Normal Ultrasonography Research Articles

Hip: Anatomy and US technique

Ultrasound (US) has always had a relatively limited role in the evaluation of the hip due to the deep location of this joint. However, many hip diseases are well detectable at US, but before approaching such a study it is necessary to be thoroughly familiar with the normal anatomy and related US images. The study technique is particularly important as optimization of various parameters is required, such as probe frequency, focalization, positioning of the probe, etc. Also the patient’s position is important, as it varies according to the area requiring examination. For the study of the anterior structures, the patient should be in the supine position; for the medial structures, the leg should be abducted and rotated outward with the knee flexed; for the lateral structures, the patient should be in the controlateral decubitus position; for the posterior structures the patient must be in the prone position. US study of the hip includes assessment of the soft tissues, tendons, ligaments and muscles, and also of the bone structures, joint space and serous bursae. The purpose of this article is to review the normal anatomy of the hip as well as the US anatomy of this joint.

Febrile UTI in Infants 0–3 Months: Importance of Normal Renal US

Research Article| April 01 2011 Febrile UTI in Infants 0–3 Months: Importance of Normal Renal US AAP Grand Rounds (2011) 25 (4): 39. https://doi.org/10.1542/gr.25-4-39 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Febrile UTI in Infants 0–3 Months: Importance of Normal Renal US. AAP Grand Rounds April 2011; 25 (4): 39. https://doi.org/10.1542/gr.25-4-39 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: fever, kidney, urinary tract infections Source: Ismaili K, Lolin K, Damry N, et al. Febrile urinary tract infections in 0- to 3-month-old infants: a prospective follow-up study. J Pediatr. 2011; 158(1): 91-94; doi: https://doi.org/10.1016/j.jpeds.2010.06.053Google Scholar Belgian investigators reviewed data collected prospectively on infants 0 to 3 months of age with a first febrile urinary tract infection (UTI) in order to characterize pathogens, antimicrobial resistance, renal abnormalities, gender predilection, and recurrences. Urine was collected using suprapubic aspiration or bladder catheterization. UTI was defined as growth of at least 100,000 colony-forming units/ml or any growth from urine collected by aspiration. Patients with multiple pathogens or nosocomial UTI were excluded. All infants were treated according to a protocol that included initial parenteral antibiotics and hospitalization. All infants underwent renal ultrasound (US) during hospitalization and a voiding cystourethrogram (VCUG) at least one month after the UTI. All patients were followed for at least one year. Of 209 children treated for a first episode of proved febrile UTI, 43 (21%) were infants 0 to 3 months of age. All infants had antenatal US of which 6 (14%) were known to be abnormal. Of the 43 infants, 32 (74%) were male. All boys were uncircumcised. Escherichia coli comprised 88% of the pathogens, Klebsiella pneumoniae 7%, and Enterobacter species and Staphylococcus aureus occurred once each. E coli resistance to ampicillin and trimethoprim-sulfamethoxazole was 71% and 47% respectively. Bacteremia accompanied the UTI in three infants (7%). Sixty-seven percent of the US results were normal. Nine infants (21%; 6 boys) had vesicoureteral reflux (VUR); six infants had low grade VUR (I-III) and all of these resolved spontaneously within two years. US was abnormal in three of the six infants with low grade VUR. All three infants with high grade VUR (IV, V) had US demonstrating hydronephrosis, signs of dysplasia, or both. Six infants (four girls) had recurrent UTI during follow-up. Three of those patients had urinary tract abnormalities. The authors conclude that 21% of children with a first febrile UTI are 0 to 3 months of age; there is a male preponderance in this age group; E coli is the most common pathogen and shows high rates of resistance to ampicillin and trimethoprim-sulfamethoxazole; and when US is normal in this population the incidence of high grade VUR is extremely low. Dr Garber has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Controversy exists over the current management of UTI in infants and children. AAP Grand Rounds has addressed the issues of imaging and antibiotic prophylaxis at least 13 times in the past decade. Guidelines vary from country to country, and there is considerable practice variation within the United States.1 The 1999 AAP practice parameter2 recommends renal US and VCUG on every patient 2 months to 2 years of age with a first febrile UTI, and antibiotic prophylaxis for those with an abnormal urinary tract.... You do not currently have access to this content.

Assessment of Deep Venous Thrombosis by Grayscale Median Analysis of Ultrasound Images

This study aimed to determine whether grayscale median (GSM) ultrasound (US) analysis could differentiate acute from subacute femoropopliteal deep venous thrombosis (DVT) classified based on (a) the time of symptoms onset and (b) sonographers' evaluation of US images. Patients who had US because of suspected DVT were included. Patients with history of previous DVT, with normal US results or US with findings of isolated calf thrombosis were excluded. A total of 128 venous segments of 63 patients were analyzed. Thrombosed veins and adjacent arteries images were recorded. Thrombi GSM were calculated. Grayscale median was compared with (a) the time of symptoms onset and (b) US image thrombi classification as acute or subacute done by 2 sonographers blinded to patient information. Statistical analysis included GSM Pearson intraobserver variability and t test comparisons of GSM means for (a) short versus long onset periods and (b) acute versus subacute US class, χ comparison between onset history and US class, creation of GSM accuracy, predictive values, and sensitivity curves for acute versus subacute DVT. Intraobserver variability correlation varied between 0.92 and 0.95. Thrombus mean GSM was 23 ± 12 versus 31 ± 16 if symptoms onset was shorter or longer than 2 weeks (P = 0.004). Mean GSM was 20 ± 11 versus 35 ± 14 for acute versus subacute thrombi (P < 0.001). Acute thrombi correlated with onset shorter than 2 weeks (P < 0.001). Grayscale median less than 13, equal to 22, or 33 or less had 85% positive predictive value (17/20), 77% accuracy (98/128), and 90% sensitivity (53/59) to differentiate acute from subacute thrombi. Grayscale median of US images documenting femoropopliteal DVT correlated with (a) the time between symptoms onset and US examination and (b) the sonographers' interpretation of acute versus subacute thrombosis.

Causes of Shoulder Pain in Women with Breast Cancer-Related Lymphedema: A Pilot Study

PurposeTo inform on shoulder pathology and to identify the disabilities and level of quality of life (QOL) associated with shoulder pain in patients with breast cancer-related lymphedema (BCRL).Materials and MethodsUsing patient history, physical examination, and ultrasound (US), we classified patients with BCRL into the following three groups: no pain with normal ultrasound (US), pain with normal US, and pain with abnormal US. We evaluated shoulder pathology using US, pain intensity using a visual analogue scale (VAS), and functional disability using the Korean version of the Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire. For assessment of QOL, we used the Korean version of the brief form of the World Health Organization Quality of Life Assessment Instrument (WHOQOL-BREF).Results28.9% of patients had no pain and normal US, 31.6% had pain with normal US, and 39.5% had pain with abnormal US. The US findings for those with pain and abnormal US revealed the following: 53.3% had a supraspinatus tear, 13.3% had biceps tenosynovitis, 13.3% had acromioclavicular arthritis, 13.3% had subdeltoid bursitis, and 53.3% had adhesive capsulitis. Patients with shoulder pain and abnormal US findings had significantly higher mean DASH and pain scores. Pain scores were positively correlated with DASH scores and negatively correlated with QOL.ConclusionWe found that BCRL with shoulder pain and evidence of shoulder pathology on US was associated with reduced QOL and increased disability. Proper diagnosis and treatment of shoulder pain are necessary to improve QOL and decrease disability in patients with BCRL.

Abstract P1-01-19: Comparison of Ultrasound-Guided Fine Needles Aspiration Cytology and Ultrasound Guided Core Biopsy in Pre-Operative Axillary Staging for Early Breast Cancer

Abstract Introduction: Pre-operative axillary staging is now widely accepted as a prerequisite in surgical management of the axilla for patients newly diagnosed with early breast cancer. For those patients having breast tumour excision who are found to have nodal involvement, axillary clearance can be performed at the same time without prior sentinel node biopsy. Ultrasound (US) alone has low sensitivity, but can be used to direct needle biopsy. We assessed and compared the sensitivity and specificity of US-guided core biopsies (USCB) and US-guided fine needle cytology (USFNAC) used in our unit. Patients and methods: A retrospective and prospective data collection was performed between November 2007 and May 2010 on all newly diagnosed breast cancer patients in our unit since the introduction of routine pre-operative axillary US. Patients whose nodes looked benign or normal on US were offered sentinel node biopsy (SNB). Patients found to have suspicious nodes were offered USFNAC or USCB, according to the individual preference of the radiologists. Patients with positive cytology or histology underwent axillary node clearances (ANC), those with benign cytology or histology were offered SNB. The final histology results were reviewed and correlated to their pre-operative histology or cytology. Results: Of 559 Axillary ultrasound scans performed in our department between November 2007 and May 2010, 229 patients had pre-operative US scans of the axilla for newly diagnosed, clinically node-negative breast cancer. Of these 46 had USFNAC, 44 had USCB and 139 had normal/benign US. The USFNAC and USCB groups had similar proportions of positive results on postoperative histology, namely 70% and 79% respectively, allowing direct comparisons to be made. Of the 46 USFNAC patients, 17 (37%) had positive cytology (all confirmed by axillary clearance final histology). The 29 USFNAC patients with negative cytology had 15 (52%) with positive histology on sentinel node biopsy. The sensitivity of USFNAC was 53% and the specificity 100%. Of the 44 USCB patients, 26 (59%) were positive (all confirmed by axillary clearance final histology). Of the 18 USCB-negative patients, 7 (39%) were found to be positive on axillary clearance. The sensitivity of USCB was 79% and the specificity 100%. Of the 139 patients with normal US, 42 (30%) were found to be positive on sentinel node biopsies. For US alone, sensitivity was 61% and specificity was 80%. Conclusion: US staging of the axilla is superior to clinical staging. However, there is still a high incidence of false negative results, making US a crude way of assessing the axilla and confirming the necessity for sentinel node biopsy in US-negative axillae. For patients with axillae that are indeterminate on US, our data supports routine use of ultrasound core biopsy (USCB) over Ultrasound fine needle aspiration cytology (USFNAC) for preoperative staging of the axilla, where technically feasible. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-19.

Renal ultrasonography with the first UTI

Increasingly, the long-term benefits of identifying children with low-grade vesicoureteral reflux, as well as the use of prophylactic antibiotics in attempt to prevent recurrent urinary tract infection (UTI) and eventual renal morbidity, are being questioned. The report by Ismaili et al from Belgium contributes to the conversation. Investigators performed a prospective 2-year cohort study of 43 infants from the time of first febrile UTI at the age of less than 3 months. Ultrasonography (US) and voiding cystourethrography were performed on all infants, and 91% were followed for a mean of 20 ± 9 months. In 67% of infants, US was normal. No infant with normal US had a congenital anomaly of the kidney or urinary tract or high-grade reflux by voiding cystourethrography. In 21% of the study population, vesicoureteral reflux was identified. In the 67% of infants with low grade reflux, all cases were resolved during follow up. UTI recurred in only 14% of the study group (first episode at a mean follow-up time of 8.3 ± 7 months); one-half of recurrences were in infants with congenital anomalies of the kidney or urinary tract, although such children made up only about 20% of the cohort. Article page 69 ▸ Febrile Urinary Tract Infections in 0- to 3-Month-Old Infants: A Prospective Follow-Up StudyThe Journal of PediatricsVol. 158Issue 1PreviewTo track the clinical evolution of febrile urinary tract infection (UTI) diagnosed in 0- to 3-month-old infants and characterize uropathogen frequencies, antimicrobial resistance rates, renal abnormalities, and differences in the sexes in this age group. Full-Text PDF

Routine use of abdominopelvic ultrasonography in severe postpartum hemorrhage: retrospective evaluation in 125 patients

The purpose of this study was to analyze the potential of abdominopelvic ultrasonography at the initial examination in women with severe postpartum hemorrhage. One hundred twenty-five women were included in the study. The therapeutic approaches that were performed to stop the bleeding were evaluated for each category of ultrasonographic finding. Seventy-one women (56.8%) had normal ultrasonography; 30 women (24%) had echogenic endometrial lining; 17 women (13.6%) had echogenic intrauterine mass, and 7 women (5.6%) had abdominopelvic free fluid effusion. Medical therapies allowed the bleeding to stop in 90.1% of women with normal ultrasonography, in 66.6% of women with echogenic endometrial lining, and in 29.4% of women with echogenic intrauterine mass. Pelvic embolization and surgery were performed less frequently in women who had normal ultrasonography results (9.9%) than in women with abnormal ultrasonography results (46.8%; P < .0001). A normal abdominopelvic ultrasonography is associated with a favorable outcome and can be considered to be a predictor for the effectiveness of conservative, noninvasive therapeutic approaches.

Fine needle aspiration cytology is a valuable adjunct to axillary ultrasound in the preoperative staging of breast cancer

AimsTo compare the predictive values of axillary ultrasound (US) combined with fine needle aspiration (FNA) cytology with tumour size (T stage) and grade in the preoperative staging of breast cancer....

990 Postnatal Follow-Up of Antenatal Hydronephrosis

Antenatal hydronephrosis is diagnosed in 1% to 5% of all pregnancies; however, the antenatal and postnatal management of hydronephrosis varies widely. The main point of postnatal management is the identification of the minority of patients whose renal function is at risk. Postnatal follow-up was considered successfully established when the patient with unresolved ANH has been evaluated in our pediatric nephrology service and had two normal postnatal USs that documented resolution of ANH. Screening of approximately 13125 ultrasound (US) reports identified 210 (1.6%) fetuses with ANH. 176 infants were included in follow-up. 30 (14%) were lost to follow-up. 4 with renal malformation were excluded. 176 infants were diagnosed with mild 105 (59.7%), moderate 59 (33.5%) and severe 12 (6.8%) hydronephrosis. 76.1% were males; unilateral and bilateral hydronephrosis were diagnosed in 116 (66%) and 60 (34%) cases, respectively; the rate of left hydronephrosis was 70.5%. Ultrasound evaluation of hydronephrosis was performed with morpho-dynamic technique. This method assesses the maximum dilation after filling bladder and then after voiding. Thus a functional or organic dilation can be detected. At 3month Us control,53% of mild-group recover spontaneously. Voiding cystourethrography was performed in 25% of mild-group. No ureteropelvic junction or obstruction and vesicoureteric reflux were detect. At the end of follow-up (24month) mild/moderate groups recover. Urinary tract malformations were found only in severe hydronephrosis while in mild/moderate group only “excretory system dysmaturity” was evidenced. Our trial showed a decreased use of invasive diagnostic procedure.

Value of Postoperative Thyroglobulin and Ultrasonography for the Indication of Ablation and131I Activity in Patients with Thyroid Cancer and Low Risk of Recurrence

This study investigated the value of postoperative stimulated thyroglobulin (Tg) combined with neck ultrasonography for the prediction of the posttherapy whole-body scanning (RxWBS) and the efficacy of ablation with 30 mCi ¹³¹I in patients with thyroid cancer and low risk of recurrence to identify those who do not require ablation or only need a low ¹³¹I activity. A total of 237 consecutive patients with well-differentiated thyroid cancer and low risk of recurrence who were initially treated by total thyroidectomy followed by remnant ablation with 1.1 or 3.7 GBq (30 or 100 mCi) ¹³¹I were studied. Neck ultrasonography, Tg after levothyroxine withdrawal, and anti-Tg antibodies (TgAb) were obtained before, and RxWBS was performed 7 days after ¹³¹I administration. Patients with TgAb were excluded. Postoperative ultrasonography revealed lymph node metastases in 5/237 (2%) patients. RxWBS showed ectopic uptake in 3/232 (1.3%) patients with negative ultrasonography. The negative predictive value of postoperative stimulated Tg <1 ng/mL (n = 132) or <10 ng/mL (n = 213) combined with negative ultrasonography was 100%. Among patients with detectable postoperative stimulated Tg <10 ng/mL and negative ultrasonography, 50 received 1.1 GBq ¹³¹I and 31 received 3.7 GBq. In the control assessment, stimulated Tg <1 ng/mL and neck ultrasonography without anomalies were achieved in 47/50 (94%) and in 29/31 patients (93.5%). All patients with stimulated Tg ≤1 ng/mL, negative TgAb, and normal ultrasonography before ablation continued to show the same results 8-12 months after initial therapy as expected, irrespective of the administration of 1.1 GBq (n = 82) or 3.7 GBq ¹³¹I (n = 50). Measurement of stimulated Tg combined with neck ultrasonography after total thyroidectomy may exclude the need for ablation in 56% of low-risk patients without TgAb (Tg <1 ng/mL) and permit the administration of an activity of 1.1 GBq ¹³¹I in another 34% with low Tg levels.

Bedside Transthoracic Sonography in Suspected Pulmonary Embolism: A New Tool for Emergency Physicians

Bedside Transthoracic Sonography in Suspected Pulmonary Embolism: A New Tool for Emergency Physicians

Ultrasound of Peroneal Tendons

Disorders of the peroneal tendon (PeT) complex are common and affect patients of many different ages. They can be traumatic, inflammatory, infective, or degenerative. Clinical assessment orients the diagnosis, but an imaging modality is almost always performed to confirm the clinical impression and to obtain additional information that is essential in choosing among different treatments. Due to its peculiar characteristics of high resolution, cost effectiveness, noninvasiveness, and dynamism, ultrasound (US) is now widely considered the first-line imaging modality to assess superficial tendons. US not only allows an optimal evaluation of the PeT complex but can also accurately assess its synovial sheath, retinacula, and adjacent tissues. This article describes the normal anatomy, technique of examination, and normal US anatomy of the PeT complex as well as illustrating the US appearance of its main disorders.

Predictability of cerebral palsy and its characteristics through neonatal cranial ultrasound in a high-risk NICU population

The aim of the study is to evaluate the predictive value of various types of brain injury detected by ultrasound in the neonatal period for the occurrence of cerebral palsy and its characteristics in a large cohort of high-risk infants. Thousand twenty-one consecutively NICU-admitted high-risk infants were assessed up to the corrected age of at least 2 years. Cerebral palsy (CP) was categorised into spastic or non-spastic, bilateral or unilateral and mild, moderate or severe CP. Different types of brain injury were identified by serial cranial ultrasound (US) during the NICU stay: white matter disease (WMD), haemorrhage, cerebral infarction, deep grey matter and parasagittal cerebral injury. There is a significant overall association between different types of brain injury and gestational age. Only 4% of the children with normal US develop CP. In the presence of any abnormal US image, the likeliness to develop CP is at least seven times higher. Within the group of infants with WMD and haemorrhage, the degree of brain involvement has a clear impact on the occurrence of CP. Concerning the characteristics of CP, deep grey matter lesion predict non-spastic CP versus spastic CP (OR = 31, P < 0.001). Cerebral infarction and haemorrhage grade IV are strong predictors of unilateral spastic CP versus bilateral spastic CP (OR = 49 and 24, respectively, P < 0.001). Deep grey matter lesion is a significant predictor for severe versus mild and moderate CP (OR = 6). In conclusion, neonatal cranial US is a useful tool in predicting CP and its characteristics.

Rheumatoid Arthritis: Treatment [151-201]: 151. Should we be Looking More Carefully for Methotrexate Induced Liver Disease?

Background: UK guidelines and a `Rheumatology' editorial suggest that liver function tests (LFTs) alone remain a satisfactory method for methotrexate (MTX) monitoring in rheumatoid arthritis (RA). Recent literature also suggests no difference in hepatotoxity between MTX treated RA and psoriatic arthritis (PsA) patients. We describe 3 cases of liver fibrosis / cirrhosis missed by conventional monitoring. Methods: Case 1: 71 yr old female, RA 35 yrs. Presented 2005. Previous breast cancer. Alcohol < 1 unit/week. Rx MTX for 20 years, up to 25mg weekly. Leflunomide (Lef) 10 mg od added 3 mths previously. LFTs normal, P3NP 6.6. 2005-6 RA well controlled, normal LFTs. Repeat P3NP 2006 11.7. Liver ultrasound (US): normal echogenicity and hepatic and portal vein flow. Attempts to stop Lef were unsuccessful and led to use of rescue depomedrone. Developed diabetes. Sept 2007 LFTs normal, albumin 35. Feb 2008: admitted with ascites, ALT 41, albumin 31, bilirubin 24. CT liver normal, US suggested fatty change with normal portal flow. Biopsy showed established cirrhosis on a background of steatohepatitis. MTX and Lef stopped. June 2008: fatal pneumonia. Case 2: 69 yr old male. RA 2007; previous type II diabetes Rx insulin. On simvastatin. Alcohol < 1 unit/week. eGFR 60. LFTs normal. Rx MTX 12.5 mg/week + folic acid. July 2008 ALT 83: MTX ↓ 10 mg, Oct 2008 ALT 89: MTX ↓7.5 mg. Nov 2008 ALT 69. Dec 2008 - Aug 2009 ALT 70, 91, 67, 65, 52 (ie < x2 normal). Aug 2009 ALT 38, alb 27. Sept 2008 ALT 85, albumin 22, INR 1.7.US: shrunken liver. Full liver screen negative. Developed spontaneous bacterial peritonitis. Died Sept 2009. Results: Case 3: 63 yr old female, presented 1999. PsA diagnosed 1993, Rx MTX 7.5mg weekly. Alcohol < 1 unit/week. 1996 ‘routine’ liver biopsy performed (i.e. after 3 yrs MTX), result missing. 1997 US liver normal. Jan 1999: AST 69. Previous liver biopsy retrieved: steatosis + perivascular fibrosis. MTX stopped. LFTs normalized and remain normal. Conclusions: The risk of liver damage in some MTX treated RA and PsA patients may be higher than we think. Patients remain on MTX long term, may resume excess alcohol consumption and may develop concommitant non alcoholic fatty liver disease and steatohepatitis (NAFLD, NASH) during the course of their illness. Polypharmacy (case 1) and diabetes (cases 1 and 2) may be further risk factors. Normal LFTs and US may offer false reasurance. However, minor elevations of liver enzymes may point towards ongoing fibrosis (Case 2). P3NP is used in psoriasis but not in RA because of the confounding factors of disease activity and joint erosion. However, normal values may give some reassurance. US is unreliable as a guide to fibrosis, but more sensitive scans, including Fibroscan, offer promise. Our cases suggest that there may be at risk MTX treated RA and PsA patients who require more detailed liver monitoring. Disclosure statement: All authors have declared no conflicts of interest.

Esteatosis hepática, resistencia a la insulina y adiponectina en una población con obesidad

Introduction To study the clinical and laboratory relationships of fatty liver disease in a group of obese children and to investigate whether circulating adiponectin is related to fatty liver disease. Patients and methods Two hundred-ninety obese patients (age 4–18 years) were studied. Baseline body mass index-standard deviation score (BMI-SDS), acanthosis nigricans, blood pressure, plasma lipids, uric acid, alanine aminotransferase (ALT) and adiponectin were assessed, and a standard oral glucose tolerance test was performed. Insulin resistance (RI) was estimated by the homeostasis model assessment (HOMA) and liver steatosis was assessed by ultrasound (US). Children were classified as having metabolic syndrome if they met three or more of the following criteria: obesity, hypertension, hypertriglyceridemia, low HDL-cholesterol and impaired glucose metabolism. Results Fifty-two subjects (18%) had fatty liver by US and 22 (8%) had elevated ALT levels (≥40 U/L). Subjects with steatosis were significantly older (12.2±2.4 frente a 11.1±2.9 yr), heavier (BMI-SDS: 4.5±1.5 frente a 3.8±1.3), and more RI (HOMA: 3.7±1.5 frente a 2.4±1.4), but were comparable in gender, pubertal status and racial distribution to those with normal US. The prevalence of metabolic syndrome and acanthosis nigricans were also higher in the steatosis frente a the normal US group. Serum adiponectin concentration was inversely correlated with age, HOMA, ALT and uric acid and directly correlated with HDL-cholesterol. In a multiple logistic regression analysis, BMI-SDS, HOMA and serum adiponectin, but not age, uric acid or triglycerides, were the covariates independently associated with the presence of steatosis (odds ratio 1.4 [1.1-1.9]; 1.3 [1.1-1.6] and 0.9 [0.8-0.9], respectively). Conclusions Obesity and RI are risk factors for liver steatosis in children and adolescents. Decreased serum adiponectin is closely and independently associated with steatosis.

The efficacy of ultrasound and dimercaptosuccinic acid scan in predicting vesicoureteral reflux in children below the age of 2 years with their first febrile urinary tract infection

We evaluated the efficacy of dimercaptosuccinic acid (DMSA) scan and ultrasound (US) in comparison with voiding cystourethrography (VCUG) in predicting vesicoureteral reflux (VUR) in children below the age of 2 years. Medical records and radiologic studies of children (<2 years) suffering their first febrile urinary tract infection (UTI) between January 2001 and May 2007 were retrospectively reviewed. We evaluated the sensitivity, specificity, and positive and negative predictive values of US and DMSA scans in diagnosing VUR. Among 220 children with their first febrile UTI, VUR was detected in 67 (30.4%). The detection rate of VUR by US was 41.7% and 86% in the low (I, II) and high grade (III~IV) groups, respectively. Detection rate of VUR by DMSA scan was 37.5% and 88.4% in the low and high grade groups, respectively. Combining US and DMSA scan, we found that the detection rate of high grade VUR was 95.3% and that of low grade was 62.5%. During follow up, most of the low grade VURs with normal DMSA and US scans resolved or were downgraded. Most high grade VURs could be detected by US and DMSA scan, but the prediction rate was not as high in low grade VURs. However, we can anticipate spontaneous improvement without complications in patients with either low or high grade reflux and negative findings on US and DMSA scan.

Longitudinal microvascularity in Achilles tendinopathy (power Doppler ultrasound, magnetic resonance imaging time–intensity curves and the Victorian Institute of Sport Assessment–Achilles questionnaire): a pilot study

To evaluate the imaging of the natural history of Achilles tendinopathy microvascularisation in comparison with symptoms, using a validated disease-specific questionnaire [the Victorian Institute of Sport Assessment-Achilles (VISA-A)]. A longitudinal prospective pilot study of nine patients with post-contrast magnetic resonance imaging (MRI), time-intensity curve (TIC) enhancement, ultrasound (US) and power Doppler (PD) evaluation of tendinopathy of the mid-Achilles tendon undergoing conservative management (eccentric exercise) over 1 year. There were five men and four women [mean age 47 (range 30-62) years]. Six asymptomatic tendons with normal US and MRI appearance showed less enhancement than the tibial metaphysis did and showed a flat, constant, but very low rate of enhancement in the bone and Achilles tendon (9-73 arbitrary TIC units). These normal Achilles tendons on imaging showed a constant size throughout the year (mean 4.9 mm). At baseline the TIC enhancement in those with tendinopathy ranged from 90 arbitrary units to 509 arbitrary units. Over time, 11 abnormal Achilles tendons, whose symptoms settled, were associated with a reduction in MRI enhancement mirrored by a reduction in the number of vessels on power Doppler (8.0 to 2.7), with an improvement in morphology and a reduction in tendon size (mean 15-10.6 mm). One tendon did not change its abnormal imaging features, despite improving symptoms. Two patients developed contralateral symptoms and tendinopathy, and one had more abnormal vascularity on power Doppler and higher MRI TIC peaks in the asymptomatic side. In patient with conservatively managed tendinopathy of the mid-Achilles tendon over 1 year there was a reduction of MRI enhancement and number of vessels on power Doppler, followed by morphological improvements and a reduction in size. Vessels per se related to the abnormal morphology and size of the tendon rather than symptoms. Symptoms improve before the Achilles size reduces and the restoration of normal imaging over time.

Sensitivity of ultrasonography in detecting renal parenchymal defects: 6 years’ follow-up

While (99m)Tc-dimercaptosuccinic acid (DMSA) scanning is still considered the most accurate method for the assessment of renal parenchymal defects (RPDs), our study 6 years previously suggested that ultrasonography (US) could be a safe and efficient substitute for this purpose, provided that it is reliably performed and that renal function parameters are followed. By comparison of the original and follow-up study data from 67 children, the accuracy of our recommendations was re-evaluated. US was performed and renal function parameters investigated and correlated to the DMSA scans from the original study. US identified all six patients with clinically significant RPD and 52/61 with clinically insignificant RPDs, seen on the DMSA scans. Twenty two out of 22 severe RPDs, 21/23 moderate RPDs and 20/40 mild RPDs seen on the DMSA scans were detected by US. In ten cases normal US findings from the original study were rendered abnormal, correlating well with the DMSA scans with respect to RPD localization and kidney size. These results further support our previous suggestion that US is a safe and harmless alternative to DMSA scanning in the detection and follow-up of RPDs. While it cannot be excluded that small RPDs missed on the initial US might 'develop' clinical significance in later life, children with normal findings on initial US should have another sonogram done, at the shortest a year later, together with an investigation of renal function parameters.

Cerebellar Injury in Preterm Infants: Incidence and Findings on US and MR Images

To investigate the incidence and characteristics of cerebellar injury in a cohort of very preterm infants by using the mastoid fontanelle (MF) and posterior fontanelle (PF) approach in addition to routine cranial ultrasonography (US) through the anterior fontanelle (AF), with magnetic resonance (MR) imaging as the reference standard. The institutional review board approved this prospective study and informed consent was obtained. A cohort of 77 preterm infants (< 32 weeks) was examined with serial cranial US throughout the neonatal period by using the AF, PF, and MF views. MR imaging was performed around term-equivalent age in 59 of 77 infants. Sensitivity, specificity, positive predictive value, and negative predictive value of routine cranial US and cranial US with additional views were calculated. At cranial US performed through the MF, seven (9%) of 77 infants were identified to have posterior fossa hemorrhage. In only two of seven infants, the lesions were seen on routine AF views. The PF approach did not increase the detection rate of posterior fossa hemorrhage. MR images confirmed cranial US findings in all cases. MR images showed punctate hemorrhage in the cerebellum in six infants with normal cranial US findings. Among the 59 infants examined with both cranial US and MR imaging, cerebellar injury was diagnosed in 11 (19%). Cerebellar injury is a frequent finding in very preterm infants. Cranial US through the MF can demonstrate injury missed by using the routine AF approach. Punctate hemorrhagic lesions may remain undetected even when the MF approach is used; the prognostic implications of these smaller lesions need further attention.

Evaluation of a thoracic ultrasound training module for the detection of pneumothorax and pulmonary edema by prehospital physician care providers

BackgroundWhile ultrasound (US) has continued to expedite diagnosis and therapy for critical care physicians inside the hospital system, the technology has been slow to diffuse into the pre-hospital system. Given the diagnostic benefits of thoracic ultrasound (TUS), we sought to evaluate image recognition skills for two important TUS applications; the identification of B-lines (used in the US diagnosis of pulmonary edema) and the identification of lung sliding and comet tails (used in the US diagnosis of pneumothorax). In particular we evaluated the impact of a focused training module in a pre-hospital system that utilizes physicians as pre-hospital providers.Methods27 Paris Service D'Aide Médicale Urgente (SAMU) physicians at the Hôpital Necker with varying levels of US experience were given two twenty-five image recognition pre-tests; the first test had examples of both normal and pneumothorax lung US and the second had examples of both normal and pulmonary edema lung US. All 27 physicians then underwent the same didactic training modules. A post-test was administered upon completing the training module and results were recorded.ResultsPre and post-test scores were compared for both the pneumothorax and the pulmonary edema modules. For the pneumothorax module, mean test scores increased from 10.3 +/- 4.1 before the training to 20.1 +/- 3.5 after (p < 0.0001), out of 25 possible points. The standard deviation decreased as well, indicating a collective improvement. For the pulmonary edema module, mean test scores increased from 14.1 +/- 5.2 before the training to 20.9 +/- 2.4 after (p < 0.0001), out of 25 possible points. The standard deviation decreased again by more than half, indicating a collective improvement.ConclusionThis brief training module resulted in significant improvement of image recognition skills for physicians both with and without previous ultrasound experience. Given that rapid diagnosis of these conditions in the pre-hospital system can change therapy, especially in systems where physicians can integrate this information into treatment decisions, the further diffusion of this technology would seem to be beneficial and deserves further study.