Intrarenal Venous Doppler as a novel marker for optimal decongestion, patient management, and prognosis in Acute Decompensated Heart Failure.

AIMS: An increase in right atrial pressure is a common feature of acute decompensated heart failure (ADHF). Such increased pressure leads to persistent kidney congestion. A marker to guide optimal diuretic therapy is missing. We aim to correlate intrarenal Doppler (IRD) ultrasound in ADHF patients with clinical outcomes to assess whether renal haemodynamic parameter changes are useful for monitoring kidney congestion. METHODS AND RESULTS: Between December 2018 and January 2020, ADHF patients requiring intravenous diuretic therapy for at least 48 h were considered for study selection. An IRD blinded examination was performed on Days 1, 3, and 5, and clinical and laboratory parameters were recorded. Venous Doppler profiles (VDP) were classified as continuous (C), pulsatile (P), biphasic (B), or monophasic (M) according to the congestion degree; B and M profiles were considered deranged. A VDP improvement (VDPimp) was defined as a change of ≥1 pattern degree or maintenance of C or P patterns. An arterial resistive index (RI) > 0.8 was considered elevated. Outcomes of death and rehospitalization were gathered at 60 days. Data were assessed by regression and Kaplan-Meier analyses. All 177 ADHF patients admitted were screened, and 72 were enrolled [27 females-median age 81 (76-87) years-median ejection fraction 40% (30-52)]. The VDP derangement decreased from 79.2% on Day 1 to 51.4% on Day 5 (P < 0.05). The RI elevation decreased from 60.6% on Day 1 to 43.1% on Day 5 (P < 0.05). At Day 5, VDPimp was registered in over half of the patients (59.7%). At Day 5, signs of congestion (dyspnoea/oedema/rales), fluid accumulation (pleural/peritoneal fluid), haematocrit, and brain natriuretic peptide improved (P > 0.05). After 60 days, 12 (16.7%) patients were readmitted and 9 (12.5%) died. The VDPimp was identified as the unique independent factor associated with readmission [Hazard Ratio (HR) 0.22, 95% (confidence interval) CI 0.05-0.94, P = 0.04] and death (HR 0.07, 95% CI 0.01-0.68, P = 0.02), with significantly better outcomes identified in VDPimp patients (log-rank test, P < 0.05). CONCLUSION: Decongestion may be associated with improvements in many clinical and instrumental parameters, but only VDPimp was associated with better clinical outcomes. The VDPimp should be incorporated in ad hoc ADHF clinical trials to better define its role in everyday practice.

High-Frame Rate Vector Flow Imaging of the Carotid Bifurcation in Healthy Adults: Comparison With Color Doppler Imaging.

OBJECTIVES: To evaluate the carotid bifurcation in healthy adults using a commercial system equipped with high-frame rate vector flow imaging (VFI) based on the plane wave and to compare VFI with color Doppler imaging. METHODS: Carotid bifurcation diameters and flow characteristics of 60 vessels in 60 healthy volunteers were evaluated quantitatively and qualitatively to assess complex flow patterns and their extension and duration. RESULTS: Complex flow in the internal carotid artery (ICA) was associated with a statistically significant difference in the ΔICA sinus-to-common carotid artery (CCA) diameter ratio (the relative change in diameter between the CCA and ICA sinus.) Vector flow imaging and color Doppler imaging were in accordance when detecting complex flow in 96.7% of cases; in 3.3% of cases, only VFI identified small recirculation areas of short duration. Vector flow imaging highlighted a larger extension of the complex flow (mean ± SD, 47.7 ± 28.5 mm2 ; median, 45.5 mm2 ) compared with color Doppler imaging (mean, 29.2 ± 19.9 mm2 ; median, 29.5 mm2 ) and better depicted different complex flow patterns; a strong correlation (r = 0.84) was found between the ΔICA sinus-to-CCA diameter ratio and the complex flow extension. Vector flow imaging showed a longer duration of the flow disturbances (mean, 380 ± 218 milliseconds; median, 352.5 milliseconds) compared with color Doppler imaging (mean, 325 ± 206 milliseconds; median, 333 milliseconds), and there was a strong correlation (r = 0.92). CONCLUSIONS: Vector flow imaging is as effective as color Doppler imaging in the detection of flow disturbances, but it is more powerful in the assessment of complex flow patterns.

Real-time tissue elastography for testicular lesion assessment.

OBJECTIVES: To assess the ability of Real-time Elastography (RTE) to differentiate malignant from benign testicular lesions. METHODS: In 88 testicles ultrasound identified 144 lesions, which were examined by RTE. Elasticity images of the lesions were assigned the colour-coded score of Itoh (Radiology 2006), according to the distribution of strain induced by light compression. RTE findings were analysed considering shape (nodular/pseudo-nodular), size (<5 mm, 6-10 mm, >11 mm) and score (SC1-5) of the lesions. RESULTS: 93.7% of all benign lesions showed a complete elastic pattern (SC1). 92.9% of benign nodules <5 mm and 100% of the pseudonodules showed a nearly complete elastic pattern (mainly SC1). 87.5% of malignant nodules showed a stiff pattern (SC4-5). RTE gave 87.5% sensitivity, 98.2% specificity, 93.3% positive predictive value, 96.4% negative predictive value and 95.8% accuracy in differentiating malignant from benign lesions. CONCLUSIONS: RTE is a useful technique in assessing small testicular nodules and pseudo-nodules. This is relevant in clinical practice allowing expectant management in RTE selected cases. The role of RTE seems less relevant for larger lesions because most of them are malignant at clinical and ultrasound assessment, limiting RTE to simply confirmation role. KEY POINTS: An emerging role for Elastography in allowing surveillance for small testicular lesions. Elastography can better differentiate benign from malignant testicular lesions. Follow up can be reduced for elastic testicular lesions at Elastography.

Thyroglobulin assay during thyroxine treatment in low-risk differentiated thyroid cancer management: comparison with recombinant human thyrotropin-stimulated assay and imaging procedures.

BACKGROUND: Circulating human thyroglobulin (TG) measurement has a pivotal role in the management of patients affected by differentiated thyroid cancer (DTC). Undetectable thyrotropin (TSH)-stimulated serum TG after thyroid ablation (i.e., thyroidectomy and radioiodine) implies the absence of residual or relapsing DTC. Recently, high-cost recombinant human TSH (rhTSH) was proposed for TG stimulation to avoid uncomfortable thyroxine (T(4)) withdrawal. However, only a small fraction of relapsing DTC patients showed undetectable TG under T(4) treatment (onT(4)-TG) by high-sensitivity assays. The present study was undertaken to compare onT(4)-TG with the rhTSH-stimulated TG assay (rhTSH-TG), (131)I scanning and neck ultrasound (US) with fine-needle aspiration biopsy. METHODS: We enrolled 117 patients with histologically proven DTC treated by total thyroidectomy and radioiodine. Inclusion criteria were: complete tumour excision, no radioiodine uptake outside of the thyroid bed at post-treatment scan and undetectable onT(4)-TG 3 months after primary treatment. At 1 year after radioiodine treatment, all patients underwent onT(4)-TG assay, rhTSH-stimulated TG assay, (131)I scanning and neck US. Based on histology, clinical data and long-term follow-up, persistent/relapsing disease was confirmed in 14 patients. RESULTS: onT(4)- and rhTSH-TG were positive in 10 and 12 patients, respectively and two patients converted from undetectable to detectable TG after rhTSH administration. Neck US was positive in 10 patients and a combination of US with onT(4)- and rhTSH-TG assays showed positivity in 13 and 14 out 14 patients, respectively. A radioiodine scan was positive in six patients, all with positive onT(4)- and rhTSH-TG levels. Globally, the negative predictive value of the onT(4)- and rhTSH-TG assays was 99% and 100%, respectively, and 104 rhTSH stimulations had to be performed to detect one local recurrence with negative onT(4)-TG. CONCLUSIONS: Our preliminary data need further confirmation on larger groups of patients, but seem to indicate that onT(4)-TG assay by a high-sensitivity method combined with neck US may avoid rhTSH stimulation in low-risk DTC patients after surgery and radioiodine thyroid ablation.