Intrapartum fetal head position II: comparison between transvaginal digital examination and transabdominal ultrasound assessment during the second stage of labor

OBJECTIVE

To test the null hypothesis that no correlation exists between transvaginal digital examination compared with the gold standard technique of transabdominal suprapubic ultrasound assessment of fetal head position during the second stage of labor. A secondary objective was to compare the performance of attending physicians vs. senior residents in depicting fetal head position by transvaginal digital examination in comparison with ultrasound assessment.

METHODS

Consecutive patients in the second-stage of labor at term with normal singleton cephalic-presenting fetuses and ruptured membranes were included. Transvaginal digital examinations were performed by either attending physicians or senior residents and were followed immediately by transverse suprapubic transabdominal sonographic assessments performed by a single sonographer. Examiners were blinded to each other's findings. Power analysis dictated sample size. Exact binomial confidence intervals around observed rates were compared with chi 2 and Cohen's kappa-tests. Logistic regression was applied. P < 0.05 was considered significant throughout.

RESULTS

One hundred and twelve patients were studied. The absolute error of transvaginal digital examinations was recorded in 65% of patients (95% confidence interval, 56-74%). Parity, pelvic station, combined spinal epidural anesthesia, length of first or second stages of labor, use of oxytocin augmentation, gestational age, mode of delivery, birth weight, and examiner experience did not significantly affect examination accuracy. Stratification, when the transvaginal digital examination was recorded as correct if occurring within +/- 45 degrees of the ultrasound assessment, reduced the error of the transvaginal digital examinations to 39% (95% confidence interval, 30-49%). Independent variables again did not affect examination accuracy in this assessment modality. Rates of agreement between the two methods for attending physicians compared with residents were not significantly different. The overall degrees of agreement were 40% (95% confidence interval, 26-55%) and 68% (95% confidence interval, 53-80%) (kappa = 0.25 and 0.30) for the absolute agreement and +/- 45 degrees assessment modalities, respectively, for attending physicians, and 31% (95% confidence interval, 20-44%) and 55% (95% confidence interval, 42-68%) (kappa = 0.14 and 0.12) for senior residents.

CONCLUSION

Using ultrasound assessment as the gold standard, our data demonstrate a high rate of error (65%) in transvaginal digital determination of fetal head position during the second stage of labor. The performance of senior residents in transvaginal digital examinations did not differ significantly from that of attending physicians. Intrapartum ultrasound increases the accuracy of fetal head position assessment during the second stage of labor.

Intrapartum fetal head position I: comparison between transvaginal digital examination and transabdominal ultrasound assessment during the active stage of labor

OBJECTIVE

To test the null hypothesis that no correlation exists between transvaginal digital and the gold standard technique of transabdominal suprapubic ultrasound assessments of fetal head position during labor. A secondary objective was to compare the performance of attending physicians vs. senior residents in depicting fetal head position by transvaginal digital examination in comparison with ultrasound, respectively.

METHODS

Consecutive patients in active labor at term with normal singleton cephalic-presenting fetuses were included. All participants had ruptured membranes, cervical dilation > or = 4 cm and fetal head at ischial spine station -2 or lower. Transvaginal sterile digital examinations were performed by either senior residents or attending physicians and followed immediately by transverse suprapubic transabdominal ultrasound assessments. Examiners were blinded to each other's findings. Power-analyses dictated number of subjects required. Statistical analyses included Chi-square, Cohen's Kappa test and logistic regression analysis. P < 0.05 was considered statistically significant.

RESULTS

One hundred and two patients were studied (n = 102). In only 24% of patients (n = 24), transvaginal digital examinations were consistent with ultrasound assessments (P = 0.002, 95% confidence interval, 16-33). Logistic regression revealed that cervical effacement (P = 0.03) and ischial spine station (P = 0.01) significantly affected the accuracy of transvaginal digital examination. Parity, gestational age, combined spinal epidural anesthesia, cervical dilation, birth weight and examiner experience did not significantly affect accuracy of the examination. The accuracy of the transvaginal digital exams was increased to 47% (n = 48) (95% confidence interval, 37-57) when fetal head position at transvaginal digital examination was recorded as correct if reported within +/- 45 degrees of the ultrasound assessment. The rate of agreement between the two assessment methods for attending physicians vs. residents was 58% vs. 33%, respectively (P = 0.02) with the +/- 45 degrees analysis.

CONCLUSIONS

Using ultrasound assessment as the gold standard, our data demonstrate an overall high rate of error (76%) in transvaginal digital determination of fetal head position during active labor, consistent with the null hypothesis. Attending physicians exhibited an almost two-fold higher success rate in depicting correct fetal head position by physical examination vs. residents in the +/- 45 degrees analysis. Intrapartum ultrasound increases the accuracy of fetal head position assessment during active labor and may serve as an educational tool for physicians in training.

Scapular position: the validity of skin surface palpation

The assessment of the resting position of the scapula forms part of the examination of upper quadrant posture. The purpose of this study was to determine if surface palpation is a valid indicator of actual scapular position. Twelve embalmed shoulders were examined and the actual location of three bony scapular landmarks and three bony thoracic landmarks were compared with surface palpation of these locations. The results, based on the upper value for a distance (with 95% confidence), suggested that the difference between the surface location of the root of the spine of the scapula, the acromial angle and the inferior angle would be less than 0.67 cm, 0.98 cm and 0.46 cm respectively from the centre of the bony locations. The difference between the twelfth thoracic spinous process (SP), the SP corresponding with the root of the spine of the scapula, and the SP corresponding with the inferior angle and the surface points would be 1.46 cm, 1.09 cm and 1.01 cm respectively. The results of this study suggest that surface palpation of scapular location is a valid method for determining the actual location of the scapula. The findings also suggest that surface palpation can determine the location of thoracic landmarks, which may serve as reference points for scapular position.

Prostate biopsy techniques and indications: when, where, and how?

Transrectal ultrasound (TRUS) and prostate biopsy have become one of the most common office-based procedures for the practicing urologist. During the past 50 years, the techniques, indications, and pathologic interpretation of prostate biopsies have evolved. The abandonment of blind finger-guided needle biopsies in favor of systematic TRUS-guided biopsies epitomizes much of this change. Similarly, the indications for prostate biopsy have become more refined. In the past, the presence of a prostatic nodule on digital rectal examination (DRE) was the primary indication for biopsy until the introduction of prostatic-specific antigen (PSA) in the 1980s and its widespread use for prostate cancer screening. Abnormalities of PSA or its derivatives now represent the most common indication for prostate biopsy. Although TRUS initially began as a tool to direct needles into various locations within the prostate, today a great deal of information can be obtained from prostate ultrasound for the discerning clinician. As such, TRUS-guided biopsy of the prostate has become an important staging and diagnostic tool for the practicing urologist. Here we review the current techniques and indications as well as pertinent pathologic and staging data obtained through TRUS and prostate biopsy.

Motion palpation findings and self-reported low back pain in a population-based study sample

BACKGROUND

Although the clinical usefulness of motion palpation has not been established, it is one of the most commonly used diagnostic methods by chiropractors. Notably, its sensitivity, specificity, and validity in general have not been adequately studied, and most study samples have consisted of student volunteers.

OBJECTIVE

To determine the prevalence of positive motion-palpation findings (so-called fixations and spontaneous pain response) in relation to self-reported low back pain status and to determine the sensitivity and specificity of the motion-palpation technique carried out on the sacroiliac and lumbar joints.

DESIGN

Study subjects were examined by 1 examiner (out of 7 possible), who was unaware of their low back pain status. Information on low back pain was then collected in a self-report questionnaire.

SETTING

Research laboratory at the Odense University Hospital, Denmark.

PARTICIPANTS

One hundred eighty-four twins, consisting of a subset of healthy twins taken from a panel of population-generated twins aged 19 to 42 years, made up the study sample. Examiners consisted of 7 biomechanics (chiropractic) students from the University of Southern Denmark who were proficient in motion palpation.

MAIN OUTCOME MEASURES

The prevalence rates of motion palpation-determined fixations and of spontaneous pain reactions in response to motion palpation were studied in relation to anatomic area, self-reported low back pain status, and each other.

RESULTS

The point period prevalence of low back pain was 14%. Fixations were found in 43% of the study sample, and 25% appeared to have a painful reaction to motion palpation. There was no logical pattern of fixations and spontaneous pain reactions in relation to the low back pain status. The sensitivity was generally low (always below 60%) for fixations and pain, whereas the specificity was higher, significantly so for pain in the mid lumbar area. There was no strong association between fixations and the examiners' interpretation of a spontaneous pain reaction in response to motion palpation.

CONCLUSION

Motion palpation does not appear to be a good method to differentiate persons with or without low back pain. It is possible to dissociate the findings of fixations and those of pain reactions.

Look before you clamp: delivery room examination of the umbilical cord

The umbilical cord is a critical connection between the embryo (and later, the fetus) and the placenta. The umbilical cord houses the blood vessels that are responsible for nourishing the fetus. Proper umbilical cord function is essential for growth and development before birth. A review of the embryologic origin of the umbilical cord aids in understanding abdominal wall and umbilical cord defects that can present in the newborn period. In the delivery room, inspection of the umbilical cord is an integral part of the first minutes of life. Any abnormality either within the cord structure or in the areas surrounding the base of the cord may necessitate a delay in shortening the cord. Surgical consultation may also be indicated. This issue of Focus on the Physical will provide a step-by-step guide to cord assessment in the delivery room setting. Pictures showing normal, atypical, and abnormal umbilical cords and common abdominal wall defects will be presented along with a brief discussion of the significance and clinical implications of each of these findings.

[Acute abdomen in primary care]

The author--using his 30 years practical medical experience, from the point of view of a family doctor giving the first diagnose, analyses the problem of acute abdomen. Gives an overview of anamnesis (heteroanamnesis) and the data and their significance investigated during the physical examination of patient (inspection, palpation, percussion, auscultation), and that of the usefulness for the right diagnose. The author orients the reader's attention to the fact, that the beginning of the third millennium in the world of instrumental and laboratory diagnostics, in case of certain illnesses--so in the case of acute abdomen--physical examinations have not lost a bit from their significance.

Diagnostic significance of digital rectal examination and transrectal ultrasonography in men with prostate-specific antigen levels of 4 NG/ML or less

OBJECTIVES

To investigate the usefulness of digital rectal examination (DRE) and transrectal ultrasonography (TRUS) for prostate cancer diagnosis and to propose a diagnostic algorithm for individual-based cancer screening in subjects with prostate-specific antigen (PSA) levels of 4.0 ng/mL or less.

METHODS

Between January 1992 and March 2000, 129 subjects with PSA levels of 4.0 or less and abnormal findings on DRE or TRUS underwent prostate biopsy. The subjects were divided into four groups according to the PSA range: 0 to 0.9 ng/mL, 1.0 to 1.9 ng/mL, 2.0 to 2.9 ng/mL, and 3.0 to 4.0 ng/mL. The reliability of the DRE and TRUS and the clinicopathologic features of prostate cancer were investigated among these four groups.

RESULTS

Of the 129 subjects, 17 (13.2%) patients with prostate cancer were diagnosed. The detection rate was 2.2% (1 of 45), 0% (0 of 27), 20.6% (7 of 34), and 39.1% (9 of 23) in subjects with PSA levels of less than 1.0 ng/mL, 1.0 to 1.9 ng/mL, 2.0 to 2.9 ng/mL, and 3.0 to 4.0 ng/mL, respectively. The proportion of patients with Stage II, III, and IV was 58.8%, 41.2%, and 0%, respectively. The percentage with Gleason scores of 8 to 10 was 17.6%. The detection rate of abnormal findings on DRE and TRUS was 14.4% (13 of 90) and 9.5% (7 of 74), respectively. Adding TRUS to DRE in the screening program of subjects with PSA levels of 2.0 to 4.0 ng/mL, increased the detection rate of prostate cancer to 30.8% (4 of 13).

CONCLUSIONS

Routine prostate biopsy should not be undertaken except for highly suspicious DRE findings in subjects with PSA levels less than 2.0 ng/mL. The additional use of TRUS in subjects with PSA levels of 2.0 to 4.0 ng/mL would improve the sensitivity of prostate cancer detection. The diagnostic algorithm proposed in the present study is useful as a screening method for prostate cancer in subjects with PSA levels of 4.0 ng/mL or less.

Design of digital hardware system for pulse signals

In this study, we have developed the digital hardware system which performs signal processing necessary for the filtering to eliminate noises by inputting pulse wave signals from the sensor group. With a view to obtain clinically effective information, we analyzed structural elements of pulse waveform and, thus, conducted a systematic classification. What is more, we performed the modeling of the digital filter by using the Steiglitz-McBride iteration method in order to get the same results with output signals coming out of an galvanometer of analog type of existing Pulse diagnosis system with input signals entering into galvanometer and coming out of the amp group of the Pulse diagnosis system.

DNA-based detection of prostate cancer in urine after prostatic massage

OBJECTIVES

Promoter hypermethylation of the glutathione-S-transferase P1 (GSTP1) gene is a specific feature of prostate cancer. This epigenetic DNA alteration served as the target for molecular detection of prostate cancer cells in urine sediments after prostatic massage.

METHODS

Bisulfite treatment followed by methylation-specific polymerase chain reaction was used to detect GSTP1 promoter hypermethylation in DNA isolated from urine sediments obtained after prostatic massage of men with and without prostate cancer.

RESULTS

GSTP1 promoter hypermethylation was demonstrated in the sediments of 1 (2%) of 45 patients diagnosed with benign prostatic hyperplasia, 2 (29%) of 7 patients with prostatic intraepithelial neoplasia, 15 (68%) of 22 patients with early, intracapsular cancer, and 14 (78%) of 18 patients with locally advanced or systemic prostate cancer, resulting in a specificity of 98% and an overall sensitivity of 73% for the detection of prostate cancer.

CONCLUSIONS

Urinalysis for GSTP1 promoter hypermethylation constitutes a sensitive and highly specific DNA-based marker for molecular detection of prostate cancer, including early stages.

Eccentric overload training for patients with chronic Achilles tendon pain--a randomised controlled study with reliability testing of the evaluation methods

The purpose was to examine the reliability of measurement techniques and evaluate the effect of a treatment protocol including eccentric overload for patients with chronic pain from the Achilles tendon. Thirty-two patients with proximal achillodynia (44 involved Achilles tendons) participated in tests for reliability measures. No significant differences and strong (r=0.56-0.72) or very strong (r=0.90-0.93) correlations were found between pre-tests, except for the documentation of pain at rest (P<0.008, r=0.45). To evaluate the effect of a 12-week treatment protocol for patients with chronic proximal achillodynia (pain longer than three months) 40 patients (57 involved Achilles tendons) with a mean age of 45 years (range 19-77) were randomised into an experiment group (n=22) and a control group (n=18). Evaluations were performed after six weeks of treatment and after three and six months. The evaluations (including the pre-tests), performed by a physical therapist unaware of the group the patients belonged to, consisted of a questionnaire, a range of motion test, a jumping test, a toe-raise test, a pain on palpation test and pain evaluation during jumping, toe-raises and at rest. A follow-up was also performed after one year. There were no significant differences between groups at any of the evaluations, except that the experiment group jumped significantly lower than the control group at the six-week evaluation. There was, however, an overall better result for the experiment group with significant improvements in plantar flexion, and reduction in pain on palpation, number of patients having pain during walking, having periods when asymptomatic and having swollen Achilles tendon. The controls did not show such changes. Furthermore, at the one-year follow-up there were significantly more patients in the experiment group, compared with the control group, that were satisfied with their present physical activity level, considered themselves fully recovered, and had no pain during or after physical activity. The measurement techniques and the treatment protocol with eccentric overload used in the present study can be recommended for patients with chronic pain from the Achilles tendon.

Transxiphoid bilateral palpation in video-assisted thoracoscopic lung metastasectomy

OBJECTIVE

To evaluate indications, limits, and merits of transxiphoid bilateral palpation during video-assisted thoracoscopy (VAT) lung metastasectomy.

DESIGN

Survey retrospective study with a minimum follow-up of 1 year.

SETTING

University hospital.

PATIENTS

From December 1995 to September 1999, 29 of 45 patients operated on for pulmonary metastasectomy were approached through a transxiphoid VAT. Primary sites were colon-rectum (n = 13), kidney (n = 4), limb osteosarcoma (n = 3), uterus (n = 2), larynx (n = 2), breast (n = 1), skin melanoma (n = 1), prostate gland (n = 1), back fibrosarcoma (n = 1), and ovary (n = 1). Bilateral palpation was performed in 23 patients, although only 10 had radiological evidence of bilateral disease.

RESULTS

No perioperative or 30-days postoperative mortality was recorded. Acute and chronic pain was similar to that of other VATs and significantly less than sternotomy. Mean +/- SD chest-drain time and hospital stay were 2.8 +/- 1.19 days and 4.3 +/- 1.78 days, respectively. Sixty-nine lesions, 60 of them metastatic, were resected by laser (n = 29) or stapler (n = 40). Bilateral exploration permitted the discovery of 15 radiologically undetected lesions, 11 of which were found to be malignant. Contralateral metastases were found in 5 patients predicted to have unilateral disease. Mean +/- SD follow-up was 22.89 +/- 10.87 months (range, 9-60 months). Six patients developed new pulmonary metastases after a mean interval of 13.6 months; 3 of these patients relapsed in the unexplored hemithorax after 6, 9, and 12 months, respectively.

CONCLUSIONS

The use of the transxiphoid VAT approach was safe, applicable in many instances, and effective in detecting occult metastases by manual bilateral palpation. The advantages of a VAT procedure can be coupled with those provided by a radical operation.

Reliability of the lateral pull test and tilt test to assess patellar alignment in subjects with symptomatic knees: student raters

STUDY DESIGN

Test-retest reliability with blinded testers.

OBJECTIVES

To determine the inter- and intra-rater reliability of the lateral pull test and patellar tilt test.

BACKGROUND

If patellar malalignment can be detected by clinical examination, then condition-specific treatment interventions may be implemented in patients with patellofemoral pain syndrome. However, several clinical tests used to assess patellar mobility have recently been shown to have poor to fair reliability. Because the lateral pull test and the patellar tilt test are widely used clinically as diagnostic tests for patellofemoral pain syndrome but have not been previously tested for reliability, we examined these tests.

METHODS AND MEASURES

Fifty-two subjects (age range, 21-48 years) provided 95 knees (19 symptomatic and 76 asymptomatic) for assessment of the lateral pull test. Two testers, blinded to the presence or absence of symptoms, independently performed the lateral pull test in random order. Fifty-five subjects (age range, 22-42 years) provided 99 knees (73 asymptomatic and 26 symptomatic) for assessment of the patellar tilt test. Three blinded testers independently performed the patellar tilt test in random order. All subjects were tested and retested within 3-5 days. A kappa (kappa) statistic was used to assess the agreement of findings within each tester and between testers.

RESULTS

The kappa coefficients for intrarater reliability varied from 0.39 to 0.47 for the lateral pull test and from 0.44 to 0.50 for the patellar tilt test, while the coefficients for interrater reliability were 0.31 for the lateral pull test and varied from 0.20 to 0.35 for the tilt test.

CONCLUSIONS

Repeated lateral pull tests and patellar tilt tests had fair intrarater and poor interrater reliability. Our results suggest that care must be taken in placing too much emphasis on these tests when making clinical decisions.

Age, prostate-specific antigen, and digital rectal examination as determinants of the probability of having prostate cancer

OBJECTIVES

The decision to perform prostate biopsy has traditionally been based on an abnormal prostate-specific antigen (PSA) level or abnormal digital rectal examination (DRE) findings. For example, a 60-year-old man with a benign DRE and PSA level of 4.1 ng/mL would be counseled for biopsy, and the same man with a PSA level of 3.9 ng/mL might be counseled against biopsy. However, the difference in these PSA levels and in the likelihood of these two men having prostate cancer is not significant. We constructed a probability nomogram for the likelihood of detecting prostate cancer, thus aiding in the decision of whether to perform a prostate biopsy.

METHODS

Using multivariate logistic regression analysis and data from 2054 men (mean age 64 years) participating in the Tyrol Screening Project between January 9, 1993 and January 9, 1997, patient age, PSA level, and DRE findings were analyzed for their ability to determine the likelihood of finding prostate cancer on transrectal ultrasound-guided biopsy.

RESULTS

DRE was suspicious in 278 men (13.5%). Overall, 498 (24.5%) of 2054 men biopsied had prostate cancer. The probability of discovering cancer on biopsy was calculated using patient age, DRE findings, and PSA level.

CONCLUSIONS

DRE status had a large influence on the likelihood of positive biopsy across all PSA and age ranges. A combination of PSA, DRE result, and age better defined the probability of a positive biopsy than any factor alone. Using this nomogram, the decision to proceed with or defer prostate biopsy can be based on an actual probability of discovering prostate cancer rather than a single PSA-based cutpoint. These data may aid physicians and patients in decision-making.

Detection and evaluation of a palpable breast mass

The discovery of a breast mass, either self-detected or identified by a clinician, is a common, often distressing occurrence for many women. Although most detected breast masses are benign, every woman presenting with a breast mass should be evaluated to exclude or establish a diagnosis of cancer. This article provides a succinct overview of normal breast anatomy and reviews common causes of breast masses. The role of the clinical breast examination is discussed, and an algorithm is provided for optimal utilization of available tools in the diagnostic evaluation of a breast mass. The evaluation should be performed expeditiously and the results communicated promptly to the patient. Regardless of the age of the woman, a clinically suspicious mass must be evaluated even if findings on a mammogram are normal.

Interexaminer reliability and validity of a three-dimensional model to assess prostate volume by digital rectal examination

OBJECTIVES

To evaluate the interexaminer reliability and accuracy compared with transrectal ultrasound (TRUS) of a three-dimensional (3D) model and other scales to improve the estimation of prostate volume by digital rectal examination (DRE).

METHODS

Volunteers from a urology clinic (n = 121) were examined independently by three examiners with different levels of experience in randomized order. During DRE, the examiners estimated the prostate size in increments of 5 g, using various rating scales and a 3D sizing model, without access to the findings of the other investigators. TRUS was then performed by each examiner.

RESULTS

The 121 volunteers were 39 to 82 years old, with a mean +/- SD total TRUS prostate size of 35.9 +/- 27.2 g. The DRE size estimates ranged from 15 to 100 g across all examiners and patients. The interexaminer reliability across examiners for the best DRE prostate size estimates (in grams) was 0.78 (95% confidence interval 0.70 to 0.84), and the correlation coefficients (r(s)) with the TRUS volume ranged from 0.61 to 0.72 for the three examiners. A 3D model showed good reliability (intraclass correlation coefficient 0.86, 95% confidence interval 0.75 to 0.93), and correlated well with the TRUS volume (r(s) = 0.67 to 0.75). Other scales showed fair reliability (0.58 to 0.68) and correlated with the TRUS measurements (0.57 to 0.67). The area under the receiver operating characteristic curve to identify prostate volumes greater than 40 g ranged from 0.78 to 0.90 for DRE estimates (in grams) and 0.69 to 0.89 for the 3D model.

CONCLUSIONS

DRE size estimates and TRUS volume were moderately to highly correlated in men without prostate cancer. A 3D sizing model showed comparable reliability and correlation with TRUS. Although the DRE estimates generally tend to underestimate the TRUS-measured prostate volume, these tools may be useful in identifying men with enlarged prostate glands.

Hand-assisted laparoscopic surgery in the United States: an overview

Hand-assisted laparoscopic surgery (HALS) was developed to bridge the gap between open surgery and advanced laparoscopic surgery. Advantages of the hand in the abdomen include tactile feedback, the ability to palpate, blunt dissection, organ retraction, control of bleeding, and rapid organ removal. There are 3 commercially available devices in the United States, as well as a fourth in Europe and a fifth in Japan. Uses for HALS include procedures requiring intact specimen removal, complex laparoscopic procedures, preventing open conversion, and overcoming a technical obstacle. HALS procedures, such as esophagectomy, gastrectomy, hepatectomy, pancreatectomy, splenectomy, bariatric surgery, colectomy, nephrectomy, hysterectomy, and aortobifemoral bypass, have all been reported in the literature. Improvement in instrumentation, specifically with newer generation devices, will allow HALS to become more popular. We advocate the use of HALS specifically for laparoscopic colectomy, laparoscopic splenectomy for massive splenomegaly, and for living-related donor nephrectomy.

Hand-assisted laparoscopic pancreatic resection

The extent of reported laparoscopic pancreatic resections vary from enucleation to pancreaticoduodenectomy. Nevertheless, most patients with pancreatic disease who require resection are still treated with a traditional approach. Technological advancements in recent years may play an important role for the future diffusion of laparoscopic pancreatectomy. In hand-assisted laparoscopic surgery, the surgeon inserts a hand into the abdomen through a small laparotomy while pneumoperitoneum is maintained, and uses the hand to assist with dissection, palpation and retraction, control of blood vessels, manipulation of organs, and removal of the specimen. We present a review of our experience and of the world literature on hand-assisted laparoscopic pancreatic resection. Based on the first encouraging results, we believe that the hand-assisted technique should allow for substantial advantages to laparoscopic pancreatic surgery in the future.

Characteristics of colorectal cancer that produce positive immunochemical occult blood test results on stool obtained by digital rectal examination

OBJECTIVE

To clarify the clinicopathological features of colorectal cancer that show positive results on an immunochemical fecal occult blood test of stool obtained by digital rectal examination.

METHODS

In a cross-sectional study, 9952 subjects received both an immunochemical fecal occult blood test of stool obtained by digital rectal examination and colonoscopy annually over a nine-year period of medical checkups; 64 patients with colorectal cancer were identified. The study subjects comprised 39 patients with colorectal cancer who had positive results (positive group) and 25 patients with colorectal cancer who had negative results (negative group) on an immunochemical fecal occult blood test of stool obtained by digital rectal examination. The positive and negative groups were compared in terms of their individual factors, such as site, size, Dukes classification and histological type of the cancer lesions.

RESULTS

The prevalence of rectal cancers was higher in the positive group than in the negative group (P<0.05), but there were no differences between the two groups with respect to any other factors.

CONCLUSIONS

These findings indicate that stool obtained during the digital rectal examination is unsuitable for detecting fecal occult blood, especially for the detection of proximal colon neoplasms.

The Prostate Cancer Prevention Trial: Current status and lessons learned

The Prostate Cancer Prevention Trial is the first phase 3 prevention trial for prostate cancer in the United States. The implementation of a large, randomized trial has provided a wealth of information that will aid in future cancer chemopreventive studies in US men. The experience from the implementation of the Prostate Cancer Prevention Trial was reviewed. Lessons learned from the study include: (1) US men are willing to enroll in prevention trials; (2) participants in chemoprevention trials are well educated and healthy; (3) the successful cancer prevention trial is viewed by participants as a "men's health trial"; (4) data management and discipline coordination at participating institutions are critical; (5) study design change is commonly required owing to changes in clinical practice over the course of the trial; and (6) training of institutional staff is essential. With proper design, robust data management, and a flexible staff, large-scale randomized chemoprevention trials can be accomplished in the United States. With the extraordinary number of potential agents, it is expected that much will be accomplished with this strategy in the near future.