Geriatrischer Ultraschall

Quistes renales y aneurismas de aorta de gran tamaño

Background Adding point-of-care ultrasound to the physical examination of patients to assess early signs of decompensation and fluid overload has been proven to add information and improve quality of care, also when performed by nurses. Few studies have examined intensive care nurses’ point-of-care ultrasound examinations in acute cardiac settings. Purpose To evaluate if the findings of intensive care nurses ultrasound examinations, after brief training, were in agreement with conventional ultrasound examination performed by physicians. Methods This comparative cross sectional interrater agreement study included 50 patients admitted with signs and symptoms of dyspnoea and suspected cardiac disease to a cardiac intensive care unit. After brief training, the study nurses performed standardized examinations of the patients’ inferior vena cava (IVC) and the pleural- and pericardial cavities using a handheld ultrasound device. A physician repeated the same examinations using conventional ultrasound, blinded of the nurses’ findings. Results Analysis using Gwets agreement coefficient (AC2) with quadratic weights showed moderate agreement for the IVC respiration variation 0.60 (95% CI 0.38-0.82), and substantial agreement for the IVC diameter 0.70 (95% CI 0.50- 0.90) and right-sided pleural effusion 0.70 (95% CI 0.52-0.88). For left-sided pleural effusion 0.85 (95% CI 0.75-0.95) and for pericardial effusion 0.95 (95% CI 0.90-1.01) the agreement was almost perfect. Conclusion This study indicates that intensive care nurses, after brief training in point-of- care ultrasound, can perform reliable examinations of the IVC and pleural- and pericardial cavities compared to a physicians conventional ultrasound examination.

Portal hypertensive ascites resolve early after liver transplantation (OLT). We report a case of progressive pleural effusion and ascites after a domino OLT. The patient was diagnosed with hepatic hydrothorax attributed to anastomotic stenosis of the donor hepatic vein and the recipient inferior vena cava. A 51 year old Asian male with cirrhosis and a 6cm hepatoma received a domino liver from a donor with Maple Syrup Urine Disease. Trans-arterial chemoembolization and radiofrequency ablation (RFA) was performed prior to OLT. A patient with Maple Syrup Urine Disease received a cadaveric liver transplant and his liver was transplanted into our patient in a domino fashion. Our patient had an uneventful recovery and was discharged with a small right pleural effusion. Progressive right pleural effusions developed two months after OLT. Thoracentesis and pleural biopsies revealed an exudative pleural effusion with repeatedly negative results for infection or malignancy. Abdominal ultrasound revealed a minimal amount of ascites. Therapeutic thoracentesis gave temporary relief but pleural effusions and ascites reaccumulated rapidly. Abdominal MRI and angiogram (MRI/A) showed a patent middle and left hepatic veins with a patent portal venous system. Hepatic venous pressure gradient was noted to be 8mm Hg between the donor hepatic vein and the recipient vena cava. Balloon venoplasty was peformed which reduced the gradient to 2 mmHg. Ascites resolved 2 months after venoplasty with significant decrease in pleural effusion. A stable right pleural effusion remained that was smaller compared to pre-venoplasty; there was no significant ascites on repeat imaging. Serum amino acid levels remained normal during the first year after OLT despite the inherent metabolic defect in the transplanted organ. Conclusions: 1. Liver grafts from patients with Maple Syrup Urine Disease can be successfully transplanted. 2. Pseudo Budd Chiari syndrome due to anastomotic stenosis of the hepatic vein and vena cava should be considered in recipients of living liver donors if pleural effusions and ascites do not resolve. 3. Venoplasty can correct major anastomotic stenosis post liver transplantation.

A ruptured mycotic aortic aneurysm in a patient with urinary retention: A case report

Certain abdominal and retroperitoneal diseases have been associated with pleural effusion without direct extension of the disease into the chest. Among these are ovarian and pelvic tumors (12), pancreatitis and carcinoma of the pancreas (6, 9, 13), cirrhosis of the liver (8, 9), subphrenic abscess (2), and retroperitoneal lymphoma (15). Overburdening of the lymphatic drainage from these organs or interruption of pleural drainage is the usual explanation for this relationship and is probably the main pathologic process. Pleural effusion has also been noted with chronic hereditary lymphedema (7), again implicating the lymphatic system. Experimental work has shown that the pleural cavity receives lymph from below the diaphragm in both health and disease (3, 12, 13). Recently, we have encountered two patients who presented with right-sided pleural effusion and were subsequently found to have hydronephrosis. When the lesions obstructing the outflow of urine were relieved, the pleural effusion abated. This led us to believe that there is a direct relationship between hydronephrosis and pleural effusion. The two clinical cases prompted us to investigate the lymphatic flow of an obstructed kidney and to attempt to produce pleural effusion in mongrel dogs by creating a hydronephrosis and altering the lymphatic flow of the pleural cavity in some of them. Case I: A 57-year-old white male was admitted to the Hospital of the University of Pennsylvania with a three-week history of right flank pain. This was occasionally felt in the left flank, and the week before admission a sharp shooting pain in the right shoulder began to develop. For three days prior to admission, he noted the onset of frequency, urgency, and a decrease in the caliber of his urinary stream. Four years before admission, a renal cyst had been excised, followed by a postoperative bout of urinary retention ascribed to a urethral stricture. Aside from bilateral inguinal herniorrhaphies more than twenty years prior to the present illness, there were no other significant features in the patient's history. The patient was in no acute distress on admission, and his vital signs were within normal limits. There was dullness at the base of the right lung, generalized tenderness in the abdomen, and moderate bilateral tenderness in the costovertebral angles. Small bilateral hydroceles and an enlarged benign prostate were found on rectal palpation. There was no peripheral edema. The hemogram was normal save for a white blood count of 10,800 with a differential shift to the left. Urinalysis was normal, and the urine was sterile. Blood urea nitrogen on admission was 51 mg per 100 cc, and serum creatinine was 3.6 mg per 100 cc. The fasting blood sugar was 135 mg per 100 cc, and an acid phosphatase was 0.4 unit. An electrocardiogram was normal.

The aim of this study is to investigate the positive association between the presence of renal cysts and AAA. A retrospective chart review on the clinical data of 396 consecutive patients, who underwent CT scans for preoperative evaluation of thoracic and cardiovascular surgery in Sapporo Medical University from the period of January 2007 to December 2008, was conducted. When comparing patients with renal cysts (n = 164) to those without (n = 233), there was a statistically significant difference between the presence of renal cysts and male gender (p = 0.007), hypertension (p = 0.003), and AAA (p < 0.001) on univariate analysis. In addition, when comparing patients with AAA to those without, although COPD but not AAA was associated with renal cysts in less than 65 years old, the presence of renal cysts was the strongest association with AAA among patients belonging to the 65 to 74 years old group and over 75 years old group on multivariate analysis. There is a statistically higher incidence of renal cysts in patients with AAA compared to patients without AAA in the group of elder cardiovascular patients. It is likely that AAA and renal cysts share a common pathogenesis.

Kidney biopsy is the gold standard diagnostic technique for nephrologists. Appropriate patient positioning facilitates physiological stability and access to target anatomy. Factors such as patient weight, size and medical history, including respiratory or circulatory disorders, should guide position selection. However, most kidney biopsies are performed exclusively in the prone position and procedures are often deferred when this is not feasible. Although lateral kidney biopsy has been reported, it remains uncommon and its applications are not well established. We aimed to demonstrate the safety and utility of lateral kidney biopsies. We retrospectively reviewed patients who underwent lateral kidney biopsy at Toranomon Hospital Kajigaya between October 2015 and February 2025. Vital signs and blood test results pre- and post-biopsy were analysed. Twenty-five patients underwent lateral kidney biopsies; six had abdominal aortic aneurysms (AAAs), 12 had respiratory distress (7 with massive ascites or pleural effusions, 2 with obesity, 2 with organomegaly and 1 with pericardial effusion), 6 had major joint pain (4 thin, 1 with scoliosis and 1 with arthritis) and 1 had stoma. All patients were histologically diagnosed and received appropriate treatment. Vital signs remained stable and only one patient with splenomegaly experienced a bleeding complication, which was not readily predictable and unlikely related to biopsy position. Lateral kidney biopsy offers a viable alternative for the accurate diagnosis of kidney diseases in patients in whom the prone position is challenging, including those with AAA, anasarca-induced respiratory distress or significant joint pain due to body habitus.

Introduction: Lymphoplasmacytic lymphoma (LPL) is a low-grade B cell lymphoma (BCL) where malignant cells proliferate in the bone marrow, lymph nodes, and spleen. Waldenstrom's macroglobulinemia (WM) is a common manifestation of LPL caused by monoclonal IgM expansion and hyper-viscous blood. Here we present a case of LPL/WM with a rare pulmonary extramedullary manifestation (EM) of malignant pleural effusions. Case Report: A 66-year-old male with no significant PMH presents with progressive dyspnea, 30lb unintentional weight loss, and urinary retention. Initial labs revealed renal failure, anemia, and hypercalcemia. Computed tomography showed an ill-defined intestinal mass and large bilateral pleural effusions. Further hematologic work up revealed high total serum protein, presence of an M protein spike, isolated IgM hypergammaglobulinemia, and hyper-viscous blood. Bone marrow biopsy showed low grade B cell lymphoma (MYD88 negative) with plasmocytic differentiation involving 10% of the marrow, consistent with a rare form of LPL/WM. Patient received plasma exchange, chemotherapy with Zanubrutinib, and bilateral thoracentesis. Pleural fluid was exudative and contained atypical lymphocytes cells. Patient was discharged with hematology/oncology and pulmonology follow-up but never presented. Several months later he presented with dense, pulmonary consolidations. Decision was made to pursue bronchoscopy with transbronchial biopsy and pathology revealed low-grade BCL. Discussion: LPL/WM is a rare lymphoid neoplasm which has a reported incidence of 3.8 cases per million persons per year[1]. Pulmonary EM, such as masses, consolidations, nodules, infiltrates, are reported to be the most common at ∼30%[1]. However, a lymphocytic pleural effusion as a manifestation is more rare[2]. A diagnosis of malignant pleural effusion due to LPL/WM can be confirmed using pleural fluid flow cytometry. Pleural fluid can also be sent for genetic mutation testing[3]. Extramedullary disease may respond to treatment with chemotherapy. Response to treatment is graded by the 11th International Workshop on Waldenstrom's macroglobulinemia on diagnostic and response criteria[4]. In our patient, progressive disease was suspected given the pleural effusions and pulmonary consolidations as well as an increase in ≥ 25% of serum IgM from the nadir despite treatment. However, there was also concern for non-compliance to Zanubrutinib, which perhaps may have lead to disease progression and the late EMs. Conclusion: This case highlights a rare presentation of LPL/WM as bilateral malignant pleural effusions. Although pulmonary EMs are common, malignant pleural effusion is unusual. This case emphasizes the importance of comprehensive pathology evaluation from both pleural fluid and lung tissue to accurately diagnose and manage LPL/WM with EMs.

To investigate the prevalence of colorectal cancer in geriatric patients undergoing endoscopy and to analyze their outcome. All consecutive patients older than 80 years who underwent lower gastrointestinal endoscopy between January 1995 and December 2002 at our institution were included. Patients with endoscopic diagnosis of colorectal cancer were evaluated with respect to indication, localization and stage of cancer, therapeutic consequences, and survival. Colorectal cancer was diagnosed in 88 patients (6% of all endoscopies, 55 women and 33 men, mean age 85.2 years). Frequent indications were lower gastrointestinal bleeding (25%), anemia (24%) or sonographic suspicion of tumor (10%). Localization of cancer was predominantly the sigmoid colon (27%), the rectum (26%), and the ascending colon (20%). Stage Dukes A was rare (1%), but Dukes D was diagnosed in 22% of cases. Curative surgery was performed in 54 patients (61.4%), in the remaining 34 patients (38.6%) surgical treatment was not feasible due to malnutrition and asthenia or cardiopulmonary comorbidity (15 patients), distant metastases (11 patients) or refusal of operation (8 patients). Patients undergoing surgery had a very low in-hospital mortality rate (2%). Operated patients had a one-year and three-year survival rate of 88% and 49%, and the survival rates for non-operated patients amounted to 46% and 13% respectively. Nearly two-thirds of 88 geriatric patients with endoscopic diagnosis of colorectal cancer underwent successful surgery at a very low perioperative mortality rate, resulting in significantly higher survival rates. Hence, the clinical relevance of lower gastrointestinal endoscopy and oncologic surgery in geriatric patients is demonstrated.

Internal Iliac Artery Embolization in the Stent-Graft Treatment of Aortoiliac Aneurysms: Analysis of Outcomes and Complications

The ACTA-Scanner has virtually unlimited potential in the evalution of any part of the body. The usefulness of the technique has already been shown in the appraisal of pathologies of the brain and cerebrospinal fluid cavities. The orbits and the eyeballs, the facial sinuses, and skull base lesions have also been elucidated. Tumors of the larynx, pharynx, thyroid, and parathyroid; lymphomas; and pathology of the spine and spinal cord are well within the reach of this new diagnostic methodology. Lung pathologies, such as emphysema, pneumonias, neoplasms, infarctions, pleural effusions and granulomatous diseases, and mediastinal pathology represent a challenging complex of lesions to be appraised by ACTA-scanning. For the heart, there is great potential for observing cardiac chamber size, hypertrophy of ventricular or atrial walls, and ventricular or aortic aneurysms, and possibly for recognizing the damaged myocardial tissue immediately after or some time after an infarction. The abdominal pathologies that can be studied are almost uncountable: gastric neoplasms, pancreatic cysts and stones, gallstones, neoplasms of the liver and pancreas, bowel tumors, abdominal aortic aneurysms, renal neoplasms and cysts, atrophy of the kidneys, bladder tumors, uterine tumors, ovarian cysts, and many more. Although bones and joints are adequately demonstrated by conventional x-ray techniques, there is no doubt that as the new technique is developed ACTA-grams will contribute significant information in the transverse plane, as well as in densitometric analyses. The impact of ACTA-scanning will not be limited to the diagnostic area, but will extend, at least indirectly, to general patient management and to some aspects of medical economics as well. Risk-laden, technically complex, and costly diagnostic procedures, sometimes requiring lengthy hospitalization, will in some cases be eliminated. The simple, innocuous, and noninvasive ACTA-scanning can be performed on an outpatient basis. Repeated follow-up examinations should be easily accepted by the patients, considering that this diagnostic test is carried out without discomfort. The entire field of diagnostic radiology is on the verge of revolutionary changes.

To describe the radionuclide three-phase whole-body bone imaging (TPWBBI) technique and discuss the usefulness of its application. TPWBBI was performed after a single intravenous injection of 555 to 925 MBq (15 to 25 mCi) Tc-99m MDP. Whole-body arterial flow (phase one) followed by blood-pool and tissue perfusion (phase two) images were obtained with the moving detector head speed set at 150 cm/minute and 40 cm/minute, respectively. Conventional whole-body static bone images (phase three) were obtained 3 hours later. When 542 consecutive TPWBBI results were reviewed, 394 (166 extraskeletal and 228 skeletal) abnormalities were detected during phases one and two. The 166 extraosseous lesions included vascular diseases: abdominal aortic aneurysms and peripheral vascular diseases and renal abnormalities, liver abnormalities, ascites, and pleural effusions. Many of these were incidentally detected clinically significant findings and would not have been identified on conventional static bone images. It helps to differentiate among acute and chronic fractures, active and inactive inflammatory diseases such as arthritis or osteomyelitis, and Paget's disease. With a single injection of Tc-99m MDP, whole-body images obtained in the arterial phase, the blood-pool and tissue perfusion phase, and the static bone phase can identify many clinically significant skeletal and soft tissue abnormalities. TPWBBI can differentiate between active and inactive phases of different disease processes and thereby provide a diagnosis that is more specific than a conventional single-phase bone scan. It may be applicable as a tool for nuclear physical examination.

This observational study aimed to define the learning curve in goal-directed ultrasound (US) after a 2-day training course dedicated to novice emergency residents. After completion of the training program, 180 patients requiring goal-directed US examination were examined by a resident and by an experienced investigator. The main endpoints were the diagnostic agreement between the two operators for 14 clinical questions, the duration of the examinations, the number of nonaddressed questions, and the final diagnosis. All criteria were analyzed according to the experience of the resident every 10 examinations. After 30 supervised examinations, residents adequately assessed with a very good or considerable agreement global left ventricular systolic dysfunction [κ=0.92; 95% confidence interval (CI): 0.80-1], severe right ventricular dilation (κ=0.73; 95% CI: 0.37-1), inferior vena cava diameter (κ=0.88; 95% CI: 0.71-1), and pericardial effusion (κ=0.85; 95% CI: 0.55-1). In general US, 20 supervised examinations were required to diagnose intraperitoneal effusion (κ=0.81; 95% CI: 0.61-1), cholelithiasis (κ=0.73; 95% CI: 0.36-1), obstructive uropathy (κ=0.85; 95% CI: 0.56-1), bladder distention (κ=1; 95% CI: 1-1), abdominal aortic aneurism (κ=0.9; 95% CI: 0.74-1), alveolar interstitial pattern (κ=0.87; 95% CI: 0.74-0.99), consolidated lung (κ=0.83; 95% CI: 0.68-0.97), or pleural effusion (κ=0.89; 95% CI: 0.77-1). After 30 supervised examinations, the overall diagnostic accuracy was judged excellent between the two investigators, with a significant improvement during the learning curve. The performance of 30 supervised and goal-oriented examinations appeared adapted to adequately answer clinical questions covered by core applications of emergency US.

Objective: The aim of this study is to investigate the positive association between the presence of renal cysts and AAA. Patients and Methods: A retrospective chart review on the clinical data of 396 consecutive patients, who underwent CT scans for preoperative evaluation of thoracic and cardiovascular surgery in Sapporo Medical University from the period of January 2007 to December 2008, was conducted. Results: When comparing patients with renal cysts (n = 164) to those without (n = 233), there was a statistically significant difference between the presence of renal cysts and male gender (p = 0.007), hypertension (p = 0.003), and AAA (p < 0.001) on univariate analysis. In addition, when comparing patients with AAA to those without, although COPD but not AAA was associated with renal cysts in less than 65 years old, the presence of renal cysts was the strongest association with AAA among patients belonging to the 65 to 74 years old group and over 75 years old group on multivariate analysis. Conclusions: There is a statistically higher incidence of renal cysts in patients with AAA compared to patients without AAA in the group of elder cardiovascular patients. It is likely that AAA and renal cysts share a common pathogenesis.

$$graphic_{18DDECD9-E3A4-4287-BF7B-119389E74916}$$ The leading causes of pleural effusions are congestive heart failure, pneumonia, cancer, pulmonary embolism, viral disease, coronary artery bypass surgery, and cirrhosis. An increasingly recognized etiology is medication-induced effusions. Pulmonary adverse effects, including pleural effusion, pulmonary hypertension, and parenchymal opacities, have been reported in approximately 35% of patients on dasatinib, a second-generation tyrosine kinase inhibitor used to treat chronic myeloid leukemia and Philadelphia chromosome positive acute lymphoblastic leukemia. In this case, we discuss a rare finding of a lymphocyte-predominate exudative chylothorax secondary to dasatinib. Our patient is a 73-year-old female with paroxysmal atrial fibrillation, type 2 diabetes mellitus, hypertension, chronic myeloid leukemia (CML), a remote history of abdominal aortic aneurysm status post stenting and thoracic aortic dissection type B status post repair. Patient showed poor tolerance to initial CML treatment with imatinib. Dasatinib was introduced five months after initial diagnosis. Cough and dyspnea developed in setting of small unilateral pleural effusion on imaging. Symptoms receded when dasatinib was held. In rechallenge with half-dose dasatinib, both cough and dyspnea worsened. Exam was notable for decreased breath sounds on auscultation and dullness to percussion. Repeat chest imaging revealed large right-sided pleural effusion. Decision was made to perform diagnostic and therapeutic thoracentesis. The drainage yielded milky-appearing, lymphocyte-predominate (97%) exudative effusion with elevated triglycerides (285 mg/dL) and cholesterol (51 mg/dL) consistent with chylothorax (Table 1). Gram stain, cultures, cytology, and flow cytometry were all unrevealing. Additional testing excluded alternate contributions such as pulmonary embolism, heart failure, autoimmune disease, or worsening CML. Following thoracentesis and discontinuation of dasatinib, the effusion resolved. The patient was started on nilotinib with no recurrence of pleural effusions. Drug-induced pleural effusion is common and often results in eosinophilic or lymphocytic-predominant exudate. While pleural effusion is commonly associated with dasatinib, chylothorax in setting of dasatinib use remains an extremely rare adverse event. To date, no other medication has been known to cause chylothorax. Few reported cases have observed a similar temporal relationship between dasatinib use and pleural effusions, with effusion recurrence noted even at reduced dosages. Although the exact mechanism remains unclear, current evidence suggests that microscopic disruptions in lymphatic channel may lead to chylous effusions. Clinical course tends to be benign with resolution upon withdrawal of the agent. With the increasing use of targeted therapies, it is essential to recognize potential medication-associated chylothorax among patients treated with dasatinib and consider alternative treatment options.