Normal Ultrasound Examination Research Articles

Improving Ultrasound Detection of Uterine Adenomyosis Through Computational Texture Analysis.

The purpose of our study was to determine if a textural analysis metric can be implemented to improve diagnosis of adenomyosis by ultrasound.We retrospectively identified 38 patients with a magnetic resonance imaging (MRI) diagnosis of uterine adenomyosis that also had a pelvic ultrasound within 6 months. We also identified 50 normal pelvic ultrasound examinations confirmed by a normal pelvic MRI within 6 months as a control group. A region of interest (ROI) was subsequently placed on the study population ultrasound image corresponding to the area of adenomyosis on MRI. An ROI was placed in the area of the junctional zone in the normal controls. The abnormal and normal ROIs were then compared against trained normal and abnormal distributions to determine the success rate, sensitivity, specificity, and negative and positive predictive values of our computer metric. The ultrasound reports performed before MRI were also reviewed to determine the radiologist correct/incorrect interpretation rate for comparison with our textural analysis metric.Using a training population of 50 normal ultrasound examinations (confirmed with a normal MRI) and 38 abnormal ultrasound examinations (MRI confirmed adenomyosis), we had an overall 75% (66/88 accurately diagnosed) success rate with a sensitivity, specificity, and negative and positive predictive values of 70%, 79%, 73%, and 76%, respectively (P < .0001). The sensitivity and false-negative rate of the initial ultrasound interpretation were 26% (10/38) and 74% (28/38), respectively.

Interrater reliability of the Saint-Anne Dargassies Scale in assessing the neurological patterns of healthy preterm newborns

Abstract Objectives: to assess the interrater reliability of the Saint-Anne Dargassies Scale in assessing neurological patterns of healthy preterm newborns. Methods: twenty preterm newborns met the inclusion criteria for participation in this prospective study. The neurologic examination was performed using the Saint-Anne Dargassies Scale, showing normal serial cranial ultrasound examination. In order to test the reliability, the study was structured as follows: group I (rater 1/physiotherapist; rater 2/neonatologist); group II (rater 3/physiotherapist; rater 4/child neurologist) and the gold standard (expert and professor in pediatric neurology). Results: high interrater agreement was observed between groups I - II compared with the gold standard in assessing postural pattern (p&lt;0.01). Regarding the assessment ofprimitive reflexes, greater agreement was observed in the evaluation of palmar grasp reflex and Moro reflex (p&lt; 0.01) for group I compared with the gold standard. An analysis of tone demonstrated heterogeneous agreement, without compromising the reliability of the scale. The probability of equality between measurements of head circumference in the two groups, compared with the gold standard, was observed. Conclusions: the Saint-Anne Dargassies Scale demonstrated high reliability and homogeneity with significant power of reproducibility and may be capable to identify preterm newborns suspected of having neurological deficits.

Parental decisions following prenatal diagnosis of sex chromosome aneuploidy in Hong Kong.

According to the published work, pregnancy termination rates due to prenatal diagnosis of fetal sex chromosome aneuploidies (SCA) vary widely. Some potentially modifiable and non-modifiable factors have been reported to be associated with parental decision. This study aimed to evaluate the rate of pregnancy termination for fetal SCA and the factors influencing parents' decisions in Hong Kong. This was a 21-year retrospective cohort study of parents' decisions following prenatal diagnosis of SCA. Univariate and multivariate analyses for the association between demographic factors, prenatal factors, or counseling provided and decision-making were conducted. The study included 399 pregnancies with prenatal diagnosis of SCA and the overall termination rate was 55.6% (91.7%, 48.0%, 23.4%, 4.8%, and 22.7% for 45,X, 47,XXY, 47,XXX, 47,XYY, and mosaicism, respectively). Pregnancies with ultrasound abnormalities were associated with higher termination rates than pregnancies with normal ultrasound findings (91.3% vs 28.3%, P < 0.0001). From multivariate regression analysis on 226 pregnancies with normal ultrasound examination, a higher likelihood to terminate was found in pregnancies affected by 45,X and 47,XXY (adjusted odds ratio, 4.72, P < 0.0001). Increased maternal age and history of infertility were associated with lower likelihood to terminate (adjusted odds ratio, 0.9, P = 0.012; and 5.12, P = 0.038, respectively). The pregnancy termination rate declined over time. A significant correlation was found between the termination of SCA-affected pregnancy and the presence of fetal sonographic abnormalities, type of SCA, maternal age, and presence of infertility.

Ultrasound Diagnosis of Clinically Unsuspected Ureteral Stone Presenting as Acute Scrotum

Ureteral colic is not generally included in the differential diagnoses of acute scrotal pain, although ureteral pathology is a recognized cause of pain referred to the scrotum. We report 3 patients presenting with acute scrotal pain who had normal scrotal color Doppler ultrasound scans; subsequent ultrasound of the ipsilateral kidney revealed hydronephrosis, which ultimately led to the clinically unsuspected diagnosis of ureteral colic. We conclude that ureteral colic should be included in the differential diagnosis of acute scrotal pain, and we further suggest that a survey ultrasound of the kidney on the side of the pain should be performed in patients presenting with acute scrotal pain and a normal color Doppler ultrasound examination of the scrotum.

Síndrome de dirección inadecuada del humor acuoso refractario: una posible complicación de la queratoplastia penetrante

Clinical caseAn 85 year-old woman presented with a flat anterior chamber of the left eye, severe ocular hypertension, and a normal ultrasound examination in the day following a penetrating keratoplasty (PK). The clinical status did not respond to maximum medical therapy, laser posterior capsulotomy, anterior hyaloidotomy, and complete 23 G vitrectomy. The patient refused further intervention, and light perception was lost after 6 months of follow-up. DiscussionThis is the first report of refractory aqueous misdirection syndrome following primary PK. Despite maximum medical and surgical management efforts, aqueous misdirection syndrome subsequent to primary PK may have a catastrophic outcome.

Diverse outcome following early prenatal diagnosis of pulmonary stenosis.

To assess the natural history and outcome of fetal pulmonary stenosis (PS), particularly that detected at 14-17 weeks' gestation. In this retrospective study we searched an electronic database of women from the general Israeli population attending a private ultrasound institute (Al-Kol ultrasound institute in Haifa) for routine complete early fetal ultrasound, including all fetal systems and a fetal echocardiogram, between 2004 and 2015. Ninety-seven percent of the women were at low risk of fetal malformations, and 3% had risk factors such as maternal Type-1 diabetes mellitus, exposure during pregnancy to teratogenic drugs, or anomalies in previous pregnancies or in other family members. At presentation at 14-17 weeks of gestation, color and pulsed Doppler imaging were performed across the four cardiac valves. We identified cases in which abnormal flow was detected, leading to suspicion of PS; in these cases, a follow-up examination was carried out at 17-19 weeks and then monthly until delivery or resolution of the finding, and postnatal echocardiography was performed at birth, 4-6 weeks thereafter, and yearly afterwards. Outcome data for suspicious cases, including postnatal diagnosis and general or specific symptoms, were collected by contacting the parents via email or telephone. Among 24 185 early prenatal transvaginal ultrasound screening examinations, 23 cases of suspected PS were identified. They were classified into three groups, according to their ultrasound findings. In Group A (n = 8), the ultrasound screen was normal except for high flow velocity across the pulmonary valve. In six cases, this finding had resolved by 20-21 weeks of gestation and all were found to be normal at postnatal follow-up, one case underwent termination of pregnancy at 19 weeks and PS was confirmed at autopsy and one case was lost to follow-up. In Group B (n = 12), there was aliasing across the pulmonary valve. Two of these cases were normal postnatally and eight had mild-to-moderate PS; the remaining two cases developed hypoplastic right ventricle and pulmonary atresia at 19-20 weeks and the pregnancies were terminated. In Group C (n = 3) PS was associated with other anomalies; all three pregnancies were terminated. There were an additional six cases (Group D) not identified in early gestation, in which PS was late-onset. One had tricuspid regurgitation at the early screen, but was subsequently diagnosed with Ebstein's anomaly and pulmonary atresia, at 22 weeks, and was terminated. The other cases had completely normal early ultrasound screening examinations: one case had Ebstein's anomaly and PS was diagnosed at birth; four had isolated mild PS, of which one was diagnosed at 22 weeks' gestation and the other three were diagnosed postnatally, before 3 months of age. The sensitivity for detection of the ascertained cases of PS was 64% (11/17) and the specificity was > 99%. There is a diverse spectrum of presentation of fetal PS in the early mid-trimester. A possible explanation for this could be different pathophysiological pathways. Further study is needed to explain the different prenatal sonographic presentations in an unselected population. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Validity of ultrasound in diagnosis of tendon injuries in penetrating extremity trauma

BackgroundTendon ruptures are common musculoskeletal injuries all around the world. Correct and timely diagnosis of tendon injuries is obviously important for improving the treatment and minimizing the community costs. Ultrasound is now being considered as one of useful modalities in this area. ObjectiveThe preset study is going to validate the diagnostic ability of ultrasound in tendon injuries induced by penetrating extremity trauma. MethodsIn this prospective, observational study, patients with penetrating extremity trauma and suspicion of tendon injuries were enrolled in our study. A team of emergency medicine (EM) residents performed ultrasound examination in these cases after attending the specific workshop and acquiring necessary skills in normal and abnormal tendon ultrasound examination. Then another team of either EM or orthopedic residents explored patients' wounds and determined intact or injured tendons under direct visual observation. The results were analyzed to validate sensitivity and specificity of ultrasound as an alternative diagnostic test. ResultsSeventy-one patients were enrolled in our study and 11 patients were excluded during one year in 2014. Sixty patients, 11 with lower extremity and 49 with upper limb injuries were evaluated, among them 32 patients had extensor zone and 28 patients had flexure zone injuries. The overall sensitivity and specificity were calculated 94.4% (95% CI 72.7–99.8%) and 100% (95% 91.5–100.0%) respectively. ConclusionsOur results were similar to previous findings. Ultrasound can effectively differentiate injured from intact tendons in penetrating extremity trauma.

Frequency and Importance of Incomplete Screening Fetal Anatomic Sonography in Pregnancy.

To determine (1) how often routine screening fetal anatomic sonography fails to completely visualize fetal anatomy; (2) the proportion of women with incomplete ultrasound examinations who are recommended for repeat screening and then undergo repeat sonography; and (3) how often abnormal fetal anatomy is detected on repeat sonography. We conducted a retrospective cohort study at a high-volume academic obstetric ultrasound center. Participants were 16,300 women at 17 through 21 weeks' gestation with a singleton pregnancy presenting for screening anatomic sonography between January 2009 and December 2013. Main outcome measures were (1) incomplete visualization of anatomy at initial screening sonography; (2) among women with incomplete but otherwise normal initial screening ultrasound examinations, recommendation for and performance of repeat sonography; and (3) among women undergoing repeat sonography, discovery of abnormal fetal anatomy within anatomic components that were previously incompletely visualized. The mean maternal age ± SD was 30.8 ± 6.3 years, and the mean gestational age was 18.8 ± 1.0 weeks. Among 16,300 initial screening ultrasound examinations, 2157 (13.2%) had incomplete visualization of fetal anatomy. Of those women eligible for follow-up, 91.5% were recommended for repeat screening, of whom 92.8% had a subsequent examination. Of 1560 repeat screening ultrasound examinations, 8 (0.5%) showed an abnormality in the components of anatomy that were previously visualized incompletely. In this large single-center study, incomplete visualization was common in screening fetal anatomic ultrasound examinations. Recommendations for repeat imaging were nearly universal, but abnormal fetal anatomy was infrequently discovered on repeat screening.

Serum cobalamin concentrations and small intestinal ultrasound changes in 75 cats with clinical signs of gastrointestinal disease: a retrospective study.

Objectives The aim of the study was to evaluate ultrasonographic changes in the small intestine of cats with clinical signs of gastrointestinal disease and low or low-normal serum cobalamin concentrations. Methods Records for client-owned cats presenting to the small animal hospital with signs of gastrointestinal disease and in which serum cobalamin concentrations were measured from 2000-2013 were reviewed. Inclusion criteria were cobalamin concentrations <500 ng/l, abdominal ultrasound within 1 month of cobalamin testing and definitive diagnosis. Results Of 751 serum cobalamin measurements, hypocobalaminemia or low-normal cobalamin was identified in 270 cats, abdominal ultrasound was performed in 207 of those cats and a diagnosis was available for 75 of them. Small intestinal ultrasound changes were detected in 49/75 (65%) cats. Abnormalities included thickening, loss of wall layer definition, echogenicity alterations and discrete masses. Serum cobalamin concentrations <500 ng/l were observed with diagnoses of inflammatory disease, neoplasia, infectious disease and normal histopathology. Cobalamin concentration was significantly lower in cats with lymphoma or inflammatory bowel disease compared with other gastrointestinal neoplasia ( P = 0.031). No difference was found between cobalamin concentration and the presence of ultrasound abnormalities, specific ultrasound changes or albumin concentration. Conclusions and relevance One-third of symptomatic cats with hypocobalaminemia or low-normal cobalamin concentrations may have an ultrasonographically normal small intestine. For the majority of cats in this study, histopathologic abnormalities were observed in the small intestine, regardless of ultrasound changes. These findings suggest gastrointestinal disease should not be excluded based on low-normal cobalamin concentrations, even with a concurrent normal ultrasound examination. Additional studies are needed in cats with low-normal serum cobalamin concentrations, as a definitive diagnosis was not pursued consistently in those cats. However, data from this study suggest that careful monitoring, histopathologic evaluation and future cobalamin supplementation may be warranted.

Incidental Suspicious Regional Lymph Nodes on Breast Sonography: Is Sampling Necessary?

Suspicious regional lymph nodes may be incidentally identified on breast ultrasound examinations in patients who present for sonographic evaluation without a known or a suspected breast malignancy, and there is a paucity of data on whether biopsy should be performed. This study aims to characterize incidental sonographically detected suspicious regional lymph nodes and determine whether tissue sampling or follow-up imaging is required. A total of 40,773 consecutive breast ultrasounds were reviewed. Overall, 7 women with nonpalpable, incidental, suspicious axillary or supraclavicular lymph nodes in an otherwise unremarkable breast and without history of malignancy or systemic disease were identified. In all, 5 women with 6 nodes underwent ultrasound-guided fine needle aspiration and 2 women with 3 nodes were recommended follow-up ultrasound. Follow-up imaging, cytology, and all-cause clinical data were reviewed to evaluate outcomes. All 6 biopsied lymph nodes (mean = 1.5cm) were benign on cytology. Follow-up imaging was available for 3 nodes (mean = 2.6 years), with all-cause follow-up for all nodes of 2.2 years. In the follow-up group, 3 lymph nodes (mean = 1.6cm) were monitored (mean = 4.3 years) with all-cause follow-up of 4.7 years. No new cancers, growth, or suspicious features were found in these nodes during follow-up for either group of women. In conclusion, women without history of prior malignancy or systemic disease with incidentally detected, nonpalpable, suspicious regional lymph nodes with an otherwise normal breast ultrasound examination underwent fine needle aspiration or were recommended short-term follow-up ultrasound. No indeterminate features or malignancies were observed at the time of tissue sampling or developed over several years of follow-up. Avoiding sampling of these nodes would reduce patient morbidity and health care costs.

Feasibility of predicting the outcome of fetal infection with cytomegalovirus at the time of prenatal diagnosis

Congenital cytomegalovirus infection occurs in 0.7% of live births with 15-20% of infected children developing long-term disability including hearing loss and cognitive deficit. Fetal cytomegalovirus infection is established by viral DNA amplification by polymerase chain reaction in amniotic fluid obtained by amniocentesis following maternal seroconversion or after the diagnosis of ultrasound features suggestive of fetal infection. Severe brain ultrasound anomalies are associated with a poor prognosis. The prognosis of an infected fetus showing either no ultrasound features or nonsevere ultrasound anomalies is difficult to establish up until late in the second or third trimester of pregnancy. We sought to evaluate the prognostic value of fetal ultrasound, amniotic fluid, and fetal blood analysis at the time of prenatal diagnosis of fetal infection. We reviewed all cases of fetal cytomegalovirus infection with a sample of amniotic fluid positive for viral DNA and/or fetal blood analyzed in our laboratory from 2008 through 2013. Prenatal ultrasound features along with cytomegalovirus DNA loads in amniotic fluid and in fetal blood and fetal platelet counts were reviewed in relation to gestational age at maternal infection, neonatal examination, and postnatal follow-up or postmortem examination. In all, 82 fetuses were infected following maternal infection mainly in the first trimester. At the time of prenatal diagnosis at a median of23 weeks, 19, 22, and 41 fetuses showed severe brain ultrasound abnormalities, nonsevere ultrasound features, and normal ultrasound examination, respectively. Nonsevere ultrasound features, higher DNA load in amniotic fluid, fetal platelet count ≤114,000/mm(3), and DNA load ≥4.93 log10 IU/mL in fetal blood were associated with a symptomatic status at birth in univariate analysis (P < .001, P= .001, and P= .018, respectively). Bivariate analysis combining ultrasound results and either adjusted viral load in amniotic fluid or fetal blood profile showed that these were independent prognostic factors of a symptomatic status at birth. Both fetal blood parameters were better predictors than amniotic fluid viral load. At the time of prenatal diagnosis, the ultrasound negative predictive valuefor symptoms at birth or at termination of pregnancy was 93%. The combined negative predictive values of ultrasound and viral load in amniotic fluid and that of ultrasound and fetal blood parameters were 95% and 100%, respectively. In fetuses presenting with nonsevere ultrasound features, the positive predictive values of ultrasound alone and in combination with amniotic fluid viral load or with fetal blood parameters were 60%, 78%, and 79%, respectively. Risk assessment of infected fetuses for being symptomatic at birth is possible as early as the time of diagnosis by using a combination of targeted ultrasound examination along with viral load in amniotic fluid and in fetal blood together with platelet count. The advantage of using amniotic fluid is that it is available at prenatal diagnosis. One may wonder if increasing the negative predictive value of the overall assessment of an infected fetus from 95-100% is worth the additional risk of cordocentesis for fetal blood sampling. This can only be an individual decision made by well-informed women and it seems therefore appropriate to use the figures presented here and their confidence intervals for counseling.

Outcomes From Polyhydramnios With Normal Ultrasound.

To investigate the short- and long-term outcomes of children from pregnancies complicated with polyhydramnios, defined as amniotic fluid index (AFI) >24 cm, and with a normal detailed ultrasound examination. This retrospective cohort study examined 134 children aged 4 to 9 years with polyhydramnios and normal detailed ultrasound examination during pregnancy compared with 268 controls with normal AFI and normal detailed ultrasound examination matched for maternal age, year of delivery, gestational week at delivery, and presence or absence of diabetes. The primary outcome was the rate of malformations diagnosed postnatally. Additional outcomes were obstetrics outcomes, genetic syndromes, and neurodevelopment. Polyhydramnios was associated with increased risk for cesarean delivery (CD) and birth weight >90th percentile. This elevation in CD was attributed to increased rate of elective CD due to suspected macrosomia. Polyhydramnios was associated with increased risk for congenital malformations (n = 25 [19%] compared with 27 [10%], respectively; P = .016) without a statistically significant increase in the rate of major malformations (11 [8%] vs. 10 [4%]; P = .057). Genetic syndromes were more prevalent in the polyhydramnios group (5 [3.7%] vs. 2 [0.75%]; P = .043), as were neurologic disorders and developmental delay (9.7% vs. 3%; P = .004). Despite a normal detailed ultrasound examination, polyhydramnios is associated with increased rate of fetal malformations, genetic syndromes, neurologic disorders, and developmental delay, which may be diagnosed only after birth.

Mammary Gland Ultrasound Evaluation of Jersey Cattle Breed

Background: Ultrasound allows the udder evaluation of lactating cattle, through parameters such as the area of the cistern of the mammary gland and teat, and can reveal structures with different echogenicity, indicating injuries as mastitis, edema, hematoma, abscess, atrophy and fibrosis in the mammary gland parenchyma. The aim of this study was to observe the clinical, morphometric and sonographic assessment of the mammary gland of Jersey cows, evaluating the correlation of this exam and the production of milk.Materials, Methods &amp; Results: Nine Jersey breed cows, aged 3 to 9 years, in a variable order of first to seventh lactation were evaluated. Animals were submitted to general and specific clinical examination of the mammary gland. For the evaluation, inspection and palpation of the gland cistern and teat cistern, measuring with tape measure the udder circumference and width and height of each mammary quarter was held, and length measurements of the four teats individually using a caliper. By palpation the mammary gland parenchyma was classified as nothing worthy of note and fibrosis. After this evaluation, the mammary glands were evaluated using ultrasound, analyzing biometrics and echotexture in order to detect and/or confirm possible changes identified in prior palpation. The diameter of the gland and teat cistern were measured, and the echogenicity of each region and each mammary quarter, checking the homogeneity of the parenchyma, evaluating the possible presence of nodules, scarring or acute injuries. The average milk production was 15.57 ± 5.4 L. There was no correlation between milk production, measured biometric data of the mammary gland and clinical and ultrasonographic changes (P &gt; 0.05). On palpation exam, a few number of animals had soft to normal consistency in mammary glands (2/9), the occurrence of fibrosis was observed, but could only be detected by ultrasonography (4/9).Discussion: Using the ultrasound examination is possible to access more accurately the morphology of the udder of lactating animals, examining and measuring the area of the cistern of the mammary gland and teat, the thickness of the wall and ceiling interface. Several studies correlate the morphology of these parameters with resistance to mastitis. The imaging aids to differentiate the teats according to animal age, milk production, lactation number, size, as well as a predisposition to mastitis. In healthy animals, the boundary between the gland cistern and teat cistern is marked by the presence of large anechoic structures. Changes in the teats of a gland with mastitis are mild inflammation, proliferation of tissues and mucosal lesions. No significant correlation between the morphology, physical examination and ultrasound changes of the mammary gland and milk production was observed. Possibly this was due to the limited number of experimental animals, and there is a wide variation in age and clinical profiles, as already observed in other studies that cows with high and wide rear udders tend to have higher milk production. In some cases ultrasound allows observe formation of gas, bruising, edema, abscess, atrophy, fibrosis, fistulae and intraluminal obstructions and parenchymal echogenicity changes during infection cases. In normal ultrasound examination, the parenchyma of the mammary gland must be homogeneous with high echogenicity and anechoic alveolus. Atresic and fibrosis are hyperechoic and lose the typical echogenicity of the udder. Thus, it is emphasized that ultrasound is a complementary method in the evaluation of the mammary gland, since it identifies not noticeable injuries on physical examination that may affect milk production.

Uptake of non-invasive prenatal testing (NIPT) and impact on invasive procedures in a tertiary referral center.

The introduction of non-invasive prenatal testing (NIPT) by isolation of cell-free fetal DNA from maternal blood is a new diagnostic option in prenatal care. The aim of the study was to investigate the algorithm of prenatal testing before and after the introduction of NIPT in a tertiary referral center and to investigate the influence of NIPT on the frequency of invasive procedures. Retrospective data analysis was conducted of all singleton pregnancies that presented for first trimester screening 17 months before and after the introduction of NIPT (n = 2271). Women were categorized into three risk groups: low risk for trisomy 21 (<1:1000), intermediate risk (1:101-1:1000) and high risk (≥1:100). The choice of diagnostic testing after FTS was analyzed. 1093 (group 1) presented before and 1178 (group 2) after the introduction of NIPT. The rate of high-risk patients was equal in both groups (14.4 vs. 15.4 %). No differences were found with regard to invasive testing (11.6 vs. 11.3 %). NIPT was chosen by 3.7 % (44/1178) in group 2. Of those with NIPT, 72.7 % had a risk estimate of <1:100, but 90.9 % were ≥35 years old. The rate of NIPT among high-risk patients with a normal ultrasound examination was 25 %. At present, NIPT is chosen mainly for reassurance by patients not considered to be at high risk. In the high-risk group, NIPT can be offered if the ultrasound examination is normal and the risk is high due to maternal age or serum screening alone. The rate of invasive testing was not reduced in this selected population.

309: Polyhydramnios with normal detailed ultrasound examination – short and long term outcomes

309: Polyhydramnios with normal detailed ultrasound examination – short and long term outcomes

Fatal Pulmonary Embolization after Negative Serial Ultrasounds

BackgroundIsolated distal deep vein thrombosis (DVT) is not traditionally viewed as a potentially life-threatening condition. There are conflicting recommendations regarding its evaluation and treatment, and wide variability in clinical practice. The presentation of this case highlights the fatal potential of this condition. Case ReportThis is the report of a previously healthy young woman who presented to the emergency department with calf pain concerning for a DVT. She received two radiologist-performed duplex ultrasound examinations of the affected extremity, both of which were negative, but suffered a sudden cardiac arrest several hours after the second study. Autopsy attributed the death to DVT and pulmonary embolism. Why Should an Emergency Physician Be Aware of This?This case highlights the risk for fatal pulmonary embolization, even after normal serial ultrasound examinations to exclude DVT.

The role of abdominal ultrasound in the diagnosis of typhoid fever: An observational study

To study the usefulness of abdominal ultrasound in the diagnosis of typhoid fever and to determine the common ultrasound findings early in the course of the disease. Abdominal ultrasound examination was performed within the first week of initiation of symptoms in 350 cases with clinical diagnosis of typhoid fever. Subsequent ultrasound follow-up examination was done 15 days later (beginning of the third week). All the patients proved to have positive Widal test and Sallmonella culture. The study was performed in Erbil-Iraq from the period January 1993 to October 2010. The following ultrasound findings were reported: hepatomegaly (31.4%), prominent intrahepatic bile ducts (64.85%), splenomegaly (100%), mesenteric lymphadenopathy (42.85%), bowel wall thickening (35.71%), acalculous cholecystitis (16.28%), perforations (1.14%), and ascites in (3.4%). The current study showed that the findings are typical enough to justify initiation of treatment for typhoid fever when serology is equivocal and culture is negative, and is fairly safe to say that normal ultrasound examination early in the course of febrile illness rules out typhoid fever.

Late trimester hydranencephaly associated with maternal exposure to methamphetamine

Acquired hydranencephaly diagnosed after a normal ultrasound examination is a rare finding in pregnancy. The etiology includes infections, bleeding diatheses, neoplasms and exposure to vasoconstrictive agents. Fetal hydranencephaly was discovered on a third trimester ultrasound examination after a normal examination a month earlier. The pregnant patient admitted to heavy use of crystal meth during the preceding month. Upon the finding of an acquired hydranencephaly, the clinician should have a high index of suspicion for maternal abuse of vasoconstrictive agents such as methamphetamine or cocaine.

Prenatal diagnosis – a comparison of rapid testing by QF-PCR versus full karyotyping in the Scottish population

Current health policy encourages the use of rapid trisomy testing rather than full karyotype analysis. We compared the results of QF-PCR with full karyotyping via a retrospective audit. Between 01/11/09...

Retinal oximetry in central retinal artery occlusion

A 69-year-old woman experienced dizziness when she woke up and realized that she had almost completely lost her vision on the left eye. She has suffered from polymyalgia rheumatica and had received oral prednisolone until 2 months earlier. The following day she had bare light perception and a pupillary afferent defect on the left eye. The left fundus showed central retinal artery occlusion with segmented blood columns (‘boxcarring’, Fig. 1) in the arterioles and venules, marked ischaemic oedema and a cherry red spot in the fovea. The right eye had normal visual acuity of 1.0. The intraocular pressure was normal in both eyes. Sedimentation rate was only 26 and 29 mm/h on repeated measurements (Elfarsson et al. 2010). Top left: the patient’s left eye approximately 30 h following the onset of the central retinal artery occlusion. The interrupted blood column (‘boxcarring’) in retinal arterioles and venules indicates the total occlusion of the central retinal artery. The box indicates the area shown on the oximetry images. Top right: temporal artery biopsy showing intimal thickening with inflammation adjacent to the internal elastic membrane and in the adventitia. Bottom left: the initial spectrophotometric retinal oximetry images taken 30 h after the onset of central retinal artery occlusion. The retinal arterioles have only 71 ± 9% oxygen saturation (mean ± SD for major arterioles) and the oxygen saturation in the venules is slightly lower; 63 ± 9%. Bottom right: retinal oximetry images taken 1 month following the onset of central retinal artery occlusion. The retinal arterioles now show oxygen saturation of 100 ± 4%, consistent with uninterrupted arterial blood flow. Given the history and arterial occlusion and a normal ultrasound examination of heart and carotid arteries, a tentative diagnosis of temporal arteritis was made. Treatment was started with prednisolone tablets 1 mg/kg and a temporal artery biopsy obtained. Histological examination confirmed temporal giant cell arteritis (Fig. 1) and prednisolone treatment was continued. Ultrasound examination of the heart and carotid arteries was performed, keeping in mind that Miyazawa et al. (2011) reported that carotid stenosis is frequently associated with central retinal artery occlusion. Also, Mansour & Younis (2011) and Pournaras et al. (2010) suggested that ocular paracentesis and hypotensive treatment may be considered, even this late (>24 h) following the onset of central retinal artery occlusion. Spectrophotometric retinal oximetry (Hardarson et al. 2006) was performed on both eyes approximately 30 h after she noticed the vision loss. Retinal arterioles showed oxygen saturation of 71 ± 9% (mean ± SD for major arterioles) and the venular oxygen saturation was 63 ± 9% (Fig. 1). The corresponding values for the normal fellow eye were 95 ± 5% (arterioles) and 66 ± 8% (venules). The low arteriovenous difference in the affected eye is consistent with stagnant blood in the vasculature, cell death and decreased oxygen consumption. One month later the eye remained blind, although the perfusion of the retinal circulation had been restored. The oxygen saturation in the arterioles had returned to 100 ± 4%, while the venous saturation was 54 ± 5% (Fig. 1). At this time, the arteriolar saturation in the fellow eye was 100 ± 4% and the venular saturation 60 ± 6%. The pathogenesis of central retinal artery occlusion has been extensively studied (Hayreh 2011) although few studies are available on the influence of occlusion on human retinal oxygenation. Hammer et al. (2009) investigated branch and central retinal artery occlusions with a two wavelength oximeter. At the time of diagnosis, which was within 48 h of the occlusion, they found low arterial saturation (78%) in the occluded branch artery, similar to our findings, and a considerable increase (91%) 5 days later, after treatment with pentoxifylline for improvement of blood flow. Saturation after central retinal artery occlusion was, however, initially close to normal (93%) although it did increase after 5 days and treatment (103%). Venous saturation in central retinal artery occlusion was initially slightly below normal (55%) and had increased to 70% 5 days later. A later paper by the same group confirmed the results for occluded branch retinal arterioles (Gehlert et al. 2010). Spectrophotometric retinal oximetry is a relatively new form of diagnostic imaging. It can clearly show decreased arterial oxygen saturation following central retinal artery occlusion and may thus become helpful in diagnosing this disorder. It also demonstrates the return of blood flow and may therefore be useful for follow-up of patients with arterial occlusions. To realize fully the usefulness of this method for diagnosis and follow-up of central retinal artery occlusion and other retinal vasculopathies, further clinical studies are needed.