EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV - EUS-guided interventions: General Aspects and EUS-guided Sampling (Short Version).

The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle-based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV - EUS-guided Interventions: General aspects and EUS-guided sampling (Long Version).

The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V.

The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation in clinical practice (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V - EUS-Guided Therapeutic Interventions (short version).

The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation (short version; the long version is published online).

[Ultrasound in palliative care medicine]. / Bedeutung der Sonografie bei palliativmedizinischen Interventionen.

This review summarizes ultrasound guided interventions in palliative care medicine.

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (Short Version).

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (long Version).

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Short Version).

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version/ short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Long Version).

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version).

Incidence of bleeding in 8172 percutaneous ultrasound-guided intraabdominal diagnostic and therapeutic interventions - results of the prospective multicenter DEGUM interventional ultrasound study (PIUS study).

PURPOSE: To analyse the incidence of bleeding after percutaneous ultrasound guided diagnostic and therapeutic intraabdominal interventions in a prospective multicentre study (DEGUM percutaneous interventional ultrasound study). MATERIALS AND METHODS: Within a time period of 2 years diagnostic and therapeutic intraabdominal interventions (with the exclusion of ascites paracentesis) performed percutaneously under continuous ultrasound (US) guidance were prospectively assessed using a pseudonymized standardized web site entry form. Number and type of intervention, operator experience, patient characteristics, medication, lab data as well as technical aspects of the procedure and bleeding complications were analysed according to the interventional radiology standards. RESULTS: 8172 US-guided intraabdominal interventions (liver n = 5903; pancreas n = 501, kidney n = 434, lymph node = 272, biliary system n = 153, spleen n = 63, other abdominal organs and extra-organic targets n = 999) were analysed in 30 hospitals. The majority were diagnostic biopsies including 1780 liver parenchyma, 3400 focal liver lesions and 404 pancreatic lesions. 7525 interventions (92.1 %) were performed in hospitalized patients (mean age 62.6 years). Most operators were highly experienced in US-guided interventions (> 500 interventions prior to the study n = 5729; 70.1 %). Sedation was administered in 1131 patients (13.8 %). Needle diameter was ≥ 1 mm in 7162 punctures (87.9 %) with main focus on core needle biopsies (18 G, n = 4185). Clinically relevant bleeding complications with need of transfusion (0.4 %), surgical bleeding control (0.1 %) and radiological coiling (0.05 %) were very rare. Bleeding complications with fatal outcome occurred in four patients (0.05 %). The frequency of major bleeding complications was significantly higher in patients with an INR > 1.5 (p < 0.001) and patients taking a medication potentially interfering with platelet function or plasmatic coagulation (p < 0.0333). CONCLUSION: This prospective multicentre study confirms the broad spectrum of percutaneous US-guided intraabdominal interventions. However diagnostic liver biopsies dominate with the use of core needle biopsies (18 G). Percutaneous US-guided interventions performed by experienced sonographers are associated with a low bleeding risk. Major bleeding complications are very rare. A pre-interventional INR < 1.5 and individual medication risk assessment are recommended.

PALEOCLIMATE: Taking the Temperature of Past Ocean Surfaces.

Accurate reconstructions of past climatic conditions on Earth are important for modeling future climate change. Researchers use climate "proxies" from deep-sea sediments, corals, or ice cores to reconstruct these past climatic conditions, but as Nürnberg explains in this Perspective, different techniques often give different answers. A relatively new technique, Mg/Ca paleothermometry, is a particularly promising tool, especially in conjunction with oxygen isotope measurements on the same planktonic foraminiferal specimens. The power of this method is exemplified by the study by Lea et al.

[What's the price of routine sonography--results of an analysis of costs and processes in a district hospital]. / Was kostet die Sonografie--Ergebnisse einer Kosten- und Prozessanalyse an einem Versorgungskrankenhaus.

PURPOSE: The introduction of Diagnostic Related Groups (DRG) in hospitals also requires a calculation of the costs for material and staff to perform ultrasonographic examinations. Ultrasonography is currently not part of the regular procedure catalog of the DRG. Is ultrasonography for inpatients cost-effective? How much is a given examination today? The goal of this study was the analysis of examination times, times during which staff is required, and non-personnel costs for defined activities within an ultrasound department. MATERIALS AND METHODS: Within three weeks we registered all activities which included 692 ultrasound examinations. We analyzed repetitive processes as well as selected procedures. The performances were registered including all activities by medical and non-medical staff. We calculated the complete non-personnel and following costs and also considered the different levels of qualification of the examiners (DEGUM-Level 1 or 2). RESULTS: With this method we were able to precisely determine the costs for frequent ultrasonographic examinations. The time of an abdominal ultrasound examination was 16 minutes. The costs for an inpatient abdominal ultrasound were under conditions of public institutions tariff east (90% of west tariff) 35.70 euros, for an emergency ultrasound 41.82 euros, for a contrast-enhanced ultrasound 105.91 euros and for an ultrasound-guided puncture 97.05 euros. For examinations of higher qualified staff (DEGUM 2), 4.29 euros were added to the basic costs. The revenue for abdominal sonography and puncture in the ambulant setting is by no means cost-effective. CONCLUSIONS: In this article we show the dimension of costs for ultrasound in the inpatient setting and make it calculable. We show what resources it requires to perform ultrasound. In perspective the next step will be the comparison and evaluation of the efficiency of the different imaging methods, but that was not the aim of this study.

Southern Hemisphere forcing of South Asian monsoon precipitation over the past ~1 million years.

The orbital-scale timing of South Asian monsoon (SAM) precipitation is poorly understood. Here we present new SST and seawater δ18O (δ18Osw) records from the Bay of Bengal, the core convective region of the South Asian monsoon, over the past 1 million years. Our records reveal that SAM precipitation peaked in the precession band ~9 kyrs after Northern Hemisphere summer insolation maxima, in phase with records of SAM winds in the Arabian Sea and eastern Indian Ocean. Precession-band variance, however, accounts for ~30% of the total variance of SAM precipitation while it was either absent or dominant in records of the East Asian monsoon (EAM). This and the observation that SAM precipitation was phase locked with obliquity minima and was sensitive to Southern Hemisphere warming provides clear evidence that SAM and EAM precipitation responded differently to orbital forcing and highlights the importance of internal processes forcing monsoon variability.

[Complications of endoscopic ultrasound and endoscopic ultrasound-guided interventions - results of a survey among German centers]. / Komplikationen der Endosonografie und endosonografischer Interventionen - Ergebnisse einer Umfrage an deutschen Zentren.

BACKGROUND: Endoscopic ultrasonography is a widely used technique in Germany and not restricted to highly specialised centres. Complementary to the traditional radial scanners, longitudinally scanning echo endoscopes have gained considerable acceptation. Multicentre data on the complications of endoscopic ultrasound and endoscopic ultrasound-guided interventions at German centres do not exist. METHOD: From 2004 to 2006 all German centres performing endoscopic ultrasonography were surveyed and asked to report on their complications. RESULTS: From 1991 to 2006 100 604 endosonographic procedures had been performed in 67 centres (85,084 diagnostic endosonographies without any intervention, 13,223 endoscopic ultrasound-guided finde-needle aspiration biopsies, 2297 endoscopic ultrasound-guided therapeutic interventions). 38 centres reported on 104 complications, of which 88 were considered to be severe (overall complication rate 0.1 %). Complications of diagnostic endoscopic ultrasound occurred at a rate of 0.034 %, almost all of them were duodenal and oesophageal perforations. There had been complications in 0.29 % of all endoscopic ultrasound-guided fine-needle aspiration biopsies and subsequent to 1.61 % of all endoscopic ultrasound-guided therapeutic interventions. The overall mortality of non-interventional and interventional endosonographic procedures was 0.01 %. CONCLUSIONS: Under the specific circumstances in Germany, endoscopic ultrasound, both conventional and interventional, was confirmed to be a safe diagnostic and therapeutic technique. In future, the prospective assessment of complications should become an essential part of quality management of endoscopic ultrasound.

[Sonographical diagnosis of pneumoretroperitoneum as a result of retroperitoneal perforation]. / Das sonografische Bild des Pneumoretroperitoneums als Folge einer retroperitonealen Perforation.

A retroperitoneal perforation is a rare incident. It can occur as a complication of ERCP with papillotomy (0.2-0.5%). Leakage of contrast agent during endoscopy raises the suspicion that this complication has occurred but doesn't always give sufficient information about the leakage extent. In the case of extreme gas emission, a plain abdominal X-ray shows classic pneumoretroperitoneum. The abdominal CT scan can display small amounts of free air which is why it is used for diagnosis in such cases. Ultrasonography also provides a reliable diagnosis and is a good method for monitoring the progression of the condition. Alternative causes of pneumoretroperitoneum can be: trauma, inflammation, infection, tumor as well as ERCP and other interventional procedures, especially endoscopies. Presacral retroperitoneal pneumoradiography was used for the diagnosis of retroperitoneal tumors in the 70 s but is no longer used today. Perforations into the retroperitoneal space come from several locations in the gastrointestinal tract. In the different types of lesions the gas can penetrate the compartments and reach as far as the mediastinum, the intraabdominal cavity, subcutaneum (cervical) or the scrotal compartment (compartment shift). Based on 11 cases (7 perforations during ERCP, 2 perforation during colonoscopy, 2 cases with damage of the distal esophagus), we show the most extensive presentation of the sonographical picture of pneumoretroperitoneum. Typical signs on abdominal ultrasound are an increased echogenicity around the right kidney ("overcasted" or "covered" kidney), air dorsal to the gallbladder, around the duodenum and the head of the pancreas and especially ventral to the great abdominal vessel which can lead to the picture of "vanishing" vessels. The extent of free air is easy to assess. Even very small amounts are detectable ventral to the right kidney. In most cases, a conservative approach with no oral intake, antibiotic coverage, and analgesia in close gastroenterological-surgical cooperation is indicated. Especially after ERCP abscess formation is repeatedly described, sometimes even with a lethal outcome. Sonography is a suitable method for detecting free air in the retro-peritoneum. Pneumoretroperitoneum following bowel-perforation can be effectively shown by ultrasound, it is possible to assess the extent of free air, and sonographic monitoring of the treatment is possible and successful.

[Ultrasound of adrenal gland tumours and indications for fine needle biopsy (uFNB)]. / Sonographie von Nebennierentumoren--wann ist die Punktion indiziert?

The normal adrenal glands can be detected by high-resolution-sonography in a high percentage of cases. Sonography is also highly sensitive in the diagnosis of tumours of the adrenal glands. Only some of those tumours are hormonally active. Amongst the benign tumours, adenomas are the most frequent (up to 8%). Pheochromocytomas are less frequent (4.8% in uFNB statistics). Amongst the malignant tumours, metastases are more frequent than primary carcinomas (32.5% vs. 19.8% in uFNB-statistics). The adrenal glands are the fourth most common location of metastases. Bronchiogenic carcinomas, malignant melanomas, carcinomas of the breast and stomach as well as renal carcinomas metastasize into the adrenals most often. Much less frequent are infiltrates of lymphomas in adrenal glands tumours (3.4%). Incidentalomas are accidentally detected tumours of the adrenal glands without clinical symptoms. Malignant tumours only represent a very small part of incidentalomas (0.2%). They seldom show hormonal activity. In the case of an accidentally detected tumour, we propose a minimal laboratory profile (24-h-urinary-catecholamines, dexamethasone-test, electrolyte metabolism). The uFNB of the adrenal glands has a high sensitivity (90-95%). Complications are rare (pneumothorax, bleeding, pain; approximately 3%). Biopsy of pheochromocytomas (2-4% malignant) is dangerous because of the risk of provoking a hypertensive crisis. Case studies have been published about this problem. On the other hand, numerous cases of uncomplicated biopsies have also been published. Considering the excellent imaging methods and laparoscopic surgery methods on hand, the indication of FNP is restricted to the following cases: 1. the presence of a metastasis leading to therapeutical consequences; 2. suspected lymphoma 3. undefined lesion (3-5 cm), hormonally inactive, without typical signs of a tumour 4. patients refusing surgery. 5. uFNB in case of tumours of undefined dignity is only justified in specific cases. Recommendations for this procedure in accidentally detected tumours of the adrenal glands: < 3 cm and hormonally inactive --> US-follow up, > 5 cm + suspected tumour --> surgery, 3-5 cm uFNB after laboratory diagnostics.

[Prevalence of cholelithiasis. Results of an epidemiologic study using sonography in East Germany]. / Prävalenz der Cholelithiasis. Ergebnisse einer epidemiologischen Studie mittels Sonographie in der DDR.

In two middle-sized towns in the northern part of the German Democratic Republic, a random sample of the population and unselected subjects, respectively, were examined for gallbladder stones (GS) by ultrasound. The prevalence of cholelithiasis (sum of GS detected by ultrasound and history of cholecystectomy for GS) ist higher than in other European populations screened by similar methods. It is suggested that dietary habits are responsible for this finding. About one third of subjects with GS had complications of GS and about one third gave a history of cholecystectomy for GS. The frequency of nonspecific dyspeptic complaints was the same in persons with GS as in persons without GS.

[Epidemiology of gallbladder calculi in young females]. / Zur Epidemiologie von Gallenblasensteinen (GS) bei jungen Frauen.

In a population sample of nearly 900 women aged less than 25 years, prevalence of gallbladder stones (GS) was estimated by ultrasound and some risk factors were analyzed. GS were found in 4.8 percent. The prevalence of GS is significantly higher in females with GS in the family history as compared to persons without known GS in the family (11.8 vs. 2.6 percent); in women who have born as compared to nulliparae (10 vs. 3 percent); in obese women (BMI 26 or higher) as compared to lean women (15.1 vs. 4.2 percent). There was no significant correlation between intake of oral contraceptive and prevalence of GS.