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The Korean Journal of Gastroenterology... Feb 2019Constipation is a common functional problem of the digestive system and may occur secondary to diet, drugs, endocrine diseases, metabolic diseases, neurological... (Review)
Review
Constipation is a common functional problem of the digestive system and may occur secondary to diet, drugs, endocrine diseases, metabolic diseases, neurological diseases, psychiatric disorders, or gastrointestinal obstruction. When there is no secondary cause, constipation is diagnosed as functional constipation. The first steps that should be taken to relieve symptoms are diet and lifestyle modifications, and if unsuccessful, laxative therapy should be initiated. If a patient does not respond to laxative therapy, diagnostic anorectal physiological tests are performed, though they are not routinely recommended. However, these tests may be considered earlier in patients strongly suspected to have a defecatory disorder. The revised guideline on the diagnosis and treatment of chronic constipation will undoubtedly aid the individualized management of chronic constipation in clinical practice.
Topics: Biofeedback, Psychology; Chronic Disease; Constipation; Diet; Digital Rectal Examination; Humans; Laxatives; Life Style; Serotonin 5-HT4 Receptor Agonists
PubMed: 30845385
DOI: 10.4166/kjg.2019.73.2.92 -
Advances in Therapy Sep 2018Prostate cancer is a common malignancy seen worldwide. The incidence has risen in recent decades, mainly fuelled by more widespread use of prostate-specific antigen... (Review)
Review
Prostate cancer is a common malignancy seen worldwide. The incidence has risen in recent decades, mainly fuelled by more widespread use of prostate-specific antigen (PSA) testing, although prostate cancer mortality rates have remained relatively static over that time period. A man's risk of prostate cancer is affected by his age and family history of the disease. Men with prostate cancer generally present symptomatically in primary care settings, although some diagnoses are made in asymptomatic men undergoing opportunistic PSA screening. Symptoms traditionally thought to correlate with prostate cancer include lower urinary tract symptoms (LUTS), such as nocturia and poor urinary stream, erectile dysfunction and visible haematuria. However, there is significant crossover in symptoms between prostate cancer and benign conditions affecting the prostate such as benign prostatic hypertrophy (BPH) and prostatitis, making it very challenging to distinguish between them on the basis of symptoms. The evidence for the performance of PSA in asymptomatic and symptomatic men for the diagnosis of prostate cancer is equivocal. PSA is subject to false positive and false negative results, affecting its clinical utility as a standalone test. Clinicians need to counsel men about the risks and benefits of PSA testing to inform their decision-making. Digital rectal examination (DRE) by primary care clinicians has some evidence to show discrimination between benign and malignant conditions affecting the prostate. Patients referred to secondary care for diagnostic testing for prostate cancer will typically undergo a transrectal or transperineal biopsy, where a number of samples are taken and sent for histological examination. These biopsies are invasive procedures with side effects and a risk of infection and sepsis, and alternative tests such as multiparametric magnetic resonance imaging (mpMRI) are currently being trialled for their accuracy and safety in diagnosing clinically significant prostate cancer.
Topics: Age Factors; Biopsy; Digital Rectal Examination; Genetic Predisposition to Disease; Humans; Incidence; Lower Urinary Tract Symptoms; Magnetic Resonance Imaging; Male; Primary Health Care; Prostate-Specific Antigen; Prostatic Neoplasms; Risk Factors
PubMed: 30097885
DOI: 10.1007/s12325-018-0766-1 -
The Turkish Journal of Gastroenterology... Mar 2023About one-third of chronically constipated patients have an evacuation disorder, and dyssynergic defecation is a common cause of the evacuation disorder. In dyssynergic... (Review)
Review
About one-third of chronically constipated patients have an evacuation disorder, and dyssynergic defecation is a common cause of the evacuation disorder. In dyssynergic defecation, the coordination between abdominal and pelvic floor muscles during defecation is disrupted and patients cannot produce a normal bowel movement. The etiology of dyssynergic defecation is still unknown. Although a detailed history taking and a careful examination including digital rectal examination could be useful, other modalities such as anorectal manometry and balloon expulsion test are necessary for the diagnosis. Biofeedback therapy is one of the most effective and safe treatments. Here, we provide an overview of dyssynergic defecation as well as how to diagnose and manage this condition.
Topics: Humans; Defecation; Constipation; Manometry; Anal Canal; Biofeedback, Psychology; Digital Rectal Examination; Ataxia
PubMed: 36919830
DOI: 10.5152/tjg.2023.22148 -
European Urology Dec 2018Urologists regularly develop clinical risk prediction models to support clinical decisions. In contrast to traditional performance measures, decision curve analysis... (Review)
Review
CONTEXT
Urologists regularly develop clinical risk prediction models to support clinical decisions. In contrast to traditional performance measures, decision curve analysis (DCA) can assess the utility of models for decision making. DCA plots net benefit (NB) at a range of clinically reasonable risk thresholds.
OBJECTIVE
To provide recommendations on interpreting and reporting DCA when evaluating prediction models.
EVIDENCE ACQUISITION
We informally reviewed the urological literature to determine investigators' understanding of DCA. To illustrate, we use data from 3616 patients to develop risk models for high-grade prostate cancer (n=313, 9%) to decide who should undergo a biopsy. The baseline model includes prostate-specific antigen and digital rectal examination; the extended model adds two predictors based on transrectal ultrasound (TRUS).
EVIDENCE SYNTHESIS
We explain risk thresholds, NB, default strategies (treat all, treat no one), and test tradeoff. To use DCA, first determine whether a model is superior to all other strategies across the range of reasonable risk thresholds. If so, that model appears to improve decisions irrespective of threshold. Second, consider if there are important extra costs to using the model. If so, obtain the test tradeoff to check whether the increase in NB versus the best other strategy is worth the additional cost. In our case study, addition of TRUS improved NB by 0.0114, equivalent to 1.1 more detected high-grade prostate cancers per 100 patients. Hence, adding TRUS would be worthwhile if we accept subjecting 88 patients to TRUS to find one additional high-grade prostate cancer or, alternatively, subjecting 10 patients to TRUS to avoid one unnecessary biopsy.
CONCLUSIONS
The proposed guidelines can help researchers understand DCA and improve application and reporting.
PATIENT SUMMARY
Decision curve analysis can identify risk models that can help us make better clinical decisions. We illustrate appropriate reporting and interpretation of decision curve analysis.
Topics: Attitude of Health Personnel; Biopsy; Clinical Decision-Making; Comprehension; Decision Support Techniques; Digital Rectal Examination; Health Knowledge, Attitudes, Practice; Humans; Kallikreins; Male; Neoplasm Grading; Patient Selection; Predictive Value of Tests; Prostate-Specific Antigen; Prostatic Neoplasms; Risk Assessment; Risk Factors; Ultrasonography; Urologists; Urology
PubMed: 30241973
DOI: 10.1016/j.eururo.2018.08.038 -
British Journal of Anaesthesia Apr 2019Caudal epidural blockade in children is one of the most widely administered techniques of regional anaesthesia. Recent clinical studies have answered major... (Review)
Review
Caudal epidural blockade in children is one of the most widely administered techniques of regional anaesthesia. Recent clinical studies have answered major pharmacodynamic and pharmacokinetic questions, thus providing the scientific background for safe and effective blocks in daily clinical practice and demonstrating that patient selection can be expanded to range from extreme preterm births up to 50 kg of body weight. This narrative review discusses the main findings in the current literature with regard to patient selection (sub-umbilical vs mid-abdominal indications, contraindications, low-risk patients with spinal anomalies); anatomical considerations (access problems, age and body positioning, palpation for needle insertion); technical considerations (verification of needle position by ultrasound vs landmarks vs 'whoosh' or 'swoosh' testing); training and equipment requirements (learning curve, needle types, risk of tissue spreading); complications and safety (paediatric regional anaesthesia, caudal blocks); local anaesthetics (bupivacaine vs ropivacaine, risk of toxicity in children, management of toxic events); adjuvant drugs (clonidine, dexmedetomidine, opioids, ketamine); volume dosing (dermatomal reach, cranial rebound); caudally accessed lumbar or thoracic anaesthesia (contamination risk, verifying catheter placement); and postoperative pain. Caudal blocks are an efficient way to offer perioperative analgesia for painful sub-umbilical interventions. Performed on sedated children, they enable not only early ambulation, but also periprocedural haemodynamic stability and spontaneous breathing in patient groups at maximum risk of a difficult airway. These are important advantages over general anaesthesia, notably in preterm babies and in children with cardiopulmonary co-morbidities. Compared with other techniques of regional anaesthesia, a case for caudal blocks can still be made.
Topics: Anesthesia, Caudal; Anesthesiology; Anesthetics, Local; Auscultation; Child; Contraindications, Procedure; Education, Medical, Graduate; Epidural Space; Humans; Pain, Postoperative; Palpation; Ultrasonography, Interventional
PubMed: 30857607
DOI: 10.1016/j.bja.2018.11.030 -
Pain Physician Jul 2018Although sacroiliac joint dysfunction (SIJD) is generally regarded as a source of lumbar pain, its anatomical position and the absence of a diagnostic 'gold standard'...
BACKGROUND
Although sacroiliac joint dysfunction (SIJD) is generally regarded as a source of lumbar pain, its anatomical position and the absence of a diagnostic 'gold standard' lead to difficulties at examination and differential diagnosis. However, since sacroiliac (SI) joint blocks only provide information about pathologies of joint origin and since SIJD developing secondary to pathologies in structures around the joint can be missed. Provocation and palpation tests also need to be used in diagnosis.
OBJECTIVES
The purpose of this study was to examine the reliability of clinical examination and provocation tests used in the diagnosis of SIJD.
STUDY DESIGN
Retrospective analysis of prospectively collected data.
SETTING
Outpatient physical medicine and rehabilitation clinic.
METHODS
One hundred and seventeen patients presenting with lumbar and/or leg pain and diagnosed with SIJD through clinical evaluation were included in the study. Range of lumbar joint movement, pain location and specific tests used in the diagnosis of SIJD were evaluated. Positivity in 3 out of 6 provocation tests was adopted as the criterion.
RESULTS
75.2% of patients were female and 24.8% were male. Mean age was 46.41 ± 10.45 years. A higher level of females was determined in ender distribution. SIJD was determined on the right in 52.6% of patients and on the left in 47.4%. When SI joint provocation tests were analyzed individually, the highest positivity, in 91.4% patients diagnosed with SIJD, was in the FABER test. The lowest positivity, in 56.4% of patients, was determined in the Ganslen test. The same patients were assessed by the same clinician at 2 different times. In these data, the simple consistence, kappa and PABAK coefficient values of all tests were close to 1 and indicating good agreement. The thigh thrust (POSH) and sacral thrust tests exhibited very good agreement with a kappa coefficient of 0.90 and a PABAK coefficient of 0.92, while the FABER test exhibited good agreement with a kappa coefficient of 0.78 and a PABAK coefficient of 0.92.
LIMITATION
Agreement between different observers was not evaluated, and also no comparison was performed with SI joint injection, regarded as a widely used diagnostic technique.
CONCLUSION
The anatomical position of the SI joint and the lack of a diagnostic 'gold standard' make the examination and diagnosis of SIJD difficult. Most SI joint clinical tests have limited reliability and validity on their own, while a multitest regimen consisting of SI joint pain provocation tests is a reliable method, and these tests can be used instead of unnecessary invasive diagnostic SI joint procedures.
KEY WORDS
Dysfunction, lumbar, sacroiliac joint, provocation test, sacroiliac joint pain, pain pattern.
Topics: Adult; Diagnosis, Differential; Female; Humans; Low Back Pain; Male; Middle Aged; Neurologic Examination; Pain Measurement; Palpation; Reproducibility of Results; Retrospective Studies; Sacroiliac Joint
PubMed: 30045603
DOI: No ID Found -
American Journal of Obstetrics and... Nov 2018Myofascial pain is characterized by the presence of trigger points, tenderness to palpation, and local or referred pain, and commonly involves the pelvic floor muscles...
BACKGROUND
Myofascial pain is characterized by the presence of trigger points, tenderness to palpation, and local or referred pain, and commonly involves the pelvic floor muscles in men and women. Pelvic floor myofascial pain in the absence of local or referred pain has also been observed in patients with lower urinary tract symptoms, and we have found that many patients report an improvement in these symptoms after receiving myofascial-targeted pelvic floor physical therapy.
OBJECTIVE
We sought to systematically review the literature for examination techniques used to assess pelvic floor myofascial pain in women.
STUDY DESIGN
We performed a systematic literature search using strategies for the concepts of pelvic floor disorders, myofascial pain, and diagnosis in Ovid MEDLINE 1946-, Embase 1947-, Scopus 1960-, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Cochrane Database of Systematic Reviews. Articles were screened by 3 authors and included if they contained a description of a pelvic myofascial physical examination.
RESULTS
In all, 55 studies met our inclusion criteria. Overall, examination components varied significantly among the included studies and were frequently undefined. A consensus examination guideline was developed based on the available data and includes use of a single digit (62%, 34/55) to perform transvaginal palpation (75%, 41/55) of the levator ani (87%, 48/55) and obturator internus (45%, 25/55) muscles with a patient-reported scale to assess the level of pain to palpation (51%, 28/55).
CONCLUSION
Physical examination methods to evaluate pelvic musculature for presence of myofascial pain varied significantly and were often undefined. Given the known role of pelvic floor myofascial pain in chronic pelvic pain and link between pelvic floor myofascial pain and lower urinary tract symptoms, physicians should be trained to evaluate for pelvic floor myofascial pain as part of their physical examination in patients presenting with these symptoms. Therefore, the development and standardization of a reliable and reproducible examination is needed.
Topics: Female; Humans; MEDLINE; Myofascial Pain Syndromes; Pain Measurement; Palpation; Pelvic Floor; Physical Examination; Urologic Diseases
PubMed: 29959930
DOI: 10.1016/j.ajog.2018.06.014 -
Annals of Family Medicine Mar 2018Although the digital rectal examination (DRE) is commonly performed to screen for prostate cancer, there is limited data to support its use in primary care. This review... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Although the digital rectal examination (DRE) is commonly performed to screen for prostate cancer, there is limited data to support its use in primary care. This review and meta-analysis aims to evaluate the diagnostic accuracy of DRE in screening for prostate cancer in primary care settings.
METHODS
We searched MEDLINE, Embase, DARE (Database of Abstracts of Reviews of Effects), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) from their inception to June 2016. Six reviewers, in pairs, independently screened citations for eligibility and extracted data. Pooled estimates were calculated for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DRE in primary care settings using an inverse-variance meta-analysis. We used QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) and GRADE (Grades of Recommendation Assessment, Development, and Evaluation) guidelines to assess study risk of bias and quality.
RESULTS
Our search yielded 8,217 studies, of which 7 studies with 9,241 patients were included after the screening process. All patients analyzed underwent both DRE and biopsy. Pooled sensitivity of DRE performed by primary care clinicians was 0.51 (95% CI, 0.36-0.67; I = 98.4%) and pooled specificity was 0.59 (95% CI, 0.41-0.76; I = 99.4%). Pooled PPV was 0.41 (95% CI, 0.31-0.52; I = 97.2%), and pooled NPV was 0.64 (95% CI, 0.58-0.70; I = 95.0%). The quality of evidence as assessed with GRADE was very low.
CONCLUSION
Given the considerable lack of evidence supporting its efficacy, we recommend against routine performance of DRE to screen for prostate cancer in the primary care setting.
Topics: Digital Rectal Examination; Early Detection of Cancer; Humans; Male; Primary Health Care; Prostatic Neoplasms
PubMed: 29531107
DOI: 10.1370/afm.2205