A novel device for the measurement of proprioception in the hand.

BACKGROUND: Together with visual information, awareness of limb position and movement is essential for limb coordination. A proprioceptive deficit has been demonstrated in a number of rheumatological disorders. There is a lack of a portable device for measuring hand proprioception in the field. METHODS: A compact portable device for measuring joint position sense in the metacarpophalangeal joint of the index finger of either hand was constructed. This device was manually operated and required the subject to match the position of the hidden finger with a surface-mounted silhouette. Reliability studies were performed over three consecutive days in 12 normal volunteers. RESULTS: Intrasubject variability [95% confidence interval (CI)] was 0.86 degrees (0.04-1.76) between days 1 and 2, and 1.23 degrees (1.04-3.50) between days 2 and 3. The intraclass correlation coefficient (95% CI) between all 3 days was 0.92 (0.85-0.96). Average proprioceptive error (95% CI) in the sample population was 5.72 degrees (1.23-10.2) over the 3 days. This value was 5.94 degrees , 5.79 degrees and 5.42 degrees on days 1, 2 and 3, respectively. No difference was found between sexes but dominant hands gave smaller errors (mean dominant error 5.11 degrees , mean non-dominant error 6.35 degrees ; t = -3.4, P = 0.002). CONCLUSIONS: This report describes a new portable device for measuring proprioception in the hand. Reproducibility was shown to be good on an individual and group basis. These results are promising and warrant larger age- and sex-related studies. The ease and portability of the device make it ideal for use in epidemiological studies of rheumatological disorders involving the hands, including joint hypermobility.

Scintigraphy versus manometry in patients with suspected biliary sphincter of Oddi dysfunction.

INTRODUCTION: Sphincter of Oddi (SO) manometry is at present the "gold standard" investigation for patients with suspected biliary SO dysfunction. Non-invasive scintigraphy in cholecystectomised patients using a complex scoring system or the transit time from the hepatic hilum to the duodenum (HDTT) have been promoted as sensitive and specific alternatives. AIM: To evaluate the scintigraphic scoring system and HDTT in patients with suspected biliary SO dysfunction undergoing SO manometry. METHODS: Cholecystectomised patients undergoing SO manometry for persistent biliary-type pain, as defined by the Rome II criteria, for which all other causes had been excluded, were prospectively studied. Scintigraphy with cholecystokinin octapeptide infusion was performed within a month prior to manometry. Scoring of the scans and measurement of HDTT was performed by independent blinded observers. Manometry of the biliary sphincter was performed per-endoscopically and defined as abnormal if basal pressure was > or = 40 mm Hg. RESULTS: Thirty two patients were enrolled (30 females, mean age 45.1 years). Three patients were excluded from analysis because manometry from the bile duct was not technically possible. Eight patients had abnormal manometry. Scintigraphic scoring had a sensitivity of 25-38%, a specificity of 86-89%, positive predictive value (PPV) of 40-60%, and a negative predictive value (NPV) of 75-79%. The coefficient of variation for interobserver variation in scores was 0.72. HDTT sensitivity was 13%, specificity 95%, PPV 50%, and NPV 74%. CONCLUSIONS: Our findings indicate that scintigraphy using these methods of analysis correlates poorly with manometry in post cholecystectomy patients with suspected biliary SO dysfunction.

99mTechnetium labelled leucocyte scanning in acute lower abdominal pain: can it reduce the negative appendectomy rate?

While the incidence of 'negative' appendectomy has long been justified as a necessary evil in the management of acute appendicitis, attempts to improve diagnostic accuracy have met with mixed results. In a prospective study of 34 selected patients who presented with acute lower abdominal pain the potential role of 99mTechnetium labelled leucocyte scanning in the diagnosis of acute appendicitis has been evaluated. Patient management was not based on the result of the nuclear scan. The clinical outcome was correlated with the scan diagnosis. There was one false positive and one false negative scan result with respect to the clinical diagnosis of appendicitis yielding a sensitivity of 90% and a specificity of 96%. 99mTechnetium labelled leucocyte scanning may have an important role in the assessment of selected patients presenting with acute lower abdominal pain.

Bone scan demonstration of progression of sacral insufficiency stress fracture.

This case documents the progression of a sacral insufficiency stress fracture, initially involving the lateral left ala and later extending across the body of the sacrum to the right ala. The 'H' shaped distribution of increased uptake on radionuclide bone scanning is characteristic of this type of fracture, although variations of this pattern are also seen according to the severity of the sacral trauma. While the differing bone scan patterns of this particular fracture type are well established, it is unusual to document the progression of this fracture on bone scan in any one patient.

Hepatic uptake of a bone scan agent (99mTc-MDP) in a patient with amyloidosis associated with plasma cell dyscrasia.

This case report describes diffuse hepatic uptake of a diphosphonate bone scan agent (Technetium-99m-MDP) in a patient with amyloidosis associated with a plasma cell dyscrasia. Amyloid infiltration is one of the more rare, but well recognized, causes of hepatic uptake of bone scan tracer. Other causes are also discussed in this case report.

Acalculous biliary pain: cholecystectomy alleviates symptoms in patients with abnormal cholescintigraphy.

A 45-minute infusion of an octapeptide of cholecystokinin (Kinevac; Squibb Diagnostics, New Brunswick, NJ) was used to measure the gallbladder ejection fraction during cholescintigraphy in 40 normal volunteers. Cholecystokinin cholescintigraphy was shown to be a reproducible test. The maximum mean gallbladder ejection fraction occurred 15 minutes after cholecystokinin infusion and was 74.5% +/- 1.9% (mean +/- SEM). A gallbladder ejection fraction greater than 40% (mean -3SD) was arbitrarily defined to be normal. The gallbladder ejection fraction test was then used to identify patients with acalculous biliary symptoms who may respond to cholecystectomy. A total of 103 patients was tested; 21 had abnormal gallbladder ejection fractions and were randomized into two groups, cholecystectomy or no operation. These patients were followed up symptomatically at 3-month intervals for 13-54 months (mean, 34 months). Of the 11 patients who underwent cholecystectomy, 10 (91%) lost their symptoms and 1 improved. Of the 10 patients in the group that did not undergo surgery, all continued to be symptomatic, 2 of whom requested cholecystectomy after 13 and 24 months, respectively. Of the 13 gallbladders obtained from surgery, 12 showed evidence of chronic cholecystitis, muscle hypertrophy, and/or narrowed cystic duct. A normal gallbladder ejection fraction was recorded in 82 patients, and further treatment was left to the discretion of their referring clinician. On follow-up, 50 patients were asymptomatic and 10 were symptomatic without specific treatment of the biliary tract; 14 underwent cholecystectomy, 8 of whom were asymptomatic. Pathological abnormalities were recorded in 6 of the removed gallbladders. It is concluded that the gallbladder ejection fraction obtained after a 45-minute infusion of cholecystokinin during cholescintigraphy is a reproducible measure of gallbladder emptying, and that cholecystectomy alleviates the biliary-type pain of patients with a reduced gallbladder ejection fraction.

The relative contributions of antithrombin III during heparin treatment, and of clinically recognisable risk factors, to early recurrence of venous thromboembolism.

The influence of antithrombin III (ATIII) level and ATIII activity, measured during intravenous heparin treatment for venous thromboembolism (VTE), on 'heparin requirement' (the heparin dose required to prolong the activated partial thromboplastin time (APTT) into its designated therapeutic range), and on the likelihood of recurrent VTE during the first month of anticoagulant therapy, were examined in a prospective study of 232 patients with VTE treated according to a standard protocol. 15 patients with recurrent VTE (6.5%) had a lower mean APTT during heparin treatment than patients without recurrence; a finding due partly to their heparin requirement. However, there was no measurable relationship between ATIII level or ATIII activity and either heparin requirement or recurrence of VTE. By contrast, both the presence of disseminated malignancy and the development of heparin induced thrombocytopenia were powerful, clinically recognisable, risk factors for recurrence during or soon after heparin therapy.

Thallium-201-technetium-99m subtraction scanning: its value in 50 cases of hyperparathyroidism submitted to surgery.

Parathyroid surgery was performed on 50 patients following thallium-technetium subtraction scanning. Parathyroid adenomata were correctly localized in 34 (83%). Of eight patients with hyperplastic glands, 15 (75%) of these glands were correctly localized. There were seven (17%) false negative scans and one (2%) false positive result. Thallium-technetium subtraction scanning is a valuable technique in the pre-operative assessment of patients with clinical evidence of hyperparathyroidism.

Safety and efficacy of warfarin started early after submassive venous thrombosis or pulmonary embolism.

Two anticoagulant regimens, similar except for the timing of warfarin therapy, were compared in patients with clinically submassive venous thromboembolism (VTE). Warfarin was begun after 7 days of continuous intravenous heparin infusion in group L (127 patients) or within 3 days (average 1 day) of starting heparin in group S (139 patients), with similar outcomes. The frequency of symptomatic VTE recurrence during the hospital stay was 4.7% in group L and 3.6% in group S, and that of symptomless new perfusion defects 8.5% in group L and 3.9% in group S. On routine iodine-125-fibrinogen leg scanning of patients presenting with distal thrombosis (in the calf, popliteal, or distal femoral veins) 3.6% of group S but no group L patients had symptomless proximal extension. The incidence of bleeding was similar with both regimens. Outpatient follow-up showed no excess recurrent VTE in either treatment group. Early warfarin treatment significantly shortened hospital stay by an average of 3.9 days (30%) in patients admitted solely because of VTE.

Gallbladder emptying in man related to fasting duodenal migrating motor contractions.

Animal studies have shown that the gallbladder (GB) empties partially during fasting in relation to phase II of the interdigestive motor cycle (IDMC). It has been assumed that in man the GB remains inert during fasting, although there have been no studies in which repeated sequential measurements of gallbladder volume have been made and related to the IDMC. In this study the possibility of linkage between the IDMC and GB volume has been examined in nine fasting human volunteers (five males/four females). A multilumen constantly perfused manometry catheter was positioned in the duodenum and motor activity recorded continuously. Phase III of the IDMC was characterized by phasic contractions, with a frequency of 10-12/min for at least 2 min, which had a distal propagative pattern and were followed by a motor quiescence (Phase I). GB volume was calculated at 15 min intervals from ultrasound measurements of the maximal length and diameter of the GB by the summation of cylinders method, and related to the time of onset of each phase III of the IDMC. In all nine subjects GB volume decreased prior to the onset of phase III and increased following its passage (P less than 0.01). GB volume decrease ranged between 6 and 56% of maximal GB volume (median 18%) and subsequent filling ranged from 14 to 53% (median 27%). The maximal volume decrease occurred 30 min prior to the onset of phase III (P less than 0.02). These studies have demonstrated that the human GB empties partially during phase II of the IDMC.(ABSTRACT TRUNCATED AT 250 WORDS)