Appraising surgeons learning sonography: measuring measurement variability

PURPOSE: Sonography is increasingly used by various clinicians in several task-specific situations. We present a method of assessing 1 aspect of a nonspecialist's ability in performing sonography, measurement variability. METHODS: An experienced radiologist and a surgeon who had received 4 weeks of sonography training each made triplicate measurements of gallbladder dimensions in 19 adult patients undergoing abdominal sonography. The observers examined the subjects in immediate succession using the same ultrasound equipment and were blinded to each other's measurements until the end of the study. Intraobserver measurement variability rates were calculated for gallbladder length, height, and width by using analysis of variance techniques and were expressed as a within-subject standard deviation and a repeatability coefficient. RESULTS: In terms of intraobserver measurements, the estimated within-subject standard deviations were comparable for the radiologist and the surgeon (length, 0.22 versus 0.17 cm; height, 0.14 versus 0.14 cm; and width, 0.12 versus 0.14 cm, respectively), as were the repeatability coefficients. The interobserver variability showed good agreement as well; the estimated within-subject standard deviations (and 95% limits of agreement) obtained were length, 0.47 cm (-1.08 to 1.48 cm); height, 0.34 cm (-1.08 to 0.49 cm); and width, 0.28 cm (-0.80 to 0.81 cm). CONCLUSIONS: The ability to measure organ dimensions accurately is an essential sonographic skill that can be readily appraised. The findings from this comparison study illustrate that this 1 small aspect of sonography can be learned by various clinicians and that their ability in this task can be appraised. In a clinical setting, the small degree of variability in measurements made by the experienced radiologist and the sonography-trainee surgeon is likely to be satisfactory.     

Color Doppler imaging of orbital vessels: personal experience and literature review

Many Doppler imaging studies have been performed in recent years in a large number of ocular disorders because of improvements in the Doppler equipment used for detecting and measuring the low blood-flow velocities that are a requisite for the quantitative evaluation of blood flow in the orbital vessels. The ophthalmic artery, central retinal artery and vein, posterior ciliary arteries, and the superior ophthalmic vein can be easily identified using color Doppler sonography. The changes in local blood flow in these vessels assessed by spectral analysis pulsed Doppler sonography have been used to characterize and to obtain new insights into different nontumoral vascular disorders including carotid artery stenosis, central retinal vein occlusion, giant cell arteritis, glaucoma, diabetes, fistulas, and tumoral processes of the eye and orbit. Our experience has confirmed the important role of Doppler sonography in the assessment of subclinical changes in the vascular bed, in the understanding of different processes, for following up after specific treatments, and for determining the long-term prognosis of these various conditions.     

Enlarged fetal bladder: Differential diagnosis and outcomes

The sonographic finding of an enlarged fetal bladder may simply be a transitory normal variant, but it may also be secondary to reflux or to obstructive, neurogenic, or myopathic causes. In this report, we describe the cases of 3 fetuses with an enlarged bladder, each of which had a different cause. The first fetus had posterior urethral valve obstruction, the second, a ruptured neurogenic bladder, and the third, megacystic-microcolon-intestinal hypoperistalsis syndrome. When sonographic examination reveals an enlarged fetal bladder, the ureter, kidneys, genitalia, and spine should be evaluated carefully. Although sonography is good at identifying urinary tract abnormalities, it often cannot provide the specific diagnosis or cause. We recommend frequent sonographic monitoring to evaluate such fetuses for persistence of or changes in bladder enlargement and for changes in the volume of amniotic fluid because these signs may be indicators of abnormalities of renal function and risk factors for a poor prognosis. Analysis of fetal electrolyte levels can also aid in determining the prognosis and whether the condition is amenable to therapeutic intervention.     

Eyelid movements in normal human fetuses

PURPOSE: We undertook this study to investigate the characteristics of blinking activity in healthy human fetuses. METHODS: Blinking activity was studied sonographically in healthy fetuses between 33 and 42 weeks' menstrual age. Horizontal and coronal sonographic views of the eye were obtained and videotaped. Fetal blinking movements were analyzed by reviewing the videotape in slow motion. Fetal vibroacoustic stimulation was also used when clinically indicated. RESULTS: We examined a total of 18 healthy fetuses. Fetal blinking was detected in 89% of cases, with a mean frequency of 6.2 movements per 60-minute observation period. Vibroacoustic stimulation was associated with increased fetal blinking in the 6 fetuses in which it was applied (mean, 15.3 movements per 60-minute observation period). CONCLUSIONS: Blinking is a normal fetal activity. The increased frequency of blinking activity associated with vibroacoustic stimulation may be considered a part of the normal startle reflex.     

High prevalence of thyroid ultrasonographic abnormalities in primary aldosteronism

The study was performed to evaluate the prevalence of thyroid abnormalities detected by ultrasonography and, in particular, of multinodular nontoxic goiter in primary aldosteronism. We analyzed 80 consecutive of patients with primary hyperaldosteronism (40 with unilateral adenoma and 40 with idiopathic hyperaldosteronism) and 80 normotensive healthy controls, comparable for age, sex, iodine intake, and geographical area. Blood pressure, thyroid palpation, thyroid function, and ultrasonography were evaluated. The prevalence of ultrasonographic thyroid abnormalities was 60% in primary aldosteronism and 27% in controls (p<0.0001). There was a statistically significant difference in prevalence of these abnormalities in unilateral adenoma and idiopathic hyperaldosteronism with respect to controls (p<0.05 and p<0.0001, respectively). The prevalence of multinodular nontoxic goiter in idiopathic hyperaldosteronism was higher than in controls (p<0.001) and, in particular, in female patients. From these data it seems to be worth considering the existence of primary hyperaldosteronism in patients with multinodular goiter and hypertension.     

Ultrasonographic evidence of phenotypic instability during hepatocarcinogenesis in N-nitrosomorpholine-treated rats

Carcinogen-induced hepatoma in immunocompetent animal models has shown a progress similar to the clinical course of human hepatoma. Ultrasonography (US) was used for consecutive evaluation of the phenotypic changes in Sprague-Dawley rats exposed for 8 weeks to N-nitrosomorpholine (NNM, 200 mg/L). Three distinctive US findings were ascites, coarseness (defined as small and heterogeneously widespread increased echogenecity), and nodularity (defined as a >0.6-cm-sized echogenic region and clearly showing a tumor-like mass). Abdominal ascites was observed in 5 of 26 rats at week 8 NNM posttreatment and the number of rats showing ascites gradually increased. Coarseness (22 of 26 rats) and nodularity (1 of 18) appeared at weeks 8 and 17 NNM posttreatment, respectively. The gross and histological findings indicated that coarseness and nodularity shown in US reflected fibrosis and hepatocellular carcinoma or cholangiofibroma, respectively. The computer-aided quantification of coarseness and nodularity showed that the regression-linked phenotypic instability was present in coarseness but not in nodularity. We conclude that the heterogeneity of preneoplasia in NNM-treated rats might be induced by phenotypic instability rather than random initiating events of preneoplastic lesion.     

Adopt a wait-and-see attitude for patent processus vaginalis in neonates

Purpose: The purpose of this paper is to describe the ultrasonographic findings of the patent processus vaginalis (PPV) in neonates.Methods: The patency of the processus vaginalis was examined by ultrasonography in 117 neonates. The ultrasonographic findings, with increment and decrement of the intraabdominal pressure, were categorized into 6 types as follows: type I, the intraabdominal organ is observed; type II, cystic PPV; type III, the PPV is widened with abdominal pressure increment, the length is ≥20 mm; type IV, the PPV contains moving fluid without PPV widening; type V, the PPV is widened with abdominal pressure increment, the length is less than 20 mm; type VI, others. The authors we regarded types I to IV as PPV with inguinal hernia.Results: Twenty-two of 40 neonates with a birth weight under 2,500 g had PPV, including 8 with type I. Twenty of 37 premature neonates 22 to 37 gestational weeks had PPV, including 8 with type I. Eighty-one percent (13 of 16) of PPV in low-birth-weight neonates and 91% (10 of 11) in premature neonates closed spontaneously. The median ages at the time of spontaneous regression of PPV were 242 days in low birth weight neonates and 262 days in premature neonates.Conclusions: Most premature or low-birth-weight neonates with PPV regress spontaneously. The inguinal hernia in neonates (especially in premature or low-birth-weight neonates) should be observed until at least 9 months of age without attempting hernia repair.     

The effect of ipsilateral whole breast ultrasonography on the surgical management of breast carcinoma

BACKGROUND: Patients can be selected for breast conservation therapy using mammography and physical examination. Whole breast ultrasonography has been shown to identify lesions not seen on mammography. This study sought to determine how often whole breast ultrasonography changes the surgical management of breast cancer. METHODS: All patients with stage 1 and 2 breast cancer undergoing whole breast ultrasonography were identified. A change in surgical management was defined as the identification by ultrasonography alone of foci of carcinoma greater than 1 cm from the primary tumor site or in another quadrant of the breast. RESULTS: There were 1385 breast cancer patients; 31% had ultrasonography. Eighteen percent of patients had abnormalities identified by ultrasonography alone. Changes in management occurred in 2.8%. The additional lesions led to four wider resections and eight mastectomies. Patients with ultrasonography abnormalities were significantly younger, and more likely to have histologic grade 2 or 3 disease. CONCLUSIONS: These findings do not support the routine use of ultrasonography in all breast cancer patients. Significant abnormalities were more commonly seen among younger patients with higher grade lesions.     

Utility of color duplex sonography in the assessment of efficacy of the stellate ganglion blockade

Purpose: 
To assess the hemodynamic changes in the upper extremity arteries after sympathetic ganglion blockade (SGB) by using spectral Doppler parameters and to determine the applicability of these parameters for the evaluation of SGB efficacy. Material and Methods: 
Spectral Doppler parameters (peak systolic velocity (PSV), end diastolic velocity (EDV), mean velocity (mean V), flow volume, resistive and pulsatility indices (RI, PI), inner arterial diameters (intima to intima) (D) with simultaneous recordings of heart rate (HR), systolic and diastolic blood pressures and upper extremity surface temperature changes) were recorded before and 5 min after during the first, fifth and tenth SGB procedures. Results: 
SGB induced an increase in skin temperature in the ipsilateral hand and persistent dilatation of the radial diameter accompanied by reduction of RI and PI in the radial and third digital arteries in all patients. Conclusion: 
Hemodynamic changes assessed by spectral Doppler parameters could be used as sensitive and objective measurements of peripheral sympathetic nervous activity and vascular tonus, and may confirm a successfully performed SGB.     

Surveillance for endometrial cancer with transvaginal ultrasonography of breast cancer patients under tamoxifen treatment

The association of endometrial thickness with the risk of developing endometrial cancer (EC) within 2 years was investigated in a consecutive cohort of 1205 breast cancer patients under tamoxifen treatment, undergoing transvaginal ultrasonography (TVUS) for follow-up purpose (asymptomatic, 1068) or for abnormal uterine bleeding (AUB, 137). Linkage with tumour registry allowed for the follow-up of 3184.3 person-years. According to underlying incidence, 1.85 EC cases were expected in the study cohort while 12 were observed (observed/expected ratio=6.49, 95% CI 3.35-11.33; asymptomatic=4.09, 95% CI 1.65-8.43, symptomatic=35.71, 95% CI 11.59-83.34). No EC was observed with thickness (half layer) <3 mm. Raising this threshold increased specificity with a substantial loss of sensitivity (>or=3, >or=4, >or=6, >or=9 mm; spec.=25.8, 44.5, 76.1, 91.5%, sens.=100, 91.6, 75.0, 66.6%). The presence of AUB was rather specific (88.94%) but poorly sensitive (41.67%). A combination of AUB presence/absence and thickness allowed the best accuracy (AUB + thickness >or=3, >or=4 or >or=5; sens.=100, 81.6 or 91.6%; spec.=22.8, 40.4, or 56.7%). Breast cancer patients under tamoxifen might be selected for further invasive assessment on the basis of AUB and endometrial thickness assessed at TVUS.