Standard Methods For Examination Research Articles

Methodological study on real-time three-dimensional echo cardiography and its application in the diagnosis of complex congenital heart disease

Real-time three-dimensional echocardiography (RT-3DE) has made revolutionized improvements of cardiac imaging during the past few years. However, there is no standard examination method for RT-3DE so far. This study aimed to establish the diagnostic method of RT-3DE and evaluate its application in the diagnosis of complex congenital heart diseases (CHD). Fifty patients with complex CHD were examined by RT-3DE with modes of Live 3DE and Full Volume. A series of novel volumetric views combined with Van Praagh sequential segmental approach were introduced to reveal the pathological morphology of the hearts, which were compared with the findings of two-dimensional echocardiography (2DE), angiography and cardiac surgery. In 50 patients, 190 image acquisitions of Full Volume were performed at several acoustic windows including subcostal, apical and parasternal regions. Among them, 94.2% (179/190) of image acquisitions were successful. Most sectional volumetric views could be clearly displayed in 92.6% of the successful image acquisitions. However, sectional volumetric views could not be clearly displayed in 7.4%, which was mainly due to poor perspective conditions of examination location, improper instrument multi-parameter setting and insufficient information of whole heart captured in Full Volume acquisitions. As compared with surgical findings and angiography, RT-3DE made correction to the diagnoses in 2 cases including 1 with corrected transposition of the great arteries and the other with single atrium and mitral cleft. The diagnoses initially made by 2DE for these 2 patients were double outlet right ventricle with transposition of the great arteries and complete atrio-ventricular septal defect. RT-3DE can clearly display the pathological morphology of complex CHD by a series of novel volumetric views combined with sequential segmental approach through providing more spatial informative cardiovascular structures, which provides a practical method for RT-3DE diagnosis.

Intraoperative endoscopy in obstructive hypopharyngeal carcinoma

To demonstrate the necessity of intraoperative endoscopy in the diagnosis of secondary primary tumors of the upper digestive tract in patients with obstructive hypopharyngeal carcinoma. Thirty-one patients with hypopharyngeal squamous cell carcinoma had been operated, with radical intent, at our Institution in the period between 1978 and 2004. Due to obstructive tumor mass, in 7 (22.6%) patients, preoperative endoscopic evaluation of the esophagus and stomach could not be performed. In those patients, intraoperative endoscopy, made through an incision in the cervical esophagus, was standard diagnostic method for examination of the esophagus and stomach. We found synchronous foregut carcinomas in 3 patients (9.7%). In two patients, synchronous carcinomas had been detected during preoperative endoscopic evaluation, and in one (with obstructive carcinoma) using intraoperative endoscopy. In this case, preoperative barium swallow and CT scan did not reveal the existence of second primary tumor within esophagus, despite the fact that small, but T2 carcinoma, was present. It is reasonable to use intraoperative endoscopy as a selective screening test in patients with obstructive hypopharyngeal carcinoma.

Localization of Manifest Right Posteroseptal Accessory Atrioventricular Pathway With the Help of the Spatial Vector-Electrocardiography

We have researched the infringements of diffusion of excitation in myocardium of ventriculars with functioning right posteroseptal accessory atrioventricular pathway (RPAP) with the help of the spatial animation vector – electrocardiography (3D-VECG). The information got by us, can be used for RPAP localization during operations. We examined 18 patients aged 12-52 (middle age 25,3) having manifest of preexcitation ventriculars syndrome. Besides standard methods of examination: ECG-12, transesophageal and endocardial pacing, all patients were examined by the original methods 3D-VECG. We used the orthogonal system of electrode leads macfee-Parungao in modification E. A. Ozola for registration and analysis of electric heart activity. ATES MEDICA (Italy) computer system was used for registration, viewing and the analysis of the vector-electrocardiogram (VECG). After registration of biopotentials of heart we looked through the correction projections of integral electric vector of heart to axes X, Y, Z. Then the most informative cardiac cycle was chosen and processed by the original program in Mathcad 7. As a result of researches we received VECG, including animated, that reflects the character of the infringements of diffusion of excitation in myocardium of ventriculars at various RPAP localization. Interpretation of our results was realized in accordance with the dipoles theory of cardiac electrogenesis and the concept of Grant-Penaloza-Tranchesi. All accessory pathways were divided into three groups in accordance with the results of RFA: 7 patients with RPAP, 3 – left posteroseptal accessory pathways, 4 – right inferior accessory pathways, 4 – right free-wall in the inferior site. We have established that 3D-VECG is able to find localization accessory pathways in the topographical difficult posteroseptal area before RFA. Coincidence of zones of localization on 3D-VECG with results of RFA has made 92,8%. Thus, 3D - VECG is a sensitive method for localization RPAP within the limits of one anatomic zone of localization. In some cases 3D – VECG is only sensitive noninvasive method of localization accessory pathways in the posteroseptal area.

CYTOGENETIC STATUS AND MORBIDITY LEVEL FOR PERSONNEL OF POLESYE STATE RADIOECOLOGICAL RESERVE

The purpose of the present study is to determine chromosome aberration frequency and morbidity level for the personnel of the Polesye State Radioecological Reserve (PSRR). The classical cytogenetic analysis, standard methods of clinical examination of the PSRR staff and statistical data processing were applied in the study. In the result, the reliable increase of chromosome aberration frequency, formation of polymorbidity syndrome, and the age dependence of the morbidity level were fixed for the PSRR personnel.

Impairment of speech and communication skills in dementia

Dementia results not only in the impairment of cognitive-mnestic skills, but also of communication skills. Symptoms include difficulties in finding words and limited expression. The diagnosis of speech and language pathologies in dementia is problematic because there are no standard examination methods. Furthermore, it is difficult to distinguish dementia from semantic dementia, Broca's aphasia and chronic progressive aphasia.

Partial characterization of the polluting load of swine wastewater treated with an integrated biodigestion system

The stabilization of swine wastewaters from swine confined housing by the combination of a upflow anaerobic sludge blanket (UASB) reactor and waste stabilization ponds is a viable alternative to minimize the environmental impact caused by inadequate disposal of swine wastewaters. In the present study, the polluting load of pre-decanted swine wastewater treated with a series of two 0.705 m 3 UASB reactors and then in parallel in aerated and non-aerated stabilization tanks was investigated from January to July, 2000. Physicochemical and microbiological analyses were made adopting standard methods (Standard Methods for Examination of Water and Wastewater, 19th ed., American Public Health Association, Washington, DC, 1995). COD values decreased as the wastewater ran through the integrated biodigestion system dropping from about 3492 ± 511–4094 mg l −1 ± 481 to 124 ± 52–490 mg l −1 ± 230, while nitrate and nitrite levels increased in stabilization tanks, ranging respectively from 4 ± 0 to 20 mg l −1 ± 3 and 3 ± 1 to 11 mg l −1 ± 24. Although the removal of Escherichia coli was more than 97% ± 6, the effluents of the treatment system still contained unacceptable levels of E. coli (1.6 × 10 3–1.2 × 10 6 100 ml −1) according to WHO guidelines for use of wastewater in agriculture and aquaculture. These results indicate the necessity of changes on operational characteristics of the treatment system such as an increase of the hydraulic retention time in UASB reactors or in stabilization tanks.

Pathologic sampling of laparoscopically morcellated kidneys: a mathematical model.

Kidney morcellation permits tissue removal through a port site; however, standard methods of histopathologic examination of the numerous specimen fragments thus produced have not been established. We developed a model to guide pathologic evaluation of the morcellated kidney. A mathematical model was created to determine the quantity of morcellated tissue needed to establish a diagnosis. Inputs into the equation included estimated lesion size, total specimen volume, and the desired certainty of identifying at least a portion of the lesion on pathologic analysis. Nomograms were calculated to illustrate the model and provide clinically relevant guidelines. The hypergeometric distribution was used to develop the formula: P = 1 - (1 - k/N)(n), where k/N represents the fraction of total specimen with tumor, n is the amount of specimen that must be sampled to yield a diagnosis, and P is the probability of encountering the tumor in the sampled tissue. The model provided nomograms that were feasible and would guide a practical approach to the pathologic analysis of laparoscopically morcellated specimens. The increasing application of laparoscopy to the removal of solid organs with suspected tumors has raised several important issues. Morcellation of these specimens precludes traditional pathologic examination and necessitates an alternative method of specimen sampling and diagnosis. We describe a novel, systematic model to assist in the histopathologic examination of morcellated specimens. Issues of pathologic staging remain unresolved, but this sampling system provides a nonarbitrary framework to help arrive at a histologic diagnosis.

Examination of models of mucosal wave propagation

Over the years, many models have been proposed to capture mucosal wave propagation along the medial surface of the vocal folds. However, historically, little quantitative data have existed with which to evaluate such models. Indeed, standard methods of laryngeal examination have imaged the medial surface vibrations of the vocal folds very poorly. However, new methods of imaging the medial surface dynamics of the vocal folds have recently been reported [D. A. Berry, D. W. Montequin, and N. Tayama, J. Acoust. Soc. Am. 110, 2539–2547 (2001)]. These data are used to evaluate a variety of models of mucosal wave propagation. [Work supported by NIDCD Grant No. R01 DC03072.]

Deterioration of a primarily normal hip without developmental disorders

Ultrasonography of the hip joint in babies has been established as a standard method for examination and classification of dysplasia of the hip as well as for monitoring of the treatment. It has been believed until now that, in a hip once classified as normal, the development of the hip joint will continue to be normal if there is no developmental disorder or other skeletal dysplasia. We report the case of a patient who clearly showed normal sonographic and radiological findings initially but who experienced significant developmental dysplasia of the hip (DDH) within the first two years of life. Even more interesting aspects are the treatment of the contralateral side for severe hip dysplasia: with both hips in optimally centered position the initially affected hip had been operated successfully while the initially normal hip deteriorated. Therefore we consider this as one of the rare examples of “endogenous hip dysplasia” which underlines the occurence of DDH and which does not necessarily mean inadequate primary diagnosis or inadequate reading of ultrasonographic or radiographic images.

Perform a death-defying act: The 90-second oral cancer examination

A comprehensive oral cancer examination takes approximately 90 seconds and includes a review of the patient's medical and dental history, extraoral and intraoral inspections of the head and neck, and manual palpation of related specific sites. The following review of an oral cancer examination is based on the standardized oral examination method recommended by the World Health Organization. It also is available in poster form from the National Institute of Dental and Craniofacial Research.1Detecting oral cancer: A guide for health professionals. National Institutes of Health, National Institute of Dental and Craniofacial Research, Bethesda, Md.1995Available at: “www.nohic.nidcr.nih.gov/pubs/detect”Google Scholar The extraoral assessment includes an inspection of the face, head and neck with special attention to patients who appear to spend a lot of time in the sun. Note any asymmetry or lesions on the skin such as crusts, fissuring and growths. The regional lymph nodes in the submandibular and neck areas should be bilaterally palpated to detect any enlarged nodes; if enlargement is detected, assess their mobility and consistency. A seven-step systematic assessment of the lips, labial mucosa, commissures and buccal mucosa, gingiva and alveolar ridges, tongue, floor of the mouth and palate is suggested. It requires adequate light, a mouth mirror and two 2 × 2-inch gauze squares. Observe the lips with the patient's mouth both closed and open. Note the color, texture and any surface abnormalities of the vermilion borders. With the patient's mouth partially open, visually examine the labial mucosa and sulcus of the maxillary vestibule and frenum, as well as the mandibular vestibule. Note the color, texture and any swelling or other abnormalities of the vestibular mucosa and gingiva. Retract the buccal mucosa. Examine first the right, then the left, buccal mucosa extending from the labial commissure and back to the anterior tonsillar pillar. Note any change in pigmentation, color, texture and other abnormalities of the mucosa. Examine the commissures carefully. Examine the buccal and labial aspects of the gingival and alveolar ridges by starting with the right maxillary posterior gingiva and alveolar ridge and then move around the arch to the left posterior area. Drop to the left mandibular posterior gingiva and alveolar ridge and move around the arch to the right posterior area. Then, examine the palatal and lingual aspects as on the facial side, from right to left on the palatal (maxillary) aspect and left to right on the lingual (mandibular) aspect. With the patient's tongue at rest and mouth partially open, inspect the dorsum of the tongue for any swelling, ulceration or variation in size, color or texture. Ask the patient to protrude his or her tongue and examine it for any abnormality of mobility or positioning. Grasp the tip of the tongue with a piece of gauze to assist in full protrusion of the tongue. Use a mouth mirror to visually assess the more posterior aspects of the tongue's lateral borders and to retract the cheek. Also, gently run your index finger along the lateral borders of the tongue to feel for any hard tissues. Then examine the ventral surface. Palpate the tongue to detect growths. The tongue should feel soft and pliable. With the tongue still elevated, inspect the floor of the mouth for changes in color, texture, swellings or other surface abnormalities. Irregularities are more easily detected if gauze is used to wipe the floor of the mouth dry; the gauze also can be used to keep the tongue out of the way. With the patient's mouth wide open and head tilted back, gently depress the base of the tongue with a mouth mirror. Inspect the hard and soft palates. Bimanually palpate the floor of the mouth for any abnormalities. All mucosal or facial tissues that seem to be abnormal should be more carefully palpated. An oral cancer examination, which is part of a comprehensive oral examination, takes only about 90 seconds. All adult patients should receive this part of a comprehensive oral examination on a routine basis. All lesions that have not resolved within two weeks of manifestation warrant a biopsy or referral to an appropriate provider. Special points to remember when screening for oral cancer are listed in the box (“Points to Remember When Screening for Oral Cancer”).

Ultrastructure of the hyperhidrotic eccrine sweat gland.

Hyperhidrosis is the secretion of inappropriately large amounts of sweat by eccrine glands; it can be very debilitating. Little is known of the causes of primary hyperhidrosis. To determine whether the glands exhibit any structural abnormality in primary hyperhidrosis. Skin biopsies were obtained from the axilla (n = 6) or neck (n = 2) of individuals aged 26-62 years with primary hyperhidrosis and from five age- and sex-matched normal individuals, with informed consent and ethical committee approval. Samples were prepared by standard methods for light and electron microscopic examination. All characteristics observed in the hyperhidrotic specimens were consistent with the changes seen in normal glands following strong activation: degranulation of the granular (dark) cells, dilatation of the basolateral infoldings and the canaliculi of the non-granular (clear) cells, contraction of the myoepithelial cells and thickening of the basal lamina, and presence of cellular debris including lipid droplets in the gland lumen. Pathological changes were not observed. The present finding of the absence of structural defects in the glands indicates that future studies should concentrate on the investigation of neurohumoral or secretory cell metabolic abnormalities.

Innervation of the human costovertebral joint: Implications for clinical back pain syndromes

Background: The diagnosis of pain in the upper back, shoulder, chest, and arm is often made with considerable confusion and may be accompanied by needless expense and suffering by the patient. Despite the paucity of evidence concerning the tissues and mechanisms responsible for interscapular and atypical chest pain or “pseudo-angina,” practitioners of manual therapy maintain that manipulation of the costovertebral elements and associated soft tissues may be helpful in the treatment of these painful conditions. Objective: We have examined the costovertebral complex in humans with respect to the presence of immune-like reactivity to neurofilament protein and the neuropeptide substance P and calcitonin gene-related peptide, markers that reveal the presence of axons in peripheral tissues. Design: Human costovertebral complexes obtained at autopsy were processed with standard histologic examination and immunocytochemical methods to detect the presence of neurofilaments, substance P, and calcitonin gene-related peptide. Main Outcome Measures: Outcomes were descriptive and did not require statistical methods. Results: All costovertebral joints contained innervation within the anterior capsule and synovial tissues. In 4 separate cases, the costovertebral joints contained large intraarticular synovial inclusions or “meniscoids” found to contain small bundles of axons with immune-like reactivity to substance P. Axon bundles were identified in serial section with monoclonal antibodies to neurofilaments as well as with urea-silver nitrate staining. Conclusions: The costovertebral joint has been considered a candidate for producing back pain and/or psuedo-angina that may be ameliorated by spinal manipulation. This study has demonstrated that the costovertebral joint has the requisite innervation for pain production in a similar manner to other joints of the spinal column. (J Manipulative Physiol Ther 2000;23:395–403)

Clinical anatomy and palpability of the inferior lateral pterygoid muscle

Statement of Problem: The intraoral palpation technique of the inferior belly of the inferior lateral pterygoid (ILP) muscle is a standard diagnostic examination method for temporomandibular joint dysfunction syndrome, although different studies have revealed inconsistent results. Purpose: This study assessed the feasibility of the ILP muscle palpation by a simulated clinical setting. Material and Methods: Three dentists performed a bilateral palpation of the ILP muscle in 53 fresh and unfixed human cadavers and decided whether the muscle was palpable or unpalpable. In a second step, it was observed through the dissected infratemporal fossa, whether the examiner’s finger did or did not touch the ILP muscle by simulating the performed palpation. Palpatory findings were supplemented by 1-dimensional measurements for determination of topographic relations of the ILP muscle within the infratemporal fossa. For statistical analysis, sensitivity, specificity, and negative and positive predictive values of the palpation technique were calculated. Interexaminer agreement was estimated with the kappa value. Results: In 86 of 106 dissected specimens, a superficial fascicle of the medial pterygoid muscle was found in direct proximity to the ILP muscle. In these cases, a residual distance of 7.8 ± 3.2 mm remained between the ILP muscle and buccinator fascia indented by the tip of the examiner’s finger. In 10 of 20 specimens with an absent superficial fascicle, the finger was able to reach the ILP muscle. Conclusion: It is recommended that the ILP muscle palpation technique should no longer be considered as a standard clinical procedure because it is nearly impossible to palpate the ILP muscle anatomically and because the risk of false-positive findings (by palpation of the medial pterygoid muscle) is high. (J Prosthet Dent 2000;83:548-54.)

Role of immunohistochemical detection of lymph-node metastases in management of breast cancer

This study was designed to ascertain whether immunohistochemical methods could improve the detection of metastases in primary breast-cancer patients whose axillary lymph nodes were classified, by conventional methods, as disease free. Ipsilateral lymph nodes (negative for metastases by routine histology) from 736 patients (participants in Trial V of the International [Ludwig] Breast Cancer Study) were examined by serial sectioning and staining with haematoxylin and eosin (two sections from each of six levels) and by immunohistochemistry of a single section (with two anticytokeratins AE-1 and CAM 5.2). After median follow-up of 12 years, disease-free and overall survival were estimated by Kaplan-Meier methods. Occult nodal metastases were detected by serial sectioning and haematoxylin and eosin in 52 (7%) of 736 patients and by immunohistochemistry in 148 (20%). Only two (3%) of 64 invasive lobular or mixed invasive lobular and ductal cancers had node micrometastases, detected by haematoxylin and eosin, compared with 25 (39%) by immunohistochemistry. Occult metastases, detected by either method, were associated with significantly poor disease-free and overall survival in postmenopausal but not in premenopausal patients. Immunohistochemically detected occult lymph-node metastases remained an independent and highly significant predictor of recurrence even after control for tumour grade, tumour size, oestrogen-receptor status, vascular invasion, and treatment assignment (hazard ratio 1.79 [95% CI 1.17-2.74], p=0.007). The immunohistochemical examination of ipsilateral axillary lymph nodes is a reliable, prognostically valuable, and simple method for the detection of occult nodal metastases. Immunohistochemistry is recommended as a standard method of node examination in postmenopausal patients.

Can we teach a gentler rectal examination?

A total of 201 first-year medical students were trained in a standard method of rectal examination; half of the year were additionally instructed to mimic a rectal examination using a clenched left fist (Group 2, n = 103). Competence in rectal examination was assessed during an objective structured clinical skills examination.Technique was assessed using a standardized marking scheme alongside global examiner assessments of gentleness and adequacy (on scales of 1, very poor to 5, very good). Students demonstrated a high standard for the technique (mean 85.1%), with no difference between groups for this score or for adequacy, though group 2 scored significantly better for gentleness. The addition of a simple, practical teaching technique of using the fist to mimic the anus and rectum resulted in an appropriately gentle examination.This approach should help students to develop the confidence to perform the examination when required and whilst ensuring patient comfort.

Comparative studies on the sensitivity of polymerase chain reaction and microscopic examination for the detection of Trypanosoma evansi in experimentally infected mice

Trypanosoma evansi, a protozoan parasite in the blood of camels is routinely diagnosed by finding the flagellates in the wet films or stained smear of peripheral blood, examined under a microscope. Although specific, this method is not sensitive at early stages of infection. We have tested the use of polymerase chain reaction (PCR) in the identification of T. evansi in different stages of infection in mice and compared its sensitivity with that of the standard microscopic examination method. Using a specific pair of primers, it was possible to identify T. evansi in the blood of infected mice. Experimentally, groups of mice were infected with T. evansi, isolated from a naturally infected local camel and blood samples were collected every day for 30 days post-infection. Direct microscopy or PCR was applied to detect parasitaemia. Results showed that during the acute phase of infection, parasites were detected by PCR three days earlier than by microscopy. Furthermore, the infected mice were consistently positive by PCR during the chronic phase while the parasites could not be demonstrated during this period using microscopic examination. These findings suggest that PCR may be applied to camel trypanosomosis during both acute and chronic phase of infection. Furthermore, it would provide an excellent tool in the evaluation of treatment of anti-trypanocidal drugs.

Telomere Length Distribution and Southern Blot Analysis

Southern blot analysis of terminal restriction fragments (TRFs) is the standard method for quantitative examination of telomere length distributions. Since TRFs contain a subtelomeric component, central parameters of the TRF distributionn(L) such as the arithmetic mean (M) or the median (Me) cannot be derived directly from Southern blot data, i.e. from the optical density distributionOD(L). Several estimates have been applied instead; the seeming arithmetic meanA, the “center of mass”C, and the positions of maximal (P) and half-maximal optical density (P12). We show thatC>A>Mfor any non-truncated distributionsn(L), andP>M>P1/2 for any symmetrical unimodaln(L).Symmetric appearance on a Southern blot, however, suggests positive skewness ofn(L). Thus, alognormalform ofn(L) may be considered. Then,C>A>M>P=Me>P12. Alternatively, aWeibulldistribution may be assumed. The latter is compatible with negative feedback-regulation of the telomere lengths. Using the maximum likelihood method we compare these distributions with FISH-data on telomere lengths in different cell types. The fit of the lognormal distribution is clearly superior. Lognormal genesis may relate to telomere breakage and recombination.Truncation of the upper end of the TRF distribution is possible due to Southern blot artifacts. Thereby, the order of the estimates may change toP>C>A. Having minimal sensitivity to truncation,Pseems to be the optimal choice. however, the variability ofPis high since peakedness ofOD(L) and DNA length resolution are inversely related.

Diagnosis and surgery of displacement of the abomasum in dairy cows in Slovenia

At the Clinic for Ruminants the authors have used, besides the standard examination method, also the method of combined percussion and auscultation of the abdomen. By this diagnostic aid at the left or the right side of the abdomen they could very successfully detect and localize a variously large, ovally-shaped area emitting a characteristic, sharp, metallic sound, the so-called "ping" caused by the abomasal displacement. From 1981 -1993, twenty-nine cases of left and eighteen cases of right sided "ping" were encountered. In most cases surgery proved successful. In surgical corrections of left side displacement of the abomasum and afterwards also the right one, the authors sutured and thus fixed the omentum using Haupter PSV silk ribbon. The method is fast, simple and reliable.

Assessment and communication of conscious level: an audit of neurosurgical referrals

Telephone referrals of 100 head-injured patients to a neurosurgical service were assessed to determine if altered consciousness was adequately described by the referring doctor. Of the patients, 60 per cent were resuscitated, assessed and referred by SHOs. Only 30 per cent of doctors were fully conversant with the Glasgow Coma Scale and 18 per cent were unable to describe altered consciousness. Assessment of motor response was often described inaccurately and this was frequently due to the use of an inappropriate stimulus. The use of a pictorial guide to motor responses and a ‘Head Injury Proforma’ are suggested as means of improving referral and enhancing audit. The majority of doctors had not received formal training in the assessment of conscious level during their undergraduate or postgraduate training. Training video tapes from neurosurgical units showing standard examination methods and typical responses would allow self-assessment and training.

膝外傷に対する超音波検査

We examined 27 patients with ligament or meniscal knee injuries by arthroscopy and ultrasonography. Of these, 15 were anterior cruciate ligament ruptures, 6 posterior cruciate ligament ruptures, 14 meniscal ruptures, 6 medial collateral ligament ruptures, and one lateral collateral ligament rupture.The aim of this comparative study was to demonstrate that the normal and pathological findings of the ligament and meniscus can be visualized on an ultrasonogram. We used a standardized examination method, scanning the cross-section of the menisci and the tangential section of ligaments, with a 5MHz linear electronic transducer.Ultrasonography should be recommended as a primary diagnostic tool due to its noninvasive nature, and accessibility.