Reconstruction of middle hepatic vein of a living-donor right lobe liver graft with recipient left portal vein.

Venous outflow problems in right lobe, living-donor liver transplantation are uncommon, but devastating when they occur. We describe the successful use of the recipient's left portal vein as an interposition graft to drain a dominant middle hepatic vein in a right lobe liver transplant. Two weeks after transplantation, the vein graft accounted for 56% of the total venous outflow of the liver.

Multifocal osteoarticular tuberculosis: report of four cases and review of management.

We report the clinical, microbiological, and radiological features of four cases of multifocal osteoarticular tuberculosis, and we review the management of this condition. In each case the initial clinical diagnosis was one of malignant disease, and the possibility of tuberculous bone infection was overlooked. There was neither clinical nor radiological evidence of pulmonary involvement in any case. Antituberculous chemotherapy was initiated in two instances on the basis of histopathologic findings compatible with tuberculous osteomyelitis; such treatment was delayed in the other two cases until the diagnosis was confirmed by culture. Antituberculous chemotherapy alone was successful in three cases, while the fourth case required emergency anterior spinal decompression as well. Two patients developed additional skeletal lesions after the initiation of appropriate antituberculous chemotherapy. Multifocal osteoarticular tuberculosis must be considered in the differential diagnosis of multiple destructive skeletal lesions in all patients from areas where tuberculosis is endemic. This condition may mimic malignant disease both clinically and radiologically.

Can ultrasound probes and coupling gel be a source of nosocomial infection in patients undergoing sonography? An in vivo and in vitro study.

OBJECTIVE: At our institution, ultrasound probes are wiped with a clean, dry, soft, absorbent paper towel after each procedure as a basic standard of probe disinfection. However, it was unclear if this provided a sufficient level of decontamination. This study was designed to determine if the ultrasound probe and coupling gel can act as a vector of nosocomial infection and to describe a cost-effective method of probe handling that allows optimal control of infection. SUBJECTS AND METHODS: In the first part of the study, the ultrasound probe was exposed to the disrupted skin of patients recruited from our inpatient population, using our routine scanning technique to look for subcutaneous collections. Twenty-seven patients were scanned: 17 with surgical wounds, seven with surgical drains, four with enteric stomas, three with biopsy sites, and three with ulcers or excoriation. Fifteen patients had a discharge associated with their disrupted skin, and seven patients had culture-proved skin infections. Each probe was wiped with a clean, dry paper towel after scanning, then immersed in a brain-heart infusion (BHI) broth, and the solution was cultured. In the second part of the study, the ultrasound probe was exposed to a large inoculum of bacteria. Sixty-one probes were used to scan fields of confluent growth of bacteria on agar plates. Twenty-six probes were cleaned by wiping with a dry, clean paper towel, and 25 probes were cleaned by wiping with a dry, clean paper towel followed by immersion in Hibidil (0.05% chlorhexidine weight/volume). Ten probes functioned as controls and were not cleaned after exposure to the bacteria. Each probe was then immersed in BHI broth, and the solution was cultured. In the third part of the study, the coupling gel was evaluated as a culture medium for bacterial growth. Twenty-five agar plates were inoculated with a confluent growth of bacteria. Half of the surface of each agar plate was covered with coupling gel, and the remaining surface was left unexposed. The resulting bacterial growth on each side of the plates was compared. RESULTS: One of the 27 probes exposed to patients with disrupted skin grew Staphylococcus epidermidis (skin flora). For probes exposed to a large inoculum of bacteria, we found no statistically significant difference in the number of probes that showed bacterial growth on culture between probes cleaned by wiping with a towel and those cleaned with Hibidil. Furthermore, the resulting bacterial growth in both sets of probes was scant and was not considered clinically significant. All 10 control probes showed clinically significant growth in all cases. As for evaluation of the coupling gel as a culture medium, the gel permitted bacterial growth and did not show any evidence of bacteriocidal or bacteriostatic properties. CONCLUSION: Ultrasound probes that are wiped with a paper towel until they are visibly clean do not contribute to nosocomial infections. Additional antiseptic solutions such as Hibidil are not necessary. We suggest that probes be simply wiped with a clean, dry, nonsterile paper towel between procedures, including probes used on contaminated scanning fields, open wounds, and cutaneous infections. After the final procedure of the day, probes should be cleaned with a liquid cleaning solution such as Hibidil to remove all traces of coupling gel, which could support the overnight growth of bacteria. This would decontaminate the probes and prevent the overnight growth of bacteria. This method would be both a cost-effective and time-efficient protocol for controlling infection.

Improved retroperitoneal and gastrointestinal sonography using oral contrast agents in a porcine model.

OBJECTIVE: Abdominal sonography can be compromised by the presence of air within the scanning field. Gas-displacing oral contrast agents have the potential to improve the diagnostic yield of routine abdominal sonography. The purpose of this study was to investigate two oral contrast agents and water and to compare their ability to improve abdominal sonography with an unenhanced baseline study and each other in a porcine model. MATERIALS AND METHODS: The acoustic properties of agent 1 (Oralex; Molecular Biosystems, San Diego, CA), a suspension of polydextrose in purified water; agent 2, a homemade agent (named BMW), a suspension of polysaccharide particles in water; and water were assessed in finger phantoms under laboratory conditions. Each solution was subsequently evaluated in 10 pigs, for a total of 30 animals. The bolus character, gas artifact, abdominal viscera, vessels, and gut wall were graded from 1 (nondiagnostic) to 5 (excellent) in the unenhanced and postcontrast states. Postcontrast grades were compared with unenhanced baseline grades using the Wilcoxon signed-rank correlation. Agents were compared with each other using the Mann-Whitney U test (Wilcoxon rank sum test). RESULTS: All three solutions were hypoechoic, were homogeneous, and showed minimal attenuation and backscatter. Both oral contrast agents had excellent bolus characteristics (agent 1, grade 5.0 +/- 0; agent 2, grade 4.6 +/- 0.5), displaced gas from the scanning field, and significantly improved visibility in all categories, particularly the gut. No difference in performance was found between agents 1 and agent 2. Water had poor bolus characteristics (grade 1.3 +/- 0.48) and did not improve visibility over baseline. CONCLUSION: The acoustic in vitro properties of agent 1 and agent 2 approach that of an ideal sonographic contrast agent. Both agents are superior to water in their improvement of direct visualization of the retroperitoneum and the gut in abdominal sonography in a porcine model.

Harmonic hepatic US with microbubble contrast agent: initial experience showing improved characterization of hemangioma, hepatocellular carcinoma, and metastasis.

PURPOSE: To characterize blood flow in focal hepatic lesions with harmonic ultrasonographic (US) imaging and a microbubble contrast agent. MATERIALS AND METHODS: Thirty patients with known hepatic masses were examined after injection of a perfluorocarbon microbubble agent. Tumor vascularity was assessed with continuous, harmonic gray-scale imaging with a low mechanical index (MI). Tumor vascular volume was assessed with brief, high-MI insonation called interval-delay imaging, which caused microbubble destruction. As the total contrast agent volume in the liver reflects the total vascular volume, quantitation of lesion enhancement relative to normal hepatic enhancement helped determine the vascular volume of the tumor relative to that of normal parenchyma. RESULTS: Low-MI continuous harmonic imaging showed lesional vessels in hepatocellular carcinomas, minimal or no vessels in hemangiomas, and variable vascularization in metastases. High-MI interval-delay imaging showed greater enhancement in hepatocellular carcinomas than in normal liver (P <.02) and showed less enhancement in hemangiomas than in normal liver (P <.02). Enhancement in metastases was greater in the margins than in the center; as a result, the lesions appeared smaller (P <.03) and less well defined on the interval-delay images. CONCLUSION: Contrast-enhanced harmonic imaging appears superior to conventional Doppler US for hepatic mass characterization. Low-MI continuous and high-MI interval-delay imaging can help assess tumor vascular pattern and microvascular volume.

Uterine arteriovenous malformations: gray-scale and Doppler US features with MR imaging correlation.

PURPOSE: To describe the gray-scale and color and duplex Doppler ultrasound (US) and the magnetic resonance (MR) imaging features of uterine arteriovenous malformations (AVMs). MATERIALS AND METHODS: Uterine AVMs in 10 patients were retrospectively evaluated. All patients underwent gray-scale US and color and duplex Doppler US. Nine underwent angiography with therapeutic embolization; four, MR imaging. The resistance index (RI), pulsatility index (PI), and peak systolic velocities (PSVs) were evaluated. RESULTS: At gray-scale US, uterine AVMs were nonspecific and manifested as subtle myometrial inhomogeneity, tubular spaces within the myometrium, intramural uterine mass, endometrial mass, or cervical mass or sometimes as prominent parametrial vessels. Color Doppler features were consistent and included intense juxtaposed signals with aliasing and apparent flow reversals. Spectral Doppler US revealed low-resistance flow (RI, 0.25-0.55; PI, 0.3-0.6) and PSVs greater than 96 cm/sec, which suggests arteriovenous shunting. MR imaging showed a bulky uterus, a focal uterine mass, disruption of the junctional zones, serpiginous flow-related signal voids, and prominent parametrial vessels. CONCLUSION: Gray-scale morphology and Doppler US features should allow noninvasive diagnosis of uterine AVMs. Doppler and MR imaging features of uterine AVMs may overlap with other causes of arteriovenous shunting, including abnormal placentation and gestational trophoblastic disease (GTD). These can be differentiated with serum beta human chorionic gonadotropin test results (negative with AVM, positive with GTD).

Gas at abdominal US: appearance, relevance, and analysis of artifacts.

PURPOSE: To describe the spectrum of ultrasonographic (US) appearances of intraluminal gas, including two clinically relevant gas artifacts. MATERIALS AND METHODS: Observations were made in patients and reproduced in an animal model, an ex vivo gut preparation, and a tissue-mimicking phantom. Appearances were classified according to a physical model of the interaction between sound and collections of gas. RESULTS: Free bubbles of gas appeared as bright echogenic foci extending artifactually owing to lateral and axial blooming. This causes bubbles that abut the gut wall to enhance the layer one echo, which corresponds to the interface between the mucosa and the luminal contents. Such bubbles can also falsely appear to be within the gut wall itself owing to elevation averaging and thereby cause the artifact pseudo-pneumatosis intestinalis. Isolated groups of small bubbles created a characteristic periodicity and tapering of the distal echo pattern. In the extreme case, in which many such echoes are superimposed, "dirty shadowing" occurs. A contiguous pocket of gas may cause the gut wall to appear artifactually thickened (i.e., pseudo-thickened gut). This was shown to be a form of mirror image artifact. CONCLUSION: Classification of the effects of gas on US images according to their physical characteristics may aid in their interpretation. Appreciating two previously undescribed artifacts, pseudo-pneumatosis intestinalis and pseudo-thickened gut, will improve the usefulness of abdominal US.

A specific sign of pneumoperitoneum on sonography: enhancement of the peritoneal stripe.

OBJECTIVE: Failure to reveal pneumoperitoneum is a recognized weakness of abdominal sonography. Our objective is to describe a reliable and reproducible sign of pneumoperitoneum that was first identified in an animal model and then confirmed in patients who had undergone laparoscopy. SUBJECTS AND METHODS: We injected 300 ml of degassed water into the peritoneal cavity of a 15-kg anesthetized pig. Sonographic images were obtained of the anterior peritoneal area after intraperitoneal injection of a single bubble, a series of bubbles, and, subsequently, a 10-ml bolus of air. Later, abdominal sonography was performed in nine patients who had undergone laparoscopy. Close attention was paid to the anterior peritoneal area and signs of free air observed in the animal model. Ten healthy volunteers functioned as a control group. RESULTS: In the pig, minute amounts of intraperitoneal air showed on sonography as enhancement of the peritoneal stripe. Larger volumes of intraperitoneal air showed as enhancement of the peritoneal stripe associated with dirty shadowing or distal multiple reflection artifacts. The stripe enhanced each time it appeared in the reflection artifact. Intraluminal gas was associated with a normal thin peritoneal stripe, superficial and distinct from the underlying gas artifact. The patients who had undergone laparoscopy showed findings suggestive of small and large pockets of free air, as we saw in the pig model. The control group showed findings consistent with intraluminal gas only. CONCLUSION: On sonography, enhancement of the peritoneal stripe alone or with reflection artifacts involving the peritoneal stripe is an accurate sign of pneumoperitoneum.

A multicenter randomized double-blind placebo-controlled trial of adjunctive corticosteroids in the treatment of Pneumocystis carinii pneumonia complicating the acquired immune deficiency syndrome.

A multicenter placebo-controlled trial of early short-term high-dose methylprednisolone enrolled 78 patients with moderate to severe Pneumocystis carinii pneumonia (PCP) complicating HIV infection. The mean pressure of oxygen (PO2) at study entry was 55 mm Hg for the 71 patients who had blood gases monitored while breathing room air. Patients were randomized to receive methylprednisolone (40 mg) or placebo parenterally twice daily for 10 days, and the first dose of study medication was given within 24 h of the first dose of antimicrobial therapy for PCP. The primary end point included death, need for mechanical ventilation for > 6 days, or a partial PO2 < 70 mm Hg while breathing room air 10 days after initiation of treatment. There was no statistically significant difference in the primary end point between patients randomized to corticosteroid (CS) or placebo (PL) (p = 0.522; 95% CI = -0.30, 0.16). The incidence of superinfections during therapy or of other HIV-associated infections or malignancies in the 6 months following treatment for PCP was not significantly different between the two groups. More patients randomized to placebo had to discontinue treatment with trimethoprim-sulfamethoxazole because of hypersensitivity than those randomized to corticosteroids (p = 0.039). We conclude that addition of corticosteroids does not significantly affect the outcome of PCP in patients with HIV and a PO2 < 70 mm Hg on room air at presentation but lowers the incidence of hypersensitivity reactions to trimethoprim-sulfamethoxazole.