Head and neck ultrasound: technical advances, novel applications and the role of elastography.

High-resolution ultrasound (US) provides superb anatomical detail in the superficial anatomy of the neck and has become the first-line imaging investigation for neck lumps and a crucial component of clinical pathways. In this article, a wide range of advances in neck US are described with a focus on the emerging role of ultrasound elastography. Selected examples of clinical utility are presented across a spectrum of scenarios with discussion of newer applications, service delivery, and training issues. The changing role of the neck ultrasound practitioner and the future of the technique in the head and neck are considered.

CT staging of colorectal cancer: what do you find in the chest?

AIM: To clarify the chest computed tomography (CT) findings in patients with a new diagnosis of colorectal adenocarcinoma. MATERIALS AND METHODS: Patients diagnosed with colorectal cancer (CRC) over a 3-year period were retrospectively studied. All CT examinations were performed within a single NHS Trust using the same CT system and protocol. Two primary outcomes were assessed: the presence of pulmonary metastases and the identification of a significant, unexpected chest abnormality. RESULTS: Five hundred and fourteen out of 568 (90.5%) CRC patients underwent complete CT staging. Thirty-one patients (6%) had lung metastases, of which four (0.8%) were isolated. Three hundred and fifty-three (68.7%) had no evidence of pulmonary metastases, but 130 (25.3%) had indeterminate lung nodules (ILNs). The ILNs of 12 patients were subsequently confirmed as metastases on follow-up. A major non-metastatic finding (pulmonary embolism or synchronous primary malignancy) was found in 15/514 patients (3%). CONCLUSIONS: Thoracic CT altered the initial TNM stage in fewer than 1% of CRC patients, but the detection of significant incidental chest disease and the establishment of an imaging baseline are useful outcomes of this imaging strategy. One-quarter of all staging examinations demonstrated ILNs.

Thoracic discitis as a complication of self-expanding metallic stents in esophageal carcinoma.

The role of metallic stents in the palliation of esophageal cancer is well established. Self-expanding metal stents (SEMSs) are frequently used, as they provide an effective and safe method of relieving malignant dysphagia. A number of complications are associated with the use of SEMSs, including esophageal perforation. We report a case of thoracic discitis occurring in a patient with advanced esophageal malignancy, treated with SEMSs. We propose that the likely etiology in this patient was esophageal perforation by a metallic stent.

Ultrasonography for suspected deep vein thrombosis: how useful is single-point augmentation?

AIMS: To assess the role of single-point augmentation of spectral Doppler flow in the diagnosis of acute deep vein thrombosis (DVT). Secondary objectives included identifying the augmentation response in non-DVT diagnoses. METHODS: Patients attending the ultrasound departments of two hospitals for investigation of suspected acute DVT during an 8-month period were recruited to the study group. Spectral Doppler assessment of the superficial femoral vein was recorded during Valsalva and calf compression manoeuvres in the asymptomatic and symptomatic legs. The Doppler waveforms from the symptomatic limb were characterized as "normal" or "abnormal" by the operator. Standard compression ultrasonography of the symptomatic leg was then performed with the presence of DVT or an alternative diagnosis documented. RESULTS: One hundred and sixty-seven patients underwent ultrasound examinations using the study methodology. Nine patients were subsequently excluded due to bilateral DVT or inability to tolerate calf compression. The mean age of the remaining 158 patients was 65.4 years with 28 DVTs identified (18% of patients). Calf compression elicited a normal response in 118/130 of non-DVT examinations (specificity 91%) and an abnormal response in 18/28 DVT examinations (sensitivity 64%). Diminished or absent augmentation was identified in alternative diagnoses that included haematoma and Baker's cyst. CONCLUSIONS: This study demonstrates that single-point augmentation has a low sensitivity in suspected lower-limb DVT, and that the majority of undetected DVTs are isolated to the calf veins. An abnormal augmentation response is a poor predictor of lower-limb DVT as alternative diagnoses can produce diminished or reduced augmentation. Therefore, single-point augmentation does not add to the standard compression ultrasound examination for suspected DVT and should not be routinely performed.

Investigating suspected acute pulmonary embolism - what are hospital clinicians thinking?

AIMS: To assess local clinical knowledge of the appropriate investigation of suspected acute pulmonary embolism (PE) and this compare with the 2003 British Thoracic Society (BTS) guidelines as a national reference standard. METHODS: A clinical questionnaire was produced based on the BTS guidelines. One hundred and eight-six participants completed the questionnaires at educational sessions for clinicians of all grades, within a single NHS Trust. The level of experience amongst participants ranged from final year medical students to consultant physicians. RESULTS: The clinicians were divided into four groups based on seniority: Pre-registration, Junior, Middle, and Senior. Forty-six point eight percent of all the clinicians correctly identified three major risk factors for PE and 25.8% recognized the definition of the recommended clinical probability score from two alternatives. Statements regarding the sensitivity of isotope lung imaging and computed tomography pulmonary angiography (CTPA) received correct responses from 41.4 and 43% of participants, respectively, whilst 81.2% recognized that an indeterminate ventilation-perfusion scintigraphy (V/Q) study requires further imaging. The majority of clinicians correctly answered three clinical scenario questions regarding use of D-dimers and imaging (78, 85, and 57.5%). There was no statistically significant difference between the four groups for any of the eight questions. CONCLUSIONS: The recommended clinical probability score was unfamiliar to all four groups of clinicians in the present study, and the majority of doctors did not agree that a negative CTPA or isotope lung scintigraphy reliably excluded PE. However, questions based on clinical scenarios received considerably higher rates of correct responses. The results indicate that various aspects of the national guidelines on suspected acute pulmonary embolism are unfamiliar to many UK hospital clinicians. Further research is needed to identify methods to improve this situation, as both clinicians and radiologists have a duty to ensure that patients are appropriately investigated.

The hypothermic response of mice to delta-9-tetrahydrocannabinol is enhanced by chlorpromazine, thioxanthenes, alpha-adrenoceptor antagonists and pentolinium but not by SCH 23390 or sulpiride.

Chlorpromazine, given either subcutaneously (0.375 mg/kg) or unilaterally into the preoptic/anterior hypothalamic area through a chronically implanted cannula (20 micrograms), was found to enhance the hypothermic response to delta-9-tetrahydrocannabinol (THC; 5 mg/kg i.p.) in unrestrained adult male MF1 mice, kept at 22 degrees C. In mg/kg terms, chlorpromazine was no more potent when injected into the preoptic/anterior hypothalamic area than when given subcutaneously. Phentolamine (54 micrograms) had no significant effect on hypothermia induced by THC when injected into the hypothalamus although it did enhance this response when given subcutaneously (15 mg/kg). Hypothermia induced by THC was also enhanced by flupentixol (0.375 mg/kg s.c.), piflutixol (23.4 micrograms/kg s.c.), pentolinium (5 mg/kg s.c.), prazosin (0.1875 mg/kg s.c.) and indoramin (6 mg/kg s.c.) but not by SCH 23390 (6 mg/kg s.c.) or sulpiride (40 mg/kg s.c.). When taken together with the results from a previous study, these data support the hypothesis that chlorpromazine enhances hypothermia induced in mice by THC by antagonizing alpha-adrenoceptors so as to decrease the capacity of the animals to minimise peripheral blood flow by vasoconstriction. The present data also support the hypothesis that flupentixol and piflutixol interacted with THC not by antagonizing dopamine at D1 or D2 receptors but rather by blocking alpha-adrenoceptors.