EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part VI - Ultrasound-Guided Vascular Interventions.

The sixth part of the Guidelines on Interventional Ultrasound produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for ultrasound guidance and assistance in vascular interventions. Based on convincing data, real-time sonographic guidance for central venous access is strongly recommended as a key safety measure. Systematic analysis of scientific literature shows that in difficult situations and special circumstances US guidance may also improve the efficacy and safety of peripheral venous and arterial access and endovascular interventions. Moreover, the recommendations of this guideline endorse the use of ultrasound to detect complications of vascular access and US-guided interventional treatment of arterial pseudoaneurysms.

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (Short Version).

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (long Version).

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (long version).

Staging of uterine cervical cancer with MRI: guidelines of the European Society of Urogenital Radiology.

OBJECTIVE: To design clear guidelines for the staging and follow-up of patients with uterine cervical cancer, and to provide the radiologist with a framework for use in multidisciplinary conferences. METHODS: Guidelines for uterine cervical cancer staging and follow-up were defined by the female imaging subcommittee of the ESUR (European Society of Urogenital Radiology) based on the expert consensus of imaging protocols of 11 leading institutions and a critical review of the literature. RESULTS: The results indicated that high field Magnetic Resonance Imaging (MRI) should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine cervix) of the pelvic content. Axial T1-weighted sequence is useful to detect suspicious pelvic and abdominal lymph nodes, and images from symphysis to the left renal vein are required. The intravenous administration of Gadolinium-chelates is optional but is often required for small lesions (<2 cm) and for follow-up after treatment. Diffusion-weighted sequences are optional but are recommended to help evaluate lymph nodes and to detect a residual lesion after chemoradiotherapy. CONCLUSIONS: Expert consensus and literature review lead to an optimized MRI protocol to stage uterine cervical cancer. MRI is the imaging modality of choice for preoperative staging and follow-up in patients with uterine cervical cancer.

Dynamic changes in the common bile duct after laparoscopic cholecystectomy: a prospective longitudinal sonographic study.

PURPOSE: The aim of this prospective study was to assess the dynamics of potential common bile duct (CBD) dilatation and to find the best predictors in patients after laparoscopic cholecystectomy due to gallstones. MATERIALS AND METHODS: Fifty patients (36 women, 14 men) with gallstones scheduled for laparoscopic cholecystectomy underwent preoperative sonography one day prior to surgery and again within 24 hours of cholecystectomy. In all patients, the diameter of the CBD was measured again on the 7 (th), 90 (th) and 180 (th) day after cholecystectomy. The luminal diameter was measured just below the bifurcation of hepatic ducts, at the level of intersection with the hepatic artery and at the level of the pancreatic head. The control group consisted of 50 healthy individuals (35 women and 15 men) with normal biochemistry and sonography, and without a history of hepatobiliary disease, clinical symptoms or surgery. RESULTS: The mean preoperative CBD diameter at three locations was 2.27 ± 0.18, 3.49 ± 0.23 and 4.31 ± 0.30, respectively. The mean diameter of the common bile duct measured within 24 hours of surgery and on the seventh postoperative day did not significantly change with respect to the preoperative measurement. Three months after cholecystectomy, the CBD was statistically wider at all three locations (p < 0.05). Six months after cholecystectomy, the CBD remained significantly wider at the proximal and distal part when compared to the preoperative measurements. CONCLUSION: The CBD showed an overall trend towards a slight, but significant, dilatation after cholecystectomy. The common bile duct dilates significantly 3 months after cholecystectomy. Familiarity with these patterns prevents ultrasound misdiagnosis when examining patients within 6 months of cholecystectomy.

Noninvasive assessment of liver fibrosis with acoustic radiation force impulse imaging: increased liver and splenic stiffness in patients with liver fibrosis and cirrhosis.

PURPOSE: To evaluate acoustic radiation force impulse imaging (ARFI) of the liver and spleen as a new method for the noninvasive assessment of liver fibrosis (LF). MATERIALS AND METHODS: Three groups of 58 examinees were studied: (A) 20 healthy volunteers; (B) 18 patients with chronic viral hepatitis (CVH) B or C having liver fibrosis stages F 1 - 4 (assessed by liver biopsy; Ishak classification); and (C) 20 patients with liver cirrhosis (LC). All participants were examined using the Siemens ACUSON S 2000 Ultrasound Virtual Touch Tissue Quantification system. Ten measurements were performed on both liver lobes and three measurements on the spleen, and the obtained mean values (shear wave velocities [SWV] expressed in m/s) were compared between the groups. In 20 patients the splenic artery pulsatility index (SAPI) was also measured and correlated to the liver and splenic ARFI and histological stage of LF. RESULTS: Hepatic ARFI measurements demonstrated a significant correlation to LB results (Spearman's ρ = 0.766; ρ < 0.001) and SWV cut-off values of 1.3 (AUC 0.96) and 1.86 (AUC 0.99) could reliably differentiate between healthy (A) and non-cirrhotic CVH (B), as well as between non-cirrhotic CVH (B) and LC (C). Splenic SWV cut-off value of 2.73 (AUC 0.82) could differentiate between the patients with LC and non-cirrhotic CVH. A significant correlation was also observed between the SAPI and liver ARFI results (ρ = 0.56; p = 0.013). CONCLUSION: The hepatic and splenic SWV measured by ARFI increase with the LF stage, and the hepatic SWV correlate well with SAPI. This new technology enables simultaneous morphological, Doppler and elastometric examinations and might improve the accuracy of noninvasive liver fibrosis assessment.

Ultrasound-guided bipolar radiofrequency ablation of breast cancer in inoperable patients: a pilot study.

PURPOSE: Radiofrequency ablation (RFA) is a promising minimal invasive modality to treat small breast cancer (BCA). In most studies cancers were surgically excised shortly after RFA. We present six patients inoperable when diagnosed with BCA, and performed RFA instead of surgery. MATERIALS AND METHODS: Ultrasound-guided bipolar RFA was performed under local anesthesia in six women aged 63 - 85 years. They had core-biopsy proven T 1 - 2N0 M0, grade I or II, 1.0 - 2.7 cm sized invasive ductal cancers, with positive estrogen receptor status. Four tumors measured > 2 cm, and three 1.0 - 1.2 cm in diameter. Patients were at high-risk for general anesthesia and surgery because of severely impaired cardiac function, advanced age, or associated diseases (acute myeloid leukaemia (AML), diabetes, hypertension, depression) and/or refused surgery. RESULTS: Six tumors in five patients were completely ablated, without recurrence during follow-up (range: 9 - 49 months). One superficially located cancer was partially ablated; the patient died two months later from myocardial infarction. The Patient with AML and BCA had an infection of the treated breast after 4 months and postponed mastectomy to an AML remission status. There were no signs of malignancy in histopathology; the patient finally died of leukemia 42 months after RFA. The remaining four patients are well, without complications. CONCLUSION: Ultrasound-guided percutaneous RFA under local anesthesia is an effective alternative to surgery for BCA < 3 cm in patients with a high-risk for surgery.

Potential role of shear wave elastography features in medullary breast cancer differentiation.

Shear wave sonoelastography is a valuable additional technique in differentiation between benign and malignant breast lesions. In this paper, a hypothesis of the potential role of this additional ultrasound technique as a very useful tool in differentiation of a medullary breast cancer subtype is proposed. Medullary breast cancer is a rare subtype, difficult for diagnosing, due to its benign radiologic features that can mislead to the wrong conclusion. After analyzing the results of nine patients diagnosed with medullary breast cancer and in comparison with two control groups (invasive ductal cancer of no specific type and fibroadenoma), we concluded that this breast cancer subtype shows specific elastography features based on qualitative and quantitative values.

Staging of endometrial cancer with MRI: guidelines of the European Society of Urogenital Imaging.

The purpose of this study was to define guidelines for endometrial cancer staging with MRI. The technique included critical review and expert consensus of MRI protocols by the female imaging subcommittee of the European Society of Urogenital Radiology, from ten European institutions, and published literature between 1999 and 2008. The results indicated that high field MRI should include at least two T2-weighted sequences in sagittal, axial oblique or coronal oblique orientation (short and long axis of the uterine body) of the pelvic content. High-resolution post-contrast images acquired at 2 min +/- 30 s after intravenous contrast injection are suggested to be optimal for the diagnosis of myometrial invasion. If cervical invasion is suspected, additional slice orientation perpendicular to the axis of the endocervical channel is recommended. Due to the limited sensitivity of MRI to detect lymph node metastasis without lymph node-specific contrast agents, retroperitoneal lymph node screening with pre-contrast sequences up to the level of the kidneys is optional. The likelihood of lymph node invasion and the need for staging lymphadenectomy are also indicated by high-grade histology at endometrial tissue sampling and by deep myometrial or cervical invasion detected by MRI. In conclusion, expert consensus and literature review lead to an optimized MRI protocol to stage endometrial cancer.

An unusual case of bronchial rupture--pneumomediastinum appearing 7 days after blunt chest trauma.

We present a case of bronchial disruption after blunt chest trauma, which is unusual because the pneumomediastinum on the chest radiograph was detected 7 days after the injury. The first day imaging methods of the thorax showed only the fractures of the first and third left rib without any complications. A computed tomography (CT) scan was done following control chest radiograph and it revealed a rupture of the left main bronchus with pleural effusion, subcutaneous emphysema and pneumomediastinum. This case shows that a finding of pneumomediastinum after blunt chest trauma should always merit further investigation of its cause, even in cases of postponed detection of pneumomediastinum and regardless of the absence of other indicators of tracheobronchial disruption. Although fiber-optic tracheobronchoscopy is considered a diagnostic golden standard, in this case, diagnosis was clearly confirmed by spiral CT scan, due to thin slices and continuous data acquisition.

[How much do we know about human brucellosis?]. / Wie viel wissen wir über die humane Brucellose?

Human brucellosis manifests as an acute or persistent febrile disease with a wide variety of symptoms. To our knowledge this is the first case report of brucellar monoarthritis of the hip in Croatia, with difficulties regarding its diagnosis and protracted clinical course.

Collaboration, campaigns and champions for appropriate imaging: feedback from the Zagreb workshop.

Leading radiologists and representatives from national radiation protection regulatory authorities and health ministries from 19 countries of the European region worked together with five experts at the workshop on justification and appropriate use of imaging in Zagreb, Croatia, from 26 to 28 October 2017 jointly organised by the IAEA and the European Society of Radiology. The workshop served as a forum to exchange information on challenges and solutions for improving justification and the appropriate use of diagnostic imaging. Common barriers to improving the use of imaging referral guidelines were discussed and the need for increased collaboration identified. Examples of good practices were presented, including use of Clinical Decision Support (CDS) systems to facilitate rapid and good justification decisions. The workshop identified some of the needs of European countries for achieving more appropriate imaging proposing wider use of collaboration, campaigns and champions. MAIN MESSAGES: • Drivers for appropriate imaging in Europe are similar to those elsewhere globally. • Implementing imaging referral guidelines is the main barrier to more appropriate imaging. • Clinical Decision Support systems (CDS) facilitates good referral practice and justification decisions. • Collaboration, campaigns and champions may improve awareness, appropriateness and audit.

Doppler visualization of ureteric jets in unilateral hydronephrosis in children and adolescents.

OBJECTIVE: to evaluate Doppler visualization of ureteric jets in the assessment of unilateral kidney collecting system dilatation in children and adolescents. METHODS AND PATIENTS: color Doppler ultrasonography was performed in 27 patients with hydronephrosis (11 female, 16 male, age range 3-21 years, mean age 10.5+/-4.4). Nine had acute obstruction due to ureteral calculus, seven had obstructive hydronephrosis due to uretero-pelvic junction (UPJ) stenosis, and 11 had non-obstructive hydronephrosis. Doppler was also performed in 32 healthy children (15 boys and 17 girls, age 2-17 years, mean age 7.8+/-3.9), who represented the control group. RESULTS: in the control group jets were visible in 57 out of 64 ureteric units (89%). The mean frequency of jets in healthy children was 4.1 jets per min. In all children with hydronephrosis, jets were visible in 25 out of 27 normal ureteric units (92.6%), and their mean frequency was 4.5 jets per min. In children with acute unilateral colic, ureteric jets were completely absent in eight of nine patients (89%). In children with obstructive hydronephrosis, due to UPJ stenosis, jets were absent in five out of seven patients (71.4%), and in children with non-obstructive hydronephrosis jets were absent in three out of eleven patients (27.3%). When jets are visible, their frequencies are much lower on the obstructed side as compared with normal side, while in cases of nonobstructive dilatation frequency of jets is similar on both sides. CONCLUSION: absence of jets in patients with acute obstruction due to ureteral calculus, strongly correlates with high-grade obstruction. In children with UPJ stenosis, presence of ureteric jet does not exclude significant obstruction, but the frequency of jets on the obstructed side is much lower as compared with the unaffected side. When there is absence of jet from the dilated side or significant asymmetry in jet frequency, hydronephrosis is likely to be obstructive.

Asymptomatic carotid stenosis: selective or routine use of intraluminal shunt.

BACKGROUND: To evaluate the use of temporary intraluminal shunt (IS) during operations in our patients for asymptomatic carotid stenosis (ACS) of the internal carotid artery (ICA). METHODS: Complications of ICA endarterectomy were reviewed in two groups of asymptomatic patients. In group A (144 patients, operation 1972-1985) temporary IS was used in 43 patients with the intraoperatively measured ICA back pressure <50 mmHg. In group B (170 patients, operation 1986-1998) shunt was used in all cases. RESULTS: The incidence of neurologic deficit was higher ia group A than in group B (5.6% vs 1.2%, p<0.05). Within group A, the incidence of neurologic deficit was significantly higher in the subgroup with back pressure >50 mmHg, and thus without shunt, than in group B with routine use of shunt (6.0% vs 1.2%, p<0.05). There were no differences in the incidence of shunt-related complications between the groups (3.0% vs 4.0%, p>0.05). We had no mortality after operations of asymptomatic patients. CONCLUSIONS: The routine use of IS reduced the rate of intraoperative and early postoperative neurologic complications of asymptomatic carotid endarterectomy, and it was not associated with a higher incidence of complications.

Renal vascular resistance in essential hypertension: duplex-Doppler ultrasonographic evaluation.

Duplex Doppler ultrasonography has been validated as a noninvasive method to evaluate hemodynamic features of renal blood flow in renal and intrarenal arteries in patients with various renal diseases. The significance of duplex Doppler sonography in the evaluation of renal vascular resistance in essential hypertension has not yet been clearly determined. The aim of the present study was to evaluate the renal vascular resistance in patients with essential hypertension by measuring intrarenal arterial resistance (RI) and to correlate RI with renal functional tests and other clinical and laboratory data. Duplex Doppler ultrasonography was used to measure RIs in intrarenal arteries in 128 patients with essential hypertension and 61 age-matched normotensive control examinees. The renal vascular resistance index (RI) was determined by use of Doppler ultrasound. Hypertension was classified according to the 1997 Joint National Committee Guidelines (JNC-VI). Mean RI in hypertensive patients was 0.66 +/- 0.05 (+/- sd) and in healthy controls 0.60 +/- 0.03 (+/- sd) (p = 0.0001). RI correlated significantly with patient's age (r = 0.577, p = 0.001), duration of hypertension (r = 0.335, p= 0.001), stage of hypertension according to the JNC-VI classification (r = 0.315, p = 0.006), creatinine clearance (r = -0.383, p = 0.001), systolic blood pressure (SBP, r = 0.41, p = 0.001) and mean blood pressure (MBP, r = 0.30, p = 0.002). RI values did not correlate significantly with plasma renin concentration (r = -0.198 NS), diastolic blood pressure (DBP, r = 0.17, p = 0.06), and cardiac pulse (r = -0.10, p = 0.16). Multiple regression analysis showed that independent variables for RI were the patient's age (multiple R = 0.53, signif. F = 0.001) and systolic blood pressure (multiple R = 0.57, signif. F = 0.03). The renal Doppler resistance index (RI) is increased in essential hypertension and it correlates with renal functional tests as well as with patient's age, duration of hypertension, with a stage of hypertension according to the JNC-VI classification, and with systolic and mean blood pressure. The increased renal vascular resistance (RI) in hypertensive patients could be a sign of developing hypertensive nephrosclerosis and consequently renal failure. The utilization of the renal vascular resistance index (RI), provides a new noninvasive parameter in the followup of patients with essential hypertension.

[The age of diagnostic radiologic equipment in Croatia]. / Starost radioloske dijagnosticke opreme u Republici Hrvatskoj.

The quality of health care also depends partly on technological equipment. Among the devices which diminish the quality of services if they are old, increasing at the same time the danger when used, are certainly those in radiodiagnostics. Besides, their age controls the dose of radiation to which patients and professional staff are exposed. The knowledge of the age of this equipment is the basis of the plans for further development. The aim of the study is to determine the age of each individual radiodiagnostic device in Croatian institutions. The assessment of each device was made by a qualified professional. The method of data collection was based on the uniform questionnaire which comprised radiodiagnostic devices older than ten years, classified according to type and location (primary health care center or hospital, in total 655 devices). Determination of the age index of generators and x-ray tubes older than seven years (according to the World Bank recommendation), included also mobile units (55 for fluoroscopy and 68 for radiography), devices for dental radiography, devices in private sector (118) and devices which are out of use but not officially blocked (88), which means in total 859 generators and 1111 x-ray tubes. In addition, the availability of image intensifiers for fluoroscopy and manufactures of all devices were determined. The results of the study reveal that in primary health care centers, out of 248 radiodiagnostic devices, 193 are older than ten years (77.8%), while 4 are of unknown age. In hospitals, out of 407 devices, there are 261 older than ten years (64.1%), while 46 are of unknown age (11.3%). Among devices for fluoroscopy, 97 out of totally 206 have no image intensifier (32%). These devices should be immediately excluded from utilization. The index of age above seven years, which is according to the recommendation of the World Bank the lifetime of devices, reveals that 859 generators out of totally 984 (91%) are too old to be used, while there are 1111 x-ray tubes out of totally 1206 (92%) which are in the same condition. Regarding the manufacturers, the ratio is also unfavourable, since 49.3% of devices have been manufactured by comparies whose technology and spare parts are now inaccessible (Elektronska industrija). Such unacceptable obsoleteness of the radiological equipment requires urgent renewal.