External Validation of a Prediction Model Assessing Risk of Delivery in Fetuses with Growth Restriction after Diagnosis of Abnormal Umbilical Artery Doppler.

OBJECTIVE: We have previously described a model using maternal, antenatal, and ultrasonographic characteristics to assess the risk of delivery within 7 days following diagnosis of abnormal umbilical artery Doppler (UAD) in pregnancies affected by fetal growth restriction (FGR). Therefore, we sought to validate this model in an independent cohort. STUDY DESIGN: Retrospective, single referral center study of liveborn singleton pregnancies from 2016 to 2019 complicated by FGR and abnormal UAD (systolic/diastolic ratio ≥95th percentile for gestational age [GA]). Prediction probabilities were calculated by applying the original model (Model 1) to the current cohort (Brigham and Women's Hospital [BWH] cohort). The variables of this model include GA at first abnormal UAD, severity of first abnormal UAD, oligohydramnios, preeclampsia, and prepregnancy body mass index. Model fit was assessed with area under the curve (AUC). Two alternative models (Models 2 and 3) were created to identify a model with better predictive characteristics than Model 1. The receiver operating characteristics curves were compared using the DeLong test. RESULTS: A total of 306 patients were assessed for eligibility, 223 of whom were included in the BWH cohort. Median GA at eligibility was 31.3 weeks, and median interval from eligibility to delivery was 17 days (interquartile range: 3.5-33.5). Eighty-two (37%) patients delivered within 7 days of eligibility. Applying Model 1 to the BWH cohort resulted in an AUC of 0.865. Using the previously determined probability cutoff of 0.493, the model was 62% sensitive and 90% specific in predicting the primary outcome in this independent cohort. Models 2 and 3 did not perform better than Model 1 (p = 0.459). CONCLUSION: A previously described prediction model to predict risk of delivery in patients with FGR and abnormal UAD performed well in an independent cohort. With high specificity, this model could assist in identifying low-risk patients and improve antenatal corticosteroid timing. KEY POINTS: · Risk of delivery in 7 days can be predicted.. · Risk of delivery can inform corticosteroid timing.. · An externally validated clinical aid can be developed..

O-RADS Ultrasound Version 1: A Scenario-Based Review of Implementation Challenges.

The Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound (US) risk stratification and management system was first published by the American College of Radiology in 2020. It provides standardized terminology for evaluation of ovarian and adnexal masses, aids risk stratification, and provides management guidelines for different categories of lesions. This system has been validated by subsequent research and found to be a useful diagnostic and management tool. However, as noted in the system's governing concepts, in some clinical scenarios, such as patients with acute symptoms or with a history of ovarian malignancy, O-RADS US does not apply, or the system's standard management may be adjusted. Additional scenarios, such as an adnexal mass in pregnancy, present challenges in the application of O-RADS US to assist diagnosis and management. The purpose of this article is to highlight 10 clinical scenarios in which O-RADS US version 1 may not apply, may be difficult to apply, or may require modified management. Additional scenarios in which O-RADS US can be appropriately applied are also described.

Hemodynamic and anatomic changes after fetal aortic valvuloplasty are associated with procedural success and postnatal biventricular circulation.

BACKGROUND: There are minimal data characterizing the trajectory of left heart growth and hemodynamics following fetal aortic valvuloplasty (FAV). METHODS: This retrospective study included patients who underwent FAV between 2000 and 2019, with echocardiograms performed pre-FAV, immediately post-FAV, and in late gestation. RESULTS: Of 118 fetuses undergoing FAV, 106 (90%) underwent technically successful FAV, of which 55 (52%) had biventricular circulation. Technically successful FAV was associated with improved aortic valve growth (p < 0.001), sustained antegrade aortic arch (AoA) flow (p = 0.02), improved mitral valve (MV) inflow pattern (p = 0.002), and favorable patent foramen ovale (PFO) flow pattern (p = 0.004) from pre-FAV to late gestation. Compared to patients with univentricular outcome, patients with biventricular outcome had less decrement in size of the left ventricle (LV) (p < 0.001) and aortic valve (p = 0.005), as well as more physiologic PFO flow (p < 0.001) and antegrade AoA flow (p < 0.001) from pre-FAV to late gestation. In multivariable analysis, echocardiographic predictors of biventricular outcome were less decline in LV end diastolic dimension (p < 0.001), improved PFO flow (p = 0.004), and sustained antegrade AoA flow (p = 0.002) from pre-FAV to late gestation. CONCLUSION: Stabilization of left heart growth and improved hemodynamics following successful FAV through late gestation are associated with postnatal biventricular circulation.

Fourfold Improved Odds of a Good First Trimester Outcome Once a Yolk Sac Is Seen in Early Pregnancy.

OBJECTIVES: To compare first trimester prognosis when an early pregnancy sonogram demonstrates a gestational sac with yolk sac versus gestational sac without yolk sac. METHODS: Our study comprised 823 transvaginal sonograms without identifiable embryo performed at least 35 days from last menstrual period (LMP), in which mean sac diameter was <16 mm and first trimester outcome (live or early pregnancy loss) was known. We recorded the presence or absence of yolk sac, first trimester outcome, and several clinical features: maternal age, time since LMP, and presence or absence of vaginal bleeding. We compared the likelihood of a successful first trimester outcome in cases with a visible yolk sac to those without a yolk sac. RESULTS: At the end of the first trimester, 113 of 270 (41.9%) cases without a yolk sac and 414 of 553 (74.9%) with a yolk sac were live (P < .000001, chi-square). This corresponds to an odds ratio of 4.14 for the presence of yolk sac, a result confirmed by logistic regression. Advanced maternal age, ≥42 days since LMP, and vaginal bleeding all carried an increased risk of loss (P < .000001, chi-square). Outcome was better with a visualized yolk sac than without a yolk sac, regardless of number of risk factors (P < .001, chi-square). CONCLUSIONS: The odds of successful first trimester outcome are 4-fold higher when a yolk sac is seen on an early pregnancy sonogram than when no yolk sac is seen. For any level of risk, based on maternal age, vaginal bleeding, and time since LMP, outcome is significantly better when a yolk sac is seen.

Role of Sonographic Characteristics of Thyroid Bed Lesions Identified Following Thyroidectomy in the Diagnosis or Exclusion of Recurrent Cancer.

Background US of the thyroid bed in patients with thyroid cancer often depicts small lesions, but it is unclear whether US characteristics of lesions can help predict cancer recurrence. Purpose To determine whether size or US features of lesions in the thyroid bed after thyroidectomy in conjunction with clinical features can help predict thyroid cancer recurrence. Materials and Methods With use of a US reporting database, all patients imaged between July 2006 and June 2016 with an indication of post-thyroidectomy follow-up were retrospectively identified. Recorded data included patient demographic characteristics; date of thyroidectomy; thyroid cancer type; presence, size, and US characteristics of thyroid bed lesions; and results of fine-needle aspiration (FNA). Images were reviewed for lesions that underwent FNA. The Fisher exact test was used for analysis. Results A total of 1885 patients (mean age ± standard deviation, 48 years ± 15; 1493 female patients) underwent 5732 US examinations. Most patients (1541 of 1885 [82%]) had papillary cancer. Overall, 3163 thyroid bed lesions were reported in 5732 US examinations (40.4%). More than half of these lesions (1860 of 3163 [58.8%]) had a maximum measurement of 6 mm or greater. FNA was performed in 144 of the 3163 lesions (4.6%), of which 61 (42.4%) were malignant, 33 (22.9%) were benign, and 50 (34.7%) were nondiagnostic. Five nondiagnostic lesions eventually proved malignant. Only the presence of punctate echogenicities in the lesion (28 of 61 malignant lesions [45.9%]; three of 33 benign lesions [9%]; 12 of 50 nondiagnostic lesions [24%]; P < .001) or the history of positive lymph nodes at thyroidectomy (44 of 61 malignant lesions [72.1%]; 10 of 33 benign lesions [30%]; 19 of 50 nondiagnostic lesions [38%]; P < .001) were associated with malignancy. Of 3019 thyroid bed lesions that did not undergo FNA, three were malignant and 2248 showed no growth at follow-up US ranging from 6 months to 10 years and are presumed benign. Of the 1303 lesions smaller than 6 mm, only two (0.2%) were malignant. Conclusion Small lesions are commonly found in the thyroid bed after thyroidectomy, and most are likely to be benign. Lesions smaller than 6 mm with no punctate echogenicities had a minimal risk for malignancy. © RSNA, 2021 See also the editorial by Grant and Malhi in this issue.

Late gestation predictors of a postnatal biventricular circulation after fetal aortic valvuloplasty.

OBJECTIVES: Fetal aortic valvuloplasty (FAV) for severe aortic stenosis (AS) has shown promise in averting progression to hypoplastic left heart syndrome. After FAV, predicting which fetuses will achieve a biventricular (BiV) circulation after birth remains challenging. Identifying predictors of postnatal circulation on late gestation echocardiography will improve parental counseling. METHODS: Liveborn patients who underwent FAV and had late gestation echocardiography available were included (2000-2017, n = 96). Multivariable logistic regression and classification and regression tree analysis were utilized to identify independent predictors of BiV circulation. RESULTS: Among 96 fetuses, 50 (52.1%) had BiV circulation at the time of neonatal discharge. In multivariable analysis, independent predictors of biventricular circulation included left ventricular (LV) long axis z-score (OR 3.2, 95% CI 1.8-5.7, p < 0.001), LV ejection fraction (OR 1.3, 95% CI 1.0-1.8, p = 0.023), anterograde aortic arch flow (OR 5.0, 95% CI 1.2-20.4, p = 0.024), and bidirectional or right-to-left foramen ovale flow (OR 4.6, 95% CI 1.4-15.8, p = 0.015). CONCLUSION: Several anatomic and physiologic parameters in late gestation were found to be independent predictors of BiV circulation after FAV. Identifying these predictors adds to our understanding of LV growth and hemodynamics after FAV and may improve parental counseling.

First-Trimester Prognosis When an Early Gestational Sac is Seen on Ultrasound Imaging: Logistic Regression Prediction Model.

OBJECTIVES: To determine the factors that jointly and independently affect first-trimester outcome of very early intrauterine pregnancies (those whose sonogram shows a gestational sac with no identifiable yolk sac or embryo) and develop a mathematical model and Web-based calculator that computes prognosis based on these factors. METHODS: Our study population included 590 very early pregnancies scanned between January 1, 2012, and June 30, 2018, with known outcomes (live or spontaneous loss) at 14 weeks. We recorded patient age, mean sac diameter (MSD), human chorionic gonadotropin (hCG) rise, and presence/absence of: vaginal bleeding, history of infertility, prior miscarriage, and pregnancy via assisted reproductive technology. We assessed the correlation between each of these factors and outcome and performed stepwise logistic regression to determine the subset that independently correlated with outcome. RESULTS: Patient age, MSD, hCG rise, vaginal bleeding, history of infertility, and assisted reproductive technology pregnancy were significantly correlated with outcome (P < .05, t test for age and MSD, χ2 for the others). Stepwise logistic regression identified age, MSD, hCG rise, and vaginal bleeding as the subset of factors that independently predicted outcome. The regression model's area under the receiver operating characteristic curve was 0.823. We incorporated the regression model into a Web-based calculator (https://tinyurl.com/Prognosis-PD) that predicts the outcome of an early intrauterine pregnancy based on these 4 key variables. CONCLUSIONS: The prognosis of very early intrauterine pregnancies is related to several clinical, biochemical, and sonographic factors. The factors that independently correlate with first-trimester outcome are patient age, MSD, hCG rise, and vaginal bleeding. The logistic regression model predicts outcome based on these variables.

Clinical Significance of Renal Allograft Urothelial Thickening Identified by Ultrasound.

OBJECTIVES: To assess the etiology and clinical implications of ultrasound (US)-diagnosed urothelial thickening (UT) in renal transplants. METHODS: Patients with renal transplants who had UT diagnosed by US from January 2000 to December 2018 were retrospectively identified and compared to patients with transplants without UT scanned during the study period. Medical records were reviewed for demographics, US findings, pathologic results, laboratory values, and clinical outcomes and compared between groups by Fisher exact and t tests. RESULTS: A total of 143 patients with UT and 128 controls comprised our cohorts. The patient age in the UT group versus controls (mean ± SD, 50.2 ± 16.5 versus 51.2 ± 15.3 years) and the time since transplant (2.9 ± 4.2 versus 2.4 ± 5.8 years) were similar. Patients with UT were more likely to be female than controls (76 of 143 [53.1%] versus 53 of 128 [41.4%]; P = .07), but the difference was not statistically significant, and patients with UT were more likely to have indwelling stents (31 of 143 [21.7%] versus 9 of 128 [7.0%]; P = .001) and hydronephrosis (25 of 143 [17.4%] versus 11 of 128 [8.6%]; P = .03). At biopsy, rejection and vascular sclerosis were more likely in patients with UT compared to controls (24 of 25 [49.0%] versus 11 of 43 [25.6%]; P = .031; 42 of 49 [85.7%] versus 22 of 43 [51.2%]; P = .0005, respectively), whereas acute tubular necrosis was similar. The sensitivity (50.0%) and specificity (74.4%) of UT for rejection were low. CONCLUSIONS: Urothelial thickening correlates with US findings of urinary obstruction and indwelling stents, suggesting a possible mechanical component to UT's etiology. Although transplant rejection and vascular sclerosis were more frequent at biopsy in the UT group than controls, UT had low sensitivity and specificity for rejection.

Prenatal Imaging Diagnosis of Suprarenal Lesions.

INTRODUCTION: Prenatal suprarenal lesions represent diverse pathologies. This study investigated prenatal imaging features and regression patterns associated with specific lesion diagnoses. METHODS: This is a multicenter retrospective review of fetuses with prenatally diagnosed suprarenal lesions between 2001 and 2019. Prenatal ultrasound and MRI characteristics, postnatal imaging, and clinical course were reviewed. Prenatal imaging findings were compared by the most common diagnoses and regression patterns. RESULTS: Forty-four fetuses were prenatally diagnosed with suprarenal lesions. Diagnoses included pulmonary sequestration (n = 12; 27.3%), adrenal hemorrhage (n = 12; 27.3%), upper quadrant cyst (including 2 duplication cysts, 1 splenic cyst, and 3 indeterminate cysts), neuroblastoma (n = 4), adrenal hyperplasia (n = 3), bilateral adrenal calcifications (n = 1), and indeterminate lesions (n = 6). Sequestrations were uniformly left-sided (100 vs. 50%; p = 0.014) and diagnosed earlier in gestation than adrenal hemorrhages (p = 0.025). Sequestrations were also significantly more likely to have a prenatal feeding vessel (p = 0.005), low T1 MRI signal (p = 0.015), and no MRI blood products (p = 0.018) compared to adrenal hemorrhages. When comparing all 44 patients, a prenatal feeding vessel and low T1 signal on prenatal MRI were significantly associated with lesion persistence (p = 0.003; p = 0.044). DISCUSSION/CONCLUSION: Imaging findings on prenatal ultrasound and MRI aid in the diagnosis of suprarenal lesions, including differentiating pulmonary sequestrations and adrenal hemorrhages.

Sonographic characteristics and follow-up of pancreatic cysts.

OBJECTIVES: To assess sonographic characteristics and outcome of patients with pancreatic cystic lesions seen by ultrasound. METHODS: From our ultrasound electronic reporting database we identified all patients in which "pancreatic cyst" or "pancreatic cysts" were reported from 1995 to 2018. In patients with more than one sonogram, the first was used for our study. For each case, we recorded sonographic characteristics, maximal diameter, cyst location, and results of follow-up ultrasound, CT or magnetic resonance imaging, as well as patient sex, age, relative clinical history, and endoscopic ultrasound (EUS) or surgical findings when available. RESULTS: Our study included 177 patients of whom 121 were female (68.4%). Mean age at diagnosis was 65 (±16, SD, range 22-99). Ultrasound was the initial diagnostic test in 122 (68.9%). Mean diameter of the index cyst was 13.7 mm (±11.5 mm, SD, range 2-91 mm). Among 177 index cysts, 155 were simple and 22 complex. Three complex cysts were surgically resected, yielding a primary pancreatic malignancy, a metastasis, and an epithelial-lined cyst. One simple cyst was resected, yielding a benign intraductal papillary mucinous neoplasm. Seventeen patients underwent EUS showing six mucinous cysts and 11 nonmucinous cysts. One hundred-eighteen patients had follow-up imaging for a mean time of 5.6 years (±3.8, range 0.25-21 years). One patient was presumed to have primary pancreatic cancer. The overall rate for primary pancreatic malignancy was 1.7% (2/118). CONCLUSIONS: Cystic pancreatic lesions seen on ultrasound are most often benign, with a low risk of pancreatic malignancy. Ultrasound is an excellent method to follow-up these cysts.

Assessment of American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS) for Pediatric Thyroid Nodules.

Background The American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) is a recognized tool for management of thyroid nodules in adults but has not been validated in pediatric patients. Purpose To assess the performance of the ACR TI-RADS criteria for guiding decisions on whether to biopsy thyroid nodules in pediatric patients in a single referral center. Materials and Methods In this retrospective study, a database of thyroid nodules in patients younger than 19 years who underwent fine-needle aspiration (FNA) biopsy between January 2004 and July 2017 was analyzed. ACR TI-RADS criteria were applied to each nodule, and an ACR TI-RADS score was created to determine how the nodule would be managed. The number of nodules that would be biopsied with FNA on the basis of ACR TI-RADS was compared with the total number of nodules biopsied with FNA in this clinic to determine if the use of ACR TI-RADS would have changed the rate of FNA (eg, decreased the number of procedures) and whether that change would have affected the timely diagnosis of cancer. Results A total of 314 patients (mean age, 14.9 years; age range, 2-18 years; 28 prepubertal patients; 286 postpubertal patients; 260 female patients) were evaluated. In these 314 patients, 404 thyroid nodules were scored, of which 19.1% (77 of 404) were malignant. Most cancers were papillary carcinoma (68 [88.3%] of 77). The use of ACR TI-RADS criteria for management of nodules in this pediatric study sample would have resulted in 17 (22.1%) of 77 cancers being missed at the patient's initial visit. Conclusion Use of the current American College of Radiology Thyroid Imaging Reporting and Data System criteria for management of pediatric thyroid nodules is inadequate because a high percentage of cancers would be missed at the initial encounter. © RSNA, 2019.

Detection of subclinical disease with baseline and surveillance imaging in high-risk cutaneous squamous cell carcinomas.

BACKGROUND: There are limited studies on imaging for management of high-risk cutaneous squamous cell carcinoma (HRCSSC). OBJECTIVE: To evaluate the impact of baseline (ie, at diagnosis) and surveillance (ie, subsequent time points after diagnosis) imaging on management of HRCSCCs. METHODS: All primary CSSCs treated at Brigham and Women's Hospital Mohs Surgery Clinic and Dana-Farber Cancer Institute High-Risk Skin Cancer Clinic from January 1, 2017 through June 1, 2019, were reviewed to identify tumors that underwent baseline or surveillance imaging. Tumors that underwent imaging were reviewed to determine the impact of imaging on management and ability of imaging to identify subclinical disease. RESULTS: Eighty-three patients underwent imaging for 87 primary HRCSCCs, of which 48 (58%) underwent surveillance imaging. A total of 146 (59%) abnormal results were obtained from 248 imaging studies. Management was altered by 42 (24%) studies. Imaging detected subclinical disease in 21% of cases studied. A majority (56%) of detections were not seen initially but rather during surveillance imaging in the 2 years after treatment. LIMITATIONS: Single institution retrospective design. CONCLUSIONS: Imaging identifies subclinical disease in HRCSCC. Prospective studies are needed to determine best practices for screening and surveillance in HRCSCC.

"Pseudogestational Sac" and Other 1980s-Era Concepts in Early First-Trimester Ultrasound: Are They Still Relevant Today?

OBJECTIVES: To determine whether an intrauterine round or oval fluid collection ("saclike structure") can prove to be either an intrauterine pregnancy or intrauterine fluid in conjunction with an ectopic pregnancy (sometimes termed "pseudogestational sac") and whether ultrasound features, including the presence or absence of an echogenic rim, "double sac sign" (DSS), or "intradecidual sign" (IDS), are helpful for establishing the diagnosis or predicting the prognosis. METHODS: We identified all sonograms obtained from women with positive serum human chorionic gonadotropin results at our institution between January 1, 2012, and June 30, 2018, meeting the following criteria: presence of an intrauterine saclike structure without a yolk sac or embryo; no extraovarian adnexal mass; and follow-up information identifying the location of the pregnancy as intrauterine or ectopic. Study authors reviewed sonograms in all cases and recorded the following information: presence or absence of each of an echogenic rim around the collection, a DSS, and an IDS, as well as the mean sac diameter. The indications for the initial ultrasound examinations were recorded. RESULTS: A total of 649 sonograms met the inclusion criteria. Of these, 598 fluid collections showed an echogenic rim, 182 a DSS, and 347 an IDS (findings not mutually exclusive). In all 649 cases, a subsequent sonogram or other clinical follow-up confirmed that the patient had an intrauterine pregnancy. That is, none of the fluid collections proved to be a pseudogestational sac. In total, 41.2% were live at the end of the first trimester, and 58.8% miscarried. The prognosis was better in cases with, compared to without, an IDS (P = .01, χ2 ), but no ultrasound feature was clinically useful for ruling in or excluding a good prognosis. CONCLUSIONS: In a woman with positive human chorionic gonadotropin results and no extraovarian adnexal mass, the ultrasound finding of an intrauterine saclike structure is virtually certain to be a gestational sac. Ultrasound features of the structure are of no diagnostic or clinically useful prognostic value. Concepts introduced 30 to 40 years ago when ultrasound equipment had far lower resolution than currently, including a DDS, an IDS, and a pseudogestational sac, have no role today in assessing early pregnancy.

Interobserver Reliability of the Antenatal Consensus Classification System for Urinary Tract Dilatation.

OBJECTIVES: The consensus classification system for urinary tract dilatation (UTD) was designed to be more objective and reproducible than previously used systems. We sought to evaluate interobserver reliability of UTD components and overall scores in a prenatal population undergoing third-trimester ultrasound examinations. METHODS: We retrospectively identified patients who underwent antenatal ultrasound examinations for UTD between 28 and 40 weeks' gestation. All images from individual studies of 300 fetuses were reviewed independently by 5 experienced sonologists (1 maternal-fetal medicine specialist and 4 radiologists). Urinary tract dilatation scores (normal, A1, or A2/3) and Society for Fetal Urology (SFU) scores were assigned. Interobserver agreement between raters was evaluated with the Fleiss κ statistic. RESULTS: Overall interobserver agreement for the antenatal UTD risk score showed substantial agreement among all 5 readers (κ = 0.657 [95% confidence interval, 0.632, 0.683]; P < .001). All 5 readers applied the same UTD risk score in 53.7% of cases. Some variability in the antenatal UTD score and individual elements was observed. At least 2 UTD risk scores were assigned to a specific individual patient in 46.3% of cases (139 of 300), and all 3 UTD risk scores were assigned to a specific individual patient in 1.7% of cases (5 of 300). In 18.0% of cases (54 of 300), at least 2 readers assigned a UTD score different from that assigned by the other readers. Agreement was lowest for parenchymal appearance (κ = 0.225). Agreement for the SFU system was fair (κ = 0.368; P < .001). CONCLUSIONS: Interobserver agreement for the antenatal UTD grading system was substantial. Compared to the SFU system, the antenatal UTD system showed better agreement among readers.

Simple Adnexal Cysts: SRU Consensus Conference Update on Follow-up and Reporting.

This multidisciplinary consensus update aligns prior Society of Radiologists in Ultrasound (SRU) guidelines on simple adnexal cysts with recent large studies showing exceptionally low risk of cancer associated with simple adnexal cysts. Most small simple cysts do not require follow-up. For larger simple cysts or less well-characterized cysts, follow-up or second opinion US help to ensure that solid elements are not missed and are also useful for assessing growth of benign tumors. In postmenopausal women, reporting of simple cysts greater than 1 cm should be done to document their presence in the medical record, but such findings are common and follow-up is recommended only for simple cysts greater than 3-5 cm, with the higher 5-cm threshold reserved for simple cysts with excellent imaging characterization and documentation. For simple cysts in premenopausal women, these thresholds are 3 cm for reporting and greater than 5-7 cm for follow-up imaging. If a cyst is at least 10%-15% smaller at any time, then further follow-up is unnecessary. Stable simple cysts at initial follow-up may benefit from a follow-up at 2 years due to measurement variability that could mask growth. Simple cysts that grow are likely cystadenomas. If a previously suspected simple cyst demonstrates papillary projections or solid areas at follow-up, then the cyst should be described by using standardized terminology. These updated SRU consensus recommendations apply to asymptomatic patients and to those whose symptoms are not clearly attributable to the cyst. These recommendations can reassure physicians and patients regarding the benign nature of simple adnexal cysts after a diagnostic-quality US examination that allows for confident diagnosis of a simple cyst. Patients will benefit from less costly follow-up, less anxiety related to these simple cysts, and less surgery for benign lesions.

Encephalopathy in neonates with subgaleal hemorrhage is a key predictor of outcome.

BACKGROUND: Subgaleal hemorrhage (SGH) is reported to be associated with severe hemodynamic instability, coagulopathy, and even mortality. The importance of the presence or absence of neonatal encephalopathy in predicting SGH outcomes has not been explored. The aim of this study was to determine the relationship of clinical encephalopathy to short-term outcomes in neonates with SGH. METHODS: Neonates ≥35 weeks gestation, diagnosed radiologically with SGH between 2010 and 2017, were included. Cases were divided into encephalopathic and non-encephalopathic. Demographic, clinical, and outcome data were compared between groups. RESULTS: Of 54,048 live births, 56 had SGH, of them 13 (23%) had encephalopathy. When compared to the non-encephalopathic neonates, encephalopathic neonates had lower Apgar scores, lower hemoglobin, lower platelet count, longer neonatal intensive care unit stay, two (15%) deaths, and four (31%) required blood transfusion. No non-encephalopathic infant with SGH died or required blood transfusion. Notably, on magnetic resonance imaging (MRI), a majority of subgaleal collections had either no or minimal blood products. CONCLUSIONS: In the absence of encephalopathy, SGH is not associated with adverse short-term outcome. Neurological assessment is likely to identify infants at higher risk for adverse outcome. The absence of MRI signal consistent with blood in subgaleal collection warrants further research.

Thyroid Nodules in Pediatric Patients: Sonographic Characteristics and Likelihood of Cancer.

Purpose To determine the relationship between demographic and sonographic characteristics of thyroid nodules and malignancy in a pediatric population. Materials and Methods All thyroid nodules in patients younger than 19 years that underwent ultrasound (US)-guided fine-needle aspiration biopsy between January 2004 and July 2017 were retrospectively identified. Age, sex, and background appearance of the thyroid gland were recorded for each patient, and sonographic characteristics and pathologic diagnosis were recorded for each nodule. Demographic and sonographic characteristics were assessed to determine which were associated with malignancy. Categorical and continuous variables and interobserver variability were assessed. Results A total of 404 nodules in 314 patients (82.8% female) (age range, 2-18 years; mean age, 14.9 years) were analyzed. A total of 77 nodules (19.1%) were malignant, the majority of which were papillary thyroid carcinoma (n = 68 [88.3%]). The likelihood of malignancy did not differ between boys and girls (27.8% vs 22.7%, P = .64), nor did it differ between prepubertal and pubertal patients (18.8% vs 19.1%, P > .99). The cancer rate in patients with a solitary nodule was higher than that in patients with multiple nodules (29.4% vs 14.2%, P = .003). Sonographic characteristics associated with malignant nodules included larger size, solid parenchyma, taller-than-wide shape, presence of speckled calcifications, lack of a smooth margin, and presence of abnormal lymph nodes. Interobserver variability for assessment of sonographic characteristics ranged from moderate to very strong. Conclusion In children with thyroid nodules, solitary nodules, larger nodule size, solid parenchyma, taller-than-wide shape, speckled calcifications, irregular margins, and abnormal lymph nodes raise concern for malignancy.

Risk Stratification Model: Lower-Extremity Ultrasonography for Hospitalized Patients with Suspected Deep Vein Thrombosis.

BACKGROUND: The Wells score for deep venous thrombosis (DVT) has a high failure rate and low efficiency among inpatients. OBJECTIVE: To create and validate an inpatient-specific risk stratification model to help assess pre-test probability of DVT in hospitalized patients. DESIGN: Prospective cohort study of hospitalized patients undergoing lower-extremity ultrasonography studies (LEUS) for suspected DVT. Demographics, physical findings, medical history, medications, hospitalization, and laboratory and imaging results were collected. Samples were divided into model derivation (patients undergoing LEUS 11/1/2012-12/31/2013) and validation cohorts (LEUS 1/1/2014-5/31/2015). A DVT prediction rule was derived using the recursive partitioning algorithm (decision tree-type approach) and was then validated. PARTICIPANTS: Adult inpatients undergoing LEUS for suspected DVT from November 2012 to May 2015, excluding those with DVT in the prior 3 months, at a 793-bed, urban academic quaternary-care hospital with ~50,000 admissions annually. MAIN MEASURES: The primary outcome was the presence of proximal DVT, and the secondary outcome was the presence of any DVT (proximal or distal). Model sensitivity and specificity for predicting DVT were calculated. KEY RESULTS: Recursive partitioning yielded four variables (previous DVT, active cancer, hospitalization ≥ 6 days, age ≥ 46 years) that optimized the prediction of proximal DVT and yield in the derivation cohort. From this decision tree, we stratified a scoring system using the validation cohort, categorizing patients into low- and high-risk groups. The incidence rates of proximal DVT were 2.9% and 12.0%, and of any DVT were 5.2% and 21.0%, for the low- and high-risk groups, respectively. The AUC for the discriminatory accuracy of the Center for Evidence-Based Imaging (CEBI) score for risk of proximal DVT identified on LEUS was 0.73. Model sensitivity was 98.1% for proximal and 98.1% for any DVT. CONCLUSIONS: In hospitalized adults, specific factors can help clinicians predict risk of DVT, identifying those with low pre-test probability, in whom ultrasonography can be safely avoided.

Obstetric and gynecologic ultrasound curriculum and competency assessment in residency training programs: consensus report.

Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With increasing educational demands and limited hours in residency programs, dedicated time for training and achieving competency in ultrasound has diminished substantially. The American Institute of Ultrasound in Medicine assembled a multisociety task force to develop a consensus-based, standardized curriculum and competency assessment tools for obstetric and gynecologic ultrasound training in residency programs. The curriculum and competency assessment tools were developed based on existing national and international guidelines for the performance of obstetric and gynecologic ultrasound examinations and thus are intended to represent the minimum requirement for such training. By expert consensus, the curriculum was developed for each year of training, criteria for each competency assessment image were generated, the pass score was established at, or close to, 75% for each, and obtaining a set of 5 ultrasound images with pass score in each was deemed necessary for attaining each competency. Given the current lack of substantial data on competency assessment in ultrasound training, the task force expects that the criteria set forth in this document will evolve with time. The task force also encourages use of ultrasound simulation in residency training and expects that simulation will play a significant part in the curriculum and the competency assessment process. Incorporating this training curriculum and the competency assessment tools may promote consistency in training and competency assessment, thus enhancing the performance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology.