Serial Ultrasonography Research Articles

Serial magnetic resonance imaging and ultrasound examinations demonstrate differential inflammatory lesion patterns in soft tissue and bone upon patient-reported flares in rheumatoid arthritis

BackgroundMagnetic resonance imaging (MRI) and ultrasonography (US) are more sensitive than clinical evaluation in assessing inflammation in rheumatoid arthritis (RA). Data is scarce regarding potential link between patient-reported flares and inflammation on imaging. The aim of the study was to explore the pattern and longitudinal associations of inflammatory lesions detected by serial MRI and US in relation to patient-reported flares in patients with RA.MethodsEighty RA patients with baseline DAS28CRP < 3.2 and no swollen joints were examined at baseline and followed for 1 year. Patients were requested to contact the hospital in case of patient-reported hand flare accompanied by ≥ 1 tender and swollen joint. The 29 patients who reported hand flare had four extra visits within 4 months from flare onset comprising clinical examination, patient-reported outcomes, MRI, and US of wrists and hands. MRI synovitis/tenosynovitis/bone marrow edema (BME) and US synovitis/tenosynovitis were scored. MRI and US scores at and after the flare were compared to baseline before the flare, and associations were explored by linear mixed models for repeated measurements.ResultsSynovitis and tenosynovitis by MRI/US increased significantly at flare onset. Synovitis waned quickly, as did US tenosynovitis. BME showed delayed increase yet persisted, once the patient-reported flare had resolved, as did MRI tenosynovitis. In univariate models, patient-reported flares were associated with all MRI and US inflammatory markers, except for BME, which was only associated with SJC28 and long-lasting flares > 14 days. Independent associations were observed between patient-reported flares and tenosynovitis by MRI and US (p < 0.05).ConclusionsPatient-reported flares were linked to inflammation detected by serial MRI and US. Differential patterns of inflammatory lesion evolution were observed by serial imaging with early synovial and tenosynovial inflammation, followed by delayed-onset BME.

Ability of a single negative ultrasound to rule out deep vein thrombosis in pregnant women: A systematic review and meta‐analysis

BackgroundThe diagnostic accuracy of ultrasound (US) for suspected lower extremity deep vein thrombosis (DVT) in nonpregnant patients has been well validated. However, in pregnant women with suspected DVT and an initial negative US, serial US is generally recommended. We aimed to determine the ability of single negative US to exclude DVT in symptomatic pregnant women. MethodsTwo authors independently reviewed the following databases: MEDLINE, PubMed, and EMBASE from inception until February 2019. We assessed the risk of bias using the CLARITY group tool for prognostic studies and performed a random effects meta‐analysis to report the pooled false negative rate of a single leg ultrasound. ResultsEight studies (seven prospective and one retrospective) were included. An overlap among study populations was identified in four of the manuscripts. Two authors performed data re‐extraction from these hard copy research charts. Risk of bias was low for the included populations and method of measurement, and low or high for completeness of follow up. A total of 635 pregnant patients with symptoms of DVT had an initial negative US examination. Of those, six were diagnosed with DVT during repeat serial testing (0.94%) and three developed DVT or PE during 3‐month follow‐up after serial ultrasonography (0.47%). The pooled false‐negative rate of a single ultrasound was 1.27% (95% confidence interval, 0.42‐2.56), I2 = 27%. ConclusionThe false‐negative rate is low with a single US for suspected DVT in pregnancy. Our results will help inform shared decision‐making around planning repeat ultrasound scans in these patients.

Imaging modalities and management of prenatally diagnosed suprarenal masses: an updated literature review and the experience at a high volume Fetal Treatment Center

Background/purpose The differential diagnosis for prenatal suprarenal masses (SRMs) is broad and includes neuroblastoma, adrenal hemorrhage, and subdiaphragmatic extralobar pulmonary sequestration (SEPS). We sought to elucidate the appropriate postnatal management for fetuses found to have an SRM. Methods We conducted a retrospective review of patients prenatally diagnosed with SRM at our institution between 1998 and 2018. Prenatal characteristics, imaging, and neonatal outcomes were collected. We also performed a PubMed literature search and pooled analysis of all patients with a prenatally diagnosed SRM previously described in the literature. Results The literature review yielded 32 studies, of which 19 were single case reports. In our case series, 12 patients were included. Seven patients were delivered vaginally, one was terminated. Postnatal diagnoses included: SEPS (n = 5), adrenal hemorrhage (n = 3), polycystic kidney (n = 2), splenic cyst (n = 1), and unknown for one patient. All but two of the final diagnoses had been on the initial diagnostic differential. With the exception of the terminated fetus, all remain alive today. On pooled analysis, patients who underwent operative management were diagnosed later 32 versus 24 weeks and had a significant predominance of left-sided lesions (59.5 versus 39.2%). The published literature demonstrates a trend toward observation versus resection over the past 30 years. Conclusions Patients prenatally diagnosed with an SRM have an excellent prognosis. Our series demonstrates a high incidence of SEPS, which were all resected, and adrenal hemorrhage, which were observed with repeat imaging. These patients can be followed with serial postnatal ultrasounds to determine the diagnosis prior to deciding the appropriate treatment.

Antenatal Recognition of Megacystis Microcolon Intestinal Hypoperistalsis Syndrome (MMIHS): An Impact on Neonatal Prognosis

Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) syndrome is an autosomal recessive disorder (in some cases) characterized by a microcolon, a distended non-obstructed bladder, and decreased or absent intestinal peristalsis. MMIHS is not commonly diagnosed in the antenatal period due to its rarity and similarities with other more common antenatal conditions. Late diagnosis is associated with poorer prognosis. Prenatal diagnosis helps parents make decisions about their pregnancy guided by pediatric prenatal consultation regarding interventions and prognosis. Most medical and surgical interventions focus on complications of MMIHS after postnatal diagnosis. This case report discusses the prenatal diagnosis of MMIHS using serial ultrasonography and the early interventions designed foreseeable complications resulting in an extension of life beyond the historical limits.

Hemorrhagic Renal Cyst, a Case Report.

A 73-year-old male presented with one day of hematuria associated with urinary frequency and acute on chronic abdominal cramping. On exam, he had diffuse abdominal tenderness, which he stated was normal for him. He was afebrile with no costovertebral angle tenderness or any other pertinent findings on physical exam. The urinalysis showed large red blood cells and small leukocyte esterase and nitrites. Labs were significant for white blood cell count (WBC) 24.6/mm3, hemoglobin 11.6 g/dL, blood urea nitrogen (BUN) 56 mg/dL, creatinine 3.8 mg/dL (baseline 2.8 six months ago), glomerular filtration rate (GFR) 16 mL/min. These findings were consistent with acute on chronic kidney injury with concomitant urinary tract infection - specifically concerning for pyelonephritis or an infected renal stone. Bedside renal ultrasound demonstrated a right renal cyst with echogenic debris consistent with a hemorrhagic cyst (red arrow). In addition, a computed tomography (CT) scan of the abdomen and pelvis revealed a 4mm non-obstructing right renal stone and bilateral renal cysts. The CT also confirmed the ultrasound finding of a right renal cyst with mild perinephric stranding possibly consistent with a hemorrhagic cyst. Simple renal cysts are typically single, unilateral, and usually possess four distinct characteristics: lack internal echoes, have increased posterior acoustic enhancement, have a uniform round/oval shape, and have thin posterior walls/demarcated borders.1 If all of these ultrasound features are met, additional imaging does not always have to be obtained.1,2 Simple renal cysts are usually benign, asymptomatic, and often appear as incidental findings on imaging.2,3 Generally, the number of renal cysts increase as a person ages.3A renal cyst may be classified as a complex cyst when it fails to be defined as a simple cyst.1 Characteristics of complex renal cysts may include septations, calcifications, internal echoes, or other irregularities.1 Cysts can also become more complex by hemorrhage or infection, which is usually evident on ultrasound by internal echoes.1 Calcifications can also form within the cyst, which can make it challenging to discriminate a simple cyst from cystic renal tumors.2 Both malignant and hemorrhagic cysts often have irregular boarders and echogenic material within their walls and within the cyst.4 On ultrasound, infected renal cysts are characterized by thickened walls sometimes with debris or gas.1,3 Calcifications may be present with increased attenuation.3 Infected cysts are diagnosed by a combination of imaging findings and clinical characteristics.3,5 While simple cysts are usually asymptomatic, malignant or more complex cysts are more likely to be symptomatic.3To further distinguish hemorrhagic cysts from malignant tumors, a CT or magnetic resistance imaging (MRI) should be performed.2 Computed tomography is more sensitive than ultrasound for identifying a renal mass, but ultrasound is effective for further characterizing a simple cyst from a complex cyst.3,6 One study reported that CT, MRI, and MRI with diffusion-weighted imaging (DWI) had 100% sensitivity at identifying the presence of possible malignant renal lesions, but CT and MRI had lower specificity (66.9% and 68.8%) than MRI with DWI (93.8%).7Further classifying the type of renal cyst - simple vs complex or hemorrhagic vs infected vs malignant - aids in guiding management. While simple cysts usually do not need additional imaging, complex cysts may need to be further characterized.2 If malignancy is unlikely, hemorrhagic cysts are typically followed with serial ultrasounds.1 If there is concern for infection, antibiotics should be started.5 Further evaluation may include aspiration and drainage.1. This patient was started on antibiotics and admitted to the hospital. Urology, nephrology, and infectious disease were consulted. He was continued on antibiotics for 3 weeks due to concern for possible infected renal cyst. The patient was discharged and recommended to follow-up with urology for an outpatient cystoscopy and repeat renal ultrasound in 3 months to evaluate for a possible neoplasm. Renal cyst, hemorrhagic cyst, hematuria, bedside ultrasound, POCUS.

Case Study of a Pancreatic Head Lesion in an Adolescent Female following Abdominal Trauma

Pancreatic trauma is rare in adults but has an increased incidence in pediatric patients. A 12-year-old, Southeast Asian patient presented with abdominal trauma to her umbilical region. On sonographic examination, a complex pancreatic head lesion was identified; multiple differentials given were that of a hematoma, walled-off pancreatic necrosis (WOPN), or a solid pseudopapillary epithelial neoplasm. A magnetic resonance imaging, blood analysis, and biopsy of this lesion were non-conclusive. Serial ultrasounds over 94 weeks from date of injury showed a change in the pancreatic echogenicity and correlated with blood work to be pancreatitis; followed by the resolution of the pancreatic head lesion. The lesion was diagnosed as a complication of pancreatic trauma and called a WOPN.

First experience: management of Prune Belly syndrome in Harapan Kita Women and Children’s Hospital

Prune belly is a rare congenital syndrome, consisting of congenital abdominal wall musculature absence, urogenital tract anomalies, and cryptorchidism in male patient. The incidence of this syndrome is 1 in 35,000 to 1 in 50,000 live births and rarely occurs in females (3-5%). One step operation of ureteral re-implantation, orchidopexy, and abdominoplasty is one option of treatment in managing this condition. This was our first experience, involving a multidisciplinary approach. A 30 year old Asian Woman G4P3A0 at 33-34 weeks of gestation was referred to the Urology Department with a fetal ultrasound showing bilateral hydronephrosis and undescended testis. Prune Belly was first suspected when abnormal abdominal circumference was noted by the obstetrician while doing a fetomaternal ultrasound at the 19 weeks gestation. No intervention was undertaken during gestation. The baby delivered spontaneously at 38 weeks gestation. Testes were impalpable and the abdominal contour was suggestive of Prune Belly. CT urography showed bilateral hydronephrosis and hydroureter. Micturating cysto-urethrography showed bilateral vesicoureteral reflux while renogram showing a cortical defect. Serial follow-ip ultrasounds were done showing bilateral hydroureter with 4th grade bilateral hydronephrosis. By the age of 2 the patient underwent one step operation of ureteral reimplantation, orchidopexy, and abdominoplasty. After the operation, the patient recovered with good function and cosmetic result. Prune belly is a rare and complex congenital syndrome. From our experience at Harapan Kita Women and Children’s Hospital, one step operation involving multidisciplinary approach of ureteral re-implantation, orchidopexy, and abdominoplasty has shown a good result. Further follow up is needed to evaluate either this choice of treatment could improve patient outcome.

Early Onset Fetal Growth Restriction: Does Path to Diagnosis Impact Outcomes and Pathology?

Objective:To evaluate demographics and outcomes of maternal-fetal pairs in early onset fetal growth restriction (FGR) requiring delivery prior to 34 weeks’ gestation based on ultrasound indication leading to diagnosis.Study Design:This is a descriptive study of maternal-fetal pairs with early FGR diagnosed prior to 30 weeks’ gestation and delivering between 22w0d and 34w0d under the care of Wake Forest University Perinatology 01/2012–12/2016. Serial ultrasounds to assess fetal growth and umbilical artery flow Doppler velocimetry were evaluated. Pairs were dichotomized into those with maternal comorbidities leading to ultrasound diagnosis, and those with ultrasound indicated only by appreciation of uterine size less than dates on exam. Patient characteristics and outcomes were tracked. Univariate and multivariate analyses were performed as appropriate.Results:56 pregnancies were identified with FGR prior to 30 weeks and subsequent delivery prior to 34 weeks. Common comorbidities present in the group with maternal comorbidities included chronic hypertension (30.5%), hypertensive disorders of pregnancy (36.1%), preexisting diabetes (13.9%), gestational diabetes (5.6%). None of the women in the S<D group developed hypertensive disorders of pregnancy or GDM. Other background characteristics were similar. Pregnancies evaluated for size less than dates were diagnosed on average 3 weeks later in gestation, had higher incidence of reverse end diastolic flow on Doppler evaluation both at diagnosis (80% vs. 22.9%, p=0.01, OR 0.08 (<0.01,0.74) and were more likely to be delivered for an urgent indication. Both groups of babies had similar survival to discharge rates and length of stay in the NICU. A subanalysis evaluating only babies with abnormal Doppler studies showed a shorter diagnosis to delivery interval and continued to show increased risk of urgent delivery due to fetal status in those pregnancies diagnosed based on size<dates.Conclusion:Women measuring size less than dates in the mid-trimester should be evaluated by ultrasound without delays. Early FGR carries a high mortality rate in all cases and in our pilot data, women measuring small were diagnosed later with fetal growth restriction and may represent a severe phenotype with poor fetal-placental circulation. These pregnancies often met criteria for urgent delivery in a short time frame, especially if abnormal umbilical artery Doppler velocimetry was noted.

950: Longitudinal assessment of fetal placental arterioles and umbilical artery in normal pregnancies using novel tools

Technological limitations have hindered understanding of the physiology of fetal placental arterioles (FPA). Novel ultrasound (US) tools can now visualize and quantify microvascular flow. To our knowledge longitudinal study of FPA in pregnancy has not been done. Our objective was to determine the physiological changes in FPA across pregnancy and the response of the umbilical artery (UA) to these changes. Normal pregnant women with singletons were consented for serial US starting between 12 0/7 and 13 6/7 wks. US was performed every 2 wks until 16 wks, then every 4 wks until delivery. Visualization of FPA was achieved by novel microvascular color imaging on sagittal section of the placenta at the cord insertion level. Number of FPA visualized (FPA#), peak systolic velocity (FPA-PSV) and Pulsatility Index (FPA-PI) were obtained by averaging 6 measurements per US. Umbilical artery PI (UA-PI) was obtained at each US, starting at 15-16 wks. Women with BMI >30 kg/m2 at enrollment or who developed any complication were excluded. Pearson's correlation was used to test for associations. 83 women were included in this study with 8 US per pregnancy. Nomograms were developed for FPA# and FPA-PSV (Figure 1) and FPA-PI and UA-PI (Figure 2). Cubic polynomial models represented best fit for FPA-#, PSV and PI. Linear regression represented best fit for UA-PI. FPA-# and FPA-PSV (Figure 1) increased and FPA-PI and UA-PI (Figure 2) decreased throughout gestation. The steepest decline in slope of FPA-PI was in the 3rd trimester (Figure 2). Strong positive correlation was noted between UA-PI and FPA-PI (R 0.67, p< 0.0001). In vivo evaluation of FPA is feasible. Reduced impedance of fetal placental bed is noted in early gestation and continues throughout pregnancy with an accelerated drop in the 3rd trimester. Increased FPA-PSV is driven by reduced FPA impedance along with increased fetal cardiac output. UA Doppler change in pregnancy is primarily driven by adaptation of FPA.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

80: Longitudinal assessment of placental shear-wave elastography and correlation with placental circulation in normal pregnancies

Evidence suggests an increase in placental elasticity in complicated pregnancies. Shear-wave elastography (SWE) is a novel ultrasound (US)-based technology that measures tissue elasticity. To our knowledge, SWE of placental tissue has not been measured longitudinally across gestation, starting in the first trimester. Our objective was to determine changes in SWE of placental tissue and its relationship with utero-placental circulation in normal pregnancies. Normal pregnant women with singletons were consented for serial US starting between 12 0/7 and 13 6/7 wks. US were performed every 2 wks until 16 wks, then every 4 wks until delivery. Guided by SWE propagation maps, placental SWE (KPa) was measured from homogeneous circular shaped SWE-ROI obtained in a sagittal plane of the placenta at the level of the cord insertion. The average of 15 SWE was used per US. Pulsatility index of spiral (SA-PI) and fetal placental arterioles (FPA-PI) were longitudinally obtained by averaging 6 measurements per US. Women who had BMI ≥ 30 kg/m2 at enrollment or who developed any complication were excluded. Pearson's correlation tested strength of associations. RM-ANOVA and TUKEY HSD were used for analysis. 83 women were included in this study with 8 US per pregnancy. SWE showed slight, but significant increase with advancing gestation (p< 0.0001) (Figure 1). Sub-group comparisons revealed significant differences between wk 14 and 16 compared to wks 28, 32, and 36 (Table 1). SWE showed no significant correlation with PI of placental vessels (SA-PI, R -0.08; FPA-PI, R -0.2). Non-invasive assessment of placental tissue elasticity throughout gestation is feasible. In our normal cohort, placental elasticity increased, within a narrow SWE range, with advancing gestation. This increase in elasticity probably represents physiologic changes in placental tissue. This SWE nomogram can be used as a reference to assess placental tissue elasticity in complicated pregnancies.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

355: sIUGR in monochorionic diamniotic twins: Is it discordance >25%, EFW < 10th percentile or both?

Selective intrauterine growth restriction (sIUGR) is a common but inconsistently defined complication of monochorionic diamniotic (MCDA) twins. We sought to compare two definitions of sIUGR: 1) Estimated fetal weight (EFW) discordance > 25th percentile plus EFW < 10th percentile in the smaller twin. 2) Only one of these criteria. This is a retrospective cohort study of MCDA twin gestations that had surveillance ultrasounds (US) at our center between 2012 and 2018. We compared sIUGR pregnancies with EFW discordance > 25th percentile plus EFW < 10th percentile for the smaller twin (Group 1) to those with only one of these criteria (Group 2). Women with uncertain chorionicity, twin to twin transfusion syndrome, fetal anomalies, or less than 4 serial US exams were excluded. Routine US was performed biweekly from 16 weeks gestational age (GA) until delivery. The primary outcome was composite perinatal morbidity and mortality (Table 2). Pregnancy characteristics including Gratacos type, indication for delivery and mode of delivery were also compared between groups. Of 293 MCDA pregnancies that met inclusion criteria, sIUGR developed in 66 (22.5%); 42 women followed at our center for the entire pregnancy. Among these women, 18 (42.8%) were in Group 1 and 24 (36.4%) were in Group 2 (8 with discordance > 25%, 16 with EFW < 10th percentile). Maternal age, race, parity, and BMI were similar between groups (Table 1). Women in Group 1 were diagnosed with sIUGR at an earlier GA (22.2 [18.3, 27.0] vs. 28.6 [25.0, 32.0] weeks, p = 0.004). They were also more likely to have Gratacos type II or III (50.0% vs. 4.2 %, p = 0.001) and deliver due to deterioration of fetal status (55.6% vs. 4.2%, p = 0.001). The composite outcome occurred more frequently in Group 1 (44.7% vs. 13%, p = 0.001). sIUGR neonates with discordance of EFW > 25th percentile plus EFW < 10th percentile have more perinatal complications than those with only one criterion. Increased US surveillance may be beneficial in these pregnancies.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Response Assessed by Ultrasonography as Target of Biological Treatment for Crohn’s Disease

Mucosal healing, determined by ileocolonoscopy, is a goal for treatment of Crohn's disease (CD), but this is an invasive assessment procedure. We investigated whether response to tumor necrosis factor (TNF) antagonists, determined by small-intestine contrast ultrasonography, associates with long-term outcomes. We performed observational study of 80 patients with CD treated with anti-TNF agents for at least 1 year who underwent serial small intestine contrast ultrasonography (SICUS) at the University of Rome, in Italy. SICUS was used to evaluate disease site (based on bowel wall thickness), extent of lesions, and presence of complications. Inclusion criteria required pre-therapy SICUS with follow-up SICUS after 18 months. At second SICUS, patients were assigned to categories of complete or partial responder or non-responder. CD-related outcomes (corticosteroid need, hospitalization, and surgery) were assessed at 1 year from the second SICUS, using multivariate models, and were analyzed after long term follow up (5 years) using Kaplan-Meier survival analysis. Based on SICUS, after a median of 18 months, 36 patients (51%) were complete responders, 30 were partial responders (34%), and 13 were non-responders (15%). At 1 year from the second SICUS, no patients with a complete response, based on ultrasonography, underwent surgery, in comparison to partial responders (P = .0003) or non-responders (P = .001). Complete respondersused smaller amounts of corticosteroids than partial responders (P = .0001) or non-responders (P < .0001). Complete responders required fewer hospitalizations than non-responders (P = .001). Kaplan-Meier survival analysis of long-term follow up data demonstrated a lower cumulative probability of need for surgery, hospitalization, and need for steroids among SICUS-categorized complete responders (P < .0001, P = .003 and P = .0001 respectively) than SICUS-categorized non-responders. In patients with CD, response to anti-TNF agents, determined by SICUS, is associated with better long-term outcomes than partial or no response. Ultrasonographic assessment therefore provides a relatively non-invasive method for monitoring response to treatment in patients withCD.

Pilot study establishing a nomogram of yolk sac growth during the first trimester of pregnancy.

The yolk sac (YS) has been reported as a reliable predictor of adverse pregnancy outcomes, however, it has always been evaluated cross-sectionally with a single ultrasound per patient. We sought to validate the use of YS dimensions in serial ultrasounds throughout the first 10 weeks of singleton and multiple gestations. This was a prospective cohort study where YS diameters were serially obtained with 2D ultrasound in singleton and multiple gestations from 5 to 11 weeks. Nonparametric test were used for comparisons with P < 0.05 indicating significance. One hundred ninety-three patients were included, 42 twins (3 monochorionic and 39 dichorionic), 2 triplets (monochorionic twins plus a singleton) and 148 singleton pregnancies (238 total fetuses). There was no difference in YS dimensions in singleton versus multiple pregnancies. Starting at 5 weeks' gestation, the YS increased 0.4 mm (95% CI 0.3-0.5 mm) per week until 10 weeks' gestation. Forty-five fetuses were lost in the first trimester. The risk of pregnancy loss was higher with a large YS until 8 weeks (P ≤ 0.001), while after 8 weeks it was higher with a small YS (P < 0.005). We established a nomogram of YS development during the first 10 weeks of pregnancy. The YS reliably detected pregnancies that ended in loss as early as 6 weeks' gestation. The YS was either smaller or larger than in ongoing pregnancies. While all pregnancies with large YS were lost within 10 weeks, those with smaller YS were lost beyond the first 10 weeks.

Emergence of Alveolar Consolidations in Serial Lung Ultrasound and Diagnosis of Ventilator-Associated Pneumonia

Lung ultrasound (LUS) has been reported as a promising diagnostic tool for ventilator-associated pneumonia (VAP), but patients with previous lung parenchyma commitment have been not studied. To evaluate whether the emergence of sonographic consolidations, rather than their presence, can improve the VAP diagnosis in a sample including patients with previous lung parenchyma diseases. Patients who completed 48 hours of mechanical ventilation were prospectively studied with daily LUS examinations. We checked the emergence of different consolidation types on the eve and on the day of a clinical suspicion of VAP. We elaborated an algorithm considering, sequentially, the emergence of (1) subpleural consolidations in anterior lung regions on the eve of suspicion; (2) lobar/sublobar consolidation in anterior lung regions on the day of suspicion; (3) lobar/sublobar consolidation with dynamic air bronchograms on the day of suspicion; and (4) any other lobar/sublobar consolidation on the day of suspicion in association with a positive Gram smear of endotracheal aspirate. Of the 188 included patients, 60 were suspected and 33 confirmed VAP. The presence of sonographic consolidations at the clinical suspicion had no diagnostic value for VAP. The emergence of subpleural consolidations in anterior lung regions on the eve of suspicion had specificity of 95% (95% confidence interval [CI], 79%-99%). The emergence of lobar/sublobar consolidations in anterior lung regions on the day of suspicion had specificity of 100% (95% CI, 87%-100%). The emergence of lobar/sublobar consolidations with dynamic air bronchograms on the day of suspicion had specificity of 96% (95% CI, 81%-99%). Finally, the proposed algorithm had sensitivity of 63% (95% CI, 46%-77%) and specificity of 85% (95% CI, 67%-94%) for VAP. The presence of sonographic consolidations was not accurate for VAP when patients with previous lung parenchyma commitment were included. However, serial LUS examinations detected the emergence of specific signs of VAP.

Remnant cholesterol, coronary atheroma progression and clinical events in statin-treated patients with coronary artery disease.

Remnant cholesterol has been proposed to promote atherosclerotic cardiovascular disease independent of low-density lipoprotein cholesterol, yet the underlying mechanisms are not well understood. We aimed to study the association of remnant cholesterol with coronary atheroma progression and clinical events. We analyzed data from 5754 patients with coronary artery disease undergoing serial intravascular ultrasonography who were enrolled in 10 trials examining various medical therapies. Remnant cholesterol was calculated as (non-high-density lipoprotein cholesterol - low-density lipoprotein cholesterol (estimated using the Hopkins-Martin equation)). Changes in percentage atheroma volume and 2-year major adverse cardiovascular events were compared across various levels of remnant cholesterol, and multivariable models were used to assess the independent relationship of remnant cholesterol with changes in percentage atheroma volume. The mean age was 58.1 ± 9.2 years, 28% were women and 96% received a statin. Percentage atheroma volume progression (changes in percentage atheroma volume > 0) occurred in a linear fashion at on-treatment remnant cholesterol levels of 25 mg/dL or greater. The highest on-treatment remnant cholesterol quartile demonstrated greater percentage atheroma volume progression (+0.53 ± 0.26 vs. -0.15 ± 0.25%, P < 0.001) and 2-year major adverse cardiovascular events (23% vs. 14%, log-rank P < 0.001) compared with the lowest. In multivariable analyses, changes in percentage atheroma volume significantly correlated with on-treatment remnant cholesterol (P < 0.001] independent of low-density lipoprotein cholesterol, apolipoprotein B, C-reactive protein, high-density lipoprotein cholesterol levels and clinical risk factors. Changes in percentage atheroma volume also significantly correlated with changes in remnant cholesterol following multivariable adjustment. In statin-treated patients with atherosclerotic cardiovascular disease, remnant cholesterol was associated with coronary atheroma progression regardless of conventional lipid parameters, C-reactive protein or clinical risk factors. Higher remnant cholesterol levels also correlated with higher major adverse cardiovascular events. These data support further investigations into remnant cholesterol-lowering interventions in statin-treated patients harboring residual atherosclerotic cardiovascular disease risk.

Measuring compliance with a maternal fetal medicine obesity protocol: a secondary analysis

Background Current trends in patient safety include protocolization of care with assumed compliance to the protocol by health care providers. In 2016, Schuster et al. found that implementation of a protocol for management of obese pregnant patients that included delivery by estimated due date (EDD) actually resulted in a decrease in cesarean deliveries. Although compliance to the aspect of the protocol that affected the primary outcome of that study was evaluated, compliance to every aspect of the protocol was not analyzed. Recent studies have suggested improvements in protocol outcomes when compliance is measured. Therefore, we sought to evaluate compliance to the other aspects of the Geisinger Maternal Fetal Medicine obesity protocol (MOP). Objective The objective of this study was to identify compliance with all elements of the Geisinger MOP and identify areas for potential improvement with regards to compliance. Study design We performed a secondary analysis of the original study to evaluate compliance with protocol aspects during the study period. Ninety-seven patients were randomly selected for chart review. We assessed compliance with each element of the protocol, including early diabetes screening, fetal monitoring, growth ultrasounds, and delivery by EDD using simple statistics. Results By obesity class, compliance was as follows: for class I obese patients, compliance with early diabetes screening was 30% (12/36 patients). For class II obese patients, compliance with early diabetes screening was 57.1% (12/21 patients), and compliance with serial growth ultrasounds was 85.7% (18/21 patients). For class III obese patients, compliance with early diabetes screening was 74.4% (29/39 patients), compliance with serial growth ultrasounds was 84.6% (33/39 patients), compliance with nonstress tests was 82.0% (32/39 patients). Compliance with the recommendation for delivery by estimated due date was 95% (37/39 class III obese patients). Conclusion Although compliance was excellent with delivery by EDD, compliance with remaining recommendations was low. This suggests additional interventions are important to maintain compliance.

Evaluation of Gastric Emptying Time of a Rice-Based Meal Using Serial Sonography.

The aim of this prospective study was to evaluate the gastric emptying time of a rice-based meal by serial ultrasonography of the stomach. After baseline ultrasonographic assessment of ten fasted healthy volunteers, volunteers ingested standardized 420 g, 536 kcal rice-based meal (bibimbap), and serial evaluations were performed every hour until the stomach became empty. At baseline, all the participants had an empty stomach. The average time of complete gastric emptying of the rice-based meal was 5.8 ± 0.8 h (95% confidence interval (CI), 5.0 h to 6.5 h). Since the first postintake cross-sectional area (CSA) measurement, a decrease was observed, and CSA was maintained until postprandial 3–4 h (P > 0.05). It declined rapidly 4 h after meal intake (P=0.031), reaching the nadir at approximately 6 h after meal intake. The gastric CSA and hunger score showed a positive correlation (correlation r = 0.616, P < 0). The rice-based meal is emptied after 5.8 ± 0.8 h on average in healthy volunteers. Based on our results, 6.5 h (upper limit of CI) of fasting after the ingestion of a rice-based meal would be a safe preoperative fasting time, and this is in accordance with the current guidelines for preoperative fasting.

Case 2: Abdominal Distention in a Term Infant with Unilateral Ventriculomegaly

An early term female neonate is born at 37 weeks, 2 days of gestation with a birthweight of 3.1 kg. She is delivered vaginally by a 26-year-old woman after induction of labor for preeclampsia with severe features; magnesium sulfate was given during labor. Prenatal history is significant for late prenatal care (14 weeks) and fetal diagnosis of right-sided ventriculomegaly noted on serial ultrasonography, first at 20 weeks of gestation and confirmed on fetal magnetic resonance imaging (MRI) at 27 weeks. All prenatal serologic findings were negative, a 1-hour oral glucose tolerance test result was within normal limits, and cell-free fetal DNA was negative for trisomies 13, 18, and 21. Maternal-fetal medicine, neonatal-perinatal medicine, and pediatric neurosurgical physician teams were involved in the prenatal care, and a plan was developed to admit the infant to the level III NICU after birth for further brain imaging.At delivery, the infant is vigorous, with Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. Birthweight is at the 50th percentile, length is greater than the 97th percentile, and occipitofrontal circumference is at the 90th percentile. The remainder of the newborn examination is unremarkable, including a perforate anus, and the infant is admitted to the NICU for known right-sided ventriculomegaly. On the day of birth, postnatal MRI demonstrates asymmetric right-sided ventriculomegaly likely secondary to a prior germinal matrix and intraventricular hemorrhage. The infant feeds orally and voids normally but no stools are noted. At birth, a chromosomal microarray is obtained, which later reveals a likely benign duplication at 7q21.12-q21.13, with no known clinical significance associated.On the day after birth, the infant develops abdominal distention with decreased bowel sounds and lethargy. Oral feeding is discontinued and intravenous fluids are initiated. Vital signs are stable and examination findings are otherwise unremarkable, with no respiratory distress noted in room air. Voiding remains normal, but again, no stools are noted.A kidney, ureter, bladder (KUB) radiograph was obtained, which demonstrated mildly dilated loops of bowel throughout the abdomen. The infant was given nothing by mouth, and a Replogle tube was placed for abdominal decompression. Intravenous antibiotics (ampicillin and gentamicin) were started after performing a sepsis screen. The complete blood cell count and C-reactive protein levels were unremarkable. A repeat KUB radiograph remained concerning for a small bowel obstruction (Fig 1), and the infant developed bilious output from the appropriately positioned Replogle tube. A water-soluble contrast enema was performed on the third day, which revealed multiple intraluminal filling defects and meconium plugging (Fig 2). Shortly after the contrast enema, the infant began to pass stools, with 5 large-volume meconium stools noted in the following 24 hours. Abdominal distention and gastric output decreased, and a repeat KUB radiograph demonstrated decreased gaseous distention. Oral feedings were reinitiated 2 days after the enema and were advanced without difficulty. Daily occipitofrontal circumference measurements remained stable throughout the infant’s hospitalization. She was discharged from the hospital on the 7th day after birth, voiding and stooling appropriately, and with follow-up scheduled with the neurosurgical team to continue to monitor the stable ventriculomegaly.The differential diagnosis of abdominal distention in a newborn includes volvulus (with or without malrotation), necrotizing enterocolitis, sepsis, Hirschsprung disease, meconium syndromes (such as ileus or plug), intestinal webs or atresias, hypertrophic pyloric stenosis, congenital microcolon, spontaneous intestinal perforation, imperforate anus, peritoneal bands, internal hernias, and rarely, lactobezoars. (1)(2) Small left colon syndrome, first described in 1974, is thought to occur because of immaturity of the myenteric plexus ganglia (1) of the colon, which leads to a transient functional obstruction in newborns and carries a strong association with maternal diabetes mellitus, (3)(4) maternal preeclampsia treated with magnesium sulfate, (1) and prematurity. (1) Maternal diabetes mellitus, either gestational or pregestational, is the most common association, reported in 40% to 50% of the few published cases of small left colon syndrome. (3) Small left colon syndrome is the most common diagnosis in newborns who fail to pass meconium within the first 48 hours after birth. (1)(3)(4)(5)(6)Abdominal radiography will demonstrate lower bowel obstruction with or without air-fluid levels. Water-soluble contrast enema is frequently both diagnostic and therapeutic in these patients, demonstrating a significant change in colonic caliber. An abrupt transition occurs at the splenic flexure to a narrow distal colon, relieving the obstruction by flushing away any meconium present in the distal colon. Normal intestinal motility without long-term complications is expected in cases of neonatal small left colon syndrome.

Serum soluble FMS-like tyrosine kinase-1 in ectopic pregnancy.

CONTEXT:The diagnosis of an ectopic pregnancy (EP) requires the usage of serial beta-human chorionic gonadotropin (hCG) measurements and ultrasonography to locate the gestational sac. With the rising trends in its incidence, a rapid, noninvasive biomarker to detect this condition at the earliest can aid in decreasing the morbidity and mortality linked with EP.AIMS:This study was performed to determine the serum level of soluble FMS-like tyrosine kinase-1 (sFLT-1) at 4–10-week gestation in EP and normal pregnancy and to identify whether it can be used as a biomarker to distinguish an EP from a normal intrauterine pregnancy.SETTINGS AND DESIGN:This was a prospective case–control study conducted over 2 years from 2015 to 2017 in 280 women between the age groups of 19 and 38 years at a tertiary level hospital.SUBJECTS AND METHODS:Levels of sFLT-1 in sera of 140 women with EP and 140 women with normal pregnancy were assayed by a sandwich enzyme-linked immunosorbent assay at Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India.STATISTICAL ANALYSIS USED:Statistical analyses were performed with SPSS software version 16.0, and P ≤ 0.05 was considered statistically significant.RESULTS:The median sFLT-1 level in EP was 419 pg/ml. This was significantly lower than the value of 898 pg/ml in normal pregnancy. Receiver operating characteristic curve analysis showed that at a cutoff of 623 pg/ml, sFLT-1 was able to distinguish an EP from a normal intrauterine pregnancy with a sensitivity of 98.6% and a specificity of 90.7%.CONCLUSIONS:The present study showed the significant early lowering of sFLT-1 in EP and may be considered as an effective biomarker compared to beta-hCG.

Determining Whether Tumor Volume Doubling Time and Growth Rate Can Predict Malignancy After Delayed Diagnostic Surgery of Follicular Neoplasm.

Background: Tumor volume doubling time (TVDT) is considered as a dynamic indicator of tumor growth and progression. We aimed to clarify whether TVDT should be considered in the cytological diagnosis of follicular neoplasms (FNs). Methods: This retrospective cohort study included 100 consecutive FN patients with a TVDT >1 year for whom surgical resection was delayed for >1 year. Changes in tumor volume and the TVDT of each nodule were calculated by serial neck ultrasonography (US) over a median follow-up of 50 months. Results: Among 100 surgically resected FNs, 58 (58%) were benign and 42 (42%) were malignant tumors. At the 5-year follow-up, most FN nodules showed volume increases of >50%, accounting for 65% of benign and 62% of malignant nodules. No significant difference was observed in tumor growth rates and time to a >50% increase in tumor volume between benign and malignant nodules (p = 0.299 and p = 0.378, respectively). The calculated TVDT and a >50% volumetric increase showed a linear relationship with a high concordance (R2 = 0.883; p < 0.001). The risk of malignancy was not significantly associated with TVDT (relative risk = 1.00; [95% confidence interval 0.99-1.01]; p = 0.784). Even when US features were considered, no significant association was found between TVDT and the risk of malignancy. Conclusions: The size of most FNs increased exponentially with time; the tumor growth rates of benign and malignant nodules were similar. Despite the usefulness of TVDT as an indicator of growing velocity of FN nodules, TVDT could not predict malignancy in FNs. Clinical surveillance based on the growth of thyroid nodules categorized as FNs on serial neck US does not predict the risk of malignancy.