Gynecologic ultrasound.

For most women, pelvic sonography using a transvaginal probe is the imaging modality of choice for evaluating the uterus and adnexae. It is reliable for detecting ovarian cysts and other adnexal masses, and it can often determine if a lesion can be observed on serial examinations or if it requires more urgent attention. Uterine ultrasound is reliable for evaluating both the normal and abnormal endometrium and myometrium. In cases that are technically limited, or in those that are difficult to interpret, a tailored MR imaging examination often can be helpful.

Reduced quality of life in patients with chronic hepatitis C: effects of interferon treatment.

BACKGROUND: Quality of life is an area of increasing interest in hepatology. Studies, so far, have assessed quality of life in patients with chronic virus C-related hepatitis in relation to antiviral therapy by means of generic questionnaires. AIM: To measure quality of life in chronic hepatitis patients without cirrhosis by means of the Nottingham Health Profile questionnaire, a measure of "distress" in comparison with the Medical Outcome Survey SF-36, an index of well-being. PATIENTS: A series of 126 outpatients with chronic hepatitis; 37 on and 89 not on active interferon treatment. METHODS: The two questionnaires were used in random order. Clinical and laboratory data were also collected. The final score of any domain of the two questionnaires, for any individual patient, was compared to age-adjusted normal values obtained in 2 random samples of Italian population. RESULTS: Patients showed a significant modification of 3 domains of Nottingham Health Profile (Energy, Social Isolation and Physical Mobility) and 6 domains of SF-36. In relation to interferon treatment, the Nottingham Health Profile questionnaire was able to detect differences in Energy, Physical Mobility and Pain, which were modified only in treated patients. SF-36 did not show any differences in relation to treatment. In addition, the Nottingham Health Profile demonstrated that treated patients had a lower prevalence of concern for family life, possibly due to expectations of treatment itself. CONCLUSIONS: Active interferon treatment causes considerable distress in chronic hepatitis C patients, adding to the perceived change in health status caused by liver disease.

Drinking habits of subjects with hepatitis C virus-related chronic liver disease: prevalence and effect on clinical, virological and pathological aspects.

Alcohol changes the progression of hepatitis C virus (HCV)-related chronic liver disease and may affect the outcome of interferon therapy. The ethanol intake of 245 patients with biopsy-proven chronic hepatitis C with or without cirrhosis, its interaction with laboratory and histological parameters common to alcohol and HCV-mediated liver damage, and its effects on therapy were evaluated. The results show that 60-70% of subjects regularly consumed alcohol (median intake >40 g/day in about 30%). Less than 50% stopped drinking after being diagnosed as having liver disease. Ethanol intake affected: fibrosis, especially in women, HCV RNA levels, which were significantly lower in abstainers than in drinkers (0.6 +/- 0.3 vs 6.9 +/- 5.9 Eq/ml x10(6); P < 0.01), and response to interferon therapy. The number of responders decreased as ethanol intake increased. There were less abstainers than drinkers among non-responders (10.7% vs 63.1% respectively; P < 0.001). Data indicate that alcohol will induce and worsen liver damage and, in subjects with chronic liver disease who continue to drink, adversely affect their response to treatment.

Can dietary intake influence plasma levels of amino acids in liver cirrhosis?

BACKGROUND: Modifications in plasma amino acid patterns in cirrhotics are attributed to impaired liver function, being more evident in alcoholic than in viral cirrhosis. AIM: To evaluate whether diet influences plasma amino acid concentrations in different aetiological groups of cirrhotics. PATIENTS: Study population comprised 40 patients with cirrhosis (25 virus- and 15 alcohol-related], all Child A, and 30 healthy subjects (controls). METHOD: A food frequency and quality questionnaire was utilized to determine dietary history and alcohol intake. Nutritional status was evaluated by anthropometric method. Amino acids were determined, on venous blood samples, using a specific analyzer while cysteine was evaluated by fluorescent high power liquid chromatography RESULTS: The total daily intake of calories, proteins, lipids, and carbohydrates was similar in all individuals. Food quality distinguished the cirrhotics from the controls, but not the different aetiological groups of cirrhotics. Plasma cysteine levels were significantly lower, while aromatic amino acids and methionine were significantly higher, in all cirrhotics (p<0.001 and p<0.01, respectively, versus controls). The decrease in cysteine and the increase in other amino acids were more marked in alcoholics (p<0.01). CONCLUSIONS: Ethanol intake, but not diet, further enhances the changes in plasma aromatic amino acids, methionine and cysteine induced by impaired liver function in patients with cirrhosis, suggesting a direct interference of alcohol in their metabolism.

Sonographically detected subarachnoid hemorrhage: an independent predictor of neonatal posthemorrhagic hydrocephalus?

Blood from an intraventricular hemorrhage (IVH) can collect in the basilar cisterns and cause ventriculomegaly and eventual need for ventriculoperitoneal (VP) shunt. We looked for sonographic evidence of subarachnoid hemorrhage (SAH) in three basal cisterns and in the Sylvian fissure of 82 infants with IVH, 30 of whom had ventriculomegaly. We found that ultrasonographically diagnosed SAH and measurement of ventricular blood volume predict ventriculomegaly and need for VP shunt.

Ethanol consumption, amino acid and glutathione blood levels in patients with and without chronic liver disease.

BACKGROUND: Ethanol abuse and liver cirrhosis cause a reduction of glutathione blood levels; liver cirrhosis induces an alteration of the plasma amino acid pattern. We evaluated whether or not ethanol abuse affects amino acid levels, particularly those that are involved in metabolizing glutathione in the plasma and erythrocytes of chronic alcohol abusers with or without liver cirrhosis. METHODS: We studied 10 chronic alcohol abusers without liver cirrhosis, 10 with alcoholic cirrhosis, 10 affected by hepatitis C virus-related cirrhosis, and 10 healthy subjects. Glutathione, y-glutamyl-cysteine, and cysteine were determined by fluorescent HPLC, glutamic acid, glycine, and other free amino acids by cation exchange chromatography both in the plasma and erythrocytes of all studied subjects. RESULTS AND CONCLUSIONS: In both alcoholics and cirrhotics, we found a significant increase of plasma-aromatic amino acid and methionine levels, whereas glutathione was significantly reduced. The erythrocytes of these patients showed a significant increase of cysteine, glutamic acid, and glycine; gamma-glutamylcysteine was normal; and glutathione and other free amino acids were significantly decreased. Data suggest that, independent of liver cirrhosis, ethanol abuse affects the metabolism of amino acids and glutathione in both the plasma and the erythrocytes.

Maternal infection, fetal inflammatory response, and brain damage in very low birth weight infants. Developmental Epidemiology Network Investigators.

Echolucent images (EL) of cerebral white matter, seen on cranial ultrasonographic scans of very low birth weight newborns, predict motor and cognitive limitations. We tested the hypothesis that markers of maternal and feto-placental infection were associated with risks of both early (diagnosed at a median age of 7 d) and late (median age = 21 d) EL in a multi-center cohort of 1078 infants <1500 x g. Maternal infection was indicated by fever, leukocytosis, and receipt of antibiotic; fetoplacental inflammation was indicated by the presence of fetal vasculitis (i.e. of the placental chorionic plate or the umbilical cord). The effect of membrane inflammation was also assessed. All analyses were performed separately in infants born within 1 h of membrane rupture (n = 537), or after a longer interval (n = 541), to determine whether infection markers have different effects in infants who are unlikely to have experienced ascending amniotic sac infection as a consequence of membrane rupture. Placental membrane inflammation by itself was not associated with risk of EL at any time. The risks of both early and late EL were substantially increased in infants with fetal vasculitis, but the association with early EL was found only in infants born > or =1 after membrane rupture and who had membrane inflammation (adjusted OR not calculable), whereas the association of fetal vasculitis with late EL was seen only in infants born <1 h after membrane rupture (OR = 10.8; p = 0.05). Maternal receipt of antibiotic in the 24 h just before delivery was associated with late EL only if delivery occurred <1 h after membrane rupture (OR = 6.9; p = 0.01). Indicators of maternal infection and of a fetal inflammatory response are strongly and independently associated with EL, particularly late EL.

White matter disorders of prematurity: association with intraventricular hemorrhage and ventriculomegaly. The Developmental Epidemiology Network.

OBJECTIVES: Because intraventricular hemorrhage (IVH) often precedes the development of sonographically defined white matter damage (WMD) in very preterm infants, we sought to identify the IVH characteristics that predict WMD. HYPOTHESES: We evaluated variations on the null hypothesis that infants with IVH are no more likely than infants without IVH to have WMD. These variations dealt with characteristics of the IVH (presence or absence of ventriculomegaly) or characteristics of the WMD (size, localization, and laterality). METHODS: A total of 1605 infants weighing 500 to 1500 g at birth between January 1991 and December 1993 underwent standardized cranial ultrasound studies with 6 standard coronal and 5 sagittal views at postnatal days 1 to 3, 7 to 10, and at 3 to 8 weeks. RESULTS: A total of 129 (8%) infants had WMD, either an echodensity alone (n = 59), an echolucency alone (n = 18), or both (n = 52). In analyses that controlled for gestational age, IVH was associated with a fivefold to ninefold increased risk of WMD regardless of size, laterality, or extent of lesions (P

Determination of plasma alpha-glutathione-S-transferases in chronic alcohol abusers: relationship with alcohol intake and liver involvement.

UNLABELLED: Alpha-gluthathione-S-transferases (alpha-GSTs) are enzymes involved in the cellular detoxifying processes; elevated circulating alpha-GSTs activity is considered to be an early index of liver damage. Glutathione (GSH) is the substrate for alpha-GST action. THE AIMS OF OUR STUDY WERE: (1) to evaluate plasma GSH levels and alpha-GST activity in chronic alcohol abusers with or without liver cirrhosis; (2) to define the relationship between these two biochemical parameters; (3) to establish their clinical relevance in patients with alcohol abuse and/or liver damage. We studied 69 subjects (18 healthy subjects and 51 chronic alcohol abusers: 29 without liver cirrhosis and 22 with). Plasma alpha-GST activity was determined on baseline samples and every following day for a total of 10 days in five alcoholics by HEPKIT (Alpha-Biotech, Biotrin International, Dublin, Ireland). GSH was determined on all subjects' baseline samples by fluorescent high-performance liquid chromatography. Alcohol intake was evaluated in all patients by determining blood-alcohol concentrations. Significant increases in plasma alpha-GSTs were observed in 9/29 (31%) alcoholics and 3/22 (13.6%) cirrhotics irrespective of their alcohol intake. GSH was significantly lower than normal values (P < 0.001) in all alcoholics with or without cirrhosis (controls 10.4 +/- 4.8; alcoholics without cirrhosis 3.9 +/- 1.4; alcoholics with cirrhosis 3.3 +/- 1.6). No correlation was observed between plasma alpha-GST and GSH levels. Our data indicate that: (1) alpha-GST activity does not correlate with GSH levels in the plasma; (2) alpha-GSTs do not have clinical relevance as markers of recent alcohol intake; (3) in cirrhotics, alpha-GST does not provide more information than other liver function tests. However, plasma alpha-GST determination may be useful in selecting a subgroup of alcoholics in whom routine biochemical markers of liver damage are within reference ranges.

Benign and malignant ovarian masses: selection of the most discriminating gray-scale and Doppler sonographic features.

PURPOSE: To determine the gray-scale and Doppler sonographic features that best enable discrimination between malignant and benign ovarian masses and develop a scoring system for accurate diagnosis with these features. MATERIALS AND METHODS: Gray-scale and Doppler sonographic features of 211 adnexal masses were correlated with the final diagnosis; the most discriminating features for malignancy were selected with stepwise logistic regression. RESULTS: Twenty-eight masses were malignant and 183 benign. All masses with a markedly hyperechoic solid component or no solid component were benign. For masses with a nonhyperechoic solid component, additional features that allowed statistically significant discrimination of benignity from malignancy were, in decreasing order of importance, (a) location of flow at conventional color Doppler imaging, (b) amount of free intraperitoneal fluid, and (c) presence and thickness of septations. A scoring formula that made use of values based on the logistic regression equation had an area under the receiver operating characteristic curve of 0.98 +/- 0.01. The cutoff score with the highest accuracy had a sensitivity of 93% and specificity of 93%. CONCLUSION: A solid component is the most statistically significant predictor of a malignant ovarian mass. A multiparameter scoring system that uses three gray-scale and one Doppler feature, developed by means of stepwise logistic regression, has high sensitivity and specificity for predicting malignancy.

The correlation between placental pathology and intraventricular hemorrhage in the preterm infant. The Developmental Epidemiology Network Investigators.

The aim of this study is to better understand the relationship between placental pathology and risk of intraventricular hemorrhage (IVH). We address two specific hypotheses. 1) Morphologic correlates of pregnancy-induced hypertension (PIH) are associated with a decreased risk of IVH. 2) Morphologic correlates of amniotic sac inflammation (ASI) are associated with an increased risk of IVH. Maternal, neonatal, and placental data were analyzed by univariate and multivariate methods in this prospective cohort study of 1095 very low birth weight infants. A cluster analysis model was used to categorize the placental pathologic features into clusters, the two main ones being PIH and ASI. Deliveries were subdivided by the interval between membrane rupture and delivery as an index of preexisting infection (<1 h) and ascending infection (> or =1 h). Univariate analysis supports both hypotheses. However, in multivariate models that adjusted for such potential confounders as gestational age, labor, and route of delivery, the only associations that persisted were the increased risk of IVH associated with the presence of chorionic or umbilical vasculitis in infants born within 1 h of membrane rupture. Placental correlates of PIH do not provide additional information about IVH risk independent of the presence of other components of the PIH and ASI clusters, and confounders such as gestational age, labor, and route of delivery. Placental correlates of ASI, specifically the fetal responses of chorionic and umbilical vasculitis to preexisting infection, are associated with an increased risk of IVH independent of confounders. Cytokines may provide the link between placental inflammation and fetal/neonatal brain hemorrhage.

Physiological profiles of elite off-road and road cyclists.

There are minimal scientific data describing international caliber off-road cyclists (mountain bikers), particularly as they compare physiologically with international caliber road cyclists. Elite female (N = 10) and male (N = 10) athletes representing the United States National Off-Road Bicycle Association (NORBA) Cross-Country Team were compared with elite female (N = 10) and male (N = 10) athletes representing the United States Cycling Federation (USCF) National Road Team. Submaximal and maximal exercise responses were evaluated during the "championship" phase of the training year when athletes were in peak condition. All physiological tests were conducted at 1860 m. Among the female athletes, physiological responses at lactate threshold (LT) and during maximal exercise (MAX) were similar between NORBA and USCF cyclists with two exceptions: 1) USCF cyclists demonstrated a significantly greater (P < 0.05) absolute (16%) and relative (10%) maximal aerobic power, and 2) MAX heart rate was significantly higher (P < 0.05) for the USCF athletes (6%). Among the male athletes, physiological responses at LT and MAX were similar between NORBA and USCF cyclists with two exceptions: 1) USCF cyclists produced significantly greater (P < 0.05) absolute (18%) and relative (16%) power at LT, and 2) USCF cyclists produced significantly greater (P < 0.05) absolute (12%) and relative (10%) power at MAX. These data suggest that, in general, elite off-road cyclists possess physiological profiles that are similar to elite road cyclists.

Solid extratesticular masses evaluated with sonography: pathologic correlation.

PURPOSE: To determine if the sonographic appearance of solid extratesticular masses enables distinction of benign from malignant disease. MATERIALS AND METHODS: Sonograms of 19 patients with palpable testicular masses who underwent biopsy were reviewed retrospectively. Appearances of masses on sonograms were correlated with pathologic diagnoses. RESULTS: All masses were well defined and ranged in size from 5.7 to 66.7 mm (mean, 21 mm). On the sonograms, five masses were within the epididymis, and six were distinct from it; seven cases were indeterminate. The epididymis was surgically absent in the remaining patient. Sonographic echogenicity ranged from hypoechoic to hyperechoic relative to that of the testis. At pathologic evaluation, there were 16 (84%) benign and three (16%) malignant lesions. Benign lesions consisted of six adenomatoid tumors, two lipomas, two epidermoid inclusion cysts, two cases of sarcoidosis, and one case each of sperm granuloma, spermatic cord leiomyoma, benign inflammatory nodule, and fibroma. The malignant lesions consisted of scrotal wall liposarcoma, epididymal leiomyosarcoma, and recurrent spindle cell malignancy of the spermatic cord. No sonographic features of masses were useful for distinguishing benign from malignant lesions. CONCLUSION: The frequency of malignancy (16%) contrasts with prior reports that suggest a very low rate of malignancy among these masses. Sonography is useful for identifying the extratesticular location of a mass but not for distinguishing the nature of the lesion.

Role of Doppler ultrasonography in the prediction of pregnancy outcome in women with recurrent spontaneous abortion.

We prospectively studied 96 patients with a history of recurrent spontaneous abortion to determine whether the resistive index of the main uterine artery or subchorionic vessels can allow prediction of pregnancy outcome. The subchorionic RI declined progressively for a mean of 0.54 at 6 weeks to 0.42 at 13 weeks (P < 10(-8), F-test). No significant difference was found in subchorionic RI values between outcomes for liveborn infants versus loss. Uterine artery RI values also declined significantly through the first trimester (P < 10(-8), F-test). Uterine artery RI values tended to be lower in pregnancies ending in loss than in successful gestations; however, there was too much overlap for this index to be clinically useful. In conclusion, first trimester RI does not allow prediction of pregnancy outcome in patients with recurrent abortion.

Effect of alcohol abuse and glutathione administration on the circulating levels of glutathione and on antipyrine metabolism in patients with alcoholic liver cirrhosis.

Glutathione (GSH) is a principal cellular scavenger of free radicals. Chronic alcohol abuse, as well as liver disease, induces a decrease of hepatic GSH. We evaluated the effect of GSH administration (2.4 g day-1 in saline i.v. for 15 days) on the concentration of GSH in plasma and erythrocytes and on liver function tests, including galactose and antipyrine tests. We studied 40 alcoholic cirrhotic patients: 22 treated with GSH (10 persistent alcohol abusers and 12 weaning from alcohol during the study) and 18 treated with saline only (8 persistent alcohol abusers and 10 abstainers). Treatment with GSH improved the concentration of GSH in plasma and erythrocytes only in abstainers from alcohol; it did not affect liver function tests or galactose clearance. Persistent alcohol consumption significantly prolonged antipyrine metabolism; GSH administration counteracted this effect.

Increasing curvature of the normal fetal ductus arteriosus with advancing gestational age.

In order to determine whether the configuration of the normal fetal ductus arteriosus changes with increasing gestational age, we prospectively collected oblique transverse sonographic images of the fetal thorax through the ductus arteriosus. Scans from 240 consecutive normal fetuses with gestational age 20 weeks or more were included in the study. The images were reviewed independently by two sonologists and the ductus arteriosus was graded as: (1) straight; (2) mildly curved (C-shaped, bending < 90 degrees from a straight line); or (3) markedly curved (C-shaped, bending > 90 degrees, or S-shaped). In cases where the two sonologists' gradings did not concur, the images were re-reviewed jointly by both sonologists and a grading was assigned by consensus. Forty-two cases were rejected, due to inadequate images. The ductus arteriosus was graded in 42 fetuses aged 20-25.9 weeks, 48 at 26-31.9 weeks, 74 at 32-37.9 weeks, and 34 at 38 weeks or more for a total of 198 cases. There was a significant trend to greater curvature with increasing gestational age (p < 0.0001). The frequency of a straight ductus arteriosus decreased steadily from 55% of fetuses aged 20-25.9 weeks to 3% of fetuses at 38 weeks or older, while the frequency of marked curvature increased from 2% in the youngest age group to 56% in the oldest. The proportion with mild curvature showed little variation throughout gestation. In summary, the configuration of the ductus arteriosus is variable but tends to become more curved as pregnancy proceeds. Marked curvature or tortuosity of the ductus arteriosus should not be misinterpreted as a great vessel anomaly.

Distal ureteral calculi: detection with vaginal US.

PURPOSE: To describe the use of vaginal ultrasonography to identify distal ureteral calculi and hydroureter. MATERIALS AND METHODS: Abdominal and vaginal sonography were performed in 13 women with distal ureteral calculi. Indications for sonography included flank pain, hematuria, and suspected appendicitis. Six patients were pregnant. RESULTS: In each patient, vaginal sonograms demonstrated a distal ureteral calculus; in only two cases was the calculus detected with transabdominal sonography. Distal hydroureter was identified with vaginal scanning in each patient but with abdominal scanning in only two. Hydronephrosis was absent in three patients, mild in six, and moderate in four. Symmetric ureteral jets were noted at transabdominal sonography in two of nine patients. Follow-up transvaginal scans obtained shortly after passage of stones in two patients revealed swelling of the trigone but normal ureteral jets. CONCLUSION: In symptomatic female patients, use of vaginal sonography should be considered to evaluate the distal ureter for calculi, particularly if the results of transabdominal examination are normal or inconclusive.

Ovarian masses: can benign and malignant lesions be differentiated with color and pulsed Doppler US?

PURPOSE: To determine whether color and pulsed Doppler ultrasound (US) can be used to differentiate benign from malignant ovarian masses. MATERIALS AND METHODS: Forty-four ovarian masses identified with sonography in 40 patients were confirmed at surgery (n = 35) or followed up to resolution with US (n = 9). Color and pulsed Doppler US were used to calculate the lowest pulsatility index (PI) and resistance index (RI) for each mass. RESULTS: Color Doppler US enabled detection of arterial flow in 24 of 36 benign masses and six of eight malignant masses. PI was lower in malignant masses than in benign masses (P = .002), as was RI (P = .001). Both indexes demonstrated overlap between benign and malignant masses; therefore, no cutoff value for either index had both high sensitivity and high specificity for malignancy: For PI cutoff of 1.0, sensitivity and specificity were 100% and 46%, respectively; for RI cutoff of 0.4, 50% and 96%. CONCLUSIONS: While PI and RI tend to be lower in malignant ovarian masses, neither index can be used reliably to differentiate benign from malignant lesions. In addition, lack of detectable flow by means of color Doppler US does not exclude ovarian malignancy.

Sonography of the fetal heart: normal variants and pitfalls.

Sonographic evaluation of the fetal heart is an important part of obstetric sonography. The sonographer and sonologist should be familiar with the sonographic appearance of the normal fetal heart and with common structural abnormalities. Occasionally, normal structures in or adjacent to the fetal heart may simulate an abnormality. Although one should seek consultative sonography in instances of uncertain or questionable findings, unnecessary referral and concern may be avoided in some cases if the sonologist is familiar with normal variants and pitfalls. In this pictorial essay, we present several such pitfalls that we and others have observed in the four-chamber view (Fig. 1) and in views of the ventricular outflow tracts (Figs. 2 and 3).

Cystic testicular mass caused by dilated rete testis: sonographic findings in 31 cases.

We reviewed the scrotal sonograms of 31 patients who had a testicular mass consisting of multiple small spherical or tubular anechoic structures in the region of the mediastinum testis. The median age of the patients was 62 years (range, 31-76 years). The abnormality was unilateral in 22 patients and bilateral in nine. Thirty-four (85%) of the 40 involved testicles had coexisting epididymal abnormalities: 32 with epididymal cysts and two with epididymitis. Follow-up sonograms were available in five patients and showed no change up to 4.5 years after the initial diagnosis. Surgical and histologic findings were available in one other patient and showed dilatation of the rete testis. The sonographic appearance and location of the lesions, the frequent presence of an epididymal abnormality, and the surgical and histologic findings in one case suggest that the lesion is due to dilatation of the rete testis, probably associated with obstruction in the epididymis. Recognition of this entity on sonograms may prevent unnecessary orchiectomy.