Point of care ultrasound (POCUS) telemedicine project in rural Nicaragua and its impact on patient management

Background

Point of care ultrasound (POCUS) is a useful diagnostic tool in medicine. POCUS provides an easy and reproducible method of diagnosis where conventional radiologic studies are unavailable. Telemedicine is also a great means of communication between educators and students throughout the world.

Hypothesis

Implementing POCUS with didactics and hands-on training, using portable ultrasound devices followed by telecommunication training, will impact the differential diagnosis and patient management in a rural community outside the United States.

Materials and methods

This is an observational prospective study implementing POCUS in Las Salinas, a small village in rural western Nicaragua. Ultrasound was used to confirm a diagnosis based on clinical exam, or uncover a new, previously unknown diagnosis. The primary endpoint was a change in patient management. International sonographic instructors conducted didactic and practical training of local practitioners in POCUS, subsequently followed by remote guidance and telecommunication for 3 months.

Results

A total of 132 patients underwent ultrasound examination. The most common presentation was for a prenatal exam (23.5 %), followed by abdominal pain (17 %). Of the 132 patients, 69 (52 %) were found to have a new diagnosis. Excluding pregnancy, 67 patients of 101 (66 %) were found to have a new diagnosis. A change in management occurred in a total of 64 (48 %) patients, and 62 (61 %) after excluding pregnancy.

Conclusion

Implementing POCUS in rural Nicaragua led to a change in management in about half of the patients examined. With the appropriate training of clinicians, POCUS combined with telemedicine can positively impact patient care.     

Contrast-enhanced ultrasound with SonoVue in the evaluation of postoperative complications in pediatric liver transplant recipients

Purpose

To evaluate the utility of contrast-enhanced sonography in the study of pediatric liver transplant recipients and its potential impact in reducing the need for invasive diagnostic procedures.

Materials and methods

From October 2002 to December 2003 we performed routine color Doppler ultrasound and contrast-enhanced ultrasound studies on 30 pediatric patients who had undergone liver transplantation. Findings indicative of complications were confirmed with invasive studies (angiography, computed tomography, and PTC).

Results

Contrast-enhanced sonography correctly identified four of the five cases of hepatic artery thrombosis and all those involving the portal (n = 6) and hepatic vein (n = 3) thrombosis. It failed to identify one case of hepatic artery thrombosis characterized by collateral circulation arising from the phrenic artery and the single case of hepatic artery stenosis. The latter was more evident on color Doppler, which revealed a typical tardus parvus waveform. The use of contrast offered no significant advantages in the study of biliary complications although it did provide better visualization of bile leaks.

Conclusions

Contrast-enhanced sonography improves diagnostic confidence and reduces the need for more invasive imaging studies in the postoperative follow-up of pediatric liver transplant recipients.     

Transrectal ultrasound guidance for early transurethral recatheterization after radical prostatectomy

Purpose

To study the usefulness of transrectal ultrasound (TRUS) for catheter guidance in cases of early reinsertion after radical prostatectomy (RP).

Methods

Since 2007, we have used TRUS for catheter guidance when early reinsertion after RP is required. A preliminary TRUS examination is done to carefully check the state of the vesicourethral anastomosis. The entire catheter insertion, from bulbar urethra to the bladder, is followed step by step by transrectal ultrasound imaging that tracks, while the probe pushes the catheter through a correct entering line. This prevents the incorrect placement of the catheter across the posterior aspect of the anastomosis in a posterior extravesical place.

Results

Between 2007 and 2011, 2,165 RPs were performed at reference hospital for prostate cancer. Early catheter reinsertion was required for 56 patients (2.6 %). All procedures were successful. The incidence of vesicourethral stricture after long-term follow-up was not different from that of patients without early recatheterization who were operated with RP in the same period of the study (4.4 vs 4.2 %, respectively; p = 0.47).

Conclusions

If early recatheterization is required in patients recently operated with RP, we suggest catheter guidance with TRUS.     

Factors influencing lengths of stay in the intensive care unit for surviving trauma patients: a retrospective analysis of 30,157 cases

Introduction

There are many potential influencing factors that affect the duration of intensive care treatment for patients who have survived multiple trauma. Yet the respective factors’ relevance to ICU length of stay (LOS) has been rarely studied. Thus, the aim of the present study was to investigate to what extent specific factors influence ICU LOS in surviving trauma patients.

Methods

We retrospectively analyzed a dataset of 30,157 surviving trauma patients from the TraumaRegister DGU® who were older than six years of age and received subsequent intensive care treatment for more than one day, from 2002 to 2011. Univariate analysis and multiple linear regression analysis were used to examine 25 categorical pre- and post-trauma parameters.

Results

Univariate analysis confirmed the impact of all analyzed factors. In subsequent multiple linear regression analyses, coefficients ranged from -1.3 to +8.2 days. The factors that influenced the prolongation of ICU LOS most were renal failure (+8.1 days), sepsis (+7.8 days) and respiratory failure (+4.9 days). Patients spent one additional day in the ICU for every 5 additional points on the Injury Severity Score (regression coefficient +0.2 per point). Furthermore, massive transfusion (+3.3 days), invasive ventilation (+3.1 days), and an initial Glasgow Coma Scale score ≤8 (+3.0 days) had a significant impact on ICU LOS. The coefficient of determination for the model was 44% (R²).

Conclusions

Treatment regimens, as well as secondary effects and complications of trauma and intensive care treatment, prolong ICU LOS more than the mechanism of trauma or pre-trauma patient conditions. Successful prevention of complicated courses of illness, such as sepsis and renal and respiratory failure, could significantly abbreviate the ICU stay in trauma patients. Therefore, the staff’s attention should be focused on preventive strategies.     

Pulmonary artery to aorta ratio for the detection of pulmonary hypertension: cardiovascular magnetic resonance and invasive hemodynamics in heart failure with preserved ejection fraction

Background

Previous work indicates that dilatation of the pulmonary artery (PA) itself or in relation to the ascending aorta (PA:Ao ratio) predicts pulmonary hypertension (PH). Whether these results also apply for heart failure with preserved ejection fraction (HFpEF) is unknown.In the present study we evaluated the diagnostic and prognostic power of PA diameter and PA:Ao ratio on top of right ventricular (RV) size, function, and septomarginal trabeculation (SMT) thickness by cardiovascular magnetic resonance (CMR) in HFpEF.

Methods and Results

159 consecutive HFpEF patients were prospectively enrolled. Of these, 111 underwent CMR and invasive hemodynamic evaluation.By invasive assessment 64 % of patients suffered from moderate/severe PH (mean pulmonary artery pressure (mPAP) ≥30 mmHg). Significant differences between groups with and without moderate/severe PH were observed with respect to PA diameter (30.9 ± 5.1 mm versus 26 ± 5.1 mm, p < 0.001), PA:Ao ratio (0.93 ± 0.16 versus 0.78 ± 0.14, p < 0.001), and SMT diameter (4.6 ± 1.5 mm versus 3.8 ± 1.2 mm; p = 0.008). The strongest correlation with mPAP was found for PA:Ao ratio (r = 0.421, p < 0.001). By ROC analysis the best cut-off for the detection of moderate/severe PH was found for a PA:Ao ratio of 0.83.Patients were followed for 22.0 ± 14.9 months. By Kaplan Meier analysis event-free survival was significantly worse in patients with a PA:Ao ratio ≥0.83 (log rank, p = 0.004). By multivariable Cox-regression analysis PA:Ao ratio was independently associated with event-free survival (p = 0.003).

Conclusion

PA:Ao ratio is an easily measureable noninvasive indicator for the presence and severity of PH in HFpEF, and it is related with outcome.     

Presence of Candida cell wall derived polysaccharides in the sera of intensive care unit patients: relation with candidaemia and Candida colonisation

Introduction

Prompt diagnosis of candidaemia and invasive candidosis is crucial to the early initiation of antifungal therapy. The poor sensitivity of blood cultures (BCs) has led to the development of fungal glycan tests as a diagnostic adjunct. We analysed the performance of tests for the detection of circulating β-D-1,3-glucan (BDG) and mannan in the intensive care unit (ICU) setting.

Methods

This retrospective, case–control study included 43 ICU patients with candidaemia and 67 controls, hospitalised on the same ward and assessed weekly for yeast colonisation with simultaneous serum sampling; 340 sera taken before and after positive BCs were available for the cases group and 203 for the controls. BDG and mannan levels were determined using the Fungitell^® and Platelia™ Candida Ag tests, respectively.

Results

BDG was detected early in sera from cases patients but was also present in several sera from controls. Increasing the cut-off from 80 pg/mL to 350 pg/mL and 800 pg/mL resulted in sensitivity/specificity ratios of 0.97/0.31, 0.65/0.74, 0.30/0.86, respectively. Detection of mannan was more specific but lacked sensitivity. No obvious correlation was found between BDG and colonisation, but a trend existed between high colonisation and high BDG. Candidaemia relapses were associated with a rise in BDG and mannan but, in contrast to the transient nature of mannan, BDG persisted up to 7 weeks after positive BCs.

Conclusion

A combination of mannan and BDG tests could be used to guide pre-emptive therapeutic decisions in ICU patients.     

Is intraoperative ultrasound (IOUS) still useful for the detection of liver metastases?

Purpose

To evaluate the clinical impact of intraoperative ultrasound (IOUS) in the detection of liver metastases during the years, as compared with those of other imaging modalities.

Materials and methods

All IOUS scans performed for detection of liver metastases from 2000 to 2006 were retrospectively reviewed and compared with the results of preoperative imaging modalities: Ultrasound (US), Computed Tomography (CT), and/or Magnetic Resonance (MR). The number of cases in which IOUS and preoperative imaging studies produced discordant results, in terms of presence/absence of focal liver lesions, was calculated per year. Statistical analysis was performed using the McNemar test. A p value < 0.05 was considered statistically significant.

Results

Eighty-three IOUS scans performed in 2000–2003 were reviewed, and discordance with preoperative imaging findings was found in 19/83 (23%) cases. Of the 42 IOUS scans done during the 2004–2006 period, 10/42 (24%) showed discordance with preoperative studies. All metastases diagnosed with imaging studies were pathologically confirmed. The number of discordant cases in the two periods were not significantly different (p = 0.2).

Conclusion

IOUS is still useful in the detection of liver metastases. Its decreased use is probably due to the improved accuracy of preoperative imaging modalities.     

Assessment of articular disc displacement of temporomandibular joint with ultrasound

Purpose

To assess pattern of articular disc displacement in patients with internal derangement (ID) of temporomandibular joint (TMJ) with ultrasound.

Materials and methods

Prospective study was conducted upon 40 TMJ of 20 patients (3 male, 17 female with mean age of 26.1 years) with ID of TMJ. They underwent high-resolution ultrasound and MR imaging of TMJ. The MR images were used as the gold standard for calculating sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of ultrasound for diagnosis of anterior or sideway displacement of the disc.

Results

The anterior displaced disc was seen in 26 joints at MR and 22 joints at ultrasound. The diagnostic efficacy of ultrasound for anterior displacement has sensitivity of 79.3 %, specificity of 72.7 %, accuracy of 77.5 %, PPV of 88.5 %, NPV of 57.1 %, PLR of 2.9 and NLR of 0.34. The sideway displacement of disc was seen in four joints at MR and three joints at ultrasound. The diagnostic efficacy of ultrasound for sideway displacement has a sensitivity of 75 %, specificity of 63.6 %, accuracy of 66.7 %, PPV of 42.8, NPV of 87.5 %, PLR of 2.06, and NLR of 0.39.

Conclusion

We concluded that ultrasound is a non-invasive imaging modality used for assessment of anterior and sideway displacement of the articular disc in patients with ID of TMJ.     

A rare case of sigmoid colon obstruction in patient with ulcerative colitis: role of transabdominal ultrasound-guided biopsy

Introduction

Endometriosis is a common chronic gynaecological disease affecting 10 % of women of reproductive age. Of these 5–12 % may present bowel endometriosis that may be asymptomatic or associated with aspecific symptoms even bowel obstruction.

Case presentation

The case of a 41-year-old woman with history of ulcerative colitis, previous diagnosis of ovarian endometriosis, recurrent abdominal pain not related to the menstrual cycle, with abdominal pain and obstinate constipation for 2 weeks was referred. The patient underwent colonoscopy, transabdominal ultrasound and ultrasound-guided fine-needle biopsy to have a diagnosis.

Discussion

Endometriosis should be considered in the differential diagnosis of every woman of childbearing age who presents with gastrointestinal or abdominal symptoms. As demonstrated in our case and by the burgeoning literature in this field, we believe that the role of transabdominal ultrasound should be reconsidered in the management of abdominal diseases because this examination associated with ultrasound-guided fine-needle biopsy allows, in expert hands, to obtain adequate histological samples avoiding patients to undergo more invasive tests to get a diagnosis.     

Suspected ventilator-associated respiratory infection in severely ill patients: a prospective observational study

Introduction

Ventilator-associated respiratory infection (VARI) is an important cause of morbidity in critically-ill patients. Clinical trials performed in heterogeneous populations have suggested there are limited benefits from invasive diagnostic testing to identify patients at risk or to target antimicrobial therapy. However, multiple patient subgroups (for example, immunocompromised, antibiotic-treated) have traditionally been excluded from randomization. We hypothesized that a prospective surveillance study would better identify patients with suspected VARI (sVARI) at high risk for adverse clinical outcomes, and who might be specifically targeted in future trials.

Methods

We performed a prospective observational study in all patients ventilated for greater than 48 hours. sVARI was identified by surveillance for changes in white blood cell count, temperature, sputum, and/or new chest X-ray infiltrates. Indices of disease co-morbidity, as well as mortality, duration of mechanical ventilation, and length of hospital or ICU stay were correlated with sVARI.

Results

Of 1806 patients admitted to the ICU over 14 months, 267 were ventilated for greater than 48 hours, and 77 developed sVARI. Incidence of sVARI was associated with iatrogenic immunosuppression or admission for respiratory illness. Any sVARI, whether suspected ventilator-associated pneumonia (sVAP) or ventilator-associated tracheobronchitis (sVAT), was associated with increased length of stay and duration of mechanical ventilation.

Conclusions

Clinical surveillance for sVARI identifies patients at risk for increased morbidity. Iatrogenically immunosuppressed patients, a subgroup previously excluded from randomized clinical trials, represent a growing proportion of the critically-ill at risk for sVARI who might be targeted for future investigations on diagnostic or therapeutic modalities.     

Contrast-enhanced ultrasound findings in soft-tissue lesions: preliminary results

Objectives

There is currently no widely available, minimally invasive first-level examination that allows physicians to identify soft-tissue lesions that are likely to be malignant. The aim of this pilot study was to explore the potential suitability of dynamic contrast-enhanced ultrasound (DCE-US) for this purpose.

Materials and methods

23 patients were referred to the Veneto Oncological Institute for work-up of superficial soft-tissue lesions. Fourteen lesions were examined with CEUS and enhancement kinetics was analyzed. Subsequently, all lesions were surgically removed and subjected to histological analysis.

Results

The 14 lesions included in the study were histologically classified as malignant (n = 7) or benign (n = 7, including 3 schwannomas). A statistically significant difference between benign and malignant lesions was found in terms of mean times to peak enhancement intensity (p = 0.03) but not mean filling times (FT). When schwannomas were analyzed as a separate group, their mean FT was found to be significantly different from that of the other benign lesions (p = 0.001) and from that of the group comprising other benign lesions as well as malignant lesions (p < 0.005).

Conclusions

CEUS with analysis of contrast-enhancement kinetics is a relatively low-cost, minimally invasive imaging technique, which appears to be a potentially effective first-level method for identifying suspicious soft-tissue masses.     

Plasma glutamine concentration after intensive care unit discharge: an observational study

Introduction

Low plasma glutamine concentration at ICU admission is associated with unfavorable outcomes. The prediction of plasma glutamine concentration after ICU discharge on outcomes has not been characterized. In the recent Scandinavian Glutamine Trial, a survival advantage was seen with glutamine supplementation as long as patients stayed in the ICU. It was therefore hypothesized that the glutamine level may drop at ICU discharge, indicative of a sustained glutamine deficiency, which may be related to outcome.

Methods

Fully fed ICU patients intravenously supplemented with glutamine for >3 days were studied at ICU discharge and post ICU. In study A, plasma glutamine level was followed every 5 to 7 days post ICU of the remaining hospital stay and compared to the level on the day of ICU discharge (n = 63). In study B, plasma glutamine level 24 to 72 hours after ICU discharge was related to 12-month all-cause mortality (n = 100).

Results

Post-ICU plasma glutamine levels were within normal range and were not found to be predictive for mortality outcome. Plasma glutamine level at discharge, on the other hand, was within normal limits but higher in nonsurvivors. In addition, it was adding prediction value to discharge SOFA scores for post-ICU mortality.

Conclusions

Post-ICU glutamine levels are not indicative of glutamine depletion. The relation between plasma glutamine concentration and glutamine availability during critical illness is not well understood, and needs to be studied further to define the possible role for glutamine supplementation.     

Diagnostic accuracy of emergency physician performed graded compression ultrasound study in acute appendicitis: a prospective study

Purpose

Accurate early diagnosis of appendicitis can decrease its complications and minimize the mortality, morbidity and costs. This prospective study evaluates the accuracy of bedside emergency physician performed ultrasound study diagnosis in acute appendicitis.

Methods

Patients who were suspicious to have appendicitis based on their clinical findings were included and underwent emergency physician performed ultrasound study. Then they were followed up until the recognition of final diagnosis based on pathology report or identification of an alternative diagnosis. Ultrasound studies were done by post-graduate year three emergency medicine residents or emergency medicine attending physicians who were attended in a 4 h didactic and practical course and with 7.5 MHz linear probe both in longitudinal and axial axes.

Results

Ninety-seven patients were included and analyzed. 27 (27.8 %) of patients had appendicitis according to the results of emergency physicians performed ultrasound studies. 19 (70.37 %) of them had appendicitis according to their pathologic reports too. Forty-three (44.3 %) of patients had appendicitis according to pathology reports. Only 19 (44.18 %) of them were diagnosed by emergency physicians. Emergency physician performed ultrasound study had a sensitivity of 44.18 %, specificity of 85.18 %, positive predictive value of 70.37 %, negative predictive value of 65.71 % and overall accuracy of 67.01 % in diagnosing appendicitis in patients clinically suspicious to have acute appendicitis.

Conclusion

Emergency physician performed bedside ultrasound has an acceptable overall accuracy but its sensitivity is low thus it can help emergency physicians to diagnose the acute appendicitis when used in conjunction with other clinical and para-clinical evaluations but not per se.     

Vessel-wall imaging and quantification of flow-mediated dilation using water-selective 3D SSFP-echo

Background

To introduce a new, efficient method for vessel-wall imaging of carotid and peripheral arteries by means of a flow-sensitive 3D water-selective SSFP-echo pulse sequence.

Methods

Periodic applications of RF pulses will generate two transverse steady states, immediately after and before an RF pulse; the latter being referred to as the SSFP-echo. The SSFP-echo signal for water protons in blood is spoiled as a result of moving spins losing phase coherence in the presence of a gradient pulse along the flow direction. Bloch equation simulations were performed over a wide range of velocities to evaluate the flow sensitivity of the SSFP-echo signal. Vessel walls of carotid and femoral and popliteal arteries were imaged at 3 T. In two patients with peripheral artery disease the femoral arteries were imaged bilaterally to demonstrate method’s potential to visualize atherosclerotic plaques. The method was also evaluated as a means to measure femoral artery flow-mediated dilation (FMD) in response to cuff-induced ischemia in four subjects.

Results

The SSFP-echo pulse sequence, which does not have a dedicated blood signal suppression preparation, achieved low blood signal permitting discrimination of the carotid and peripheral arterial walls with in-plane spatial resolution ranging from 0.5 to 0.69 mm and slice thickness of 2 to 3 mm, i.e. comparable to conventional 2D vessel-wall imaging techniques. The results of the simulations were in good agreement with analytical solution and observations for both vascular territories examined. Scan time ranged from 2.5 to 5 s per slice yielding a contrast-to-noise ratio between the vessel wall and lumen from 3.5 to 17. Mean femoral FMD in the four subjects was 9%, in good qualitative agreement with literature values.

Conclusions

Water-selective 3D SSFP-echo pulse sequence is a potential alternative to 2D vessel-wall imaging. The proposed method is fast, robust, applicable to a wide range of flow velocities, and straightforward to implement.     

Characterization of a murine model of cardiorenal syndrome type 1 by high-resolution Doppler sonography

Abstract

Cardiorenal syndrome type 1 (CRS-1) is the acute kidney disfunction caused by an acute worsening of cardiac function. CRS-1 is the consequence of renal vasoconstriction secondary to renin–angiotensin system (RAS) activation. No animal models of CRS-1 are described in literature.

Purpose

To characterize a murine model of CRS-1 by using a high-resolution ultrasound echo-color Doppler system (VEVO2100).

Materials

Post-ischemic heart failure was induced by coronary artery ligation (LAD) in seven CD1 mice. Fifteen and thirty days after surgery, mice underwent cardiac and renal echo-color Doppler. Serum creatinine and plasma renin activity were measured after killing. Animals were compared to seven CD1 control mice.

Results

Heart failure with left ventricle dilatation (end diastolic area, p < 0.05 vs. controls) and significantly reduced ejection fraction (EF; p < 0.01 vs. controls) was evident 15 days after LAD. We measured a significant renal vasoconstriction in infarcted mice characterized by increased renal pulsatility index (PI; p < 0.05 vs. controls) associated to increased creatinine and renin levels (p < 0.05 vs. controls)

Conclusions

The mice model of LAD is a good model of CRS-1 evaluable by Doppler sonography and characterized by renal vasoconstriction due to the activation of the renin–angiotensin system secondary to heart failure.     

Carotid plaque regression following 6-month statin therapy assessed by 3T cardiovascular magnetic resonance: comparison with ultrasound intima media thickness

Background

Cardiovascular magnetic resonance (CMR) allows volumetric carotid plaque measurement that has advantage over 2-dimensional ultrasound (US) intima-media thickness (IMT) in evaluating treatment response. We tested the hypothesis that 6-month statin treatment in patients with carotid plaque will lead to plaque regression when measured by 3 Tesla CMR but not by IMT.

Methods

Twenty-six subjects (67 ± 2 years, 7 females) with known carotid plaque (> 1.1 mm) and coronary or cerebrovascular atherosclerotic disease underwent 3T CMR (T1, T2, proton density and time of flight sequences) and US at baseline and following 6 months of statin therapy (6 had initiation, 7 had increase and 13 had maintenance of statin dosing). CMR plaque volume (PV) was measured in the region 12 mm below and up to 12 mm above carotid flow divider using software. Mean posterior IMT in the same region was measured. Baseline and 6-month CMR PV and US IMT were compared. Change in lipid rich/necrotic core (LR/NC) and calcification plaque components from CMR were related to change in PV.

Results

Low-density lipoprotein cholesterol decreased (86 ± 6 to 74 ± 4 mg/dL, p = 0.046). CMR PV decreased 5.8 ± 2% (1036 ± 59 to 976 ± 65 mm³, p = 0.018). Mean IMT was unchanged (1.12 ± 0.06 vs. 1.14 ± 0.06 mm, p = NS). Patients with initiation or increase of statins had -8.8 ± 2.8% PV change (p = 0.001) while patients with maintenance of statin dosing had -2.7 ± 3% change in PV (p = NS). There was circumferential heterogeneity in CMR plaque thickness with greatest thickness in the posterior carotid artery, in the region opposite the flow divider. Similarly there was circumferential regional difference in change of plaque thickness with significant plaque regression in the anterior carotid region in region of the flow divider. Change in LR/NC (R = 0.62, p = 0.006) and calcification (R = 0.45, p = 0.03) correlated with PV change.

Conclusions

Six month statin therapy in patients with carotid plaque led to reduced plaque volume by 3T CMR, but ultrasound posterior IMT did not show any change. The heterogeneous spatial distribution of plaque and regional differences in magnitude of plaque regression may explain the difference in findings and support volumetric measurement of plaque. 3T CMR has potential advantage over ultrasound IMT to assess treatment response in individuals and may allow reduced sample size, duration and cost of clinical trials of plaque regression.     

Use of ultrasound–magnetic resonance image fusion to guide sacroiliac joint injections: a preliminary assessment

Background

The sacroiliac joint is one of the sources of chronic lower back pain. Intra-articular injections of anesthetic drugs and/or steroids are currently used in these cases for diagnostic and therapeutic purposes. However, given the anatomic and functional complexity of the joint, imaging guidance is mandatory during such procedures. In this context, the technique of fusing images obtained with two different modalities can often overcome the limitations and enhance the advantages of single-modality guidance.

Aim

The aim of this study was to evaluate the technique of ultrasound (US)–magnetic resonance (MR) image fusion to guide intra-articular injections of drugs into the sacroiliac joint.

Materials and methods

We evaluated seven sacroiliac joints in six patients with sacroiliac pain syndrome (four females, two males; mean age 59 years; range 46–76 years). Five were candidates for radiofrequency thermolysis, and a therapeutic nerve block was performed in the sixth. Using the volume navigation system, we fused three-dimensional MR images with simultaneously acquired real-time ultrasound images and used them to guide the intra-articular injections.

Results

In all patients, spatial accuracy was considered excellent, with definition of registration errors of less than 3 mm. The diagnostic blocks produced positive results in all patients with 80 % reductions in pain (measured with a Numerical Rating Scale, NRS) relative to baseline. The patient who underwent the therapeutic nerve block experienced complete resolution of symptoms that has been maintained over time. There were no complications.

Conclusions

US–MR imaging fusion guidance of sacroiliac joint injections is feasible and effective, in accordance with the data in the literature. The use of the MR for three-dimensional imaging eliminates the risk of radiation exposure.     

Sonography of the optic nerve sheath beyond the hyperacute stage of intracerebral hemorrhage

Purpose

To evaluate the feasibility and utility of serial measuring of the optic nerve sheath diameter beyond the hyperacute and acute stage of intracerebral hemorrhage (ICH).

Methods

Four patients with extensive ICH in the left basal ganglia were followed using ultrasound (US) and cerebral CT scans.

Results

Optic nerve sheath diameter values assessed beyond the acute stage of ICH showed a high correlation (ρ = 0.84, p = 0.0022) with midline shift of the third ventricle seen on CT scans.

Conclusions

Optic nerve sonography can be useful to evaluate patients with extensive ICH beyond the acute stage and help monitoring clinical evolution in these patients, when ICP monitoring is not feasible.     

Variations in atherosclerosis and remodeling patterns in aorta and carotids

Background

Atherosclerosis is a progressive disease that causes vascular remodeling that can be positive or negative. The evolution of arterial wall thickening and changes in lumen size under current "standard of care" in different arterial beds is unclear. The purpose of this study was to examine arterial remodeling and progression/regression of atherosclerosis in aorta and carotid arteries of individuals at risk for atherosclerosis normalized over a 1-year period.

Methods

In this study, 28 patients underwent at least 2 black-blood in vivo cardiovascular magnetic resonance (CMR) scans of aorta and carotids over a one-year period (Mean 17.8 ± 7.5 months). Clinical risk profiles for atherosclerosis and medications were documented and patients were followed by their referring physicians under current "standard of care" guidelines. Carotid and aortic wall lumen areas were matched across the time-points from cross-sectional images.

Results

The wall area increased by 8.67%, 10.64%, and 13.24% per year (carotid artery, thoracic aorta and abdominal aorta respectively, p < 0.001). The lumen area of the abdominal aorta increased by 4.97% per year (p = 0.002), but the carotid artery and thoracic aorta lumen areas did not change significantly. The use of statin therapy did not change the rate of increase of wall area of carotid artery, thoracic and abdominal aorta, but decreased the rate of change of lumen area of carotid artery (-3.08 ± 11.34 vs. 0.19 ± 12.91 p < 0.05).

Conclusions

Results of this study of multiple vascular beds indicated that different vascular locations exhibited varying progression of atherosclerosis and remodeling as monitored by CMR.     

Sonoelastography findings of biceps tendinitis and tendinosis

Objective

The purpose of this study was to evaluate sonoelastography (SE) in the assessment of the long head of biceps tendon (LHBT) in patients with symptoms of biceps tendinitis or tendinosis and in patients without biceps lesion. The findings were compared with those obtained at clinical examination, using ultrasonography (US).

Materials and methods

36 shoulders of 34 consecutively registered patients with clinical symptoms and US findings of biceps tendinitis or tendinosis, and 114 shoulders of 98 patients without biceps lesions were assessed with SE. Transverse and longitudinal images of LHBT were obtained using SE. SE images were evaluated by reviewers using an experimentally proven color grading system.

Results

The transverse images of SE showed a mean sensitivity of 69.4 %, a mean specificity of 95.6 % and a mean accuracy of 89.3 %. Good correlation of conventional ultrasound findings was found (p < 0.001, r = 0.763). The longitudinal images of SE showed a mean sensitivity of 94.4 %, a mean specificity of 92.1 % and a mean accuracy of 92.7 %. Good correlation of conventional ultrasound findings was found (p < 0.001, r = 0.585). Inter-observer reliability of SE was in “almost perfect agreement” with a weighted kappa coefficient of 0.84.

Conclusions

SE has potential to be clinically useful in the detection of the intratendinous and peritendinous alterations of LHBT and has excellent accuracy and excellent correlation with conventional ultrasound findings.