Israel Medical Association Journal

Background: Successful neuraxial block performance relies on assessment and palpation of surface landmarks, potentially challenging in patients with high body mass index (BMI). 

Objectives: To evaluate the use of ultrasound-assisted neuraxial bock in a non-obstetric population with BMI above versus below 30 kg/m2.

Methods: Healthy adult patients undergoing extracorporeal shock wave lithotripsy (ESWL) under neuraxial block were observed in this quality assurance study. Prior to the neuraxial block, an ultrasound examination was performed to identify the puncture site. Neuraxial anesthesia block was performed under aseptic surgical conditions with the patient in the sitting position. Following block placement, external landmarks were palpated. Our primary study outcome was the number of attempts (skin insertions with the needle) after pre-puncture ultrasound identification of the insertion point, comparing patients with BMI above versus below 30 kg/m2. Our secondary outcome was assessment by palpation of external anatomical landmarks.

Results: Our study group included 63 consecutive patients undergoing neuraxial block for ESWL. Data were assessed according to BMI (above versus below 30 kg/m2). An overall success rate at the first attempt of 90.5% (CI 0.8–0.95) was achieved using ultrasound-guided neuraxial block. This block placement success rate was similar for all patients, regardless of BMI above versus below 30 kg/m2. In contrast, the ease of palpation of anatomic landmarks, P = 0.001, and the ease of palpation of iliac crest, P < 0.001, differed significantly between the patients above versus below 30 kg/m2. The reported verbal pain scores (VPS) due to block insertion was similar among all patients regardless of BMI category (above versus below 30 kg/m2).

Conclusions: We observed high success rates when ultrasound-assisted neuraxial block is performed, regardless of BMI above versus below 30 kg/m2, despite expected differences in surface landmark palpation. 

 

Background: Selection of appropriate reference charts for fetal biometry is mandatory to ensure an accurate diagnosis. Most hospitals and clinics in Israel use growth curves from the United States. Charts developed in different populations do not perform well in the Israeli population.

Objectives: To construct new reference charts for fetal biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL), using a large sample of fetuses examined at 14–42 weeks gestational age in a medical center and a community ultrasound unit located in two different regions of Israel. 

Methods: Data from the medical center and the community clinic were pooled. The mean and standard error of each measure for each week was calculated. Based on these, reference charts were calculated using quantiles of the normal distribution. The performance of the reference charts was assessed by comparing the new values to empirical quantiles.

Results: Biometric measurements were obtained for 79,328 fetuses. Growth charts were established based on these measurements. The overall performance of the curves was very good, with only a few exceptions among the higher quantiles in the third trimester in the medical center subsample.

Conclusions: We present new local reference charts for fetal biometry, derived from a large and minimally selected Israeli population. We suggest using these new charts in routine daily obstetric practice.

 

Breast magnetic resonance imaging (MRI) has an important role in the detection and diagnosis of breast cancer. Suspicious findings on MRI are further evaluated with ultrasound. This case series illustrates the use of automated breast volumetric ultrasound (ABVS) as a tool for second-look ultrasound (SLUS) following MRI. Seven women underwent breast MRI with findings necessitating SLUS. ABVS was used for second look and all MRI lesions were detected. Four cancers, one fibroadenoma and two benign lesions, were diagnosed. This case series shows that ABVS can be used as a tool for SLUS following MRI and in some cases is superior to hand-held ultrasound.

Objectives: To assess the influence of ultrasound performed by intensive care physicians.

Methods: This retrospective descriptive clinical study was performed in a medical-surgical intensive care unit of a university-affiliated general hospital. Data were collected from patients undergoing ultrasound examinations performed by a critical care physician from January 2010 to June 2011.

Results: A total of 299 ultrasound exams were performed in 113 mechanically ventilated patients (70 males, mean age 65 years). Exams included trans-cranial Doppler (n=24), neck evaluation before tracheostomy (n=15), chest exam (n=83), focused cardiac echocardiography (n=60), abdominal exam (n=41), and comprehensive screening at patient admission (n=30). Ultrasound was used to guide invasive procedures for vascular catheter insertion (n=42), pleural fluid drainage (n=24), and peritoneal fluid drainage (n=7). One pneumothorax was seen during central venous line insertion but no complications were observed after pleural or abdominal drainage. The ultrasound study provided good quality visualization in 86% (258 of 299 exams) and was a diagnostic tool that induced a change in treatment in 58% (132 of 226 exams).

Conclusions: Bedside ultrasound examinations performed by critical care physicians provide an important adjunct to diagnostic and therapeutic performance, improving quality of care and patient safety. 

Ultrasonography in the intensive care unit (ICU) has become a valuable tool for expeditiously, safely and effectively diagnosing and treating a myriad of conditions commonly encountered in this setting. Most surgeons are familiar with FAST (focused assessment with sonography in trauma) and can readily grasp the fundamentals of a limited or directed ultrasonographic exam. Thus, with appropriate training and practice, surgeons can utilize this tool in visualizing, characterizing and treating life-threatening conditions in their role as intensivists in the surgical ICU (SICU). In this review we will discuss the role of ultrasonography in evaluating the acute cardiac status of a patient in the SICU as well as its use in general critical care for assessing the thoracic, abdominal and vascular systems.
 

Background: The rate of brain abnormalities in asymptomatic term neonates varies substantially in previous studies. Some of these rates may justify general screening of healthy newborns by head ultrasound.

Objectives: To assess the incidence of intracranial abnormalities among asymptomatic term newborns with HUS[1] and to detect high-risk populations that might need such screening.

Methods: This was a prospective study in 493 term newborns who underwent HUS and a neurological evaluation during the first 3 days of life. The neurological examination results were unknown to the sonographist and the examiner was blinded to the HUS findings. The abnormal HUS findings were classified as significant or non-significant according to the current literature.

Results: Abnormal HUS was found in 11.2% of the neonates. Significant findings were noted in 3.8% of the infants. There was no association between non-structural HUS findings (hemorrhage or echogenicity) and mode of delivery. There was no relationship between any HUS abnormality and birth weight, head circumference and maternal age, ethnicity, education or morbidity. The rate of abnormal neurological, hearing or vision evaluation in infants with a significant abnormal HUS (5.2%) was comparable to the rate in infants with normal or non-significant findings on HUS (3.1%).

Conclusions: There is no indication for routine HUS screening in apparently healthy term neonates due to the relatively low incidence of significant brain abnormalities in these infants in our population.

Background: An accurate preoperative definition of tumor and lymph node status is needed for reaching the correct decision regarding rectal cancer treatment. Transrectal ultrasonography is the most commonly used diagnostic modality for the local staging of rectal cancer.

Objectives: To determine the accuracy of TRUS[1] in the staging of rectal cancer.

Methods: We conducted a retrospective study on 95 patients evaluated by TRUS. The rectum was subdivided into two parts (lower and upper).

Results: Sixty patients underwent radical surgery. Of these, 34 received no preoperative chemo-irradiation owing to µT1, µT2 tumor or the patient’s choice (neo-adjuvant treatment was suggested to patients with adenocarcinoma that proved to be µT3). The overall accuracy rate was 80% for T stage. Overstaging was found in 13.3% and understaging in 6.7%.The N-stage was correctly assessed in 70%. The overall accuracy rate for tumors was 73.9% in the lower part and 90.9% in the upper. A trend towards a lower accuracy rate for low-lying tumors compared to high-located rectal tumors was found (P = 0.532), which did not reach statistical significance.

Conclusions: TRUS gave better results for T1 and T3 stage rectal tumors but was inaccurate for stage T2, indicating the possible need for local excision in order to base the final treatment for T2 tumors on pathologic staging.
[1] TRUS = transrectal ultrasonography
 

Background: Although the comprehensive evaluation of the fetal heart includes echocardiography by an experienced pediatric cardiologist, economic constraints sometimes dictate the need to select patients.

Objectives: To analyze the usefulness of fetal echocardiography in the detection of congenital heart disease according to the referral indication.

Methods: This retrospective survey relates to all 3965 FE studies performed in our center from January 2000 to December 2004. The diagnosed cardiac anomalies were classified as significant and non-significant malformations. All FE[1] studies were done by a single operator (A.L.) at Meir Medical Center, a referral center for a population of about 400,000. The 3965 FE studies were performed for the following indications: abnormal obstetric ultrasound scans, maternal and family history of cardiac malformations, medication use during the pregnancy, and maternal request. The relative risk of detecting CHD[2] was calculated according to the various referral indications.

Results: Overall, 228 (5.8%) cases of CHD were found. The most common indication for referral was suspicion of CHD during a four-chamber view scan in a basic system survey or during a level II ultrasound survey. No correlation was found between maternal age and gestational age at the time of scanning and the likelihood of finding CHD.

Conclusions: Our data suggest that a suspicious level-II ultrasound or the presence of polyhydramnios is an important indication for FE in the detection of significant CHD.

Background: The role of endoscopic ultrasound in evaluating the response of esophageal cancer to neoadjuvant chemotherapy is controversial.

Objectives: To evaluate the accuracy of EUS[1] in restaging patients who underwent NAC[2].

Methods: The disease stage of patients with esophageal cancer was established by means of the TNM classification system. The initial staging was determined by chest and abdominal computed tomography and EUS. Patients who needed NAC underwent a preoperative regimen consisting of cisplatin and fluouracil. Upon completion of the chemotherapy, patients were restaged and then underwent esophagectomy. The results of the EUS staging were compared with the results of the surgical pathology staging. This comparison was done in two groups of patients: the study group (all patients who received NAC) and the control group (all patients who underwent primary esophagectomy without NAC).

Results: NAC was conducted in 20 patients with initial stage IIB and III carcinoma of the esophagus (study group). Post-chemotherapy EUS accurately predicted the surgical pathology stage in 6 patients (30%). Pathological down-staging was noted in 8 patients (40%). However, the EUS was able to observe it in only 2 patients (25%). The accuracy of EUS in determining the T status alone was 80%. The accuracy for N status alone was 35%. In 65% of examinations the EUS either overestimated (35%) or underestimated (30%) the N status. Thirteen patients with initial stage I-IIA underwent primary esophagectomy after the initial staging (control group). EUS accurately predicted the surgical pathology disease stage in 11 patients (85%).

Conclusions: EUS is an accurate modality for initial staging of esophageal carcinoma. However, it is not a reliable tool for restaging esophageal cancer after NAC and it cannot predict response to chemotherapy.

Background: Acute focal nephritis is an inflammatory process of the renal parenchyma affecting principally the cortex of the kidney. It is considered a midpoint in the spectrum of upper urinary tract infections, ranging from uncomplicated pyelonephritis to intrarenal abscesses, and until recently the hyperechoic sonographic appearance of this lesion was considered uncommon.  

Objectives: To determine the relative prevalence of hyperechoic and hypoechoic sonographic appearance of focal renal lesions in patients with the clinical diagnosis of acute pyelonephritis and to correlate the findings with those of the color Doppler examinations.

Methods: We reviewed the sonograms of 367 patients hospitalized with the clinical diagnosis of acute pyelonephritis. The sonograms were reviewed for acute renal inflammatory changes. When a focal lesion was detected, we noted the echogenicity, side, form, location and color Doppler characteristics.

Results: Abnormal sonographic findings related to the infection were found in 78 cases. In 52 patients a focal lesion was diagnosed. Forty-seven focal lesions appeared hyperechoic related to the adjacent parenchyma. These lesions were more frequently located at the upper pole and were wedge-shaped in most of the cases. The areas appeared hypo/avascular on the color Doppler examination.

Conclusions: Our data suggest that the most common appearance of acute focal nephritis is an area of increased echogenicity in the parenchyma of the affected kidney.
 

Background: Klippel-Trenaunay syndrome, a congenital disorder, is characterized by capillary malformation, varicosities and bony or soft tissue hypertrophy. Since there is no cure for this syndrome, treatment is directed towards secondary prevention of venous hypertension and preservation of functional integrity of the legs. Elastic stockings are the mainstay of treatment and are indicated in all cases. Surgery is reserved only for a few selected symptomatic patients, however the outcome is unsatisfactory in most cases, with recurrent pain, edema, poor cosmetic result and limb deformity. Ultrasound-guided foam sclerotherapy is a recently introduced minimally invasive ambulatory procedure for the treatment of chronic venous insufficiency. It was recently introduced to treat this disorder.

Objectives: To evaluate the efficacy of USFS[1] in the treatment of patients with Klippel-Trenaunay syndrome.

Methods: Seven patients diagnosed with Klippel-Trenaunay, with massive lower extremity involvement, were treated with USFS between October 2003 and October 2005. Sclerovein® (polidocanol, Resinag, Switzerland) 2–4% was used as the sclerosant. The signs, symptoms and overall patient satisfaction were assessed before, during and after the treatment.

Results: Patients' mean age was 26 years (range 15–54). The CEAP[2] clinical classification, with ascending severity ranging from 0 (no signs) to 6 (active venous ulcer), was C4 in 5 patients (71.5%) and C5 and C6 in one patient each. The average number of sessions was 14.5 (range 9–21). No major complications were encountered. All seven patients reported improvement in signs and symptoms. Five of the 7 patients (71%) were very satisfied with the cosmetic result.

Conclusion: USFS is an effective minimally invasive ambulatory technique, essentially pain-free and with excellent short-term results in patients with Klippel-Trenaunay syndrome (when the deep system is functional). Long-term results and larger study groups are warranted. 

Background: When encountering complaints of pain in the area of Achilles tendon with a suspected lesion, the clinician seldom reaches a precise diagnosis based only on X-ray and clinical examination. Ultrasonography is useful for evaluating the pathology and treatment.

Objectives: To assess the relative contribution of real-time intraoperative ultrasound examination and immediate postoperative ultrasound in patients with acute rupture of the Achilles tendon treated by percutaneous suture method. The combination of both procedures provides a unique advantage that could facilitate better results.

Methods: Ultrasound examination was used in 20 patients with acute rupture of the Achilles tendon who were treated surgically. Intraoperative as well as postoperative ultrasound examinations were performed in 5 patients whereas 15 patients underwent an immediate postoperative ultrasound.

Results: Ultrasound pathologies were found in all patients. Percutaneous surgical correction of ruptured Achilles tendon with accurate positioning of the foot using real-time sonography was successful in all the patients.

Conclusion: As in many other soft tissue lesions, ultrasonography is a useful tool for evaluating the pathology and for planning the surgical correction of ruptures in the Achilles tendon.