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Hand-held sonomammography was used intraoperatively to localize 52 masses in 45 women in an out patient operating suite. All but five women had a positive X-ray mammogram. The ultrasound mammogram was able to identify all lesions. In 42 women studied by a preoperative ultrasound examination before the operating room procedure, all the masses were successfully identified. Precise localization was successfully performed in the operating room before sterile preparation in less than 10 minutes. Relocalization after incision in the sterile operating field was necessary in two cases. This technique requires no ionizing radiation and expedites outpatient surgical removal of the lesion. Of the 52 masses, there were 32 fibroadenomas, three carcinomas, three cysts, six cases of focal fibrous mastitis, and eight patients with focal fibrocystic disease. In patients with positive sonograms for nonpalpable masses, ultrasound localization is a fast, accurate alternative to X-ray needle placement.

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The evaluation of pelvic masses is routinely performed by transabdominal ultrasound. However, by placing the transducer into the vagina (the endovaginal approach), imaging resolution is improved and morphologic detail of true pelvic organs is increased. Twenty-one cases in which nonobstetrical pelvic pathology was suspected clinically were evaluated by both the endovaginal and (conventional) transabdominal approach. Each case was evaluated for efficacy of the two approaches independently and the results compared to the clinical outcome. Endovaginal scanning offered more accurate diagnostic information in 13 of the 21 cases (62%). Additional information was obtained by the endovaginal approach in seven of these 13 cases (55%). No significant difference was observed in 33%. Endovaginal ultrasound offers a diagnostic tool complementary to the transabdominal technique in the evaluation of pelvic masses in the female patient.

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Three patients with clinically suspected pseudoaneurysm as a complication of femoral puncture were referred for ultrasound (US) evaluation with both conventional duplex Doppler US and color Doppler imaging. Pseudoaneurysm (n = 2) and simple hematoma (n = 2) were depicted with both Doppler systems, and a separate pseudoaneurysm and a hematoma were found in one patient. These diagnoses were confirmed surgically. Distinctive Doppler spectral waveforms and color Doppler findings enabled confident diagnoses. Color Doppler imaging allowed faster detection of intraaneurysmal flow, and the track between the injured artery and the pseudoaneurysm was identified only with color Doppler imaging. Duplex Doppler US with color Doppler imaging allows for the rapid, unequivocal diagnosis of pseudoaneurysm, thus enabling prompt treatment without the need for invasive diagnostic modalities.

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Endovaginal ultrasound (US) was performed in 38 pregnant women at 5-12 menstrual weeks, when the initial transabdominal sonograms had been considered inconclusive or equivocal. Clinical follow-up disclosed 32 intrauterine pregnancies (12 living, 18 spontaneous incomplete abortions, and two embryonic demises) and six ectopic pregnancies. In the 32 intrauterine pregnancies (normal and abnormal), the correct diagnosis was made in all cases with endovaginal US. The endovaginal images demonstrated the intrauterine embryo, its heart motion, and the yolk sac more clearly and more often when these structures were not apparent on the transabdominal scans. Abnormal gestational sacs were better resolved. In the six cases of ectopic pregnancy, while an extrauterine ectopic sac was visualized in only three, absence of an intrauterine gestational sac was confirmed in all cases with endovaginal scanning. No endovaginal study yielded less information than its transabdominal counterpart. Endovaginal sonography is likely to be diagnostic when transabdominal images fail to yield a definitive diagnosis in early pregnancies.

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The sonograms of 76 hemorrhagic ovarian cysts were reviewed to ascertain the full spectrum of sonographic findings. All cases were proved either by surgery or by documented resolution on sonography and/or clinical follow-up. The overwhelming majority (92%) had increased sound through-transmission, signifying the basic cystic nature of the lesion. The sonographic patterns were variable. The most common appearance was that of a heterogeneous mass (83%), almost half of which were predominantly anechoic with hypoechoic material. The other cases (17%) were completely homogeneous, either hypo- or hyperechoic. No masses were completely anechoic. Additional sonographic features included a thick rim, septations, and associated cul-de-sac fluid. A rounded hyperechoic mass, representing blood clot, was contained within 13 masses. In addition, some women appeared to have an increased tendency to form ovarian cysts, suggested by the fact that 26% of them had a past, concurrent, or future episode of simple or hemorrhagic ovarian cysts. Because hemorrhagic ovarian cysts have variable sonographic findings, they should be included in the differential diagnosis of any adnexal mass that has good sound through-transmission.

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The increasing use and availability of renal transplantation has resulted in a demand for noninvasive methods to study possible complications. One of the most serious adverse reactions is acute rejection, a possibly reversible cause of transplant failure if treated promptly. Differentiation from other causes of acute renal failure frequently is difficult, and the lack of specificity in many imaging studies has been troublesome. Eighty-one patients with renal transplants, including 41 with acute rejection, were examined. Duplex Doppler examination of the intrarenal arteries and a simplified formula, the resistive index ([peak systolic frequency shift--lowest diastolic frequency shift]/[peak systolic frequency shift]), were used to diagnose rejection. With a resistive index greater than 0.90, a 100% positive predictive value was obtained for the diagnosis of acute rejection. A value less than 0.70 was unlikely to be rejection (negative predictive value, 94%). This approach uses a simple analysis of the waveform. Use of a duplex Doppler examination and the formula described here appears to be an accurate method for the detection of acute rejection and for the differentiation of acute rejection from the various other causes of acute renal failure.

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A retrospective study of 55 twin pregnancies was performed to determine the role of sonography in distinguishing between dichorionic and monochorionic diamniotic gestations solely by evaluating the thickness of the membrane between the fetuses. The presence of a thick dividing membrane indicated a dichorionic diamniotic gestation in 38 (90%) of 42 cases in which it was identified. Inability to identify a membrane between dichorionic diamniotic twins occurred most commonly during the third trimester. A thin membrane indicated monochorionic diamniotic twinning and was seen in three (25%) of 12 cases. Membrane thickness was indeterminate in one case. Therefore, on the basis of the thickness of the dividing membrane imaged by sonography, dichorionic diamniotic gestations can be distinguished from monochorionic diamniotic gestations. Inability to show a separating membrane by sonography, however, can occur with any form of twin gestation, particularly in the third trimester. Membrane thickness should be used in conjunction with other sonographic criteria to predict the amnionicity and chorionicity of twin gestations.

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Basic technique of evaluating renal mass lesions is presented. The analytic criteria of separating cystic from solid lesions are reviewed along with the differential points of the intermediate mass lesion that does not meet the classical hallmark of a simple cyst. Experience has shown that sonography could be the first evaluation step in a renal mass since it is not invasive, does not employ ionizing radiation, and is cost effective.

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Although percutaneous aspiration and drainage of abdominal abscesses will frequently avert an open surgical procedure, patients remain hospitalized during drainage. The authors treated 9 patients for abscesses using percutaneous drainage catheters and sent them home with the catheter in place. All had an uneventful recovery. An average of $12,050 was saved in each case. The authors suggest that outpatient drainage of abdominal abscesses is significantly less expensive than inpatient treatment, yet does not jeopardize patient care.

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Inaccuracies in total intrauterine volumes calculated using the prolate ellipse equation have been reported. No previous study has examined all the sources of error. In this study, a comprehensive approach was undertaken. Measurements were obtained from scans of the pregnant uterus in the prone position using an automated water-path scanner (Octoson) and in the supine position using standard static B-mode scanners. Several conclusions could be drawn: 1) From the Octoson prone scans, uterine volumes obtained using the prolate ellipse formula were markedly different from the true uterine volumes obtained by the summation of stepped areas. This showed that the prolate ellipse formula was inaccurate. 2) From the static supine scans, many observer inconsistencies were found in uterine volumes obtained from the prolate ellipse formula. This made the prolate ellipse formula unreliable. 3) Previously published graphs calculated from the prolate ellipse equation, comparing fetal age with total intrauterine volume, were found to vary accuracy, presumably as a result of 1 and 2. A more accurate approach is proposed. Using the outer uterine wall as the boundary, the stepped area-to-volume values of transverse scans taken at 3-cm intervals were found to closely approximate true volumes, with an average error of only 3.5 per cent. Since these measurements encompass the intrauterine contents and the myometrium, it is suggested that the term "total uterine volume" be used instead of "total intrauterine volume."

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The prolate ellipse formula has been shown to be inaccurate and inconsistent in the calculation of total uterine volume. The stepped area-to-volume technique has proven to be both accurate and consistent and provides a value equal to the true uterine volume. When these true volumes were plotted on previously published graphs of total uterine volume derived from the prolate ellipse formula, the graphs were found to be inaccurate. New graphs based on normal values have been constructed, comparing total uterine volume with both biparietal diameter and average gestational age. When 26 abnormal values were plotted on the total uterine volume versus biparietal diameter graph, almost all fell outside the 90 per cent confidence limits. Seven of the abnormal value were from fetuses found to have growth retardation. Six of these cases, including two not appreciated either clinically or ultrasonographically, were detected by this method. The stepped area-to-volume technique should allow reconsideration of the total uterine volume concept and aid in the detection of the subtle changes in uterine size.

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Selective pulmonary arteriography, with superselective magnification views of the lung bases or other areas where abnormalities are shown on perfusion lung scans, performed within 24-48 hours after the onset of symptoms, can effectively rule out clinically significant pulmonary thromboembolism. One hundred and eighty consecutive patients (minimum follow up, six months) with suspected pulmonary embolism and negative pulmonary arteriograms were studied. Not one of the 167 untreated patients died as a result of thromboembolic disease during the acute illness (20 died from unrelated causes), and none of the 147 patients who survived suffered "recurrent embolism" during follow up.

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