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Background: The anterior drawer test is traditionally used to assess ankle instability, but we believe that there is room for a small but effective improvement by adding digital palpation of the talus. We aimed to determine the accuracy of anterolateral talar palpation (ATP) in the diagnosis of ankle instability by comparing it with the traditional anterior drawer test., Methods: Fourteen symptomatic and 10 asymptomatic patients were examined for excessive mobility through comparison of both ankles by two blinded orthopedic surgeons, each one using one of the above-mentioned tests. Symptomatic patients were also referred for stress radiography and magnetic resonance imaging (MRI)., Results: ATP was the most sensitive test, but also the least specific, yielding more positive results than the other tests, including tests with negative MRI. ATP and radiography had the highest accuracy and highest level of agreement with MRI., Conclusions: ATP significantly improved diagnostic accuracy in detecting ankle instability., Level of Evidence: IV: cross-sectional study., (Copyright © 2017. Published by Elsevier Ltd.)

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.

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.

During minimally invasive spinal surgery, correct identification of the affected intervertebral disc space is critical. Percutaneous palpation is commonly used, but results may be unreliable. Fluoroscopy is the gold standard but can be cumbersome and exposes operators to ionizing radiation. Spinal ultrasound has been described in veterinary medicine and could be a feasible alternative. This prospective, methods comparison study mimicked a minimally invasive spinal surgery in 10 canine cadavers and compared the accuracy of ultrasound and percutaneous palpation for thoracolumbar intervertebral disc space identification, using fluoroscopy as the reference standard. For each experiment, a disc space was randomly chosen. Identification was then attempted using both percutaneous palpation and ultrasound. For ultrasound, a linear probe was used to guide the operator to the correct location. The time necessary to perform each method was recorded. Accuracies for each method were calculated and statistically compared. Effects of body condition score, location of the targeted thoracolumbar intervertebral disc space and learning curve for each method were also evaluated. Ultrasonographic identification was more accurate (96.7% vs. 76.7%; P < 0.03) but took longer (147 s vs. 29 s; P < 0.0001) than percutaneous palpation. Findings from this cadaver study indicated that percutaneous palpation alone had low accuracy for correctly identifying a targeted thoracolumbar intervertebral disc space and supported the use of ultrasound as a method for improving the accuracy. Future studies are needed to assess the method in clinical cases, especially in obese dogs and/or those in which the targeted site is distant from palpable anatomical landmarks., (© 2018 American College of Veterinary Radiology.)

Background: Misidentification of the cricothyroid membrane is frequent in females, placing them at risk of difficult or failed cricothyroidotomy in the event of failed oxygenation. If anatomy is impalpable, the current guidelines of the Difficult Airway Society, based on expert opinion, recommend an 8-10 cm vertical incision to facilitate access to the cricothyroid membrane. At present no evidence-based guideline exists regarding optimum site or length. We investigated the likelihood of inclusion of the cricothyroid membrane, within hypothetical vertical midline incisions, in a female population., Methods: We asked clinicians to identify the cricothyroid membrane in both the neutral and extended head positions using palpation, the point identified acting as the theoretical midpoint of a cricothyroidotomy incision. We then identified the cricothyroid membrane using ultrasound. We determined the minimum incision length that would be required to ensure that the cricothyroid membrane lay within its boundaries, if clinician digital palpation was the method of cricothyroid membrane localisation., Results: Ninety female subjects were recruited. Theoretical incisions of 7 and 8 cm were required for successful cricothyroidotomy in the neutral and extended head positions respectively. This was necessary because of the high failure rate of cricothyroid membrane identification (80.9%) and the wide range of error (7.2 cm in a vertical plane)., Conclusions: Based on clinical estimation of the location of the cricothyroid membrane, an incision length of 8 cm, using the clinician's best estimate as its midpoint, would overlie all cricothyroid membrane locations. Our data support the current Difficult Airway Society guidelines for cricothyroidotomy incision length., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Myofascial pain is characterized by the presence of trigger points, tenderness to palpation, and local or referred pain, and commonly involves the pelvic floor muscles in men and women. Pelvic floor myofascial pain in the absence of local or referred pain has also been observed in patients with lower urinary tract symptoms, and we have found that many patients report an improvement in these symptoms after receiving myofascial-targeted pelvic floor physical therapy., Objective: We sought to systematically review the literature for examination techniques used to assess pelvic floor myofascial pain in women., Study Design: We performed a systematic literature search using strategies for the concepts of pelvic floor disorders, myofascial pain, and diagnosis in Ovid MEDLINE 1946-, Embase 1947-, Scopus 1960-, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Cochrane Database of Systematic Reviews. Articles were screened by 3 authors and included if they contained a description of a pelvic myofascial physical examination., Results: In all, 55 studies met our inclusion criteria. Overall, examination components varied significantly among the included studies and were frequently undefined. A consensus examination guideline was developed based on the available data and includes use of a single digit (62%, 34/55) to perform transvaginal palpation (75%, 41/55) of the levator ani (87%, 48/55) and obturator internus (45%, 25/55) muscles with a patient-reported scale to assess the level of pain to palpation (51%, 28/55)., Conclusion: Physical examination methods to evaluate pelvic musculature for presence of myofascial pain varied significantly and were often undefined. Given the known role of pelvic floor myofascial pain in chronic pelvic pain and link between pelvic floor myofascial pain and lower urinary tract symptoms, physicians should be trained to evaluate for pelvic floor myofascial pain as part of their physical examination in patients presenting with these symptoms. Therefore, the development and standardization of a reliable and reproducible examination is needed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Context.—: Although fine-needle aspiration (FNA) practice by pathologists is now well established, it has been primarily performed by manual palpation. In recent years, pathologists have begun to venture into ultrasound-guided FNAs (UGFNAs). Reports on experiences with this relatively new technique for pathologists have shown promising results. However to date, there have been few studies in the literature comparing pathologist-performed UGFNA with the more traditional pathologist-performed palpation-guided FNA (PGFNA)., Objective.—: To compare UGFNA to PGFNA by cytopathologists at an academic medical center., Design.—: A retrospective study of FNAs performed by cytopathologists within the University of California, Los Angeles (UCLA) pathology departmental FNA clinic was performed. Data collected included performance technique (UGFNA versus PGFNA), lesion site and size, adequacy status (nondiagnostic rate), and number of passes per procedure. Corresponding surgical pathology/flow cytometric/cytogenetic result follow-up was compared to FNA results. Findings between UGFNA and PGFNA cases were compared., Results.—: Of 1029 FNA cases during the study period, there were 449 UGFNA cases (43.6%) and 580 PGFNA cases (56.4%). Nondiagnostic rates with UGFNA and PGFNA were 6.7% (30 of 449 cases) and 20.7% (120 of 580 cases), respectively. Nondiagnostic rate was also significantly lower with UGFNA than with PGFNA for lesions within the thyroid (6.0% versus 33.3%), head and neck (6.6% versus 21.2%), and salivary gland (6.2% versus 17.1%), and across all nodule sizes. A total of 495 of 1029 FNA cases (48.1%) had follow-up. Discordance rate was significantly lower with UGFNA than with PGFNA (5.4% versus 12.8%)., Conclusions.—: This study shows improved performance characteristics of cytopathologist-performed UGFNA versus PGFNA.

Background: The cricothyroid membrane is the most commonly accessed location for invasive surgical airway. Although the laryngeal handshake method is recommended for identifying the cricothyroid membrane, there is no clinical data regarding the utility of the laryngeal handshake method in cricothyroid membrane identification. The objective of this study was to compare the accuracy of cricothyroid membrane identification between the laryngeal handshake method and simple palpation., Methods: After anaesthesia induction, the otorhinolaryngology resident and anaesthesia resident identified and marked the needle insertion point for cricothyroidotomy using simple palpation and the laryngeal handshake method, respectively. The cricothyroid membrane was confirmed with ultrasonography. Identification was determined successful if the marked point was placed within the longitudinal area of the cricothyroid membrane and within 5 mm from midline transversely. The accuracy of cricothyroid membrane identification using the laryngeal handshake method and simple palpation was compared., Results: A total of 123 patients were enrolled. The cricothyroid membrane was correctly identified in 87 (70.7%, 95% confidence interval 61.8-78.6%) patients using the laryngeal handshake method compared to 78 (63.4%, 95% confidence interval 54.3-71.9%) patients using simple palpation (P = .188). The time required to identify the cricothyroid membrane was longer when using the laryngeal handshake method (15 [3-48] seconds vs 10.9 [3-55] seconds, P = .003)., Conclusion: The success rate of identifying the cricothyroid membrane was similar among the anesthesiologists who performed the laryngeal handshake method and also among otorhinolaryngologists who used simple palpation., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Introduction: Use of intraoperative ultrasound (IOUS) has been shown to help achieve satisfactory cosmesis and negative margins in breast conserving surgery (BCS). This study has been done to compare the oncological and cosmetic outcomes following BCS using conventional palpatory method and IOUS., Materials and Methods: This is a prospective randomized controlled trial conducted at a tertiary care teaching and research institute in India. Patients with early operable breast cancer willing for BCS were included. Tumors were excised with 1 cm margin. In palpatory group, tumor was palpated and 1 cm margin was taken with a measuring scale while in the second group, IOUS was used to mark the margins. Histopathological evaluation was done to assess margins and cosmesis was assessed by patient, resident doctor, and nurse independently., Results: Sixty patients were included, 32 in the ultrasonography-guided and 28 in palpation-guided wide local excision. The mean age of patients was 48.78 years. In both groups, mean tumor size was 3.18 cm. Margin thickness and positivity was higher in palpatory group (though P > 0.05). Most patients were satisfied with cosmesis. There was no significant difference in complications and specimen volume in both groups. Presence of ductal carcinoma in situ component and expression of Her2neu by tumor cells had a significant impact on margin positivity., Conclusions: Intraoperative use of ultrasound offers a real-time assessment of margin status and may reduce the margin positivity rate compared to conventional palpation-guided method., Competing Interests: None

Objective: Despite the increasing awareness of the contribution of myofascial dysfunctions to upper limb pain in breast cancer survivors, reliability of the identification of myofascial trigger points (MTPs) in this population has not yet been investigated. Therefore, the aim of the present study was to investigate the interrater reliability of the identification of MTPs by palpation at the upper limb region in breast cancer survivors with upper limb pain., Design: Interrater reliability study., Setting: University Hospitals Leuven, Belgium., Subjects: Thirty breast cancer survivors with pain at the upper limb region., Methods: Nine muscles (upper trapezius, levator scapulae, infraspinatus, supraspinatus, teres major and minor, subscapularis, pectoralis major, and scalene muscles) at the operated side were examined. The weighted kappa (WK) coefficient and Absolute Agreement with 95% confidence intervals were calculated., Results: Moderate agreement was found for all examined upper limb muscles (WK = 0.41-0.60), except for the trapezius muscle, for which the agreement was almost perfect (WK = 0.83), and the supraspinatus muscle (WK = 0.23), for which the agreement was only fair., Conclusions: For most muscles, moderate interrater reliability for the identification of MTPs by palpation in breast cancer survivors with upper limb pain was found. Therefore, we concluded that the identification of MTPs by palpation may add to the diagnosis of the myofascial pain syndrome in breast cancer survivors.

Background: Peripheral vein cannulation is a routine and straightforward invasive procedure, although i.v. access can be difficult to obtain. To increase the success rate of inserting an i.v. catheter, many devices have been proposed, including ultrasonography. The objective of this study was to compare ultrasound guidance with the traditional approach of palpation and direct visualisation for peripehral vein cannulation. The primary outcome was successful peripheral i.v. cannulation., Methods: Database search was performed on PubMed, Clinical Key, CINAHL, Cochrane Library of Clinical Trials, and Trip Database (from January 2000 to December 2017). Random-effect meta-analysis was performed to determine the pooled odds ratio for success in peripheral i.v. cannulation., Results: After database review and eligibility screening, eight studies were included in the final analysis, with a total of 1660 patients. The success rate in the ultrasound group was 81% (n=855), and was 70% (n=805) in the control group, resulting in a pooled odds ratio for success upon ultrasound-guided peripheral i.v. cannulation of 2.49 (95% confidence interval 1.37-4.52, P=0.003). Furthermore, the ultrasound-guided technique reduced the number of punctures and time needed to achieve i.v. access, and increased the level of patient satisfaction, although it did not result in a decreased number of complications., Conclusions: Ultrasound guidance increases the success rate of peripheral i.v. cannulation, especially in patients with known or predicted difficult i.v. access., (Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Purpose: To determine whether a fluoroscopic technique can be used to improve the accuracy of the determination of the femoral origin of the lateral collateral ligament (LCL)., Methods: A 1-cm incision was made over the lateral epicondyle in 13 fresh-frozen cadaveric knee specimens, and the LCL origin was determined first by palpation and then with a previously described fluoroscopic method. Both points for the LCL origin were marked with 2-mm Kirschner wires. The distances between the center of the anatomic LCL origin and the LCL origin points determined by palpation and fluoroscopic imaging were calculated. An independent t-test was used to compare the distances between the anatomic LCL origin center and the determined LCL origin points., Results: The LCL origin points determined by fluoroscopic imaging were significantly (P = .005) closer to the anatomic center of the LCL origin point than the ones determined by palpation (3.2 mm ± 1.6 mm vs 5.0 mm ± 1.6 mm, respectively). A total of 92.7% fluoroscopically determined LCL origin points were within a 5 mm radius surrounding the anatomic LCL origin point. In contrast, only 53.8% LCL origin points determined by palpation were within a 5 mm radius surrounding the anatomic LCL origin point., Conclusions: The use of palpation to identify the LCL origin may not be an accurate method for performing an isometric and anatomic LCL reconstruction. The use of fluoroscopic imaging appears to be a feasible method for identifying the LCL origin in clinical practice and may increase the accuracy of LCL origin identification. Fluoroscopic guidance improves accuracy in determining the anatomic LCL origin, which may help avoiding tunnel malplacement during LCL reconstruction. CLINICAL RELEVANCE: The use of a previously described radiographic method for identifying the LCL origin may be used to achieve a more anatomic LCL reconstruction., (Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: We compared characteristics and outcomes of palpable versus nonpalpable, hormone-sensitive, early-stage breast cancers., Methods: Patients from the North American Fareston vs. Tamoxifen Adjuvant (NAFTA) trial were divided into palpable (n = 513) and nonpalpable (n = 1063) tumor groups. Differences in pathological features, loco-regional therapy, disease-free survival (DFS) and overall survival (OS) were analyzed., Results: Patients with palpable tumors were older, had larger tumors, and higher rates of lymph-node involvement. The tumors were more likely to be poorly differentiated, of high nuclear grade, and display lymphovascular invasion. After mean followup of 59 months, DFS and OS were significantly lower for palpable than nonpalpable tumors (DFS 93.5% vs. 98.4%, p < 0.001, OS 88.5% vs. 95.6%, p < 0.001). Controlling for age, size and nodal status, palpability was an independent factor for DFS (OR = 2.56; 95%CI, 1.37-4.79, p = 0.003) and OS (OR = 2.12; 95%CI, 1.38-3.28, p < 0.001)., Conclusions: In a group of hormone-sensitive, mostly postmenopausal early-stage breast cancer patients, palpable tumors were more likely to have more aggressive features and metastatic potential, which translated in to a higher incidence of breast cancer-related events and worse overall survival., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The goal of this prospective pilot study was to use naturally occurring canine mast cell tumors of various grades and stages as a model for attempting to determine how glucose uptake and markers of biologic behavior are correlated. It was hypothesized that enhanced glucose uptake, as measured by 2-[fluorine-18]fluoro-d-glucose-positron emission tomography/computed tomography (F18 FDG PET-CT), would correlate with histologic grade. Dogs were recruited for this study from a population referred for treatment of cytologically or histologically confirmed mast cell tumors. Patients were staged utilizing standard of care methods (abdominal ultrasound and three view thoracic radiographs), followed by a whole body F18 FDG PET-CT. Results of the F18 FDG PET-CT were analyzed for possible metastasis and standard uptake value maximum (SUV max ) of identified lesions. Incisional or excisional biopsies of the accessible mast cell tumors were obtained and histology performed. Results were then analyzed to look for a possible correlation between the grade of mast cell tumors and SUV max . A total of nine animals were included in the sample. Findings indicated that there was a correlation between grade of mast cell tumors and SUV max as determined by F18 FDG PET-CT (p-value = 0.073, significance ≤ 0.1). Based on the limited power of this study, it is felt that further research to examine the relationship between glucose utilization and biologic aggressiveness in canine mast cell tumors is warranted. This study was unable to show that F18 FDG PET-CT was a better staging tool than standard of care methods., (© 2018 American College of Veterinary Radiology.)

Background: Accurate diagnosis of musculoskeletal disorders relies heavily on the physical examination, including accurate palpation of musculoskeletal structures. The literature suggests that there has been a deterioration of physical examination skills among medical students and residents, in part due to increased reliance on advanced imaging. It has been shown that knowledge of musculoskeletal anatomy and physical examination skills improve with the use of ultrasound; however, the literature is limited., Objective: To determine whether ultrasound can improve the ability of physicians in training (residents) to palpate the long head of the biceps tendon (LHBT) in the bicipital groove., Design: Prospective study design., Setting: Tertiary care center., Participants: Ten physical medicine and rehabilitation residents served as subjects. Exclusion criteria included the presence of any condition that precluded their ability to palpate. Three volunteers were used as models. Model exclusion criteria included anything that distorted normal shoulder anatomy or inhibited examiner palpation. Three investigators with experience performing diagnostic musculoskeletal ultrasound were used to confirm palpation attempts., Methods: Subjects attempted to palpate the LHBT bilaterally in the bicipital groove of each model. Investigators assessed the accuracy of the palpation attempt using real-time ultrasonography. Subjects participated in a 30-minute ultrasound-assisted training session learning how to palpate the LHBT in the bicipital groove with ultrasound confirmation. After the ultrasound training session, subjects again attempted to palpate the LHBT in the bicipital groove of each model with investigator confirmation., Main Outcome Measurements: LHBT palpation accuracy rates preintervention versus postintervention., Results: Pretraining LHBT palpation accuracy was 20% (12/60 attempts). Post-ultrasound training session accuracy was 51.7% (31/60 attempts; P ≤ .001)., Conclusions: Our findings demonstrate that palpation accuracy improves after ultrasound assisted LHBT palpation training. These data suggest that the use of ultrasound may be beneficial when teaching musculoskeletal palpation skills to health care professionals., Level of Evidence: II., (Copyright © 2018 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of this observational study was to determine the accuracy of musculoskeletal palpation of the medial joint line of the knee, medial patellar tendon, and posterior tibialis tendon verified by ultrasound imaging among physical medicine and rehabilitation residents., Methods: Eighteen physical medicine and rehabilitation resident physicians at a single specialized institution were asked to identify the medial joint line of the knee, medial patellar tendon, and posterior tibialis tendon on 2 separate standardized patient models during a single data collection. They were asked to place a paper clip flat on the surface of the skin parallel to the specified anatomic structure. A high-frequency linear array transducer was used to identify whether the paper clip was correctly placed over the structures and to measure the distance from the intended structure., Results: The accuracy rates for palpation of the medial joint line, medial patellar tendon, and posterior tibialis tendon in both models were 14%, 36%, and 28%, respectively, for all levels of residents. Accuracy rates for all of the structures by level of education were 19%, 29%, and 31% for postgraduate years 2, 3, and 4. Median confidence scores were 3.75, 3.5, and 2 for the medial joint line, medial patellar tendon, and posterior tibialis tendon., Conclusions: This study highlights the level of inaccuracy of musculoskeletal palpation skills and draws further attention to an area of much-needed improvement in our musculoskeletal residency training programs. Ultrasound imaging is an effective noninvasive method for providing swift feedback to medical students and residents and thereby reduce the instances of inaccurate musculoskeletal palpation., (© 2017 by the American Institute of Ultrasound in Medicine.)

Objective: To compare Transperineal (TP) and Transabdominal (TA) ultrasound in the assessment of fetal head position during the second stage of labor., Method: A prospective comparative Study including low risk parturients. The assessment of fetal head position was performed for each patient at full dilation. The ultrasound examination was performed by one examiner using TP technique first then TA. A routine digital vaginal examination was performed by a different examiner blinded to ultrasound findings. Considering TA as reference, the three methods were compared., Results: Fifty two patients were enrolled in the study group. Agreement between the clinical examination and TA ultrasound was average with Kappa index = 0.579. Agreement between TA and TP Ultrasound was good with Kappa index = 0.766. TP technique was accurate in the diagnosis of fetal head position (sensitivity =91.3%, specificity=98.38%, PPV=87.5%, NPV=98.91%). TA ultrasound was the most reliable method in case of high presentations. For lower fetal presentations, the TP approach was more relevant., Conclusions: Assuming that an accurate diagnosis of fetal head position is required before any instrumental delivery where, by definition, fetal presentation is engaged, the TP ultrasound is advised. In a single time this technique provides the necessary information about the station, and the position of the fetal head.

Objective: Successful treatment of knee joint disease requires an accurate diagnosis. In addition to a differentiated history, clinical examination is the most important component in the diagnosis of knee joint diseases., Method: The present video explains the common provocation and functional tests that are used in the basic clinical examination of the knee joint. In addition to general inspection and palpation, the focus here is on the individual region's patella, menisci, cruciate ligaments and collateral ligaments., Conclusion: The present methods of basic clinical examination allow a structured approach to clinical issues and can be a good basis for the diagnosis of knee joint diseases, if supplemented by further specific and individual tests., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

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/purpose: Very little is known about the methods of integrating palpation techniques to existing mobile teleskin imaging that delivers low quality tactile information (roughness) for telepalpation. However, no study has been reported yet regarding telehaptic palpation using mobile phone images for teledermatology or teleconsultations of skincare., Methods: This study is therefore aimed at introducing a new algorithm accurately reconstructing a haptic augmented skin surface for telehaptic palpation using a low-cost clip-on microscope simply attached to a mobile phone. Multiple algorithms such as gradient-based image enhancement, roughness-adaptive tactile mask generation, roughness-enhanced 3D tactile map building, and visual and haptic rendering with a three-degrees-of-freedom (DOF) haptic device were developed and integrated as one system., Results: Evaluation experiments have been conducted to test the performance of 3D roughness reconstruction with/without the tactile mask. The results confirm that reconstructed haptic roughness with the tactile mask is superior to the reconstructed haptic roughness without the tactile mask. Additional experiments demonstrate that the proposed algorithm is robust against varying lighting conditions and blurring. In last, a user study has been designed to see the effect of the haptic modality to the existing visual only interface and the results attest that the haptic skin palpation can significantly improve the skin exam performance., Conclusion: Mobile image-based telehaptic palpation technology was proposed, and an initial version was developed. The developed technology was tested with several skin images and the experimental results showed the superiority of the proposed scheme in terms of the performance of haptic augmentation of real skin images., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The currently available prostate palpation simulators are based on either a physical mock-up or pure virtual simulation. Both cases have their inherent limitations. The former lacks flexibility in presenting abnormalities and scenarios because of the static nature of the mock-up and has usability issues because the prostate model must be replaced in different scenarios. The latter has realism issues, particularly in haptic feedback, because of the very limited performance of haptic hardware and inaccurate haptic simulation. This paper presents a highly flexible and programmable simulator with high haptic fidelity. Our new approach is based on a pneumatic-driven, property-changing, silicone prostate mock-up that can be embedded in a human torso mannequin. The mock-up has seven pneumatically controlled, multi-layered bladder cells to mimic the stiffness, size, and location changes of nodules in the prostate. The size is controlled by inflating the bladder with positive pressure in the chamber, and a hard nodule can be generated using the particle jamming technique; the fine sand in the bladder becomes stiff when it is vacuumed. The programmable valves and system identification process enable us to precisely control the size and stiffness, which results in a simulator that can realistically generate many different diseases without replacing anything. The three most common abnormalities in a prostate are selected for demonstration, and multiple progressive stages of each abnormality are carefully designed based on medical data. A human perception experiment is performed by actual medical professionals and confirms that our simulator exhibits higher realism and usability than do the conventional simulators., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Accurate and reliable palpation is needed to identify anatomical landmarks as well as to assess motion and dysfunctions. Although different trials suggested that training might increase reliability of palpation, the poor dependability of the examined tests may show the need to review the teaching methods to improve palpatory accuracy? The aims of this study were: METHODS: 82 examiners with different years of experience were enrolled from AIMO institute. Two different type of training sessions were performed (individual and group training). A total of 5 training sessions were performed during 5 weeks and 5 different models with a similar BMI were used. A uni-variated statistical analysis was used to evaluate the main effect of type and number of trainings, a multi-variated analysis was used to verify cross-effects., Results: Overall results show moderate reliability for the correct detection of the position of the heel lift (Random probability being 33%, GT = 58.6% and SIPS = 57.1%, both P-value < 0.001). No difference was shown between the types of training (p-value GT = 0.503, p-value PSIS = 1) and no overall improvement was shown after the first training (P-value(GT) = 0.25, P-value(PSIS) = 0.96). The professional group improved the reliability during the training sessions starting from substantial reliability and ended with an almost perfect reliability (P-value GT = 0.0029, P-Value PSIS<0.001). Whereas the 3rd 4th and 5th showed a decreased performance., Conclusions: Type of training sessions seems not to influence reliability of palpation accuracy. The improvement of reliability during the training sessions seems to be related to the experience of examiners, which plays an important role in reliability and the learning experience., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: To describe the dorsal 4-finger technique (DFFT) in examining metacarpophalangeal (MCP) joints of patients with rheumatoid arthritis (RA) and compare it to the traditional 2-finger technique (TFT) using ultrasound (US) as a gold standard., Methods: Four rheumatologists evaluated 180 MCP joints of 18 patients with RA. All patients underwent US for greyscale (GSUS) and power Doppler US (PDUS). Agreements between rheumatologists, the 2 techniques, and US were evaluated using Cohen κ and the first-order agreement coefficient (AC1) κ methods., Results: The population comprised 17 females (94.4%) with a mean (SD) age and disease duration of 56.8 (14.4) and 21.8 (12.9) years, respectively. Eight patients (44.4%) were taking methotrexate monotherapy, while 10 patients (55.6%) were receiving biologics. US evaluation revealed 69 (38.3%) and 30 (16.7%) joints exhibited synovitis grade 2-3 by GSUS and PDUS, respectively. Effusion was documented in 30 joints (16.7%). The mean intraobserver agreement using the DFFT and TFT were 80.5% and 86%, respectively. The mean interobserver agreements using the DFFT and TFT were 84% and 74%, respectively. κ agreement with US findings was similar for both techniques in tender joints but was higher for the DFFT in nontender joints (0.33 vs 0.07, p = 0.015 for GSUS) and (0.48 vs 0.11, p = 0.002 for PDUS). The DFFT had a higher sensitivity in detecting ballottement by GSUS (0.47 vs 0.2, p < 0.001) and PDUS (0.60 vs 0.27, p < 0.001)., Conclusion: The DFFT is a novel, reproducible, and reliable method to examine MCP joints, and it has a better correlation with US than the traditional TFT.

In addition to palpation tests, dynamic/static tests have been proposed to complement temporomandibular disorders (TMD) patients' evaluation in the clinical setting. The aim of this study was to assess the intra- and inter-observer reliability of the palpation tests and of the dynamic/static tests, and to determine whether those tests would yield comparable outcomes in terms of pain diagnoses. Ninety-eight (N = 98) consecutive adult patients were examined during 2 clinical sessions by 2 independent examiners, based on muscle and joint palpation techniques described in the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). They also underwent dynamic/static tests. The intra-observer reliability of palpation tests was generally poor, with fair-to-good to excellent ICC values only for the superior masseter and intra-oral sites. The inter-observer reliability of palpation was fair-to-good for muscles, but it was poor for the TMJ lateral pole. Both intra- and inter-observer reliability for the dynamic/static tests varied from fair-to-good to excellent. The intra-observer reliability for muscle pain diagnoses based on palpation tests was between poor and fair-to-good, whereas the inter-observer reliability was excellent. The intra-observer reliability for pain diagnoses based on dynamic/static tests was fair-to-good, and the inter-observer reliability varied from fair-to-good to excellent., Conclusions: Some features of the dynamic/static tests make them potentially more useful than palpation tests for selected clinical purposes, such as discriminating between joint and muscle pain as well as monitoring symptoms course. Thus, findings from this investigation suggest that both tests should be included in the TMD diagnostic algorithms., (© 2018 John Wiley & Sons Ltd.)

Despite the advancement of measuring technologies, there was a need for palpation by hands to be able to better diagnose skin diseases and to learn about the tactile properties of in vivo skin surface. However, directly touching in vivo skin surface can cause secondary infections or damages. Therefore, a technology providing infection- and damage-free skin palpations and precise haptic skin roughness rendering is needed. A multidimensional (2D and 3D) rendering system was developed for multimodal (visual and haptic) rendering that can run with any given in vivo input skin images. For haptic rendering, a commercial haptic device with 3 degrees of freedom (3DOF), Geomagic Touch X, was used. To improve haptic roughness rendering, a force shading algorithm that reduces force discontinuity on rough surface patches but preserves the original roughness values was implemented and applied. In addition, a new image-based roughness estimation method was introduced and the results were compared with haptic roughness results to verify roughness rendering in the system. The developed haptic roughness rendering system will help to diagnose abnormalities on in vivo skin surfaces by virtual haptic palpation with no concern about secondary infections or damages (caused by touch interactions) especially in case of psoriasis, atopic dermatitis, or aging, which results in significant changes of skin roughness. Besides, the system can also be a good tool to examine skin condition changes before and after the use of skin care products (cosmetics). In addition, the proposed 2D skin roughness estimation method can be applied for mobile applications to provide an online roughness estimation tool with a simple phone camera.

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 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.

Objectives: To identify success rates for radial artery cannulation in a pediatric critical care unit using either palpation or ultrasound guidance to cannulate the radial artery., Methods: A prospective randomized comparative study of critically ill children who required invasive monitoring in a tertiary referral center was conducted. All patients were randomized by a stratified block of 4 to either ultrasound-guided or traditional palpation radial artery cannulation. The primary outcomes were the first attempt and total success rates., Results: Eighty-four children were enrolled, with 43 randomized to the palpation technique and 41 to the ultrasound-guided technique. Demographic data between the groups were not significantly different. The total success and first attempt rates for the ultrasound-guided group were significantly higher than those for the palpation group (success ratio, 2.03; 95% confidence interval, 1.13-3.64; P = .018; and success ratio, 4.18; 95% confidence interval, 1.57-11.14; P = .004, respectively). The median time to success for the ultrasound-guided group was significantly shorter than that for the palpation group (3.3 versus 10.4 minutes; P < .001). Cannulation complications were lower in the ultrasound-guided group than the palpation group (12.5% versus 53.3%; P < .001)., Conclusions: The ultrasound-guided technique could improve the success rate and allow for faster cannulation of radial artery catheterization in critically ill children., (© 2017 by the American Institute of Ultrasound in Medicine.)

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.

Purpose To test the hypothesis that appendiceal spectral Doppler waveforms can distinguish patients with and patients without appendicitis. Materials and Methods In this retrospective study, Doppler waveforms were obtained from intramural appendiceal arteries identified with color Doppler imaging in 60% (93 of 155) of consecutive patients whose appendices were visualized at graded compression ultrasonography (US) performed for suspected appendicitis (53 male and 40 female; age, 1-56 years; mean, 14.5 years) over the 5-month period from November 2015 through March 2016. Point, non-angle-corrected peak systolic velocity (PSV) and resistive index (RI) values were compared between patients with and patients without appendicitis by utilizing histopathologically proven appendicitis and 6-week clinical follow-up as diagnostic reference standards. Data were assessed by using the Student t test, exact binomial distribution, two-sample test of proportions, and receiver operating characteristic analysis. Results Among the 93 patients, 36 (38.7%) had proven appendicitis (mean PSV, 19.7 cm/sec; mean RI, 0.69) and 57 patients (61.2%) did not (mean PSV, 7.1 cm/sec, P < .0001; mean RI, 0.50, P < .0001). The area under the receiver operating characteristic curve for the diagnosis of appendicitis was 0.97 (95% confidence interval [CI]: 0.95, 1.00) for PSV and 0.86 (95% CI: 0.78, 0.95; P = .011) for RI. Chosen discriminatory criteria of PSV greater than 10 cm/sec and RI greater than 0.65 yielded specificity for appendicitis of 94.7% and 96.5% with sensitivity of 88.9% and 63.9% (P = .013) and negative predictive value of 93.1% and 80.9% (P = .045), respectively. Original clinical graded compression US interpretations based on established US findings demonstrated specificity of 96.2% and sensitivity of 100.0%. Considering the subset of 20 patients whose maximum outer diameter measured 6-8 mm, the discriminatory criteria of PSV greater than 10 cm/sec and RI greater than 0.65 yielded specificity for appendicitis of 88.9% each, with sensitivity of 100.0% and 63.6% and negative predictive value of 100.0% and 66.6%, respectively. Conclusion In patients with visualized appendices at US, those with appendicitis exhibit significantly higher point PSV and point RI values than do patients without appendicitis and are distinguishable with high specificity by using a PSV greater than 10 cm/sec and an RI greater than 0.65 as diagnostic criteria. © RSNA, 2017.

Background: Taenia solium is a neglected zoonotic parasite. The performances of existing tools for the diagnosis of porcine cysticercosis need further assessment, and their shortcomings call for alternatives. The objective of this study was to evaluate the performance of tongue palpation and circulating antigen detection for the detection of porcine cysticercosis in naturally infected pigs of slaughter age compared to full carcass dissections (considered the gold standard). Additionally, alternative postmortem dissection procedures were investigated. A total of 68 rural pigs of slaughter age randomly selected in the Eastern Province of Zambia were dissected. Dissections were conducted on full carcasses (or half carcass in case cysticerci were already detected in the first half), including all the organs. Total cysticercus counts, location and stages were recorded and collected cysticerci were identified morphologically and molecularly. All sera were analysed with the B158/B60 antigen detecting ELISA (Ag-ELISA)., Results: Key findings were the high occurrence of T. solium infected pigs (56%) and the presence of T. solium cysticerci in the livers of 26% of infected animals. More than half of the infected carcasses contained viable cysticerci. Seven carcasses had T. hydatigena cysticerci (10%), out of which five carcasses were co-infected with T. hydatigena and T. solium; two carcasses (3%) had only T. hydatigena cysticerci. Compared to full carcass dissection, the specificity of the Ag-ELISA to detect infected carcasses was estimated at 67%, the sensitivity at 68%, increasing to 90% and 100% for the detection of carcasses with one or more viable cysticerci, and more than 10 viable cysts, respectively. Tongue palpation only detected 10% of the cases, half carcass dissection 84%. Selective dissection of the diaphragm, tongue and heart or masseters can be considered, with an estimated sensitivity of 71%, increasing to 86% in carcasses with more than 10 cysticerci., Conclusions: Depending on the aim of the diagnosis, a combination of Ag-ELISA and selective dissection, including investigating the presence of T. hydatigena, can be considered. Full carcass dissection should include the dissection of the liver, kidneys, spleen and lungs, and results should be interpreted carefully, as small cysticerci can easily be overlooked.

Study Design: Systematic review., Introduction: Physiotherapists routinely assess the position of the humeral head (HH) in patients with shoulder pain., Purpose of the Study: To conduct a systematic review to determine the quality and content of studies that evaluated the reliability of clinical measurement methods for assessing the HH position., Methods: Five databases and gray literature were searched for studies fitting the eligibility criteria. After abstract and full-text review, the included studies were appraised using the Quality Appraisal of Reliability Studies checklist. Articles were considered of high quality if 8 was achieved on the checklist, and the overall quality of evidence was classified using prespecified criteria. Multiple raters extracted and performed quality ratings; a consensus process was used to finalize the reliability data that were synthesized and presented in a narrative synthesis. Reliability was classified as excellent if the intracorrelation coefficients or intercorrelation coefficients (ICCs) reported exceeded 0.75., Results: Fifteen studies on the reliability of ultrasound (US) and 3 studies on palpation were included. The methodologic quality was moderate in 17 of 18 studies. The intrarater reliability for all studies was excellent (ICC, 0.76-0.99) with the exception of the 90° abduction in internal rotation position (ICC, 0.48) for palpation. The inter-rater reliability tended to be lower (ICC, 0.48-0.68) for palpation and higher (ICC, 0.66-0.99) for US. Physiotherapists demonstrated excellent intrarater reliability across different levels of training in ultrasonography., Discussion: Our study found a moderate overall level of evidence to support the use of US for assessing HH position in symptomatic or asymptomatic subjects., Conclusion: A moderate overall level of evidence exists for the use of US to reliably assess the HH position. Limited research supports the methods used for palpation within a clinical setting., Level of Evidence: 2a., (Copyright © 2017 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.)

Background: Migraine patients usually report a high prevalence of neck pain preceding or during the migraine attack. A recent investigation of musculoskeletal dysfunctions in migraine patients concluded that neck pain is not simply a symptom of the migraine attack but corresponds to identifiable muscle and joint alterations. Particularly pain provocation using palpation of the joints in the upper cervical spine was significantly more prevalent in patients with migraine than in headache-free participants., Methods: One hundred seventy-nine migraineurs (diagnosed according to IHS classification criteria version III beta) and 73 age- and gender-matched healthy controls were examined by a physiotherapist blinded towards the diagnosis, using a palpation technique over the upper cervical spine. The palpation combined oscillating movements and sustained pressure., Findings: Using simple palpation of the upper cervical spine, migraine patients can be stratified into three groups: painfree (11%), local pain only (42%), and pain referred to the head during sustained pressure (47%). Combining both test components (palpation and sustained pressure) has a high sensitivity and specificity for migraine., Conclusions: The response to palpation of the upper cervical spine may indicate migraine subtypes. The presence of musculoskeletal dysfunctions of the upper cervical spine should be identified and treated to avoid ongoing nociceptive input into the trigeminocervical complex., Trial Registration: German Clinical Trial Register DRKS-ID: DRKS00009622 .

Background: Atrial fibrillation (AF) is often asymptomatic and undiagnosed until an ischaemic stroke occurs. An irregular pulse is a key manifestation of AF. We assessed whether pulse self-palpation is feasible in screening of AF., Methods: Altogether 205 residents of Lieto municipality aged ≥75 years were randomized in 2012 to receive brief education on pulse palpation focusing on evaluating rhythm regularity. Self-detected pulse irregularity and new AF diagnoses were recorded, and the subjects' quality of life and use of health care services were assessed during a three-year follow-up., Results: The subjects' median age was 78.2 [3.8] years, and 89 (43.4%) were men. Overall, 139 (68%) subjects had initial good motivation/capability for regular palpation. At four months, 112 (80.6%) subjects with good and 26 (39.4%) with inadequate motivation/capability palpated their pulse daily. At 12 months, 120 (58.5%) and at 36 months, 69 (33.7%) subjects palpated their pulse at least weekly. During the intervention, 67 (32.7%) subjects reported pulse irregularity. New AF was found in 10 (4.9%) subjects, 7 (70%) of whom had reported pulse irregularity. Pulse irregularity independently predicted new AF, but only one (0.5%) subject with new AF sought undelayed medical attention due to pulse irregularity. Quality of life and number of outpatient clinic visits remained unchanged during follow-up., Conclusion: Pulse palpation can be learned also by the elderly, but it is challenging to form a continuing habit. The low persistence of pulse self-palpation limits its value in the screening of AF, and strategies to promote persistence and research on alternative screening methods are needed., Trial Registration: http://www.ClinicalTrials.gov identifier: NCT01721005. The trial was registered retrospectively on October 26, 2012.

Purpose: Atrial fibrillation (AF) may first present as an ischemic stroke. Pulse palpation is a potential screening method for asymptomatic AF. We aimed to assess the reliability of pulse palpation by the elderly in detecting AF., Materials and Methods: After brief information and training session conducted by a nurse, 173 subjects aged ≥75 years were instructed to palpate their pulse regularly for a month. After this, their ability to distinguish sinus rhythm (SR), SR with premature ventricular contractions (PVC) and AF by pulse palpation was assessed using an anatomic human arm model programmable with various rhythms. A control group of 57 healthcare professionals received the same information but not the training. Subjects unable to find the pulse were excluded (25 (14.5%) of the elderly and none in the healthcare group)., Results: The median age of the elderly subjects was 78.4 [3.9] years and 98 (56.6%) were women. There were no differences between the elderly and healthcare groups in detecting SR (97.3% vs. 96.5%) or SR with PVCs (74.3% vs. 71.4%), but the elderly subjects identified slow (81.8% vs. 56.1%) and fast AF (91.9% vs. 80.7%) significantly better than the healthcare group. The ability to recognize SR with PVCs by the elderly was independently predicted by previous pulse palpation experience, secondary or higher level of education and one-point increase in MMSE score, while identifying the other rhythms had no predictors., Conclusions: The elderly can learn to reliably distinguish a normal rhythm after education. Pulse self-palpation may be a useful low-cost method to screen for asymptomatic AF.

Objectives: The aim of this study was to investigate if there were differences in the two-point discrimination (2-PD) of fingers among students at different stages of a chiropractic program., Methods: This study measured 2-PD thresholds for the dominant and nondominant index finger and dominant and nondominant forearm in groups of students in a 4-year chiropractic program at the International Medical University in Kuala Lumpur, Malaysia. Measurements were made using digital calipers mounted on a modified weighing scale. Group comparisons were made among students for each year of the program (years 1, 2, 3, and 4). Analysis of the 2-PD threshold for differences among the year groups was performed with analysis of variance., Results: The mean 2-PD threshold of the index finger was higher in the students who were in the higher year groups. Dominant-hand mean values for year 1 were 2.93 ± 0.04 mm and 1.69 ± 0.02 mm in year 4. There were significant differences at finger sites (P < .05) among all year groups compared with year 1. There were no significant differences measured at the dominant forearm between any year groups (P = .08). The nondominant fingers of the year groups 1, 2, and 4 showed better 2-PD compared with the dominant finger. There was a significant difference (P = .005) between the nondominant (1.93 ± 1.15) and dominant (2.27 ± 1.14) fingers when all groups were combined (n = 104)., Conclusions: The results of this study demonstrated that the finger 2-PD of the chiropractic students later in the program was more precise than that of students in the earlier program., (Copyright © 2017. Published by Elsevier Inc.)

Background: Evidence on the diagnostic performance of palpatory methods and possible confounding factors is scarce., Objectives: To examine the sensitivity of palpatory methods for location of lumbopelvic landmarks and to assess its association with personal characteristics., Methods: Eighty-three participants (41 men, 55.6 (16.5) years, 25.9 (4.8) kg/m2 [mean (SD)]) were enrolled in this single-blinded study. Fourteen body and softy-tissue landmarks were sequentially palpated from the spinous process of L4 to the ischial tuberosity. CT-scan images were used to assess what landmark was located., Results: Sensitivity for location was in range 22-86% for soft-tissues and 26-69% for bony landmarks. Reduction in sensitivity was observed from the quadratus lumborum to the inferior and lateral angle of the sacrum (86-26% and 75-33%, left and right sides, respectively). Palpations of L4 and L5 spinous processes were systematically more cephalic than other landmarks. Gender was weakly correlated to almost all landmarks (rp⁢b= 0.333 or weaker). Body mass index was weakly correlated to the accurate location of ILAS and quadratus lumborum, great trochanter, PSIS, and piriformis (rp⁢b=-0.307 or weaker)., Conclusions: Systematic and propagation errors were present using sequential palpatory methods. Palpation in men was more sensitive and higher BMI was associated with lower sensitivity for lumbopelvic landmarks.

Background/purpose: A problem in skin rendering with haptic feedback is the reconstruction of accurate 3D skin surfaces from stereo skin images to be used for touch interactions. This problem also encompasses the issue of how to accurately remove haptic spatial noise caused by the construction of disparity maps from stereo skin images, while minimizing the loss of the original skin roughness for cloning real tough textures without errors. Since the haptic device is very sensitive to high frequencies, even small amounts of noise can cause serious system errors including mechanical oscillations and unexpected exerting forces. Therefore, there is a need to develop a noise removal algorithm that preserves haptic roughness., Methods: A new algorithm for a roughness preserving filter (RPF) that adaptively removes spatial noise, is proposed. The algorithm uses the disparity control parameter (λ) and noise control parameter (k), obtained from singular value decomposition of a disparity map. The parameter k determines the amount of noise to be removed, and the optimum value of k is automatically chosen based on a threshold of gradient angles of roughness (R a )., Results: The RPF algorithm was implemented and verified with three real skin images. Evaluation criteria include preserved roughness quality and removed noise. Mean squared error (MSE), peak signal to noise ratio (PSNR), and objective roughness measures R a and R q were used for evaluation, and the results were compared against a median filter. The results show that the proposed RPF algorithm is a promising technology for removing noise and retaining maximized roughness, which guarantees stable haptic rendering for skin roughness., Conclusion: The proposed RPF is a promising technology because it allows for any stereo image to be filtered without the risk of losing the original roughness. In addition, the algorithm runs automatically for any given stereo skin image with relation to the disparity parameter λ, and the roughness parameters R a or R q are given priority. Although this method has been optimized by graph-cut disparity map building, it can be extended to other disparity map building methods because the parameter k is determined by actual roughness R a data that can be obtained by simple measurement., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

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.

Introduction: Strengthening exercises for pelvic floor muscles (SEPFM) are considered the first approach in the treatment of stress urinary incontinence (SUI). Nevertheless, there is no evidence about training parameters., Objective: To identify the protocol and/or most effective training parameters in the treatment of female SUI., Method: A literature research was conducted in the PubMed, Cochrane Library, PEDro, Web of Science and Lilacs databases, with publishing dates ranging from January 1992 to March 2014. The articles included consisted of English-speaking experimental studies in which SEPFM were compared with placebo treatment (usual or untreated). The sample had a diagnosis of SUI and their age ranged between 18 and 65 years. The assessment of methodological quality was performed based on the PEDro scale., Results: Seven high methodological quality articles were included in this review. The sample consisted of 331 women, mean age 44.4±5.51 years, average duration of urinary loss of 64±5.66 months and severity of SUI ranging from mild to severe. SEPFM programs included different training parameters concerning the PFM. Some studies have applied abdominal training and adjuvant techniques. Urine leakage cure rates varied from 28.6 to 80%, while the strength increase of PFM varied from 15.6 to 161.7%., Conclusion: The most effective training protocol consists of SEPFM by digital palpation combined with biofeedback monitoring and vaginal cones, including 12 week training parameters, and ten repetitions per series in different positions compared with SEPFM alone or a lack of treatment.

Background: Traditional palpation technique for peripheral venous catheter (PVC) placement can be challenging. We aimed to compare the Dynamic Needle Tip Positioning (DNTP) ultrasound technique with the palpation technique for PVC placement in anaesthetised toddlers undergoing elective, low-risk procedures., Methods: The study was a randomised, controlled, crossover study. Five operators applied both techniques for PVC on 50 children < 4 years. The primary endpoint was first attempt success rate. The secondary endpoints were: (1) overall success rate, (2) number of skin perforations, (3) number of needle redirections, (4) number of catheters used, (5) total time, (6) needle manipulation time, (7) distance to the nearest flexion crease, (8) anatomical region of catheterisation, (9) size of the catheters and (10) the effects of visibility, and palpability of the veins., Results: The first attempt success rate and the overall success rate were significantly higher in the DNTP group (42/50 vs. 30/50, P = 0.029), (50/50 vs. 42/50, P = 0.008). Furthermore, a lower number of skin perforations (60 vs. 84, P = 0.013) and needle redirections (14 vs. 131, P < 0.001) and increased distance to the nearest flexion crease (P < 0.001) were seen in the DNTP group. There were no significant differences in number of catheters used (60 vs. 75 P = 0.050) or total time (P = 0.073), however, the needle manipulation time was longer in the DNTP group (P = 0.011). The success rate decreased with less visible and palpable veins in the palpation group (p = 0.006)., Conclusion: Ultrasound-guidance outperforms the traditional palpation technique for peripheral venous catheterisation in anaesthetised toddlers undergoing elective, low-risk procedures., (© 2017 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

The perception of stiffness and slipperiness of a breast mass on palpation is used by physicians to assess the level of suspicion of a lesion as being malignant or benign. However, most current ultrasound elastography imaging methods provide only stiffness-related information. There is no existing approach that provides information about the local rigid body rotation undergone by only a loosely bonded, asymmetrically oriented lesion subjected to a small quasi-static compression. The inherent poor lateral resolution in ultrasound imaging poses a limitation in estimating the local rigid body rotation. Several techniques have been reported in the literature to improve the lateral resolution in ultrasound imaging, and among them is spatial compounding. In this study, we explore the feasibility of obtaining better-quality rotation elastograms with spatial compounding through simulations using Field II and experiments on tissue-mimicking phantoms. The phantom was subjected to axial compression (∼1%-2%) from the top, and the angular axial and lateral displacement estimates were obtained using a multilevel 2-D displacement tracking algorithm at different insonification angles. A rotation elastogram (RE) was obtained by taking half of the difference between the lateral gradient of the axial displacement estimates and the axial gradient of the lateral displacement estimates. Contrast-to-noise ratio was used to quantify the improvements in quality of RE. Contrast-to-noise ratio values were calculated by varying the maximum steering angle and the incremental angle, and its effects on RE quality were evaluated. Both simulation and experimental results corroborated and indicated a significant improvement in the quality of RE using compounding technique., (Copyright © 2017 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Background: The sacroiliac joint (SIJ) has been implicated as a potential source of low back and buttock pain. Several types of motion palpation and pain provocation tests are used to evaluate SIJ dysfunction., Objective: The purpose of this study was to investigate the relationship between motion palpation and pain provocation tests in assessment of SIJ problems., Design: This study is Descriptive Correlation., Methods: 50 patients between the ages of 20 and 65 participated. Four motion palpation tests (Sitting flexion, Standing flexion, Prone knee flexion, Gillet test) and three pain provocation tests (FABER, Posterior shear, Resisted abduction test) were examined. Chi-square analysis was used to assess the relationship between results of the individuals and composites of these two groups of tests., Results: No significant relationship was found between these two groups of tests., Conclusions: It seems that motion palpation tests assess SIJ dysfunction and provocative tests assessed SIJ pain which do not appear to be related., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Physical examination of the abdomen is an essential skill. Knowledge of its clinical anatomy and application is vital for making diagnoses. Misinterpretation of anatomy during examination can have serious consequences. This review addresses understanding of the anatomy, methodology, and complications of abdominal physical examination. It includes particular reference to modern technology and investigations. Physical examination is performed for diagnostic purposes. However, the art of physical examination is declining as more and more clinicians rely on newer technology. This can have regrettable consequences: negligence, waste of time and resources, and deterioration of clinical skills. With a sound knowledge of clinical anatomy, and realization of the importance of physical examination of the abdomen, clinician, and patients alike can benefit. Clin. Anat. 30:352-356, 2017. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

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.

Aim: To outline the pathophysiology, clinical presentation, imaging features, and relevant investigations of the different subtypes of breast tuberculosis (TB)., Materials and Methods: A review was undertaken of all cases (33 in total) of breast TB presenting to Barts Health NHS Trust within a 10-year period, including patient demographics, imaging features, and route of diagnosis., Results: Thirty-three cases of proven granulomatous TB of the breast were identified (11 mastitis obliterans, 10 nodular caseous form, five sclerosing form, four disseminated disease, and three abnormal axillary lymph nodes). No cases of miliary breast TB were identified. Fine-needle aspiration cytology aided diagnosis in six patients (<20% of cases); however, the majority of patients required further investigation; namely core biopsy. Over a third of patients (12/33) had multiple clinic attendances prior to diagnosis. Mean delay in diagnosis was 3.7 months (median 0 months, IQR= 3)., Conclusion: Breast TB is a rare challenging diagnosis with a wide range of imaging features. Core biopsy is essential for definitive diagnosis. A multidisciplinary approach involving surgeons, radiologists, TB consultants, and microbiologists is required, coupled with a high index of clinical suspicion in order to aid timely diagnosis, and initiate prompt treatment to reduce complications., (Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.)

Background: The Valsalva maneuver, the most sensitive test for patent foramen ovale (PFO) detection, is difficult during transesophageal echocardiography (TEE), especially after sedation. The aim of this study was to compare PFO detection effectiveness between inferior vena cava (IVC) compression and the Valsalva maneuver., Methods: A total of 293 patients with paroxysmal atrial fibrillation undergoing TEE before initial atrial fibrillation ablation were prospectively enrolled. Agitated saline was injected in 290 patients under three conditions: Valsalva maneuver under conscious sedation, at rest, and IVC compression under deep sedation. Three patients with newly diagnosed atrial septal defects on TEE were excluded. The IVC compression maneuver consisted of manual compression 5 cm to the right of the epigastric region and depressed the abdominal wall by 5 cm for 30 sec and compression release immediately before right atrial opacification with microbubbles by agitated intravenous saline., Results: The overall PFO detection rate was better with IVC compression (57 PFOs [19.7%]) than at rest (15 patients [5.2%]) (P < .0001) or with the Valsalva maneuver (37 patients [12.8%]) (P = .024). There were no significant differences in PFO detection between IVC compression and the Valsalva maneuver (IVC compression, 43 patients [22.5%]; Valsalva maneuver, 35 patients [18.3%]; P = .31), even in patients who could perform the Valsalva maneuver effectively (n = 191)., Conclusions: IVC compression is feasible and effective for detecting PFO and is not inferior to the Valsalva maneuver. In particular, IVC compression could be an alternative diagnostic method for PFO using TEE when the Valsalva maneuver cannot be performed under deep sedation., (Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this work is to introduce a useful method for the clinical diagnosis of leg-length inequality: distance between the malleoli and the ground (DMG)., Methods: A transversal observational study was performed on 17 patients with leg-length discrepancy. Leg-length inequality was determined with different clinical methods: with a tape measure in a supine position from the anterior superior iliac spine (ASIS) to the internal and external malleoli, as the difference between the iliac crests when standing (pelvimeter), and as asymmetry between ASISs (PALpation Meter [PALM]; A&D Medical Products Healthcare, San Jose, California). The Foot Posture Index (FPI) and the navicular drop test were also used. The DMG with Perthes rule (perpendicular to the foot when standing), the distance between the internal malleolus and the ground (DIMG), and the distance between the external malleolus and the ground were designed by the authors., Results: The DIMG is directly related to the traditional ASIS-external malleolus measurement (P = .003), the FPI (P = .010), and the navicular drop test (P < .001). There are statistically significant differences between measurement of leg-length inequality with a tape measure, in supine decubitus, from the ASIS to the internal malleolus, and from the ASIS to the external malleolus., Conclusions: This new method (the DMG) is useful for diagnosing leg-length discrepancy and is related to the ASIS-external malleolus measurement. The DIMG is significantly inversely proportional to the degree of pronation according to the FPI. Conversely, determination of leg-length discrepancy with a tape measure from the ASIS to the malleoli cannot be performed interchangeably at the level of the internal or external malleolus.