A sonographic classification of adenomyosis: interobserver reproducibility in the evaluation of type and degree of the myometrial involvement.

OBJECTIVE: To study the interobserver reproducibility of our new ultrasonographic mapping system to define the type and extension of uterine adenomyosis. DESIGN: Interobserver study involving two observers with different medical backgrounds and gynecological ultrasound experience. SETTING: University hospital. PATIENTS: Seventy consecutive women who underwent transvaginal ultrasound for suspected endometriosis, pelvic pain, heavy menstrual bleeding, and infertility. INTERVENTION: Two operators (observers A and B), who were blinded, independently reviewed the ultrasound videos offline, assessing the type of adenomyosis and the severity of the disease. Diagnosis of adenomyosis was made when typical ultrasonographic features of the disease were observed at the examination. Adenomyosis was defined as diffuse, focal, and adenomyoma according to the ultrasonographic characteristics. The severity of adenomyosis was described using a new schematic scoring system that describes the extension of the disease considering all possible ultrasound adenomyosis features. MAIN OUTCOME MEASURES: Reproducibility of the new mapping system for adenomyosis and rate agreement between two operators. RESULTS: Multiple rate agreements to classify the different features and the score of adenomyosis (diffuse, focal adenomyoma, and focal or diffuse alteration of junctional zone) ranged from substantial to almost perfect (Cohen κ = 0.658 - 1) except for adenomyoma score 4 (one or more adenomyomas with the largest diameter >40 mm) in which interobserver agreement was moderate (κ = 0.479). CONCLUSION: Our new scoring system for uterine adenomyosis is reproducible and could be useful in clinical practice. The standardization of the transvaginal approach and of the sonographer training represent a crucial point for a correct diagnosis of myometrial disease.

Heterogeneity of Doppler waveform description is decreased with the use of a dedicated classification.

BACKGROUND: The analysis of Doppler ultrasound waveforms (DW) provides a method for detecting and evaluating arterial stenosis in the lower limb arteries but no recommendation exists on how to describe the DWs. Aims of this study were to assess the heterogeneity of the description of DWs among vascular residents and the impact of the use of a 4-item classification. METHODS: Thirty different DWs were presented to residents using Microsoft PowerPoint® slides. They were invited to describe the 30 DWs before and after the presentation of a 4-item classification (triphasic, biphasic, monophasic, and others). The heterogeneity was assessed by the number of different answers used by the residents. Nineteen residents with six to eighteen months of vascular medicine training and ultrasound experience were included. RESULTS: The average of different answers was 9 ± 4 for the whole analysis of the 30 DWs without the use of a specific classification, whereas the average was 2 ± 1 using the 4-item classification (p < 0.005). There was a significant difference in correct answers, i. e. in combined continuous waveforms and pulsed waveforms between experienced residents and younger residents (p < 0.05). CONCLUSIONS: Using a 4-item classification for DWs reduced the heterogeneity of the DW description. There is an urgent need to standardize the DW description in order to improve the patients care with peripheral artery disease.

Preliminary Definitions for the Sonographic Features of Synovitis in Children.

OBJECTIVE: Musculoskeletal ultrasonography (US) has the potential to be an important tool in the assessment of disease activity in childhood arthritides. To assess pathology, clear definitions for synovitis need to be developed first. The aim of this study was to develop and validate these definitions through an international consensus process. METHODS: The decision on which US techniques to use and the components to be included in the definitions, as well as the final wording, were developed by 31 US experts in a consensus process. A Likert scale of 1-5 (where 1 = complete disagreement and 5 = complete agreement) was used. A minimum of 80% of the experts scoring 4 or 5 was required for final approval. The definitions were then validated on 120 standardized US images of the wrist, metacarpophalangeal joints, and tibiotalar joints, displaying various degrees of synovitis at various ages. RESULTS: B-mode and Doppler should be used for assessing synovitis in children. A US definition of the various components (i.e., synovial hypertrophy, effusion, and Doppler signal within the synovium) was developed. The definition was validated on still images with a median of 89% of participants (range 80-100) scoring it as 4 or 5 on a Likert scale. CONCLUSION: US definitions of synovitis and its elementary components covering the entire pediatric age range were successfully developed through a Delphi process and validated in a web-based still-images exercise. These results provide the basis for the standardized US assessment of synovitis in clinical practice and research.

Variação anatômica venosa rara em membros inferiores / A rare venous anatomic variation of the lower limb

Resumo A anatomia do sistema venoso dos membros inferiores é uma das mais complexas no corpo humano. Devido a essa condição, é de extrema importância saber identificar variações que possam acometê-la, como as malformações congênitas. Em casos de agenesia de veias profundas, como uma malformação vascular rara, o quadro clínico pode manifestar-se com insuficiência venosa crônica, que pode evoluir com edema, hiperpigmentação e úlcera de membro inferior. Assim, em muitos casos, torna-se uma doença incapacitante e de difícil tratamento. Apresenta-se um caso de agenesia de segmento venoso femoropoplíteo no membro inferior direito em paciente de 36 anos de idade, que cursou com edema e varizes de grosso calibre no membro acometido.

Abstract The anatomy of the venous system of the lower limbs is among the most complex in the human body. In view of this, it is extremely important to know how to identify variations that can affect it, such as congenital malformations, for example. In cases of a rare vascular malformation such as agenesis of deep veins, clinical status may manifest with chronic venous insufficiency, which can progress with edema, hyperpigmentation, and lower limb ulcers. This is very often therefore an incapacitating disease that is difficult to treat. This article describes a case of agenesis of a segment of femoropopliteal vein in the right lower limb of a 36-year-old patient who had edema and large caliber varicose veins in the affected limb.

In vitro verification of multiple-receiver Doppler ultrasound for velocity estimation improvement.

The coherent scattering effect, which introduces noise in Doppler-derived velocity estimates, is caused by constructive and destructive interference of sound waves scattered from multiple particles. Because the phase relationship between signals scattered from different particles depends on the orientation of the receiver, the error in a given velocity estimate depends on the receiver location. To examine this dependence, the velocity of a steady uniform flow was measured simultaneously with a transceiver and three receivers, and the cross-correlation coefficients between velocity estimates for pairs of crystals were calculated. The velocity estimates were nearly independent, with cross-correlation coefficients of approximately 0.2. This result agrees with our previously published numerical simulation studies which demonstrated that the coherent scattering noise in receivers separated by 5 degrees or more was nearly uncorrelated. Consequently, the contribution of coherent scattering noise can be reduced by averaging out noise in signals obtained from multiple receivers.

Sonographic imaging of the posterior fossa utilizing the foramen magnum.

In this essay, we describe our experience with a sonographic technique utilizing the foramen magnum to more clearly define anatomy in the neonatal posterior fossa. This approach can be used as an additional problem-solving tool in neonates with post-hemorrhagic hydrocephalus and a variety of posterior fossa abnormalities. The foramen magnum view is easily mastered and produces diagnostic images with little additional scanning time.

Postoperative monitoring of microsurgical free tissue transfers for head and neck reconstruction: a systematic review of current techniques--part I. Non-invasive techniques.

A systematic review of the literature relating to methods of monitoring viability of microvascular free tissue transfers in the head and neck region was conducted. The aim of this review is to identify the best method of monitoring that would allow timely salvage of potentially failing free flaps. An analysis and description of the various studied techniques is also given. In this first part, non-invasive modalities are covered.

A new method for diagnosis of cirrhosis disease: complex-valued artificial neural network.

In this study, complex-valued artificial neural network (CVANN) that is a new technique for biomedical pattern classification was proposed for classifying portal vein Doppler signals recorded from 54 patients with cirrhosis and 36 healthy subjects. Fast Fourier transform values of Doppler signals were calculated for pre-processing and obtained values, which include real and imaginary components, were used as the inputs of the CVANN for classification of Doppler signals. Classification results of CVANN show that Doppler signals were classified successfully with 100% correct classification rate using leave-one-out cross-validation. Besides, CVANN has 100% sensitivity and 100% specificity. These results were found to be compliant with the expected results that are derived from physician's direct diagnosis. This method would be to assist the physician to make the final decision.

A classification system for selective intrauterine growth restriction in monochorionic pregnancies according to umbilical artery Doppler flow in the smaller twin.

OBJECTIVES: To evaluate a classification of selective intrauterine growth restriction (sIUGR) in monochorionic (MC) twins based on the characteristics of umbilical artery (UA) Doppler flow in the smaller twin, in terms of association with clinical outcome and with the pattern of placental anastomoses. METHODS: One hundred and thirty-four MC twins diagnosed with sIUGR at 18-26 weeks were classified as Type I (UA Doppler with positive diastolic flow, n = 39), Type II (persistent absent or reversed end-diastolic flow, n = 30) and Type III (intermittent absent or reversed end-diastolic flow, n = 65). Perinatal outcome, placental sharing and the pattern of anastomoses were compared with those in 76 uncomplicated MC twins. RESULTS: Mean gestational age at delivery was 35.5 (range, 30-38) weeks in controls, 35.4 (range, 16-38) weeks in Type I, 30.7 (range, 27-40) weeks in Type II (P < 0.0001) and 31.6 (range, 23-39) weeks in Type III (P < 0.0001) pregnancies. Fetal weight discordance was significantly higher in Type II (38%) and Type III (36%) than in Type I (29%) (P < 0.0001) pregnancies. Deterioration of the growth-restricted fetus occurred in 90% of Type II cases, compared with 0% and 10.8% of Types I and III, respectively (P < 0.001). Unexpected intrauterine fetal death of the smaller twin occurred in 15.4% of Type III cases, compared with 2.6% and 0% of Types I and II respectively (P < 0.05). Parenchymal brain lesions in the larger twin were observed in 19.7% of Type III cases and less than 5% in the other groups (P < 0.05). Placental discordance (larger/smaller) was 1.3 in controls, compared with 1.8, 2.6 and 4.4 in Types I, II and III, respectively (P < 0.01). The proportion of cases with arterioarterial anastomoses > 2 mm in diameter was 55% in controls, 70% in Type I, 18% in Type II (P < 0.01) and 98% in Type III (P < 0.01). CONCLUSION: sIUGR can be classified on the basis of umbilical artery Doppler into three types that correlate with different clinical behavior and different patterns of placental anastomoses. This classification may be of help in clinical decision-making and when comparing clinical studies.

Effects of window types on classification of carotid artery Doppler signals in the early phase of atherosclerosis using complex-valued artificial neural network.

In this study, carotid artery Doppler ultrasound signals were acquired from left carotid arteries of 38 patients and 40 healthy volunteers. The patient group had an established diagnosis of the early phase of atherosclerosis through coronary or aortofemoropopliteal angiographies. Doppler signals were processed using fast Fourier transform (FFT) with different window types, Hilbert transform and Welch methods. After these processes, Doppler signals were classified using complex-valued artificial neural network (CVANN). Effects of window types in classification were interpreted. Results for three methods and five window types (Bartlett, Blackman, Boxcar, Hamming, Hanning) were presented as comparatively. CVANN is a new technique for solving classification problems in Doppler signals. Furthermore, examining the effects of window types in addition to CVANN in this classification problem is also the first study in literature related with this subject. Results showed that CVANN, whose input data were processed by Welch method for each window types stated above, had classified all training and test patterns, which consist of 36 healthy, 34 unhealthy and four healthy, four unhealthy subjects, respectively, with 100% classification accuracy for both training and test phases.

Applications of Doppler imaging in the musculoskeletal system.

Pathological conditions affecting the musculoskeletal system often result in alterations of regional blood flow. The assessment of a Doppler signal in inflammatory or infective processes complements the grayscale findings, helping to evaluate the severity of disease. Doppler imaging can also be used to determine therapeutic response or help guide injections. In addition, Doppler interrogation enables vascular characterization of solid masses. The presence of a Doppler signal can also help differentiate solid from cystic lesions. This article reviews the wide range of applications for Doppler imaging of the musculoskeletal system.

Subendometrial power Doppler quantification: a new classification proposal.

Fifty-two women with regular menses were enrolled in the study. The patients were not allowed to use non-steroidal anti-inflammatory drugs within 24 h of any examination. All patients were examined during the mid-luteal phase (6-9 days after ovulation, according to previous ultrasound record). Power Doppler energy levels were classified into five categories according to the per cent area of sub-endometrial signal: I (<10%), II (10-25%), III (25-50%), IV (50-75%) and V (>75%). The colour Doppler signal was considered positive when it reached at least the endometrial basal layer. The picture of the endometrium was analysed and the regions of interest were identified and marked for further analysis. Each recorded image was then independently evaluated and classified by three blinded observers. According to the power Doppler classification, age, body mass index (BMI) and endometrial thickness were analysed, and no significant differences were observed among them. The Kappa test (0.70) demonstrated an excellent agreement among examiners (P = 0.0001). This study has validated a very simple and cost-effective classification for sub-endometrial vascularization. This method of quantification may potentially be of use, and its relevance to clinical practice should be explored.

Tratamiento médico de la claudicacion intermitente / The medical treatment of intermittent claudication

Introducción. El diagnóstico de claudicación intermitente por afectación arteriosclerótica de las arterias de las extremidades inferiores (EEII) implica un incremento significativo del riesgo de complicaciones cardiovasculares (CCV), así como una limitación importante de la calidad de vida. Objetivo. Considerar la modificación de los factores de riesgo de progresión de la arteriosclerosis como factor prioritario de tratamiento. Conclusiones. La aspirina constituye el fármaco de primera elección en la prevención secundaria de las CCV en pacientes con enfermedad arterial periférica, y el clopidogrel, con efecto potencialmente más eficaz, representa una alternativa en pacientes con isquemia crónica de las EEII. Los datos actuales son insuficientes para recomendar el uso sistemático de un fármaco específico en todos los pacientes con claudicación (AU)

Embolismo en la arteria cerebral media por perdigón de escopeta de caza / Middle cerebral artery embolism caused by a shotgun pellet

Presentamos un caso de embolización traumática por perdigón de escopeta de caza, desde el ventrículo izquierdo a la arteria cerebral media derecha, con isquemia cerebral y el posterior infarto con secuelas neurológicas. Se discuten los problemas que surgen debidos a la presencia de un émbolo metálico en la circulación cerebral y cómo debe tratarse esta lesión nada corriente (AU)

Differentiation of benign and malignant breast tumors by logistic regression and a classification tree using Doppler flow signals.

In breast examinations with Doppler, an increased flow is found in malignant tumors. With the relatively new color Doppler, we measured different flow values in 133 cancer patients and in 325 women with benign disease. These measurements were used to develop diagnostic rules. For the highly correlated flow values, we used a stepwise procedure to select a final logistic regression model and a tree-based approach, which is a different way of modeling. With both approaches we developed simple diagnostic rules of which the sensitivity and the specificity exceeded 90%. There are no differences between the two approaches concerning discriminative ability. As complex statistical modeling leads to an overoptimism in the assessment of the error rates, we applied sensitivity analysis, investigated the stability of the selected logistic regression model, and estimated the magnitude of the overoptimism of the diagnostic rules with resampling methods. The results indicate that the estimates of sensitivity and specificity are probably close to realistic values for a clinical setting.