Quantitative ultrasound (QUS) in the evaluation of liver steatosis: data reliability in different respiratory phases and body positions

Liver steatosis is the most common chronic liver disease and affects 10-24% of the general population. As the grade of disease can range from fat infiltration to steatohepatitis and cirrhosis, an early diagnosis is needed to set the most appropriate therapy. Innovative noninvasive radiological techniques have been developed through MRI and US. MRI-PDFF is the reference standard, but it is not so widely diffused due to its cost. For this reason, ultrasound tools have been validated to study liver parenchyma. The qualitative assessment of the brightness of liver parenchyma has now been supported by quantitative values of attenuation and scattering to make the analysis objective and reproducible. We aim to demonstrate the reliability of quantitative ultrasound in assessing liver fat and to confirm the inter-operator reliability in different respiratory phases. We enrolled 45 patients examined during normal breathing at rest, peak inspiration, peak expiration, and semi-sitting position. The highest inter-operator agreement in both attenuation and scattering parameters was achieved at peak inspiration and peak expiration, followed by semi-sitting position. In conclusion, this technology also allows to monitor uncompliant patients, as it grants high reliability and reproducibility in different body position and respiratory phases.

Imaging of Ganglioneuroma: A Literature Review and a Rare Case of Cystic Presentation in an Adolescent Girl

Retroperitoneal ganglioneuroma is a rare neuroectodermal tumor with a benign nature. We performed a literature review among 338 studies. We included 9 studies, whose patients underwent CT and/or MRI to characterize a retroperitoneal mass, which was confirmed to be a ganglioneuroma by histologic exam. The most common features of ganglioneuroma are considered to be a solid nature, oval/lobulated shape, and regular margins. The ganglioneuroma shows a progressive late enhancement on CT. On MRI it appears as a hypointense mass in T1W images and with a heterogeneous high-intensity in T2W. The MRI-"whorled sign" is described in the reviewed studies in about 80% of patients. The MRI characterization of a primitive retroperitoneal cystic mass should not exclude a cystic evolution from solid masses, and in the case of paravertebral location, the differential diagnosis algorithm should include the hypothesis of ganglioneuroma. In our case, the MRI features could have oriented towards a neurogenic nature, however, the predominantly cystic-fluid aspect and the considerable longitudinal non-invasive extension between retroperitoneal structures, misled us to a lymphatic malformation. In the literature, it is reported that the cystic presentation can be due to a degeneration of a well-known solid form while maintaining a benign character: the distinguishing malignity character is the revelation of immature cells on histological examination.

Gastric cancer surgery: clinical outcomes and prognosis are influenced by perioperative blood transfusions

Gastric cancer in patients is often associated with bleeding; when it occurs, especially in the presence of an anemia, a transfusion is necessary to avoid further deterioration of the patient's clinical state. The aim of this study was to evaluate the relationship between the administration of peri-operative transfusions due to the anemia or the clinical status and the post-operative clinical outcomes. 188 patients diagnosed with of gastric cancer were recruited at Surgery 2 of the Department of General and Specialist Surgery of the Tertiary Care Hospital "A. Cardarelli" of Naples. All patients had a total or a subtotal gastrectomy accompanied by D2 lymphectomy for gastric cancer. The clinical data most frequently associated with blood transfusion is the appearance of a post-operative infection (OR 2.26, 95% CI 0.87-5.79, P = 0.061). If the administration time of transfusion is considered, the clinical outcomes are different: preoperative transfusions showed a higher incidence of infections (OR 2.26, 95% CI 0.87-5.79, P = 0.061) and acute renal failure (OR 2.82, 95% CI 0.70-10.78, P = 0.078); patients who received intra or post-operative transfusions showed a prolonged hospitalization (OR 8.66, 95% CI 1.73-83.00, P = 0.002). The administration of blood products in the perioperative period is correlated in a statistically significant manner to the incidence of infections, acute renal failure and prolonged hospitalization; therefore, transfusions should be avoided unless clinically necessary and in particular intraoperative transfusions should be avoided because the immunomodulation effect linked to surgical stress may be enhanced hence worsening the prognosis.

Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion

OBJECTIVE

To investigate the association between application of fundal pressure during the second stage of labor (Kristeller maneuver) and the risk of levator ani muscle (LAM) injury.

METHODS

This was a prospective case-control study of women recruited immediately after their first vaginal delivery in our university hospital between March 2014 and September 2016. Women who underwent the Kristeller maneuver were recruited as cases. For each case, a control (no Kristeller) was recruited matched for body mass index, use of epidural analgesia, duration of second stage of labor and birth weight. All women were invited to undergo four-dimensional (4D) transperineal ultrasound (TPU) 3-6 months postpartum. The main outcome measure was the presence of LAM avulsion on 4D-TPU. TPU results were compared between cases and controls. Multivariate logistic regression analysis was performed to identify independent risk factors for LAM avulsion.

RESULTS

During the study period, 134 women in the Kristeller maneuver group and 128 women in the control group underwent TPU assessment. Women who underwent the Kristeller maneuver had a higher prevalence of LAM avulsion than did controls (38/134 (28.4%) vs 18/128 (14.1%); P = 0.005). In addition, women in the Kristeller-maneuver group had a larger hiatal area on maximum Valsalva maneuver and a greater increase in hiatal area from rest to maximum Valsalva. On multivariate logistic regression analysis, use of the Kristeller maneuver was the only independent factor associated with LAM avulsion (odds ratio, 2.5 (95% CI, 1.29-4.51)).

CONCLUSION

The Kristeller maneuver is associated with an increased risk of LAM avulsion when applied in women during their first vaginal delivery. This should be taken into account when deciding to use fundal pressure to accelerate the second stage of labor and when counseling women following childbirth. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Is curved three-dimensional ultrasound reconstruction needed to assess the warped pelvic floor plane?

OBJECTIVES

Caudal distension of the female pelvic floor is common and results in perineal descent and a caudally curved levator hiatus (warping). Image reconstruction of the pelvic floor using currently available ultrasound techniques involves a linear approach (flat-plane reconstruction). We aimed to evaluate the feasibility, reproducibility and potential usefulness of a new three-dimensional (3D) technique capable of reconstructing a curved plane of the levator hiatus.

METHODS

Primiparous women were recruited to undergo a 3D/four-dimensional transperineal ultrasound examination 3-6 months after delivery. Levator ani muscle warping was evaluated on Valsalva maneuver by measuring the distance between the plane extending from the pubic rami to the anorectal angle and the plane of minimal hiatal dimensions on the coronal plane. Warping distance was used to reconstruct a curved plane of the levator hiatus using the curved OmniView volume contrast imaging (VCI) technique (C-OV). Intra- and interobserver reproducibility of the C-OV technique were assessed, as was intermethod agreement between the C-OV technique and the linear OmniView-VCI (L-OV) technique, for the measurement of levator hiatal area on Valsalva maneuver.

RESULTS

Measurement of the levator hiatal area using C-OV was feasible in all 84 women recruited. The warping distance ranged from -3.5 to 9.7 mm, confirming that the 1-2-cm slice thickness traditionally used for linear reconstruction was adequate for proper assessment of levator hiatal area in our population. C-OV showed excellent intra- and interobserver reproducibility, as well as excellent agreement with the L-OV technique for measuring levator hiatal area. No systematic difference was demonstrated in any of the reproducibility studies performed.

CONCLUSIONS

3D reconstruction of the warped levator hiatal plane is feasible and highly reproducible. In our population, reconstruction of a curved plane to correct for levator hiatal warping did not offer any benefit over the traditionally performed linear reconstruction. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Caregiver's satisfaction with a video tutorial for shoulder dystocia management algorithm

In our questionnaire, a video tutorial illustrating the management of shoulder dystocia was considered by health personnel as a useful complementary training tool. We prepared a 5-min video tutorial on the management of shoulder dystocia, using a simulator that includes maternal pelvic and baby models. We performed a survey among obstetric personnel in order to assess their opinion on the tutorial by inviting them to watch the video tutorial and answer an online questionnaire. Five multiple-choice questions were set, focusing on the video's main objectives: clarity, simplicity and usefulness. Following the collection of answers, global and category-weighted analyses were conducted for each question. Out of 956 invitations sent, 482 (50.4%) answered the survey. More than 90% of all categories found the video tutorial to be clinically relevant and clear. For revising the management of shoulder dystocia most obstetric personnel would use the video tutorial together with traditional textbooks. In conclusion, our video tutorial was considered by health personnel as a useful complementary training tool.