Iohexol: effects on uptake of radioactive iodine in the thyroid and on thyroid function.

RATIONALE AND OBJECTIVES: The authors attempted to determine whether the use of nonionic contrast media causes uptake of iodine by the thyroid to be blocked and whether use of these agents could cause iodine-induced hyperthyroidism. MATERIALS AND METHODS: Twenty-eight persons, including 22 with thyroid disease, were included in the study. Subjects underwent computed tomography (CT) of the thyroid after injection of 100 mL of iohexol. Thyroid function variables were measured before CT scanning and 1 week and 1 month later. In 16 subjects, uptake of iodine-131 by the thyroid was measured before and 1 week after CT. RESULTS: I-131 uptake was reduced to 53.4% at 1 week after the injection of iohexol but became normal within a few weeks (followed up in one patient). An accelerated escape of I-131 from the thyroid was seen during the 1st days after the iohexol administration. Eight of 22 patients with an underlying thyroid disease had a temporary change in thyroid function. In four patients, the serum thyrotropin level was increased 1 week after the iohexol administration. In four other patients, temporary hyperthyroidism developed during the following months. CONCLUSION: Iohexol can be used in patients with an underlying thyroid disease, but close monitoring in the following months is necessary.

[Hepatic metastases disclosed by laparoscopy and echographic laparoscopy. Impact of ultrasound-guided biopsy]. / Métastases hépatiques découvertes par laparpscopie et écho-laparoscopie. Impact de la biopsie échoguidée.

UNLABELLED: The aim of this prospective study was to study the impact of biopsies of liver metastases guided by laparoscopic ultrasound (LUS) and to evaluate various biopsy techniques. MATERIAL AND METHODS: Laparoscopy with LUS was performed on 18 consecutive patients with liver metastases considered to be surgically curable. Any new liver lesion which could lead to a therapeutic modification was biopsied, with a forceps or guided by LUS using four different techniques. RESULTS: Of 17 patients successfully examined, a biopsy was indicated in 12 cases (71%), extension of the surgical procedure was decided in four cases (24%), and laparotomy was avoided in six cases (35%). The preoperative staging was correct in 15 stages (88%) and incorrect in two cases (12%). The positioning of the puncture needle in the axis of the scanning plane by "free hand" or in association with an abdominal transducer was effective, without complications. CONCLUSION: Any liver lesion discovered by LUS which could lead to a modification or abstention of surgery should be biopsied, with LUS-guidance in the case of deep lesions. However, an optimal and universal guiding system for LUS-probes, has not yet been developed.

[Cardiovascular effects of a calcium channel blocker in hypoxia caused by altitude]. / Effets cardiovasculaires d'un bloqueur calcique en hypoxie d'altitude.

OBJECTIVE: High altitude pulmonary oedema can be successfully treated and prevented by calcium channel blockers. Moreover, calcium entering in the cells could explain the congestive phenomena of acute mountain sickness (AMS). These findings led us to study the action of a calcium channel blocker, isradipine, in the prevention of non-complicated AMS. METHODS: In a double blind randomized study, 20 healthy volunteers received 5 mg of isradipine (n = 6) or placebo (n = 6) for 8 days. After 5 days of treatment in normoxia, the subjects were rapidly transported to an altitude of 4350 m. The efficiency of the treatment was then estimated by the AMS symptom score, haemodynamic parameters and renal function. RESULTS: The administration of isradipine did not significantly modify AMS symptom score nor most of other parameters measured in high altitude hypoxia. Heart rate was an average of 15 b/min lower in the isradipine group, probably because of a direct action of isradipine on the sinus node. Otherwise, the effects of hypoxia were similar in both groups and were in accordance with the literature. There was no clear explanation for the increase in cardiac output and stroke volume when the subjects moved from supine to standing position. Renal blood flow, measured by Doppler or para-aminohippuric acid clearance was not modified by hypoxia. Cerebral blood flow was elevated, due to the direct vasodilator effect of hypoxia. However this increase did not seem to be the main mechanism responsible for the congestive phenomena. On the other hand, the increase in capillary permeability (demonstrated by the increased transcapillary escape rate of albumin, and albuminuria) appeared to play a major role in the pathogenesis of AMS and high altitude cerebral oedema. Isradipine had no protective effect on these phenomena and its use should be restricted to the treatment of high altitude pulmonary oedema.

Impact of intraoperative ultrasonography on surgical treatment of liver tumours.

PURPOSE: The aim of this study was to evaluate the impact of intraoperative ultrasonography (IOUS) on surgical decision-making in patients with liver tumours. MATERIAL AND METHODS: IOUS of the liver was performed in 116 patients undergoing surgery for liver tumours. The patients were evaluated preoperatively by ultrasonography, CT and in some cases, by ERCP and scintigraphy. IOUS findings were compared with the results of preoperative imaging and surgical findings. RESULTS: The surgical procedures were altered in 50 cases (43%), extended in 19 cases (16%) and reduced in 8 cases (7%). Twenty-three patients (20%) were found inoperable. Intraoperative evaluation caused surgical modification by IOUS in 13 patients (11%), by surgical findings in 14 patients (12%) and by a combination of both in 23 patients (20%). CONCLUSION: IOUS is a precise diagnostic method for staging the operability of liver tumours. Unnecessary surgical procedures can be avoided. In total, IOUS altered the preoperative plan in one-third of our patients and is therefore recommended as a routine procedure in connection with major liver surgery.

Power Doppler ultrasonography for assessment of synovitis in the metacarpophalangeal joints of patients with rheumatoid arthritis: a comparison with dynamic magnetic resonance imaging.

OBJECTIVE: To evaluate the effectiveness of power Doppler ultrasonography (PDUS) for assessing inflammatory activity in the metacarpophalangeal (MCP) joints of patients with rheumatoid arthritis (RA), using dynamic magnetic resonance imaging (MRI) as a reference method. METHODS: PDUS and dynamic MRI were performed on 54 MCP joints of 15 patients with active RA and on 12 MCP joints of 3 healthy controls. PDUS was performed with a LOGIQ 500 unit by means of a 7-13-MHz linear array transducer. Later the same day, MRI was performed with a 1.0T MR unit. A series of 24 coronal T1-weighted images of the second through the fifth MCP joints was obtained, with intravenous injection of gadolinium diethylenetriaminepentaacetic acid after the fourth image (dynamic MRI). From the MR images, the rate of early synovial enhancement (RESE; defined as the relative enhancement per second during the first 55 seconds postinjection) was calculated and compared with the flow signal on PDUS, which was scored as present or absent. RESULTS: In RA patients, flow signal on PDUS was detected in 17 of 54 MCP joints examined. Postcontrast MR images revealed an RESE of > or = 1.0%/second in 18 of 54 RA MCP joints. PDUS showed no flow in 47 of 48 MCP joints with an RESE of <1.0%/second and revealed flow in 16 of 18 MCP joints with an RESE of > or = 1.0%/second. Using dynamic MRI as a reference, PDUS had a sensitivity of 88.8% and a specificity of 97.9%. CONCLUSION: PDUS was reliable for assessing inflammatory activity in the MCP joints of RA patients, using dynamic MRI as the standard. PDUS and clinical assessment of joint swelling/tenderness were only weakly correlated.

Intramuscular myxoma and fibrous dysplasia of bone--Mazabraud's syndrome. A case report.

We present a case of Mazabraud's syndrome, a rare benign disease, with multiple intramuscular myxomas of the thoracic wall associated with fibrous dysplasia of bone. CT, MR imaging and ultrasonography (US) of the thorax showed 2 well circumscribed homogeneous intramuscular tumors. A US-guided needle biopsy with a large-core needle (2.0 mm) and a fine needle (0.8 mm) showed that the tumors were intramuscular myxomas with no sign of malignancy. 99mTc bone scintigraphy showed a markedly increased uptake in the right lower skull, and multiple smaller foci. CT of the skull revealed a right-sided unilateral bone thickening of the orbit and the ethmoidal cells, and right-sided exophthalmia. This case history suggests that patients with multiple intramuscular myxomas should be preoperatively examined for osseous lesions. A postoperative follow-up should also be performed to detect other soft-tissue myxomas not as yet clinically detectable, or rare osseous complications.

Liver volume, portal vein flow, and clearance of indocyanine green and antipyrine in hyperthyroidism before and after antithyroid treatment.

BACKGROUND: The aim of the study was to examine liver volume, portal vein flow, and indocyanine green (ICG) and antipyrine clearance in hyperthyroidism before and after antithyroid drug treatment. METHODS: Liver volume and blood flow in the portal vein were investigated in nine fasting patients with hyperthyroidism by means of computed tomography scan and Doppler ultrasound, respectively. ICG clearance was estimated by bolus injection of ICG (0.5 mg/kg body weight) and antipyrine clearance with a one-sample technique. All patients were investigated before and after 3 months of antithyroid treatment, when euthyroidism had been achieved. The Wilcoxon matched-pairs test was used for statistical analysis. RESULTS: The median liver volume increased by 238 (155-289) ml (median, 95% confidence interval), corresponding to 19%, and the weight by 5.0 (0.0-8.0) kg (8%), and the antipyrine clearance decreased by 8 (3.1-34.4) ml/min (16%). These changes were all significant (P < 0.05). The relation between liver volume and body weight increased from 19.9 (16.5-23.7) ml/kg to 21.4 (17.1-21.9) ml/kg (P = 0.11). The liver blood flow as estimated by ICG clearance and Doppler ultrasound was not altered significantly after the treatment period (P = 0.07 and 0.77, respectively). CONCLUSIONS: The liver volume increased by 19% in nine hyperthyroid patients during treatment with antithyroids. Antipyrine clearance was reduced by 16%, whereas liver blood flow, as estimated by ICG clearance and Doppler ultrasound examination of portal vein flow, was not significantly altered. A differential regulation of liver volume and oxidative metabolic capacity in hyperthyroidism was seen.

Lymphocyte subset composition in peripheral blood from normal subjects may be influenced by both spleen size and plasma norepinephrine.

The aim of the present study was twofold: (a) to confirm a previously observed negative relationship between plasma catecholamines and the percentage of natural killer (NK) cells in peripheral blood from resting human subjects, and (b) to examine the relationship between the size of the spleen and the composition of circulating lymphocyte subsets in resting subjects. A total of 14 young healthy male subjects were investigated in a supine resting position. Lymphocyte subset composition was determined with two-colour flow cytometry, and lymphocyte subsets were expressed as percentages of mononuclear cells. Spleen size was evaluated with ultrasonography. Plasma catecholamines were determined. Plasma norepinephrine and the percentage of NK-cells (CD3-CD56+) were negatively correlated (rs = -0.62, p = 0.019). The CD4/CD8 ratio and plasma norepinephrine were positively correlated (rs = 0.57, p = 0.037) and the major part of this correlation was due to a correlation between plasma norepinephrine and the percentage of CD4+ cells. The percentage of NK cells (CD3-CD56+) was predicted by a multiple regression model including the percentage of CD8+ cells and the spleen index, a measure of spleen size (r = 0.93, p < 0.001). The correlation in the resting state between plasma norepinephrine and the percentage of NK cells (negative correlation) on the one hand and the CD4/CD8 ratio (positive correlation) on the other contrasts with the acute mobilizing effects of epinephrine, isoproterenol and exercise on lymphocyte subsets. These relationships remain unexplained, but results accord with the hypothesis that catecholamines may have dual effects on lymphocyte subsets. The results support the view that the spleen may have a depot function for NK cells.

Ultrasonic measurement of the anterior translation in the shoulder joint.

A new method for measuring the anterior translation in the shoulder joint by dynamic ultrasound was evaluated. We placed a 3.5-MHz transducer on the shoulder anteriorly. By using 3 bony landmarks, we then measured the anterior translation of the humeral head with a force of 90 N applied posteriorly. We performed such measurements in 20 subjects with healthy shoulders and in 20 patients with unilateral shoulder instability. There was a mean translation of 1.9 mm in healthy shoulders and 4.9 mm in unstable shoulders (P < .01). The mean difference between the 2 sides in subjects with normal shoulders was 0.7 mm, whereas the mean difference in patients with instability was 2.8 mm (P < .01). The normal shoulders were examined by 2 examiners to determine the degree to which different examiners' measurements might vary. Although one examiner recorded higher values than the other, the new method seems suitable for measuring increased laxity in unstable shoulders.

Haemodynamic effects of eating: the role of meal composition.

1. The purpose of this study was to investigate the effect of fractional meal stimulation on postprandial haemodynamic changes, the possible correlation between these changes and the potential mediating role of circulating catecholamines and insulin. 2. Healthy young subjects were studied before and after ingestion of isocaloric, isovolumetric high-protein, carbohydrate or fat meals (80-85% of total energy), 60 kJ per kg of body weight. Multigated radionuclide cardiography with autologous 99mTc-labelled erythrocytes was performed for assessment of cardiac output, venous occlusion plethysmography to obtain forearm blood flow and Doppler-ultrasonography for portal vein flow. Plasma levels of catecholamines and insulin were determined by radioimmunoassay. 3. Cardiac output increased considerably after each meal, including the control meal (water) with only minor differences in extent and timing. Left ventricular volumes increased after food intake, most pronounced after carbohydrate and protein. Forearm blood flow increased only after carbohydrate and protein. Portal vein flow increased after all meals, especially after fat, but also after the control meal. There was a significant correlation between the increment in cardiac output and changes in forearm and portal vein flow, but no correlation between either haemodynamic response and plasma catecholamines or insulin. 4. Postprandial cardiovascular changes are not substantially different after various isocaloric and isovolumic meal compositions. Gastric distension seems to play a role in the increase in cardiac output, accomplished by ventricular dilatation. These changes seem to some extent to be linked to changes in muscle and splanchnic flow.

Acute puerperal breast abscesses: US-guided drainage.

Breast abscesses typically develop in lactating women. The recommended treatment is surgical incision and drainage with the patient under general anesthesia. Ultrasonically guided percutaneous drainage with local anesthesia was performed in 19 consecutive patients referred for treatment because of clinical signs of acute puerperal breast abscess. Eighteen of the 19 patients (95%) were successfully treated. Long-term follow-up (median, 12 months) did not show any recurrences, and the cosmetic results were excellent. Eight of the 19 patients (42%) continued nursing during and after treatment. Ten of the 19 (53%) were treated on an outpatient basis. On the basis of these results, the authors recommend ultrasonically guided percutaneous treatment for use in patients with acute puerperal breast abscesses.

Ultrasonography in arthritis of the knee. A comparison with MR imaging.

Ultrasonography (US) of the knee in gonarthritis was evaluated with gadolinium-DTPA-enhanced MR imaging as a reference. The study included 13 patients with gonarthritis, 2 patients with osteoarthritis and 5 healthy controls. Compared to MR, US identified 100% (12/12) of joint effusions, 100% (5/5) of Baker's cysts, 57% (8/14) of the synovial membranes of the suprapatellar recess and 38% (3/8) of bone erosions. No MR or clinical findings characterized the patients with ultrasonographically identifiable synovial membranes. Quantitative MR- and US-estimates of effusion, synovial membrane and cartilage thicknesses were correlated. The Spearman correlation coefficients were 0.87, 0.86 and 0.82, respectively. US reliably demonstrated joint effusions and Baker's cysts but showed lack of sensitivity for demonstration of the synovial membrane and bone erosions. When the synovial membrane was identifiable, the measurements of synovial thickness by US appeared precise. Cartilage evaluation by US seemed dependable. The clinical value was limited, because the weight-bearing areas were inaccessible.

Doppler ultrasound assessment of TIPS patency and function--the need for echo enhancers.

PURPOSE: The aim of this study was to illustrate the versatility of an i.v. administered echo enhancer for Doppler US assessment of TIPS patency and function. MATERIAL AND METHODS: A total of 22 Doppler US evaluations of TIPS patency and function were performed in 5 patients with alcoholic cirrhosis and recurrent oesophageal bleeding who had been treated with TIPS. TIPS patency was evaluated by means of colour or power Doppler US. The volume flow (VF) was assessed in the TIPS and in the portal vein by spectral Doppler. The ratio of the VF in the TIPS to the VF in the portal vein (T/P ratio) was used to express the functional status of the TIPS. If Doppler signals were inconclusive or absent, echo-enhanced US was performed. RESULTS: In 22 follow-up Doppler US examinations, echo-enhanced Doppler US was required in 7 cases (29%). The Doppler enhancement persisted in the range of 3-5 min. No adverse effects were observed. An apparently normal TIPS function reflected a T/P ratio in the range of 0.44-1.10, median 0.78 +/- 0.20 (2SD). CONCLUSION: The i.v. administration of echo enhancers would seem to be indicated in the assessment of the TIPS function if conventional Doppler US fails to prove normal TIPS patency and function. The T/P ratio may be a convenient monitoring parameter for reflecting the TIPS function.

Thyroid volume measured by ultrasonography and CT.

PURPOSE: To evaluate measurements of thyroid volume by two different US methods and CT in a blinded design. MATERIAL AND METHODS: Four observers evaluated 27 patients. Observer 1 used US and calculated thyroid volume based on recordings of cross-sections through the gland. Observer 2 used US and calculated the volume of each lobe as a rotation ellipsoid. Observers A and B used CT images and calculated thyroid volume based on recordings of cross-sections through the gland. All measurements were made twice. RESULTS: The median thyroid volume was 81 ml (range 7-470 ml) evaluated by CT. All three methods had fair reproducibility. When correlating the two different methods using US, an r of 0.837 was found. When correlating data from patients without intrathoracic goitre evaluated by US (Observer 1) and CT, r = 0.945. The method based on a rotation ellipsoid systematically produced smaller thyroid volumes than those of the cross-sectional method. Evaluation by US systematically produced smaller thyroid volumes than CT. CONCLUSION: Calculation of thyroid volume based on US recordings of cross-sectional areas is a reproducible method in patients without substernal goitre extension. The US method calculating thyroid volume as a rotation ellipsoid is less reproducible, especially in large goitres. Measurement of thyroid volume using CT should be preferred in goitres with substernal extension.

US-guided fine-needle aspiration biopsy of thyroid nodules.

PURPOSE: To determine which nodular areas provide most adequate and accurate material for cytology during US-guided fine-needle aspiration biopsy (FNAB) of thyroid nodules. MATERIAL AND METHODS: In a prospective multicentre study, US-guided FNAB (0.8 mm) was performed in 342 thyroid nodules (338 patients, 285 women, 18-83 years, 285 palpable). Histology was obtained in 169 nodules, revealing 75 neoplasms (44.4%) including 18 cancers (10.7%). In 206 solid nodules, 2 passes (central and peripheral) were compared. In 82 complex nodules, 2 passes (solid area and cystic area) were compared. RESULTS: The inadequacy rate was 16.4% and the false-negative rates were 2.2% and 28.1% for the diagnosis of cancer and neoplasm, respectively. In solid nodules, material was more adequate with peripheral passes compared to central passes, but the difference was not significant. In complex nodules, the inadequacy rate was much higher for passes in cystic areas (80.5%) compared to passes in solid areas (46.3%). CONCLUSION: Cystic areas due to degeneration seldom provided adequate material when aspirated. Aspiration should always be obtained from solid areas, at best using US-guidance. Adenomas and non-neoplastic nodules were difficult to distinguish.

Perioperative Doppler ultrasonography: renal detection of renal graft perfusion.

Irreversible damage of renal transplants may be prevented if insufficient graft perfusion can be detected perioperatively. Colour and spectral Doppler ultrasonography were performed in 30 consecutive renal transplants. The perfusion of the graft and the Resistive Index (RI) were evaluated perioperatively (perioperatively and less than 15 min postoperatively) and 24 h after the operation in all patients. In four cases (13.3%) RI > 0.9 was detected and immediate surgical correction of the cause led to a normalization (RI < 0.8) in all four cases. A RI < 0.9 required no intervention in 26 cases (86.7%). All renal grafts in this series were functioning 1 month postoperatively. In a comparative group, 30 consecutive transplants carried out at our institution without perioperative Doppler ultrasonography evaluation, a loss of four renal grafts perioperatively was recorded retrospectively. We conclude that perioperative ultrasonography Doppler evaluation may provide an easy applicable and reliable method for early detection of insufficient renal graft perfusion, allowing surgical correction before irreversible damage of the graft occurs. RI > 0.9 is pathological. A continuation of the study is required to clarify the long-term value of perioperative Doppler ultrasonography graft monitoring.