The expanding role of sonography for the diagnosis of deep infiltrating endometriosis: Results of a large case series

OBJECTIVE

To investigate the value of the sonographic identification of deep infiltrating endometriosis (DIE) in women presenting with complaints suggestive of DIE. Sonography findings were correlated with subsequent surgical exploration, and histologic verification.

METHODS

A retrospective observational case series was investigated to document the ability of the use of sonography to accurately detect the presence of deep infiltrating endometriosis. The clinical observations were performed consistent with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations for observational studies. Recognizing the real-world office setting for this may introduce the importance of the practical clinical aspects of diagnostic procedures in general.

RESULTS

Three-dimensional transvaginal sonography was able to accurately identify deep invasive endometriosis in 92% of the 100 women subjectively complaining of the associated symptoms of endometriosis, who underwent sonography, surgical exploration, and pathologic analysis. Additional sonographic evidence of pelvic pathology was found during the course of this investigation, perhaps complementing other means for diagnosing endometriosis.

CONCLUSION

Three-dimensional transvaginal sonography is a diagnostic tool that can effectively identify deep infiltrating endometriosis, which may otherwise go undetected and untreated. These findings should encourage the use of sonography for the detection of this subtype of endometriosis.

Proposal for standardized ultrasound analysis of the salivary glands: Part 1 submandibular gland

Objectives

The Salivary Gland Committee of the American Academy of Otolaryngology-Head and Neck Surgery seeks to standardize terminology and technique for ultrasonograpy used in the evaluation and treatment of salivary gland disorders.

Methods

Development of expert opinion obtained through interaction with international practitioners representing multiple specialties. This committee work includes a comprehensive literature review with presentation of case examples to propose a standardized protocol for the language used in ultrasound salivary gland assessment.

Results

A multiple segment proposal is initiated with this focus on the submandibular gland. We provide a concise rationale for recommended descriptive language highlighted by a more extensive supplement that includes an extensive literature review with additional case examples.

Conclusion

Recommendations are provided to improve consistency both in performing and reporting submandibular gland ultrasound.

The clinical value of color ultrasound screening for fetal cardiovascular abnormalities during the second trimester: A systematic review and meta-analysis

BACKGROUND

This meta-analysis aimed to investigate the diagnostic value of color ultrasound screening for fetal cardiovascular abnormalities during the second trimester in China.

METHODS

A literature search was conducted to evaluate the clinical value of color ultrasound screening for fetal cardiovascular abnormalities during the second trimester using English and Chinese databases. Numerical values for sensitivity and specificity were obtained from false-negative, false-positive, true-negative, and true-positive rates, presented alongside graphical representations with boxes marking the values and horizontal lines showing the confidence intervals. Summary receiver operating characteristic (SROC) curves were applied to assess the performance of the diagnostic tests. Data were processed using Review Manager 5.3.

RESULTS

Four studies (151 patients with fetal cardiovascular abnormalities and 3397 undiagnosed controls) met our evaluation criteria. The sensitivity was 0.91 and 0.96, respectively, and the specificity was 1.00. The Area Under the Curve (AUC) from the SROC curves was >90%; therefore, it was classified as excellent. Furthermore, there were 6 types of fetal cardiovascular abnormalities, and the pooled screening rate of atrioventricular septal defects was the highest.

CONCLUSION

Our meta-analysis showed that the use of color ultrasound during the second trimester can be an excellent diagnostic tool for fetal cardiovascular abnormalities.

Role of Ultrasonography and Color Doppler in the Assessment of High-Risk Pregnancies and Their Accuracy in Predicting Fetal Outcome

Introduction Various methods are employed to evaluate the well-being of the fetus in high-risk pregnancies which consists of a biophysical profile (BPP), a non-stress test (NST), and daily fetal movements. Detection of aberrant blood flow in fetoplacental beds has been revolutionized by recent developments in ultrasound technology, such as color Doppler flow velocimetry. The cornerstone of maternal and fetal care is lowering maternal and perinatal mortality and morbidity is antepartum fetal surveillance. Doppler ultrasound is a non-invasive way of obtaining a qualitative and quantitative evaluation of maternal and fetal circulation and is utilized to investigate complications like fetal growth restriction (FGR) and fetal distress. Thus, it is useful in making distinctions between fetuses that are truly growth restricted and small for gestational age and healthy fetuses. The aim of the current study was to determine the role of Doppler indices in high-risk pregnancies and their accuracy in predicting fetal outcomes. Material and methods This prospective cohort study included 90 high-risk pregnancies in the III trimester (after 28 weeks of gestation) on whom ultrasonography and Doppler were performed. Ultrasonography was performed using PHILIPS EPIQ 5, a curvilinear probe of frequency 2-5MHz. Gestational age was determined with a biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femoral length (FL). Placental grading and position were noted. Estimated fetal weight and the amniotic fluid index were calculated. BPP scoring was done. Doppler study was conducted and the findings of Doppler indices that is pulsatility index (PI) and resistive index (RI) of the middle cerebral artery (MCA), umbilical artery (UA), and uterine artery (UTA), and cerebroplacental (CP) ratio in these high-risk pregnancies were documented and compared with standard. The flow patterns in MCA, UA, and UTA were also assessed. These findings were correlated with fetal outcomes.  Results Among 90 cases, the common high-risk factor in pregnancy was preeclampsia without severe features (30%). Growth lag was present in 43 (47.8%) participants. Among the study population, HC/AC ratio was increased in 19 (21.1%) participants which indicates asymmetrical intrauterine growth restriction. Adverse fetal outcomes were seen in 59 (65.6%) of the subjects. CP ratio and UA PI had better sensitivity (83.05% and 79.66%, respectively) and positive predictive value (PPV) (87.50% and 90.38%, respectively) in identifying the adverse fetal outcomes. Diagnostic accuracy of CP ratio and UA PI (Accuracy=81.11%) was highest in predicting adverse outcomes than all the other parameters. Conclusion CP ratio and UA PI had better sensitivity, PPV, and diagnostic accuracy in identifying adverse fetal outcomes than other parameters. The study's findings support that the use of color Doppler imaging in high-risk pregnancies will help in the early identification of adverse fetal outcomes and aid in early intervention. This study is non-invasive, simple, safe, and reproducible. This study can also be performed bedside in high risk and unstable patients. This study is required to accurately assess fetal well-being in all high-risk pregnancies in order to improve fetal outcomes and to incorporate this procedure as a part of the protocol for the assessment of fetal well-being in these patients.

Comparison of PDA diameter measurements using color and 2D echocardiography in newborn infants

BACKGROUND

Patent ductus arteriosus (PDA) diameter is a frequently measured echocardiographic parameter when assessing the PDA. Though, there are recommendations to use 2D echocardiography to measure the PDA diameter, there is paucity of data on how PDA diameter compares when measured using 2D and color echocardiography. The aim of this work was to examine the bias and limits of agreement between measuring PDA diameter using color and 2D echocardiography in newborn infants.

METHODS

This retrospective study examined the PDA using the high parasternal ductal view. Using colour compare, three consecutive cardiac cycles were used to measure PDA diameter at the narrowest point where the PDA joined the left pulmonary artery in both 2D and colour echocardiography by a single operator.

RESULTS

The bias between PDA diameter using color and 2D echocardiography was examined in 23 infants (mean gestation: 28.7weeks). The mean (SD, 95% LoA) bias between color and 2D were 0.45(0.23, -0.005 to 0.91) mm.

CONCLUSION

Color measurements exaggerated PDA diameter measurements when compared to 2D echocardiography.

A Comparative Study on a Novel Quality Assessment Protocol Based on Image Analysis Methods for Color Doppler Ultrasound Diagnostic Systems

Color Doppler (CD) imaging is widely used in diagnostics since it allows real-time detection and display of blood flow superimposed on the B-mode image. Nevertheless, to date, a shared worldwide standard on Doppler equipment testing is still lacking. In this context, the study herein proposed would give a contribution focusing on the combination of five test parameters to be included in a novel Quality Assessment (QA) protocol for CD systems testing. A first approach involving the use of the Kiviat diagram was investigated, assuming the diagram area, normalized with respect to one of the gold standards, as an index of the overall Doppler system performance. The QA parameters were obtained from the post-processing of CD data through the implementation of custom-written image analysis methods and procedures, here applied to three brand-new high-technology-level ultrasound systems. Experimental data were collected through phased and convex array probes, in two configuration settings, by means of a Doppler flow phantom set at different flow rate regimes. The outcomes confirmed that the Kiviat diagram might be a promising tool applied to quality controls of Doppler equipment, although further investigations should be performed to assess the sensitivity and specificity of the proposed approach.

Quantitative Assessment of Boiling Histotripsy Progression Based on Color Doppler Measurements

Boiling histotripsy (BH) is a mechanical tissue liquefaction method that uses sequences of millisecond-long high intensity focused ultrasound (HIFU) pulses with shock fronts. The BH treatment generates bubbles that move within the sonicated volume due to acoustic radiation force. Since the velocity of the bubbles and tissue debris is expected to depend on the lesion size and liquefaction completeness, it could provide a quantitative metric of the treatment progression. In this study, the motion of bubble remnants and tissue debris immediately following BH pulses was investigated using high-pulse repetition frequency (PRF) plane-wave color Doppler ultrasound in ex vivo myocardium tissue. A 256-element 1.5 MHz spiral HIFU array with a coaxially integrated ultrasound imaging probe (ATL P4-2) produced 10 ms BH pulses to form volumetric lesions with electronic beam steering. Prior to performing volumetric BH treatments, the motion of intact myocardium tissue and anticoagulated bovine blood following isolated BH pulses was assessed as two limiting cases. In the liquid blood the velocity of BH-induced streaming at the focus reached over 200 cm/s, whereas the intact tissue was observed to move toward the HIFU array consistent with elastic rebound of tissue. Over the course of volumetric BH treatments tissue motion at the focus locations was dependent on the axial size of the forming lesion relative to the corresponding size of the HIFU focal area. For axially small lesions, the maximum velocity after the BH pulse was directed toward the HIFU transducer and monotonically increased over time from about 20-100 cm/s as liquefaction progressed, then saturated when tissue was fully liquefied. For larger lesions obtained by merging multiple smaller lesions in the axial direction, the high-speed streaming away from the HIFU transducer was observed at the point of full liquefaction. Based on these observations, the maximum directional velocity and its location along the HIFU propagation axis were proposed and evaluated as candidate metrics of BH treatment completeness.

5 Early Pregnancy Diagnosis inbos Taurus beef Replacement Heifers Using Color Doppler Ultrasonography

The objective of this study was to evaluate the use of corpus luteum (CL) color doppler ultrasonography (CD) for early pregnancy diagnosis in Bos taurus beef replacement heifers. Beef heifers (n = 183) from two locations were exposed to a 7-d CO-Synch + CIDR protocol followed by fixed-time artificial insemination (day 0). On days 20 and 22, B-mode and CD ultrasonography were performed to evaluate CL morphometries and blood perfusion, respectively. Heifers were considered non-pregnant when CL area was < 20 mm2 or estimated luteal blood perfusion was ≤ 25%. Conventional ultrasonography on day 29 was utilized to determine pregnancy status and considered the gold standard method for pregnancy diagnosis. Pregnant heifers had greater CL diameter, CL area, and CL volume when compared to non-pregnant heifers on days 20 and 22 (P < 0.001). Additionally, percentage of central, peripheral, and total luteal blood perfusion, as well as the respective blood perfusion scores were greater (P < 0.001) in pregnant compared with non-pregnant heifers on both day 20 and 22. Sensitivity, specificity, positive predicted value (PPV), negative predicted value (NPV), and accuracy for CD on day 20 were 100, 70, 86, 100, and 90, respectively. Sensitivity, specificity, PPV, NPV, and accuracy for CD on day 22 were 100, 76, 90, 100, and 92, respectively. Pairwise comparison of receiver operating characteristics curve analysis indicated no differences (P = 0.47) between CD on days 20 and 22 (area under the curve = 0.82 and 0.84, respectively). In conclusion, CD successfully detected most non-pregnant replacement heifers on day 20 and 22, while false negative results were absent (NPV = 100%).

Luteal color doppler ultrasonography and pregnancy-associated glycoproteins as early pregnancy diagnostic tools and predictors of pregnancy loss in Bos taurus postpartum beef cows

The objective of this study was to evaluate the use of luteal color doppler (CD) ultrasonography and plasma concentrations of pregnancy-associated glycoproteins (PAG) for early pregnancy diagnosis in Bos taurus beef cows. Additionally, CD and PAG were evaluated as potential predictors of late embryonic/early fetal mortality (LEM). Postpartum beef cows (n = 212) were exposed to estrus synchronization followed by fixed-time artificial insemination (day 0). On days 20 and 22, B-mode and CD ultrasonography were performed to evaluate corpus luteum (CL) morphometries and blood perfusion. Moreover, blood samples were collected on days 25 and 29 to quantify circulating concentrations of PAG. Conventional ultrasonography on days 29 and 100 was utilized as the gold-standard method for pregnancy diagnosis. Cows that experienced pregnancy loss between days 29 and 100 were classified as LEM. Pregnant cows had larger and more vascularized CL compared with nonpregnant cows on days 20 and 22 (P < 0.001 for all response variables). Accuracy for CD on days 20 and 22 were 87% and 92%, respectively. Accuracy for PAG on days 25 and 29 were 84% and 99%, respectively. No false negative (FN) results were observed for CD on both days 20 and 22; however, there were 7.1% FN results for PAG on day 25. Cows that experienced LEM had decreased (P = 0.04) circulating PAG on day 29 of gestation compared with cows that maintained pregnancy; however, there were no differences in luteal blood perfusion on days 20 and 22 (P ≥ 0.53) or circulating PAG on day 25 (P = 0.46) between LEM cows and cows that maintained pregnancy. Sensitivity and specificity of PAG on day 29 as predictors of LEM were 83% and 77%, respectively. In conclusion, CD resulted in accurate pregnancy diagnosis in B. taurus beef cows on both days 20 and 22 of gestation, while having no FN results. Circulating concentrations of PAG were decreased in cows that experienced LEM; however, further research is required to utilize PAG as a predictor of LEM commercially.

Unilateral deep vein thrombosis with gangrene involving the ascending aorta with sepsis and pulmonary thromboembolism-a pertinent cutaneous marker of severity of COVID-19

While myriad skin manifestations have been reported with COVID, they are insignificant as compared to the number of cases and do not indicate specificity as the studies that report them have either been based on telephonic consultation or have not been compared with case‐control analysis from a normal skin OPD or IPD referral population. The most feared complication of COVID‐19 is the combination of coagulopathy and thromboembolism, which is consequent to thrombo‐inflammation and a heightened prothrombotic state. It is exaggerated in severe COVID associated with sepsis and skin manifestations that correlate with severity are more useful to clinicians. We had a case of COVID‐positive 65‐year‐old man with features of thromboembolism followed by general symptoms of cough and fever. D‐dimer test was positive, and the Ultrasound Doppler showed thrombosis in the right lower limb arteries and deep vein thrombosis in right lower limb veins.

Fetal carotid-jugular fistula: A case report

RATIONALE

Fetal carotid-jugular fistula is an extremely rare clinical entity that presents as an abnormal passage between the carotid artery and the jugular vein. It is difficult to treat and the chance for a cure is very low. The fetal carotid-jugular fistula causes congestive heart failure and death of the fetus.

PATIENT CONCERNS

We report a case of fetal carotid-jugular fistula diagnosed at 27 weeks of pregnancy. She had no history of viral infection, no history of toxic and radiation exposure, no trauma during pregnancy, and no known family history of malformations or genetic disease.

DIAGNOSES

Ultrasound revealed fetal left carotid-jugular fistula formation, massive reflux in the fetal tricuspid, a large amount of fetal pericardial effusion, fetal left ear microtia and full heart enlargement.

INTERVENTIONS

The pregnant patient experienced termination of the pregnancy at 27 weeks.

OUTCOMES

There were no complications in the patient. Post-termination, diagnosis of carotid-jugular fistula and left ear microtia was confirmed in the fetus.

LESSONS

Our case indicated that the congenital neck artery and venous fistula of the fetus are extremely rare, and its most serious clinical symptom is congestive heart failure leading to intrauterine cessation of pregnancy. In addition, it is difficult to treat and the chance for a cure is very low. At present, there is no treatment record related to the fetal carotid artery and venous fistula, so it is very important to make a correct diagnosis as early as possible for the health of pregnant women.

Assessment and management of a 1.77-cm2 mitral leaflet perforation as a subclinical cause of mitral regurgitation

Anterior mitral valve perforations are commonly due to underlying infective endocarditis, which can lead to significant mitral valve insufficiency. In these cases, clinicians should have a high index of suspicion for infective endocarditis. After appropriate imaging, immediate surgical intervention is unequivocally the choice of management here for optimal patient outcomes.

The Diagnostic Value of Color Doppler Ultrasonography in Predicting Thyroid Nodules Malignancy

BACKGROUND AND OBJECTIVE

Thyroid nodules are common medical and surgical problems. Although ultrasound has been proposed for evaluation of these nodules by many studies, but there is no consensus regarding its diagnostic accuracy and discriminatory cutoffs. We aimed to investigate the diagnostic value of Gray-scale and Color Doppler US in predicting thyroid nodules malignancy.

METHOD

This is an analytical cross-sectional study which was conducted on 63 patients with thyroid nodules. The patients with nodular goiter were evaluated by Color Doppler and Gray scale US, fine needle aspiration and surgery was performed in all the subjects. The sensitivity, specificity, positive predictive value, and negative predictive value of the finding in US and their cut offs were calculated. Data were analyzed by Chi-square and Mann Whitney U test in SPSS19. P-value less than 0.05 considered as statistically significant.

RESULTS

63 patients consisting of 55 (87.3%) female and 8 (12.7%) male patients with the age range of 20-70 years were enrolled in this study. 14% of nodules were reported as malignant in pathology. Singularity, hypo echogenicity, irregular margin, and micro calcification were significantly correlated with malignancy in nodules (p<0.05). Micro calcification and hypo echogenicity of the nodule were the most and the least discriminator of malignancy in nodules (sensitivity 77%, specificity 76% vs. 24%, PPV 41% vs., 14% and NPV 94% vs. 86%) respectively. Pulsatility Index and Mean Systolic Velocity were the most and the least predictor factors of thyroid malignancy (PPV 62% vs. 23% and NPV 100% vs. 91%, respectively). There was a significant association between Resistive Index and Pulsatility Index with malignancy with a cutoff of RI ≥ 0.715 (P=0.005) and PI ≥ 0.945 (P=0.007), respectively. The combination of calcification, RI ≥ 0.715 with PI ≥ 0.945 had a very diagnostic yield for diagnose of malignancy (PPV 66.6% and NPV 98.4%).

CONCLUSION

According to results, it seems that Grayscale US combined with Color Doppler are valuable modalities for evaluating thyroid nodules and can be used as a para-clinical method in order to assess the risk of malignancy in the patient with thyroid nodules.

CoQ10-loaded liposomes combined with UTMD prevented early nephropathy of diabetic rats

Nephropathy is one of the most severe complications of diabetic patients. The therapeutic strategies for diabetic patients should not only focus on the control of blood glucose but also pay attention to the occurrence of diabetic nephropathy (DN). Coenzyme Q10 (CoQ10) has great therapeutic potential for DN. However, the clinical application of CoQ10 has been limited because of its low water-solubility and non-specific distribution. Liposomes were supposed to be an effective way for delivering CoQ10 to kidney. CoQ10 was effectively encapsulated into the liposome (CoQ10-LIP) with a high entrapment efficiency of 86.15 %. The CoQ10-LIP exhibited a small hydrodynamic diameter (180 ± 2.1 nm) and negative zeta potential (-18.20 mV). Moreover, CoQ10-LIP was combined with ultrasound-mediated microbubble destruction (UTMD) to enhance specific distribution of CoQ10 in kidney. In early stage of diabetic mellitus (DM), rats were administrated with CoQ10-LIP followed by UTMD (CoQ10-LIP+UTMD) to prevent occurrence of DN. Results revealed that CoQ10-LIP+UTMD effectively prevented the renal morphology and function of diabetics rats from damage. The protective mechanism of CoQ10-LIP was highly associated with protecting podocyte, promoting vascular repair and inhibiting cell apoptosis. Conclusively, CoQ10-LIP in combination with UTMD might be a potential strategy to prevent occurrence of DN.

Evaluation of Prostatic Lesions by Transrectal Ultrasound, Color Doppler, and the Histopathological Correlation

Objective

To evaluate the role of a transrectal ultrasound (TRUS) guided biopsy and a color Doppler test in the detection of prostate cancer in patients with increased serum prostate-specific antigen (PSA) levels and/or an abnormal digital rectal examination (DRE).

Method

A total of 40 cases, ranging in age from 50 to 80 years and showing increased serum PSA levels (4-10 ng/ml) and/or abnormal DRE, were enrolled and underwent TRUS evaluation followed by color Doppler flowmetric studies. A TRUS-guided biopsy was performed in all the cases. The findings were confirmed histopathologically. Data were analyzed using the chi-square test.

Results

Histopathologically, a total of 13 cases (32.5%) were malignant. On TRUS, irregular shape, heterogeneous echotexture loss of differentiation between the peripheral and internal zones, less mean weight of the prostate, and capsular invasion were significantly associated with malignancy. On flowmetry, moderate vascularity and focal asymmetry were significantly associated with malignancy. The combined use of TRUS and color Doppler flowmetry was found to be 100% sensitive and 92.6% specific and had a positive predictive value (PPV) and a negative predictive value (NPV) of 86.7% and 100%, respectively.

Conclusion

TRUS with color Doppler flowmetry was highly sensitive and specific in the detection of prostate malignancy.

Antenatal diagnosis and prognostic factors of aneurysmal malformation of the vein of Galen: A case report and literature review

RATIONALE

Vein of Galen aneurysmal malformation (VGAM) is a rare complex malformation of the cerebral vascular system consisting of arteriovenous shunts between the vein of Galen and the cerebral arteries.

PATIENT CONCERNS

We present the case of a 31-year-old pregnant woman, para 1, gravida 1.

DIAGNOSES

At 26 weeks' gestation who was examined for an anechoic mass on the cerebral median midline with color and pulsed Doppler. She presented with positive flow on the color and pulsed Doppler test, associated with hydrocephalus, cortical hypoplasia, cardiomegaly, jugular vein distension.

INTERVENTIONS

No intervention for VGAM was done.

OUTCOMES

This case of a VGAM was associated with negative prognostic factors.

LESSONS

The ultrasound color Doppler together with the 3D power Doppler allowed reconstruction of the vascular connections and of the relationship of these with other anatomical structures, which contributed to establishing the prognosis.

Intra-Parenchymal Renal Resistive Index Variation (IRRIV) Describes Renal Functional Reserve (RFR): Pilot Study in Healthy Volunteers

An increase of glomerular filtration rate after protein load represents renal functional reserve (RFR) and is due to afferent arteriolar vasodilation. Lack of RFR may be a risk factor for acute kidney injury (AKI), but is cumbersome to measure. We sought to develop a non-invasive, bedside method that would indirectly measure RFR. Mechanical abdominal pressure, through compression of renal vessels, decreases blood flow and activates the auto-regulatory mechanism which can be measured by a fall in renal resistive index (RRI). The study aims at elucidating the relationship between intra-parenchymal renal resistive index variation (IRRIV) during abdominal pressure and RFR. In healthy volunteers, pressure was applied by a weight on the abdomen (fluid-bag 10% of subject's body weight) while RFR was measured through a protein loading test. We recorded RRI in an interlobular artery after application of pressure using ultrasound. The maximum percentage reduction of RRI from baseline was compared in the same subject to RFR. We enrolled 14 male and 16 female subjects (mean age 38 ± 14 years). Mean creatinine clearance was 106.2 ± 16.4 ml/min/1.73 m(2). RFR ranged between -1.9 and 59.7 with a mean value of 28.9 ± 13.1 ml/min/1.73 m(2). Mean baseline RRI was 0.61 ± 0.05, compared to 0.49 ± 0.06 during abdominal pressure; IRRIV was 19.6 ± 6.7%, ranging between 3.1% and 29.2%. Pearson's coefficient between RFR and IRRIV was 74.16% (p < 0.001). Our data show the correlation between IRRIV and RFR. Our results can lead to the development of a "stress test" for a rapid screen of RFR to establish renal susceptibility to different exposures and the consequent risk for AKI.

Impaired uterine artery flow associated with the presence of ovarian endometrioma: preliminary results of a prospective study

BACKGROUND

Aim of this prospective, case-control study was to evaluate uterine arteries' blood flow before and after laparoscopic surgery in patients with ovarian endometriosis and its possible correlation with infertility.

METHODS

We prospectively enrolled 110 women of reproductive age; 69 with ovarian endometriomas and scheduled for surgery, and 41 controls. At enrolment, a detailed medical, gynecologic and obstetric history was collected. Fertility and pregnancy desire were assessed. All patients underwent complete physical and gynecologic examination. Transvaginal ultrasound with Doppler color flow was performed to evaluate Resistance Index (RI) of uterine arteries during the secretory phase, at enrolment (T0) and 3 months after laparoscopic surgery (T1).

RESULTS

Among cases, 27 patients were excluded because they did not meet the inclusion criteria. At enrolment (T0) unilateral or bilateral flow alterations (RI ≥ 0.8) were found in 38 out of 42 patients with ovarian endometriosis (90%), whereas in the control group only 17 women (41%) had Doppler alterations. The difference in uterine artery RI values between cases and controls was statistically significant (P < 0.0001). A statistically significant improvement in uterine artery flow (P <0.0001) was found 3 months after surgical treatment of endometriosis. Nineteen patients with endometriosis (45%) were infertile before surgery; all of them presented uterine artery Doppler alterations at T0. After surgery the pregnancy rate was significantly higher in patients who presented uterine artery flow normalization than in those with persistent uterine artery flow alterations (p = 0.002).

CONCLUSIONS

A strong correlation was found between uterine artery flow abnormalities and ovarian endometriosis. Uterine artery flow improvement following surgery seems to increase the probabilities of achieving pregnancy.

TRAP Sequence - An Interesting Entity in Twins

Twin reversed arterial perfusion (TRAP) sequence, is a rare malformation occurring in monozygotic multiple gestations. One well-developed normal (pump) twin and the other twin with absent cardiac structure (acardiac), who is hemodynamically dependent on the normal (pump) twin are characteristic of this syndrome. The acardiac twin develops multiple anomalies that make survival difficult. The prognosis of the pump twin is variable with mortality rate ranging from 50% to 70%. Complications that affect the prognosis of the pump twin include complications of congestive cardiac failure due to increased cardiac demand, prematurity secondary to preterm delivery, and polyhydramnios. Because of these complications prompt detection, follow-up, and treatment of this condition is very important. We report two cases of TRAP sequence that emphasizes the importance of gray-scale and color Doppler imaging in diagnosis, detection of poor prognostic features, follow-up, and management of TRAP sequence.

Comparison of ultrasonography with Doppler and MRI for assessment of disease activity in juvenile idiopathic arthritis: a pilot study

BACKGROUND

In juvenile idiopathic arthritis (JIA), the trend towards early therapeutic intervention and the development of new highly effective treatments have increased the need for sensitive and specific imaging. Numerous studies have demonstrated the important role of MRI and US in adult rheumatology. However, investigations of imaging in JIA are rare, and no previous study has been comparing MRI with Doppler ultrasonography (US) for assessment of arthritis. The aim of the present study was to compare the two imaging methods regarding their usefulness for evaluating disease activity in JIA, and to compare the results with those obtained in healthy controls.

METHODS

In 10 JIA patients (median age 14 years, range 11-18), 11 joints (six wrists, three knees, two ankles) with arthritis were assessed by color Doppler US and MRI. The same imaging modalities were used to evaluate eight joints (three wrists, three knees, two ankles) in six healthy age- and sex-matched controls. The US examinations of both the patients and controls were compared with the MRI findings.

RESULTS

In 10 JIA patients, US detected synovial hypertrophy in 22 areas of 11 joints, 86% of which had synovial hyperemia, and MRI revealed synovitis in 36 areas of the same 11 joints. Erosions were identified by US in two areas of two joints and by MRI in six areas of four joints. Effusion was shown by US in nine areas of six joints and by MRI in 17 areas of five joints. MRI detected juxta-articular bone marrow edema in 16 areas of eight joints.

CONCLUSIONS

The results of this pilot study indicate that both MRI and US provide valuable imaging information on disease activity in JIA. Importantly, the two techniques seem to complement each other and give partly different information. Although MRI is considered to be the reference standard for advanced imaging in adult rheumatology, US seems to provide useful imaging information that could make it an option in daily clinical practice, in JIA as well as in adult rheumatology. However, the current work represents a pilot study, and thus our results need to be confirmed in a larger prospective clinical investigation.

Ultrasonography and color Doppler in juvenile idiopathic arthritis: diagnosis and follow-up of ultrasound-guided steroid injection in the wrist region. A descriptive interventional study

BACKGROUND

The wrist region is one of the most complex joints of the human body. It is prone to deformity and functional impairment in juvenile idiopathic arthritis (JIA), and is difficult to examine clinically. The aim of this study was to evaluate the role of ultrasonography (US) with Doppler in diagnosis of synovitis, guidance of steroid injections, and follow-up examinations of the wrist in JIA.

METHODS

In 11 patients (median age 12.5 years, range 2-16), 15 wrists with clinically active arthritis were assessed clinically by US and color Doppler (Logiq 9, GE, 16-4 MHz linear transducer) prior to and 1 and 4 weeks after US-guided steroid injection.

RESULTS

US detected synovitis in the radio-carpal joints, the midcarpal joints, and the tendon sheaths in 87%, 53% and 33% of the wrists, respectively. Multiple compartments were involved in 67%. US-guidance allowed accurate placement of steroid in all 21 injected compartments, with a low rate of subcutaneous atrophy. Synovial hypertrophy was normalized in 86% of the wrists, hyperemia in 91%, and clinically active arthritis in 80%.

CONCLUSIONS

US enabled detection of synovial inflammation in compartments that are difficult to evaluate clinically and exact guidance of injections, and it was valuable for follow-up examinations. Normalization of synovitis was achieved in most cases, which supports the notion that US is an important tool in management of wrist involvement in JIA.

Preoperative localization of parathyroid lesion: diagnostic usefulness of color doppler ultrasonography

INTRODUCTION

Recently, minimally invasive parathyroidectomy (MIP) has been developed and is gaining popularity among surgeons. For this reason, preoperative localization is playing an important role to detect the precise location of the affected gland and to increase the success rate.

MATERIAL AND METHODS

From June 2007 to June 2011, 56 consecutive patients (11 men and 45 women) with primary or secondary hyperparathyroidism in our center underwent Gray scale, color Doppler and 99m-Tc MIBI scan prior to operative management of parathyroid lesions.

RESULTS

The sensitivity, specificity and accuracy of US and MIBI scan for pHPT was 88%, 94%, 91% and 70%, 100% and 85% respectively. In patients with sHPT, the sensitivity, specificity and accuracy of US and MIBI scan was 54%, 93%, 76% and 25%, 100% and 72.9% respectively. The overall sensitivity of combined US and MIBI scan in pHPT and sHPT was 97% and 45% respectively. The overall sensitivity, specificity and accuracy of CDUS in diagnosis of parathyroid lesions in pHPT and sHPT is 97%, 100%, 98.6% and 62%, 100% and 83% respectively.

CONCLUSION

The overall sensitivity and specificity of US and MIBI in preoperative localization of parathyroid adenoma in sHPT is lower than pHPT and performing CDUS can increases the overall sensitivity and specificity of imaging methods in accurate localization of parathyroid lesion.

Cervical varix as a cause of vaginal bleeding during pregnancy: prenatal diagnosis by color Doppler ultrasonography

Vaginal bleeding during pregnancy is a risk factor for adverse pregnancy outcome. Beyond 20 weeks of gestation, the most frequent causes of bleeding associated with maternal and perinatal morbidity and mortality are placenta previa and placental abruption. Cervical varix during pregnancy is a rare condition. To our knowledge, only six cases have been reported in the literature. Most of these cases were associated with preterm birth and high maternal morbidity. The optimal management and mode of delivery remain undetermined. We report a case of cervical varix diagnosed by transvaginal ultrasound at 21 weeks of gestation. The pregnancy was complicated by several episodes of vaginal bleeding and the patient delivered at 32 weeks. Color and power Doppler examination of the cervix played a key role in establishing the diagnosis.