Diagnostic ultrasound in the urologist's office

The clinical value of diagnostic ultrasound in the management of urologic patients is now firmly established. The use of real time diagnostic ultrasound equipment in the solo office practice of a urologist was evaluated by retrospective office record review covering a period of at least one year. The appropriate use of this equipment in daily office practice is shown to be clinically useful, cost-effective, and easily performed by a urologist. The routine use of diagnostic ultrasound by urologists is recommended.     

Office urologic ultrasound

Advances in technology have made ultrasound equipment available for office use. The indications for examination vary depending on the region of the body where disease is suspected. For some conditions, ultrasound may not be an appropriate diagnostic modality. It is the responsibility of the physician to decide whether office ultrasonography is of value. As the equipment is assimiliated into the diagnostic armamentarium, more information on the cost effectiveness and efficacy of office ultrasound for the urologist will become available. Ultrasonography should be performed by the clinician only after appropriate training. Office-based, urologist-operated ultrasound should not replace the proper evaluation of the patient by a radiologist who is trained specifically to make diagnoses using this modality. However, for quick, efficient evaluation of the patient to uncover a disease process, office ultrasonography may supplement the information available through routine history, physical examination, and laboratory studies.     

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目的评价灰阶超声造影对肝脏肿瘤的诊断效能。方法2004年3～8月对114例肝肿瘤病人经外周静脉注射造影剂SonoVue后用对比脉冲序列成像技术行超声造影，依据肿瘤的影像增强特征作出定性诊断，结果与病理或临床确诊标准对照，用诊断性试验评价超声造影的诊断效能。结果超声造影定性诊断肝肿瘤的敏感性、特异性和阳性预测值分别为：肝细胞癌90％(61／68)、93％(43／46)和95％(61／64)；肝内胆管癌为80％(4／5)、98％(97／99)和67％(4／6)；肝转移瘤为86％(12／14)、100％(90／90)和100％(12／12)；肝血管瘤为93％(25／27)、99％(86／87)和96％(25／26)。结论超声造影为临床定性诊断肝脏肿瘤提供了一种准确而简易的新方法。     

弹性成像、二维超声与多普勒超声在乳腺肿块鉴别诊断中比较分析

目的对比在乳腺癌患者的临床诊断中,应用弹性成像、二维超声和多普勒超声的临床诊断价值。方法将2013年6月至2014年12月期间确诊的230例乳腺肿块患者作为研究对象,分别采用弹性成像、二维超声和多普勒超声进行鉴别诊断。所有数据均采用SPSS17.0软件进行统计分析,以病理结果为金标准,良、恶性乳腺病变弹性成像分级间的比较采用配对χ~2检验;二维超声和弹性成像及联合应用的诊断效能,采用χ~2检验,以P0.05认为差异有统计学意义。结果病理结果显示,此次共有良性和恶性病灶各113个和130个。弹性成像结果显示,其敏感度为93.85%(122/130),特异度94.69%(107/113),准确率为94.24%(229/243),其准确率显著高于二维超声(81.89%,199/243)和多普勒超声(213/243,87.65%),差异有统计学意义(P0.05)。结论在乳腺癌患者的临床诊断中,应用弹性成像的诊断价值较高,其准确性显著优于二维超声和多普勒超声,可准确诊断肿块的良恶性,建议广泛推广。     

Transvaginal ultrasound for the diagnosis of urethral diverticulum

PURPOSE: We reviewed our experience with urethral diverticula and transvaginal ultrasound to evaluate female patients with this condition. MATERIALS AND METHODS: All female patients who underwent transvaginal ultrasound during evaluation for urethral diverticulum at our institution between May 1995 and April 2002 were identified by searching a data base. We reviewed the diagnostic evaluation and compared diagnostic techniques with transvaginal ultrasound for diagnosing urethral diverticulum. RESULTS: Of the 25 patients with suspected urethral diverticulum who underwent transvaginal ultrasound as a diagnostic procedure 10 (40%) were diagnosed with urethral diverticulum, including 10 in whom it was confirmed by surgery or other diagnostic procedures. Transvaginal ultrasound was less expensive than the other diagnostic modalities and in no case did it miss a urethral diverticulum that was identified by another diagnostic technique. Urethral diverticulum was detected on 1 of 3 voiding cystourethrograms (33%) and this study missed the diagnosis in 1 case that was diagnosed by transvaginal ultrasound. Three cases of urethral diverticulum were noted on transvaginal ultrasound after they were missed by cystoscopy. Videourodynamics were unable to diagnose urethral diverticulum. CONCLUSIONS: Transvaginal ultrasound is effective for evaluating patients with suspected urethral diverticulum. It is less expensive and may identify diverticula missed by other diagnostic modalities.     

Standardised ultrasound scanning of the elbow

Musculoskeletal ultrasound (US) is noninvasive, nonionisating and cost-effective imaging diagnostic technique. It is a useful imaging modality for the diagnosis of joint and soft tissue pathology and can be considered as an extension of physical examination. Elbow is easily accessed due to its superficial position. A high resolution, multi-frequency (10-15 MHz) linear transducer should be used. US investigation of the elbow includes scanning of the anterior, medial, lateral and posterior part of the joint. Common flexor and extensor origin at the humearal epicondyles, triceps tendon, distal biceps tendon and ulnar nerve should be analised. The most frequent US finding of the elbow is lateral epicondylitis. In inflammatory arthropaties bursal distension and joint effusion are easily accessed by US. Power Doppler sonography is used for detection of sinovial vascularisation. In this paper standardized techinque for the US examination of the elbow is described. The normal ulrasound anatomy of the elbow is illustrated.     

Prehospital ultrasound in the management of trauma patients: Systematic review of the literature

IntroductionEmergency ultrasound methods such as Focused Assessment with Sonography in Trauma (FAST) are a widely used imaging method. This examination can be performed to examine the presence of several life-threatening injuries. Early diagnosis may lead to better outcome, but the effect of timely diagnosis in the prehospital setting is not yet clear. Therefore, the aim is to determine the diagnostic accuracy and the effect of prehospital ultrasound performed in (poly)trauma patients.MethodsA literature search was performed in PubMed, Embase and Cochrane's Library. Articles were included if prehospital ultrasound was performed as a diagnostic intervention in patients with trauma. The main outcome measures included diagnostic accuracy, changes in prehospital diagnosis/treatment, changes in destination hospital and in-hospital response. Case reports and case series were excluded.ResultsAfter screening 3343 articles, nine studies met the inclusion criteria. These included three retrospective and six prospective observational studies, with a total number of 2,889 patients. Five studies report at least one change in polytrauma management, ranging from 6% to 48,9% of the cases. The diagnostic accuracy of prehospital ultrasound was adequate in eight (out of nine) articles. High sensitivity and high specificity were found on several endpoints (pneumothorax, free abdominal fluid, haemoperitoneum, both on site and during transport).ConclusionPrehospital ultrasound led to a change in polytrauma management in all studies that included this as an outcome measure. The diagnostic accuracy was described in eight studies, high sensitivity and specificity were found. Overall, the studies seem to suggest a positive influence of performing ultrasound. However, additional research with homogenous accuracy endpoints and uniformly trained prehospital care providers is recommended.     

乳腺微小占位性病灶的超声弹性成像与病理检查结果对照分析

目的探讨超声弹性成像鉴别乳腺微小(≤10 mm)占位性病灶良恶性的价值。方法回顾性分析2014-01—2016-05间经手术治疗105例患者的139个乳腺微小占位性病灶。所有患者均经常规超声检查和超声弹性成像评分,并与术后的病理结果进行对照。结果超声弹性成像诊断恶性乳腺微小占位性病灶的敏感度、特异度和准确率分别为89.1%(41/46)、90.3%(84/93)和89.9%(125/139)。常规超声诊断恶性乳腺微小占位性病变敏感度、特异度、准确度分别为53.5%(23/43)、71.9%(69/96)、66.2%(92/139),二者差异有统计学意义(P0.05)。结论实时超声弹性成像对鉴别乳腺微小占位性病灶的良恶性具有较高的临床价值。     

The role of surgeon-performed ultrasound in patients with possible cardiac wounds.

OBJECTIVE: The authors evaluate surgeon-performed ultrasound in determining the need for operation in patients with possible cardiac wounds. BACKGROUND DATA: Ultrasound quickly is becoming part of the surgeon's diagnostic armamentarium; however, its role for the patient with penetrating injury is less well-defined. Although accurate for the detection of hemopericardium, the lack of immediate availability of the cardiologist to perform the test may delay the diagnosis, adversely affecting patient outcome. To be an effective diagnostic test in trauma centers, ultrasound must be immediately available in the resuscitation area and performed and interpreted by surgeons. METHODS: Surgeons performed pericardial ultrasound examinations on patients with penetrating truncal wounds but no immediate indication for operation. The subcostal view detected hemopericardium, and patients with positive examinations underwent immediate operation by the same surgeon. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded. RESULTS: During 13 months, 247 patients had surgeon-performed ultrasound. There were 236 true-negative and 10 true-positive results, and no false-negative or false-positive results; however, the pericardial region could not be visualized in one patient. Sensitivity, specificity, and accuracy were 100%; mean examination time was 0.8 minute (246 patients). Of the ten true-positive examinations, three were hypotensive. The mean time (8 patients) from ultrasound to operation was 12.1 minutes; all survived. Operative findings (site of cardiac wounds) were: left ventricle (4), right ventricle (3), right atrium (2), right atrium/superior vena cava (1), and right atrium/inferior vena cava (1). CONCLUSIONS: Surgeon-performed ultrasound is a rapid and accurate technique for diagnosing hemopericardium. Delay times from admission to operating room are minimized when the surgeon performs the ultrasound examination.     

Transrectal biopsy of the prostate guided by transrectal ultrasound

The use of transrectal ultrasound in combination with the Biopty System provides a high accurate, efficient, and safe method for the diagnosis and staging of prostate cancer. Because both diagnosis and staging may be attained easily using one comprehensive procedure, we recommend ultrasound guidance be used for all initial biopsies of the prostate. When transrectal ultrasound-guided biopsy of a palpable hypoechoic abnormality is negative for cancer, digitally guided biopsy must subsequently be performed. In some cases, palpable abnormality may not be seen on ultrasound. We advocate the use of our biopsy procedure as an integral extension of transrectal ultrasound of the prostate. In an outpatient setting, biopsy may be performed immediately after finding a suspect lesion on ultrasound. In this way, patients are spared time and anxiety, and society is spared medical costs.     

Doppler ultrasound and supraorbital photoplethysmography for noninvasive screening of carotid occlusive disease

Doppler ultrasound and supraorbital photoplethysmography (PPG) were performed on 156 vessels of 76 consecutive patients undergoing contrast arteriography for suspected cerebrovascular disease. Each screening technic was approximately 95 per cent accurate in identifying or excluding significant (≥50 per cent) stenosis or occlusion of the extracranial internal carotid artery. Supraorbital PPG was slightly more sensitive but less specific than Doppler ultrasound. When the results of the two technics were in agreement, the diagnostic sensitivity was 100 per cent and the specificity 97 per cent in 139 vessels studied. Although noninvasive diagnostic technics are of limited value in symptomatic patients with cerebrovascular disease, a combination of Doppler ultrasound and supraorbital PPG is a simple, rapid, and accurate technic to screen asymptomatic or high risk patients for significant carotid occlusive disease.     

Accuracy of trauma ultrasound in major pelvic injury

BACKGROUND: Trauma ultrasound (US) utilizing the focused assessment with sonography in trauma (FAST) is often performed to detect traumatic free peritoneal fluid (FPF). Yet its accuracy is unclear in certain trauma subgroups such as those with major pelvic fractures whose emergent diagnostic and therapeutic needs are unique. We hypothesized that in patients with major pelvic injury (MPI) trauma ultrasound would perform with lower accuracy than has previously been reported. METHODS: Retrospective analysis of adult trauma patients with pelvic fractures seen at an urban Level I emergency department and trauma center. Patients were identified from the institutional trauma registry and ultrasound database from 1999 to 2003. All patients aged >16 years with MPI (Tile classification A2, all type B and C pelvic fractures, and type C acetabular fractures determined by a blinded orthopedic traumatologist) and who had a trauma US performed during the initial emergency department evaluation were included. All ultrasounds were performed by emergency physicians or surgeons using the four-quadrant FAST evaluation. Results of US were compared with one of three reference standards: abdominal/pelvic computed tomography, diagnostic peritoneal tap, or exploratory laparotomy. Two-by-two tables were constructed for diagnostic indices. RESULTS: In all, 96 patients were eligible; 9 were excluded for indeterminate ultrasound results. Of the remaining 87 patients, the pelvic fracture types were distributed as follows: 9% type A2, 72% type B, 16% type C, and 3% type C acetabular fractures. Overall US sensitivity for detection of FPF was 80.8%, specificity was 86.9%, positive predictive value was 72.4%, and negative predictive value was 91.4%. Categorization of sensitivity according to pelvic ring fracture type is as follows: type A2 fractures: sensitivity and specificity, 75.0%; type B fractures: sensitivity, 73.3%, specificity, 85.1%; and type C fractures (pelvis and acetabulum): sensitivity and specificity, 100%. Of the true-positive US results, blood was the FPF in 16 of 21 (76%) and urine from intraperitoneal bladder rupture in 4 in 21 (19%) patients. CONCLUSION: US in the initial evaluation of traumatic peritoneal fluid in major pelvic injury patients has lower sensitivity and specificity than previously reported for blunt trauma patients. Additionally, uroperitoneum comprises a substantial proportion of traumatic free peritoneal fluid in patients with MPI.     

Correlation between urodynamics and perineal ultrasound in female patients with urinary incontinence

AIMS: We performed urodynamics and perineal ultrasound in female patients with urinary incontinence to assess morphology and function of the bladder base-urethra complex and of the detrusor muscle, and to find the correlation between these investigations in the diagnosis of (a) bladder neck and urethral hypermobility and (b) detrusor overactivity; we wanted to compare the tolerabililty of the urodynamic investigation and of the perineal ultrasound. METHODS: We considered 66 female patients referred to our outpatient clinic for urinary incontinence; we also studied 14 healthy control patients. After accurate case-history collection and physical examination, urodynamic investigation and perineal ultrasound were performed, with recording of parameters specific to both investigations. The statistical analysis was performed by ANOVA, Bonferroni post hoc test, and Spearman correlation test. The tolerability index between the diagnostic investigations performed was assessed by a 3-point scale suggested by the patient. RESULTS: In patients with stress incontinence the posterior urethro-vesical angle, the angle of urethral inclination, and the proximal pubo-urethral distance are significantly different under stress compared to the resting phase; in patients with urge incontinence, the detrusor wall is thicker and is accompanied by an increase in opening detrusor pressure and detrusor pressure at maximum flow; it is also accompanied by detrusor overactivity with increased urethral functional length. Increased urethral functional length is suggested on axial US images by alteration of its normal characteristic target-like appearance with four concentric rings of different echogenicity. In all cases the tolerability of perineal ultrasound has been higher than that of urodynamics. CONCLUSIONS: There is a good correlation between urodynamic and perineal ultrasound in the diagnosis of bladder neck and urethral hypermobility; perineal ultrasound can also be useful in the diagnosis of urge incontinence. Functional compressive urethral obstruction can be diagnosed on the basis of the ultrasound aspect of the urethral sphincter.     

Conventional and Doppler ultrasound in thyroid disease diagnosis

Ultrasonography is a useful tool for diagnosis diseases of the thyroid gland. The method is reliable, inexpensive and of high diagnostic efficiency. The structural information provided by the ultrasound technique complements the results of laboratory tests and other in-vivo techniques. The article reviews the indications, the accuracy and the usefulness of conventional and Doppler ultrasonography in the diagnosis of thyroid diseases. In our opinion ultrasound examinations should immediately follow the patient's history and physical examination. Additional in vivo methods should be performed according to the specified problems.     

The efficacy of ultrasound in the evaluation of dynamic scapholunate ligamentous instability

BACKGROUND: The accuracy of diagnostic imaging modalities that are currently used to evaluate dynamic scapholunate ligamentous instability is equivocal. Ultrasound is commonly used for a wide variety of diagnostic purposes in orthopaedics. The purpose of the present study was to determine the efficacy of ultrasound in the diagnosis of dynamic scapholunate ligamentous instability. METHODS: Two groups of individuals were prospectively studied. Group A included patients with a clinical diagnosis of unilateral dynamic scapholunate ligamentous instability, and Group B included asymptomatic volunteer control subjects. Dynamic ultrasound examinations of the dorsal portion of the scapholunate ligament in both wrists of all individuals were performed by radiologists. The radiologists were blinded with regard to the group to which each person belonged as well as with regard to the affected wrist in the patients in Group A. Arthroscopic examinations of the affected wrist in all of the patients in Group A were then performed by surgeons who were blinded with regard to the results of the ultrasound examination, and the results of the arthroscopic and ultrasound examinations were compared. The ability of ultrasound to discern asymptomatic from symptomatic individuals was also determined. RESULTS: Over a period of 1.5 years, a total of sixty-four wrists were evaluated in fourteen patients (Group A) and eighteen normal subjects (Group B). All fourteen nonaffected wrists in Group A and all thirty-six wrists in Group B were correctly identified as normal with use of ultrasound. Of the fourteen affected wrists in Group A, thirteen were found to have scapholunate ligament laxity on the basis of arthroscopy (twelve wrists) or arthrotomy (one wrist); six of these thirteen wrists had been correctly identified as abnormal with use of ultrasound (a true-positive result), and seven had false-negative results. There was one true-negative result. The ability of ultrasound to differentiate between normal and abnormal wrists was significant (p < 0.001). For the sixty-four wrists, statistical analysis revealed that ultrasound had a sensitivity of 46.2%, a specificity of 100%, and an accuracy of 89.1%. CONCLUSIONS: We conclude that ultrasound has a high specificity and accuracy but a low sensitivity for the evaluation of dynamic scapholunate ligamentous instability, and we recommend its use as an adjunct to other diagnostic modalities for this purpose.     

Ocular examination for trauma; clinical ultrasound aboard the International Space Station

BACKGROUND: Ultrasound imaging is a successful modality in a broad variety of diagnostic applications including trauma. Ultrasound has been shown to be accurate when performed by non-radiologist physicians; recent reports have suggested that non-physicians can perform limited ultrasound examinations. A multipurpose ultrasound system is installed on the International Space Station (ISS) as a component of the Human Research Facility (HRF). This report documents the first ocular ultrasound examination conducted in space, which demonstrated the capability to assess physiologic alterations or pathology including trauma during long-duration space flight. METHODS: An ISS crewmember with minimal sonography training was remotely guided by an imaging expert from Mission Control Center (MCC) through a comprehensive ultrasound examination of the eye. A multipurpose ultrasound imager was used in conjunction with a space-to-ground video downlink and two-way audio. Reference cards with topological reference points, hardware controls, and target images were used to facilitate the examination. Multiple views of the eye structures were obtained through a closed eyelid. Pupillary response to light was demonstrated by modifying the light exposure of the contralateral eye. RESULTS: A crewmember on the ISS was able to complete a comprehensive ocular examination using B- and M-mode ultrasonography with remote guidance from an expert in the MCC. Multiple anteroposterior, oblique, and coronal views of the eye clearly demonstrated the anatomic structures of both segments of the globe. The iris and pupil were readily visualized with probe manipulation. Pupillary diameter was assessed in real time in B- and M-mode displays. The anatomic detail and fidelity of ultrasound video were excellent and could be used to answer a variety of clinical and space physiologic questions. CONCLUSIONS: A comprehensive, high-quality ultrasound examination of the eye was performed with a multipurpose imager aboard the ISS by a non-expert operator using remote guidance. Ocular ultrasound images were of diagnostic quality despite the 2-second communication latency and the unconventional setting of a weightless spacecraft environment. The remote guidance techniques developed to facilitate this successful NASA research experiment will support wider applications of ultrasound for remote medicine on Earth including the assessment of pupillary reactions in patients with severe craniofacial trauma and swelling.     

Utility of operative ultrasound in the surgical management of liver tumors.

In this study the utility of operative ultrasound in the surgical management of 98 consecutive patients with liver and gastrointestinal tumors was assessed. All patients had preoperative work-up including ultrasound study of the liver as well as selective hepatic arteriography (50 patients) and computerized tomography of the liver (45 patients). At surgery, inspection and palpation of the liver as well as operative ultrasound examination were performed in all cases. Fifty-six patients were known to have liver tumors before operation, while 42 patients had their liver examined as part of the treatment of a primary gastrointestinal malignancy. A total of 126 liver tumors were found in 58 patients, all of whom were confirmed histologically. Eighteen nodules unsuspected before operation were found at surgery--nine by inspection and palpation of the liver, and nine others that were nonpalpable were found by operative ultrasound only. Eighteen lesions that were missed by all diagnostic modalities were found as secondary lesions on pathologic examination of the resected specimens. In addition to diagnostic applications, operative ultrasound was useful in localizing nodules and permitting guided biopsies deep in the hepatic parenchyma. In eight cases, segmental resections were performed with operative ultrasound to localize the plane of section and to catheterize the intrahepatic portal vein branch afferent to the tumor in order to perform balloon catheter occlusion of the vessel for control of bleeding. Operative ultrasound was found to be important in the surgical management of 19 of 98 patients (19%).     

Optimized management of polytraumatized patients by prehospital ultrasound

AIM: The purpose of the study was to evaluate the practicability and the benefit of focused abdominal sonography for trauma (FAST) on scene. METHODS: Prehospital ultrasound was performed on 61 patients being suspicious for abdominal trauma. Free fluid in the Koller's and Morison's pouch, pelvis and pleural space was investigated. After admission routine ultrasound and computer tomography scan was obtained to control prehospital findings. RESULTS: The mean investigation time was 2.8+/-1.2 min. In 16 patients (26.2%) free fluid was detected with 7 massive and 9 moderate findings. 3 patients died on the scene due to their abdominal injuries. 4 patients underwent laparotomy immediately after admission with 3 splenectomies performed. There was one false positive but no negative FAST resulting in a specificity of 97.5% and sensitivity of 100%. In 37% of the cases the prehospital management was modified and hospital selection was influenced in 21% of the cases due to the findings of the FAST. CONCLUSION: In the present study the data have shown that the prehospital ultrasound is a useful and reliable tool for diagnostic procedure on the scene. The data are the basis for a multicenter study in the helicopter rescue service. This study will try to answer the question whether prehospital ultrasound may be generally recommended in trauma patients suspicious for abdominal trauma.     

B型超声诊断结肠肿瘤的探讨

目的：探讨B型超声在诊断结肠肿瘤方面的临床价值。方法：采用B型超声诊断134例结肠肿物并与纤维结肠镜及手术、病理对照分析。结果：B型超声诊断结肠肿瘤的符合率91．8％，结论：B型超声对结肠肿瘤的诊断有较大临床价值。     

Evaluation of pre-procedure ultrasound examination as a screening tool for difficult spinal anaesthesia*

We performed a pre-procedure ultrasound examination of the spine on 60 patients undergoing lower extremity orthopaedic surgery under spinal anaesthesia. We hypothesised that the inability to identify the posterior longitudinal ligament or vertebral body easily with ultrasound would be associated with difficulty placing a spinal anaesthetic. Clinicians blinded to the ultrasound scan performed the injections using the traditional landmark technique. The spinal procedure was videotaped and subsequently reviewed by independent investigators. We defined procedure difficulty by total procedure time (> 400 s) and number of needle passes (≥ 10) required to achieve return of cerebrospinal fluid, or abandonment of the procedure due to unsuccessful dural puncture. When images of the posterior longitudinal ligament were poor (low score group), the mean (SD) number of passes was 21.2 (30.6), compared with 4.8 (7.5) with good ultrasound images (high score group) (p < 0.01). The mean (SD) time for placement was 420 (300) s in the low score group vs 176 (176) s in the high score group (p < 0.01). You can respond to this article at http://www.anaesthesiacorrespondence.com.