Negative Physical Examination Research Articles

Artificial intelligence assisted ultrasound for the non-invasive prediction of axillary lymph node metastasis in breast cancer

PurposeA practical noninvasive method is needed to identify lymph node (LN) status in breast cancer patients diagnosed with a suspicious axillary lymph node (ALN) at ultrasound but a negative clinical physical examination. To predict ALN metastasis effectively and noninvasively, we developed an artificial intelligence-assisted ultrasound system and validated it in a retrospective study.MethodsA total of 266 patients treated with sentinel LN biopsy and ALN dissection at Peking Union Medical College & Hospital(PUMCH) between the year 2017 and 2019 were assigned to training, validation and test sets (8:1:1). A deep learning model architecture named DeepLabV3 + was used together with ResNet-101 as the backbone network to create an ultrasound image segmentation diagnosis model. Subsequently, the segmented images are classified by a Convolutional Neural Network to predict ALN metastasis.ResultsThe area under the receiver operating characteristic curve of the model for identifying metastasis was 0.799 (95% CI: 0.514–1.000), with good end-to-end classification accuracy of 0.889 (95% CI: 0.741–1.000). Moreover, the specificity and positive predictive value of this model was 100%, providing high accuracy for clinical diagnosis.ConclusionThis model can be a direct and reliable tool for the evaluation of individual LN status. Our study focuses on predicting ALN metastasis by radiomic analysis, which can be used to guide further treatment planning in breast cancer.

An Image-Rich Educational Review of Breast Pain.

Breast pain is extremely common, occurring in 70% to 80% of women. Most cases of breast pain are from physiologic or benign causes, and patients should be reassured and offered treatment strategies to alleviate symptoms, often without diagnostic imaging. A complete clinical history and physical examination is key for distinguishing intrinsic breast pain from extramammary pain. Breast pain without other suspicious symptoms and with a negative history and physical examination result is rarely associated with malignancy, although it is a common reason for women to undergo diagnostic imaging. When breast imaging is indicated, guidelines according to the American College of Radiology Appropriateness Criteria should be followed as to whether mammography, US, or both are recommended. This review article summarizes the initial clinical evaluation of breast pain and evidence-based guidelines for imaging. Additionally, the article reviews cyclical and noncyclical breast pain and provides an image-rich discussion of the imaging presentation and management of benign and malignant breast pain etiologies.

Demography, aetiology, and positional test findings of 187 consecutive patients diagnosed as having BPPV at ENT unit, Teaching Hospital Anuradhapura

Benign Paroxysmal Positional Vertigo (BPPV) is the most common vestibular disorder encountered in balance clinics. Diagnosis by Dix-Hallpike test is straightforward. However, diagnosis can still be complicated due to the presence of number of different subtypes and negative findings. Objectives of the study are to determine demographic pattern, positional test findings in patients diagnosed as having BPPV and to discuss the reasons for positional vertigo with negative physical examination findings. A subgroup analysis was done from a cross sectional descriptive study that was carried out at ENT clinic at Teaching Hospital Anuradhapura from 1st of March 2016 to 28th February 2017. Hundred and eighty-seven (187) consecutive patients with symptoms suggestive of BPPV were assessed .Posterior semi-circular canal involvement as the commonest variant with 70% diagnosed without video Frenzels. Although symptomatic during positional testing, we could not demonstrate clear nystagmus in 24.6% patients in light. Geotrophic or apogeotrophic horizontal nystagmus on supine roll test and down beating nystagmus on Dix-Hallpike test were found 4.2% and 1% respectively.Our findings on posterior canal and positional test negative BPPV are compatible with previously published data. However, diagnosis of lateral appears to be still inadequate. Early referral, routine use of video Frenzel recording at clinics, routine use of seated pitch test, repeated testing may help in reducing false negative rates and finding a specific diagnosis.

How Ready are Pediatricians and Family Physicians in Saudi Arabia to Perform Clinical Screening of Developmental Dysplasia of the Hip?

Developmental dysplasia of the hip (DDH) is one of the most common hip pathologies in pediatric age group and late diagnosis remains a major concern in Saudi Arabia. The aim of this study is to examine the ability of Saudi Arabian pediatricians and family physicians to conduct clinical screening for (DDH) by estimating their clinical knowledge and skills and analyzing the gaps therein to determine whether there is potential to launch a national screening protocol for DDH in Saudi Arabia. This is a multicenter cross-sectional study from three major regions in Saudi Arabia (Central, Eastern and Western provinces). The assessed aspects are risk factors, age of screening, incidence in Saudi Arabia, physical signs and diagnostic markers, and treatment, along with their 'clinical knowledge and skills' score. Half of the participants were pediatricians, while the rest were family physicians. More than a third of the participants were considered to have adequate knowledge, ie, above the mean score. Dimensions with the most significant knowledge gaps included the incidence of DDH in Saudi Arabia, adverse effects of swaddling, and the management of a high-risk infants presenting with a negative physical examination. Additionally, there were relatively low rates of awareness regarding positive risk factors as well as a generally poor ability to identify physical signs. Clinical knowledge and skill levels were significantly lower among family physicians. Pediatricians and family physicians in Saudi Arabia still need further training to improve their clinical skills for DDH screening. The proper administration of training programs could eventually enable the gradual implementation of a national systematic screening program.

Value of Thoracic CT in Blunt Trauma Patients With High Glasgow Coma Scale and Low Injury Severity Scale.

To determine the value of ordering a routine chest CT (CCT) in patients with blunt trauma presenting to the emergency department with a high GCS and low ISS, we retrospectively collected patient data including CT scan results, when physical examination and initial chest X-ray were normal in the trauma bay area. A retrospective data collection of 901 consecutive blunt trauma patients seen in the ED between 2017 and 2019 was analyzed. Data included physical examination, age, gender, current use of anticoagulation therapy, comorbid conditions, as well as the result of radiologic images, hospital length of stay, surgical intervention, and mortality. The patients were divided into two groups: group one (patients with negative physical examination; chest x-ray and CT) and group 2 (negative physical examination, positive or negative chest x-ray, and positive CT). Statistical analysis was performed using student's t-test and chi-square test. Of the 901 patients there were 489 (54%) males and 412 (46%) females with a mean age of 56 years. There were 461 patients who had a physical examination, chest x-ray, abdominal and CCT done. Group one included 442 (96%) patients, with negative physical examination, negative chest X-ray and CT scan. In group 2, 19 (4%) patients who had positive CT and or chest x-ray. Both groups were similar in GCS and ISS. Of the 19 patients, sixteen patients had a positive CCT, and thirteen of those had a positive chest x-ray. In the three patients who had negative physical examination and chest x-ray, the CT findings included one with a nondisplaced 10th rib fracture and two patients with osteoporotic compression fractures of dorsal vertebrae. The rate of both chest x-ray and CCT being positive among a group of screened patients was 16% (3/19) and the rate of a negative chest x-ray but positive CT was 16% (3/19). The odds ratio between the two outcomes was one. In blunt trauma patients presenting to the ED with a high GCS and low ISS score, when initial physical examination and chest x-ray are negative, routine CCT is of little value.

Association between the rs820218 Variant within the SAP30BP Gene and Rotator Cuff Rupture in an Amazonian Population.

Rotator cuff disease is one of the leading causes of musculoskeletal pain and disability, and its etiology is most likely multifactorial but remains incompletely understood. Therefore, the objective of this research was to investigate the relationship of the single-nucleotide rs820218 polymorphism of the SAP30-binding protein (SAP30BP) gene with rotator cuff tears in the Amazonian population. The case group consisted of patients who were operated on due to rotator cuff tears in a hospital in the Amazon region between 2010 and 2021, and the control group was composed of individuals who were selected after negative physical examinations for rotator cuff tears. Genomic DNA was obtained from saliva samples. For the genotyping and allelic discrimination of the selected single nucleotide polymorphism (rs820218) in the SAP30BP gene, real-time PCR was performed. The frequency of the A allele in the control group was four times as high as that in the case group (AA homozygotes); an association of the genetic variant rs820218 of the SAP30BP gene with rotator cuff tears was not established (p = 0.28 and 0.20), as the A allelic frequency is ordinarily low in the general population. The presence of the A allele indicates protection against rotator cuff tears.

A novel nomogram for the preoperative prediction of sentinel lymph node metastasis in breast cancer.

A practical noninvasive method to identify sentinel lymph node (SLN) status in breast cancer patients, who had a suspicious axillary lymph node (ALN) at ultrasound (US), but a negative clinical physical examination is needed. To predict SLN metastasis using a nomogram based on US and biopsy-based pathological features, this retrospective study investigated associations between clinicopathological features and SLN status. Patients treated with SLN dissection at four centers were apportioned to training, internal, or external validation sets (n=472, 175, and 81). Lymph node ultrasound and pathological characteristics were compared using chi-squared and t-tests. A nomogram predicting SLN metastasis was constructed using multivariate logistic regression models. In the training set, statistically significant factors associated with SLN+ were as follows: histology type (p < 0.001); progesterone receptor (PR: p=0.003); Her-2 status (p=0.049); and ALN-US shape (p=0.034), corticomedullary demarcation (CMD: p < 0.001), and blood flow (p=0.001). With multivariate analysis, five independent variables (histological type, PR status, ALN-US shape, CMD, and blood flow) were integrated into the nomogram (C-statistic 0.714 [95% CI: 0.688-0.740]) and validated internally (0.816 [95% CI: 0.784-0.849]) and externally (0.942 [95% CI: 0.918-0.966]), with good predictive accuracy and clinical applicability. This nomogram could be a direct and reliable tool for individual preoperative evaluation of SLN status, and therefore aids decisions concerning ALN dissection and adjuvant treatment.

Chest Pain in Young Patients (5-15 Years) Referred to Pediatric Cardiology Outpatient Clinic

Background: Chest pain is the communal complaint among pediatric age groups. Chest pain due to heart disease is rare in children and adolescents, with an incidence of less than 6%. History and physical examination may be sufficient to identify the most important etiologies. Aim: The aim of the study is to review various causes of chest pain in young patients admitted to a pediatric cardiology clinic. Method: We retrospectively analyzed the clinical data of our patients visited to emergency or outpatient clinics in our hospital with chest pain from March 2022 to October 2022. A total of 56 patients (36 females and 20 males), aged 5-15 years were included in this study. Follow-up of the patients was carried out by calling all relatives of the patient and asking about the child's condition and chest pain. Clinical history and physical examination were performed. Results: A total of 56 patients between the ages of 5 and 15 were enrolled in the study, with a mean age of 11.78 ± 2.95 years. Six cases (10.7%) were identified to have a cardiac cause. 16 individuals (28.6%) had a respiratory cause identified. 3(5.4%) of patients referred to a gastroenterology clinic with gastrointestinal causes. The diagnosis of idiopathic chest pain was made in 6 individuals (10.7%) after a negative history, physical examination, and testing. Conclusion: Chest pain in children is usually mild. However, thorough physical examination and detailed history should be performed to detect any signs of disease. Keywords: Chest pain, Pediatric patients, Echocardiography.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the presentation of paediatric acute appendicitis: an observational study

AimTo determine whether there were differences in the clinical presentation of patients imaged to evaluate for acute appendicitis in 2020 compared to 2019 with the hope that this information might better identify patients who should undergo imaging work-up and those who should not.Materials and methodsThis retrospective observational study included patients <18 years who were evaluated for appendicitis between 1 March and 31 May 2019 and 2020. A total of 465 patients were stratified by final diagnosis (appendicitis versus not appendicitis) and compared based on presenting symptoms, physical examination findings, vital signs, and laboratory test results.ResultsSymptoms and physical examination findings that were significant in the positive cohort in both years included right lower quadrant pain, pain with movement, migration of pain, right lower quadrant tenderness, and peritoneal findings. Reporting upper respiratory symptoms was an independent predictor of negative results among all patients and in 2019. Both negative cohorts were more likely to have negative physical examinations. Anorexia and nausea/vomiting were more likely among positive cases in 2019 whereas diarrhoea was more likely among positive cases in 2020.ConclusionsThe COVID-19 pandemic did not significantly change the presenting features of acute appendicitis. The results of the present study emphasise the importance of the physical examination. The ambiguity of symptoms that mimic gastroenteritis justifies imaging in these patients.

Dysmenorrhea in adolescents

Studies show that between 41% and 91.5% of young women, school-aged and university-aged, are affected by dysmenorrhea. Primary dysmenorrhea, which is caused by the production of prostaglandins, is defined as cramping pain in the lower abdomen and/or pelvis occurring just before or during menstruation, in the absence of other diseases such as endometriosis, and typically lasting 1-3 days and with a negative physical examination. Secondary dysmenorrhea presents with similar signs and symptoms but is a result of underlying pelvic pathology, for example endometriosis or uterine fibroids. Dysmenorrhea most typically presents as abdominal cramping; however, it can also present with headaches, nausea, vomiting or other generalized symptoms. The diagnosis is mainly clinical, but other tests such as a pelvic examination, a pregnancy test and STI screening may be helpful in ruling out other sources of pain. Although the mainstay of treatment for dysmenorrhea is NSAIDs and hormonal therapy, lifestyle changes and complementary/alternative medicine can also be helpful approaches. Lifestyle changes include aerobic exercise and stretching, while complementary alternative medicine include peppermint, cinnamon, ginger and other herbs and supplements. Finally, endometriosis must be considered as a potential cause for secondary dysmenorrhea and would warrant a prompt referral to gynecology.

The Value of Abdominal and Pelvic CT Scan in Trauma Patients With Low Injury Severity Score and High Glasgow Coma Scale.

Computed tomography scans became the mainstay of emergency department (ED) evaluation of trauma patients including those with a high Glasgow Coma Scale (GCS) and a low Injury Severity Score (ISS). We elected to find the value of abdominal and pelvic CT in patients with negative physical examination and Focused Assessment of Sonography for Trauma (FAST) on arrival to the ED. This study is a retrospective analysis of 901 consecutive patients from 2017 to 2019 who presented to the ED with level 2 and 3 activation criteria. Each patient received a physical examination, CT abdomen and pelvis, and FAST exam. Data were collected on external factor including GCS, ISS, age, sex, comorbidities, anticoagulation use, and surgical intervention. The patients were divided into 2 groups, Group A and B. Group A consisted of patients with a negative physical exam, FAST, and CT result. Group B included patients with a negative physical exam and FAST exam with positive CT findings. Statistical analysis was done using a Student's t-test and chi-square test for significance value of P < .05. Institutional Review Board approval was obtained for this study. A total of 901 patients were analyzed which included 489 (54.3%) male and 412 (45.7%) female with a mean age of 56.2 (SD = 22.62) years. Out of the 901 patients, 461 patients received a physical, FAST, and CT exam. Group A consisted of 442 (95.9%) patients and Group B had 19 (4.1%) patients. Both groups were similar in GCS and ISS scoring with no significance difference in age, sex, comorbidities, and anticoagulation use. There was a significant difference in the ICU and hospital mean length of stay when CT scan was positive [2 (SD = 4.23) days vs. .6 (SD = 1.33) days with P < .0001 and 4.57 (SD ± 4.17) days vs. 2.5 (SD = 2.00) days with P < .0001, respectively]. The CT findings of the 19 patients in group B consisted of 6 incidentalomas, 5 vertebral compression fractures, 4 pelvic bone fractures, 1 minor liver contusion, 1 non-specific bowel thickening, 1 non-displaced rib fracture, and 1 case of small amount of free fluid in the pelvis. None of the CT findings required surgical intervention. Computed tomography of the abdomen and pelvis in trauma patients with high GCS and low ISS with initial negative physical and FAST examination did not provide additional critical information.

A Single Institution Experience in Hypertrofic Pyloric Stenosis

Abstract The most common causes of non-bilious vomiting in infants are hypertrophic pyloric stenosis and pylorospasm. Differential diagnosis between the pathologies establishes the correct treatment. The aim of our study is to present the management of the pathologies cured in our department. The longer the duration of vomiting symptoms the higher muscle thickness was shown. Dehydration and lethargy was associated with higher muscle thickness. There were no intraoperative or postoperative complications recorded in our cases. Ultrasonography is the gold standard in imaging technique but it requires an experienced radiologist. In case of negative physical examination and ultrasonography, but high suspicion of the diagnosis a fluoroscopy may be required. The correct diagnosis avoids unnecessary surgery combined with general anesthesia.

Does Postmortem Imaging Provide Additional Findings After Unexpected Deaths in Infants and Children?

We performed a retrospective study of unexpected deaths in children 2 years or younger between 2008 and 2018. Children with known traumatic deaths and those transferred after a cardiopulmonary arrest at an outside institution were excluded. We collected patient demographics, physical examination findings, and type of PMI performed along with their results. We analyzed 150 deaths with majority (128; 85.3%) being infants. No PMI was performed in 20 children (13.3%). An autopsy was not performed in 22 children (14.6%). A skeletal survey and an autopsy were performed only in 72.6% (93/128) infants. PMI provided additional findings in 51 infants (34%) and 13 children (59.1%) aged 13 to 24 months. PMI identified abuse in 11 children with a negative physical examination result, 3 of whom had a negative autopsy. The American Academy of Pediatrics recommendations of performance of a skeletal survey and an autopsy were not adhered to after all infant deaths. PMI is useful in identification of additional findings in children 2 years or younger, especially those concerning for physical abuse in infants with a negative physical examination.

Efficacy of routine post-operative head computed tomography on cranial surgery patients outcome.

Objectives:To identify the role of routine postoperative head CT in changing postoperative management after elective craniotomies.Methods:We conducted a retrospective study on adult patients who underwent cranial surgery. Exclusion criteria includes cranial CTs done postoperatively for urgent clinical indications, pediatric patients, CSF diversion procedures and sedated patients. Patients were placed into “positive” group if the physical assessment changed from the baseline in the form of clinical deterioration, and the “negative” group if the exam did not change. The data then were analyzed to identify which patients needed further medical or surgical management based on CT findings only with “negative” physical examination.Results:Total of 222 were included in the study. 151 patients had negative physical examination. Only 8 out of 151 patients had positive CT findings. Two patients out of 222 (0.9%) had a negative physical exam and positive CT findings that required additional action that wouldn’t be done urgently without routine postoperative brain CT. Only one patient out of 222 (0.4%) who was re-operated urgently based CT findings only and negative physical examination.Conclusion:Routine postoperative routine brain CT did not alter the course of medical management, even in the presence of significant radiological findings.

The new dynamic isotonic manipulation examination (DIME) is a highly sensitive secondary screening tool for supraspinatus full-thickness tears

Traditional shoulder physical examination (PE) tests have suboptimal sensitivity for detection of supraspinatus full-thickness tears (FTTs). Therefore, clinicians may continue to suspect FTTs in some patients with negative rotator cuff PE tests and turn to magnetic resonance imaging (MRI) for definitive diagnosis. Consequently, there is a need for a secondary screening test that can accurately rule out FTTs in these patients to better inform clinicians which patients should undergo MRI. The purpose of this study was to assess the ability of 2 new dynamic PE tests to detect supraspinatus pathology in patients for whom traditional static PE tests failed to detect pathology. We prospectively enrolled 171 patients with suspected rotator cuff pathology with negative findings on traditional rotator cuff PE, who underwent 2 new dynamic PE tests: first, measurement of angle at which the patient first reports pain on unopposed active abduction and, second, the dynamic isotonic manipulation examination (DIME). Patients then underwent shoulder magnetic resonance arthrogram. Data from the new PE maneuvers were compared with outcomes collected from magnetic resonance arthrogram reports. Pain during DIME testing had a sensitivity of 96.3% and 92.6% and a negative predictive valueof 96.2% and 94.9% in the coronal and scapular planes, respectively. DIME strength ≤86.0 N had a sensitivity of 100% and 96.3% and a negative predictive value of 100% and 95.7% in the coronal and scapular planes, respectively. Pain at ≤90° on unopposed active abduction in the coronal plane had a specificity of 100% and a positive predictive value of 100% for supraspinatus pathology of any kind (ie, tendinopathy, "fraying,"or tearing). DIME is highly sensitive for supraspinatus FTTs in patients with negative traditional rotator cuff PE tests for whom there is still high clinical suspicion of FTTs. Thus, this test is an excellent secondary screening tool for supraspinatus FTTs in patients for whom clinicians suspect rotator cuff pathology despite negative traditional static PE tests. Given its high sensitivity, a negative DIME test rules out supraspinatus FTT well in these patients, and can therefore better inform clinicians which patients should undergo MRI. In addition, the angle at which patients first report pain on unopposed active shoulder abduction is highly specific for supraspinatus pathology.

Abstract P4-02-13: Comparison of lymph node ultrasound and pathological characteristics of breast cancer patients with positive and negative sentinel lymph node

Abstract Background: Few data exist to elucidate sentinel lymph node (SLN) status in breast cancer patients who have a suspicious axillary lymph node (ALN) at ultrasound but a negative clinical physical examination. This study compared various ALN statuses in the breast cancer patients who have a suspicious axillary lymph node (ALN) at ultrasound but a negative clinical physical examination to guide further ALN management. Methods: From Jan 1st 2014 to Jan 1st 2019 in PUMCH (Peking Union Medical College &amp; Hospital), breast cancer patients who had a suspicious axillary lymph node (ALN) at ultrasound but a negative clinical physical examination and treated with sentinel lymph node (SLN) biopsy were retrospectively analyzed. The SLN status, and SLN positive rate in the entire population were analyzed. Lymph node ultrasound and pathological characteristics were compared between patients with positive SLNs and negative SLNs. Results: A total of 483 breast cancer patients (365 SLN negative and 118 SLN positive) were eligible for the final analysis, the SLN positive rate in the enrolled entire population was 32.33%, while in DCIS (Ductal carcinoma in situ) subgroup the SLN positive rate was 12.26%. The patients’ lymph node ultrasound and basic clinical pathological characteristics are listed in table 1. The histology type (P = 0.000), ultrasound lymph node shape (P = 0.000), ultrasound lymph node CMD (corticomedullary demarcation) (P = 0.000), ultrasound lymph node blood flow (P = 0.034) and PR status (P=0.004) had statistical significance between the positive SLNs group and negative SLNs group. Conclusions: 1/3 patients with a suspicious ALN at ultrasound but a negative clinical physical examination had ALN metastasis. IDC, PR positive, ultrasound LN with irregular shape, unclear CMD and blood flow are more likely to have positive SLN. Table 1. Lymph node ultrasound and basic clinical pathological characteristics between SLN negative and positive groupSLN negativeSLN positiveP valuen=365n=118Age(Year)50.14±11.6848.19±10.420.088Histology Type0.000DCIS10613IDC259105Ki67(%)30.69±24.3131.02±23.260.898Ultra-LN Size (cm)1.42±0.691.30±0.730.111Ultra-LN Shape0.000regular359108irregular610Ultra-LN CMD0.000clear32690unclear3928Ultra-LN Blood0.034presence21155absence15463T stage0.071I22779II13133III76ER0.141positive26694negative9924PR0.004positive23292negative13326Her20.067positive10925negative25693Abbreviation:DCIS (Ductal carcinoma in situ); IDC (Invasive ductal carcinoma); Ultra-LN (Ultrasound of lymph node); Ultra-LN CMD (Corticomedullary demarcation in lymph node ultrasound); Ultra-LN Blood (Blood flow in lymph node ultrasound). Citation Format: Xuefei Wang, Shafei Wu, Guochao Zhang, Jiaxin Li, Jianhua Du, Yidong Zhou, Feng Mao, Yan Lin, Songjie Shen, Xiaohui Zhang, Qiang Sun. Comparison of lymph node ultrasound and pathological characteristics of breast cancer patients with positive and negative sentinel lymph node [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-02-13.

Does use of axillary ultrasound in clinically node-negative patients receiving neo-adjuvant systemic therapy for breast cancer lead to surgical overtreatment?

Increased use of neo-adjuvant chemotherapy (NAC) for breast cancer has raised uncertainty regarding staging of the axilla, particularly for patients with a clinically negative axillary physical examination (PE). We sought to determine whether axillary ultrasound (AUS) prior to NAC to identify occult nodal disease is beneficial in patients with a clinically negative examination by evaluating the difference in nodal burden on final pathology in those with abnormal vs normal AUS. A retrospective review of an institutional cancer registry identified patients who underwent NAC for breast cancer and had a pretreatment AUS. Differences in the number of positive lymph nodes (PLN) in patients with a normal axillary PE and abnormal vs normal AUS prior to NAC were determined. A total of 120 patients who received NAC had a negative axillary PE prior to treatment. Fifty-three had an abnormal AUS and biopsy-proven lymph node (LN) involvement. In patients with an abnormal AUS, median number of PLNs at surgery was 1 vs 0 for those with a normal AUS (mean difference of 2.12, P<.0001). Of those patients with an abnormal AUS and biopsy-proven LN involvement, 87% underwent axillary lymph node dissection (ALND) and nearly half had no PLN on final pathology (N=23, 43%). Patients with a clinically negative axilla and an abnormal AUS were more likely to have PLN at the time of surgery. However, almost half of those patients had no residual LN involvement. Routine AUS prior to NAC may lead to more extensive surgical management of the axilla.

Routine pelvic X-rays in asymptomatic hemodynamically stable blunt trauma patients: A meta-analysis

IntroductionThere is no consensus on how pelvic X-rays should be ordered selectively in blunt trauma patients which may save time, reduce radiation exposure and costs. The aim of this systematic review and meta-analysis was to assess the need for routine pelvic X-rays in awake, respiratory and hemodynamically (HD) stable blunt trauma patients without signs of pelvic fracture. Criteria to identify patients who could safely forgo pelvic X-ray were evaluated. MethodsA literature search was performed for prospective comparative cohort studies. Inclusion criteria were: blunt force trauma, hemodynamically and respiratory stable and awake patients, physical examination (PE) for pelvic fractures was adequately described, and the reliability of negative PE findings could be evaluated. Primary outcome was the negative predictive value (NPV) of PE for all and for clinically relevant pelvic fractures. Additionally sensitivity, specificity and positive predictive value (PPV) were calculated. ResultsTen studies were included; yielding a total of 11,423 patients. The NPV of PE for all pelvic fractures ranged from 0.96 to 1.00 with a median of 0.996. Combining studies, total NPV was 0.991. For clinically relevant fractures, the NPV of PE ranged from 0.996 to 1.00 with a median of 1.00. In patients with negative findings during PE, 0.9% had fractures, and 0.1% had clinically relevant fractures, none requiring surgical management. ConclusionsIn awake, hemodynamically and respiratory stable blunt trauma patients, PE could identify those patients who could safely forgo pelvic X-ray. Selective ordering of pelvic X-ray may lead to a decrease in patient work-up time, lower radiation exposure, and reduce costs. A decision making flow chart is proposed..

Is The Pain Real or Not?

Chronic pain (constant pain lasting 6 months or longer) is a subjective experience, which is influenced by many pre-morbid (before the onset of pain) psychological problems. However, chronic pain often can produce depression, anxiety, and marital difficulties. Although physical examination and other studies, including x-ray studies, 3D-CT, electromyelograms (EMG), nerve conduction velocity studies and MRI in many cases may document an organic basis of chronic back pain, some organic syndromes defy definition by objective tests. This may be a greater problem for women, where physician prejudice can result in a significantly less extensive evaluation of their complaints of back pain. Also, any litigation may influence symptoms and the type of litigation may influence outcomes [8]. Therefore, there is a need to differentiate between “organic” and “functional” (negative physical and laboratory examination) back pain.

Is The Pain Real or Not?

Chronic pain (constant pain lasting 6 months or longer) is a subjective experience, which is influenced by many pre-morbid (before the onset of pain) psychological problems. However, chronic pain often can produce depression, anxiety, and marital difficulties. Although physical examination and other studies, including x-ray studies, 3D-CT, electromyelograms (EMG), nerve conduction velocity studies and MRI in many cases may document an organic basis of chronic back pain, some organic syndromes defy definition by objective tests. This may be a greater problem for women, where physician prejudice can result in a significantly less extensive evaluation of their complaints of back pain. Also, any litigation may influence symptoms and the type of litigation may influence outcomes. Therefore, there is a need to differentiate between “organic” and “functional” (negative physical and laboratory examination) back pain.