Background: Central venous catheter (CVC) placement is a frequently performed procedure in the emergency department (ED). We aim to compare two different ultrasound (US)-guided techniques, the short-axis (SAX) approach and the oblique axis (OAX) approach for the insertion of internal jugular vein (IJV) catheters in an ED setting. Methods: This prospective, observational study was conducted in the ED of a single tertiary care teaching hospital on patients requiring IJV cannulation. CVC placement was done using both the SAX and OAX approaches as per the ED physician's discretion. Outcome measures included acute complications, successful insertion of an IJV catheter, number of attempts, and access times. The Chi-square test was used to compare the study variables (acute complications, number of cannulation attempts, and successful cannulation) between the two approaches. Mann–Whitney U-test was applied to compare the mean differences of flash time and cannulation time. Results: Sixty patients were enrolled, of which 30 underwent IJV cannulation by the SAX technique and 30 by the OAX technique. We noted a total of 22 acute complications, 56.7% in the SAX group and 16.7% in the OAX group. A significant incidence of posterior venous wall puncture was noted in the SAX group (50.0%). No significant statistical differences were noted on analysis of other outcome measures. Conclusion: The OAX approach is a useful alternative technique to IJV cannulation in the ED setting. Further multicentric studies in this domain will be required to consider this technique as the primary approach to US-guided IJV cannulation in the ED setting.

Background: The aim of this study was to assess the diagnostic role of acoustic radiation force impulse imaging (ARFI) in differentiating benign and malignant cervical nodes. Methods: This was a diagnostic accuracy cross-sectional study. All patients who underwent ultrasound-guided fine-needle aspiration cytology (FNAC) of cervical nodes were included. Patients without FNAC/biopsy and patients in whom cervical nodes were cystic or completely necrotic were excluded. FNAC was used as reference investigation to predict the diagnostic accuracy. In all cases, FNAC was carried out after the B-mode, color Doppler and the ARFI imaging. In patients with multiple cervical lymph nodes, the most suspicious node based on grayscale findings was chosen for ARFI. ARFI included Virtual Touch imaging (VTI), area ratio (AR), and shear wave velocity (SWV) for each node, and the results were compared with FNAC/biopsy. Results: The final analysis included 166 patients. Dark VTI elastograms had sensitivity and specificity of 86.2% and 72.1%, respectively, in identifying malignant nodes. Sensitivity and specificity of AR were 71.3% and 82.3%, respectively, for a cutoff of 1.155. Median SWV of benign and malignant nodes was 1.9 [95% confidence interval (CI), 1.56–2.55] m/s and 6.7 (95% CI, 2.87–9.10) m/s, respectively. SWV >2.68 m/s helped in identifying malignant nodes with 81% specificity, 81.6% sensitivity, and 81.3% accuracy. ARFI was found to be inaccurate in tuberculous and lymphomatous nodes. Conclusion: Malignant nodes had significantly darker elastograms, higher AR and SWV compared to benign nodes, and SWV was the most accurate parameter. ARFI accurately identifies malignant nodes, hence could potentially avoid unwarranted biopsy.

Background: The multifactorial etiology of acute respiratory failure (ARF) often complicates diagnosis at an early stage of clinical presentation. Despite being a common life-threatening disorder, accurate and timely diagnosis is hindered by bad quality of bedside radiographs and nonavailability of immediate computed tomography imaging. This study was an attempt to evaluate the diagnostic accuracy of ultrasound in diagnosing ARF. Methods: This hospital-based cross-sectional study investigated the underlying etiological factor in 130 patients presenting with ARF and admitted to the intensive care unit. Lung ultrasound was performed according to the Bedside Lung Ultrasound in Emergency (BLUE) protocol. The diagnostic accuracy of lung ultrasound by emergency protocol was measured against each final diagnosis. Results: The mean age observed was 49.28 ± 14.9 years among the cohort. Of the 130 patients, pneumonia was the most common cause of ARF, seen in 42 patients. Breathlessness (56.15%) and fever accompanied by cough (25.38%) were the chief complaints. Diagnostic accuracy of ultrasound lung emergency protocol was 95.38% in the diagnosis of pulmonary edema, 100% for pneumothorax, 93.85% for pneumonia, 96.92% for chronic obstructive pulmonary disease, 99.23% for pulmonary thromboembolism, and 95.38% for acute respiratory distress syndrome. Conclusion: Lung ultrasound is a reliable modality that provided accurate and timely diagnosis of ARF in this study. Therefore, BLUE protocol is feasible, easily implementable in the intensive care unit, and must be scaled up in respiratory health-care settings.

Background: Endometrial cancer is the most common gynecological cancer among women in developed countries. Sono-elastography is an extended ultrasonographic technique that has been shown to be useful in a wide range of conditions ranging from breast, prostate, and thyroid nodules to chronic liver disease and musculoskeletal conditions. The aim of this study is to compare the sonoelastographic features of endometrial malignancy and normal endometrium. Methods: This case–control observational study was conducted at a single institution. Participants with histologically proven endometrial cancer according to the results from microcurettage or hysteroscopic biopsy and scheduled for total hysterectomy were included as cases, while asymptomatic women scheduled for routine screening ultrasound examination were recruited as controls. Both cases and controls underwent conventional B-mode transvaginal ultrasonography and strain elastography. Demographic, ultrasonographic, and histopathologic findings were analyzed. Results: A total of 29 endometrial cancer patients (cases) and 28 normal females (controls) were included in the analysis. There was no significant difference in the mean age between the two groups, but the mean body weight was significantly higher in the case group (P < 0.001). The strain ratio and elastographic thickness ratio of the endometrium were statistically significantly different between the case and the control group (P ≤ 0.05) due to increased endometrial stiffness in cancer patients as compared to the normal group. Conclusion: Our results suggest that endometrial cancer can result in increased stiffness that is detectable by transvaginal sonoelastography. Sonoelastography may serve as an adjunct to conventional ultrasound in evaluating the endometrium of women with abnormal uterine bleeding.

Background: This study assessed the hepatic vein waveform (HVW) and mean maximum portal vein velocity (MM-PVV) on Doppler ultrasound in patients with liver cirrhosis (LC) and compared it with that of age and sex-matched controls. It correlated the degree of HVW abnormality and MM-PVV changes with liver function based on Child-Turcotte-Pugh (CTP) to determine which was more predictive of CTP. Methods: Sixty patients with LC and 60 healthy controls were consecutively recruited into this study. Each patient was classed based on the CTP system after relevant tests. Doppler evaluation of the hepatic vein (HV) and MM-PVV were performed. HVW obtained was classified either into triphasic, biphasic, or monophasic. Results: Sixty cirrhotic and 60 age-matched control subjects aged 19–69 and 18–69 years, respectively, completed this study. All control subjects had a normal HVW pattern while 46 (76.7%) cirrhotic subjects had abnormal HVW (P < 0.001). The MM-PVV was significantly lower in cirrhotic subjects than in controls; 22.8 cm/s versus 33.6 cm/s (P < 0.001). The degree of HVW abnormality among cirrhotics showed a significant positive correlation with CTP (r = 0.283, P = 0.029). MM-PVV on the other hand showed no correlation with CTP class (r = −0.124; P = 0.346). Linear regression showed that HVW was a significant predictor of hepatic dysfunction based on CTP. Conclusion: Changes in the waveform pattern of the HVs are a good predictor of the derangement of hepatic function in patients with LC than changes in PVV. HVW pattern could therefore serve as an adjunct to CTP class in hepatic function assessment.

Background: The purpose of this study was to compare the performance between noncontrast-enhanced computed tomography (NECT) plus abdominal ultrasound (US) (NECT + US) with contrast-enhanced computed tomography (CECT) for the detection of hepatic metastasis in breast cancer patient with postsurgical follow-up. Methods: A total of 1470 patients without already diagnosed hepatic metastasis were included. All patients underwent US and multiphase CECT including the NECT. Independent reviewers analyzed images obtained in four settings, namely, abdominal US, NECT, NECT + US, and CECT and recorded liver metastases using a 5-grade scale of diagnostic confidence. Sensitivity, specificity (diagnostic performance), and area under the receiver operating characteristic curve (AUC, diagnostic confidence) were calculated. Interoperator agreement was calculated using the kappa test. Results: Reference standards revealed no metastases in 1108/1470 patients, and metastasis was detected in 362/1470 patients. Abdominal US (P < 0.01) and NECT (P = 0.01) significantly differed from CECT, but NECT + US did not significantly differ from CECT in terms of sensitivity (P = 0.09), specificity (P = 0.5), and AUC (P = 0.43). After an additional review of abdominal US, readers changed the diagnostic confidence scores of 106 metastatic lesions diagnosed using NECT. Interobserver agreements were good or very good in all four settings. Additional review of abdominal US with NECT allowed a change in the therapeutic plan of 108 patients. Conclusion: Abdominal US + NECT showed better diagnostic performance for the detection of hepatic metastases than did NECT alone; its diagnostic performance and confidence were similar to those of CECT.

Background: The purposes of this study were to calculate the negative predictive value (NPV) of nondiagnostic ultrasound (US) in patients with suspected appendicitis and to identify the clinical factors that were associated with the nondiagnostic US. Methods: We conducted a retrospective review of 412 patients who had graded-compression appendiceal US performed during January 2017 and December 2017. The NPV of the nondiagnostic US in combination with clinical parameters was calculated. Multivariate regression analysis was used to determine the independent predictors for the nondiagnostic US. Results: The US exam was nondiagnostic in 64.8% of the patients, giving an NPV of 70.8%. The NPV of nondiagnostic US increased to 96.2% in patients who had an Alvarado score of <5. The patients who did not have migratory pain, did not have leukocytosis, and had a pain score of <7 were more likely to have a nondiagnostic US study (P < 0.001). Conclusion: Alvarado score had an inverse effect on the NPV of nondiagnostic appendiceal US. Patients who had nondiagnostic US and Alvarado score of <5 were very unlikely to have appendicitis. Active clinical observation or re-evaluation rather than immediate computed tomography may be a safe alternative approach in these low-risk patients. However, the Alvarado score itself was not a predictive factor of nondiagnostic US. The absence of migratory pain, absence of leukocytosis, and low pain score were the independent predictors of nondiagnostic appendiceal US.

A significant limitation of homemade phantoms is shelf life. Our goal was to compare the impact on shelf life of easily obtained additives. Fifteen additives were mixed into a gelatin-psyllium hydrophilic mucilloid fiber phantom; three of these additives were used as a layer on top of the phantom. The mixtures were stored in the refrigerator and at room temperature. The samples were evaluated daily for microbial growth and phantom degradation. A 4% of chlorhexidine gluconate layer on top of the phantom quickly made the phantom unusable. The addition of benzoic acid and bleach to the mixture negatively affected phantom appearance with ultrasound imaging. The addition of household bleach or 4% chlorhexidine gluconate to the mixture or a 10% povidone-iodine layer on top of the phantom was the best way to preserve samples stored at room temperature. The refrigerated sample outlasted the paired room temperature sample in every case, with most room temperature samples becoming unusable by day 10 and most refrigerated samples lasting past 50 days.

Corpus spongiosum abscess is a rare condition with no case reported as of now diagnosed on ultrasonography (USG). Here, we report a unique case of a 40-year-old Indian male with a 15 days' history of pain and difficulty during micturition. The patient had swelling and erythema in distal 1/3 of the penis. The patient was a known case of type 2 diabetes mellitus. Pain aggravated during micturition, there was no history of any urethral catheterization, trauma, or urethritis. On USG, fluid collection was noted in the corpus spongiosum on the posterior aspect of the distal penile urethra. The abscess was drained percutaneously under ultrasound guidance and was send for culture and sensitivity test. The culture yielded Acinetobacter and the patient was treated with 1 week of intravenous antibiotic according to the culture sensitivity test.

A 27-year-old male patient presented in the emergency department (ED) with right acute abdominal pain, tenderness of the abdominal wall, and abdominal guarding. With suspicion of acute appendicitis, we performed bedside sonography. A blind-ending tubular structure, originating from the base of cecum with the presence of an intraluminal calcified “stone,” with the presence of clear peristalsis was seen. Whether this structure represented the appendix or the small bowel, it was not distinguishable sonographically. A consequent surgical consultation indicated a computer tomography scan, and the finding showed acute appendicitis with appendicolith. An inflamed appendix of 15 cm in length was seen laparoscopically and consequently an appendectomy was performed. The histology confirmed a putrid, ulcero-phlegmonous, and hemorrhagic appendicitis with appendicolith. Postoperatively, the patient made a good recovery without complications. The absence of peristalsis is a well-known criterion for diagnosing acute appendicitis. However, we have shown here, that this should be taken into account with caution, as in rare cases such as this appendicitis can be present with peristalsis.

Infectious mononucleosis is caused by Epstein.Barr virus (EBV) infection. Although typically self.limiting, complications such as splenic infarction and splenic rupture are described. A 17.year.old man presented in the emergency department due to a 3 days history of fever with chills, soreness, fatigue, and loose stool. Ultrasound examination showed a homoechogenic splenomegaly. Viral enteritis was diagnosed and the patient was dismissed. Six days later, he reassessed due to increasing left upper quadrant abdominal pain. Ultrasound showed inhomogeneous splenomegaly with irregular hypoechogenic subcapsular lesions. Contrast.enhanced ultrasound (CEUS) characterized the lesions as not perfused tissue until the late venous phase, compatible with spleen infarctions. Serologic studies were positive for EBV. In the literature, splenic infarction is considered under.recognized. Contrast.enhanced computed tomography (CECT) and magnetic resonance imaging are associated with costs and radiation (CECT). B.mode ultrasound examination is usually used as the first imaging modality, although showing a poor sensitivity in the question of splenic lesions/infarctions. CEUS has shown instead very good sensitivity and does not harm. Therefore, we recommend CEUS examination as the first imaging modality if suspicion of spleen infarction arises, especially when B.mode ultrasound is normal.

Ultrasound provides direct visualization of blood vessels and soft tissues around the sympathetic chain and potentially minimizes injury to these critical anatomic structures when performing stellate ganglion block (SGB). We report an atypical left vertebral artery course detected during an ultrasound prescan before performing a SGB. The left vertebral and inferior thyroid arteries were identified on the longus colli muscle's ventral surface at the C6 level. This report was the first to demonstrate ultrasound images of a vulnerable vertebral artery to intravascular injection. The study emphasized the importance of identifying the sonoanatomy before performing procedures involving the anterior cervical vertebrae.

Fetal cardiac hypertrophy (CH) in pregnant women with diabetes is believed to be a benign condition. We encountered a rare case of fetal CH in a pregnant woman with type 1 diabetes, which developed into severe fetal circulatory insufficiency and acidemia. Fetal echocardiography at 37-week gestation showed cardiomegaly with a ventricular hypertrophy. Cardiac function was impaired, and pulsed Doppler findings indicated circulatory failure. The patient was diagnosed with fetal compromise due to fetal CH, and a large for gestational age boy was delivered by an urgent cesarean section. Despite myocardial hyperplasia and left ventricular outflow tract stenosis, the neonate was hemodynamically stabilized by fluid resuscitation alone. Although the neonatal course was favorable, we speculated that the neonate was on the verge of death because he was already acidemic at birth. Therefore, comprehensive fetal echocardiography should be performed in pregnant women with diabetes, and clinicians should not miss the optimal timing of delivery.

We report a case of giant well-differentiated esophageal liposarcoma in a Chinese patient. Liposarcoma is a common soft tissue malignant tumor that usually arises in the lower extremities, trunk, and the retroperitoneum, but it is very rare that liposarcoma locates in the gastrointestinal tract, especially in the esophagus. Endoscopic ultrasound could be an efficient tool for preliminary examination. Moreover, the patient underwent combined thoraco-laparoscopic surgery, after reviewing the published articles, this surgery was first applied in the excision of esophageal liposarcoma due to the detailed preoperative information from the ultrasound technique.

Epidermoid cyst of the spleen is a rare, benign cystic lesion of congenital origin. Although most epidermoid cysts of the spleen are asymptomatic and detected incidentally on ultrasonography, the entity needs to be included in the differential diagnosis of cystic lesion mimics of the spleen, especially in patients with left hypochondriac pain. This case report describes the typical sonological appearance of epidermoid cyst of the spleen in a 31-year-old male.