OP06.02: Diagnostic values of clinical and ultrasound examination in women with acute pelvic pain

There is still lack of consensus regarding the most effective follow-up for stage I and II melanoma patients although some consensus conferences have provided guidelines stating that clinical examination should be the standard. Our aim was to study the value of adding ultrasound lymph node examination (7.5 MHz) to the routine clinical examination recommended by French guidelines in melanoma follow-up. A cohort of melanoma patients was enrolled between 1 July 1995 and 1 July 2000 in a follow-up protocol including clinical examination performed four times a year for thick melanomas (Breslow index > or = 1.5 mm) and twice a year for thin melanomas (Breslow index < 1.5 mm) according to French guidelines, and ultrasound lymph node examination performed every 6 months for thick melanomas and every year for thin melanomas. Follow-up was continued up to 1 July 2003. When clinical or ultrasound examination indicated signs of node recurrence, surgical biopsy of the involved node was performed. When ultrasound examination was only suspicious, another ultrasound examination was performed within the following 3 months. The results of both clinical and ultrasound examinations were compared with histopathology examination when node biopsy was performed. Ultrasound follow-up was performed for 373 patients (213 females and 160 males). Mean age at diagnosis of melanoma was 59 years (range 14-90, SD 15). In total, 1909 ultrasound examinations combined with clinical examination were analysed. Node biopsy was performed in 65 patients and demonstrated melanoma metastases in 54. Sensitivity of clinical examination and ultrasound examination was 71.4%[95% confidence interval (CI) 55.4-84.3] and 92.9 (95% CI 80.5-98.5), respectively, P = 0.02. Specificity of clinical examination and ultrasound examination was 99.6% (95% CI 99.2-99.8) and 97.8% (95% CI 97.0-98.4), respectively. Despite this apparent superiority of ultrasound examination over palpation, only 7.2% of the patients really benefited from ultrasound examination (earlier lymph node metastasis detection or avoidance of unnecessary surgery), while 5.9% had some deleterious effect from ultrasound examination (unnecessary stress caused by repetition of ultrasound examination for benign lymph nodes, useless removal of benign lymph node). This study confirms the greater sensitivity of ultrasound examination to clinical examination in the diagnosis of node metastases from cutaneous melanoma. However, the place of ultrasound in routine follow-up is at least questionable as only a very small proportion of patients (1.3%) really benefited from adding ultrasound examination to clinical examination.

BackgroundJIA is the commonest rheumatologic disease of childhood with a quoted prevalence of 1:1000. Assessment of children with JIA includes:Clinical, laboratory and more recently US evaluation of joints. Rapid attainment...

Background:There is a well-known association between inflammatory bowel diseases (IBD) and spondyloarthritis (SpA) that can involve the axial, peripheral oligoarthritis, peripheral polyarthritis, enthesitis and dactylitis domains. Enthesitis has been reported...

IntroductionDiagnostic accuracy of first-line sonographic evaluation by obstetrics/gynecology residents in determining the need for emergency surgery in women with acute pelvic pain is unknown. Aim of this study was to evaluate the diagnostic accuracy of routine ultrasound evaluation by obstetrics/gynecology residents, available 24 hours a day, in patients with acute pelvic pain.MethodsA cross-sectional retrospective study included consecutive patients who underwent emergency laparoscopy for acute pelvic pain at a teaching hospital gynecologic emergency unit, between January 1, 2004, and December 31, 2006. The laparoscopic diagnosis was the reference standard. Gynecologic and nongynecologic conditions requiring immediate surgery to avoid severe morbidity or death were defined as surgical emergencies. In all patients, obstetrics/gynecology residents routinely performed clinical examination and standardized ultrasonography was routinely recorded. Sonograms were re-interpreted for the study, blinded to physical examination and laparoscopic findings, according to evidence-based predetermined criteria. Sensitivity, specificity, and likelihood ratios were computed for clinical data alone, sonographic data alone, and the combination of both.ResultsEmergency laparoscopy was performed in 234 patients, diagnosing 139 (59%) surgical emergencies. Clinical and sonographic examinations performed by the residents each independently predicted a need for emergency surgery. Combining both examinations was superior over each examination alone and had an acceptable false-negative rate of 1%.ConclusionsFirst-line combined clinical and sonographic examination by obstetrics/gynecology residents is effective in ruling out surgical emergencies in patients with acute pelvic pain.

Background: During infancy, among developmental abnormalities of the hip joint, a broad-spectrum anomaly is developmental dysplasia of the hip (DDH). To examine this abnormality, no standardized screening protocol is available. Clinical examination is most frequently followed, and in doubtful cases, ultrasound (US) examination is used to confirm the diagnosis. Aims: The present study aims to compare the sensitivity and specificity of clinical to US examination in neonatal hip screening to detect DDH. Materials and Methods: This is a 1-year hospital-based cross-sectional study. Newborns who were referred to the Department of Orthopaedics with suspected DDH and examined by both clinical examination and US examination were included in the study. The Chi-square test and Fisher’s t-test were used for statistical analysis. Results: Out of the 75 babies, referred two-thirds were girls. The mean age of the babies was 6.25 ± 3.50 days. The breech presentation was the common risk factor (85.33%) for DDH, and LSCS was the standard mode of delivery. Clinical diagnosis of DDH was positive among babies, more on the left side than the right side. Eight babies (10.67%) were diagnosed to have DDH based on Graf’s test using USG. Among them, 4 (50%) babies had a clinical diagnosis of DDH. The sensitivity of the clinical trial with USG as reference standard was 50% Conclusion: Due to the lower sensitivity of clinical examination, USG screening should be done to detect DDH.

Diagnosing Pneumonia by Medical History and Physical Examination

Background: Acute pelvic pain accounts for up to 40% of the visits to gynecological emergency departments and may indicate a serious condition. Potentially life-threatening gynecological emergencies are acute pelvic conditions that may spontaneously evolve into a life threatening situation. They may also carry a risk of sequelae (organ failure or organ removal) or death in the absence of prompt diagnosis and treatment.The most common gynecological emergencies are ruptured ectopic pregnancy, adnexal torsion, and complicated pelvic inflammatory disease (tubo-ovarian abscess (TOA) and pyos-alpinx). Missing these high-risk conditions may delay treatment that could lead to potentially negative patient outcomes.Methods: This study was carried out over 1 year from September 2016 to September 2017 on 30 female patients. The records of all patients were review and data were collected prospectively. Our study included patients presented to the Emergency Department with gynecological emergencies.These gynecological emergencies included patients pre-sented with acute pelvic pain (e.g. ectopic pregnancy, torsion ovarian cyst, rupture ovarian cyst, pelvic inflammatory disease, tubo-ovarian abscess (TOA), and acute salpingitis) and/or vaginal bleeding (e.g. rupture uterus, and uterine tumors).Results: Ectopic pregnancy was the most common gyne-cological emergency seen in our study (about 46.67% of patients). Other diagnosis found in this study were adnexal torsion (about 16.67%), ovarian cyst rupture (about 13.33%), PID (about 13.33%), and uterine mass (about 10%).In this study, only about 53.33% of patients were diagnosed clinically before ultrasound was done. About 93.33% of patients were diagnosed after assessment by ultrasonography. There was statistically significant difference between clinical diagnosis and diagnosis after ultrasonography. (p<0.05).According to this study, there was a significant difference between clinical and radiological diagnosis using ultrasonog-raphy in diagnosis of ectopic pregnancy, adnexal torsion, and ovarian cyst rupture. (p<0.05).According to our data, physical examination cannot be used alone to safely rule out a surgical emergency in a woman presenting with acute pelvic pain. This suggests the benefit of adding bedside ultrasonography in the first-line diagnostic management of suspected gynecological emergencies.Conclusion: Adding Ultrasonography as a bedside test was found to be superior to physical examination in diagnosis of acute pelvic pain. If a gynecologic disorder couldn't be confirmed, or the sonographic finding are equivocal, Multi-Detector Computed Tomography (MDCT) is another imaging choice.Ultrasound is generally accepted as the first imaging modality used in patients with acute pelvic pain. The true value of ultrasound in acute pelvic pain lies in its ability to detect gynecologic disorders.

Objectives: The aim of this study is to understand whether or not, and to what extent, clinical examination (CE) of joint involvement in rheumatoid arthritis depends on clinical experience and whether or not, despite clinical experience, ultrasound examination provides more accurate results than CE. Methods: 51 rheumatologists with different professional experience measured in years since MD graduation. All clinicians studied the same patient and they evaluated the wrists and indicated the presence/absence of swelling and its extent (mild, moderate, severe). Three experienced sonographers blinded to clinical findings each performed ultrasound (US) examination of the patient's wrists. Results: US analysis showed that the patient’s right wrist had moderate joint effusion, whereas the left wrist had mild joint effusion; similar results were obtained with power Doppler imaging of both wrists. Only about 50% of the clinicians involved recognized joint effusion in both wrists. The CE findings were independent of clinical experience. The results of CE were coherent with US evaluation only in a percentage of 23%. Conclusions: This study underscores again the superiority of US in the assessment of inflammatory processes and the inaccuracy of CE, even if performed by rheumatologists with extensive professional experience.

The aim of this article is to assess the accuracy of early clinical and ultrasound (US) examination in terms of predicting arteriovenous fistula (AVF) dialysis use. Physical and US examination of patent AVF was performed 4 weeks after fistula creation. AVF dialysis use was defined as subsequent use of an AVF for at least six consecutive dialysis sessions with two needles and a blood flow of more than 200 mL/min. Of 119 AVF patent at 4 weeks, 26 (22%) failed. Clinical examination was 96% sensitive for predicting successful dialysis, but only 21% specific for failure. Vein diameter above 5 mm and an arterial end-diastolic velocity above 110 cm/s were the best US predictors for dialysis use. Vein diameter was slightly better than arterial velocity in terms of predicting maturity (sensitivity: 83% vs 67%, specificity: 68% vs 65%). All assessments predicted AVF maturity (positive predictive value: clinical = 81%, US diameter = 90%, US velocity = 87%) much better than AVF failure (negative predictive value: clinical = 63%, US diameter = 53%, US velocity = 37%). One month after surgery, a new AVF with a thrill or a vein diameter >5 mm is likely to be used for dialysis. An AVF not meeting these criteria has an increased risk of failure and further investigations may be required.

To investigate the early and late stages of posterior vitreous detachment (PVD) in the foveal area in correlation with age and gender. Three hundred and thirty-five emmetropic eyes of 271 Caucasian patients (216 women/119 men) were examined by optical coherence tomography (OCT) and ultrasound (US). Eyes were classified into groups according to the patients age (up to 69.9; 70-74.9; 75-79.9; over 80 years) and to the clinical findings [Vitreous state: Detached in US; Detached in OCT; Foveal adhesion (FA); Attached vitreous]. The mean age was 76 ± 8 ranging from 44 to 89 years in female and 72 ± 10 ranging from 46 to 87 years in male subjects. The vitreous was attached in 32% of all eyes, 18.5% had FA, 18.5% were detached in OCT and 68% were detached in US. While prevalence of FA decreases with increasing age, OCT-diagnosed detachments did not change significantly with age. Between the ages of 70 and 75, an increase in PVD rates occurred. The prevalence of PVD was similar in both genders. Women were significantly older than men in the late-stage PVD in the eyes. The use of OCT and US enabled us to detect a partial or total PVD in 80% of the eyes. A sudden increase in late-stage PVD between the ages of 70 and 75 was observed, correlating with the reported age prevalence of various macular diseases. In contrast to myopics, both genders of elderly emmetropics have a similar prevalence of PVD.

Infants born preterm are at risk of cerebral palsy (CP) and motor or cognitive developmental delay. For clinicians, it is essential to know the relative predictive accuracy of the most commonly used neuroimaging and neurophysiological tests for the early prediction of adverse neurodevelopmental outcome. The aim of this study was to compare the accuracy of these tests in survivors of a population of infants born very preterm. A retrospective cohort study was performed in 163 children born before 32 weeks gestational age. We compared the accuracy in predicting adverse neurodevelopmental outcome at the age of 2 years 6 months of early and late cranial ultrasound (CUS), magnetic resonance imaging, somatosensory evoked potentials after stimulation of the posterior tibial nerve, and electroencephalography by calculating positive and negative likelihood ratios. An abnormal early CUS is the best predictor of the presence of CP (positive likelihood ratio 6.09), motor developmental delay (positive likelihood ratio 3.11), and cognitive developmental delay (positive likelihood ratio 5.66). Overall, negative likelihood ratios were poor, ranging between 0.49 and 0.98, meaning that a normal test result had only minimal influence on the probability of adverse neurological outcome. None of the diagnostic tests had a good performance in predicting future neurodevelopmental problems in infants born preterm. A normal test result provided very little clinically useful information. An abnormal early cranial ultrasound (positive test result) is the best predictor of adverse neurodevelopmental outcome. All negative results have poor predictive value of future neurodevelopmental problems.

It has been reported that clinical evaluation consistently underestimates the severity of hidradenitis suppurativa (HS). To determine the usefulness of ultrasound as a diagnostic tool in HS compared with clinical examination and to assess the subsequent modification of disease management. Cross-sectional multicentre study. Severity classification and therapeutic approach according to clinical vs. ultrasound examination were compared. Of 143 HS patients were included. Clinical examination scored 38, 70 and 35 patients as Hurley stage I, II and III, respectively; with ultrasound examination, 21, 80 and 42 patients were staged with Hurley stage I, II and III disease, respectively (P<0.01). In patients with stage I classification as determined by clinical examination, 44.7% changed to a more severe stage. Clinical examination indicated that 44.1%, 54.5% and 1.4% of patients would maintain, increase or decrease treatment, respectively. For ultrasound examination, these percentages were 31.5%, 67.1% and 1.4% (P<0.01). Concordance between clinical and ultrasound intra-rater examination was 22.8% (P<0.01); intra-rater and inter-rater (radiologist) ultrasound agreement was 94.9% and 81.7%, respectively (P<0.01). The inability to detect lesions that measure ≤0.1mm or with only epidermal location. Ultrasound can modify the clinical staging and therapeutic management in HS by detecting subclinical disease.

The results of preoperative pelvic examination and eventual ultrasound examination were correlated with the laparoscopic findings in 316 women with acute pelvic pain. The predictive values of normal and abnormal findings at pelvic examination were 46.9 and 82.1%, respectively. 42.1% of the women had ultrasound examination performed. This investigation showed to be helpful especially in patients with normal findings at pelvic examination. If ultrasonic findings were abnormal the results at laparoscopy were also abnormal in 90%. On the contrary, normal findings at ultrasound examination did not exclude abnormal pelvic findings. The predictive value of normal results at ultrasound examination was 50.0%. This discrepancy between ultrasonic and pelvic findings can be explained by the size of the pelvic masses. Ultrasound examination is a valuable tool in the evaluation of patients with acute pelvic pain, but it cannot replace laparoscopy.

POS0260 ULTRASOUND ASSESSMENT OF HANDS AND FEET FOR SYNOVITIS PRIOR TO FIRST CLINICAL VISIT MARKEDLY REDUCES TIME TO DIAGNOSIS - EXPERIENCE FROM ROUTINE CARE

BackgroundFor early detection of developmental dysplasia of the hip (DDH), neonatal hip screening using clinical examination and/or ultrasound has been recommended. Although there have been many studies on the reliability of both screening techniques, there is still controversy in the screening strategies; clinical vs. selective or universal ultrasound screening. To determine the screening strategy, we assessed the agreement among the methods; clinical examination by an experienced pediatric orthopedic surgeon, sonographic morphology, and sonographic stability.MethodsFrom January 2004 to June 2009, a single experienced pediatric orthopedic surgeon performed clinical hip screenings for 2,686 infants in the neonatal unit and 43 infants who were referred due to impressions of hip dysplasia before 3 months of age. Among them, 156 clinically unstable or high-risk babies selectively received bilateral hip ultrasound examinations performed by the same surgeon using the modified Graf method. The results were analyzed statistically to detect any correlations between the clinical and sonographic findings.ResultsAlthough a single experienced orthopedic surgeon conducted all examinations, we detected only a limited relationship between the results of clinical and ultrasound examinations. Ninety-three percent of the clinically subluxatable hips were normal or immature based on static ultrasound examination, and 74% of dislocating hips and 67% of limited abduction hips presented with the morphology below Graf IIa. A total of 80% of clinically subluxatable, 42% of dislocating and 67% of limited abduction hips appeared stable or exhibited minor instability on dynamic ultrasound examination. About 7% of clinically normal hips were abnormal upon ultrasound examination; 5% showed major instability and 3% showed dysplasia above Graf IIc. Clinical stability had small coefficients between ultrasound examinations; 0.39 for sonographic stability and 0.37 for sonographic morphology. Between sonographic stability and morphology, although 71% of hips with major instability showed normal or immature morphology according to static ultrasound examination, the coefficient was as high as 0.64.ConclusionsDiscrepancies between clinical and ultrasound examinations were present even if almost all of the exams were performed by a single experienced pediatric orthopedic surgeon. In relation to screening for DDH, it is recommended that both sonographic morphology and stability be checked in addition to clinical examination.