Barbara A. Carroll

Pneumatic compression versus low molecular weight heparin in gynecologic oncology surgery: a randomized trial ☆

OBJECTIVE: To compare the efficacy and treatment-related complications of low molecular weight heparin and external pneumatic compression in the prevention of venous thromboembolism of postoperative gynecologic oncology patients. METHODS: A total of 211 patients over age 40 years, undergoing a major operative procedure for gynecologic malignancy, were randomized to receive perioperative thromboembolism prophylaxis with either low molecular weight heparin (n = 105) or external pneumatic compression (n = 106). Demographic data and clinical outcome were recorded for each patient. All patients underwent bilateral Doppler ultrasound of the lower extremities on postoperative days 3–5 to evaluate for the presence of occult deep vein thrombosis. A follow-up interview 30 days after surgery sought to detect patients who developed deep vein thrombosis or pulmonary embolism after hospital discharge. RESULTS: Venous thrombosis was diagnosed in two patients receiving low molecular weight heparin and in one patient receiving external pneumatic compression. The frequency of bleeding complications, measured by the number of required perioperative transfusions, and estimated intraoperative blood loss was similar between the two groups. CONCLUSION: Low molecular weight heparin and external pneumatic compression are similarly effective in the postoperative prophylaxis of thromboembolism. The use of low molecular weight heparin is not associated with an increased risk of bleeding complications when compared with external pneumatic compression. We believe that both modalities are reasonable choices for prophylaxis in this high-risk group of patients.

Computerized cranial tomography in cerebral diseases of white matter.

Computerized tomographic scans were performed on 31 patients with primary diseases of the white matter. Among 18 patients with multiple sclerosis, acute lesions were visualized in five, all with symptomatic cerebral hemisphere disease. Characteristic white matter lesions were also demonstrated in adrenoleukodystrophy, spongiform encephalopathy, progressive multifocal leukoencephalopathy, disseminated necrotizing leukoencephalopathy, and an undiagnosed leukoencephalopathy associated with malignancy. Besides identifying white matter abnormalities, the CT scan patterns were often specific enough to help distinguish among the various etiologic possibilities for the abnormalities. Useful diagnostic characteristics included the anatomic distribution of lesions, mass effect, atrophic changes, and enhancement after contrast infusion.

Gelatin encapsulated nitrogen microbubbles as ultrasonic contrast agents.

Gelatin encapsulated nitrogen microbubbles were effective ultrasonic contrast agents in in vitro phantom and in vivo rabbit V2 carcinoma studies. Intra-arterial injection of 80-micrometer gelatin encapsulated nitrogen microbubbles appeared to improve tumor visualization by rim enhancement, which persisted for several minutes.

Diagnosis of Progressive Multifocal Leukoencephalopathy by Computed Tomography

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system which predominantly affects immunologically compromised hosts. The distinctive CT appearance in three documented cases includes low-density lesions of central and convolutional white matter with scalloped lateral borders. Lesions demonstrate no mass effect or contrast material enhancement. Findings are discussed with reference to other entities which may produce a similar CT appearance.

Ultrasonographically guided manual compression of femoral artery injuries.

To determine the success and complication rates of ultrasonographically guided manual compression in patients with femoral arterial injuries after femoral arterial catheterization, we performed 53 sonographically guided compression repairs in 51 patients. Ultrasonographically guided compression repair was performed on 40 pseudoaneurysms in non‐anticoagulated patients, seven pseudoaneurysms in anticoagulated patients, four arteriovenous fistulas on non‐anticoagulated patients, and one pseudoaneurysm combined with an arteriovenous fistula. One pseudoaneurysm underwent two separate ultrasonographically guided compression repairs: once when the patient was anticoagulated and once after anticoagulants were withheld. Ultrasonographically guided compression repair was successful in 37 of 48 pseudoaneurysms (77%). Of the 40 pseudoaneurysms in non‐anticoagulated patients, ultrasonographically guided compression repair was successful in 36 (90%). This repair technique failed in all seven pseudoaneurysms in anticoagulated patients. Ultrasonographically guided compression repair was successful in 13 of 16 (81%) multilobulated pseudoaneurysms but failed in all arteriovenous fistulas and the one case of pseudoaneurysm combined with an arteriovenous fistula. Ultrasonographically guided compression repair is a safe and effective alternative to surgery for the repair of pseudoaneurysms, including multilobulated pseudoaneurysms. The procedure does not appear to be effective in the anticoagulated patient or in patients with an arteriovenous fistula.

MR Imaging with Surface Coils in Primary Hyperparathyroidism

The use of magnetic resonance (MR) to preoperatively evaluate patients with primary hyperparathyroidism was assessed using a 1.5 T system and surface coil reception. Twenty-five patients with primary hyperparathyroidism were studied before surgical exploration. Axial images, 5 mm thick, were obtained from the thyroid cartilage to the sternal notch. Both T1-weighted [short repetition time (TR), short echo time (TE)] and T2-weighted (long TR, long TE) spin echo sequences were performed in most cases. Parathyroid adenomas typically demonstrated greater signal than surrounding tissues on T2-weighted sequences, yet demonstrated signal intensity that was less than or equal to normal thyroid tissue on T1-weighted sequences. Using these criteria, MR correctly identified 17 of 20 surgically proven parathyroid adenomas in the neck. Magnetic resonance appeared less sensitive in two patients with parathyroid hyperplasia, identifying only one of six hyperplastic glands. We conclude that MR with surface coils provides high contrast, anatomic delineation of the neck and is useful for preoperative localization of parathyroid tumors.

Bilateral lower extremity evaluation of deep venous thrombosis with color flow and compression sonography

Recognition of the accuracy of CUS for diagnosis of DVT has led to increased requests for bilateral lower extremity CUS studies. Compared to unilateral lower limb CUS studies, these examinations are often requested when the clinical suspicion of DVT is less strong. We undertook a 15 month prospective study of bilateral lower extremity CUS examinations to determine the diagnostic yield of positive studies and any correlation with clinical parameters. Eighty‐six patients were studied; six patients (7%) had studies positive for acute DVT, and 78 patients (91%) had negative studies. Positive studies did not correlate with clinical parameters except erythema. Concurrently, 23% of unilateral lower limb sonographic studies were positive. Bilateral lower limb CUS is a low yield investigation, which may be indicated in view of the morbidity and mortality associated with DVT and pulmonary embolism.

Urinary bladder diverticula: sonographic diagnosis and interpretive pitfalls.

Diverticula of the urinary bladder can occasionally appear as complex pelvic masses not obviously connected to the bladder. Such presentations can lead to diagnostic confusion and interpretative error. Sonographic findings and clinical histories were reviewed in 11 patients in whom bladder diverticula were initially mistaken for other types of pathologic pelvic processes. Sonographic techniques that were helpful in elucidating the true nature of the lesions included scanning from different perspectives with increasing increments of bladder distention, postvoid images, endovaginal views, and color Doppler interrogation. The diagnosis of bladder diverticula should be considered and actively pursued when sonologists are confronted with pelvic masses of ambiguous origin.

Nonuniformity of fetal umbilical systolic/diastolic ratios as determined with duplex Doppler sonography.

Fetal umbilical arterial systolic/diastolic (S/D) ratios are said to be uniform throughout the umbilical cord. We evaluated this phenomenon by performing duplex Dopper on 73 fetuses at three sites in the umbilical cord: near the placental origin, in the free‐floating midcord, and near the fetal abdominal wall insertion. Twenty‐one of 73 fetuses examined (29%) demonstrated pronounced nonuniformity of the S/D ratios with a discrepancy of 1 or greater between any two S/D measurements. Studies demonstrated the highest S/D ratios at the fetal abdominal wall and lowest S/D ratios at the placental origin. These findings suggest that umbilical arterial flow velocity waveforms (FVWs) and S/D ratios are not uniform throughout the cord in all patients. The significance of this finding is uncertain; however, this variability in umbilical cord flow velocity waveforms stresses the importance of identifying the portion of the umbilical cord from which S/D ratios are obtained.

Primary megaureter mimicking hydrosalpinx on ultrasonography.

Tubular adnexal masses are common findings during pelvic sonography and engender a reasonably short and straightforward list of differential diagnoses. Prominent in this list is hydrosalpinx, the dilated fallopian tube that typically appears as a fluid-filled tubular structure, often with folds or turns. •-.1 Although the possible confusion between a hydrosalpinx and other adnexal entities, such as dilated pelvic veins, fluid-filled loops of bowel, and ovarian cysts, is well described,1.2.~.s the additional possibility of a dilated ureter has not, to our knowledge, been similarly emphasized. We describe the clinical and ultrasonographic findings in a patient with a primary megaureter that mimicked a hydrosalpinx on ultrasonography, and we discuss ultrasonographic features that may serve to distinguish the two conditions.