Ultrasound and Osteoporosis

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There is an insidious nature to osteoporosis. It is a gradual loss of bone tissue that is so slow that it is usually not noticed until there is a traumatic event like a fracture. Screens exist that can predict osteoporosis and allow treatment to begin early, and one of the best screens is ultrasound based.

Quantitative ultrasound (QUS) measures the speed of sound and broad band ultrasonic attenuation of the ultrasound beam as it passes between two ultrasound transducers. QUS can become a screen that may be predict future fractures in peri-menopausal and immediate post-menopausal women, and senior citizens of both genders. Those who have low QUS values for the ankle bone, the most common bone screened, are referred for further testing, like measurements of the spine.

QUS works by measuring how the ultrasound machine beam changes as it passes through the bone. The name for this type of ultrasound is Broad Band Ultrasonic Attenuation, or BUA. QUS can also measure how quickly the ultrasound beam passes through the patient’s bone; the name for this is Speed of Sound, abbreviated as SOS.

These two readings when taken together can tell us about how bones are structured, whether or not they are elastic, and how strong they are—in short, measures of the quality of the bone. That can be compared to the bone density. Taken together, these two assessments can help doctors predict each patient’s risk of suffering a bone fracture.

The bones of the foot are used because just like the lumbar spine, as we age these bones change. Spinal changes cause the majority problems in patients with osteoporosis. In addition, QUS is a simple process, the equipment is portable, and for the patient there is no radiation exposure.

In the three-year multicenter study, 6,174 women age 70 to 85 with no previous formal diagnosis of osteoporosis were screened with heel-bone quantitative ultrasound (QUS), a diagnostic test used to assess bone density. QUS was used to calculate the stiffness index, which is an indicator of bone strength, at the heel. Researchers added in risk factors such as age, history of fractures or a recent fall to the results of the heel-bone ultrasound to develop a predictive rule to estimate the risk of fractures. The results showed that 1,464 women (23.7 percent) were considered lower risk and 4,710 (76.3 percent) were considered higher risk.
Study participants where mailed questionnaires every six months for up to 32 months to record any changes in medical conditions, including illness, changes in medications or any fracture. If a fracture had occurred, the patients were asked to specify the fracture's precise location and trauma level and to include a medical report from the physician in charge.
In the group of higher risk women, 290 (6.1 percent) developed fractures whereas only 27 (1.8 percent) of the women in the lower risk group developed fractures. Among the 66 women who developed a hip fracture, 60 (90 percent) were in the higher risk group.
The results show that heel QUS is not only effective at identifying high-risk patients who should receive further testing, but also may be helpful in identifying patients for whom further testing can be avoided.
"Heel QUS in conjunction with clinical risk factors can be used to identify a population at a very low fracture probability in which no further diagnostic evaluation may be necessary".

 Studies have shown that a combination of QUS and an inquiry about personal and familial risk factors would detect more cases of osteoporosis and had slightly better chance to predict fractures than the risk factors inquiry alone. It has also been discovered that ultrasound test alone have much better predictive value than risk factors alone. It is, however, still good clinical practice to do an overall assessment of risk for osteoporosis rather than QUS alone.

Ultrasound machine scanning, therefore, is a simple, quick, safe, portable, and inexpensive clinical test. It can provide physicians an opportunity to improve on the current method of identifying patients at risk for osteoporosis and the associated fractures.

THYROID NODULES: ROLE of CORE-NEEDLE BIOPSY

Abstract

Purpose: To evaluate the role of core-needle biopsy (CNB) in thyroid nodules with nondiagnostic results at previous fine-needle aspiration (FNA).

Materials and Methods: From October 2008 to July 2011, 155 nodules from 155 patients (37 men, 118 women) with a mean age of 51.8 years (age range, 22–76 years) with nondiagnostic results at previous FNA were reviewed retrospectively. The Bethesda system for reporting thyroid cytopathologic results was used to assign FNA and CNB findings. Malignant nodules (n = 37) were diagnosed after surgery. Benign nodules (n = 79) were diagnosed either after surgery, with benign findings after FNA and/or CNB that had been repeated at least twice, or after benign cytology findings at FNA or CNB with a stable size at follow-up. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ultrasonographically guided CNB were evaluated.

Results: At CNB, two nodules (1.3%) showed nondiagnostic results, and 135 nodules (87.1%) had conclusive diagnoses. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of core biopsies for the detection of malignancy were 94.6% (35 of 37), 100% (79 of 79), 100% (35 of 35), 97.5% (79 of 81), and 98.3% (114 of 116), respectively. For 28 nodules, nondiagnostic results were found after two or more FNA procedures; however, diagnostic surgery was performed in only one patient.

Conclusion: CNB of the thyroid nodule demonstrates high rates of conclusive and accurate diagnoses in patients for whom previous FNA results were nondiagnostic, thereby reducing the need for unnecessary diagnostic surgery.

© RSNA, 2013

NHÂN CA PSEUDOMYXOMA PERITONEI ở MEDIC

Xem Appendiceal Mucocele: US Findings
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Pseudomyxoma peritonei (PMP) usually begins as a slow-growing tumour in the appendix, called a Low-Grade Mucinous Appendiceal Neoplasm (LAMN). Rarely, PMP starts in other parts of the bowel, ovary or bladder.

Over time, the tumour produces a jelly-like substance called mucin. This can cause the appendix to swell up like a balloon. The tumour can then break through the wall of the appendix and spread tumour cells into the lining of the tummy (the peritoneum).

The tumour cells and mucin build up in the lining of the tummy, putting pressure on the bowel and causing symptoms. It can be many years before symptoms become obvious. Unlike other cancers, PMP rarely spreads via the lymphatic system or the bloodstream. It usually remains inside the tummy, spreading along its internal surfaces.

Causes of pseudomyxoma peritonei

The cause of PMP is unknown.

Signs and symptoms of pseudomyxoma peritonei

Most people don't have any symptoms for a long time. When symptoms occur they may include any of the following:

• slow increase in waist size
• hernia (a swelling on the abdomen)
• loss of appetite
• unexplained weight gain
• abdominal or pelvic pain
• changes in bowel habits
• appendicitis.

Most people with these symptoms won't have PMP, but it's important to have any symptoms checked by your doctor.

How pseudomyxoma peritonei is diagnosed

PMP can be difficult to diagnose. It may be found during investigations into abdominal symptoms, or it may be discovered during an operation for another problem.

CT (computerised tomography) scan

A CT scan takes a series of x-rays that build up a three-dimensional picture of the inside of the body. The scan is painless. It can help to find where the tumour started and check whether it has spread within the abdomen. It usually takes 10-30 minutes. CT scans use a small amount of radiation, which is very unlikely to harm you and won't harm anyone you come into contact with. You will be asked not to eat or drink for at least four hours before the scan.

You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it's important to let your doctor know beforehand.

Sometimes the pictures from the CT scan are enough to make the diagnosis, but sometimes biopsies or an operation are needed to be sure of the diagnosis of PMP.

Treatment

The treatment of PMP depends on a number of factors. These include how far the tumour has spread and your general health. Some of the standard cancer treatments, such as radiotherapy, aren't suitable for treating PMP. This is because PMP cells aren't sensitive to radiotherapy and they are often spread over too large an area for this treatment.

Surgery

You may be offered surgery| to treat this kind of cancer. There are two types of surgery:

• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).
• Debulking surgery.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC)

This may be an option for some people. It‘s an intensive treatment that aims to remove the tumour to try to cure PMP. It is also known as the Sugarbaker technique (named after the surgeon who first developed it). It involves removing the lining of the abdomen or organs such as the bowel, omentum (fatty tissue in the tummy) and gallbladder. In women, the womb (uterus) and ovaries may also be removed. About half (50%) of people who have a Sugarbaker operation will need a stoma (colostomy). Most of the stomas are temporary and will be reversed after about six months.

Once the surgeon has removed all or most of the tumour, a heated chemotherapy drug is put in the tummy (hyperthermic intraperitoneal chemotherapy) for 90 minutes during the operation. The combination of the chemotherapy drug and heat aims to kill any tumour cells that are left behind.

This is a major operation and may take up to 10 hours. Afterwards, you’ll be nursed in a critical care unit for several days and will stay in hospital for about 2 weeks. This operation has potentially serious complications and the surgeon will discuss these with you.

The National Institute for Health and Clinical Excellence (NICE)| is an organisation that currently advises doctors on treatments for all types of illness. It has produced guidelines about this type of surgery with intraperitoneal chemotherapy. You can read the guidelines on the NICE website.

It's very important to discuss this operation with specialist doctors, as the Sugarbaker technique is a very complicated procedure and isn't suitable for everyone. It should only be carried out at a specialist centre. There are two in the UK:

• The Basingstoke and North Hampshire Hospital
• The Christie Hospital – Manchester.

Debulking surgery

This is done when it’s not possible to have cytoreductive surgery. It aims to remove as much of the tumour as possible to reduce the symptoms of the cancer. This may involve removing the omentum (fatty tissue in the tummy) and part of the bowel. In women, the womb (uterus) and ovaries may also be removed.

Unfortunately, this surgery will not take away all the tumour cells and the PMP is likely to grow back. Further debulking operations may be needed. However, each operation becomes more difficult to do, with less benefit and more risks of complications each time.

Sometimes, a permanent stoma is needed after debulking surgery. It can help to prevent the bowel from becoming blocked (obstructed). Your specialist nurse can give you more information about looking after a stoma.

Chemotherapy

Chemotherapy| can be used to treat PMP. Some people who can’t have surgery may benefit from chemotherapy. It does not cure the cancer but can be used to slow it down. Research into other treatments for PMP is ongoing and advances are being made. Cancer specialists use clinical trials| to assess new treatments. You may be asked to take part in a clinical trial. Your doctor must discuss the treatment with you so that you have a full understanding of the trial and what it means to take part.

Watchful waiting

For some people, the risks of treatment may outweigh the potential benefits, especially as this can be a slow-growing cancer. If you're in this situation, your specialist may suggest watchful waiting. This involves being monitored closely with regular check-ups. Only if the PMP begins to cause you problems will your specialist discuss starting treatment.

Reviewing information is just one of the ways you could help when you join our Cancer Voices network|.

Content last reviewed: 1 February 2013

Ultrasound Helps Diagnose Lung Congestion in Dialysis Patients

 

 

Asymptomatic lung congestion has been shown to increase dialysis patients’ risks of dying prematurely or experiencing myocardial infarctions or other cardiac events, according to recent research.

The findings also revealed that utilizing lung ultrasound to identify this congestion aids in diagnosing patients at risk. Italian investigators recently measured the degree of lung congestion in 392 dialysis patients by using a very simple and inexpensive technique – lung ultrasound.

Lung congestion due to fluid accumulation is very common among kidney failure patients on dialysis, but it frequently does not cause any symptoms. To see whether such asymptomatic congestion affects dialysis patients’ health, Carmine Zoccali, MD, from Ospedali Riuniti (Reggio Calabria, Italy; www.rc.ibim.cnr.it) and his colleagues published their study findings February 28, 2013, in the  Journal of the American Society of Nephrology (JASN).

Among the major findings (1) Lung ultrasound revealed very severe congestion in 14% of patients and moderate-to-severe lung congestion in 45% of patients. (2) Among those with moderate-to-severe lung congestion, 71% were asymptomatic. (3) Compared with those having slight or no congestion, those with very severe congestion had a 4.2-fold increased risk of dying and a 3.2-fold increased risk of experiencing heart attacks or other cardiac events over a two-year follow-up period. (4) Lastly, asymptomatic lung congestion identified by lung ultrasound was a better predictor of patients’ risk of dying prematurely or experiencing cardiac events than symptoms of heart failure.

By evaluating subclinical pulmonary edema can help better establish dialysis patients’ prognoses, according to the findings.The researchers will soon initiate a clinical trial that will integrate lung fluid measurements by ultrasound and will examine whether dialysis intensification in patients with asymptomatic lung congestion can reduce the risk of heart failure and cardiac events and prevent premature death.

From MII, June 2013

 Background

Advancement in dialysis technology and new drug therapies of uremic complications are major achievements of modern nephrology. As a result of progress in the care of ESRD, a continuous increase in survival of dialysis 4 patients has been documented over the last 13 years in the European Renal Association-European Dialysis Transplant Association (ERA-EDTA) registry (1). Adequate control of fluid balance is a primary goal of dialysis treatment and experience in centres applying strict volume control policies documented a remarkable reduction in mortality in comparison with average mortality rate in well matched cohorts in the USRDS and in the ERA-EDTA Registry (2). Even though specific recommendations in past and current guidelines emphasise the risk of volume overload, the problem still remains pervasive in the dialysis population (3). Unsatisfactory control of volume expansion depends on various reasons encompassing both medical and non-medical factors such as reimbursement of the cost of extra or longer dialyses and other organizational and logistic factors. As to the medical factors, it is widely agreed that the high prevalence of patients with LV dysfunction and heart failure and the lack of simple, non-expensive, bedside techniques that may serve to estimate and monitor parameters of central hemodynamics for guiding the prescription of ultrafiltration (UF) and drug treatment  is a factor of major clinical relevance.

Extra-vascular lung water (LW), a fundamental component of body fluids volume, represents the water content of the lung interstitium which is strictly dependent on the filling pressure of the left ventricle (4; 5). Chest ultrasound (US) has recently emerged as a reliable technique for detecting LW in intensive care patients (6) and in patients with heart failure (7). The basic principle of this technique is that in the presence of excessive LW, the ultrasound beam is efflected by subpleural thickened interlobular septa, a low impedance structure surrounded by air with a high acoustic mismatch. US reflection generates hyperechoic reverberation artefacts between thickened septa and the overlying pleura which are defined “lung comets” (8). These artefacts are easily detected with standard US probes and chest US has been formally validated as a reliable technique to estimate LW in patients with heart diseases (9). This method captures changes in LW which occur across dialysis and the feasibility and repeatability of chest US studies in hemodialysis patients has been recently described (10). However the clinical usefulness of this technique in the everyday care in ESRD patients is still untested and it remains unknown whether systematic application of chest US may translate into better clinical outcomes in these patients. With this background in mind the European Renal and Cardiovascular Medicine (EURECA-m) working group of the ERA-EDTA designed a randomised, multicenter, clinical trial investigating whether a treatment policy based on LW monitoring in haemodialysis patients by chest US is more effective than standard clinical monitoring for reducing death, decompensated heart failure and myocardial infarction and prevent the evolution of LVH and LV dysfunction in patients with myocardial ischemia or heart failure over a 2-year follow-up.

 

This trial will be the first which formally tests a biomarker as a guide the optimize volume control and drug treatment in high risk dialysis patients. Other promising indicators of fluid volume in dialysis patients - such as body impedance analysis (BIA) or cardiac natriuretic peptides - have never been tested into a clinical trial, which is a basic requirement for recommending systematic use of biomarkers in clinical practice.

DIAGNOSIS of INCISIONAL HERNIA: DYNAMIC ULTRASOUND versus CT

Femoral hernias, Henry Robert Whalen, Gillian A Kidd, Patrick J O’Dwyer

BMJ2011;343doi: http://dx.doi.org/10.1136/bmj.d7668(Published 8 December 2011)

Cite this as:BMJ2011;343:d7668

 

An overweight 65 year old woman visits her general practitioner with discomfort in her right groin. On examination, the suggestion of a reducible groin lump is noted. She is routinely referred to the surgical outpatient clinic with a possible diagnosis of inguinal hernia. However, two weeks later and before her surgical appointment, she again visits her general practitioner, this time with vomiting, diarrhoea, and colicky abdominal pain. She is immediately referred to the emergency department. An abdominal radiograph shows small bowel obstruction. She is admitted to the surgical ward with a diagnosis of obstructed femoral hernia and has a small bowel resection and emergency hernia repair.

What is a femoral hernia?

A femoral hernia is the protrusion of a peritoneal sac through the femoral ring into the femoral canal, posterior and inferior to the inguinal ligament. The sac may contain preperitoneal fat, omentum, small bowel, or other structures.

How common are femoral hernias?

·         About 5000 femoral hernia repairs are carried out in the United Kingdom each year

·         Femoral hernias account for a fifth of all groin hernias in females but less than 1% of groin hernias in males

·         The 40% of femoral hernias that present acutely are associated with a 10-fold increased risk of mortality1 2

Why is a femoral hernia missed?

Evidence is scarce as to the reason why femoral hernias are often missed and present as emergencies. Patients may be aware of groin discomfort or a groin lump, but they may not realise its clinical importance and may be reluctant to seek medical help. Initially some patients present to primary care with vague symptoms including groin discomfort that may be attributed to other disease such as osteoarthritis. As femoral hernias are typically small, they may be easily missed on examination, particularly in obese patients. Furthermore, owing to the difficulty in clinically distinguishing groin hernias, femoral hernias may be mistaken for inguinal hernias and referred for surgical opinion on a non-urgent basis.3

In an emergency, patients may present with signs of bowel obstruction, which include colicky abdominal pain, vomiting, and abdominal distension. About a third of patients do not complain of symptoms directly attributable to a hernia,4 and a groin lump is not always present. Other diagnoses, such as gastroenteritis, enlarged groin lymph node, diverticulitis, or constipation, may be made in error.⇓

Inguinal hernias are usually reducible and above the inguinal ligament. Femoral hernias are often irreducible and below the inguinal ligament. Adapted with permission from Ellis H. Clinical anatomy. 6th ed. Blackwell Scientific, 1977

Retrospective studies have observed that about 40% of hernias causing symptoms of acute bowel obstruction are missed owing to a lack of groin examination.5 6 The researchers concluded that female patients and all patients with femoral hernia were less likely to have a groin examination, despite signs of bowel obstruction being noted.5

Why does this matter?

Although femoral hernias are less common than inguinal, they are associated with higher rates of acute complication. The cumulative probability of strangulation for femoral hernias is 22% three months after diagnosis, rising to 45% 21 months after diagnosis, whereas the probability of strangulation for an inguinal hernia is 3% and 4.5% respectively over the same time period.7

Several studies have shown that acute femoral hernias and their subsequent complications are associated with increased morbidity and mortality.1 2 8 9 10 Examples of morbidity resulting from acute presentation include increased rates of bowel resection, wound infection, and cardiovascular and respiratory complications.10 As elective femoral hernia repair has been shown to be a relatively safe procedure (even in patients aged over 80), it is generally accepted that femoral hernias should be referred urgently and repaired electively.2 10 11 12

Missed femoral hernia at emergency presentation delays time to surgery.5 One study has shown an increased likelihood of bowel resection if surgery is undertaken more than 12 hours after the onset of acute symptoms.13 Preoperative delay is clearly linked with an increase in bowel resection, and this is associated with mortality rates that are about 20 times higher than those for patients having elective hernia repair (which would not require a bowel resection).2

How is it diagnosed?

Clinical

Classically, femoral hernias present as mildly painful, non-reducible groin lumps, located inferolateral to the pubic tubercle. In contrast, inguinal hernias are found superomedially. However, femoral hernias tend to move superiorly to a position above the inguinal ligament, where they may be mistaken for an inguinal hernia. Differentiation of groin hernias on clinical grounds is therefore unreliable, irrespective of the experience of the examining doctor.14 In patients presenting electively, only about 1% of groin hernias in males are likely to be femoral, whereas the likelihood in females is about 20%.1 Clinical examination alone is inaccurate in differentiating groin hernia.14 Therefore in females, owing to the greater prevalence of femoral hernia, consider all groin hernia to be femoral until proved otherwise.

Femoral hernias may also present without a palpable lump and with only vague symptoms of abdominal or groin pain. However, symptoms may vary and there is a lack of evidence to predict the likelihood of a particular symptom indicating the presence of a femoral hernia. Patients may present later with clinical features of bowel obstruction. Undertake a detailed groin examination in all patients presenting with bowel obstruction.

Investigations

Ultrasonography, magnetic resonance imaging, and computed tomography (CT) have all been shown to be accurate in detecting and differentiating groin hernias.

Ultrasonography is widely available, non-invasive, and highly accurate in differentiating inguinal from femoral hernia—with sensitivities and specificity of 100% being reported in two studies.15 16 Its accuracy is, however, operator dependent.

Magnetic resonance imaging has been reported to be more accurate than ultrasonography in detecting inguinal hernia.17 However, there is a lack of evidence for whether magnetic resonance imaging is better than ultrasonography in detecting and differentiating groin hernia. Therefore ultrasonography should be the first choice for electively investigating suspected groin hernia as it is more widely available, less costly, and accurate.

CT scanning has been shown to be accurate in differentiating groin hernias. One retrospective study reports the correct identification of 74 of 75 hernias (28 femoral and 47 inguinal), which were later confirmed at operation.18 This is broadly comparable with the non-invasive modalities outlined above, but as there is a substantial radiation dose associated with CT scanning, it should not be used electively for investigating suspected groin hernia. In the acute abdomen, however, consider CT as the first choice for investigating suspected small bowel obstruction in the presence of a negative clinical examination.

How is it managed?

In males, a groin hernia suspected as being femoral on clinical examination requires urgent referral, due to the risks of acute complications outlined above. All groin hernia in females should be urgently referred for assessment.

Electively, both open and laparoscopic repair using mesh have significantly lower recurrence rates than repair using sutures only.1 Open repair has the advantage that it can be performed under local anaesthetic. No evidence suggests superiority of either method in the acute setting.

Some research has suggested that femoral hernias may be overlooked during repair of suspected inguinal hernias.19 So during surgical repair of all groin hernias examine the femoral canal if an obvious inguinal hernia is not observed.

Key points

·         Femoral hernias are more common in females and in people aged over 65 years and are associated with higher rates of complications such as strangulation

·         Emergency surgery for femoral hernia is associated with a 10-fold increased risk of mortality, which is further increased by preoperative delays

·         Clinical examination is unreliable in differentiating femoral from inguinal hernia

·         Refer all females with groin hernia for urgent assessment and management

·         Examine the groins of all patients presenting with signs of small bowel obstruction

·         Ultrasound is the first line elective investigation for suspected uncomplicated groin hernia, but in acute small bowel obstruction, CT scanning is first choice