Utility of additional abdominopelvic CT in detecting occult cancer in patients with unprovoked venous thromboembolism.

AIM: To analyse the positive rate for cancer on additional abdominopelvic computed tomography (CT) in patients with unprovoked venous thromboembolism (VTE), evaluate the subsequent emergence of a cancer diagnosis in the clinical follow-up period, and identify any possible predictive factors of cancer in this cohort, which may allow better selection of patients for additional imaging. MATERIALS AND METHODS: Consecutive adult patients with VTE were retrospectively identified in two large teaching hospitals between January 2013 and June 2014, including a subset of those with unprovoked VTE. Relevant demographic data were extracted and analysed. All patients had a minimum of 12 months clinicoradiological follow-up. RESULTS: One thousand four hundred and forty-six patients with VTE were deemed eligible, of which 699 (48%) were male; the median age (range) was 66 (16-102) years. The prevalence of pre-existing cancer in these patients was 343/1446 (24%), and 388/1446 (27%) were classified as unprovoked VTE. In 12/1446 (0.8%), cancer was diagnosed synchronously with VTE on the initial imaging investigation. Additional screening imaging was performed in 232/388 (60%) including abdominopelvic CT in 205 (53%) patients with unprovoked VTE. Only five additional cancers were identified, all of these occurring in patients with clinical symptoms suspicious for cancer. None of the additional CT examinations identified any clinically occult cancer in asymptomatic patients, and subsequent mean follow-up of 22 (SD=6) months also failed to reveal any further cancer diagnosis. CONCLUSION: Contrary to the National Institute of Health and Care Excellence (NICE) guidance, the yield of performing additional abdominopelvic CT as a screening tool for occult cancer in asymptomatic patients with unprovoked VTE is negligible. A more selective and clinically-driven assessment of these patients is recommended.

Emergency department imaging protocol for suspected acute renal colic: re-evaluating our service.

OBJECTIVES: The objective of our study is to determine the positive rate for urolithiasis in male and female patients, and evaluate whether there has been any change at our institution in the use and outcome of unenhanced multidetector CT (CT KUB) performed in the emergency department (ER) for patients presenting with suspected acute renal colic. METHODS: A retrospective review of all 1357 consecutive cases between August 2007 and August 2009 admitted to the ER and investigated with CT KUB. RESULTS: The positive rate for urolithiasis was 47.5% and the rate of other significant findings was 10%. Female patients had a significantly lower positive rate than male patients (26.8% vs 61.6%, p<0.001). Urological intervention was required in 37% and these patients had a larger average stone size. In young female patients with a significantly sized ureteric calculus (>4 mm), the presence of hydronephrosis vs no hydronephrosis was 83% vs 17%, respectively. Among them, only three patients required ureteroscopy for stone removal. CONCLUSION: Contrary to other studies there has been no "indication creep" in the use of CT KUB at our institution. However, the young female patient presenting with suspected urolithiasis presents a particular diagnostic problem, and the significant percentage of negative examinations in females implies that an improvement in current practice is needed. The indiscriminate use of CT KUB in all female patients with flank pain should be avoided, and it is suggested that they should be initially evaluated with ultrasound to detect the presence of hydronephrosis.

Duplex sonography in the planning and evaluation of arteriovenous fistulae for haemodialysis.

This paper describes how to perform duplex sonography in the planning and evaluation of arteriovenous fistulae in haemodialysis patients, discusses its roles in these settings, and presents a review of commonly encountered complications.

Outcome following saphenopopliteal surgery: a prospective observational study.

OBJECTIVES: High recurrence rates following small saphenous varicose vein surgery have been reported. The aim of this study was to ascertain initial success rates following saphenopopliteal junction (SPJ) surgery using pre- and postoperative duplex scanning. METHODS: A prospective study was performed on patients with ultrasound-proven SPJ reflux. Patients underwent preoperative duplex skin marking and a postoperative quality assurance scan. RESULTS: Ninety procedures were performed in 88 patients. The SPJ was successfully ligated in 87 (96.7%) cases. Reflux was completely abolished in 51 (56.7%) cases, but persisted solely in the small saphenous vein (SSV) in 32.2%. Subsequently, 10 consecutive patients underwent 11 SPJ ligations with stripping of the SSV. Follow-up ultrasound scan demonstrated successful ligation of the SPJ and elimination of superficial venous reflux. CONCLUSION: This study demonstrates that preoperative duplex SPJ marking results in a high percentage of successful ligation. Given that residual persistent reflux was avoided in patients who underwent stripping of the SSV, we propose that patients who require SPJ surgery undergo duplex marking along with specific consideration with regard to treatment of the residual SSV.

Magnetic resonance imaging in fetal medicine: a pictorial review of current and developing indications.

Improvements in magnetic resonance (MR) imaging now permit diagnostic images of the fetus to be obtained. Ultrasound remains vital in all aspects of fetal imaging but MR provides a useful second line imaging test. Its value is best researched in fetal central nervous system disorders but it can be applied in other areas too. This pictorial review shows many of the commonly encountered problems. The pictures have a powerful impact on parental understanding. Future research must involve determination of the prognosis of abnormalities found at MR.

Discriminative MRI features of fallopian tube masses.

Fallopian tube disease, both acute and chronic, is a common cause of a sonographically indeterminate adnexal mass and may mimic ovarian cancer. Magnetic resonance imaging (MRI) is now widely used as a problem-solving tool in these circumstances. The purpose of this review is to provide the discriminative MRI features of Fallopian tube masses and illustrate the key signs that establish their origin and nature. Familiarity with these characteristics enables distinction of tubal disease from malignant adnexal disease with major impact on management. On MRI, Fallopian tube disease exhibits features that parallel the classical sonographic findings, but which can be more reliably recognized due to improved contrast and spatial resolution, multiplanar capacity, effective field of view, and tissue characterization. Recognition of these characteristic morphological features and specific MRI signal patterns are key to a specific diagnosis. The anatomical and histopathological basis of these MRI signs is emphasized, covering also the differential diagnosis and pitfalls. Two new signs, "synechiae" and "amorphous shading", are also described that have not been well described previously in MRI of tubal disease.

Intra-operative Doppler flow measurement do not predict 'at-risk' status of infrainguinal bypass grafts.

AIMS: Patients undergoing infrainguinal arterial reconstruction using vein conduits, frequently undergo intra-operative Doppler flow measurements to determine technical adequacy. The aim of this study was to determine the proportion of vein grafts with normal intra-operative haemodynamic parameters that were subsequently discovered to be 'at risk' on post-operative duplex surveillance scanning. METHODS: We prospectively collected data on 82, primary infrainguinal vein bypass grafts. Post papaverine graft flow and peripheral resistance were measured using the Scimed Opdop intra-operative Doppler machine. All grafts were determined to be technically adequate on the basis of measured peripheral resistance units (mPRU) being < or =1. At 1 week, a post-operative duplex surveillance scan was performed. At risk status was determined and compared to the intra-operative Doppler flow measurement. Statistical analysis was performed using the Mann-Whitney U-test. RESULTS: The post-operative duplex scan demonstrated that 53 (65%) of the 82 vein bypass grafts were diagnosed as being 'not at risk'; and 29 (35%) were regarded as at risk. When the groups were compared, there was no significant difference in intra-operative haemodynamic parameters between those not at risk and those at risk (P=0.19, Mann-Whitney U-test). The 1 month primary patency rate was 79% with a secondary patency rate of 100%. CONCLUSION: Despite normal intra-operative Doppler flow measurements, 35% of vein grafts were regarded as being at risk at the 1 week post-operative duplex surveillance scan. No single value may be universally applicable for identifying at risk grafts intraoperatively. Indeed, graft failure appears to be a multifactorial process.

Percutaneous nephrostomy insertion: outcome data from a prospective multi-operator study at a UK training centre.

AIM: To determine the success and complication rates of percutaneous nephrostomies (PCNs) performed at a UK training centre over a one-year period by different groups of operators. MATERIALS AND METHODS: During 2002, a total of 276 PCNs were performed in 190 patients by operators of varying experience. We employed two different techniques: (1) a "Seldinger" technique (ultrasound-guided puncture with a 19G sheathed needle followed by guide-wire insertion and track dilatation to accommodate 8-12F nephrostomy catheters), with or without fluoroscopic guidance, and (2) an ultrasound-guided "one-stab" technique using a 6F Bonanno catheter. Selection of technique was according to configuration of the collecting system and whether the procedure was performed out of hours. RESULTS: There were 218 procedures using the Seldinger technique and 62 using the one-stab technique. The Seldinger technique and one-stab technique were compared: primary technical success rate was 98 versus 93%, the major complication rate was 4.1 versus 3.2%, the minor complication rate was 5 versus 13%, and tube complications, such as drainage catheter dislodgement and blockage, were 29.5 versus 17.7%, respectively. The 30-day mortality was 4.3%, none of which were procedure related. CONCLUSION: Based on data from the USA, proposed targets for primary technical success rates are 88-99%, major complications 4-8%, and minor complications 3-15%, and the results were within these target ranges. The ultrasound-guided one-stab technique is a quick and safe procedure in selected cases, and we recommend this method for temporary urinary diversion in cases with moderate to severe degrees of pelvicalyceal system dilatation. These data may help to form a baseline for outcome targets in the UK.

Lower moiety pelvic-ureteric junction obstruction (PUJO) of the duplex kidney presenting with pyonephrosis in adults.

The most common congenital abnormality of the urinary tract is a duplex kidney. Pelvic-ureteric junction obstruction (PUJO) is a rare association that can affect the lower moiety of incomplete duplex kidneys. We report two adult cases of PUJO of the lower moiety in a duplex kidney that both presented with pyonephrosis. This late presentation of lower moiety PUJO with pyonephrosis has not been described previously. We describe the imaging appearances of this rare association and highlight this important diagnostic consideration in lower moiety hydronephrosis of the adult patient.

A family study and the natural history of prenatally detected unilateral multicystic dysplastic kidney.

PURPOSE: We document the inheritance pattern of multicystic dysplastic kidney in 3 affected families and screen first-degree relatives of a cohort of children with prenatally detected multicystic dysplastic kidney for renal anomalies. The study also afforded an opportunity to document the natural history of prenatally detected multicystic dysplastic kidney. MATERIALS AND METHODS: We identified 3 families during clinical treatment of children with prenatally detected multicystic dysplastic kidneys. Other members of these families were evaluated with renal ultrasonography. For the family screening study index cases were identified from a fetal uropathy database. A total of 94 first-degree relatives (52 parents, 35 full siblings and 7 half siblings) of 29 children with prenatally detected multicystic dysplastic kidneys were studied with urinary tract ultrasonography, blood pressure measurement, urinalysis and plasma biochemistry. RESULTS: Two families had affected sibling pairs, 1 of which also had a half sibling with vesicoureteral reflux. The third family included 3 individuals with multicystic dysplastic kidney and 1 with renal agenesis thought to have resulted from involution of multicystic dysplastic kidney. This family is consistent with autosomal dominant inheritance with variable expressivity and reduced penetrance. In the screening study ultrasonography did not demonstrate significant renal anomalies in any of the 94 first-degree relatives of the multicystic dysplastic kidney index cases. Followup assessment of prenatally detected multicystic dysplastic kidneys in index cases demonstrated total involution in 52% at a median age of 6.5 years with no multicystic dysplastic kidney related morbidity. CONCLUSIONS: Multicystic dysplastic kidney can be familial but is most commonly a sporadic anomaly. Formal screening of relatives is not recommended. Followup data on a cohort of children with prenatally detected multicystic dysplastic kidney add further support to conservative management.

Barentsz is essential for the posterior localization of oskar mRNA and colocalizes with it to the posterior pole.

The localization of Oskar at the posterior pole of the Drosophila oocyte induces the assembly of the pole plasm and therefore defines where the abdomen and germ cells form in the embryo. This localization is achieved by the targeting of oskar mRNA to the posterior and the localized activation of its translation. oskar mRNA seems likely to be actively transported along microtubules, since its localization requires both an intact microtubule cytoskeleton and the plus end-directed motor kinesin I, but nothing is known about how the RNA is coupled to the motor. Here, we describe barentsz, a novel gene required for the localization of oskar mRNA. In contrast to all other mutations that disrupt this process, barentsz-null mutants completely block the posterior localization of oskar mRNA without affecting bicoid and gurken mRNA localization, the organization of the microtubules, or subsequent steps in pole plasm assembly. Surprisingly, most mutant embryos still form an abdomen, indicating that oskar mRNA localization is partially redundant with the translational control. Barentsz protein colocalizes to the posterior with oskar mRNA, and this localization is oskar mRNA dependent. Thus, Barentsz is essential for the posterior localization of oskar mRNA and behaves as a specific component of the oskar RNA transport complex.

Leading into the future: coaching and mentoring Generation X employees.

Managers who recognize that Generation X employees are looking for workplaces that allow them to develop their competencies as well as have a balance in their personal and professional lives, are more successful in attracting and retaining employees in this age group. Savvy managers understand that adapting to meet the needs of Generation X employees also assists the manager in transitioning into the Information Age and the workplace of the future.

Early report: comparison of breath-hold MR excretory urography, Doppler ultrasound and isotope renography in evaluation of symptomatic hydronephrosis in pregnancy.

AIM: To compare assessment by MR excretory urography (MREU), Doppler ultrasound and isotope renography of women with symptomatic hydronephrosis in pregnancy and to define its cause. MATERIALS AND METHODS: Eleven women at 19-34 weeks of gestation were studied prospectively with gadolinium-enhanced breath-hold gradient echo MREU and transabdominal Doppler ultrasound compared with a 'gold standard' of isotope renography employing frusemide challenge. All studies were performed within 24 h, were reported independently in a blinded fashion and employed clearly defined criteria. Obstetric and infant outcomes were obtained. RESULTS: There were no adverse reactions to gadolinium administration in pregnancy and no adverse obstetric or infant outcomes. Three of the 11 women were unable to tolerate the complete MREU protocol. Ultrasound indices could not be used to predict ureteric obstruction as shown by isotope renography. MREU agreed with renographic findings in five of the six cases with obstruction and in two without obstruction. MREU directly demonstrated hydronephrosis to result from extrinsic compression of the ureter between the gravid uterus and iliopsoas muscle. CONCLUSION: MR excretory urography is a promising technique which affords equivalent functional and additional anatomical information to isotope renography. It is more accurate than Doppler ultrasound in the assessment of ureteric obstruction in pregnancy.Spencer, J. A. (2000). Clinical Radiology55, 446-453.