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   Table of Contents - Current issue
January-March 2021
Volume 29 | Issue 1
Page Nos. 1-74

Online since Saturday, March 20, 2021

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The application of clinical ultrasound in fetal therapy p. 1
Tzu-Yi Lin, Chen-Ai Sung, Steven W Shaw
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Application of point-of-care cardiac ultrasonography in COVID-19 infection: Lessons learned from the early experience p. 3
Mingxing Xie, Yi-Hong Chou, Li Zhang, Danqing Zhang, Chui-Mei Tiu
The outbreak of the SARS-CoV-2 infection, also known as coronavirus disease 2019 (COVID-19), was formally defined a pandemic by the World Health Organization (WHO) in March 2020, and is still a global health issue. Since there is a high prevalence of acute cardiac injury in patients with COVID-19 infection, point-of-care cardiac ultrasound (PoCCUS) may be used for longitudinal monitoring of patients infected with COVID-19. However, there is still limited experience on the application of PoCCUS in the COVID-19 pandemic. Within the point of care setting in our system, focused cardiac US exams were performed with specific imaging protocols on the basis of suspicion of a specific disease, such as ruling out tamponade or thrombotic complications. Our preliminary experience shows that PoCCUS helps distinguish the causes of dyspnea in febrile patients. The COVID-19 infection may play a role in unmasking or exacerbating underlying chronic cardiovascular conditions, especially in patients with inadequate past history. In hospitalized patients with COVID-19, CURB-65 score for pneumonia severity and raised D-dimer were significantly associated with deep vein thrombosis (DVT). COVID-19 patients with DVT had worse prognosis, and patients with lower leg edema deserve further evaluation by using point-of-care ultrasound for the lower legs and heart. In COVID-19 patients with arrhythmia, PoCCUS used by experienced hands may reveal abnormal right ventricle (RV) functional parameters and lead to a more comprehensive cardiac US study. When there is suspicion of cardiac disease, PoCCUS can be done first, and if information is inadequate, limited transthoracic echocardiography (TTE), and critical care echocardiography (CCE) can be followed. Ultrasound practitioners should follow the standard precautions for COVID-19 as outlined by the Centers for Disease Control and Prevention to prevent transmission of infection, regardless of suspected or confirmed COVID-19.
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Point of care ultrasound in Coronavirus Disease 2019 pandemic: One modality helping multiple specialties p. 9
Sangam Yadav, Abhishek Singh, Kalung Manisha, Puneet Khanna
After the detection of novel coronavirus (2019) as the cause of a cluster of pneumonia in Wuhan, China, at the end of 2019, more than 10 million confirmed cases of coronavirus disease 2019 (COVID-19) have been reported around the globe. In the COVID-19 intensive care unit (ICU), the use of stethoscope is minimal for obvious reasons. Shifting of COVID-19 patients out of ICU setup increases the risk of transmission of infection to health-care workers as well as jeopardizes the safety of patients. Hence, diagnostic imaging has emerged as a fundamental component of the current management of COVID-19. Lung ultrasound (LUS) imaging has become a safe bedside imaging alternative that does not expose the patient to radiation and minimizes the risk of contamination. Ultrasound (USG) can be used to scan almost all vital organs (heart, kidney, vascular, brain, etc.) and also help in rapid decision-making regarding the management of COVID-19 patients. In this note, we review the current state of the art of LUS in evaluating pulmonary changes induced by COVID-19. The goal is to identify characteristic sonographic findings most suited for the diagnosis of COVID-19 pneumonia infections as well as to assess the impact of infection on other organs and utilizing the same in the management of COVID patients without compromising on the safety of patient or health-care provider.
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Ultrasonography: An unchartered modality in the current pandemic – A study among patients admitted in the COVID-19 intensive care unit p. 15
Humsheer Singh Sethi, Kamal Kumar Sen, Akshat Agrawal, Ajay Sharawat, B Arun Kumar
Background: The objectives were to perform an analysis of lung ultrasonography (LUS) findings in severely ill patients with novel coronavirus disease-2019 (COVID-19) and to compare the accuracy with high-resolution computed tomography (HRCT) of the thorax. Methods: Sixty-two intensive care unit (ICU) patients with COVID-19 were evaluated during their hospital stay. LUS was performed with convex and linear transducers using a designated ultrasonography machine placed in the COVID-19 ICU. The thorax was scanned in 12 areas. Initial LUS was performed on admission and follow-up LUS was done in 7 (mean) days. At the time of the initial LUS, HRCT was performed in 28/62 patients and a chest radiography in 19/62 patients. Results: On admission, LUS detected pleural line thickening (>6 lung areas) in 49/62, confluent B-lines in 38/62, and separate B-lines in 34/62, consolidation in 12/62, C prime profile in 19/62, and pleural and cardiac effusions in 4/62 and 1/62, respectively. The single beam “torchlight” artifact was seen in 16/62, which may possibly be a variation of the B-line which has not been described earlier. Follow-up LUS detected significantly lower rates (P < 0.05) of abnormalities. Conclusion: Ultrasound demonstrated B-lines, variable consolidations, and pleural line irregularities. This study also sheds light on the appearance of the C prime pattern and “torchlight” B-lines which were not described in COVID-19 earlier. LUS findings were significantly reduced by the time of the follow-up scan, insinuating at a rather slow but consistent reduction in some COVID-19 lung lesions. However, the lung ultrasound poorly correlated with HRCT as a diagnostic modality in COVID-19 patients.
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Renal volumetry-based prediction of the presence of accessory renal artery: Computed tomographic angiography-based study with clinical implications on renal doppler p. 22
Syed Mohammad Danish Qaseem, Anoop Singhal, Nitin P Ghonge
Background: The objective was to validate the hypothesis and evaluate whether the presence or absence of accessory renal artery can be predicted on the basis of volumetric parameters of kidney and diameter of the main renal artery (mRA). Methods: This retrospective analysis was performed in a total of 60 kidneys in 30 patients, who had computed tomographic (CT) angiography. The kidneys were segregated into control and study groups depending on the absence or presence of accessory renal artery. The total renal volumes were measured using renal length, breadth, and height in mm3. The renal artery diameters were also measured in mm, in the postostial segment. Renal volume/renal artery diameter (V/d) was measured for each kidney in two groups, and the difference in mean V/d values (in mm2) in two groups was measured for statistical significance. Results: The mean V/d value in the study group with presence of the accessory renal artery was found to be 23,444.7 mm2 (range: 16,229.1–32,490.0). The V/d value in the control group with the absence of accessory renal artery was found to be 19,717.15 mm2 (range: 13,704.6–28,000.0). The mean values in the two groups showed a statistically significant difference in the V/d with a P value of 0.001 (P < 0.05). Conclusion: The study suggests that the possibility of the presence of the accessory renal artery is directly proportional to the total renal volume and inversely proportional to the diameter of mRA. The use of integrated volumetric parameter (V/d) is therefore likely to play a key role in the prediction of the presence of accessory renal artery on imaging studies. Renal volumetry on CT angiography may help predict the presence of accessory renal artery and thus may have implications on renal Doppler studies.
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Ultrasonographic measurements of the liver, gallbladder wall thickness, inferior vena cava, portal vein and pancreas in an Urban Region, Malaysia p. 26
Abdul Sattar Arif Khammas, Rozi Mahmud
Background: Ultrasonographic (USG) measurements of the liver length, gallbladder wall thickness (GBWT), diameters of the inferior vena cava (IVC), portal vein (PV), and pancreas are valuable and reliable in diagnosis hepatobiliary and pancreas conditions. This study is aimed to determine the normal values of liver length, GBWT, AP diameters of the IVC and PV, AP diameter of the head and body of the pancreas. Methods: A prospective cross–sectional study was carried out in this study. A total of the 408 participants were randomly recruited using a systematic method. According to the USG reports, the subjects who had normal USG report for liver, biliary system, and pancreas were described as normals, whereas the subjects who had hepatobiliary diseases such as fatty liver, liver cysts, hemangioma, cirrhosis, gallbladder wall thickening, acute cholecystitis, gallstones, and polyps were recorded as abnormal subjects. Results: Of the 408 participants with a mean of 52.6 ± 8.4 years old. Of those, 294 (72.1%) participants were normal and 114 (27.9%) subjects were reported as abnormal. More than half of the study population was males, 52.9% versus 47.1% of females. There was a significant difference of liver length, head, and body of the pancreas between genders (P = 0.004, 0.002, and P < 0.001, respectively). Moreover, the pancreatic body only was significantly correlated with age (P = 0.026). There also was a significant difference of the liver length, head, and body of the pancreas between normal and abnormal subjects (P < 0.001, P = 0.007, and P < 0.001). Conclusion: Liver length, diameter of the head, and body of the pancreas were significantly associated with gender and hepatobiliary diseases. In addition, only the diameter of the body of the pancreas was significantly correlated with age.
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Echotexture analysis of L4 supraspinous enthesis in ankylosing spondylitis p. 32
Kuo-Lung Lai, Fang-Chuan Kuo, Chih-Wei Tseng, Hsin-Hua Chen, Yin-Yin Liao
Background: Enthesopathy is a main characteristic of ankylosing spondylitis (AS). However, ultrasonographic features of supraspinous enthesis in AS have not yet been reported. Methods: Forty-seven AS patients and 22 healthy individuals were enrolled and completed the study. L4 supraspinous entheses were assessed through an ultrasound (US) unit with the participants in a lateral decubitus position. Entheseal echogenicity was interpreted upon inspection of the US image. An entheseal grayscale (GS) value determination, along with an echotexture analysis using a gray-level co-occurrence matrix algorithm, was performed. The thoracolumbar fascia just above the enthesis was also analyzed. An enthesis-to-fascia ratio (EFR) of each texture feature was used for the purpose of intergroup comparison. Results: The prevalence of abnormal entheseal echogenicity in the AS and healthy groups was 19.1% and 13.6%, respectively (P = 0.42). The AS group experienced a higher GS EFR (0.56 [0.10–1.08] vs. 0.40 [0.12–0.89], P = 0.007), higher contrast EFR (0.62 [0.15–1.23] vs. 0.49 [0.23–1.33], P = 0.049), higher variance EFR (0.44 [0.06–1.21] vs. 0.35 [0.13–1.10], P = 0.023), and lower homogeneity EFR (1.07 [0.97–1.27] vs. 1.11 [1.04–1.19], P = 0.011) in comparison to the healthy group. Conclusion: Echotexture analysis identified the subtle structural changes in L4 supraspinous enthesis in AS patients. It proved to be superior to the inspection method and may possess the potential for providing early detection of supraspinous enthesopathy in AS.
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Ultrasonographic evaluation of osteoarthritis-affected knee joints: Comparison with Kellgren–Lawrence grading and pain scores p. 39
Abhay Pratap Singh, Sonal Saran, Brij Bhushan Thukral, Ravikant Kaushik
Background: The objective was to compare ultrasonographic findings with clinical and radiographic findings in osteoarthritis (OA)-affected knee joints. Methods: This prospective study was conducted in Subharti Medical College, Meerut, after getting clearance from the ethical committee. Eighty-five symptomatic knees fulfilling American College of Rheumatology criteria for OA were included in the study. Patients with trauma, inflammatory, and infective conditions of the knee and with a history of intra-articular interventions and surgery were excluded. Demographic data, body mass index (BMI), visual analog scale (VAS), and Western Ontario and McMaster Universities Arthritis (WOMAC) questionnaire score were obtained. Kellgren–Lawrence (K-L) score was obtained on radiography. Ultrasonographic findings which were recorded include effusion, meniscal extrusion, femorotrochlear cartilage grading, maximum length of osteophytes at medial and lateral compartments, and presence or absence of Baker cyst. Results: A total of 85 consecutive symptomatic knees were examined. The male: female ratio was 22:63, with a mean age of 54.52 ± 9.44 years, mean duration of disease of 24.24 ± 19.14 months, mean BMI of 28.91 ± 3.69 kg/m2, and mean score of VAS and WOMAC pain scale of 6.27 ± 1.45 and 62.45 ± 10.96, respectively. K-L grading of 1, 2, 3, and 4 was reported in 12.9%, 21.2%, 25.9%, and 40% of the knees, respectively. The mean VAS score and WOMAC score showed statistically significant correlation with KL grading (P < 0.05). Knees with the presence of osteophytes, medial meniscal extrusion, effusion, and medial femoral trochlear cartilage grading showed statistically significant correlation with VAS and WOMAC scores (P < 0.05). However, the correlation was not significant for lateral meniscus extrusion and lateral femoral trochlear cartilage grading. Conclusion: Our study found that K-L grading and few ultrasonographic criteria showed a significant positive correlation with pain scores, while few other ultrasonographic criteria did not. Both imaging modalities are complementary to each other, rather than one being superior to the other.
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The impact of khat (Catha edulis) on hemodynamics of the common carotid arteries in regular khat chewers: A casecontrol study using doppler ultrasound p. 46
Moawia Gameraddin, Bushra A Abdalmalik, Mohamed Ibrahim
Background: To evaluate the effect of chewing khat on the hemodynamics of the common carotid arteries (CCAs) using Doppler ultrasound imaging. Methods: This is a cross-sectional case–control study. Fifty volunteers who were chronic regular khat chewers were selected and compared with healthy nonkhat chewers. They were examined using Doppler imaging with a 7–10 MHz linear transducer. The resistivity index (RI), pulsatility index (PI), peak systolic velocity (PSV), and end-diastolic velocity of the CCAs were determined according to the standard protocol of carotid Doppler ultrasound. Results: The RI and PI of the right and left CCAs were significantly higher in khat chewers compared to controls (P < 0.001). The PSV of the right and left CCAs was considerably higher in khat chewers compared to controls (P < 0.001 and 0.04, respectively). Conclusion: The Doppler values of blood flow velocity, resistivity, and pulsatility were significantly higher in chronic regular khat chewers compared to nonkhat chewers. Khat is a significant contributory factor for increasing the hemodynamics of the CCAs.
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In vitro demonstration of melanoma metastasis in lymph nodes of prepared specimens using a light-emitting diode-based multispectral photoacoustic ultrasound imaging system p. 50
Tomoyuki Ohta, Takako Shirakawa, Shinya Okada, Naohiro Ishii, Shigeru Kiryu
Although an excellent photoacoustic (PA) ultrasound method has been reported for the evaluation of lymph node melanoma metastasis in animal experiments, it remains to be evaluated in clinical trials. Recently, we performed PA ultrasound assessment using light-emitting diodes to detect metastatic melanoma in the lymph nodes of specimens prepared for microscopic examination. The PA effect was not obvious in amelanotic melanoma, but was seen in melanotic melanoma by PA imaging (PAI) and histopathological correlation in cases of primary melanotic melanoma accompanied by metastatic lymph nodes, including the coexistence of amelanotic melanoma and melanotic melanoma. Clinical workup should be performed with not only PAI but also conventional ultrasonography in cases with metastasis related to amelanotic transformation, which would likely be missed by PAI alone.
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Impacted fish bone in buccal space associated with an abscess: Role of point-of-care ultrasonography in dental emergencies p. 53
Naren Kishore Rayudu, Santosh Palla, Phani Himaja Devi Vaaka, Dagilla Priyanka Rao
Fish bone impaction in buccal space abscess is an uncommon dental scenario. A case of young adult with partially edentulous state contributing to this emergency is presented. The history, clinical imaging findings, surgical procedure, and checklist for clinical assessment are briefly described. The point-of-care ultrasonography (POCUS) was used in our case to identify, locate, and perform an ultrasonography-guided removal of impacted fish bone in consolidated abscess of the buccal space. The role of POCUS in cases of dental swellings or uncommon emergencies is emphasized in clinical settings.
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Secretory carcinoma of the breast: A case report and literature review p. 57
I-Kai Wu, Yi-Chen Lai, Hong-Jen Chiou, Chih-Yi Hsu
Secretory carcinoma of the breast is a rare subtype of breast cancer. It can occur at any age but is usually diagnosed in patients under 30 years. It is the most common subtype of breast malignancy in the pediatric population and has a favorable outcome. Surgical excision is the best treatment and adjuvant therapies are still under debate. We present the case report of a 26-year-old patient with secretory carcinoma of the breast, including imaging, histologic findings, and clinical outcome.
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Application of color doppler ultrasound to evaluate chemotherapeutic effect on primary thyroid lymphoma p. 60
Cheng-Chuan Hu, Chih-Wei Wang, Jia-Hong Chen
Primary thyroid lymphoma (PTL) is a rare disease which responds well to rituximab-based chemotherapy. Here, we describe a case who was diagnosed through core needle biopsy as having diffuse large B-cell lymphoma in the right lobe of thyroid gland. Positron emission tomography computed tomography (PET-CT) revealed no other foci of hot spots, so PTL was considered. She was treated with rituximab plus bendamustine for three cycles, and color Doppler ultrasound revealed significant reduction of blood flow signals in the tumor but no significant decrease of its size (<25% extent). Then, the chemotherapy regimen was adjusted to rituximab, cyclophosphamide, vincristine, prednisone (R–COP), and complete remission was noted on ultrasound and PET-CT after three cycles of R–COP treatment. This case is reported to tell that color Doppler ultrasound, in addition to PET-CT, is useful to evaluate chemotherapeutic effect on PTLs.
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Beware of artifacts images created by the acoustic enhancement of the endometria in ultrasound examination p. 64
Gabrielle Emmylou Prisca Andrianah, Hasina Dina Ranoharison, Herizo Tolojanahary Andrianjakamanana, Lova Hasina Narindra Rajaonarison Ny Ony, Honjaniana Rasolohery, Christian Tomboravo, Ahmad Ahmad
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Abnormal fetal profile at first-trimester ultrasound scan complicated by severe polyhydramnios at the second half of pregnancy p. 65
Ana Portela Carvalho, Catarina Estevinho, Maria Coelho, Juliana Rocha, Carla Marinho, Graça Rodrigues
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An often missed finding in ultrasonographic shoulder examination p. 68
Ève Boissonnault, Min Cheol Chang, Mathieu Boudier-Revéret
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An ultrasound diagnosis of a congenital periorbital rare condition p. 71
Rita Ladeiras, Joana Sousa Nunes, Sílvia Torres, Carla Duarte, Elsa Pereira, Adosinda Rosmaninho
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Spine abnormality in a fetus at 21 weeks of gestation p. 72
Cláudia Miranda, Diana Coelho, Elsa Pereira, Adosinda Rosmaninho, José Manuel Furtado
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CME Test p. 74

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