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Chronic venous insufficiency is one of the most common benign diseases in America. For treatment, minimally invasive techniques have become the first-line option. The literature shows that these procedures are well tolerated and work effectively without leaving the patient with unaesthetic operative scars. We discuss the case of a patient who developed two right lower extremity neuromas as a rare complication following endovenous laser ablation and microphlebectomy procedures for the treatment of varicose veins. Ultrasound is the preferred imaging modality for the visualization and diagnosis of a neuroma and should be performed in post-phlebectomy patients with severe and persistent sensory pattern disruption as neuroma formation can lead to significant complications for the patient.

Preoperative ultrasound-guided lateral abdominal wall botulinum toxin injection is a promising method for improving patient outcomes and reducing recurrence rates after ventral hernia repair. A review of the literature demonstrates variability in the procedural technique, without current standardization of protocols. As radiologists may be increasingly asked to perform ultrasound-guided botulinum toxin injections of the lateral abdominal wall, familiarity with the procedure and current literature is necessary.

Targeted ultrasound of the median, ulnar, and radial nerves is a well-established technique for suspected upper extremity peripheral neuropathy. However, sonographic imaging of the brachial plexus and smaller peripheral nerve branches is more technically difficult and the anatomy is less familiar to many radiologists. As imaging techniques improve, many clinicians refer patients for imaging of previously less-familiar structures. In addition, some patients may present with injuries that could involve local neurovascular structures. Finally, patients presenting with isolated peripheral neuropathies may be referred for perineural injections with local anesthetic for diagnostic purposes, or steroid for therapeutic reasons. This requires sonologists to have a firm understanding of the courses of these nerves and the surrounding anatomic landmarks that can be used to accurately identify and characterize them. We discuss clinical syndromes referable to specific peripheral nerve branches in the upper extremity, the relevant anatomy, and sonographic technique.

Pathology of the fascia lata attachment at the iliac crest (FLAIC) is an under-recognized and often misdiagnosed cause of lateral hip pain. The fascia lata has a broad attachment at the lateral iliac crest with contributions from the tensor fascia lata muscle, the iliotibial band, and the gluteal aponeurosis. The FLAIC is susceptible to overuse injuries, acute traumatic injuries, and degeneration. There is a paucity of literature regarding imaging and image-guided treatment of the FLAIC. We review anatomy and pathology of the FLAIC, presenting novel high-resolution (18–24 MHz) ultrasound images including ultrasound guidance for targeted therapeutic treatment.

The common peroneal nerve arises from the sciatic nerve and is subject to a variety of abnormalities. Although diagnosis is often is based on the clinical findings and electrodiagnostic tests, high-resolution sonography has an increasing role in determining the type and location of common peroneal nerve abnormalities and other peripheral nerve disorders. This article reviews the normal sonographic appearance of the common peroneal nerve and the findings in 21 patients with foot drop related to common peroneal neuropathy.

The purpose of this study was to identify threshold right and left portal vein sonographic velocities that are correlated with subsequent development of hepatofugal flow in the main portal vein (MPV), a marker of portal hypertension.A database containing 6019 Doppler liver ultrasound reports from an academic hospital was parsed using a Visual Basic computer algorithm. Right and left portal vein velocities were identified from 65 patients who developed hepatofugal MPV flow. Patients with a liver transplant or transjugular intrahepatic portosystemic shunt were excluded. Similarly, right and left portal vein velocities were identified from 195 patients free of chronic hepatic disease. The right and left portal vein velocities of these 2 groups were analyzed using a receiver operating characteristic curve to identify threshold velocities with the optimal sensitivity and specificity for patients who will develop hepatofugal flow in the MPV.A threshold velocity of 11 cm/s in the right portal vein is associated with 81.8% sensitivity and 93.5% specificity in distinguishing patients who develop hepatofugal flow from otherwise healthy control subjects. Likewise, a threshold velocity of 8 cm/s in the left portal vein is associated with a 62.3% sensitivity and a 94.5% specificity.A threshold right portal vein velocity of 11 cm/s can be used with high sensitivity and specificity to identify patients who may develop hepatofugal flow in the MPV. A left portal vein velocity less than 8 cm/s is 94.5% specific for the development of hepatofugal flow.

The role of the radiologist is to initially raise suspicion of a mucopolysaccharidoses syndrome and determine the extent of involvement.

Colorectal cancer remains one of the most common causes of cancer death in this country. This malignancy is ideally suited for screening because the detection and removal of the precursor adenomatous polyp can prevent most colorectal cancers from ever forming. The choice of a test for screening involves consideration of various individual parameters, including patient age and the presence of risk factors for the development of colorectal cancer. Computed tomographic colonography (CTC) has emerged as the leading imaging technique for colorectal cancer screening in average-risk individuals on the basis of the evidence presented in this paper. The double-contrast barium enema is an alternative imaging test that is appropriate particularly when CTC is not available. In 2008, the American Cancer Society guideline for colorectal cancer screening was revised jointly with the US Multi-Society Task Force on Colorectal Cancer and the ACR to include CTC every 5 years as an option for average-risk individuals. Computed tomographic colonography is also the preferred test for colon evaluation after an incomplete colonoscopy. Imaging tests including CTC and the double-contrast barium enema are usually not indicated for colorectal cancer screening in high-risk patients with polyposis syndromes or inflammatory bowel disease. This paper presents the new colorectal cancer imaging test ratings and is the result of evidence-based consensus by the ACR Appropriateness Criteria ® Expert Panel on Gastrointestinal Imaging.

The original version of this article unfortunately contained mistake. Fig. 13a (Anatomy of the Ulnar Digital nerve of the Thumb) as originally published erroneously depicts the ulnar digital nerve of the thumb as a branch of the ulnar nerve.

In the past decade, new therapeutic agents have been developed that permit gastroenterologists to treat virtually all forms of Crohn's disease. The success of these treatments depends on an accurate diagnosis of the nature and extent of disease. Fortunately, radiologists now possess a powerful arsenal of imaging techniques to guide the choice of therapy. This article discusses the usefulness of both traditional and newer imaging techniques in the management of Crohn's disease and its various clinical presentations.

The emergence of methicillin-resistant Staphylococcus aureus (MRSA) within the community has altered health care practice because it is a major public health threat and has several important clinical implications. As the incidence of MRSA increases in the community, empirical treatment of communityacquired skin and soft tissue infections and necrotizing pneumonia without obtaining microbiological cultures from the infected site may not be appropriate and can lead to treatment failure if initial therapy includes a $-lactam antibiotic or other agents to which the bacteria is resistant. The Infectious Disease Society of America in their recently published guideline on community-acquired pneumonia recommends that although methicillin-resistant strains of S. aureus are still in the minority, the high mortality associated with inappropriate antibiotic therapy would suggest that empirical coverage should be considered when community-associated MRSA

Objectives Learning to perform physical examination of the abdomen is a challenge for medical students. Medical educators need to find engaging, effective tools to help students acquire competence and confidence in abdominal examination techniques. This study evaluates the added value of ultrasound training when Year 1 medical students learn abdominal examination. Methods The study used a randomised trial with a wait-list control condition. Year 1 medical students were randomised into 2 groups: those who were given immediate ultrasound training, and those for whom ultrasound training was delayed while they received standard instruction on abdominal examination. Standardised patients (SPs) used a clinical skills assessment (CSA) checklist to assess student abdominal examination competence on 2 occasions − CSA-1 and CSA-2 − separated by 8 weeks. Students also estimated SP liver size for comparison with gold-standard ultrasound measurements. Students completed skills confidence surveys. Results Proficiency in abdominal examination technique acquired from traditional instruction boosted with ultrasound training showed no advantage at CSA-1. However, at CSA-2 the delayed ultrasound training group showed significant improvement. Students uniformly underestimated SP liver sizes and the estimates were not affected by ultrasound training. Student confidence in both groups improved from baseline to CSA-1 and CSA-2. Conclusions Ultrasound training as an adjunct to traditional means of teaching abdominal examination improves students' physical examination technique after students have acquired skills with basic examination manoeuvres.

Athletic pubalgia, or "sports hernia", represents a constellation of pathologic conditions occurring at and around the pubic symphysis. These injuries are primarily seen in athletes or those involved in athletic activity. In this article, we review the sonographic appearance of the relevant complex anatomy, scanning technique for ultrasound evaluation of athletic pubalgia, and the sonographic appearances of associated pathologic conditions.

Objectives: Clinically palpable thyroid nodules are present in between 4% and 7% of the population, with only a small percentage of those harboring malignancy. Thus, it is important to find a cost-effective way to determine which nodules are more likely to be malignant. The purpose of this study was to evaluate the use of intrathyroidal calcifications detected on ultrasound as a risk factor for malignancy. Study Design: Retrospective chart review. Methods: One hundred fifty-nine patients with thyroid disease were included in this study. Patients were selected from a thyroid ultrasound (TUS) database. Charts were then reviewed, and only those patients who had a preoperative TUS and underwent surgery for tissue diagnosis were included. Results: Of the 159 patients, 66 (41.5%) were diagnosed with cancer. Of those with malignancy, 52 (78.8%) had calcifications noted on TUS. Ninety-three of the patients were diagnosed with benign pathology. Of those 93 patients, 36 (38.7%) had TUS findings consistent with calcifications, whereas 57 (61.3%) did not. Statistical analysis using a chi-square test showed a strong association between cancer status and calcification, with P < .001. In our study, calcifications on TUS had a sensitivity of 78.8% and a specificity of 61.3%, with an odds ratio of 5.88. Conclusion: The presence of calcifications detected on TUS should alert the physician for the possibility of malignancy, and further work-up should be pursued. This information may be used to improve the sensitivity of other diagnostic tests such as fine needle aspiration biopsies. Given the relatively low sensitivity and specificity of the test, its use alone as a marker of malignancy is limited, but it may be used in combination with other known risk factors and tests to decide on the most appropriate treatment plan.

Uterine artery embolization (UAE) is an effective, safe, nonsurgical treatment for uterine myomas. Although menstrual irregularities and transient amenorrhea have occurred after UAE, these reports did not provide proper hormonal documentation of ovarian failure. Our patient experienced elevated follicle-stimulating hormone (FSH) levels and vasomotor symptoms (hot flushes) within 4 weeks after the procedure. To our knowledge, this is the first report in the literature of ovarian failure after UAE confirmed by comparing preprocedure FSH levels with postprocedure levels over 12 months.

The terms wandering liver, hepatic torsion, and hepatic vagrancy have been applied to cases in which hepatic hypermobility results in displacement of the liver from its normal position within the right upper quadrant of the abdomen. This is thought to result from multiple factors, including the lack of normal hepatic suspensory ligaments, persistence of the ventral mesentery, and lack of inferior vena cava tethering Siddins and Cade (Aust N Z J Surg 60:400-403, 1990). A wandering liver has been described in both adults Siddins and Cade (Aust N Z J Surg 60:400-403, 1990), Tate (Am Surg 59:455-458, 1993), Chiavarini and Chang (Radiology 115:47-48, 1974), Cope and Levy (South Afr Med J 40:366-369, 1966), Sharov (Vestn Roentgenol Radiol 35:63-64, 1960), Puthenpurayil et al. (AJR 177:1113-1115, 2001), Fuentes et al. (AJR 188:331-333, 2007) and children Feins and Borger (AJR 188:331-333, 2007), Al-Ali et al. (Pediatr Radiol 27:287, 1997), and it is usually associated with bowel obstruction Siddins and Cade (Aust N Z J Surg 60:400-403, 1990), Tate (Am Surg 59:455-458, 1993), Chiavarini and Chang (Radiology 115:47-48, 1974), Cope and Levy (South Afr Med J 40:366-369, 1966), Sharov (Vestn Roentgenol Radiol 35:63-64, 1960), Fuentes et al. (AJR 188:331-333, 2007), Feins and Borger (AJR 188:331-333, 2007). We report a case of an incidental wandering liver in an adult without associated obstruction, diagnosed by multidetector computed tomography with multiplanar reformations.

Objectives Symptomatic groin hernias in women may be difficult to assess clinically and commonly mimic pathologic musculoskeletal and gynecologic conditions. The objective of our study was to investigate the accuracy of sonography in women with groin pain and normal physical examination findings. Methods A consecutive group of 87 women (median age, 44.6 years; range, 19-82 years) with groin pain and normal physical examination findings were included in the study. All patients had a standardized sonographic examination of the groin performed by an experienced radiologist or a sonographer. If a groin hernia was identified, it was classified as indirect, direct, or femoral. Normal examination findings and alternate pathologic groin conditions were also recorded. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the sonographic findings and compared to the findings for patients sent for surgery. Results Of the 87 women with groin pain, 37 groin hernias were diagnosed in 35 patients. Surgery was performed in 26 patients (27 groins). Sonography correctly depicted and classified groin hernias in 18 of the 21 groins that had surgical confirmation. Six women without groin hernias also had surgical exploration of the affected side. The sensitivity, specificity, positive predictive value, and negative predictive value for the patients with surgical confirmation were 95%, 75%, 95%, and 75%, respectively. Groin pain in 26 patients was attributed to other causes. The remainder of the patients had normal examination findings or were lost to follow-up. Conclusions Groin hernias in women can be occult and confound the clinical diagnosis. In a woman with groin pain and normal or indeterminate physical examination findings, we have found that sonography can accurately depict and classify groin hernias and other pathologic processes.

Non-randomised studies of haemopoietic stem-cell transplantation (HSCT) in systemic sclerosis have shown improvements in lung function and skin flexibility but high treatment-related mortality. We aimed to assess safety and efficacy of autologous non-myeloablative HSCT in a phase 2 trial compared with the standard of care, cyclophosphamide.In our open-label, randomised, controlled phase 2 trial, we consecutively enrolled patients at Northwestern Memorial Hospital (Chicago, IL, USA) who were aged younger than 60 years with diffuse systemic sclerosis, modified Rodnan skin scores (mRSS) of more than 14, and internal organ involvement or restricted skin involvement (mRSS14) but coexistent pulmonary involvement. We randomly allocated patients 1:1 by use of a computer-generated sequence with a mixed block design (blocks of ten and four) to receive HSCT, 200 mg/kg intravenous cyclophosphamide, and 6·5 mg/kg intravenous rabbit antithymocyte globulin or to receive 1·0 g/m(2) intravenous cyclophosphamide once per month for 6 months. The primary outcome for all enrolled patients was improvement at 12 months' follow-up, defined as a decrease in mRSS (25% for those with initial mRSS14) or an increase in forced vital capacity by more than 10%. Patients in the control group with disease progression (25% increase in mRSS or decrease of10% in forced vital capacity) despite treatment with cyclophosphamide could switch to HSCT 12 months after enrolment. This study is registered with ClinicalTrials.gov, number NCT00278525.Between Jan 18, 2006, and Nov 10, 2009 we enrolled 19 patients. All ten patients randomly allocated to receive HSCT improved at or before 12 months' follow-up, compared with none of nine allocated to cyclophosphamide (odds ratio 110, 95% CI 14·04-∞; p=0·00001). Eight of nine controls had disease progression (without interval improvement) compared with no patients treated by HSCT (p=0·0001), and seven patients switched to HSCT. Compared with baseline, data for 11 patients with follow-up to 2 years after HSCT suggested that improvements in mRSS (p0·0001) and forced vital capacity (p0·03) persisted.Non-myeloablative autologous HSCT improves skin and pulmonary function in patients with systemic sclerosis for up to 2 years and is preferable to the current standard of care, but longer follow-up is needed.None.

The diagnostic imaging of patients presenting with right lower quadrant pain and suspected appendicitis may be organized according to age and gender and to the presence or absence of "classic" signs and symptoms of acute appendicitis. Among adult patients presenting with clinical signs of acute appendicitis, the sensitivity and specificity of CT are greater than those of ultrasound, with improved performance when CT is performed with intravenous contrast. The use of rectal contrast has been associated with decreased time in the emergency department. Computed tomography has also been shown to reduce cost and negative appendectomy rates. Both CT and ultrasound are also effective in the identification of causes of right lower quadrant pain unrelated to appendicitis. Among pediatric patients, the sensitivity and specificity of graded-compression ultrasound can approach those of CT, without the use of ionizing radiation. Performing MRI after inconclusive ultrasound in pregnant patients has been associated with sensitivity and specificity of 80% to 86% and 97% to 99%, respectively. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Objective To assess the frequency of and factors associated with supramalleolar posterior tibial tendon (PTT) pathology that often may be missed on sonography because of the limited field of view of ultrasound. Design Retrospective cross-sectional study. Setting Large academic center. Patients Patients with medial ankle pain and tenderness and with normal radiographs who presented for sonographic assessment (n = 217). Methods Two experienced musculoskeletal radiologists interpreted the studies by consensus. Main Outcome Measurement PTT pathology. Results Of the 217 patients, 33.2% had grade 1 PTT pathology (n = 72), 14.3% had grade 2 pathology (n = 31), and 2.8% had grade 3 pathology (n = 6). When stratified by location, 29.0% of patients (n = 63) had inframalleolar abnormalities, 11.5% had retromalleolar pathology (n = 25), and 11 patients had supramalleolar pathology (5.1%). Four patients had PTT subluxation or dislocation. Age was significantly associated with PTT pathology ( P = .02). A higher proportion of patients with supramalleolar (81.8%) and retromalleolar (72.0%) PTT pathology were women compared with patients who had inframalleolar (57.1%) PTT pathology. A higher proportion of patients with supramalleolar and retromalleolar PTT pathology had grade 2 tears compared with those with inframalleolar PTT pathology (36.4% for supramalleolar, 44.0% for retromalleolar, and 22.2% for inframalleolar pathology). Conclusions We present one of the largest studies on PTT pathology. PTT pathology can occur in the supramalleolar area, a region that often is not assessed on imaging. Although data are unavailable with regard to whether the natural history of supramalleolar PTT is different from that of other regions, patients with supramalleolar PTT pathology had more severe grades of tear and increased prevalence of tenosynovitis and were more often women. It is essential to recognize supramalleolar PTT pathology so that consequences of nontreatment such as medial arch collapse can be prevented.

No definite objective guidelines for selecting patients for pelvic nodal or seminal-vesicle irradiation exist in radical radiotherapy for prostate cancer. Developing such guidelines will aid in decrea

The goal of this experiment was to investigate changes in the thickness of the soft tissue overlying the ischial tuberosity (IT) due to changes in hip flexion angle and the addition of a sitting load. Eleven healthy subjects were tested. An apparatus constructed from foam blocks and an air bladder was used to position the subjects in different postures within an MRI tube. MRI images of the buttocks and thigh were obtained for four postures: Supine, 45° Hip Flexion, Non-Weight-Bearing 90° Hip-Flexion, and Weight-Bearing 90° Hip-Flexion. The thickness of muscle, adipose tissue, and skin was measured between the IT tip and skin surface, perpendicular to the cushion placed beneath the thighs. The tissue overlying the IT was found to be significantly (P < 0.001) thinner in 90° Hip-Flexion (73.8 ± 9.0 mm) than in the supine position (135.9 ± 8.1 mm). Muscle thickness decreased significantly from Supine to Non-Weight-Bearing 90° Hip-Flexion (59.1 ± 8.5%, P < 0.001), and further decreased from Non-Weight-Bearing to Weight-Bearing 90° Hip-Flexion (46.2 ± 7.9%, P < 0.001). Under Weight-Bearing 90° Hip-Flexion, the muscle tissue deformed significantly (P < 0.001) more than the adipose tissue and skin. We concluded that the tissue thickness covering the IT significantly decreased with hip flexion, and further decreased by nearly half during loading caused by sitting. In addition, the muscle tissue experienced the largest deformation during sitting. The results of this study may improve our understanding of risk factors for pressure ulcer development due to changes in tissue padding over the IT in different postures.

We report two cases of invasive infections caused by Panton-Valentine leukocidin-positive, community-associated, methicillin-resistant Staphylococcus aureus (CA-MRSA) after kidney transplantation. This report emphasizes the clinical importance of considering CA-MRSA as a causative agent in the differential diagnosis of infections of the skin and soft tissues in organ transplant recipients.

Spastic hypertonia has reflex/non-reflex and dynamic/static components, which were investigated in ankles of 24 spastic hemiparetic and 32 normal subjects. Furthermore, the spastic ankles were treated with an intelligent stretching device with outcome evaluated in terms of phasic and tonic stretch-reflex gains, reflex threshold, joint elastic stiffness, and viscous damping. We found that joint elastic stiffness was increased in spastic ankles, especially in the plantar flexors. The increase was due to an increase in passive stiffness instead of intrinsic stiffness. Viscous damping was increased in spastic plantar flexors. Reflexively, spastic ankles showed higher dynamic reflex gain in spastic plantar flexors, indicating exaggerated phasic stretch reflex. The static stretch-reflex gain was increased in spastic ankles, indicating hyperactive tonic stretch reflex, and spastic muscles did not regulate tonic stretch reflex as controls did. Reflex hyperexcitability in spasticity was associated with both increased tendon reflex gain and decreased threshold. After stretching, the patients were able to generate higher plantar flexion MVC torque, which was corroborated by increased torques induced by matched electrical stimulation of the spastic muscles. They were also able to move in large ROM. Achilles tendon properties evaluated by ultrasonography corroborated the strength increase.

A portable stretching device with intelligent control was developed to treat the spastic/contractured ankle of neurologically impaired patients and evaluate the outcome. The device stretched the ankle throughout the range of motion (ROM) to extreme dorsiflexion and plantar flexion until a specified peak resistance torque was reached with the stretching velocity controlled based on the resistance torque. Stretching velocity was adjusted constantly. It was slow at the joint extreme positions, making it possible to reach a larger ROM safely, and it was fast in the middle ROM so the majority of the treatment was spent in stretching the problematic extreme ROM. The ankle was held at the extreme position for a period of time to let stress relaxation occur before it was rotated back to the other extreme position. Furthermore, the device evaluated treatment outcome quantitatively in multiple aspects, including active and passive ROM, joint stiffness and viscous damping, and reflex excitability. Combined with ultrasonography, the device was used to evaluate changes in mechanical properties of the Achilles tendon-aponeurosis induced by the stretching. The intelligent stretching reduced spasticity and contracture, including increases passive and active ROMs, decreases in elastic stiffness and viscous damping, and increase in muscle force-generating capacity.

Physical examination revealed palpable subcutaneous lesions in the upper outer quadrant and periareolar region of the right breast and on the patient’s back. which were thought to be sebaceous cysts. The mammogram revealed overlying skin thickening and fine spicules surrounding the 1.0- to 1.5-cm nodules (Fig. I A). Sonography showed heterogeneous. predominantly echogenic. subcutaneous nodules (Fig. I B). The right breast lesions. along with the nodule on the patient’s back. were excised. Histologic studies of all lesions showed metastatic TCC located in the subcutaneous fat of the breast (Fig. IC) and back that was morphologically similar to the primary urinary bladder tumor. The patient died 8 months later despite aggressive chemotherapy.

Aguado A, Grant T, Miller F, Garnett J(AQ1) ibrosis is a well-known complication of radiation therapy. The consequences of therapy can be obvious or subtle and can occur months to years after the completion of treatment. Available data concerning irradiation of the male reproductive system show potential effects that may include decreased testicular volume, erectile dysfunction, infertility, and decreased libido [1]. We report the sonographic and MRI findings of a case of radiation-induced spermatic cord fibrosis which, to our knowledge, has not been reported in the literature.

This study was conducted to determine the reliability of mediastinal biopsy using a computed tomography-guided extrapleural approach. Twenty patients (16 men and 4 women) between the ages of 30 to 79 years underwent 22 percutaneous biopsies. The sampled masses ranged in size from 1.6 to 8 cm. A coaxial 17-gauge needle system was advanced into the fascia subjacent to the parietal pleura. An extrapleural fluid collection was created using a 20%/80% ratio of 1% lidocaine and normal saline. The blunt cannula was then advanced through the fluid to the edge of the lesion, and core or cytologic specimens were obtained. A diagnosis was obtained in 18 of 20 patients (90%). There were 10 malignant and 8 benign diagnoses. Complications included pneumothorax (1), vasovagal reactions (1), intercostal neuritis (1), and transient Homer's syndrome (1). In this series, both a high diagnostic yield as well as a low complication rate were obtained.

and alcohol intake seem to be common antecedent factors. I Preceding symptoms can be dyspeptic in nature. I The diagnosis may require multiple endoscopies, arteriography, and sometimes laparotomy. Mortality is high. I Treatment is usually surgical and the lesion is either oversewed or excised. Electrocoagulation was partially successful in one patient. I Laser photocoagulation has been used in the treatment of a variety of bleeding gastrointestinal lesions including gastric and duodenal ulcers, arteriovenous malformations, and Mallory-Weiss tears. We found no reports in the English literature describing its use in treating bleeding Dieulafoy's lesions. In our case, Nd:YAG laser photocoagulation was successful in avoiding a high risk operation by elimination of the lesion as documented by repeat endoscopy. The small ulcer seen by repeat endoscopy is probably the result of laser therapy. Since no histologic data are available from our patient, we cannot comment on the long-term follow-up and the possibility of recurrent bleeding in the future. Laser photocoagulation is not without hazard when used in the treatment of Dieulafoy's lesion since vaporization instead of coagulation can lead to exacerbation of bleeding. It is therefore advisable to apply treatment as short high-energy bursts around the lesion before treating the center of the lesion.

Transrectal ultrasound was used in 2 patients with supralevator perirectal fluid collections. In one instance, this technique was used to diagnose and plan surgical drainage of a perirectal abscess. In another patient needle aspiration under sonographic guidance was performed for removal of a septated fluid collection.

Pulmonary lymphatic visualization during lymphangiography was demonstrated without evident abnormality of the lymphatic system. Such visualization has not heretofore been reported in the absence of chylothorax. Filling from the thoracic duct via the inferior pulmonary ligaments and from the basal pleural lymphatics to the pulmonary lymphatics is the probable direction of flow.

This study is both a retrospective and prospective evaluation of the clinical usefulness of shoulder sonography. Ninety-eight patients suspected of having rotator cuff tears underwent sonography of both shoulders. Sixty-two patients underwent double-contrast arthrography performed on the same day as sonography, and 38 patients underwent surgery after sonography. A comparison of the results from ultrasound and arthrography, using published diagnostic criteria, demonstrated a sensitivity of 75% and a specificity of 43% for detection of a rotator cuff tear. In this study, use of more restricted criteria, a subset of the published criteria, yielded a sensitivity of 68% and a specificity of 90%. A comparison of sonography with surgery, using this study's criteria, demonstrated a sensitivity of 57% and a specificity of 76%. This report shows that shoulder sonography is less reliable than previously reported and appears to have a very limited role in the evaluation of rotator cuff injuries.

The sonographic appearance of the endometrium was evaluated in 97 infertile women, 51 from a fertility unit (FU) and 46 from an in vitro fertilization (IVF) program. Three groups of patients were identified: those with normal findings, those with an incomplete endometrial echo, and those without any endometrial echo. Findings were correlated with the type of ovulation induction protocol, the peak estradiol level, and the number of successful pregnancies. In the IVF group, 72% of the patients did not exhibit normal endometrial echoes but had adequate estradiol levels, compared with 62% of the FU patients with normal endometrial echoes but significantly lower estradiol. The data suggest that IVF patients have a nonresponsive endometrium rather than inadequate estrogen stimulation and therefore that an endometrial abnormality may be an important cause of their infertility. Ultrasound may be used as a screening method to identify such patients.

REGIONAL enteritis is associated with many complications; these include abdominal abscesses, hemorrhage, fistula formation, bowel obstruction, and malabsorption syndrome. Involvement of the duodenum is an unusual but well-established manifestation. Duodenobiliary communication, however, has been reported in only three cases, 1 and liver abscess is rare. 2,3 The following report describes a case of regional enteritis that was complicated by both a duodenobiliary fistula and a hepatic abscess. Report of a Case A 42-year-old man was admitted to Michael Reese Hospital and Medical Center with a 14-year history of regional enteritis. In 1960, he had undergone resection of the terminal ileum and ascending colon at another hospital. In April 1969, he had had a laparotomy for a right-lower-quadrant abscess, and a jejunotransverse colostomy was performed, leaving approximately 2 meters of functioning small bowel. The patient's status worsened progressively during the next two years, with recurrent attacks of cramping pain and fever.