Ultrasound in Elbow Fractures.

Avci et al published in the American Journal of EmergencyMedicine findings of their study of point-of-care ultrasound (POCUS) and computed tomography (CT) for patients presenting with elbow injuries in emergency departments. 

The authors examined 49 patients aged 5 to 65 years, who had at least 1 fracture of the elbow joint bones, and underwent CT scanning in emergency room. Patients were first evaluated with direct radiography, and then with POCUS by trained emergency physicians. Emergency physicians made treatment decisions based on the ultrasonography results. Then, CT scans were performed and were interpreted by radiologists. Orthopedic surgeons made treatment decisions based on the CT interpretations.

Of the 49 patients with elbow injury were included in the study 18 (37%) were women, and 31 (63%) were men. Compared with CT, sensitivity, specificity, positive predictive value, and negative predictive value of POCUS in fracture detection were 97%, 88%, 94%, and 93%, respectively. Although the sensitivity and specificity of POCUS in the decision for reduction were 95% and 100%, respectively, it was 93% and 100% in the decision for surgery.

The authors concluded that POCUS is effective in the diagnosis and management of elbow fractures when direct radiology is inconclusive and CT is required.

MRI in Cirrhotic Patients at High Risk for Hepatocellular Carcinoma

Kim at al reported in JAMA Oncology their experience regarding the accuracy of MRI with liver specific contrast versus ultrasonography in the surveillance of patients with cirrhosis who are at high risk in developing hepatocellular carcinoma.

Ultrasonography (US) is considered the study of choice for screening patients with cirrhosis at risk of hepatocellular carcinoma.  The current recommendation is for US to be performed every 6 months.

Liver MRI was performed on a 1.5Tesla scanner and Gadoxetic acid (Primovist) was administered at a dose of 0.025 mmol/kg.  Axial T1 weighted images of the arterial, portal, delayed and hepatobilliary phases at 4-mm thickness sections were obtained.   

The authors conducted a prospective study of 407 cirrhotic patients who underwent semi-annual US and MRI studies.  The patients were followed with dynamic computed tomography 6 months after the screening imaging studies.

A total of 407 patients received 1100 screenings with both MRI and US.  Hepatocellular carcinomas were diagnosed in 43 patients.  Ultrasound diagnosed only one HCC, MRI detected 26, 11 by both, and 5 were missed by both.

The HCC detection rate of the MRI was 86%, higher than the 27.9% of US.  MRI showed significantly lower false-positive findings than US, 3% versus 5.6% of US.  Of the 43 patients with HCC 32 had a single less than 2 cm nodule and received curative treatments.  The 3-year survival of the patients with HCC (86%) was at par to those without HCC.

The 5-year survival rate of HCC is lower than 20%, and early diagnosis is essential for the possibility of a cure.  The current recommendation for patients at high risk of developing HCC is US needs to be reviewed as the  accuracy of US is low.

The authors conclude that screening of patients with cirrhosis with MRI and liver specific contrast resulted in higher HCC detection rate and fewer false positive findings when compared with US.

JAMA Oncology, Online First, September 22, 2016