Is there value in repeating lower limb doppler ultrasound for suspected deep venous thrombosis, without clinical reassessment?

Category: Ultrasound Purpose: Lower limb deep vein thrombosis (DVT) causes significant morbidity, posing a diagnostic challenge. The National Institute for Health and Care Excellence (NICE) advises repeat ultrasound evaluation six to eight days after an initial negative scan, if the Well’s Score is ≥2 and D-dimer >230 ng/ml. Occasionally, in our trust, patients in whom symptoms improved have returned for repeat scans. We question the value in rescanning without clinical reassessment, aiming to investigate: a) the frequency of positive repeat scans and b) factors increasing the likelihood of DVT on the second scan. Our aims evolved in the context of the coronavirus (COVID-19) pandemic. Methods and materials: We evaluated 13 months of data (January 2018 to January 2019). Patients with two scans within six weeks (no DVT on initial scan and arranged as per NICE guidance) were selected. We retrospectively analysed data from the trust’s ultrasound database, the CDN radiology information system (CRIS) and electronic patient records system (PPM+). We analysed five months of data following the first UK COVID-19 lockdown (23 March 2020) to evaluate how the positive yield was impacted. Results: Pre-pandemic, of 1,006 patients (412 male, 594 female;age range 18–101), 19 had repeat ultrasound scans that were positive (1.9%). Following the UK national lockdown, of 170 patients, 11 were positive (6.5%). Conclusion: In the pre-lockdown setting, positive yield after a negative ultrasound is low (<2%). We support a clinical reassessment before rescan, combining persistent clinical suspicion with positive D-dimer. In a pandemic context, this has improved diagnostic yield (6.5%, p<0.01);however, long-term safety data is required.

Axillary lymphadenopathy following COVID-19: A case series

Introduction: Since the commencement of the COVID-19 vaccination program, adverse reactions have been thoroughly researched. A mild but clinically significant reaction is axillary lymphadenopathy on the side of vaccination. Moderna have reported an incidence of 11%-16% of patients presenting with symptomatic adenopathy postvaccination, whilst Pfizer and AstraZenaca trials report adenopathy to be a rare event. Axillary lymphadenopathy is of particular interest to the radiology community as it may be a marker of acute inflammatory or malignant disease. A recent paper by Feamann, et al identified a 394% increase in symptomatic and asymptomatic lymphadenopathy detection since early 2021 when compared to the 2 years prior. Lymphadenopathy in oncology and high-risk patients presenting for screening/surveillance, the detection of adenopathy can be highly anxiety inducing. This paper aims to present a case series of patients who presented between March 2021 and February 2022 with imaging detected adenopathy following recent COVID-19 vaccination. Method: A report search of the Radiology Information System (RIS) was performed to identify ultrasound studies between March 2021 and February 2022 with keywords in the report. 114 examinations met the inclusion criteria which were systematically assessed for: time between vaccination and imaging, number/location of abnormal nodes, maximal lymph node size, maximal cortical thickness, presence/ absence of a fatty hilum, hypervascularity, changes to surrounding tissue, follow up imaging, time to resolution. Discussion: Lymphadenopathy may present in a variety of clinical settings including COVID-19 vaccination. This paper will describe the changes to lymph nodes that occur following vaccination and support decision.