Contrast-Enhanced Ultrasound Appearance of Hypervirulent Klebsiella pneumoniae Liver Abscesses.

There has been a paradigm shift with Klebsiella pneumoniae (KP) emerging as the most frequently isolated bacterium in pyogenic liver abscesses in immunocompetent patients. Colonization of this hypervirulent KP strain has led to community-acquired liver abscesses. Septic seeding to distant sites of the body has been recognized and is strongly associated with diabetes. Contrast-enhanced computed tomographic features have been described. Grayscale ultrasound (US) features remain inconclusive, with variable US appearances. Here we describe the contrast-enhanced US features of KP liver abscesses, which correlated with previously described computed tomographic findings. The use of contrast-enhanced US eliminates the need for radiation exposure.

Clinical Importance and Natural History of Biliary Sludge in Outpatients.

OBJECTIVES: Gallbladder sludge is a common diagnosis on routine abdominal sonography, yet its clinical importance is uncertain, especially in outpatients. To determine its natural history and potential future complications in this setting, we reviewed the imaging and clinical histories of nonhospitalized patients with a diagnosis of sludge on sonography. METHODS: We conducted a retrospective search of our institutional radiology information system for all sonographic reports using the key words "biliary sludge without gallstones" over a 3-year period. For each of the 104 patients with isolated biliary sludge on initial sonography, we reviewed the electronic medical records and all imaging for the development of pancreaticobiliary complications. RESULTS: We found an overall prevalence of biliary sludge in outpatients of 1.8%. Of the 104 patients reviewed with a mean follow up of 630 days (21 months), 25 developed a pancreaticobiliary complication, including cholelithiasis, cholecystitis, choledocholithiasis, and pancreatitis. The most frequent complication was cholecystitis, with a total of 14 diagnoses (12 chronic acalculous and 2 acute with gallstones). An additional 6 patients developed gallstones without cholecystitis features; 4 patients developed pancreatitis; and 1 developed choledocholithiasis. Biliary sludge remained quiescent or resolved in 76% of patients. CONCLUSIONS: Biliary sludge always represents a pathologic process, but its clinical implications among outpatients have not been previously investigated. Our ambulatory population developed pancreaticobiliary complications at similar rates as prior mixed-patient setting studies. Regardless of the patient setting, biliary sludge is likely of more clinical importance than previously regarded.

Utility of compact ultrasound in a mass surgical selection program in Africa: experience of a sonologist at the MV Africa Mercy Hospital Ship's screening day.

Compact ultrasound (US) was introduced in an austere setting with no other available imaging for an annual mass surgical screening day. Compact US examinations were performed on 25 patients from more than 7000 potential patients, as deemed possibly useful by the screening surgeons. Of the 20 patients with recorded data, compact US was helpful in 14 of 20 as a decision-making tool, obviating computed tomography for preoperative planning. Compact US was helpful in most cases, saving resources (computed tomography), technologist time, and radiation risk in this select population.

Intramural ectopic pregnancy: An individual patient data systematic review.

Intramural pregnancies (IMP) are very rare and represent about 1% of ectopic pregnancies (EPs). Despite a few reported cases, there is limited awareness & knowledge among sonographers and physicians. Moreover, no established diagnostic or treatment protocol exists for such a condition. This study identifies and synthesizes what is known about IMP, including etiology and pathophysiology, common clinical presentations, imaging features, laparoscopic and hysteroscopic findings, and management. PUBMED and Google Scholar were queried to identify eligible studies. All articles on IMP in human subjects available in English and French languages were included. Other types of ectopic pregnancies, including cesarean scar and cervical ectopic pregnancies, were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines and a narrative synthesis approach were used to systematically review the medical literature. 82 cases distributed around 27 countries with an average maternal age of 32.07 years and gestational age of 9.27 weeks were eventually selected for this study. History of curettage was the most common risk factor reported in 30 (36.58%) patients, followed by history of salpingectomy, assisted reproduction with embryo transfer, and previous cesarean delivery, in 10(12.19%), 10(12.19%), and 9(10.97%) patients respectively. Ultrasound was performed in 80(97.56%) cases. Of the 66 reported ultrasound findings, 29 were diagnostic or suggestive of IMP. MRI, laparoscopy (both diagnostic & surgical) and diagnostic hysteroscopy were carried out on 18(21.95%), 36(43.9%) and 22(26.83%) patients respectively. Histopathologic examination mainly performed after surgery was the gold standard for confirming the diagnosis. Management involved conservative (3.65%) approach, medical treatment with methotrexate or potassium chloride (23.17%), and surgical interventions. The latter includes laparoscopic surgery (25.61%), laparotomic surgery (23.17%), and hysterectomy (13.41%). IMP is a rare but potentially lethal clinical entity. A significant proportion of patients are asymptomatic and have no known risk factors. Correlation between clinical history and imaging findings is vital to establish a prompt diagnosis and reduce the risk of a catastrophic outcome.

Radiology on the Africa Mercy, the largest private floating hospital ship in the world.

OBJECTIVE: The Africa Mercy, a rehabilitated Danish ferry, is the largest private hospital ship in the world, devoted to providing medical and surgical care to the residents of West Africa, one of the poorest regions on the globe. CONCLUSION: There is a small radiology department on board, along with six operating rooms and a small ICU and inpatient wards, and the former is described in this report, as well as opportunities for humanitarian work by volunteer radiologists.

Image quality in real-time teleultrasound of infant hip exam over low-bandwidth internet links: a transatlantic feasibility study.

Evolution of communication systems, especially internet-based technologies, has probably affected Radiology more than any other medical specialty. Tremendous increase in internet bandwidth has enabled a true revolution in image transmission and easy remote viewing of the static images and real-time video stream. Previous reports of real-time telesonography, such as the ones developed for emergency situations and humanitarian work, rely on high compressions of images utilized by remote sonologist to guide and supervise the unexperienced examiner. We believe that remote sonology could be also utilized in teleultrasound exam of infant hip. We tested feasibility of a low-cost teleultrasound system for infant hip and performed data analysis on the transmitted and original images. Transmission of data was accomplished with Remote Ultrasound (RU), a software package specifically designed for teleultrasound transmission through limited internet bandwidth. While image analysis of image pairs revealed statistically significant loss of information, panel evaluation failed to recognize any clinical difference between the original saved and transmitted still images.

Compact ultrasound donations to medical facilities in low-resource countries: a survey-based assessment of the current status and trends.

OBJECTIVES: Many ultrasound (US) specialists, independently or as part of institutionally directed teams, have donated compact US equipment and training to rural and urban clinics in low-resource regions. The objective of our study was to assess the scope, impact, and characteristics of these donation and training activities. METHODS: We designed a 1-page, 10-question survey soliciting responses on donors, equipment, donation sites, training, and follow-up. Physicians and sonographers with qualifying donation experience were located by means of personal references, professional networking, and referral from US manufacturers. Respondents were also solicited at several online sites for medical imagers. The survey was active from May 2010 to March 2011 and was available via an interactive website (www.surveymonkey.com) or as an electronic download directly from the authors. RESULTS: Fifteen respondents provided data on deployments spanning a 7-year period from 2004 to early 2011. Forty-eight compact US units were donated to sites in 15 different nations on 4 continents; 69% of the units went to sites in Africa. All but 4 sites received initial training. Donated systems were reported as "operational and functional" for all units for which the current status was available. CONCLUSIONS: Results suggest involvement by a broad variety of participants. The number of successful deployments and excellent equipment durability support the premise that small-scale, individual donation and training activities have the potential for a substantial public health impact. The authors recommend better coordination of effort and the need for additional data.

Incarcerated gravid uterus: A rare but potentially devastating obstetric complication.

Incarceration of the gravid uterus is a rare obstetric complication characterized by entrapment of the gravid uterus between the sacral promontory and pubic symphysis. Clinical symptoms are highly variable and may include low back pain, urinary retention, and nausea. A presumptive diagnosis can often be established based on correlation of clinical history and physical examination. However, ultrasound and/or pelvic magnetic resonance imaging are essential for confirmation. Herein, we describe a 30-year-old female who presented with uterine incarceration and discuss the diagnosis, imaging features, and management of this uncommon but important clinical entity.

Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work.

This study examined the HIV risk behaviors and life experiences of 151 transgender female youth, ages 15-24, in Los Angeles and Chicago. Descriptive analyses and logistic regression modeling were used to identify life factors associated with ever having engaged in sex work. Sixty-seven percent of participants had ever engaged in sex work and 19% self-reported being HIV positive. Many factors were significantly associated with sex work for this sample population. A final multivariate logistic regression model found that lower education status, homelessness, use of street drugs, and perceived social support remained significantly associated with sex work when controlling for other factors. Findings highlight the complex HIV risk environment and suggest a need for sex work initiation research for transgender female youth. HIV prevention efforts for this population need to include broad-based approaches that take into account individual, social, and community-level factors relevant to the lives of transgender female youth.

Compact ultrasound for improving maternal and perinatal care in low-resource settings: review of the potential benefits, implementation challenges, and public health issues.

OBJECTIVE: Ultrasound imaging, a front-line diagnostic tool for perinatal care, is rarely available in the developing world, where maternal and newborn mortality rates are starkly higher than elsewhere. The development of portable and inexpensive medical ultrasound machines (compact ultrasound) offers the possibility of broader use of ultrasound. Our objective was to assess the potential benefits and challenges of deploying compact ultrasound in developing countries for improving obstetric health. METHODS: Existing literature on perinatal care, compact ultrasound, and issues in the deployments of medical technology in low-resource settings was reviewed. Anecdotal evidence was assessed, and the authors' field experiences in Nicaragua and Mali were evaluated as a template for wider deployments. RESULTS: Few published studies directly concerned with compact ultrasound in low-resource settings were found. These, however, in combination with available anecdotal data, support the view that compact ultrasound in less-developed regions is feasible and would result in a relatively low-cost improvement in perinatal care. CONCLUSIONS: The development of lightweight, portable, and relatively inexpensive ultrasound systems offers a great opportunity for reducing maternal and neonatal mortality in low-resource settings. Evidence-based analysis of compact ultrasound deployments as a public-health response to obstetric needs in less-developed countries has been hampered by limited data in 3 key areas: maternal and perinatal mortality and morbidity in these settings, evaluations of compact ultrasound systems as reliable alternatives to full-sized systems, and the lack of outcomes data based on actual deployments of compact ultrasound for this purpose. Field trials of compact ultrasound on a scale commensurate with public health interventions should be undertaken.

The chorionic bump in an ectopic pregnancy.

The chorionic bump, an irregular, convex bulge of the choriodecidual surface into the gestational sac (GS), is a recently described, uncommon abnormality of the 1st-trimester GS and is associated with a guarded prognosis for early pregnancy. The case of this 42-year-old female demonstrates a previously unreported relationship: a transvaginal sonographic finding of a chorionic bump associated with a spontaneous tubal ectopic pregnancy. This might support the hypothesis that the chorionic bump represents a small hematoma that bulges into the GS.

Developing a rational tumor vaccine therapy for renal cell carcinoma: immune yin and yang.

In patients with progressive malignancy, the natural balance between proinflammatory (Yang) and inhibitory (regulatory or Yin) immune pathways is disrupted and favors cancer-specific immune suppression. Therapy with interleukin 2 (IL-2) can mobilize immune effector cells that recognize and destroy cancer. High-dose IL-2 is the only therapy that has consistently induced complete durable remissions in patients with metastatic renal cell carcinoma (RCC) but only in a few of them. The lack of benefit in most metastatic RCC patients is likely due to the ineffective manipulation of other immune circuits critical in regulating tumor cytotoxic pathways. The limited clinical activity of IL-2, RCC vaccines, and other immune therapies to date leads us to postulate that effective clinical treatment strategies will need to simultaneously enhance proinflammatory pathways and disrupt regulatory pathways. We present preliminary studies in RCC patients to highlight the complexity of the regulatory pathways and our approach to shifting the balance of proinflammatory and regulatory immune pathways using dendritic cell-tumor lysate vaccine followed by cytokine therapy.

The feasibility of real-time transmission of sonographic images from a remote location over low-bandwidth Internet links: a pilot study.

OBJECTIVE: We sought to show that sonography can be performed in teleconference settings, "telesonography," in which a remotely located sonography interpreter can monitor the examination in real-time and guide the examiner with voice commands while the patient simultaneously undergoes imaging, albeit at low resolution, thus helping to overcome the lack of trained operators in certain areas. CONCLUSION: This system of image transfer offers the potential for sonography to be performed at a remote underdeveloped region and interpreted in real-time at a distant site by trained radiologists, thereby extending the presence of physicians in virtual space.

Clinical impact of systematic genetic sonogram screening in a low-risk population.

OBJECTIVE: To determine the clinical impact of a genetic sonogram (GS) on a population at low risk for trisomy 21 (T21). STUDY DESIGN: A GS evaluating common major and minor markers was created and prospectively applied to consecutive women at 15-20 weeks' gestation presenting for routine ultrasound and at low T21 risk. Prenatal diagnosis (PND) referral occurred if 1 major marker, 2 minor markers, major malformation or choroid plexus cysts (CPCs) were seen. Neonatal outcomes were determined by chart review for neonates born at our institution and by letter for those born elsewhere. Using an ultrasound database, a similar population was identified prior to study inception and the GS retrospectively applied. PND referrals in both periods were confirmed by chart review. The rates of isolated minor marker (IMM), positive GS and PND referrals were compared using chi2 analysis. RESULTS: IMM detection was unchanged (43 of 434, 10.1%) in the study vs. (23 of 243, 9.5%) control group. Excluding CPCs, 6 of 18 (33.3%) subjects of vs. 2 of 28 (7.1%) controls with IMM were referred for prenatal diagnosis (p < 0.03). The frequency of positive GS was unchanged: 14 of 434 (3.2%) subjects vs. 5 of 243 (2.1%) controls. CONCLUSION: Currently no prospectively studied, effective ultrasound models exist for screening low-risk populations at 15-20 weeks. A GS with clear criteria for counseling on an increased T21 risk decreased inappropriate referrals without increasing positive screens.

ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group.

Acute pelvic pain in premenopausal women frequently poses a diagnostic dilemma. These patients may exhibit nonspecific signs and symptoms such as nausea, vomiting and leukocytosis. The cause of pelvic pain includes a myriad of diagnostic possibilities such as obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The choice of the imaging modality is usually determined by a suspected clinical differential diagnosis. Thus the patient should undergo careful evaluation and the suspected differential diagnosis should be narrowed before an optimal imaging modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice, to assess for pelvic pain, when an obstetric or gynecologic etiology is suspected and computed tomography is often more useful when gastrointestinal or genitourinary pathology is thought to be more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies owing to its lack of ionizing radiation.The American College of Radiology Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

The disruptive radiologist.

Radiologists interact with many individuals during daily practice, including patients, technologists, and other physicians. Some interactions may potentially negatively affect patient care and are termed "disruptive" behaviors. These actions are not uncommon and may begin during training, long before a radiologist enters clinical practice. The causes of disruptive behavior are multifactorial, and it is important that educators and radiologists in practice alike be able to identify them and respond accordingly. An escalated approach for both trainees and practicing radiologists is recommended, with substantial penalties after each incident that can include termination of employment. Training programs and practices must have clearly defined methods for confronting this potentially time-consuming and difficult issue.

ACR appropriateness Criteria® infertility.

Appropriate imaging for women undergoing infertility workup depends upon the clinician's suspicion for potential causes of infertility. Transvaginal US is the preferred modality to assess the ovaries for features of polycystic ovary syndrome (PCOS), the leading cause of anovulatory infertility. For women who have a history or clinical suspicion of endometriosis, which affects at least one third of women with infertility, both MRI and pelvic US can provide valuable information. If tubal occlusion is suspected, whether due to endometriosis, previous pelvic inflammatory disease, or other cause, hysterosalpingogram (HSG) is the preferred method of evaluation. To assess for anatomic causes of recurrent pregnancy loss (RPL) such as Müllerian anomalies, synechiae, and leiomyomas, saline infusion sonohysterography, MRI and 3-D US are most appropriate. Up to 10% of women suffering recurrent pregnancy loss have a congenital Müllerian anomaly. When assessment of the pituitary gland is indicated, MRI is the imaging exam of choice.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR appropriateness criteria staging and follow-up of ovarian cancer.

Imaging is used to detect and characterize adnexal masses and to stage ovarian cancer both before and after initial treatment, although the role for imaging in screening for ovarian cancer has not been established. CT and MRI have been used to determine the resectability of tumors, the candidacy of patients for effective cytoreductive surgery, the need for postoperative chemotherapy if debulking is suboptimal, and the need for referral to a gynecologic oncologist. Radiographic studies such as contrast enema and urography have been replaced by CT and other cross-sectional imaging for staging ovarian cancer. Contrast-enhanced CT is the procedure of choice for preoperative staging of ovarian cancer. MRI without and with contrast may be useful after equivocal CT, but is usually not the best initial procedure for ovarian cancer staging. Fluorine-18-2-fluoro-2-deoxy-D-glucose-PET/CT may not be needed preoperatively, but its use is appropriate for detecting and defining post-treatment recurrence. Ultrasound is useful for evaluating adnexal disease, but has limited utility for staging ovarian cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.