Search

Supplemental Digital Content is available in the text., Background: Abdominal aortic aneurysm (AAA) can occur in patients who are ineligible for routine ultrasound screening. A simple AAA risk score was derived and compared with current guidelines used for ultrasound screening of AAA. Methods: United Kingdom Biobank participants without previous AAA were split into a derivation cohort (n=401 820, 54.6% women, mean age 56.4 years, 95.5% White race) and validation cohort (n=83 816). Incident AAA was defined as first hospital inpatient diagnosis of AAA, death from AAA, or an AAA-related surgical procedure. A multivariable Cox model was developed in the derivation cohort into an AAA risk score that did not require blood biomarkers. To illustrate the sensitivity and specificity of the risk score for AAA, a theoretical threshold to refer patients for ultrasound at 0.25% 10-year risk was modeled. Discrimination of the risk score was compared with a model of US Preventive Services Task Force (USPSTF) AAA screening guidelines. Results: In the derivation cohort, there were 1570 (0.40%) cases of AAA over a median 11.3 years of follow-up. Components of the AAA risk score were age (stratified by smoking status), weight (stratified by smoking status), antihypertensive and cholesterol-lowering medication use, height, diastolic blood pressure, baseline cardiovascular disease, and diabetes. In the validation cohort, over 10 years of follow-up, the C-index for the model of the USPSTF guidelines was 0.705 (95% CI, 0.678–0.733). The C-index of the risk score as a continuous variable was 0.856 (95% CI, 0.837–0.878). In the validation cohort, the USPSTF model yielded sensitivity 63.9% and specificity 71.3%. At the 0.25% 10-year risk threshold, the risk score yielded sensitivity 82.1% and specificity 70.7% while also improving the net reclassification index compared with the USPSTF model +0.176 (95% CI, 0.120–0.232). A combined model, whereby risk scoring was combined with the USPSTF model, also improved prediction compared with USPSTF alone (net reclassification index +0.101 [95% CI, 0.055–0.147]). Conclusions: In an asymptomatic general population, a risk score based on patient age, height, weight, and medical history may improve identification of asymptomatic patients at risk for clinical events from AAA. Further development and validation of risk scores to detect asymptomatic AAA are needed.

Introduction: The prenatal diagnosis of conotruncal defects (CTDs) has improved over the past decade, particularly with inclusion of outflow tract imaging at routine ultrasound. Appropriate prenatal counseling for CTDs demands an accurate diagnosis, as even more subtle cardiac pathology could complicate clinical outcomes. We sought to determine the anatomical accuracy of fetal echocardiography in evaluating common CTDs and factors that contribute to accuracy. Methods: All cases of tetralogy of Fallot(TOF), double outlet right ventricle(DORV) and truncus arteriosus(TA) encountered in our institution from 2007-2018 were reviewed. Discrepancies in anatomical findings between prenatal (most accurate exam) and postnatal (echo/surgery) or autopsy exams were categorized as: C1) no difference C2) minor difference with no impact on outcome (e.g.aberrant right subclavian artery), C3) minor difference that could make a minor difference to the delivery plan or surgery (e.g.branch pulmonary artery stenosis), C4) major difference that changes the course of the pregnancy, delivery or surgical planning (e.g.ductal dependency). Results: Of the 255 CTD cases, 162 had prenatal and postnatal and/or autopsy data available. Of the 162, 107(65.6%) fit C1, 35(21.5%) C2, 12(7.4%) C3, and 8(5.5%) C4. The greatest accuracy was observed in TOF, with 69/71(97.2%) in C1 and C2 versus 56/69(81.2%) in DORV and 16/22(72.7%) in TA(p=0.003). Excluding 5 cases at 10-16weeks, there was a tendency towards a greater proportion in C1 and C2 when examined at 17-23 weeks (60/64, 93.4%) versus 24-32 weeks (50/57, 87.7%) and >32 weeks (28/36, 77.8%) (p=0.06). Era of assessment also revealed a difference with 43/55(78.2%) of studies performed from 2007-2011 in C1 and C2 versus 99/107(92.5%) from 2012-2018 (p=0.01).When we compared pregnancies with one versus serial exams, we observed a lower proportion of C4 cases from 9.6% to 2.7%, respectively. In those with serial exams, 20% had achieved C1 or C2 only at serial exam. Conclusions: The diagnostic accuracy of fetal echocardiography in CTDs is generally high, especially for TOF and when performed at 17-24weeks. There has been significant improvement in accuracy since 2011. Serial exams potentially improve diagnostic accuracy.

This study aimed to evaluate the advantages of routine ultrasound (US), contrast-enhanced US (CEUS), and the combination of these 2 methods in diagnosing papillary thyroid carcinoma (PTC). We subjected 89 patients with calcified thyroid nodules to conventional US and CEUS and then retrospectively analyzed the US and CEUS features of 89 patients with single, solid PTC. On this basis, we then evaluated the ability of US, CEUS, and their combination to diagnose PTC. In the 89 patients with thyroid nodules, US findings differed significantly from CEUS findings (P < 0.05). In the US group, the diagnostic sensitivity, specificity, and accuracy were 87.5%, 78.8%, and 88.0%, respectively; in the CEUS group, these values were 92.9% (P < 0.05), 87.9% (P < 0.05), and 92.9% (P < 0.05), respectively; and when the methods were combined, the diagnostic sensitivity, specificity, and accuracy were 96.7%, 92.7%, and 94.9%, respectively. A typical PTC nodule can be definitively diagnosed using US and CEUS; more specifically, the features of slow progression, late enhancement, and low enhancement were highly associated with a diagnosis of PTC. When these features were combined, they exhibited higher diagnostic performance than any individual method.

Summary:. A distal deep vein thrombosis is generally believed to be clinically unimportant because of a low incidence of pulmonary emboli. To the author’s knowledge, a symptomatic pulmonary embolism has not been reported in association with an isolated calf deep vein thrombosis in a plastic surgery outpatient. This case report provides the clinical details of a pulmonary embolism occurring after routine ultrasound detection of a distal deep vein thrombosis. Proximal deep venous thromboses originate in the calf and are dangerous because they frequently embolize. Ultrasound surveillance provides early detection of subclinical distal deep vein thromboses. Anticoagulation is initiated, suppressing propagation of the thrombosis to the deep veins of the thigh, and reducing the risk of a catastrophic pulmonary embolism.

Hepatoblastoma is an uncommon fetal neoplasm that may represent an isolated malignancy or a component of a familial cancer or syndromic diagnosis.A large fetal liver mass was detected on routine ultrasound examination of a 23-year-old woman with thyroid nodules and hypertension. Inferior vena cava compression prompted delivery; postnatal biopsy revealed hepatoblastoma. Maternal thyroid biopsy revealed papillary carcinoma. Neonatal and maternal cytomolecular analysis revealed APC gene disruption at 5q22.2. Pedigree analysis exposed multigenerational colon cancer and thyroid cancer, which in conjunction with genetic testing is consistent with familial adenomatous polyposis.This is a novel means of familial adenomatous polyposis diagnosis. Obstetricians and perinatologists should be alert for familial cancer or syndromic diagnoses presenting as fetal neoplasms.

While controversy continues about the appropriateness of routine ultrasound screening, there are little data on actual clinical practices or trends in the United States.To examine changes in prenatal ultrasound utilization over time and determine whether ultrasound utilization is associated with maternal age, race/ethnicity, payer status, region of the country, or pregnancy risk group.Data on prenatal visits to office-based physicians and hospital outpatient departments from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey in 1995 to 2000, 2005, and 2006.Prenatal ultrasound use as recorded by a checkbox on the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey survey forms. We calculated the percent of visits with ultrasound, average number of ultrasounds per pregnancy, and adjusted odds ratios (ORs) of receiving an ultrasound.Overall, the estimated average number of ultrasounds per pregnancy increased from 1.5 in 1995-1997 to 2.7 in 2005-2006. For low-risk pregnancies, the estimated number of ultrasounds during that time period increased from 1.3 to 2.1. For high-risk pregnancies, the number increased from 2.2 to 4.2. In an adjusted analysis, the odds of a woman receiving an ultrasound in 2005-2006 were twice those of a visit in 1995-1997 [OR = 2.02; 95% CI (1.36, 3.00); P0.01]. High-risk women had odds of receiving an ultrasound that were almost twice that of women in the low-risk group [OR = 1.91; 95% CI (1.41, 2.59); P0.01].Both low-risk and high-risk pregnant women in the United States are much more likely to receive repeated ultrasound examinations today than they were 10 years ago.

Percutaneous liver biopsy is a commonly performed procedure in modern hepatology. Although it is a safe procedure and performed in most cases on an outpatient basis, complications including mortality have been reported. It is widely perceived that the use of ultrasound guiding for the biopsy produces a decrease in complications and is safer. There is now a trend for more centers to adopt a policy of ultrasound-guided biopsies only. There are, however, no official guidelines that recommend such a policy. This trend for ultrasound guidance of invasive procedures is also becoming apparent in other areas such as the insertion of a central venous line in children. The literature in support of such a position is far from conclusive. Because there are medicolegal and economic implications for the policy of routine ultrasound guiding of biopsies, we suggest that there is a need for the major professional organizations to make a clear declaration on this issue.

The benefits of screening ultrasonography in low-risk pregnancies are uncertain and require further investigation. As researchers organize future trials, however, they will need to define clearly the structure and content of the screening ultrasound examination and explicitly detail those outcomes considered important. Such studies must examine the effectiveness of screening sonography in comparison with and in the context of other available prenatal tests and screens. Until studies showing efficacy are available, screening ultrasound in low-risk pregnancies should be considered only when patients, guided by clinicians, consider the potential benefits to be of value.

Background Second trimester routine ultrasound evaluation of the fetal heart by means of the four-chamber view has been proposed for prenatal detection of cardiac anomalies. The aim of this study was to evaluate the efficacy of this procedure. Methods and Results A prospective follow-up study on 6922 scanned fetuses was performed. Pregnant women without known risk factors who were scheduled for a routine fetal ultrasound examination between 16 and 24 weeks gestation were invited to participate. Follow-up until 6 months postpartum was available for 5660 subjects (81.8%), of whom 5319 fulfilled all eligibility criteria. By comparing the prenatal diagnosis to the postnatal diagnosis, we obtained sensitivity, specificity, and predictive value (positive and negative). A total of 80 cases of congenital malformations were diagnosed during the study: 44 cases of congenital heart disease, 40 cases of noncardiac malformations, and a combination of the two in 4 cases. The fetal four chamber–view examination was considered abnormal in 7 women who were subsequently referred for extensive fetal ultrasound examination. Two proved to be carrying an affected fetus. Similarly, prenatal referral of 14 women because of suspected noncardiac malformations yielded 12 such cases. The fetal four chamber–view examination had a sensitivity of 4.5% (95% CI, 0.6% to 15%). Sensitivity for noncardiac anomalies was 30% (95% CI, 16.6% to 46.5%). Overall sensitivity of ultrasound examination was 16.3% (95% CI, 2.09% to 48.8%). Specificity and negative predictive value were high (>98%). The positive predictive value was low with wide CIs. Conclusions These results suggest that the current mode of routine prenatal ultrasound screening for congenital malformations is inefficient, particularly for cardiac anomalies.

In the USA, the cost-effective use of health-care dollars is currently of great importance. The routine use of technology such as ultrasound will undergo great scrutiny. Both the American College of Obstetricians and Gynecologists and the US National Institutes of Health have recommended that ultrasound be used only for indicated reasons because of concerns about safety and efficacy.

We present a case of pentalogy of Cantrell which was diagnosed prenatally on routine ultrasound examination. There were several associated limb defects. We discuss the differential diagnosis and conclude that our case probably had a variant form of this syndrome.

The interest in studying routine ultrasound in pregnancy has provided useful results that can be applied to practice. There is no consistent evidence of risk caused by ultrasound, neither biologic risk for the fetus nor increased use of health services as a result of ascertained conditions. There is also no consistent benefit to routine ultrasound in terms of important health outcomes. In the United States, this finding may be related to the excellent care provided to women in the usual-care arm of trials and possibly also to practice patterns. For example, with a high background induction rate in the United States, the prevalence of perinatal morbidity from post-term pregnancy may be so low that differences could not be ascertained between routine-ultrasound and usual care arms of the RADIUS study. The evidence from the use of ultrasound to screen for anomalies reveals substantial concern regarding interobserver variability, as might be expected when using a test for screening that requires considerable skill. The range of observed sensitivities underscores the disadvantages of performing basic ultrasound on a routine basis rather than on selected patients. Because routine ultrasound can reduce perinatal deaths in a population of women who would consider pregnancy termination, pretest counseling may identify a subset of women for whom screening may be effective in improving health outcomes. This remains to be demonstrated in the United States.

Routine ultrasound examination was performed in 9012 fetuses of a general pregnant population to detect fetal malformations. The examination was done on 3098 fetuses at 18 weeks, and on 5914 fetuses it was repeated at 34 weeks. Ninety-three infants (1.03%) showed 123 major malformations, of which 65 (52.8%) in 54 children were visualized in utero. The sensitivity of detection of malformed fetuses was 58.1% (54 of 93), specificity 99.9%, positive predictive value 91.5%, and negative predictive value 99.6%. Five fetal hydronephroses were the only false-positive cases (0.06%), with apparent spontaneous resolution after birth. Fetal growth retardation, polyhydramnios, or oligohydramnios was observed in 43% of the malformed cases, suggesting the importance of these conditions in ultrasound screening. Abnormality of pregnancy was suspected clinically in only 25.8% of the cases at the time of diagnosis of fetal malformation, emphasizing the necessity for ultrasound examination of all pregnancies.

Routine ultrasound examination of the fetus is already established in most obstetric units in Britain. A simple method was devised to evaluate one section of the fetal heart systematically. Examination of this section, the four chamber view, may readily be incorporated into routine obstetric screening. Severe cardiac abnormalities detectable in this view occur in two per 1000 pregnancies. For six years the department of paediatric cardiology at Guy's Hospital, London, served as a referral centre for fetal echocardiography. As teaching became more widespread an increasing proportion of cases of cardiac anomaly were referred because the obstetrician suspected abnormality on examination of the four chamber view. Currently 80% of detected abnormalities are referred for this reason. Further extension and organisation of teaching might result in most severe cardiac malformations being detected in early prenatal life.