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   Table of Contents - Current issue
Coverpage
January-March 2022
Volume 30 | Issue 1
Page Nos. 1-77

Online since Wednesday, March 23, 2022

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EDUCATIONAL FORUM  

Application of ultrasound in rheumatic skin disorders: Taking psoriasis as an example p. 1
Jia-Feng Chen, Tien-Tsai Cheng, Ying-Chou Chen
DOI:10.4103/jmu.jmu_153_21  
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Ultrasound scoring systems for evaluation of synovitis and tenosynovitis in patients with rheumatoid arthritis p. 3
Ching-Tsai Lin, Kuo-Lung Lai
DOI:10.4103/jmu.jmu_146_21  
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REVIEW ARTICLE Top

Application of ultrasound in spine kinematic determination: A systemic review p. 6
Mohammad Reza Effatparvar, Stephane Sobczak
DOI:10.4103/jmu.jmu_200_21  
Spine kinematic determination is required to diagnose or rehabilitate back pain due to spinal instability. Ultrasound imaging, as a less harmful and cost-effective method, has been recently applied to kinematic analysis. This study reviews all available published articles to see how much progress has been made in spine kinematic measurement by ultrasound. In this regard, we searched PubMed, Scopus, and Google Scholar among all available studies until 2021, using keywords such as ultrasound, spine, kinematics, rotation, twist, flexion, and bending. Finally, after identifying and scanning 183 articles, only nine articles were included, which analyzed spine kinematics by ultrasound. Among these nine articles, three reported axial displacements, three reported flexion/extension, and three reported axial rotation. Although ultrasound is a suitable alternative to other kinematic measurement methods, very little research and progress have been made in this area. Today, this method is still not used practically for spine kinematic measurement because the bone scans via ultrasound imaging are challenging to understand, and no three-dimensional kinematic measurement technique has been reported. However, recent advances in converting ultrasound images into three-dimensional images can pave the way for further improvements.
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ORIGINAL ARTICLES Top

Indigenously developed ultrasound phantom model versus a commercially available training model: randomized double-blinded study to assess its utility to teach ultrasound guided vascular access in a controlled setting p. 11
Siju V Abraham, Ronald Jaison Melit, S Vimal Krishnan, Tijo George, Meenhas Oravil Kunhahamed, CK Kassyap, Sanjeev Bhoi, Tej Prakash Sinha
DOI:10.4103/JMU.JMU_48_21  
Background: The commercially available training phantoms being expensive, homemade models are popular surrogates for training. We intended to study how comparable our indigenously developed ultrasound phantom (IDUP) was with the commercially available model for ultrasound-guided vascular access (USGVA) training. We also assessed the change in confidence among trainees using a 21-h standardized program. Methods: A prospective randomized double-blinded, parallel design study, with sequential allocation, was done after a standardized point of care ultrasound training course. Over three consecutive courses, 48 trainees volunteered to take part in the study. The models (IDUP and commercial phantom) were allocated as model A and model B. In each course, participants were also allotted sequentially to either perform in-plane or out of plane approach first, at the testing stations. Wilcoxon signed-rank test was used to compare pretest with posttest scores. Results: There was a statistically significant difference between IDUP and commercial phantom with respect to the resemblance to human tissue on tactile feedback and ease to perform the procedure. However, both models did not show a statistically significant difference in terms of ease of use, visual resemblance to human tissue, needle visualization, and artifacts on ultrasonography display. A significant change in the confidence levels of participants was seen postcourse. Conclusion: IDUP was a comparable alternative to the commercial model for USGVA training in a resource-limited setting. A 21-h standardized training program improved the trainee's confidence in performing and teaching USGVA.
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Sonographic finding of medial ankle subcutaneous edema and its association with posterior tibial tenosynovitis p. 20
Kyle L Dammeyer, Chad L Klochko, Steven B Soliman
DOI:10.4103/JMU.JMU_4_21  
Background: To evaluate if the sonographic finding of medial ankle subcutaneous (subQ) edema is associated with posterior tibial tenosynovitis (PTTS). Methods: Sonographic images of the medial ankle soft tissues from 40 patients with PTTS and 37 patients with a normal posterior tibial tendon (PTT) were randomized and independently evaluated by two musculoskeletal radiologists for the presence or absence of subQ edema. Both radiologists were blinded to the images and status of the PTT and the patient's history. Statistical analyses included the Chi-square test and Cohen's Kappa statistics for inter-observer agreement. Results: A statistically significant association was seen for the presence of medial ankle subQ edema and PTTS among both radiologists' findings. Of the 40 patients with PTTS, 33 (82.5%) were found positive by the first radiologist for medial ankle subQ edema, while no subQ edema was found in 28 of the 37 (75.7%) patients with a normal PTT (P < 0.001). Similarly, the second radiologist found that 33 of the 40 (82.5%) with PTTS were positive for subQ edema, while no subQ edema was found in 24 of the 37 (64.9%) patients with a normal PTT (P < 0.001). There was also substantial inter-observer agreement between the 2 radiologists (κ-value = 0.79; 95% confidence intervals: 0.65, 0.93). Conclusion: A statistically significant association was present for the association of the sonographic finding of medial ankle subQ edema and the presence of PTTS. Further studies could evaluate if the sonographic finding of medial ankle subQ edema is an early predictor of PTT dysfunction.
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Intricacies of ultrasound-guided lumbar plexus block in octogenarians: A retrospective case series p. 26
Sandeep Diwan, Abhijit Nair, Madhuri Dadke, Parag Sancheti
DOI:10.4103/JMU.JMU_174_20  
Background: Ultrasound (US)-guided lumbar plexus block (LPB) could be technically challenging in elderly patients. The lumbar paravertebral sonoanatomy is undescribed in the elderly. In an attempt to understand the relevant sonoanatomy, identify the lumbar plexus elements, and understand the difficulties that encountered while performing LPB in elderly patients, we retrospectively analyzed US of 23 elderly patients who were administered US-guided LPBs. Methods: After institutional ethics committee approval, we retrospectively reviewed stored US images of lumbar paravertebral sonoanatomy in 23 elderly patients and analyzed psoas major muscle, lumbar vertebral body, lumbar nerve, and lumbar artery. Results: On US examination, features of psoas major muscle, lumbar vertebral body, lumbar nerve, and lumbar artery were noted and analyzed. Conclusion: US-guided visualization of the components of the lumbar paravertebral area is difficult and inconsistent in the elderly. Therefore, we suggest performing a scout scan, identify the structures, and use neurostimulation all the time for performing LPB in these patients.
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Role of shear wave elastography of synovium to differentiate rheumatoid and tubercular arthritis p. 30
Karamvir Chandel, Mahesh Prakash, Anindita Sinha, Aman Sharma, Devendra K Chouhan, Manavjit Singh Sandhu
DOI:10.4103/jmu.jmu_80_21  
Background: Synovitis is the underlying pathology in various arthritis, and sometimes, it is difficult to differentiate various arthritis clinically or even by imaging. The purpose of our study was to use shear wave elastography (SWE) to evaluate rheumatoid arthritis (RA) and tubercular (TB) arthritis and to differentiate them using synovial stiffness. Methods: The prospective study was performed on Supersonic Imagine Aixplorer Ultrasound (USG) machine using a linear array probe SL10-2 (2–10 MHz). A total of 29 participants, 15 of RA (ACR/EULAR criteria) and 14 of proven TB arthritis were included. Region of interest of 1 mm was applied on the hypertrophied synovium and quantitative SWE data in form of elasticity (kPa) and velocity (m/s) were measured. Discrete categorical data were presented as n (%). Mean values were recorded along with standard deviation and the range of values. To find a maximal cutoff value of elasticity and velocity - receiver operating characteristic curve were plotted. Results: The mean elasticity and velocity values were 54.81 ± 10.6 kPa and 4.2 m/s ± 0.42 for RA and 37 ± 10 kPa and 3.4 ± 0.47 m/s for TB group. Significant difference (P < 0.001) was seen in elastic modulus values between rheumatoid and TB group with cutoff of 43.6 kPa to differentiate the two groups (sensitivity – 86.7% and specificity – 80%). Similar significant (P < 0.001) results were seen with velocity values, with cutoff of 3.76 m/s (sensitivity – 86.7% and specificity – 80%). Conclusion: SWE shows the potential to be a useful adjunct to gray scale and color Doppler USG in differentiating various arthritis on the basis of elastic properties of the synovium. Elastic modulus and velocity are useful SWE quantitative parameters for synovial evaluation and can differentiate RA and TB arthritis.
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Fabrication of low-cost realistic three-dimensional static kidney phantom for ultrasound-guided biopsy applications p. 36
Firas Fohely, Ammar A Oglat, Khaled Sabarna, Zakaria Shweiki, Bayan Hamoudeh, Rulin Shalaan
DOI:10.4103/JMU.JMU_181_20  
Background: The rapid growth of using ultrasound-guided interventional procedures, including biopsy and drainage, which considered painful procedures, leads to improving the practice cycle of ultrasound-guided procedures. Fabrication of low-cost tissue-mimicking phantoms that serve as a training tool medium for kidney needle biopsy procedures has dramatically overcome the drawbacks associated with these practices, such as reducing the number of miss lesions, medical errors, and recurrence rate as well as these phantoms are widely available and considered a good substitute for cadavers which were not always available and relativity expensive. However, several drawbacks are associated with current kidney phantom models, mainly the short shelf life and the high fabrication cost. Methods: This study aims to fabricate a realistic three-dimensional static mature human kidney phantom from low cost and available material for training on ultrasound-guided interventional procedures mainly biopsy test; the material used to fabricate our model is the gelatin-agar mixture. Results: This model proved that it is a tissue-mimicking material by measuring their acoustic properties which nearly the same as real human kidney tissue. Conclusion: The results of practicing interventional procedures on our phantom model showed good and easy uses for interventional procedures training as well as make it a preferable and economically affordable model.
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Comparison of magnetic resonance imaging and ultrasonography in tumor size: Evaluation of equality in advanced cervical cancer patients p. 41
Sigit Purbadi, Lisa Novianti, Gregorius Tanamas, Trifonia Pingkan Siregar
DOI:10.4103/JMU.JMU_2_21  
Background: Cervical cancer is the fourth most common cancer among women worldwide. In Indonesia, cervical cancer is the second most frequent disease related to cancer. Based on staging system criteria, clinical findings are the main criteria to determine cervical cancer stage. In the revised version of the Federation of Gynecology and Obstetrics staging system criteria for cervical cancer, radiological examination for pretreatment evaluation in gynecological malignancies has been used in routine modalities. Magnetic resonance imaging (MRI) and ultrasonography (USG) are commonly used in the presurgery determination of tumor size and the follow-up of cervical cancer patients. Tumor size determines cancer stage which influences the treatment and the survival. The equality of diagnostic accuracy was compared for MRI and ultrasound in this study for tumor size evaluation of cervical cancer patients. Methods: This was a prospective study including 195 patients with cervical cancer Stage IIIB in Dr. Cipto Mangunkusumo Hospital from 2016 to 2018. The tumor sizes and stages of cervical cancer were assessed on MRI and ultrasound. This study evaluated diagnostic accuracy between MRI and US. The sensitivity and specificity were compared by using McNemar test. Results: The result of the study showed that from 195 patients, 76 patients fulfilled the study inclusion criteria. There is a significant difference in assessing tumor size in cervical cancer patients between ultrasound and MRI (mean, 1.72 cm; P < 0.0001). US had 82% sensitivity, 88% specificity, and 82% diagnostic accuracy (P = 0.003, McNemar test). Conclusion: Ultrasound examination showed a comparable accuracy to MRI for assessing tumor size in cervical cancer. US is an affordable and feasible diagnostic staging tool with accuracy comparable to MRI.
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CASE REPORTS Top

Ectopic cervical thymus in an adult: A rare presentation p. 45
Reddy Ravikanth
DOI:10.4103/JMU.JMU_152_20  
Ectopic cervical thymus is an essentially benign condition related to embryological development of the thymus and is exceedingly rare among the adult population. Precise and early diagnosis of the entity on high-resolution ultrasonography may help avoid further investigations and unnecessary surgical intervention. This case report describes the typical sonological appearance of ectopic cervical thymus in a 44-year-old male.
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Intramural gastric metastasis: A rare presentation of esophageal squamous cell carcinoma p. 47
Pradeep Kumar Roul, Sonal Saran, Dharma Ram Poonia, Pranoy Paul
DOI:10.4103/JMU.JMU_1_21  
Intramural gastric metastasis of the esophageal carcinoma, excluding the direct extension of primary neoplasm, is rare. However, intramural metastasis to the esophagus is commoner than this. These are more common in squamous cell carcinoma variant. This signifies a poor prognosis. It is due to the spread of pathology through the intramural lymphatic channels. Sometimes the metastatic lesion is more extensive in volume than the primary. This is more often diagnosed on histopathology in postoperative specimens. We share our imaging experience with surface esophageal squamous cell carcinoma with giant intramural gastric metastasis infiltrating the liver in a 39-year-old male. Due to its rarity, and secondary lesion being more extensive than the primary leads to misinterpretation and wrong diagnosis. Knowledge of this rare phenomenon can prevent misdiagnosis, fasten the imaging workup, and ultimately improve the patient's survival.
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Ultrasound findings in suspected ascites referred for paracentesis p. 50
Jan Christian Droste, Christy Riggott, Tracey Maxfield, Jodie Bennett
DOI:10.4103/JMU.JMU_35_21  
Complications of diagnostic and therapeutic paracentesis include bowel perforation, hemorrhage, and death. At present, medical practitioners identify an area for paracentesis using either physical examination alone or with the addition of ultrasound. The preferable method is still debated within the medical literature. This case series compares photographs of patients with abdominal distension, diagnosed as ascites by physical examination, to the respective ultrasound findings. The ultrasound images show a variety of findings: large volume ascites, bowel loops extending to the abdominal wall (unilaterally or bilaterally), and distended bowel loops due to intestinal obstruction in the absence of substantial ascites. Studies have shown that performing ultrasound before ascites paracentesis procedures improves the procedure success rate and reduces complications. This case series illustrates examples of why ultrasound-assisted paracentesis has a better safety profile and a lower procedure failure rate, compared to physical examination techniques alone.
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Novel use of contrast-enhanced ultrasound in the pretreatment planning prior to endovascular repair of endoleak after endovascular aortic aneurysm repair in a patient with chronic renal insufficiency: A case report and literature review p. 54
Jeffrey C Cruz, Kathryn L McGillen, William Pryor, Daniel Esslinger, Benjamin Shin
DOI:10.4103/JMU.JMU_173_20  
Endoleaks are a common complication in patients who have undergone endovascular stent-graft repair of abdominal aortic aneurysms. The management of these complications depends on the type of endoleak seen at follow-up imaging, with embolization being generally accepted treatment option for Type 2 endoleaks in certain clinical scenarios. Endovascular endoleak embolization can be arduous, time-consuming, and require large amounts of iodinated contrast during the angiographic procedure. This article describes a novel use of contrast-enhanced ultrasound as a clinical problem-solving tool in the preprocedural planning of patient undergoing an endoleak embolization.
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Zinner syndrome: A case report of rare urogenital anomaly p. 59
Bibek Gurung, Om Biju Panta, Vivek Dhakal, Ram Kumar Ghimire
DOI:10.4103/JMU.JMU_125_20  
Zinner Syndrome is a rare urogenital tract anomaly with unilateral renal agenesis, ipsilateral seminal vesicle cyst, and ipsilateral ejaculatory duct obstruction. The syndrome occurs due to an insult to the development of the paramesonephric duct during embryogenesis. Patients may present late due to dysejaculation as a result of obstruction of the ejaculatory duct or commonly remain asymptomatic. Here, we present such a case presenting with dysejaculation which was diagnosed with Zinner syndrome on ultrasound.
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A rare case of malrotation and midgut volvulus with whirlpool sign p. 62
Lung-Huang Lin
DOI:10.4103/JMU.JMU_121_20  
We report a rare case of midgut malrotation and volvulus with “whirlpool sign” in a new-born infant. The “whirlpool sign” is an imaging characteristic of midgut volvulus and has a high predicting value for volvulus. Malrotation or malrotation with volvulus can be effectively diagnosed based on these characteristics. Ultrasound diagnosis has the advantage of no radiation exposure. Color Doppler documenting the reversal or aberrant superior mesenteric vein/superior mesenteric artery axis is not only predictive but also diagnostic of malrotation of gut. The rapid and accurate diagnosis of volvulus by ultrasound helps to establish the diagnosis of malrotation in time and thus allows for urgent surgical intervention to avoid bowel necrosis.
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RESEARCH LETTER Top

Acquired encysted hydrocele of the cord secondary to trauma in a child: Sonological appearances of a rare entity p. 65
Reddy Ravikanth
DOI:10.4103/JMU.JMU_73_20  
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CORRESPONDENCE Top

Comment on fetal gestational age determination using ultrasound placental thickness p. 67
Rujittika Mungmunpuntipantip, Viroj Wiwanitkit
DOI:10.4103/jmu.jmu_187_21  
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Reply to comments on fetal gestational age determination using ultrasound placental thickness p. 68
Bukunmi Michael Idowu
DOI:10.4103/jmu.jmu_199_21  
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IMAGING FOR RESIDENTS ANSWER Top

Small stiff swelling over the flexor aspect of the finger: Digital ganglion arising from the A2 pulley p. 69
Sonal Saran, Manvendra Gaur
DOI:10.4103/JMU.JMU_176_20  
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A Female Patient with Posterior Lateral Right Knee Pain and a Palpable Mass p. 71
Steven B Soliman
DOI:10.4103/JMU.JMU_169_20  
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IMAGING FOR RESIDENTS QUIZ Top

A 3-year-old girl with recurrent respiratory tract infections p. 74
Ozlem Kadirhan, Sonay Aydin, A Mecit Kantarci
DOI:10.4103/JMU.JMU_162_20  
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A male patient with left inguinal bulge and left scrotal pain p. 76
Suresh V Phatak, Megha Manoj, Soumya Jain, KB Harshith Gowda
DOI:10.4103/JMU.JMU_170_20  
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CME TEST Top

CME test p. 77
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