Validity of the diagnostic criteria for chronic cerebrospinal venous insufficiency and association with multiple sclerosis.

BACKGROUND: The chronic cerebrospinal venous insufficiency theory proposes that altered cerebral venous hemodynamics play a role in the pathophysiology of multiple sclerosis. We aimed to explore the validity of this hypothesis by assessing the diagnostic criteria for chronic cerebrospinal venous insufficiency in persons with and without multiple sclerosis. METHODS: We compared the proportion of venous outflow abnormalities between patients with multiple sclerosis and healthy controls using extracranial Doppler ultrasonography and gadolinium-enhanced magnetic resonance venography. Interpreting radiologists were blinded to the clinical status of participants. RESULTS: We enrolled 120 patients with multiple sclerosis and 60 healthy controls. High proportions of both patients (67/115 [58%]) and controls (38/60 [63%]) met 1 or more of the proposed ultrasound criteria for diagnosis of chronic cerebrospinal venous insufficiency (p = 0.6). A minority of patients (23/115 [20%]) and controls (6/60 [10%]) fulfilled 2 or more of the proposed criteria (p = 0.1). There were no differences between patients and controls in the prevalence of each individual ultrasound criterion. Similarly, there were no differences in intracranial or extracranial venous patency between groups, as measured by magnetic resonance venography. INTERPRETATION: We detected no differences in the proportion of venous outflow abnormalities between patients with multiple sclerosis and healthy controls. Moreover, our study revealed significant methodologic concerns regarding the proposed diagnostic criteria for chronic cerebrospinal venous insufficiency that challenge their validity.

Help is in your pocket: the potential accuracy of smartphone- and laptop-based remotely guided resuscitative telesonography.

BACKGROUND: Ultrasound (US) examination has many uses in resuscitation, but to use it to its full effectiveness typically requires a trained and proficient user. We sought to use information technology advances to remotely guide US-naive examiners (UNEs) using a portable battery-powered tele-US system mentored using either a smartphone or laptop computer. MATERIALS AND METHODS: A cohort of UNEs (5 tactical emergency medicine technicians, 10 ski-patrollers, and 4 nurses) was guided to perform partial or complete Extended Focused Assessment with Sonography of Trauma (EFAST) examinations on both a healthy volunteer and on a US phantom, while being mentored by a remote examiner who viewed the US images over either an iPhone(®) (Apple, Cupertino, CA) or a laptop computer with an inlaid depiction of the US probe and the "patient," derived from a videocamera mounted on the UNE's head. Examinations were recorded as still images and over-read from a Web site by seven expert reviewers (ERs) (three surgeons, two emergentologists, and two radiologists). Examination goals were to identify lung sliding (LS) documented by color power Doppler (CPD) in the human and to identify intraperitoneal (IP) fluid in the phantom. RESULTS: All UNEs were successfully mentored to easily and clearly identify both LS (19 determinations) and IP fluid (14 determinations), as assessed in real time by the remote mentor. ERs confirmed IP fluid in 95 of 98 determinations (97%), with 100% of ERs perceiving clinical utility for the abdominal Focused Assessment with Sonography of Trauma. Based on single still CPD images, 70% of ERs agreed on the presence or absence of LS. In 16 out of 19 cases, over 70% of the ERs felt the EFAST exam was clinically useful. CONCLUSIONS: UNEs can confidently be guided to obtain critical findings using simple information technology resources, based on the receiving/transmitting device found in most trauma surgeons' pocket or briefcase. Global US mentoring requires only Internet connectivity and initiative.

The clinical and technical evaluation of a remote telementored telesonography system during the acute resuscitation and transfer of the injured patient.

BACKGROUND: Ultrasound (US) has an ever increasing scope in the evaluation of trauma, but relies greatly on operator experience. NASA has refined telesongraphy (TS) protocols for traumatic injury, especially in reference to mentoring inexperienced users. We hypothesized that such TS might benefit remote terrestrial caregivers. We thus explored using real-time US and video communication between a remote (Banff) and central (Calgary) site during acute trauma resuscitations. METHODS: A existing internet link, allowing bidirectional videoconferencing and unidirectional US transmission was used between the Banff and Calgary ERs. Protocols to direct or observe an extended focused assessment with sonography for trauma (EFAST) were adapted from NASA algorithms. A call rota was established. Technical feasibility was ascertained through review of completed checklists. Involved personnel were interviewed with a semistructured interview. RESULTS: In addition to three normal volunteers, 20 acute clinical examinations were completed. Technical challenges requiring solution included initiating US; audio and video communications; image freezing; and US transmission delays. FAST exams were completed in all cases and EFASTs in 14. The critical anatomic features of a diagnostic examination were identified in 98% of all FAST exams and a 100% of all EFASTs that were attempted. Enhancement of clinical care included confirmation of five cases of hemoperitoneum and two pneumothoraces (PTXs), as well as educational benefits. Remote personnel were appreciative of the remote direction particularly when instructions were given sequentially in simple, nontechnical language. CONCLUSIONS: The remote real-time guidance or observation of an EFAST using TS appears feasible. Most technical problems were quickly overcome. Further evaluation of this approach and technology is warranted in more remote settings with less experienced personnel.

An Unusual Neonatal Presentation of Scimitar Syndrome.

Scimitar syndrome is characterized by partial or total anomalous pulmonary venous return from the right lung along with pulmonary hypoplasia. We present a case of a 37 weeks' gestation male infant with antenatal ultrasound findings of suspected partial anomalous pulmonary venous return (PAPVR) and coarctation of the aorta. The newborn presented with respiratory distress, a chest X-ray and chest computed tomography (CT) angiogram confirmed the diagnosis of scimitar syndrome. The combination of scimitar syndrome with aortic coarctation is extremely rare with only a few cases previously reported.

Medical educators' perspectives of teaching physical examinations using ultrasonography at the undergraduate level.

BACKGROUND: Ultrasonography is increasingly used for teaching physical examination in medical schools. This study seeks the opinions of educators as to which physical examinations would be most enhanced by the addition of ultrasonography. We also asked when ultrasound-aided physical examination teaching could have deleterious effects if used outside its intended scope. METHODS: All of the educators from the University of Calgary Master Teacher Program were invited to complete a 22-item paper-based survey. Survey items were generated independently by two investigators, with input from an expert panel (n = 5). RESULTS: Of the 36 educators, 27 (75%) completed the survey. Examinations identified to be potentially most useful included: measuring the size of the abdominal aorta, identifying the presence/absence of ascites, identifying the presence/absence of pleural effusions, and measuring the size of the bladder. Examinations thought to be potentially most harmful included: identifying the presence/absence of intrauterine pregnancy, measuring the size of the abdominal aorta, and identifying the presence/absence of pericardial effusion. CONCLUSIONS: Examinations that are potentially the most useful may also be potentially the most harmful. When initiating an ultrasound curriculum for physical examinations, educators should weigh the risks and benefits of examinations chosen.