Drainage of Pancreatic Pseudocysts Using Lumen-apposing Metal Stents (LAMS): Experience in Two Referral Centers in Colombia

Introduction: Endoscopic ultrasound (EUS)-guided drainage and luminal-apposing metal stents (LAMS) are the options for managing symptomatic pancreatic pseudocysts. Aim: To evaluate the effectiveness and safety of LAMS for EUS-guided drainage of symptomatic pancreatic pseudocysts in two referral centers in Colombia. Materials and methods: A multicenter prospective cohort study between June 2019 and December 2021 included 13 patients diagnosed with symptomatic pancreatic pseudocysts who underwent EUS-guided drainage with LAMS. Technical success, clinical success, and successful stent removal were evaluated as outcomes. Safety outcomes included stent-related adverse events and general adverse events. Follow-up was carried out for eight weeks, collecting data on stent removal. Results: The average age was 53.4 years; 8/13 were men. The mean size of the pseudocyst was 9.56 ± 2.3 cm. Technical success was 100%, and clinical success was 92.3%. The stents were removed on average after 8 ± 2 weeks. The mean procedural time from puncture to stent deployment was 3.2 ± 2.4 minutes. In the imaging check-up, the collections had adequate drainage in all cases. There was a low frequency of complications; bleeding was documented in one case requiring surgery. Conclusions: LAMS is safe and effective in managing symptomatic pancreatic pseudocysts, reducing hospital stay and cost overruns. Clinical symptomatology prevails in the surgery decision.

Introducción: el drenaje guiado por ultrasonido endoscópico (USE) y el uso de stent metálico luminal de aposición (LAMS) son de elección en el manejo de los pseudoquistes pancreáticos sintomáticos. Objetivo: evaluar la efectividad y seguridad del LAMS para el drenaje por USE de pseudoquistes pancreáticos sintomáticos en dos centros de referencia en Colombia. Materiales y métodos: estudio de cohorte prospectivo multicéntrico entre junio de 2019 y diciembre de 2021, se incluyeron a 13 pacientes con diagnóstico de pseudoquistes pancreáticos sintomáticos sometidos a drenaje por USE con LAMS. Se evaluaron como desenlaces el éxito técnico, el éxito clínico y la extracción exitosa del stent. Y los desenlaces de seguridad incluyeron eventos adversos relacionados con el stent y los eventos adversos generales. Se realizó seguimiento a 8 semanas, en las que se recopilaron datos relacionados con el retiro del stent. Resultados: la edad promedio fue 53,4 años, 8/13 fueron hombres. El tamaño medio del pseudoquiste fue de 9,56 ± 2,3 cm. El éxito técnico fue del 100% y el éxito clínico fue 92,3%. Los stents fueron retirados en promedio a las 8 ± 2 semanas. El tiempo medio del procedimiento desde la punción hasta el despliegue del stent fue 3,2 ± 2,4 minutos. En el control imagenológico hubo un adecuado drenaje de las colecciones en todos los casos. Hubo baja frecuencia de complicaciones, se documentó sangrado en 1 caso con requerimiento quirúrgico. Conclusiones: el uso de LAMS es seguro y efectivo en el manejo de pseudoquistes pancreáticos sintomáticos, disminuye la estancia hospitalaria y sobrecostos. La sintomatología clínica prima en la decisión de intervención.

Aplicaciones actuales de la ultrasonografía en anestesia / Current applications of ultrasonography in anesthesia

La ecografía es una herramienta segura, portátil, económica y de fácil acceso. Los médicos anestesiólogos pueden beneficiarse con esta herramienta diagnóstica rápida y precisa en su práctica habitual. Existen múltiples áreas potenciales donde la ecografía desempeña un papel importante, para la orientación de intervenciones a ciegas e invasivas, el diagnóstico de condiciones críticas y la evaluación de posibles variaciones anatómicas que pueden conducir a la modificación del plan anestésico. Esta revisión narrativa describe las principales aplicaciones de la ecografía en anestesia, las técnicas ecoguiadas y las tendencias actuales del manejo anestésico perioperatorio del paciente quirúrgico. Se realizó una búsqueda en las bases de datos PubMed y Cochrane, se incluyeron artículos originales, estudios aleatorizados y de revisión, en español y en inglés, publicados entre 2017-2021. El uso de ecografía ha entrado en el campo de la medicina del dolor, anestesia regional y del intervencionismo analgésico durante la última década, e incluso es el estándar de la práctica, por tanto, la capacitación y un adecuado aprendizaje en la ecografía deben ser parte del plan de estudios de cualquier programa de anestesiología

Ultrasound is a safe, portable, inexpensive, and easily accessible tool. Anesthesiologists can benefit from this fast and accurate diagnostic tool in their routine practice. There are multiple potential areas where ultrasound plays an important role in the guidance of blind and invasive interventions, diagnosis of critical conditions, and assessment of possible anatomical variations that may lead to modification of the anesthetic plan. This narrative review describes the main applications of ultrasound in anesthesia, ultrasound-guided techniques, and current trends in the perioperative anesthetic management of the surgical patient. A search was conducted in PubMed and Cochrane databases. Original articles, randomized and review studies in Spanish and English published between 2017-2021 were included. The use of ultrasound has entered the field of pain medicine, regional anesthesia, and interventional analgesia during the last decade and is even the standard of practice. Therefore, training and adequate learning in ultrasound should be part of the curriculum of any anesthesiology program

Disección coronaria espontánea. Primer reporte a nivel nacional / Spontaneous coronary dissection. First nationwide report / Dissecção coronariana espontânea. Primeiros relatórios em todo o país

Resumen: La disección coronaria espontánea (DCE) es una causa infrecuente de síndrome coronario agudo (SCA), de presentación principalmente en mujeres de mediana edad. Se realizó una revisión de la base de datos institucional, desde la incorporación en nuestro centro de tecnología para adquisición de imagen intracoronaria hasta la actualidad (julio de 2013 a diciembre de 2019). Se encontró DCE en 13 de 4.706 coronariografías diagnósticas (0,3%). Presentamos angiografía y ultrasonografía intracoronaria (IVUS) representativa de lo observado en la serie. La edad media de presentación fue 52 ± 14 años, 11 de los 13 casos eran mujeres. El tiempo medio de seguimiento fue 39 ±27 meses. La forma clínica de presentación más frecuente fue SCA sin elevación del ST (6/13). El vaso más frecuentemente afectado fue la arteria descendente anterior (n=8). En todos los casos se registró elevación significativa de troponinas (> percentil 99). Se realizó tratamiento conservador en 11 casos y angioplastia exitosa en dos. Un paciente que recibió tratamiento conservador falleció durante la internación. Se requirió de imagenología intracoronaria en nueve de los 13 casos. Se presenta el primer reporte nacional de DCE, describiendo sus características clínicas, imagenológicas, tratamiento y evolución.

Summary: Spontaneous coronary dissection is an infrequent cause of acute coronary syndrome, particularly in middle-aged women. We made review of the database of our center since the date of acquisition of intracoronary imaging techniques in our laboratory (July 2013 - December 2019). Coronary spontaneous dissection was found in 13 patients of 4706 diagnostic coronary angiograms (0.3%). We present angiography and coronary ultrasonography studies representative of this case series. The mean age of presentation was 52 ± 14 years, 11 of 13 of the cases were women. The mean follow-up time was 39 ± 27 months. The most frequent clinical presentation was acute coronary syndrome without ST elevation 6/13. The most frequently affected vessel was the anterior descending artery (n = 8). In all cases, troponins above the 99 percent were found. Conservative treatment was performed in 11 cases and successful angioplasty in the other two cases. One patient under conservative treatment died during hospitalization. The use of intracoronary imaging was required in 9 of the 13 cases. In conclusion, we present for the first time, a national registry of spontaneous coronary dissection describing its clinical, image, treatment and evolution characteristics.

Resumo: A dissecção coronariana espontânea é uma causa pouco frequente da síndrome coronariana aguda, principalmente em mulheres de meia idade. Realizamos uma revisão do banco de dados de nosso centro a partir da data de aquisição das técnicas de imagem intracoronária em nosso laboratório (julho de 2013 a dezembro de 2019). Dissecção coronariana espontânea foi encontrada em 13 pacientes de 4706 angiografias coronárias diagnósticas (0,3%). Apresentamos angiografia coronariana representativa e estudos ultrassonográficos desta série de casos. A idade média de apresentação foi de 52 ± 14 anos, 11 dos 13 casos eram do sexo feminino. O tempo médio de acompanhamento foi de 39 ± 27 meses. A apresentação clínica mais frequente foi síndrome coronariana aguda sem supradesnivelamento do segmento ST 6/13. O vaso mais acometido foi a artéria descendente anterior (n = 8). Em todos os casos, as troponinas foram encontradas acima de 99%. O tratamento conservador foi realizado em 11 casos e a angioplastia em 2, com sucesso. Um paciente em tratamento conservador morreu durante a internação. O uso de imagens intracoronárias foi necessário em 9 dos 13 casos. Concluindo, relatamos, pela primeira vez, um registro nacional de dissecção coronariana espontânea de que descreve suas características clínicas, de imagem, de tratamento e de evolução.

Diagnosis and treatment of emergency interventional ultrasound under the epidemic of coronavirus disease 2019 / 第二军医大学学报

Objective To explore the diagnosis and treatment process and experience of emergency interventional ultrasound in our hospital under the coronavirus disease 2019 (COVID-19) epidemic situation, so as to provide reference for the safe and effective implementation of interventional ultrasound during the epidemic. Methods This study summarized and reviewd the experience of interventional ultrasound for the diagnosis and treatment of three emergency patients in the department of ultrasound of our hospital during the COVID-19 epidemic, focusing on the screening of severe COVID-19 patients, the selection of indications for interventional puncture, the perioperative protection and postoperative management. Results According to epidemiological screening, patient 1 had close contact with the confirmed COVID-19 patient. Chest CT showed diffused interstitial exudation in the lower lobes of both lungs, and the patient was seen as a suspected case after consultation with the hospital expert group, who had retropharyngeal space infection on admission and needed to remove the infection focus quickly. COVID-19 was excluded in patient 2, who was diagnosed as acute episode of calculous incarcerated cholecystitis on admission, requiring rapid drainage of bile to relieve gallbladder obstruction. Patient 3 was excluded from COVID-19 and diagnosed as acute pericardial tamponade on admission, requiring rapid drainage of pericardial effusion. All 3 patients underwent strict COVID-19 screening procedures to identify the indications of interventional puncture. During the operation, tertiary protective measures were adopted for patient 1, and primary protective measures were adopted for the other two patients. Three severe patients were successfully treated by interventional ultrasound, with short average time, less bleeding and improved clinical symptoms. Conclusion Interventional ultrasound is minimally invasive, convenient and efficient, making it suitable for the emergency treatment during the COVID-19 epidemic. It can be used as an alternative to some emergency surgery, or provide a safe window period for confirmed or suspected severe COVID-19 patients. Our experience may provide a reference for the safe and effective practice of interventional ultrasound during the COVID-19 epidemic..

Avaliação de custo-efetividade do cateterismo em veia jugular interna guiado por ultrassom no Sistema Único de Saúde brasileiro / Evaluation of cost-effectiveness of internal jugular vein catheterization by ultrasound in the Brazilian National Health System

Objetivo: Determinar a factibilidade econômica da técnica de cateterismo central em veia jugular interna guiada pelo ultrassom comparado à técnica-padrão, sob a perspectiva pagadora do Sistema Único de Saúde brasileiro. Métodos: Análise de custo-efetividade utilizando modelo de árvore de decisão sob uma população de pacientes adultos em um cenário de uma unidade terciária. Os custos diretos dos materiais e procedimentos foram estimados utilizando bancos de registros de compras nacionais. Os desfechos foram a ocorrência ou não da punção arterial acidental grave (principal complicação associada ao sítio de punção). Também foram conduzidas análises de sensibilidade determinística e probabilística, bem como curva de aceitabilidade. Resultados: A intervenção onerou o modelo em R$ 53,81. A razão de custo-efetividade incremental calculada foi de R$ 17.936,66 por complicação grave evitada e a curva de aceitabilidade evidenciou que a técnica é custo-efetiva sob uma intenção de pagar de R$ 18.125,00. Na análise de sensibilidade probabilística, 63,6% das simulações mostraram-se custo-efetivas. Conclusão: A intervenção é custo-efetiva, contribuindo para a redução das complicações graves, e o resultado pode proporcionar segurança para tomadas de decisões quanto à padronização do uso da ultrassonografia como orientador do procedimento.

Objective: To determine the economic feasibility of the central catheterization technique in the internal jugular vein guided by the ultrasound compared to the standard technique, under the perspective of the Brazilian Unified Health System. Methods: Cost-effectiveness analysis using decision tree model under a population of adult patients in a tertiary unit scenario. The direct costs of the materials and procedures were estimated using banks of national procurement records. The outcomes were the occurrence or not of severe accidental arterial puncture (the main complication associated with the puncture site). Analyzes of deterministic and probabilistic sensitivity were also conducted, as well as acceptability curve. Results: The intervention cost the model in R$ 53.81. The calculated incremental cost-effectiveness ratio was R$ 17,936.66 due to a serious complication avoided and the acceptability curve showed that the technique is cost-effective under an intention to pay R$ 18,125.00. In the probabilistic sensitivity analysis, 63.6% of the simulations were cost-effective. Conclusion: The intervention is cost-effective, contributing to the reduction of severe complications and the result can provide security for decision making regarding the standardization of the use of ultrasonography as a guideline of the procedure

Manejo del drenaje percutáneo guiado por imágenes en un hospital de tercer nivel / Management of imaging guided percutaneous drainage at a third level of care Colombian hospital

Introducción. El drenaje percutáneo de las colecciones intraabdominales, guiado por ultrasonografía o por tomografía computadorizada, ha sido el tratamiento de elección para los abscesos abdominales o pélvicos, entre otros. Objetivo. Describir la experiencia en el manejo percutáneo de colecciones abdominales en pacientes del Hospital Universitario San José de Popayán entre octubre de 2014 y abril de 2016. Materiales y métodos. Se trata de una serie de casos de 79 pacientes a quienes se les hizo manejo intervencionista de colecciones abdominales por medio de cirugía percutánea guiada por imágenes, los cuales cumplieron con los criterios de inclusión y exclusión. El análisis estadístico se hizo con el programa SPSS Statistics™. Resultados. Se realizaron 106 procedimientos percutáneos para drenar diferentes colecciones intraabdominales. La intervención más frecuente fue el drenaje de colecciones hepáticas (32,1 %), en su mayoría, abscesos hepáticos, seguida del drenaje de abscesos posquirúrgicos de cirugías abiertas o laparoscópicas. Conclusiones. Las técnicas intervencionistas en manos de un cirujano entrenado son un tratamiento eficaz y seguro para las diferentes colecciones intraabdominales. El procedimiento fue exitoso en el 99 % de los pacientes de la presente serie

Introduction: Percutaneous drainage of intraabdominal collections guided by ultrasonography or computerized axial tomography has been the treatment of choice for the management of abdominal or pelvic abscesses. Objective: To describe the experience with the percutaneous ultrasonography-guided drainage of abdominal collections in patients at the San José University Hospital in Popayán, Colombia, in the period October 2014 and April 2016. Materials and methods: This is a case series of 79 patients who underwent interventional management of abdominal collections by a percutaneous procedure guided by images; all patients met the inclusion and exclusion criteria. The statistical analysis was carried out with the SPSS Statistics program. Results: 106 percutaneous procedures were performed for drainage of different intra-abdominal collections. The most frequent intervention was the drainage of hepatic collections (32.1%), mostly hepatic abscesses, followed by drainage of postoperative abscesses following open or laparoscopic surgery. Conclusions: The management of interventional techniques in the hands of the trained surgeon is an effective and safe method for the treatment of different intra-abdominal collections. The procedure was successful in 99% of the patients

Microwave ablation for hyperparathyroidism of forearm transplanted autograft: A report of two cases and review of literature / 第二军医大学学报

Objective To explore the treatment effect and technical safety of ultrasound-guided microwave ablation for hyperparathyroidism of forearm transplanted autograft. Methods Two patients who had undergone parathyroidectomy with autotransplantation (PTX+AT) and maintenance hemodialysis were diagnosed as having hyperparathyroidism of forearm transplanted autograft based on the increased serum intact parathyroid hormone (iPTH) and aggravated accompanying symptoms. The multimodal high frequency ultrasound was performed to examine the autografts, and ultrasound-guided percutaneous microwave ablation was used to treat the hyperparathyroidism of the patients. Curative effect and symptoms of the patients were observed after treatment. Results Ultrasonography clearly showed the location, number, size and blood perfusion of the parathyroid gland autografts in the forearm of the two patients. After measuring the levels of iPTH in the transplanted tissues of the two patients, one with the lowest iPTH level was retained and the others were treated with microwave ablation, and the ablation treatment was technically successful. In the two patients, 5 and 4 parathyroid gland autografts were ablated and the largest ones were 15 mm×6 mm and 13 mm×5 mm, respectively. The levels of iPTH on the graft side and non-graft side were 87.3 ng/L and 79.6 ng/L, and 66.3 ng/L and 65.2 ng/L after 1 day of microwave ablation, respectively. During the follow-up period of 1 year after microwave ablation, calcium, phosphorus and alkaline phosphatase levels of the two patients were decreased and remained stable, bone and joint pains were relieved, and no numbness or abnormal movement of fingers and wrist joints were found in the transplanted side. Conclusion Hyperparathyroidism of forearm transplanted autograft can occur after PTX+AT. Microwave ablation is effective and safe in the treatment of the hyperparathyroidism.

Clinical observation on transrectal ultrasound-guided puncture and cathetering drainage in treatment of high-position perianal abscess / 第二军医大学学报

Objective To explore the clinical effect of transrectal ultrasound-guided puncture and cathetering drainage in the treatment of high-position perianal abscess. Methods Eighty patients with high-position perianal abscess, who admitted to Shuguang Hospital of Shanghai University of Traditional Chinese Medicine from Jan. of 2015 to 2018, were randomized into interventional therapy group and surgical treatment group, with 40 cases in each group. The patients in the interventional therapy group were treated with cathetering drainage guided by transrectal ultrasound, and the patients in the surgical treatment group were treated with traditional incision drainage. The clinical effect was evaluated in the two groups, and the pain, fever and exudation scores, white blood cell count, C-reactive protein level, maximal section area of abscess cavity, and wound healing time were compared between the two groups before operation and on 3 days and 7 days after operation. Results The total effective rates of the interventional therapy and surgical treatment groups were 87.5% (35/40) and 80% (32/40), respectively, and the difference was significant (χ2=1.385, P=0.709). On 3 days and 7 days after operation, the pain score, exudation score, white blood cell count, C-reactive protein level and maximum section area of the abscess cavity were significantly lower in the interventional therapy group than those in the the surgical treatment group (all P<0.01). The patients with retrorectal abscess or high intersphincteric abscess in the interventional therapy group had shorter wound healing time versus the patients in the surgical treatment group (both P<0.01). Conclusion Compared with traditional incision drainage, cathetering drainage guided by transrectal ultrasound can reduce pain and decrease exudation of the patients with high-position perianal abscess to effectively control infection.

Application of ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach in anatomical segmentectomy / 中华消化外科杂志

Objective To investigate the feasibility and safty of indocyanine green (ICG) fluorescence staining by laparoscopic ultrasound and three-dimensional (3D) visualization guided portal branch puncture approach in anatomical segmentectomy.Methods The retrospective cross-sectional study was conducted.The clinical data of 26 patients who underwent anatomical segmentectomy using ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach in the Zhongshan Hospital of Fudan University between December 2016 and April 2018 were collected.The preoperative 3D visualization reconstruction and areas of portal branch perfusion were analyzed,laparoscopic ultrasound localization was intraoperatively applied to tumor and portal vein of targeted hepatic segment,and then portal branch puncture and staining were done under laparoscopic ultrasound and 3D visualization,finally laparoscopic anatomical segmentectomy was performed.Observation indicators:(1) intraoperative situations:success rate of portal vein puncture,targeted hepatic segment,effect of ICG fluorescence staining,intraoperative complications,operation time,volume of intraoperative blood loss,blood transfusion,conversion to open surgery,tumor diameter,the minimum resection margin to tumor;(2) postoperative situations:postoperative complications (Clavien-Dindo classification as a criteria) and duration of hospital stay;(3) follow-up situations:cases with follow-up,follow-up time and postoperative tumor recurrence.Follow-up using outpatient examination and telephone interview was performed to detect postoperative tumor recurrence up to April 2018.Measurement data with normal distribution and count data were respectively described as average (range) and percentage.Results (1) Intraoperative situations:a success rate of laparoscopic ultrasound and 3D visualization guided portal branch puncture in 26 patients was 100.0％ (26/26),and punctures in S8,S7,S2,S3,S6,S5 and S4 of the liver were respectively performed to 7,6,4,3,3,2 and 1 patients.Of 26 patients,22 achieved expected effect of ICG fluorescence staining,with a statisfaction of 84.6％ (22/26) and 4 failed to get expected effect,including 2 with uneven dying,1 with staining-uncovered partial areas of targeted liver segment and 1 with adjacent hepatic segmental staining induced to unclear boundary.All the 26 patients were not complicated with ICG injection induced to allergy.Average operation time and volume of intraoperative blood loss were 184 minutes (range,60-315 minutes) and 97 mL (range,10-400 mL),without intraoperative blood transfusion and conversion to open surgery.Average tumor diameter and average minimum resection margin to tumor in 26 patients were respectively 3.2 cm (range,1.2-10.0 cm) and 1.5 cm (range,0.4-3.0 cm).(2) Postoperative situations:of 26 patients,2 with grade Ⅰ-Ⅱ of Clavien-Dindo classification were improved by drug treatments (1 with deep venous thrombosis of the lower extremities and 1 with pleural effusion),no patient had grade Ⅲ and above complications,and there was no bile leakage,infection and hepatic dysfunction.Average duration of hospital stay in 26 patients was 6.9 days (range,5.0-14.0 days).(3) Follow-up situations:26 patients were followed up for 0.3-17.0 months,with a median time of 6.0 months.During the follow-up,1 patient with hepatocellular carcinoma had adrenal metastasis and 25 had tumor-free survival.Conclusion Laparoscopic anatomical segmentectomy with ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approaeh is safe and feasible,especially suitable in posterosuperior liver segments.

Needle guides enhance tissue adequacy and safety of ultrasound-guided renal biopsies

BACKGROUND: Needle guides have recently come into use for ultrasound-guided percutaneous renal biopsies; however, it is not yet clear if the use of needle guides leads to decreased post-biopsy complication rates and improved tissue yields. Thus, we conducted a retrospective single center study comparing biopsy yield, adequacy, and rates of complications before and after utilization of a needle guide device. METHODS: A retrospective analysis was performed on all native kidney biopsies performed before and after June 2015 corresponding to the start of needle guide use. All biopsies in the latter period of the study were performed by a single operator. We compared clinical characteristics, indications, type of investigation, tissue yield, adequacy of procedure, and rates of major and minor complications. RESULTS: A total of 343 biopsies were analyzed, 140 in the pre-needle guide use period (Period I) and 203 in the needle guide use period (Period II). Biopsy yields were similar, irrespective of the use of needle guides. Tissue adequacy was better in Period II (93.7% vs. 84%, P < 0.001, with respect to pathologist-reported inconclusive biopsies. There were no differences in terms of major complications (1.7%) for the two periods; however, the rate of minor complications (8.4%) was significantly reduced in Period II (P = 0.006). According to multiple logistic regression analysis, not using a needle guide (odds ratio, 3.70; P < 0.001) along with low hemoglobin level, higher pre-dialysis serum creatinine level, and high urinary red blood cell count were significant predictors of biopsy complications. CONCLUSION: Use of a needle guide improves biopsy adequacy and is associated with reduced rates of minor complications in native renal biopsies. Therefore, needle guides may be recommended in percutaneous renal biopsies, especially when transitioning to single-operator performed procedures.

Advances in Intravascular Imaging: New Insights into the Vulnerable Plaque from Imaging Studies

The term “vulnerable plaque” denotes the plaque characteristics that are susceptible to coronary thrombosis. Previous post-mortem studies proposed 3 major mechanisms of coronary thrombosis: plaque rupture, plaque erosion, and calcified nodules. Of those, characteristics of rupture-prone plaque have been extensively studied. Pathology studies have identified the features of rupture-prone plaque including thin fibrous cap, large necrotic core, expansive vessel remodeling, inflammation, and neovascularization. Intravascular imaging modalities have emerged as adjunctive tools of angiography to identify vulnerable plaques. Multiple devices have been introduced to catheterization laboratories to date, including intravascular ultrasound (IVUS), virtual-histology IVUS, optical coherence tomography (OCT), coronary angioscopy, and near-infrared spectroscopy. With the use of these modalities, our understanding of vulnerable plaque has rapidly grown over the past several decades. One of the goals of intravascular imaging is to better predict and prevent future coronary events, for which prospective observational data is still lacking. OCT delineates microstructures of plaques, whereas IVUS visualizes macroscopic vascular structures. Specifically, plaque erosion, which has been underestimated in clinical practice, is gaining an interest due to the potential of OCT to make an in vivo diagnosis. Another potential future avenue for intravascular imaging is its use to guide treatment. Feasibility of tailored therapy for acute coronary syndromes (ACS) guided by OCT is under investigation. If it is proven to be effective, it may potentially lead to major shift in the management of millions of patients with ACS every year.

The value of intraoperative ultrasonography during the resection of relapsed irradiated malignant gliomas in the brain

PURPOSE: The aim of this study was to investigate whether intraoperative ultrasonography (IOUS) helped the surgeon navigate towards the tumor as seen in preoperative magnetic resonance imaging and whether IOUS was able to distinguish between tumor margins and the surrounding tissue. METHODS: Twenty-five patients suffering from high-grade gliomas who were previously treated by surgery and radiotherapy were included. Intraoperatively, two histopathologic samples were obtained a sample of unequivocal tumor tissue (according to anatomical landmarks and the surgeon’s visual and tactile impressions) and a small tissue sample obtained using a navigated needle when the surgeon decided to stop the resection. This specimen was considered to be a boundary specimen, where no tumor tissue was apparent. The decision to take the second sample was not influenced by IOUS. The effect of IOUS was analyzed semi-quantitatively. RESULTS: All 25 samples of unequivocal tumor tissue were histopathologically classified as tumor tissue and were hyperechoic on IOUS. Of the boundary specimens, eight were hypoechoic. Only one harbored tumor tissue (P=0.150). Seventeen boundaries were moderately hyperechoic, and these samples contained all possible histological results (i.e., tumor, infiltration, or no tumor). CONCLUSION: During surgery performed on relapsed, irradiated, high-grade gliomas, IOUS provided a reliable method of navigating towards the core of the tumor. At borders, it did not reliably distinguish between remnants or tumor-free tissue, but hypoechoic areas seldom contained tumor tissue.

Percutaneous ethanol injection versus conservative treatment for benign cystic and mixed thyroid nodules

ABSTRACT Objective To evaluate the efficacy and safety of percutaneous ethanol injection (PEI) in reducing the volume of cystic and mixed thyroid nodules. Materials and methods A total of 36 patients with nodules treated with PEI and 13 individuals who declined PEI and were followed clinically or received other non surgical treatment (control group). Assessments were performed at baseline (immediately before treatment in the PEI group or evaluation of the nodule on ultrasonography in the control group) at short-term (on average 30 days after the last injection in the PEI group), and long-term (on average 14 months after baseline in the PEI group or 26 months after baseline in the control group). Results In the PEI group, the mean baseline volume of 10.4 ± 9.8 cm3 reduced at short-term follow-up to 2.9 ± 3.1 cm3 (67.7 ± 19.9%, p < 0.001) and at long-term follow-up to 2.0 ± 2.5 cm3 (78.2 ± 19.5%, p < 0.01 versus baseline and p = 0.009 versus short-term follow-up). Both types of nodules showed similar degrees of reduction. In the control group, mean volume was 5.8 ± 3.4 cm3 at baseline and 6.2 ± 3.0 cm3 at long-term follow-up (p = 0.507). Compared with the control group, the PEI group showed larger reduction (p < 0.001). Conclusions PEI is effective in reducing the volume of cystic and mixed benign thyroid nodules, with sustained long-term efficacy and better outcome when compared with conservative therapies. Treatment with PEI is a safe alternative, with minimal, transient and self-limited adverse events.

A pictorial review of signature patterns living in musculoskeletal ultrasonography

The musculoskeletal system is mainly composed of the bones, muscles, tendons, and ligaments, in addition to nerves and blood vessels. The greatest difficulty in an ultrasonographic freeze-frame created by the examiner is recognition of the targeted structures without indicators, since an elephant's trunk may not be easily distinguished from its leg. It is not difficult to find descriptive ultrasonographic terms used for educational purposes, which help in distinguishing features of these structures either in a normal or abnormal anatomic condition. However, the terms sometimes create confusion when describing common objects, for example, in Western countries, pears have a triangular shape, but in Asia they are round. Skilled experts in musculoskeletal ultrasound have tried to express certain distinguishing features of anatomic landmarks using terms taken from everyday objects which may be reminiscent of that particular feature. This pictorial review introduces known signature patterns of distinguishing features in musculoskeletal ultrasound in a normal or abnormal condition, and may stir the beginners' interest to play a treasure-hunt game among unfamiliar images within a boundless ocean.

A pictorial review of signature patterns living in musculoskeletal ultrasonography

The musculoskeletal system is mainly composed of the bones, muscles, tendons, and ligaments, in addition to nerves and blood vessels. The greatest difficulty in an ultrasonographic freeze-frame created by the examiner is recognition of the targeted structures without indicators, since an elephant's trunk may not be easily distinguished from its leg. It is not difficult to find descriptive ultrasonographic terms used for educational purposes, which help in distinguishing features of these structures either in a normal or abnormal anatomic condition. However, the terms sometimes create confusion when describing common objects, for example, in Western countries, pears have a triangular shape, but in Asia they are round. Skilled experts in musculoskeletal ultrasound have tried to express certain distinguishing features of anatomic landmarks using terms taken from everyday objects which may be reminiscent of that particular feature. This pictorial review introduces known signature patterns of distinguishing features in musculoskeletal ultrasound in a normal or abnormal condition, and may stir the beginners' interest to play a treasure-hunt game among unfamiliar images within a boundless ocean.

Gelatin model for training ultrasound-guided puncture / Treinamento de punção ecoguiada em modelo de gelatina

It is indispensable that members of the medical profession receive the technical training needed to enable them to rapidly obtain effective vascular access. Training procedures should be used judiciously to familiarize students with the technique. However, existing models are expensive or ineffective, and models need to be developed that are similar to what will be encountered in real patients.OBJECTIVES: To demonstrate creation and application of a gelatin model for training ultrasound-guided puncture.METHOS: The model was made using a mixture of colorless gelatin and water in a transparent plastic receptacle with two pairs of orifices of different diameters, through which two plastic tubes were inserted, to simulate blood vessels.RESULTS: The model was a close approximation to the real medical procedure in several aspects, since gelatin has a similar consistency to human tissues, providing a more faithful reproduction of the tactile sensation at the moment when the needle reaches the interior of a vessel and its contents are aspirated.CONCLUSIONS: The method proposed here can be used to easily construct a low-cost model using everyday materials that is suitable for large-scale training of ultrasound-guided puncture.

É imprescindível a capacitação técnica da classe médica para a obtenção de um acesso vascular rápido e eficiente, sendo que os procedimentos de treinamento devem ser usados sabiamente como forma de familiarizar o aluno à técnica. Os modelos comerciais existentes são de alto custo ou não são eficientes, devendo ser criados novos modelos semelhantes ao que será visto num paciente.OBJETIVOS: Demonstrar a criação e a utilização de um modelo de gelatina para o treinamento da punção ecoguiada por ultrassom.MÉTODOS: Modelo criado através da mistura de água com gelatina incolor num recipiente plástico transparente com dois orifícios de diferentes diâmetros, nos quais foram colocados dois canos plásticos simulando os vasos sanguíneos.RESULTADOS: O modelo proposto se aproxima da realidade do procedimento médico em vários aspectos, pois a consistência da gelatina é próxima aos tecidos humanos, promovendo a preservação da sensação tátil ao atingir o interior do vaso e durante a aspiração do conteúdo.CONCLUSÕES: O método proposto permite criar um modelo de baixo custo e fácil confecção utilizando-se materiais de uso cotidiano para treino de punção ecoguiada em larga escala.

Arterial Pseudoaneurysm in Neonates with Hemophilia: Successful Treatment with Noninvasive Clotting Factor Replacement and Ultrasound-guided Compression

Vascular cannulation is an invasive procedure that carries the risk of complications such as pseudoaneurysms. Hemophilia, the most common severe bleeding disorder of inheritance, increases the risk of such complications through underlying hypocoagulability. Although surgical ligation has been considered the gold standard treatment, less invasive options are currently available. Here we present 2 hemophiliac neonates for whom clotting factor replacement and ultrasound (US)-guided compression were successfully used. A 3-week-old male infant and a 4-week-old male infant presented with masses in the left antecubital area and the radial aspects of both wrists, respectively, after arterial punctures. The US confirmed the presence of pseudoaneurysms located at the left brachial artery and right radial artery. US-guided compressions with clotting factor administration initially attempted while confirming a thrombus inside the pseudoaneurysm sac indicated successful management. Arterial cannulation and other procedures in hemophiliac neonates must be attempted with caution because pseudoaneurysms or uncontrolled bleeding may occur. If laboratory analyses or invasive procedures are needed for neonates with a bleeding tendency or a suspected hemophiliac disorder, arterial or venous cannulation requires more caution or should be avoided if possible. This case report suggests that US-guided compression and clotting factor administration are suitable modalities for the treatment of small pseudoaneurysms in hemophilia patients.

Preparation and management of complications in prostate biopsies / Preparo e manejo de complicações em biópsias de próstata

Transrectal ultrasonography-guided biopsy plays a key role in prostate sampling for cancer detection. Among interventional procedures, it is one of the most frequent procedures performed by radiologists. Despite the safety and low morbidity of such procedure, possible complications should be promptly assessed and treated. The standardization of protocols and of preprocedural preparation is aimed at minimizing complications as well as expediting their management. The authors have made a literature review describing the possible complications related to transrectal ultrasonography-guided prostate biopsy, and discuss their management and guidance to reduce the incidence of such complications.

Isolated Left Main Coronary Artery Spasm Detected by Multidetector Computed Tomography

Although atherosclerotic obstruction is the main cause of left main coronary artery (LMCA) disease, it can also be associated with vasospasm. We report a case of a 61-year-old male who presented with ostial stenosis of the LMCA, detected by 64-slice multi-detector computed tomographic coronary angiography (MDCT-CA). Careful review of MDCT and intravascular ultrasound findings showed suspicion of an isolated spasm of the LMCA without a significant atherosclerotic lesion. The patient was successfully treated with nitrates and a calcium channel blocker.

Ultrasound puncture holder guided catheterization in internaljugular vein: report of 124 cases / 国际外科学杂志

ObjectiveOne hunred and twenty-four To probe into application value of ultrasound guided Catheterization in internal jugular vein. MethodsOne hundrel and twenty-four guided by ultrasound puncture holder, single-channel or three-channel catheter was embedded into jugular vein. ResultsThe catheter was inserted successfully by only one procedure in all the 124 patients. There was no complication. ConclusionsThe catheterization becomes safer, convenient and quickly with ultrasound puncture holder guidance, decreasing failure rate and complication of the procedure.