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Thread: Neovascularity Pictures - Atlas of Colon and Ileum

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    Default Neovascularity Pictures - Atlas of Colon and Ileum

    Study design
    The study design was a case series designed to investigate the prevalence of neovascularity in the rotator cuff and subacromial bursa in people with a clinical diagnosis of unilateral rotator cuff tendinopathy.

    Ethics
    Permission to conduct this study was granted by the Wandsworth Research Ethics Committee, St George's University of London, London, UK. Research Ethics Committee reference number: 07/Q0803/1. All subjects signed witnessed informed consent documents and were aware of all their rights, including the right to withdraw from the study at any stage of the investigation.

    Setting and data collection
    The investigation took place in a dedicated diagnostic ultrasound clinic in a major acute NHS (National Health Service) teaching hospital in London, UK. Data collection took place from July 2007 to March 2009.

    Participants
    Potential participants included people aged between 30 to 75 years with a diagnosis of unilateral shoulder pain who were referred to the radiological department by their physical therapist, orthopaedic surgeon or general medical practitioner with a special interest in musculoskeletal disorders for a routine diagnostic ultrasound scan of the rotator cuff.

    Inclusion/exclusion criteria
    Inclusion criteria for the participants were; (i) unilateral shoulder pain, exacerbated during movement located in the C4/C5 dermatome, (ii) age range between 30 to 75 years, (iii) pain experienced on flexion and/or abduction, (iv) pain experienced during the Neer Sign and/or Hawkin's Test, (v) pain on resisted abduction and/or resisted external rotation and or during the 'full cans' test and/or the 'empty cans' test, and (vi) passive shoulder range to be greater than active range. The exclusion criteria were; (i) the reproduction of shoulder pain during physiological cervical spine movements, (ii) a history of shoulder subluxations and/or dislocations, (iii) an injection to the shoulder in the past 12 months, (iv) physiotherapy, osteopathic or chiropractic treatment to the shoulder within the past 12 months, (v) recent or previous shoulder girdle fractures, (vi) open wounds or skin infections in the region of the shoulder, and (vii) concurrent involvement in another research investigation.

    Procedure
    Potential participants who were being routinely referred for a diagnostic ultrasound scan of the rotator cuff were informed of the investigation and if interested in learning more were provided with a participant information document by their referring physical therapist, orthopaedic surgeon or general medical practitioner. In addition, potential participants were encouraged to discuss possible participation with family, friends, healthcare workers and if so wished with the chief investigator. The design ensured that those wishing and those not wishing to participate, and those fulfilling and not fulfilling the inclusion criteria would receive their scans at the same time point following referral. Those wishing to participate or discuss participation in more detail met with the chief investigator prior to the ultrasound scan. On the day of the scan, at approximately one hour before the ultrasound scan was performed, the participant met with the chief investigator to discuss the study and answer any further questions. Any potential participant not wanting to participate would proceed directly to have their scans. Those agreeing to participate signed witnessed informed consent documents. Following this, the chief investigator performed a routine clinical investigation involving; impingement tests, shoulder range of movement, shoulder resisted movement tests and cervical screening procedures, principally to ensure compliance with the inclusion and exclusion criteria on the day of the ultrasound scan. In addition to this each participant provided routine demographic information and completed the Oxford Shoulder Score

    Clinical tests and functional measurements
    The following are descriptions and interpretations of the clinical procedures used to include and exclude the potential participants.
    Neovascularity Pictures Atlas Colon Ileum attachment.php?s=f65872b16db938e2ca9dc93af859b1ca&attachmentid=2044&d=1442167180

    Neer Sign
    The patient is seated and the examiner standing. Scapular movement is restricted by one of the examiners hands firmly placed on the scapula. The examiners other hand forces the patient's arm into shoulder elevation (described as somewhere between flexion and abduction). A positive response was pain around the acromion during this manoeuvre.

    Hawkin's test
    Hawkins and Kennedy described a test that involves flexion of the humerus to 90° and forcibly internally rotating the shoulder. A positive response was pain around the acromion during this manoeuvre.

    Resisted abduction 30°
    Liu et al reported that the peak abduction moment for the supraspinatus tendon occurs at 30° of abduction. A positive clinical response to an isometric contraction at this point in the range was pain under or lateral to the acromion.

    'Full can' and 'empty can' test
    Jobe and Jobe described a supraspinatus test where the arm is placed at 90° of abduction in neutral rotation (full can) and resistance to elevation is applied. The shoulder is then internally rotated and angled forwards by 30° so that the thumb faces the floor (empty can) and resistance to elevation is repeated. Increased pain or increased pain and weakness during the 'empty can' test was positive.

    Shoulder active and passive range of movement
    Shoulder flexion (assessed in the sagittal plane performed with the thumb facing upwards) and abduction (assessed in the plane of the scapula with the thumb facing upwards) range were measured actively in both shoulders and passively (only in the symptomatic shoulder), in standing. Active movement was measured at the first point of pain and passive movement, was assessed at the end range of movement or at the point an increase of pain did not allow any further movement. Active range was measured using a gravity dependent inclinometer as has been described previously Passive range was not measured with the inclinometer but was recorded as equal, less than or more than the active range.

    Cervical screening procedure
    No clinical test has been documented that conclusively substantiates the relationship between cervical structures and shoulder symptoms. In an attempt to exclude cervical referred shoulder pain, each subject was requested to actively flex, extend and rotate the cervical spine to the left and right to the end of their available range to determine if these movements reproduced the individuals shoulder pain. If symptoms were produced in the shoulder the participant would be excluded.

    Oxford Shoulder Score
    The Oxford Shoulder Score is a validated 12 question shoulder disability completed independently by the individual, with a score ranging from 0 to 48, where 0 represents maximal disability and 48 no disability

    Ultrasound procedure
    Ultrasound of both shoulders was performed using a Philips HDI 5000 sono CT (Philips Medical Systems, Surrey, UK) with the patient sitting upright and the examiner scanning from the front. A linear high frequency probe (5-12 MHz) was used with the musculoskeletal shoulder setting preset with the room darkened to enhance monitor visualization. The ultrasound scan was performed using a standard protocol beginning with examination of biceps tendon in transverse and longitudinal planes with the patient's forearm or hand resting in a supinated position on thigh. Following this the acromioclavicular joint was assessed in the same position. The subscapularis tendon was then examined with the patients arm externally rotated. Imaging of supraspinatus tendon was performed by asking the patient to place the hand in the back pocket area with the palm facing toward the gluteal muscles while keeping the elbow directed posteriorly. The supraspinatus tendon was examined in the transverse and longitudinal planes. Vascularity was then assessed in both planes with power Doppler optimized for low flow imaging and a pulse repetition frequency of 700 MHz. The posterior glenohumeral joint, infraspinatus and teres minor were examined with patient's arm across the chest with the hand placed on the opposite shoulder.

    Blinding of the interpretation of the ultrasound scans
    To reduce knowledge of the side of symptoms as a source of bias, a third radiologist who was not present at the time of the ultrasound investigation, and was therefore blinded to the clinical symptoms and side of shoulder pain, assessed the images for the presence of grey scale changes and neovascularity. The third radiologist was provided with the hospital identification number of the participants and the ultrasound studies were then reviewed on hospitals digital imaging system without reference to any clinical details. The anonymization was performed by disabling any clinical information (i.e. request form or reports) available on the electronic patient archiving and communication system information window.

    After the third radiologist completed the blinded assessment of the ultrasound scans his findings were compared with the initial reports. It was planned that any uncertainties would be resolved by consensus between the third radiologist and the two involved in the scanning. This arbitration process was not required. There was good consensus between the three radiologists in detecting and/or scoring neovascularisation. This has been reflected in other studies. Sengkerij et al demonstrated excellent inter-observer reliability when scoring neovascularisation in the mid portion of the Achilles tendon
    Neovascularity Pictures Atlas Colon Ileum attachment.php?s=f65872b16db938e2ca9dc93af859b1ca&attachmentid=2045&d=1442167191

    Grey scale ultrasound appearances of tendinopathy include swelling of affected tendon and abnormal tendon echotexture with a heterogeneous hypoechoic appearance. Tendon swelling is interpreted as focal or more often diffuse increase in tendon thickness. In the case of the supraspinatus, a difference in tendon thickness of 1.5 to 2.5 mm between the affected and unaffected side or an absolute thickness of more than 8 mm is thought to indicate tendinopathy. The abnormal echotexture represent subtle fibrillar tears and area of mucoid degeneration interspersed with reparative process in tendon substance. A partial thickness tear is diagnosed on ultrasound when a true defect or cleft within the tendon substance is detected in both longitudinal and transverse planes. A full thickness tear extends from the bursal to articular surface and associated with other indirect signs. We devised a simple grading system to describe the amount of neovascularity identified. Grade 0, no neovascularity; Grade I, mild neovascularity with no recognisable vessels; Grade II, identifiable vessels involving less than 50% of the area imaged; and, Grade III, identifiable prominent vessels involving more than 50% of the area imaged. In addition to the grade, the location of any observed neovascularity was also recorded. A positive correlation exists between tendinopathy and neovascularisation However, the exact significance of this correlation is yet to be determined.

    Statistical methods
    Associations between neovascularity and (i) pain and (ii) the Oxford Shoulder Score were tested. Fisher's Exact test was used to test the association with dichotomous measures. For continuous measures Wilcoxon's test was used. All tests were two-tailed and statistical significance was set at p = 0.05.

    Sample size calculation
    There was a conceptual assumption that the prevalence of neovascularity would be 0% in the shoulders without symptoms. This was based on previously published research. We estimated a prevalence of 30% for the presence of neovascularity in people with symptomatic shoulders with a clinical diagnosis of rotator cuff tendinopathy. Based upon this hypothesis it was estimated that 20 subjects with unilateral shoulder symptoms would have a 58% power to show statistical significance.

    References:
    BMC Musculoskeletal Disorders | Full text | The prevalence of neovascularity in patients clinically diagnosed with rotator cuff tendinopathy











    Last edited by Medical Photos; 09-13-2015 at 05:59 PM.

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