Ronald H. Gottlieb

Calf sonography for detecting deep venous thrombosis in symptomatic patients: Experience and review of the literature

We determined the accuracy of sonography in the detection of isolated calf deep venous thrombosis (DVT) and the rate of indeterminate ultrasound examinations in patients with physical signs or symptoms suggestive of DVT.

Torsion and Beyond New Twists in Spectral Doppler Evaluation of the Scrotum

Objective. To illustrate how spectral Doppler waveform analysis plays an adjunctive but very definite role in scrotal sonography. Methods. The cases illustrate a variety of testicular disorders that were collected at a referral tertiary care center. Results. Normal and a variety of pathologic conditions of the testes are discussed, along with their signature spectral waveforms. Conclusions. Analysis of the spectral waveform provides important additional information in various scrotal disorders with acute pain. Spectral waveform analysis is critical to diagnosing incomplete torsion when color and power Doppler examinations are indeterminate.

Testicular epidermoid cysts: sonographic features with histopathologic correlation.

Testicular epidermoid cysts are rare, accounting for 1% of all testicular tumors. We present the sonographic appearances of epidermoid cysts in 3 cases, together with the histopathologic correlation. In case 1, sonography showed an intratesticular hypoechoic mass with a well‐defined echogenic rim; the mass measured 1.8 × 1.5 × 1.5 cm, and there was no evidence of calcification. In case 2, sonography showed a well‐circumscribed mass measuring 1.3 × 1.3 × 1.0 cm, with alternating hypoechoic and hyperechoic rings (onion‐ring appearance) and no calcifications. In case 3, sonography showed a 2.4‐ × 2.3‐ × 2.3‐cm, well‐circumscribed, oval mass with a heterogeneous echotexture and an outer hypoechoic halo. The mass contained plaque‐like regions of increased echogenicity, with peripheral acoustic shadowing from refraction artifact. Hypoechoic clefts were visualized posterior to the plaque‐like areas. The triad of findings—sonographic appearance of an onion ring, avascularity on Doppler sonography, and negative results of tumor marker studies—is highly suggestive of an epidermoid cyst.

Magnetic resonance imaging : a cost-effective alternative to bone scintigraphy in the evaluation of patients with suspected hip fractures

Abstract Objective. To evaluate the cost-effectiveness of magnetic resonance imaging (MRI) compared with radionuclide bone scan in the evaluation of patients with clinically suspected hip fractures. Design. The medical records of all patients who had been seen in the emergency room over a 4-year period with a clinically suspected hip fracture, negative or equivocal plain films, and either a subsequent bone scan or MRI examination were retrospectively reviewed. The time to diagnosis, admission rate, and time to surgery were determined. A two-sample t-test was used to assess the statistical significance of the results. A theoretical cost analysis was performed using current charges to estimate all expenses. Patients. Forty patients (11 male, 29 female; age 28–99 years) satisfied our inclusion criteria. Results and conclusions. Twenty-one patients had bone scans (six with fractures), and 19 had MRI (four with fractures). The time to diagnosis was 2.24±1.30 days for bone scanning and 0.368±0.597 days for MRI (P<0.0001). Twenty patients in the bone scan group were admitted compared with 13 in the MRI group. The time to surgery was at least 1 day longer in patients undergoing bone scanning. Bone scanning resulted in higher patient costs compared with MRI because of the delay in diagnosis. In the evaluation of patients with suspected hip fractures, early MRI is more cost-effective than delayed bone scanning. Further prospective studies comparing the cost-effectiveness of early MRI with early bone scanning are needed.

Effective ultrasonographically guided intervention for diagnosis of musculoskeletal lesions.

Current algorithms recommend computed tomography or fluoroscopic guidance rather than ultrasonography for musculoskeletal intervention. We analyzed our ultrasonographically guided experience to evaluate its efficacy. Forty‐seven patients underwent needle aspirates or biopsies or both in 13 extremity and 34 axial locations for 12 inflammatory lesions, 23 soft tissue masses, and 12 lesions arising from bone. Four lesions were initially imaged by ultrasonography; the remaining lesions were identified by computed tomography (25) or magnetic resonance imaging (18). Forty‐six samples were diagnostic; one needle aspirate of an inflammatory mass yielded no diagnostic material. No complications occurred. Ultrasonographically guided musculoskeletal aspiration and biopsy are diagnostic and effective throughout the body, and with appropriate lesion access, they should be considered as an alternative to computed tomographic‐guided procedures.

Treated Needles Do They Facilitate Sonographically Guided Biopsies

Objective. We sought to compare needle visualization and diagnostic yield rates resulting from the use of several commercially available treated needles in sonographically guided biopsies. Methods. We conducted a randomized prospective study in which 61 patients (42 women and 19 men; mean age, 57 years; range, 19–84 years) were assigned to undergo biopsies (37 thyroid and 24 liver, 2 passes per patient) with 1 of 4 different 22‐gauge needles: Teflon coated, etched tip, echogenic polymer coated, and untreated. Two blinded radiologists independently scored needle shaft and tip visualization from 0 (no visualization) to 4 (excellent visualization). After blinded cytologic evaluation, the individual passes were rated as adequate or inadequate for establishing a tissue diagnosis. Results. The echogenic polymer‐coated needle had the highest mean score ± SD for visualization of both the shaft (3.4 ± 0.90) and tip (3.5 ± 0.87) compared with the untreated (shaft, 2.2 ± 0.77; P = 0.003; tip, 2.8 ± 0.92; P = 0.01), Teflon‐coated (shaft, 2.7 ± 0.94; tip, 3.1 ± 0.75), and etched tip (shaft, 3.0 ± 0.82; tip, 3.0 ± 0.56) needles. Diagnostic yield rates for the 4 different needle types were 75.0% for the echogenic polymer‐coated, 64.7% for the Teflon‐coated, 56.3% for the etched tip, and 75.0% for the untreated needles (no significant difference). Conclusions. The echogenic polymer‐coated needle was the best visualized of all needles evaluated, both treated and untreated. No significant difference was found in diagnostic yield rates, but that may be reflective of the relatively small sample size.

Renal sonography: Can it be used more selectively in the setting of an elevated serum creatinine level?

The objectives of our study were to (1) assess the outcomes resulting from the use of sonography in patients referred to our institutions ultrasound laboratory for an elevated serum creatinine level and (2) determine relevant clinical parameters in these patients to better triage them for sonography. We retrospectively identified and determined outcomes of 60 patients (20 women, 40 men; mean age, 61 years; range, 33 to 100 years) referred for sonographic evaluation because of an increased serum creatinine level (> or = 1.3 mg/dL). Ultrasound findings (hydronephrosis, renal size, and echogenicity) were correlated with clinical outcomes. Twenty-one patients (35%) had hydronephrosis, with 14 of these patients confirmed to be obstructed and five not obstructed. Two were indeterminate for obstruction. Eight of 14 obstructed patients were successfully treated. All obstructed patients had a suggestive history for obstruction with at least one of the following: pelvic mass (n = 9), stone disease (n = 4), or flank pain (n = 1). Only 2 of 44 patients, who were not obstructed, had any of these parameters (statistically significant difference, P < 0.0001). Thirty of the patients, who were not obstructed, had more likely alternative causes for renal failure, with sonography having no effect on patient management. Renal size and echogenicity had little effect on patient management. Sonography was efficacious in guiding management in patients with a suggestive history for obstruction (eg, pelvic mass, stone disease, or flank pain) but not in most patients who had no suggestive history and other more likely causes for renal failure.

Iodixanol: risk of subsequent contrast nephropathy in cancer patients with underlying renal insufficiency undergoing diagnostic computed tomography examinations.

Objective: To assess the risk of contrast-induced nephropathy in cancer patients with underlying renal insufficiency receiving the iso-osmolar intravenous contrast agent iodixanol for diagnostic computed tomography (CT) examinations. Methods: Institutional review board approval was obtained with waiver of informed consent. Our study was a retrospective evaluation comparing the incidence of contrast-induced nephropathy in consecutive patients with underlying renal insufficiency undergoing diagnostic CT examinations receiving iodixanol from November 2003 to June 2005 with a comparison group of patients with normal baseline renal function over the same period. Renal insufficiency was considered a serum creatinine level more than 1.2 mg/dL in females and more than 1.5 mg/dL in males. Contrast nephropathy was considered an absolute elevation of 0.5 mg/dL or 25% elevation in serum creatinine level. Results: In the group of patients receiving iodixanol with underlying renal insufficiency (189 patients), 9.0% developed contrast nephropathy (P = 0.015) with 4.8% of patients developing irreversible renal damage (P = 0.03). This compared with 4.9% of patients receiving iodixanol (185 patients) and 3.1% of patients receiving iohexol (194 patients) with normal baseline renal function developing contrast nephropathy (P = 0.38) with 3.2% of the iodixanol patients and 1.0% of the iohexol patients developing irreversible renal damage (P = 0.13). Conclusions: The risk of contrast-induced nephropathy is significantly higher in patients with underlying renal insufficiency receiving iodixanol than that for patients with normal baseline renal function, but this should not serve as an absolute contraindication for these patients to receive intravenous iodinated contrast for diagnostic CT examinations particularly in patients with life-threatening clinical questions in which contrasted CT may provide valuable information.

Sonography: A useful tool to detect the mechanical causes of renal transplant dysfunction

The purpose of this study was to evaluate the utility of sonography in distinguishing between mechanical and nonmechanical causes for renal transplant dysfunction.

Imaging for whom : Patient or physician?

OBJECTIVE Radiologic imaging examinations are being ordered beyond the margin of medical necessity. Radiologists can assess the value of imaging in a variety of clinical situations by gathering data regarding test ordering patterns and their effects on patient outcomes. CONCLUSION Emerging information technologies have the potential to facilitate the collection of data and permit the dissemination of appropriate guidelines to limit the number of unnecessary and possibly harmful examinations.