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   Table of Contents - Current issue
July-September 2022
Volume 30 | Issue 3
Page Nos. 165-244

Online since Wednesday, September 21, 2022

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Ultrasound-guided pain management for chronic musculoskeletal pain p. 165
Hong-Jen Chiou
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Accuracy of prenatal ultrasound scans for screening cleft lip and palate: A systematic review p. 169
K Divya, P Iyapparaja, Anusha Raghavan, Madankumar Parangimalai Diwakar
Children born with clefts encounter various postnatal issues which have a negative impact and long-term psychological effects on both the parents and themselves. This systematic review aims to find the accuracy of two-dimensional (2D)/3D scans for screening cleft lip and palate which would help the parents to be mentally and psychologically prepared to plan for future surgeries. To identify relevant literature, an electronic search was performed using PubMed, Trip database, Cochrane, and Google Scholar database. The search yielded 927 articles, of which 10 fulfilled the eligibility criteria and were included in this systematic review. These studies showed that the combination of 2D and 3D ultrasound scans has increased the specificity and sensitivity in detecting orofacial clefts, as they aid in improved visualization of the fetal face. However, in future, the visualization of the palate can be improved by inventing other modified views as cleft palate diagnosis is more prone to error.
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Sonographic evaluation of the heel pad thickness in diabetics in Nigeria p. 176
Olugbenga Olumide Adegbehingbe, Christianah Mopelola Asaleye, Babatope Ayodeji Kolawole, Anthonia Adenike Adegbehingbe
Background: Diabetes mellitus is a chronic disease process affecting millions of people worldwide. Its prevalence is forecasted to reach a value of 7.7% by 2030. It carries severe morbidities and even mortality. Hyperglycemia and increased formation of advanced glycosylation end products causes the majority of soft tissue changes seen among diabetics. The effects are observed particularly in the heel pad and plantar fascia where thinning or thickening, fibre disorganization, calcification and hypoechoic foci are among the changes seen. Methods: This cross-sectional descriptive study was carried out at the Department of Radiology, OAUTHC, Ile Ife, Osun state, Southwest Nigeria. 40 years old and above subjects with Type 2 diabetes mellitus were recruited from the diabetic clinic of the institution and Ultrasound evaluation of the heel fat pad and plantar fascia were subsequently performed for those who met the criteria using ultrasound machine equipped with a 7.5- 12.0 MHz high frequency linear array transducer. Results: The mean heel pad thickness on the right feet was greater than that of the left in the study subjects. There was statistical significant difference in the heel fat pad thickness of diabetic subjects and the control group, in both feet. (P=0.000). The heel pad thickness is higher in diabetic subject than in non-diabetic control subjects. However, there was no statistical significant difference in the right and left heel fat pad thickness of the participants of this study (P value 0.6062). Only HPT was a statistically significant predictor of foot ulcers among other variables after binary regression was computed. Using Spearman's rank correlation to test the relationship between the BMI of diabetic subjects and mean heel pad thickness, it revealed a moderate positive correlation, with good statistically significance (Spearman's rho = 0.4397, P=0.0000). The relationship between the BMI of diabetic subjects and mean plantar fascia thickness showed a weak positive correlation, with good statistical significance (Spearman's rho = 0.2635, P=0.0008). Conclusion: The duration of diabetes mellitus did not determine the heel pad thickness and plantar fascia thickness. The findings in the study suggested that history of foot ulcer in the diabetic predispose them to have reduce HPT and further foot ulcers. Sonographic measurement of heel pad thickness can therefore be an additional imaging modality to evaluate and be used in the management of the diabetic patients' feet.
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Triplex sonographic evaluation of portal vein indices among adults in Port Harcourt, Nigeria p. 184
Gbenga Jacob Aderibigbe, Chukwuemeka Agi, Ebbi Donald Robinson
Background: Chronic liver disease is characterized by progressive hepatic fibrosis and changes in hepatic vascular hemodynamics. Sonography is a readily available tool in the assessment of the hepatic hemodynamic alterations that occur in chronic liver diseases. Aim: This study was aimed at sonographically determining the portal vein indices in apparently healthy adults by estimating the portal vein diameter, cross-sectional area, and portal vein velocity. Methods: This was a prospective, cross-sectional study carried out among 62 apparently healthy individuals. The participants underwent gray scale and Doppler ultrasonographic examinations of the portal vein. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) IBM Corp. version 23.0 (Armonk, NY: USA). The comparison of means of two groups was with the unpaired t-test, and level of significance was set at 5% (P < 0.05). Results: Forty-six (74.2%) of the 62 participants recruited were male and 16 (25.8%) were female. Participants were aged 18–65 years with a mean age of 39.90 ± 10.34 years. The means of portal vein diameter, cross-sectional area, and portal vein velocity are 1.15 ± 0.12 cm, 0.88 ± 0.18 cm2, and 18.37 ± 2.04 cm/s, respectively. There was no statistically significant difference of all portal vein ultrasound parameters between males and females, except portal vein flow velocity which was higher in males, t-test = 2.273 and P = 0.027 (>0.05). There was no significant correlation between age and ultrasound parameters P > 0.05. Conclusion: The normal values of portal vein diameter, cross-sectional area, and portal vein velocity were established.
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Diagnosis and severity evaluation of ulnar neuropathy at the elbow by ultrasonography: A case-control study p. 189
Y Muralidhar Reddy, Jagarlapudi M K. Murthy, L Suresh, Shyam Krishnakumar Jaiswal, Lalitha Pidaparthi, ES S. Kiran
Background: Traditional diagnostic techniques such as clinical examination and electrodiagnosis are less sensitive in diagnosing ulnar neuropathy at the elbow (UNE). Ultrasonography (USG) is increasingly being used to diagnose UNE. However, clinical applicability is limited by the lack of uniformity in the previous studies. Therefore, we aimed to study in the Indian patients the diagnostic utility of the ulnar nerve cross-sectional area (CSA) and a novel parameter-entrapment index (EI) in UNE measured by USG and to find if both these parameters correlate with the electrodiagnostic severity. Methods: This retrospective casecontrol study included 28 patients (36 nerves) of UNE and 12 (24 nerves) age- and gender-matched healthy controls. Electrodiagnostic severity was graded using the Padua classification. USG was performed in both groups, and CSA was measured at the medial epicondyle (ME) and 5 cm proximally and distally. EI was calculated by multiplying the ratio of CSA above ME over CSA at ME by 100. Best cutoffs were derived by the receiver operating characteristic curve analysis. Results: UNE group had significantly higher CSA at all three locations and lower EI than the control group. CSA at ME ≥9.7 mm2 and EI ≤61.5 has sensitivity and specificity of 88.9%/87.5% and 72.2%/79.2%, respectively. There was no significant difference in CSA and EI between nonsevere and severe UNE groups. Conclusion: CSA at ME and EI have good sensitivity and specificity in diagnosing UNE. However, they cannot differentiate nonsevere from severe UNE.
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Deep learning for detecting supraspinatus calcific tendinopathy on ultrasound images p. 196
Pei-Hsin Chiu, Mathieu Boudier-Revéret, Shu-Wei Chang, Chueh-Hung Wu, Wen-Shiang Chen, Levent Özçakar
Background: The aim of the study was to evaluate the feasibility of convolutional neural network (CNN)-based deep learning (DL) algorithms to dichotomize shoulder ultrasound (US) images with or without supraspinatus calcific tendinopathy (SSCT). Methods: This was a retrospective study pertaining to US examinations that had been performed by 18 physiatrists with 3–20 years of experience. 133,619 US images from 7836 consecutive patients who had undergone shoulder US examinations between January 2017 and June 2019 were collected. Only images with longitudinal or transverse views of supraspinatus tendons (SSTs) were included. During the labeling process, two physiatrists with 6-and 10-year experience in musculoskeletal US independently classified the images as with or without SSCT. DenseNet-121, a pre-trained model in CNN, was used to develop a computer-aided system to identify US images of SSTs with and without calcifications. Testing accuracy, sensitivity, and specificity calculated from the confusion matrix was used to evaluate the models. Results: A total of 2462 images were used for developing the DL algorithm. The longitudinal-transverse model developed with a CNN-based DL algorithm was better for the diagnosis of SSCT when compared with the longitudinal and transverse models (accuracy: 91.32%, sensitivity: 87.89%, and specificity: 94.74%). Conclusion: The developed DL model as a computer-aided system can assist physicians in diagnosing SSCT during the US examination.
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Cysts of the fetal abdomen: Antenatal and postnatal comparison p. 203
Neval Cayonu Kahraman, Ozge Yucel Celik, Mehmet Obut, Ozgur Arat, Cagla Celikkan, Cantekin Iskender, Sevki Celen, Yaprak Engin Ustun
Background: To evaluate cases diagnosed with fetal abdominal cyst diagnosed in prenatal period. Methods: We retrieved the cases diagnosed with fetal abdominal cyst between the years 2018 and 2020 from hospital's database. The localization, origin, dimensions, properties (simple or complex), and characteristics (solid, cystic, vascularity) were noted both in prenatal and postnatal period. We also tested the diagnostic performance of ultrasonography according to endpoint diagnosis revealed postnatally. Results: During the study period, a total of 29 cases diagnosed as fetal abdominal cyst. Of them, there were 11 (37.9%) gastrointestinal, 9 (31%) ovarian, 6 (20.6%) genitourinary, 3 (10.3%) hepatobiliary system cysts. In our study, we were able to identify 5 (45%) of 11 fetuses with postnatally confirmed gastrointestinal system cysts, 1 (33%) of 3 fetuses with hepatobiliary system cysts, 3 (50%) of 6 fetuses with urinary system cysts and 6 (66%) of 9 fetuses with ovarian cysts. Conclusion: İn this study, the most common abdominal cyst was ovarian cysts. The most difficult to diagnose cysts are those that originated from gastrointestinal system and hepatobiliary system.
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Evaluation of adherence to emergency department point-of-care ultrasound documentation and billing following intervention p. 211
Shadi Lahham, John Moeller, Ami Kurzweil, Heesun Choi, Soheil Saadat, Eric Dang, Proma Mazumder
Background: Over the past few years, both the scope and utility of point-of-care ultrasound (POCUS) have tremendously expanded in the clinical setting. Despite this growth, few studies have evaluated the compliance, documentation, and billing of POCUS in the emergency department (ED). The objective of this study was to evaluate the compliance of billing and documentation of POCUS and determine if a single, individualized e-mail feedback can help improve billing and documentation. Methods: We performed a 6-week prospective review of ED POCUSs performed. Following this review, all emergency physicians were sent an individualized e-mail regarding their ultrasound performance including the total number of ultrasounds, ultrasounds per shift, and breakdown of specific ultrasound types. Following this intervention, we collected data from an additional 6 weeks regarding ultrasound billing performance. Results: A total of 1532 POCUS scans were recorded for data collection. Eight hundred and five scans were enrolled in the preintervention group and 727 scans in the postintervention group. Twelve different types of POCUS scans were recorded. The preintervention group had documented 484/805 scans resulting in a 60.1% (confidence interval [CI] 56.7%–63.5%) documentation ratio. The postintervention group had documented 521/727 resulting in a 71.7% (CI 68.2%–74.9%) documentation ratio. Conclusion: The implementation of timely quality assurance with continuous billing reminders is essential for the maintenance and fiscal sustainability of an emergency medicine ultrasound program. Future studies should further elucidate and quantify the financial impact of modifiable factors within EDs' ultrasound documentation and billing practices.
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Bedside USG-guided paracentesis – A technical note for beginners p. 215
Karamvir Chandel, Shaleen Rana, Ranjan Kumar Patel, Tara Prasad Tripathy, Amar Mukund
Paracentesis is a routinely performed low-risk daycare procedure most commonly performed in patients with cirrhosis. Although uncommon, devastating bleeding complications may occur, particularly in patients with coagulopathy. Hence to avoid any such complication, it is important for the intervention radiologists, as well as clinicians, particularly beginners, to have basic knowledge of the major anterior abdominal wall arteries, their course, and their sonographic appearance. Here, we briefly describe the relevant abdominal wall anatomy and sonographic planes to use for paracentesis.
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Acute ultrasonographic changes in lower extremity muscle structure after motor complete spinal cord injury p. 217
Matthew Rong Jie Tay
Background: There is a lack of studies examining ultrasonographic muscle changes in patients with acute spinal cord injury (SCI). Methods: We recruited adults with motor complete acute SCI and performed longitudinal ultrasound measurements. The primary outcome measures were rectus femoris and medial gastrocnemius thickness and echo intensity. Results: This study recruited 20 patients, with a mean time to the first ultrasound measurement of 17.2 ± 2.14 days, with the second measurement done 4 weeks after the first measurement. We found that there was a mean decrease in the rectus femoris muscle thickness of 18.7% (P = 0.027), as well as a mean increase in the rectus femoris echo intensity of 13.0 a.u. (P = 0.009), although no significant differences were found for the medial gastrocnemius. Conclusion: This study demonstrates decreased thickness and increased echo intensity in the rectus femoris but not in the medial gastrocnemius in patients with motor complete SCI.
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Usage of point-of-care ultrasonography for rapid diagnosis of cardiac perforation by pacemaker lead p. 221
Chia-Ching Chen, Sai-Wai Ho
Cardiac perforation after pacemaker placement is a rare form of cardiovascular emergency. A case of an elderly adult undergoing hemodialysis that contributed to this emergency is presented. The history, clinical imaging findings, and surgical procedures for clinical assessment are briefly described. Point-of-care ultrasonography (POCUS) was used to identify, locate, and perform ultrasonography-guided pericardiocentesis. The role of POCUS in cases of tamponade has been emphasized in clinical settings.
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Pediatric gastritis on point-of-care ultrasound p. 223
Eric Scheier
Point of care ultrasound (POCUS) is used routinely in pediatric emergency medicine. I present a case in which repeat POCUS after admission directed the evaluation and followed the recovery of a child admitted with epigastric pain. POCUS of the epigastrium may decrease the number of imaging examinations and endoscopies in the evaluation of pediatric epigastric pain.
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Pyogenic liver abscesses with an elevated carcinoembryonic antigen level p. 226
Yao-Kang Huang, Kui-Lin Cheng
Serological tumor markers are useful for the detection of malignancies and evaluation of disease progression. These markers are not checked as part of a routine examination for patients with benign diseases and without any clinical suspicion of malignancy. However, some markers appear to be elevated in patients with benign diseases and without malignancies. We present a case of pyogenic liver abscesses with an elevated serum carcinoembryonic antigen (CEA) level associated with neither evidence of malignancy nor elevation of other tumor markers such as carbohydrate antigen (CA 19-9) and alpha-fetoprotein (AFP) levels. The serological level of CEA decreased and subsequently became within normal limits with treatment. This case also demonstrates that diabetic patients with a liver abscess may present with no infectious symptoms and that fine-needle aspiration is as effective as catheter drainage in the treatment of pyogenic liver abscess.
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Submental ectopic thyroid in a patient with an orthotopic thyroid gland p. 229
Chee-Wai Mak
Ectopic thyroid is a rare clinical disease, with the majority of the patient presented with hypo-functional thyroid tissue and absence of orthotopic thyroid gland. During embryogenesis, the thyroid gland descends from the foramen cecum to its normal position located below the larynx and hyoid bone, anterior to the 2nd, 3rd, and 4th tracheal cartilaginous rings. Any defect that occurs during this period will result in ectopic thyroid. Hence, ectopic thyroid is usually found along the course of the thyroglossal duct, laterally in submandibular glands and even in distant places such as mediastinum or very rarely in sub-diaphragmatic organs. However, the presence of an orthotoptic thyroid may lead some difficulties in the diagnosis of this disease; hence, fine-needle aspiration is recommended to avoid unnecessary operation provided the patient is asymptomatic.
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Sciatic nerve hemangioma, a challenge in klippel–Trenaunay syndrome for perioperative analgesia p. 233
Nitin Gawai, Ganesh Bhong, Sandeep Diwan, Parag Sancheti
Children with Klippel–Trenaunay syndrome have vascular malformations, varicosities at unusual distribution, and unilateral soft and skeletal tissue hypertrophy of the lower extremity. Corrective surgery of the deformity is necessary to improve gait and wear acceptable footwear. Perioperative pain relief for debulking of the right great toe in a known case of KTS with sciatic hemangioma was achieved with ultrasound-guided sciatic nerve block in an avascular area.
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A 73-year-old man with bilateral posterior ankle pain p. 235
Yi-Hsiang Chiu, Tyng-Guey Wang
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Lateral retromalleolar swelling and pain - Peroneus brevis tendon tear (Boomerang Sign) Highly accessed article p. 237
Anuj Taparia, Sunil Kumar, Sonal Saran
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Diverging artifact in a subcutaneous abscess derived from spatial compound imaging p. 239
Wei-Ting Wu, Yu-Chun Hsu, Ke-Vin Chang
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21-week routine antenatal ultrasound scan p. 241
Ravi Shanker Singh, Vikrant Bardhan, KS Sunil Kumar, Sonal Saran
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A triathlete with lateral retromalleolar pain p. 242
Édouard Giroux, Martin Lamontagne, Mathieu Boudier-Revéret
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CME Test p. 244

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