Sensitive Exam Research Articles

Apport des signes d’appel échographiques dans le diagnostic anténatal des valves de l’urètre postérieur : expérience de 3 ans à la maternité de l’hôpital Bicêtre

Posterior urethral valves (PUV) are the most common cause of renal impairment in boys during early childhood. The aim of this study was to evaluate the value of ultrasound (US) criteria currently used to diagnose PUV. From 2009 to 2012, 31patients were referred to the Bicêtre Hospital after detection of fetal bilateral hydronephrosis in male fetus. The ultrasound criteria were bladder dilation, thick-walled bladder, urethral dilation ("keyhole sign"), and amniotic fluid volume. Patients were divided in two groups: suspected or not to have PUV. US diagnosis of PUV was done in 18fetuses and confirmed in 14new borns, one of them without prenatal diagnosis. Sensitivity and specificity of US scan were 92.8 and 66.7%. The likelihood ratio (LHR) was 4.8 for a thick-walled bladder, 4.2 for oligohydramnios, 3.6 for the "keyhole sign", 2.4 for bladder dilation and 1.6 for ureteral dilation. The first four signs were combined in four fetuses, all of them with PUV. US scan is a very sensitive exam for the diagnosis of PUV but with a low specificity. A thick-walled bladder seems to have a better diagnostic performance than the "keyhole sign".

Peptic Perforation of the 4th Duodenal Segment. Case Report

Introduction: Even if the prevalence of peptic ulcer disease has decreased in the last years, duodenal perforation remains a life threatening complication. The duodenum is the second most common site of gastrointestinal perforations after the colon and perforation of the 4th portion is very rare. Case Presentation: A 67-yers-old man was admitted to the emergency department of the Annecy Hospital with intense abdominal pain, vomiting and no transit for the last 24 hours. The laboratory count showed an inflammatory syndrome. A CT scan revealed free air and fluid near the Treitz’s angle. An exploratory laparotomy was performed that revealed a perforation of the forth portion of the duodenum. A duodenal resection with duodeno-jejunal anastomosis was performed. Discussions: Peptic ulcer disease is a common disease and the perforation is one of its most life threatening complications. The localization of the DP on the forth segment of the duodenum is very unusual. The most frequent localization of DP is the first duodenal segment. Abdominal CT scan is the most sensitive radiological exam if there is suspicion of a DP. A Zollinger-Ellison syndrome must be taken into count. Peritonitis is an indication for immediate laparoscopy or laparotomy, taking into account the patient’s condition. Despite the successful medication therapy and the progress in treatment of duodenal ulcer, perforation remains a serious complication, requiring an emergency surgical treatment. Conclusion: Duodenal perforation of the fourth portion is an extremely rare complication of the peptic ulcer disease and the surgery is the primary modality of treatment.

Place de la tomographie d’émission de positons (TEP) pour l’évaluation thérapeutique et le suivi du cancer du sein

Positron emission tomography (PET) with fluorodeoxyglucose (FDG) is a nuclear imaging method whose interest in oncology has only grown over the past fifteen years. This article summarizes the results in monitoring and therapeutic evaluation of breast cancer. For the search of locoregional or distant recurrence, the performance of FDG-PET are very interesting. The impact of FDG-PET on the therapeutic management is undeniable. For therapeutic evaluation, this imaging is useful to evaluate the neoadjuvant chemotherapy and hormonotherapy efficacy. FDG-PET is indicated in cases of suspected recurrence (clinical, biological or imaging suspicious). It is the most sensitive exam for the detection of bone or visceral metastases. It allows the re-staging during a relapse proved whether local or remote, and can change the therapeutic management.

“Drug mules” as a radiological challenge

Purpose The purpose of this pictorial essay was to retrospectively evaluate the specificity, sensitivity and accuracy of computed tomography (CT), digital radiography (DR) and low-dose linear slit digital radiography (LSDR, Lodox) whlist emphasizing on radiological signs and pitfalls in the detection of internal cocaine containers. Methods Institutional review board approval was obtained. The presented study collective consisted of 83 patients (76 male, 7 female, 16–45 years) suspected of having incorporated cocaine drug containers. All underwent radiological imaging, a total of 135 exams were performed: n CT=35, n DR=70, n LSDR=30. An overall calculation of all “drug mules” and a specific evaluation of body packers, pushers and stuffers were performed. The gold standard was stool examination in a dedicated holding cell equipped with a drug toilet. Results There were 54 drug mules identified in this study. CT of all drug carriers showed the highest diagnostic accuracy 97.1%, sensitivity 100% and specificity 94.1%. DR in all cases was 71.4% accurate, 58,3% sensitive and 85,3% specific. LSDR of all patients with internal cocaine was 60% accurate, 57.9% sensitive and 63.4% specific. Conclusion CT was the most accurate test studied. Therefore, the detection of internal cocaine drug packs should be performed by CT, rather than by conventional x-ray, in order to apply the most sensitive exam in the medico-legal investigation of suspected drug carriers. Nevertheless, the higher radiation applied by CT than by DR or LSDR needs to be considered. Future studies should include evaluation of low dose CT protocols in order to address germane issues and to reduce dosage.

Continuous quality improvement of colorectal cancer screening

Quality assurance is a key issue in colorectal cancer screening, because effective screening is able to improve primary prevention of the cancer. The quality measure may be described in terms: how well the screening test tells who truly has a disease (sensitivity) and who truly does not have a disease (specificity). This paper raises concerns about identification of the optimal screening test for colorectal cancer. Colonoscopy vs flexible sigmoidoscopy in colorectal cancer screening has been a source of ongoing debate. A multicentre randomised controlled trial comparing flexible sigmoidoscopy with usual care showed that flexible sigmoidoscopy screening is able to diminish the incidence of distal and proximal colorectal cancer, and also mortality related to the distal colorectal cancer. However, colonoscopy provides a more complete examination and remains the more sensitive exam than flexible sigmoidoscopy. Moreover, colonoscopy with polypectomy significantly reduces colorectal cancer incidence and colorectal cancer-related mortality in the general population. The article considers the relative merits of both methods and stresses an ethical aspect of patient's involvement in decision-making. Patients should be informed not only about tests tolerability and risk of endoscopy complications, but also that different screening tests for bowel cancer have different strength to exclude colonic cancer and polyps. The authorities calculate effectiveness and costs of the screening tests, but patients may not be interested in statistics regarding flexible sigmoidoscopy screening and from an ethical point of view, they have the right to chose colonoscopy, which is able to exclude a cancer and precancerous lesions in the whole large bowel.

Tumores neuroendócrinos pancreáticos: análise retrospetiva de 12 anos de experiência do Instituto Português de Oncologia de Lisboa

IntroductionPancreatic neuroendocrine tumors (PNETs) have a broad spectrum of clinical behavior, histopathological characteristics and prognosis. Hormonal production distinguishes functional from nonfunctional tumours. The aim was to review the cases of PNETs diagnosed and/or followed, between 2000 and 2011, at Instituto Português de Oncologia de Lisboa, Francisco Gentil (IPOLFG). MethodsData of clinical files of PNETs of the IPOLFG was analysed. Patients were identified through South Regional Cancer Registry and databases of IPOLFG's Pathology and Endocrinology Departments. Results44 PNETs were identified, 68.2% nonfunctioning and 31.8% functioning (11 insulinomas and 3 gastrinomas). 52.3% of the cases were male. The median age at diagnosis was 55 years (range 31-83). The majority of all PNETs was symptomatic (79.5%), unifocal (70.5%) and well-differentiated (63.6%). Loco-regional disease and metastases were present in 61.4% and 56.8% of the cases, respectively. Magnetic resonance and endoscopic ultrasonography were the most sensitive exams. Surgery was the main treatment offered. Median follow-up time was 32 months (±35; range 1 to 130 months) and median survival was 85 months (±11).Comparison between nonfunctioning and functioning PNETs, revealed that patients in the former group were less symptomatic (73.3 vs 92.9%), presented more often loco-regional disease (73.3 vs 35.7%), metastases (70.0 vs 28.6%), higher proliferative indexes and tumoural diameter (5.4 vs 2.9cm). Median survival was higher in functioning tumors (106 vs 72 months). Factors associated with a more favorable prognosis were: hormonal secretion; histological differentiation; absence of angioinvasion; absence of locorregional disease or metastization; low proliferative indexes. ConclusionAs observed in other series, the majority of PNETs were nonfunctional and the prognosis of these cases was worse than the prognosis of functional tumours.

Magnetic Resonance Imaging Versus Musculoskeletal Ultrasound for Identification and Localization of Plantar Plate Tears

Plantar plate injuries have been identified as a cause of forefoot pain and deformity. Magnetic resonance imaging (MRI) and musculoskeletal ultrasound (US) have been suggested as appropriate imaging modalities for this pathology. A comparison of these two modalities utilizing intra-operatively pathology as the reference standard has not been published. 51 feet of 42 consecutive patients presenting to clinic with forefoot pain and a suspected unilateral plantar plate tear at the 2nd metatarsophalangeal (MTP) joint were identified. A two plane (longitudinal and transverse) US was performed on the painful second MTP joint. Longitudinal ultrasound images were graded as 'torn' or 'intact'. Transverse ultrasound images were used to localize pathology. All ultrasound exams were performed by the same reconstructive foot & ankle fellow. A pre-operative MRI was performed on these patients and read by a Fellowship Trained Musculoskeletal Radiologist. The physicians reading US and the MRI were blinded to each other's findings. All 51 feet were examined intra-operatively. 46 plantar plate tears were identified. The sensitivity, specificity, positive predictive value and negative value of MRI were 73.9%, 100%, 100%, 29.4% respectively while the same values for US were 91.5%, 25%, 91.5%, 25% respectively. MRI identified 4 collateral ligaments tears not identified on ultrasound. Discussion & Both MRI and US are appropriate modalities for imaging of the plantar plate. While US is a highly sensitive exam, MRI is a more specific exam. Overall these results do not suggest that MR should be replaced by US in all cases. Diagnostic, Level I.

“Drug mules” as a radiological challenge: Sensitivity and specificity in identifying internal cocaine in body packers, body pushers and body stuffers by computed tomography, plain radiography and Lodox

PurposeThe purpose of our study was to retrospectively evaluate the specificity, sensitivity and accuracy of computed tomography (CT), digital radiography (DR) and low-dose linear slit digital radiography (LSDR, Lodox®) in the detection of internal cocaine containers. MethodsInstitutional review board approval was obtained. The study collectively consisted of 83 patients (76 males, 7 females, 16–45 years) suspected of having incorporated cocaine drug containers. All underwent radiological imaging; a total of 135 exams were performed: nCT=35, nDR=70, nLSDR=30. An overall calculation of all “drug mules” and a specific evaluation of body packers, pushers and stuffers were performed. The gold standard was stool examination in a dedicated holding cell equipped with a drug toilet. ResultsThere were 54 drug mules identified in this study. CT of all drug carriers showed the highest diagnostic accuracy 97.1%, sensitivity 100% and specificity 94.1%. DR in all cases was 71.4% accurate, 58.3% sensitive and 85.3% specific. LSDR of all patients with internal cocaine was 60% accurate, 57.9% sensitive and 63.4% specific. ConclusionsCT was the most accurate test studied. Therefore, the detection of internal cocaine drug packs should be performed by CT, rather than by conventional X-ray, in order to apply the most sensitive exam in the medico-legal investigation of suspected drug carriers. Nevertheless, the higher radiation applied by CT than by DR or LSDR needs to be considered. Future studies should include evaluation of low dose CT protocols in order to address germane issues and to reduce dosage.

Fatal systemic air embolism after blunt chest trauma: Postmortem computed-tomography findings

Systemic air embolism (SAE) frequently has a fatal outcome, actually for 80% in blunt trauma and 48% in penetrating ones. Several diagnosis tools can detect intracardiac and cerebral air, but should not be necessary to confirm SAE. Our observation underlines that computed-tomography is an interesting and sensitive exam enough, and can be performed also in post-mortem in case of unexplained fatal outcome of chest trauma.

”Sensitive” Examination Workshop for Medical Clerkship Students

OPEN ACCESSDecember 15, 2010”Sensitive” Examination Workshop for Medical Clerkship Students Glenn Posner, MD, FRCSC, MEd Glenn Posner, MD, FRCSC, MEd University of Ottawa Faculty of Medicine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.7936 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail Abstract Introduction: When students practice rectal or pelvic examinations on patients, it is difficult for teachers to guide them because the structures being examined cannot be seen. There is also a tendency for students to perform these exams hastily and awkwardly, since they are concerned about causing patient discomfort. At many institutions, part of this training is accomplished using paid gynecologic teaching associates (GTAs), women who allow students to perform pelvic exams on them and teach them how to do so in a respectful manner. A curriculum was designed for a workshop during the preclerkship period to instruct students in the proper technique of physical exam of the breast, female pelvis, male genitalia, and rectum (the “sensitive” exams). Methods: The workshop consists of five small-group sessions covering the bimanual pelvic exam, speculum exam and Pap test, breast exam and catheterization, digital rectal exam, and male genitalia exam. The workshop can be administered to approximately 45 students, with each small group containing seven or eight students. The session begins as a large-group session where videos are presented to provide a uniform base of knowledge. The small-group sessions then involve hands-on learning. Results: Using a 7-point Likert scale (7 = outstanding), 169 students rated the presenters, the content and the process of the session. Over 70% of students rated each characteristic as a 6 or 7, and over 92% rated each characteristic as a 5 or above. Written comments indicated that the sessions were appreciated and offered constructive feedback to guide future improvements. We then evaluated the effectiveness the female pelvic examination component. 151 students were tested on the bimanual and speculum exams using an objective structured clinical examination. The mean score was 76% with a range of 32%-100%, and only 18 students failed to achieve a score of 60%. Discussion: Simulation cannot replace the experience gained from examining a real patient, but given a proper knowledge base, a proper approach to the patient, and extensive practice on models, students will be more comfortable when they do examine real patients. Medical students at our university are now instructed in these sensitive exams using medical simulation models rather than GTAs. Educational Objectives By the end of this session, learners will be able to: Explain the techniques of physical examination of the breasts, female pelvis, male genitalia, and rectum.Discuss the sensitive nature of these exams and how to carry them out with professionalism while preserving patient dignity.Confidently and comfortably develop their abilities to navigate the sensitive parts of the physical exam. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: SOGC Policy Statement.pdf Sensitive Examination Session Evaluation (Master).doc Sensitive Examination Workshop Student Information.doc Sensitive Examination Intro.ppt Sensitive Examination Curriculum Tutors 2009.doc Curriculum Document Sensitive Exam GDP.doc To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. CitationPosner G. ”Sensitive” Examination Workshop for Medical Clerkship Students. MedEdPORTAL. 2010;6:7936. https://doi.org/10.15766/mep_2374-8265.7936 Copyright & Permissions© 2010 Posner. This is an open-access publication distributed under the terms of the Creative Commons Attribution-Share Alike license.KeywordsGenital ExaminationDigital Rectal ExaminationPhysical ExaminationBreast ExaminationPelvic Examination Disclosures None to report. Funding/Support None to report. Loading ...

Abstract P1-10-13: Mexican American Men and Female Cancer Screening: Is the TexasMexico Border Different?

Abstract Background Husband/partner support is a major determinant of breast/cervical cancer screening in Hispanic women and may adversely affect these rates in south Texas border communities. The Esperanza y Vida/Life Skills project is a pilot, community based, breast/cervical cancer education, screening, and treatment program for Hispanic women and men. The current study evaluated knowledge, attitudes and beliefs (KAB) about breast/cervical cancer screening among Mexican American men in 3 border communities. Methods Semi-structured, bilingual interviews were conducted in male focus groups held in Laredo, Eagle Pass and Nueces County Texas. Audiotaped interviews were transcribed, coded and content analysis used to identify themes across codes. Each participant completed a bilingual survey of beast/cervical cancer KAB. Results 27 male participants median age 59y (range 26-91y; age distribution <50-29%, 50-69 37%, 70+-33%) were recruited by our community partners. 85.2% had lived at their current residence >2y. 56% had less than a high school education and 14.8% had no education. Annual household income was less than $10,000 in 59% and 63% were unemployed. Bumping/bruising and touching the breast were believed to increase breast cancer risk in 41% and 33% of men respectively. While 55.5% correctly identified family history as a breast cancer risk factor only 25.9% identified age. Only 11/27 (42.6%) associated advancing age with an increased likelihood of cervical cancer. Clinical breast exam and Pap testing frequency were correctly identified by 51.8% and 41% of men respectively. Qualitatively, men feared cancer and were likely to have a fatalistic view of it. They expressed some knowledge of breast and cervical cancer, but also had questions and concerns about it. Performance of screening exams by male providers did not pose a barrier but the men preferred that female nurses be present during sensitive exams. They did not express any jealousy or negative feelings towards having their wives screened by males. The men recognized the importance of cancer screening and actively supported screening in their spouses. Screening and early detection were important to keep the family together as was support for women who had cancer. Men felt it was important for them to ‘push’ their wives to get screened. They expressed concern about limited community resources for cancer information and mainly identified clinics, physicians and hospitals as primary cancer information resources. The men identified a need for more primary care physicians who had cancer screening service access. They were embarrassed about teaching their daughters about breast and cervical cancer screening and felt that was more of the mother's role. Conclusions Men in Texas-Mexico border communities were willing to openly discuss breast and cervical cancer. They recognized the importance of cancer screening, family education/awareness and actively support screening in their spouses. Male providers did not pose a barrier to cancer screening for Mexican men. The men have some knowledge, but would benefit from additional information and resources within their communities. Addressing cultural barriers, knowledge issues and access will be helpful in these communities. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-10-13.

Bêta-thalassémie intermédiaire compliquée d’une compression médullaire. Étude de trois observations et méta-analyse

Extramedullary hematopoiesis is common in patients who suffer from beta-thalassemia. Extramedullary hematopoiesis is a compensatory mechanism of chronic anemia. Although the diagnosis is relatively easy, management is still the subject of considerable controversy. The aim of the present paper is to report three cases of spinal cord compression due to beta-thalassemia followed by a meta-analysis. In one of the three cases reported, spinal compression revealed beta-thalassemia. Forty-three cases have been reported in the last 10 years, i.e., four cases per year. The diagnosis was made by CT and myelography and confirmed by histology after surgical treatment. Two patients were followed in the hematology department. Young patients accounted for 95.45% of cases. The time to diagnosis was 3.33 months (3 days to 12 months). The most sensitive exam for diagnosis is magnetic resonance imaging before surgery. The MR image shows a hypointense lesion on T1-weighted sequences in 30.43% of cases or isointense on T2-weighted sequences in 34.78% of cases, and hypointense on T1-weighted sequences enhanced with gadolinium in 42.85% of cases. When MRI is absent, as in our patients, myelography can provide the diagnosis. The vertebrae are enlarged and translucent in 85.71% of cases with a hypodense lesion compressing the spinal cord. Laboratory tests show chronic microcytosis hemolytic anemia in 97.17% of cases. The diagnosis was established by histology performed after surgical removal. The patients recovered 97.5% of their neurologic deficiency after specific treatment. The mean follow-up was 2 years (4 weeks to 15 years).

Increasing Patient Acceptance of Medical Student Participation: Using Interactive Theatre for Faculty Development

Background : Interactive theatre (IT) has been used to train faculty the skills and strategies to address challenging dynamics in educational settings. Purpose : This study described the development, implementation, and evaluation of an IT approach to improve preceptors' skills for increasing patients' acceptance of medical student participation in clinical care. Methods : Focus groups were conducted with faculty, residents, medical students, and clinic staff to discuss issues related to patients declining medical student participation. Findings were used to develop a faculty development session using an IT approach. At a Family Medicine grand rounds presentation, faculty and resident preceptors (n = 42) participated in the IT workshop and completed a pre–post survey assessing skills specific to increasing students' training opportunities in patient care and educational impact of the session. Results : Following the IT session, preceptors reported greater self-efficacy for helping patients feel more comfortable with medical students in the exam room (p =.031, d = 0.338) and increased comfort level with talking to patients about medical students performing sensitive exams (p =.010, d = 0.357). Eighty-eight percent of preceptors agreed or strongly agreed that the session was relevant to improving clinical precepting skills and helped them develop strategies for enhancing medical student involvement in care. Conclusions : Findings suggest that the interactive theatre approach to faculty development is an innovative and effective method to increase preceptors' comfort with discussing medical student involvement with patients.

In newly diagnosed breast cancer, is a contralateral prophylactic mastectomy necessary following a negative MRI?

627 Background: With more centers using MRI to aid in initial staging, there is apprehension that the highly sensitive MRI exam may lead to “unnecessary” mastectomies. We evaluated whether a negative contralateral MRI could be used to rule out a synchronous contralateral carcinoma and hence avoid a prophylactic contralateral mastectomy (CPM) at initial breast cancer diagnosis. Methods: Data of women with a new diagnosis of breast cancer (invasive or DCIS) from February 2003-November 2007 at our institution were reviewed. Women who had a negative MRI of the contralateral breast and who subsequently underwent CPM were included. A CPM was one in which there was no histological confirmation of cancer in the contralateral breast before surgery. All mastectomy specimens were analyzed pathologically. True negatives were mastectomy samples which contained no cancer following pathologic examination. False negatives were mastectomy samples which were found to have cancer after pathologic review. Results: 538 women were identified. 51 women met the study criteria. Median patient age was 56 years (range, 33–77). Of the 51 women who underwent a CPM, 2 were found to have pathologic confirmation of cancer. One occult cancer was a 0.3 cm grade 1, invasive lobular carcinoma; the second a 0.5 cm, low grade DCIS. The overall prevalence of synchronous occult contralateral cancer after a negative MRI was 3.9% (95% CI 0.5 - 13.5%). The negative predictive value of MRI was 96.1% (95% CI 86.5 - 99.5%). Conclusions: This study provides pathologic data regarding the utility of a negative contralateral breast MRI in women with newly diagnosed breast cancer. The prevalence of a synchronous occult contralateral cancer after a negative MRI in women with newly diagnosed breast cancer is very low. Physicians and patients can be assured that the risk of occult cancer is low in the setting of a normal contralateral MRI, an important fact when considering CPM after a diagnosis of unilateral breast cancer. No significant financial relationships to disclose.

When patients decline medical student participation: the preceptors’ perspective

Patients' receptivity towards medical student participation has been examined predominantly from the patient and/or the medical student perspective. Few studies have investigated the preceptor's perspective. The study examined preceptors' experience with patients declining medical student participation in clinical care and identified preceptor-related factors associated with this experience. Preceptors (n = 42) were recruited from a Family Medicine educational presentation and completed a survey assessing encounters with patients declining medical student participation, methods for obtaining patient consent, and self-rated clinical education skills. Forty-eight percent and 62% of preceptors have "sometimes" or "often" had patients decline student involvement due to student's status and in the context of a gynecological/urological exam, respectively. Fifty-eight percent "never" or "seldom" obtain patient consent with the student outside the exam room, while 46% "often" or "always" have the student directly inform patients about his/her involvement. Being a faculty preceptor (versus resident preceptor) (r = 0.463, p = 0.026) and feeling uncomfortable talking to patients about students performing the exam (r = -0.482, p = 0.020) were associated with patients declining student participation for a genital exam. Findings indicate that preceptors encounter patients declining medical student involvement in general and sensitive exam scenarios. In addition, patients are more likely to decline student participation when preceptors are faculty members and less comfortable discussing student involvement.

Men's experiences of physical exams and cancer screening tests: a qualitative study

Background American men have lower overall rates of cancer screening than women. This study was designed to elicit men's health care experiences and knowledge of testicular, prostate, and colorectal cancer (CRC) screening. Methods Fifty-three men participated in eight physician-led semistructured focus groups in Rhode Island and New Hampshire. Four groups (ages 18–35; N = 20) discussed testicular cancer screening. Four groups of older men (ages 40–79; N = 33) discussed prostate and colorectal cancer screening. Results Men in this study prefer physicians who establish interpersonal relationships with male patients. Lack of explanations during physical exams resulted in negative experiences. Men were eager to learn more about their health, but commonly complained that they received neither appropriate cancer screening nor sufficient explanations from their physicians. When PSA screening was offered, discussion was often inadequate. Although men expressed interest in participating in the PSA decision, sole responsibility for this complex decision was seen as undesirable. These men desired more discussion and better sources of health information during medical encounters. Conclusions Clinician attention to communication, relationship building, patient education, and consideration for patient privacy and modesty are important for the care of male patients especially with sensitive exams and topics important to men's cancer screening.

Les fractures occultes du scaphoïde carpien Détection par la radioscintigraphie quantitative. Incidences sociales et médico-légales

Fractures of the scaphoid of the wrist are not easily diagnosed and when they are eventually recognized due to late complications, the prognosis is much poorer than it would have been at injury. Medical negligence and poorly-performed or interpreted x-rays are frequently cited as reasons for non-diagnosis. Often these fractures are trabecular, so-called occult, and they cannot be seen on a conventional exam, even if well-performed. Tomography and tomodensitometry have yielded poor results. Quantitative radioscintigraphy (QRS), the exam we are proposing, is a modification of scintigraphy, which is a very sensitive exam (100%) but has little specificity. The first step in QRS is to quantify the fixation of the tracer on the injured side and compare it to that of the uninjured side. If the injured side fixation is double that of the uninjured side, a fracture (often scaphoid) is present. MRI is our reference. In the second step in QRS, a computer-assisted fusion is made of the scintigraphic image and the x-ray (quantitative scintigraphy has the same diagnostic value as MRI). The center of the fracture is localized, thus yielding a specificity of nearly 100% for this exam. Out of a prospective series of 154 patients who had a conventional examination: 41% were diagnosed to have a scaphoid fracture using QSR, therefore a number higher than supposed. Rare carpal fractures were also detected. The cost of this exam is low. The exam climinates non-diagnosed fractures which can lead to non-union and arthrosis. Due to the frequency of carpal trauma, this exam should have a significant effect on the individual, on social security costs and litigations.