Successful surgical treatment of intraorbital arteriovenous malformations: case report

OBJECTIVE: Our purpose was to establish whether obstetric ultrasonography interpreted by a live video telemedicine link is comparable to interpretation by videotape review in a low-risk patient population. STUDY DESIGN: An Integrated Services Digital Network (ISDN 6) was established from three satellite offices to our central prenatal diagnostic center. Patients seen at these satellite offices had a complete fetal anatomic survey recorded onto videotape by a trained ultrasonographer. A live interactive video telemedicine link was then established to our center by the digital network, and a perinatologist directed the ultrasonographer through the anatomy survey. Subsequently a different perinatologist, blinded to the telemedicine interpretation, reviewed the videotaped examination. The reports from the videotaped and telemedicine scans were then compared on the basis of a score of 33 anatomic items. RESULTS: The first 200 patients seen at the satellite offices were included. Telemedicine and videotape interpretations provided similar scores in 84% of scans. In 17 of the 33 anatomic categories telemedicine provided significantly better scores than videotape, whereas in the remaining 16 anatomic categories the scores were equivalent. More videotape than telemedicine examinations required repeat ultrasonography because of suboptimal imaging (10% vs 3%, p = 0.003). CONCLUSIONS: The interpretation of obstetric ultrasonography with use of live video telemedicine is comparable to videotape review. Fetal telemedicine may prove to be a useful tool for providing ultrasonographic interpretation of fetal anatomy to a network of low-risk obstetric practices.     

Fetal anomaly detection by second-trimester ultrasonography in a tertiary center

OBJECTIVE: Our purpose was to determine the relative accuracy of indicated versus screening second-trimester ultrasonography for detection of fetal anomalies and to assess the cost effectiveness of anomaly screening. STUDY DESIGN: The study population consisted of 2031 pregnant women with singleton gestations who prospectively underwent ultrasonographic scanning between 15 and 22 weeks and received complete obstetric care at the Medical University of South Carolina between July 1, 1993, and June 30, 1996. Patients were divided into two groups: (1) indicated and (2) screening. The cost of screening ultrasonography was compared with the cost of newborn care for selected anomalous fetuses. RESULTS: Forty-seven fetuses (2.3%) were diagnosed by ultrasonography as having a major anomaly: 8.6% in the indicated group and 0.68% in the screening group (p=0.001). The sensitivity for detecting the anomalous fetus was 75.0% overall: 89.7% in the indicated group and 47.6% in the screening group (p=0.001). Of the 47 patients diagnosed with fetal anomalies, 11 (23.4%) chose pregnancy termination; of the 35 (74.5%) live-born anomalous infants, 29 (82.9%) were discharged alive. Projected newborn cost savings offset the cost of routine midtrimester screening. CONCLUSIONS: Detection of anomalous fetuses was significantly better in the indicated compared with the screening group. Nevertheless, routine ultrasonographic screening appeared cost-effective in our population.     

Interobserver reliability of digital and endovaginal ultrasonographic cervical length measurements

OBJECTIVE: Our purpose was to prospectively evaluate the interobserver reliability of digital and endovaginal ultrasonographic cervical length measurements. STUDY DESIGN: Forty-three women were recruited from our antepartum clinic to participate in this study. Two independent and blinded digital cervical examinations were performed by the first author and a second examiner. Instructions were given to estimate the cervical length in millimeters. After micturition endovaginal ultrasonographic cervical length measurements were performed by two independent, blinded registered diagnostic medical sonographers. Cervical lengths were compared with the Student t test and Pearson's correlation coefficient. A kappa statistic was calculated for interobserver reliability at three levels of agreement +/- 1 mm, +/- 4 mm, and +/- 10 mm. Data are expressed as means +/- SD. RESULTS: Digital cervical lengths were not different between the two examiners (18.7 +/- 4.8 mm, 20.5 +/- 6.2 mm) nor between the two ultrasonographic measurements (38.6 +/- 6.1 mm, 39.2 +/- 5.4 mm). The digital cervical lengths agreed (+/- 1 mm) 35% of the time (R2 0.10, p = 0.02). The endovaginal ultrasonographic measurements agreed (+/- 1 mm) 74% of the time with a stronger correlation (R2 0.53, p = 0.0001). The kappa statistic for interobserver variability was marginal for both digital and endovaginal cervical length measurements when agreement was defined as +/- 1 mm. Endovaginal ultrasonography was significantly more reliable than digital examination when agreement between examiners was defined as either +/- 4 mm or +/- 10 mm. CONCLUSION: Although both digital and endovaginal ultrasonographic cervical length measurements show correlation between examiners, endovaginal ultrasonography is significantly more reliable when agreement is defined as > or = +/- 4 mm. Serial cervical length measurements to predict preterm labor will be enhanced by the interobserver reliability of endovaginal ultrasonography.     

Hepatitis C. Issues for women and their partners

OBJECTIVE: To evaluate the diagnostic accuracy of transvaginal ultrasonography in detecting and measuring free pelvic fluid. STUDY DESIGN: Eighty-two patients undergoing diagnostic or therapeutic laparoscopy at a tertiary care center were prospectively assessed before surgery by transvaginal ultrasound. Free pelvic fluid was measured in two ultrasonographic planes. These measurements were compared to the volume of fluid aspirated during laparoscopy. RESULTS: The mean volumes reported for transvaginal ultrasound were significantly lower than those observed at laparoscopy (mean milliliters +/- SEM, 2.54 +/- 0.5 versus 9.42 +/- 1.3, P < .001). The smallest volume of free pelvic fluid that was consistently detected by ultrasound was 8 mL. Whenever no fluid or < 1 mL was detected by transvaginal ultrasound, a small volume of fluid was found at laparoscopy (mean milliliters +/- SEM, 1.6 +/- 0.47). The sensitivity of transvaginal ultrasound was 83% and specificity was 69%. CONCLUSION: Transvaginal ultrasound is a sensitive method of detecting the presence of > 8 mL of free pelvic fluid and therefore is an important diagnostic tool in the assessment of pelvic pathology associated with increased peritoneal fluid.     

Three-dimensional ultrasonography in obstetrics and gynecology: preliminary experience

OBJECTIVE: Technologic advances in ultrasonographic imaging have revolutionized the management of women's health care. We recently began to evaluate the clinical applications of three-dimensional ultrasonography. STUDY DESIGN: This study prospectively evaluated 161 obstetric and gynecologic patients. Both two- and three-dimensional imaging data were acquired from real-time ultrasonography. Three orthogonal planes were displayed on a monitor and were used to create the rendered three-dimensional images. RESULTS: To date, 201 three-dimensional ultrasonographic studies have been performed, 165 transabdominally and 36 transvaginally. Transabdominally, an average of eight acquisitions per patient were obtained. Of the clinically suspected abnormalities, 29 of 32 (91%) were confirmed by three-dimensional imaging. Three of 32 (9%) improved the diagnostic capabilities or changed the diagnosis. Of the 36 transvaginal studies, an average of four acquisitions per patient were done. Thirty (83%) of these patients had suspected abnormalities and all were confirmed. CONCLUSIONS: Three-dimensional ultrasonographic imaging appears to be highly promising in the clinical setting.     

Ultrasonographic estimate of birth weight at 24 to 34 weeks: a multicenter study

OBJECTIVE: The study was intended to compare the accuracies of ultrasonographic estimates of birth weights among infants born between 24 and 34 weeks' gestation at 3 tertiary centers. STUDY DESIGN: In this retrospective study subjects were matched for gestational age (1:1); all underwent ultrasonographic examination within 2 weeks of delivery. The estimates of birth weight were obtained according to 26 published regression equations and their accuracies were assessed with the mean standardized absolute error. For each center the equation with the lowest error was selected to generate (1) receiver-operating characteristic curves for an estimate to identify actual weight < 1500 g and (2) prediction limit calculations to determine the estimate that ensures at 70% confidence a birth weight > 1500 g. RESULTS: One hundred seventy-one cases were analyzed at each center. Comparison of the 26 mean standardized errors at each center indicated that (1) the range was rather wide (eg, 89 +/- 87 to 365 +/- 313 g/kg) and (2) 73% (19/26) of the equations had significantly (P < .05) different accuracies. Receiver-operator characteristic curves show that fetal weight estimates of > or = 1600 g at 2 centers and > or = 1700 g at the third center are required to predict actual birth weight < 1500 g. Prediction limit calculation suggests that different fetal weight estimates (> 1600 g at center 1, > 1900 g for the center II, and > 1800 g at center III) are needed to predict actual weight > 1500 g with a 70% accuracy. CONCLUSIONS: Ultrasonographic estimates of weight for preterm infants, as obtained from 26 equations, are characterized by a rather wide range of accuracy; for most of the equations the accuracies of estimates differ markedly among centers.     

A prospective evaluation of fetal pericardial fluid in 506 second-trimester low-risk pregnancies

OBJECTIVE: To measure fetal pericardial fluid in low-risk second-trimester pregnancies and to evaluate outcome for those with measurements greater than 2 mm. METHODS: Five hundred and six women were referred for sonography between 16 and 25 weeks' gestation for common obstetric indications (dating, fetal survey, and placental location) unrelated to an increased risk of anomalies. All cases were evaluated with two-dimensional and M-mode real-time ultrasonography with the use of a mechanical sector transducer. The maximum distance of the fetal hypoechoic cardiac rim was recorded. We reviewed maternal and infant charts for those with measurements greater than 2 mm. RESULTS: Median (range) maternal age was 25 (15-42) years. Median gravidity and parity were two (1-14) and one (0-11), respectively. Median estimated gestational age was 20.4 (16.3-24.9) weeks. Fetal pericardial fluid was seen in 360 of 506 (71%) fetuses. Of these 360 fetuses, the mean distance (+/- 2 standard deviation) of the fetal hypoechoic cardiac rim was 1.20 mm +/- 0.91 mm (95% confidence interval 1.15, 1.25). Among the 506 cases, the maximum measurement was 3 mm. Ten of the 506 (2%) cases had measurements greater than 2 mm. None of these ten fetuses had a cardiac structural abnormality or arrhythmia, and perinatal outcome was unremarkable. CONCLUSION: During second-trimester fetal ultrasonographic examination, visualization of pericardial fluid up to 2 mm in the fetus with current high-resolution technology is common and should not be regarded as pathologic.     

First-trimester neck abnormalities: three-dimensional evaluation

In order to study the first trimester ultrasonographic differences between nuchal translucency and hygroma colli, we rescanned 25 fetuses (13 with nuchal translucency and 12 with hygroma colli) using transvaginal and three-dimensional ultrasonography, after obtaining a fetal karyotype report. Our objective was to test the premise that the different physiopathologic mechanisms of both processes would be reflected in detectable sonographic differences. Our retrospective analysis showed that the most striking ultrasonographic difference was the presence of bullae as well as greater irregularity, extent, and amplitude of the membrane in cases of hygroma colli. Fetuses with simple nuchal translucency had a more homogeneous linear membrane. Although detailed analysis was impossible in 30% of cases, we found three-dimensional ultrasonography to be a useful technique for establishing the differences between these two entities.     

Maternal-fetal transfers: indications, appropriateness, and cost

The objective of this study was to assess the indications, appropriateness, and cost of maternal-fetal transfers to a tertiary care facility in an era of managed care. Our perinatal database was reviewed from January 1, 1996 through June 30, 1997 to determine maternal and fetal indications for transfer, referring institution characteristics, utilization of tertiary level services, and cost of transfer. There were 273 transfers from 53 referring hospitals ranging in distance from <20 miles (n = 102) to >100 miles (n = 41). Thirty-one patients were transferred by air (average cost $7656), 238 by ground (average cost $920), 4 by private car. The referring diagnosis was preterm premature rupture of membranes (PPROM) (n = 80), preterm labor (n = 76), preeclampsia (n = 42), medical complications (n = 25), or other (n = 50). Mean gestational age (GA) at transfer was 28.5+/-5.5 weeks. Patients were referred from hospitals with a self-designated nursery level I (n = 115), II (n = 111), III (n = 45), or none (n = 2). In 42 patients, (15%) no maternal or fetal indication for hospital transfer was identified after evaluation at the tertiary center. The most common referring misdiagnoses were preterm labor (n = 25), PPROM (n = 10) and preeclampsia (n = 3). One hundred and sixty-five patients delivered during transfer admission (mean GA = 29.6+/-4.8 weeks); 79 infants (48%) required admission to a level III, and 52 (31%) to a level II nursery. Most patients require the services of a tertiary facility after maternal fetal transfer. If delivered during transfer admission, the majority of neonates require care in an intermediate or intensive care nursery.     

The primary lesion in leprosy

PURPOSE: To report the feasibility of real-time video and audio transmission of slit-lamp images of the eye using conventional telephone systems. METHOD: We analyzed the feasibility and benefits of telemedicine in the diagnosis and follow-up of ocular surface disorders in referral patients using a real-time audio-video system that functions through integrated services digital network lines at a transmission speed of 384 kilobytes per second. RESULTS: Real-time slit-lamp images obtained through integrated services digital network lines offered satisfactory visual resolution of the ocular surface for the diagnosis and follow-up of ocular surface and corneal disease, while simultaneous audio transmission allowed for direct communication with the patient and attending physician when necessary. CONCLUSION: Telemedicine using conventional telecommunication infrastructures offers sufficient information for the diagnosis and follow-up of ocular surface disorders in referral patients.     

The impact of routine obstetric ultrasonographic screening in a low-risk population

OBJECTIVES: Our goal was to develop a framework for evaluating the current controversy regarding routine obstetric ultrasonography in a population of low-risk pregnancies. STUDY DESIGN: A retrospective chart review was performed for all low-risk pregnancies from a single obstetric practice during 1990 to 1994, to determine the accuracy of screening ultrasonography for fetal anomalies. All patients received a routine ultrasonographic examination at 18 to 20 weeks' gestation. Neonatal records for all patients were evaluated for the presence of both major and minor anomalies. The data were analyzed with attention to the classification of anomalies (all anomalies vs major anomalies, detectable vs nondetectable). RESULTS: A total of 860 fetuses in 854 pregnancies were evaluated. Anomalies were present in 5.35% (46/860); these were major anomalies in 1.16% (10/860) and minor anomalies in 4.19% (36/860). The sensitivity, specificity, and positive and negative predictive values for the diagnosis of all anomalies were 8.7%, 99.9%, 80%, and 95.7%, respectively. However, if only major anomalies detectable by ultrasonography are included, these values become 75%, 100%, 100%, and 99.9%, respectively. There was one false-positive diagnosis not affecting outcome, a small ventriculoseptal cardiac defect. Postnatal ascertainment of anomalies was excellent, as determined by an incidence of ventriculoseptal defects of 1 in 120. CONCLUSION: Distinguishing between major and minor anomalies and between ultrasonographically detectable versus nondetectable anomalies is essential in the evaluation of the diagnostic accuracy of screening ultrasonography. Any comparisons of studies examining the effectiveness of prenatal screening for congenital anomalies with ultrasonography should use the same outcome: major anomalies identifiable by ultrasonography.     

Three-dimensional ultrasonography of the fetal distal lower extremity: normal and abnormal

The objective of this study was to compare two-dimensional and three-dimensional ultrasonographic evaluation of fetal distal lower extremities. Data from two-dimensional and three-dimensional ultrasonographic examinations from 40 distal lower extremities in 33 fetuses from a predominantly high-risk patient population were compared. Three-dimensional ultrasonography routinely provided three orthogonal planes (coronal, sagittal, and axial) for distal lower extremity evaluation. Specific features of distal lower extremity evaluation were not different using two-dimensional and three-dimensional ultrasonography. Rotation of the rendered volume provided assistance in assessing all but one of 40 distal lower extremities. Time from image acquisition to assessment for two views (coronal and sagittal) was longer with three-dimensional ultrasonography (8.2 min) than with two-dimensional ultrasonography (3.2 min). Confidence in the diagnosis of abnormal distal lower extremities was slightly improved using three-dimensional ultrasonography compared to two-dimensional ultrasonography. Pregnancy management was assisted in three of the four cases with isolated limb anomalies. In conclusion, three-dimensional ultrasonography improves the ability to evaluate the fetal distal lower extremity because of the multiplanar nature of volume assessment and the ability to rotate volume data sets. In addition, it provides assistance in counseling families, particularly for cases involving isolated limb anomalies.     

Ultrasonographic examination of intrauterine growth for multiple fetal dimensions in a Chinese population. Central-South China Fetal Growth Study Group

OBJECTIVE: We sought to construct an ultrasonography-based growth curve in a Chinese population. STUDY DESIGN: Routine ultrasonographic examination was performed in 5496 normal pregnancies (>95% first births) in five obstetric ultrasonography laboratories in Central-South China from January 1, 1992, to December 31, 1993. RESULTS: All the fetal growth measures increased with gestational age, whereas the ratios either decreased or remained constant across gestation. Biparietal diameter and cerebral hemispheric width were higher at early gestational ages, whereas femur length, thoracic circumference, and abdominal circumference were lower at later gestational ages in our study than in previous studies. The ratio of lateral ventricular width/cerebral hemispheric width was lower at an early gestational age but higher in later gestational ages in our study. CONCLUSIONS: A different standard of ultrasonography-based fetal growth is needed for different populations. The ultrasonography-based growth curve constructed in this large Chinese population provides an additional tool for the evaluation of fetal growth and development.     

Three-dimensional fetal echocardiography: gated versus nongated techniques

The purpose of this study was to compare gated with nongated three-dimensional fetal echocardiography in terms of the ability to demonstrate fetal cardiac anatomy. We examined nine fetuses in utero using conventional two-dimensional sonographic imaging equipment, an electromagnetic position sensor, and a computer-graphics workstation. Free-hand sweeps were performed through the fetal heart and great vessels in either transverse or sagittal orientations with respect to the fetal heart. Seven transverse and five sagittal sweeps were selected for reconstruction and analysis. Cardiac gating was performed by using a temporal Fourier transform to determine the fundamental frequency of cardiac motion. Two-dimensional data from each sweep were reprojected to a series of volume data sets. Each series was then condensed to a single volume, so that each two-dimensional sweep could be compared with its respective gated and nongated volume data sets. The two-dimensional data were reviewed utilizing a display with forward and backward cineloop capability. The gated and nongated volume data sets were displayed interactively as a series of three orthogonal planes, with the ability of the observer to control the location of each image plane within the volume. The gated data were animated with variable display frame rates. Conventional two-dimensional imaging provided a fairly complete evaluation of the fetal heart when scanning included the four-chamber view with a sweep across the outflow tracts. Nongated three-dimensional fetal echocardiography allowed visualization of some structures and views not demonstrated with two-dimensional ultrasonography. Gated three-dimensional fetal echocardiography provided significantly better visualization and comprehension of cardiac anatomy than nongated three-dimensional fetal echocardiography. The superiority of gated over nongated three-dimensional fetal echocardiography appears to come from both improved image quality and the anatomic clues that derive from the ability to view cardiac motion.     

Development of a frameless and armless stereotactic neuronavigation system with ultrasonographic registration

OBJECTIVE: We have developed a frameless stereotactic neuronavigation system that allows navigation during neurosurgical procedures through an image formed from integrating ultrasonography and preoperative magnetic resonance (MR) imaging and/or x-ray computed tomography. METHODS: The system consists of a ultrasound imaging scanner, a workstation with an image capture board, and an ultrasonic tracking sensor with a 5-MHz ultrasonographic transducer. The ultrasonic tracking sensor measures the position and orientation of the ultrasonographic transducer. The oblique plane of the MR/computed tomographic image corresponding to the ultrasound image is then displayed on the workstation monitor. A three-dimensional computer graphic representation of the integrated image is also reported as a preliminary test. For the patient-image registration, the coordinates of digitized and imaged markers on a specifically developed reference frame are used. The reference frame is noninvasive because it is not bolted but only fastened to the patient's head with silicon. RESULTS: Based on the findings from the clinical application of the system in three cases, the system was advantageous because of the surgical procedures could be controlled by intraoperative ultrasonography as well as by preoperative MR/computed tomographic images. Missing parts in the ultrasonogram were supplemented with preoperative MR/computed tomographic images. At other times, spatial positioning and visualization by ultrasonography were useful for identifying anatomical objects in the image. CONCLUSION: This preliminary study of the frameless integration of ultrasonography into stereotactic space demonstrated its clinical usefulness. We believe that the concept of pre- and intraoperative image-guided surgery presented here will find increasing use in the future.     

Personal computer teleradiology interhospital image transmission to facilitate tertiary pediatric telephone consultation and patient transfer: soft-tissue lateral neck and elbow radiographs

Although teleradiology systems are available commercially, they are expensive ($30,000), and different makes are incompatible with each other, making them unusable for interhospital image transfers. Standard components were added to a personal computer (PC) to build a functional teleradiology unit capable of interhospital image transmission at a low cost ($600 upgrade). This PC teleradiology system was studied to assess its accuracy in the interpretation of soft-tissue lateral neck x-rays with epiglottitis or retropharyngeal abscesses and elbow x-rays with joint effusions, fractures, or both. A radiologist and a pediatric emergency physician were asked to read the PC teleradiology images. Both physicians read 13 of 13 soft-tissue lateral neck x-rays and 15 of 15 elbow x-rays correctly. This study supports the premise that PC teleradiology can be used to facilitate telephone consultation and patient transfers between tertiary pediatric emergency centers by transmitting pertinent radiographic information over a phone line. Although verbal communication can often suffice in a telephone consultation or transfer, there are many instances when visualizing a radiographic image such as an x-ray or computed tomography scan can provide important information that cannot be optimally described verbally. Rural hospitals can form interhospital image transmission links with tertiary center resources. Tertiary centers may elect to organize interhospital image transmission and referral networks with their rural hospital sources.     

Doppler ultrasonography of canine maternal and fetal arteries during normal gestation

Two-dimensional ultrasonography was used in combination with colour-flow imaging and pulsed wave Doppler ultrasonography to study the maternal circulation and the development of fetal vascularization in six Beagles during normal gestation. For the first time, the development of the circulation was demonstrated in the bitch and her fetuses intra vitam. The bloodstream was examined in small uteroplacental arteries, the umbilical artery, the fetal aorta and the common carotid artery. The duration of the study was from week 3 after insemination until birth. Relatively large vessels were detected by cross-sectional ultrasonography, and small vessels were detected by colour-flow imaging. In pulsed wave Doppler ultrasonography, the blood flow was measured and described using the parameters of systolic peak velocity, diastolic peak velocity, end-diastolic velocity, pulsatility index, resistance index, A:B ratio (systolic peak velocity:end-diastolic velocity) and S:D parameter (systolic peak velocity:diastolic peak velocity). The development of the measured parameters is typical and similar to that in humans. The systolic peak velocity of the canine maternal uteroplacental arteries shows important differences in comparison with humans. The pulsatility index, resistance index and A:B ratio decrease in nearly all vessels. Only the fetal common carotid artery has constant pulsatility and resistance indices during gestation. For the first time, the quality and quantity of the normal blood flow have been monitored during the whole of gestation. A normal circulation is fundamental for supplying the fetus adequately with oxygen and nutrients and thus for physiological development. These ultrasonographic results are the basis for further clinical studies.     

Prenatal sonographic diagnosis of Treacher Collins syndrome: a case and review of the literature

We report the prenatal ultrasonographic diagnosis of a fetus with mandibulofacial dysostosis (Treacher Collins syndrome). Sonographic findings included: polyhydramnios, microcephaly, abnormal fetal facial features (slanting forehead, microphthalmos, micrognathia), and abnormal fetal swallowing. A review of the current literature pertaining to prenatal diagnosis of this condition is presented.     

Transmission of paratuberculosis

Antenatally, as more women are being treated in the home setting rather than the hospital setting, diagnostic modalities such as ultrasonographic imaging need to be available for use by the home care provider. In the home setting, the care provider and treatment modalities are brought to the patient, whereas patients managed in the hospital setting must attend the provider site to receive the same services. Without the availability of diagnostic ultrasonography in the home setting, pregnant women who are treated in the home rather than the hospital are required to incur an added financial and physical burden associated with attendance at care. Financially, nonreimbursed out-of-pocket costs incurred by the patient may include costs of transportation, costs of child care, and loss of wages. Physically, patients are prevented from maintaining recommended bed rest and dietary treatment regimens. Ultrasonographic evaluations can be performed safely in the home setting by nurses who have received added educational preparation and ultrasonographic imaging experience, thereby providing the essential care often necessary for women who experience pregnancies complicated by high-risk conditions.