US-guided Procedure Research Articles

Ultrasound-Guided Peripheral Venipuncture Decreases the Procedure's Pain and Positively Impacts Patient's Experience: The PRECISE Randomized Clinical Trial.

This study aimed to compare patients' experience of pain during ultrasound (US)-guided peripheral venipuncture versus conventional peripheral venipuncture. This randomized clinical trial was conducted at a public university hospital in 2021. Adult patients with indication for intravenous therapy compatible with peripheral intravenous catheters (PIVCs) were included: intervention group (IG), US peripheral venipuncture executed by specialist nurses; control group (CG), conventional peripheral venipuncture executed by clinical practice nurses. The primary outcome was patient experience of pain during the procedure and patient experience related to the PIVC placement method. Sixty-four patients were included, 32 for each group. The pain experienced was none-to-mild in the IG for 25 patients (78.1%) and moderate-to-severe in the CG for 21 patients (65.7%; P < .001). The overall pain rating was 2 (1-3) in the IG and 4 (3-6) in the CG (P < .001). The recommendation of the procedure in IG (net promoter score [NPS] + 90.6%) versus CG (NPS + 18.8%) was considered excellent and good, respectively (P < .001). Patients had less pain and significantly recommended the US-guided procedure. Patient experience with US-guided PIVC, performed by a specialist nurse, was superior to that of conventional peripheral venipuncture.

The Effect of Ultrasound-guided Central Venous Catheterization on Complications and Success Rate in Critically Ill Children: A Multicenter Study

Objective: The aims of this study were to compare the results of ultrasound (US) guidance and the landmark (LM) technique for central venous catheter (CVC) placement in pediatric intensive care units (PICUs) as performed by clinicians. Material and Methods: The patients were divided into two groups according to the technique used: an LM group (459 patients) and a US-guided group (200 patients). We evaluated the success rate, the number of attempts, and the complication rates based on each patient’s age and weight. Results: The time required for the successful placement of the CVC was significantly different between the two groups: 10.9±10.8 min in the LM group and 8.1±7.6 min in the US-guided group (p=0.012). Additionally, the average number of attempts for successful catheterization was 1.8±0.8 in the US-guided group; and 2.5 ± 1.4 in the LM group (p=0.024). A total of 115 (17.3%) complications were noted: 24 (3.6%) in the US-guided group and 91 (13.7%) in the LM group (p=0.014). The frequency of complications decreased as the age and weight of the patients increased. When the inserted catheters used by ultrasound were evaluated, 59.5% of them were placed by clinicians who had ultrasound training while 40.5% were inserted by clinicians who did not have ultrasound training. There was no significant difference in the complication rate, number of punctures, and success rates between the ultrasound-trained and untrained clinicians (p=0.476). Conclusion: This is the largest multicenter study comparing the US-guided vs. LM technique for CVC placement in children. We believe that the US-guided CVC procedure is more safe and takes less time than the LM technique. Also, point-of-care ultrasound is useful, beneficial, and easily available for pediatric intensivists.

Ultrasound-guided and CT-guided selective cervical nerve root injection for the treatment of cervical radicular pain: A retrospective clinical study.

To compare the clinical effects and safety of ultrasound (US)-guided selective cervical nerve root injection (SCNI) and computed tomography (CT)-guided SCNI for patients with cervical radicular pain (CRP). Forty-two CT-guided SCNI procedures (26 eligible patients) and forty-two US-guided SCNI procedures (25 eligible patients) performed to treat CRP were identified from the medical record system between October 2017 and July 2021 and enrolled in the study. The numeric rating scale was used to assess pre- and postprocedural pain levels, and the neck disability index was used to assess the level of function. All immediate and delayed clinical complications were also recorded. The cost of each procedure and the radiation dose of the CT procedure were documented. The follow-up data were obtained by telephone calls or outpatient visits. Five patients in the CT group and one patient in the US group were lost to follow-up at 1 year. No procedure-related complications were observed in either group. Significant pain relief and cervical function improvement were achieved after treatment in both the CT-guided SCNI and US-guided SCNI groups; however, there were no significant differences between the two groups. The average cost per CT-guided SCNI procedure was 133.2 USD, which was higher than the cost per US-guided SCNI procedure (42.2 USD). Meanwhile, the necessary radiation dose per patient in the CT group was 0.36 ± 0.08 mGy. US-guided SCNI and CT-guided SCNI have similar efficacy in treating CRP, but US-guided SCNI is radiation free and less costly than the CT-guided procedure.

The Advantage of Using an Optical See-Through Head-Mounted Display in Ultrasonography-Guided Needle Biopsy Procedures: A Prospective Randomized Study.

An optical see-through head-mounted display (OST-HMD) can potentially improve the safety and accuracy of ultrasonography (US)-guided fine-needle aspiration. We aimed to evaluate the usefulness of an OST-HMD in US-guided needle-puncture procedures. We conducted a prospective randomized controlled study in which we compared the accuracy and safety of the US-guided needle puncture procedure and the stress on the practitioner when using OST-HMD versus standard US display (SUD). Inexperienced medical students were enrolled and randomly divided into two groups. A breast phantom was used to evaluate the required time and accuracy of the US-guided needle puncture. Practitioner stress was quantified using a visual analog scale (VAS). When the procedure was performed for the first time, the time required to reach the target lesion at a shallow depth was significantly shorter in the OST-HMD group (39.8 ± 39.9 s) than in the SUD group (71.0 ± 81.0 s) (p = 0.01). Using the OST-HMD significantly reduced the unintentional puncture of a non-target lesion (p = 0.01). Furthermore, the stress felt by the practitioners when capturing the image of the target lesion (p < 0.001), inserting and advancing the needle more deeply (p < 0.001), and puncturing the target lesion (p < 0.001) was significantly reduced in the OST-HMD group compared with that in the SUD group. Use of OST-HMD may improve the accuracy and safety of US-guided needle puncture procedures and may reduce practitioner stress during the procedure.

A Randomized, Single-Blind Clinical Trial Comparing Robotic-Assisted Fluoroscopic-Guided with Ultrasound-Guided Renal Access for Percutaneous Nephrolithotomy.

We conducted a randomized, single-blind clinical trial comparing the surgical outcomes of robotic-assisted fluoroscopic-guided (RAF group) and ultrasound-guided (US group) renal access in mini-percutaneous nephrolithotomy (PCNL). We recruited patients who underwent mini-PCNL with ureteroscopic assistance for large renal stones between January 2020 and May 2021. Block randomization was performed using online software. Automated needle target with x-ray was used for fluoroscopic-guided renal access in the RAF group. PCNL was performed by residents using a pneumatic lithotripsy system with 16.5Fr/17.5Fr tracts. The primary outcome was single puncture success, and the secondary outcomes were stone-free rate, complication rate, parameters measured during renal access and fluoroscopy time. In total, 71 patients (35 in US group, 36 in RAF group) were enrolled. No difference was seen in the single puncture success rate between the US and RAF groups (34.3% and 50.0%, p=0.2). In 14.3% cases in the US group vs no cases in the RAF group, the resident was unable to obtain access due to difficult targeting (p=0.025). The mean number of needle punctures was significantly fewer, and the median duration of needle puncture was shorter in the RAF group (1.83 vs 2.51 times, p=0.025; 5.5 vs 8.0 minutes, p=0.049, respectively). The stone-free rate at 3 months after surgery was 83.3% and 70.6% in the RAF and US groups, respectively (p=0.26). Multivariate analysis revealed that RAF guidance reduced the mean number of needle punctures by 0.73 times (p=0.021). RAF renal access in mini-PCNL may have further potential applications in this field.

Ultrasound-guided transforaminal approach for nusinersen delivery in adult spinal muscle atrophy patients with challenging access.

Previous papers on ultrasound (US)-guided delivery of nusinersen in patients with spinal muscle atrophy (SMA) described good results with translaminar approach. However, this approach is not possible in patients with spinal fusion and no visible interlaminar space on pre-procedural computed tomography (CT). US-guided transforaminal nusinersen delivery is a potential option that warrants investigation. Twenty adult SMA patients with challenging access were treated in our institution under cone beam CT (CBCT) guidance. The patients were already in the maintenance phase of the dosing protocol and were prospectively evaluated for US-guided transforaminal approach. After they completed one injection via US-guided transforaminal approach, success and safety of the approach were analyzed. Patients shared their experience on US-guided in comparison to CBCT-guided injections. US-guided transforaminal puncture was possible in 14 (70.0%) patients, although 2 of them required needle repositioning under fluoroscopy due to inadvertent access of a prominent vein. US-guided transforaminal approach was therefore successful in 60% of patients. Mild adverse events were recorded in four patients. The survey on patients' experience showed that seven reported no difference in the two approaches, six preferred the US-guided procedure, and one preferred the CBCT-guided procedure. US-guided transforaminal lumbar approach is an effective and safe method of intrathecal nusinersen delivery in adult SMA patients with challenging spinal access and could be considered the first option in appropriately selected adult SMA patients requiring transforaminal nusinersen delivery.

Safety, patient acceptance and diagnostic accuracy of ultrasound core needle biopsy of parotid or submandibular glands in primary Sjögren’s syndrome with suspected salivary gland lymphoma

BackgroundEnlargement of the major salivary glands (SGs) is a major risk factor for B-cell lymphoma among patients with primary Sjögren’s syndrome (pSS). Ultrasound-guided core needle biopsy (US-guided CNB) could be...

Impact of a multidisciplinary approach to ultrasound- guided thyroid fine-needle aspiration biopsy at Tygerberg Hospital, Cape Town, South Africa: A retrospective audit

Background. Thyroid nodules are common and mostly benign. Inadequate sampling generally occurs in 13 - 17% of thyroid fine-needle aspiration biopsies (FNABs), but the proportion was found to be as high as 45% on evaluating 100 ultrasound (US)-guided FNABs in a previous unpublished audit at Tygerberg Hospital, Cape Town, South Africa (SA). Objectives. Primary aim: To determine the diagnostic yield of US-guided thyroid biopsy after implementing changes to existing practices, involving the creation of a specialised clinic and applying protocols for referral and FNAB. Secondary aim: To compare the results with other centres in SA. Methods. A retrospective audit of 178 thyroid biopsies was conducted. All US-guided thyroid biopsies performed in the specialised clinic between January 2017 and July 2018 were included. Data were analysed using descriptive statistics. Results. The 178 nodules were biopsied in 159 patients. The mean age was 53.7 years, with a gender ratio of 9.6:1 (female/male). A reduction in non-diagnostic biopsies was noted compared with the historical cohort (45% v. 32.6%). Sixty-one nodules (34.3%) had previously been biopsied with inadequate cytology results. When repeat biopsies were excluded, only 16.2% (n=19) were classified as insufficient. Conclusions. These findings illustrate the importance of the multidisciplinary approach and standardisation of the US-guided biopsy procedure and the value of consistency and quality control in a health system. While nodular thyroid disease is common and FNAB is relatively simple, early referral to a central specialised unit to minimise the incidence of inadequate FNAB should be considered.

Photoacoustic-guided endovenous laser ablation: Characterization and in vivo canine study

Endovenous laser ablation (EVLA) is a minimally invasive surgical procedure, often guided by ultrasound (US) imaging, for treating venous insufficiencies. US imaging limitations in accurately visualizing the catheter and the lack of a temperature monitoring system can lead to sub-optimal outcomes. An integrated photoacoustic (PA)-guided EVLA system has been previously developed and reported to overcome the shortcomings of US-guided procedure. In this study, we further characterized the system and tested the in vivo utility. In addition, PA thermometry was further explored by compensating the variation of PA signal with temperature with respect to the temperature-dependent absorption of blood and water. In vivo imaging results indicated that the PA-guided EVLA system can provide high contrast and accurate images of the ablation catheter tip overlaid on US images of the background tissue. Additionally, absorption-compensated PA signal amplitudes over a relevant range of temperature were measured and demonstrated.

PO38: Commissioning and Workflow Development for a Real-Time, Ultrasound-Guided Prostate HDR Brachytherapy Program

Purpose: This work presents the commissioning of a real-time, ultrasound (US)-guided HDR brachytherapy system (Elekta AB, Inc.), including the hardware, US imaging system, treatment planning system (TPS) (Oncentra Prostate), and the developed workflow.Materials and Methods: Commissioning tasks were separated into (1) US imaging, (2) stepper mechanicals, and (3) treatment planning aspects. Quality assurance US imaging measurements consisted of benchmarking the spatial resolution, accuracy, and low-contrast detectability. Mechanical tests were first performed to validate the electronic encoders used within the stepper and were later expanded to evaluate the needle free length calculation accuracy. Several system-integrated measurements were performed to verify needle positioning accuracy and imaging origin coincidence measurements using the needle free length measurement as a surrogate marker, as this remains one of the largest potential sources of error. The workflow was developed through a multi-disciplinary team, including physicians, radiation-therapists, nurses, physicists, administration staff, sterilization and anesthesia staff and included multi-dry-runs of the full procedure. A detailed description of each party's role was also developed, including checklists for the planning physicist, a secondary check physicist, and a radiation therapist.Results: Needle placement accuracy was verified to within 1 mm for both sagittal and transverse imaging planes. Needle reconstruction accuracy was also rigorously evaluated. The source strength was also calibrated with the interstitial needle and was found to be 1.14% lower than when measured in a plastic needle. The calibration length of each probe was redundantly check between the calculated and measured needle free length, which was found to be within 1 mm for a variety of scenarios. Dose calculations in the TPS and secondary dose calculation software were benchmarked against manual TG-43 calculations, which were within 1% for all calculated points. Source positioning and dummy coincidence was also verified. The US-guided HDR prostate procedure consisted of six primary components: (1) the delineation of personnel and their roles, (2) HDR suite preparation prior to the treatment day, (3) day of treatment preparations, (4) patient setup, (4) pre-needle insertion plan, (5) initial insertion and live reconstruction, and (6) final imaging and planning. A set of plan evaluation metrics were established based on the currently available guidelines (ABS, ESTRO, and RTOG) and the culmination of clinical experiences across multiple institutions.Conclusions: The commissioning of real-time, US-guided HDR prostate systems requires careful consideration among several facets including the image quality, dosimetric and mechanical accuracy. The TPS relies on each of these components to develop and administer a treatment plan, and as such, should be carefully examined.

Thoracic duct identification with indocyanine green fluorescence: a simplified method.

We read with interest the article by Vecchiato et al. ‘Thoracic duct identification with indocyanine green fluorescence during minimally invasive esophagectomy with the patient in a prone position’. recently published in Dis Esophagus.1 The authors described a method to visualize the thoracic duct (TD) during esophagectomy by performing an ultrasound-guided (US) injection of indocyanine green (ICG) in the inguinal nodes. Chylothorax is a rare but serious complication in esophageal surgery. It delays oral intake, increases hospital stay, and negatively affects overall survival.2,3 Preventive measures aimed at decreasing the incidence of TD injuries could potentially reduce the postoperative morbidity associated with this complication. In our experience, the use of ICG US-guided inguinal node injection to identify TD during robotic esophagectomy using Firefly® system is safe and reproducible but the US-guided procedure could be complex, requires trained staff, and extends operating times. Recently we revised the procedure...

Longitudinal trends using a point-of-care gelatin-based model for ultrasound-guided central venous catheter insertion

ABSTRACT Ultrasound (US)-guided central venous catheter (CVC) insertion is a procedure that carries the risk of significant complications. Simulation provides a safe learning atmosphere, but most CVC simulators are not available outside of simulation centers. To explore longitudinal trends in US-guided CVC insertion competency in internal medicine (IM) interns, we studied the use of a low-fidelity, gelatin-based, US-guided CVC insertion simulation model combined with a simulation curriculum. This prospective observational study of IM interns was performed over the course of one academic year. Interns (n = 56) underwent model-based, US-guided procedure simulation training program and a repeated training course prior to their intensive care unit (ICU) rotation. CVC insertion competency at different timepoints was recorded. Survey data about intern experience and attitudes were also collected. Out of the 56 interns initially trained, 40 were included in the final analysis. Across all outcomes, interns experienced skill atrophy between initial training and the beginning of their ICU month. However, by the end of the month, there was a significant improvement in competency as compared to initial procedural training, which then waned by the end of the intern year. Attitudes toward the model were generally positive and self-reported confidence improved throughout the course of the year and correlated with objective measures of competency. Over the course of their intern year, which included simulation training using a gelatin-based model, interns demonstrated consistent competency trends. The use of a gelatin-based CVC insertion simulation model warrants further study as an adjunctive aid to existing simulation training.

Ring-arrayed Forward-viewing Ultrasound Imaging System: A Feasibility Study.

Current standard workflows of ultrasound (US)-guided needle insertion require physicians to use their both hands: holding the US probe to locate interested areas with the non-dominant hand and the needle with the dominant hand. This is due to the separation of functionalities for localization and needle insertion. This requirement does not only make the procedure cumbersome, but also limits the reliability of guidance given that the positional relationship between the needle and US images is unknown and interpreted with their experience and assumption. Although the US-guided needle insertion may be assisted through navigation systems, recovery of the positional relationship between the needle and US images requires the usage of external tracking systems and image-based tracking algorisms that may involve the registration inaccuracy. Therefore, there is an unmet need for the solution that provides a simple and intuitive needle localization and insertion to improve the conventional US-guided procedure. In this work, we propose a new device concept solution based on the ring-arrayed forward-viewing (RAF) ultrasound imaging system. The proposed system is comprised with ring-arrayed transducers and an open whole inside the ring where the needle can be inserted. The ring array provides forward-viewing US images, where the needle path is always maintained at the center of the reconstructed image without requiring any registration. As the proof of concept, we designed single-circle ring-arrayed configurations with different radiuses and visualized point targets using the forward-viewing US imaging through simulations and phantom experiments. The results demonstrated the successful target visualization and indicates the ring-arrayed US imaging has a potential to improve the US-guided needle insertion procedure to be simpler and more intuitive.

Ultrasound-Guided Procedures in Rheumatology Daily Practice: Feasibility, Accuracy, and Safety Issues.

The aims of this study were to describe in detail the ultrasound (US)-guided procedures in our daily rheumatology practice, to evaluate the feasibility and accuracy of US-guided procedures, and to test the efficacy of our disinfection protocol in preventing infectious complications. This was a cross-sectional and monocentric study. Information regarding patients' age, sex, body mass index, rheumatic disease, US pathological findings, aspirated and/or injected anatomical site, US equipment (ie, probe type and frequency), and needle type was consecutively collected for each US-guided procedure in a third-level rheumatology center. A total of 643 US-guided procedures were performed, with a mean of 5.2 procedures per working-day. In 94.2% of the patients, only one procedure was carried out, whereas in 5.8%, more than one. The mean time was 7 ± 2.5 minutes. Ultrasound-guided procedures were highly accurate (accuracy rate higher than 95%) and safe (adverse events were reported in 0.8%). Our disinfection protocol was effective in preventing infectious complications. Probes with frequency values between 8 to 13 MHz and 20-, 21-, and 22-gauge needles were the most frequently used at shoulder, knee, wrist, elbow, and ankle level. High-frequency linear probes (ranging between 18 and 22 MHz) and 23- and 25-gauge needles were used for injecting small joints of the hands and feet. Convex low-frequency probe (2-7 MHz) and 18- and 20-gauge needles were the most used for performing hip joint aspirations and/or injections. This study reports useful information for setting up a service providing US-guided procedures in rheumatology and supports the feasibility, accuracy, and safety of US-guided procedures.

Thiel-embalmed cadavers as a novel training model for ultrasound-guided supine endoscopic combined intrarenal surgery.

To evaluate Thiel-embalmed cadavers (TEC) as a training model for percutaneous nephrolithotomy (PCNL), more specifically for ultrasound (US)-guided supine endoscopic combined intrarenal surgery (ECIRS). Thirteen urologists (nine experienced endourologists, four fellows/residents) performed an US-guided supine ECIRS procedure on a TEC. The model was evaluated by way of a questionnaire (5-point Likert scale). Descriptive statistical analysis was performed and results were graphically presented using divergent bar graphs. US images were appreciated as lifelike in all aspects. Although distention of the collecting system was not ideal in one out of three TEC, US visualisation of the distended calyces during puncture was good. Skin penetration was more difficult and less realistic in TEC, while kidney puncture and dilatation were deemed very realistic. Ureteric and collecting system anatomy and consistency were similar to real life, although the mucosa appeared paler. US needle guidance was perceived as excellent. Overall, needle puncture assessment was realistic and useful as a training tool. Overall quality and satisfaction of TEC in US-guided supine ECIRS was good to excellent and comparable to a real-life procedure. Overall appropriateness of the TEC model was considered excellent for both initial and advanced supine PCNL training. Despite the minor drawbacks of tough skin and non-ideal collecting system dilatation during ureteroscopy, the TEC model was considered good to excellent as a training model for US-guided PCNL, in particular, US-guided needle puncture of the kidney during supine ECIRS.

Ultrasound assessment of the myofascial trigger point, where is the local twitch response located?

Background A myofascial trigger point (MTrP) is defined as a nodule or hyperirritable spot of focal pain in response to pressure which is found on a palpable taut band of skeletal muscle. For the physical therapy diagnosis, assessment tools such as musculoskeletal ultrasound have shown that it is possible to visualize the MTrP in gray scale (B mode) and in elastography; however, no previous studies have evaluated the correlation between the appearance of a local twitch response and the presence of a myoaponeurotic septum. The aim of the present study was to evaluate the correlation between the local twitch response and the presence of a myoaponeurotic septum at the time of the response. Material and Methods A prospective observational study was performed at the Sannus Clinic center (Madrid) including patients with the following inclusion criteria: subjects over the age of 18, with the presence of active MTrPS according to the criteria established by Travell &amp; Simons. The ultrasound-guided dry needling technique was performed (US-guided DN) on the dysfunctional muscles, according to the methods described by Valera &amp; Minaya, as follows: 1) manual identification and localization of the myofascial trigger point; 2) Ultrasound assessment of the area corresponding to the identified MTrP. The palpatory hand was substituted in this case by the ultrasound probe which applies pressure upon this band, for its study; 3) Establishment of safety measures during the procedure; 4) The extremes of the probe were marked using a dermographic pen; 5) Removal of the probe and asepsis of the skin of the area prior to needling; 6) Pre-intervention measures: hand-washing, use of non-sterile gloves and a probe cover, followed by preparation of the sterile needle and gauze; 7) The probe was placed on the area of study, with the marks established on the skin; 8) Ultrasound-guided intervention; 9) Needle removal and compression during 30 seconds; 9) Re-assessment. Once the local twitch response was visualized, the position of the needle tip was marked on the ultrasound image. Results The sample was comprised of 40 patients (23 men; 17 women) who received the US-guided DN procedure in the following muscles: upper trapezius (n = 32), extensor digitorum (n = 25), infraspinatus (n = 14), medial gastrocnemius (n = 8), gluteus medius (n = 12). In 87.9% of muscles (n = 80) a local twitch response was obtained when the needle tip was close to the myoaponeurotic septum. Discussion From our point of view, the myoaponeurotic septum of a muscle with an active MTrP could represent a place for load transmission, which would justify the activation of the muscle tissue, and the genesis of the MTrP. Considering the diagnostic criteria of the MTrP, the local twitch response is one of the most determinant elements, therefore, its location in the proximity of this anatomical area could be used as a reference. Conclusions The local twitch response is often obtained in the proximity of a myoaponeurotic septum of the dysfunctional muscle.

Ultrasound-guided angioplasty of dialysis fistulas in renal transplant patients.

IntroductionPercutaneous endovascular angioplasty has become the treatment of choice for dialysis fistula stenosis. The ultrasound-guided endovascular procedure is used in patients with severe renal impairment and advanced renal transplant failure, when the need for nephrotoxic contrast administration in standard angioplasty may worsen renal function.AimTo evaluate endovascular angioplasty guided by ultrasound for dialysis fistula stenosis in renal transplant patients with severe graft insufficiency.Material and methodsWe compared ultrasound (US)-guided angioplasty, performed in patients after renal transplantation, with standard contrast angioplasty performed in dialysis patients. We treated 10 kidney allograft recipients (9 kidneys and 1 kidney-pancreas) with significantly compromised renal transplant function and significant stenosis in dialysis fistulas, as detected during US examination. Patients were qualified for percutaneous angioplasty under US guidance. The mean period from transplantation was 32.7 months (5–100 months). Results of their treatment were compared to the control group of 20 end-stage renal disease patients with dialysis fistula stenosis treated by angioplasty under standard contrast visualization.ResultsThe immediate effectiveness of the angioplasty was 100% in both groups. No early complications of angioplasty or problems with the guidewire crossing the stenosis were observed. Twelve months of primary patency was observed in 80% and 45% in the US-guided and control groups, respectively.ConclusionsThe US-guided endovascular procedure is an effective and safe method of treating dialysis fistula stenosis in patients with impaired renal transplant function.

The role of percutaneous ultrasound-guided true-cut needle biopsy in patients with sheet-like pleural thickening

Background Pleural biopsy for histological confirmation is the standard diagnostic procedure for pleural diseases. Aim To identify the role of percutaneous ultrasound (US)-guided true-cut needle biopsy in patients with sheet-like pleural thickening. Patients and methods A prospective interventional simple controlled trial was conducted on 60 patients with computed tomographic evidence of pleural thickening. Percutaneous US-guided pleural biopsies using a true-cut needle were performed for pathological tissue characterization; complications were recorded. Results All patients were diagnosed, with only five (8%) patients found to have self-limiting pneumothorax, with no need for a chest tube. Fifty-three percent of patients had a histopathological diagnosis of mesothelioma, 14% had a histopathological result of adenocarcinoma, whereas 33% had chronic fibrosing pleuritis. Conclusion The US-guided procedure has a major advantage as it is being real time, rapid, available bedside, and well tolerated, and no serious complications were observed in good case selection and procedure.

Accuracy of ultrasound-guided and non-US-guided botulinum toxin injection into cadaver salivary glands

Recent investigations have reported the increased efficacy and safety of BTX injection under US guidance, there have not been any studies comparing the injection accuracy between blind and US-guided approaches. This study was designed to evaluate the injection accuracy of blind and US-guided botulinum injections into the parotid and submandibular glands of fresh cadavers. Two rehabilitation physician injected dye into three sites in the salivary glands (two sites in the parotid gland, and one site in the submandibular gland) on one side of each cadaver (one was injected on the right side, while the other was injected on the left side), using either a non-US-guided injection procedure based on superficial landmarks or a US-guided procedure. Orange dye was used for the US-guided procedure, and green dye was used for the blind procedure. Two physicians uninvolved with the injection procedures and who were blinded to the method of injection dissected the cadavers to identify whether the dye was accurately injected into each target site. The accuracies of the blind and US-guided injections into the parotid gland were 79.17% and 95.83%, respectively. In the submandibular gland, the accuracies of the blind and US-guided injections were 50.00% and 91.67%, respectively. The difference in accuracy between the two procedures was statistically significant only in the submandibular gland ( P = 0.025). There were no significant differences in the accuracy of US-guided and non-US-guided injections between the two physicians for the two sites in the parotid gland ( P = 0.278 and P = 0.146, respectively). US-guided BTX injection into the submandibular gland offers significantly greater accuracy over blind injection. For the treatment of drooling by injecting BTX into the submandibular gland, clinicians should consider using US guidance for improved accuracy.

Importance of Regular Ultrasound Imaging in Renal Allografts for Early Diagnosis of De Novo Renal Cell Carcinoma

Introduction Renal malignancy development after kidney transplantation (KT) in renal allograft is a rare and an essential long-term complication. Renal cancer occurs mostly in native, end-stage kidneys rather than renal allografts. Prolonged use of immunosuppressive therapy, acquired cystic kidney disease, autosomal dominant polycystic kidney disease are among the increasing factors of malignancy. Renal cell carcinoma (RCC) with a papillary type is the most encountered pathology in allograft kidneys, followed by clear cell type. Case Reports We report here two separate cases of de novo clear cell RCC in kidney allografts. The first case is a 36-year-old female, who was diagnosed end stage renal disease (ESRD) of unknown origin 9 years ago and was performed a living related KT from his father in the following year. Seven years after KT, coming to the clinic with no complaints, on her ultrasonography (US) examination a 2 cm-sized of hyperechoic, hypervascular solid mass was detected in the renal cortex of the allograft (Figure 1). Looking retrospectively to her reports, she was seen to skip her ultrasound follow-ups for the last 2 years. Nephron-sparing surgery was performed after an US-guided stereotactic procedure with a 14-gauge wire. Clear cell RCC of a T1a, N0, M0 tumor with negative margins was reported. The patient is free of recurrence and allograft dysfunction after two years now. Our second case is a 46-year-old male, who had an ESRD due to pyelonephritis and underwent living related KT from his brother 19 years ago. During annual US follow-ups, a very small hyperechoic nodule was visualised in the posterior cortex of the allograft and short-term US follow-up was suggested. The patient was re-examined in 3 months by a different radiologist and a 9L4 linear transducer was used for screening the graft in addition to the routine 6C1 curvilinear transducer. This revealed multiple foci of hyperechoic nodules in the allograft which could not be determined in the prior US evaluation (Figure 2). Fine needle aspiration was RCC and no evidence of metastasis was noted with imaging modalities. In order to preserve graft function, nephron-sparing surgery was planned. During surgery, multiple foci were removed, and one in deep location of reach was ablated US-guided with alcohol. After partial nephrectomy, the patient still had millimetric foci of tumors seen on the US, therefore graft nephrectomy was performed in the following months. The patient is in good health now after 1 year, with no evidence of metastasis. Conclusion RCC in renal allografts is a rare and increasing malignancy detected after KT. US follow-ups after transplantation regularly with sensitive transducers for a more detailed screening, improves the early diagnosis of this cancer leading to better long-term results and preserving the allograft.