bluuebunny/crossref_metadata_2025 huggingface dataset:
EWOLUTION: Design of a registry to evaluate real‐world clinical outcomes in patients with AF and high stroke risk‐treated with the WATCHMAN left atrial appendage closure technology
Authors: Boersma Lucas V.A. , Schmidt Boris , Betts Tim R. , Sievert Horst , Tamburino Corrado , Teiger Emmanuel , Stein Kenneth M. , Bergmann Martin W.
Published: December 2015

Background

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and the rate of ischemic stroke attributed to non‐valvular AF is estimated at 5% per year. Several multi‐center studies established left atrial appendage closure as a safe and effective alternative to oral anticoagulation, but there is a need for additional real world data.

Methods

The purpose of this observational, prospective, single‐arm, multicenter clinical study is to compile real‐world clinical outcome data for WATCHMAN™ LAA (left atrial appendage) Closure Technology. One thousand subjects at up to 70 institutions in Europe, the Middle East, and Russia will be enrolled. Patients will be followed for 2 years after WATCHMAN implantation, according to standard medical practice. Primary endpoints include procedural and long‐term data including stroke/embolism, bleeding, and death. This article presents the background of the LAAC device and describes the design of the study.

Results

Results for peri‐procedural analyses are expected toward the end of 2015; long‐term follow‐up data are expected in the latter half of 2017.

Conclusion

The EWOLUTION study will formally expand knowledge of LAA closure into a broader real world setting. © 2015 Wiley Periodicals, Inc.
Removal of Copper from Aqueous Solution Using Chemically Treated Potato (Solanum tuberosum) Leaf Powder
Authors: Moyo Mambo , Chirinda Admire , Nharingo Tichaona
Published: December 2015

The present investigation describes the use of an agricultural waste; leaves powder derived from a specially cultivated Solanum tuberosum (potato) plant, as an adsorbent for copper removal from aqueous solutions. Batch experiments were performed based on parameters, such as pH at point of zero charge, pH, dosage, contact time, initial metal concentration, and temperature to study their effects on the removal capacity of copper from aqueous solutions. The kinetic data fitted well to the pseudo‐second order model, with a calculated adsorption capacity (qe) value (23.70 mg g−1) close to the experimental (qe) value (24.60 mg g−1). The adsorption data conformed best to the Langmuir isotherm as revealed by a lower non‐linear Chi‐square (χ2) value of 0.25 and a higher correlation value of 0.991 when compared to the Freundlich isotherm with a higher χ2 value of 0.78 and a lower correlation value of 0.985. The maximum adsorption capacity for the leaves powder was 42.74 mg g−1. The thermodynamic parameters (ΔG°, ΔS°, and ΔH°) showed that adsorption was feasible, spontaneous and endothermic. Fourier transform infrared (FTIR) spectroscopy confirmed the involvement of OH, NH, and CH of carboxylic acids and amino acids on the removal of copper from aqueous solutions. The results obtained in the present study indicated that S. tuberosum leaves powder can be used effectively to remove copper ions from aqueous solutions.
Isoform‐specific localization of Nogo protein in the optic pathway of mouse embryos
Authors: Wang Liqing , Wang Jun , Ma Ding , Taylor Jeremy S.H. , Chan Sun‐On
Published: December 2015

Expression of Nogo protein was investigated in the optic pathway of embryonic mice by using isoform‐specific antibodies Bianca and 11C7, which recognize Nogo‐A/B and Nogo‐A, respectively. Our previous reports from using antibody N18 have shown that Nogo is localized on the radial glia in the retina and at the midline of the ventral diencephalon in mouse embryos during the ingrowth of retinal ganglion cells (RGCs) axons. This glial‐specific localization is markedly different from findings in other studies. This study showed Nogo‐A/B primarily on radial glia in the retina at E13 and then later on retinal ganglion cells and axons at E14 and E15, whereas Nogo‐A was expressed preferentially by RGCs and their axons. In the ventral diencephalon, Nogo‐A/B was expressed strongly on radial glia, particularly in those located in the midline region of the chiasm but also on RGC axons. In Nogo‐A knockout embryos, the isoform Nogo‐B (revealed by Bianca) was observed on radial glia in the ventral diencephalon and on RGCs and their axons. We concluded that Nogo‐A is localized on the ganglion cells and retinal axons, whereas Nogo‐B is expressed by the radial glia in the optic pathway. Nogo‐B may play an important role in guiding axon growth in decisive regions of the visual pathway, which include the optic disc and the optic chiasm. J. Comp. Neurol. 524:2322–2334, 2016. © 2016 Wiley Periodicals, Inc.
Genetic cell targeting uncovers specific neuronal types and distinct subregions in the bed nucleus of the stria terminalis
Authors: Nguyen Amanda Q. , Dela Cruz Julie A.D. , Sun Yanjun , Holmes Todd C. , Xu Xiangmin
Published: December 2015

The bed nucleus of the stria terminalis (BNST) plays an important role in fear, stress, and anxiety. It contains a collection of subnuclei delineated by gross cytoarchitecture features; however, there has yet to be a systematic examination of specific BNST neuronal types and their associated neurochemical makeup. The present study focuses on improved characterization of the anterior BNST based on differing molecular and chemical expression aided by mouse genetics. Specific Cre driver lines crossed with a fluorescent reporter line were used for genetic cell targeting and immunochemical staining. Using this new approach, we were able to robustly identify specific excitatory and inhibitory cell types in the BNST. The presence and distribution of excitatory neurons were firmly established; glutamatergic neurons in the anterior BNST accounted for about 14% and 31% of dorsal and ventral BNST cells, respectively. GABAergic neurons expressing different isoforms of glutamic acid decarboxylase were found to have differential subregional distributions. Almost no parvalbumin‐expressing cells were found in the BNST, while somatostatin‐expressing cells and calretinin‐expressing cells account for modest proportions of BNST cells. In addition, vasoactive intestinal peptide‐expressing axonal plexuses were prominent in the oval and juxtacapsular subregions. In addition, we discovered that corticotropin‐releasing hormone‐expressing cells contain GABAergic and glutamatergic subpopulations. Together, this study reveals new information on excitatory and inhibitory neurons in the BNST, which will facilitate genetic dissection and functional studies of BNST subregions. J. Comp. Neurol. 524:2379–2399, 2016. © 2016 Wiley Periodicals, Inc.
Thermodynamics of action and organization in a system
Authors: Chatterjee Atanu
Published: December 2015

Complexity in nature is astounding yet the explanation lies in the fundamental laws of physics. The Second Law of Thermodynamics and the Principle of Least Action are the two theories of science that have always stood the test of time. In this article, we use these fundamental principles as tools to understand how and why things happen. In order to achieve that, it is of absolute necessity to define things precisely yet preserving their applicability in a broader sense. We try to develop precise, mathematically rigorous definitions of the commonly used terms in this context, such as action, organization, system, process, etc., and in parallel argue the behavior of the system from the first principles. This article, thus, acts as a mathematical framework for more discipline‐specific theories. © 2015 Wiley Periodicals, Inc. Complexity 21: 307–317, 2016
Calculating entropy at different scales among diverse communication systems
Authors: Febres Gerardo , Jaffé Klaus
Published: December 2015

We evaluated the impact of changing the observation scale over the entropy measures for text descriptions. MIDI coded Music, computer code, and two human natural languages were studied at the scale of characters, words, and at the Fundamental Scale resulting from adjusting the symbols length used to interpret each text‐description until it produced minimum entropy. The results show that the Fundamental Scale method is comparable to using words when measuring entropy levels in written texts. However, the Fundamental Scale can also be used to analyze communication systems lacking conventional words, such as music. Measuring symbolic entropy at the fundamental scale allows to calculate quantitatively, relative levels of complexity for different communication systems. Here, we showed that music and written language share some characteristics as communication systems but differ in others. The results open novel vistas on the similarities and differences among the structure of the various communication systems that are used by humans and by nature in general. © 2016 Wiley Periodicals, Inc. Complexity 21: 330–353, 2016
ASSOCIATION BETWEEN INFANT NIGHTTIME‐SLEEP LOCATION AND ATTACHMENT SECURITY: NO EASY VERDICT
Authors: Mileva‐Seitz Viara R. , Luijk Maartje P.C.M. , van Ijzendoorn Marinus H. , Bakermans‐Kranenburg Marian J. , Jaddoe Vincent W.V. , Hofman Albert , Verhulst Frank C. , Tiemeier Henning
Published: December 2015

We tested whether mother–infant bed‐sharing is associated with increased secure infant–mother attachment, a previously unexplored association. Frequency of bed‐sharing and mothers’ nighttime comforting measures at 2 months were assessed with questionnaires in 550 Caucasian mothers from a population‐based cohort. Attachment security was assessed with the Strange Situation Procedure (M.D.S. Ainsworth, M.C. Blehar, E. Waters, & S. Wall, 1978) at 14 months. When using a dichotomous variable, “never bed‐sharing” (solitary sleepers) versus “any bed‐sharing,” the relative risk of being classified as insecurely attached for solitary‐sleeping infants (vs. bed‐sharers) was 1.21 (95% confidence interval: 1.05–1.40). In multivariate models, solitary sleeping was associated with greater odds of insecure attachment, adjusted odds ratio (OR): 1.50, 95% CI = 1.02–2.20) and, in particular, with greater odds of resistant attachment, adjusted OR = 1.74, 95% CI = 1.10–2.76); and with a lower attachment security score, β = −0.12, t(495) = −2.61, p = .009. However, we found no evidence of a dose–response association between bed‐sharing and secure attachment when using a trichotomous bed‐sharing variable based on frequency of bed‐sharing. Our findings demonstrate some evidence that solitary sleeping is associated with insecure attachment. However, the lack of a dose–response association suggests that further experimental study is necessary before accepting common notions that sharing a bed leads to children who are better or not better adjusted.
The value of screening for major fetal abnormalities during the nuchal translucency examination
Authors: Wye Deborah , Benzie Ron
Published: December 2015

The nuchal translucency (NT) scan provides an opportunity to examine fetal anatomy. Current opinion on the advantages and limitations of assessing fetal anatomy at this early gestation is divided. Two case studies from our centre will be presented where assessing fetal anatomy was of great benefit – one in finding abnormalities, the other in excluding them.

These cases along with review of the literature support the view that a limited fetal anatomy scan should be performed as part of the NT examination.
Vein of Galen abnormality
Authors: Roberts Harley , Mein Brendan , Miceli Francis
Published: December 2015

Vein of Galen abnormality is a rare congenital malformation of blood vessels of the brain and while often referred to as “Vein of Galen aneurysm” its is really not an aneurysm but usually an arteriovenous (AV) malformation. The following case report will be of interest to sonographers as it demonstrates early prenatal diagnosis of this intracranial vascular abnormality causing cardiac overload and subsequent cardiac failure. Diagnosis of the AV malformation can be graphically demonstrated using colour Doppler or 3D colour power angiography.
Absent fetal hand: a case report
Authors: Joshi Sneha , Uppal Talat
Published: December 2015

Isolated congenital fetal hand malformation is a rare finding1. The prevalence of limb reduction deformities is about 3–8 per 20,000 births2. An isolated amputation of an extremity can be due to amniotic band syndrome, exposure to a teratogen or a vascular accident2. A comprehensive obstetric ultrasonographic assessment as well as genetic counselling are ideal when a fetal hand abnormality is detected, so as to determine whether a karyotype analysis is appropriate.

We report a case of an absent left fetal hand and explore the parental distress with the diagnosis at almost 20 weeks of gestation. This case also highlights parental perception of medical inertia in terminating a pregnancy of this gestational age and complication.
Recurrent viable ectopic pregnancy in the salpingectomy stump
Authors: Anwar Sonia , Uppal Talat
Published: December 2015

Ipsilateral ectopic pregnancy after total salpingectomy is a rare occurrence and in theory should not happen. We report a case where a spontaneous ectopic pregnancy was found in the stump of the previously removed tube. This case highlights the need for further consideration of the diagnosis of an ectopic pregnancy in the setting of a previous ipsilateral salpingectomy.
RBC motion and the basis of ultrasound Doppler instrumentation
Authors: Uppal Talat , Mogra Ritu
Published: December 2015

Ultrasonography has become one of the most popular techniques for noninvasive body assessment. The advent of sophisticated Doppler imaging has added an “information about blood flow” dimension. However, searching for complex details, despite enhanced system design and capabilities, place an increased demand on the operator. Examination technique and equipment settings are potential sources of error and therefore to obtain and interpret Doppler indices well it is essential to understand the physics of the Doppler principle and the dynamics of blood flow.
The use of intra‐operative saline sonovaginography to define the rectovaginal septum in women with suspected rectovaginal endometriosis: a pilot study
Authors: Reid Shannon , Bignardi Tommaso , Lu Chuan , Lam Alan , Condous George
Published: December 2015

Objectives: The aim of this study was to perform saline sonovaginography (SVG) in women with suspected rectovaginal endometriosis (RVE) in order to establish the thickness of the rectovaginal septum (RVS) in this population and to predict the presence or absence of RVE.

Methods: Prospective observational pilot study. Women undergoing laparoscopy for possible endometriosis on the basis of history or clinical examination were offered to participate in the study. All women underwent saline SVG during general anesthesia just prior to their laparoscopy. RVS nodules were visualised as hypoechoic lesions of various shapes. The sonologist predicted whether or not a nodule was present in the retrocervical area or in the RVS. The thickness of the posterior vaginal wall ± RVS was then taken at three points in the mid‐sagittal plane: at the posterior fornix (retrocervical area), at the middle third of the vagina (upper RVS) and just above the perineal body (lower RVS). The diagnosis of RVE was established using the gold standards of laparoscopy and histological confirmation. The RVS thickness was then compared between women with RVE and the absence of RVE.

Results: Twenty‐three women were enrolled in the study. Mean age was 38 years (33–44 years). A history of endometriosis was present in 72.7% (8/11). RVE was confirmed in 17.4% (4/23). Visualisation of a hypoechoic nodule at saline SVG demonstrated sensitivity and specificity of 75% and 95%, respectively. All rectovaginal nodules were located in the retrocervical region. Mean diameter (SD) of RVE nodules was 27.3 (± 9.4) mm. Mean thickness of vaginal wall ± RVS at the posterior fornix, at the middle third of the vagina and just above the perineal body was 5.1, 1.4 and 4.0 mm, respectively. These measurements were not significantly different in the presence of a rectovaginal nodule.

Conclusions: Using saline SVG, we have established the mean RVS thickness in a small group of women with suspected RVE. Although the numbers are small, there was no correlation between RVS thickness and presence of RVE. The visualisation of hypoechoic lesions at saline SVG seems to be the best ultrasonographic predictor for RVE. SVG is a valuable pre‐operative tool for the assessment of RVS and for the prediction of RVE, which allows for the mapping and planning of advanced endometriosis surgery.
The role of imaging in the investigation of Asherman's syndrome
Authors: Tan I‐Ferne , Robertson Meiri
Published: December 2015

Asherman's syndrome has significant reproductive implications for patients. In most case series, the rate of fertility and full term birth directly correlates to extent of disease. However, there does not seem to be a connection between number of prior curettages, nor aetiology of adhesions in predicting outcome. Without a universally accepted classification system, comparison of research data and results for imaging modalities is difficult.
A heterotopic pregnancy involving a caesarean section scar
Authors: Paoletti Debra
Published: December 2015

Heterotopic pregnancy refers to the presence of simultaneous pregnancies in two different implantation sites, generally one intra‐uterine pregnancy and one extra‐uterine pregnancy (usually tubal). This is a rare case of a heterotopic pregnancy involving concurrent intra‐uterine pregnancy and caesarean section scar pregnancy (CSEP). CSEPs are at a high risk of bleeding and uterine rupture, carrying with them significant maternal morbidity.
Appendicitis: a pictorial essay
Authors: Seow Stewart
Published: December 2015

Appendicitis is a common disorder which requires careful diagnosis to avoid complications. Ultrasound is being increasingly used for diagnosis because of its ease and simplicity. In this series, a range of abnormal findings are presented, as well as useful teaching points on technique and pitfalls.
Obstetric ultrasonography practice in Fiji
Authors: Kumar Sanjalesh
Published: December 2015

In Fiji, a Pacific island nation, ultrasonography practice is still in its infancy. Ultrasounds are performed by radiographers who independently interpret the ultrasonographic images and write the diagnostic reports on behalf of the radiologists. This paper presents research on the practices and procedures that are used to perform the mid‐trimester obstetric ultrasonography examinations at an urban public hospital in Fiji. The participants comprised a cohort of “on‐the‐job” trained radiographers, radiologists and obstetricians involved in obstetric ultrasonography. In‐field observations, questionnaires and interviews yielded predominantly qualitative data. The radiographers' scanning criteria were evaluated against the stipulated ASUM mid‐trimester guidelines.

This study revealed that even the most experienced radiographers barely met 50% of ASUM's mid‐trimester scanning requirements. They spent less than five minutes performing a scan and insufficient expertise, training and supervision, excessive workload and a lack of resources were major constraints affecting the standards of ultrasonography practice in Fiji. However, the absence of a standard protocol was also a major cause for disparate scanning patterns amongst the radiographers. This paper highlights the gaps and limitations associated with the obstetric ultrasonography practice in Fiji, and suggests the need for international assistance in ultrasonography education.
The term “pregnancy of unknown location” is here to stay
Authors: Condous George , Winder Simon , Reid Shannon
Published: December 2015

The term “pregnancy of unknown location” is an ultrasound classification and not a final diagnosis. The use of this terminology is here to stay and should continue as long as there is an appreciation for what it really means. It is the responsibility of the clinician, who follows up these women with a PUL, to ensure that a final diagnosis is achieved while preserving the well‐being of these women.
Spontaneous septostomy in monochorionic diamniotic twins resulting in cord entanglement and fetal demise
Authors: Fleming Tina , Miller Trent
Published: December 2015

Monoamniotic twins are known to be at risk of cord entanglement, and have an elevated perinatal morbidity and mortality associated with this. We present a case of cord entanglement in a monochorionic diamniotic (MCDA) twin pregnancy thought to be due to spontaneous septostomy. Unfortunately the cord entanglement was detected postpartum, and ultimately resulted in the demise of one of the twins. Literature review reveals this as a recognised, albeit rare, phenomena.
Prenatal diagnosis of a left ventricular diverticulum
Authors: Paoletti Debra , Robertson Meiri
Published: December 2015

A congenital left ventricular diverticulum is a rare prenatal finding. The four‐chamber view of the heart is a standard part of the 18–20 week morphology scan, and evaluation of the heart with colour Doppler imaging has greatly enhanced the detection of rare and subtle cardiac anomalies.
Estimating fetal weight for best clinical outcome
Authors: Westerway Susan Campbell
Published: December 2015

Clinical decisions are often based on the results of third trimester sonograms, particularly with small or large babies and so accuracy of estimating fetal weight (EFW) is essential. There are numerous EFW formula available and yet in Australia no one formula has been recommended for use due to the lack of clinical evidence as to their accuracy.

Objectives: 1 To assess inter/intra observer error for fetal parameter measurements with multiple observers. 2 To compare six of the most commonly used EFW formulae and analyse inter/intra formulae variations for different weight range.

Method: EFW of 121 pregnancies assessed within 7 days of birth by measuring the BPD, OFD, HC, AC, FL and comparing to actual birth weight.

Results: Inter‐observer error: 1.3 to 3.1%. Intra‐observer error: 1.1 to 1.9% depending on fetal parameter. Accuracy of each EFW formula changed with different weight ranges. For all formulae the highest random error occurred in the macrosomic group. The lowest random error in all weight groups was the Hadlock B formula incorporating the HC/AC/FL (7.7%).

Conclusion: Considering the possible problems of head moulding this study suggests the use of: Hadlock FP et al (1982) – Formula B – incorporating HC/AC/FL.
Megalourethra: a case report managed with a single intrauterine bladder aspiration
Authors: Asma Basha , Jumana Baramki
Published: December 2015

Congenital megalourethra is a rare mesenchymal anomaly of the male urethra, characterised by severe dilatation of the penile urethra due to congenital absence of the corpus spongiosum and/or corpus cavernosum. Postnatal complications include voiding and erectile dysfunction as well as renal insufficiency and pulmonary hypoplasia. We present a unique case of congenital megalourethra diagnosed prenatally in the early second trimester. The parents opted to continue pregnancy and vaginal delivery of a live neonate occurred with a favourable outcome.
Low PAPP‐A: what are the clinical implications?
Authors: Lau Harmonie , Amarasekara Chaminda , Uppal Talat
Published: December 2015

Ultrasound and pulsed Doppler can assist in confirming impaired placentation looking at fetal biometry and umbilical artery Dopplers. The authors recommend confirmation of fetal wellbeing at 28–30 weeks with a PAPP‐A level below the first centile.
Meigs' and Pseudo‐Meigs' syndrome
Authors: Saha Sumi , Robertson Meiri
Published: December 2015

Diagnosing Meigs' syndrome is challenging in that it can be mistaken for a number of other conditions. Ultrasound can identify ascites and pleural effusions, which is essential in accurate identification.
Massive ovarian cystic teratomas diagnosed at a rural Nepal camp
Authors: Williams Alan
Published: December 2015

This case report presents the findings of significantly large sized (> 8 cm) symptomatic unilateral cystic teratomas in two perimenopausal patients in remote Nepal.

Ovarian dermoid cysts consist of cystic, solid and fat tissue. Traditionally, cells differentiate along the various germ lines, essentially recapitulating various body tissues. The characteristic sonographic features include a dermoid plug, dermoid mesh, a fat‐fluid level and the “tip of the iceberg” sign.

The presence of two or more of these typical features confidently supports an ultrasound‐based diagnosis of ovarian dermoid cyst.

The presence of intratumoral hair, teeth, fat, and skin tissue revealed at surgery confirmed the initial ultrasound based diagnosis.
Targeted liver ultrasound for chronic liver disease: time to focus?
Authors: Gibson Robert N
Published: December 2015

Increasing prevalence of chronic liver disease has led to dramatically increased demands on ultrasound for diagnosis, monitoring and surveillance of complications. Targeted ultrasound of the liver provides an efficient and possibly more accurate means of meeting this demand. It uses a matrix to guide the ultrasound examination to address the specific clinical questions commonly asked in this population. It is easy to implement and can be modified to meet local preferences and emerging technologies.
Aortic plaque defined by contrast transthoracic echocardiography
Authors: Cursaro Michael , Simmonds Ivan , Bradley Julie , Shirazi Mitra , Disney Patrick , Cunnington Michael
Published: December 2015

The authors explore the use of third generation echo contrast to define plaque in the ascending aorta and exclude more invasive procedures.
Creating thoracic phantoms for diagnostic and procedural ultrasound training
Authors: Rippey James , Gawthrope Ian
Published: December 2015

The use of pleural and lung ultrasound is being performed increasingly by respiratory and critical care clinicians around the world. This article describes how to create cheap and reliable lung and pleural phantoms for teaching. The phantoms described replicate the appearance of normal ventilating lung, pneumothorax (including the contact or lung point), pulmonary oedema, pleural effusion and empyema. The pleural effusion phantom can be used to teach procedural ultrasound (pleurocentesis).
Portal vein thrombosis with contrast‐enhanced ultrasound in a patient with hepatocellular carcinoma: a case study
Authors: Salman Saba
Published: December 2015

Portal vein thrombosis (PVT) is the presence of thrombus in the portal vein that causes partial or complete occlusion. It is prevalent in hepatocellular carcinoma (HCC), where it can be either bland or malignant depending on the presence of invasion. Recent studies have identified contrast‐enhanced ultrasound (CEUS) as the most reliable method of imaging to make this distinction. The arterial neovascularisation that is evident in a neoplastic thrombus can be visualised on CEUS with enhancement and pulsation, witnessed in real‐time. This case study describes the use of contrast‐enhanced ultrasound used as a non‐invasive method to define the bland and malignant components of portal vein thrombosis in a 76‐year‐old male with hepatocellular carcinoma and cirrhosis.
Dynamic echocardiography in evaluation of platypnoea‐orthodeoxia
Authors: Yastrebov Konstantin , Sader Mark , Youssef George , Nojoumian Haidy
Published: December 2015

Platypnoea‐orthodeoxia is an infrequent syndrome that is usually associated with positional intracardiac right‐to‐left shunting. The authors report the case of a patient who presented with deteriorating severe dyspnoea and deoxygenation in the upright position that was partially relieved by recumbent repositioning. Dynamic echocardiography provided insight into the underlying anatomical and pathophysiological mechanisms as well as guidance for definitive therapy.
A review of congenital diaphragmatic hernia
Authors: Marlow Jay , Thomas Joseph
Published: December 2015

Background: Congenital diaphragmatic hernia (CDH) is a simple diaphragmatic defect that is seen frequently in antenatal scans. Though the surgical repair is relatively easy in the neonate, the mortality is high due to pulmonary hypoplasia and pulmonary vascular changes.

Materials and Methods: The goals of prenatal imaging are to establish the diagnosis. Assessment in a tertiary scanning center would identify prognostic factors which assist in counselling and planning antenatal management. However, the pulmonary hypoplasia associated with the CDH in moderate and severe cases makes the prognosis poor.

Conclusions: Fetal intervention such as, fetal tracheal occlusion, is being trialled and may change the outcomes in the future.
The use of interventional ultrasound in early pregnancy complications
Authors: Reid Shannon , Casikar Ishwari , Condous George
Published: December 2015

Background: The use of ultrasound to establish pregnancy location, viability and gestational age in the first trimester is well established. In addition to the conventional uses of ultrasound in early pregnancy, interventional ultrasound may also be used to guide clinicians during surgical procedures for the management of early pregnancy complications (i.e. treatment of ectopic pregnancy, caesarean section scar pregnancy, molar pregnancy, retained products of conception, and removal of intra‐uterine devices in early pregnancy).

Aims: This review discusses the role of interventional ultrasound as it pertains to the management of first trimester complications, particularly with regard to the use of ultrasound in conjunction with surgical modalities.

Materials and Methods: This review was based on recently published research, as cited in the PubMed database, regarding the use of either transvaginal or transabdominal ultrasound to assist with the management of early pregnancy complications.

Conclusions: In addition to the diagnostic capabilities of ultrasound in early pregnancy, interventional ultrasound plays an important role in the management of various first trimester pregnancy complications. With the advent of more conservative approaches to early pregnancy complications, interventional ultrasound is a viable option which is not only safe in experienced hands but also enables fertility preservation.
Pelvic congestion syndrome
Authors: Robertson Meiri , McCuaig Ruth
Published: December 2015

Background: The precise aetiology of pelvic congestion syndrome (PCS) remains poorly understood but is believed to be multifactorial having mechanical, hormonal and psychological components.

Materials and methods: Minimally invasive techniques of embolisation or sclerotherapy of the ovarian veins has become the mainstay of treatment for PCS. Studies report a technical success rates from 89–100% and clinical success rates of 58–100%.

Conclusions: Embolisation and sclerotherapy can be done as a day surgery procedure concurrently with diagnostic venography and given current evidence provide better long term pain relief than medical therapy.
Heterotopic pregnancy: a report of two cases
Authors: Farnaghi Soheil , Kothari Alka
Published: December 2015

Background: A heterotopic pregnancy is defined as the presence of a concomitant intrauterine and extrauterine pregnancy. Its estimated incidence is 1/30,000 in spontaneous pregnancies. It is also reported to be as high as 1 in 3900 when the pregnancy is a result of assisted reproductive technology (ART). However, clomiphene citrate (CC) could be associated with a higher rate of heterotopic pregnancy as it amplifies the rate of twinning. Furthermore, heterotopic pregnancies are a diagnostic and therapeutic challenge for obstetricians. If undiagnosed, they are associated with significant maternal morbidity and mortality.

Case presentation: We present two cases of coincidental intra and extra‐uterine pregnancy. In the first case, heterotopic pregnancy was a result of induction of ovulation with CC. There was a delay in the diagnosis of the ectopic pregnancy component resulting in an emergency laparoscopy. Fortunately, after the laparoscopy the intrauterine pregnancy was not affected and it is progressing satisfactorily. Alternatively, the second case occurred spontaneously and was treated with methotrexate as the intrauterine pregnancy miscarried on its own accord.

Conclusions: These cases highlight the fact that as clinicians, we should be aware of the possibility of a heterotopic pregnancy in any patient presenting with pelvic pain, even when an intrauterine pregnancy has been confirmed. This is even more imperative after induction of ovulation by CC or ART. We would also like to emphasise that an early diagnosis is critical to safeguard the intrauterine pregnancy and avoid maternal morbidity and mortality due to the ectopic pregnancy.
Spontaneous expulsion of large submucosal uterine fibroid without embolisation – a case study
Authors: De Cure Natalie , Sullivan Tegan , Robertson Meiri , Hallam Lavinia , Whale Karen
Published: December 2015

Background: This case involved a 35‐year‐old G6P0 with multiple uterine fibroids detected at 12 weeks gestation. Fibroid growth was monitored throughout pregnancy, and intrauterine growth restriction (< 5th centile) was detected at 20 weeks. Fetal demise occurred at 22+ weeks gestation at which time the largest of fibroids measured 150 × 100 × 118 mm and labour was induced.

Materials and methods: Serial ultrasounds following delivery showed features of reduced vascularity and separation of the fibroid from the myometrium, consistent with spontaneous degeneration. Our patient re‐presented with severe pain and went on to expel the fibroid spontaneously 41 days post induction of labour. Histopathology confirmed fibroid degeneration.

Conclusion: This case demonstrates spontaneous fibroid degeneration and expulsion without embolisation. This may have resulted from the hormonal and mechanical effects of induction of labour. This case also demonstrated the effects of large intrauterine fibroids on fetal growth and increased risk of fetal demise, highlighting the importance of closer monitoring of fetal growth in such pregnancies.
Rationalising the change in defining non‐viability in the first trimester
Authors: Infante Fernando , Casikar Ishwari , Menakaya Uche , Condous George
Published: December 2015

Introduction: With the publication of four papers in late 2011, international cut‐offs for definitions of non‐viability in the first trimester of pregnancy were challenged. These definitions were inconsistent across different international guidelines. For example, a gestational sac with absent yolk sac or embryo and a mean diameter of ≥ 16 mm would be classified as a miscarriage in the USA, whereas the same sac would have to measure ≥ 20 mm in the UK or Australia to meet this definition. Likewise, an embryo with no detectable heartbeat and a CRL of ≥ 5 mm would also meet criteria for missed miscarriage in the USA, compared to a CRL ≥ 6 mm in the UK or Australia.

Methods: Later in 2011 and then in 2012, guidelines across the three countries were updated and are now consistent, defining an empty gestational sac with a mean diameter of > 25 mm as a non‐viable pregnancy and/or an embryo with CRL > 7 mm and no detectable heartbeat. In this paper we explore the rationale that led to these changes in order to potentially avoid wrongly diagnosing miscarriage at the decision boundary measurements and in turn avoiding inadvertent termination of potentially viable pregnancies.

Conclusion: Although reducing women's anxiety and making a definitive diagnosis as early as possible is desirable, the need for absolute certainty is paramount before diagnosis of the death of an early pregnancy is made.
The value of early recognition of fetal lymphangioma
Authors: Farnaghi Soheil , Kothari Alka
Published: December 2015

Introduction: Lymphangiomas are very rare benign tumors of the lymphatic system, appearing as uniseptate or multiseptate cystic masses, which are usually located in the cervical or axillary area. Postnatal outcome depends on the size and location of the lesion. An increasing number of such congenital abnormalities are detected on routine conventional prenatal ultrasonography. Although prenatal evaluation for the prognosis of fetal lymphangioma has been based on two‐dimensional ultrasonography, magnetic resonance imaging may help in assessing the extent of a lesion. Isolated lymphangiomas generally have a favourable prognosis and sclerotherapy or surgical resection is effective in most of the cases.

Case presentation: We present two cases of fetal axillary lymphangioma. In the first case, the lymphangioma was diagnosed antenatally, so parents were comprehensively counselled and post natal follow up was organised at a tertiary hospital. The second case remained undiagnosed until birth. This caused significant distress to both the parents and clinicians, especially after a coincident traumatic delivery.

Conclusion: Both these cases emphasise that early diagnosis of fetal lymphangioma is critical and a combination of ultrasonography and magnetic resonance imaging can facilitate detection of lesions which are relatively limited and accessible to therapy in utero. This would also enable clinicians to perform a karyotype and comprehensively consult parents regarding the treatment and delivery options as well as outcome of the pregnancy.
A pictorial guide for the second trimester ultrasound
Authors: Bethune Michael , Alibrahim Ekaterina , Davies Braidy , Yong Eric
Published: December 2015

Introduction: The second trimester ultrasound remains an important screening tool for detecting fetal abnormalities. This pictorial guide for the second trimester ultrasound is designed to assist practitioners to produce a high quality diagnostic survey of the fetus by demonstrating and describing recommended images.

Methods: Each image is discussed in detail and has an associated drawn line diagram to aid in the identification of the important features of that image. There is a description of the salient landmarks and relevant measurements.

Result: The authors hope this article may act as a useful guide to all practitioners performing second trimester ultrasounds.
Simplifying ultrasound assessment of the fetal heart: Incorporating the complete Three Vessel View into routine screening
Authors: Mogra Ritu
Published: December 2015

Introduction: As our experience and ultrasound resolution have improved significantly in last 30 years it is possible to detect most of the major cardiac abnormalities prenatally with high degree of accuracy.

Method: Current screening techniques have poor detection rate for congenital heart diseases (CHD) and nearly half of the major cardiac abnormalities mainly of Great Arteries goes unrecognised. A high detection rate for major CHDs can be achieved in a screening setting by improving techniques of routine screening in the low risk population.

Conclusion: This article summarises the alternative strategies to examine the outflow tracts and Great Arteries, its correct interpretation and examples of abnormal views.
Diagnostic accuracy of basic lung ultrasound in breathless patients over 60 years of age; stressing the protocol
Authors: Baker Kylie , Mitchell Geoffrey , Thompson Angus G , Stieler Geoffrey
Published: December 2015

Introduction: Emergency department differentiation of pulmonary oedema from chronic obstructive airways disease causing acute breathlessness is inaccurate 25% of the time despite clinical acumen, clinician‐reported chest x‐ray and ECG. This research investigates whether a basic lung ultrasound protocol (LUS) could improve identification of pulmonary oedema in breathless elderly patients. Method: Researchers prospectively sampled patients over 60 years, describing any breathlessness on presentation to a suburban emergency department. LUS studies were acquired by experienced or novice sonologists, interpreted by a blinded reviewer and compared with cardiologist chart audit for diagnosis at admission (gold standard). The admitting doctor's diagnosis, blinded to LUS, was compared with the chart audit result.

Results: 204 LUS were collected, 145 by experienced sonologist and 59 by inexperienced. Diagnostic accuracy compared to cardiologist audit was 86.2% (95% CI 80.9 to 90.3), significantly higher than 70.2%, diagnostic accuracy for admission diagnosis, difference in proportion of 16% (95%CI 7.7 to 24.4%).

Conclusion: A simple lung scanning protocol can help exclude pulmonary oedema in any breathless elderly patient.
Is bedside ultrasound now a routine part of specialist obstetrics and gynaecology outpatient consultation?
Authors: Van Der Wal Sarah , Robson Stephen J , Choong Shawn
Published: December 2015

Introduction: Portable ultrasound is extensively used in the delivery suite, and there is anecdotal evidence that ultrasound is increasingly common in routine outpatient gynaecological practice. We could find no published data regarding the prevalence of ‘rooms’ ultrasound use in outpatient gynaecology.

Methods: A survey instrument was developed containing demographic questions about ‘rooms’ ultrasound use, and three clinical vignettes regarding dysmenorrhoea in a young woman, bleeding in early pregnancy, and postmenopausal bleeding. For each vignette, respondents were asked whether they would refer for ‘formal’ ultrasound or rely on their own findings. The anonymous questions were sent to every obstetrician/gynaecologist in private practice in Australia.

Results: 438 surveys were posted and 242 returned (response rate 55%). 226 respondents (93.8%) reported using ultrasound in their consulting rooms, with 201 (88.9%) using transvaginal ultrasound. For the dysmenorrhoea vignette, 59% of respondents would rely on their own ultrasound findings and not refer for additional imaging. For the bleeding in early pregnancy vignette, 91% would rely on their own ultrasound findings and not refer for additional imaging. For post‐menopausal bleeding, 54% would rely on their own clinical and ultrasound findings and would not refer for additional imaging. Conclusion: The majority of practitioners would not refer for tertiary ultrasound if their own imaging revealed apparent normal findings.
Sonographic demonstration of stomach pathology: Reviewing the cases
Authors: Deslandes Alison
Published: December 2015

Introduction: The stomach can be the source of complaints for many patients attending for upper abdominal ultrasound. It is not routinely imaged as part of most upper abdominal ultrasound protocols, with sonographers and sonologists alike commonly muttering the line; “I can't see the stomach on ultrasound”. However, this is incorrect, as the gastric antrum can almost always be visualised sonographically.

Discussion: It is possible to detect a range of pathologies affecting the stomach sonographically, from common, largely tolerable conditions such as hiatus hernias through to life‐threatening neoplasms. Conclusion: The stomach can easily be assessed during routine abdominal ultrasound providing the sonographer has knowledge of stomach anatomy, normal ultrasound appearances and limitations to its visualisation. While endoscopy is the gold standard for investigation of the stomach and upper gastrointestinal tract, many patients will initially present for abdominal ultrasound due to its easy, non‐invasive nature, ready availability and low cost. For patients with mild abdominal symptoms, a normal abdominal ultrasound may be the extent of their imaging investigations meaning stomach pathologies may go undiagnosed.
Ultrasound measurements of the liver: an intra and inter‐rater reliability study
Authors: Childs Jessie T , Esterman Adrian J , Thoirs Kerry A
Published: December 2015

Introduction: Ultrasound is an easy and inexpensive method to rapidly assess the size of the adult liver. The literature addressing reliability of liver measurements using ultrasound is poorly reported and inadequate. In this study, intra and inter‐rater reliability of multiple measurements of the right lobe, left lobe and entire adult liver were assessed.

Methods: Two examiners acquired ultrasound images of the liver in multiple positions. Fifteen measurements were taken from each set of images by each examiner. One examiner repeated the images and measurements.

Results: Results demonstrated high intra‐rater reliability for all measurements (ICC's 0.67–0.97). Inter‐rater reliability also demonstrated high reliability (ICC's 0.71–0.94) for nine of the fifteen measurements (six representing the right lobe, one representing the left lobe and two representing the entire liver. Further analysis using paired samples t‐tests and Bland Altman plots were performed on these nine measurements.

Conclusion: From this study, the most reliable measurements are suggested to be MCL Dome to tip and MCL Max AP for the right lobe and Midline Max AP for the left lobe. The only measurement to truly encompass both lobes (Max Trans) was not shown to be reliable.
Complicated multiple pregnancy referral, treatment and outcomes at the NSW Fetal Therapy Centre
Authors: Tetstall Emma , Shand Antonia W , Welsh Alec W , Chen Katie Q , Henry Amanda
Published: December 2015

Objectives: To determine the indications for referral, sonographic workload, diagnoses and outcomes of women with a multiple pregnancy referred to the New South Wales Fetal Therapy Centre (NSW FTC). Methods: Retrospective cohort study of twin and higher order multiple (HOM) pregnancies referred to the NSW FTC at the Royal Hospital for Women (RHW) Department of Maternal Fetal Medicine (MFM), Sydney from January 2007 to December 2009.

Results: There were 176 twin pregnancies (138 monochorionic diamniotic, 29 dichorionic diamniotic and nine monoamniotic), and 26 HOMs referred (23 triplet and three quadruplet pregnancies). Indications for referral were: twin to twin transfusion syndrome (TTTS) 103 women, fetal anomaly 31 women, intrauterine growth restriction (IUGR) 12 women, serial surveillance of twins or HOM 37 women, and fetal reduction of HOM (nine women). In 80.2% the pathological referral diagnosis was confirmed. The average number of ultrasounds was five (range 1–24), with 90 women (45%) receiving invasive therapy. Thirty‐five percent (71) of referrals were from outside Sydney, including eight interstate and 11 overseas referrals. Two‐thirds of out of area referrals were able to return to their referral hospital for birth: 95 women (47%) delivered at RHW.

Conclusion: TTTS was the most common reason for referral, with a high concordance between referral and initial diagnosis. RHW accepted a large number of out of area referrals, in keeping with its role as the NSW FTC. Twin and HOM pregnancy referrals represent a significant workload for the 5 department, with many women also requiring invasive therapy.