Standard Physical Exam Research Articles

Associations between accurate measures of adiposity and fitness, blood proteins, and insulin sensitivity among South Asians and Europeans.

South Asians (SAs) may possess a unique predisposition to insulin resistance (IR). We explored this possibility by investigating the relationship between 'gold standard' measures of adiposity, fitness, selected proteomic biomarkers, and insulin sensitivity among a cohort of SAs and Europeans (EURs). A total of 46 SAs and 41 EURs completed 'conventional' (lifestyle questionnaires, standard physical exam) as well as 'gold standard' (dual energy X-ray absorptiometry scan, cardiopulmonary exercise test, and insulin suppression test) assessments of adiposity, fitness, and insulin sensitivity. In a subset of 28 SAs and 36 EURs, we also measured the blood-levels of eleven IR-related proteins. We conducted Spearman correlation to identify correlates of steady-state plasma glucose (SSPG) derived from the insulin suppression test, followed by multivariable linear regression analyses of SSPG, adjusting for age, sex and ancestral group. Sixteen of 30 measures significantly associated with SSPG, including one conventional and eight gold standard measures of adiposity, one conventional and one gold standard measure of fitness, and five proteins. Multivariable regressions revealed that gold standard measures and plasma proteins attenuated ancestral group differences in IR, suggesting their potential utility in assessing IR, especially among SAs. Ancestral group differences in IR may be explained by accurate measures of adiposity and fitness, with specific proteins possibly serving as useful surrogates for these measures, particularly for SAs.

The benefits of undergraduate medical students delivering free preparticipation physical evaluations in collaboration with a K-12 school district

BackgroundStudent-run free clinics are present at many medical schools throughout the United States. While many work with adult homeless or uninsured populations, few work with pediatric populations. We investigated the impact of volunteering at a free preparticipation sports physical clinic on medical students’ educational motivation, school engagement, confidence in their clinical skills, connectedness to community, and self-efficacy.MethodsFirst and second year undergraduate medical students who volunteered at a preparticipation sports physical clinic were eligible for the study. 30 students participated in the study, some volunteering multiple times, for a total of 55 post-volunteering surveys. Pre- and post-volunteering surveys were administered via REDCap. The surveys were designed using Likert scales and the General Self-Efficacy scale. Paired two tailed t-tests were used to analyze pre- and post-volunteering data.ResultsStudents had statistically significant increases in their confidence in working with pediatric populations, performing a standard physical exam, working in an interdisciplinary setting, and communicating with patients. They also demonstrated statistically significant increases in their feelings of connectedness to their reason for practicing medicine and to the greater local community.ConclusionsThis research demonstrated measurable increases in motivation and confidence in clinical skills for medical students that participated. This is a valuable experience for medical students and is a model that other medical schools can adopt to help diversify and strengthen their curriculum. In the future, we would like to collect more data to further evaluate the impact of this volunteering on medical students, patients, families, and other community stakeholders.

Breaking Stereotypes: Sectoral Varicocele Diagnosis Revolutionized by Doppler Ultrasound Advancements

Varicocele is a common cause of male infertility and is traditionally diagnosed by physical examination. However, earlier research demonstrated physical examination has limited reliability. This study investigated the accuracy of Doppler ultrasound (DUS) for varicocele diagnosis compared to the standard physical exam. In a cohort of 200 patients with possible varicocele, sensitivity and specificity of physical examination alone were 61.4% and 71.4%, respectively, versus DUS at 91.7% and 94.3%, respectively. When combining physical exam findings with DUS, sensitivity and specificity increased to 92.9% and 95.7%. These findings suggest DUS should replace physical exam as the primary diagnostic tool given its much higher accuracy. Widespread adoption of DUS would enable earlier diagnosis and treatment of varicocele, improving patient outcomes and advancing our understanding of varicocele etiology.

Application of a Clinical Approach to Diagnosing Primary Pain: Prevalence and Correlates of Primary Back and Neck Pain in a Community Physiatry Clinic

Chronic back or neck pain (CBNP) can be primary (nociplastic or neuroplastic; without clear peripheral etiology) or secondary (to nociceptive or neuropathic causes). Expanding on available models of nociplastic pain, we developed a clinic-ready approach to diagnose primary/nociplastic pain: first, a standard physical exam and review of imaging to rule out secondary pain; and second, a detailed history of symptom presentation to rule in primary pain. We trained a physician who evaluated 222 patients (73.9% female, age M = 59.6) with CBNP; patients separately completed pain and psychosocial questionnaires. We estimated the prevalence of primary CBNP and explored biomedical, imaging, and psychological correlates of primary CBNP. Although almost all patients (97.7%) had at least 1 spinal anomaly on imaging, the diagnostic approach estimated that 88.3% of patients had primary pain, 5.0% had secondary pain, and 6.8% had mixed pain. Patients with primary pain were more likely than the other 2 groups of patients (combined as “non-primary pain”) to report certain functional conditions, central sensitization, and features such as sensitivity to light touch, spreading pain, and pain worsening with stress; however, no difference was detected in depression, anxiety, and pain catastrophizing between those with primary and nonprimary pain. These findings are consistent with prior estimates that 85 to 90% of CBNP is “nonspecific.” Further research is needed to validate and perhaps refine this diagnostic approach, which holds the potential for better outcomes if patients are offered treatments targeted to primary pain, such as pain neuroscience education and several emerging psychological therapies. PerspectiveWe developed an approach to diagnose chronic primary pain, which was applied in a physiatry clinic to 222 patients with CBNP. Most patients (88.3%) had primary pain, despite almost universal anomalies on spinal imaging. This diagnostic approach can guide educational and psychological treatments tailored for primary pain.

Sensitivity of benchmarked behavioral assays for distress: Should we attend to certain behaviors during exams?

Behavioral, emotional, and physical signs of distress are increasingly recognized in veterinary patients during routine care. Visits to veterinarians are associated with development or worsening of fearful behaviors. Veterinary patients experiencing fear and distress create a welfare concern. These negative emotional states may result in deferred veterinary care and incomplete veterinary evaluations. This study is part of our ongoing series of studies on assessing fear and distress in clinical situations using one population of dogs. We sought to evaluate whether there was one or a subset of behaviors in a benchmarked, behavioral scale that best predicted or correlated with a 5-point, subjective, ordinal scale. Both scales were used to evaluate each dog’s behavior throughout a 10-step standardized physical exam. Here we discuss the association between global scoring and the more detailed physical exam scoring. We evaluated dogs (n = 35) that were enrolled in a randomized, placebo-controlled, double-blind study testing a novel pharmaceutical intervention for fear associated with veterinary exams. In the original study, the dogs were videotaped at the baseline visit and 2weeks later at the interventional visit. All videos were coded and blinded. For the purposes of our study, the order of the exams and whether the dogs received placebo, or the novel compound were not revealed. Four people evaluated all videos: three residents and an experienced specialist/researcher who participated in the original pharmaceutical study. The benchmarked behavioral scales indicated that dogs with low body or tail posture (scores of 4-5) during the paw-lift stage of the physical exam, stayed aroused for all subsequent parts of the exam. This was not the case for dogs with lower scores when their paws were lifted. A score of 4 or 5 for tail and/or body posture is a sensitive predictor of future exam behavior in this context, and lifting a paw appears to be a provocative intervention for many fearful dogs. These key behaviors are sufficiently informative so that these should be evaluated at specified exam stages during a standardized exam, as part of a valid baseline behavioral database.

Using standardized scales to assess fear at veterinary visits: Intra- and inter-rater reliability

Behavioral, emotional, and physical signs of distress are increasingly recognized in veterinary patients during routine care. Fear and distress are humane and welfare concerns themselves, but such behavior may also result in deferred veterinary care and less thorough veterinary evaluations. The first step in preventing and treating this fear is to routinely assess it. The aim of this study was to assess the inter-rater reliability of two five-point, subjective, standardized, and benchmarked Likert scales evaluating the dog’s behavior during the entry into the exam room and throughout the exam, and one benchmarked, behavioral scale that evaluated 8 behavioral components for entry into the exam room and for each of 10 steps of a standardized physical exam. We also assessed repeatability/intra-rater reliability for these scales for a subset of domestic dogs (Canis familiaris) studied. Dogs (N = 35) were enrolled in a randomized, placebo-controlled, double-blind study testing a novel pharmaceutical intervention for fear associated with veterinary exams. Dogs were videotaped at the baseline or no intervention visit and 2 weeks later at the interventional (compound/placebo) visit. All videos were coded and blinded with respect to visit order and treatment. Videos were never unblinded for treatment for this study. Videos were only unblinded for order, after the videos were assessed and the data with the statistician. Four people evaluated all videos: three behavior-resident and an experienced specialist/researcher. As part of a series of studies on this population of dogs, we report on inter-rater reliability for all scores among the residents and comparing the specialist’s versus residents’ scoring, and the residents’ intra-rater reliability/repeatability. The results show a fair-to-moderate inter-rater and intra-rater agreement. These data suggest that a standardized scale can be used reliably by multiple people and may be an essential component of a valid baseline behavioral database.

8942 Development of a Novel Physical Exam for Patients Undergoing Laparoscopic Excision of Endometriosis

Study Objective To create and validate a standardized physical exam for patients undergoing laparoscopic excision of endometriosis surgery. Design Prospective observational feasibility study. Setting Large academic hospital. Patients or Participants Patients (n = 17) undergoing operative laparoscopy for management of endometriosis were consented and enrolled before surgery and followed up to 6 weeks postoperatively. This is an ongoing study with plan to enroll 30 participants. Interventions N/A. Measurements and Main Results We developed a physical exam that included numerical pain ratings from regions typically affected by endometriosis. The complete exam was conducted at the preoperative visit and a modified version was performed at 2-week and 6-week postoperative visits for patient comfort. Composite pain scores were calculated from the modified physical exam to quantify physical symptom severity. These scores were compared to a validated patient-reported outcome measure for pain, Brief Pain Inventory (BPI). The composite physical exam pain scores improved progressively following surgery, decreasing from a median of 22.5 (IQR 14-34.29) preoperatively to 11.5 (IQR 5.26-16) at 6-weeks postoperative (p=0.072 using Wilcoxon signed-rank test). This was consistent with a decrease in average pain reported using BPI (p= 0.063). Spearman correlation coefficients showed a moderate correlation between preoperative physical exam scores and BPI (rho = 0.5419). Conclusion Currently, there is no consensus physical exam to describe symptom severity for patients with chronic pelvic pain. We report a novel standard physical exam to describe endometriosis symptom severity. Even though our results were not statistically significant, we observed a reduction in physical exam pain scores reported before and after surgery, which correlated with pain scores collected using a validated pain questionnaire. This proposed exam could be used to objectively follow up success of endometriosis excision. Our study is currently underpowered and anticipate achieving statistical significance after completing recruitment. To create and validate a standardized physical exam for patients undergoing laparoscopic excision of endometriosis surgery. Prospective observational feasibility study. Large academic hospital. Patients (n = 17) undergoing operative laparoscopy for management of endometriosis were consented and enrolled before surgery and followed up to 6 weeks postoperatively. This is an ongoing study with plan to enroll 30 participants. N/A. We developed a physical exam that included numerical pain ratings from regions typically affected by endometriosis. The complete exam was conducted at the preoperative visit and a modified version was performed at 2-week and 6-week postoperative visits for patient comfort. Composite pain scores were calculated from the modified physical exam to quantify physical symptom severity. These scores were compared to a validated patient-reported outcome measure for pain, Brief Pain Inventory (BPI). The composite physical exam pain scores improved progressively following surgery, decreasing from a median of 22.5 (IQR 14-34.29) preoperatively to 11.5 (IQR 5.26-16) at 6-weeks postoperative (p=0.072 using Wilcoxon signed-rank test). This was consistent with a decrease in average pain reported using BPI (p= 0.063). Spearman correlation coefficients showed a moderate correlation between preoperative physical exam scores and BPI (rho = 0.5419). Currently, there is no consensus physical exam to describe symptom severity for patients with chronic pelvic pain. We report a novel standard physical exam to describe endometriosis symptom severity. Even though our results were not statistically significant, we observed a reduction in physical exam pain scores reported before and after surgery, which correlated with pain scores collected using a validated pain questionnaire. This proposed exam could be used to objectively follow up success of endometriosis excision. Our study is currently underpowered and anticipate achieving statistical significance after completing recruitment.

Acquiring the Skills to Perform Point of Care Ultrasound of the Infant Hip Through Simulation

Developmental dysplasia of the hip (DDH) is the most common anatomical pathology in newborns. Traditionally, the standard physical exam for newborns includes hip stability testing using the Barlow and Ortolani maneuvers. If the pediatrician detects hip instability, then they are referred for a hip ultrasound—the gold standard for DDH diagnosis. We present our experience with a simulation model for teaching point of care ultrasound examination of an infant hip with which we have successfully and consistently taught numerous residents and attendings how to swiftly and accurately assess DDH in an infant's hip.

Point of Care Ultrasound as Performed by the Clinician for the Enhancement of Physical Examination: A Technique Guide for Developmental Hip Dysplasia.

The online version contains supplementary material available at 10.1007/s43465-021-00570-8.

Pelvic floor, abdominal and uterine tenderness in relation to pressure pain sensitivity among women with endometriosis and chronic pelvic pain

ObjectivePelvic floor pain, abdominal wall pain, and central nervous system pain amplification can be contributing factors in chronic pelvic pain (CPP), however; limited research has investigated the association of pelvic floor, abdominal, and uterine tenderness with central nervous system pain amplification. We assessed whether pressure pain thresholds on the non-dominant thumbnail, a marker of central nervous system pain amplification, were associated with pelvic floor, abdominal, and uterine tenderness among women with endometriosis or CPP. Study designWe conducted a cross-sectional study among 88 females with endometriosis and/or CPP. Abdominal (6 locations), pelvic floor (6 locations) and uterine (1 location) tenderness were assessed via a standardized physical exam. Participants reported their pain levels (0–10 scale) with application of 2 kg of pressure at each area, with a pain rating of ≥4 on the 0–10 scale considered moderate to severe pain. Pain sensitivity was measured on the non-dominant thumbnail by applying discrete pressure stimuli using a previously validated protocol. ResultsOverall, 50% (44/88), 42% (37/88), and 58% (51/88) of participants reported high pelvic floor, abdominal, and uterine tenderness, respectively. Pressure intensities needed to elicit ‘faint’ and ‘mild’ pain were lower for participants with high vs. low pelvic floor tenderness (median intensity for ‘faint’ pain = 0.50 kgf/cm2(min–max:0.25–3.25) vs. 1.06(0.25–3.00), p-value = 0.006; median intensity for ‘mild’ pain = 2.00(0.63–4.88) vs. 2.63(0.75–6.00), p-value = 0.03). No association was observed between pressure pain sensitivity and abdominal or uterine tenderness (p > 0.11). Participants with endometriosis without pain were less likely to have high pelvic floor (22.2%), abdominal (11.1%), and uterine (25.9%) tenderness compared to participants with endometriosis with pain (63.0%, 50%, 65.2%, respectively) and participants with chronic pelvic pain (60%, 73.3%, 93.3%, respectively). ConclusionsThese results suggest that high pelvic floor tenderness among women with endometriosis/CPP may be a marker of heightened pain sensitivity suggestive of central nervous system pain amplification and may impact treatment response. Future research should examine whether this clinical phenotype predicts response to medical and behavioral treatments (e.g, anti-convulsants, behavioral therapy, Physical Therapy).

The Sonographic Sliding Sign: can it predict the need for open as opposed to minimally invasive surgery, a case report

: The “sliding sign” seen on transvaginal ultrasound (TVS) was originally described to pre-operatively identify adhesions in the pelvis. The absence of freely moving intestine in a whirlwind pattern is consistent with a “negative” sliding sign and increased risk of adhesions. We began using it in pregnant patients with previous cesarean section to see if this information could help alert obstetricians to the presence of dense adhesions to the myometrium, and therefore, guide better management of these patients during child birth. We also theorized that a search for a “sliding sign” trans-abdominally could help guide general surgeons enter the abdomen in patients who had previous abdominal surgery. A patient with a history of previous hysterectomy and oophorectomy who subsequently required colectomy underwent sonographic evaluation for the sliding sign and the absence of the “sliding sign” changed the scheduling of the operative approach from a laparoscopic right colectomy to an open approach. We believe that ultrasonographic evaluation for the “sliding sign” should become standard for all patients with a previous history of abdominal surgery who are being considered for a minimally invasive approach. As ultrasonographic robes with bluetooth capabilities that interface with smart phones become more affordable, it is felt that ultrasonographic examinations could become part of the standard physical exam done by abdominal surgeons.

Pelvic floor myofascial pain in gynecology oncology patients: A pilot study

Objective: Here we present a pilot study investigating the prevalence of pelvic floor myofascial pain in patients presenting to an academic tertiary care gynecologic oncology clinic. We describe patients’ responses to a pain survey including the pain disability index. Methods: An IRB approved prospective survey and chart review was conducted. Patients underwent standard physical exam maneuvers for detection of pelvic floor myofascial pain. Consented patients completed a pain survey and pain disability index on presentation to clinic. Statistical analysis included Chi square test and Mann Whitney test. Results: Twenty-nine percent (45/155) of patients exhibited pelvic floor myofascial pain, while 71% (110/155) did not. Of those with malignancy, 28% (16/57) had pelvic floor myofascial pain and 72% (41/57) did not. Patients with pelvic floor myofascial pain had a significantly higher rating of “pain right now” ( p = 0.001) and “usual level of pain during the past week” ( p = 0.003) than those without such pain. Patients with pelvic floor myofascial pain had significantly greater disability in family/home responsibilities ( p = 0.01), recreation ( p = 0.001), social activity ( p = 0.008), occupation ( p = 0.015), sexual behavior ( p = 0.025), and life support activities ( p = 0.007) compared to those without pelvic floor myofascial pain. Conclusion: Pelvic floor myofascial pain affects 28% of patients with malignancy. Routine incorporation of a myofascial exam can identity those with such pain, which can lead to improved quality of life in gynecologic oncology patients with pelvic floor disorders.

Physical examination score predicts need for surgery in neonates with necrotizing enterocolitis.

To evaluate the utility of a standardized physical exam score (PE-NEC) in predicting need for surgery or death in neonates with necrotizing enterocolitis (NEC). This prospective, multicenter, observational study was conducted from 3/1/14 to 2/29/16 with three regional perinatal centers in upstate New York. Infants with NEC Bell's Stage ≥ 2 had physical exams and laboratory data recorded at 12-24 h intervals for 48 h following diagnosis. PE-NEC score was comprised of seven components: bowel sounds, capillary refill time, abdominal wall erythema, girth, discoloration, induration, and tenderness. Surgical timing was determined by surgeons blinded to the PE-NEC score. Optimal sensitivity and specificity of PE-NEC score for surgery/death (primary outcome) was determined by receiver operating characteristic curve analysis. Of 100 infants with NEC, 5 had pneumoperitoneum at diagnosis and were excluded yielding 95 for analyses. Of those, 35 infants experienced the primary outcome: 3 died from NEC prior to surgery and 32 had surgery (30 laparotomies, 2 drains). The PE-NEC score was found to be sensitive and specific for need for surgery/death (AUC = 0.89, 95% CI 0.82-0.97); a score of ≥3 had a sensitivity of 0.88 (95% CI 0.72-0.97), specificity of 0.81 (95% CI 0.69-0.90). All components of the PE-NEC score were more likely to be present among infants with surgical NEC or who died. PE-NEC score is sensitive and specific in predicting need for surgery in infants with NEC and should be validated as a clinical decision-making tool.

Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey

ObjectivesOur aim was to determine whether emergency physicians (EPs) felt their standard patient evaluation practice was modified by two non-private clinical encounters: hallway encounters and encounters during which a companion...

Safety of total hip arthroplasty for femoral neck fractures using the direct anterior approach: a retrospective observational study in 86 elderly patients.

BackgroundThe femoral neck fracture is one of the most common fractures in the elderly. A variety of methods and approaches are used to treat it. Total hip arthroplasty is a preferred approach in independent, mobile, elderly patients, given its more favorable long-term outcome.Our hypothesis is that the direct anterior approach in geriatric trauma patients has a lower dislocation-rate with the advantage of early recovery due to a muscle sparing approach and therefore early possible full weight-bearing.MethodsPatients were retrospectively sought who suffered a femoral neck fracture from 2008 to 2013. All patients were treated through a direct anterior approach and using the same brand of implants. Medical history, standardized physical exam, conventional pelvic plain and axial hip x-rays, Harris Hip Score, Merle D'Aubigné and Postel and SF-36 were assessed.ResultsEighty-six patients were included in the study with a mean age of seventy-five years. The mortality rate was 16.7 %. Complications were encountered in nineteen patients (22.0 %) who needed operative revision and one postoperative complication (1.2 %) which could be handled conservatively. There were five intraoperative complications (5.8 %), two dislocations (2.3 %), one aseptic loosening in a non-cemented stem (1.2 %), six periprosthetic fractures in non-cemented stems (6.9 %), one displacement of a non-cemented cup (1.2 %), two early infections (2.3 %) and three hematomas (3.5 %) recorded.ConclusionsAlthough the direct anterior approach is associated with a rather long learning curve we have found it to preserve the soft-tissues with no injury to abductors. It therefore shows an early advantage in elderly patients in terms of early recovery and therefore early possible full weight-bearing. Fracture treatment with dual mobility cups might lead to lower dislocation rates, but are associated with higher costs. Due to higher complication rates in non-cemented versus cemented shafts, we have changed our practice towards favoring cemented femoral stems in patients with suspected or manifest osteoporosis.

Proactive medicine: the "UCI 30," an ultrasound-based clinical initiative from the University of California, Irvine.

This article discusses the benefits of integrating point-of-care diagnostic ultrasound into the four-year medical school curriculum. Handheld ultrasound devices have been used to teach medical students at the University of California (UC), Irvine, since August 2010, and the article explains how the use of this inexpensive, safe, and noninvasive tool enhances the ability of a physician conducting a standard physical exam to confirm suspected findings and uncover other suspected pathology at a reasonable cost. The authors describe the ultrasound curriculum at UC Irvine and the process of its implementation. In the appendix to the article, the authors describe the specific diagnostic benefits of using a handheld ultrasound device for each element of the Stanford 25 physical exam. Their ultrasound-enhanced approach to the physical exam is referred to as the "UCI 30." They make recommendations for how and when to integrate ultrasound into the physical exam. The article points out that early training of medical students in the use of ultrasound can avoid the diagnostic problems of ultrasound by maximizing students' comfort and ability to obtain accurate ultrasound images for diagnostic and procedural purposes.

CARDIOVASCULAR SCREENING IN NCAA ATHLETES: FINDINGS FROM A MULTICENTER ECG-INCLUSIVE PROGRAM

BackgroundThe optimal pre-participation screening strategy in competitive athletes is debated.ObjectiveTo evaluate the accuracy of cardiovascular screening in NCAA athletes using a standardized history, physical exam (PE), and electrocardiogram (ECG).DesignProspective multi-center...

Generation iUltrasound: Bedside diagnostic imaging with Hand-Held Cardiac Ultrasound

In the early nineteenth century, an enquiring physician rolled up a notebook and placed it upon the chest of a young woman in order to hear her heart and understand its rhythmic beating more clearly. Thus began the teaching of a new approach to ‘les maladies cardiologiques’ [1]. Two-hundred years later this tube remains the cornerstone of the cardiac physical exam; an object evocative of our profession (Figs. 1, 2). As clinical educators, are we ready for a change in diagnostic technology? Whether we are or not, the availability of small, portable Hand-Held Cardiac Ultrasound (HHCU) devices portends a tidal change in diagnostic ability with important implications to the physical exam and point-of-care diagnosis (Fig. 3). We are now tasked with establishing the capabilities and limitations of these new medical devices in the hands of various users. Some consensus is emerging: studies have shown that these devices are a valuable tool for augmenting the diagnostic value of the standard physical exam and even novel learners can be taught to identify specific cardiac pathologies using HHCU [2–4]. However it is now clearly recognized that bedside examination with HHCU is not to be considered a substitute for a comprehensive or limited echocardiogram, and with the current technology these machines are only suited to performing focused cardiac ultrasound examinations, even when used by expert sonographers [5]. Within the practice of focused cardiac ultrasound, the image acquisition and interpretation skills of the user are the major factors determining the efficacy of these devices as a mechanism for improving the diagnostic power of a standard cardiac exam [6]. Further research into the development and implementation of HHCU training is warranted. The Cardiovascular Imaging Network at Queen’s (CINQ) has sought to gain experience in developing a critical framework for teaching HHCU skills in new learners. Our group is led by expert Level III trained echocardiographers with expertise in medical education. Our work has been presented at several conferences across Canada and the USA [2, 7] and we lead the Canadian National Working Group on HHCU Education. We recently advanced this work by conducting a preliminary study in 10 senior internal medical residents demonstrating that HHCU improved clinical management of patients in the Emergency Department and improved the confidence of these physicians in their assessment of patients referred for cardiology assessment [8]. Although this exciting preliminary work shows feasibility of a formal HHCU training program for residents, careful further study is required to investigate the optimal method of delivering this integrative skill. Acquisition of HHCU skill is becoming recognized as an emerging essential competency, however, currently medical residency has objectives set by the Royal College which do not incorporate these specific skills. Thus, additional training of this complex integrative skill requires recognition of the current time and resource constraints placed upon learners and educators. To address these challenges, we developed rich electronic modules in coordination with our Information Technology experts at Queen’s School of Medicine, and worked with our Simulation Laboratory to acquire and develop a state-of-the-art cardiac ultrasound simulation program. In addition to the lecture based curriculum developed by expert educators in our laboratory, we developed resources available for delivering HHCU programming in post-graduate training. We now intend to look at various combinations of these resources to determine the optimal method of delivering HHCU skill to internal medicine trainees during their busy residency. COMMENTARIES Cardiology Journal 2014, Vol. 21, No. 1, pp. 98–99 DOI: 10.5603/CJ.2014.0009 Copyright © 2014 Via Medica ISSN 1897–5593

FRI0349 Is interspinous bursitis the explanation of cervical and lumbar pain in polymyalgia rheumatica? a study with fdg-pet/ct.

BackgroundPolymyalgia rheumatica (PMR) is a common inflammatory disease of the elderly characterized by girdle pain and cervical and lumbar aching. Interspinous bursitis has been suggested as potential cause of the...

Ultrasonic Characterization of the Upper Trapezius Muscle in Patients with Chronic Neck Pain

Myofascial trigger points (MTrPs) are palpable, tender nodules in taut bands of skeletal muscle that are painful on compression. MTrPs are characteristic findings in myofascial pain syndrome (MPS). The role of MTrPs in the pathophysiology of MPS is unknown. Localization, diagnosis, and clinical outcome measures of painful MTrPs can be improved by objectively characterizing and quantitatively measuring their properties. The goal of this study was to evaluate whether ultrasound imaging and elastography can differentiate symptomatic (active) MTrPs from normal muscle. Patients with chronic (>3 months) neck pain with spontaneously painful, palpable (i.e., active) MTrPs and healthy volunteers without spontaneous pain (having palpably normal muscle tissue) were recruited for this study. The upper trapezius muscles in all subjects were imaged, and the echotexture was analyzed using entropy filtering of B-mode images. Vibration elastography was performed by vibrating the muscle externally at 100 Hz. Color Doppler variance imaging was used to quantify the regions of color deficit exhibiting low vibration amplitude. The imaging measures were compared against the clinical findings of a standardized physical exam. We found that sites with active MTrPs (n = 14) have significantly lower entropy (p < 0.05) and significantly larger nonvibrating regions (p < 0.05) during vibration elastography compared with normal, uninvolved muscle (n = 15). A combination of both entropy analysis and vibration elastography yielded 69% sensitivity and 81% specificity in discriminating active MTrPs from normal muscle. These results suggest that active MTrPs have more homogeneous texture and heterogeneous stiffness when compared with normal, unaffected muscle. Our methods enabled us to improve the imaging contrast between suspected MTrPs and surrounding muscle. Our results indicate that in subjects with chronic neck pain and active MTrPs, the abnormalities are not confined to discrete isolated nodules but instead affect the milieu of the muscle surrounding palpable MTrPs. With further refinement, ultrasound imaging can be a promising objective method for characterizing soft tissue abnormalities associated with active MTrPs and elucidating the role of MTrPs in the pathophysiology of MPS.