Decontamination of transvaginal ultrasound probes: review of national practice and need for national guidelines.

AIM: To determine the national practice of transvaginal ultrasound (TVUS) probe decontamination in English hospitals and to develop recommendations for guidance. MATERIALS AND METHODS: A literature review was undertaken to clarify best practice and evaluate methods of decontamination of TVUS probes. A questionnaire was developed to ascertain TVUS probe decontamination programmes in current use within English hospitals. This was sent to ultrasound leads of 100 English hospitals; 68 hospitals responded. RESULTS: There is a wide variation in TVUS probe decontamination across English hospitals. Although the majority of respondents (87%, 59/68) reported having clear and practical written guidelines for TVUS decontamination, the frequency, methods, and types of decontamination solutions utilized were widely variable and none meet the standards required to achieve high-level disinfection. CONCLUSION: While the decontamination of other endoluminal medical devices (e.g., flexible endoscopes) is well defined and regulated, the decontamination of TVUS probes has no such guidance. There appears to be incomplete understanding of the level of risk posed by TVUS probes, and in some cases, this has resulted in highly questionable practices regarding TVUS hygiene. There is an urgent need to develop evidence-based national guidance for TVUS probe decontamination.

MRI appearances of acute idiopathic scrotal oedema in an adult.

Acute idiopathic scrotal oedema is an uncommon cause of acute painless scrotal swelling that is usually seen in children. Traditionally, ultrasound has been used to help establish the diagnosis in the appropriate clinical setting. We report the MRI appearances of acute idiopathic scrotal oedema in a 51-year-old male with associated involvement of the penis.

The effect of reporting speed on plain film reporting errors.

AIM: To determine whether reporting plain films at faster rates lead to a deterioration in accuracy. METHODS: Fourteen consultant radiologists were asked to report a total of 90 radiographs in three sets of 30. They reported the first set at the rate they would report normally and the subsequent two sets in two thirds and one half of the original time. The 90 radiographs were the same for each radiologist, however, the order was randomly generated for each. RESULTS: There was no significant difference in overall accuracy for each of the three film sets (p=0.74). Additionally no significant difference in the total number of false-negatives for each film set was detected (p=0.14). However, there was a significant decrease in the number of false-positive reports when the radiologists were asked to report at higher speeds (p=0.003). CONCLUSIONS: When reporting accident and emergency radiographs increasing reporting speed has no overall effect upon accuracy, however, it does lead to less false-positive reports.

Use of colour duplex Doppler imaging in the postoperative assessment of buried free flaps.

The postoperative assessment of free flaps is essential to identify and act on signs of incipient flap failure. Where the flap is completely buried, this becomes almost impossible unless part of the flap is exteriorised or an overlying skin window is used. Alternatively, complicated and often impractical monitoring devices have been advocated, but these have failed to gain widespread acceptance. A simpler solution to this problem has been evaluated in a series of patients using colour duplex Doppler imaging. This re-appraisal of a previously reported technique has been facilitated by updated technology in diagnostic radiology. Duplex Doppler imaging was confirmed as an accurate, non-invasive, and inexpensive tool for the postoperative measurement of blood flow within the pedicles of five buried free flaps in four patients undergoing surgery in our unit.

Sonographic demonstration of a pharyngoesophageal diverticulum.

We report a case of pharyngoesophageal (Zenker's) diverticulum in a 91-year-old woman. Sonography of the thyroid gland showed diffuse enlargement of the gland and a well-defined, heterogeneous hyperechoic mass that appeared to be in the posterior left lobe. The mass had a smooth hypoechoic wall with a layered appearance anteriorly. Real-time sonography performed during the patient's ingestion of water showed transient changes in the size, margins, and echogenicity of the lesion, which subsequently reverted to its original appearance.

Incisional hernia: an unusual cause of acute pain and swelling following renal transplant.

We present a case in which a strangulated incisional hernia following a renal transplant was sonographically diagnosed. The patient presented with acute pain and swelling over the transplant site 6 weeks after surgery. Sonograms showed a normal-sized kidney with normal echotexture, no evidence of hydronephrosis, and no perinephric collections. Color Doppler sonography and spectral analysis demonstrated normal blood flow throughout the kidney. Sonograms showed that the palpable mass was a dilated loop of fluid-filled small bowel. Sonography allowed the correct diagnosis to be established, and early surgical intervention allowed revascularization of viable bowel.

Screening for gynecological malignancy.

Treatment for gynecological malignancy depends for its efficacy at least in part on the stage at presentation. Earlier diagnosis would allow the opportunity for more effective and potentially curative treatment. As a consequence, and in common with initiatives for many other cancers, a search for effective methods of screening is a high priority for the detection of early gynecological cancer. Such methods already exist for cervical cancer, and in many countries screening programs are in place to provide such early diagnosis. Patients with endometrial cancer often present symptomatically at stage I and as a consequence the value of screening of asymptomatic patients may be of lesser importance than for other cancers. Ovarian cancer, however, characteristically presents late and is insidious in onset and progress. Transvaginal ultrasound, together with serum tumor markers, may offer the possibility of early diagnosis and modification of therapy with the potential for improved outcome. However, the evidence from the literature is at present confusing, and it is worthwhile to review the current status of research data to evaluate the place of screening procedures for ovarian and other gynecological malignancies.

Isolated clinic hypertension is not an innocent phenomenon: effect on the carotid artery structure.

This study examines the common carotid intimal-medial wall thickness (CCA-IMT) in untreated patients with elevated clinic blood pressure (BP) but normal ambulatory BP (isolated clinic hypertension, n = 22), in comparison with a group with elevated clinic and ambulatory BP (hypertensives, n = 41) and a group with normal clinic and ambulatory BP (normotensives, n = 17) readings. The three groups did not differ in age, male/female ratio, lipid profile, glucose tolerance test, or smoking habits. No difference existed in CCA-IMT values between the groups with hypertension (0.67 +/- 0.18 mm) and isolated clinic hypertension (0.68 +/- 0.14 mm), but the values in these two groups were significantly higher (one-way ANOVA; F = 8.09, P < .001) than in the group of normotensives (0.50 +/- 0.09 mm). The CCA-IMT did not correlate with clinic systolic or diastolic BP readings or with BP derivatives of 24-h ambulatory monitoring. Mean 24-h BP in the isolated clinic hypertensives did not differ from that in the normotensives, whereas both were lower than in the hypertensives. We conclude that changes in the CCA-IMT occuring in subjects with isolated clinic hypertension are equal to the changes in sustained hypertension, indicating that isolated clinic hypertension may not be a benign condition.

Screening for chromosomal abnormality.

Screening for fetal abnormalities has become one of the most high profile health care issues of modern times. This issue is predicated on major advances in health care technology that permit wider detection of fetal anomalies, including the development of more advanced biochemical markers and improvements in ultrasound imaging. The effectiveness of these screening methods and their rational application is a point of great controversy, and is the cause of considerable unease in clinical obstetrical practice. This article reviews the general concepts of fetal screening for fetal chromosome abnormalities and then focuses on certain aspects of ultrasound screening that are particularly controversial. The scientific basis for each ultrasound finding (e.g., nuchal translucency) is reviewed, as well as the frequently divergent clinical experience with the finding. Finally, a plea is made for the development of a more scientific database for fetal ultrasound screening, and the setting of fetal screening guidelines for practicing physicians based on diagnostic accuracy and cost-effectiveness.

Antenatal renal pelvis dilatation: a predictor of vesicoureteral reflux?

OBJECTIVE: The purpose of our study was to evaluate the role of antenatally diagnosed renal pelvis dilatation (RPD) as a predictor of vesicoureteral reflux (VUR) in infants. SUBJECTS AND METHODS: All cases of RPD (i.e., those with a renal pelvis diameter equal to or greater than 5 mm) detected on routine antenatal sonography at our institution over a 3-year period were followed throughout infancy with serial sonographic evaluation. Infants with moderate to severe RPD on the initial postnatal study (i.e., those with a renal pelvis diameter greater than 15 mm) were further evaluated with voiding cystography or nuclear scintigraphy (99mTc-2,3-dimercaptosuccinic acid or 99mTc-benzoylmercaptoacetyltriglycerine). We have now reviewed all postnatal imaging on these infants. In addition, the records of all infants who presented to our institution with clinically symptomatic VUR during this same period have been retrieved. Antenatal sonograms were available for review in most of these cases. RESULTS: Seventy-six cases of RPD were detected on antenatal sonography at our institution over a 3-year period. Eight cases were lost to follow-up in early infancy. The remaining 68 infants had serial sonography performed throughout infancy. Twenty-five infants showed no evidence of urinary tract dilatation on postnatal sonography. Extrarenal pelves were present in eight cases, and 35 infants had moderate to severe RPD at 72 hr. On further evaluation of this last group with voiding cystography or nuclear scintigraphy, diagnoses were VUR (n = 6), pelvic-ureteric junction obstruction (n = 5), renal dysplasia (n = 1), and congenital megaureter (n = 1). VUR was detected in five male infants and one female infant. Twenty-two infants with moderate to severe RPD had neither an obstructive uropathy nor VUR. During this same period (July 1988-June 1991), 20 cases of VUR were detected at our institution. Antenatal sonograms were available for review in 16 of these cases. These showed evidence of RPD in five fetuses, whereas the remaining 11 antenatal studies were unremarkable. Our results show the positive predictive value of RPD for VUR to be 17%. CONCLUSION: Antenatally detected RPD, in isolation, is a weak predictor of VUR. Postnatal sonographic evaluation is, however, important in this group. Further investigation of infants showing moderate to severe RPD in the neonatal period is merited, as such investigation will lead to early detection of VUR in a significant number of cases (17% of RPD).

Hepatic venous Doppler waveforms: changes in pregnancy.

A total of 75 fasted healthy normal volunteers were examined during various stages of pregnancy. Examinations were performed in a supine position using an Acuson 128 ultrasound scanner with a 3.5 MHz transducer. Doppler interrogation of the middle hepatic vein was made during quiet respiration by one of three examiners. The Doppler waveforms were subsequently assessed blindly by one of the authors and categorized as normal, damped, or flat. Between 12 and 20 weeks, the majority of patients had normal hepatic pulsatility (64%) with 20% damped and 16% flat. Between 20 and 30 weeks there was a significant change (p > 0.001) with 68% being flat, 20% damped, and only 12% normal. In the last 10 weeks of pregnancy the changes were more marked: 80% were flat, 12% dampened, and 8% normal. There was a profound change in hepatic venous pulsatility during pregnancy. Hepatic waveforms changed from their normal pulsatile nature to become completely flat with increasing gestation. These changes were more frequent and more marked the further gestation progressed.

Lipomata of the inferior vena cava: a normal variant?

Recently, focal fat collections adjacent to the intrahepatic portion of the inferior vena cava (IVC) have been described as a normal variant. We present seven similar cases, and demonstrate the computed tomographic and sonographic findings. The differential diagnosis is discussed. We believe that the origin of these masses has not yet been satisfactorily proven, and that they may arise within the IVC. They appear to be benign, but there is a risk that they may be mistaken for more sinister pathology.

Significant disease of the celiac and superior mesenteric arteries in asymptomatic patients: predictive value of Doppler sonography.

OBJECTIVE: The purpose of this study was to assess the frequency of significant disease (i.e., occlusion or stenosis > 70%) of the celiac and superior mesenteric arteries in asymptomatic patients. SUBJECTS AND METHODS: Using duplex sonographic criteria obtained from previous angiographic-duplex Doppler correlation studies, we assessed the frequency of significant disease in the celiac and superior mesenteric arteries in 184 patients who had no signs or symptoms of mesenteric ischemia. RESULTS: For patients less than 65 years old, the frequency of significant disease was 3%, and it was isolated to the celiac artery. Significant disease was found in 18% of patients more than 65 years old (in 11%, isolated to one vessel; in 7%, disease of both vessels). Single-vessel disease was more common in the celiac artery (81%) than in the superior mesenteric artery (19%). CONCLUSION: These results indicate that the finding of significant abnormality of the celiac and superior mesenteric arteries on Doppler sonograms does not necessarily indicate mesenteric ischemia.

Endosonographic monitoring of transurethral cryoprostatectomy.

Cryoprostatectomy, the use of subzero temperatures to ablate prostate tissue gained favour in the 1960s because of its speed and lack of haemodynamic effects. It fell from use because the freezing process could not be monitored and this led to a high incidence of local complications. We have performed transrectal real time ultrasound in 12 patients undergoing cryoprostatectomy. In all the freezing process was easily visualized as an advancing hyperechoic 'iceball' with distal acoustic shadowing. Monitoring allowed maximum prostate ablation without breaching the prostatic capsule. There were no significant complications and all but one patient gained symptomatic relief. Ultrasound at 1 month showed a heterogeneous echo pattern with very little cavity formation but by 3 months a significant cavity was seen. This study demonstrates that it is possible to monitor the freezing process during transurethral cryoprostatectomy. This, theoretically, should significantly reduce the local complications encountered in previous studies.

Renal transplantation: the normal morphological and Doppler ultrasound examination.

If ultrasound imaging and image-directed Doppler examination of the renal allograft is to provide information with respect to graft complications and graft failure, then a clear understanding of normal characteristics is required. Criteria for abnormality of a graft will include change in size, in parenchymal pattern, and in blood flow characteristics in the main and branch renal arteries and within the renal vein. Normal measurements for the renal allograft are presented as well as morphological and numerical data relating to cortico medullary differentiation. A wide range of values for indices quantifying Doppler data is recorded in the literature. Mean values and standard deviations from the mean are presented. The importance of different parameters as potential indicators of disease are stressed, but the limitations, usually as a result of normal variation and lack of specificity, are presented. The normal features of color-coded Doppler vascular supply, perfusion, and drainage are described.