Association of paraoxonase 1 gene polymorphism and enzyme activity with carotid plaque in rheumatoid arthritis.

OBJECTIVE: To investigate the relationship of genetic and biochemical determinants of paraoxonase 1 activity to carotid plaque as a surrogate marker of cardiovascular (CV) risk in patients with rheumatoid arthritis (RA). METHODS: The relationships between paraoxonase 1 activity, PON1 genotype (for the functional polymorphism at position 192), and carotid plaque presence were determined in 168 RA patients. After an overnight fast, blood was collected for lipoprotein analysis, and paraoxonase 1 activity was measured using paraoxon as the substrate. The PON1 Q192R genotype was determined for all patients. Lipoprotein cholesterol levels, traditional CV risk factors, medication use, and RA disease characteristics were assessed for all patients. RESULTS: Paraoxonase 1 activity values in the RA patients were highest for the RR genotype, intermediate for the QR genotype, and lowest for the QQ genotype (P < 0.0001). Compared to patients with either the QQ genotype or the QR genotype, patients with the RR genotype demonstrated decreased risk of carotid plaque on multivariate analysis, controlling for traditional CV risk factors, high-sensitivity C-reactive protein levels, prednisone use, and cholesterol-lowering medication use (P < 0.05). Additional multivariate logistic regression analysis controlling for the above factors also revealed a significant association of plasma paraoxonase 1 activity with carotid plaque in RA patients. Lower plasma paraoxonase 1 activity was associated with increased risk of carotid plaque (P < 0.05). CONCLUSION: The current findings suggest a relationship of the genetic determinants and activity of paraoxonase 1 to CV risk in RA patients, as assessed by the presence or absence of carotid plaque. Further CV outcome studies are warranted to validate the utility of paraoxonase 1 as a biomarker of CV risk in patients with RA.

Doppler US for suspicion of hepatic arterial ischemia in orthotopically transplanted livers: role of central versus intrahepatic waveform analysis.

PURPOSE: To compare the diagnostic performance of combinations of parameters derived from main hepatic artery (MHA) and intrahepatic artery (IHA) waveforms at Doppler ultrasonography (US), with the aim of developing a systematic approach to the evaluation of the hepatic arteries in orthotopic liver transplants in patients suspected of having hepatic arterial ischemia. MATERIALS AND METHODS: This HIPAA-compliant retrospective study was approved by an institutional review board, with waiver of informed consent. From January 1, 2002, to November 1, 2011, 195 transplanted livers in 189 adults (129 men, 60 women; mean age, 53 years; age range, 18-73 years) who underwent Doppler US and follow-up (computed tomographic, magnetic resonance, or conventional) angiographic study within a 2-week interval were included. Diagnostic performance of the standard IHA and MHA criteria (resistive index [RI] < 0.5 and classic parvus tardus waveforms) with and without peak systolic velocity (PSV) thresholds (determined with receiver operating characteristic curve analysis) was assessed. The results of no-flow analysis and the most optimal MHA and IHA criteria were combined to create an algorithm, which was then applied to all liver transplants. RESULTS: The standard criteria (RI < 0.5 and classic parvus tardus) demonstrated greater sensitivity (80% vs 55%, P = .008) when applied to IHA waveforms compared with MHA waveforms. Optimal PSV cutoff values were less than 67 cm/sec and 39 cm/sec for MHA and IHA, respectively. The addition of a PSV threshold resulted in significant decrease in overall accuracy when applied to IHA (87% vs 73%, P < .001) and MHA (82% vs 66%, P = .002) criteria. Application of an algorithm reflecting a combination of the most optimal MHA and IHA criteria and the results of no-flow analysis resulted in 96% sensitivity and 83% specificity. CONCLUSION: An algorithmic approach involving a tailored evaluation of the geographic distribution of absent flow and the quantitative parameters and waveform morphology of the MHA and IHAs allows for improved diagnostic performance in the detection of hepatic arterial complications in at-risk patients with orthotopic liver transplants. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12120557/-/DC1.

Migration of intrauterine devices: radiologic findings and implications for patient care.

Intrauterine devices (IUDs) are a commonly used form of contraception worldwide. However, migration of the IUD from its normal position in the uterine fundus is a frequently encountered complication, varying from uterine expulsion to displacement into the endometrial canal to uterine perforation. Different sites of IUD translocation vary in terms of their clinical significance and subsequent management, and the urgency of communicating IUD migration to the clinician is likewise variable. Expulsion or intrauterine displacement of the IUD leads to decreased contraceptive efficacy and should be clearly communicated, since it warrants IUD replacement to prevent unplanned pregnancy. Embedment of the IUD into the myometrium can usually be managed in the outpatient clinical setting but occasionally requires hysteroscopic removal. Complete uterine perforation, in which the IUD is partially or completely within the peritoneal cavity, requires surgical management, and timely and direct communication with the clinician is essential in such cases. Careful evaluation for intraabdominal complications is also important, since they may warrant urgent or emergent surgical intervention. The radiologist plays an important role in the diagnosis of IUD migration and should be familiar with its appearance at multiple imaging modalities.

High plasma leptin levels confer increased risk of atherosclerosis in women with systemic lupus erythematosus, and are associated with inflammatory oxidised lipids.

BACKGROUND: Patients with systemic lupus erythematosus (SLE) are at increased risk of atherosclerosis, even after accounting for traditional risk factors. High levels of leptin and low levels of adiponectin are associated with both atherosclerosis and immunomodulatory functions in the general population. OBJECTIVE: To examine the association between these adipokines and subclinical atherosclerosis in SLE, and also with other known inflammatory biomarkers of atherosclerosis. METHODS: Carotid ultrasonography was performed in 250 women with SLE and 122 controls. Plasma leptin and adiponectin levels were measured. Lipoprotein a (Lp(a)), oxidised phospholipids on apoB100 (OxPL/apoB100), paraoxonase, apoA-1 and inflammatory high-density lipoprotein (HDL) function were also assessed. RESULTS: Leptin levels were significantly higher in patients with SLE than in controls (23.7±28.0 vs 13.3±12.9 ng/ml, p<0.001). Leptin was also higher in the 43 patients with SLE with plaque than without plaque (36.4±32.3 vs 20.9±26.4 ng/ml, p=0.002). After multivariate analysis, the only significant factors associated with plaque in SLE were leptin levels in the highest quartile (≥29.5 ng/ml) (OR=2.8, p=0.03), proinflammatory HDL (piHDL) (OR=12.8, p<0.001), age (OR=1.1, p<0.001), tobacco use (OR=7.7, p=0.03) and hypertension (OR=3.0, p=0.01). Adiponectin levels were not significantly associated with plaque in our cohort. A significant correlation between leptin and piHDL function (p<0.001), Lp(a) (p=0.01) and OxPL/apoB100 (p=0.02) was also present. CONCLUSIONS: High leptin levels greatly increase the risk of subclinical atherosclerosis in SLE, and are also associated with an increase in inflammatory biomarkers of atherosclerosis such as piHDL, Lp(a) and OxPL/apoB100. High leptin levels may help to identify patients with SLE at risk of atherosclerosis.

A Panel of Biomarkers Associates With Increased Risk for Cardiovascular Events in Women With Systemic Lupus Erythematosus.

OBJECTIVE: The increase in cardiovascular events (CVEs) in systemic lupus erythematosus (SLE) is not fully explained by traditional risk factors. We previously identified four biomarkers (proinflammatory high-density lipoprotein, leptin, soluble TNF-like weak inducer of apoptosis (sTWEAK), and homocysteine) that we combined with age and diabetes to create the predictors of risk for elevated flares, damage progression, and increased cardiovascular diseasein patients with SLE (PREDICTS) risk profile. PREDICTS more accurately identified patients with SLE at risk for progression of subclinical atherosclerosis than any individual variable. We examined whether PREDICTS can also identify patients with SLE at risk for future CVEs. METHODS: A total of 342 patients with SLE and 155 matched control subjects participated in this longitudinal prospective study. A high PREDICTS score was defined as three or more predictors or diabetes + one or more predictor. The biomarkers were measured at baseline using published methods. All major adverse CVEs (MACEs) were confirmed by medical record review. RESULTS: During 116 months of follow-up, 5% of patients with SLE died, 12% had a cerebrovascular event, and 5% had a cardiac event. Overall, 20% of patients with lupus experienced any new MACE compared with 5% of control subjects (P < 0.0001). More patients with SLE with a new MACE had high PREDICTS score at baseline (77%) versus patients with no new events (34%) (P < 0.0001). High baseline PREDICTS score also associated with cerebrovascular (P < 0.0001) and cardiac events (P < 0.0001) in SLE. Using Cox regression, a baseline high PREDICTS score associated with a 3.7-fold increased hazard ratio (HR) for a new MACE (P < 0.0001) in SLE. Hypertension (HR = 2.1; P = 0.006) was also a risk. CONCLUSION: A high PREDICTS score and hypertension confer increased risk for new MACEs in patients with SLE.

How diagnostic is ultrasound-guided neck mass biopsy (fine-needle capillary sampling biopsy technique)?: evaluation of 132 nonthyroid neck mass biopsies with pathologic analysis over 7 years at a single institution.

OBJECTIVE: The purpose of this study was to evaluate the diagnostic value of ultrasound-guided neck mass biopsy (fine-needle capillary sampling biopsy [FNC] technique). METHODS: With Institutional Review Board approval, all patients who had an ultrasound-guided neck mass FNC biopsy between January 2000 and December 2006 were retrieved from the ultrasound database. A total of 132 neck mass biopsies were performed in 124 patients. Patient demographics, procedure characteristics, and pathologic diagnoses were recorded. RESULTS: Of the 124 patients, 73 were female (mean age, 51.4 years). Biopsies were performed twice in 8 patients. A significant 200% increase from 2000 through 2002 to 2003 through 2004 and from 2003 through 2004 to 2005 through 2006 was found (P < .05). The most biopsied location was in the lymph nodes (34.8%), followed by perithyroid soft tissue masses (28.0%). A 25-gauge needle was used most frequently (97.7%). A total of 41 biopsies were diagnostic for thyroid diseases (31.1%), with the most common being thyroid papillary carcinoma. We found metastases in 31 biopsies (23.5%). Following these 2 were 29 lymph node biopsies. No major complications were noted. Of the 132 neck masses biopsied, 8 were pathologically nondiagnostic (93.9% diagnostic yield), yielding sensitivity, specificity, and accuracy of greater than 95% (97.1%, 95.2%, and 95.8%, respectively). CONCLUSIONS: Ultrasound-guided FNC of neck masses is highly diagnostic. The diagnostic yield is especially high for detection of malignancy, including metastases. Together with a high clinical suspicion, ultrasound-guided needle biopsy should be performed to form a correct diagnosis and make appropriate management plans.

Fine Needle Elastography (FNE) device for biomechanically determining local variations of tissue mechanical properties.

Diseased tissues exhibit changes in mechanical properties and thus possess clinical diagnostic significance. We report the design and development of a Fine Needle Elastography (FNE) prototype device integrated with Fine Needle Aspiration Cytology (FNAC) needle that allows for quantitative and sensitive assessment of tissues and materials based on local variations in elastic, friction, and cutting forces on needle insertion. A piezoelectric force-sensor at the base of FNA needle measures the forces opposing needle penetration with micrometer scale resolution. Measurement precision (±5 µm) and axial resolution (~20 µm) of FNE device was tested using control mm size gelatin matrices and unripe pear in assessing needle penetration resistance, force heterogeneity and optimization of needle penetration velocity. Further, we demonstrated the usefulness of FNE in quantitative, biomechanical differentiation of simulated thyroid tumor nodules in an ultrasound neck phantom. Fluid or solid nodules were probed in the phantom study coupled with ultrasound guidance. Our data shows significantly higher force variations (1-D force heterogeneity; HF,a=6.5 mN, HF,q=8.25 mN and stiffness heterogeneity; HS,a=0.0274 kN/m, HS,q=0.0395 kN/m) in solid nodules compared either to fluid nodules or to regions corresponding to healthy thyroid tissue within the ultrasound phantom. The results suggest future applications of in vivo FNE biopsies based on force heterogeneity to diagnose thyroid tumors in areas where ultrasound instrumentation or access to a qualified pathologist for FNAC are unavailable, as well as an ancillary diagnostic tool in thyroid cancer management.

Translabial ultrasonography for evaluation of synthetic mesh in the vagina.

OBJECTIVE: To compare the clinical and surgical findings using translabial ultrasonography (US) in the evaluation of symptoms after transvaginal synthetic mesh placement. METHODS: From 2009 through 2010, a retrospective observational study was conducted to evaluate patients presenting with complaints after transvaginal mesh implantation for the treatment of stress urinary incontinence or pelvic organ prolapse repair. The clinical and translabial US findings were compared with the intraoperative findings, with a focus on mesh location, erosion, and extrusion. RESULTS: A total of 51 consecutive patients (mean age 59 years) were evaluated by history and physical examination, translabial US, and intraoperative findings. Using intraoperative findings as the reference standard, translabial US was able to predict the location of the sling in relationship to the urethra (6 distal, 25 mid-urethral, and 20 at the bladder neck), to differentiate between transobturator (n = 21) and retropubic (n = 30) slings, and to detect all anterior (n = 21) and posterior (n = 15) placed mesh. Translabial US was superior to physical examination in identifying mesh erosion into the periurethral fascia or sphincteric unit. US was inferior to physical examination in diagnosing vaginal extrusion but was superior for locating the mesh. CONCLUSION: Translabial US can identify the mesh material used to treat stress urinary incontinence and pelvic organ prolapse. It provides additional information on sling type, mesh location, and morphology compared with the clinical findings and could help in surgical planning and counseling. Prospective clinical studies evaluating the reliability of this technique in larger patient populations are warranted.

A panel of biomarkers is associated with increased risk of the presence and progression of atherosclerosis in women with systemic lupus erythematosus.

OBJECTIVE: An increased frequency of atherosclerosis (ATH) in systemic lupus erythematosus (SLE) is well-documented but not fully explained by the presence of traditional cardiac risk factors. Several nontraditional biomarkers, including proinflammatory high-density lipoprotein (piHDL) and leptin, have been individually associated with subclinical ATH in SLE. The aim of this study was to examine whether these and other biomarkers can be combined into a risk profile, the Predictors of Risk for Elevated Flares, Damage Progression, and Increased Cardiovascular Disease in Patients with SLE (PREDICTS), that could be used to better predict future progression of ATH. METHODS: In total, 210 patients with SLE and 100 age-matched healthy control subjects (all women) participated in this prospective cohort study. The longitudinal presence of carotid plaque and intima-media thickness (IMT) were measured at baseline and followup (mean ± SD 29.6 ± 9.7 months). RESULTS: At followup, carotid plaque was present in 29% of SLE patients. Factors significantly associated with plaque, determined using Salford Predictive Modeling and multivariate analysis, included age ≥48 years (odds ratio [OR] 4.1, P = 0.002), high piHDL function (OR 9.1, P < 0.001), leptin levels ≥34 ng/dl (OR 7.3, P = 0.001), plasma soluble TWEAK levels ≥373 pg/ml (OR 28.8, P = 0.004), and history of diabetes (OR 61.8, P < 0.001). Homocysteine levels ≥12 µmoles/liter were also a predictor. However, no single variable demonstrated an ideal combination of good negative predictive values (NPVs), positive predictive values (PPVs), sensitivity, and specificity. A high-risk PREDICTS profile was defined as ≥3 positive biomarkers or ≥1 positive biomarker plus a history of diabetes; for high-risk SLE patients, the PPV was 64%, NPV was 94%, sensitivity was 89%, and specificity was 79%. In multivariate analysis, SLE patients with the high-risk profile had 28-fold increased odds for the longitudinal presence of plaque (P < 0.001) and increased progression of IMT (P < 0.001). CONCLUSION: A high-risk PREDICTS score confers 28-fold increased odds of the presence of any current, progressive, or acquired carotid plaque, both in patients with SLE and in control subjects, and is significantly associated with higher rates of IMT progression.

Intra-lymph node prime-boost vaccination against Melan A and tyrosinase for the treatment of metastatic melanoma: results of a phase 1 clinical trial.

PURPOSE: The goal of this study was to test the safety and activity of a therapeutic vaccine, MKC1106-MT, in patients with metastatic melanoma. EXPERIMENTAL DESIGN: MKC1106-MT comprises a plasmid (pMEL-TYR) and two peptides (E-MEL and E-TYR), corresponding to Melan A and tyrosinase, administered by intra-lymph node injection in a prime-boost sequence. All 18 patients were HLA-A*0201 positive and received a fixed priming dose of plasmid and a low or a high peptide dose. Enumeration of antigen-specific T cells was done prior to and throughout the treatment. Patients who did not exhibit disease progression remained on study and could receive up to eight cycles of treatment. RESULTS: The MKC1106-MT regimen was well tolerated and resulted in an overall immune response rate of 50%. The treatment showed disease control, defined as stable disease that lasted for 8 weeks or more in 6 of 18 (33%) of the patients: 14% and 46% in the low and high peptide dose, respectively. Interestingly, four patients, all with tumor burden largely confined to lymph nodes and Melan A-specific T cells at baseline, showed durable disease control associated with radiologic evidence of tumor regression. There was no noticeable correlation between the expansion of antigen-specific T cells in blood and the clinical outcome; yet, there was evidence of active tumor-infiltrating lymphocytes (TIL) in two regressing lesions. CONCLUSIONS: MKC1106-MT showed immunogenicity and evidence of disease control in a defined patient population. These findings support further development of this investigational agent and the concept of therapeutic vaccination in metastatic melanoma.

Low physical activity is associated with proinflammatory high-density lipoprotein and increased subclinical atherosclerosis in women with systemic lupus erythematosus.

OBJECTIVE: To investigate the association between physical activity, functional activity of high-density lipoprotein (HDL), and subclinical cardiovascular disease in patients with systemic lupus erythematosus (SLE). METHODS: A total of 242 SLE patients (all women) participated in this cross-sectional study from February 2004 to February 2008. Carotid plaque and intima-media thickness (IMT), antioxidant function of HDL, and traditional cardiac risk factors were measured. Physical activity was assessed from self-reports by calculating the metabolic equivalents (METS) per week and by the physical function domain of the Medical Outcomes Study Short Form 36 (SF-36). Data were analyzed using bivariate and multivariate regression analyses. RESULTS: Number of METS per week spent performing strenuous exercise was negatively correlated with IMT (r = -0.4, P = 0.002) and number of plaques (r = -0.30, P = 0.0001). Physical function as assessed by the SF-36 was also negatively correlated with IMT (r = -0.14, P = 0.03) and number of plaques (r = -0.14, P = 0.04). In multivariate analyses, number of strenuous exercise METS was significantly associated with IMT (t = -2.2, P = 0.028) and number of plaques (t = -2.5, P = 0.014) when controlling for markers of SLE disease activity and damage, but not after controlling for traditional cardiac risk factors. Low physical activity, defined as <225 total METS per week, was associated with the presence of proinflammatory HDL (P = 0.03). CONCLUSION: Low physical activity is associated with increased subclinical atherosclerosis and proinflammatory HDL in patients with SLE. Increased strenuous exercise may reduce the risk of atherosclerosis in SLE.

Dysfunctional proinflammatory high-density lipoproteins confer increased risk of atherosclerosis in women with systemic lupus erythematosus.

OBJECTIVE: Women with systemic lupus erythematosus (SLE) have an increased risk of atherosclerosis. Identification of at-risk patients and the etiology underlying atherosclerosis in SLE remain elusive. The antioxidant capacity of normal high-density lipoproteins (HDLs) is lost during inflammation, and these dysfunctional HDLs might predispose individuals to atherosclerosis. The aim of this study was to determine whether dysfunctional proinflammatory HDL (piHDL) is associated with subclinical atherosclerosis in SLE. METHODS: Carotid artery ultrasound was performed in 276 women with SLE to identify carotid plaques and measure intima-media thickness (IMT). The antioxidant function of HDL was measured as the change in oxidation of low-density lipoprotein after the addition of HDL cholesterol. Two antiinflammatory HDL components, paraoxonase 1 and apolipoprotein A-I, were also measured. RESULTS: Among the SLE patients, 48.2% were determined to have piHDL on carotid ultrasound, while 86.7% of patients with plaque had piHDL compared with 40.7% of those without plaque (P<0.001). Patients with piHDL also had a higher IMT (P<0.001). After multivariate analysis, the only factors found to be significantly associated with plaque were the presence of piHDL (odds ratio [OR] 16.1, P<0.001), older age (OR 1.2, P<0.001), hypertension (OR 3.0, P=0.04), dyslipidemia (OR 3.4, P=0.04), and mixed racial background (OR 8.3, P=0.04). Factors associated with IMT measurements in the highest quartile were the presence of piHDL (OR 2.5, P=0.02), older age (OR 1.1, P<0.001), a higher body mass index (OR 1.07, P=0.04), a cumulative lifetime prednisone dose>or=20 gm (OR 2.9, P=0.04), and African American race (OR 8.3, P=0.001). CONCLUSION: Dysfunctional piHDL greatly increases the risk of developing subclinical atherosclerosis in SLE. The presence of piHDL was associated with an increased prevalence of carotid plaque and with a higher IMT. Therefore, determination of piHDL may help identify patients at risk for atherosclerosis.

Evidence-based assessment of the role of ultrasonography in the management of benign thyroid nodules.

BACKGROUND: Although ultrasonographic (US) evaluation is currently recommended for the workup of all palpable thyroid nodules, little guidance exists regarding the manner in which US data are to be used. Herein, we examine the available evidence and recommend how US can be used most effectively to predict malignancy. We discuss the role of US-guided fine needle aspiration (FNA) and other special topics regarding US evaluation and management of benign nodules. METHODS: We also present a systematic review of the literature using evidence-based criteria. RESULTS: US features alone cannot predict malignancy or benignity, but techniques that combine US features and FNA cytology are most effective and most accurate for predicting malignancy (Level III and IV evidence). US features suggesting malignancy include a blurred or ill-defined margin, irregular shape, solid echo structure, hypoechogenicity, absent halo, fine calcifications, and intranodular vascular pattern. Most patients with malignancies have more than two US features characteristic of malignancy. US-guided FNA has nonsignificantly higher sensitivity, specificity, and accuracy than the palpation-guided technique (Level III and IV evidence). US guidance is particularly beneficial in patients with nonpalpable, multiple, or heterogeneous nodules for preferentially aspirating a specific segment of the nodule (large or partially cystic nodule) or when nodule palpation is difficult (patients with diffuse glandular disease or obesity). CONCLUSIONS: US is an essential component of thyroid nodule evaluation and management. Techniques that combine US features and FNA cytology for thyroid nodule workup are more accurate than either technique alone. US-guided FNA can decrease the rate of nondiagnostic aspirates.

In vivo analysis of fracture toughness of thyroid gland tumors.

BACKGROUND: Human solid tumors that are hard or firm on physical palpation are likely to be cancerous, a clinical maxim that has been successfully applied to cancer screening programs, such as breast self-examination. However, the biological relevance or prognostic significance of tumor hardness remains poorly understood. Here we present a fracture mechanics based in vivo approach for characterizing the fracture toughness of biological tissue of human thyroid gland tumors. METHODS: In a prospective study, 609 solid thyroid gland tumors were percutaneously probed using standard 25 gauge fine needles, their tissue toughness ranked on the basis of the nature and strength of the haptic force feedback cues, and subjected to standard fine needle biopsy. The tumors' toughness rankings and final cytological diagnoses were combined and analyzed. The interpreting cytopathologist was blinded to the tumors' toughness rankings. RESULTS: Our data showed that cancerous and noncancerous tumors displayed remarkable haptically distinguishable differences in their material toughness. CONCLUSION: The qualitative method described here, though subject to some operator bias, identifies a previously unreported in vivo approach to classify fracture toughness of a solid tumor that can be correlated with malignancy, and paves the way for the development of a mechanical device that can accurately quantify the tissue toughness of a human tumor.

US of abnormal uterine bleeding.

Any significant deviation from a woman's established menstrual pattern may be considered abnormal uterine bleeding, and several factors direct evaluation of a patient with such bleeding. Premenopausal disorders that are well evaluated with ultrasound (US) include endometriosis, adenomyosis, and leiomyomas. A positive pregnancy test in a woman of childbearing age prompts a search for an intrauterine pregnancy. Possible complications that may contribute to bleeding include ectopic pregnancy; placental factors including position, trauma, and infection; gestational trophoblastic disease; preterm labor; and postpartum complications. Atrophic changes, hormonal status, and carcinoma are considerations in the postmenopausal patient with abnormal uterine bleeding. Foreign bodies, trauma, infection, polyps, and iatrogenic causes can be observed in all groups. Differential diagnoses for abnormal uterine bleeding in premenopausal, pregnant, and postmenopausal patients are well evaluated with US, and US techniques have greatly facilitated evaluation of pelvic disease. Urgent and emergent conditions such as ectopic pregnancy, placenta previa, and preterm labor are readily identifiable.

Fibrin sealant sclerotherapy for treatment of lymphoceles following renal transplantation.

PURPOSE: Fibrin sealant is used in various surgical fields for hemostasis and as an adhesive to approximate tissues. Its use was recently reported as a sclerosing agent for percutaneous treatment of lymphoceles following renal transplantation. We report on the use of fibrin glue sclerotherapy at this institution for the management of renal transplant related lymphoceles. MATERIALS AND METHODS: We reviewed the records of 8 patients at a single institution with lymphoceles after renal transplantation treated with percutaneous fibrin glue sclerosis. RESULTS: Treatment success was achieved in 6 patients (75%), with resolution of lymphoceles assessed with clinical and imaging findings. Four patients (50%) required 2 applications of fibrin sealant, with 2 (25%) subsequently requiring surgical management of the lymphoceles. Clinical followup averaged 27.7 months (range 4 to 44). Complications included lymphocele recurrence, clogging of drainage catheters and catheter dislodgement. CONCLUSIONS: The experience of 8 patients suggests that fibrin glue sclerotherapy may be considered a safe and effective method of treating symptomatic lymphoceles when simple percutaneous drainage has failed. The percutaneous approach does not require hospital admission and is less invasive than surgical treatment.

False-normal appearance of the endometrium on conventional transvaginal sonography: comparison with saline hysterosonography.

OBJECTIVE: The objective of this article is to assess the utility of transvaginal saline hysterosonography in patients presenting with a normal-appearing endometrium on conventional transvaginal pelvic sonography. MATERIALS AND METHODS: Between August 1997 and October 1999, 180 patients underwent saline hysterosonography for abnormal vaginal bleeding. All patients had conventional transvaginal pelvic sonography before saline hysterosonography. On conventional transvaginal sonography, the sonographic appearance of the endometrium was classified according to the following parameters: normal or abnormal thickness, homogeneous or heterogeneous echogenicity, bulbous contour, discontinuous, or obscured. A comparison was performed between the endometrial appearance on conventional transvaginal sonography with that of the uterine cavity on saline hysterosonography. RESULTS: Saline hysterosonography showed abnormalities in 114 patients. Polyps were identified in 53 patients, submucosal leiomyomas in 37 patients, uterine anomalies in two patients, a uterine anomaly and a submucosal leiomyoma in one patient, uterine synechiae in three patients, a synechia and a polyp in one patient, thick endometrial walls in six patients, nondistensible cavities in two patients, and polyps and submucosal leiomyomas in nine patients. Sixteen (14%) of 114 patients showed abnormalities (polyps and submucosal leiomyomas) on saline hysterosonography despite normal-appearing endometria on conventional transvaginal sonography. CONCLUSION: Conventional transvaginal pelvic sonography does not appear to be a screening procedure of sufficient diagnostic value in the symptomatic patient with abnormal vaginal bleeding. In patients presenting with the chief complaint of abnormal vaginal bleeding, diagnostic evaluation with a saline hysterosonogram may be warranted despite normal findings on a transvaginal pelvic sonogram.