Association between diabetes mellitus and postoperative urinary retention after cerebral angiography.

AIMS: The aim of this study is to examine the association between diabetes mellitus and postoperative urinary retention on cerebral angiography (including intravascular interventional therapy). METHODS: We collected data on the demographic characteristics and comorbidities, imaging and routine laboratory data, surgical information, and medications of patients who underwent cerebral angiography. Multivariate logistic regression was used to explore the correlation between diabetes and the incidence of postoperative urinary retention. RESULTS: A total of 932 patients were included, with a mean age of 59.7 years (74.1% men). Postoperative urinary retention occurred in 40.8% of the diabetes mellitus group and 30.3% of the group without diabetes. Compared with the group without diabetes, those with diabetes were more likely to experience postoperative urinary retention. Patients with higher glycosylated hemoglobin A1c levels had a higher risk of developing postoperative urinary retention. CONCLUSIONS: Diabetes was independently linked to postoperative urinary retention following cerebral angiography and patients with glycosylated hemoglobin A1c levels > 6% were more likely to experience postoperative urinary retention. Therefore, clinically regulating blood glucose levels may help to reduce the likelihood of postoperative urinary retention after cerebral angiography.

A Cost-Effectiveness Analysis of Post-Void Residual Bladder Scan Thresholds in the Postoperative Setting.

INTRODUCTION AND HYPOTHESIS: To identify the optimal cost-effectiveness threshold of post-void residual (PVR) by bladder scan in postoperative urogynecologic patients. METHODS: A cost-effectiveness analysis was performed as a secondary analysis of a previously published study of patients undergoing urogynecologic procedures with planned voiding trials, setting thresholds for postoperative PVR bladder scan volumes at 100 ml, 150 ml, and 200 ml. Patient-based scenarios were modeled for ambulatory office or emergency department (ED) resource utilization and to determine the cost-effectiveness of each threshold. Costs were obtained from a southeastern academic medical center, only utilizing direct medical costs and hospital costs, not including societal costs. Quality-adjusted life years (QALY's) were used as health outcomes determining the incremental cost-effectiveness ratio (ICER). RESULTS: A total of 151 patients from the original study were included. A willingness to pay threshold of $100,000 per QALY was assumed. A PVR of 100 ml exceeded this at $373,824. A PVR threshold of 150 ml was dominant (-$1,211,716), while minimizing ED visits for postoperative urinary retention (POUR) and unnecessary clinic appointments. While a PVR of 200 ml appeared a cost-effective strategy (-$488,389), there was increased ED utilization and under-detection of postoperative urinary retention (POUR). CONCLUSION: A PVR threshold of 100 ml created a healthcare system burden due to increased office voiding trials. Both PVR thresholds of 150 ml and 200 ml were cost-effective strategies; however, ED utilization for POUR increased with 200 ml. Utilizing 150 ml as the PVR cut-off proved the most cost-effective strategy, avoiding POUR under-detection and undue health costs.

Ovarian mucinous cystadenoma causing acute urinary retention.

Acute urinary retention rarely occurs in women, and is only infrequently caused by a pelvic mass. We describe a case of acute urinary retention caused by a large ovarian mucinous cystadenoma. Point of care ultrasound characterized and localized the lesion, while computerized tomography demonstrated the anatomic distortions resulting in urinary retention. The patient's symptoms resolved immediately following a laparoscopic right salpingo-oophorectomy with complete tumor removal.

Implementation of a standardized voiding management protocol to reduce unnecessary re-catheterization - A quality improvement project.

OBJECTIVE: To design and implement a standardized postoperative voiding management protocol that accurately identifies patients with urinary retention and reduces unnecessary re-catheterization. METHODS: A postoperative voiding management protocol was designed and implemented in patients undergoing major, inpatient, non-radical abdominal surgery with a gynecologic oncologist. No patients had epidural catheters. The implemented quality improvement (QI) protocol included: 1) Foley removal at six hours postoperatively; 2) universal bladder scan after the first void; and 3) limiting re-catheterization to patients with bladder scan volumes >150 ml. A total of 96 patients post-protocol implementation were compared to 52 patients pre-protocol. Along with baseline demographic data and timing of catheter removal, we recorded the presence or absence of urinary retention and/or unnecessary re-catheterization and postoperative urinary tract infection rates. Fisher's exact test and student's t-tests were performed for comparisons. RESULTS: The overall rate of postoperative urinary retention was 21.6% (32/148). The new voiding management protocol reduced the rate of unnecessary re-catheterization by 90% (13.5% vs 2.1%, p = 0.01), without overlooking true urinary retention (23.1% vs 20.8%, p = 0.83). Additionally, there was a significant increase in hospital-defined early discharge prior to 11:00 AM (4.0% vs 22.0%, p = 0.022). There was no difference in the postoperative urinary tract infection rate between the groups (p = 1.00). Risk factors associated with urinary retention included older age (p < 0.01), use of medications with anticholinergic properties (p < 0.01), and preexisting urinary dysfunction (p < 0.01). CONCLUSIONS: Implementation of this new voiding management protocol reduced unnecessary re-catheterization, captured and treated true urinary retention, and facilitated early hospital discharge.

Ultrasonographic Assessment of Bladder Volumes in Children Undergoing Penile Surgery: Does the Type of Anesthesia Matter?

BACKGROUND: There are scant data reporting postoperative ultrasonographically measured bladder volumes in children undergoing penile surgery. STUDY QUESTION: We studied the effect of various anesthesia techniques on return of micturition after penile surgery in children, using ultrasonographically measured bladder volumes. DATA SOURCES: Ultrasonographically measured postvoiding residual bladder volumes indexed to age-appropriate capacity, and time elapsed between the end of surgery and spontaneous voiding after pediatric circumcision, distal hypospadias repair, or repair of urethrocutaneous fistula, were studied. STUDY DESIGN: Children between 4 months and 12 years were randomized to caudal block, intravenous (IV) fentanyl or penile block, in association with inhaled general anesthesia. Bladder volumes were measured before surgery and immediately after voiding for the first time. Time to first postsurgery void was also recorded. RESULTS: Thirty-one children completed all assessments; 12 underwent caudal block, 9 IV fentanyl anesthesia, and 7 were given penile block. The mean first postvoid bladder residual volumes were highest in the caudal and lowest in the penile block children (27.5 vs. 17.3 mL, P = 0.003). The time elapsing between the end of surgery and first voiding was the longest in the fentanyl group compared with caudal and penile blocks (232, 178, 150 minutes, respectively, P = 0.02). CONCLUSIONS: None of the anesthetic techniques provoked postoperative urinary retention after minor penile surgery in children. The penile block appears superior to caudal block or to IV fentanyl-based anesthesia with regard to postoperative recovery of normal micturition.

Can we replace the catheter when evaluating urinary residuals?

AIMS: To test the different formulae to calculate the bladder volume using ultrasound; the accuracy of patients hearing/feeling "bubbles" at the end of urodynamics testing as a measure of being empty; and how good we are at estimating PVR using X-ray at the end of video urodynamics testing. METHODS: This was a prospective cohort study. Using Sonosite 180 plus, bladder volumes were calculated as, height × width × depth × proportionality constant (0.52, 0.625, 0.65, and 0.7) Patients were asked whether the patient heard or felt "bubbles" at the end of the investigation. Each patient was fluoroscopically screened and the clinician estimated the volume and compared with single-use catheter volume. RESULTS: A total of 85 patients were assessed. All four formulae were significantly correlated. The PC, 0.52, correlated best (r = 0.938, P < 0.001) with no significant difference with the actual volumes ( P = 0.275). The "bubbles test" had a positive predictive value of 93%. A video postvoid residual (PVR) estimation significantly correlated with catheterised bladder volume ( r = 0.842, P < 0.001). There was no significant difference between the estimated and actual bladder volumes ( P = 0.579). CONCLUSION: This study showed that although all four formulae correlated significantly, the PC of 0.52 was the only formula without a significant difference from the actual volume. More work is needed to produce patient individualised PC. Our clinicians were able to accurately estimate the PVR on X-ray. This study has identified the best formula to accurately estimate bladder volume and that video estimation along with the "bubbles" test can avoid unnecessary intervention.

Acute urinary retention in two adolescent girls with imperforate hymen.

Acute urinary retention is rare symptom in young adolescent girls. Imperforate hymen can be a cause of acute urinary retention possibly due to the pressure effect of the distended vagina (hematocolpos) on the lower urinary tract. However, the mechanism of progression to urinary retention is unknown. We report on two cases of adolescent girls with imperforate hymen who presented with acute urinary retention. A series of volume tolerance tests of the urinary bladder and urodynamic studies before operation revealed highly elevated urethral resistance, which was induced by interaction of large amount of urinary volume in the bladder and the large size of hematocolpos. After operation, urinary retention could not be observed and the urethral pressure returned to normal.

Efficacy of Prostatic Artery Embolization for Catheter-Dependent Patients with Large Prostate Sizes and High Comorbidity Scores.

PURPOSE: To evaluate efficacy and safety of prostate artery embolization (PAE) in urinary catheter-dependent patients with large prostate volumes and high comorbidity scores. MATERIALS AND METHODS: A retrospective single-center review was conducted of 30 patients with urinary retention at time of PAE from November 2014 through February 2017. Mean (range) age was 73.1 years (48-94 y), age-adjusted Charlson comorbidity index was 4.5 (0-10), duration of urinary retention was 63.4 days (2-224 d), International Prostate Symptom Score quality-of-life (IPSS-QOL) was 5.3 (3-6), and prostate volume was 167.3 cm3 (55-557 cm3). These parameters were collected at 3, 6, and 12 months after PAE. Trials of voiding were performed approximately 2 weeks after PAE and, if failed, every 2 weeks thereafter. Adverse events were graded using the Clavien-Dindo classification. RESULTS: At a mean (range) of 18.2 days (1-72 d), 26 (86.7%) patients were no longer reliant on catheters. Follow-up was obtained in all patients eligible at 3 and 6 months and 17 of 20 (85.0%) patients eligible at 1 year. Mean (range) IPSS-QOL improved significantly to 1.2 (0-5), 0.7 (0-4), and 0.6 (0-4) at 3, 6, and 12 months (all P < .001). Mean (range) prostate volume decreased significantly to 115.9 cm3 (27-248 cm3) at 3 months (P < .001). Two patients experienced grade II urosepsis complications, which were successfully treated with intravenous antibiotics. All other complications were self-limited grade I complications. CONCLUSIONS: PAE represents a safe and effective option for management of patients with urinary retention, especially patients with large prostates who are not ideal surgical candidates.

Particulate wear debris osteolysis, acute urinary retention and delirium as late complications of hip arthroplasty.

Intrapelvic mass formation as a result of particulate wear debris induced osteolysis is a recognised late complication of cementless total hip arthroplasty. Clinical presentation typically involves hip and/or leg pain resulting in functional impairment, and obstructive urinary symptoms developing 3-20 years after surgery. An acute confusional state has never been described in this scenario. We report the case of an 86-year-old gentleman with a diagnosis of dementia brought to our emergency department with an acute confusional state. Abdominal imaging revealed a distended bladder, a large pelvic mass and a lytic lesion within his right acetabulum. Cytological and microbiological examination of fluid obtained with radiologically guided aspiration of the mass was negative for neoplasia and infection.

Low incidence of postoperative urinary retention with the use of a nurse-led bladder scan protocol after hip and knee arthroplasty: a retrospective cohort study.

PURPOSE: Postoperative urinary retention (POUR), defined as the inability to empty the bladder voluntary after surgery, is a commonly reported complication. This study reports the incidence and possible risk factors for POUR after elective fast-track hip or knee arthroplasty when using a nurse-led bladder scan protocol. METHODS: This retrospective cohort study included data from 803 patients who underwent unilateral hip or knee arthroplasty. Patients' digital clinical records were reviewed for eligibility. Patients with incomplete data registration, preoperative bladder volume >250 ml, preexisting bladder catheterization, and/or patients following the outpatient pathway were excluded. Bladder volumes were assessed at different moments pre- and postoperatively. The outcome was the incidence of POUR, defined as the inability to void spontaneously with a bladder volume >600 ml, treated with indwelling catheterization. Further analysis between POUR and non-POUR patients was performed to detect possible risk factors for POUR. RESULTS: Six hundred and thirty-eight patients operated on primary unilateral hip or knee arthroplasty were analyzed. The incidence of POUR was 12.9% (n = 82, 95% CI 9.4-15.5). Gender, age, BMI, ASA classification, preoperative bladder volume, type of anesthesia, type of arthroplasty, and perioperative fluid administration were not significant different between POUR and non-POUR patients. Patients with a bladder volume of >200 ml at the recovery room were at higher risk (OR 5.049, 95% CI 2.815-9.054) for POUR. CONCLUSIONS: When using a nurse-led bladder scan protocol in fast-track hip and knee arthroplasty, the incidence of POUR was 12.9%, with a bladder volume of >200 ml at the recovery room as a risk factor for POUR. LEVEL OF EVIDENCE: A retrospective cohort study, Level III.

Ultrasound detrusor wall thickness measurement in combination with bladder capacity can safely detect detrusor underactivity in adult men.

PURPOSE: Detrusor underactivity (DU) has lately gained increasing interest because this bladder condition is an important cause of post-void residual urine and lower urinary tract symptoms (LUTS) in adult men. Until now, DU can only be diagnosed by pressure-flow measurement. Therefore, the aim of this study was to search for noninvasive tests which can safely predict DU in adult men. METHODS: Unselected, treatment-naïve male patients aged ≥40 years with uncomplicated, non-neurogenic LUTS were prospectively evaluated. All men received-after standard assessment of male LUTS-ultrasound detrusor wall thickness (DWT) measurements at a bladder filling ≥250 ml and computer urodynamic investigation. DU was defined as incomplete bladder emptying (>30 ml) in the absence of bladder outlet obstruction or dysfunctional voiding. Classification and regression tree (CART) analysis was used to determine parameters and threshold values for DU. RESULTS: The study population consisted of 143 consecutive men with medians of 62 years, IPSS 16, and prostate volume 35 ml. In total, 33 patients (23.1 %) had DU. CART analysis showed that all men with DWT ≤ 1.23 mm plus bladder capacity >445 ml had DU. This multivariate model has a sensitivity of 42 %, specificity of 100 %, positive predictive value of 100 %, and negative predictive value of 85 %. CONCLUSIONS: This study showed that all men with ultrasound DWT ≤ 1.23 mm + bladder capacity >445 ml have DU. Combination of these two tests could help physicians to diagnose DU noninvasively in clinical practice. A prospective independent study should confirm these results.

Optimal Lead Positioning in Sacral Neuromodulation: Which Factors Are Related to Treatment Outcome?

OBJECTIVES: Sacral neuromodulation (SNM) is a well-established treatment for overactive bladder (OAB) and non-obstructive urinary retention (NOR). During test stimulation, the lead is positioned along the third sacral nerve, which ideally results in a response in all four contact points (active electrodes). However, it is unclear whether the position of the lead (depth, angle, deflection) and the number of active electrodes is related to the outcome of SNM. METHODS: All patients who underwent test stimulation using the tined lead between January 2011 and September 2016 were included in this retrospective study. Success was defined as >50% improvement in voiding diary parameters compared to baseline. The correlation between lead position and outcome of test stimulation was evaluated. The lead position was determined by evaluating the depth, angle and deflection with respect to the sacral foramen. Binary logistic regression was used in order to determine the predictive value of these factors. RESULTS: We included 189 patients of whom 105 were diagnosed with OAB and 84 with NOR. After a SNM test period of 4 weeks, 111 patients (59%) were successful and received a permanent implant. The position of the lead and the number of active electrodes did not predict success of test stimulation in neither the OAB group nor the NOR. However, lateral deflection of the lead was associated with finding more active electrodes (p = 0.01). CONCLUSION: In our study, the position of the lead or the number of active electrodes did not predict the outcome of SNM test stimulation. However, the impact of lead positioning and number of active electrodes on long-term outcome remains to be proven.

The role of intravesical prostatic protrusion (IPP) in the evaluation and treatment of bladder outlet obstruction (BOO).

AIMS: Intravesical prostatic protrusion (IPP) may be an underutilized modality for the assessment of bladder outlet obstruction (BOO). Pressure flow studies or urodynamics have long been the gold standard for the evaluation of lower urinary tract symptoms (LUTS) in men but are invasive, time-consuming and costly. Potentially, IPP may be a useful adjunct prior to performing urodynamics. METHODS: Measurement of IPP is taken in the sagittal view, using the transabdominal ultrasound. It is the vertical height from the tip of the protrusion to the base of the prostate. This technique was previously described. We reviewed previous publications that studied the accuracy, positive predictive value and clinical use of IPP. In addition, we noted the comments regarding the challenges of using this technique. RESULTS: IPP has been shown to have a positive predictive value of 72% for BOO. It has been calculated to have an area under curve (AUC) value of 0.71 and 0.84 in some stuies. Clinically, it may be used to predict the outcome of a trial without catheter following acute retention of urine. Patients with higher IPP grade were noted to have a higher risk of clinical progression. Studies have also shown that men with higher IPP are poorer responders to medical treatment such as α-blockers. CONCLUSIONS: Compared to other modalities, the advantage of IPP in assessing BOO may be its easy applicability and non-invasive nature. Therefore, there is a consideration for a larger role of IPP in bedside assessment and management of BOO in daily practice. Neurourol. Urodynam. 35:535-537, 2016. © 2015 Wiley Periodicals, Inc.

Accuracy of Post-Void Residual Urine Volume Measurement Using an Ultrasound Bladder Scanner among Postoperative Radical Hysterectomy Patients.

Background: Postoperative urinary retention occurs in 17 to 42% of Radical hysterectomy (RH) cases. The gold standard assessment of post-void residual urine volume (PVR) is bladder catheterization. The use of the 3D portable ultrasound device (VerathonBladderScan BVI 9400) to evaluate PVR is quick, safe, non-invasive, painless, and comfortable for patients as well as being easy to use. Objective: To compare the accuracy of ultrasound bladder scanner with that of urethral catheterization in the assessment of post-void residual urine volume (PVR). Material and Method: This was a prospective study. After removal of Foley's catheter in postoperative radical hysterectomy(RH) patients, the voiding care schedule consisted of voids after six hours or earlier if the patient had the urge. Promptly after voiding, PVR was measured using the BladderScan (Scan volume). Immediately after the procedure, urethral catheterization was performed to obtain the actual PVR (Catheter volume). The process was repeated in subsequent voids, and correlations between scan volume and catheter volume were analyzed. Results: Seventy patients (140 measurements) were included. A high correlation was found between the scan volume and the catheter volume (r = 0.89, p<0.001). A 91.0% specificity and 93.1% negative predictive value(NPV) were obtained using the scan volume in predicting a catheter volume of <100 ml. The difference in measurements between the two methods was not related to age, body mass index, parity, co-existing illness, type of surgical incision or duration of indwelling catheter. When catheter volume >100 ml was the cutoff for determining the need for re-catheterization, the scan volume returned 90.0% accuracy. Repetition of ultrasound scan in patients who had a first scan volume of <100 ml yielded a 97.2% specificity and 100% NPV in predicting catheter volume of <100 ml. Conclusion: The Bladder Scan provides good correlation together with high rates of specificity and NPV, and it could be an alternative modality to catheterization for the measurement of PVR in postoperative RH patients.

Undiagnosed nephrogenic diabetes insipidus as a cause of acute urinary retention in a young soldier.

We present a case of undiagnosed nephrogenic diabetes insipidus as a cause of acute urinary retention in a 21-year-old male soldier. Soldiers live in close quarters, and have a regimented lifestyle that may not allow for frequent voiding; therefore, undiagnosed nephrogenic diabetes insipidus may result in acute urinary retention.

[A giant fecalith complicated by acute urinary retention, hydronephrosis and acute obstructive pyelonephritis].

The article reports a rare case of a 30-year-old man with Hirschsprung's disease, who developed a giant fecalith in the rectum and sigmoid (weight 3.5 kg, the largest diameter 20 cm). The fecalith impaired urine flow by compressing urinary tract, thereby causing acute urinary retention and right-sided hydronephrosis with acute obstructive pyelonephritis. Removing fecalith resulted in the patient recovery and normal functioning of genitourinary system.

Diagnosis of Postoperative Urinary Retention Using a Simplified Ultrasound Bladder Measurement.

BACKGROUND: In this study, we sought to determine whether a simplified ultrasound measurement of the largest transverse diameter, using a standard ultrasound machine, could be used to diagnose postoperative urinary retention (POUR). This method may replace expensive bladder volume measuring devices or a more complex ultrasound procedure (involving the measurement of 3 bladder diameters). METHODS: Patients at risk of POUR if unable to void after orthopedic surgery were evaluated in the postanesthesia care unit before discharge. Bladder diameter was first measured using a portable ultrasound device (Vscan®; GE Healthcare, Wauwatosa, WI). An automated evaluation of bladder volume was then performed (Bladderscan® BVI 3000; Diagnostic Ultrasound, Redmond, WA). Finally, when a bladder catheterization was performed, the actual urinary volume was measured. The main outcome was a bladder volume ≥600 mL as measured using the automated ultrasound scanner (Bladderscan BVI 3000) or by catheterization. Correlations between bladder volumes and diameter were studied and receiver operating characteristic curves were constructed to determine the performance in predicting a bladder volume ≥600 mL. A "gray zone" approach was developed because a single cutoff value may not always be clinically significant. RESULTS: One hundred patients were included and underwent a Bladderscan measurement. Urinary volume after catheterization was obtained in 49 patients. A significant correlation was found between the largest transverse diameter and urinary volumes assessed by the 2 methods (Bladderscan and catheterization). Pearson correlation coefficients were r = 0.80 (95% confidence interval [CI], 0.72-0.86; P < 0.001) and r = 0.79 (95% CI, 0.65-0.88; P < 0.001), respectively. The area under the receiver operating characteristic curves for the prediction of a bladder volume ≥600 mL were 0.94 (95% CI, 0.88-0.98) and 0.91 (95% CI, 0.79-0.97), respectively, for urinary volumes assessed by Bladderscan and catheterization. The optimal cutoff value was 9.7 cm for both methods. The gray zone was narrow, ranging from 9.7 to 10.7 cm thus limiting inconclusive measurements. CONCLUSIONS: A simple ultrasound measurement of the largest transverse bladder diameter seemed to be helpful to exclude or confirm POUR.

Abnormal voiding parameters in children with severe idiopathic constipation.

OBJECTIVE: It is suggested that idiopathic constipation may associate with abnormal voiding parameters. In this study, we investigate the voiding parameters in children with constipation. METHODS: Since 2010, seventeen consecutive children (12 boys, 5 girls) aged 5-17 (median = 14) with significant constipation according to Rome III criteria and who were not responding to conventional treatment (diet, laxatives & bowel training) for over 6 months were recruited. The rectal diameter (RD) was measured by transpubic ultrasonography (USG), RD >3.5 cm was considered as dilated. Each patient had uroflow measurement and bladder USG done to measure the maximal flow rate (Vmax), voided volume (VV), and post-void residual urine (PVR). Abnormal voiding parameters were defined as Vmax <12 ml/sec, VV <65 or >150% of age-adjusted expected bladder capacity (EBC) and/or PVR >20 ml. RESULTS: Rectal diameter ranged from 1.7 to 8.2 cm (median = 3 cm) and was abnormally dilated in eight children. Vmax was normal in all children (median = 23.7 ml/sec). Voided volume ranged from 30 to 289% of EBC and was abnormal in six children (35.5%). Post-void residual urine varied from 0 to 85 ml and was abnormal in six (35.5 %) children. Three children (17.6 %) had both abnormal VV and PVR. On the whole, the prevalence of abnormal voiding parameters in constipated children was 52.9 %. Mean RD in normal and abnormal parameters groups was 2.8 and 4.7 cm, respectively. Rectal dilation was associated with abnormal voiding parameters (p = 0.015). CONCLUSION: Abnormal voiding parameters including voided volume and post-void residual urine are prevalent in constipated children. Dilated rectum is associated with abnormal voiding parameters.

Rapid evaluation of urinary retention and penile pain using point-of-care ultrasound.

We describe the case of an 18-year-old male with a history of nephrolithiasis presenting with acute urinary retention and penile pain. Point-of-care ultrasound was used to rapidly identify a urethral calculus causing obstruction of urinary outflow and allowed for expedited care. Further visualization of the kidneys gave reassurance that the presentation was not complicated by the presence of hydronephrosis.

Focused abdominal ultrasound.

A focused point-of-care abdominal ultrasound is an examination performed at the patient's location and interpreted within the clinical context. This review gives an overview of this examination modality. The objective is to rapidly address predefined dichotomised questions about the presence of an abdominal aortic aneurysm, gallstones, cholecystitis, hydronephrosis, urinary retention, free intraperitoneal fluid, and small bowel obstruction. FAUS is a valuable tool for emergency physicians to promptly confirm various conditions upon the patients' arrival, thus reducing the time to diagnosis and in some cases eliminating the need for other imaging.