Diversity of current ultrasound practice within and outside radiology departments with a vision for 20 years into the future: a position paper of the ESR ultrasound subcommittee

Ultrasound practice is a longstanding tradition for radiology departments, being part of the family of imaging techniques. Ultrasound is widely practiced by non-radiologists but becoming less popular within radiology. The position of ultrasound in radiology is reviewed, and a possible long-term solution to manage radiologist expectations is proposed. An international group of experts in the practice of ultrasound was invited to describe the current organisation of ultrasound within the radiology departments in their own countries and comment on the interaction with non-radiologists and training arrangements. Issues related to regulation, non-medical practitioners, and training principles are detailed. A consensus view was sought from the experts regarding the position of ultrasound within radiology, with the vision of the best scenario for the continuing dominance of radiologists practising ultrasound. Comments were collated from nine different countries. Variable levels of training, practice, and interaction with non-radiologist were reported, with some countries relying on non-physician input to manage the service. All experts recognised there was a diminished desire to practice ultrasound by radiologists. Models varied from practising solely ultrasound and no other imaging techniques to radiology departments being central to the practice of ultrasound by radiologists and non-radiologist, housed within radiology. The consensus view was that the model favoured in select hospitals in Germany would be the most likely setup for ultrasound radiologist to develop and maintain practice. The vision for 20 years hence is for a central ultrasound section within radiology, headed by a trained expert radiologist, with non-radiologist using the facilities.Critical relevance statement The future of ultrasound within the radiology department should encompass all ultrasound users, with radiologists expert in ultrasound, managing the ultrasound section within the radiology department. The current radiology trainees must learn of the importance of ultrasound as a component of the 'holistic' imaging of the patient.Key points: 1. Ultrasound imaging within radiology departments precedes the introduction of CT and MR imaging and was first used over 50 years ago.2. Non-radiology practitioners deploy ultrasound examinations to either 'problem solve' or perform a comprehensive ultrasound examination; radiologists provide comprehensive examinations or use ultrasound to direct interventional procedures.3. Radiology does not 'own' ultrasound, but radiologists are best placed to offer a comprehensive patient-focused imaging assessment.4. A vision of the future of ultrasound within the radiology department is encompassing all ultrasound users under radiologists who are experts in ultrasound, positioned within the radiology department.5. The current radiology trainee must be aware of the importance of ultrasound as a component of the 'holistic' imaging of the patient.

Intraoral and transcutaneous point-of-care-ultrasound: an adjunct bedside tool for oral and maxillofacial clinicians

Point-of-care-ultrasound (PoCUS) is performed by the clinician at the patient's bedside and is an essential diagnostic tool in many medical subspecialties, in hospital-based care, emergencies, trauma, and in general practice. A simple, novel approach for implementation of PoCUS of the oral cavity and maxillofacial complex is introduced. Relevant indications include differentiating abscess from cellulitis, detecting jaw and facial fractures, assessment of surgical complications, removing foreign bodies, and evaluating soft tissue masses. Intraoral and transcutaneous approaches may be used alone or in combination. This pilot series shows the capability of PoCUS to improve diagnostic accuracy, speed diagnosis, guide procedures, and improve management. Prospective studies are underway to determine the strengths and weaknesses of the method and its impact on patient outcomes.

Point Shear Wave Elastography for Assessing Liver Stiffness in Chronic Liver Diseases of Different Etiologies Compared to Biopsy

BACKGROUND

Point shear-wave elastography (pSWE) is a new method to assess the degree of liver fibrosis. It has been shown to be effective in detecting stiffness in viral hepatitis.

OBJECTIVES

To determine the feasibility of pSWE for assessing liver stiffness and fibrosis in liver diseases of different etiologies.

METHODS

This prospective single-center study included a population of adult patients with chronic liver diseases from different etiologies, who were scheduled for liver biopsy, and a control group of healthy adults who prospectively underwent pSWE. Ten consecutive pSWE measurements of the liver were performed using a Philips iU22 ultrasound system. Stiffness degree was compared to liver biopsy results. Fibrosis degree was staged according to METAVIR scoring system.

RESULTS

The study group was comprised of 202 patients who underwent liver biopsy and pSWE test and a control group consisting of 14 healthy adults who underwent pSWE for validation. In the study group, the median stiffness was 5.35 ± 3.37 kilopascal (kPa). The median stiffness for F0-1, F2, F3, and F4 as determined by liver biopsy results were 4.9 kPa, 5.4 kPa, 5.7 kPa, and 8 kPa, respectively. The median stiffness in the control group was 3.7 ± 0.6 kPa. Subgroup analyses were conducted for viral hepatitis vs. non-viral hepatitis and steatohepatitis vs. non-steatohepatitis groups.

CONCLUSIONS

pSWE is a reproducible method for assessing liver stiffness and is in a linear relationship with fibrosis degree as seen in pathology. Compared with patients with non-significant fibrosis, healthy controls showed significantly lower values.

Transthoracic parametric Doppler for bedside diagnosis of pulmonary embolism: A pilot study

Transthoracic parametric Doppler (TPD), unlike conventional ultrasonography, measures signals originating from movements of pulmonary blood vessel walls. In this pilot study, we tested TPD in 15 patients diagnosed with pulmonary embolism on computed tomography pulmonary angiography. Results were mapped to the upper, middle, and lower thirds of the right lung. In the lower third, TPD yielded 100% specificity and positive predictive value for acute pulmonary embolism. If validated in a larger series, this rapid bedside technique might obviate the need for computed tomography in specific cases. This could be advantageous in patients who are unstable, in intensive care, or have allergies to iodinated contrast material.

Sparing ultrasound in emergency department patients with suspected deep vein thrombosis by using clinical scores and D-dimer testing

PURPOSE

To evaluate compliance with a management strategy for use in emergency department (ED) patients with suspected deep vein thrombosis (DVT) based on Wells score (WS), D-dimer concentrations, and sonographic (US) examinations.

METHODS

Retrospective and prospective data on risk factors, physical examination findings, D-dimer concentrations, and US results were collected and reviewed. The prevalence of DVT for each WS category and D-dimer level was calculated.

RESULTS

In the retrospective part of the study, 475 consecutive patients were included. Patients' risk for DVT was scored as high (n = 129 [27.2%]), moderate (n = 95 [20%]), or low (n = 251 [52.8%]). D-Dimer test results were available for 34 (7.2%) of the patients. DVT was diagnosed in 105 (22.1%) patients: 99 (76.7%) at high, 4 (4.2%) at moderate, and 2 (0.8%) at low risk. The mean D-dimer concentration was 3,071.7 ng/ml in patients with DVT. In the prospective part of the study, 50 patients were enrolled. Their risk levels for DVT were scored as high (n = 23 [46%]), moderate (n = 7 [14%]), and low (n = 20 [40%]). D-Dimer testing was performed in all patients. The mean D-dimer concentration was 2,966.9 ng/ml in patients with DVT. DVT was diagnosed in 13 (26%) of these 50 patients: 12 (52.2%) at high and 1 (14.3%) at moderate risk for DVT. No patients in the low-risk group and with normal D-dimer concentrations had DVT.

CONCLUSIONS

We identified significant correlation between WS, D-dimer concentration, and diagnosis of DVT on US examination. DVT can be excluded with certainty in patients admitted to the ED with a low-risk score for DVT and a negative D-dimer concentration, thus avoiding the need for performing US examinations. A low level of compliance with this management strategy was found in our ED.

Antiatherosclerotic effects of licorice extract supplementation on hypercholesterolemic patients: decreased CIMT, reduced plasma lipid levels, and decreased blood pressure

Background

Ethanolic extract of licorice root has been shown to reduce low-density lipoprotein (LDL) oxidation in atherosclerotic mice and in both hypercholesterolemic and normal lipidemic humans.

Objective

This study examined the effect of licorice-root extract on carotid intima-media thickness (CIMT) in individuals with hypercholesterolemia.

Design

Individuals with hypercholesterolemia (total cholesterol ≥6.18 mmol/L [240 mg/dL]) and without significant stenosis were randomly allocated to two groups: an experimental group that consumed 0.2 g/day of ethanolic extract of licorice root for 12 months, and a control group that received a placebo.

Results

Of 110 eligible participants, 94 (41–80 years old) completed the study. A significant CIMT decrease from 0.92±0.25 mm to 0.84±0.21 mm was observed in the experimental group compared with an increase from 0.85±0.17 mm to 0.88±0.19 mm in the control group. Mean plasma total cholesterol levels and LDL cholesterol decreased, at the range baseline to 1 year, from 284±32 mg/dl to 262±25 mg/dl and from 183±8.5 mg/dl to 174±9.1 mg/dl, respectively, for the experimental group (p<0.001) and from 291±35 to 289±31 mg/dl and from 177.6±10.7 to 179.3±9.6 (p=0.08), respectively, for the control group. Mean high-density lipoprotein (HDL) did not change significantly in either group. In the experimental group, systolic blood pressure decreased from 138±12 mmHg to 125±13 mmHg after 1 year (p=0.01) and increased from 136±15 mmHg to 137±13 mmHg in the control group. Diastolic blood pressure decreased from 92±9 mmHg to 84±10 mmHg (p=0.01) in the experimental group and increased from 89±11 mmHg to 90±8 mmHg in the control group.

Conclusion

Following 1 year of licorice consumption, mean CIMT, total cholesterol, LDL levels, and blood pressure were decreased. This suggests that licorice may attenuate the development of atherosclerosis and of related cardiovascular diseases.

Guidelines for Performing Dermatologic Ultrasound Examinations by the DERMUS Group

OBJECTIVES

To support standardization for performing dermatologic ultrasound examinations.

METHODS

An international working group, called DERMUS (Dermatologic Ultrasound), was formed, composed of physicians who have been working on a regular basis and publishing in peer-reviewed articles on dermatologic ultrasound. A questionnaire on 5 critical issues about performance of the examinations was prepared and distributed by e-mail. The areas of discussion included technical aspects, main areas of application, minimum number of examinations per year required for assessing competence, qualifications of the personnel in charge of the examination, and organization of courses. Final recommendations were approved on the basis of the agreement of more than 50% of the members.

RESULTS

The minimum frequency recommended for performing dermatologic examinations was 15 MHz. Routine use of color Doppler ultrasound and the performance of spectral curve analysis for assessing the main vascularity of lesions were suggested. Three-dimensional reconstructions were considered optional. The main dermatologic applications were benign tumors, skin cancer, vascular anomalies, cosmetic field, nail disorders, and inflammatory diseases. The minimum number of examinations per year suggested by the group for assessing competence was 300. A physician and not a sonographer was recommended to be the person in charge of performing the examination. On course organization, a minimum of 2 levels of complexity (basic and advanced) was suggested.

CONCLUSIONS

There is a need to standardize the performance and quality of dermatologic ultrasound examinations. The present guidelines written by an international group of specialists in the field may support this objective.

Dynamic high-resolution sonography compared to magnetic resonance imaging for diagnosis of temporomandibular joint disk displacement

OBJECTIVES

The purpose of this study was to determine the value of dynamic high-resolution sonography for evaluation of temporomandibular joint (TMJ) disk displacement compared to magnetic resonance imaging (MRI) with the mouth closed and during the maximal mandibular range of motion.

METHODS

Dynamic high-resolution sonography with the mouth closed and during the maximal mandibular range of motion was performed on 39 consecutive patients (78 joints; 13 male and 26 female; age range, 18-77 years; mean age ± SD, 37.23 ± 16.26 years) with TMJ disorders. A TMJ MRI study was performed 1 to 7 days after sonography. We searched for signs of disk displacement and findings compatible with degenerative joint disease. Both studies were performed and interpreted independently by blinded operators.

RESULTS

Magnetic resonance imaging depicted 22 normal joints (28.2%), 21 (26.9%) with anterior disk displacement with reduction, 15 (19.2%) with anterior disk displacement without reduction, and 20 (25.6%) with degenerative disease. Sonography depicted 30 normal joints (38.5%), 22 (28.2%) with anterior disk displacement with reduction, 12 (15.4%) with anterior disk displacement without reduction, and 14 (17.9%) with degenerative disease. The overall sensitivity, specificity, and accuracy of sonography for diagnosis of disk displacement were 74.3%, 84.2%, and 77.7%, respectively. The sensitivity, specificity, and accuracy for diagnosis of disk displacement with reduction were 78.6%, 66.7%, and 73.0%, and the values for diagnosis of disk displacement without reduction were 66.7%, 78.6%, and 73.0%.

CONCLUSIONS

Dynamic high-resolution sonography is a potential imaging method for diagnosis of TMJ disk displacement and degenerative diseases. Further studies are needed to make dynamic high-resolution sonography the first-line test for diagnosis of TMJ disk displacement.

Age-related ultrasonic properties of breast tissue in vivo

The aim of the current work was to quantify the ultrasonic properties of the whole breast in vivo as a function of age. Forty-four women were scanned using a computerized ultrasonic scanner developed in our laboratory. Raster scans in two orthogonal views, mediolateral and craniocaudal, were obtained using the ultrasonic through-transmission method. By combining the information from the two views, we estimated two acoustic properties: speed of sound and attenuation coefficient. On the basis of the results, both the attenuation coefficient and the speed of sound follow a three-phase age-related pattern. During the first phase, which corresponds to ages 20 to 35 y, both properties decrease with time and then remain roughly unchanged until about 55 y. During the third phase corresponding to ages >55 y, values decrease again with time. The mean speed of sound decreases from 1504 ± 35 m/s at <30 y to 1452 ± 9 m/s at >60 y (p < 0.01), and the attenuation coefficient decreases from 1.27 ± 0.32 to 0.96 ± 0.13 dB/cm/MHz (p < 0.03), respectively. In conclusion, both the ultrasonic speed of sound and the attenuation coefficient of breast tissue are age related. Both parameters decrease during life, markedly during the first and third phases. These changes may be attributed to anatomic and physiologic changes associated with reproductivity and menopause.

Comparative study of high-resolution multifrequency ultrasound of the plantar skin in patients with various types of hereditary palmoplantar keratoderma

BACKGROUND

High-variable-frequency ultrasound is used as an imaging tool for various cutaneous disorders. We utilized this tool in pachyonychia congenita (PC) patients, who typically present with plantar hyperkeratosis and often severely debilitating pain, compared to patients with epidermolytic palmoplantar keratoderma (EPPK) and mal de Meleda (MDM).

OBJECTIVE

To ascertain the feasibility of ultrasound technology for the diagnosis of PC.

METHODS

The study included a total of 16 patients, 7 with PC, 5 with EPPK and 4 with MDM, who underwent ultrasound examination of the plantar skin with high-resolution multifrequency ultrasound equipment.

RESULTS

Ultrasound scans performed over the proximal and distal plantar foot calluses in PC patients demonstrated hyperechoic dots and lines within the epidermis compatible with hyperkeratosis, engorged varicose veins in the dermis and an anechoic layer interposed between the epidermis and the dermis, corresponding to blister fluid below the calluses. In contrast to PC patients, patients with MDM and EPPK demonstrated no blisters.

CONCLUSION

PC patients, as opposed to a group of patients with MDM and EPPK, displayed subepidermal blistering beneath their calluses. This finding may help in the diagnosis of PC and in partially explaining plantar pain as part of PC symptomatology.

Feasibility study of contrast-enhanced automated acoustic mammography

The feasibility of implementing image subtraction in through-transmission breast sonography was examined. Acoustic mammograms of women with suspicious findings were obtained using through-transmission imaging. Precontrast images were initially acquired. Then a perflutren liquid microsphere contrast agent solution was injected intravenously, and new sets of images were acquired. Precontrast-postcontrast subtraction images depicting the resulting changes were then obtained and visually compared with other imaging modalities. The ability to detect changes stemming from contrast agent injection in the through-transmission mode was verified. The comparability with x-ray mammography and magnetic resonance imaging was shown. Finally, the ability to compare images obtained before and several months after surgery was confirmed.

Shoulder ultrasonography: performance and common findings

Ultrasound (US) of the shoulder is the most commonly requested examination in musculoskeletal US diagnosis. Sports injuries and degenerative and inflammatory processes are the main sources of shoulder pain and functional limitations. Because of its availability, low cost, dynamic examination process, absence of radiation exposure, and ease of patient compliance, US is the preferred mode for shoulder imaging over other, more sophisticated, and expensive methods. Operator dependence is the main disadvantage of US examinations. Use of high range equipment with high resolution transducers, adhering to a strict examination protocol, good knowledge of normal anatomy and pathological processes and an awareness of common pitfalls are essential for the optimal performance and interpretation of shoulder US. This article addresses examination techniques, the normal sonographic appearance of tendons, bursae and joints, and the main pathological conditions found in shoulder ultrasonography.

A 10-year experience with treatment of high and standard risk Hodgkin disease: six cycles of tailored BEACOPP, with interim scintigraphy, are effective and female fertility is preserved

Therapy of Hodgkin lymphoma (HL) is designed to prolong survival and minimize toxicity. A total of 124 patients with newly diagnosed HL and adverse prognostic factors were prospectively studied between July, 1999 and August, 2005. Patients with early unfavorable and advanced disease were eligible for the study. Patients were assigned to therapy based on international prognostic score (IPS). Those with IPS ≥ 3 received three cycles of escalated BEACOPP (EB). All others received two cycles of standard BEACOPP (SB). Subsequent therapy was prospectively assigned according to early interim GA(67) or positron emission tomography (PET)/computerized tomography (CT). Four cycles of EB or SB were administered following a positive or negative scan, respectively. Complete remission rate, 10-year progression free (PFS), and overall survival (OS) were 97, 87, and 88%, respectively, at a median follow-up of 89 months (5-144). PFS and OS were similar in both groups. Fertility status was assessed in 38 females aged <40 years; 94% of females younger than 40 years preserved their cyclic ovarian function. Nineteen conceived during follow-up for 30 pregnancies, delivering 24 babies. Deliveries were reported up to 7 years from diagnosis. Predictive value of negative interim Ga(67) or PET/CT was 87 and 93%, respectively. Six cycles of tailored BEACOPP, for patients with adverse prognostic factors, provide encouraging long-term PFS and OS, and fertility is preserved in most females.

Color-coded duplex sonography compared to multidetector computed tomography for the diagnosis of crohn disease relapse and complications

OBJECTIVES

The purpose of this study was to evaluate the accuracy of color-coded duplex sonography for the diagnosis of Crohn disease relapse and complications compared to multidetector computed tomography (CT).

METHODS

The Institutional Ethics Committee approved the protocol research, and written consent forms were obtained. Patients with a diagnosis of Crohn disease presenting with symptoms of relapse or complications (54 patients; 27 female; ages 9-80 years; mean, 34.6 years) were enrolled. Patients underwent color-coded duplex sonography and multidetector CT examinations within 2 weeks of each other. Multidetector CT was the reference standard. The location and extent of diseased bowel, wall thickness, stenosis, hyperemia, mesenteric fat thickening, lymphadenopathy, abscesses, fistulas, peritoneal fluid, and signs of hepatobiliary disease were searched for.

RESULTS

About of 80% of the patients had terminal ileal involvement, and 55% had disease confined to the ileum. A significant correlation between the two modalities was found regarding wall thickness, abscesses, and fistulas (P < .05). Color-coded duplex sonography had sensitivity and specificity of 88% and 53%, respectively, for diagnosis of luminal stenosis. Hyperemia was more commonly diagnosed on color-coded duplex sonography. Color-coded duplex sonography had sensitivity and specificity of 84% and 83% for diagnosis of mesenteric fat thickening and lymphadenopathy and 66% and 86% for peritoneal fluid. Fatty liver was found in 18% and gallstone disease in 6%.

CONCLUSIONS

Color-coded duplex sonography was accurate in diagnosing the disease location, wall thickness, and extraintestinal inflammatory findings associated with Crohn disease, potentially placing it as the first-line imaging modality for the diagnosis of Crohn disease relapse and complications.

Imaging acute appendicitis: state of the art

The goal of this review is to present the state of the art in imaging tests for the diagnosis of acute appendicitis. Relevant publications regarding performance and advantages/disadvantages of imaging modalities for the diagnosis of appendicitis in different clinical situations were reviewed. Articles were extracted from a computerized database (MEDLINE) with the following activated limits: Humans, English, core clinical journals, and published in the last five years. Reference lists of relevant studies were checked manually to identify additional, related articles. Ultrasound (US) examination should be the first imaging test performed, particularly among the pediatric and young adult populations, who represent the main targets for appendicitis, as well as in pregnant patients. A positive US examination for appendicitis or an alternative diagnosis of possible gastrointestinal or urological origin, or a negative US, either showing a normal appendix or presenting low clinical suspicion of appendicitis, should lead to a final diagnosis. A negative or indeterminate examination with a strong clinical suspicion of appendicitis should be followed by a computed tomography (CT) scan or alternatively, a magnetic resonanace imaging (MRI) scan in a pregnant patient. A second US examination in a patient with persistent symptoms, especially if the first one was performed by a less experienced imaging professional, is a valid alternative to a CT.

Cross-sectional analysis of cardiovascular risk factors in children with parental history of premature ischemic heart disease

This study aimed to evaluate the presence of cardiovascular risk factors in children with a parental history of premature ischemic heart disease (two- or three-vessel disease diagnosed before the age of 55 in men and 65 in women). A prospective cross-sectional study was performed on 55 children. The following parameters were assessed: body mass index (BMI), waist and hip circumference, blood pressure, lipids profile, fasting glucose (FG), C-reactive protein (CRP), and carotid intimal-medial thickness (CIMT). Twenty-eight children had hypercholesterolemia, and 11 had other forms of dyslipidemia. Sixteen children had a high BMI; 17 had increased CRP levels; 2 were hypertensive; and 2 had impaired FG. CIMT levels were not correlated with age (Pearson r = -0.486; p = 0.78) and height (Pearson r = -6.31; p = 0.84), but they were correlated with cholesterol levels (Spearman r = 0.375; p < 0.005). Most patients (83%) had ≥ 2 risk factors; half of them had ≥ 3 risk factors. We concluded that these at-risk children should be carefully screened for all known risk factors.

From arteritis to mycotic aneurysm: visualization of the progression of mycotic aneurysm development following femoral arterial line insertion in an infant

Although uncommon, mycotic aneurysms in infants can be lethal because of the high risk of rapid expansion and rupture. Most catheter-associated mycotic aneurysms reported in the first year of life develop following umbilical artery catheterizations. We describe the sonographic detection of an early stage mycotic aneurysm in a 4-month-old following femoral artery catheterization complicated by methicillin-resistant Staphylococcus aureus (MRSA) septicemia. We also describe the sonographic and radiographic progression of this mycotic aneurysm before surgery.

Investigation of acoustic changes resulting from contrast enhancement in through-transmission ultrasonic imaging

Through-transmitted ultrasonic waves can be used for computed projection imaging of the breast. The goal of this research was to analyze the acoustic properties changes associated with the propagation of ultrasonic waves through media before and after ultrasound contrast agent (UCA) injection and to study the feasibility of a new imaging method combining projection imaging and UCA. Two transmission techniques were examined: Gaussian pulses and pulse inversion. In the latter, three different double inverted pulses were studied: double Gaussian, double square and double sine. A computerized automatic ultrasonic scanning system was used for imaging. To simulate blood vessels, a phantom, consisting of a latex tube through which saline was circulated, was assembled. The phantom was placed within the scanner and sets of acoustic projection images were acquired. Then, a suspension of the UCA Definitely was added to the saline and a new set of images was obtained. The pre and postcontrast images were quantitatively compared in terms of amplitude and time-of-flight (TOF). In addition, nonlinearity was evaluated by comparing the relative alteration of the positive and negative parts of the signal. Statistically significant (p < 0.001) changes in the projection images resulting from the UCA injection were observed in wave amplitude (22% +/- 13%), TOF (7.9 ns +/- 6.3 ns) and nonlinear properties (35% +/- 32% and 56% +/- 17% for Gausian pulses and pulse inversion, respectively). One in vivo study of a female breast is also presented and its preliminary outcomes discussed. Together, these results indicate the technical feasibility of the suggested method and its potential to detect breast tumors.

Asymptomatic deep vein thrombosis in advanced cancer patients: the value of venous sonography

PURPOSE

Although guidelines for venous thromboembolism prevention are available, the implementation of anticoagulant prophylaxis in patients with advanced cancer has yet to be more clearly defined. We aim to determine the incidence of lower extremity deep vein thrombosis (DVT) diagnosed by Doppler sonography (USD) in asymptomatic nonambulatory patients with advanced cancer.

METHOD

In a prospective study, 44 nonambulatory cancer patients with grade 3-4 World Health Organization performance status, asymptomatic for lower extremity DVT, underwent bilateral venous USD studies of the lower extremities. Different risk factors and laboratory data were registered and correlated with the incidence of DVT.

RESULT

Asymptomatic DVT was detected in 15 of 44 patients (34%, 95% CI, 0.21-0.49). Twenty-three percent of all patients had isolated deep calf vein thrombi and 11% of all patients had thrombi in the proximal veins. The only significant risk factor was the number of metastatic sites. DVT was found in 4 of 23 (17.4%) patients with one metastatic site as opposed to 11 of 21 (52.3%) with two or more sites (p < 0.01).

CONCLUSION

USD of the lower extremities detected asymptomatic DVT in 34% of advanced nonambulatory cancer patients and may serve as an additional decision-making tool in the consideration of anticoagulant therapy for this specific population.

A functional dynamic scoring model to elucidate the significance of post-induction interim fluorine-18-fluorodeoxyglucose positron emission tomography findings in patients with Hodgkin's lymphoma

BACKGROUND

The findings of interim fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET/CT) predict progression-free survival of patients with Hodgkin's lymphoma. Historically, the assessment was based on a static all-or-none scoring system. However, the clinical significance of any positivity in interim FDG-PET/CT has not been defined.

DESIGN AND METHODS

Ninety-six patients with Hodgkin's lymphoma who underwent interim FDG-PET/CT were evaluated using dynamic and visual scores, employing mediastinal or liver blood pool uptake as a comparator. FDG-PET/CT was prospectively defined as positive if any abnormal F(18)FDG uptake was present. In a retrospective analysis dynamic score 0 indicated resolution of all disease sites; score 1 defined a single residual focus; score 2 denoted a reduction in the number of foci; score 3 defined a reduction in intensity with no reduction in number; and score 4 indicated no change in the number and intensity of foci or appearance of new foci.

RESULTS

The dynamic visual score review reduced the number of positive interim studies from 24 to 6 if a score of 2 or less was considered negative, with significantly better specificity (96%) as compared to static visual scores (78%-86%). The 5-year progression-free survival and overall survival rates in patients who had a negative dynamic score were 92% and 97%, respectively; the corresponding figures for patients with positive results were 50% and 67%.

CONCLUSIONS

A dynamic visual score may be a better indicator for tailoring therapy than static visual scoring.

Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department

OBJECTIVE

The purpose of this study was to examine the triage role of scrotal Doppler ultrasonography (DUS) as the primary preoperative diagnostic tool in patients presenting to the emergency department (ED) with acute scrotum.

METHODS

Patients who presented to the ED with acute scrotum and underwent scrotal DUS in the ultrasound unit over a 3-year period (2004-2007) were included in the study. Patient characteristics, DUS findings, and clinical management were retrospectively collected and reviewed. Doppler ultrasonographic diagnoses were compared with histopathologic findings for patients who underwent exploration and with final diagnoses at the time of discharge for patients undergoing medical treatment.

RESULTS

A total of 620 consecutive patients with 669 DUS examinations were included. The most common scrotal DUS diagnoses were epididymitis, hydrocele, varicocele, and orchitis. Scrotal trauma was present in 77 cases. Hospitalization followed the initial ED evaluation for 155 patients; 68 underwent surgery. Testicular torsion was ultrasonographically suspected in 20 patients and confirmed in 18. Scrotal malignancy was incidentally diagnosed in 13 patients and testicular hematoma in 8. Doppler ultrasonography for the diagnosis of testicular torsion had 94% sensitivity, 96% specificity, 95.5% accuracy, an 89.4% positive predictive value (PPV), and a 98% negative predictive value (NPV). Doppler ultrasonography for the diagnosis of testicular malignancy had 92% sensitivity, 95% specificity, 94% accuracy, a 78.5% PPV, and a 98% NPV.

CONCLUSIONS

Scrotal DUS is a highly sensitive preoperative diagnostic tool, thereby validating its routine use in the initial triage of patients with acute scrotum presenting to the ED.

Sonographic detection of pneumothorax by radiology residents as part of extended focused assessment with sonography for trauma

OBJECTIVE

The purpose of this study was to assess the accuracy of sonographic pneumothorax detection by radiology residents as a part of extended focused assessment with sonography for trauma (eFAST).

METHODS

In a prospective study, a sonographic search for pneumothoraces was performed as part of a standard FAST examination by the on-call resident. Each lung field was scanned at the second to fourth anterior intercostal spaces and the sixth to eighth midaxillary line intercostal spaces. A normal pleural interface was identified by the presence of parietal-over-visceral pleural sliding with "comet tail" artifacts behind. Absence of these normal features indicated a pneumothorax. The sonographic diagnosis was correlated with supine chest radiography and chest computed tomography (CT).

RESULTS

A total of 338 lung fields in 169 patients were included in the study. Patients underwent eFAST, chest radiography, and chest CT when clinically indicated. Chest CT was considered the reference standard examination. Computed tomography identified 43 pneumothoraces (13%): 34 small and 9 moderate. On chest radiography, 7 pneumothoraces (16%) were identified. Extended FAST identified 23 pneumothoraces (53%). Compared with CT, eFAST had sensitivity of 47%, specificity of 99%, a positive predictive value of 87%, and a negative predictive value of 93%. All of the moderate pneumothoraces were identified by eFAST. Twenty small pneumothoraces missed by eFAST did not require drainage during the hospitalization period.

CONCLUSIONS

Extended FAST performed by residents is an accurate and efficient tool for early detection of clinically important pneumothoraces.

Fever of unknown origin: the role of 18F-FDG PET/CT

Fever of unknown origin (FUO) is a challenging diagnostic problem. Timely identification and precise localization of the causing process are critical for appropriate patient management. The present prospective study evaluates the role of PET/CT using (18)F-FDG in the investigation of FUO.

METHODS

A total of 48 consecutive patients (25 men, 23 women; age range, 24-82 y) with FUO underwent (18)F-FDG PET/CT scans. FUO was defined as a fever of more than 38.3 degrees C that lasted for more than 3 wk and failure to reach diagnosis after more than 1 wk of inpatient investigation. The performance of PET/CT for identifying the etiology of FUO was assessed. Final diagnosis was based on histopathology, microbiologic assays, or clinical and imaging follow-up.

RESULTS

PET/CT detected suggestive foci of increased (18)F-FDG uptake in 27 patients. In 22 of these 27 positive studies (81%), PET/CT identified the underlying disease and diagnosed infection in 9 patients, an inflammatory process in 10 patients, and malignancy in 3 patients. (18)F-FDG PET/CT was negative in 21 patients. All these patients were diagnosed as having systemic nonfocal infection or drug-induced fever or showed spontaneous resolution of the febrile state with no further evidence of a localized inflammatory, infectious, or malignant process for a clinical follow-up period of 12-36 mo.

CONCLUSION

(18)F-FDG PET/CT identified the underlying cause of the fever in 46% of the present study population and contributed to the diagnosis or exclusion of a focal pathologic etiology of the febrile state in 90% of patients. (18)F-FDG PET/CT has a high negative predictive value (100%) for assessment of FUO. If confirmed by further studies, (18)F-FDG PET/CT may be used in the future as an initial noninvasive diagnostic modality for assessment of this group of patients.

Growth hormone-stimulated IGF-1 generation in cirrhosis reflects hepatocellular dysfunction

BACKGROUND/AIMS

Previous studies reported decreased serum IGF-1 levels in cirrhosis. We aimed to correlate GH-stimulated IGF-1 responses with both MELD and Child-Pugh scores and determine the impact of portal hypertension and nutrition on IGF-1 responses.

METHODS

Fifty-three patients (56+/-2 yrs) with cirrhosis were enrolled. Serum IGF-1 levels were measured by RIA before and 24h after a single injection of GH (0.06 mg/kg).

RESULTS

Compared to controls, basal IGF-1 levels were significantly decreased in patients with cirrhosis (17.3+/-6.3 vs 13.6+/-5.1, P<0.001). Increments in IGF-1 levels were significantly lower in cirrhotic patients (controls: 133% vs 49% in MELD score <10, 38% in MELD score 11-18, and 13% in MELD score 19-24, p<0.001). 37% of patients had blunted IGF-1 responses. Increments in IGF-1 levels correlated with albumin (r=0.6), portal congestive index (r=0.4), and MAMC (r=0.25). By multivariate analysis, only CP (OR 5.7) and MELD scores (OR 4.5) accurately differentiated between blunted or non-blunted IGF-1 responses and not portal hypertension (OR 0.9) or malnutrition (OR 1.35).

CONCLUSIONS

Cirrhosis is associated with low IGF-1 levels and an attenuated response to exogenous GH. These findings correlate better with the extent of hepatic dysfunction rather than the presence of portal hypertension or malnutrition.

FDG avidity and PET/CT patterns in primary gastric lymphoma

PURPOSE

The use of 18F-fluoro-deoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in primary gastric lymphoma (PGL) is challenging due to physiologic FDG activity in the stomach and variability in the degree of uptake in various histologic subtypes. This study assesses FDG avidity and PET/CT patterns in newly diagnosed PGL.

METHODS

Sixty-two PET/CT studies of newly diagnosed PGL were reviewed (24 low-grade mucosa-associated lymphoid tissue [MALT], 38 aggressive non-Hodgkin's lymphoma [AGNHL]). FDG avidity, patterns (focal/diffuse), and intensity (visually vs. the liver and SUVmax) were assessed and compared to 27 controls. Gastric CT abnormalities and extragastric sites were recorded.

RESULTS

Gastric FDG uptake was found in 55/62 (89%) PGL (71% MALT vs. 100% AGNHL, p < 0.001) and 63% controls. A diffuse pattern was found in 60% PGL (76% MALT vs. 53% AGNHL, p = NS) and 47% controls. FDG uptake higher than liver was found in 82% PGL (58% MALT vs. 97% AGNHL, p < 0.05) and 63% controls. SUVmax in FDG-avid PGLs was 15.3 +/- 11.7 (5.4 +/- 2.9 MALT vs. 19.7 +/- 11.5 AGNHL, p < 0.001) and 4.6 +/- 1.4 in controls. CT abnormalities were found in 79% PGL (thickening, n = 49; ulcerations, n = 22). Extra-gastric FDG-avid sites were seen in none of MALT, but 61% of AGNHL (nodal, n = 18; nodal and extranodal, n = 5).

CONCLUSIONS

FDG avidity was present in 89% of PGLs, including all patients with AGNHL but only 71% of MALT. FDG uptake can be differentiated, in particular in AGNHL-PGL, from physiologic tracer activity by intensity but not by pattern. Extragastric foci on PET and structural CT abnormalities are additional parameters that can improve PET/CT assessment of PGL. Defining FDG avidity and PET/CT patterns in AGNHL and a subgroup of MALT-PGL before treatment may be important for further monitoring therapy response.

Evaluating tissue changes with ultrasound during radiofrequency ablation

The purpose of this study was to estimate tissue changes during radiofrequency (RF) ablation by correlating echo frequency shifts and temperature elevations. Experiments were performed on phantoms (tissue mimicking gel) and in-vitro turkey breast. Heating was performed with a modified RF-ablation system. Intermittent RF was applied and the temperature at the electrode tip was continually measured by an embedded thermocouple. Various voltages (10-30V) were applied to achieve a wide range of temperature elevations between 10 and 80 degrees C and ablation sizes between 5 and 27 mm in width. B-mode images and raw data were acquired every 5 s by a modified ultrasound imaging system. The raw data from each line and frame was processed using an algorithm to measure spectral shifts of the echo signals in the power spectrum. The phantom experiments showed positive frequency shifts as the temperature rose, with dependency on the heating rate. A linear relationship (R(2) > 0.96) was found between the RF-applied voltage and the width of the heated area, defined by frequency changes larger than 0.05 MHz. In-vitro experiments showed a correlation (R(2) = 0.84) between the width of the coagulated area and the maximal width of the region with more than 0.12 MHz frequency shifts, but a lower correlation (R(2) = 0.4) between the width of the coagulated area and the temperature elevation. In conclusion, correlation was found between echo frequency shifts and temperature elevations and between echo frequency shifts and the width of the ablated area during intermittent RF ablation. Our results suggest that, with further refinement and validation, ultrasound could be used to measure RF heating and its induced coagulation.

Utility of sonographically guided biopsy in metabolically suspected recurrent lymphoma

OBJECTIVE

The purpose of this study was to determine the diagnostic accuracy of sonographically guided biopsy of [(18)F]fluorodeoxyglucose (FDG)-avid foci on positron emission tomography (PET)/computed tomography (CT) in patients with lymphoma.

METHODS

We retrospectively reviewed the medical records of 56 patients with lymphoma (25 male and 31 female; mean age, 48.5 years; range, 22-80 years) who underwent sonographically guided biopsy of hypermetabolic FDG-avid foci precisely localized by PET/CT. Biopsies were performed up to 3 months after PET/CT. The accuracy of core biopsy was calculated and compared with clinical follow-up and histopathologic results of open biopsy.

RESULTS

Sixty-six sonographically guided biopsies were performed in the 56 patients. Histopathologic results were conclusive in 53 (80%) of 66. No complications occurred during or after the procedure. The overall sensitivity, specificity, positive predictive value, and accuracy for diagnosis of lymphoma were 100%, 95%, 97%, and 98%, respectively.

CONCLUSIONS

Sonographically guided biopsy is a safe and effective means for investigating metabolically active lesions on FDG-PET/CT in patients with known lymphoma.

Sonographic evaluation of vascular injuries

OBJECTIVE

The purpose of this presentation is to highlight the color Doppler duplex sonographic features of procedure-related and blunt or penetrating trauma-related vascular injuries.

METHODS

Different kinds of vascular complications such as pseudoaneurysms, arteriovenous fistulas, dissection, and thrombosis are discussed. Cases of vascular injuries in the extremities, neck, and abdomen are presented to illustrate the spectrum of sonographic appearances.

RESULTS

Color Doppler duplex sonography is valuable in the diagnosis and monitoring of most vessel injuries and in the treatment of pseudoaneurysms. It is useful for flow analysis and for follow-up after treatment. However, because of limitations inherent to sonography, such as bones, air, casts, skin burns, and relatively slow performance of the test, magnetic resonance imaging, computed tomography, and angiography are necessary for further evaluation in selected cases.

CONCLUSIONS

Color Doppler duplex sonography is a widely available, noninvasive, and accurate technique for evaluating vascular injuries and should be the first-line imaging modality in most patients.

The utility of focused assessment with sonography for trauma as a triage tool in multiple-casualty incidents during the second Lebanon war

OBJECTIVE

The purpose of this study was to evaluate the role of focused assessment with sonography for trauma (FAST) as a triage tool in multiple-casualty incidents (MCIs) for a single international conflict.

METHODS

The charts of 849 casualties that arrived at our level 1 trauma referral center were reviewed. Casualties were initially triaged according to the Injury Severity Score at the emergency department gate. Two-hundred eighty-one physically injured patients, 215 soldiers (76.5%) and 66 civilians (23.5%), were admitted. Focused assessment with sonography for trauma was performed in 102 casualties suspected to have an abdominal injury. Sixty-eight underwent computed tomography (CT); 12 underwent laparotomy; and 28 were kept under clinical observation alone. We compared FAST results against CT, laparotomy, and clinical observation records.

RESULTS

Focused assessment with sonography for trauma results were positive in 17 casualties and negative in 85. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FAST were 75%, 97.6%, 88.2%, 94.1%, and 93.1%, respectively. A strong correlation between FAST and CT results, laparotomy, and clinical observation was obtained (P < .05).

CONCLUSIONS

In a setting of a war conflict-related MCI, FAST enabled immediate triage of casualties to laparotomy, CT, or clinical observation. Because of its moderate sensitivity, a negative FAST result with strong clinical suspicion demands further evaluation, especially in an MCI.

Immuno-chemotherapy in metastatic renal cell carcinoma: long-term results from the rambam and linn medical centers, Haifa, Israel

Nephrectomy, immuno-chemotherapy and resection of residual disease have been the treatment of choice for patients with metastatic renal cell carcinoma during the past decades. The aim of this study was to report the long-term results of this treatment approach. Sixty-two patients with metastatic renal cell carcinoma participated in a Phase II study. At diagnosis, 32 patients had localized disease, 30 had metastatic disease and 53 underwent nephrectomy. Metastatic sites were lungs, lymph nodes, bones and liver. Immuno-chemotherapy consisted of: interleukin-2, interferon alpha, 5-fluorouracil and vinblastine. All patients were evaluated for toxicity and response to treatment. CR was achieved in 4 patients and PR in 14. Seven patients, with maximum response to immuno-chemotherapy underwent resection of residual tumor and reached CR. Therefore, CR was achieved in 11 patients (18%) with a median survival of +67 months. Flu-like symptoms were the common side effects. Performance status and histology type significantly affected survival. Nephrectomy, immuno-chemotherapy and resection of residual disease are recommended for patients with metastatic renal cell carcinoma.

Difference of CBD width on US vs. ERCP

PURPOSE

To investigate the relationship between US and ERCP in the measurement of common bile duct (CBD) width after application of Compound and Harmonic imaging on ultrasound.

METHODS

We prospectively evaluated the CBD width as measured on endoscopic retrograde cholangiopancreatography (ERCP) and ultrasonography (US), applying Compound and Harmonic US techniques, on 100 patients. Furthermore, we retrospectively re-examined US and ERCP images of 48 patients who underwent ERCP and US during the same hospitalization period.

RESULTS

The average difference in measurements by US compared to ERCP was 2.3 mm (P < 0.01) in the retrospective and 1.9 mm in the prospective study (P < 0.001). The average difference in measurements between US and ERCP in post-cholecystectomy patients was 4.0 mm in the retrospective study (10 patients), and 3.8 in the prospective study (25 patients). The difference between the measurements on both examinations decreased with increasing CBD width. There was a good correlation between ERCP and US measurements of CBD width (r = 0.73 for all patients and r = 0.88 for patients with intact gallbladder, P < 0.001).

CONCLUSIONS

There is a gap between measurement of CBD width on US and ERCP of about 2 mm. The application of Compound and Harmonic techniques in the prospective study probably enabled a more accurate sonographic measurement.

Prevalence of upper extremity deep venous thrombosis diagnosed by color Doppler duplex sonography in cancer patients with central venous catheters

OBJECTIVE

The purpose of this study was to review the literature concerning upper extremity deep venous thrombosis (UEDVT) diagnosed by color Doppler duplex sonography (CDDS) in cancer patients with indwelling central venous catheters (CVCs).

METHODS

From computerized databases (MEDLINE and Ovid), relevant publications regarding CDDS of the upper limb veins in cancer patients with CVCs were reviewed.

RESULTS

Patients with malignancy have a higher rate of thrombosis, which is increased by the presence of CVCs. Screening CDDS in asymptomatic patients showed CVC-related UEDVT in 11.7% to 44% of patients. In symptomatic cancer patients, the range was similar to the asymptomatic ones, 6.7% to 48%. The presence of a CVC almost doubled the incidence of UEDVT in symptomatic patients. Color Doppler duplex sonography is an accurate examination for the diagnosis of UEDVT, with sensitivity ranging from 78% to 100% and specificity ranging from 82% to 100%. The main obstacle for the diagnosis of UEDVT is the presence of overlying bones, making it difficult to visualize and impossible to directly assess by compression techniques. Color and spectral Doppler sonography and the use of small transducers aid in the diagnosis. When several parameters are evaluated in combination, CDDS is a reliable method for diagnosing CVC-related thrombosis.

CONCLUSIONS

Great variability in the prevalence of catheter-related thrombosis in cancer patients has been reported, although it is uniformly higher compared with patients without cancer. Color Doppler duplex sonography is the modality of choice for the diagnosis of CVC-related UEDVT in symptomatic cancer patients and for screening for asymptomatic thrombosis in this specific population.

Sonographically guided percutaneous needle biopsy of soft tissue masses with histopathologic correlation

OBJECTIVE

The purpose of this study was to evaluate the accuracy of sonographically guided percutaneous core biopsy of soft tissue masses.

METHODS

We retrospectively reviewed the medical records of patients who underwent sonographically guided biopsy of soft tissue masses at our institution during a 50-month period. Core biopsy histopathologic results were compared with surgical or clinical follow-up.

RESULTS

One hundred eighty-three patients, 76 male and 107 female, with a mean age of 48.5 years were included in the study. Thirteen patients had more than 1 biopsy, and the total number of biopsies performed was 196. Five patients were lost to follow-up. Biopsy results were diagnostically accurate in 174 (91%) cases. Thirteen biopsies were inconclusive. No complications occurred. The overall sensitivity, specificity, positive predictive value, and accuracy in separating malignant from benign lesions were 97%, 99%, 99%, and 98%, respectively.

CONCLUSIONS

Sonographically guided core needle biopsy is an accurate and safe means to obtain tissue samples for the histopathologic diagnosis of soft tissue masses. It obviates the need for open biopsy and should be performed routinely for treatment planning.

Current approaches and controversial issues in the diagnosis of deep vein thrombosis via duplex Doppler ultrasound

Duplex and color Doppler sonography (DUS) is currently the technique of choice for the diagnosis of deep venous thrombosis (DVT) in symptomatic patients, because it has proven safe and cost-effective, with a very high sensitivity and specificity (96% and 98%, respectively) for the diagnosis of proximal DVT. Several issues regarding its method and clinical indications remain controversial, however. Although isolated calf vein thrombosis does not seem to have a significant adverse outcome in the short term, scanning the calf only in patients with localized symptoms or signs is cost-effective. Bilateral examination is indicated in high-risk patients or when screening asymptomatic patients. When negative, a complete DUS examination of the proximal and distal veins, at least down to the level of the popliteal trifurcation, allows withholding anticoagulant therapy without the risk of major complications. This examination may be repeated if signs or symptoms worsen. Some populations of asymptomatic patients at high risk of DVT may benefit from DUS screening. Bilateral DUS examination of lower limb veins should be performed as the initial examination in the workflow of pulmonary embolism only in patients with risk factors for DVT. Recurrent thrombosis is a challenging diagnosis for all imaging modalities. A diagnostic strategy combining clinical probability score and D-dimer test may refine the selection of patients. The pitfalls and limitations of venous DUS are related to vein anatomy, flow changes, technical issues, and operator expertise.

PET/CT imaging in patients with suspected recurrence of pancreatic cancer

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Background: The goal of the study was to review our clinical experience with 18F-FDG PET/CT in patients (pts) with suspected recurrence of pancreatic cancer. Methods: Nine pts (M/F=3/6, age 47–73y) with increasing levels of CA 19–9 and/or CEA during follow-up and negative or equivocal CT scan were included. Seven pts were asymptomatic and 2 pts had mild abdominal pain. Previous treatment included pancreaticoduodenectomy in 6 pts and distal pancreatectomy in 3 pts. Adjuvant chemoradiation was given to 5 pts as well. Tumor markers first increased 2 to 14 months after the operation. CT scan was done within one month in all pts, and found to be normal in 6 pts and equivocal in 3 pts. PET/CT was performed one months (5 pts), 2 months (2 pts) and 3 months (2 pts) later. However, the last 2 pts had a 2nd normal CT scan 1–2 months after the PET/CT. A final diagnosis of recurrence was confirmed by histopathology or by further clinical and radiologic follow up. Results: Of the 9 pts, 8 exhibited PET/CT findings consisted with recurrent cancer. Increased tracer uptakes with abnormal findings on CT were found in 5 pts with CT scan previously defined as normal ( 2 in tumor bed and 3 in distant sites, 1 liver, 1 liver and lymph nodes, 1 abdominal wall). PET/CT was also positive in 3 pts with equivocal CT findings (2 tumor bed, 1 liver with a new unsuspected positive site in tumor bed). Chemotherapy (followed by surgery in 1 pt and by radiation therapy in 1 pt, both with local recurrence) was instituted in 7 pts following PET/CT findings. One pt underwent resection of an isolated abdominal recurrence. After a median follow-up of 7 months (range, 4 -27 m) 4 pts had died of disease, 2 are alive with progressing disease, one has responded to treatment (PET/CT became normal) and one is undergoing ghemotherapy. One of the 9 pts had a false negative PET/CT test, as abdominal spread was later found by an additional CT scan, still with a 2nd negative PET/CT image. Conclusions: PET/CT is a useful tool for detecting recurrent pancreatic cancer, and can demonstrate recurrence site when CT is non-diagnostic. Its impact on clinical management and treatment results should be further evaluated.

No significant financial relationships to disclose.

Impaired cerebral CO2 vasoreactivity: association with endothelial dysfunction

Conflicting data exist on the role of nitric oxide (NO) in cerebral blood flow (CBF) autoregulation. Previous studies involving human and animal subjects seem to indicate that NO involvement is limited to the CO(2)-dependent mechanism (chemoregulation) and not to the pressure-dependent autoregulation (mechanoregulation). We tested this hypothesis in patients with impaired endothelial function compared with healthy controls. Blood pressure, heart rate, end-tidal Pco(2), CBF velocities (CBFV), forearm blood flow, and reactive hyperemia were assessed in 16 patients with diabetes mellitus and/or hypertension and compared with 12 age- and sex-matched healthy controls. Pressure-dependent autoregulation was determined by escalating doses of phenylephrine. CO(2) vasoreactivity index was extrapolated from individual slopes of mean CBFV during normocapnia, hyperventilation, and CO(2) inhalation. Measurements were repeated after sodium nitroprusside infusion. Indexes of endothelial function, maximal and area under the curve (AUC) of forearm blood flow (FBF) changes, were significantly impaired in patients (maximal flow: 488 +/- 75 vs. 297 +/- 31%; P = 0.01, AUC DeltaFBF: 173 +/- 17 vs. 127 +/- 11; P = 0.03). Patients and controls showed similar changes in cerebrovascular resistance during blood pressure challenges (identical slopes). CO(2) vasoreactivity was impaired in patients compared with controls: 1.19 +/- 0.1 vs. 1.54 +/- 0.1 cm.s(-1).mmHg(-1); P = 0.04. NO donor (sodium nitroprusside) offsets this disparity. These results suggest that patients with endothelial dysfunction have impaired CO(2) vasoreactivity and preserved pressure-dependent autoregulation. This supports our hypothesis that NO is involved in CO(2)-dependent CBF regulation alone. CBFV chemoregulation could therefore be a surrogate of local cerebral endothelial function.

Esophageal Varices: Evaluation with Esophagography with Barium versus Endoscopic Gastroduodenoscopy in Patients with Compensated Cirrhosis—Blinded Prospective Study

PURPOSE

To prospectively evaluate the accuracy of esophagography with barium in diagnosis of esophageal varices (EV) in patients with compensated cirrhosis, with endoscopic gastroduodenoscopy as the reference standard.

MATERIALS AND METHODS

In this study, which was approved by the local Helsinki Committee and in which all patients consented to participate, 61 patients with cirrhosis (34 men, 27 women; mean age, 61 years; range, 36-76 years) received a diagnosis clinically or with liver biopsy. In 87% (n = 53) of patients, Child-Pugh classification was A; in 13% (n = 8), Child-Pugh classification was B. They were evaluated with endoscopic gastroduodenoscopy, according to Japanese general criteria. Esophagography was performed within 3 weeks of endoscopic gastroduodenoscopy, and EV were assigned grades as follows: 0, no EV were seen; 1, EV manifested as very mild irregularities of the folds; and 2, the irregularity of the folds (EV) was clearly present. They were also assigned grades for shape and size: grade F0, no EV detected; grade F1, small straight EV; grade F2, slightly enlarged tortuous EV occupying less than one-third of esophageal lumen; and grade F3, large coil-shaped EV that occupied more than one-third of esophageal lumen. The sensitivity and specificity and positive and negative predictive values of esophagography for identification of each grade of EV were calculated separately, as was the 95% confidence interval.

RESULTS

All large EV (grades F2 and F3) were diagnosed at esophagography. Sensitivity declined with small EV (grade F1) to 71. The overall sensitivity of esophagography was 89% (95% confidence interval: 75.9%, 96.5%), the overall specificity was 83% (95% confidence interval: 64.5%, 94.7%), the overall positive predictive value was 89%, and the overall negative predictive value was 83% (95% confidence interval: 64.5%, 94.7%). Overall accuracy was 87%.

CONCLUSION

Esophagography is highly accurate in diagnosis of EV and can be considered a viable noninvasive alternative for determination of patients who should be selected for prophylactic treatment.

Diagnosing carotid stenosis by Doppler sonography: state of the art

OBJECTIVE

The goal of this review article is to present the state of the art in the clinical applications and technical performance and interpretation of carotid sonographic examinations.

METHODS

Relevant publications regarding color and duplex Doppler sonography (CDDS) of the carotid arteries extracted from a computerized database (MEDLINE) and from references cited in these articles not appearing on the Internet were reviewed.

RESULTS

The ability to quickly and efficiently identify stenosis in the carotid artery is an important goal for clinicians and vascular surgeons. Identification of potentially treatable carotid stenosis enables selection of appropriate candidates for endarterectomy or stent implantation. Advances in performance and interpretation of carotid sonographic studies over the last 20 years have been driven by technological improvements in gray scale and CDDS examinations and have made carotid sonography an important means to reach this goal. On the basis of CDDS, intima-media thickness measurements and plaque location and characterization on gray scale imaging, flow disturbance and areas of stenosis on color Doppler sonography, and flow velocities on spectral Doppler sonography are obtained. The degree of the diameter of a stenosis of the internal carotid artery is the main parameter used for therapeutic approaches. Advantages and limitations of the method are included.

CONCLUSIONS

Carotid sonography is a unique imaging method for the investigation of carotid abnormalities. Noninvasive, accurate, and cost-effective, it provides morphologic and functional information. It is increasingly becoming the first and often the sole imaging study before endarterectomy, whereas costly and invasive procedures are reserved for special cases.

Computerised analysis of liver texture with correlation to needle biopsy

AIM

To assist in tissue characterisation for the non-invasive diagnosis of diffuse fatty liver infiltration by providing quantitative indices of ultrasonic (US) backscatter with correlation to histology.

METHODS AND MATERIALS

US images from patients referred to US-guided liver needle biopsy (LNB) for persistently elevated liver enzymes or serologically positive markers for viral hepatitis were recorded. The histopathological reports were reviewed. Steatosis, inflammation and degree of fibrosis were scored from 0 (normal) to 3 (severe). Patients with level 3 steatosis without inflammation or fibrosis were selected. US images from twenty-four healthy subjects served as control. Four textural indices were calculated for a selected ROI corresponding to the biopsy site. Sensitivity and specificity of discrimination between the two groups were evaluated.

RESULTS

Fatty and healthy livers formed two distinct clusters. However, in all parametric subspaces there was a slight overlap between the groups with a few numbers of cases located across the dichotomy line.The sensitivity for all the indices was high (90 - 100 %). The specificity for each of the indices was moderate. The co-occurrence local homogeneity index yielded the highest specificity (88.5 %), with a sensitivity equivalent to two of the other indices (90 %).

CONCLUSIONS

Highly accurate "ultrasonic biopsy" may be obtained for severe fatty liver. The described indices can serve as a tool in US computer- aided diagnosis (CAD) of diffuse parenchymal liver disease, in particular for severe steatosis of the liver.

The additional value of PET/CT over PET in FDG imaging of oesophageal cancer

PURPOSE

The aim of this study was to assess the value of combined PET/CT compared with PET reviewed side-by-side with CT, in patients with oesophageal cancer, before and after surgery.

METHODS

Forty-one FDG PET/CT studies were performed in 32 patients with oesophageal cancer, before surgery (n = 18) or during follow-up after resection of the primary tumour (n = 23). One hundred and fifteen sites suspicious for malignancy were evaluated. PET/CT was prospectively compared with PET reviewed side-by-side with CT, for detection, accurate localisation and characterisation of malignant sites. PET/CT performance in different anatomical regions was compared before and after surgery. The impact of fused data on patient management was retrospectively assessed.

RESULTS

PET/CT had an incremental value over PET for interpretation of 25 of 115 sites (22%), changing the initial characterisation of ten sites to either malignant (n = 1) or benign (n = 9), and defining the precise anatomical location of 15 sites. PET/CT provided better specificity and accuracy than PET for detecting sites of oesophageal cancer (81% and 90% vs 59% and 83% respectively, p < 0.01). Fusion was of special value for interpretation of cervical and abdomino-pelvic sites, for disease assessment in loco-regional lymph nodes before surgery and in regions of postoperative anatomical distortion. PET/CT had an impact on the further management of four patients (10%), by detecting nodal metastases that warranted disease upstaging (n = 2) and by excluding disease in sites of benign uptake after surgery (n = 2).

CONCLUSION

PET/CT improves the accuracy of FDG imaging in oesophageal cancer and provides data of diagnostic and therapeutic significance for further patient management.

Is 18F-FDG PET/CT useful for imaging and management of patients with suspected occult recurrence of cancer?

Rising serum tumor markers may be associated with negative imaging in the presence of cancer. CT and (18)F-FDG PET may yield incongruent results in the assessment of tumor recurrence. The present study evaluates the incremental role of (18)F-FDG PET/CT for the diagnosis and management of cancer patients with increasing levels of tumor markers as the sole indicator of potential recurrence after initial successful treatment.

METHODS

Thirty-six cancer patients with increasing levels of tumor markers during follow-up and negative CT underwent (18)F-FDG PET/CT, which showed 111 sites of increased tracer uptake. PET/CT was compared with PET results on a site-based analysis for characterization of (18)F-FDG foci and on a patient-based analysis for diagnosis of recurrence. The clinical impact of PET/CT on further patient management was evaluated.

RESULTS

Thirty patients (83%) had recurrence in 85 malignant sites (77%). For the site-based analysis, PET had a sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 96%, 50%, 85%, 85%, and 82%, respectively, as compared with the performance indices of PET/CT of 100%, 89%, 97%, 97%, and 100%, respectively. There was a statistically significant difference between the specificity (P < 0.05) and accuracy (P < 0.001) of PET and PET/CT for precise characterization of suspected lesions. For the patient-based analysis, PET had a sensitivity, specificity, and accuracy of 93%, 50%, and 86%, respectively, as compared with PET/CT with values of 93%, 67%, and 89%, respectively (P = not significant). PET/CT was the single modality that directed further management and treatment planning in 12 patients (33%).

CONCLUSION

The results of this study indicate that PET/CT may improve the accuracy of occult cancer detection and further lead to management changes in patients with increasing levels of tumor markers as the sole suspicion of recurrent malignancy.