Exuberant sprouting of sensory and sympathetic nerve fibers in nonhealed bone fractures and the generation and maintenance of chronic skeletal pain

Skeletal injury is a leading cause of chronic pain and long-term disability worldwide. While most acute skeletal pain can be effectively managed with nonsteroidal anti-inflammatory drugs and opiates, chronic skeletal pain is more difficult to control using these same therapy regimens. One possibility as to why chronic skeletal pain is more difficult to manage over time is that there may be nerve sprouting in nonhealed areas of the skeleton that normally receive little (mineralized bone) to no (articular cartilage) innervation. If such ectopic sprouting did occur, it could result in normally nonnoxious loading of the skeleton being perceived as noxious and/or the generation of a neuropathic pain state. To explore this possibility, a mouse model of skeletal pain was generated by inducing a closed fracture of the femur. Examined animals had comminuted fractures and did not fully heal even at 90+days post fracture. In all mice with nonhealed fractures, exuberant sensory and sympathetic nerve sprouting, an increase in the density of nerve fibers, and the formation of neuroma-like structures near the fracture site were observed. Additionally, all of these animals exhibited significant pain behaviors upon palpation of the nonhealed fracture site. In contrast, sprouting of sensory and sympathetic nerve fibers or significant palpation-induced pain behaviors was never observed in naïve animals. Understanding what drives this ectopic nerve sprouting and the role it plays in skeletal pain may allow a better understanding and treatment of this currently difficult-to-control pain state.

The impact of digital cervical examination on expectantly managed preterm rupture of membranes

OBJECTIVE

The purpose of this study was to examine the effects of digital cervical examination on maternal and neonatal outcomes among women with preterm rupture of membranes.

STUDY DESIGN

This analysis includes data from a previously reported trial of antibiotic treatment during expectant management of rupture of membranes at 24 to 32 weeks' gestation in singleton and twin gestations. Patients from both the randomized trial (n = 299 in the antibiotic group and n = 312 in the placebo group) and the observational component (n = 183) are included in this analysis. The groups were divided into those with one (n = 161) or two digital cervical examinations (n = 27) and those with no digital cervical examinations (n = 606).

RESULTS

The gestational ages at enrollment were similar in the two groups (29 +/- 2 weeks' gestation for one or two examinations vs 29 +/- 2 weeks' gestation for no examinations; P =.85). There were no differences in chorioamnionitis (27% vs 29%; P =.69), endometritis (13% vs 11%; P =.5), or wound infection (0.5% vs 1%; P >.999) between the group with one or two examinations and the no-examination group. Infant outcomes were also similar in the two groups, including early sepsis (6% vs 5%; P =.68), respiratory distress syndrome (51% vs 45%; P =.18), intraventricular hemorrhage (7% vs 7%; P =.67), necrotizing enterocolitis (5% vs 3%; P =.19), and perinatal death (7% vs 5%; P =.45). A composite outcome made up of these neonatal outcomes was not different (56% vs 48%; P =.10) between the group with one or two examinations and the no-examination group. The time from rupture to delivery was shorter in the digital examination group (median value, 3 vs 5 days; P <. 009). Multivariable analysis to adjust for antibiotic study group, group B streptococcal culture status, race, and maternal transfer did not modify these results.

CONCLUSION

Performance of one or two digital cervical examinations during the course of expectant management of rupture of membranes between 24 and 32 weeks' gestation was associated with shorter latency but did not appear to worsen either maternal or neonatal outcome.

Referred pain elicited by palpation and by needling of myofascial trigger points: a comparison

OBJECTIVE

To investigate the occurrence of referred pain (ReP) elicited by palpation (Pal-ReP) or by needle injection (Inj-ReP) of myofascial trigger point (MTrP), and to assess the correlated factors, including the pain intensity of an active MTrP and the occurrence of local twitch response (LTR).

DESIGN

Correlational study.

PATIENTS

Ninety-five patients who were treated with MTrP injections.

INTERVENTION

MTrP injections.

MAIN OUTCOME MEASURE

Pain intensity of MTrP and occurrence of Pal-ReP, Inj-ReP, and LTR.

RESULTS

Both Pal-ReP and Inj-ReP were elicited in 53.9% of MTrPs, Inj-ReP, but not Pal-ReP, was elicited in 33.7% of MTrPs. Both Pal-ReP and Inj-ReP were unobtainable in 12.3% of MTrPs. The occurrence of ReP was significantly correlated to the pain intensity of active MTrP and the occurrence of LTR.

CONCLUSION

ReP could be elicited more frequently by needling than by palpation. The frequency of occurrence in ReP mainly depends on pain intensity of an active MTrP.

Transvaginal sonographic measurement of cervical length vs. Bishop score in labor induction at term: tolerability and prediction of Cesarean delivery

OBJECTIVES

To compare transvaginal sonography for cervical length measurement and digital examination for Bishop score assessment in women undergoing labor induction at term, to assess their tolerability (in terms of pain) and ability to predict need for Cesarean delivery.

METHODS

A prospective study was performed on 249 women admitted for labor induction. Cervical length was measured using transvaginal ultrasound examination. A 10-point visual analog scale (VAS) for procedure-related pain was obtained. Bishop score was determined just before labor induction and another pain score was obtained. Delivery outcome was recorded. Analyses were by t-test, Fisher's exact test, receiver-operating characteristics (ROC) curves and multivariate logistic regression.

RESULTS

Transvaginal sonography was significantly less painful than digital examination for Bishop score assessment (mean difference in VAS score 3.46; P<0.001). Analyses of the ROC curves for cervical length and Bishop score indicated that both were predictors of Cesarean delivery (area under the curve 0.611 vs. 0.607; P=0.012 vs. P=0.015, respectively) with optimal cut-offs for predicting Cesarean delivery of >20 mm for cervical length and Bishop score<or=5. Cervical length had superior sensitivity (80% vs. 64%) and marginally better positive (30% vs. 27%) and negative (89% vs. 83%) predictive values. Multivariate logistic regression analysis revealed that only nulliparity (adjusted odds ratio (AOR) 4.1; 95% CI, 2.1-8.1; P<0.001) and transvaginal sonographic cervical length>20 mm (AOR 3.4; 95% CI, 1.4-8.1; P=0.006) were independent predictors of Cesarean delivery.

CONCLUSIONS

Transvaginal sonography for cervical length measurement is better tolerated than digital examination for Bishop score assessment. Both cervical length and Bishop score are useful predictors of the need for Cesarean delivery following labor induction. A cervical length>20 mm at labor induction at term is an independent predictor of Cesarean delivery.

Ultrasound versus 'clinical touch' for catheter guidance during embryo transfer in women

BACKGROUND

Many women undergoing an Assisted Reproductive Technology (ART) cycle will not achieve a live birth. Failure at the embryo transfer stage may be due to lack of good quality embryo/s, lack of uterine receptivity, or the transfer technique itself. Numerous methods, including the use of ultrasound guidance for proper catheter placement in the endometrial cavity, have been suggested as a more effective technique of embryo transfer. This review evaluates the effectiveness of ultrasound guided embryo transfer (UGET) compared with 'clinical touch' (CTET) the traditional method of embryo transfer.

OBJECTIVES

To determine whether ultrasound guidance influences treatment outcomes in women undergoing embryo transfer (ET) during assisted reproductive technology (ART) cycles.

SEARCH STRATEGY

Electronic databases were searched in November 2009. We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched November 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2009), MEDLINE (1970-2009), EMBASE (1985-2009), BIO Extracts (1980-2009). Relevant conference proceedings were also hand searched (ASRM, ESHRE and FIGO).

SELECTION CRITERIA

Only randomised controlled trials were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and quality of trials and extracted data from those selected.

MAIN RESULTS

This update identified 59 potential trials of which 42 were excluded. Data for analysis was available in seventeen studies. One study reported live births and personal communication resulted in data relating to this outcome being obtained in two additional studies. There is no evidence of a significant difference in the outcome of live birth (OR 1.14 (95%CI0.93 to 1.39; P=0.02) although heterogeneity was high (64%) and the results should be interpreted with caution. Seven studies reported on ongoing pregnancies. The ongoing pregnancies per woman randomised associated with UGET (441/1254) was significantly higher than for clinical touch (350/1218) OR 1.38, 95%CI 1.16 to 1.64, P<0.0003). No statistically significant differences in the incidence of adverse events were identified between the comparison groups. These events are relatively rare and sample sizes limit the ability to detect such differences.

AUTHORS' CONCLUSIONS

The studies are limited by their quality with only two studies reporting details of both computerised randomisation techniques and adequate allocation concealment. Ultrasound guidance does appear to improve the chances of live/ongoing and clinical pregnancies compared with clinical touch methods. The quality of future studies should be improved with adequate reporting of randomisation, allocation concealment, and power calculations. The primary outcome measure of future studies should be the reporting of live births per woman randomised.

Changes in physical examination caused by use of spinal immobilization

The standard of care for patients following blunt trauma includes midline palpation of vertebrae to rule out fractures. Previous studies have demonstrated that spinal immobilization does cause discomfort.

OBJECTIVE

To determine whether spinal immobilization causes changes in physical exam findings over time.

METHODS

This was a single-blinded, prospective study at a tertiary care university teaching hospital. Twenty healthy volunteers without previous back pain or injuries, 13 male and seven female, were fully immobilized for one hour, with a cervical collar and strapped to a long wooden backboard. Midline palpation of vertebrae to illicit pain was performed at 10-minute intervals. In addition, the participants were asked to rate neck and back pain on a scale from 1 to 10 (1 for no pain, and 10 for unbearable pain), to see whether subjective pain from immobilization correlated with tenderness to palpation.

RESULTS

Three patients had point tenderness of cervical vertebrae within 40 minutes. Five patients developed point tenderness of vertebrae by 60 minutes. Eighteen of 20 participants complained of increasing discomfort over time. The median initial pain scale was 1 (range 1-1), in contrast to 4 (range 1-9) at 60 minutes, p < 0.05.

CONCLUSION

This study shows that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness. In order to reduce this high false-positive rate for midline vertebral tenderness, the authors recommend that, initially on arrival to the emergency department, immediate evaluation occur of all immobilized patients. Furthermore, backboards should be modified to reduce patient discomfort to prevent the iatrogenically induced midline vertebral tenderness, thereby reducing subsequent false-positive examinations.

Palpation thyroiditis (multifocal granulomatour folliculitis)

Disseminated inflammatory lesions constituting a multifocal granulomatous folliculitis in the thyroid are described. These lesions were present in the majority (greater than 83%) of thyroids removed surgically because of thyroid or nonthyroid (carcinoma of the larynx) disease. They also were found at autopsy in patients who died while hospitalized but not in those who died at home. An identical lesion was produced experimentally in dogs by vigorously squeezing their thyroids. The human folliculitis is believed to result from traumatic injury or rupture of isolated thyroid follicles caused by palpation of the gland (palpation thyroiditis). Palpation thyroiditis may have little, if any, clinical importance. The remote possibility that it might be associated with iatrogenically produced metastasis of thyroid carcinoma is being investigated.

Inadvertent spread of cancer at surgery

Surgical cure requires that a given cancer be removed without inadvertent spillage of cancer cells by technical error. Potential mishaps include pressing a ligature, while tying, against a protruding tumor and cutting into it; inserting a hemostat into the tumor area to gain control of an escaped short pancreaticoduodenal artery stump which has retracted; grasping a lymph node with forceps which invariably fragments it spilling any cancer cells it may contain; and injecting local anesthesia into or adjacent to a lesion for biopsy. If the lesion is a cutaneous melanoma or other cancer the resulting pressure may force cancer cells into the lymphatic or bloodstream. Other misadventures include touching that portion of a biopsy needle which has been in the tumor and doing an intraoperative biopsy which allows blood or tissue fluid to flow out the opening from the tumor. Sensitivity to such dangers appears essential to avoiding spillage of cancer cells and obtaining maximal benefit from surgery.

Plasma cortisol response in dairy cows to vaginoscopy, genital palpation per rectum and artificial insemination

Response of plasma cortisol concentrations after vaginoscopic examination, palpation of the genital organs per rectum and artificial insemination were investigated in six Holstein-Friesian cows weighing between 510 to 620 kg. Blood samples were collected by indwelling jugular catheter. The experiment was begun at 09:00 hours on the day when cows came into estrus. Blood samples were collected from 30 minutes before to 60 minutes after each treatment at intervals of 5 to 10 minutes. Cows were initially blood-sampled for 90 minutes at the same intervals without giving any treatment and then were subjected to vaginoscopy for 1.5 minutes, palpation of the uterus and ovaries per rectum for 4 minutes and artificial insemination by the recto-vaginal method for 5 minutes. No significant increase in plasma cortisol was shown in cows in estrus following vaginoscopy. Palpation per rectum as well as artificial insemination caused a significant increase in plasma cortisol (P < 0.01) 5 to 10 minutes after the initiation of treatments in cows in estrus. There was a tendency for cows in the luteal phase to show higher plasma cortisol levels after the vaginoscopy than cows in estrus. Adrenal response to palpation per rectum in cows in the luteal phase was similar to that in cows in estrus. Thus, in cows in estrus, palpation per rectum as well as artificial insemination may be potential stressors for cows, causing an increase in plasma cortisol levels. However, the pathophysiological importance of the rise in plasma cortisol levels is not known.

Pregnancy attrition associated with pregnancy testing by rectal palpation

The objective of this study was to estimate the effect on calving risk of interval from AI date until scheduled date of pregnancy examination. First AI (n = 7105) from 65 dairy herds in the United States and Canada were followed for 294 d to determine whether cows calved. Calving was modeled as a function of the number of days in the interval, herd, season, and breeding at PGF2 alpha-induced estrus by multivariate logistic regression. The main effects of herd and AI following PGF2 alpha-induced estrus were significantly associated with calving rate from first AI. The main effects of interval and season were not significantly associated with calving.

Ultrasound versus 'clinical touch' for catheter guidance during embryo transfer in women

BACKGROUND

Many women undergoing an assisted reproductive technology (ART) cycle will not achieve a live birth. Failure at the embryo transfer stage may be due to lack of good-quality embryo/s, lack of uterine receptivity, or the transfer technique itself. Numerous methods, including the use of ultrasound guidance for proper catheter placement in the endometrial cavity, have been suggested as more effective techniques of embryo transfer. This review evaluates the efficacy of ultrasound-guided embryo transfer (UGET) compared with 'clinical touch' (CTET), which is the traditional method of embryo transfer and relies on the clinician's tactile senses to judge when the transfer catheter is in the correct position.

OBJECTIVES

To determine whether ultrasound guidance compared with clinical touch improves pregnancy outcomes in women undergoing embryo transfer during ART cycles.

SEARCH METHODS

For the 2016 update of this review, we ran updated searches in the Cochrane Gynaecology and Fertility Group trials register (May 2015), the Cochrane Central Register of Controlled Trials (the Cochrane Library, May 2015), MEDLINE (2009 to May 2015), and EMBASE (2009 to May 2015). We also handsearched relevant conference proceedings: American Society for Reproductive Medicine (ASRM), European Society for Human Reproduction and Embryology (ESHRE), and International Federation of Gynecology and Obstetrics (FIGO). There were no language restrictions.

SELECTION CRITERIA

We included only randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and quality of trials and extracted data from those selected. We calculated odds ratio (OR) and 95% confidence interval (CI) for dichotomous outcomes. No outcomes were reported using continuous data. We assessed the overall quality of the evidence for the main findings using the GRADE working group methods.

MAIN RESULTS

This systematic review now has 21 included studies (four of which we added in the 2016 update), two studies awaiting assessment, and 47 excluded studies. In total, data for meta-analyses were available in 21 trials (n = 6218 women), of which only four reported live births.UGET was associated with an increased chance of a live birth/ongoing pregnancy compared with CTET (OR 1.47, 95% CI 1.30 to 1.65; 13 trials; n = 5859 women; I(2) = 74%; low-quality evidence). Sensitivity analysis by including only trials with low risk of selection bias or by using a random-effects model did not alter the effect. We estimate that for women with a chance of a live birth/ongoing pregnancy of 23% using CTET, this would increase to between 28% and 33% using UGET. We considered the quality of the evidence using GRADE methodology to be low.UGET was associated with an increase in the chance of a clinical pregnancy (OR 1.31, 95% CI 1.17 to 1.45; 20 trials; n = 6711 women; I(2) = 42%; moderate-quality evidence). We identified no differences between groups for the incidence of adverse events including multiple pregnancy, ectopic pregnancy, or miscarriage. These events were relatively rare, and sample sizes limited the ability to detect such differences.

AUTHORS' CONCLUSIONS

The evidence suggests ultrasound guidance improves the chance of live birth/ongoing and clinical pregnancies compared with clinical touch, without increasing the chance of multiple pregnancy, ectopic pregnancy, or miscarriage. Methodological limitations included: only four studies reporting details of both computerised randomisation techniques and adequate allocation concealment, only four studies reported on the outcome of live birth, and none of the nine studies that reported on ongoing pregnancy reported on live birth, suggesting possible reporting bias. Adequate reporting of randomisation and allocation concealment will improve the quality of future studies. The primary outcome measure of future studies should be the reporting of live births per woman randomised.

Epidemiological investigations of an outbreak of intestinal atresia in two Israeli dairy herds

An epidemiological investigation of an outbreak of intestinal atresia in Israeli Holstein-Friesian newborn calves showed a linkage with rectal palpation for early pregnancy diagnosis, performed less than 42 days after insemination. The odds of an exposed calf, i.e., one born to a dam that was diagnosed by early palpation as having intestinal atresia were 119.7 times higher than one born in normal control herds (95% CI; 7.4-1946.3). A total of 682 calves-at-risk was recorded from mid-1998 to mid-2000 and a total of 47 calves (6.9%) were born with intestinal atresia during this period. Two forms of intestinal atresia were recognized at post-mortem: atresia coli and atresia ilei.

Serum thyroglobulin levels after fine-needle aspiration of thyroid nodules

OBJECTIVE

To investigate whether a minor insult to the thyroid gland attributable to fine-needle aspiration (FNA) or external thyroid palpation can cause a release of serum thyroglobulin (Tg) into the circulation.

METHODS

We determined serum Tg levels before and at 60 minutes and 15 days after FNA in 25 patients with thyroid nodules. Results were compared with those obtained in 25 patients with thyroid nodules, in whom serum Tg concentrations were determined before and 60 minutes after palpation of the thyroid, and in 15 healthy subjects without thyroid disease, who had no thyroid palpation and no FNA, from whom 2 blood specimens were obtained 60 minutes apart. All participants had normal results of thyroid function tests and no detectable antithyroglobulin or thyroid peroxidase antibodies.

RESULTS

After FNA, 22 of 25 patients had significant elevation of serum Tg concentrations. The Tg levels returned to baseline values 15 days after FNA. In 4 of the 25 patients with thyroid nodules who had palpation of the thyroid, a significant increase in serum Tg levels was elicited. None of the 15 healthy subjects with normal thyroid glands (and with no FNA or thyroid palpation) had significant Tg elevations.

CONCLUSION

FNA causes a significant increase in serum Tg concentrations, which may persist for 15 days. Therefore, Tg assay should not be scheduled prematurely after FNA.

Histopathologic study of the so called 'palpation thyroiditis'

We have reviewed 1066 thyroid lesions and compared the relative incidence of the so called 'palpation thyroiditis' between autoimmune thyroiditis and normal thyroid parenchyme surrounding the nodular thyroid lesion and also discussed the pathogenesis of palpation thyroiditis. The typical histopathologic features of 'palpation thyroiditis' were seen in 275 cases among 467 adenomatous goiters and in none of the autoimmune thyroiditis. We here in this paper suggest that the so called 'palpation thyroiditis' is not merely a secondary phenomenon to mechanical follicular damage by vigorous palpation, but this lesion more likely develops in conditions where certain types of physiologic alteration has occurred in follicular basement membrane, just like a pathogenesis of subacute granulomatous thyroiditis.

Management of rectal tears

Rectal tears have important medicolegal implications, and severe tears have a poor prognosis. Prompt diagnosis, immediate application of first aid measures, early referral, use of appropriate definitive treatments, and aggressive aftercare will improve the prognosis. The grade of rectal injury will determine the definitive treatment, but there are few guidelines to determine which treatment is best in each case. Bypass procedures, such as colostomy and indwelling rectal liner, have their own advantages and disadvantages, but can facilitate healing and prevent life-threatening complications if they are used with minimum delay. Suture of the tear can be difficult, but should be attempted to hasten healing and to prevent progression of the tear to a more severe injury.

Relevance of carcass palpation in lambs to protecting public health

We recently reviewed the Food Safety and Inspection Service's (FSIS's) inspection procedures for lambs. As a result, FSIS published a Federal Register notice informing the public of its intent to change from an inspection system that requires extensive carcass palpation to an inspection system that requires no carcass palpation for lambs. This decision was based on the following three points. (i) Extensive carcass palpation in lambs does not routinely aid in the detection of food safety hazards that result in meat-borne illnesses. (ii) Hands are capable of spreading or adding contamination to the carcasses. (iii) FSIS inspection systems must reflect science-based decisions as they pertain to meat-borne illnesses consistent with a Pathogen Reduction/Hazard Analysis and Critical Control Point environment.

Effect of student transrectal palpation on early pregnancy loss in dairy cattle

Transrectal palpation of the reproductive tract is the most common method for pregnancy determination in cattle and is considered a veterinary skill that new veterinary medicine (DVM) graduates should perform proficiently. However, using privately owned cattle to train students can be difficult because producers may believe that transrectal palpation by inexperienced students increases the risk of pregnancy wastage compared with examination by an experienced clinician. We used a randomized field trial of 1,216 healthy Holstein and Jersey cattle in 2 commercial dairy herds to estimate the effect of veterinary student transrectal palpation on early pregnancy loss. All cattle were determined to be pregnant using transrectal ultrasonography at approximately 37 d after artificial insemination. Cattle were then allocated into 2 groups based upon their ear tag number (study group = 598; control group = 618). Cattle in the study group were immediately palpated after ultrasonography by a fourth-year veterinary student, whereas control cattle were not subject to any additional pregnancy assessment. For analysis, the student palpators were divided into 2 groups: students who had previously had formal palpation training via an elective bovine palpation class (n = 30) and students who had not had palpation training (n = 134). All cattle were reevaluated using transrectal ultrasonography approximately 70 d after artificial insemination. A total of 53 (4.36%) animals lost their pregnancy between the first and second pregnancy assessments. Of the animals that lost their pregnancy, 26 (4.35%) were study group cows and 27 (4.37%) were control cows. Of the 26 cows documented to have had pregnancy loss within the study group, 20 out of 378 (5.3%) had been palpated by students who had not taken the palpation elective and 6 out of 220 (2.7%) had been palpated by students who had completed the elective. We found no difference in pregnancy loss between student-palpated and clinician-ultrasounded cattle, supporting the safety of using privately owned animals for student bovine palpation and pregnancy diagnosis training without affecting early pregnancy loss.