Advantages of US in percutaneous dilatational tracheostomy: randomized controlled trial and review of the literature.

PURPOSE: To compare procedure times and complication rates of preincisional ultrasonographic (US) evaluation and perioperative US guidance in percutaneous dilatational tracheostomy ( PDT percutaneous dilatational tracheostomy ) with those of the current standard of care, PDT percutaneous dilatational tracheostomy performed without image guidance. MATERIALS AND METHODS: Between December 2007 and January 2011, 341 patients were included in this institutional review board-approved study after informed consent was obtained from the patients or their relatives. The patients were divided randomly into two groups. In group A (n = 166), the possible causes of complications, such as aberrations of tracheal, thyroidal, and vascular structures, were determined with US, and tracheal measurements were performed by using US. The clinician's initial considerations at physical examination were compared with the US findings. PDT percutaneous dilatational tracheostomy was subsequently performed with US guidance in suitable cases. In group B (n = 175), PDT percutaneous dilatational tracheostomy was performed solely on the basis of physical landmarks. The procedure times and complication rates were compared across groups by using the Fisher exact test. RESULTS: In group A, the puncture sites designated at the physical examination were reconsidered in 39 (23.8%) of 164 cases. The perioperative complication rates were slightly lower in group A (7.8% [12 of 154]) than in group B (15.0% [25 of 167]); however, the difference did not achieve statistical significance (P = .054). The mean procedure times for groups A and B were 24.09 minutes ± 8.05 (standard deviation) (range, 14-68 minutes) and 18.62 minutes ± 6.34 (range, 12-81 minutes), respectively (P = .001), and the numbers of patients in each group who required multiple puncture attempts were six (3.9%) of 154 and 23 (13.6%) of 169 (P = .003), respectively. CONCLUSION: The use of US guidance before and during PDT percutaneous dilatational tracheostomy could render the procedure easier and safer, with fewer complications but a slightly longer procedure time.

Renal function and linear growth of children with nephrocalcinosis: a retrospective single-center study.

The aim of this study was to analyze the etiology of nephrocalcinosis (NC) and whether it has any effect on growth and renal function in children. Forty-three children who were diagnosed with bilateral NC were studied retrospectively. Two neonates treated with furosemide and five premature infants were excluded from the study. The most common condition leading to NC was hereditary tubulopathies (50%). Data of 27 children who had a follow-up period of at least two years were examined in more detail. Of the 27 patients, the median age at first examination was 12 (range: 2-132) months and median follow-up time was 57 (range: 24-209) months. Thirteen of 27 (48.1%) patients had height standard deviation scores (hSDS) <-2 at presentation, and 6 (22.2%) patients who had normal glomerular function were still below -2 SDS at the last examination. Hypercalciuria was present in 25 (92.6%) patients at the first evaluation and in 6 (22.2%) patients at the last examination. The degree of NC worsened in 6 (22.2%), remained stable in 15 (55.5%) and decreased in 6 (22.2%) patients during the followup period. Chronic renal insufficiency (CRI) developed in 5 patients without there being any increase in the degree of NC. In conclusion, growth and renal function in these patients generally depend on the nature of the underlying disease but not the degree of NC.

Bi-RADS category 3 nonpalpable breast masses on sonography: long-term results of a prospective cohort study.

PURPOSE: To determine the frequency of BI-RADS category 3 nonpalpable masses detected using only sonography (US) and the malignancy rate among these lesions. Second, to validate a proposed short-term follow-up regimen based on long-term observational results. METHODS: This prospective cohort study was conducted between September 2003 and April 2010. We conducted a 2-year short-term follow-up protocol composed of five US examinations at 3-month intervals for the first 6 months, and at 6-month intervals for the next 18 months, followed with age-appropriate screenings. Biopsy was recommended for the masses increasing in size and with changing imaging features. RESULTS: The frequency of category 3 nonpalpable masses detected only on US in 11,373 consecutive women was 5.3%. Of 562 lesions found in 451 women, 394 (70.1%) remained stable during the short-term and subsequent follow-up. Seventy-four (13.1%) masses showed interval regression and 79 (14.0%) showed interval progression. The malignancy rate was 0.3% (2 of 562), with about 85% of interval changes occurring within the first 2 years. The negative predictive value of US in the detection of cancer was 99.6% (95% CI, 98.7-99.9). The mean follow-up time was 65.5 ± 8.7 months. CONCLUSIONS: The frequency of BI-RADS 3 nonpalpable masses detected using sonography alone was 5.3%. During follow-up, the majority of interval changes occurred within the first 2 years. Because these masses have a very low malignancy rate, a 2-year follow-up instead of immediate biopsy is an appropriate option.

Probability of urinary tract infection in infants with ureteropelvic junction obstruction: is antibacterial prophylaxis really needed?

In infants with ureteropelvic junction obstruction (UPJO), the risk of urinary tract infection (UTI) is unknown, and there is a lack of prospective studies showing definitive evidence regarding the benefits and necessity of antibiotic prophylaxis. The aim of this study was to assess the risk of UTI in infants with UPJO and to determine whether the risk varies according to the degree of hydronephrosis. Infants with hydronephrosis detected prenatally or within the postnatal 28th day and who had no previous history of UTI were followed prospectively without antibacterial prophylaxis. Imaging studies were performed according to our Pediatric Uro-Nephrology Study Group protocol. Dimercaptosuccinate (DMSA) scintigraphy was performed in all infants at the end of 1 year of follow-up. Eighty-four infants (56 boys, 28 girls) were included in the study. The distribution of patients in each hydronephrosis grading group was incidentally similar. Within a median follow-up period of 18 (12-24) months, none of the patients had UTI. Furthermore, no pyelonephritic scar was found on DMSA scans in any patient. We conclude that prophylactic antibiotic usage is not indicated in infants with UPJO, regardless of the severity of hydronephrosis, as the risk of UTI is minimal in this population.

Urolithiasis in the first year of life.

Data on urolithiasis (UL) in infancy are limited. The objective of this study was to increase awareness of infant UL and to investigate the influence of possible risk factors in this very specific age group. Nonfasting, second-voiding urine samples were obtained to test for urinary excretions of calcium, oxalate, citrate, magnesium, uric acid, and creatinine. Blood analysis included calcium, phosphate, magnesium, uric acid, creatinine, sodium, potassium, chloride, and alkaline phosphatase. Patients received follow-up testing every 1-2 months; serial ultrasonography was used to track UL status. Fifty infants with a median age of 5 months were enrolled in the study. Hypercalciuria was detected in 9/47, hyperoxaluria in 5/39, hypocitraturia in 4/31, and cystinuria in 2/50 infants. We identified at least one metabolic abnormality in 46% of our patients; no metabolic abnormality was identified in 27 infants. Within a mean follow-up period of 14 months, 17 infants became stone free, stones increased in number in ten patients and decreased in number in 16, and recurrence was detected in seven. This study showed that UL could be detected in very early life, even in the newborn period, and could be the source of late childhood/adulthood UL. Infants with nonspecific symptoms such as restlessness may have UL and should undergo ultrasonographic examination. Metabolic evaluation of UL in this specific age group carries some diagnostic challenges, e.g. unsatisfactory data regarding normal ranges of urinary mineral excretion, and collection of 24-h urine samples.

Superficial temporal artery pseudoaneurysm: ultrasonographic diagnosis in the ED.

Superficial temporal artery pseudoaneurysm (STAP) is an uncommon complication of blunt and penetrating trauma. It accounts for only 1% of all traumatic aneurysms. Superficial temporal artery pseudoaneurysm usually has the characteristic appearance of a cystic pulsatile mass in the region of the superficial temporal artery. Here we present a case of posttraumatic STAP detected by US in the emergency department (ED). A 58-year-old woman presented to our ED with a tender right frontoparietal mass. Two weeks before presentation, the patient was involved in a motor vehicle accident (MVA) and was taken to the state hospital where the result of a computed tomography scan of the head was shown to be normal except for right frontoparietal soft tissue swelling and hematoma formation. A few days after discharge, the diameter of the soft tissue swelling decreased and the patient was well.However, 2 weeks after the MVA, the patient presented to our ED with a throbbing headache and dramatic increase in the diameter of the lesion. Examination showed a 5 x 5-cm swelling, which was soft, tender, and fluctuant on palpation. The swelling was not pulsatile. Ultrasound was performed using a 7.5-MHz probe and demonstrated a well-defined, pulsatile, anechoic mass measuring approximately 50 x 50 mm in diameter. Ultrasound is a valuable and readily available tool in the ED to confirm the diagnosis.

Breast involvement in visceral leishmaniasis.

Visceral leishmaniasis usually involves the bone marrow, lymph nodes, liver and spleen. Involvement of the eye or respiratory or gastrointestinal systems is very rare and usually occurs in immunodepressed patients. Only one case of breast involvement by protozoa has been reported in the literature. We report a case of a visceral leishmaniasis with a solid breast mass caused by leishmania and diagnosed by sonography-guided core biopsy.

Hepatobiliary fascioliasis: sonographic and CT findings in 87 patients during the initial phase and long-term follow-up.

OBJECTIVE: The purpose of our study was to describe the initial and long-term imaging findings in hepatobiliary fascioliasis. CONCLUSION: Most patients with fascioliasis have typical hepatobiliary imaging findings. It is important to know that residual fibrotic or necrotic foci may remain for years after cure. Long-term complications are rare in fascioliasis, and malignancy or cirrhosis related to the disease has not been observed.

Percutaneous imaging-guided treatment of hydatid liver cysts: do long-term results make it a first choice?

AIM: To evaluate the long-term results of percutaneous imaging-guided treatment of hydatid liver cysts. MATERIALS AND METHODS: Sixty patients with 77 hydatid liver cysts underwent percutaneous treatment with ultrasonography (US) or computed tomography (CT) guidance. Absolute alcohol and hypertonic saline were used for sclerosing the cysts after aspiration. Prophylactic albendazole treatment was given before and after the procedures. Follow-up US and CT were obtained periodically, and changes in cyst morphology were recorded. Minimum follow-up period for the patients included in this study was 12 months. Serological correlation was also available for a group of patients. The outcome of the procedures were categorized into five groups based on morphological changes observed by imaging. RESULTS: Procedures were regarded as successful in 80% and unsuccessful in 20% of patients. Failures most often occurred with type III cysts; less than half (39%) of the total type III cysts had a successful outcome. On the other hand, all type I cysts ended up with cure. Anaphylaxis, pneumotorax and severe pain interrupting the procedures were also among the reasons of failure. CONCLUSION: Percutaneous aspiration, injection and reaspiration (PAIR) of types I and II hydatid liver cysts is effective and safe in the long-term. Surgery should no longer be regarded as the first choice treatment in all hydatid liver cysts but should be reserved for type III and certain active type IV cysts.

The reliability of color doppler "twinkling" artifact for diagnosing millimetrical nephrolithiasis: comparison with B-Mode US and CT scanning results.

PURPOSE: To compare the effectiveness of B-Mode and color-Doppler ultrasound imaging features, including "twinkling-artifact" with unenhanced CT for detecting millimetrical nephrolithiasis. METHODS: 397 patients were examined for suspected urolithiasis with US and CT were included. US findings such as echogenic focuses, posterior acoustic shadowing and twinkling artifact were examined for their ability to detect millimetricalcalculies (greatest diameter ≤5 mm) using CT findings as the gold-standard. The accuracy of US for measuring stone size was also investigated. RESULTS: 219 millimetriccalculies in 164 cases were detected by CT. The sensitivity and positive-predictive-values for the detection of microcalculies were 76.7 and 94.9 %, 85.8 and 88.3 %, 40.6 and 97.8 %, 68.9 and 94.4 %, and 38.4 and 97.7 % for the presence of B-Mode echogenity, twinkling-artifact, B-Mode echogenity with acoustic shadowing, B-Mode echogenity with twinkling-artifact, B-Mode echogenity with acoustic shadowing and twinkling-artifact, respectively. No significant difference between US and CT was observed in quantification of nephrolithiasis sizes (p = 913). CONCLUSION: Twinkling-artifact based color-Doppler US is preferable for the sensitive detection of millimetrical nephrolithiasis; however, the high false-positive value of this technique, which can lead to an overestimation of the stone number, has to be considered.

Mature cystic renal teratoma.

Teratomas are rare germline tumors that originate from one or more embryonic germ cell layers. Teratoma of the kidney is extremely rare, and less than 30 cases of primary intrarenal teratomas have been published to date. We report the main radiologic features of an unusual case of mature cystic teratoma arising from the left kidney in a two-year-old boy. A left-sided abdominal mass was detected on physical examination and B-Mod Ultrasound (US) examination revealed a heterogeneous mass with central cystic component. Computed tomography (CT) demonstrated a lobulated, heterogeneous, hypodense mass extending craniocaudally from the splenic hilum to the level of the left iliac fossa. Nephrectomy was performed and a large, fatty mass arising from the left kidney was excised. The final pathologic diagnosis was confirmed as cystic renal teratoma.

US-guided femoral and sciatic nerve blocks for analgesia during endovenous laser ablation.

PURPOSE: Endovenous laser ablation may be associated with significant pain when performed under standard local tumescent anesthesia. The purpose of this study was to investigate the efficacy of femoral and sciatic nerve blocks for analgesia during endovenous ablation in patients with lower extremity venous insufficiency. METHODS: During a 28-month period, ultrasound-guided femoral or sciatic nerve blocks were performed to provide analgesia during endovenous laser ablation in 506 legs and 307 patients. The femoral block (n = 402) was performed at the level of the inguinal ligament, and the sciatic block at the posterior midthigh (n = 124), by injecting a diluted lidocaine solution under ultrasound guidance. After the blocks, endovenous laser ablations and other treatments (phlebectomy or foam sclerotherapy) were performed in the standard fashion. After the procedures, a visual analogue pain scale (1-10) was used for pain assessment. RESULTS: After the blocks, pain scores were 0 or 1 (no pain) in 240 legs, 2 or 3 (uncomfortable) in 225 legs, and 4 or 5 (annoying) in 41 legs. Patients never experienced any pain higher than score 5. The statistical analysis revealed no significant difference between the pain scores of the right leg versus the left leg (p = 0.321) and between the pain scores after the femoral versus sciatic block (p = 0.7). CONCLUSIONS: Ultrasound-guided femoral and sciatic nerve blocks may provide considerable reduction of pain during endovenous laser and other treatments, such as ambulatory phlebectomy and foam sclerotherapy. They may make these procedures more comfortable for the patient and easier for the operator.

Follow-up versus tissue diagnosis in BI-RADS category 3 solid breast lesions at US: a cost-consequence analysis.

PURPOSE: The aim of this study was to compare the economic effect of a proposed follow-up strategy for managing category 3 breast masses. The strategy incorporated direct tissue diagnosis at the patient's discretion for masses that had been assessed only based on ultrasonography (US) and for which mammography made no diagnostic contribution. MATERIALS AND METHODS: This prospective cohort study was conducted between 2003 and 2006 and included 174 patients. We used a two-year short-term follow-up protocol composed of five steps. A biopsy was recommended for masses that were increasing in size and changing in nature. The long-term results were available at the end of 2010. The mean and total costs were calculated for the women who preferred our follow-up protocol and for those who preferred direct tissue diagnosis. The cost savings were calculated by comparing the costs of the current study protocol to the costs of two different scenarios. RESULTS: Two malignancies were found among the 18 women who underwent tissue diagnosis on the recommendation of the radiologist during follow-up. Thirteen of these women underwent biopsy at the request of the patient or surgeon, and these biopsies all revealed benign tumors. The overall negative predictive value was 99.2% (95% confidence interval, 98.46%-100%). There was a statistically significant difference between the mean costs for the women who chose our follow- up regimen (147.57±106.7 TL) and those who preferred direct tissue diagnosis (426.89±149.8 TL) (P = 0.0001). The use of our follow-up protocol decreased the cost of diagnosis by 60% compared with the cost of using direct tissue diagnosis as the initial procedure. CONCLUSION: Our long-term results indicate that following-up solid category 3 masses detected only by US for at least two years at short intervals is a cost-effective alternative to direct breast biopsy.

An Effective Way to Solve Equivocal Mammography Findings: The Rolled Views.

SUMMARY: BACKGROUND: The aim of this study was to investigate the efficacy of the rolled views taken in craniocaudal (CC) and mediolateral oblique (MLO) projections in solving equivocal mammography findings. PATIENTS AND METHODS: The rolled views were taken by changing the positioning of the breast but not the obliquity of the X-ray beams. The breast was rolled medially or laterally in the rolled CC view, and inferiorly or superiorly in the rolled MLO view to separate overlapping structures from each other. RESULTS: We evaluated equivocal findings in 87 asymptomatic women undergoing either CC (n = 48, 55%) or MLO (n = 39, 45%) rolled views between 2001 and 2008. The rolled views were helpful in solving equivocal mammographic findings and making proper decisions on management in 85 of the 87 (97.7%) women. This technique was used for breast asymmetries in 55 of the 87 (63.2%) women, and was sufficient to directly show summation artifacts in 59 of 79 (74.6%) women. The rolled views revealed 4 intramammary lymph nodes, 2 circumscribed masses out of 6 obscured masses, 7 summation artifacts, and 2 circumscribed masses out of 9 questionable masses. CONCLUSIONS: The rolled view is an effective method of differentiating summation artifacts from real lesions on mammography in both the CC and the MLO view.

[Mammography-related pain and anxiety]. / Mamografi çekimine bagli agri ve kaygi.

PURPOSE: To investigate whether informing patients about mammographic compression changed the anxiety and pain that they experience during mammography. MATERIALS AND METHODS: Five hundred and one patients were enrolled in the study. Two hundred and fifty seven (51.3%) were informed before the procedure by written forms explaining the necessity of compression. The remaining 244 (48.7%) didn't get any pre-procedural information. All participants completed demographic form and Spielberger's State Anxiety Inventory while they were waiting for mammography. They marked the level of pain due to compression on a 100-mm visual analog scale (VAS) after the procedure. Chi square, Pearson's correlation and Student's t tests were used for statistical analyses. RESULTS: We didn't find any significant difference between the anxiety scores of the informed (41.4+/-7.9) and uninformed (40.9+/-7.7) women, but the pain level was significantly lower in the informed group (16.5+/-22.4) than in the uninformed group (24.5+/-28.1). There was no statistically significant relationship between the anxiety and pain levels. Women who had recently felt tense and nervous or had a fear of breast cancer diagnosis had higher anxiety levels. CONCLUSION: Our data shows that informing patients about examination decreases the level of pain due to mammographic compression, but does not alter the anxiety level. The main cause of anxiety appears to be the fear of a malignant diagnosis. Any intervention to decrease this fear may increase the compliance rates for screening mammography.