Abnormal Physical Examination Research Articles

Targeted fascicular biopsy of the brachial plexus- rationale and operative technique

Objectif Nerve biopsy is useful in the diagnosis and the management of neuromuscular disorders and is commonly performed in distal, noncritical sensory nerves without using imaging to target the most involved regions. In general, these procedures are diagnozed in 20–50%. In selected cases where preoperative evaluation points towards a more localized (usually a more proximal) process, targeted biopsy would likely capture the disease. Synthesis of data obtained from clinical examination, electrophysiological testing and MRI allows a targeted fascicular biopsy of a major nerves to be performed safely and efficiently. Herein, our experiences with the brachial plexus are reported and a description of the operative technique is provided. Methods All cases of brachial plexus biopsy performed between 2003 and 2015 were reviewed. Only cases of targeted nerve biopsy approached from supraclavicular, deltopectoral and proximal medial arm were included. Demographic data, clinical presentation and the presence of percussion tenderness for each patient were recorded. Reviewed studies included electrodiagnostic tests and high resolution MR imaging. Previous nerve and muscle biopsies were noted. All details of the procedure, final pathology and its treatment implications were recorded. The complication rate was carefully assessed for temporary as well as permanent complications. Results Seventy-seven cases (29 men and 48 women) of brachial plexus biopsy were performed. Mean patient age was 57.25 years. Sixty-eight (87.1%) patients presented with symptoms in one upper extremity, 8 (10.4%), in both upper limbs, and 1 (17%), with all limb. All 74 patients (100%) patients had abnormal physical examinations, electrodiagnostic studies and MRIs. The overall diagnostic yield of biopsy was 74.4% ( n = 55). The most common diagnoses included breast carcinoma (17), neurolymphomatosis (9), inflammatory demyelination (13), perineurinoma (7) and nonspecific inflammatory changes (4). The series included 4 cases of (5.4%) increased numbness and 3 (4.0%) with additional weakness. Conclusion Targeted fascicular biopsy of the brachial plexus is an efficient diagnostic procedure and in highly selected cases can be offered as the initial procedure over distal cutaneous nerve biopsy. Diagnoses were very diverse and included entities considered very rare. Even for the most prevalent diagnoses, this biopsy technique allowed a more targeted approach resulting in a higher diagnostic yield and justification for more aggressive treatment.

Retrospective Analysis of Women with Only Mastalgia

Mastalgia is the most common symptom in women, who has gone under breast imaging. 70% of women face with mastalgia at least once in their lifetime. In our study, we aimed to investigate the examinations and the results of the females referred to our outpatient clinics with mastalgia and to determine the frequency of malignancy. Files of all women patients referred to General Surgery Outpatient Clinics between 01.06.2014-31.05.2015 has been investigated retrospectively. Cases only with breast pain complaint (n=789) out of 2798 women has been included in the study. Women with lump in breast, nipple discharge, redness, breast retraction and pregnant and lactating women were excluded. Breast examination findings, ultrasonography (USG), mammography results, whether biopsies are done or not and diagnoses have been investigated retrospectively. Mean age was 42.97±12.36 (16-74) years. 59.7% (n=471) of the women had bilateral mastalgia and 91.1% (n=719) of the breast examinations were found to be normal. USG was required from 664 (84.2%) women and mammography was required from 448 (56.8%) women. Considering diagnoses; fibrocystic changes in 32.3% (n=201), ductal ectasia in 8.8% (n=55), fibroadenomas in 6.1% (n=38), reactive lymphoid hyperplasia in 1.1% (n=7) was observed. Only 1 (0.2%) woman was diagnosed with invasive ductal carcinoma. According to researches, 0.5% of the women with mastalgia were diagnosed with breast cancer. In our study this rate was found as 0.2%. Women with only mastalgia without any abnormality in physical examination should be informed about dealing with pain.

Use of Yunnan Baiyao and epsilon aminocaproic acid in dogs with right atrial masses and pericardial effusion.

To describe the utility of Yunnan Baiyao (YB) alone or in combination with epsilon aminocaproic acid (EAC) for the treatment of dogs with echocardiographically identified right atrial (RA) masses and pericardial effusion (PE). Retrospective case-controlled study. Two private practice referral hospitals. Client-owned dogs with RA masses and PE identified echocardiographically over a 3-year period. None. There were 67 dogs identified with RA masses and PE during the study period. Sixteen dogs were treated with YB alone while 8 dogs were treated with YB in combination with EAC in addition to pericardiocentesis. Forty-three dogs were treated with pericardiocentesis alone and were considered to be the control group. There was no difference between the groups in regards to signalment, physical examination abnormalities, and diagnostic test results on presentation. There was no significant difference between the 2 groups with respect to number of pericardiocenteses performed and there were no side effects attributed to the YB or EAC in any of the dogs. Median time to recurrence of clinical signs was not significantly different between the treatment (12 d, range 1-186 d) and control group (14.5 d, range 1-277 d). The median survival of dogs treated with YB alone or in combination with EAC (18 d, range 1-186 d) was also not significantly improved compared to dogs treated with pericardiocenteses alone (16 d, range 1-277 d). This study suggests YB alone or in combination with EAC is relatively safe but does not significantly delay recurrence of clinical signs or improve survival in dogs with RA masses and PE. Due to the small cohort size, further prospective studies evaluating these drugs and their effects on hemostasis in dogs with RA masses and PE are warranted.

ESTABLISHMENT OF A FIBRINOGEN REFERENCE INTERVAL IN ORNATE BOX TURTLES (TERRAPENE ORNATA ORNATA).

This study sought to establish a reference interval for fibrinogen in healthy ornate box turtles ( Terrapene ornata ornata). A total of 48 turtles were enrolled, with 42 turtles deemed to be noninflammatory and thus fitting the inclusion criteria and utilized to estimate a fibrinogen reference interval. Turtles were excluded based upon physical examination and blood work abnormalities. A Shapiro-Wilk normality test indicated that the noninflammatory turtle fibrinogen values were normally distributed (Gaussian distribution) with an average of 108 mg/dl and a 95% confidence interval of the mean of 97.9-117 mg/dl. Those turtles excluded from the reference interval because of abnormalities affecting their health had significantly different fibrinogen values (P = 0.313). A reference interval for healthy ornate box turtles was calculated. Further investigation into the utility of fibrinogen measurement for clinical usage in ornate box turtles is warranted.

Parsing Atherosclerosis: The Unnatural History of Peripheral Artery Disease.

Parsing Atherosclerosis: The Unnatural History of Peripheral Artery Disease.

Utajony zespół Brugadów — sukces czy porażka? Odpowiedzi dostarczy wszczepialny rejestrator zdarzeń

29-year-old patient was admitted to a hospital due to 2 episodes of presyncope and one syncopal episode. There were no significant abnormalities in medical history, physical examination and additional tests. Resting surface ECG showed changes suggestive of type 2 Brugada syndrome. Ajmaline challenge revealed typical ECG features of type 1 Brugada syndrome. Due to low risk of sudden cardiac death, and unclear mechanism of syncope a implantable cardioverterdefibrillator was not implanted. However the patient was provided with an implantable loop recorder in order to verify arrhythmic etiology of syncope.

Septic Embolism: The Importance of an Adequate Clinical Approach: A Case Report, Bogota, Colombia

Neurological complications of infectious endocarditis have a high prevalence globally and its clinical presentation remains a clinical challenge. A previously healthy 36-year old male presented at the emergency room with persistent fever and headache. The patient was referred to Neurology section after initial diagnostics and treatment. They detected abnormal skin lesions and cardiac murmur. Based on the presentation and abnormal physical examination findings, their impression was an embolic process with infectious etiology prompting medical treatment. Patient was concomitantly referred to Cardiology section and infective endocarditis was confirmed by echocardiogram. Cranial Magnetic Resonance Imaging (MRI) confirmed an ischemic embolic process. Successful surgical treatment followed. This highlights the importance of good clinical history and physical examination as the cornerstone of diagnosis, even for the clinically challenging cases. Good clinical approach and appropriate use of imaging technology greatly benefited the patient by allowing early diagnosis and treatment hence prevention of further complications.

Continuous physical examination during subcortical resection in awake craniotomy patients: Its usefulness and surgical outcome

ObjectivesTo evaluate the value of physical examination as a monitoring tool during subcortical resection in awake craniotomy patients and surgical outcomes. Patients and methodsAuthors reviewed medical records of patients underwent awake craniotomy with continuous physical examination for pathology adjacent to the eloquent area. ResultsBetween January 2006 and August 2015, there were 37 patients underwent awake craniotomy with continuous physical examination. Pathology was located in the left cerebral hemisphere in 28 patients (75.7%). Thirty patients (81.1%) had neuroepithelial tumors. Degree of resections were defined as total, subtotal, and partial in 16 (43.2%), 11 (29.7%) and 10 (27.0%) patients, respectively. Median follow up duration was 14 months. The reasons for termination of subcortical resection were divided into 3 groups as follows: 1) by anatomical landmark with the aid of neuronavigation in 20 patients (54%), 2) by reaching subcortical stimulation threshold in 8 patients (21.6%), and 3) by abnormal physical examination in 9 patients (24.3%). Among these 3 groups, there were statistically significant differences in the intraoperative (p=0.002) and early postoperative neurological deficit (p=0.005) with the lowest deficit in neuronavigation group. However, there were no differences in neurological outcome at later follow up (3-months p=0.103; 6-months p=0.285). There were no differences in the degree of resection among the groups. ConclusionContinuous physical examination has shown to be of value as an additional layer of monitoring of subcortical white matter during resection and combining several methods may help increase the efficacy of mapping and monitoring of subcortical functions.

Use of a proactive duplex ultrasound protocol for hemodialysis access

Arteriovenous fistula (AVF) creation is the preferred approach for hemodialysis access; however, the maturation of AVFs is known to be poor. We established a proactive early duplex ultrasound (DUS) surveillance protocol for evaluating AVFs before attempted access. This study determined the effect of this protocol related to improving AVF maturation. From 2008 to 2013, 153 patients received new upper extremity AVFs and an early DUS surveillance protocol at a single academic institution. The protocol involved an early DUS evaluation before hemodialysis cannulation of the AVF at 4 to 8weeks after AVF creation. A positive DUS result was identified as a peak systolic velocity of >375cm/s or a >50% stenosis on gray scale imaging, along with decreased velocity in the outflow vein. Patients with positive DUS findings underwent prophylactic endovascular or open intervention to assist with AVF maturation. Nature of secondary interventions, as well as AVF patency and maturation, were assessed. Overall clinical outcomes and fistula patency were investigated. During the study period, 183 upper extremity AVFs were created in 153 patients, including 82 radiocephalic, 63brachiocephalic, and 38 brachiobasilic AVFs. A mortality rate of 43% (n= 66) was observed in a median follow-up period of 34.5months (interquartile range, 19.6-46.9). A total of 164 early DUS were performed at a median of 6weeks (interquartile range, 3.4-9.6weeks) after the initial creation. Early DUS showed nine AVFs were occluded and were excluded from further analysis. Hemodynamically significant lesions were found in 62 AVFs (40%); however, only 17 (11%) were associated with an abnormal physical examination. Positive DUS finding prompted a secondary intervention in 81% of the patients. Among those with positive early DUS findings, AVF maturation was 70% in those undergoing a secondary intervention compared with 25% in those not undergoing a prophylactic intervention (P= .011). Primary-assisted patency for AVFs with early positive and negative DUS findings were 83% and 96% at 6months, 64% and 89% at 1year, and 52% and 82% at 2years, respectively (P< .001). Early DUS surveillance of AVFs before initial access is reasonable to identify problematic AVFs that may not be reliably detected on clinical examination. Although DUS criteria for AVFs have yet to be universally accepted, proactive early postoperative DUS interrogation assists in the early detection of dysfunctional AVFs and improvement of fistula maturation. Despite improved patency in those with positive DUS findings who undergo prophylactic secondary intervention, overall patency remains inferior to those without an abnormality detected on early DUS imaging.

Multiparametric MRI of the prostate: the hope for the urology community.

The introduction of PSA in the early nineties of the previous century has strengthened interest in the screening of prostate cancer (PCa). The urology community soon indiscriminately adopted PSA testing, witnessing a revolution in the detection and treatment of PCa. Subsequently, two randomized trials confirmed the significant favorable influence of PSA-based screening on prostate cancer mortality. Surprisingly, the United States Preventive Services Task Force declined PSA testing as a PCa screening modality, highlighting unacceptable rates of overdiagnosis and overtreatment. These two have become the major challenges our societies have to overcome in order to implement widespread PCa screening programs. According to EAU Guidelines, the current strategy for detection of prostate cancer is based on TRUS-guided random systematic biopsy (TRUS-Bx) performed in men with elevated PSA and/or abnormal physical examination (DRE) [1]. Combined with other clinical characteristics, biopsy results are decisive in guiding a patient towards the most appropriate treatment modality, mainly either active surveillance (AS) or radical therapy. AS, tailored to cope with overdiagnosis, underestimates the stage or grade of disease in a third of cases, posing, at least theoretically, a risk to their prognosis. Therefore, there is an urgent need to embrace a detection tool that would diminish the rates of unnecessary biopsies leading to the diagnosis of insignificant PCa, improve risk stratification of those undergoing AS and guide the biopsy in those with previously negative TRUS-Bx to identify aggressive lesions that would be otherwise left undetected.

Remembering the Importance of an Old Friend: History Taking in Preoperative Evaluation of Healthy Children - A Single Center Experience

Objective: To investigate the consequences of routine laboratory tests that lead to surgical delay or high cost in patients with a normal medical history and physical examination who undergo minor surgical interventions. Patients and Method: Files of 1,322 patients aged between 0-16 years that had undergone elective surgical intervention within six years were reviewed. Results: Of the 1,322 patients, 1,246 (94.3%) had normal physical examination and laboratory findings. Seventy-six children who had abnormalities in laboratory findings and physical examination were referred to pediatrics. Of the 76 pediatric referees, 42 (55.3%) were reevaluated and were diagnosed with upper respiratory tract infection ( n =23; 30.2%), iron deficiency anemia ( n =5; 6.5%), innocent murmur ( n =4; 5.3%), thalassemia minor ( n =2; 2.6%), lower respiratory tract infection ( n =2; 2.6%), urinary tract infection ( n =1; 1.3%), mumps ( n =1; 1.3%), acute gastroenteritis ( n =1; 1.3%), minimal aortic and tricuspid valve insufficiency ( n =1; 1.3%), minimal aortic stenosis ( n =1; 1.3%), atrial septal defect ( n =1; 1.3%). Surgical interventions were delayed until the recovery of the infectious diseases. In 25 of the patients, repeated tests showed normal ranges after the second test; however nine ( n =9) of the patients showed increased or decreased numbers of white blood cell counts and whose medical history and physical examination revealed signs and symptoms related to infection. Conclusion: Routine laboratory tests contribute little to preoperative evaluation of children with normal history and physical examination undergoing low grade surgery.

Open a senescent's heart and look into his brain to find the Takotsubo trigger!

We would like to thank for the very interesting comment on our case report, and fully agree that in the vast majority of patients with TTC can find the trigger. Our patient did not indicate that pain was preceded by mental stress or physical exertion. However, as she was 98 years old, her memories of the World War II returned, even several times a day. In our registry, about 10% of cases were not able to identify a specific triggering factor. In another registry it was possible only in 57% patients.[1] If the neurological diseases are concerned, the patient did not have such problems in the anamnesis. She did not have any symptoms at admission and during hospitalization, which indicating subarachnoid bleeding, epilepsy or stroke. Additionally, there were no abnormalities in the neurological physical examination. Because of hypotension, the patient received an infusion of dopamine in the regional hospital before transporting to our hospital. Dopamine was discontinued during coronary angiography. We would like to emphasize that intraventricular pressure gradient as well as left ventricular outflow tract obstruction was absent in this patient; and the first echocardiography exam was performed after 15 min from the admission to the cardiac intensive care unit. Fortunately, despite the risk of hemodynamic deterioration,[2] the patient was stable in further observation. The patient had not received beta-adrenolytic before occurrence of TTC because beta adrenolytic administration did not protect against TTC in predisposed patients in our observation.[3] The patient received dopamine during transport to our clinic as we mentioned above, aspirin, clopidogrel and unfractioned heparin, were discontinued after coronary angiography. She also received diuretic, statins and low molecular weight heparin until disappearance of wall motion abnormalities. Because of the trends to bradycardia she did not receive β-adrenaline. At discharge the patient received β-adrenaline, diuretic and statins. In the comment, there are the questions about creatinine clearance at admission and at discharge and on the liver function parameters of the patient. As we mentioned, the patient suffered from third stage of chronic kidney disease. The creatinine clearance at admission was 31 mL/min per 1.73 m2 and at discharge 30 mL/min per 1.73 m2. If the liver parameters are concerned aspartate aminotransferase was 51 U/L, alanine transaminase 34 U/L. The coagulation parameters were normal. The reason to implant dual chamber pacemaker was symptomatic bradycardia with pauses because of sinus node disease. The patient did not suffer from atrioventricular block. In our opinion, bradycardia was not the complication of TTC.

The Role of Risk Assessment at Antenatal Care Clinics in the Prediction of Pre-Eclampsia in a High Altitude Area

Background: Hypertensive disorders are common causes of maternal and fetal mortality and morbidity. Objective: This study aimed to examine the prognostic value of risk assessment at level of antenatal care clinics in predicting pre-eclampsia at a high altitude (3133 m above sea level). Methods: This cross-sectional study, carried out in Abha Maternity and Pediatric Hospital (AMPH), Saudi Arabia, between January and June 2013, included 176 patients (88 pre-eclamptic women and 88 with normal pregnancies). Patient data including age, parity, blood pressure, body mass index, and complete blood count components were recorded. Results: Physical examination of systolic blood pressure, diastolic blood pressure and BMI between two groups showed high statistical significance with a P value of <0.001. Also, parity was found to be statistically significant with a P value of <0.05. The mean hemoglobin among pre-eclamptic women was 12.27 ± 2.01 g/dL versus 11.92 ± 2.43 g/dL in the control group (P = 0.291). Mean plasma hematocrit levels in the study and the control groups were 38.49% ± 4.32% and 37.92% ± 7.04%, respectively; this was not found to be statistically significant (P = 0.518). Although there was an increase in laboratory blood tests of maternal hematocrit and hemoglobin levels, both parameters failed to show any statistical significance. Conclusion: Risk assessment at level of antenatal care clinics can be considered as valuable prognostic tool for prediction of preeclampsia. Any pregnant lady with abnormal physical examination findings of: BMI, systolic and diastolic blood pressure and obstetric history following risk assessment in antenatal care clinics should be observed for possibility of pre-eclampsia.

Diagnosis and treatment of urolithiasis in client-owned chelonians: 40 cases (1987-2012).

To calculate the prevalence of urolithiasis in client-owned chelonians examined at a veterinary teaching hospital and to describe the clinical signs, diagnosis, and treatment of urolithiasis in chelonians. Retrospective case series. 40 client-owned turtles and tortoises with urolithiasis. The medical record database of a veterinary teaching hospital was searched from 1987 through 2012 for records of client-owned chelonians with urolithiasis. The prevalence of urolithiasis was calculated for client-owned chelonians examined at the hospital. Signalment and physical examination, hematologic, biochemical, urinalysis, diagnostic imaging, treatment, and necropsy results were described. The mean prevalence of urolithiasis in client-owned chelonians for the study period was 5.1 cases/100 client-owned chelonians examined. Thirty-one of the 40 chelonians were desert tortoises. Only 5 of 40 chelonians had physical examination abnormalities associated with the urogenital tract. Surgery was performed on 17 chelonians; 5 developed postoperative complications, and 4 of those died. Necropsy was performed on 18 chelonians, and urolithiasis contributed to the decision to euthanize or was the cause of death for 9. Uroliths from 13 chelonians were analyzed, and all were composed of 100% urate. Results indicated chelonians with urolithiasis have various clinical signs and physical examination findings that may or may not be associated with the urinary tract. Hematologic, biochemical, and urinalysis findings were nonspecific for diagnosis of urolithiasis. Many chelonians died or were euthanized as a consequence of urolithiasis, which suggested the disease should be identified early and appropriately treated.

Clinical and Financial Impact of Ordering an Echocardiogram in Children with Left Axis Deviation on Their Electrocardiogram.

Left axis deviation (LAD) on the electrocardiogram (ECG) is associated with congenital heart disease (CHD), prompting the clinician to order further testing when evaluating a patient with this finding. The purpose is to (1) compare the physical examination (PE) by a pediatric cardiologist to echocardiogram (ECHO) findings in patients with LAD on resting ECG and (2) assess cost of performing ECHO on all patients with LAD on ECG. An IRB approved, retrospective cohort study was performed on patients with LAD (QRS axis ≥0° to -90°) on ECG between 01/02 and 12/12. age >0.25 and <18 years, non-postoperative, and PE and ECHO by pediatric cardiologist. A decision tree model analyzed cost of ECHO in patients with LAD and normal/abnormal PE. Cost of complete ECHO ($239.00) was obtained from 2014 Medicare reimbursement rates. A total of 146 patients met inclusion criteria with 46.5% (68) having normal PE and ECHO, 1.4% (2) having normal PE and abnormal ECHO, 47.3% (69) having abnormal PE and ECHO, and 4.8% (7) having an abnormal PE and normal ECHO. Sensitivity and specificity of PE for detecting abnormalities in this population was 97% and 90%. Positive and negative predictive value of PE was 91% and 97.5%. In patients with normal PE, the cost to identify an ECHO abnormality was $8365, and $263 for those with abnormal PE. In presence of LAD on ECG, the sensitivity, specificity, and positive and negative predictive values of PE by a pediatric cardiologist are excellent at identifying CHD. Performing an ECHO on patients with LAD on ECG is only cost effective in the presence of an abnormal PE. In the presence of normal PE, there is a possibility of missing incidental structural cardiac disease in approximately 2% if an ECHO is not performed.

Torso Computed Tomography Can be Bypassed after Thorough Trauma Bay Examination of Patients who Fall from Standing

Reliance on CT imaging in the evaluation of low-impact blunt trauma is a major source of radiation exposure, cost, and resource utilization. This study sought to determine if torso (chest and abdomen) CT could be avoided in patients with ground level falls. This was a retrospective chart review of patients admitted to the trauma service between January 2013 and April 2014. The mechanism of injury was ground level fall or fall from sitting. Patient demographics, physical examination (PE) findings, imaging results, length of stay, and complications were reviewed. History and physical data were based on chief resident or attending documentation. A significant thoracic injury was defined as a hemothorax, a pneumothorax, greater than three rib fractures, or aortic injury. A significant abdominal injury was defined as a solid organ injury, an intra-abdominal hematoma, a hollow viscus injury, aortic injury, or a urologic injury. The trauma service evaluated 156 patients. Nine patients were excluded for intubation or Glasgow Coma Scale (GCS) < 13. Of the 147 remaining, mean age was 69 years, mean GCS was 14.8. A chest CT was obtained in 111 (76%). Eight (7%) had a significant thoracic injury. All patients with significant thoracic injury had positive examination findings. No patient with a normal PE was found to have a significant thoracic injury (negative predictive value of 100%). An abdominal CT was obtained in 86 (59%). Five (6%) were found to have a significant abdominal injury. All patients who had a significant radiographic injury had an abnormal PE (negative predictive value of 100%). In conclusion, thorough history and physical in the trauma bay allow the clinician to obtain selective torso CT imaging. Routine torso CT warrants re-evaluation in low-impact injury mechanisms as there appears to be little benefit compared with the resource utilization and expense.

Efficacy and Safety of Pitavastatin in Children and Adolescents at High Future Cardiovascular Risk

To assess the safety and efficacy of pitavastatin in children and adolescents with hyperlipidemia. A total of 106 children and adolescents with hyperlipidemia, ages 6 to 17 years, were enrolled in a 12-week randomized, double-blind, placebo-controlled study and randomly assigned to pitavastatin 1 mg, 2 mg, 4 mg, or placebo. During a 52-week extension period, subjects were up-titrated from 1 mg pitavastatin to a maximum dose of 4 mg in an effort to achieve an optimum low-density lipoprotein cholesterol (LDL-C) treatment target of <110 mg/dL (2.8 mmol/L). Adverse events rates, including abnormal clinical laboratory variables, vital signs, and physical examination were assessed. Compared with placebo, pitavastatin 1, 2, and 4 mg significantly reduced LDL-C from baseline by 23.5%, 30.1%, and 39.3%, respectively, and in the open-label study 20.5% of the subjects reached the LDL-C goal <110 mg/dL (2.8 mmol/L). No safety issues were evident. Pitavastatin at doses up to 4 mg is well tolerated and efficacious in children and adolescents aged 6-17 years. Registered with EudraCT 2011-004964-32 and EudraCT 2011-004983-32.

150 pre-participation cardiovascular disease screening, with or without an additional electrocardiogram and echocardiography, in potential recruits to the british army

Background The British Army Initial Recruit Medical includes a history and physical examination. The study objective was to compare the incremental value of adding an electrocardiogram (ECG) and echocardiogram to this medical, in order to detect cardiac disease. Methods A physical examination, ECG and echocardiogram were prospectively performed in volunteers when there was no history suggestive of cardiac disease. Electrocardiograms and echocardiograms were analysed according to published criteria. Further investigations were determined by clinical need. A pragmatic ‘Gold standard’ of ECG, echocardiogram and other investigations elsewhere, when clinically indicated, was used. Enlistment eligibility was decided using military guidelines. Results 812 candidates volunteered. A murmur was detected in 73 (8.9%) candidates, 98 (12.1%) had an ECG abnormality and 161 (19.8%) had either a murmur or ECG abnormality. Sixteen candidates were diagnosed with disease on the day. Seventeen candidates (2.1%) required further cardiac investigations with disease ultimately excluded in sixteen (2.0%). Cardiac disease was detected in seventeen (2.1%) candidates with six conditions associated with sudden death in asymptomatic individuals. Thirteen (1.6%) candidates were prevented from enlisting. Diagnostic test evaluation Physical examination only: Sensitivity: 52.94%, Specificity: 91.95%, Positive Predictive Value: 12.33%, Negative Predictive Value: 98.92%. Additional electrocardiogram: Sensitivity: 88.24%, Specificity: 81.53%, Positive Predictive Value: 9.26%, Negative Predicted Value: 99.69%. Conclusions Adding an ECG to the Initial Recruit Medical is more sensitive in identifying disease than physical examination alone, but has a higher false-positive rate. When physical examination or ECG abnormalities are discovered additional echocardiography reduces the failure rate on the day to 4.1% and of these approximately half ultimately have a disease diagnosis.

Effect of screening abdominal ultrasound examination on the decision to pursue advanced diagnostic tests and treatment in dogs with neurologic disease.

BackgroundAbdominal ultrasound examinations (AUS) are commonly performed before advanced neurodiagnostics to screen for diseases that might affect diagnostic plans and prognosis.ObjectivesDescribe the type and frequency of abnormalities found by AUS in dogs presenting with a neurological condition, identify risk factors associated with abnormalities, and evaluate treatment decisions based on findings.AnimalsSeven hundred and fifty‐nine hospitalized dogs.MethodsRetrospective study. Medical records of dogs presented from 2007 to 2009 for neurologic disease were searched for signalment, neuroanatomic localization, and AUS findings. Whether dogs had advanced neurodiagnostics and treatment was analyzed.ResultsFifty‐eight percent of dogs had abnormal findings on AUS. Probability of abnormalities increased with age (P < 0.001). Nondachshund breeds had higher probability of abnormal AUS than dachshunds (odds ratio [OR] = 1.87). Eleven percent of dogs did not have advanced neurodiagnostics and in 1.3%, this was because of abnormal AUS. Dogs with ultrasonographic abnormalities were less likely than dogs without to have advanced neurodiagnostics (OR = 0.3 [95% confidence interval [CI]: 0.17, 0.52]), however, the probability of performing advanced diagnostics was high regardless of normal (OR = 0.95 [95% CI: 0.92, 0.97]) or abnormal (OR = 0.85 [95% CI: 0.81, 0.88]) AUS. Treatment was more often pursued in small dogs and less often in dogs with brain disease.Conclusions and Clinical ImportanceFindings from screening AUS had a small negative effect on the likelihood of pursuing advanced neurodiagnostics. Although it should be included in the extracranial diagnostic workup in dogs with significant history or physical examination abnormalities, AUS is considered a low‐yield diagnostic test in young dogs and dachshunds.

Survey of ophthalmic anterior segment findings and intraocular pressure in 95 North American box turtles (Terrapene spp.).

To describe the ophthalmic biomicroscopy findings and intraocular pressures (IOP) in a captive population of box turtles and to determine whether a relationship exists between body morphometrics or health status and IOP. Hundred and three box turtles (69 Gulf coast, 24 three-toed, one ornate, one eastern, and eight unidentified) were triaged into three different color-coded groups: green (healthy), yellow (abnormal physical examination with no need for immediate care), and red (immediate care required). Both eyes were evaluated by rebound tonometry and slit-lamp biomicroscopy. Body weight and morphometric data were recorded. Intraocular pressures measurements were available for 190 eyes, slit-lamp biomicroscopy was available for 170 eyes, and morphometric data were available for 81 turtles. IOP in Gulf coast turtles (138 eyes) was 6.7±1.4mmHg OU. IOP in three-toed turtles (48 eyes) was 8.3±1.5mmHg OU, which was significantly higher than in Gulf coast turtles (P<0.0001). No significant IOP differences were noted between genders in both subspecies (P=0.768). There was a correlation between IOP and health status in three-toed turtles only. There was a mild negative correlation between morphometrics and IOP in Gulf coast and three-toed turtles. Fifteen of 87 turtles had unilateral corneal or lenticular opacities; 3/87 had bilateral corneal or lenticular disease; and 3/87 had adnexal abnormalities. Different subspecies of box turtles have different normal intraocular pressures as measured by rebound tonometry, which was influenced by the animals' health status in one subspecies. Some morphometric parameters were found to be associated with IOP. Box turtles are often affected with ophthalmic abnormalities of unknown clinical significance.