Tentative diagnoses facilitate the detection of diverse lesions in chest radiographs.

The influence of clinical history upon detection has been frequently studied. In a unique investigation, detection of diverse abnormalities commonly encountered in practice was tested, and the influence of clinical history was conceptualized as suggesting a tentative diagnosis. Categorical prompts that were correct for specific abnormalities resulted in detection superior to that with unprompted reading. Prompts that were plausible but incorrect for abnormal and normal cases led to very few false-positive responses, and subsequent reports of specific abnormalities were as accurate as in unprompted reading. It is concluded that appropriate clinical history results in improved perceptual performance rather than simply improved decision-making.

Magnetic resonance imaging of anomalous fetuses.

Magnetic resonance imaging (MRI) has been used sparingly in obstetrics. The reasons for this relate mainly to cost, availability, difficulty obtaining clear images because of fetal movement, and the convenience and utility of ultrasound. However, MRI use is expanding and has the potential to play an important role in selected problem pregnancies. We studied the pregnancies of five women whose fetuses showed anomalies by ultrasound. These included cases of a large body wall defect, a diaphragmatic hernia, hydrocephalus, Meckel-Gruber syndrome, and iniencephaly with a diaphragmatic hernia (the iniencephaly sequence). Three of these examinations followed fetal neuromuscular blockade, and two were associated with oligohydramnios without fetal paralysis. Paralysis provided superior images. The fetal central nervous system, subcutaneous tissue, and liver imaged particularly well. This study illustrates that MRI can enhance and even clarify certain information provided by ultrasound.

Abnormal pregnancy sonogram: selective indication for fetal karyotype.

The inability to make a definitive diagnosis in the fetus with a sonographically identified abnormality often results in parental and physician uncertainty. An antenatal chromosome evaluation could resolve this uncertainty. Forty-one fetuses with an abnormal ultrasound examination were tested for karyotypic abnormality using a variety of specimens. Nearly one-third (13 of 41) of these fetuses had various chromosome abnormalities. There were only seven survivors in this series, underscoring the often poor prognosis when a significant ultrasound defect is detected antenatally. Knowledge of the fetal chromosome constitution in the setting of an abnormal ultrasound has important epidemiologic, cost-benefit, counseling, and pregnancy management implications.

Management and outcome of pineal region tumors.

The management and outcome of 45 patients with tumors in the pineal region are reviewed. The overall male to female ratio was 2:1, and over one-half of the patients presented during the 2nd decade of life. Sixteen of the 21 survivors are presently gainfully employed and suffer only minor deficits. Two of 3 survivors in whom the lesion was biopsied harbored germinomas, while the third had an epidermoid. Among the 18 nonsurvivors, all of whom died of their tumors, 15 succumbed within 2 1/2 years of hospital admission. Twelve of the 13 nonsurvivors in whom histological confirmation was obtained by operation or autopsy had malignant tumors. Computed axial tomography was helpful in making the diagnosis of tumor type in 7 of the 11 cases with confirmed pathology. Cerebrospinal fluid cytology disclosed malignant cells in 4 of 11 patients with proven pineal malignancy. Irradiation and shunting were performed in nearly all survivors and in a little over one-half of the nonsurvivors. Where noninvasive studies are equivocal for malignancy, biopsy may be indicated.

Teaching physical examination of the adult liver with use of real-time sonography.

RATIONALE AND OBJECTIVES: The authors developed and evaluated an approach to teaching examination of the liver that incorporates real-time ultrasound (US) imaging as immediate feedback to improve diagnostic accuracy. MATERIALS AND METHODS: Second-year medical students participating in a course in physical examination were assigned to receive instruction in measuring liver span without (group 1) or with (group 2) real-time sonography. Students from each group attended a practice session given by one of two physicians who were board certified in radiology and internal medicine with special expertise in US. During the practice session for group 2, students were shown the boundaries of the liver of the practice patient with real-time US. Both groups of students then made three measurements each of the liver span of a healthy practice patient and a single healthy test patient without US. The vertical liver span reference standard was determined by one of the authors. RESULTS: Students in group 2 showed greater accuracy in measuring liver span during both the practice and the test sessions than did students in group 1. The differences were significant for the third practice measurement and all three test measurements (P < .05). CONCLUSION: The use of real-time US as an aid in teaching physical examination improves students' accuracy in measuring liver size.

Specimen xeroradiography after needle localization and biopsy of noncalcified, nonpalpable breast lesions.

Xeroradiography was used to detect and aid in needle localization of 63 nonpalpable breast lesions over an 8-year period. In 28 patients (44%), no microcalcifications were present in the lesion biopsied. Xeroradiographs of these noncalcified lesions after their submersion in water carried a clean and close resemblance to their in vivo appearance and aided the pathologist in localizing the abnormality within the biopsy specimen. This simple method improved the accuracy of the needle-guided biopsy while allowing excision of minimal breast tissue. A total of 17 (27%) lesions revealed malignancy. At the time of mastectomy, all carcinomas were at an early stage with no nodal involvement. No recurrence has been detected to date with a mean follow-up period of 24 months. This procedure requires close cooperation between the surgeon, radiologist, and pathologist.

Transsphenoidal encephaloceles.

Transsphenoidal encephaloceles are rare congenital anomalies that may be immediately apparent in infants that present with multiple cranial midline defects. They should also be suspected in patients presenting with cerebrospinal fluid rhinorrhea, an epipharyngeal soft tissue mass, a visual defect, or an endocrinologic disturbance, especially when associated with midfacial and optic nerve anomalies. Plain x-ray films of the skull may show absence of the sellar floor and a soft tissue mass; the diagnosis is confirmed by computed tomography scanning. Surgical therapy may be indicated for persistent cerebrospinal fluid rhinorrhea, symptomatic epipharyngeal respiratory distress, or progression of neurological deficits. Two cases of transsphenoidal encephalocele are reported.

Solitary intrahepatic biliary cyst: diagnostic and therapeutic strategy.

This paper describes a newborn infant in whom an intrahepatic biliary cyst was successfully demonstrated by antenatal ultrasound. Postnatally, percutaneous cyst aspiration and computed tomography enhanced with intravenous cholangiographic contrast proved extremely helpful in the selection of surgical procedure. The lesion was completely removed at 12 weeks of age without complications.

Radiologic appearance of the upper cervical canal in women with a history of premature delivery.

The aim of this study was to compare the radiologic appearance of the upper cervical canal at hysterography between a group of women with a history of premature delivery and a control group. A standardized technique was used that corrects for the magnification inherent in taking measurements directly from the x-ray films. Some women with a history of premature delivery had abnormally wide upper cervical canals in the nonpregnant state. Premature labor might not have been an acute pregnancy-specific event in those women but might have been a reflection of an underlying abnormality.

Ultrasonography of the right lower quadrant.

Whereas acute appendicitis is the most common cause of right lower quadrant (RLQ) pain, numerous other conditions may cause signs and symptoms that mimic acute appendicitis. These include other appendiceal diseases, inflammatory bowel diseases, nonbowel gastrointestinal conditions, urinary diseases, and, in females, gynecologic diseases and conditions associated with pregnancy. The important role of ultrasonography in the diagnosis of not only acute appendicitis but also each of the other conditions that cause RLQ pain is described. The ultrasound criteria for the positive, negative, and indeterminate appendix ultrasound examination and the sensitivity, specificity, and positive and negative predictive values of this modality are discussed. The limitations of ultrasound in such diagnoses are also discussed, and an algorithm for the management of patients with RLQ pain is suggested.

Duplex Doppler sonography of the hepatic vein in tricuspid regurgitation.

Patients with tricuspid regurgitation may present initially with vague abdominal symptoms and elevated liver enzymes. In the absence of diagnostic sonographic findings, patients may be subjected to an unnecessary invasive liver biopsy for an accurate diagnosis. We recently described the association of the pulsatile portal venous waveform on duplex Doppler sonography with tricuspid regurgitation in 15 patients. In this study I describe the changes in the hepatic venous waveform in these patients and compare the findings with the final diagnosis as determined by Doppler echocardiography (n = 14) or ultrafast CT (n = 1). All patients had clinical findings consistent with liver dysfunction and were referred for sonography to rule out diseases of the liver, biliary tree, or hepatic or portal veins. All patients had persistently dilated hepatic veins and inferior venae cavae. Twenty-four volunteers, 11 of whom had simultaneous ECG tracings, served as a control group. The main findings on the hepatic duplex sonogram in the disease group were a decrease in the size of the antegrade systolic wave with a systolic/diastolic flow velocity ratio of less than 0.6 (n = 4) or reversal of the systolic wave (n = 10). In all volunteers, systolic flow was antegrade and the ratio was more than 0.6. Two diagnoses were false positive and one was false negative. In some patients with sonographic signs of congestive heart failure, duplex Doppler sonography of the hepatic vein may be helpful in the diagnosis of one of the causes of liver dysfunction, tricuspid regurgitation.

Benign prostatic hyperplasia: tissue characterization using suprapubic ultrasound.

Fifty-one patients with pathologically proved benign prostatic hyperplasia were examined with transabdominal ultrasound. The echo-textural patterns of the prostate were analyzed in detail. This analysis suggested various criteria that would be helpful in the diagnosis of this neoplasm. The most frequently encountered sonographic findings were the adenoma echo pattern (47 cases), shadowing echo-dense foci at any location, foci with an echo density brighter than that of the capsule, focal densities less than 6 mm thick, and location of a focus within the adenoma, junctional zone, or periurethral zone. Other suggestive signs included intact capsule (46 cases), uninvolved bladder (all but one case), and normal seminal vesicles (all cases). Based on these criteria, a definite diagnosis of benign prostatic hyperplasia was made in 43 cases with a diagnostic accuracy of 84%.

Normal and respiratory variations of the hepatic and portal venous duplex Doppler waveforms with simultaneous electrocardiographic correlation.

To understand hepatic vein (HV) and portal vein (PV) duplex waveforms and their normal and respiratory variations, HV and PV duplex sonography with simultaneous electrocardiography was performed on 11 volunteers. Absolute velocities of the waveforms' components and their ratios were determined at mid-inspiration, full inspiration, full expiration, and Valsalva maneuver. The normal HV waveform was variable in shape and component velocities and ratios but essentially consisted sequentially of (1) an antegrade systolic wave resulting from movement of the tricuspid annulus toward the cardiac apex and occurring shortly after QRS; (2) a retrograde v-wave resulting from atrial overfilling and occurring immediately after the T-wave; (3) an antegrade diastolic wave resulting from opening of the tricuspid valve and occurring shortly after the T-wave; and (4) a retrograde a-wave resulting from atrial contraction and occurring immediately after the P-wave. The ratio of the maximum systolic velocity to maximum diastolic velocity varied from 1.0 to 2.8 (mean 1.4). Systolic-to-diastolic ratio decreased during inspiration but was always greater than 0.6 and increased during expiration. The Valsalva maneuver diminished waveform pulsatility. PV waveforms were more triphasic than biphasic but less pulsatile, flow was totally antegrade, and respiratory changes were less remarkable than HV waveforms. All normal HV and most normal PV waveforms showed multiphasicity that corresponded to cyclic cardiac changes. The shapes of these waveforms were variable and were modified by respiratory movements.

Transabdominal ultrasound in the evaluation of prostate size.

This paper stresses the value of transabdominal ultrasound that utilizes basic ultrasound equipment in evaluating the size of the prostate. We performed ultrasound examinations on 43 patients with benign prostatic hyperplasia, and in 33 of these, sonography was done prior to surgery in an effort to compare the size of the prostate estimated by ultrasound with that of the postoperative specimen. In the vast majority of these patients, the difference between the estimated size and that of the specimen was insignificant. Ultrasound examination is easy, fast, noninvasive and reasonably accurate.

Pulsatile venous Doppler flow in lower limbs: highly indicative of elevated right atrium pressure.

OBJECTIVE: The purpose of this study was to determine if pulsatile flow in lower limbs as seen on venous Doppler waveforms correlates with increased right atrium pressure. MATERIALS AND METHODS: Of 429 patients who, over a 14-month period, underwent venous Doppler imaging of the lower limb to exclude deep venous thrombosis, 343 records were available for review at the time of the study. Of these, 74 had right atrium pressure measurements available for correlation. Seventeen patients were excluded because of thrombosis in the common femoral vein. Six other patients were also excluded because the time difference between the Doppler and the correlative studies was more than 4 weeks. The remaining 51 patients constituted the study subjects. In 18 of these, the right atrium pressure was measured within 1 week, 31 within 2 weeks, 42 within 3 weeks, and 51 within 4 weeks. In the study, we evaluated the three major veins of the lower limb (the common femoral, superficial femoral, and popliteal) by venous Doppler imaging. Data from only the common femoral vein were included in our analysis because this vessel was the least involved with thrombosis. The findings were correlated with the presence or absence of right-sided heart failure as determined by right atrium pressure measurement. A Doppler waveform was considered pulsatile when it had a cyclic retrograde component. A right atrium pressure of more than 8 mm Hg was considered elevated. RESULTS: Of 51 patients, 17 (33%) had pulsatile lower limb venous Doppler flow waveforms and 33 (65%) had elevated right atrium pressure. We found a statistically significant correlation between the presence of these abnormal waveforms and elevated right atrium pressure. The sensitivity of lower limb venous Doppler imaging for detecting right-sided heart failure as determined by right atrium pressure measurement was 46%, specificity was 94%, positive predictive value was 94%, negative predictive value was 50%, and accuracy was 65%. CONCLUSION: Pulsatile lower limb venous Doppler waveform correlates well with right-sided heart failure, as indicated by a right atrium pressure measurement of more than 8 mm Hg. However, because of its low sensitivity, lower limb venous Doppler imaging cannot be used to screen for right-sided heart failure.

Prostatic carcinoma: detection and staging using suprapubic US.

Eighteen patients with pathologically proved carcinoma of the prostate were examined with suprapubic ultrasound (US) to assess the capability of the modality in the detection and staging of the disease. Five of the patients were evaluated for recurrent disease. A detailed, retrospective, echo-textural analysis of the prostate and periprostatic structures was performed. The most frequently encountered US findings were recorded and used as criteria in the diagnosis and staging. Most diagnostic of the echo patterns were the presence of a large (greater than 6 mm) focal density within the peripheral zone that was as bright as or less bright than the density of the capsule, a mixed or diffuse pattern, and loss of integrity of the capsule, seminal vesicles, or bladder. Using these criteria, we were able to correctly diagnose 17 of 18 cases, with an accuracy rate of 94%. US was also used to assess the extent of local disease in carcinoma of the prostate. The US staging was compared with the staging by digital rectal examination and by clinicopathologic results. We correctly staged 15 of 18 cases (83%) with US, while the rectal examination helped to stage correctly only 10 of 18 cases (56%). All errors were due to understaging. We find suprapubic US to be very helpful in the diagnosis and staging of prostatic cancer. Since there is some overlap between the findings in benign and malignant disease, we cannot recommend US as an alternative to prostate biopsy. Further experience in detection and staging with prospective studies may be necessary before final conclusions can be made.