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   Table of Contents - Current issue
Coverpage
July-September 2021
Volume 29 | Issue 3
Page Nos. 151-233

Online since Wednesday, September 15, 2021

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EDUCATIONAL FORUM  

Focused assessment with sonography for trauma p. 151
Pei-Hsiu Wang, Hao-Yang Lin, Po-Yuan Chang, Wan-Ching Lien
DOI:10.4103/jmu.jmu_128_21  
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Ultrasound for the abdominal aorta p. 154
An-Fu Lee, Cheng-Heng Liu, Po-Yuan Chang, Wan-Ching Lien
DOI:10.4103/jmu.jmu_129_21  
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REVIEW ARTICLE Top

A review of carotid artery phantoms for doppler ultrasound applications p. 157
Kyermang Kyense Dakok, Mohammed Zubir Matjafri, Nursakinah Suardi, Ammar Anwar Oglat, Seth Ezra Nabasu
DOI:10.4103/JMU.JMU_164_20  
Ultrasound imaging systems need tissue-mimicking phantoms with a good range of acoustic properties. Many studies on carotid artery phantoms have been carried out using ultrasound; hence this study presents a review of the different forms of carotid artery phantoms used to examine blood hemodynamics by Doppler ultrasound (DU) methods and explains the ingredients that constitute every phantom with their advantages and disadvantages. Different research databases were consulted to access relevant information on carotid artery phantoms used for DU measurements after which the information were presented systematically spanning from walled phantoms to wall-less phantoms. This review points out the fact that carotid artery phantoms are made up of tissue mimicking materials, vessel mimicking materials, and blood mimicking fluid whose properties matched those of real human tissues and vessels. These materials are a combination of substances such as water, gelatin, glycerol, scatterers, and other powders in their right proportions.
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ORIGINAL ARTICLES Top

Sonographic evaluation of the pancreas in Type 1 diabetes mellitus: A case-control study Highly accessed article p. 167
Safa Abdulrahman, Ahmed Abdelrahim Ibrahim, Mohamed Adam Mohamed, Moawia Gameraddin, Magbool Alelyani
DOI:10.4103/JMU.JMU_89_20  
Background: Pancreas is a vital insulin-producing gland, and it is subjected to various disorders which produce alteration in the morphology and function. Ultrasound (US) of the pancreas is sensitive for evaluating the gland and provides the accurate diagnosis of pancreatic diseases. The aim of this study is to determine whether there were alterations in pancreatic size and echogenicity in type 1 diabetes mellitus (DM). Methods: A total of 100 patients with Type-1 DM (insulin dependent) were examined using the ultrasonography. They were compared to 22 healthy controls. Measurements of the pancreas were performed on type 1 diabetic patients and controls. Results: Pancreatic diameters of the head, body, and tail of the pancreas were reduced in Type 1 DM versus controls (1.78 vs. 1.80 cm, 95% confidence interval [CI]: −0.147 −0.099, P = 0.699 for the head of the pancreas; and 1.093 vs. 1.13 cm: 95% CI: −2.97–1.196, P = 0.484 for the body of the pancreas; 1.12 vs. 1.46 cm, 95% CI: −0.491–0.194, P < 0.001 for the tail of the pancreas). The echogenicity of the pancreas in patients with Type 1 DM increased significantly as the duration of the disease increased (P = 0.015). Conclusion: Individuals with Type 1 DM have reduced pancreatic size in comparison with controls. Patients with Type 1 DM have increased echogenicity of the pancreas as the duration of the disease increased.
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Evaluation of training in pediatric ultrasound-guided vascular cannulation using a model p. 171
José Manuel Lopez-Alvarez, Olivia Pérez-Quevedo, Joaquín Naya-Esteban, Teresa Ramirez-Lorenzo, Sira Alonso-Graña López-Manteola, Dionisio Lorenzo Lorenzo-Villegas
DOI:10.4103/JMU.JMU_109_20  
Background: The study objective was to evaluate a training program and a training model for pediatric ultrasound-guided vascular cannulation (USGVC) by inexperienced operators. Methods: An observational descriptive study was conducted at the pediatric intensive care unit of a level-III hospital. The study protocol comprised the following parts: (1) pretraining test; (2) theory and practice training session consisting of an explanation of basic vascular ultrasound concepts plus performing vascular cannulation in a model; (3) posttraining test; and (4) evaluation of the training model. Results: A total of 25 health-care professionals participated in the study. All of them possessed the skills to locate vessels and ultrasound planes, and they performed USGVC using the training model. On a 1–5 scale, the model was rated to have 87.6% fidelity with real pediatric patients; the best regarded aspect of it was utility (93%). Differences were found between pre- and post-training scores: 2.72 ± 0.84 versus 4.60 ± 0.50; P < 0.001 (95% confidence interval: −2.28, −1.47). Altogether, 300 ultrasound-guided cannulation procedures were carried out (12 per participant) distributed along the longitudinal axis in plane and the transverse axis out of plane, with 150 punctures in each of them. The success rate for USGVC in the training model was 79.7%, the mean time for the procedure was 115.6 ± 114.9 s, and the mean time for achieving successful cannulation was 87.69 ± 82.81 s. The mean number of trials needed for successful USGVC was 1.49 ± 0.86. Conclusion: After undergoing the theory–practice training, participants: (a) improved their knowledge of ultrasound-guided vascular access; (b) positively evaluated the USGVC training model, in particular its utility and fidelity as compared with cannulation in pediatric patients; and (c) achieved a high USGVC success rate in a relatively short time.
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Comparison of three ultrasound views for internal jugular venous cannulation in patients undergoing cardiac surgery: A randomized trial p. 176
GN Chennakeshavallu, Shrinivas Gadhinglajkar, Rupa Sreedhar, Saravana Babu, Sruthi Sankar, Prasanta Kumar Dash
DOI:10.4103/JMU.JMU_135_20  
Background: The quality of needle visualization during ultrasound-guided internal jugular vein (IJV) cannulation determines the ease of procedure, whereas posterior IJV wall puncture is the most common risk associated. The IJV can be imaged in different views, which offer certain advantages over each other. We compared three different ultrasound views for IJV cannulation short axis (SAX), long axis (LAX), and oblique axis (OAX) with respect to the quality of needle visualization, first pass success rate, and posterior IJV wall puncture. Methods: Two hundred ten patients undergoing elective cardiac surgery were analyzed in this prospective randomized clinical trial. Patients were randomly assigned to one of the three groups: SAX (n = 70), LAX (n = 70), and OAX (n = 70). The quality of needle visualization, first pass success rate, and incidence of posterior IJV wall puncture in each of the three ultrasound views were studied. The Chi-square test and ANOVA were used for the comparison of means and proportion between the groups. Results: The quality of needle visualization was graded as good in 90% patients in OAX group, 81.4% patients in LAX group, and 14.2% patients in SAX group, respectively (P < 0.0001). OAX group had the highest first pass success rate (94.2%) followed by SAX (88.5%), and then, LAX (82.8%), but it was statistically insignificant among the groups (P = 0.105). The mean IJV access time was longer in LAX group when compared to OAX and SAX group (P < 0.0001). The incidence of IJV posterior wall puncture was 14.2% patients in SAX group and none in other groups (P = 0.0011). Conclusion: The results suggest that OAX view can be adopted as standard approach during ultrasound-guided IJV cannulation as it safe and reliable.
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Influence of demographic factors on nerve ultrasound of healthy participants in a multiethnic Asian Population p. 181
Cheng-Yin Tan, Siti Nur Omaira Razali, Khean-Jin Goh, Nortina Shahrizaila
DOI:10.4103/JMU.JMU_105_20  
Background: High-resolution nerve ultrasound provides morphological information of peripheral nerves. We aimed to determine the normal ultrasonographic reference values of nerve cross-sectional area (CSA) in multiethnic Malaysian healthy participants. Methods: Nerve ultrasound of the median, ulnar, radial, tibial, fibular, and sural nerves was performed in 84 healthy participants at anatomical-defined locations. The CSA at each scanned site was measured by tracing circumferentially inside the hyperechoic rim of each nerve. Comparisons were made between genders and ethnic groups. Correlations with age, ethnicity, gender, height, weight, and body mass index (BMI) were evaluated. Results: CSA values and reference ranges in healthy participants were generated. Nerve CSA was significantly different in different gender (P = 0.002–0.032) and ethnic groups (P = 0.006–0.038). Men had larger nerve CSA than women, and Malay participants had larger nerve CSA compared to other ethnic groups. Nerve CSA had significant correlations to age, height, weight, and BMI (r = 0.220–0.349, P = 0.001–0.045). Conclusion: This study provides normative values for CSA of peripheral nerves in a multiethnic Malaysian population, which serves as reference values in the evaluation of peripheral nerve disorders. The ethnic differences in nerve CSA values should be considered during nerve ultrasound.
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Initial progressions of carotid artery plaque are associated with risk factors of cardiovascular disease p. 187
Mami Ishikawa, Mutsumi Nagai, Eiji Matsumoto, Masaaki Hashimoto
DOI:10.4103/JMU.JMU_107_20  
Background: Carotid artery plaque, white matter disease (WMD), and silent lacunae infarcts (initial indicators) are associated with symptomatic cerebral infarction (CI) caused by atherosclerosis. We retrospectively examined the association between the initial indicators and risk factors for cerebrovascular disease, considering the primary prevention of symptomatic CI. Methods: We divided 1503 individuals who were neurologically healthy and enrolled in a brain screening program (brain dock) at our institution, into three initial plaque grades (grade 0, 1, and 2) based on having no plaques, having plaques on the right or left carotid artery, or having plaques on both carotid arteries, respectively. We analyzed the risk factors according to the presence/absence of the initial indicators. Results: WMD and the risk factors (low-density lipoprotein [LDL], hemoglobin A1c, systolic blood pressure [BP], and smoking cigarettes) were positively correlated with the initial plaque grades, even when their laboratory values were within normal ranges. Systolic BP (116.5 ± 14.0 mmHg) was significantly lower in group 00 (without carotid plaque and WMD) than that in age-adjusted others (with carotid plaque or WMD). In young participants aged between 40 and 52 years, LDL (132.8 ± 24.5 mg/dl) was significantly higher in subgroup ++ (with carotid plaque and WMD) compared to others (without carotid plaque or WMD). Conclusion: Initial plaque grade and WMD grade as clinical initial indicators of symptomatic CI are associated with risk factors. To avoid deterioration of the initial indicators, it was suggested that the risk factors should be maintained at the lower ends of normal ranges and smoking cessation should be recommended.
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A high intensity focused ultrasound system for veterinary oncology applications p. 195
Kyriakos Spanoudes, Nikolas Evripidou, Marinos Giannakou, Theocharis Drakos, George Menikou, Christakis Damianou
DOI:10.4103/JMU.JMU_130_20  
Background: Magnetic resonance-guided focused ultrasound surgery is an incisionless energy-based thermal method that is used for ablating tumors in the veterinary clinic. Aims and Objectives: In this article we describe a prototype of a veterinary system compatible with magnetic resonance imaging intended for small-to-medium-sized companion animals that was developed and tested in vivo in adult rabbits. Methods: Real-time monitoring of the ablation during the experiment was possible with MR thermometry. Experiments involved thermal monitoring of sonications applied in the thigh of the rabbits. A 38-mm diameter transducer operating at 2.6 MHz was used with a 60-mm-focal length. The robotic system employed 3 linear axes and one angular axis. For this study, only X and Y axis were enabled. Due to the target size limitations, motion in Z and Θ was not needed. The functionality of the positioning device was evaluated by means of MR thermometry, demonstrating sufficient heating and accurate motion in both axes of operation. Results: The postmortem findings confirm the ability of the system to induce thermal ablations in vivo in the absence of adverse effects. Conclusions: The device is a reliable and affordable solution for companion animal hospitals, offering and additional tool for the veterinary oncology society.
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BRIEF COMMUNICATION Top

Undescribed vascular signatures: A contraindication to ultrasound-guided parasagittal infraclavicular block! A retrospective observational study p. 203
Sandeep Diwan, Divya Sethi, Ganesh Bhong, Parag Sancheti, Abhijit Nair
DOI:10.4103/JMU.JMU_8_21  
Background: The ultrasound-infraclavicular block (US-ICB) is a popular and efficient block for below-elbow surgeries. However, the vascular anatomy of infraclavicular area close to the brachial plexus has remained unresearched. We aimed to explore the presence of aberrant vasculature in the infraclavicular area that could pose a contraindication to US-ICB. Methods: In this retrospective observational study, we reviewed the US images of patients undergoing below-elbow surgery under US-ICB. Before performing the block, a scout scan of parasagittal infraclavicular areas was performed and the scan images were saved. The primary objective was to find the prevalence of aberrant vasculature due to which the US–ICB was abandoned. The secondary objective was to understand the pattern and position of the aberrant vessels. Results: Out of 912 patients, 793 patients underwent surgery under US–ICB and in 119 patients (13.05%), the USG-ICB was abandoned due to aberrant vasculature close to the brachial cords and intended position of the needle tip. The anomalous vessels were identified in the lower inner, lower outer, and upper outer quadrants around the axillary artery (AA). Some of these vascular structures also had classical patterns which we described as “satellites,” “clamping,” or “hugging” of the AA. Conclusion: Anomalous vascular structures in the infraclavicular area were seen in 13.05% of patients planned for US–ICB. We, therefore, recommend, that a thorough scout US scan should be mandatorily performed ICB and in the presence of aberrant vascular structures, an alternative approach to brachial plexus block may be adopted.
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CASE REPORTS Top

Management of hand spasticity with ultrasound-guided ethyl alcohol injection to the deep branch of the ulnar nerve p. 207
Min Cheol Chang, Mathieu Boudier-Revéret
DOI:10.4103/JMU.JMU_110_20  
Patients with stroke commonly experience limb spasticity, which can prevent functional recovery and cause functional disability, due to muscle tightness and joint stiffness in the affected limb. Using the ability of ultrasound (US) to visualize nerves, we successfully performed US-guided neurolysis of the motor branch of the ulnar nerve in Guyon's canal, while avoiding injury of its sensory branch, in a 63-year-old woman with upper limb poststroke spasticity. We believe that our method has the merit of precluding the development of neuropathic pain, following injury to the sensory branch of the ulnar nerve. Moreover, our method reduces operation time and perioperative pain.
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Ultrasound to the rescue: Management of looped guidewire during hemodialysis catheter insertion in the left internal jugular vein p. 209
Jhanvi Bajaj, Mohammed Saif Khan
DOI:10.4103/JMU.JMU_99_20  
Hemodialysis catheters are commonly placed in the major central vein for the purpose of dialysis. Coiling or looping of guidewire is a rare but reported complication of a central vascular catheter insertion. We report a case in which we encountered a rare complication of looping of the guidewire used for dialysis catheter placement and how we correctly diagnosed and repositioned it under ultrasound guidance. A 68-year-old man diagnosed with Carcinoma of Pyriform Fossa admitted in our ICU had Acute Renal Failure. An attempt to insertion of hemodialysis catheter in left internal jugular vein was made. Following successful puncture, the guide wire was threaded through needle. After five centimeter length of guide wire was threaded, resistance was felt and a loop of guidewire was visualized which was abutting the posterior wall of vein in out-of-plane view, creating a dual-point echogenicity. Under ultrasound guidance, we slowly pulled out the guidewire till the loop disappeared. The catheter was then inserted without repeat puncture of the vessel, thus preventing chance of thrombosis by repeated attempts. Real time USG guidance not only improves the success rates but also decreases the number of attempts and complications related to hemodialysis catheterization. Moreover, it benefits the patients by reducing the risks and discomforts of the procedure by reducing the duration of cannulation. The intelligent use of real-time ultrasound guidance in each step of the central venous catheterization is absolutely the need of the hour to prevent catastrophic yet preventable complications.
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Infrared thermography and ultrasonography of the hands in rheumatoid arthritis patients p. 212
Koichi Yabunaka, Noriyuki Hayashi, Yutaka Furumitsu, Yoshiteru Ohno, Masayo Matsuzaki, Shinichi Yamauchi
DOI:10.4103/JMU.JMU_113_20  
Ultrasonography (US) and power Doppler US (PDUS) are used worldwide for diagnosing rheumatoid arthritis (RA). Superb microvascular imaging (SMI) is a good tool for evaluating inflammatory activity. Thermal imaging is a noncontact, noninvasive procedure using skin temperature measurement. We report a case wherein the thermal and ultrasound images of the hand are compared and evaluated for inflammatory activity in patients with RA. Case: US imaging of the left hand of a 75-year-old woman with RA revealed a hypoechoic lesion of the left wrist joint. PDUS and SMI evaluated blood flow according to the blood flow at Grade 2. The temperature of the hypoechoic lesion with high blood flow was higher than that of the same location on the opposite side. This study shows that combining thermal and blood flow images may be useful for detecting inflammatory activity levels in RA patients.
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Need for a change – Extended-FAST to extended diaphragmatic-FAST p. 215
Sasikumar Mahalingam, Gunaseelan Rajendran, Vishwanath Balassoundaram, Balamurugan Nathan
DOI:10.4103/JMU.JMU_104_20  
Post-traumatic hypoxia can be due to different causes, namely airway problems, pneumothorax, hemothorax, lung contusion, flail chest, traumatic diaphragmatic injuries (TDI), aspiration due to low sensorium, a respiratory paradox in cervical spine injury, severe hypotension, etc., It is a great challenge to identify the cause of hypoxia in a trauma setting because the contributing factors can be multiple or can be a remote cause, which is often missed out. Here, we describe a 50-year-old female who presented to our emergency department with Post-traumatic hypoxia whose sensorium, blood pressure, chest X-ray, E-FAST computed tomography of brain, and other baseline investigation were completely normal, diagnosed later as TDI with the help of diaphragmatic ultrasound and computed tomography of thorax.
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Missed case of pancreatogenic diabetes diagnosed using ultrasound p. 218
M Deyananda Chakravarthy, Prabha Thangaraj, S Saraswathi
DOI:10.4103/JMU.JMU_138_20  
Nonalcoholic pancreatogenic diabetes mellitus (type 3c DM) is an often-misdiagnosed entity usually seen in young men of tropical countries. Although most of the patients present with abdominal pain and symptoms of exocrine pancreatic insufficiency, there is still a subset that does not present with these classical symptoms, which emphasizes the need for special diagnostic considerations. The significance of identifying this subset of diabetic lies not only in the change in management of the disease but also in early detection for pancreatic carcinoma that is more common among those patients. In our case, ultrasound with X-ray played a vital role in diagnosis, prompting us to consider it as an essential part of the investigation panel in all newly diagnosed nonobese diabetic individuals.
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RESEARCH LETTER Top

Ultrasonographic diagnosis and treatment of suprascapular neuropathy secondary to ganglion cyst p. 221
Mustafa Turgut Yildizgoren
DOI:10.4103/JMU.JMU_63_20  
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IMAGING FOR RESIDENTS ANSWER Top

A needle in a haystack p. 223
Christopher Mares, Min Cheol Chang, Mathieu Boudier-Revéret
DOI:10.4103/JMU.JMU_60_20  
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Skeletal defect at first-trimester ultrasound scan p. 226
Marília Freixo, Elisa Soares, Maria Coelho, Carla Marinho, Juliana Rocha, Graça Rodrigues
DOI:10.4103/JMU.JMU_62_20  
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IMAGING FOR RESIDENTS QUIZ Top

Ultrasound imaging for a male with anterior knee pain p. 229
Yi-Chen Huang, Wei-Ting Wu, Ke-Vin Chang
DOI:10.4103/JMU.JMU_83_20  
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Cesarean section scar nodule, ovarian cyst, and dysmenorrhea p. 230
Manuel Goncalves-Henriques, Pedro Brandão, Amélia Almeida, Paula Ramôa
DOI:10.4103/JMU.JMU_70_20  
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A 19-year-old female with primary amenorrhea p. 232
Tanvi Khanna, Sonal Saran
DOI:10.4103/JMU.JMU_171_20  
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CME TEST Top

CME Test p. 233

DOI:10.4103/0929-6441.326009  
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