements was excellent (>0.85), with differences noted for sitting versus lateral position in mean area of fluid 0.34 mm versus 0.31 mm (difference, 0.03; 95% confidence interval [CI], 0.005-0.068), dorsal fluid pocket 0.23 mm versus 0.15 mm (difference, 0.08; 95% CI, 0.031-0.123), and nerve root-to-canal ratio 0.44 versus 0.51 (difference, 0.07; 95% CI, 0.004-0.117)., Conclusions: Ultrasound can verify the presence of fluid at interspaces determined by the landmark palpation technique and identify additional suitable spaces at higher levels. There were statistically greater fluid measurements in sitting versus lateral positions. These novel fluid measurements were shown to be reliable.

Background: Radial arterial cannulation is most commonly done using palpation, but the use of ultrasound has increased the cannulation success rate. This improvement, albeit significant, has not led to a very high success rate especially in trainees. A modified ultrasound technique for vascular cannulation (dynamic needle tip positioning) has been described for peripheral venous cannulation. We therefore assessed the success rate of this technique compared to the palpation technique for radial artery cannulation in adult surgical patients., Methods: We enrolled patients who were having nonemergent operations that required a radial arterial catheter for intraoperative monitoring. Patients were randomized to either palpation or dynamic needle tip positioning technique. Arterial cannulation was performed by anesthesia residents or faculty members. The primary end point was successful cannulation on the first pass. Secondary end points were overall 5-minute success rate and number of attempts within 5 minutes., Results: Two hundred sixty patients were evaluated. The first-pass success rate was 83% in the dynamic needle tip positioning technique group (n = 132) and 48% in the palpation group (n = 128; P < .001); relative risk was 2.5; 95% confidence interval, 1.7-3.6. The overall 5-minute success rate was 89% in the dynamic needle tip positioning technique group compared to 65% in the palpation group (P < .001), relative risk was 2.4; 95% confidence interval, 1.2-1.6. The number of skin puncture attempts was significantly more in the palpation group (P < .001). The median cannulation times and interquartile ranges were 81.5 (61-122) seconds in the dynamic needle tip positioning and 76 (48-175) seconds (P = .7) in the palpation group., Conclusions: The use of the ultrasound-guided dynamic needle tip positioning technique increased the first and overall success rates compared to palpation in anesthesia residents and faculty members.

Objective: Develop new performance evaluation standards for the clinical breast examination (CBE)., Summary Background Data: There are several, technical aspects of a proper CBE. Our recent work discovered a significant, linear relationship between palpation force and CBE accuracy. This article investigates the relationship between other technical aspects of the CBE and accuracy., Methods: This performance assessment study involved data collection from physicians (n = 553) attending 3 different clinical meetings between 2013 and 2014: American Society of Breast Surgeons, American Academy of Family Physicians, and American College of Obstetricians and Gynecologists. Four, previously validated, sensor-enabled breast models were used for clinical skills assessment. Models A and B had solitary, superficial, 2 cm and 1 cm soft masses, respectively. Models C and D had solitary, deep, 2 cm hard and moderately firm masses, respectively. Finger movements (search technique) from 1137 CBE video recordings were independently classified by 2 observers. Final classifications were compared with CBE accuracy., Results: Accuracy rates were model A = 99.6%, model B = 89.7%, model C = 75%, and model D = 60%. Final classification categories for search technique included rubbing movement, vertical movement, piano fingers, and other. Interrater reliability was (k = 0.79). Rubbing movement was 4 times more likely to yield an accurate assessment (odds ratio 3.81, P < 0.001) compared with vertical movement and piano fingers. Piano fingers had the highest failure rate (36.5%). Regression analysis of search pattern, search technique, palpation force, examination time, and 6 demographic variables, revealed that search technique independently and significantly affected CBE accuracy (P < 0.001)., Conclusions: Our results support measurement and classification of CBE techniques and provide the foundation for a new paradigm in teaching and assessing hands-on clinical skills. The newly described piano fingers palpation technique was noted to have unusually high failure rates. Medical educators should be aware of the potential differences in effectiveness for various CBE techniques.

Objective: To achieve a statistical estimate of the agreement of manual palpation for identification of myofascial trigger points (MTrPs) and secondarily to investigate potential factors impacting the agreement of this technique., Methods: We searched MEDLINE(R) and Embase for studies examining the reproducibility of manual palpation for the identification of MTrPs from the year 2007 to present. In addition, we utilized studies identified by 2 comprehensive systematic reviews that covered the period before 2007. The included studies were original peer-reviewed research articles and included Cohen κ measures or data with which to calculate Cohen κ. Studies were excluded if they lacked a measure of variability or information required to calculate variability. Studies that examined palpation through body cavities were also excluded. Of the 18 potentially relevant articles only 6 met inclusion criteria including 363 patients. Modified QUADAS tool was used to assess study validity. Subgroup comparisons were made utilizing Q and Z tests., Results: An estimate of κ=0.452 (95% confidence interval, 0.364-0.540) was obtained for interrater agreement of manual palpation of MTrPs. Localized tenderness (κ=0.676) and pain recognition (κ=0.575) were the most reliable criteria. Only 1 study met inclusion criteria for intrarater agreement and therefore no meta-analysis was performed., Discussion: Use of manual palpation for identification of MTrPs is unreliable, and future investigation should focus on integration with more reliable techniques.

Objectives: To identify the negative predictive value of examination under anesthesia (EUA) for determining pelvic ring stability and union without further displacement., Design: Retrospective cohort study., Setting: Two academic Level 1 trauma centers., Patients/participants: Thirty-four adult patients with closed pelvic ring injuries treated over a 5-year period., Interventions: Pelvic stress EUA., Main Outcome Measures: Pelvic ring union and pelvic ring displacement at final follow-up., Results: Thirty-four patients with closed pelvic ring injuries who underwent pelvic EUA during the study period and had a negative examination (indicating a stable pelvis) were identified. Mean age was 38 years (range 16-76), and 19 patients (55.9%) were male. Twenty-two patients (64.7%) had Young-Burgess lateral compression (LC)-1 injuries with complete sacral fractures, 4 patients (11.8%) had LC-2 injuries, and 8 patients (23.5%) had anteroposterior compression (APC)-1 injuries. Eight patients (23.5%) had associated injuries requiring restricted weight-bearing on one or both lower extremities and were excluded from the analysis. Immediate weight-bearing as tolerated was permitted bilaterally in the remaining 26 patients. Mean pelvic ring displacement at the time of injury was 3.8 mm (range 1-15 mm) for LC injuries and 9.1 mm (range 2-20 mm) for APC injuries. Patients were followed for a mean of 8 months (range 3-34 months). At final follow-up, mean displacement was 3.7 mm (range 0-17 mm) for LC injuries and 7.1 mm (range 2-19 mm) for APC injuries. Mean change in displacement from injury to union was -0.1 mm for LC injuries and -2.0 mm for APC injuries, indicating decreased pelvic ring displacement at union. All patients were able to tolerate full weight-bearing bilaterally with no pain, and there were no instances of delayed operative fixation after negative EUA., Conclusions: Negative pelvic EUA after closed pelvic ring injury accurately predicts pelvic stability and union without displacement after nonoperative treatment with full weight-bearing bilaterally. Unless otherwise dictated by associated injuries, immediate weight-bearing as tolerated seems safe in patients with pelvic ring injuries who have had a negative EUA., Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Misidentification of the cricothyroid membrane in a "cannot intubate-cannot oxygenate" situation can lead to failures and serious complications. The authors hypothesized that preprocedure ultrasound-guided identification of the cricothyroid membrane would reduce complications associated with cricothyrotomy., Methods: A group of 47 trainees were randomized to digital palpation (n = 23) and ultrasound (n = 24) groups. Cricothyrotomy was performed on human cadavers by using the Portex device (Smiths Medical, USA). Anatomical landmarks of cadavers were graded as follows: grade 1-easy = visual landmarks; 2-moderate = requires light palpation of landmarks; 3-difficult = requires deep palpation of landmarks; and 4-impossible = landmarks not palpable. Primary outcome was the complication rate as measured by the severity of injuries. Secondary outcomes were correct device placement, failure to cannulate, and insertion time., Results: Ultrasound guidance significantly decreased the incidence of injuries to the larynx and trachea (digital palpation: 17 of 23 = 74% vs. ultrasound: 6 of 24 = 25%; relative risk, 2.88; 95% CI, 1.39 to 5.94; P = 0.001) and increased the probability of correct insertion by 5.6 times (P = 0.043) in cadavers with difficult and impossible landmark palpation (digital palpation 8.3% vs. ultrasound 46.7%). Injuries were found in 100% of the grades 3 to 4 (difficult-impossible landmark palpation) cadavers by digital palpation compared with only 33% by ultrasound (P < 0.001). The mean (SD) insertion time was significantly longer with ultrasound than with digital palpation (196.1 s [60.6 s] vs. 110.5 s [46.9 s]; P < 0.001)., Conclusion: Preprocedure ultrasound guidance in cadavers with poorly defined neck anatomy significantly reduces complications and improves correct insertion of the airway device in the cricothyroid membrane.

Objective: The objective of this study was to compare the quantitative and qualitative shear-wave elastographic (SWE) features of breast cancers with mechanical elasticity and histopathologic characteristics., Materials and Methods: This prospective study was conducted with institutional review board approval, and written informed consent was obtained. Shear-wave elastography was performed for 30 invasive breast cancers in 30 women before surgery. The mechanical elasticity of a fresh breast tissue section, correlated with the ultrasound image, was measured using an indentation system. Quantitative (maximum, mean, minimum, and standard deviation of elasticity in kilopascals) and qualitative (color heterogeneity and presence of signal void areas in the mass) SWE features were compared with mechanical elasticity and histopathologic characteristics using the Pearson correlation coefficient and the Wilcoxon signed rank test., Results: Maximum SWE values showed a moderate correlation with maximum mechanical elasticity (r = 0.530, P = 0.003). There were no significant differences between SWE values and mechanical elasticity in histologic grade I or II cancers (P = 0.268). However, SWE values were significantly higher than mechanical elasticity in histologic grade III cancers (P < 0.001), which have low amounts of fibrosis, high tumor cellularity, and intratumoral necrosis. In addition, color heterogeneity was correlated with intratumoral heterogeneity of mechanical elasticity (r = 0.469, P = 0.009). Signal void areas in the masses were present in 43% of breast cancers (13 of 30) and were correlated with dense collagen depositions (n = 11) or intratumoral necrosis (n = 2)., Conclusions: Quantitative and qualitative SWE features reflect both the mechanical elasticity and histopathologic characteristics of breast cancers.

Objectives: To compare test-retest variability of palpation between a new palpometer and manual palpation using (1) right or left hand, (2) index or middle finger, (3) randomized or fixed sequence of force levels, (4) palpation on soft or hard surface, and (5) palpation for 2 or 10 seconds., Methods: Twelve clinicians were instructed to target 0.5, 1.0, and 2.0 kg on a force meter using a palpometer (adjustable spring-coil with a small pin touching the examiner's hand when the correct pressure is achieved) and manual palpation with right or left hand, index or middle finger, randomized or fixed sequence of force levels, on hard or soft surface, and for 2 or 10 seconds. During all experiments, 10 force measures were taken and variability was determined as coefficient of variation (CV) and compared with analyses of variance., Results: In all experiments, the palpometer had lower variability compared with manual palpation (P<0.001). There were no differences between the CVs of right and left hand (P=0.122), index and middle finger (P=0.240), and soft and hard surface (P=0.240). Random sequence of force levels had higher CVs than fixed sequence with manual palpation (P=0.004), but not with palpometer (P=0.856). CVs for 2 seconds palpation were higher than 10 seconds (P=0.002)., Conclusions: The palpometer had low test-retest variability and provided a more accurate and reproducible pressure stimulus than manual palpation. The findings of this study may help to standardize palpation of human muscles required for accurate and reliable diagnosis of musculoskeletal pain conditions.

Purpose: Although ultrasound (US)-guided subacromial injection has shown increased accuracy in needle placement, whether US-guided injection produces better clinical outcome is still controversial. Therefore, this study aimed to compare the efficacy of subacromial corticosteroid injection under US guidance with palpation-guided subacromial injection in patients with chronic subacromial bursitis., Methods: Patients with chronic subacromial bursitis were randomized to a US-guided injection group and a palpation-guided injection group. The subjects in each group were injected with a mixture of 0.5 mL dexamethasone suspension and 3 mL lidocaine into the subacromial bursa. The primary outcome measures were the visual analog scale for pain and active and passive ranges of motion of the affected shoulder. Secondary outcome measures were the Shoulder Pain and Disability Index, the Shoulder Disability Questionnaire, and the 36-item Short-Form Health Survey (SF-36). The primary outcome measures were evaluated before, immediately, 1 wk, and 1 month after the injection; the secondary outcome measures were evaluated before, 1 wk, and 1 month after the injection., Results: Of the 145 subjects screened, 46 in each group completed the study. Significantly greater improvement in passive shoulder abduction and in physical functioning and vitality scores on the SF-36 were observed in the US-guided group. The pre- and postinjection within-group comparison revealed significant improvement in the visual analog scale for pain and range of motion, as well as in the Shoulder Pain and Disability Index, Shoulder Disability Questionnaire, and SF-36 scores, in both groups., Conclusions: The US-guided subacromial injection technique produced significantly greater improvements in passive shoulder abduction and in some items of the SF-36. US is effective in guiding the needle into the subacromial bursa in patients with chronic subacromial bursitis.

Objective: The aim of this study was to investigate the effectiveness of device-assisted ultrasound-guided steroid injection for treating plantar fasciitis., Design: An ultrasound-guided injection device designed with space for securing a transducer and syringe was used to guide steroid injection. Patients with unilateral plantar fasciitis were enrolled and randomly divided into device-assisted ultrasound-guided and palpation-guided groups. Pain intensity was measured using a visual analog scale and tenderness threshold. Ultrasound and pain intensity evaluations were performed before injection and at 3 wks and at 3 mos postinjection. Betamethasone (7 mg) and 1% lidocaine (0.5 ml) were injected into the inflamed plantar fascia., Results: Thirty-three patients who received either device-assisted ultrasound-guided or palpation-guided injection had significantly lower visual analog scale scores (P < 0.001) and higher tenderness threshold (P < 0.01) postinjection. However, the device-assisted group had higher tenderness threshold (9.02 ± 1.38 vs. 7.18 ± 2.11 kg/cm; P = 0.007), lower visual analog scale score (1.88 ± 2.13 vs. 3.63 ± 2.60; P = 0.046), and lower hypoechogenicity incidence in the plantar fascia (3/16 vs. 9/16; P = 0.033) than the palpation-guided group did at 3 mos postinjection. The heel pad was significantly thin (P = 0.004) in the palpation-guided group postinjection., Conclusions: Device-assisted ultrasound-guided injection for treating plantar fasciitis results in better therapeutic outcomes than palpation-guided injection does.

Background: The cricothyroid membrane (CTM) is the recommended site of access to the airway during cricothyroidotomy to provide emergency oxygenation. Despite the apparent simplicity of the technique, this rescue maneuver frequently fails to achieve its goals and complications are numerous. The reasons for this failure are unclear. We sought to determine the ability of physicians to correctly identify the CTM in female patients., Methods: Using fluorescent "invisible" ink, the physician was asked to mark the CTM with the patient in the supine neutral position and then with the head extended. The actual level was identified using ultrasound and the distance between the actual and estimated margin of the CTM was measured. A correct estimation was defined as a mark made between the upper and lower limits of the membrane and within 5 mm of midline. Participants were also asked to assess the ease of CTM palpation using a 10-cm visual analog scoring (VAS) scale., Results: Fifty-six patients participated of whom 15 were obese. In the supine neutral neck position, the CTM was identified in 10/41 vs 0/15 (P = 0.048) in nonobese versus obese, respectively. Of the 46 incorrectly identified CTMs in this position, 24 were above (maximum 3 cm) and 22 below (maximum 3 cm) the actual level. Similar results were observed when the patients were placed with the neck in the extended position; the CTM was identified correctly in 12/41 vs 1/15 nonobese and obese patients, respectively. The range of values was also extensive; the estimation of the position of the membrane was as high as 2.5 cm above and 4 cm below the actual level, and up to 1.6 cm laterally. Participating doctors found palpation of the CTM subjectively more difficult in the obese than nonobese groups; VAS score for palpation difficulty was 5.25 ± 2.5 vs 3.3 ± 2.5, respectively, P = 0.005. Using multiple linear regression, VAS scores for palpation correlated negatively with increased patient height (P < 0.001) and greater thyromental distance (P = 0.006), and correlated positively with increased sternomental distance (P = 0.011) and neck circumference (P = 0.001)., Conclusions: Misidentification of the CTM in female patients is common and its localization is less precise in those who are obese. This has implications for the likely success of invasive airway access via the CTM.

A partial splenectomy is a good way to prevent postsplenectomy infections by preservation of the immune role of the spleen for select patients. Although a laparoscopic total splenectomy is a safe and feasible treatment modality, the laparoscopic approach has not been generally adopted for a partial splenectomy because of technical difficulties. The hand-assisted technique provides an excellent means to explore, to retract safely, and to apply immediate hemostasis in solid organ resection. The hand-assisted laparoscopic partial splenectomy using an endopath monopolar sealer (Salient EndoSH2.0 Monopolar Sealer) was performed successfully. The segmental arteries and veins were isolated and divided using a tactile feedback. Splenic parenchyma was dissected and sealed using an endopath monopolar sealer. The surgical field was almost bloodless during the parenchymal transection and the transection time was around 15 minutes. The hand-assisted laparoscopic approach allows partial splenectomy as a safe and bloodless surgery for select patients.

For reasons unknown, temporomandibular disorder (TMD) can manifest as localized pain or in conjunction with widespread pain. We evaluated relationships between cytokines and TMD without or with widespread palpation tenderness (TMD-WPT or TMD+WPT, respectively) at protein, transcription factory activity, and gene levels. Additionally, we evaluated the relationship between cytokines and intermediate phenotypes characteristic of TMD and WPT. In a case-control study of 344 females, blood samples were analyzed for levels of 22 cytokines and activity of 48 transcription factors. Intermediate phenotypes were measured by quantitative sensory testing and questionnaires asking about pain, health, and psychological status. Single nucleotide polymorphisms (SNPs) coding cytokines and transcription factors were genotyped. TMD-WPT cases had elevated protein levels of proinflammatory cytokine monocyte chemotactic protein (MCP-1) and antiinflammatory cytokine interleukin (IL)-1ra, whereas TMD+WPT cases had elevated levels of proinflammatory cytokine IL-8. MCP-1, IL-1ra, and IL-8 were differentially associated with experimental pain, self-rated pain, self-rated health, and psychological phenotypes. TMD-WPT and TMD+WPT cases had inhibited transcription activity of the antiinflammatory cytokine transforming growth factor β1 (TGFβ1). Interactions were observed between TGFβ1 and IL-8 SNPs: an additional copy of the TGFβ1 rs2241719 minor T allele was associated with twice the odds of TMD+WPT among individuals homozygous for the IL-8 rs4073 major A allele, and half the odds of TMD+WPT among individuals heterozygous for rs4073. These results demonstrate how pro- and antiinflammatory cytokines contribute to the pathophysiology of TMD and WPT in genetically susceptible people. Furthermore, they identify MCP-1, IL-1ra, IL-8, and TGFβ1 as potential diagnostic markers and therapeutic targets for pain in patients with TMD., (Published by Elsevier B.V.)

Introduction: The incorporation of haptics, the sense of touch, into medical simulations increases their capabilities by enabling the users to "feel" the virtual environment. We are involved with haptics-augmented virtual reality training for palpatory diagnosis. We have developed a stiffness discrimination program to train and test users in finding subtle differences in human tissue stiffness for medical diagnoses. In this article, we studied the effect of surface stiffness on the stiffness discrimination task and analyzed the palpation force and speed during haptic exploration., Methods: The ability to discriminate stiffness differences was studied by means of a psychophysical experiment with 13 second-year medical students (eight women and five men). Subjects were asked to identify the stiffer of two virtual computer-generated surfaces (top surfaces of two cylinders) by means of a PHANToM Omni (SensAble Inc.) haptic device with a modified stylus to accommodate their fingers. The modification of the stylus provided the mechanical advantage to simulate surface stiffness values that are beyond the original capability of the haptic device. An adaptive two-alternative forced-choice procedure was used on each trial. Palpation velocity and force vectors were recorded directly from the haptic device for further analyses. Weber fraction was determined by using an automated mastery algorithm., Results: Four standard stiffness values (0.25, 0.50, 1.00, and 1.25 N/mm), typical of the stiffness range of human soft tissues, were used as references. The average experimental Weber fractions observed were 0.20, 0.27, 0.26, and 0.30, respectively, with higher Weber fractions corresponding to lower stiffness discrimination ability. At 1.00 and 1.25 N/mm standard stiffness, the correlation analysis for Weber fraction and the palpation speed revealed significant differences (P < 0.05). These differences suggested that the subjects with a higher palpation velocity tended to have a higher Weber fraction. There was no significant difference between male and female subjects. There was no significant difference between subjects new to the haptic device and those who had used it previously. The average amount of force that was applied by the subjects to the standard stiffness side and the comparison stiffness side within the sessions was not significantly different. However, the subjects increased the average force they applied with increasing standard stiffness value across the sessions (P < 0.05)., Conclusions: For the four standard stiffness values investigated, 0.25, 0.50, 1.00, and 1.25 N/mm, the resulting average stiffness-discrimination Weber fractions were 0.20, 0.27, 0.26, and 0.30, respectively. The average of the forces applied by the subjects was constant within a single session (with a single standard stiffness value). This average force monotonically increased as the standard stiffness value increased across the sessions. We also found positive correlation between the Weber fraction and the palpation speed in the sessions tested with 1.00 and 1.25 N/mm standard stiffness. This correlation suggested that higher speed is related to lower sensitivity in discrimination of stiffness differences for these two standard stiffness values. Our results are applicable to tasks involving stiffness discrimination between multiple objects.

Introduction: Prostate carcinoma (and other prostate irregularities and abnormalities) is detected in part via the digital rectal examination. Training clinicians to use particular palpation techniques may be one way to improve the rates of detection., Methods: In an experiment of 34 participants with clinical backgrounds, we used a custom-built simulator to determine whether certain finger palpation techniques improved one's ability to detect abnormalities smaller in size and dispersed as multiples over a volume. The intent was to test abnormality cases of clinical relevance near the limits of size perceptibility (ie, 5-mm diameter). The simulator can present abnormalities in various configurations and record finger movement. To characterize finger movement, four palpation techniques were quantitatively defined (global finger movement, local finger movement, average intentional finger pressure, and dominant intentional finger frequency) to represent the qualitative definitions of other researchers., Results: Participants who used more thorough patterns of global finger movement (V and L) ensured that the entire prostate was searched and detected more abnormalities. A higher magnitude of finger pressure was associated with the detection of smaller abnormalities. The local finger movement of firm pressure with varying intensities was most indicative of success and was required to identify the smallest (5-mm diameter) abnormality. When participants used firm pressure with varying intensities, their dominant intentional finger frequency was about 6 Hz., Conclusions: The use of certain palpation techniques does enable the detection of smaller and more numerous abnormalities, and we seek to abstract these techniques into a systematic protocol for use in the clinic.

Study Design: Retrospective radiographic review., Objective: To determine the utility of the mandibular angle as a landmark for identification of cervical spinal level., Summary of Background Data: Improper localization of the skin incision during anterior cervical spine surgery may lead to increased technical difficulty of the surgery. Although the use of traditional palpable anterior neck landmarks (hyoid bone, cricoid cartilage, thyroid cartilage, and carotid tubercle) help identify appropriate spinal levels, their reliability has not been validated in actual surgeries. We hypothesize that the angle of the mandible (AM) is a consistently palpable landmark, and that the mandible can be used to accurately template the distance to subaxial cervical levels using preoperative radiographs., Methods: As a pilot study, we prospectively evaluated 30 consecutive patients who underwent anterior cervical diskectomy and fusion to assess the interobserver accuracy of palpating the mandibular angle, hyoid, carotid tubercle, and thyroid and cricoid cartilages. In a second set of 26 consecutive patients undergoing anterior cervical diskectomy and fusion, we then retrospectively reviewed standing preoperative lateral plain radiographs of the cervical spine, in addition to supine lateral cervical spine radiographs taken at the time of surgery, to assess: (1) the position of the AM relative to the corresponding cervical spinal level, and (2) whether or not the position of the AM relative to the subaxial cervical levels is different on preoperative standing films and intraoperative supine films. In these same 26 patients, we also measured the vertical distance between the AM and the location of each subaxial intervertebral disc space. These measurements were repeated for the hyoid bone as a control for each patient., Results: The interobserver accuracy was 100% between observers for identifying the AM, hyoid bone, thyroid cartilage, and cricothyroid membrane, and 93% for carotid tubercle. The frequency with which anterior neck landmarks were palpable by the surgeon and assisting senior residents was as follows: AM (100%), hyoid bone (83%), thyroid cartilage and cricothyroid membrane (93%), and carotid tubercle (Surgeon: 63%, Resident: 57%, P = 0.79). There was 100% correlation between the position of the mandibular angle in the preoperative standing lateral radiograph and the intraoperative supine lateral radiograph, compared with 65% with the hyoid bone. The distances between the AM or hyoid to each disc space did not vary significantly between preoperative and intraoperative radiographs (P > 0.05)., Conclusion: The mandibular angle was shown to be the most consistently palpable landmark. Further, the distance from the mandible, measured on preoperative plain lateral cervical spine radiographs, is an accurate template to determine cervical spine levels during anterior cervical spine surgery.

Objective: To compare ultrasound (US)-guided radial artery cannulation with the traditional palpation technique., Design: : Prospective randomized study., Setting: Operating room in a tertiary care pediatric center., Patients: One hundred fifty-two children under 18 yrs of age requiring radial artery cannulation., Interventions: Patients were randomized to either 1) palpation or 2) US guidance technique for radial artery cannulation., Measurements and Main Results: The primary end point of the study was the time taken for attempted cannulation by the first operator at the first site. Secondary end points included the number of attempts at arterial cannulation, the number of cannulae used, and the need for additional assistance from another anesthesiologist. Eighty and 72 children were randomized to the palpation and the US-guided groups, respectively. There were no statistically significant differences in age, gender, weight, and systolic blood pressure between the two study groups. The designated first operator (20 pediatric subspecialty trainees and eight consultant anesthesiologists) had previous experience in US-guided arterial cannulation in <10 cases, with 94% having experience in <5 cases. Although the radial artery was eventually cannulated in all patients, the designated operator was successful at the first site of cannulation in only 66% and 69% in the palpation and US groups, respectively. There were no statistically significant differences between the groups in time to successful cannulation, total number of attempts, number of successful cannulations during the first attempt, or in the number of cannulae used for catheterization., Conclusions: US guidance did not facilitate faster cannulation of the radial artery in children in our study.

Background: Palpation has been shown to be inaccurate at identifying lumbar interspinous spaces. Our goal in this study was to compare ultrasound imaging of the region to palpation., Methods: Using ultrasound in the postpartum period, we estimated the interspinous level used for obstetric neuraxial anesthesia in 121 women and compared this estimation with the level estimated by palpation and documented in the chart by the anesthesiologist., Results: In 67 of 121 (55%) patients, the vertebral level of the puncture mark documented by the treating anesthesiologist was in agreement with vertebral level as assessed using ultrasound, and in 39 (32%) women, the skin puncture level was estimated by ultrasound to be at least one interspace higher. The unweighted kappa was 0.08 (95% confidence interval: 0.02, 0.14)., Conclusions: There was poor agreement between palpation and ultrasound estimation of the specific lumbar interspace, and when there was disagreement, the ultrasound estimate was more often higher than the palpitation estimate.

The aim of this study was to evaluate the use of computerized cuff pressure algometry (CPA) in fibromyalgia (FM) and to correlate deep-tissue sensitivity assessed by CPA with other disease markers of FM. Forty-eight women with FM and 16 healthy age-matched women were included. A computer-controlled, pneumatic tourniquet cuff was placed over the gastrocnemius muscle. The cuff was inflated, and the subject rated the pain intensity continuously on an electronic Visual Analogue Scale (VAS). The subject stopped the inflation at the pressure-pain tolerance and the corresponding VAS-score was determined (pressure-pain limit). The pressure at which VAS firstly exceeded 0 was defined as the pressure-pain threshold. Other disease markers (FM only): Isokinetic knee muscle strength, tenderpoint-count, myalgic score, Beck Depression Inventory, and Fibromyalgia Impact Questionnaire. Student's T-test was used to compare pressure-pain threshold and pressure-pain tolerance and the Mann-Whitney test to compare pressure-pain limit. Pearson's correlation was used to detect linear relationships. Pressure-pain threshold and pressure-pain tolerance assessed by CPA were significantly lower in FM compared to healthy controls. There was no difference in pressure-pain limit. CPA-parameters were significantly correlated to isokinetic muscle strength where more hypersensitivity resulted in lower strength. Pressure-pain threshold and pressure-pain tolerance assessed by CPA were significantly lower in patients with FM indicating muscle hyperalgesia. CPA was associated with knee muscle strength but not with measures thought to be influenced by psychological distress and mood.

Objective: The aim was to investigate whether increased pericranial tenderness or decreased pressure pain threshold (PPT) was related to headache intensity, duration, and frequency in chronic tension-type headache (CTTH)., Methods: Twenty-five CTTH patients and 25 matched controls were studied. A headache diary was kept for 4 weeks to substantiate the diagnosis and record the pain history. Three tenderness (total, cephalic, and neck) scores and PPT at both cephalic and neck points were objectively and blinded assessed. Bodily pain perceived by the patients was assessed with the Short Form-36 questionnaire., Results: CTTH patients showed decreased PPT and increased tenderness as compared with controls (P<0.001). Negative correlations were found between PPT on each point and their respective tenderness scores. Within the CTTH group, neither increased tenderness nor decreased PPT seemed to directly influence headache intensity, frequency or duration; or vice versa., Discussion: Increased tenderness may predispose the patients to other perpetuating factors in inducing headache attacks. Further research is needed to clearly define the role of pericranial tender tissues or other factors in the genesis and maintenance of CTTH.

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.

Background: The potential role of prostate cancer screening in reducing mortality is uncertain. To examine whether screening with the prostate-specific antigen (PSA) test or digital rectal examination is associated with reduced prostate cancer mortality, we conducted a population-based case-control study in 4 health maintenance organizations., Methods: Cases were 769 health plan members who died because of prostate adenocarcinoma during the years 1997-2001. We randomly selected 929 controls from the health plan membership and matched them to cases on health plan, age, race, and membership history. Medical records were used to document all screening tests in the 10 years before and including the date on which prostate cancer was first suspected., Results: Among white participants, 62% of cases and 69% of controls had a least 1 screening PSA test or digital rectal examination (odds ratio = 0.73; 95% confidence interval = 0.55-0.97). The corresponding proportions for blacks were 59% and 61% (1.0; 0.59-1.4). Most screening tests were digital rectal examinations; therefore, in the subgroup with no history of PSA screening, the association between digital rectal screening and prostate cancer mortality was similar to the overall association (0.65 [0.48-0.88] among whites; 0.86 [0.53-1.4] among blacks). Very few men received screening PSA without screening digital rectal examination (6% of cases and 7% of controls among whites)., Conclusions: Digital rectal screening was associated with a reduced risk of death due to prostate cancer in our population. Because of several data limitations, this study could not accurately estimate the effect of PSA screening separate from digital rectal examination.

Study Design: A systematic review., Objectives: To determine the quality of the research and assess the interexaminer and intraexaminer reliability of spinal palpatory diagnostic procedures., Summary of Background Data: Conflicting data have been reported over the past 35 years regarding the reliability of spinal palpatory tests., Methods: The authors used 13 electronic databases and manually searched the literature from January 1, 1966 to October 1, 2001. Forty-nine (6%) of 797 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus or a content expert reconciled discrepancies., Results: The quality scores ranged from 25 to 79/100. Subject description, study design, and presentation of results were the weakest areas. The 12 highest quality articles found pain provocation, motion, and landmark location tests to have acceptable reliability (K = 0.40 or greater), but they were not always reproducible by other examiners under similar conditions. In those that used kappa statistics, a higher percentage of the pain provocation studies (64%) demonstrated acceptable reliability, followed by motion studies (58%), landmark (33%), and soft tissue studies (0%). Regional range of motion is more reliable than segmental range of motion, and intraexaminer reliability is better than interexaminer reliability. Overall, examiners' discipline, experience level, consensus on procedure used, training just before the study, or use of symptomatic subjects do not improve reliability., Conclusion: The quality of the research on interreliability and intrareliability of spinal palpatory diagnostic procedures needs to be improved. Pain provocation tests are most reliable. Soft tissue paraspinal palpatory diagnostic tests are not reliable.

This study was carried out to test the hypothesis that palpation for lumps may be more difficult in large breasts than in small breasts, resulting in a delay in the detection and diagnosis of breast cancer, and to determine whether this hypothesis is confirmed in Asian women. Of 833 new breast cancer patients registered in the Daegu Cancer Registry in 1997-1999, 579 were used in the final data analysis, after excluding patient records containing many missing data on study variables related with cancer staging. There was no difference in means of body mass index (BMI) according to tumour, either in all cases or in those under 49 years of age. In the 50+ age group, the means+/-standard deviations of BMI of T1, T2 and T3 were 23.7+/-2.8, 24.2+/-3.0, and 26.2+/-4.3, respectively (P=0.01). In univariate logistic regression of tumour characteristics with BMI, no statistically significant odds ratios were found either by continuous or quartiles of BMI. In conclusion, these results suggest that the hypothesis is partially confirmed in Korean breast cancer patients and further studies are needed to clarify the relationship between BMI and tumour stage at diagnosis.

Study Design: Determination of the fusion level by direct observation and palpation of anatomic landmarks is compared with the finding obtained from a lateral intraoperative radiograph., Objectives: To assess the reliability of the use of intraoperative anatomic landmarks in determination of the fusion level., Summary of Background Data: Accurate determination of the level to be fused in noninstrumented posterolateral fusion is crucial. No studies are available in which the value of direct observation and palpation of the anatomic landmarks in determination of the fusion level has been assessed., Methods: Eighty patients who underwent posterolateral fusion without instrumentation in the lumbosacral spine were included in this study. During surgery, first, the cephalad transverse process at the desired level to be fused was determined by direct observation and palpation of the anatomic landmarks; second, a metal mark was placed beneath the cephalad transverse process at the level determined by anatomic landmarks. This was followed by a lateral radiograph. The consistency and discrepancy between the use of the anatomic landmarks and lateral radiography in determining the desired fusion level were recorded., Results: The fusion level determined by direct observation and palpation of the anatomic landmarks was accurate in 76 (95%) cases. In the remaining four cases, intraoperative x-rays determined that the selection of the cephalad transverse process for fusion was one level too high in three cases and one level too low in the other case. All errors in determination of the level to be fused occurred in patients who had extensive laminectomy at L4-S1., Conclusions: Determination of fusion level by direct observation and palpation of the anatomic landmarks is not reliable in patients who have had or require decompressive procedures. A lateral radiograph should be routinely obtained for accurate identification of the level to be fused.

The routine head-to-toe home care assessment should include screening for abnormal lymph nodes. This can provide critical information about existing disease states or underlying problems that may have been overlooked. This article details the lymph node examination for the home care client that is easily incorporated into the initial examination, allows for fast documentation of findings, and provides helpful assessment information for disease detection in adults and children.

A description of the technique for standard cardiovascular assessment as it applies to patients in the home care setting is provided in this two-part article. The first, Initial Cardiovascular Assessment, covers basic physical assessment of the cardiovascular patient. The second article, Assessing Blood Pressure and Cardiac Function, which will appear in the August, 1998 issue, provides information that home care nurses can use to develop a thorough method of blood pressure, heart, and breath sound assessment.

Vascular disease is a widespread health problem. Despite the advent of new, noninvasive and invasive testing methods, a thorough health history and physical examination remain the primary means of diagnosis. In this article, the author discusses vascular assessment of acute and critically ill patients, including inspection, palpation, and auscultation. Specific assessments for arterial disease and venous disease are discussed. A thorough vascular assessment aids in the planning and implementation of care and evaluation of response to treatment for these patients.

Physical examination of the augmented breast should include an evaluation of both the natural breast tissue and the implant. By displacing the implant with one hand, the other hand can palpate breast tissue separately. This technique facilitates breast cancer screening and can also be used to evaluate the symptomatic patient. The patient with breast implants presents certain unique physical findings.

In this randomized clinical trial, we compared the vertical strip (VS) and the concentric circle (CC) patterns of breast palpation in order to determine which pattern provided the most thorough self-examination and the best lump detection in breast models. The sample consisted of 34 adult women from a Veterans Outpatient Clinic in the Northwest who were assigned according to breast size (large or small) to one of two groups. Subjects were pretested and randomly taught one method of palpation. Proficiency in the palpation technique, area covered, and number of lumps detected were evaluated. Interrater reliability for proficiency evaluation was 86%. During breast self-examination, the VS group covered significantly more area than the CC group (t = 2.72, p = 0.01). Breast size did not affect breast area covered. Lump detection using breast models did not differ between the two groups. Though this study did not support the conclusion that increased thoroughness leads to increased lump detection, there is support in the literature. Lack of difference in lump detection in this study may have been due to the constraints of the breast models used. However, further research is needed.

Estimation of endotracheal (ET) cuff pressure by finger palpation is one of the methods currently used in the clinical setting. We compared the accuracy of this method with instrumental intracuff pressure measurement in tracheal model tests by 20 members of our ICU team. Four different ET tubes at three different pressure levels were examined. Accuracy for the estimated method by finger palpation was 69% for high pressures, 58% for normal pressures, and 73% for low pressures. We observed differences in terms of sensitivity, specificity, and positive predictive power between different tubes reflecting differences in tube characteristics and interobserver variability. We conclude that precise intracuff pressure measurement is mandatory to prevent complications of over- or underinflation.

In the 1980 Standards and Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care, the recommended method for determining cardiac arrest in infants was changed from palpation of the apical impulse to palpation of the brachial pulse. The importance of adequately assessing the heart beat before initiating chest compressions due to the potential hazards is well established. This study was designed to ascertain which pulse parents could palpate most readily and accurately count within a given time. The results demonstrated the brachial pulse was much easier to palpate and more accurately counted by parents than the apical impulse. These findings formed the basis for the 1980 revised recommendation for determining cardiac arrest in infants.

Heart rate, determined by palpation of the carotid, radial, or temporal artery, is commonly used to monitor exercise intensity. It is known that massage of the carotid artery has a baroreceptor reflex effect on the heart rate. The heart rate, monitored with and without carotid palpation, at rest, during exercise, and immediately post-exercise was determined in 60 male cardiac patients (39-65 years of age) following either myocardial infarction (n=52), bypass surgery (n=6), or those with angina pectoris (n=2). The mean changes in heart rate with carotid palpation in the testing group were -3.5 bpm at rest and -2.2 bpm during exercise; in the training group the changes were +0.8 bpm at rest -3.1 bpm post exercise. While the mean decrease at rest in the testing group was statistically significant, each of the decreases in resting, during, and post-exercise heart rates were too small to be accurately monitored by palpation over a 10- or 15-sec count, a usual procedure in exercise rehabilitation programs. Provided the patients are correctly instructed and technique regularly checked, there appears to be no reason why carotid palpation should not be used in cardiac exercise rehabilitation programs to determine resting, exercise, or post-exercise heart rates.

The purpose of the study presented in this article was to examine predictors of breast self-examination (BSE) practice among elderly female subjects in selected senior citizen centers. The health belief model served as the theoretical framework for the research study. Both the frequency of BSE performance and the technique subjects used to examine their breasts were measured by a questionnaire. Subjects who perceived few barriers to BSE had higher BSE technique scores. The findings also indicated that receiving instruction through a class on BSE was related to improved BSE technique. Perceived susceptibility to breast cancer and perceived benefits of BSE were not found to be significantly predictive of BSE practice.

There has been little attention paid to the persistence of the pulse following complete forearm arterial transection, and we found no report that has established the etiology or frequency of this phenomenon. Eighteen patients with documented complete radial or ulnar artery transections were evaluated. Nine of the 18 patients had persistently palpable pulse distal to the transections. Seven of the pulses were due to retrograde flow and two were due to transmission from the proximal arterial stump or large collaterals. The Allen test was accurate in demonstrating arterial occlusion in each case. Digital compression of the intact artery eliminated the pulse in those cases due to retrograde flow. Documentation of flow direction and collateral vessels was performed with the Doppler directional velocity meter. The fallibility of the peripheral pulse following complete arterial injury is stressed. The Allen test, digital compression of the intact artery, and Doppler studies should be performed on patients with suspected arterial injuries. The exploration of all wounds in the region of major arteries from which profuse bleeding has occurred is recommended.