[Ultrasound of gallbladder and bile duct]

The cystic nature of the gallbladder and bile duct when dilated, and the advantages of ultrasound as a quick, reproducible, convenient, cheap and low risk technique, with a high sensitivity and specificity, make it the most eligible technique in biliary pathology studies. Ultrasound has become a valuable tool for doctors studying biliary pathology and its complications, from abnormal liver function results, right upper quadrant pain, or jaundice, to cholelithiasis, cholecystitis, or suspicion of biliary tumors.

[Ultrasound of the large abdominal vessels]

Ultrasound has recently become an indispensable tool for the family physician, whether exercised in primary care and emergency department; and likewise it has spread to many other specialties: internal medicine, critical care, neurology, pneumology, digestive, etc. and that ultrasound has proven to be a safe diagnostic tool and have great capacity. We firmly believe that ultrasound done to «bedside» the patient by the family doctor, can greatly complement the physical examination and greatly improve clinical effectiveness, allowing the browser an immediate view of the anatomy and physiology of certain structures. It is within this context is particularly relevant ultrasonography of the Aorta and large abdominal vessels, made by the family doctor or the emergency itself, which will develop along this chapter.

[Review of the current value of ultrasonography in the characterization of thyroid nodules]

The widespread use of medical imaging to study diseases of the neck reveals the prevalence of thyroid nodules can be as high as 67%. This is an important problem for the healthcare system because after analyzing the characteristics of the nodules a decision must be made regarding whether to perform fine-needle aspiration cytology to determine whether the lesion is malignant. In this article, we review the techniques for ultrasonographic study and fine-needle aspiration. We discuss the different guidelines for characterizing thyroid nodules and the criteria that help determine which patients need fine-needle aspiration for diagnosis and when an invasive procedure is unnecessary and can be avoided. Close collaboration with the different specialists involved in the management of thyroid nodules helps optimize resources and diagnostic performance.

[Pancreatic ultrasonography]

Despite the recent technological advances in imaging, abdominal ultrasonography continues to be the first diagnostic test indicated in patients with a suspicion of pancreatic disease, due to its safety, accessibility and low cost. It is an essential technique in the study of inflammatory processes, since it not only assesses changes in pancreatic parenchyma, but also gives an indication of the origin (bile or alcoholic). It is also essential in the detection and tracing of possible complications as well as being used as a guide in diagnostic and therapeutic punctures. It is also the first technique used in the study of pancreatic tumors, detecting them with a sensitivity of around 70% and a specificity of 90%.

Ultrasound guided injection inside the common sheath of the sciatic nerve at division level has a higher success rate than an injection outside the sheath

BACKGROUND AND OBJECTIVE

The recommendations for the level of injection and ideal placement of the needle tip required for successful ultrasound-guided sciatic popliteal block vary among authors. A hypothesis was made that, when the local anesthetic is injected at the division of the sciatic nerve within the common connective tissue sheath, the block has a higher success rate than an injection outside the sheath.

METHODS

Thirty-four patients scheduled for hallux valgus repair surgery were randomized to receive either a sub-sheath block (n=16) or a peri-sheath block (n=18) at the level of the division of the sciatic nerve at the popliteal fossa. For the sub-sheath block, the needle was advanced out of plane until the tip was positioned between the tibial and peroneal nerves, and local anesthetic was then injected without moving the needle. For the peri-sheath block, the needle was advanced out of plane both sides of the sciatic nerve, to surround the sheath. Mepivacaine 1.5% and levobupivacaine 0.5% 30mL were used in both groups. The progression of motor and sensory block was assessed at 5min intervals. Duration of block was recorded.

RESULTS

Adequate surgical block was achieved in all patients in the subsheath group (100%) compared to 12 patients (67%) in the peri-sheath group at 30min. Sensory block was achieved faster in the subsheath than peri-sheath (9.1±7.4min vs. 19.0±4.0; p<.001).

CONCLUSIONS

Our study suggests that for successful sciatic popliteal block in less than 30min, local anesthetic should be injected within the sheath.

Ultrasound skin imaging

The interaction of high-frequency ultrasound waves with the skin provides the basis for noninvasive, fast, and accessible diagnostic imaging. This tool is increasingly used in skin cancer and inflammatory conditions as well as in cosmetic dermatology. This article reviews the basic principles of skin ultrasound and its applications in the different areas of dermatology.

[Hypoglossal nerve neuropraxia after shoulder hemiarthroplasty]

We report a case of hypoglossal nerve damage after shoulder hemiarthroplasty with the patient in "beach chair" position, performed with general anesthesia with orotracheal intubation, and without complications. An ultrasound-guided interscalene block was previously performed in an alert patient. After the intervention, the patient showed clinical symptomatology compatible with paralysis of the right hypoglossal nerve that completely disappeared after 4 weeks. Mechanisms such as hyperextension of the neck during intubation, endotracheal tube cuff pressure, excessive hyperextension, or head lateralization during surgery have been described as causes of this neurological damage. We discuss the causes, the associated factors and suggest preventive measures.

[Usefulness of bedside ultrasound compared to capnography and X-ray for tracheal intubation]

OBJECTIVES

The aim of this study was to assess the usefulness of bedside ultrasound compared to capnography and X-ray for endotracheal intubation in children and newborns.

MATERIALS AND METHODS

Hemodynamically stable children intubated in pedriatric and neonatal intensive care unit were included. Endotracheal tube insertion was checked after every intubation attempt by tracheal ultrasound and capnography simultaneously. The endotracheal tube insertion depth was then checked by assesment of lung sliding by thoracic ultrasound. Thereafter, Chest X-ray was performed and interpreted as usual. Time to perform each technique was recorded.

RESULTS

The study included 31 intubations in 26 patients (15 in PICU and 16 in NICU). There were no statistically significant differences between tracheal ultrasound and capnography or between thoracic ultrasound and x-ray in identifying the correct endotracheal intubation and assessment of endotracheal tube insertion depth, respectively. Sensibility and specificity of ultrasound compared to capnography was 92% and 100%, and 100% and 75% compared to X-ray. Ultrasound was significantly slower compared to capnography [12 (4-16) vs 6 (3-12) seconds; P<.001] and significantly quicker compared to X-ray [0.22 (0.17-0.40) vs. 20 (17-25) minutes, P<.001].

CONCLUSIONS

Ultrasound appears to be as effective as capnography, although slower, for identifying endotracheal intubation. Ultrasound may be useful in clinical situations, such as cardiopulmonary resuscitation where capnography is less reliable. Ultrasound is as effective and quicker than X-ray for assessment of endotracheal tube insertion depth, and it may contribute to decrease the routine use of X-ray after tracheal intubation.

[Diagnosis. Radiological study. Ultrasound, computed tomography and magnetic resonance imaging]

La radiología simple, por su bajo coste, alta disponibilidad en atención primaria y fácil interpretación, debe ser la primera técnica de imagen que el médico de familia se plantee para el diagnóstico y/o seguimiento del paciente artrósico. No obstante, la indicación de esta prueba siempre debe estar fundamentada y si se solicita es porque puede influir en la toma de decisiones con el paciente.

Pese al aumento de indicaciones en el paciente reumatológico, el papel de la ecografía en el paciente artrósico sigue siendo limitado.

La tomografía computarizada (TC) tiene su utilidad, aunque limitada, en la artrosis, especialmente para el estudio de articulaciones complejas (como las sacroilíacas y las vertebrales interapofisarias).

La resonancia magnética (RM) ha supuesto un avance importante a la hora de valorar el estado del cartílago articular y del hueso subcondral en el paciente con artrosis, pero el coste elevado y la rentabilidad diagnóstica-pronóstica de esta técnica obliga a indicarla en casos muy seleccionados.

Las indicaciones de la ecografía, la TC y la RM en el paciente artrósico siguen siendo limitadas en atención primaria y, probablemente, coinciden a menudo con situaciones en las que puede ser necesario derivar al paciente al nivel hospitalario.

El aspecto de la seguridad del paciente debe ser tenido en cuenta, intentando proteger al paciente de excesivas radiaciones ionizantes, mediante repeticiones innecesarias de radiografías o proyecciones inadecuadas, o por solicitud de pruebas como TC, cuando no están indicadas.

Usefulness of ultrasonography in the assessment of peripheral enthesis in spondyloarthritis

Enthesitis is one of the characteristic etiopathogenic manifestations of spondyloarthritis. However, in clinical practice, its presence often goes unnoticed because of the lack of precision and sensitivity of physical examination to detect it. Viable, valid and reliable imaging tests are needed for early diagnosis, as well as a good sensitivity to change to monitor therapeutic response. In this paper we review the most relevant aspects of current knowledge of the enthesis and discusses the validity of ultrasound for assessing enthesitis in spondyloarthritis and its sensitivity to change to monitor therapeutic response.

Systematic review of the value of ultrasound and magnetic resonance musculoskeletal imaging in the evaluation of response to treatment of gout

BACKGROUND

Imaging may be useful for monitoring response to therapy. Within the OMERACT proposal for the core set domains for outcome measures in chronic gout, serum urate levels, recurrence of gouty flares, tophus regression, and joint damage imaging have been included, among other proposed issues.

OBJECTIVES

To perform a systematic literature review of the usefulness of magnetic resonance imaging (MRI) and ultrasound (US) on assessment of treatment response in patients with gout.

METHODS

MEDLINE, EMBASE, Cochrane Library (up to February 2012), and abstracts presented at the 2010 and 2011 meetings of the American College of Rheumatology and European League Against Rheumatism, were searched for treatment studies of any duration and therapeutic options, examining the ability of MRI/US to assess treatment response in gouty patients. Meta-analyses, systematic reviews, randomized clinical trials, cohort and case-control studies and validation studies were included. Quality was appraised using validated scales.

RESULTS

There were only 3 US published studies in the literature that analysed US utility on assessment of response to treatment in patients with gout. All of them were prospective case studies with a small number of patients and they were reviewed in detailed. A total of 36 patients with gout were examined with US. All of them had a baseline serum urate >6mg/dL. US features of gout (double contour sign, hyperechoic spots in synovial fluid, hyperechoic cloudy areas, tophus diameter and volume) achieved significant reduction in patients who reached the objective of uricemia ≤6mg/dL in all the studies; however, patients in whom levels did not drop below 6mg/dL had no change of US features of gout. Other parameters evaluated in one study included ESR, CRP, number of tender joints (TRN), number of swollen joints, and pain score (SP). All of them decreased with uricemia reduction, but only TRN and SP were statistically significant. No data was found on the value of MRI on treatment response assessment in patients with gout.

CONCLUSIONS

The improvement in ultrasound features shows concurrent validity with uric acid reduction. According to the published evidence, US can be a useful tool for monitoring treatment of gouty patients, although more research is needed. The value of MRI on treatment response assessment in patients with gout remains to be determined.

Abdominal ultrasound and medical education

INTRODUCTION

Ultrasound is a very versatile diagnostic modality that permits real-time visualization of multiple internal organs. It is of invaluable help for the physical examination of the patients.

AIM

To assess if ultrasound can be incorporated into medical education and if the students can perform a basic abdominal ultrasound examination without the necessity of a long period of training.

METHODOLOGY

Twelve medical students were trained in basic abdominal ultrasound during a 15-h training program including a 5-h theoretical and practical course and supervised practice in 20 selected patients. Subsequently, we conducted an evaluation test that assessed the ability of students to obtain the ultrasound views and to detect various pathologies in five different patients.

RESULTS

The students were able to correctly identify the abdominal views more than 90% of the times. This percentage was only lower (80%) in the right subcostal view to locate the gallbladder. The accuracy or global efficiency of the ultrasound for the diagnosis of relevant pathological findings of the patients was greater than 90% (91.1% gallstones, abdominal aortic aneurysm 100%; splenomegaly 98.3%, ascites 100%; dilated inferior vena cava 100%; acute urinary retention 100%).

CONCLUSION

The ultrasound may be a feasible learning tool in medical education. Ultrasound can help students to improve the physical examination.

The value of thyroglobulin in washout of fine needle aspirate from 16 cervical lesions in patients with thyroid cancer

BACKGROUND AND OBJECTIVE

Thyroglobulin in the needle washout (Tg-FNA) and cytology of fine needle aspiration (cyto-FNA) are recommended for diagnosis of metastatic lymphadenopathies and recurrence of differentiated thyroid cancer. The objective of this study was to assess the value of these procedures in 16 cervical masses from patients with thyroid cancer of the follicular epithelium (TC).

PATIENTS AND METHODS

The study included six patients with TC and cervical lymphadenopathies evaluated before initial thyroid surgery and 10 patients followed up after TC surgery with cervical lumps discovered. FNA was performed in all 16 masses. Results of cyto-FNA, Tg-FNA and of the combined tests were compared to the final diagnosis of each lesion.

RESULTS

Among 10 lesions proven to be malignant at surgery, cyto-FNA, Tg-FNA and the combination of both allowed for adequate diagnosis in 7, 9, and 10 cases respectively. Among 6 lesions considered to be benign, cyto-FNA was able to confirm diagnosis in 4, was non-diagnostic in one, and was falsely negative in the remaining case, while Tg-FNA was below the established cut-off value (to consider malignancy) in all cases.

CONCLUSIONS

In patients with TC and suspect cervical masses, Tg-FNA improved the diagnostic yield of cyto-FNA alone, thus warranting its routine recommendation when FNA is performed. However, universal standardization of the technique and definition of valid cut-off thyroglobulin values (depending on the immunoassay used) above which the lesion should be considered to be malignant are still pending.

[Mesenteric flow in an experimental model of ischaemia-reperfusion in rats]

INTRODUCTION

Maintained acute occlusion followed by reperfusion of the superior mesenteric artery (SMA) in a few hours can trigger irreversible bowel damage. The aim of the study was to determine the changes in mesenteric flow measured by colour Doppler Ultrasound and correlating with histological lesions in an experimental model of ischaemia-reperfusion.

METHOD AND MATERIAL

Three groups of Sprague-Dawley 17 day-old rats were studied (control, ischemia and reperfusion). The model used was ischaemia-reperfusion over the SMA. Intra-abdominal ultrasound was then performed. The parameters recorded were: Maximum systolic velocity (MSV), pulsatility index (PI), resistance (RI) and systole-diastole (S/D). The histological variables were: intestinal lesion (Wallace/Keenan-Chiu scale), morphometrics (mean villus height [MVH]), and goblet cells. The Spearman (rs) correlation was used.

RESULTS

The MSV in the reperfusion group was 74.3 cm/s, the PI 7.33 and S/D 25.75 in the SMA, which were higher than the controls (41.35 cm/s; 3.12 and 12.45, respectively). A direct association (P<.01) was found between MSV, PI and S/D regarding: Wallace/Kennan scoring system (rs = 0.655; rs = 0.593; rs = 0.63) and the Chiu (rs = 0.569; rs = 0.522; rs = 0.47). While the correlation was the reverse (P<.01) when associated with the MVH (rs = -0,495; rs = -0,452; rs = -0,459) and goblet cells of the colon (rs = -0,525; rs = -0,45; rs = -0,518).

CONCLUSIONS

The reperfusion phase increased mesenteric flow expressed by the MSV and PI and could significantly predict the potential bowel damage at macroscopic and microscopic level.

[Diagnosing pneumothorax with ultrasonography]

The ultrasonographic diagnosis of pneumothorax is based on the analysis of artifacts. It is possible to confirm or rule out pneumothorax by combining the following signs: lung sliding, the A and B lines, and the lung point. One fundamental advantage of lung ultrasonography is its easy access in any critical situation, especially in patients in the intensive care unit. For this reason, chest ultrasonography can be used as an alternative to plain-film X-rays and computed tomography in critical patients and in patients with normal plain films in whom pneumothorax is strongly suspected, as well as to evaluate the extent of the pneumothorax and monitor its evolution.

[Transrectal biopsy scheme can predict incorrect histological grading in prostate cancer]

OBJECTIVE

To identify factors that might explain why a prostate with a Gleason score (GS) <7 in the biopsy specimen can turn out to have a GS ≥7 in the surgical specimen.

MATERIAL AND METHODS

We compared the GS of biopsy specimens with the GS of surgical specimens in 185 patients who underwent surgery for prostate cancer. We calculated the sensitivity, specificity, and predictive values for the GS of the biopsy specimens. We used Cohen's kappa to determine the degree of concordance between a GS of <7 and ≥7 for the biopsy specimen and the surgical specimen. Age, a family history of prostate cancer, total prostate-specific antigen (tPSA), digital rectal examination, prostate structure and volume, and the number of biopsy cores (biopsy scheme) were analyzed using multivariable logistic regression.

RESULTS

Histological study of biopsy specimens yielded high sensitivity (98%) but low specificity (49%) for GS ≤6 and low sensitivity (35, 26%) and high specificity (93, 99%) for GS=7 and GS ≥7, respectively. Cohen's kappa for the GS from the biopsy and surgical specimens was 0.43 (95% CI=30-56%). The biopsy scheme was the only predictor of discordance in the GS between the two techniques. Among the other variables included in the model, only tPSA showed a slightly significant association. Taking a scheme with less than 7 cores as a reference, we found no difference with 8 to 9 cores but we did find a difference with 10 to 11 cores and with 12 or more cores, with a prevalence ratio of 0.138 (95% CI=0.030-0.513) and 0.277 (95% CI=0.091-0.806), respectively.

CONCLUSION

The GS of the biopsy depends on the scheme. This factor must be taken into account when choosing a treatment option in patients with low tumor grade in biopsy specimens.

[Granular cell tumour of the breast. A diagnosis to consider]

The granular cell tumour is a very rare tumour which originates in the Schwann cells, and is generally benign. It is usually located in the head and neck, and its appearance in the breast is uncommon. Although it is rare tumour, granular cell tumours of the breast have a higher prevalence than previously recognised. This tumour usually imitates breast cancer due to its clinical and imaging data, with its diagnosis being by histopathology. The treatment is a wide local excision, and its prognosis is good with a low recurrence rate. We present two cases of granular tumours of the breast in post-menopausal women that simulated a breast carcinoma in the ultrasound and mammography. The first was detected in the breast cancer screening program, and the second during follow up of an invasive ductal carcinoma.

[Infantile myofibromatosis. Study of a case using whole body ultrasound and MRI]

Infantile myofibromatosis, despite being considered a rare condition, is the most common fibrous tumour in infancy. It is characterised by the presence of benign fibroblastic-myofibroblastic lesions. It usually occurs in children under two years-old, but it can appear at any age. The solitary form (myofibromas) may affect the skin, subcutaneous cellular tissue, muscle or bone. In the multi-centred form (myofibromatosis), there may also be visceral lesions. The lesions usually regress spontaneously in one or two years, with the prognosis being excellent in these cases. However, when there is visceral involvement, the prognosis is poor and treatment with chemotherapy is indicated. Lung involvement is more associated with a poor prognosis. Although the definitive diagnosis is by histopathology, diagnostic imaging tests are essential for characterising the lesions, establishing the extent of the disease, assessing visceral involvement, and following up the progression of the lesions.

[Complete unilateral dilation of the vas deferens as a cause of an inguinal mass]

The complete unilateral dilation of the vas deferens is an extremely rare radiologic finding. Most cystic structures adjacent to the prostate can be grouped into cysts and diverticula. The finding of an inguinal mass makes it necessary to rule out intestinal hernias and other entities. We present the case of a patient who developed an inguinal mass secondary to unilateral dilation of the vas deferens.