Repeat US Research Articles

US LI-RADS in surveillance for recurrent hepatocellular carcinoma after curative treatment.

To investigate the performance of US LI-RADS in surveillance for recurrent hepatocellular carcinoma (RHCC) after curative treatment. This study enrolled 644 patients between January 2018 and August 2018 as a derivation cohort, and 397 patients from September 2018 to December 2018 as a validation cohort. The US surveillance after HCC curative treatment was performed. The US LI-RADS observation categories and visualization scores were analyzed. Four criteria using US LI-RADS or Alpha-fetoprotein (AFP) as the surveillance algorithm were evaluated. The sensitivity, specificity, and negative predictive value (NPV) were calculated. A total of 212 (32.9%) patients in derivation cohort and 158 (39.8%) patients in validation cohort were detected to have RHCCs. The criterion of US-2/3 or AFP ≥ 20µg/L had higher sensitivity (derivation, 96.7% vs 92.9% vs 81.1% vs 90.6%; validation, 96.2% vs 90.5% vs 80.4% vs 89.9%) and NPV (derivation, 95.7% vs 93.3% vs 88.0% vs 91.8%; validation, 94.6% vs 89.4% vs 83.6% vs 89.0%), but lower specificity (derivation, 35.9% vs 48.2% vs 67.6% vs 51.9%; validation, 43.5% vs 52.7% vs 66.1% vs 54.0%) than criterion of US-2/3, US-3, and US-3 or AFP ≥ 20µg/L. Analysis of the visualization score subgroups confirmed that the sensitivity (89.2-97.6% vs 81.0-83.3%) and NPV(88.4-98.0% vs 80.0-83.3%) of score A and score B groups were higher than score C group in criterion of US-2/3 in both two cohorts. In the surveillance for RHCC, US LI-RADS with AFP had a high sensitivity and NPV when US-2/3 or AFP ≥ 20µg/L was considered a criterion. The criterion of US-2/3 or AFP ≥ 20µg/L improves sensitivity and NPV for RHCC surveillance, which provides a valuable reference for patients in RHCC surveillance after curative treatment. • US LI-RADS with AFP had high sensitivity and NPV in surveillance for RHCC when considering US-2/3 or AFP ≥ 20µg/L as a criterion. • After US with AFP surveillance, patients with US-2/3 or AFP ≥ 20µg/L should perform enhanced imaging for confirmative diagnosis. Patients with US-1 or AFP < 20µg/L continue to repeat US with AFP surveillance. • Patients with risk factors for poor visualization scores limited the sensitivity of US surveillance in RHCC.

Emergence of a novel urogenital-tropic Neisseria meningitidis.

Neisseria meningitidis (Nm) is primarily associated with asymptomatic nasopharyngeal carriage and invasive meningococcal disease (sepsis and meningitis), but like N. gonorrhoea (Ng), Nm can colonize urogenital and rectal mucosal surfaces and cause disease. First noted in 2015, but with origins in 2011, male urethritis clusters caused by a novel Nm clade were reported in the USA (the US_NmUC). This review describes research developments that characterize this urogenital-tropic Nm. The US_NmUC evolved from encapsulated Nm serogroup C strains. Loss of capsule expression, lipooligosaccharide (LOS) sialylation, genetic acquisition of gonococcal alleles (including the gonococcal anaerobic growth aniA/norB cassette), antimicrobial peptide heteroresistance and high surface expression of a unique factor-H-binding protein, can contribute to the urethra-tropic phenotype. Loss-of-function mutations in mtrC are overrepresented in clade isolates. Similar to Ng, repeat US_NmUC urethritis episodes can occur. The US_NmUC is now circulating in the UK and Southeast Asia. Genomic sequencing has defined the clade and rapid diagnostic tests are being developed for surveillance. The US_NmUC emerged as a cause of urethritis due to acquisition of gonococcal genetic determinants and phenotypic traits that facilitate urogenital tract infection. The epidemiology and pathogenesis of this urogenital-tropic pathogen continues to be defined.

SAT-363 Renal Papillary Necrosis Associated with Normocalcemic Hyperparathyroidism

IntroductionHypercalciuria is generally considered to be the most common identifiable metabolic risk factor for calcium nephrolithiasis. Important renal manifestations of primary hyperparathyroidism (PHPT) include asymptomatic nephrolithiasis, hypercalciuria, nephrocalcinosis, and chronic renal insufficiency. However renal papillary necrosis (RPN) occurring in PHPT has not been reported previously. We report a 50-year-old woman who manifested RPN associated with hypercalciuria and normocalcemic PHPT. Case ReportA 50-year-old Caucasian woman was evaluated in 2006 for hypercalcemia. She had no history of nephrolithiasis, fractures, or symptoms of hypercalcemia. Laboratory: serum calcium 11.8 mg/dL, ionized calcium 6.3 mg/dL, phosphorus 1.8 mg/dL, intact PTH 98 pg/mL (ref 15–65), urine calcium 543 mg/24 hrs (ref <235). Renal ultrasound showed no evidence of nephrocalcinosis or nephrolithiasis. A parathyroid scan was consistent with a left superior parathyroid adenoma. Patient underwent parathyroidectomy and became normocalcemic with normal serum PTH levels postoperatively. One year later she was diagnosed with a left sided bronchial carcinoid tumor. Surveillance Gallium-68 PET/CT scan done 2 years later was negative for any metastases. Twelve years later she reported to our clinic for follow up. She had no symptoms of hypercalcemia, fractures, nephrolithiasis, history of pyelonephritis, diabetes mellitus, analgesic use, or hypertension. Serum calcium was 9.1 mg/dL, serum phosphorous 3.8mg/dL, PTH 82 pg/mL, 25-OH vitamin D 34 ng/mL, 1,25-vitamin D 38 pg/mL, and a urorisk panel was normal except for a 24-hour urine calcium of 410 mg. However renal ultrasound showed bilateral RPN and this diagnosis was also confirmed by a CT scan. A urinalysis showed only microalbuminuria with no red cells. She had no history of any analgesic drug abuse, pyelonephritis, sickle cell disease, or diabetes mellitus. A glucose tolerance test was completely normal. Discussion RPN is characterized by coagulative necrosis of the renal medullary pyramids and papillae brought on by several associated disorders and toxins that exhibit synergism toward the development of ischemia. Although the initial kidney US was normal, a repeat US done 12 years later showed evidence of RPN. This finding along with hypercalciuria and a diagnosis of normocalcemic PHPT suggests that RPN may be associated with hypercalciuria and normocalcemic PHPT. Furthermore she had no other risk factors for RPN. Additional studies with large number of patients are needed to confirm the association between these 2 disorders.

1828 Surgical Management of a Fused Non-Communicating Rudimentary Uterine Horn with Significant Myometrial Connection

Video Objective In this video we present the surgical management of a fused non communicating, rudimentary uterine horn with significant myometrial invasion. The objectives of this video are to review the diagnostic imaging features that are suggestive of surgical complexity with non communicating fused rudimentary horn resections. And review the steps involved in their resection. Setting A 12 year old previously healthy female presenting with 8 months of progressively worsening, severe dysmenorrhea. Onset 5 months post menarche. Her pain was not alleviated with ibuprofen, naproxen or acetaminophen. Initial Abdominal & Pelvic US: possible uterine fibroid, unremarkable kidneys. A Repeat US suggestive of a unicornuate uterus with an obstructed left rudimentary horn. She was started on menstrual suppression with a continuous combined oral contraceptive. A MRI was done confirming the presence of a left fused, non communication rudimentary horn, with significant myometrial invasion. Interventions A laparoscopic left uterine horn resection was performed. The surgery was divided into four steps. These include to perform a anatomical survey to confirm the patients anatomy, lateral isolation of hemi-uterus, division of the myometrial connection and finally, myometrial reconstruction. Conclusion In summary, the surgical steps in the management of a fused non communicating rudimentary uterine horn with significant myometrial connection include: To perform a anatomical survey to confirm the patients anatomy, lateral isolation of hemi-uterus, division of the myometrial connection and finally, myometrial reconstruction. A non-communicating functional fused rudimentary horn with significant myometrial invasion can present as a surgical challenge to gynecologists. It is important to do a pre-operative MRI in adolescents or with complex anomalies to assess the complexity of anticipated surgery. Post operative imaging with a MRI can assess for any residual endometrium from the resected horn.

SUN-493 Spontaneous Remission of Primary Hyperparathyroidism Presenting as Acute Chest and Neck Pain

Primary hyperparathyroidism is characterized by sustained hypercalcemia and is most often caused by a parathyroid adenoma. The disease is often indolent, without measurable morbidity and consequently followed without specific treatment. If therapy is chosen the surgical removal of the adenoma is the therapy of choice. Herein we report a 58 years old female with spontaneous remission of primary hyperparathyroidism. The patient was first seen in 2009 with high PTH and slightly high calcium level. She had the US identification of a likely parathyroid adenoma, 1.4 x 0.6 x 0.5 cm lying inferior to the left thyroid lobe. Her serum calcium was at the upper limits of normal, bone density was with positive T scores at wrist, spine and hip, and there was no history of renal stones. Options were discussed and she choose surveillance rather than surgery. She returned in 2011 when a similar structure was seen on repeat US. She was lost to follow up until in 7/2017 when she experienced upper chest pressure “like something was stuck in my esophagus" which radiated to left breast, shoulder blade, and left neck. She went to ER where CT of the chest identified a 1.8 x 0.9 cm heterogenic mass inferior to the left thyroid lobe, judged atypical for parathyroid adenoma, with a differential including an inflammatory process or esophageal duplication cyst. Lab from ER indicated Ca 10.3 mg/dl. Cardiac evaluation was negative and her pain resolved over 4 days. ENT and GI evaluations were unrevealing and she was prescribed Pepcid. When she returned to our office 8/2017, her biochemical studies showed normal serum levels of calcium (9.5 mg/dl) and PTH (41 pg/mL). Her subsequent neck ultrasound failed to identify the lesion inferior to the left thyroid lobe. Spontaneous remission of primary hyperparathyroidism is considered to be an extremely rare event and was first described in 1946. The most common cause for a spontaneous remission of primary hyperparathyroidism appears to be an infarction of the parathyroid adenoma (1). A larger sized adenoma (>2 cm) appears to be a risk factor for infarction according to a case series described by Kovacs et al. in 1998 (1). Therefore, hemorrhage and infarction might be a reasonable hypothesis to explain the pain and parathyroid enlargement and subsequent disappearance of the adenoma, which led to the spontaneous remission of primary hyperparathyroidism.

Donʼt Ask, Donʼt Tell: A Lesson on Evaluating Acute Hepatitis

Acute hepatitis A virus (HAV) infection is common in developing countries. It can range from asymptomatic to fulminant hepatitis. The mean peak of total bilirubin in acute HAV infection is usually less than 10 mg/dL with mean jaundice lasting about 4 weeks. Cases of prolonged or relapsing cholestatic HAV were reported at a global incidence of 5-10%. Acute HAV infection with prolonged cholestatic jaundice (PCJ) is rare. We present a severe prolonged cholestatic HAV infection likely complicated by concurrent Chikungunya virus infection and drug induced liver injury. A 39 year old female, born in India, presented to our hospital with subjective fevers, malaise, and myalgias for 3 weeks. She returned from a trip to India 1 month ago. On admission she had a temperature of 100.1°F. Her physical exam was within normal limits with no documented hepatomegaly. Her initial blood work showed elevated transaminases (aspartate aminotransferase (AST u/L) 122, alanine aminotransferase (ALT u/L) 143)with normal alkaline phosphatase (ALP) and total bilirubin (TB). Three days into her admission she showed some clinical improvement but with worsening of AST to 1958 and ALT to 1605 reaching a peak of AST 3804 and ALT 3335; ALP remained normal and TB increased to 4.0 mg/dL. US of abdomen showed hepatic steatosis. Viral markers were positive for HAV IgM but negative for acute EBV, CMV, HBV, HCV and HEV infection. Her autoimmune panel was negative. She was discharged 1 week later with clinical improvement; AST 556 and ALT 1418, ALP 77 and INR 1.58. Her TB remained elevated to 7.6. She was readmitted to the hospital 2 weeks later with pruritus and worsening fatigue. Her AST was 88 and ALT 59, with ALP of 148 and a TB of 23.4. Her INR was 2.09. A repeat US showed no biliary ductal dilation or stones. She tested positive for Chikungunya IgM. She admitted to ingesting multiple herbal products. Her liver tests normalized at 4 months with positive HAV and Chikungunya IgG.FigureFigureFigureWe present a severe prolonged cholestatic HAV infection likely complicated by concurrent Chikungunya infection and drug induced liver injury. Acute HAV infection with prolonged cholestatic jaundice (PCJ) is rare. Acute Chikungunya has been documented as a cause of acute cholestatic hepatitis. A thorough history of drug exposure is essential in the evaluation of cholestatic liver injury. Furthermore, CDC recommendation for HAV vaccination for travelers should be reinforced even on immigrants from endemic countries.

A Case of Echinococcosis: Surgical Management of Hepatic Hydatid Cyst

Echinococcosis is a parasitic infection, also known as hydatidosis, caused by of the tapeworm Echinococcus. In regions endemic to cystic echinococcosis the World Health Organization reports incidence rates over 50 per 100,000 person-years. It is globally distributed and commonly seen in regions with pastoral and rangeland areas. Humans are accidental intermediate hosts through ingesting food and water contaminated with the parasites eggs. The species Echinococcus granulosus causes cystic echinococcosis predominately affecting the liver. A 34 year old female Yemeni immigrant, presented with the chief complaint of right upper quadrant abdominal pain, and slightly elevated transaminases. An abdominal CT with contrast noted a 10.1 X 9.3 cm cyst in the superior right hepatic lobe. Using ultrasound guidance cyst 500 ml of colorless fluid was aspirated from the cyst. Cytology demonstrated parasitic structures with hooklets consistent with Echinococcus. She was treated with a 10 day course of Albendazole, however she continued to have persistent abdominal pain. Repeat CT and US revealed recurrence of the cyst with findings concerning for daughter cyst formation. Based on World Health Organization staging criteria treatment options included; repeat cyst aspiration or surgical resection with concomitant Albendazole. In light of the cystic septations noted on MRI surgery was favored and she underwent hepatic segment VII resection with the encapsulated cyst. She had an uneventful recovery with normal hepatic function and was discharged home with 4 weeks of albendazole therapy. Repeat ultrasound 2 months post op revealed no evidence of recurrent cyst formation. The diagnosis of hepatic hydatid cysts requires a high degree of clinical suspicion and knowledge of the subtle signs and symptoms of the disease. Early diagnosis and appropriate treatment prevents complications of the disease including pressure symptoms, cyst leakage, cholangitis and anaphylaxis. Treatment options are dependent on the stage of the hydatid cysts, and surgery should be considered for patients who have not responded to medical management and have evidence of cyst criteria not amenable to percutaneous drainage. Rates of recurrent infection are significantly lower after radical surgical procedures however follow up is still recommended for up to 5 years post treatment with periodic imaging.Figure: Cut sections of the single hepatic cyst with multiple concentric membranes and yellow scoleces.Figure: Admission CT abdomen and pelvis with contrast shows right hepatic lobe cyst measuring 10.1 x 9.3 cm.Figure: MRI w contrast demonstrating the floating membranes.

Diagnostic accuracy of point-of-care ultrasound for catheter-related thrombosis in children.

Compared with consultative US performed by the radiology department, point-of-care US performed by non-radiology physicians can accurately diagnose deep venous thrombosis in adults. In preparation for a multicenter randomized controlled trial, we determined the accuracy of point-of-care US in diagnosing central venous catheter-related thrombosis in critically ill children. Children <18years old with a central venous catheter who were admitted to the intensive care unit were enrolled. Consultative and point-of-care compression ultrasounds with Doppler were done on the vein where the catheter was inserted within 24h after insertion. Repeat US was obtained within 24h of removal of the catheter. All images were centrally, blindly and independently adjudicated for thrombosis by a team of pediatric radiologists. Chance-corrected agreement between readings was calculated. From 84 children, 152 pairs of consultative and point-of-care ultrasounds were analyzed. A total of 38 (25.0%) consultative and 17 (11.2%) point-of-care ultrasounds were positive for thrombosis. The chance-corrected agreement between consultative and point-of-care ultrasounds was 0.17 (standard error: 0.07; P = 0.008). With consultative US as a reference, the sensitivity of point-of-care US was 28.1% (95% confidence interval: 13.7%-46.7%) with a specificity of 91.8% (95% confidence interval: 84.4%-96.4%). A catheter in the subclavian vein was associated with discordant readings (adjusted odds ratio: 4.00; 95% confidence interval: 1.45-13.94). Point-of-care US, when performed by non-radiology physicians and centrally adjudicated by pediatric radiologists in the setting of a multicenter randomized controlled trial, may not accurately diagnose catheter-related thrombosis in critically ill children.

OP0054 Ultrasound Synovitis Reflects Synovial Inflammation at A Histopathological Level

BackgroundUltrasound (US) is widely used by rheumatologists to assess inflammatory burden on patients with inflammatory arthritis. Some studies have shown that US measures of inflammation reflects aspects of histological synovitis...

Perforated appendicitis: an underappreciated mimic of intussusception on ultrasound

We encountered multiple cases in which the US appearance of ruptured appendicitis mimicked intussusception, resulting in diagnostic and therapeutic delay and multiple additional imaging studies. To explore the clinical and imaging discriminatory features between the conditions. Initial US images in six children (age 16months to 8years; 4 boys, 2 girls) were reviewed independently and by consensus by three pediatric radiologists. These findings were compared and correlated with the original reports and subsequent US, fluoroscopic, and CT images and reports. All initial US studies demonstrated a multiple-ring-like appearance (target sign, most apparent on transverse views) with diagnostic consensus supportive of intussusception. In three cases, US findings were somewhat discrepant with clinical concerns. Subsequently, four of the six children had contrast enemas; two were thought to have partial or complete intussusception reduction. Three had a repeat US examination, with recognition of the correct diagnosis. None of the US examinations demonstrated definite intralesional lymph nodes or mesenteric fat, but central echogenicity caused by debris/appendicolith was misinterpreted as fat. All showed perilesional hyperechogenicity that, in retrospect, represented inflamed fat "walling off" of the perforated appendix. There were four CTs, all of which demonstrated a double-ring appearance that correlated with the US target appearance, with inner and outer rings representing the dilated appendix and walled-off appendiceal rupture, respectively. All six children had surgical confirmation of perforated appendicitis. Contained perforated appendicitis can produce US findings closely mimicking intussusception. Clinical correlation and careful multiplanar evaluation should allow for sonographic suspicion of perforated appendicitis, which can be confirmed on CT if necessary.

The Biopsy-Proven Benign Thyroid Nodule: Is Long-Term Follow-Up Necessary?

Thyroid nodules are common, and of those biopsied by fine-needle aspiration (FNA), the majority will be benign colloid nodules (BCN). Current guidelines suggest these BCN should be followed by ultrasonographic examination (US) every 3 years, with no endpoint specified. This study evaluated if long-term follow-up of benign thyroid nodules was associated with change in treatment or improvement in diagnosing a missed malignancy compared with short-term follow-up. All patients with FNA-based diagnosis of BCN at our institution from 1998 to 2009 were identified. Patients observed after the diagnosis were divided into short-term follow-up (<3 years) and long-term follow-up (≥3 years). Rates of repeat FNA, thyroidectomy, and malignancy detection were compared. Of 738 patients with BCN, 92 patients underwent thyroid resection after the initial US. Six hundred forty-six patients were observed, of which 366 returned for 1 or more follow-up US: 226 in the short-term group (median 13 months) and 140 in the long-term group (median 57 months). There were more follow-up US in long-term vs short-term (medians 4 vs 2, p < 0.01), more repeat FNAs in the long-term group (18 of 140 vs 8 of 226, p < 0.01); but no difference in interval thyroidectomies (13 of 140 vs 31 of 226, p = 0.25) or malignant final pathology (0 of 13 vs 2 of 31, p > 0.99). For all patients undergoing surgery, pathology was malignant in 2 of 136 (1.5%). Long-term follow-up of patients with BCN is associated with increased repeat FNA and US without improvement in the malignancy detection rate. After 3 years of follow-up, consideration should be given to ceasing long-term routine follow-up of biopsy-proven BCN.

The correct interpretation of thyroid FNAB cytological result by the endocrinologist as a basis for further optimal diagnostics and treatment

Adopted by the Polish Society of Endocrinology and the Polish Thyroid Association American system of the classification of FNAB cytological smears - the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) determines exactly how to run diagnostics and therapy for each category of smears. Cytopathologist establishing diagnosis should provide it in such way as to include detailed description of both the observed specimen [existing types of cells, their abundance (their number) and the spatial arrangements (layouts) which they form, as well as other components of the smear, such as, e.g. colloid protein masses] and diagnostic conclusion which assigns smear to one of six (6) categories TBSRTC. In order to avoid unintentional mistake during the process of assigning in question, the endocrinologists should have basic idea of what kind cellular and/or acellular components determine and prejudge the qualification of cytological smear to specific TBSRTC category. It should be noted that having this skill is not to control the description of cytological result as morphological diagnostics (within the meaning of the direct microscopic evaluation of slides) is beyond the reach of an endocrinologist and other doctors who are not cytopathologists, just check whether there is compliance of the diagnostic conclusion and morphological description of the smear, because it is TBSRTC category which decisively determines further medical management. As shown by us in the proposed algorithm, the assignment of the specimen to each category, together with, the so-called, US risk pattern (which is defined in 3-stage as pattern of high, intermediate or low risk) are decisive for the recommendation of surgical treatment or abandonment of such treatment and further follow up; they also are decisive as regards the frequency of repeat US and FNAB cytology. Thus, the essence of the present lecture is to familiarize endocrinologists with the significance of individual components of the smear, as described in cytology, in determining the appropriate TBSRTC category. In practice, the most important issue is to properly differentiate categories II, III and IV, because there is little doubt as regards treatment of patients with other smear categories (I, V and VI). Therefore, it is necessary to remember that the normotypic thyroid cells (tfc), both dispersed and arranged in large and/or medium-sized spatial patches and groups, and sometimes nests, are characteristic rather for benign lesions. On the other hand, small spatial layouts, especially arrangements of rosettes type are characteristic for category IV (follicular or suspicious for neoplasm). It should be added, however, that large spatial layouts may also be present in papillary thyroid carcinoma; undoubted help in case of detection of this cancer is, however, characteristic appearance of cells and their typical cytological features. Cytological smears obtained from benign lesions may contain cells with different abundance, and also variety of other cells can be the smear components, such as, e.g. cells typical for inflammatory processes (lymphocytes, neutrophils, multi- and mononucleated macrophages), anisocytosis is frequently observed (sometimes anisocaryosis), and - which is particularly characteristic - considerable quantities of colloid are present in the smear. In contrast to the above components, follicular neoplasm in cytological smear has no colloid at all or its trace amount, monomorphic tfc occurring usually in large numbers and arranged in small layouts, which characteristically take the form of the, so-called, rosettes. Anisocytosis generally does not occur, cell types other than monomorphic tfc and larger spatial arrangements are very rare. In case of smears collected from oncocytic lesions, the assignment to the category IV is determined by the percentage of oncocytes in the smear (above 75%). Oncocytic cells should have described the presence of nucleoli, anisocytosis may occur in this case and spatial arrangements can be of any type. Finally, it is noted that smears of category III, called by some authors as a category of exclusion, contain both components characteristic for category II and may also include elements of morphological smears of category IV, but in such proportion that would not allow to categorically qualify them as benign lesions or as “a suspicion of neoplasm”.

Diagnostic accuracy and standardization of fine needle biopsy in the characterization of liver nodules in cirrhosis.

e14576 Background: The diagnostic sensitivity of fine needle biopsy (FNB) for liver nodules in cirrhotic patients is both operator and disease characteristic dependant. The performance FNB needs to be not standardized. Aim: To compare the diagnostic accuracy of one vs. two FNB intra-nodule plus one extra-nodule passage. Methods: A FNB was performed with a 21-gauge trenchant needle for microhistology (Biomol, HS Hospital Service, Italy) with two passages within and one outside the nodule, and processed separately. The diagnosis was made by histology and confirmed by enhanced follow-up for non malignant lesions. FNB was repeated in all patients with unsolved histological diagnosis, i.e., similar histologic features within and outside the liver nodule. Patients with non malignant nodules underwent a repeat US every 3 months, an abdominal CT/MRI every 6 months and repeated FNB if nodules changed in size/vascular pattern. The histological diagnosis was according the International Working Party criteria. Results: 48 prospectively enrolled cirrhotics, 44 (92%) Child-Pugh A, had 67 liver nodules (mean diameter 1.9 cm); 2 (3%) < 1 cm, 39 (58%) 1-2 cm, 15 (22%) 2-3 cm, 11 (17%) > 3 cm. The final diagnosis was 41 (61%) hepatocellular carcinoma (HCC), 1 (2%) cholangiocarcinoma (CCC), 15 (22%) MRN, 4 (6%) low grade dysplastic nodule (LGDN), 4 (6%) high grade dysplastic nodule (HGDN), 2 (3%) lymphoma. 36 HCC (82%) were diagnosed with first passage whereas 5 additional HCC (8%) were diagnosed with the second passage. FNB needed to be repeated in 2 (3%) cases with similar histological features within and outside the liver nodule. In the 39 nodules of 1-2 cm, the corresponding final diagnosis was: 17 (43%) HCC, 1 (3%) CCC, 3 (8%) MRN, 11 (28%) LGDN, 5 (13%) HGDN, 2 (5%) lymphoma. Fifteen HCC (37%) were identified by one passage and 2 (5%) by two passages. FNB needed to be repeated in 2 patients. A parenchymal sub-glissonian hematoma (1%) was the only complication. Conclusions: Two passages FNB allows to increase by 12% the final diagnosis of HCC in small liver nodules detected during surveillance of patients with cirrhosis. No significant financial relationships to disclose.

Litigants' Characteristics and Outcomes in US Forest Service Land-Management Cases 1989 to 2005

Abstract This research identifies and analyzes all parties involved in 949 US Forest Service land-management court cases initiated between 1989 and 2005. We identified 2,501 parties, the frequency and type of their involvement, and their success rates. Almost 75% of the parties were only involved in one case. All 12 of the most frequent parties opposing the US Forest Service were environmental organizations, whereas the top 12 most frequent US Forest Service supporters included four different types of organizations. Repeat US Forest Service opponents were more successful than nonrepeat opponents. However, only one US Forest Service opponent involved in an average of one or more cases per year won more cases than they lost, and one-half of these opponents settled more often than the average settlement rate. By identifying litigants, policymakers, stakeholders, and the public can understand the prevalence of repeat and one-time litigants and can assess strategies to address these types of parties' propensity to litigate.

Ultrasound averts inadvertent injury during internal jugular vein cannulation

To the Editor, We report a case where ultrasound imaging (US) was used for internal jugular vein (IJV) cannulation. Not only was US helpful in locating the IJV for central venous catheter (CVC) placement, it also identified a partially occluded IJV. A 17-year-old female patient with a body mass index of 20.7 kg m was scheduled for removal of an osteogenic sarcoma from her T6 vertebra. She had undergone surgery one year previously for removal of an osteogenic sarcoma from her maxillary sinus on the left side. As a part of her anesthetic management, we planned to site a CVC in the right IJV under US guidance. After sterile preparation, the anterior triangle of the neck was scanned at a point halfway between the mastoid process and the sternal notch, with a GE Logic-e unit (GE Medical Systems, Wuxi, Jiangsu, China) using a linear 12 MHz transducer. An initial needle puncture was made over the right IJV where the vein appeared fully patent under real time US guidance. The needle was seen to enter the vein, and after free aspiration of blood, a guide wire was passed into the needle. At approximately 3 cm beyond the needle tip threading of the guide wire encountered resistance, and consequently, both the guide wire and the needle were removed. A repeat US scan caudal to the needle insertion site showed a partially occluded IJV with the lumen reducing to less the 2 mm (Fig. 1). The procedure was abandoned on the right side and the CVC was eventually placed in the fully patent left IJV, under US guidance in a single attempt. We are aware of the safety recommendations and studies demonstrating the benefits of US for CVC placement, including rapid vein localization, a reduction in needle attempts, and fewer complications. This case further highlights the importance of US in preventing inadvertent injury to a partially occluded IJV. In this case, the patient had a sarcoma that predisposed to venous thrombosis, and hence, there was significant thrombosis involving IJV, though the patient had no reported symptoms. With a conventional landmark technique, the vascular abnormality would not have been detected, and repeated attempts might have resulted in trauma, or even a tear of the IJV. We would like to emphasize that when US is used for IJV cannulation, it is valuable to scan the course of the IJV in the neck and not a single location before selecting the needle insertion point. Such a preliminary scan can reveal vascular and non-vascular pathology and guide CVC placement. As availability of US units continues to grow in the operating suites, and as practice guidelines are being established, this case highlights how the use of US for central venous cannulation is well justified.

Isolated traumatic gallbladder rupture: US findings and the role of repeat US in diagnosis

We represent the US findings of isolated gallbladder rupture caused by blunt abdominal trauma in a 13-year-old boy. At the initial US examination, although a pericholecystic fluid collection was observed, the mildly collapsed gallbladder was regarded as a contracted gallbladder. Even though the patient was haemodynamically stable, repeat US examination after 24 h revealed gallbladder perforation. In haemodynamically stable trauma patients repeated US examinations can be useful and are strongly recommended.

Convenience, the bane of our existence, and other barriers to donating

To prevent donor loss and improve retention, it is important to understand the major deterrents to blood donation and to identify factors that can be effectively addressed by blood centers. A 30-item self-administered questionnaire was completed in 2003 by 1705 first-time and 2437 repeat US donors who had not donated in 2 to 3 years. Asian, Hispanic, black, and white first-time and repeat donors rated the importance of deterrents to donation in their decision to not return with a 1 to 5 scale. Categorical analysis of variance methods were used to compare the importance of deterrents between first-time and repeat donors of different race or ethnicity. Not having a convenient place to donate was most commonly cited as an important or very important reason for not returning by 32 to 42 percent of first-time and 26 to 43 percent of repeat respondents. Although bad treatment and poor staff skills were less of a barrier than convenience, they were more important for minority donors. Other factors such as physical side effects, foreign travel, or length of the process appeared less important. Inconvenience is a major barrier to donating, suggesting that mobile collections and increased hours of operation might help recapture lapsed donors. The finding that lapsed minority donors were more likely to give bad treatment and poor staff skills as important reasons to not donate is disconcerting in light of the changing donor demographics and increased efforts to recruit these donors.

Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis.

BackgroundUltrasound (US) has largely replaced contrast venography as the definitive diagnostic test for deep vein thrombosis (DVT). We aimed to derive a definitive estimate of the diagnostic accuracy of US for clinically suspected DVT and identify study-level factors that might predict accuracy.MethodsWe undertook a systematic review, meta-analysis and meta-regression of diagnostic cohort studies that compared US to contrast venography in patients with suspected DVT. We searched Medline, EMBASE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Reviews of Effectiveness, the ACP Journal Club, and citation lists (1966 to April 2004). Random effects meta-analysis was used to derive pooled estimates of sensitivity and specificity. Random effects meta-regression was used to identify study-level covariates that predicted diagnostic performance.ResultsWe identified 100 cohorts comparing US to venography in patients with suspected DVT. Overall sensitivity for proximal DVT (95% confidence interval) was 94.2% (93.2 to 95.0), for distal DVT was 63.5% (59.8 to 67.0), and specificity was 93.8% (93.1 to 94.4). Duplex US had pooled sensitivity of 96.5% (95.1 to 97.6) for proximal DVT, 71.2% (64.6 to 77.2) for distal DVT and specificity of 94.0% (92.8 to 95.1). Triplex US had pooled sensitivity of 96.4% (94.4 to 97.1%) for proximal DVT, 75.2% (67.7 to 81.6) for distal DVT and specificity of 94.3% (92.5 to 95.8). Compression US alone had pooled sensitivity of 93.8 % (92.0 to 95.3%) for proximal DVT, 56.8% (49.0 to 66.4) for distal DVT and specificity of 97.8% (97.0 to 98.4). Sensitivity was higher in more recently published studies and in cohorts with higher prevalence of DVT and more proximal DVT, and was lower in cohorts that reported interpretation by a radiologist. Specificity was higher in cohorts that excluded patients with previous DVT. No studies were identified that compared repeat US to venography in all patients. Repeat US appears to have a positive yield of 1.3%, with 89% of these being confirmed by venography.ConclusionCombined colour-doppler US techniques have optimal sensitivity, while compression US has optimal specificity for DVT. However, all estimates are subject to substantial unexplained heterogeneity. The role of repeat scanning is very uncertain and based upon limited data.

Mesenteric lymphadenopathy in children examined by US for chronic and/or recurrent abdominal pain.

Children with recurrent abdominal pain often undergo US to confirm or exclude organic disease. To assess the prevalence of mesenteric lymphadenopathy on US in these children. We prospectively studied 189 children with recurrent abdominal pain with US of the abdomen, using graded compression. The results were compared with 73 children in a control group. The children in both groups were divided into three age groups. The size, number, morphology and location of mesenteric lymph nodes were noted, as well as additional findings. Pediatricians followed the patients from 3 months to 1 year, and a repeat US study was done in 30 children. Mesenteric lymphadenopathy was present in 116 of 189 children (61.4%), with the greatest prevalence in boys in the younger age groups. The location of the nodes was mainly in the right lower quadrant. In the control group, 7 of 73 children had mesenteric lymphadenopathy, a significantly lower prevalence than in the study group ( P<0.001). Additional findings, apart from lymphadenopathy, were present in 27 (14.2%) of the 189 children in the study group, and in 5 (6.8%) of the 73 children in the control group. Mesenteric lymphadenopathy is a common, and often the only abnormal, finding on US in children with recurrent abdominal pain.

Endoscopic management of post laparoscopic cholecystectomy bile leak in a child

A 9-year-old boy was referred to us 6 days after LC. The child had 3 episodes of biliary colic during a period of 6 weeks prior to LC and US showed gallstones. During LC the surgeon thought that the cystic duct was edematous and inflamed. The procedure was completed and a drain was placed in the subhepatic area. Thereafter the child developed fever and abdominal pain, and daily output from the drain was 200 to 300 mL bilious fluid. On examination he was febrile, the abdomen was tender on palpation and there was free fluid. US showed free fluid in the abdomen but the biliary tree was normal. At ERCP contrast-free selective cannulation of common bile duct was achieved using a method described previously.3 The cholangiogram disclosed a large leak from the cystic duct stump (Fig. 1A). A 7F nasobiliary drain (NBD) was placed in the bile duct. The daily output of bile through the NBD was 400 to 600 mL. The child was treated with antibiotics according to the results of culture and sensitivity of the ascitic fluid. Following NBD placement, output from the subhepatic drain gradually subsided and the drain was removed on the seventh day of admission. Repeat US (on the tenth day after NBD placement) showed 2 loculated fluid collections instead of free fluid in the abdomen. From 1 collection 20 mL bilious fluid was aspirated under US guidance. A cholangiogram 12 days after NBD placement demonstrated closure of the leak (Fig. 1B). The NBD was removed on the twenty-second day. Repeat US did not show a fluid collection in the abdomen. The child was discharged after 28 days in hospital. At discharge and 1 month thereafter he was asymptomatic.