Diagnostic Accuracy and Reproducibility of Predicting Cul-de-Sac Obliteration by General Gynaecologists and Minimally Invasive Gynaecologic Surgeons.

OBJECTIVE: Knowledge of rectouterine cul-de-sac state and consistent classification among surgeons are important in the surgical management of women with endometriosis. The objective of this study was to determine the diagnostic accuracy and interobserver and intraobserver agreement among general gynaecologists (GGs) and minimally invasive gynaecologic surgeons (MIGSs) in the prediction of cul-de-sac obliteration at off-line analysis of laparoscopic videos. METHODS: Five GGs and five MIGSs viewed 33 prerecorded laparoscopic video sets off-line to determine cul-de-sac obliteration state (non-obliterated, partially obliterated, or completely obliterated) on two occasions (at least 7days apart). Diagnostic accuracy and interobserver and intraobserver agreement were evaluated. RESULTS: The interobserver agreements for all 10 observers for the description of cul-de-sac state ranged from fair to substantial agreement, with moderate overall agreement. MIGSs had slightly higher within-group interobserver agreement compared with GGs. MIGSs achieved overall almost perfect intraobserver agreement compared with substantial agreement for GGs. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for MIGSs classifying the cul-de-sac state were 83.9%, 88.5%, 88.5%, 89.2%, 92.0%, and 84.7%, respectively, whereas for GGs, they were 79.1%, 79.4%, 88.1%, 89.9%, and 76.1%, respectively. CONCLUSION: Diagnostic accuracy and interobserver and intraobserver agreement for cul-de-sac obliteration state classification is acceptable in both groups. MIGSs had greater diagnostic accuracy and exhibited high interobserver and intraobserver agreement, a finding suggesting that their advanced training makes them more reliable in cul-de-sac obliteration assessment. Partial cul-de-sac obliteration was the most commonly incorrectly diagnosed state, thus implying that partial obliteration is not well understood.

A futuristic vision of pocket ultrasound machines: watch this space.

Introduction: Australian medical ultrasound started in 1959 with the establishment of the Ultrasonics Institute. Since then the technology has advanced tremendously. We are now not only able to obtain clearer images on high specification ultrasound machines but also on pocket-sized ultrasound machines that are compact, lightweight and affordable. Method: The following descriptive review will examine the indication for use of pocket ultrasound machines in different clinical settings as well as provide evidence of its image clarity and accuracy. Potentially eligible studies were sought primarily through searches of the electronic databases PubMed, Medline (1996-Present), Embase (1996-Present) and Cochrane Library. Conclusion: Pocket ultrasound machines, with appropriate ultrasound knowledge and training, can be incorporated successfully in patient management. The addition of point-of-care ultrasound has been shown to improve management recommendations and outcomes.

Sonographic diagnosis of spontaneous uterine rupture at the site of cornual wedge resection scar - a case report.

Introduction: Uterine rupture and uterine dehiscence during pregnancy are known complications of a scarred uterus. Spontaneous uterine rupture at the site of prior cornual wedge resection has been previously reported in the literature, however remains rare. Discussion: We present a case of uterine rupture at 30 weeks gestation. This woman had previous right sided interstitial pregnancy treated with uncomplicated laparoscopic cornual wedge resection at eight weeks gestation. The index pregnancy occurred eight months after surgery. An emergency ultrasound prompted by non-specific abdominal pain and tenderness at 30 weeks gestation enabled diagnosis of uterine dehiscence. At emergency caesarean section four hours later full thickness wall rupture and haemoperitoneum were found. Surgical intervention resulted in a good outcome for both mother and baby. Conclusion: A brief account on uterine rupture in late pregnancy and relevant sonographic features related to this case are presented. This case demonstrates the value of ultrasound in the assessment of subtle clinical signs and symptoms in patients at risk of uterine rupture.

Congenital Epulis: a clinical case presentation.

Congenital Epulis (CE) is a rare, benign tumour of the mucosa of the mouth in a neonate. It presents as an intraoral tumour and is rarely diagnosed prenatally. Complications include neonatal airway compromise, difficulty feeding and aesthetic considerations. Ultrasound is useful in aiding decisions regarding site, age, method of delivery and preparing parents and staff for the appearances of the tumour at birth. We present a case where CE was identified at 35 weeks gestational age during a routine third trimester prenatal ultrasound. The patient was scanned at a rural centre, referred to a tertiary institution for follow up and delivered at a specialist perinatal surgical centre, in preparation for neonatal surgery. The outcome was excellent and this case is a good example of multi-centre cooperation.

The effect of preliminary training on quantitative evaluation of sonographer performance in the fetal morphology ultrasound examination.

Introduction: The aim of this study is to provide a quantitative scoring system to assess sonographer performance by reviewing images from the fetal morphology examination. Methods: Ten ultrasound images from patients at 18-22 weeks gestation were assessed and scored for quality according to predefined criteria. One hundred normal cases were randomly selected and 10 images from each case were analysed by four experienced reviewers. The preliminary training incorporated the first 25 cases and involved a training period for reviewers; the remaining 75 cases were allocated to post training. The scores acquired by each reviewer were statistically analysed using Pearson's and intra-class correlations to determine the reproducibility of the results. Results: The preliminary training results were calculated separately and compared to the post training study. The preliminary intra-class correlation coefficient was 0.12. In the post training study the intra-class correlation coefficient was doubled at 0.24. The greatest correlation was observed between reviewers 1 and 4 with a coefficient of 0.71. Reviewers 3 and 4 demonstrated the lowest correlation coefficient of 0.30. Discussion: A significant increase in the intra-class correlation coefficient indicated that training reviewers achieves more reproducible results. Suggested improvements to the study include recording fetal position, maternal BMI and assessing individual reviewer variability. An instruction manual defining each criterion might also yield better results. Conclusion: The quantitative method used in this study assessed ultrasound images by placing a numerical value on image quality. Analysis of the preliminary training period demonstrates improved reproducibility of the results. Further investigation into the criteria is necessary to refine the quantitative method.