Effect of student transrectal palpation on early pregnancy loss in dairy cattle

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

Ultrasound versus 'clinical touch' for catheter guidance during embryo transfer in women

BACKGROUND

Many women undergoing an assisted reproductive technology (ART) cycle will not achieve a live birth. Failure at the embryo transfer stage may be due to lack of good-quality embryo/s, lack of uterine receptivity, or the transfer technique itself. Numerous methods, including the use of ultrasound guidance for proper catheter placement in the endometrial cavity, have been suggested as more effective techniques of embryo transfer. This review evaluates the efficacy of ultrasound-guided embryo transfer (UGET) compared with 'clinical touch' (CTET), which is the traditional method of embryo transfer and relies on the clinician's tactile senses to judge when the transfer catheter is in the correct position.

OBJECTIVES

To determine whether ultrasound guidance compared with clinical touch improves pregnancy outcomes in women undergoing embryo transfer during ART cycles.

SEARCH METHODS

For the 2016 update of this review, we ran updated searches in the Cochrane Gynaecology and Fertility Group trials register (May 2015), the Cochrane Central Register of Controlled Trials (the Cochrane Library, May 2015), MEDLINE (2009 to May 2015), and EMBASE (2009 to May 2015). We also handsearched relevant conference proceedings: American Society for Reproductive Medicine (ASRM), European Society for Human Reproduction and Embryology (ESHRE), and International Federation of Gynecology and Obstetrics (FIGO). There were no language restrictions.

SELECTION CRITERIA

We included only randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and quality of trials and extracted data from those selected. We calculated odds ratio (OR) and 95% confidence interval (CI) for dichotomous outcomes. No outcomes were reported using continuous data. We assessed the overall quality of the evidence for the main findings using the GRADE working group methods.

MAIN RESULTS

This systematic review now has 21 included studies (four of which we added in the 2016 update), two studies awaiting assessment, and 47 excluded studies. In total, data for meta-analyses were available in 21 trials (n = 6218 women), of which only four reported live births.UGET was associated with an increased chance of a live birth/ongoing pregnancy compared with CTET (OR 1.47, 95% CI 1.30 to 1.65; 13 trials; n = 5859 women; I(2) = 74%; low-quality evidence). Sensitivity analysis by including only trials with low risk of selection bias or by using a random-effects model did not alter the effect. We estimate that for women with a chance of a live birth/ongoing pregnancy of 23% using CTET, this would increase to between 28% and 33% using UGET. We considered the quality of the evidence using GRADE methodology to be low.UGET was associated with an increase in the chance of a clinical pregnancy (OR 1.31, 95% CI 1.17 to 1.45; 20 trials; n = 6711 women; I(2) = 42%; moderate-quality evidence). We identified no differences between groups for the incidence of adverse events including multiple pregnancy, ectopic pregnancy, or miscarriage. These events were relatively rare, and sample sizes limited the ability to detect such differences.

AUTHORS' CONCLUSIONS

The evidence suggests ultrasound guidance improves the chance of live birth/ongoing and clinical pregnancies compared with clinical touch, without increasing the chance of multiple pregnancy, ectopic pregnancy, or miscarriage. Methodological limitations included: only four studies reporting details of both computerised randomisation techniques and adequate allocation concealment, only four studies reported on the outcome of live birth, and none of the nine studies that reported on ongoing pregnancy reported on live birth, suggesting possible reporting bias. Adequate reporting of randomisation and allocation concealment will improve the quality of future studies. The primary outcome measure of future studies should be the reporting of live births per woman randomised.

Exuberant sprouting of sensory and sympathetic nerve fibers in nonhealed bone fractures and the generation and maintenance of chronic skeletal pain

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

Fetal manipulation for facilitating tests of fetal wellbeing

BACKGROUND

Manual fetal manipulation has been suggested to improve the efficiency of antepartum fetal heart rate testing.

OBJECTIVES

The objective of this review was to assess the merits or adverse effects of the use of manual fetal manipulation in conjunction with tests of fetal wellbeing.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013).

SELECTION CRITERIA

All published and unpublished randomised controlled trials assessing the use of fetal manipulation versus mock stimulation, no stimulation or other types of stimulation, used in conjunction with cardiotocography or other tests of fetal wellbeing.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed studies for inclusion, assessed trial quality and extracted data. Data were checked for accuracy. We contacted authors of published and unpublished trials for further information.

MAIN RESULTS

We included four trials with a total of 1280 women with 2670 episodes of participation. No trial was at low risk of bias for all domains and only two trials were at low risk of bias for both selection and attrition bias.Fetal manual manipulation decreased the incidence of non-reactive antenatal cardiotocography test compared to mock or no stimulation. However, this was not statistically significant (average risk ratio (RR) 0.31, 95% confidence interval (CI) 0.02 to 6.20, I² = 96%; two trials, N = 2350). There was also no significant reduction in the mean testing time to achieve a reactive result (mean difference -2.29 minutes, 95% CI -9.61 minutes to 5.03 minutes, I² = 97%; two trials, N = 560).Comparing fetal manual manipulation with vibroacoustic stimulation, there was no significant difference in the incidence of non-reactive cardiotocography or the need for contraction-stress test.There were no data available on other outcomes such as perinatal mortality, fetal distress, maternal anxiety and gestation at delivery.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the use of manual fetal manipulation during cardiotocography or other tests of fetal wellbeing. More studies of manual fetal manipulation that utilises standardised protocol should be encouraged.

[Elastic modulus measured by spherical indentation used toward the clinical application of the brain stiffness]

OBJECTIVE

Palpation of brain stiffness is one of techniques that leads to successful neurosurgical procedures. In order to evaluate brain stiffness quantitatively, we studied the potential clinical applicability of a spherical indenting tactile sensor.

METHODS

The sensor had a spherical rigid indenter (diameter=5.0 mm; contact pressure=1.0 gf/mm2), and the indenter was rapidly pushed and pulled at a constant speed by a computer-controlled motor. The pressure-depth hysteresis curve was obtained using the sensor, and the shear elastic modulus (G) was calculated on the basis of the Hertz contact theory. We adopted the G-value at the maximum depth (G_max) as an indicator of brain stiffness.

RESULTS

First, to calibrate the sensor, we investigated the elasticity of silicone plates. The optimal settings for clinical application was an indenting speed of 1.5 mm/s and an indenting maximum depth of 2-3 mm. Next, we measured the elasticity of a decompressive site in 7 patients who had been stable for more than 21 days after undergoing decompressive craniectomy. The G_max of the decompressive site was 1.71 ± 0.75 kPa. Finally, we measured the intraoperative brain elasticity in a case of brain tumor with severe brain edema. The transdural elasticity of the edematous brain was G=4.87 kPa, and the direct elasticity of the brain surface decreased to G=4.34 kPa after dura incision.

CONCLUSIONS

The spherical indentation method for measuring brain elasticity seems applicable to neurosurgical procedures.

Ultrasound versus 'clinical touch' for catheter guidance during embryo transfer in women

BACKGROUND

Many women undergoing an Assisted Reproductive Technology (ART) cycle will not achieve a live birth. Failure at the embryo transfer stage may be due to lack of good quality embryo/s, lack of uterine receptivity, or the transfer technique itself. Numerous methods, including the use of ultrasound guidance for proper catheter placement in the endometrial cavity, have been suggested as a more effective technique of embryo transfer. This review evaluates the effectiveness of ultrasound guided embryo transfer (UGET) compared with 'clinical touch' (CTET) the traditional method of embryo transfer.

OBJECTIVES

To determine whether ultrasound guidance influences treatment outcomes in women undergoing embryo transfer (ET) during assisted reproductive technology (ART) cycles.

SEARCH STRATEGY

Electronic databases were searched in November 2009. We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched November 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2009), MEDLINE (1970-2009), EMBASE (1985-2009), BIO Extracts (1980-2009). Relevant conference proceedings were also hand searched (ASRM, ESHRE and FIGO).

SELECTION CRITERIA

Only randomised controlled trials were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and quality of trials and extracted data from those selected.

MAIN RESULTS

This update identified 59 potential trials of which 42 were excluded. Data for analysis was available in seventeen studies. One study reported live births and personal communication resulted in data relating to this outcome being obtained in two additional studies. There is no evidence of a significant difference in the outcome of live birth (OR 1.14 (95%CI0.93 to 1.39; P=0.02) although heterogeneity was high (64%) and the results should be interpreted with caution. Seven studies reported on ongoing pregnancies. The ongoing pregnancies per woman randomised associated with UGET (441/1254) was significantly higher than for clinical touch (350/1218) OR 1.38, 95%CI 1.16 to 1.64, P<0.0003). No statistically significant differences in the incidence of adverse events were identified between the comparison groups. These events are relatively rare and sample sizes limit the ability to detect such differences.

AUTHORS' CONCLUSIONS

The studies are limited by their quality with only two studies reporting details of both computerised randomisation techniques and adequate allocation concealment. Ultrasound guidance does appear to improve the chances of live/ongoing and clinical pregnancies compared with clinical touch methods. The quality of future studies should be improved with adequate reporting of randomisation, allocation concealment, and power calculations. The primary outcome measure of future studies should be the reporting of live births per woman randomised.

Rectovaginal examinations and human papillomavirus: can we decrease the risk of colorectal infection?

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

Transvaginal sonographic measurement of cervical length vs. Bishop score in labor induction at term: tolerability and prediction of Cesarean delivery

OBJECTIVES

To compare transvaginal sonography for cervical length measurement and digital examination for Bishop score assessment in women undergoing labor induction at term, to assess their tolerability (in terms of pain) and ability to predict need for Cesarean delivery.

METHODS

A prospective study was performed on 249 women admitted for labor induction. Cervical length was measured using transvaginal ultrasound examination. A 10-point visual analog scale (VAS) for procedure-related pain was obtained. Bishop score was determined just before labor induction and another pain score was obtained. Delivery outcome was recorded. Analyses were by t-test, Fisher's exact test, receiver-operating characteristics (ROC) curves and multivariate logistic regression.

RESULTS

Transvaginal sonography was significantly less painful than digital examination for Bishop score assessment (mean difference in VAS score 3.46; P<0.001). Analyses of the ROC curves for cervical length and Bishop score indicated that both were predictors of Cesarean delivery (area under the curve 0.611 vs. 0.607; P=0.012 vs. P=0.015, respectively) with optimal cut-offs for predicting Cesarean delivery of >20 mm for cervical length and Bishop score<or=5. Cervical length had superior sensitivity (80% vs. 64%) and marginally better positive (30% vs. 27%) and negative (89% vs. 83%) predictive values. Multivariate logistic regression analysis revealed that only nulliparity (adjusted odds ratio (AOR) 4.1; 95% CI, 2.1-8.1; P<0.001) and transvaginal sonographic cervical length>20 mm (AOR 3.4; 95% CI, 1.4-8.1; P=0.006) were independent predictors of Cesarean delivery.

CONCLUSIONS

Transvaginal sonography for cervical length measurement is better tolerated than digital examination for Bishop score assessment. Both cervical length and Bishop score are useful predictors of the need for Cesarean delivery following labor induction. A cervical length>20 mm at labor induction at term is an independent predictor of Cesarean delivery.

Serum thyroglobulin levels after fine-needle aspiration of thyroid nodules

OBJECTIVE

To investigate whether a minor insult to the thyroid gland attributable to fine-needle aspiration (FNA) or external thyroid palpation can cause a release of serum thyroglobulin (Tg) into the circulation.

METHODS

We determined serum Tg levels before and at 60 minutes and 15 days after FNA in 25 patients with thyroid nodules. Results were compared with those obtained in 25 patients with thyroid nodules, in whom serum Tg concentrations were determined before and 60 minutes after palpation of the thyroid, and in 15 healthy subjects without thyroid disease, who had no thyroid palpation and no FNA, from whom 2 blood specimens were obtained 60 minutes apart. All participants had normal results of thyroid function tests and no detectable antithyroglobulin or thyroid peroxidase antibodies.

RESULTS

After FNA, 22 of 25 patients had significant elevation of serum Tg concentrations. The Tg levels returned to baseline values 15 days after FNA. In 4 of the 25 patients with thyroid nodules who had palpation of the thyroid, a significant increase in serum Tg levels was elicited. None of the 15 healthy subjects with normal thyroid glands (and with no FNA or thyroid palpation) had significant Tg elevations.

CONCLUSION

FNA causes a significant increase in serum Tg concentrations, which may persist for 15 days. Therefore, Tg assay should not be scheduled prematurely after FNA.

[Rectal tears in the horse: malpractice or an unfortunate accident?]

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

Transmural rectal intestinal evisceration associated with parturition in a primiparous mare

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

Epidemiological investigations of an outbreak of intestinal atresia in two Israeli dairy herds

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

Surface alterations in the bovine pelvic peritoneum following rectal examination of reproductive organs: a scanning electron microscopy study

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

Changes in physical examination caused by use of spinal immobilization

The standard of care for patients following blunt trauma includes midline palpation of vertebrae to rule out fractures. Previous studies have demonstrated that spinal immobilization does cause discomfort.

OBJECTIVE

To determine whether spinal immobilization causes changes in physical exam findings over time.

METHODS

This was a single-blinded, prospective study at a tertiary care university teaching hospital. Twenty healthy volunteers without previous back pain or injuries, 13 male and seven female, were fully immobilized for one hour, with a cervical collar and strapped to a long wooden backboard. Midline palpation of vertebrae to illicit pain was performed at 10-minute intervals. In addition, the participants were asked to rate neck and back pain on a scale from 1 to 10 (1 for no pain, and 10 for unbearable pain), to see whether subjective pain from immobilization correlated with tenderness to palpation.

RESULTS

Three patients had point tenderness of cervical vertebrae within 40 minutes. Five patients developed point tenderness of vertebrae by 60 minutes. Eighteen of 20 participants complained of increasing discomfort over time. The median initial pain scale was 1 (range 1-1), in contrast to 4 (range 1-9) at 60 minutes, p < 0.05.

CONCLUSION

This study shows that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness. In order to reduce this high false-positive rate for midline vertebral tenderness, the authors recommend that, initially on arrival to the emergency department, immediate evaluation occur of all immobilized patients. Furthermore, backboards should be modified to reduce patient discomfort to prevent the iatrogenically induced midline vertebral tenderness, thereby reducing subsequent false-positive examinations.

Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women

OBJECTIVE

To investigate the influence of the traditional hands-on versus the innovative hands-poised method on the risk of perineal trauma during vaginal delivery and on neonatal outcomes.

STUDY DESIGN

In a prospective, randomized, multicenter study, 1,161 of 1,505 women giving birth at the Departments of Obstetrics and Gynecology of the University Hospital of Vienna and Semmelweis Women's Hospital, Vienna, between February and September 1999, were randomized into the trial. In the hands-on method, the left hand of the midwife puts pressure on the infant's head, and the right hand is placed against the perineum. In the hands-poised method, the midwife guides the parturient through the birth without touching the perineum, prepared to apply light pressure on the infant's head.

RESULTS

One hundred eighty-seven of 574 women (32.5%) in the hands-on group and 180 of 502 women (35.8%) in the hands-poised group experienced perineal tears (P = .5). Sixteen women (2.7%) treated with the hands-on method developed third-degree perineal tears as compared with five women (0.9%) treated with the hands-poised method (P < .05). In the hands-on group, 103 women (17.9%) underwent episiotomy as compared with 51 cases (10.1%) in the hands-poised group (P < .01). No significant differences in neonatal outcomes were observed between the two groups.

CONCLUSION

Our data suggest that a policy of hands-poised care is more suitable for preserving the perineum during birth and is a safe and effective birthing alternative for women.

Fetal manipulation for facilitating tests of fetal wellbeing

BACKGROUND

Manual fetal manipulation has been suggested to improve the efficiency of antepartum fetal heart rate testing.

OBJECTIVES

The objective of this review was to assess the merits or adverse effects of the use of manual fetal manipulation in conjunction with tests of fetal wellbeing.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register in June 2001.

SELECTION CRITERIA

All published and unpublished randomized controlled trials assessing the merits of the use of fetal manipulation in conjunction with tests of fetal wellbeing.

DATA COLLECTION AND ANALYSIS

Both reviewers independently extracted data and assessed trial quality. Authors of published and unpublished trials were contacted for further information.

MAIN RESULTS

Only two trials with a total of 1090 women with 2110 episodes of participation were included. Manual fetal manipulation did not decrease the incidence of non-reactive antenatal cardiotocography test (odds ratio 1.28 confidence interval 0.94-1.74).

REVIEWER'S CONCLUSIONS

Manual fetal manipulation has not been shown to reduce the incidence of non-reactive cardiotocography. Trials of manual fetal manipulation should take into consideration that there have not been any benefits demonstrated as yet.

The impact of digital cervical examination on expectantly managed preterm rupture of membranes

OBJECTIVE

The purpose of this study was to examine the effects of digital cervical examination on maternal and neonatal outcomes among women with preterm rupture of membranes.

STUDY DESIGN

This analysis includes data from a previously reported trial of antibiotic treatment during expectant management of rupture of membranes at 24 to 32 weeks' gestation in singleton and twin gestations. Patients from both the randomized trial (n = 299 in the antibiotic group and n = 312 in the placebo group) and the observational component (n = 183) are included in this analysis. The groups were divided into those with one (n = 161) or two digital cervical examinations (n = 27) and those with no digital cervical examinations (n = 606).

RESULTS

The gestational ages at enrollment were similar in the two groups (29 +/- 2 weeks' gestation for one or two examinations vs 29 +/- 2 weeks' gestation for no examinations; P =.85). There were no differences in chorioamnionitis (27% vs 29%; P =.69), endometritis (13% vs 11%; P =.5), or wound infection (0.5% vs 1%; P >.999) between the group with one or two examinations and the no-examination group. Infant outcomes were also similar in the two groups, including early sepsis (6% vs 5%; P =.68), respiratory distress syndrome (51% vs 45%; P =.18), intraventricular hemorrhage (7% vs 7%; P =.67), necrotizing enterocolitis (5% vs 3%; P =.19), and perinatal death (7% vs 5%; P =.45). A composite outcome made up of these neonatal outcomes was not different (56% vs 48%; P =.10) between the group with one or two examinations and the no-examination group. The time from rupture to delivery was shorter in the digital examination group (median value, 3 vs 5 days; P <. 009). Multivariable analysis to adjust for antibiotic study group, group B streptococcal culture status, race, and maternal transfer did not modify these results.

CONCLUSION

Performance of one or two digital cervical examinations during the course of expectant management of rupture of membranes between 24 and 32 weeks' gestation was associated with shorter latency but did not appear to worsen either maternal or neonatal outcome.

Relevance of carcass palpation in lambs to protecting public health

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

Caudal anaesthesia in the clinical assessment of painful anal lesions

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

Effect of digital cervical examination on the expression of fetal fibronectin

OBJECTIVE

To determine whether oncofetal fibronectin (fFN) assays from symptomatic women are influenced by digital examination of the cervix.

STUDY DESIGN

Cervicovaginal fFN specimens were obtained from women at 22-34 weeks' gestational age with symptoms of preterm labor immediately prior to a digital examination of the cervix and two hours after. Fetal fibronectin was assayed by a specific enzyme-linked immunoassay. Results were reported as positive (> or = 50 ng/mL) or negative (< 50 ng/mL). Paired initial and repeat fFN results were compared for statistical difference, and the clinical outcomes were used to assess the accuracy of the initial and repeat results.

RESULTS

Fifty symptomatic women at an average gestational age of 29.3 +/- 2.0 weeks were enrolled. Eighty-six percent of the repeat fFN results remained unchanged after a digital examination, (P = .26, beta = .2). The predictive value of a negative fFN obtained after a digital examination was 97% for the absence of spontaneous preterm delivery in < 8 or < 15 days. Two of 16 initially positive results became negative after an examination, and one patient delivered two days later. Five of 34 initially negative fFN results became positive after an examination, and 5/5 delivered more than seven days later.

CONCLUSION

Digital examination of the cervix has an effect on fFN results. The routine use of fFN after a digital examination is not recommended.

[Pysical examination--rebound tenderness]

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

Referred pain elicited by palpation and by needling of myofascial trigger points: a comparison

OBJECTIVE

To investigate the occurrence of referred pain (ReP) elicited by palpation (Pal-ReP) or by needle injection (Inj-ReP) of myofascial trigger point (MTrP), and to assess the correlated factors, including the pain intensity of an active MTrP and the occurrence of local twitch response (LTR).

DESIGN

Correlational study.

PATIENTS

Ninety-five patients who were treated with MTrP injections.

INTERVENTION

MTrP injections.

MAIN OUTCOME MEASURE

Pain intensity of MTrP and occurrence of Pal-ReP, Inj-ReP, and LTR.

RESULTS

Both Pal-ReP and Inj-ReP were elicited in 53.9% of MTrPs, Inj-ReP, but not Pal-ReP, was elicited in 33.7% of MTrPs. Both Pal-ReP and Inj-ReP were unobtainable in 12.3% of MTrPs. The occurrence of ReP was significantly correlated to the pain intensity of active MTrP and the occurrence of LTR.

CONCLUSION

ReP could be elicited more frequently by needling than by palpation. The frequency of occurrence in ReP mainly depends on pain intensity of an active MTrP.

Management of rectal tears

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

The effect of routine breast examination on serum prolactin levels

OBJECTIVE

To evaluate the effect of a routine breast examination on serum PRL levels.

DESIGN

Prospective clinical study.

SETTING

University-based reproductive endocrinology unit.

PATIENTS

Eleven nonlactating, euprolactinemic women of reproductive age with a history of regular menstrual cycles and currently taking no medications.

INTERVENTIONS

Breast examination using standard technique.

MAIN OUTCOME MEASURE

Changes in serum PRL levels after breast examination.

RESULTS

Baseline PRL levels ranged from 3.64 to 19.23 ng/mL (mean 7.17 ng/mL; conversion factor to SI unit, 1.00). There were no significant increases in PRL levels after breast examination, with mean PRL levels after 15, 30, and 45 minutes of 6.59, 6.84, and 6.45 ng/mL, respectively.

CONCLUSION

Routine breast examination does not alter acutely serum PRL levels in normal women.

[Intestinal perforation in a llama mare following rectal palpation (veterinary expert opinion)]

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

Effect of digital rectal examination on serum prostate-specific antigen in a primary care setting. The Internal Medicine Clinic Research Consortium

BACKGROUND

Measurement of serum prostate-specific antigen (PSA) and digital rectal examination (DRE) are commonly used for prostate cancer screening. Clinicians have been advised to avoid measuring serum PSA after DRE because of the possibility of spurious elevation. However, studies in healthy volunteers have found no change. We sought to determine whether DRE performed by internists affects PSA levels in a primary care clinic population.

METHODS

Men older than 49 years enrolled in a Veterans Affairs internal medicine clinic were eligible for the study. For all patients, prostate size and nodularity were assessed by DRE. Blood for determination of PSA levels was drawn immediately before DRE and 30 minutes after DRE. All patients completed a questionnaire regarding voiding.

RESULTS

Two hundred two men aged 50 to 85 years (mean, 67 years) were enrolled and had complete data. The mean PSA level increased by 0.26 micrograms/L after DRE (P < .001). Six patients (2.9%; 95% confidence interval, 0.6% to 5.3%) had an increase in PSA level from less than 4 micrograms/L to more than 4 micrograms/L after DRE. There was a statistically significant but weak correlation between voiding score and PSA level (coefficient, .17; P = .02). Patients with an enlarged prostate gland had higher PSA levels than did patients with normal prostates or borderline results of examination. Nodularity did not predict an increased PSA level.

CONCLUSIONS

We conclude, in an elderly veteran population, that DRE causes a statistically significant but clinically insignificant increase in serum PSA level. Additionally, we found that symptoms and physical examination results cannot be used to select a population for whom PSA screening would likely be useful.

Pregnancy attrition associated with pregnancy testing by rectal palpation

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

Ultrasonographic diagnosis of urachal cyst in three calves

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

Plasma cortisol response in dairy cows to vaginoscopy, genital palpation per rectum and artificial insemination

Response of plasma cortisol concentrations after vaginoscopic examination, palpation of the genital organs per rectum and artificial insemination were investigated in six Holstein-Friesian cows weighing between 510 to 620 kg. Blood samples were collected by indwelling jugular catheter. The experiment was begun at 09:00 hours on the day when cows came into estrus. Blood samples were collected from 30 minutes before to 60 minutes after each treatment at intervals of 5 to 10 minutes. Cows were initially blood-sampled for 90 minutes at the same intervals without giving any treatment and then were subjected to vaginoscopy for 1.5 minutes, palpation of the uterus and ovaries per rectum for 4 minutes and artificial insemination by the recto-vaginal method for 5 minutes. No significant increase in plasma cortisol was shown in cows in estrus following vaginoscopy. Palpation per rectum as well as artificial insemination caused a significant increase in plasma cortisol (P < 0.01) 5 to 10 minutes after the initiation of treatments in cows in estrus. There was a tendency for cows in the luteal phase to show higher plasma cortisol levels after the vaginoscopy than cows in estrus. Adrenal response to palpation per rectum in cows in the luteal phase was similar to that in cows in estrus. Thus, in cows in estrus, palpation per rectum as well as artificial insemination may be potential stressors for cows, causing an increase in plasma cortisol levels. However, the pathophysiological importance of the rise in plasma cortisol levels is not known.

Spontaneous rupture of the spleen in association with idiopathic thrombocytopaenic purpura

Spontaneous rupture of the spleen is rare and has not been previously reported in association with idiopathic thrombocytopaenic purpura. Its rarity makes familiarity with its presentation difficult and may result in a potentially fatal delay in diagnosis and treatment.

Fetal loss associated with palpation per rectum to diagnose pregnancy in cows

A prospective observational study was performed to determine whether palpation per rectum of cows in the first 6 weeks of gestation to diagnose pregnancy contributed to fetal attrition. Pregnancy diagnoses were made by private practitioners as part of their routine herd-health service on 9 dairies in the San Joaquin Valley of California. To determine whether there was an association between abortion and fetal age at time of palpation, the probability of abortion was tested as a function of fetal age at palpation, controlling for possible modifying and confounding effects of herd, age at conception, gravidity, parity, and number of days-in-lactation at conception. Results of logistic regression analyses for 19,411 pregnancies followed for up to 90 days after palpation indicated that, during the 28- to 42-day period, palpation of fetuses earlier in the period was associated with a significantly (P < 0.0001) low probability of abortion, compared with that for palpation later in the period. An association between abortion and palpation of fetuses > 42 days of age was not found. Results were suggestive that, given conditions and techniques typical of private practice, fetal death may not be a usual manifestation of early palpation of cows to diagnose pregnancy, rather, that there may be a slight increase in risk of fetal death as the fetal age at palpation increases from 28 to 42 days.

Inadvertent spread of cancer at surgery

Surgical cure requires that a given cancer be removed without inadvertent spillage of cancer cells by technical error. Potential mishaps include pressing a ligature, while tying, against a protruding tumor and cutting into it; inserting a hemostat into the tumor area to gain control of an escaped short pancreaticoduodenal artery stump which has retracted; grasping a lymph node with forceps which invariably fragments it spilling any cancer cells it may contain; and injecting local anesthesia into or adjacent to a lesion for biopsy. If the lesion is a cutaneous melanoma or other cancer the resulting pressure may force cancer cells into the lymphatic or bloodstream. Other misadventures include touching that portion of a biopsy needle which has been in the tumor and doing an intraoperative biopsy which allows blood or tissue fluid to flow out the opening from the tumor. Sensitivity to such dangers appears essential to avoiding spillage of cancer cells and obtaining maximal benefit from surgery.

Rectal palpation and transmission of bovine leukemia virus in dairy cattle

To determine whether rectal palpation, using common obstetrical sleeves, serves as a mode of transmission of bovine leukemia virus in dairy cattle, field studies were conducted at 2 dairies. At a commercial dairy, significant difference was not observed in rate of seroconversion in heifers and cows in which the same sleeve or new sleeves were used for palpations. At a university dairy, where cattle were used to teach dairy husbandry and veterinary procedures, significantly (P less than 0.02) greater rate of seroconversion was observed in heifers and cows palpated with unwashed common sleeves than that observed in heifers and cows palpated with sleeves washed between use. Although rectal transmission of bovine leukemia virus under field conditions was documented, it was related to frequency of palpation and age of cattle.

Lack of evidence of transmission of bovine leukemia virus by rectal palpation of dairy cows

A study was undertaken in a California dairy to estimate the risk of transmission of bovine leukemia virus associated with rectal palpation of cows. The probability of seroconversion within 3 months after rectal palpation was examined as a function of the prevalence of infection in cows at the time of palpation. It was hypothesized that the probability of seroconversion within 3 months after palpation would be higher for cows in a group with high prevalence of infection than for cows in a group with low prevalence. The probability of seroconversion after rectal palpation was equal to 0.034, and results of logistic regression, using data from 1,116 noninfected and 1,047 infected cows, did not indicate any significant association between probability of seroconversion after rectal palpation and prevalence of infection (P = 0.189). Results of this study suggest that risk of bovine leukemia virus transmission by rectal palpation typically used in reproductive tract examination of cows either does not occur or is uncommon.

Histopathologic study of the so called 'palpation thyroiditis'

We have reviewed 1066 thyroid lesions and compared the relative incidence of the so called 'palpation thyroiditis' between autoimmune thyroiditis and normal thyroid parenchyme surrounding the nodular thyroid lesion and also discussed the pathogenesis of palpation thyroiditis. The typical histopathologic features of 'palpation thyroiditis' were seen in 275 cases among 467 adenomatous goiters and in none of the autoimmune thyroiditis. We here in this paper suggest that the so called 'palpation thyroiditis' is not merely a secondary phenomenon to mechanical follicular damage by vigorous palpation, but this lesion more likely develops in conditions where certain types of physiologic alteration has occurred in follicular basement membrane, just like a pathogenesis of subacute granulomatous thyroiditis.