The learning curve of contrast-enhanced 'microbubble' voiding urosonography-validation study.

INTRODUCTION: Vesicoureteral reflux (VUR) is a common pediatric urologic condition associated with urinary tract infection and pyelonephritis. It can be diagnosed via fluoroscopic voiding cystourethrogram (VCUG) and, more recently, contrast-enhanced voiding ultrasonography (ceVUS), which does not expose the patient to ionizing radiation. Voiding urosonography contrast agents used for the diagnosis of VUR have been widely available in Europe but were approved by the Food and Drug Administration for use in the United States only in 2016. OBJECTIVE: The objective was to optimize a protocol and compare the diagnostic performance of ceVUS to fluoroscopic VCUG in an academic medical center naïve to previous use of contrast-enhanced voiding urosonography. STUDY DESIGN: Thirty-nine patients referred for clinically indicated evaluation of VUR were enrolled between September 2016 and March 2017. Patients underwent contrast-enhanced ultrasonography with prediluted Lumason and under the same catheterization underwent fluoroscopic VCUG. Comparative grading was performed by pediatric radiologists on-site at the time of examination. RESULTS: Reflux was observed in 16 of 39 patients (20 of 64 renal units) ranging from grades 1 through 5. VCUG and ceVUS were concordant for detecting reflux in 10 of 39 patients (14 of 84 renal units) and excluding reflux in 23 of 39 patients (64 of 84 renal units) (Fig. 1). Using contrast enhanced voiding urosonography, 1 of 20 renal units had high-grade and 2 of 20 renal units had low-grade reflux that was not found on fluoroscopy. Using fluoroscopy, 1 of 20 renal units had high-grade and 2 of 20 renal units had low-grade reflux that had not been found on ceVUS. Two of 20 renal units were upgraded from low-grade on ceVUS to high-grade on fluoroscopy. This corresponds to a Cohen's kappa of 0.72 (confidence interval [CI] 0.54-0.91) or 'moderate.' DISCUSSION: During our investigation, we noted that there was a technical learning curve related to poor contrast mixing and the need to titrate the concentration of Lumason. However, over the course of the study, we were able to correct the technical aspects. Ultimately, our results showed good correlation between VCUG and Lumason ceVUS and only slightly less correlation than published studies by experienced centers. Future studies with voiding should allow for improved urethral visualization. CONCLUSION: While there is a considerable learning curve to the implementation of ceVUS for the diagnosis of pediatric VUR, these technical aspects can be corrected. Even a center previously naïve to contrast-enhanced ultrasound technology can, over a short period of time, demonstrate good correlation between VCUG and ceVUS in the diagnosis of VUR. Translation of ceVUS into clinical practice is an alternative to VCUG for diagnosis of reflux, is feasible, and can eliminate the radiation exposure associated with a VCUG.

[Management of fetal mediastinal shift: a practical approach]. / Conduite à tenir devant une déviation médiastinale fœtale: une approche pratique.

The purpose of this article is to review the technique of fetal chest ultrasound screening evaluation, the diagnostic work-up in the presence of fetal mediastinal shift and which ultrasound imaging features to look for. The first step in evaluating the fetal thorax is to confirm situs. Then, a median sagittal line is drawn from a four-chamber view to assist in spatial orientation followed by echotexture analysis of the structures of the thorax in the presence of mediastinal shift. We propose a systematic approach based on the direction of the mediastinal shift and echogenicity of the compressing hemithorax. When the hemithorax contralateral to the mediastinal shift is enlarged, which is the most frequent situation, diaphragmatic hernia and macrocystic congenital cystic adenomatoid malformation are the most likely etiologies when the mass is heterogeneous. Microcystic congenital cystic adenomatoid malformation, sometimes associated with sequestration, is the most frequent etiology when the mass is homogeneous. When the hemithorax ipsilateral to the mediastinal shift is small, which is less frequent, and the contralateral hemithorax is homogeneously isoechoic, then a diagnosis of lung hypoplasia-agenesis-aplasia should be considered.

Magnetic resonance imaging in the prenatal diagnosis of congenital diarrhea.

OBJECTIVE: Congenital diarrhea is very rare, and postnatal diagnosis is often made once the condition has caused potentially lethal fluid loss and electrolyte disorders. Prenatal detection is important to improve the immediate neonatal prognosis. We aimed to describe the prenatal ultrasound and magnetic resonance (MRI) imaging findings in fetuses with congenital diarrhea. METHODS: The study reports the pre- and postnatal findings in four fetuses that presented with generalized bowel dilatation and polyhydramnios. We analyzed the fetal ultrasound and MRI examinations jointly, then compared our provisional diagnosis with the amniotic fluid biochemistry and subsequently with the neonatal stool characteristics. RESULTS: In each of the four cases an ultrasound examination between 22 and 30 weeks' gestation showed moderate generalized bowel dilatation and polyhydramnios suggesting intestinal obstruction. MRI examinations performed between 24 and 32 weeks' gestation confirmed that the dilatation was of gastrointestinal (GI) origin, with a signal indicating intraluminal water visible throughout the small bowel and colon. The expected hypersignal on T1-weighted sequences characteristic of physiological meconium was absent in the colon and rectum. This suggested that the meconium had been completely diluted and flushed out by the water content of the bowel. The constellation of MRI findings enabled a prenatal diagnosis of congenital diarrhea. The perinatal lab test findings revealed two cases of chloride diarrhea and two of sodium diarrhea. CONCLUSION: Congenital diarrhea may be misdiagnosed as intestinal obstruction on prenatal ultrasound but has characteristic findings on prenatal MRI enabling accurate diagnosis; this is important for optimal neonatal management.

Phase II and III studies with new drugs for non-small cell lung cancer: a systematic review of the literature with a methodology quality assessment.

We carried out a systematic review of new drugs active in non-small cell lung carcinoma (NSCLC). Fifty five phase II and III trials were reviewed (vinorelbine (19 trials), paclitaxel (15), gemcitabine (11), docetaxel (6), topotecan (2) or irinotecan (2)). The first four ones could be considered as active drugs when given as single agent. More information is required for the camptothecin derivatives. Four phase III randomised studies were available, all concerning vinorelbine. They showed that in combination with cisplatin, vinorelbine improved the response rate and perhaps survival, in comparison to vinorelbine alone and that vinorelbine was better than 5 fluorouracil and vindesine. A quantitative overview was impracticable, because of too few randomised trials. A qualitative overview was carried out using the European Lung Cancer Working Party score. The overall median quality score was 65.3%. There was no statistically significant difference between the drugs, but there was a positive correlation between the score and the number of patients. There was also an improvement of the quality score in favour of the randomised trials. Some important methodological aspects were often missing in the articles. In conclusion, gemcitabine, vinorelbine, paclitaxel and docetaxel are active against NSCLC but more good-quality data are required to define their exact role in the routine.