Repeat Ultrasound Scan Research Articles

Management and outcomes of axial isolated distal deep vein thrombosis at North Shore Hospital, New Zealand: a retrospective audit

It is standard of care to treat proximal vein deep vein thrombosis (DVT) for a minimum of 3 months. Conversely, management of isolated distal DVT (IDDVT) is controversial, with options including observation and repeat ultrasound scan within 1 week to detect and anticoagulate those with proximal propagation, or anticoagulation for periods of up to 3 months. The aim was to assess the rates of proximal propagation and venous thromboembolism (VTE) recurrence within 3 months of diagnosis of IDDVT, and to examine how the duration of treatment might influence this. Study patients were identified by retrospective audit of data from the North Shore Hospital VTE database. All patients presenting with established axial vein distal DVT from July 2007 to June 2012 were included. A 6-week treatment duration cut-off was used to separate the treatment arms (<6 weeks vs 6 weeks vs >6 weeks), and Fisher's exact or Pearson's Chi-squared tests were used to assess between-group comparisons. Five hundred and seven patients were included in the study, mean age 59.7 years; 53% female. There were three cases of proximal propagation, all occurring in those receiving <6 weeks treatment. There were six VTE recurrences, three in the <6 week and three in the ≥6 week treatment groups respectively. Malignancy was the only significant predictor of VTE recurrence (P = 0.001). A 6-week duration of anticoagulation appears to be an effective and safe treatment for isolated axial distal DVT, with low rates of VTE recurrence and proximal propagation.

Rare sequelae of a testicular tumor: A 'burnt-out' tumor

Introduction: Testicular tumors typically present as a palpable lump. Some tumors have been known to spontaneously regress, thus have been referred to as ‘burnt-out’ tumors or vanishing tumors. Case Report: A 28-year-old male was seen in urology clinic with clinical findings of a small atrophic left testis, with a prior history of a painful left testicular lump not responsive to antibiotics, which had spontaneously resolved. Ultrasound scan revealed an initial solid testicular lesion of 19x12x10 mm with internal vascularity, which upon repeat ultrasound scan two months later found a 12-mm coarse calcification and a hypoechoic region, but regression of the initial solid lesion. The diagnosis of a burnt-out tumor was made and he underwent urgent radical orchidectomy and prosthesis insertion. Computed tomoraphy (CT) staging scan showed significant paraortic lymphadenopathy, therefore the patient further underwent chemotherapy. Treatment has been successful and the patient is progressing well with no complications. Conclusion: The diagnosis of a burnt-out testicular tumor is an important differential to consider in patients with spontaneously regressing testicular lumps, abnormal findings on ultrasound scan and subsequent presentation of testicular atrophy of unknown cause. This diagnosis should also be considered in patients with secondary metastatic tumors of unknown primary (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 6 No. 1, January 2015. ISSN – [0976-3198] Int J Case Rep Images 2015;6(1):16–20. www.ijcasereportsandimages.com Kum et al. 16 CASE REPORT OPEN ACCESS Rare sequelae of a testicular tumor: A ‘burnt-out’ tumor Francesca Kum, Faisal Ghumman, Matin Sheriff

Is the third trimester repeat ultrasound scan for placental localisation needed if the placenta is low lying but clear of the os at the mid-trimester morphology scan?

It is unclear whether women with a low-lying placenta (not overlapping the internal cervical os) at the mid-trimester scan need follow-up. The aim of the study was to determine the rate of placenta praevia, vasa praevia and cord prolapse in the third trimester in this cohort of women. A retrospective cohort study of women with a documented low-lying placenta (<30mm from the internal cervical os) at the mid-trimester morphology ultrasound scan was done. A composite outcome of rate of placenta praevia, vasa praevia or cord prolapse at term was evaluated. Multivariate analysis was performed to investigate the variables influencing the composite outcome. In addition, a meta-analysis of methodologically similar studies was performed to investigate the effect of the placenta to os distance at the mid-trimester scan on the rate of placenta praevia at term. One hundred and eighty-one women with a low-lying placenta not overlapping the os at mid-trimester scan were identified. The composite outcome was documented in 20 (11.0%) women, including placenta praevia in 15 (8.3%). Based on multivariate analysis, multiparity, distance from os<10mm and antenatal bleeding were independently associated with the composite outcome. Meta-analysis demonstrated significant reduction in rate of placenta praevia for every 10-mm increase in placenta-os distance at mid-trimester. Our study supports the recommendation to follow up all women with a placenta lying <20mm from the cervical os at mid-trimester.

An unusual case of familial cystic kidney disease.

A 46-year-old woman with a prior diagnosis of autosomal dominant polycystic kidney disease (ADPKD) was referred to the nephrology clinic with abdominal fullness. She had been diagnosed with ADPKD by ultrasound 10 years previously at a different renal unit and was subsequently lost to follow-up. Her father was diagnosed with polycystic kidney disease at the age of 74 with a normal kidney function. Her sister was also diagnosed with polycystic kidney disease at a different renal unit following this patient’s diagnosis. Her past medical history included severe menorrhagia, iron deficiency anaemia, anxiety, bilateral pleural effusions and polycystic ovaries. She was on perindopril for hypertension though her compliance had been variable. She never suffered from haematuria, back pain or cyst infections. Systemic enquiry did not reveal any significant symptoms. She presented to her general practitioner 2 years prior to this presentation with bilateral swelling of the legs that resolved spontaneously after a month. On examination she was well. Her blood pressure was 130/92 mmHg. Abdominal examination revealed bilaterally enlarged kidneys. Examination of other systems was unremarkable apart from minimal peripheral oedema. Urine dipstick revealed +protein and no blood. Renal function was normal with a creatinine of 50 μmol/L. She had a normal MRA and MRI of the head which had been requested to rule out berry aneurysms, as there was a family history of death due to ‘stroke’. A repeat ultrasound scan of the abdomen showed bilateral polycystic kidneys. There was a small amount of free fluid within the pelvis and as part of the investigation of this a computed tomography (CT) of the abdomen and pelvis was requested. This showed (Figures 1 and 2) bilateral perinephric fluid collections and a trace of free fluid. The other organs appeared normal. There was no lymphadenopathy.

Ectopic Ovarian Leiomyoma Presenting as Chronic Pelvic Pain

Abstract Background: The presence of an “ectopic ovary” is rare, and the diagnosis can be difficult to establish preoperatively. Histologic confirmation is usually necessary. There has not been any case reported so far of a true ectopic ovarian leiomyoma as a cause of chronic pelvic pain. Such a case is reported in this article. Case: A 32-year-old woman presented with an incidental finding of a solid pelvic mass that had been diagnosed with a ultrasound (US) scan during a miscarriage that she had. During follow-up, she reported having symptoms of pelvic pain and deep dyspareunia. A repeat US scan showed no change in the mass that appeared to be arising from, or abutting, the posterior wall of her uterus, suggestive of a fibroid growth. Standard serum tumor markers were all normal. Magnetic resonance imaging (MRI) initially showed on only a hemorrhagic ovarian cyst. However, an initial diagnostic laparoscopy revealed a normal left ovary with a hemorrhagic cyst and a normal right ovary. However, there was ...

Dilemma in Differentiating between Acute Osteomyelitis and Bone Infarction in Children with Sickle Cell Disease: The Role of Ultrasound

BackgroundDistinguishing between acute presentations of osteomyelitis (OM) and vaso-occlusive crisis (VOC) bone infarction in children with sickle cell disease (SCD) remains challenging for clinicians, particularly in culture-negative cases. We examined the combined role of ultrasound scan (USS), C - reactive protein and White blood counts (WCC) in aiding early diagnosis in children with SCD presenting acutely with non-specific symptoms such as bone pain, fever or swelling which are common in acute osteomyelitis or VOC.MethodsWe reviewed the records of all children with SCD who were discharged from our department from October 2003 to December 2010 with a diagnosis of osteomyelitis based on clinical features and the results of radiological and laboratory investigations. A case control group with VOC who were investigated for OM were identified over the same period.ResultsIn the osteomyelitis group, USS finding of periosteal elevation and/or fluid collection was reported in 76% cases with the first scan (day 0–6). Overall 84% were diagnosed with USS (initial +repeat). 16% had negative USS. With VOC group, USS showed no evidence of fluid collection in 53/58 admissions (91%), none of the repeated USS showed any fluid collection. Mean C-reactive protein (CRP), and white cell count (WCC) were significantly higher in the OM.ConclusionThe use of Ultrasound in combination with CRP and WCC is a reliable, cost-effective diagnostic tool for differentiating osteomyelitis from VOC bone infarction in SCD. A repeat ultrasound and/or magnetic resonance imaging (MRI) scan may be is necessary to confirm the diagnosis.

Learning curve with MRI in diagnosing spinal anomalies: a rare case of caudal tail diagnosed on ultrasound but inconclusive on MRI

A low risk 29–year-old primigravida booked at 8 weeks. Booking ultrasound was normal. Second trimester serum screening was abnormal with a raised AFP of 2.17MoM. Following this she had an...

Management and outcome of vasa praevia in a teaching hospital over a 10 year period

IntroductionRCOG have recently published guidelines regarding vasa praevia. Routine screening is not recommended but additional ultrasonography is advised if vasa praevia is suspected from previous ultrasound scans or clinical suspicion....

Vaginal delivery after myomectomy: challenges and opportunities

A 33-year-old patient was booked for antenatal care at 6 weeks during her Wrst pregnancy. She had a previous abdominal myomectomy 6 years earlier for heavy periods that made her anaemic. She had a hospital report indicating that the Wbroid was located in the lower posterior uterine wall, encroaching on the cervix and measured 8 £ 7 £ 6 cm. It distorted the uterine cavity and obliterated the pouch of Douglas. The incision was made over the Wbroid, through the posterior wall of the uterus. An opening of half a centimeter was made into the uterine cavity during the operation and the patient was advised to have an elective section. The uterine wall was closed with vicryl, and the peritoneum was closed with prolene. She was counseled about the risk of uterine scar rupture and was oVered an elective caesarean section, which she declined and requested a trial of vaginal delivery. Her pregnancy progressed uneventfully and repeat ultrasound scans showed no signiWcant change in the size of her Wbroids or any thinning of her uterine wall. She was admitted in spontaneous labour 9 days after her due date. A venXon was inserted, blood taken for group and save, and an epidural sited. She was kept under continuous cardiotocography monitoring. She progressed from 5 cm cervical dilatation to 9 cm in 4 h. The patient then took 4 h to reach full dilatation, as the vertex rotated from occiptoposterior position to right occiptoanterior position. There was no progress, despite an hour of pushing and the patient was counseled again regarding the need for emergency section, but insisted on continuing the trial. There was no progress despite an hour of pushing and the patient was counseled regarding the need for emergency section, but insisted on continuing the trial. The consultant was called in and agreed to a trial of instrumental delivery in theatre. The vertex was presenting in the right occiptoanterior position at 0 station. Nivelle Barns forceps were applied and the head was delivered after three pulls, with a right mediolateral episiotomy performed. A 4.220 kg active term male baby was born and the placenta was removed manually. The patient sustained a third degree tear, which was repaired alongside the episiotomy. She lost 1,500 ml of blood and was started on oral iron, alongside antibiotics and laxatives for the third degree tear. The patient recovered well and had no problems with anal incontinence when seen for postnatal check. She was keen on vaginal delivery in a subsequent pregnancy.

Case report: Vaginal delivery after surgical treatment for stress incontinence using transobturator tape: a case report

A 36-year-old woman presented at the one-stop urodynamic clinic with a 12-month history of urinary stress incontinence. She had no other urinary symptoms or history of urinary tract infection. She had a 17-month-old daughter delivered by spontaneous vaginal delivery. Stress incontinence occurred soon after her first delivery. She was single and had no plans for a second child. On clinical examination, the woman was found to have a normal abdomen and pelvis. Urodynamic assessment showed moderate urodynamic stress incontinence, with a stable normal capacity bladder and no voiding dysfunction. This woman was offered a transobturator tape (TOT) (Advantage Mid-Urethral Sling; Boston Scientific, St Albans, UK) as a surgical option for treatment, with preoperative physiotherapy. The operative details, together with risks and complications, were described, and a handout leaflet was given describing the operation. The woman decided to opt for conservative treatment initially while she thought matters were over. She was referred to the continence care clinic where she was examined and assessed for bladder re-education and pelvic floor muscle strength and tone. She was given a pelvic floor educator and instruction on pelvic floor exercises and fluid intake. Four months later, she requested surgery, and a TOT procedure was performed. Her last menstrual period was noted to be 2 weeks before. The urinary pregnancy test performed on admission was negative. A TOT (Boston Scientific) was inserted under general anaesthesia using a 1–2 cm midurethral incision in the anterior vaginal wall and an incision on each upper thigh over the obturator fossa, on a line levelling the clitoris. The polypropylene tape was placed loosely to form a suburethral hammock. The woman was returned from theatre without a urethral catheter. She voided normally, with residual volumes of less than 100 ml, noted on bladder scanning. She was discharged home on the second postoperative day. Two weeks later, the woman telephoned the hospital seeking advice after having a positive home pregnancy test and was given an appointment for the one-stop urodynamic clinic. An ultrasound scan showed a gestational sac of 5 weeks. Comprehensive counselling was provided by the urogynaecologist and the consultant anaesthetist involved with her case. She decided to continue with the unplanned pregnancy. Repeat ultrasound scan 4 weeks later confirmed a viable intrauterine pregnancy of 9 weeks of gestation. The woman’s GP was contacted and she was referred for antenatal booking at her local hospital, with written information to the obstetrician concerning her recent surgery. The woman’s antenatal progress was entirely uneventful. Serial urinalysis was negative for protein and bacterial culture. There was no stress incontinence antenatally. There was good communication between the obstetric unit and the one-stop urodynamic clinic during the antenatal period. There was a detailed discussion about the mode of delivery, and the woman decided that she would prefer vaginal delivery if possible. Spontaneous vaginal delivery occurred at 39 weeks of gestation. She was in labour in hospital for 75 minutes, with 10 minutes in the second stage. The baby weighed 3018 g and was normal. The woman required two sutures to the perineum for a first-degree tear. She was seen at 4 weeks postnatal in the one-stop urodynamic clinic. She had resumed normal voiding immediately after delivery and reported no stress incontinence on any occasion. Vaginal examination revealed that the tape was well placed, as previously, with no tightening or erosion.

Abdominal pregnancy: A cause of failed induction of labour

Induction of labour is a common mode of management of intrauterine fetal deaths, and the process usually involves ripening of the cervix by traditional methods of intracervical Foley's catheter insertion or the use of prostaglandin preparations intravaginally. Such methods are usually very effective independently. The objective of this case report is to call the attention of practising obstetricians to the possibility of an abdominal pregnancy as a cause of failure to ripen the cervix and that careful re-evaluation and use of ultrasound scan can improve diagnostic acumen with favorable outcome of management in such cases The case file of the patient was thoroughly reviewed. A literature search on the subject of abdominal pregnancy using local and international journals and relevant textbooks was done to document the current status of the management of such cases. A 29-year-old Gravida 4 para 3+0 (2 alive) presented at an estimated gestational age of 32 weeks with loss of fetal movement, which was suggestive of fetal death and was referred as such from a private hospital. A process of induction of labour was commenced; to ripen the cervix with intracervical Foleys catheter and misoprostol tablet and stimulate uterine contraction, but this was not successful due to failure of the cervix to ripen. This prompted further review of the patient with the aim of excluding the possibility of an abdominal ectopic pregnancy. A repeat ultrasound scan was done and this confirmed a diagnosis of abdominal pregnancy. The patient had laparotomy done to deliver a dead fetus and the placenta was removed with the right tube and ovary as they were deeply embedded in the placental mass. The definitive diagnosis was that of a secondary abdominal pregnancy. She made a satisfactory postoperative recovery and was discharged home. A high index of suspicion is needed to make a first time diagnosis of abdominal pregnancy. With timely diagnosis and appropriate management, the prognosis in most cases is favourable.

Fitz-Hugh-Curtis-Syndrome Mimicking Acute Cholecystitis: Value of New Ultrasound Findings in the Differential Diagnosis

Fitz-Hugh-Curtis is a rare syndrome characterised by perihepatitis following pelvic inflammatory disease. We report the case of a patient with a right ovarian teratoma, abnormal liver tests and pain in the right abdomen and shoulder, initially attributed to an acalculous cholecystitis. Before gynaecological surgery, a repeat ultrasound scan found several small avascular peritoneal masses at the upper dome of the liver, not reported in the initial examination. This prompted laparoscopic exploration of the subdiaphragmatic space, and the final diagnosis of Fitz-Hugh-Curtis-syndrome was made. Such ultrasound finding appears to be a new diagnostic feature of this syndrome.

Intermittent gastric volvulus secondary to gall bladder adhesions: a rare cause of gastric outlet obstruction

A51-year-old man presented with a history of intermittent epigastric pain over a course of 18 months, associated with feeling bloated, and episodic nausea and non-bilious vomiting, which relieved the pain. During recent months vomiting had been replaced by severe retching. Ultrasound scan of the gall bladder revealed gallstones. Clinical examination was unremarkable. Routine haematological and biochemical investigations were also normal. Two gastroscopies were incomplete, since on both occasions the endoscope could not be negotiated beyond the antrum and the pylorus could not be visualized. A water-soluble contrast swallow revealed a ‘cup and fill’ configuration (Figure 1), suggesting mesenteroaxial gastric volvulus. A repeat ultrasound scan revealed a thick-walled gall bladder with several calculi. Laparoscopy confirmed the presence of the gastric volvulus, with the stomach adherent to the body of a chronically-inflamed gall bladder. At initial intraoperative gastroscopy the endoscope failed to pass beyond the antrum. Following adhesiolysis, cholecystectomy and anterior suture gastropexy, a gastroscope could easily be passed into the pylorus and duodenum. He made an uneventful recovery and remains asymptomatic 1.5 years after the operation.

Proximal femoral focal deficiency in a newborn

Proximal femoral focal deficiency in a newborn

Laparoscopic cholecystecomy in a 16-day-old infant with chronic cholelithiasis

A 16-day-old girl with demonstrated evidence of cholelithiasis was treated initially conservatively on the assumption that the gallstone would resolve spontaneously. However, when repeat ultrasound scan showed a large gallstone and intrahepatic ductal dilatation indicative of antenatal common duct obstruction, the infant underwent laparoscopic cholecystectomy with an intraoperative cholangiogram. The patient did well postoperatively and was on regular feeding by postoperative day 1. An intraoperative cholangiogram showed an impacted stone in the infidibulum of the gallbladder. Gross and histopathologic findings indicated chronic cholecystitis. Based on an extensive review of the literature, this case appears to be the first reported incidence of chronic cholecystitis in a neonate and that of the youngest patient to undergo a laparoscopic cholecystectomy with intraoperative cholangiogram.

Hysteroscopic management of cornual ectopic pregnancy

A 32 year old woman attended the accident and emergency department with a two day complaint of vaginal bleeding and cramping lower abdominal pain, and a brown vaginal discharge since her last menstrual period which was 24 days prior to presentation. She had discontinued the combined oral contraceptive pill two months prior to her last menstrual period. Her urine pregnancy test (Guest Medical, UK) was positive. On abdominal examination, there was tenderness noted in the right iliac fossa. Vaginal examination revealed no cervical excitation but there was right adnexal tenderness. A transabdominal and transvaginal ultrasound scan (Diagnostic Sonar, multifrequency abdominal probe and 6.5 Hz transvaginal probe) revealed an empty uterus with an endometrial thickness of 11 mm. There was a right-sided ovarian cyst measuring 77 54 66 mm and a small amount of free fluid in the pouch of Douglas. Her serum h-hCG quantitative assay (Immulite 2000, immunoassay calibrated to WHO 3rd International Standard) at that point was 2830 IU/mL. A diagnostic laparoscopy was performed the following day to exclude an ectopic pregnancy. At laparoscopy, the finding of a right ovarian cyst was confirmed, with normal tubes, uterus and left ovary. A laparoscopic right ovarian cystectomy was performed as this was presumed to be the cause of her pain. A repeat h-hCG level the following day (48 hours after admission) was 3116 IU/mL. A repeat ultrasound scan two days later (four days after admission) showed what was presumed to be a viable intrauterine pregnancy, which was high within the uterine fundus. The possibility of a cornual pregnancy was raised. It was decided to rescan her in two weeks. A repeat ultrasound scan two weeks later revealed a left-sided cornual ectopic pregnancy, with a 25 mm gestational sac containing a 6 mm fetal pole. There was a large vascular signature from the surrounding decidual reaction, no fetal heart activity was seen and there was no free fluid in the pouch of Douglas. The serum h-hCG level at this stage was 15,208 IU/mL. Management options were discussed with the patient and she opted for surgical management. The following day, a laparoscopy and hysteroscopy were performed. The laparoscopy confirmed the diagnosis of a left-sided cornual ectopic pregnancy. A dilute solution of vasopressin (20 units in 20 mL of normal saline) was injected around the pregnancy. A hysteroscopy (5 mm, 30j forward angled scope) with normal saline showed a pregnancy beyond the left tubal ostium. The hysteroscope was advanced beyond the dilated left ostium and the sac was ruptured. The fetus was seen floating in the irrigation fluid. The hysteroscope was then withdrawn and a No. 6 flexible suction cannula (Rocket Medical, UK) inserted into the uterine cavity. Under transabdominal ultrasound guidance, the flexible suction cannula was advanced into the cornual gestation. Suction was then applied under direct laparoscopic control to ensure that the cannula did not perforate the uterine cornu. The suction evacuation yielded products of conception, which were sent for histology. There was minimal bleeding and the patient was kept in the hospital for observation. The serum h-hCG level fell to 1929 IU/mL by the third post-operative day. She recovered well and was discharged home. She was followed up in the Early Pregnancy Assessment Unit with weekly serum h-hCG levels, which fell gradually and became undetectable by five weeks following the operation. The histology confirmed products of conception.

Screening for abdominal aortic aneurysms

Eur J Vasc Endovasc Surg 25, 377-379 (2003)

The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial

Opposing views have been published on the importance of ultrasound screening for abdominal aortic aneurysms. The Multicentre Aneurysm Screening Study was designed to assess whether or not such screening is beneficial. A population-based sample of men (n=67800) aged 65-74 years was enrolled, and each individual randomly allocated to either receive an invitation for an abdominal ultrasound scan (invited group, n=33839) or not (control group, n=33961). Men in whom abdominal aortic aneurysms (> or =3 cm in diameter) were detected were followed-up with repeat ultrasound scans for a mean of 4.1 years. Surgery was considered on specific criteria (diameter > or =5.5 cm, expansion > or =1 cm per year, symptoms). Mortality data were obtained from the Office of National Statistics, and an intention-to-treat analysis was based on cause of death. Quality of life was assessed with four standardised scales. The primary outcome measure was mortality related to abdominal aortic aneurysm. 27147 of 33839 (80%) men in the invited group accepted the invitation to screening, and 1333 aneurysms were detected. There were 65 aneurysm-related deaths (absolute risk 0.19%) in the invited group, and 113 (0.33%) in the control group (risk reduction 42%, 95% CI 22-58; p=0.0002), with a 53% reduction (95% CI 30-64) in those who attended screening. 30-day mortality was 6% (24 of 414) after elective surgery for an aneurysm, and 37% (30 of 81) after emergency surgery. Our results provide reliable evidence of benefit from screening for abdominal aortic aneurysms.

Expansion rates and outcomes for the 3.0-cm to the 3.9-cm infrarenal abdominal aortic aneurysm

Objective: This study was performed for the determination of the expansion rates and outcomes and for recommendations for the surveillance of the 3.0-cm to 3.9-cm abdominal aortic aneurysm (AAA). Design: The study was observational with data from patients screened with ultrasound scanning for AAA at five Veterans Affairs Medical Centers for enrollment in the Aneurysm Detection and Management Trial. The eligibility requirements included: AAA from 3.0 cm to 3.9 cm in diameter and at least one repeat ultrasound scan more than 90 days after the initial screening. Patients also completed a questionnaire for demographic data and the determination of the presence of risk factors associated with AAA. The study endpoints included: 1, both mean and median expansion rates; 2, moderate expansion (>4 mm/year); 3, no expansion; 4, all causes of death; 5, AAA rupture; 6, expansion to 4 cm or more; 7, expansion to 5.0 cm or more; and 8, operative repair. Results: Ultrasound scan screening results identified 1445 patients with 3.0-cm to 3.9-cm AAAs. Seven hundred ninety men met the ultrasound scan criterion of having at least two ultrasound scan studies during the study period, and these 790 men were used for this study. Mean AAA size was 3.3 cm, with an average follow-up period of 3.89 ± 1.93 years. The median expansion rate was 0.11 cm/year. Expansion rates were significantly different (P <.001) between 3.0-cm and 3.4-cm cm AAA and 3.5-cm and 3.9-cm AAA. There were no reported AAA ruptures during the study period, although cause of death data were available in only 43% of the patients. Few 3.0-cm to 3.9-cm AAAs expanded to 5.0 cm or more during the study period. The patients with 3.0-cm to 3.9-cm AAAs who underwent operative repair during the study period were younger, had larger initial AAA diameters, and had more rapid expansion rates. Conclusion: AAAs of 3.0 cm to 3.9 cm expanded slowly, did not rupture, and rarely had operative repair or expanded to more than 5.0 cm in our study of male patients. Expansion rates and the incidence rate of operative repair are more common in the 3.5-cm to 3.9-cm AAA when compared with the 3.0-cm to 3.4-cm AAA. (J Vasc Surg 2002;35:666-71.)

Short-stay, out-of-hospital, radiologically guided liver biopsy.

To evaluate the safety, the quality and adequacy of specimens obtained and the cost benefits associated with performing liver biopsy out of hospital, on a short-stay basis, using radiological guidance. A prospective study undertaken over a three-year period, from March 1998 to March 2001, in a private radiology practice. PATIENTS AND PROCEDURES: 251 patients (159 men) with stable liver disease participated. Coagulation studies were performed within a two-week period before biopsy, which was carried out under the guidance of ultrasound (143 patients) or computed tomography (108 patients). A disposable, spring-loaded gun with an 18-gauge biopsy needle was used in each case. A repeat ultrasound or CT scan was performed after the procedure to monitor for complications such as haemorrhage. Complications of liver biopsy; adequacy of specimens for histological examination; cost of out-of-hospital procedures compared with liver biopsies performed in the hospital setting. Two hundred and twenty nine patients (91.2%) were discharged 60 minutes after the biopsy. The only post-biopsy complication was pain, either at the biopsy site or in the right shoulder. Pain was severe in three patients and, for one of these patients, a subcapsular hepatic haematoma was found on ultrasound eight days after the biopsy. Sufficient material for histopathological examination was obtained from all patients. The cost of out-of-hospital biopsies was substantially less than the cost of hospital-based, day-stay procedures. Short-stay, out-of-hospital, radiologically guided liver biopsy is safe for patients who have stable chronic liver disease and acceptable coagulation profiles.