Cost analysis model: US versus endometrial biopsy in evaluation of peri- and postmenopausal abnormal vaginal bleeding

PURPOSE: To develop a cost minimization analysis model from the societal perspective of Medicare reimbursement to determine whether endometrial biopsy or transvaginal ultrasonography (US) is less expensive in evaluating peri- and postmenopausal women with abnormal vaginal bleeding and to assess whether this strategy is equally effective in populations at low and high risk for endometrial carcinoma. MATERIALS AND METHODS: Clinical algorithms were constructed that detailed diagnostic evaluation of the target population by using office-based endometrial biopsy versus transvaginal US as starting points. An economic model based on Medicare reimbursement and average wholesale drug price data and using disease prevalences and modality sensitivities from the scientific literature was then created to examine common bleeding causes in this population. All models included the cost of obtaining a tissue diagnosis for focal or diffuse endometrial thickening found at US. Modality sensitivities and prevalences of disease states were varied within the model to discover limits at which each modality became cheaper versus the other for assessing a population of women. RESULTS: Population prevalence of neoplastic disease is the principal factor governing total cost between competing diagnostic algorithms. In populations with 31% or less combined prevalence of endometrial carcinoma/atypical adenomatous hyperplasia, algorithms utilizing transvaginal US as the initial test are most cost minimizing. At combined endometrial carcinoma/atypical adenomatous hyperplasia prevalence of 10%, savings of up to 11% and 16% over pathways initiated with endometrial biopsy are predicted. In populations with a high incidence of neoplastic disease (>31%), biopsy-based algorithms should become least costly. CONCLUSION: Transvaginal US-initiated triage predicts substantial cost savings versus biopsy-based algorithms in evaluating typical populations of peri- and postmenopausal women with abnormal vaginal bleeding seen in clinical practice.     

宫腔声学造影对绝经后阴道出血子宫内膜病变的诊断价值

目的:评价经宫腔声学造影对绝经后阴道出血子宫内膜病变的诊断价值。方法:对我院收治的98例绝经后阴道出血患者行阴道彩色多普勒超声检查和宫腔声学造影检查,在腹部超声的引导下对病变部位行钳夹、基地搔刮,清出组织行病理检查,并与宫腔声学造影诊断结果进行比较。结果:①98例宫腔声学造影均成功,其中经宫腔声学造影诊断为子宫内膜息肉46例,子宫肌瘤11例,子宫内膜癌4例,子宫内膜增生8例,子宫内膜无改变29例。②经组织病理学证实,经阴道彩超宫腔声学造影诊断的灵敏度为98%,特异度为88%,阳性预测值为94%,阴性预测值为97%。结论:经阴道彩超宫腔声学造影检查具有简便、无创、准确率高的特点,是子宫内膜病变筛查、诊断的首选、可靠方法,值得临床推广应用。     

Ultrasonographic evaluation of ascaris in the biliary tract

Ascaris in the biliary tract may cause cholecystitis and obstruction of the common bile ducts. Two cases are presented where worms that were identified in the common bile duct caused obstructive jaundice. The image of the ascaris is typical in its morphology and movement. Ultrasonography is useful in the identification of this parasite in the biliary tract where other conventional radiological methods are frequently unsatisfactory.     

US evaluation of the uterus in patients with postmenopausal bleeding: A positive effect on diagnostic decision making

PURPOSE: To assess the accuracy of hysterosonography (HSG) and its role in diagnostic confidence and therapeutic clinical decision making among referring physicians caring for patients with postmenopausal bleeding (PMB). MATERIALS AND METHODS: One hundred twenty-three patients with PMB underwent transvaginal ultrasonography (US) and HSG. They were examined for cancer, polyp, leiomyoma, and hyperplasia. Physicians assessed the effect of the studies on diagnostic confidence and care, including biopsy, dilation and curettage, hysteroscopy, hormone manipulation, and/or patient reassurance. Abnormality was proved with histopathologic evaluation, and normality, with 6-month follow-up. RESULTS: In 10 patients, HSG was unsuccessful, and in 15, follow-up was incomplete; this left 98 patients. Endometrial polyps were seen in 46 (47%) patients; leiomyoma, in 11 (11%); cancer, in four (4%); hyperplasia, in eight (8%); and normal findings, in 29 (30%). Our calculations yielded a sensitivity of 98% and a specificity of 88%. In 86 (88%) patients, US added certainty to the diagnosis; in 78 (80%), it resulted in a change in patient treatment. CONCLUSION: HSG and transvaginal US in patients with PMB improves diagnostic accuracy, clinical decision making, and the clinician's diagnostic certainty. In patients with benign causes of PMB, the absence of abnormality at HSG and a normal endometrial biopsy result may eliminate the need for further studies.     

Ultrasonographic evaluation of Peyronie's disease

High-resolution ultrasonography was performed on 58 patients with Peyronie's disease and on 6 healthy men; in 3 patients the examination was repeated during medical treatment for a follow-up period of 4 months. Peyronie's plaques always corresponded to abnormal echographic findings. In 54/58 cases (93%) they appeared as hyperechoic lesions. In 4 cases (7%) the plaques were hypoechoic and corresponded to a localized widening of the pericavernous tissues: this condition was observed more frequently in the earliest stages of the disease. There was good agreement between the palpable size of the plaques and their size measured by ultrasonography, with some degree of clinical overestimation of the smallest lesions. Calcified mature plaques corresponded to dense hyperechoic lesions with acoustical shadowing. High-resolution ultrasonography is proposed as a first-line diagnostic approach and as a reliable follow-up examination for Peyronie's disease. The possibility of differentiating calcified plaques from the more recent ones is helpful to allow a correct choice of medical or surgical treatment.     

Ultrasonographic evaluation of wrist ganglia

This study was performed to assess the effectiveness of ultrasonography in the diagnosis of wrist ganglia and in their differentiation from other lesions. Sonographic examination of 73 patients with palpable masses was performed; their healthy hands and those of 25 healthy volunteers constituted the reference standard. Ganglia appeared sonographically as anechoic oval, round, or lobulated cystic structures. Ultrasound proved an accurate tool in their diagnosis, with the general advantages of easy, quick, and inexpensive application.     

Ultrasonographic evaluation of renal infections

Renal sonography can be easily performed and provides valuable information concerning the underlying disease process, helping to decide appropriate management. This article reviews the important renal infections, such as pyelonephritis, emphysematous pyelonephritis, renal abscess, hydatid disease, renal tuberculosis, pyonephrosis, and HIV-associated nephropathy.     

Ultrasonographic evaluation of congenital dislocation of the knee

The authors describe ultrasonographic findings in a newborn girl with congenital dislocation of the knee (CDK). Ultrasonography showed a hyperechoic area and focal narrowing of the distal quadriceps as compared to the unaffected contralateral side, indicating the presence of fibrosis, which is the main pathologic feature of congenital dislocation of the knee. The hyperechoic area decreased after reduction of the dislocation and with patient growth. Ultrasonography was useful in evaluating CDK because it provided a direct view of the pathologic lesion, was painless, and did not involve exposure to X-rays. Further, we were able to serially evaluate the abnormal findings and provide advice regarding daily activity to the parents of the patient with CDK.     

Treating the vaginal vault in carcinoma of the endometrium using the Buchler afterloading system.

The advent of high-dose-rate afterloading intracavitary radiotherapy has implications for both staff safety and the possibility of convenient, outpatient-based treatment for the patient. We have carried out a retrospective analysis of its use with high-activity iridium 192 and the Buchler machine to treat the vaginal valut in patients with adenocarcinoma of the endometrium, most of whom also received external-beam radiotherapy to the pelvis. We have compared the survival, complication and local control rates with a comparable group of historical controls treated with low-dose-rate intracavitary caesium ovoids. Complication rates, which included vaginal stenosis not volunteered by the patient, were 16% (95% confidence intervals 6-26%) in the study group and 28% (95% confidence intervals 17-41%) in the control group, with no serious complications requiring surgery. The actuarial survival was 92% at 5 years in the study group, and 94% at 5 years in the control group. Local control was 94% at 5 years in the control group and 98% at 5 years in the study group. The authors suggest that the use of high-dose-rate intracavitary radiotherapy, with the Buchler afterloading system, for vaginal vault irradiation in carcinoma of the endometrium is a convenient, safe and quick method, which does not necessitate admission or sedation of the patient. In addition it provides complete radiation protection for staff.     

Ultrasonographic evaluation of renal transplantation.

Ultrasonography of the renal transplant is still a key screening examination for transplant dysfunction. The addition of Doppler technology has permitted screening for hemodynamic alterations. Ambitious researchers predicted that these hemodynamic profiles would permit the differentiation of rejection from other complicating factors; however, recent research and clinical experience has shown this to be ineffective. Imaging identification of a dilated collecting system identifies the patient population that should undergo a Whitaker procedure. Identification of large or increasing fluid collections helps focus attention to possible hemorrhage or urine leak. Similarly, the ultrasonographic identification of a lymphocele as the cause of leg edema or hydronephrosis rapidly focuses surgical treatment. Doppler evaluation of hemodynamics must be performed on all renal transplant recipients. Although the role of the resistive index in predicting rejection has been minimized lately, numerous vascular complications, if untreated, would result in loss of the kidney. Doppler sonography identifies those patients who would benefit most from renal arteriography. The evaluation of renal morphology on the basis of ultrasonography alone has little role in predicting the cause of transplant dysfunction. We continue to evaluate renal size and to correlate it with the clinical presentation as well as resistive index to defer patients from biopsy if a more obvious cause of dysfunction is identified.     

Ultrasonographic evaluation of vertebral venous valves

To date, vertebral venous valves have not been studied clinically or by sonography. This report reveals that these valves could be studied noninvasively by using sonographic techniques. Real-time sonography clearly showed the opening and closing of the two cusps of vertebral venous valves at the junction of the vertebral vein and the brachiocephalic vein, which move synchronously with the internal jugular venous valves. This is the first time the vertebral venous valves have been studied by using clinical sonography. This might provide a new point of view for evaluating the clinical significance of vertebral venous valves.     

Ultrasonographic evaluation of pericholecystic abscesses.

Pericholecystic abscess formation is a serious complication of cholecystitis that develops after gallbladder perforation and is usually associated with acute inflammatory signs and symptoms. Ultrasonographic findings in three surgically proven cases of pericholecystic abscess are reported. The findings ranged from a well defined band of low-level echoes around the gallbladder to multiple, poorly defined hypoechoic masses surrounding an irregular, indistinct gallbladder outline. The former situation correlated with a well encapsulated pericholecystic inflammatory process, while the latter was associated with extensive abscess formation resulting from gallbladder rupture. Cholelithiasis was identified in two of the three cases. Ultrasound for preoperative detection of pericholecystic abscess is discussed.     

超声评价强直性脊柱炎患者外周肌腱端病的临床应用

目的探索强直性脊柱炎患者外周肌腱端病的病变特征。方法通过二维及彩色多普勒超声检测30例强直性脊柱炎患者外周肌腱端,观察其声像图特征和血流情况,并对检查结果进行分析。结果所有受检的强直性脊柱炎患者均发现肌腱端异常,但是各个肌腱端的肌腱端病的发病率并不相同,且各个肌腱端的肌腱端病的异常声像表现也有明显差异。结论强直性脊柱炎患者肌腱端病的发病率很高,且各个肌腱端的肌腱端病的发病率和发病特点也各不相同,而超声可较敏感地探查出AS患者肌腱端的异常。