Can Ultrasound in Combination with Virtual Touch Imaging Quantification Predict the Dignity of a Parotid Tumor?

Pre-operative evaluation of a parotid gland tumor is crucial in guiding treatment. This study evaluates the diagnostic performance of B-mode ultrasound in combination with Virtual Touch imaging quantification (VTIQ) in the assessment of parotid lesions. A prospective study of 268 patients with parotid lesions was conducted. Pre-operative ultrasound findings and VTIQ data were compared against histologic results. Ill-defined margins on ultrasound were associated with a significantly higher risk of malignancy (odds ratio [OR] = 1224.0, 95 % confidence interval [CI]: 151.8–9872.7). Faster mean shear waves on VTIQ (OR = 1.81, 95% CI: 1.47–2.23, per 1 m/s increase) and an area with shear wave velocity >6.0 m/s involving >70 % of the lesion (OR = 19.80, 95 % CI: 6.22–63.07) were associated with higher risk of malignancy. Addition of VTIQ to routine pre-operative B-mode ultrasound can provide supplemental information on the dignity of a parotid tumor, allowing for peri-operative procedural optimization.     

Can Therapeutic Ultrasound Influence the Integration of Skin Grafts?

Therapeutic ultrasound (TUS) is a widely used coadjuvant physical means to promote biological tissue repair. In the present investigation, the influence of TUS on the integration of full-thickness skin graft was studied in rabbits. Twenty female adult rabbits were used and two 2x2-cm square full-thickness skin grafts were obtained from both scapular regions and swapped, the one cut out on the right being placed on the left and vice versa. The graft on the right was irradiated with TUS (3 MHz, 0.5 W/cm2, 5-min duration) once a day for seven consecutive days, beginning on the third postoperative day; the graft on the left was submitted to simulated irradiation. The animals were killed on the 11th day and the grafted areas were resected (graft+safety margin) for histological examination. Five-mum-thick sections were alternatively stained with Gomori's trichrome, proliferating cell nuclear antigen (PCNA) and picrosirius red and examined under the light microscope, and the epidermal and dermal areas were measured and proliferating cells and new blood vessels counted. The results showed a significant increase (p=0.007) in the number of proliferating epidermal cells (12.18% and 7.34% of the total number of cells in the irradiated and control grafts, respectively) and new blood vessels per field (p=0.0001) in the irradiated grafts (6.27 compared with 3.07). Despite the increased number of proliferating cells and blood vessels, there was no significant difference between the epidermis (246,392 microm2 and 200,626 microm2 in groups 1 and 2, respectively; p=0.07) and dermis (2,157,730 microm2 and 2,109,150 microm2 in groups 1 and 2, respectively; p=0.21) areas as a function of thickness for both groups. We conclude that TUS induces morphological alterations in biological processes, such as epidermic germinative layer cell proliferation and neoangiogenesis, which are involved in the integration of full-thickness skin grafts. This has a potential for clinical use in humans.     

Dislocation of the Knee: An Epidemic in Waiting?

Background

Knee dislocation is an uncommon but serious injury that has traditionally been associated with high velocity injuries such as motor vehicle accidents. More recently, individual cases of obese individuals sustaining knee dislocation from a low velocity mechanism have been noted. Associated injuries of knee dislocation are common and include popliteal vessel damage requiring surgical repair and injuries to the peroneal nerve. Prompt diagnosis and reduction is essential to reduce the risk of these complications.

Objectives

We aim to highlight the importance of prompt diagnosis and management of obese patients presenting with knee pain after a seemingly innocuous injury who may have a knee dislocation.

Cases

We present a series of four cases of dislocation of the knee that have presented to our hospital over the course of 1 year. Each was sustained by a morbidly obese female of body mass index range 35–41, age range 33–52 years, experiencing a simple mechanical fall from standing. Magnetic resonance image scanning revealed multiple knee ligament rupture in all four cases. One case had peroneal nerve palsy.

Conclusion

This is the first series of such injuries that we are aware of and highlights a potential future increase in incidence of these major injuries as body mass in society increases, placing more strain on health care resources. Practitioners in the Emergency Department need to be aware that serious injury can be present in morbidly obese patients that have sustained no more than a fall from standing height. Prompt investigation and management is essential.     

Can Ultrasound Be Used to Improve the Palpation Skills of Physicians in Training? A Prospective Study

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.

Can the Death of a Child Be Good?

Fifty-four thousand children die each year despite the advances in care for children with acute and chronic illnesses. Demands for improved palliative and end-of-life care for children exist. Good death is a concept frequently used in the adult hospice movement. However, how can the death of a child be good? Analysis of good death can assist pediatric nurses to understand the concept and provide a framework for nurses in the clinical and research arenas to work together to develop and provide evidence-based, developmentally appropriate care for dying children and their families.     

Can Clinician-Stabilization with Hand-Held Dynamometry Yield a Reliable Measure of Knee Flexion Torque?

BackgroundAssessment of knee flexion torque is a relevant clinical measure following various injuries and surgeries to determine progress in rehabilitation and inform decision making. A variety of methods using hand-held dynamometry have been shown to be reliable in obtaining this measure, and typically require a means of external fixation or stabilization. Clinically efficient methods of reliable clinician-stabilization are sparse in the literature.Hypothesis/PurposeDetermine inter and intra-rater reliability of two clinically efficient methods of assessing isometric knee flexion torque using hand-held dynamometry with clinician-stabilization. The hypothesis was that each method would yield good to excellent reliability.Study DesignCross-Sectional StudyMethodsTwenty healthy individuals were assessed by two clinicians on two separate days. During each session, knee flexion torque was assessed with hand-held dynamometry with two methods: 1) in the seated position with the hip and knee flexed to 90 degrees while the clinician stabilized the dynamometer between the participant’s leg and table and 2) in prone with the hip at 0 degrees and knee at 90 degrees while the clinician assumed a stride stance with elbows locked in extension to stabilize the dynamometer on the participant’s leg. Inter and intra-rater reliability were determined for each method.ResultsICC values were 0.88-0.94 and 0.77-0.90 for inter and intra-rater reliability respectively with the seated method. The prone method yielded ICC values of 0.84-0.96 and 0.89-0.94 for inter and intra-rater reliability respectively. MDC values ranged from 30-62% with the seated method and 21-40% with the prone method.ConclusionInter and intra-rater reliability were good to excellent for assessing knee flexion torque with hand-held dynamometry using both the seated and prone methods with clinically efficient clinician-stabilization approaches. The prone method may be more sensitive to detecting change over time due to lower MDC values.Level of Evidence2b     

Ultrasound imaging of forearm fractures in children: a viable alternative?

OBJECTIVE: A pilot study to investigate whether ultrasonography can be reliably used to demonstrate uncomplicated greenstick and torus fractures in children. METHOD: Children between the ages of 2 and 14 years with a high clinical suspicion of a non-articular, undisplaced forearm fracture were included. Ultrasound imaging of the injury was performed by a consultant radiologist who gave an immediate report. Standard radiographs of the forearm were then obtained and the patient treated in the normal way. The radiograph was formally reported on at a later date. RESULTS: 26 patients were included. There was an absolute correlation between the ultrasound and radiographic findings. The procedure was well tolerated. CONCLUSION: Ultrasound seems effective for detecting uncomplicated forearm fractures in children. The procedure is easy to perform and the images easy to interpret. A larger study will now be undertaken to confirm these initial findings.     

Ultrasound imaging of forearm fractures in children: a viable alternative?

Objective—A pilot study to investigate whether ultrasonography can be reliably used to demonstrate uncomplicated greenstick and torus fractures in children.

Method—Children between the ages of 2 and 14 years with a high clinical suspicion of a non-articular, undisplaced forearm fracture were included. Ultrasound imaging of the injury was performed by a consultant radiologist who gave an immediate report. Standard radiographs of the forearm were then obtained and the patient treated in the normal way. The radiograph was formally reported on at a later date.

Results—26 patients were included. There was an absolute correlation between the ultrasound and radiographic findings. The procedure was well tolerated.

Conclusion—Ultrasound seems effective for detecting uncomplicated forearm fractures in children. The procedure is easy to perform and the images easy to interpret. A larger study will now be undertaken to confirm these initial findings.

     

Can Ultrasound of the Tibial Nerve Detect Diabetic Peripheral Neuropathy?: A cross-sectional study

OBJECTIVE

Peripheral nerve imaging by portable ultrasound (US) may serve as a noninvasive and lower-cost alternative to nerve conduction studies (NCS) for diagnosis and staging of diabetic sensorimotor polyneuropathy (DSP). We aimed to examine the association between the size of the posterior tibial nerve (PTN) and the presence and severity of DSP.

RESEARCH DESIGN AND METHODS

We performed a cross-sectional study of 98 consecutive diabetic patients classified by NCS as subjects with DSP or control subjects. Severity was determined using the Toronto Clinical Neuropathy Score. A masked expert sonographer measured the cross-sectional area (CSA) of the PTN at 1, 3, and 5 cm proximal to the medial malleolus.

RESULTS

Fifty-five patients had DSP. The mean CSA of the PTN in DSP compared with control subjects at distances of 1 (23.03 vs. 17.72 mm²; P = 0.004), 3 (22.59 vs. 17.69 mm²; P < 0.0001), and 5 cm (22.05 vs. 17.25 mm²; P = 0.0005) proximal to the medial malleolus was significantly larger. Although the area under the curve (AUC) for CSA measurements at all three anatomical levels was similar, the CSA measured at 3 cm above the medial malleolus had an optimal threshold value for identification of DSP (19.01 mm²) with a sensitivity of 0.69 and a specificity of 0.77 by AUC analysis.

CONCLUSIONS

This large study of diabetic patients confirms that the CSA of the PTN is larger in patients with DSP than in control subjects, and US is a promising point-of-care screening tool for DSP.Ultrasound (US) for nerve imaging is increasingly used by various medical specialties for both diagnostic and therapeutic purposes (1,2). Modern US machines permit real-time, point-of-care imaging of nerves and their surrounding structures with high fidelity and without patient discomfort or radiation exposure. One promising application of US technology of interest to internists, anesthesiologists, and surgeons may be its ability to rapidly and reliably identify peripheral neuropathy, which traditionally requires resource-intensive nerve conduction studies (NCS) for formal diagnosis (3,4). Preliminary data signal a direct relationship that is independent of BMI, age, height, or weight between the presence of diabetic neuropathy and a greater cross-sectional area (CSA) of peripheral nerves as visualized by US (5,6). However, these previously published studies are limited by small sample sizes and cannot offer predictive values for US as a diagnostic test (6–8). In this larger observational study, we aimed to determine whether US can reliably detect the presence and severity of diabetic sensorimotor polyneuropathy (DSP). We hypothesized that the CSA of the posterior tibial nerve (PTN) as measured by US is higher in diabetic patients with DSP compared with diabetic patients without DSP.     

Can the Contrast-Enhanced Ultrasound Washout Rate Be Used to Predict Microvascular Invasion in Hepatocellular Carcinoma?

The objective of this study was to investigate use of the washout rate of hepatocellular carcinoma on contrast-enhanced ultrasound (CEUS) for pre-operative determination of the presence of microvascular invasion. The study included 271 patients who underwent liver resection for hepatocellular carcinoma between April 2008 and December 2012, and were examined with contrast-enhanced ultrasound before surgery. Patients were followed up at 3-mo intervals for 3 y. Four washout patterns were classified according to the start time of washout: rapid, portal, delayed and slow. Rapid washout, presence of two or more tumors and tumor size ≥5 cm were identified as independent pre-operative predictors of microvascular invasion on multivariate analysis. Recurrence rates for patients with none, one, two or three predictors were 22.6%, 34.7%, 57.6% and 75.0%, respectively. In combination with tumor number and tumor size, contrast-enhanced ultrasound washout rate may have a role in identifying hepatocellular carcinoma patients with microvascular invasion.     

Laboratory Tests in Adults with Monoarticular Arthritis: Can They Rule Out a Septic Joint?

It is difficult to differentiate septic arthritis from other causes of monoarticular arthritis solely with a history and physical examination. The clinician must rely on ancillary tests to make a diagnosis, such as the white blood cell count of peripheral blood (WBC), the erythrocyte sedimentation rate (ESR), and the white blood cell count of the joint fluid (jWBC) obtained from arthrocentesis. Although it is known that septic arthritis is associated with abnormalities in these tests, the majority of the data are based on studies in the pediatric population. In addition, although several emergency medicine texts indicate that a jWBC greater than 50,000 cells/mm(3) is "positive," it is known that septic arthritis can occur in patients with low jWBCs. OBJECTIVES: To determine whether specific ancillary tests have sufficiently high sensitivities to rule out septic arthritis in adults. METHODS: This was a retrospective consecutive case series of patients from an urban emergency department (ED). Patients at least 18 years old who had septic arthritis confirmed by positive arthrocentesis culture or operative findings were included in the study. WBC greater than 11,000 cells/mm(3), ESR greater than 30 mm/hr, and jWBC greater than 50,000 cells/mm(3) were considered elevated. RESULTS: Seventy-three patients met the inclusion criteria. The sensitivities of an elevated WBC, ESR, or jWBC in adults who had septic arthritis were 48%, 96%, and 64%, respectively. There were broad ranges of WBC, ESR, or jWBC among the patients. More than one third of adult patients with septic arthritis had jWBCs less than 50,000 cells/mm(3). All patients had an abnormality in at least one of these tests. CONCLUSIONS: The WBC, ESR, and jWBC are extremely variable in adults with septic arthritis. Laboratory tests do not rule out septic arthritis with accuracy.     

Can a flowchart improve the quality of bystander cardiopulmonary resuscitation?

Background

Since the introduction of basic life support in the 1950s, on-going efforts have been made to improve the quality of bystander cardiopulmonary resuscitation (CPR). Even though bystander-CPR can increase the chance of survival almost fourfold, the rates of bystander initiated CPR have remained low and rarely exceed 20%. Lack of confidence and fear of committing mistakes are reasons why helpers refrain from initiating CPR. The authors tested the hypothesis that quality and confidence of bystander-CPR can be increased by supplying lay helpers with a basic life support flowchart when commencing CPR, in a simulated resuscitation model.

Materials and methods

After giving written informed consent, 83 medically untrained laypersons were randomised to perform basic life support for 300s with or without a supportive flowchart. The primary outcome parameter was hands-off time (HOT). Furthermore, the participants’ confidence in their actions on a 10-point Likert-like scale and time-to-chest compressions were assessed.

Results

Overall HOT was 147 ± 30 s (flowchart) vs. 169 ± 55 s (non-flowchart), p = 0.024. Time to chest compressions was significantly longer in the flowchart group (60 ± 24 s vs. 23 ± 18 s, p < 0.0001). Participants in the flowchart group were significantly more confident when performing BLS than the non-flowchart counterparts (7 ± 2 vs. 5 ± 2, p = 0.0009).

Conclusions

A chart provided at the beginning of resuscitation attempts improves quality of CPR significantly by decreasing HOT and increasing the participants’ confidence when performing CPR. As reducing HOT is associated with improved outcome and positively impacting the helpers’ confidence is one of the main obstacles to initiate CPR for lay helpers, charts could be utilised as simple measure to improve outcome in cardiopulmonary arrest.