Exploring the anatomical factors influencing testes elasticity via ultrasound shear wave elastography: Preliminary results

PURPOSE

The aim of this study is to evaluate the anatomical factors influencing elasticity values of normal testicular parenchyma using shear wave elastography (SWE).

METHODS

This study examined 68 healthy male volunteers (117 testes in which standard transverse axis ultrasonography views could be obtained) via conventional scrotal ultrasonography and SWE. Both the mean (EMean) and standard deviation (ESD) elasticity values were acquired.

RESULTS

In the standard transverse axis view of the rete testis at the mid-lateral edge of the testes, the EMean values in 2mm the testicular parenchyma from the rete testis and the testicular capsule at the same level as the rete testis were all significantly larger than in the central zone (P<0.001, P<0.001, respectively). The EMean value in the testicular parenchyma 2mm from the testicular capsule on the line formed approximately 45° below the horizontal line of the rete testis was significantly larger than in the rete testis approximately 45° above the horizontal line (P<0.001). In two standard transverse axis views, the ESD values in other regions were significantly larger than those in the central zones (all P<0.001). Also, the EMean values in the transmediastinal arteries were larger than those of the surrounding normal testicular parenchyma (P<0.001).

CONCLUSION

Based on SWE, factors including the testicular capsule, the density of testicular fibrous septa, the depth of the Q-Box™, and the transmediastinal artery may influence the testes elasticity measurement.

[Perineural dexamethasone in ultrasound-guided interscalene brachial plexus block with levobupivacaine for shoulder arthroscopic surgery in the outpatient setting: randomized controlled trial]

BACKGROUND AND OBJECTIVES

In shoulder arthroscopy, on an outpatient basis, the patient needs a good control of the postoperative pain that can be achieved through regional blocks. Perineural dexamethasone may prolong the effect of these blocks. The aim of this study was to evaluate the effect of perineural dexamethasone on the prolongation of the sensory block in the postoperative period for arthroscopic shoulder surgery in outpatient setting.

METHODS

After approval by the Research Ethics Committee and informed consent, patients undergoing arthroscopic shoulder surgery under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomized into Group D - blockade performed with 30 mL of 0.5% levobupivacaine with vasoconstrictor and 6 mg (1.5 mL) of dexamethasone and Group C - 30 mL of 0.5% levobupivacaine with vasoconstrictor and 1.5 mL of 0.9% saline. The duration of the sensory block was evaluated in 4 postoperative moments (0, 4, 12 and 24 hours) as well as the need for rescue analgesia, nausea and vomiting incidence, and Visual Analog Pain Scale (VAS).

RESULTS

Seventy-four patients were recruited and 71 completed the study (Group C, n=37; Group D, n=34). Our findings showed a prolongation of the mean time of the sensitive blockade in Group D (1440±0 min vs. 1267±164 min, p<0.001). It was observed that Group C had a higher mean pain score according to VAS (2.08±1.72 vs. 0.02±0.17, p <0.001) and a greater number of patients (68.4% vs. 0%, p <0.001) required rescue analgesia in the first 24 hours. The incidence of postoperative nausea and vomiting was not statistically significant.

CONCLUSION

Perineural dexamethasone significantly prolonged the sensory blockade promoted by levobupivacaine in interscalene brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period.

[Correlation of the epidural space measured intraoperatively and estimated by MRI or US: an observational study]

BACKGROUND AND OBJECTIVES

To assess the agreement between the epidural depth measured from the surgical site with the epidural depths estimated with magnetic resonance imaging (MRI) and ultrasound scanning.

METHODS

Fifty patients of either sex, scheduled for L4-5 lumbar disc surgery under general anesthesia were enrolled in this prospective observational study, and the results of 49 patients were analyzed. The actual epidural depth was measured from the surgical site with a sterile surgical scale. The MRI-derived epidural depth was measured from the MRI scan. The ultrasound estimated epidural depth was measured from the ultrasound image obtained just before surgery.

RESULTS

The mean epidural depth measured from the surgical site was 53.80 ± 7.67mm, the mean MRI-derived epidural depth was 54.06 ± 7.36mm, and the ultrasound-estimated epidural depth was 53.77 ± 7.94mm. The correlation between the epidural depth measured from the surgical site and MRI-derived epidural depth was 0.989 (r² = 0.979, p < 0.001), and the corresponding correlation with the ultrasound-estimated epidural depth was 0.990 (r² = 0.980, p < 0.001).

CONCLUSIONS

Both ultrasound-estimated epidural depth and MRI-derived epidural depth have a strong correlation with the epidural depth measured from the surgical site. Preprocedural MRI-derived estimates of epidural depth are slightly deeper than the epidural depth measured from the surgical site, and the ultrasound estimated epidural depths are somewhat shallower. Although both radiologic imaging techniques provided reliable preprocedural estimates of the actual epidural depth, the loss of resistance technique cannot be discarded while inserting epidural needles.

Prenatal factors associated with fetal visceral adiposity

OBJECTIVE

To assess fetal visceral adiposity and associated factors during pregnancy.

METHODS

Secondary analysis of prospective cohort data with 172 pairs (pregnant woman/fetus) treated at public health units. Anthropometric data, metabolic (glucose, glycated hemoglobin, insulin, insulin resistance, total cholesterol and fractions, triglycerides) measures, fetal biometry, and visceral and subcutaneous adiposity in the binomial (pregnant woman/fetus) were evaluated at the 16^th, 28^th and 36^th gestational weeks by ultrasonography. Pearson's correlation coefficient and multiple linear regression were used, with a significance level of 5%.

RESULTS

At the 16^th week, the mean age of the pregnant women was 26.6±5.8 years and mean weight was 62.7±11.5kg; 47.0% had normal weight, 28.3% were overweight, 13.3% were underweight, and 11.2% were obese. At 36 weeks, 44.1% had inadequate gestational weight gain, 32.5% had adequate gestational weight gain, and 23.3% had excessive gestational weight gain. Fetal visceral adiposity at week 36 showed a positive correlation with maternal variables: weight (r=0.15) and body mass index (r=0.21) at the 16^th; with weight (r=0.19), body mass index (r=0.24), and gestational weight gain (r=0.21) at the 28^th; and with weight (r=0.22), body mass index (r=0.26), and gestational weight gain (r=0.21) at the 36^th week. After multiple linear regression, adiposity at the 28^th week remained associated with fetal variables: abdominal circumference (p<0.0001), head circumference (p=0.01), area (p<0.0001), and thigh circumference (p<0.001). At the 36^th week, adiposity remained associated with the abdominal circumference of the 28^th (p=0.02) and 36^th weeks (p<0.001).

CONCLUSION

Adiposity was positively correlated with the measurements of the pregnant woman. After the multivariate analysis, the persistence of the association occurred with the abdominal circumference, a central adiposity measurement with a higher metabolic risk.

[Ultrasound-guided costoclavicular block as an alternative for upper limb anesthesia in obese patients]

BACKGROUND AND OBJECTIVES

Costoclavicular brachial plexus block is an anesthesia performed through the infraclavicular route described in the literature as a safe and effective route for upper limb anesthesia distal to the elbow. The following report describes the case of a patient whose traditional plexus blocking techniques presented ultrasound visualization difficulty, but the costoclavicular approach was easy to visualize for anesthetic blockade.

CASE REPORT

A grade 3 obese patient scheduled for repair of left elbow fracture and dislocation. Ultrasound examination revealed a distorted anatomy of the supraclavicular region and the axillary region with skin lesions, which made it impossible to perform the blockade in these regions. It was decided to perform an infraclavicular plexus block at the costoclavicular space, where the brachial plexus structures are more superficial and closer together, supported by a muscular structure, lateral to all adjacent vascular structures and with full view of the pleura. The anesthetic block was effective to perform the procedure with a single injection and uneventfully.

CONCLUSION

Costoclavicular brachial plexus block is a good alternative for upper limb anesthesia distal to the elbow, being a safe and effective option for patients who are obese or have other limitations to the use of other upper limb blocking techniques.

Intra-abdominal fat measurement by ultrasonography: association with anthropometry and metabolic syndrome in adolescents

OBJECTIVE

To associate intra-abdominal fat thickness measured by ultrasonography to the factors related to metabolic syndrome and to determine cutoff points of intra-abdominal fat measurement associated with a greater chance of metabolic syndrome in adolescents.

METHODS

This was a cross-sectional study, with 423 adolescents from public schools. Intra-abdominal fat was measured by ultrasonography. Anthropometric data were collected, and biochemical analyses were performed.

RESULTS

Intra-abdominal fat was measured by ultrasonography, showing a statistically significant association with the diagnosis of metabolic syndrome (p=0.037), body mass index (p<0.001), elevated triglyceride levels (p=0.012), decreased plasma HDL levels (p=0.034), and increased systemic blood pressure values (p=0.023). Cutoff values of intra-abdominal fat thickness measurements were calculated by ultrasound to estimate the individuals most likely to develop metabolic syndrome. In the logistic regression models, the cutoff values that showed the highest association with metabolic syndrome in males were 4.50, 5.35, 5.46, 6.24, and 6.50cm for the ages of 14, 15, 16, 17, and 18/19 years, respectively. In the female gender, the cutoff values defined for the same age groups were 4.46, 4.55, 4.45, 4.90, and 6.46cm. In an overall analysis using the ROC curve, without gender and age stratification, the cut-off of 3.67cm showed good sensitivity, but low specificity.

CONCLUSION

Ultrasonography is a useful method to estimate intra-abdominal adipose tissue in adolescents, which is associated with the main factors related to obesity and metabolic syndrome.

[Ultrasound assessment of gastric antrum in term pregnant women before elective cesarean section]

BACKGROUND AND OBJECTIVES

Pregnant women are considered patients at risk for pulmonary aspiration of gastric contents. The study aim was to evaluate the gastric antral cross-sectional area using ultrasound.

METHOD

In this prospective study, 85 scheduled term pregnant women underwent gastric ultrasound. The outcomes were the measurement of the gastric antral cross-sectional area (main outcome), the estimated gastric volume, the incidence of pregnant women at risk for pulmonary aspiration, and the association between gastric antral cross-sectional area and clinical-demographic characteristics. Gastric antral cross-sectional area and gastric volume were compared according to body mass index <30 or ≥ 30.

RESULTS

The median (IIQ) for gastric antral cross-sectional area was 4cm² (2.8-6.3), for the estimated gastric volume it was 49.8mL (33.7-87.2), and for the gastric volume estimated in mL.kg^-1 it was 0.62mL.kg^-1 (0.39-0.95). The 95^th percentile [95% confidence interval (CI)] of the gastric antral cross-sectional area and the estimated gastric volume were ≤ 10.3cm² (95% CI: 7.6-15.6) and 1.42mL.kg^-1 (95% CI: 1.20-2.64), respectively. The incidence of pregnant women at risk for pulmonary aspiration was 3.5% (CI: 3.5 (1.2-9.8). There was a positive correlation between gastric antral cross-sectional area and weight, p <0.001 and body mass index <0.001. Patients with a body mass index ≥ 30 had a gastric antral cross-sectional area and an estimated gastric volume greater than those with a body mass index <30, respectively, p <0.01 and p <0.02.

CONCLUSION

Measuring the gastric antral cross-sectional area of pregnant women is feasible and easy. There was positive correlation between gastric antral cross-sectional area, body weight and body mass index. The estimation of gastric volume by measuring the gastric antral cross-sectional area can identify patients at risk for pulmonary aspiration. Obese patients had a gastric antral cross-sectional area and an estimated gastric volume greater than non-obese patients.

[Continuous quadratus lumborum type II block in partial nephrectomy]

BACKGROUND AND OBJECTIVES

Quadratus lumborum block was first described in 2007 and currently there are descriptions of its achievement through four different injection points. This blockage provides abdominal wall and visceral analgesia, and one of its mechanisms is the dispersion of the local anesthetic into the paravertebral space. We describe the performance of a continuous quadratus lumborum type II block for postoperative analgesia in a partial nephrectomy.

CASE REPORT

A 64-year-old woman, scheduled for partial left laparoscopic nephrectomy. During the procedure, due to technical difficulties, an incision was made in the left flank to facilitate the surgical approach. In the early postoperative period, a continuous quadratus lumborum type II block was performed using ultrasonography as part of the multimodal analgesic strategy. Initially, 20ml of 0.2% ropivacaine was administered and 3cm of catheter were introduced into the interfascial space. Subsequently, a continuous infusion of 5.2mL.h^-1 of 0.2% ropivacaine was given for 48hours. In the first 24 postoperative hours, the patient reported no pain at rest or on movement. In the following 24hours, she was free of pain at rest and only a slight pain (2/10) on movement.

CONCLUSIONS

Continuous quadratus lumborum type II block was an effective postoperative analgesic option. Blocking of somatic nerves and visceral afferent pathways provided abdominal and visceral wall analgesia, allowing the reduction of opioid consumption. We consider relevant to explore the analgesic capacity of the quadratus lumborum block and its different approaches, as well as the possibility of it becoming an alternative in patients scheduled for kidney surgery.

A predictive model to distinguish malignant and benign thyroid nodules based on age, gender and ultrasonographic features

Introduction

A discussion in literature about a standardized decision support tool for the management of thyroid nodules remains.

Objective

The purpose of this study was to create a statistical prediction model for thyroid nodules management.

Methods

Two hundred and four benign and 57 malignant thyroid nodules were selected for a retrospective study. The variables age, gender and ultrasonographic features were examined using univariate and multivariate models. A statistical formula was used to calculate the risk of cancer of each case.

Results

In multivariate analysis, irregular shape, absence of halo, lower mean age, homogeneous echotexture, microcalcifications and solid content were associated with cancer. After applying the formula, 20 cases (7.6%) with a calculated risk for malignancy ≤3.0% were found, all of them benign. Setting the calculated risk in ≥80%, 21 (8.0%) cases were selected, and in 85.7% of them cancer was confirmed in histopathology. Internal accuracy of the prediction formula was 92.5%.

Conclusions

The prediction formula reached high accuracy and may be an alternative to other decision support tools for thyroid nodule management.

Accuracy of low dose CT in the diagnosis of appendicitis in childhood and comparison with USG and standard dose CT

OBJECTIVES

Computed tomography should be performed after careful consideration due to radiation hazard, which is why interest in low dose CT has increased recently in acute appendicitis. Previous studies have been performed in adult and adolescents populations, but no studies have reported on the efficacy of using low-dose CT in children younger than 10 years.

METHODS

Patients (n=475) younger than 10 years who were examined for acute appendicitis were recruited. Subjects were divided into three groups according to the examinations performed: low-dose CT, ultrasonography, and standard-dose CT. Subjects were categorized according to age and body mass index (BMI).

RESULTS

Low-dose CT was a contributive tool in diagnosing appendicitis, and it was an adequate method, when compared with ultrasonography and standard-dose CT in terms of sensitivity (95.5% vs. 95.0% and 94.5%, p=0.794), specificity (94.9% vs. 80.0% and 98.8%, p=0.024), positive-predictive value (96.4% vs. 92.7% and 97.2%, p=0.019), and negative-predictive value (93.7% vs. 85.7% and 91.3%, p=0.890). Low-dose CT accurately diagnosed patients with a perforated appendix. Acute appendicitis was effectively diagnosed using low-dose CT in both early and middle childhood. BMI did not influence the accuracy of detecting acute appendicitis on low-dose CT.

CONCLUSION

Low-dose CT is effective and accurate for diagnosing acute appendicitis in childhood, as well as in adolescents and young adults. Additionally, low-dose CT was relatively accurate, irrespective of age or BMI, for detecting acute appendicitis. Therefore, low-dose CT is recommended for assessing children with suspected acute appendicitis.

Quadratus lumborum block in chronic pain after abdominal hernia repair: case report

BACKGROUND AND OBJECTIVES

The quadratus lumborum blockade was described by R. Blanco in its two approaches (I and II). The local anesthetic deposition in this location can provide blockade to T6-L1 dermatomes. We performed this fascia blockade guided by ultrasound for treating a chronic neuropathic pain in the abdominal wall.

CASE REPORT

Male patient, 61 years old, 83kg, with a history of thrombocytopenia due to alcoholic cirrhosis, among others; had chronic pain in the abdominal wall after multiple abdominal hernia repairs in the last year and a half, with poor response to treatment with neuromodulators and opioids. On clinical examination, he revealed a neuropathic pain, with prevalence of allodynia to touch, covering the entire anterior abdominal wall, from T7 to T12 dermatomes. We opted for a quadratus lumborum block type II, guided by ultrasound, with administration of 0.2% ropivacaine (25mL) and depot (vial) methylprednisolone (20mg) on each side. The procedure gave immediate relief of symptoms and, after six months, the patient still had a significant reduction in allodynia without compromising the quality of life.

CONCLUSIONS

We consider that performing the quadratus lumborum block type II was an important analgesic option in the treatment of a patient with chronic pain after abdominal hernia repair, emphasizing the effects of local anesthetic spread to the thoracic paravertebral space. The technique has proven to be safe and well tolerated. The publication of more clinical cases reporting the effectiveness of this blockade for chronic pain is desirable.

Relevant aspects of imaging in the diagnosis and management of gout

Gout is an inflammatory arthritis characterized by the deposition of monosodium urate crystals in the synovial membrane, articular cartilage and periarticular tissues leading to inflammation. Men are more commonly affected, mainly after the 5th decade of life. Its incidence has been growing with the population aging. In the majority of the cases, the diagnosis is made by clinical criteria and synovial fluid analysis, in search for monosodium urate crystals. Nonetheless, gout may sometimes have atypical presentations, complicating the diagnosis. In these situations, imaging methods have a fundamental role, aiding in the diagnostic confirmation or excluding other possible differential diagnosis. Conventional radiographs are still the most commonly used method in gout patients' evaluation; nevertheless, this is not a sensitive method, since it detect only late alterations. In the last years, there have been several advances in imaging methods for gout patients. Ultrasound has shown a great accuracy in the diagnosis of gout, identifying monosodium urate deposits in the synovial membrane and articular cartilage, in detecting and characterizing tophi and in identifying tophaceous tendinopathy and enthesopathy. Ultrasound has also been able to show crystal deposition in patients with articular pain in the absence of a classical gout crisis. Computed tomography is an excellent method for detecting bone erosions, being useful in spine involvement. Dual-energy CT is a new method able to provide information about the chemical composition of tissues, with high accuracy in the identification of monosodium urate deposits, even in the early stages of the disease and in cases of difficult characterization. Magnetic resonance imaging is useful in the evaluation of deep tissues not accessible by ultrasound. Besides the diagnosis, with the emergence of new drugs that aim to reduce tophaceous burden, imaging methods have become useful tools in monitoring the treatment of patients with gout.

[Ultrasound guidance improves the success rate of axillary plexus block: a meta-analysis]

OBJECTIVE

To evaluate the value of real-time ultrasound (US) guidance for axillary brachial plexus block (AXB) through the success rate and the onset time.

METHODS

The meta-analysis was carried out in the Anesthesiology Department of the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China. A literature search of Medline, Embase, Cochrane database from the years 2004 to 2014 was performed. The literature searches were carried out using medical subject headings and free-text word: "axilla", "axillary", "brachial plexus", "ultrasonography", "ultrasound", "ultrasonics". Two different reviewers carried out the search and evaluated studies independently.

RESULTS

Seven randomized controlled trials, one cohort study and three retrospective studies were included. A total of 2042 patients were identified. 1157 patients underwent AXB using US guidance (US group) and the controlled group included 885 patients (246 patients using traditional approach (TRAD) and 639 patients using nerve stimulation (NS)). Our analysis showed that the success rate was higher in the US group compared to the controlled group (90.64% vs. 82.21%, p<0.00001). The average time to perform the block and the onset of sensory time were shorter in the US group than the controlled group.

CONCLUSION

The present study demonstrated that the real-time ultrasound guidance for axillary brachial plexus block improves the success rate and reduce the mean time to onset of anesthesia and the time of block performance.

Update on the approach of urinary tract infection in childhood

OBJECTIVE

Urinary tract infection (UTI) is the most common bacterial infection in childhood. UTI may be the sentinel event for underlying renal abnormality. There are still many controversies regarding proper management of UTI. In this review article, the authors discuss recent recommendations for the diagnosis, treatment, prophylaxis, and imaging of UTI in childhood based on evidence, and when this is lacking, based on expert consensus.

SOURCES

Data were obtained after a review of the literature and a search of Pubmed, Embase, Scopus, and Scielo.

SUMMARY OF THE FINDINGS

In the first year of life, UTIs are more common in boys (3.7%) than in girls (2%). Signs and symptoms of UTI are very nonspecific, especially in neonates and during childhood; in many cases, fever is the only symptom.

CONCLUSIONS

Clinical history and physical examination may suggest UTI, but confirmation should be made by urine culture, which must be performed before any antimicrobial agent is given. During childhood, the proper collection of urine is essential to avoid false-positive results. Prompt diagnosis and initiation of treatment is important to prevent long-term renal scarring. Febrile infants with UTIs should undergo renal and bladder ultrasonography. Intravenous antibacterial agents are recommended for neonates and young infants. The authors also advise exclusion of obstructive uropathies as soon as possible and later vesicoureteral reflux, if indicated. Prophylaxis should be considered for cases of high susceptibility to UTI and high risk of renal damage.

Ultrasound guidance improves the success rate of axillary plexus block: a meta-analysis

OBJECTIVE

To evaluate the value of real-time ultrasound (US) guidance for axillary brachial plexus block (AXB) through the success rate and the onset time.

METHODS

The meta-analysis was carried out in the Anesthesiology Department of the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China. A literature search of Medline, EMBASE, Cochrane database from the years 2004 to 2014 was performed. The literature searches were carried out using medical subject headings and free-text word: "axilla", "axillary", "brachial plexus", "ultrasonography", "ultrasound", "ultrasonics". Two different reviewers carried out the search and evaluated studies independently.

RESULTS

Seven randomized controlled trials, one cohort study and three retrospective studies were included. A total of 2042 patients were identified. 1157 patients underwent AXB using US guidance (US group) and the controlled group included 885 patients (246 patients using traditional approach (TRAD) and 639 patients using nerve stimulation (NS)). Our analysis showed that the success rate was higher in the US group compared to the controlled group (90.64% vs. 82.21%, p<0.00001). The average time to perform the block and the onset of sensory time were shorter in the US group than the controlled group.

CONCLUSION

The present study demonstrated that the real-time ultrasound guidance for axillary brachial plexus block improves the success rate and reduce the mean time to onset of anesthesia and the time of block performance.

Imagiological Diagnosis of Gastrointestinal Diseases - Diagnostic Criteria of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the leading causes of neoplastic morbidity and mortality worldwide, and despite recent treatment advances, the prognosis remains dismal, with a 5-year mortality rate of 85%.

The surveillance and timely diagnosis is therefore of crucial importance in order to improve survival rates and alleviate the health burden imposed by the HCC.

Previously, HCC diagnosis warranted liver biopsy, an invasive process with limited diagnostic accuracy. In the past 15 years, HCC diagnosis based solely on imaging criteria was accepted by all the major national and international guidelines, and is now widely employed across the globe.

Current European guidelines for the HCC diagnosis support the use of both dynamic contrasted computer tomography as well as magnetic resonance imaging for the non-invasive diagnosis of HCC for nodules >1 cm in a cirrhotic liver. The non-invasive diagnosis of HCC depends on radiological hallmarks, such as homogeneous contrast uptake during the arterial phase and wash-out during the venous and late phases, but while such tumoral behaviour is frequent in nodules >2 cm, high-end equipment and superior expertise is often needed for the correct diagnosis of early HCC.

Nevertheless, the accuracy of imaging techniques for the diagnosis of HCC is permanently improving, and supports the progressively reduced need for liver biopsy during liver nodule workout in a cirrhotic liver.

The role of transrectal ultrasound in the diagnosis of prostate cancer: new contributions

Objective

The present study was aimed at evaluating the contribution of transrectal prostate ultrasound in the screening for prostate neoplasias and in the guidance of prostate biopsies.

Materials and Methods

Prospective study developed over a one-year period. All the patients with indication for prostate biopsy were evaluated. Regardless of PSA values, the patients underwent ultrasound in order to identify suspicious nodules (confirmed by two observers). Sextant biopsy was subsequently performed. In cases of finding suspicious nodules, an additional puncture directed to such nodules was done.

Results

In a total of 155 cases the prevalence of malignancy was of 53%. Suspicious nodules were detected in 34 patients, and 25 where malignant (positive predictive value of 74%). The specificity and sensitivity for suspicious nodules were 88% and 31% respectively. Comparatively with the randomly obtained sextant specimens, the rate of findings of neoplasia was higher in the specimens obtained with puncture directed to the nodule (p = 0.032). No statistically significant difference was observed in the Gleason score for both types of specimens (p = 0.172).

Conclusion

The high positive predictive value and the high rate of findings of neoplasia in specimens of suspicious nodules should be taken into consideration in the future. The authors suggest a biopsy technique similar to the one described in the present study (sextant biopsy plus puncture directed to the suspicious nodule).

[Ultrasonography as a tool in diagnosis of carpal tunnel syndrome]

OBJECTIVE

We aimed to determine the value of ultrasonography (US) in the diagnosis of carpal tunnel syndrome (CTS).

METHODS

Two hundred patients (400 hands) were submitted to wrist US to measure median nerve area (MNA), questioning on paresthesia and pain in the median nerve territory, Tinel and Phalen maneuvers. An MNA > 9 mm(2) was considered diagnostic of CTS.

RESULTS

Measurement of MNA by US was > 9 mm(2) in 27% of the hands. A good association with pain (p < 0.0001), paresthesia (p < 0.0001), Tinel test (p < 0.0001) and Phalen test (p < 0.0001) was found. According to the clinical criteria for classification of CTS from American Academy of Neurology the MNA by US had 64.8% of sensibility and 77.0% of specificity in this sample.

CONCLUSION

Measurement of MNA by US performs well and can be used as first option for the investigation of patients with CTS.

[Quadratus lumborum block in chronic pain after abdominal hernia repair: case report]

BACKGROUND AND OBJECTIVES

The quadratus lumborum blockade was described by R. Blanco in its two approaches (I and II). The local anesthetic deposition in this location can provide blockade to T6-L1 dermatomes. We performed this fascia blockade guided by ultrasound for treating a chronic neuropathic pain in the abdominal wall.

CASE REPORT

Male patient; 61 years old; 83kg; with a history of thrombocytopenia due to alcoholic cirrhosis, among others; had chronic pain in the abdominal wall after multiple abdominal hernia repairs in the last year and a half, with poor response to treatment with neuromodulators and opioids. On clinical examination, he revealed a neuropathic pain, with prevalence of allodynia to touch, covering the entire anterior abdominal wall, from T7 to T12 dermatomes. We opted for a quadratus lumborum block type II, guided by ultrasound, with administration of 0.2% ropivacaine (25mL) and depot (vial) methylprednisolone (20mg) on each side. The procedure gave immediate relief of symptoms and, after six months, the patient still had a significant reduction in allodynia without compromising the quality of life.

CONCLUSIONS

We consider that performing the quadratus lumborum block type II was an important analgesic option in the treatment of a patient with chronic pain after abdominal hernia repair, emphasizing the effects of local anesthetic spread to the thoracic paravertebral space. The technique has proven to be safe and well tolerated. The publication of more clinical cases reporting the effectiveness of this blockade for chronic pain is desirable.

[Achilles tendon xanthoma imaging on ultrasound and magnetic resonance imaging]

The Achilles tendon xanthoma is a rare disease and has a high association with primary hyperlipidemia. An early diagnosis is essential to start treatment and change the disease course. Imaging exams can enhance diagnosis. This study reports the case of a 60-year-old man having painless nodules on his elbows and Achilles tendons without typical gout crisis, followed in the microcrystalline disease clinic of Unifesp for diagnostic workup. Laboratory tests obtained showed dyslipidemia. The ultrasound (US) showed a diffuse Achilles tendon thickening with hypoechoic areas. Magnetic resonance imaging (MRI) showed a diffuse tendon thickening with intermediate signal areas, and a reticulate pattern within. Imaging studies showed relevant aspects to diagnose a xanthoma, thus helping in the differential diagnosis.

[Factors that influence bone mass of healthy children and adolescents measured by quantitative ultrasound at the hand phalanges: a systematic review]

Objective:

To analyze the main factors that influence bone mass in children and teenagers assessed by quantitative ultrasound (QUS) of the phalanges.

Data source:

A systematic literature review was performed according to the PRISMA method with searches in databases Pubmed/Medline, SciELO and Bireme for the period 2001-2012, in English and Portuguese languages, using the keywords: children, teenagers, adolescent, ultrasound finger phalanges, quantitative ultrasound of phalanges, phalangeal quantitative ultrasound.

Data synthesis:

21 articles were included. Girls had, in QUS, Amplitude Dependent Speed of Sound (AD-SoS) values higher than boys during pubertal development. The values of the parameters of QUS of the phalanges and dual-energy X-ray Absorptiometry (DXA) increased with the increase of the maturational stage. Anthropometric variables such as age, weight, height, body mass index (BMI), lean mass showed positive correlations with the values of QUS of the phalanges. Physical activity has also been shown to be positively associated with increased bone mass. Factors such as ethnicity, genetics, caloric intake and socioeconomic profile have not yet shown a conclusive relationship and need a larger number of studies.

Conclusions:

QUS of the phalanges is a method used to evaluate the progressive acquisition of bone mass during growth and maturation of individuals in school phase, by monitoring changes that occur with increasing age and pubertal stage. There were mainly positive influences variables of sex, maturity, height, weight and BMI, with similar data when compared to the gold standard method, the DXA.

Doppler velocimetry of the fetal middle cerebral artery and other parameters of fetal well-being in neonatal survival during pregnancies with placental insufficiency

OBJECTIVE

To study the Doppler velocimetry of the fetal middle cerebral artery in pregnancies complicated by placental insufficiency, and to verify its role in the prognosis of neonatal survival.

METHODS

This was a prospective study of 93 pregnant women with diagnosis of placental insufficiency detected before the 34(th) week of pregnancy. Placental insufficiency was characterized by abnormal umbilical artery (UA) Doppler (> 95(th) percentile). The following parameters were analyzed: umbilical artery (UA) pulsatility index (PI); middle cerebral artery (MCA) PI; brain-placenta ratio--BPR (MCA-PI/UA-PI); MCA peak systolic velocity (MCA-PSV); and PI for veins (PIV) of ductus venosus (DV). The parameters were analyzed in terms of absolute values, z-scores (standard deviations from the mean), or multiples of the median (MoM). The outcome investigated was neonatal death during the hospitalization period after birth.

RESULTS

Of the 93 pregnancies analyzed, there were 25 (26.9%) neonatal deaths. The group that died, when compared to the survival group, presented a significant association with the diagnosis of absent or reversed end-diastolic flow (88% vs. 23.6%, p<0.001), with a higher median of UA PI (2.9 vs. 1.7, p<0.001) and UA PI z-score (10.4 vs. 4.9, p<0.001); higher MCA-PSV MoM (1.4 vs. 1.1, p=0.012); lower BPR (0.4 vs. 0.7, p<0.001); higher PIV-DV (1.2 vs. 0.8, p<0.001) and DV z-score (3.6 vs. 0.6, p<0.001). In the logistic regression, the independent variables predictive of neonatal death were: gestational age at birth (OR=0.45; 95% CI: 0.3 to 0.7; p<0.001) and UA PI z-score (OR=1.14, 95% CI: 1.0 to 1.3, p=0.046).

CONCLUSION

Despite the association verified by the univariate analysis between neonatal death and the parameters of fetal cerebral Doppler velocimetry, the multivariate analysis identified prematurity and degree of insufficiency of placental circulation as independent factors related to neonatal death in pregnancies complicated by placental insufficiency.