Sobreuso de ecografía transvaginal en un hospital universitario privado de Argentina: estudio de corte transversal / Transvaginal ultrasound overuse in a private university hospital in Argentina: a cross-sectional study

Introducción. Si bien contamos con recomendaciones basadas en la evidencia en contra de realizar tamizaje de cáncer ovárico con ecografía transvaginal debido a que aumenta el riesgo de resultados falsamente positivos y de cascadas diagnósticas, sin disminuir la mortalidad por esta enfermedad, su solicitud en mujeres sanas es frecuente. Sin embargo, no conocemos la magnitud de la implementación de esta práctica, que constituye un cuidado de bajo valor. Objetivo. Documentar el sobreuso de ecografías transvaginales realizadas en forma ambulatoria en un hospital universitario privado de Argentina. Métodos. Estudio de corte transversal de una muestra aleatoria de ecografías realizadas en forma ambulatoria durante 2017 y 2018. Mediante revisión manual de las historias clínicas, la solicitud de cada ecografía fue clasificada como apropiada cuando algún problema clínico justificaba su realización, o inapropiada cuando había sido realizada con fines de control de salud o por una condición clínica sin indicación de seguimiento ecográfico. Resultados. De un total de 1.997 ecografías analizadas, realizadas a 1.954 mujeres adultas (edad promedio 50 años),1.345 (67,4 %; intervalo de confianza [IC] 95 % 65,2 a 69,4) habían sido solicitadas en el contexto de un control de saludo sin un problema asociado en la historia clínica y otras 54 (8,3 %; IC 95 % 6,3 a 10,7), por condiciones de salud para las que no hay recomendaciones de realizar seguimiento ecográfico. Conclusiones. Esta investigación documentó una alta proporción de sobre utilización de la ecografías transvaginales en nuestra institución. Futuras investigaciones permitirán comprender los motivos que impulsan esta práctica y ayudarán a diseñar intervenciones para disminuir estos cuidados de bajo valor. (AU)

Background. Although we have evidence-based recommendations against screening for ovarian cancer with transvaginalultrasound because it increases the risk of false positive results and diagnostic cascades without reducing mortality from this disease, its request in healthy women is frequent. However, we do not know the magnitude of the implementation of this practice, which constitutes low-value care. Objective. To document the overuse of transvaginal ultrasounds performed on an outpatient basis in a private university hospital in Argentina. Methods. Cross-sectional study of a random sample of outpatient ultrasounds performed during 2017 and 2018. Through a manual review of the medical records, the request for each ultrasound was classified as appropriate when a clinical problem justified its performance or inappropriate when it was carried out for health control purposes or for a clinical condition that had no indication for ultrasound follow-up. Results. Of a total of 1997 ultrasounds analyzed, performed on 1954 adult women (average age 50 years), 1,345 (67.4 %;95 % confidence interval [CI] 65.2 to 69.4) had been requested in the context of a health check-up or without a documented problem in the medical history that would support its performance, and another 54 (8.3 %; 95 % CI 6.3 to 10.7), for health conditions for which there are no treatment recommendations to perform ultrasound follow-up. Conclusions. This research documented a high proportion of overuse of transvaginal ultrasound in our institution. Future research will allow us to understand the reasons that drive this practice and will help design interventions to reduce thislow-value care. (AU)

Utilidad de la 18f-colina pet/tc en hiperparatiroidismo primario persistente o recurrente: experiencia inicial / Usefulness of 18f-choline pet / tc in persistent or recurrent primary hyperparathyroidism: initial experience

El hiperparatiroidismo persistente/recurrente representa un desafío en la localización del tejido paratiroideo hiperfuncionante. En esta subpoblación, los métodos convencionales ofrecen un menor rédito diagnóstico. La 18F-colina PET/TC podría ser una buena alternativa dada su mejor resolución espacial, capacidad de detectar glándulas ectópicas y la conjunción de la imagen molecular y anatómica. Sin embargo, la evidencia en este subgrupo de pacientes es escasa. Objetivo: evaluar la utilidad de la 18F-colina PET/TC como método de localización en el hiperparatiroidismo persistente o recurrente. Materiales y métodos: se analizaron los pacientes con 18F-colina PET/TC para hiperparatiroidismo entre diciembre de 2015 y enero de 2018 en un centro terciario de alto volumen. Se analizaron el número de lesiones, su localización, tamaño y el Standard Uptake Value máximo (SUV max) en las imágenes tempranas y tardías. Se compararon los resultados con los métodos convencionales. Resultados: 7 de 15 pacientes habían sido operados previamente (persistentes/recurrentes). La 18F-colina PET/TC detectó 6/7 casos (83,33%), la ecografía cervical 1/4 (25%) y el SPECT de paratiroides y la resonancia nuclear magnética 2/5 (40%). El SUV max obtenido fue variable, en la mitad de los casos a los 10 minutos y en los restantes a la hora; el tamaño promedio de las lesiones fue 8,61 mm (6-12 mm). Conclusiones: la 18F-colina PET/TC muestra una alta tasa de detección en los pacientes con hiperparatiroidismo persistente/recurrente. La combinación del comportamiento biológico del PET con los hallazgos morfológicos aportados por la TC con contraste endovenoso le ofrecería ventajas sobre otros estudios que podrían posicionarlo como método de primera línea en esta subpoblación. (AU)

Persistent or recurrent hyperparathyroidism represents a challenge regarding the localization of the hyper-functioning parathyroid tissue. In this subpopulation of hyperpharathyroid patients, conventional methods have a low diagnostic yield. The 18F-choline PET /CT could be a good alternative given its better spatial resolution, ability to detect ectopic glands, and the conjunction of the molecular and anatomical image. However, the evidence in this subgroup of patients is limited. Objective: to evaluate the utility of 18F-choline PET/ CT as a localization method in persistent or recurrent hyperparathyroidism. Materials and methods: patients with 18F-choline PET / CT for hyperparathyroidism between December 2015 and January 2018 in a high-volume tertiary center were included. The number of lesions, and their location, size, and maximum Standard Uptake Value (SUV) in the early and late images were analyzed. The results were compared to conventional methods. Results: 7 of 15 patients had been previously operated (persistent/recurrent). 18F-choline PET / CT detected 6/7 cases (83,33%), cervical ultrasound 1/4 (25%) and parathyroid SPECT and magnetic resonance 2/5 (40%). The maximum SUV was variable, one half at 10 minutes and the other half at 60 minutes; the average size of the lesions was 8.61 mm (6-12 mm). Conclusions: 18F-Choline PET / CT shows a high detection rate in patients with persistent / recurrent hyperparathyroidism. The combination of the biological behavior of PET with the morphological findings provided by CT with intravenous contrast would offer advantages over other studies that could position it as a first line method in this subpopulation. (AU)

Ultrassonografia do nervo óptico no modo A para o diagnóstico do glaucoma / A mode optic nerve ultrassonography for glaucoma diagnosis

Resumo Objetivos: Determinar se a medida do diâmetro horizontal ou refletividade do nervo óptico retrobulbar no modo A apresenta correlação com a relação da escavação pelo diâmetro do nervo óptico no glaucoma, considerando: a correlação das medidas, a sensibilidade e especificidade entre os métodos e qual a medida tem maior sensibilidade e especificidade para discriminar glaucomatosos. Métodos: Estudo mascarado, prospectivo e comparativo de nervos ópticos de 38 pacientes com glaucoma de ângulo primário de ângulo aberto e 37 pacientes controles, que foram examinados para determinação ecográfica retrobulbar de seus diâmetros no modo A (DNA) e das suas refletividades (RNA). Biomicroscopicamente foram estabelecidas as relações do comprimento vertical ou horizontal da escavação pelo diâmetro correspondente dos discos ópticos (EV/DV ou EH/DH). Estas medidas foram avaliadas quanto às suas correlações, consistências, sensibilidades e especificidades. Resultados: A média de DNA foi de 2,93 mm no grupo controle e de 2,72 mm no grupo glaucomatoso (p<0,001) e a do RNA foi de 32,22% no grupo controle e 31,59% no grupo glaucomatoso (p=0,577). DNA correlacionou-se moderada e significativamente com EH/DH (-0,450, p <0,01) e EV/DV (-0,463, p<0,01) e o RNA se correlacionou de forma insignificante com EH/DH e EV/DV. A consistência das medidas de DNA foi de 0,6780(IC95%: 0,5883-0,7561) e de RNA foi de 0,6902(0,6010-0,7640) e a elas foram inferiores às medidas de consistência do disco. A medida de 2,85 mm de DNA foi a de maior sensibilidade (0,757) e especificidade (0,714) para diagnóstico de glaucoma. Conclusão: A ecografia A Estandardizada da medida do diâmetro do nervo óptico retrobulbar foi a mais indicado para diagnóstico do glaucoma.

Abstract Objectives: Determine if retrobulbar optic nerve horizontal diameter measurement or reflectivity correlates with the optic disc excavation diameter relation in glaucoma, considering: measurements correlation, the sensitivity and specificity between the methods and which value has greater sensitivity and specificity to differentiate patients with and without glaucoma. Methods: In a masked study, the optic nerves of 38 patients with open angle primary angle glaucoma and 37 control patients were examined for retrobulbar echographic determination of their A mode (DNA) and their reflectivity (RNA) diameters. Biomicroscopically the relationships of the vertical or horizontal length of the excavation by the corresponding diameter of the optical discs (EV / DV or EH / DH) were estahed. These measures were evaluated for their correlations, consistencies, sensitivities and specificities. Results: Mean DNA was 2.93 mm in the control group and 2.72 mm in the glaucomatous group (p <0.001) and that of the RNA was 32.22% in the control group and 31.59% in the glaucomatous group (p = 0.577). DNA was moderately and significantly correlated with EH / DH (-0.450, p <0.01) and EV / DV (-0.463, p <0.01) and RNA correlated insignificantly with DH / DH and EV / DV. DNA measurements was 0.6780 (95% CI: 0.5883-0.7561) and RNA was 0.6902 (0.6010-0.7640) and were lower than the consistency measurements of the disc. The measurement of 2.85 mm of DNA was the one of greater sensitivity (0.757) and specificity (0.714) for diagnosis of glaucoma. Conclusion: The standard method A of retrobulbar optic nerve diameter measurement was the most suitable for glaucoma diagnostic.

Thyroid cancer burden and economic impact on the Brazilian public health system

ABSTRACT Objective: Recent data indicates an increasing incidence of thyroid cancer not accompanied by a proportional increase in mortality, suggesting overdiagnosis, which may represent a big public health problem, particularly where resources are scarce. This article aims to describe and evaluate the procedures related to investigation of thyroid nodules and treatment and follow-up of thyroid cancer and the costs for the Brazilian public health system between 2008 and 2015. Materials and methods: Data on procedures related to investigation of thyroid nodules and treatment/follow-up of thyroid cancer between 2008 and 2015 in Brazil were collected from the Department of Informatics of the Brazilian Unified Health System (Datasus) website. Results: A statistically significant increase in the use of procedures related to thyroid nodules investigation and thyroid cancer treatment and follow-up was observed in Brazil, though a reduction was noted for procedures related to the treatment of more aggressive thyroid cancer, such as total thyroidectomy with neck dissection and higher radioiodine activities such as 200 and 250 milicuries (mCi). The procedures related to thyroid nodules investigation costs increased by 91% for thyroid ultrasound (p = 0.0003) and 128% in thyroid nodule biopsy (p < 0.001). Costs related to treatment and follow-up related-procedures increased by 120%. Conclusion: The increase in the incidence of thyroid cancer in Brazil is directly associated with an increased use of diagnostic tools for thyroid nodules, which leads to an upsurge in thyroid cancer treatment and followup-related procedures. These data suggest that substantial resources are being used for diagnosis, treatment and follow-up of a potentially indolent condition.

Abdominal B-mode and Doppler ultrasonography of chemically restrained agouti (Dasyprocta prymnolopha Wagler, 1831) / Ultrassonografia abdominal em Modo B e Doppler de cutias (Dasyprocta prymnolopha Wagler, 1831) contidas quimicamente

Agoutis are small-sized wild animals whose body weight can reach up to 4kg, and are found throughout Brazil. They are considered important seed dispersers, especially for big trees and there are species that rely almost exclusively on these animals for their territorial distribution. The objective of the present study was B scan and Doppler ultrasound characterization of the abdominal organs of healthy agoutis reared in captivity. Fifteen agoutis, chemically restrained, were used from the Nucleus for Wild Animal Studies and Conservation (Núcleo de Estudos e Preservação de Animais Silvestres - NEPAS), CCA-UFPI, submitted to B scan and Doppler ultrasound examination. The urinary bladder wall was hyperechogenic, thin, smooth and regular throughout its anatomic path, with 0.09±0.03cm mean thickness. The kidneys showed fine and homogeneous echotexture, preserved global echogenicity, hyperechogenic in relation to the spleen and isoechogenic or discreetly hyperechogenic in relation to the liver. The spectral Doppler trace showed systolic and diastolic peaks, wide and thread-like, with low flow resistance and a continuous and full diastolic portion that decreased gradually during the diastole (75.83±1.42cm/s, for the right kidney and 80.43±1.22cm/s, for the left kidney). The right adrenal gland was 0.61-1.18cm long and 0.17-0.32cm in diameter, while the left adrenal gland was 0.62-1.16 long with 0.14-0.25cm diameter. The agouti spleen was filiform in shape, with pointed poles and 1.02±0.18cm in diameter. The agouti liver occupied all the abdominal cavity cranial space in direct contact with the diaphragm. The intrahepatic vascular flow allowed individualization of the portal vein (PV) and hepatic vein (HV). The portal veins were distinguished from the hepatic veins mainly by their wall echogenic pattern. The pancreas was 0.51±0.1 cm thick and the pancreatic duct measured 0.12±0.02cm. The stomach was placed to the left the spleen and to the right of the proximal intestine and the transversal colon and the walls were 0.16±0.05cm thick. The abdominal aorta was 0.43±0.04cm in diameter and showed 95.2±2.16cm/s vascular flow. This study characterized agouti organs and abdominal blood vessels by B scan and Doppler ultrasound, that permitted definition of the size, shape, position, echogenicity and echotexture of the anatomic constituents and established reference values for the vascular network and blood flow in the species.(AU)

As cutias são animais silvestres de pequeno porte, cujo peso corpóreo pode chegar até 4kg, e existem em todo território brasileiro. São considerados importantes dispersores de sementes, especialmente para árvores de grande porte, existindo espécies que dependem quase que exclusivamente destas para sua distribuição territorial. Este trabalho teve por objetivo a caracterização ultrassonográfica modo B e Doppler dos órgãos abdominais de cutias hígidas criadas em cativeiro. Foram utilizadas 15 cutias, contidas quimicamente, oriundas do Núcleo de Estudos e Preservação de Animais Silvestres - NEPAS, CCA-UFPI, submetidas a exame ultrassonográfico em modo B e Doppler. A parede da vesícula urinária presentou-se hiperecogênica, fina, lisa e regular em todo seu trajeto anatômico, com espessura média de 0,09±0,03cm. Os rins demonstraram ecotextura fina e homogênea, ecogenicidade global preservada, hipoecogênico em relação ao baço e isoecogênico ou discretamente hipoecogênico em relação ao fígado. O traçado em Doppler espectral mostrou pico sistólico e diastólico, amplo e afilado, exibindo baixa resistência de fluxo, com uma porção diastólica contínua e cheia, que diminui gradativamente no decorrer da diástole (75,83±1,42cm/s para o rim direito e 80,43±1,22 cm/s para o esquerdo. A adrenal direita apresentou uma variação de comprimento entre 0,61 a 1,18cm e diâmetro variando entre 0,17 a 0,32cm, enquanto a adrenal esquerda evidenciou comprimento de 0,62 a 1,16 e diâmetro de 0,14 a 0,25cm. O baço das cutias mostrou formato filiforme, com polos pontiagudos e diâmetro de 1,02±0,18cm. O fígado da cutia ocupa todo o espaço cranial da cavidade abdominal, em contato direto com o diafragma. O fluxo vascular intrahepático permitiu individualizar as veias porta (VP) e veias hepáticas (VH). As veias porta foram distinguidas, particularmente pelo padrão ecogênico de suas paredes, quando comparadas com as veias hepáticas. A espessura do pâncreas foi de 0,51±0,1cm e o ducto pancreático mediu 0,12±0,02cm. O estômago relaciona-se à esquerda com o baço e a direita com o duodeno proximal e colón transverso. Sua espessura de parede mensurada foi de 0,16±0,05cm. A aorta abdominal possui diâmetro de 0,43±0,04cm e fluxo vascular de 95,2±2,16cm/s. Este estudo caracterizou os órgãos e vasos sanguíneos abdominais de cutias, por meio de ultrassonografia modo B e Doppler, o que permitiu definir o tamanho, formato, posição, ecogenicidade, ecotextura dos constituintes anatômicos, além de estabelecer valores de referência para a rede vascular e fluxo sanguíneo na espécie.(AU)

Aplicación de la técnica de árboles de clasificación y regresión en la valoración ecográfica de los nódulos tiroideos / Using Classification and Regression Trees in the ultrasound evaluation of thyroid nodules

Objetivo: Evaluar la capacidad de los árboles de clasificación y regresión (CART) en la valoración ecográfica de los nódulos tiroideos malignos. Materiales y métodos: Se realizaron 404 punciones aspiración con aguja fina (PAAF) a 384 pacientes. De los nódulos analizados, se registraron las características ecográficas (localización, tamano, morfología, contorno, consistencia, ecoestructura, ecogenicidad, calcificaciones y vascularización) y los resultados de la elastografía. Se aplicó el CART para investigar la relación entre los hallazgos ecográficos, la elastografía y el cáncer de tiroides. Resultados: El análisis CART determinó que la realización de una elastografía no aporta datos relevantes y que las zonas homogéneas pueden clasificar a los nódulos tiroideos en: 1.ª zona) caracterizada por ausencia de áreas de degeneración coloide e hipoecogenicidad asociada a malignidad; 2.ª zona) diferenciada por presencia de áreas de degeneración coloide combinada con ausencia de microcalcificaciones, constituyendo un indicador fiable de benignidad de los nódulos tiroideos; y 3.ª zona) la ausencia de hipoecogenicidad y una lesión menos alta que ancha deparan un indicador fiable de benignidad. El árbol de clasificación alcanzó una sensibilidad del 87,5% y un valor predictivo negativo del 98,8%. Discusión: El CART muestra una elevada capacidad de predicción de los nódulos malignos frente a otras técnicas lineales. Conclusión: La utilización de los árboles de clasificación provee una herramienta simple para la toma de decisión clínica con el objeto de reducir las PAAF innecesarias, con una elevada sensibilidad.

Objective: To evaluate the use of Classification and Regression Trees (CART) in the ultrasound evaluation of malignant thyroid nodules. Materials and methods: A study was performed on 404 fine needle aspirates (FNA), with biopsies being performed on 384. The information collected about the thyroid nodules was: ultrasound features (location, size, morphology, contour, consistency, echo-structure, echogenicity, calcification, and vascularisation) and elastography results. The CART technique was used to investigate the relationship between ultrasound findings and the thyroid cancer. Results: The CART analysis showed that elastography does not provide any relevant data, and that the homogeneous areas could classified the thyroid nodules into: 1st area) characterised by the absence of colloid degeneration areas and a hypo-echogenicity associated with malignancy; 2nd area) differentiated by the presence of colloid degeneration areas combined with absence of microcalcifications, constituting a reliable indicator of benign thyroid nodules; and a 3rd area) the absence of hypo-echogenicity and a lesion wider than it is long that provides a reliable indicator of being benign. The optimum tree produced a sensitivity of 87.5% and negative predictive value of 98.8%. Discussion: The CART technique demonstrated a high predictive capacity for malignant nodules compared to other linear techniques. Conclusion: The use of classification trees provides us with a simple tool for clinical decision making, in order to reduce unnecessary FNA biopsies, as well as achieving a high sensitivity.

Accuracy of a new sonographic classification system in differentiating benign from malignant solid thyroid nodules

Objective: To determine diagnostic accuracy of sonographic criteria in differentiating benign from malignant solid thyroid nodule by using new sonographic classification system

Study Design: Cross sectional validation study

Place and Duration of Study: Department of Radiology, Combined Military Hospital Multan from Oct 2014 to Mar 2015

Material and Methods: A total of 150 consecutive cases of either sex ranging in age from 19-60 years with palpable thyroid nodules referred for diagnostic workup were subjected to ultrasound [US] examination for assessment of solid thyroid nodules and it was followed by US-guided fine-needle aspiration [FNA] of all solid thyroid nodules. Each of the biopsied nodule was subsequently placed into one of five categories on the basis of sonographic features i.e. [malignant] [suspicious for malignancy] [borderline] probably benign] and [benign]. Evaluation of accuracy of sonographic diagnosis for solid thyroid nodule was done by comparing results of fine needle aspiration biopsy [FNAB]

Results: The mean age of the patients [n=150] was 42.34 +/- 4.78 years; seventy three percent [n=109] were females and twenty seven percent [n=41] were males. Frequency of thyroid nodules [on FNAB as gold standard] was revealed as 20.7% [n=31] malignant and 79.3% [n=119] benign, accuracy of a new sonographic classification system in differentiating benign from malignant solid thyroid nodules, keeping FNAB as gold standard showed 18.7% [n=28] true positive, 4.7% [n=7] false positive, 2% [n=3] false negative and 74.6% [n=112] true negative

Ultrasound finding has sensitivity of 90.3%, specificity of 94.12% and diagnostic accuracy of 93.3%

Conclusion: Accuracy of a new sonographic classification system in differentiating benign from malignant solid thyroid nodules, while keeping FNAB as gold standard was high and is recommended for diagnosis of malignant solid thyroid nodules

Criptoftalmos bilateral / Bilateral cryptophthalmos

El criptoftalmos se origina por un defecto congénito en la migración de la cresta neural que da lugar a un desarrollo anormal de los párpados y de las estructuras oculares anteriores. Se presenta la evolución de un lactante masculino de 6 meses de edad con criptoftalmos. Al examen oftalmológico se constata agenesia de los párpados. La piel transcurre desde la frente pasando por encima del esbozo de los globos oculares hasta la mejilla y ausencia de toda la arquitectura palpebral. El resto de las estructuras faciales son normales. El diagnóstico fue basado en la historia clínica y la realización de pruebas como la ecografía ocular, la tomografía axial computadorizada de órbita y cráneo, así como otros estudios, los cuales confirman el diagnóstico(AU)

Cryptophthalmos comes from a congenital defect in the neural crest migration that gives rise to abnormal development of eyelids and of the anterior ocular structures. Here is the case of a male 6 months-old infant with cryptophthalmos. The ophthalmological exam revealed eyelid agenesis. The infant´s skin went down from the forehead, passing over the eyeball up to the cheek, but the eyelid architecture was absent. The rest of the facial structures were normal. The diagnosis was based on the medical history and some tests as the ocular echography, the orbit and cranial computerized tomography and other studies which confirm the diagnosis(AU)

Correlation of Thyroid Imaging Reporting and Data System [TI-RADS] and fine needle aspiration: experience in 1, 000 nodules / Correlação entre a classificação Thyroid Imaging Reporting and Data System [TI-RADS] e punção aspirativa por agulha fina: experiência com 1. 000 nódulos

ABSTRACT Objective To correlate the Thyroid Imaging Reporting and Data System (TI-RADS) and the Bethesda system in reporting cytopathology in 1,000 thyroid nodules. Methods A retrospective study conducted from November 2011 to February 2014 that evaluated 1,000 thyroid nodules of 906 patients who underwent ultrasound exam and fine needle aspiration. Results A significant association was found between the TI-RADS outcome and Bethesda classification (p<0.001). Most individuals with TI-RADS 2 or 3 had Bethesda 2 result (95.5% and 92.5%, respectively). Among those classified as TI-RADS 4C and 5, most presented Bethesda 6 (68.2% and 91.3%, respectively; p<0.001). The proportion of malignancies among TI-RADS 2 was 0.8%, and TI-RADS 3 was 1.7%. Among those classified as TI-RADS 4A, proportion of malignancies was 16.0%, 43.2% in 4B, 72.7% in 4C and 91.3% among TI-RADS 5 (p<0.001), showing clear association between TI-RADS and biopsy results. Conclusion The TI-RADS is appropriate to assess thyroid nodules and avoid unnecessary fine needle aspiration, as well as to assist in making decision about when this procedure should be performed.

RESUMO Objetivo Apresentar a correlação entre o Thyroid Imaging Reporting and Data System (TI-RADS) e o sistema Bethesda, para relatar citopatologia em 1.000 nódulos tireoidianos. Métodos Estudo retrospectivo realizado no período de novembro de 2011 a fevereiro de 2014, que avaliou 1.000 nódulos tireoidianos de 906 pacientes submetidos a exame de ultrassonografia e à punção aspirativa por agulha fina. Resultados Observou-se associação significativa entre o TI-RADS e o resultado da classificação de Bethesda (p<0,001). A maioria dos indivíduos com TI-RADS 2 ou 3 teve resultado citológico Bethesda 2 (95,5% e 92,5%, respectivamente). Entre aqueles classificados TI-RADS 4C e 5, a maioria teve resultado Bethesda 6 (68,2% e 91,3%, respectivamente; p<0,001). A proporção de malignidades em TI-RADS 2 foi 0,8% e em TI-RADS 3 foi 1,7%. Entre TI-RADS 4A, foi de 16,0%, 43,2% em 4B, 72,7% em 4C e em 5 foi de 91,3% (p<0,001), mostrando clara associação entre o TI-RADS e os resultados da biópsia. Conclusão O TI-RADS é apropriado para avaliar nódulos da tireoide e evitar punção aspirativa por agulha fina desnecessária, além de auxiliar na decisão sobre quando este procedimento deve ser realizado.

Correspondencia clínica, hormonal y ecográfica en el diagnóstico del síndrome de ovarios poliquísticos / Clinical, hormonal and echographic correspondence in the diagnosis of polycystic ovary syndrome

Introducción: el síndrome de ovarios poliquísticos es el trastorno endocrino más frecuente en la mujer en edad reproductiva. Se caracteriza por trastornos menstruales, hiperandrogenismo y ovarios poliquísticos por ultrasonido, y afecta la fertilidad y el metabolismo femeninos. Objetivo: determinar la frecuencia de aparición de los criterios diagnósticos de síndrome de ovarios poliquísticos en mujeres con sospecha de esta afección, y la posible correspondencia entre el diagnóstico clínico, hormonal y ecográfico. Métodos: se realizó un estudio descriptivo correlacional en 140 mujeres. Se les practicó interrogatorio y examen físico, ultrasonido diagnóstico y estudio de las hormonas folículo estimulante, luteinizante y testosterona. Para el análisis estadístico se utilizaron tablas de frecuencia y la prueba de chi cuadrado (p< 0,05). Resultados: la edad media fue 26,3 años. De 96 mujeres (68,5 por ciento) con alteraciones del ciclo menstrual, 76 (79,2 por ciento) refirieron oligomenorrea. Hubo sobrepeso en 64 pacientes (45,7 por ciento). La testosterona elevada fue la alteración hormonal predominante (52,7 por ciento). El 84,3 por ciento presentó volumen ovárico ≥ 10 cc. Hubo asociación significativa entre las alteraciones menstruales y la presencia de ovarios poliquísticos (p= 0,000), hirsutismo (p= 0,001) y acné (p= 0,000), pero no ocurrió así con las variables hormonales. Hubo coincidencia entre el diagnóstico ecográfico y la testosterona elevada en el 46,2 por ciento de las pacientes. Conclusiones: Existe asociación entre las variables clínicas y el diagnóstico de síndrome de ovarios poliquísticos, pero no así entre los criterios diagnósticos ecográficos y hormonales, ni entre las alteraciones hormonales y el diagnóstico clínico y ecográfico del síndrome de ovarios poliquísticos, en estas pacientes(AU)

Introduction: polycystic ovary syndrome is the most common endocrine disorder in a woman at reproductive age. It is characterized by menstrual disorders, hyperandrogenism and CT-detected polycystic ovaries and it has an effect on fertility and metabolism. Objective: to determine the frequency of occurrence of diagnostic criteria of polycystic ovary syndrome in women suspected of suffering this disease, and the possible correspondence among the clinical, hormonal and echographic diagnoses. Methods: a correlational descriptive study was conducted in 140 women. They were questioned and physically examined in addition to performing diagnostic ultrasound and study of the follicle-stimulating hormone, the luteinizing hormone and testosterone. For the statistical analysis, the frequency tables and the Chi-square test (p< 0.05) were used. Results: the average age was 26.3 years. Of 96 women (68.5 percent) with menstrual disorders, 76 (79.2 percent) said they had oligomenorrhea. Sixty four were overweighed (45.7 percent). Elevated testosterone was the predominant hormonal alteration (52.7 percent). In the group, the ovary volume was equal to or higher than 10 cc in 84.3 percent of the group. Significant association was observed between the menstrual disorders and the presence of polycystic ovaries (p= 0.000), hirsutism (p= 0.001) and acne (p= 0.000), but this did not occur with the hormonal variables. The echographic diagnosis and the elevated testosterone showed correspondence in 46.2 percent of patients. Conclusions: there is association between the clinical variables and the diagnoses of polycystic ovary syndrome, but neither the echographic and hormonal diagnostic criteria, nor the hormonal alterations and the clinical and echographic diagnosis of polycystic ovary syndrome were related(AU)

Bloqueo neurolítico de neuromas recidivantes guiado por ultrasonografía / Neurolytic blockof recurrent neuromas guided by ultrasound

Los neuromas de muñón son causa de dolor intenso de difícil control. El bloqueo neurolítico es una alternativa en el tratamiento, y el uso de la ultrasonografía se impone para garantizar la efectividad del proceder. En este reporte de caso se describe la realización de la neurolisis con alcohol absoluto de varios neuromas recidivantes en un muñón de miembro superior, guiados por ultrasonido, en un paciente con dolor crónico que no resuelve con tratamiento médico.

Stump-neuromas cause difficult deep pain control. Neurolytic block is an alternative treatment, and ultrasound guarantee the certainty of the procedure. This case report describes the realization of neurolysis with total alcohol of various stump-neuromas, guided by ultrasound, in a patient with chronic pain that don´t solve with medic treatment.

Image Guided Neurosurgery by Using Neuronavigation Integrated with Intraoperative Three-Dimensional Ultrasound.

Introduction: Intra-operative ultrasound provides low cost real time imaging that is simple and rapid to use. In recent years there has been a signifi cant improvement in the quality of ultrasound imaging. Ultrasound integrated neuronavigation can be used to optimize the approach, and achieving safe maximal resection, thereby improving outcomes for patients with diff erent localization and histology of brain tumors, vascular patology, spontaneous intra-cerebral hemorrhage. Material and Methods: Since 2007 till 2010, in the Institute of Neurology and Neurosurgery, 130 operations with application of 2D iUS have been performed. Starting from March till May 2012, 17 patients went under surgical treatment using the intraoperative ultrasound integrated neuronavigation system. Results: We applied ultrasound neuronavigation system in 17 cases on patients with diverse pathologies, including brain tumors (craniopharyngeoma, corpus callosum and intracerebral glioblastoma, intraaxial glioma), vascular patology (arteriovenous malformations, aneurysms), spontaneous intracerebral hemorrhage. Application of ultrasound neuronavigation system aids in improving postoperative outcomes for these patients. Conclusions: Th e integration of 3D US with neuronavigation technology created an effi cient and inexpensive tool for intraoperative imaging in neurosurgery. Th e technology has been applied to optimize surgery of brain tumors, but it has also been found to be useful in other procedures such as operations for aneurysms or arteriovenous malformations. iUS is easy to use and has a rapid learning curve which makes it a useful tool to the neurosurgeons intraoperative armamentarium.

Endoftalmitis poscirugía de catarata por Sphingomonas paucimobilis / Sphingomonas paucimobilis-induced endophthalmitis after cataract surgery

Se presenta la caracterización y manejo terapéutico de un caso de endoftalmitis bacteriana posoperatoria causada por el germen Sphingomonas paucimobilis. La endoftalmitis es la inflamación de los tejidos intraoculares, considerada como la más devastadora de las complicaciones posoperatorias; posee pronóstico visual muy reservado y un elevado riesgo de secuela. Las Sphingomonas paucimobilis son bacterias gramnegativas con forma de bacilo, quimioheterótrofa y estrictamente aerobias que causan enfermedades en los seres humanos, principalmente infecciones hospitalarias que típicamente son tratadas fácilmente con antibióticos. Por sus capacidades biodegradantes y biosintéticas, son pocos los reportes hallados de infección intraocular por este germen. El pronóstico visual es favorable con un diagnóstico precoz y la aplicación del tratamiento adecuado. En este artículo se presentan un caso de endoftalmitis poscirugía de catarata por Sphingomonas paucimobilis reportado en Cuba en el mes de septiembre de 2009.

The characterization and therapeutic management of a case of postsurgery bacterial endophthalmitis caused by Shingomonas paucimobilis was presented. Endophthalmitis is the inflammation of the intraocular tissues and considered as the most devastating postoperative complication. The visual prognosis of this disease is very reserved judgement and high risk of sequelae. Sphingomonas paucimobilis are bacillus-shaped, chemoheterotrophic and strictly aerobic Gramnegative bacteria that cause diseases in the human being, mainly nosocomial infections that are typically treated with antibiotics. Based on its biodegrading and biosynthetic capacities, there are few reports on intraocular infections caused by this germ. The visual prognosis is favourable when the disease is early diagnosed and adequately managed. A case of endophthalmitis following a cataract surgery and caused by Shingomonas paucimobilis in Cuba in September 2009 was presented in this article.

Percutaneous transthoracic needle aspiration, lavage and instillation of clindamycin-gentamycin in peripheral pyogenic lung abscess

Lung abscess are defined as localized suppurative necrotizing collection occurring within the pulmonary parenchyma. Some authors emphasized image-guided aspiration of lung abscess before antibiotics use in order to identify the pathogen. Antibiotic lavage is currently widely used in the treatment of patients with peritonitis, but not used previously in lung abscesses. Is to asses the role of percutaneous transthoracic needle aspiration, lavage and instillation of clindamycin-gentamycin on the treatment of peripheral pyogenic lung abscess. Twenty-six patients with peripheral pyogenic lung abscess are included in this study and classified into two groups. Group I received systemic empirical antibiotic, remod-ulated after the result of sputum culture and sensitivity. While group II underwent ultrasound guided percutaneous transthoracic needle aspiration, lavage and local instillation of antibiotics [clindamycin-gentamycin] associated with receiving systemic empirical parentral antibiotics, that were remodulated after the result of aspiration culture and sensitivity. Chest X-ray and chest ultrasound were done pre, post and after intervention by one week and before discharge. There was a statistically significant difference between group I and II as regard duration of systemic antibiotic use, duration of hospital stay, duration of radiological improvement, and size of abscess after intervention. Moreover complications occurred in group I were higher than in group II. Succeeded patients [according to clinical and radiological improvement of lung abscess] were more obvious among group II than group I. Aspirates culture and sensitivity revealed gram negative bacteria and anaerobic microorganisms, which are sensitive to local instillation of antibiotics [clindamycin-gentamycin]. Percutaneous aspiration of peripheral lung abscess has an accurate determination of the causative organisms inside the abscess. The resolution of the abscesses clinically and radiolog-ically was hastened by needle aspiration, lavage and instillation of clindamycin-gentamycin. Early intervention can improve symptoms, decrease morbidity and complications

Assessment of the co-incidence between non alcoholic fatty liver disease and carotid atherosclerosis

Non-alcoholic fatty liver disease [NAFLD] is currently the most common cause of abnormal liver biochemistry and cryptogenic cirrhosis. Those with NAFLD have a higher prevalence of atherosclerosis, as shown by increased carotid artery intimal media thickness [CIMT]. The aim of this study is to assess the co-incidence and prevalence between NAFLD and carotid atherosclerosis. In this study seventy-two subjects were categorized into 2 groups. QL 52 patients diagnosed as NAFLD with diabetes mellitus type 2 or obesity or hyperlipedemia. Gil: 20 diseased controls diagnosed as NAFLD without other predisposing factor. CIMT and plaque prevalence were estimated by carotid ultrasonography as a single trained operator who was blind to clinical characteristics of participants. The results showed that CIMT by carotid duplex ultrasonography was significantly higher in group A than group B but CIMT did not reveal any significant difference as regards to the etiology of NAFLD. CIMT was significantly higher in cases with bright liver than those with homogenous liver [by abdominal US] in group I and II. CIMT was significantly higher in those with moderate steatosis than those with mild steatosis [in GI and Gil]

Predictive value of phosphorylated insulin-like growth factor binding protein-1 [PIGFBP-1] [bedside test] in preterm labor

This study evaluated the predictive value of phosphorylated insulin like growth factor binding protein-1 in cervical secretion as bedside test for prediction of preterm labor in symptomatic women.A total of 57 patients with singleton pregnancy at 24-34 weeks gestation, with symptoms suggestive of preterm labor were included in this study. A rapid cervical sample for PIGFBP-1 determination [Actim partus test, Medix Biochemical, and Kaunianen, Finland] was taken by means of a polyester-tipped swab during a speculum examination of the cervix, and extracted with specimen- extraction solution. We analyzed the prevalence of preterm labor in these patients within seven days upon admission. And calculate sensitivity, specificity, positive predictive value [PPV] and negative predictive value [NPV] for PIGFBP-1. This study was done at Kuwait Oil Company hospital [KOC] and Taiba hospital [Kuwait] during the period between April 2011 and June 2012.The test was positive in 50.9% of patients and negative in 49.1%, among those tests was positive 64% delivered less than a week, and among those tests was negative 35.7 delivered less than one week, with 74.3% sensitivity, 61% spesivity, 76.3% PPV and 73.6% NPV

Role of semirigid thoracoscopy in the diagnosis of exudative pleural effusion: Assiut University Hospital experience

The procedure of medical thoracoscopy provides a window into the pleural space to perform biopsy under direct visualization, particularly when thoracocentesis and closed pleural biopsy are inconclusive. The development of the semirigid thoracoscope, which is handled similarly to a bronchoscope, has made this procedure feasible and successful by most pulmonologists. It remains unknown whether certain pleural lesions, as visualized on thoracoscopy, has potential diagnostic value. We aimed to assess diagnostic value of the semirigid thoracoscope and correlate endoscopic finding with the histological diagnosis. From January 2010 to January 2012, 64 diagnostic medical thoracoscopies were performed to 64 patients with undiagnosed pleural effusion, in a tertiary care university hospital. All patients had thoracoscopy with visually directed biopsies and pleural lesion rating under local anaesthesia and mild sedation. Endoscopic findings were classified as: pleural thickening, nodules, adhesions and whitish lymphedema. The yield of the thoracoscopic biopsy in reaching final diagnosis was [98.4%]. Thoracoscopic diagnosis of malignancy in our study was [76.6%] whereas benign diagnosis was [23.4%]. Thoracoscopy was well tolerated under local anaesthesia and in most cases it was a one day procedure. Significant relations were found between endoscopic and pathology findings. Presence of nodules and lymphedema had a trend a positive relation with malignancy, p-value [0.002] and [0.009] respectively. Medical thoracoscopy is a simple relatively low-cost procedure. In the hands of experienced physicians it is generally safe, and highly effective at achieving a histological diagnosis. The presence of nodules and lymphedema, carries a high possibility of the effusion to be of a malignant etiology

Value of TC-99M DMSA scintigraphy in urinary tract infection: comparative study with other imaging modalities

Urinary tract infection [UTI] is a common medical problem. It causes considerable morbidity specially if complicated, can cause severe renal damage. The aim of this study is to evaluate value of Tc-99m DMSA in UTI comparing with ultrasound and CT scan. We analyzed a random sample of 63 patients approved to have urinary tract infection. Abdominal ultrasound, CT, and [99m] Tc-DMSA scintigraphy of the kidneys were performed in all patients. Tc-99m DMSA scan showed scintigraphic changes consistent with pyelonephritis in all patients. The involvement was either unilateral in 53 patients [84%] or bilateral in 10 patients [16%]. The number of diseased kidneys were 73/126 [58%], 16/73 kidneys had abnormal unifocal defects [22%], 27/73 kidneys had multifocal defects [37%], while 30/73 kidneys had diffuse hypoactivity [41%]. The sensitivity of CT scan in detecting pyelonephritis was 82.8% while the sensitivity of ultrasound was poor [23.8%] and there was a statistically significant difference between the sensitivity of ultrasound and that of Tc-99m DMSA. Tc-99m DMSA is reliable diagnostic, cost-effective, simple, safe and noninvasive modality and may be taken as a routine procedure for the patients with clinical suspicion of upper UTI whenever the facilities are available

Apoptotic and anti-apoptotic seromarkers for assessment of disease severity of non-alcoholic steatohepatitis

This study aimed to find out non-invasive markers for the assessment of severity of non-alcoholic steatohepatitis [NASH] in an attempt to decrease the need for liver biopsy. It also aimed to evaluate the key role of apoptosis in the pathogenesis of the disease and the suggested role of anti-apoptotic factors in therapeutic modalities and disease prognosis. The serum levels of soluble Fas [s. Fas], s. Fas ligand, cytokeratin 18 [CK-18] fragment and Bcl-2 were measured in 80 patients and 15 non-hepatic subjects as control. The patients were divided based on histological examination of liver biopsy into three groups. Group I included 40 patients with NASH, group II had 40 patients with non-alcoholic fatty liver disease [NAFLD] non-NASH and group III had 15 non-hepatic subjects as control. Apoptosis of hepatocytes was assessed by morphological examination using a light microscope and expressed as number per square millimeter. There was a significant increase in the serum levels of s. Fas, s. Fas ligand and CK-18 fragments in the NASH group. The anti-apoptotic protein Bcl-2 showed significantly low levels in NASH patients. Apoptosis of hepatocytes was significantly higher in the NASH group. The degree of apoptosis was inversely correlated with the level of Bcl-2. A significant correlation between both s. Fas and CK-18 fragment with liver histology with regard to lobular inflammation and ballooning was found. Increased serum levels of s. Fas and CK-18 fragment in the NASH group and its correlation with the severity of disease suggested the key role of apoptosis in NASH pathogenesis which can be used for the assessment of the severity of NASH. A high level of anti-apoptotic Bcl-2 in NAFLD suggests its protective role in disease progress