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Pelvic Floor Diagnosis

A new vaginal speculum for pelvic organ prolapse quantification (POPQ).
Diokno AC, Borodulin G
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):384-8. Epub 2005 Jan 21.

The purposes of this study were to introduce a new vaginal speculum, describe the technique of using the new speculum in identifying and measuring the severity of pelvic organ prolapse (POP), and present results of a pilot study comparing the new speculum to the conventional instruments used in performing POP quantification (POPQ). The new speculum has retractable upper and lower blades marked in centimeters. POPQ was performed with one instrument using the new speculum and multiple instruments performing the conventional technique. Twenty-two patients underwent POPQ-11 using the new speculum and 11 using conventional instruments. The duration of the procedure and the level of discomfort were assessed. The POPQ method using the new speculum is described. Preliminary experience with the new speculum showed that the length of examination is significantly shorter (p<0.001) and the comfort level is better than with the conventional technique (p=0.088). A new vaginal speculum with adjustable blades simplifies POPQ. Preliminary testing suggests potential savings in procedure time and reduction in patient discomfort.

A Stoma Quality of Life Scale.
Baxter NN, Novotny PJ, Jacobson T, Maidl LJ, Sloan J, Young-Fadok TM
Dis Colon Rectum. 2006 Jan 6;.

PURPOSE: Few studies have evaluated the impact of a stoma on patient quality of life because of a lack of specific validated measures. This study documents the development and initial application of a Stoma Quality of Life Scale. METHODS: Content experts generated initial questions. Patient focus groups were conducted to ensure that the questions addressed all stoma-related issues considered important by patients. Responses from pilot groups allowed refinement to produce the final measure, the Stoma Quality of Life Scale, a 21-item questionnaire. Three scales are featured: Work/Social Function (6 items), Sexuality/Body Image (5 items), and Stoma Function (6 items). In addition, one item (scored separately) measures financial impact, one measures skin irritation, and two measure overall satisfaction. This questionnaire was administered to 100 consecutive ostomy patients, and readministered three weeks later. Reliability was assessed by using coefficient alpha for internal consistency and intraclass correlation coefficient for test-retest reproducibility. To test validity in extreme groups, scores were compared for patients with improved quality of life vs. those whose stoma worsened their quality of life. To evaluate convergent validity, we analyzed correlation of instrument scales with the SF12. RESULTS: The Stoma Quality of Life scales demonstrated adequate test-retest reproducibility (intraclass correlation coefficient >0.8) and acceptable internal consistency (coefficient alpha approximately 0.8). The scales were capable of discriminating between patients with better and worse quality of life after stoma formation (P < 0.02 for all scales). The Stoma Quality of Life scales significantly correlated (range, 0.12-0.75) with the Physical and Mental Health Composite Scale Scores of the SF-12. CONCLUSIONS: The Stoma Quality of Life Scale demonstrates reasonable psychometric properties for measuring quality of life in patients with stomas. Further studies are needed to refine the instrument.

Appearance of the levator ani muscle in pregnancy as assessed by 3-D MRI.
Boreham MK, Zaretsky MV, Corton MM, Alexander JM, McIntire DD, Twickler DM
Am J Obstet Gynecol 2005 Dec;193(6):2159-64.

OBJECTIVE: The purpose of this study was to describe levator ani (LA) anatomy in postterm nulliparas using 3-dimensional (3-D) magnetic resonance (MR). STUDY DESIGN: Nulliparas (n = 84) with uncomplicated, postterm pregnancies underwent an MR (4 mm slices, 0 gap) of the uterus and pelvis. LA volume and morphometry were assessed using 3-D post-processing software. RESULTS: LA insertion into the symphysis was visible in 93%, and the iliococcygeus muscle assumed a convex shape (arch) in the 92% of the 84 women. The LA shape was characterized as "U" in 53% and "V" in 47%. Mean LA volume was 13.5 (3.7) cm3. There was a positive association between LA volume and higher fetal station (P = .02) and increasing BMI (P < .001). However, no relationship between LA volume and station was found after adjusting for BMI. CONCLUSION: BMI was correlated with LA volume in postterm nulliparas. LA insertion into the symphysis and the iliococcygeus arch were well-preserved overall and morphometry was variable.

Ultrasonography, computed tomography and magnetic resonance imaging in the assessment of pelvic pathology.
Balan P
Eur J Radiol 2005 Nov 8;.

OBJECTIVE: Ultrasound (US) is the primary imaging modality in the investigation of pelvic pathology in women however it can be very inaccurate. MRI and CT provide a more detailed pelvic examination and hence we compared their accuracies with that of ultrasound to find out if these two modalities should be used more often. PATIENTS AND METHODS: 136 women who had MRI examination of the pelvis for investigation of probable pelvic pathology were studied. Hundred and twenty-five of these women had an initial ultrasound scan and 23 had an initial CT. Diagnostic accuracy was assessed against histopathology or clinical follow-up. RESULTS: Histopathology was available in 127/136 women. Overall 36% of the lesions were malignant. The overall accuracy of MRI, US and CT were 97%, 77% and 87%, respectively. MRI confidently identified the tissue of origin in 94% compared to only 66% for US. There was a significant difference in accuracy between MRI and US in diagnosing adnexal and uterine pathology. MRI was better than CT and US in diagnosing peritoneal metastases whereas CT was superior in diagnosing omental infiltration. CONCLUSION: We suggest that all women with a pelvic abnormality identified on US or in whom there is a strong clinical suspicion of disease should undergo MR pelvic imaging in preference to CT because of its better soft tissue resolution and multi-planar capability.

Assessment of pelvic floor movement using transabdominal and transperineal ultrasound.
Thompson JA, O'Sullivan PB, Briffa K, Neumann P, Court S
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):285-92. Epub 2005 Mar 22.

The aims of the study were (1) to assess the reliability of transabdominal (TA) and transperineal (TP) ultrasound during a pelvic floor muscle (PFM) contraction and Valsalva manoeuvre and (2) to compare TA ultrasound with TP ultrasound for predicting the direction and magnitude of bladder neck movement in a mixed subject population. A qualified sonographer assessed 120 women using both TA and TP ultrasound. Ten women were tested on two occasions for reliability. The reliability during PFM was excellent for both methods. TP ultrasound was more reliable than TA ultrasound during Valsalva. The percentage agreement between TA and TP ultrasound for assessing the direction of movement was 85% during PFM contraction, 100% during Valsalva. There were significant correlations between the magnitude of the measurements taken using TA and TP ultrasound and significant correlations with PFM strength assessed by digital palpation.

Effect of test position on pelvic floor muscle assessment.
Frawley HC, Galea MP, Phillips BA, Sherburn M, Bo K
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 5;:1-7.

The aims of this study were to analyse the effect of different body positions on pelvic floor muscle (PFM) assessment using digital muscle testing, manometry and transabdominal ultrasound. In addition, subject acceptance of each testing position was recorded. Subjects were 20 women's health physiotherapists. The testing protocol included the best of three maximum voluntary contractions tested in each of four positions (crook lying, supine, sitting and standing). Significant differences in muscle strength and subject acceptance between positions were found with each tool, most often between lying and upright positions. Digital muscle testing and vaginal squeeze-pressure scores were highest in the lying position, and vaginal resting pressure and transabdominal ultrasound scores were highest in the standing position. Subjects preferred the lying positions for internal examinations. The clinical significance of these differences and the reasons for these variations require further investigation.

CT images of abdomen and pelvis: effect of nonlinear three-dimensional optimized reconstruction algorithm on image quality and lesion characteristics.
Rizzo SM, Kalra MK, Schmidt B, Raupach R, Maher MM, Blake MA, Saini S
Radiology 2005 Oct;237(1):309-15.

The purpose of this study was to retrospectively assess the effect of a postprocessing nonlinear three-dimensional optimized reconstruction algorithm on image quality and lesion characteristics in abdominal and pelvic computed tomographic (CT) images. Institutional review board approved the HIPAA-compliant study protocol; informed consent was waived. Abdominal and pelvic CT images (40 patients; male-female ratio, 20:20; age range, 28-86 years) at 5-mm (n = 20) and 2-mm (n = 20) section thicknesses were postprocessed with the algorithm at three noise reduction levels. Image noise at the level of porta hepatis and acetabulum was evaluated with a five-point scale (1, no or minimal noise; 5, unacceptable noise), and presence and number of lesions and conspicuity were assessed. Statistical analysis was performed (Wilcoxon signed rank test, analysis of variance). Significant noise reduction was noted at all three levels with the algorithm (P < .05). Reduction in image contrast was noted with only one noise reduction level (P < .0001). The algorithm improves image noise without affecting lesion conspicuity and detection on low-dose abdominal and pelvic CT images.

Predictive value of prolapse symptoms: a large database study.
Tan JS, Lukacz ES, Menefee SA, Powell CR, Nager CW
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):203-9; discussion 209. Epub 2004 Oct 23.

We sought to describe the relationship between patient symptoms and pelvic organ prolapse (POP) and report the sensitivity, specificity, and positive and negative predictive value of these POP symptoms. Two urologists and four urogynecologists developed a standardized pelvic floor questionnaire based on face validation for use at three female pelvic floor disorder clinics. Specific questions related to prolapse included questions on urinary splinting, digital assistance for defecation, and a bulge per vagina. Prolapse was assessed with the standardized Pelvic Organ Prolapse Quantitative (POP-Q) terminology. The analysis included 1912 women. Urinary splinting was uncommon (< 10%) when Ba < 0, but ranged between 23 and 36% for stage III and IV Ba prolapse. Digital assistance was equally common in stage II Bp prolapse (21-38%) and stage III-IV Bp prolapse (26-29%). Only 6-11% of women with stage 0 or I POP reported symptoms of bulge, but with stage II it increased to 77%. Urinary splinting is 97% specific for anterior prolapse. The report of a bulge has an 81% positive predictive value and a 76% negative predictive value. Very few patients without anterior prolapse will report urinary splinting. Digital assistance for fecal evacuation is no more common with massive posterior prolapse than with moderate posterior prolapse. Patient report of a bulge is a valuable screening tool for POP and should prompt a careful exam.

The ability of history and a negative cough stress test to detect occult stress incontinence in patients undergoing surgical repair of advanced pelvic organ prolapse.
Kleeman S, Vassallo B, Segal J, Hungler M, Karram M
Int Urogynecol J Pelvic Floor Dysfunct 2005 Aug 11;.

To determine if a negative preoperative reduction cough stress test is a viable method of detecting occult stress incontinence or urge incontinence in women undergoing surgical repair of advanced pelvic organ prolapse. A retrospective chart review was done on all patients who denied any urinary complaints and had repair of advanced pelvic organ prolapse, grade two or greater, without the addition of an anti-incontinence procedure. Additionally patients had a simple office filling study done at the time of initial examination that failed to show the sign of stress incontinence or detrusor instability. Any urinary dysfunction that developed postoperatively was noted. A total of 53 patients met the inclusion criteria. Of these patients, one patient (1.9%) developed genuine stress incontinence, and one patient complained of urgency (1.9%). Patients without urinary complaints and a negative office filling study, who were present for surgical correction of advanced pelvic organ prolapse, have a low incidence of developing occult stress incontinence. Further work-up would not be cost effective.

Reevaluating occult incontinence.
Haessler AL, Lin LL, Ho MH, Betson LH, Bhatia NN
Curr Opin Obstet Gynecol 2005 Oct;17(5):535-40.

PURPOSE OF REVIEW: Occult incontinence is a controversial subject without significant exposure in the literature. Conventionally, it has been assumed to be a marker for increased risk of postoperative stress urinary incontinence (POSUI) after repair of pelvic organ prolapse. The controversy surrounds the performance of prophylactic incontinence procedures based on this assumption. Until 2004 no article in the English language had been published demonstrating an association between occult incontinence and increased risk of stress urinary incontinence after repair of severe pelvic organ prolapse in previously continent women. We will explore the evidence regarding occult incontinence, review the data on intervention trials, and address questions that remain. RECENT FINDINGS: The limited evidence suggests 11-22% of continent patients with severe pelvic organ prolapse will develop POSUI. New evidence suggests that patients with occult incontinence are at substantially more risk. Since anti-incontinence procedures in patients with occult incontinence reduces the incidence of POSUI (to 0-15%), there appears to be some benefit from screening and intervention. Most studies on the subject are small and limited by their design. Results differ regarding whether a negative stress test can be used to rule out the risk of POSUI. SUMMARY: Minimal existing evidence in the English language suggests that patients with occult incontinence are at increased risk of POSUI. Outcomes in occult incontinence patients undergoing repair of pelvic organ prolapse need systematic study. Until there is adequate solid evidence on the predictive values of our screening test, we cannot counsel patients regarding our ability to prevent POSUI or protect them from unnecessary procedures.

Effects of voluntary pelvic floor contraction and relaxation on the urethral closure pressure.
Baessler K, Miska K, Draths R, Schuessler B
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):187-90; discussion 190-1. Epub 2004 Sep 22.

The aim of this study was to assess the effects of voluntary pelvic floor contraction and voluntary pelvic floor relaxation on the urethral closure pressure at rest. In 104 consecutive women, three urethral pressure profiles were performed: standard profile at rest, with voluntary pelvic floor contraction and with voluntary pelvic floor relaxation. A low-pressure urethra was defined as a maximum urethral closure pressure of < or =20 cmH(2)O. The age ranged between 24 and 82 years. The maximum urethral closure pressure at rest was significantly augmented during pelvic floor contraction (mean: 18 cmH(2)O). Compared with the first profile, it decreased significantly with pelvic floor relaxation (mean decrement: 8 cmH(2)O). A low-pressure urethra was detected in 5 women during the first profile and in a further 11 during pelvic floor relaxation. Because of the significant influence of pelvic floor activity on the urethral closure pressure at rest, the scientific and clinical credibility of urethral pressure measurements remain questionable.

Dynamic magnetic resonance imaging of the pelvic floor in patients with idiopathic combined fecal and urinary incontinence.
Siegel C
J Urol 2005 Jul;174(1):220-1.

A randomized double-blinded,sham-controlled trial of postpartum extracorporeal magnetic innervation to restore pelvic muscle strength in primiparous patients.
Culligan P, Blackwell L, Murphy M, Ziegler C, Heit M.
Am J Obstet Gynecol 2005;192:1578-82.

OBJECTIVE: The purpose of this study was to determine the effects of extracorporeal magnetic innervation (ExMI) on pelvic muscle strength of primiparous patients. STUDY DESIGN: Primigravid patients were randomized to receive either active or sham ExMI postpartum treatments for 8 weeks. The main outcome measure was pelvic muscle strength measured by perineometry at baseline (midtrimester), 6 weeks (before treatments), 14 weeks, 6 months, and 12 months postpartum. Mixed randomized-repeated measures ANOVA was used to analyze the mean perineometry values between the 2 groups and across all 5 time periods. RESULTS: Fifty-one patients enrolled, and 18 were lost to attrition. There were no differences in demographics or delivery characteristics between the active and sham groups. There was an overall time effect, F(3,85) = 3.1, P = .049, but no group, F(1,31) = 0.007, P = .94, or (group)(time) interaction, F(3,85) = 1.8, P = .15. CONCLUSION: We found no differences in pelvic muscle strength between patients receiving active or sham ExMI treatments in the early postpartum period.

A comparison of perineometer to brink score for assessment of pelvic floor muscle strength.
Hundley AF, Wu JM, Visco AG.
Am J Obstet Gynecol 2005 May;192(5):1583-91.

The Brink scale is a commonly used digital assessment of pelvic floor muscle strength. The Peritron perineometer, a compressible vaginal insert that records pressure in centimeters of water, offers an objective method for this evaluation. This study evaluates the inter- and intrarater reliability of perineometry measurements and correlates those values with Brink scores. STUDY DESIGN: Subjects were prospectively enrolled and underwent pelvic floor muscle strength assessment by 2 examiners each using a perineometer and the Brink scale. Perineometer measurements of maximum pressure, average pressure, and total duration were recorded for 3 consecutive pelvic floor muscle contractions (Kegels). The Brink assessment was performed by placing 2 fingers vaginally during a single Kegel contraction. Brink scores consisted of 3 separate 4-point rating scales for pressure, vertical finger displacement, and duration. The order of the examiners and the 2 assessment methods were randomized, and each examiner was blinded to the results of the other. Pearson and Spearman correlation coefficients were used for analysis as appropriate. Repeated-measures analysis of variance was used to assess intrarater reliability between repeated perineometer measurements. RESULTS: One hundred women were consecutively enrolled and completed the study. Interrater reliability for the perineometer maximum squeeze pressure (r = 0.88) and baseline resting pressure (r = 0.78) was high. Maximum squeeze pressure correlation was unaffected by the presence or absence of estrogen (r = 0.89 versus r = 0.85), nulliparity versus parity (0.85 versus 0.88), or genital hiatus 4 or greater or less than 4 (r = 0.96 versus r = 0.86). Total Brink score and each individual submeasurement showed good correlations (total: r = 0.68; pressure: r = 0.68; displacement: r = 0.58; duration: r = 0.44). The correlation between maximum squeeze pressure and total Brink score during the first and second exams was good (r = 0.68 versus r = 0.71). For intrarater reliability, there were no significant differences among the 3 maximum squeeze pressures recorded during the first exam (P = .11), but for the second exam, the first squeeze was significantly stronger than the successive 2 (P = .009) attempts. CONCLUSION: Perineometer measurements of pelvic floor muscle contractions show very good inter- and intrarater reliability. The Brink total and pressure scores had a slightly lower interrater reliability. Variables such as estrogen status, parity, and genital hiatus did not appear to affect correlation. There was good correlation between the maximum perineometer pressure and the total Brink score, suggesting that these 2 methods of assessment have similar levels of reproducibility. Additionally, the perineometer demonstrated good short-term test-retest reliability.

Digital Rectal Examination is Barrier to Population-Based Prostate Cancer Screening.
Nagler HM, Gerber EW, Homel P, Wagner JR, Norton J, Lebovitch S, Phillips JL.
Urology 2005 May 25;.

OBJECTIVES: To determine whether use of the digital rectal examination (DRE) results in decreased participation in prostate cancer (PCa) screening, which, in turn, would result in lower detection. Population-based PCa screening includes prostate-specific antigen (PSA) measurement with or without a DRE. PSA and DRE screening provide greater sensitivity than PSA alone; however, the increased participation rate resulting from PSA-alone screening may result in a greater detection rate. METHODS: We performed a survey of 13,580 healthy men undergoing PSA-only population-based screening. In addition to the basic demographic information, the survey asked whether the participant would still be willing to participate in the screening if it included a DRE. We modeled the willingness to participate to assess the effect of PSA screening versus PSA and DRE screening on the basis of previously published data and our results. RESULTS: The results of our study indicated that only 78% of men would participate in screening that included both DRE and PSA. Thus, 7800 men of a theoretical population of 10,000 would participate in a screening that included both DRE and PSA. The positive screen rate (PSA >/= 4.0 ng/mL and/or abnormal DRE) would then have been 2013, with 472 PCa cases and 1540 negative biopsies. In the PSA-alone arm, all 10,000 men would have agreed to participate, and the positive screen rate (PSA >/= 4.0 ng/mL) would have been 1480, with 499 PCa cases and 980 negative biopsies. The PSA-alone arm would thus have detected 27 more cancers and performed 560 fewer negative biopsies. CONCLUSIONS: The results of our study have demonstrated that DRE is a significant barrier to participation in PCa screening. PSA plus DRE-based programs result in fewer cases of PCa detected, with a significant increase in negative biopsies. We, therefore, suggest that future mass screening efforts include only PSA determination and omit the DRE.

Diagnostic Imaging Costs: Are They Driving Up the Costs of Hospital Care?
Beinfeld MT, Gazelle GS
Radiology 2005 Apr 15;.

PURPOSE: To retrospectively determine how changes in utilization of computed tomography (CT), magnetic resonance (MR) imaging, and other imaging technologies between 1996 and 2002 influenced costs of inpatient hospital care at one large academic medical center. MATERIALS AND METHODS: Institutional review board did not require its approval or patient informed consent for studies with use of billing data. Patient anonymity was protected by removal of potentially identifying information. Data on hospital costs for 17 139 patients admitted to Massachusetts General Hospital, Boston, Mass, between 1996 and 2002 were downloaded from hospital cost-accounting system; sample was restricted to inpatients with diagnoses in diagnosis-related groups 014-015 (Stroke and TIA [transient ischemic attack]), 164-167 (Appendectomy), 082 (Lung Cancer), 182-183 (Upper Gastrointestinal Conditions), 148-149 (Colon Cancer), and 243 (Back Problems). For each patient, data on demographics, all products and services used, and costs associated with each product or service were obtained. By using institutional codes, we calculated costs of CT, MR imaging, and total imaging relative to total hospital costs. Statistical analyses were performed with Student t test and multiple linear regression analysis. RESULTS: Between 1996 and 2002, number of inpatient CT and MR images obtained at the hospital more than doubled. In 2002, hospital costs were 155% those of 1996 levels; inpatient imaging costs were 151% those of 1996 levels. Total costs increased an average of 7.8% per year; imaging costs increased 8.3% per year. Although highly variable over the study period, as a percentage of total imaging costs, CT and MR imaging costs appeared to remain stable relative to costs of other imaging modalities. CONCLUSION: Despite substantial increases in utilization of inpatient CT, MR imaging, and other imaging technologies, diagnostic imaging costs increased at approximately same rate as did total costs for inpatients with several diagnoses. CT and MR imaging do not appear to be driving the cost increases seen between 1996 and 2002. (c) RSNA, 2005.

Triphasic MRI of pelvic organ descent: sources of measurement error.
Morren GL, Balasingam AG, Wells JE, Hunter AM, Coates RH, Perry RE
Eur J Radiol 2005 May;54(2):276-83.

PURPOSE: To identify sources of error when measuring pelvic organ displacement during straining using triphasic dynamic magnetic resonance imaging (MRI). MATERIALS AND METHODS: Ten healthy nulliparous woman underwent triphasic dynamic 1.5T pelvic MRI twice with 1 week between studies. The bladder was filled with 200ml of a saline solution, the vagina and rectum were opacified with ultrasound gel. T2 weighted images in the sagittal plane were analysed twice by each of the two observers in a blinded fashion. Horizontal and vertical displacement of the bladder neck, bladder base, introitus vaginae, posterior fornix, cul-de sac, pouch of Douglas, anterior rectal wall, anorectal junction and change of the vaginal axis were measured eight times in each volunteer (two images, each read twice by two observers). Variance components were calculated for subject, observer, week, interactions of these three factors, and pure error. An overall standard error of measurement was calculated for a single observation by one observer on a film from one woman at one visit. RESULTS: For the majority of anatomical reference points, the range of displacements measured was wide and the overall measurement error was large. Intra-observer error and week-to-week variation within a subject were important sources of measurement error. CONCLUSION: Important sources of measurement error when using triphasic dynamic MRI to measure pelvic organ displacement during straining were identified. Recommendations to minimize those errors are made.

Pelvic floor muscle strength and thickness in continent and incontinent nulliparous pregnant women.
Morkved S, Salvesen KA, Bo K, Eik-Nes S
Int Urogynecol J Pelvic Floor Dysfunct 2004 Nov-Dec;15(6):384-9; discussion 390. Epub 2004 Jul 3.

The aim of the study was to measure pelvic floor muscle function in continent and incontinent nulliparous pregnant women. The study group consisted of 103 nulliparous pregnant women at 20 weeks of pregnancy. Women reporting urinary incontinence once per week or more during the previous month were classified as incontinent. Function was measured by vaginal squeeze pressure (muscle strength) and increment in thickness of the superficial pelvic floor muscles (urogenital diaphragm) assessed by perineal ultrasound. Seventy-one women were classified as continent and 32 women as incontinent. Continent women had statistically significantly higher maximal vaginal squeeze pressure and increment in muscle thickness when compared with incontinent women. There was a strong correlation between measurements of vaginal squeeze pressure and perineal ultrasound measurements of increment in muscle thickness. This study demonstrates statistically significant differences in pelvic floor muscle function measured by strength and thickness in continent compared with incontinent nulliparous pregnant women.

Assessment of pelvic floor movement using transabdominal and transperineal ultrasound.
Thompson JA, O'sullivan PB, Briffa K, Neumann P, Court S
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar 22;.

The aims of the study were (1) to assess the reliability of transabdominal (TA) and transperineal (TP) ultrasound during a pelvic floor muscle (PFM) contraction and Valsalva manoeuvre and (2) to compare TA ultrasound with TP ultrasound for predicting the direction and magnitude of bladder neck movement in a mixed subject population. A qualified sonographer assessed 120 women using both TA and TP ultrasound. Ten women were tested on two occasions for reliability. The reliability during PFM was excellent for both methods. TP ultrasound was more reliable than TA ultrasound during Valsalva. The percentage agreement between TA and TP ultrasound for assessing the direction of movement was 85% during PFM contraction, 100% during Valsalva. There were significant correlations between the magnitude of the measurements taken using TA and TP ultrasound and significant correlations with PFM strength assessed by digital palpation.

A ruler for interpreting diagnostic test results.
Hellmich M, Lehmacher W
Methods Inf Med 2005;44(1):124-6.

OBJECTIVES: Bayes' rule formalizes how the pre-test probability of having a condition of interest is changed by a diagnostic test result to yield the post-test probability of having the condition. To simplify this calculation a geometric solution in form of a ruler is presented. METHODS: Using odds and the likelihood ratio of a test result in favor of having the condition of interest, Bayes' rule can succinctly be expressed as "the posttest odds equals the pre-test odds times the likelihood ratio". Taking logarithms of both sides yields an additive equation. RESULTS: The additive log odds equation can easily be solved geometrically. We propose a ruler made of two scales to be adjusted laterally. A different, widely used solution in form of a nomogram was published by Fagan. CONCLUSIONS: Whilst use of the nomogram seems more obvious, the ruler may be easier to operate in clinical practice since no straight edge is needed for precise reading. Moreover, the ruler yields more intuitive results because it shows the change in probability due to a given test result on the same scale.

Telemedical wound care using a new generation of mobile telephones: a feasibility study.
Braun RP, Vecchietti JL, Thomas L, Prins C, French LE, Gewirtzman AJ, Saurat JH, Salomon D
Arch Dermatol 2005 Feb;141(2):254-8.

BACKGROUND: Leg ulcers are an important cost factor in health care systems. It has been shown that a telemedical wound care consultation can improve quality of care and help reduce costs. In this study, we evaluated the feasibility of telemedical wound care using a new generation of mobile telephones with integrated cameras. OBSERVATIONS: Three physicians separately evaluated 61 leg ulcers for the following 9 variables: epithelialization, fibrin, necrosis, and granulation tissue at the center and normal border, erythema, cyanosis, eczema, and hyperpigmentation at the periphery. One physician performed the face-to-face consultation (gold standard), and 2 others performed the remote evaluation. The image was obtained with the mobile telephone and immediately sent via e-mail. To measure the agreement of the evaluation among the 3 physicians, we used Cohen kappa statistics. Overall, the agreement between the remote and face-to-face evaluations was very good, with kappa values of up to 0.94 The image quality was judged to be good in 36 cases (59%) and very good in 12 (20%). The participants felt comfortable making a diagnosis based on the pictures in 50 cases (82%). CONCLUSION: Although this study was performed with the first generation of these devices, we were able to demonstrate the feasibility of such a telemedical wound care consultation.

MR techniques for in vivo molecular and cellular imaging.
Delikatny EJ, Poptani H
Radiol Clin North Am 2005 Jan;43(1):205-20.

MR-based molecular imaging is a science in infancy. Current clinical contrast agents are often geared toward the assessment of gross physiologic function, rather than targeting specific biochemical pathways. The development of specific targeted smart contrast agents for Food and Drug Administration approval or clinical trials has only begun. The fact that MR imaging can obtain images of extremely high resolution, coupled with its ability to simultaneously assess structure and function through the use of targeted contrast agents indicates that MR will play a pivotal role in clinical molecular imaging of the future. Many of the challenges that face MR imaging and spectroscopy are inherent to all modalities in the rapidly growing field of molecular imaging. The development of smart contrast agents to report on receptor function, and to monitor gene expression or the results of gene therapy in humans is paramount. These compounds need to undergo rigorous testing to be approved for clinical use: the assessment of acute toxicity, pharmacokinetics, long-term accumulation, and subsequent chronic effects. For receptor-targeted contrast agents, the degree of receptor occupancy and the intrinsic agonist or antagonist properties of the probe that may affect normal cellular function need to be determined to avoid undesired side effects. The particular problems that face MR imaging, those of sensitivity and target specificity, need to be overcome. Signal amplification achieved through high relaxivity contrast agents containing multiple paramagnetic centers, or of larger superparamagnetic particles, is the first step in this direction. The modulation of relaxivity through oligomerization, or other modifications that cause restriction of rotational motions, shows great promise for improving the discriminative powers of MR imaging, and may permit multiple targets to be assessed simultaneously. Moreover, the introduction of smart indicators that lead to changes in spectroscopic properties will allow further discrimination to be achieved through the implementation of chemical shift or spectroscopic imaging. The growing number of MR imaging applications in this rapidly expanding field point to a bright future for MR imaging in molecular imaging.