Pocket-Sized Versus Conventional Ultrasound for Detecting Fatty Infiltration of the Liver.

BACKGROUND AND AIMS: The high prevalence of nonalcoholic fatty liver disease (NAFLD) in the general population warrants determining whether pocket-sized ultrasound devices (PoCUS) might serve as point-of-care screening for NAFLD in busy office practices. METHODS: One hundred adult subjects undergoing conventional abdominal ultrasound (US) examinations for various indications were screened by PoCUS immediately prior to the conventional US procedure. The PoCUS examination only assessed the presence or absence of excess fat. Assessment of other liver pathology was not performed. Investigators (conventional US: an experienced radiologist and PoCUS: a general internist recently trained in the use of PoCUS) were blinded to the results of the alternative imaging. RESULTS: Forty patients (40%) had fatty infiltration of the liver on both conventional US and PoCUS, and 49 (49%) were negative by both modalities. A consensus was reached in two of the 11 remaining subjects with initially discrepant results. The overall sensitivity and specificity of PoCUS relative to conventional US were 91% and 88%, respectively. CONCLUSIONS: These findings support the use of PoCUS by a trained physician for point-of-care screening of patients at risk for NAFLD.

Static in vitro digestion model adapted to the general older adult population: an INFOGEST international consensus.

Understanding the mechanisms of food digestion is of paramount importance to determine the effect foods have on human health. Significant knowledge on the fate of food during digestion has been generated in healthy adults due to the development of physiologically-relevant in vitro digestion models. However, it appears that the performance of the oro-gastrointestinal tract is affected by ageing and that a model simulating the digestive conditions found in a younger adult (<65 years) is not relevant for an older adult (>65 years). The objectives of the present paper were: (1) to conduct an exhaustive literature search to find data on the physiological parameters of the older adult oro-gastrointestinal tract, (2) to define the parameters of an in vitro digestion model adapted to the older adult. International experts have discussed all the parameters during a dedicated workshop organized within the INFOGEST network. Data on food bolus properties collected in the older adult were gathered, including food particle size found in older adult boluses. In the stomach and small intestine, data suggest that significant physiological changes are observed between younger and older adults. In the latter, the rate of gastric emptying is slowed down, the pH of the stomach content is higher, the amount of secretions and thus the hydrolytic activities of gastric and intestinal digestive enzymes are reduced and the concentration of bile salts lower. The consensus in vitro digestion model of the older adult proposed here will allow significant progress to be made in understanding the fate of food in this specific population, facilitating the development of foods adapted to their nutritional needs. Nevertheless, better foundational data when available and further refinement of the parameters will be needed to implement the proposed model in the future.

A tailored automated nutrition screening tool for rapid identification of risk in acute-care hospital settings.

Malnourishment is prevalent in hospitalized patients and associated with adverse medical outcomes. Thus, nutrition screening to identify high-risk patients is widespread. However, no single universal tool has been shown to be suitable for all hospital departments. To address this challenge, a novel, tailored, electronic tool for nutritional screening was developed and evaluated. The Rambam Automated Nutrition Computerized Screening tool efficiently screens all newly admitted patients and does not rely on self-reported height and weight estimates. Validation was carried out in medical wards (n=94), and compared to the Malnutrition Universal Screening Tool, length of stay and an independent assessment by a professional dietician. Results from this research support the use of automated, flexible tools that instantaneously incorporate relevant available data from the electronic health record. Tools that are adaptable to meet the needs of individual hospital departments, can save valuable time and ensure full screening of all admitted patients.

Characterization of subendometrial myometrial contractions throughout the menstrual cycle in normal fertile women.

The objective was to study the characteristics of ultrasonographically detected subendometrial myometrial contractions. The contractions were evaluated by 328 ultrasound scans throughout the menstrual cycle. Reproducibility of these findings were studied in consecutive cycles. Eighteen healthy ovulatory volunteers with proven fertility were evaluated for at least one complete menstrual cycle in the follicular, periovulatory, and luteal phases. Multiple cycles were studied in 10 volunteers. The results showed that the contractions increase in frequency, amplitude, and percentage toward the fundus throughout the follicular and periovulatory phases. The pattern is essentially reversed in the luteal phase. There is reproducibility of these patterns from cycle to cycle. We conclude that there is a definite identifiable pattern of subendometrial myometrial contractility that varies with the phases of the normal menstrual cycle and recurs in a similar fashion from cycle to cycle.

Ultrasound in the first trimester of pregnancy.

High-resolution sonography, including transvesical and endovaginal techniques, has resulted in enhanced visualization of embryonic and extraembryonic structures. With endovaginal sonography, the gestational sac may be seen within the decidua at about 4.5 weeks menstrual age. The yolk sac is the first structure to be seen within the gestational sac, and confirms the presence of a gestational sac rather than a decidual cast. The embryo is identified by endovaginal sonography early in the 6th week, and cardiac activity is routinely identified by a crown-rump length of 3 to 5 mm. On endovaginal sonography, absent cardiac activity in an embryo having a crown-rump length of greater than 3 to 5 mm indicates embryonic death. With endovaginal scanning, a gestational sac of greater than 8 mm without a yolk sac, or greater than 16 mm without an embryo, also indicates a nonviable pregnancy. Routine sonography primarily to assess the menstrual age should be performed in the second trimester, when added clinically relevant information may be obtained. Although it is possible to diagnose some anomalies in the first trimester, most remain second trimester sonographic diagnoses.

Early diagnosis of nonviable pregnancy with endovaginal US.

The mean diameter of the gestation sac and the presence or absence of a yolk sac or embryo and/or cardiac pulsations on endovaginal ultrasound (US) images were correlated with normal and abnormal outcomes of pregnancy. Sixty-two patients who were less than 10 weeks pregnant (menstrual age) underwent endovaginal US. In 59 patients with gestation sacs greater than or equal to 8 mm, the absence of a yolk sac predicted a nonviable pregnancy with a sensitivity of 67% and a specificity of 100%. In 35 patients with gestation sacs greater than or equal to 16 mm, the absence of an embryo predicted a nonviable pregnancy with a sensitivity of 50% and a specificity of 100%. When the absence of cardiac pulsations was added to the latter group of patients, the sensitivity was 100% and the specificity was 100%. The combination of these criteria (gestation sac size; demonstration of yolk sac, embryo and/or cardiac pulsations) enabled the early (less than 10 weeks menstrual age) diagnosis of a nonviable pregnancy with endovaginal US.

First-trimester umbilical cord cysts.

Cystic masses of the umbilical cord have been detected in the 2nd and 3rd trimesters of pregnancy in association with fetal abdominal wall defects and chromosomal anomalies. With high-resolution endovaginal ultrasound (US), umbilical cord cysts can be visualized during the 1st trimester. Their origin and significance must be considered for proper obstetric management. The authors report eight cases in which cystic masses of the umbilical cord were detected during US examinations performed at 8-9 weeks menstrual age. In the five cases followed to term, both the infant and the umbilical cord were found to be normal at physical examination. Sonographically, all cysts appeared to be eccentric in relation to the umbilical cord, and, although all were closer to the fetus, the cysts were clearly extraembryonic. Cyst size was 2.0-7.5 mm (mean, 5.2 mm). Seven cysts resolved by 12 weeks menstrual age. The incidence of cysts in patients who underwent US at the authors' institution between 8 and 12 weeks menstrual age was 0.4%; the true frequency is unknown without routine 1st-trimester scanning of all patients.

Suspected ectopic pregnancy: endovaginal and transvesical US.

Until the advent of endovaginal ultrasonography (US), transvesical US was the only US technique availab le for evaluation of patients with suspected ectopic gestation. A study was undertaken to assess the predictive ability of transvesical and endovaginal US and determine whether endovaginal US could be used alone. Fifty-three patients who had a positive pregnancy test finding and who were at risk for ectopic pregnancy were examined with both endovaginal and transvesical US. Twenty-nine were examined retrospectively and 24 were examined prospectively. Standard sonographic criteria were used to differentiate between intrauterine pregnancy and ectopic gestation. The clinical or pathologic diagnosis was ectopic pregnancy in 18 patients (34%), normal intrauterine pregnancy in 19 (36%), and abnormal intrauterine pregnancy in 16 (30%). Endovaginal US increased the sensitivity of detecting a live ectopic pregnancy (from 6% to 17%). Endovaginal US, by allowing early diagnosis of intrauterine pregnancy, significantly increased the diagnostic accuracy for ectopic pregnancy (from 60% to 83%). Endovaginal US provided significant additional information in women referred for sonography with a suspected ectopic gestation. On the basis of these findings it is concluded that endovaginal US can be used alone in the majority of women with suspected ectopic gestation.

Contractions of the inner third of the myometrium.

Forty-six consecutive endovaginal ultrasound examinations were screened for the presence of myometrial contractions. The study group contained pregnant women up to 10 weeks' menstrual age, nonpregnant, and postmenopausal women. Rhythmic myometrial contractions of the inner myometrial third not previously reported were seen in 35 studies in pregnant, nonpregnant, and postmenopausal women. The contractions involved the inner third of the myometrium in all but two cases. In these two cases, all three muscular layers were involved. The majority of women showed retrograde contractions, with the contraction wave moving from the cervix to the fundus. In menstruating women and one case of abortion, the contractions were antegrade. It is our speculation that these retrograde contractions of the inner myometrial third may be important in sperm transport and for the conservation of early pregnancies within the uterine cavity.

Endovaginal sonographic diagnosis of ectopic twin gestation.

Endovaginal sonography has permitted earlier diagnosis of ectopic pregnancy. Twin ectopic pregnancy is rare. Until now, antenatal diagnosis of twin ectopic pregnancy using endovaginal sonography had not been reported. Three cases of twin ectopic pregnancy diagnosed via the intracavitary probe are presented.

Endovaginal US: demonstration of cardiac activity in embryos of less than 5.0 mm in crown-rump length.

The authors reviewed the endovaginal ultrasonographic (US) findings for 96 patients with embryos with crown-rump lengths of less than 5.0 mm. Of the 71 patients with adequate follow-up, initial endovaginal US demonstrated cardiac activity in 46 embryos and no cardiac activity in 25. Initial endovaginal US failed to demonstrate cardiac activity in five of 40 normal embryos, three with crown-rump lengths of less than 2.0 mm and two, between 2.0 and 3.9 mm. Endovaginal US identified cardiac activity in all 12 normal embryos with crown-rump lengths of 4.0-4.9 mm. The presence of cardiac activity was associated with a 24% risk of spontaneous abortion. In embryos between 2.0 and 4.9 mm in crown-rump length, absent cardiac activity was associated with a 91% risk of abortion. All 17 patients with vaginal bleeding and embryos demonstrating no cardiac activity subsequently aborted. The embryonic yolk sac was absent in 35% of patients who subsequently aborted. Variation outside of the 95% confidence limits of the mean for crown-rump length compared with mean gestational sac diameter and yolk sac diameter was also helpful in predicting an abnormal outcome. Nonvisualization of cardiac activity at endovaginal US in embryos less than 4.0 mm in crown-rump length may be normal and warrants follow-up US examination.

Endovaginal and translabial ultrasound in pregnancy.

Endovaginal sonography provides earlier and enhanced visualization of the gestational sac and its contents than does transvesical sonography. This paper discusses the role of endovaginal sonography in common first trimester diagnostic problems, including pregnancy dating, first trimester pregnancy loss, ectopic pregnancy, and early diagnosis of fetal anomalies, and reviews the use of endovaginal color flow Doppler in the diagnosis of ectopic pregnancy. A brief discussion of the role of endovaginal and translabial sonography in the second and third trimesters is included.

Decidual cyst: endovaginal sonographic sign of ectopic pregnancy.

PURPOSE: To determine the prevalence of decidual cysts in patients with ectopic pregnancy and assess the value of endovaginal sonographic demonstration of decidual cysts in predicting ectopic pregnancy. MATERIALS AND METHODS: A series of 288 proved ectopic pregnancies was reviewed, and a series of 179 patients with pregnancies of less than 8 weeks menstrual age was prospectively examined. RESULTS: Decidual cysts were identified in 30 (14.4%) of 208 ectopic pregnancies. In 12 patients a decidual cyst was the first sonographic sign of ectopic pregnancy, and in six patients it was the only abnormal sonographic finding. Four of five patients with decidual cysts had an ectopic pregnancy. Decidual cysts had a sensitivity of 21%, specificity of 92%, positive predictive value of 80%, and negative predictive value of 42% in the diagnosis of ectopic pregnancy. CONCLUSION: Patients with decidual cysts are at high risk for ectopic pregnancy and should be monitored or treated appropriately, depending on the clinical findings.

The value of combined pulsed-Doppler and high-resolution real-time sonography of the extracranial carotid system.

Duplex carotid sonography (DCS) (high-resolution real-time with combined pulsed Doppler) was performed in 374 symptomatic patients. Biplane angiographic correlation was available in 172 extracranial carotid systems. Degree of stenosis was estimated by the Doppler spectrum and by real-time appearances and categorized as: normal; less than 10% diameter reduction; 10-49% diameter reduction; 50-99% diameter reduction; or occlusion. The overall accuracy of sonography was 88%. Normal arteries were identified with a specificity of 96% and a positive predictive value of 97%. Hemodynamically, significant lesions were differentiated from less severe disease with an accuracy of 95%, a positive predictive value of 87%, and a negative predictive value of 100%. Occlusions were identified with a sensitivity of 80% and a positive value of 91%. Duplex sonography is an accurate, noninvasive method of evaluating the extracranial carotid system.

Angiomyolipoma with lymph node involvement.

A renal mass accompanied by adenopathy was found incidentally in an asymptomatic 25-year-old woman. The computed tomography and ultrasonography findings suggested a malignant neoplasm. At pathological examination, however, renal angiomyolipoma was diagnosed; the lesion contained almost no fat and involved the lymph nodes, an unusual presentation for this tumour.

Interstitial line: sonographic finding in interstitial (cornual) ectopic pregnancy.

PURPOSE: To evaluate the relationship of the endometrial canal and decidua vera to the interstitial gestational sac and to determine if this relationship can be used to increase the predictive value of ultrasound (US) in the diagnosis of interstitial ectopic pregnancy. MATERIALS AND METHODS: The US findings in 12 patients with interstitial ectopic pregnancy were reviewed. Radiologists also reviewed the cases of 40 patients with various diagnoses to assess the accuracy of the interstitial line sign. RESULTS: US showed a definite gestational sac in four of the 12 patients (33%); the rest had a heterogeneous mass in the cornual region. Thinning of the myometrial mantle was seen in these four patients. The gestational sac appeared eccentric in three of these but in only three of 12 (25%) overall. The endometrial canal or interstitial portion of the tube was identified in 11 of 12 patients (92%). The interstitial line had better sensitivity (80%) and specificity (98%) than eccentric gestational sac location (sensitivity, 40%; specificity, 88%) and myometrial thinning (sensitivity, 40%; specificity, 93%) for the diagnosis of interstitial ectopic pregnancy. CONCLUSION: The interstitial line sign is a useful diagnostic sign of interstitial ectopic pregnancy.

Yolk sac number, size and morphologic features in monochorionic monoamniotic twin pregnancy.

OBJECTIVE: To determine the relation between three characteristics of the yolk sac (number, size and morphologic features) and outcome in monochorionic monoamniotic twin pregnancy. METHODS: The authors reviewed data for the four sets of monochorionic monoamniotic twins detected by first-trimester ultrasonography between January 1990 and June 1994 at their institution. Data analysed included yolk sac number, size and morphologic features, as well as the outcome of the pregnancy. RESULTS: In all four sets of twins, only one yolk sac was identified. In one case the yolk sac was irregular in contour, and in two it was abnormally large. Two of the four mothers delivered healthy twins at 34 weeks gestational age, one had conjoined twins ( and underwent elective termination of the pregnancy), and one had a twin ectopic pregnancy (and underwent salpingectomy). CONCLUSION: A single yolk sac in cases of monochorionic monoamniotic twins may be a normal finding.

Yolk sac diameter and shape at endovaginal US: predictors of pregnancy outcome in the first trimester.

Four hundred eighty-six consecutive women who underwent endovaginal sonography when their fetuses were less than 10 weeks menstrual age (MA) were evaluated to establish the normal size and shape of the secondary yolk sac (YS) and to assess the value of YS measurement in predicting pregnancy outcome in the first trimester. A YS diameter more than two standard deviations (SDs) above the mean when compared with the mean gestational sac diameter allowed prediction of an abnormal pregnancy outcome with a sensitivity of 15.6%, a specificity of 97.4%, and a positive predictive value of 60.0%. A YS diameter more than two SDs below the mean allowed prediction of an abnormal outcome with a sensitivity of 15.6%, a specificity of 95.3%, and a positive predictive value of 44.4%. No pregnancy with a normal outcome had a YS diameter of greater than 5.6 mm at less than 10 weeks MA. In six patients, the YS diameter was greater than 5.6 mm. All six had an abnormal outcome. Of seven patients with abnormal YS shape at initial sonography, three had abnormal YS shape at follow-up examinations. All three had an abnormal outcome.