Phyllis Glanc

A Randomized, Controlled Trial of Heparin Versus Placebo Infusion to Prolong the Usability of Peripherally Placed Percutaneous Central Venous Catheters (PCVCs) in Neonates: The HIP (Heparin Infusion for PCVC) Study

BACKGROUND. Mechanical and infectious complications shorten the effective duration of peripherally inserted central venous catheters. Heparin use to prevent such complications and prolong the usability of peripherally inserted central venous catheters is inconclusive. OBJECTIVE. Our goal was to evaluate the effectiveness of heparin in prolonging the usability of peripherally inserted central venous catheters in neonates. DESIGN/METHODS. We performed a multicenter, randomized, controlled trial of heparin infusion (0.5 U/kg per hour) versus placebo for peripherally inserted central venous catheters in neonates. The primary outcome was duration of catheter use. Secondary outcomes were occlusion, catheter-related sepsis, thrombosis, and adverse effects of heparin. To detect a 168-hour (1-week) difference in the duration of catheter use, 192 patients were needed. Kaplan-Meier and Cox regression analyses were performed. RESULTS. A total of 201 neonates were enrolled (heparin group: n = 100; control group: n = 101). Baseline demographics were similar between the groups. Duration of catheter use was longer in the infants in the heparin versus the placebo group. Study center, gender, birth weight, and type and position of the catheter were not predictors of duration of catheter use. For those in the heparin versus the placebo group, the incidence of elective catheter removal (therapy completed) was 63% vs 42%, of occlusion was 6% vs 31%, of thrombosis was 20% vs 21%, and of catheter-related sepsis was 10% vs 6%, respectively. No adverse events were noted. CONCLUSIONS. Heparin infusion prolonged the duration of peripherally inserted central venous catheter usability, which permitted a higher percentage of neonates to complete therapy without increasing adverse effects.

Molar Tooth Sign in Fetal Brain Magnetic Resonance Imaging Leading to the Prenatal Diagnosis of Joubert Syndrome and Related Disorders

Joubert syndrome is a rare autosomal recessive disorder characterized by ataxia, developmental delay, and oculomotor and respiratory abnormalities in relation to cerebellar vermian and midbrain dysgenesis. The midbrain dysgenesis is responsible for the molar tooth sign on axial magnetic resonance imaging (MRI). This classic hallmark of Joubert syndrome has been identified in other disorders sharing overlapping clinical and radiologic features with Joubert syndrome. Recent identification of two different genes points to genetic heterogeneity in this group of disorders, now entitled Joubert syndrome and related disorders, making a genetic prenatal diagnosis not readily available. In addition, fetal ultrasonography lacks sensitivity in regard to posterior fossa malformation. Fetal MRI is now acknowledged as the method of choice to delineate posterior fossa malformation in a fetus. The identification of a molar tooth sign has, however, rarely been documented by a fetal brain MRI. We report a case of Joubert syndrome diagnosed prenatally using fetal MRI. We also discuss the etiology of Joubert syndrome in view of the recent genetic advances and murine models of cerebellar dysgenesis. (J Child Neurol 2006;21:320—324; DOI 10.2310/7010.2006.00075).

ACR Appropriateness Criteria Staging and Follow-up of Ovarian Cancer

In the management of epithelial ovarian cancers, imaging is used for cancer detection and staging, both before and after initial treatment. The decision of whether to pursue initial cytoreductive surgery for ovarian cancer depends in part on accurate staging. Contrast-enhanced CT of the abdomen and pelvis (and chest where indicated) is the current imaging modality of choice for the initial staging evaluation of ovarian cancer. Fluorine-18-2-fluoro-2-deoxy-d-glucose PET/CT and MRI may be appropriate for problem-solving purposes, particularly when lesions are present on CT but considered indeterminate. In patients who achieve remission, clinical suspicion for relapse after treatment prompts imaging evaluation for recurrence. Contrast-enhanced CT is the modality of choice to assess the extent of recurrent disease, and fluorine-18-2-fluoro-2-deoxy-d-glucose PET/CT is also usually appropriate, as small metastatic foci may be identified. If imaging or clinical examination confirms a recurrence, the extent of disease and timing of disease recurrence then determines the choice of treatments, including surgery, chemotherapy, and radiation therapy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria on acute pelvic pain in the reproductive age group.

Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation.

Adnexal masses in the pregnant patient: a diagnostic and management challenge.

Ultrasound is a valuable diagnostic tool, which can be used to stratify pregnant women with adnexal masses into a conservative management protocol versus those that require further diagnostic and management decisions. Familiarity with the natural history and sonographic features of common adnexal lesions, such as simple cysts, hemorrhagic cysts, endometriomas, mature cystic teratomas, and ovarian conditions specific to pregnancy, may permit stratification of patients into management protocols. The goal of ultrasound evaluation in the pregnant patient with an adnexal mass is to identify those patients in whom conservative management is appropriate versus those who require more immediate interventions such as surgery. The risk of surgical interventions needs to be balanced against the potential risks of nonintervention, which may include torsion, rupture, hemorrhage, or the rare spread of a malignant cancer. Atypical features or persistent large lesions should initiate a multidisciplinary team approach to optimize diagnostic and management strategy. Acute symptoms may precipitate emergency intervention at any point in the pregnancy. We will present a diagnostic and management algorithm based on clinical symptoms, timing of detection, natural history, and sonographic features of adnexal masses in pregnancy.

Acute Abdomen in Pregnancy Role of Sonography

Objective. The purpose of this presentation is to review the role of sonography in evaluation of acute abdomen during pregnancy. Methods. Illustrative cases were collected from gravid patients who presented with signs and symptoms suspicious for acute abdomen and subsequently underwent sonography. Results. This presentation shows sonographic findings of various maternal complications that can present with acute abdominal pain in pregnant patients. Conclusions. Sonography remains the first line of imaging in pregnant patients presenting with acute abdomen. Patient triage or additional imaging may be obtained on the basis of the sonographic findings.

How does maternal obesity affect the routine fetal anatomic ultrasound

Objective. To determine the completion rate for the routine anatomic survey in obese pregnant women with body mass index (BMI) ≥30 as compared to normal weight controls (BMI: 20–25). Methods. A retrospective analysis of the routine anatomic survey was performed in 100 consecutive women with a BMI ≥30. Each subject was matched to two normal weight controls, controlling for gestational age. Exclusion criteria such as anatomic abnormalities or multiple gestations were known. The degree of visibility (satisfactory, moderate or unsatisfactory), indication for repeat examination and placental location were assessed. Results. Average BMI in the index cases was 35.7 (range: 30–64.8). Twenty-six (26%) of index cases were considered incomplete as compared to 5 (2.5%) of the 200 controls. The anatomic survey was completed in 74 (74%) of index cases compared with 195 (97.5%) of controls. Visibility was satisfactory in 28 (28%) of index cases, moderate in 46 (46%) and unsatisfactory in 26 (26%). In comparison, 177 (88.5%) were satisfactory, 17 (8.5%) moderate and 6 (3%) were poor in controls. Conclusions. The completion rate for the routine anatomic survey in obese (BMI ≥30) pregnant women was significantly lower as compared to normal weight pregnant women.

Imaging and Obesity: A Perspective During Pregnancy

OBJECTIVE Obesity is a rapidly growing global pandemic that has surpassed all other risk factors in obstetric care, converting 40% of pregnant women into a high-risk category, with the attendant increased burden on our health care systems. This article will review the role of the imaging specialist in understanding the determinants of poor pregnancy outcome in the mother and her baby. We will also review how obesity affects the quality of patient care in terms of the limitation in completion of fetal anatomic surveys, ergonomic risks to the imaging specialist, and techniques that may improve imaging quality and ensure patient safety. We urgently need refinement in our ability to detect those fetuses at greatest risk for stillbirth and growth restriction, macrosomia, and congenital anomalies, and to understand the potentially multigenerational impact of maternal obesity on the incidence of obesity and the metabolic syndrome for the future. Utilization of emerging technologies such as laser Doppler, evolving MRI technology, and expanded roles for ultrasound such as ultrasound guidance for placement of labor anesthesia will become increasingly important. CONCLUSION The far-reaching implications of obesity on the mother and her children will continue have a progressive impact on our health care systems and resources.

ACR appropriateness criteria pretreatment evaluation and follow-up of endometrial cancer of the uterus

Endometrial cancer is one of the common malignancies in the female genital tract. Imaging in pretreatment evaluation may play an important role in an assessment of morphological prognostic factors including tumor size, depth of myometrial invasion, endocervical extent, and lymph node status. Imaging is also useful in posttreatment evaluation of patients with clinically suspected recurrence. Various modalities including MRI, CT ultrasound and FDG PET-CT-CT have been used for evaluation of the endometrial cancer in both before and after treatment settings. Literature on the indications and usefulness of these imaging studies for endometrial cancer is reviewed.

Diagnostic approach in prenatally detected genital abnormalities.

†The Prenatal Diagnosis and Medical Genetics Program, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto and ‡Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada *Correspondence. The Prenatal Diagnosis and Medical Genetics Program, The Ontario Power Generation Building, 700 University Avenue, Room 3292, M5G 1Z5, Toronto, Ontario, Canada (e-mail: dchitayat@mtsinai.on.ca)