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Background: We hypothesized that gallbladder (GB) volume is affected by serial changes during the early infancy period in extremely premature infants. Methods: We conducted a prospective study of extremely premature infants admitted to the neonatal intensive care unit of Fukushima Medical University Hospital, Fukushima City, Japan between January 2014 and December 2015. GB volume was measured by an abdominal ultrasound ellipsoid method between Day 0 and Day 56 after birth within 60 minutes before enteral feeding. We calculated GB volume (mL)/weight (kg), which was evaluated as GV/W. Results: In total, 30 infants were included. The median gestational age of the infants was 26 weeks 5 days (range, 23 weeks 1 day–28 weeks 6 days), and the median birth weight was 731 g (range, 398–1220 g). The detection rate of GB decreased in the infants over time; the rates were > 93% between Day 0 and Day 7 and < 77% between Day 10 and Day 56 after birth. GV/W decreased in the infants over time. The median GV/W values were 0.18 (range, 0.05–0.59) in infants on admission and constantly

Objective To validate an ocular phantom as a realistic educational tool utilizing in vivo and phantom optic nerve sheath (ONS) images obtained by ultrasound. Methods This prospective study enrolled 51 resident physicians from the Denver Health Residency in Emergency Medicine (EM) and 10 ultrasound fellowship-trained EM attending physicians. Participants performed optic nerve sheath diameter (ONSD) measurements on five in vivo and five phantom ocular ultrasound images and rated the realism of each image on a 5-point Likert scale. Chi-square analysis was performed to evaluate the subjective “realness” of in vivo and phantom images. Results Sixty-one participants performed ONSD measurements. Mean Likert scale values were 3.43 (95% confidence interval: 3.31–3.55) for in vivo images and 3.41 (95% confidence interval: 3.28–3.54) for phantom images. There was no statistical difference in subjective “realness” between in vivo and phantom ONSD ultrasound images among EM residents. Ultrasound fellowship-trained EM attending physicians aptly differentiated between in vivo (p < 0.01) and phantom (p < 0.01) images, as compared with EM residents. Conclusion Our ocular phantom simulates in vivo posterior ocular anatomy. EM resident physicians found the phantom indistinguishable from in vivo images. Our ONS model provides an inexpensive and realistic educational tool to teach bedside ONSD sonography.

Purpose This study aims to evaluate patients with right-sided colonic diverticulitis detected at ultrasonography (US). Methods We retrospectively analyzed 14 patients. Demographic data, clinical features, and US images were documented. Results In the 14 patients, clinical manifestations included right lower abdominal tenderness (93%), leukocytosis (57.1%), and fever (28.6%). Diverticulitis occurred in cecum and ascending colon with a similar frequency (35.7%). US features included diverticular wall thickening (50%), surrounding echogenic fat (50%), intradiverticular echogenic material (50%), adjacent lymph node enlargement (21.4%), intradiverticular or peridiverticular fluid collection (28.6%), and color flow signals on or surrounding the diverticula (14.3%). Two (14.2%) patients suffered from recurrence. Two (14.3%) patients had abscess formation, and one (7.1%) patient had diverticulum perforation. Most (85.7%) patients received conservative treatment only. One (7.1%) patient received computed tomography-guided drainage due to diverticulum perforation and pocket of abscess formation. One patient underwent surgery due to recurrent diverticulitis-related fistula. Conclusion Common US features of diverticulitis include diverticular wall thickening, surrounding echogenic fat, and intradiverticular echogenic material. Proper recognizing of these features helps in differentiating diverticulitis from appendicitis and may obviate an unnecessary emergent surgery.

Background Timely and adequate laryngeal elevation along with hyoid bone movement is an essential component of the swallowing movement under normal physiological conditions. The purpose of this study was to verify the reproducibility of using ultrasonography to evaluate hyoid bone displacement during swallowing through the assessment of inter- and intrarater reliability and examine its accuracy by comparing the results with videofluoroscopic swallowing study (VFSS). Methods A self-designed water balloon was fixed to the transducer, which provided good contact between the transducer and the submental skin. Ten participants with dysphagia were recruited. The measurements of hyoid bone displacement using ultrasonography were performed by two of the authors. All the participants underwent ultrasonographic examinations and VFSS within 24 hours. Results The intrarater intraclass correlation coefficient (ICC) of the two examiners was 0.996 and 0.959, respectively (p < 0.01); the interrater ICC between the two examiners was 0.892 (p < 0.05). ICCs between VFSS and ultrasonography for two researchers were 0.815 and 0.916 (p < 0.01). Conclusion Submental ultrasonography is a reliable and accurate method for assessing the hyoid bone movement.

Background In the past 2 decades, there has been increasing interest in calprotectin. It is released and detected in serum and body fluids as a potentially useful clinical inflammatory marker. The protein has been described in synovial tissue in rheumatoid arthritis (RA) patients, specifically in the lining layer adjacent to the cartilage–pannus junction, which is the primary site of cartilage destruction and bone erosion. Assessment of inflammatory activity in RA is of pivotal importance for the optimal treatment. Our aim in this study is to measure the serum calprotectin levels in RA patients and to assess its association—if there is any—with disease activity score and radiological findings using the musculoskeletal ultrasound. Patients and methods In our case control study, we included 44 RA patients (Group I) and 20 age- and sex-matched healthy volunteers who served as the control group (Group II). Both groups were subjected to full history taking and thorough clinical examination. Assessment of RA disease activity state was done for all RA patients using the Disease Activity Score 28. Laboratory investigations included the measurement of complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, anticitrullinated peptide antibodies, kidney, liver functions; serum calprotectin levels were determined using enzyme-linked immunosorbent assay and radiological joint assessment was done using musculoskeletal ultrasound score. Results There was a statistically significant elevation of serum calprotectin levels among RA patients when compared with healthy controls. Statistically significant correlations were also found between serum calprotectin and the ultrasound grading score, Disease Activity Score 28, and erythrocyte sedimentation rate, which reflect the degree of inflammatory activity in the affected joints in RA patients. Moreover, the study yielded a significant correlation between serum calprotectin levels and rheumatoid autoantibodies (rheumatoid factor and anticitrullinated peptide antibodies), which are strong predictors of the aggressiveness of the disease. Serum calprotectin at a cutoff level of 93.9 μg/dL had 88.6% sensitivity and 100% specificity for diagnosis of RA. Conclusion Calprotectin was found to have high association with laboratory and ultrasonography markers of inflammation in RA patients, so it is recommended for use as a marker of inflammatory activity in RA patients especially for the follow-up of patients on biological therapy to assess its efficacy.

Purpose To determine the intra- and interrater agreement of mean flow velocity (MFV) and pulsatility index (PI) measurement in middle cerebral arteries, assessed by transcranial Doppler (TCD) with M-mode. Methods Masked experienced neurosonologists performed TCD with M-mode using handheld probe in healthy adult volunteers. The Bland–Altman method for concordance and intraclass correlation coefficient were used. Results Seventy-seven healthy volunteers and seven raters participated (3 on regular TCD shift and 4 off-shift). The intrarater absolute mean difference between measurements was 5.5 cm/s [95% confidence interval (CI), 4.7–6.3] for MVF and 0.073 (95% CI, 0.063–0.083) for PI. The difference between MFV measurements was significantly higher in off-shift raters ( p =0.015). The interrater absolute mean difference between measurements was 6.5 cm/s (95% CI, 5.5–7.5) for MVF and 0.065 (95% CI, 0.059–0.071) for PI. No influence was found for the middle cerebral artery side, volunteer's sex, or age, and there was no significant difference between raters. The intraclass correlation coefficient was 82.2% (95% CI 77.8–85.6) and 72.9% (95% CI 67.4–77.6) for MFV and PI, respectively. Conclusions There exists good intra- and interrater agreement in MFV and PI measurements using M-mode TCD. These results support the use of this noninvasive tool and are important for clinical and investigational purposes.

Objective To present the complete history of a case with placenta accreta and demonstrate the special clues of ultrasonography finding during whole trimesters from early pregnancy to delivery. Case Report A multiparous 28-year-old female with a history of multiple cesarean deliveries was found with suspected precesarean section scar pregnancy at 6 weeks of gestation. We performed a series of ultrasonography scans, which revealed placenta previa totalis and placenta accreta at 15 and 32 weeks of gestation, respectively. A well-planned cesarean section with hysterectomy was performed at the 35 th week of gestation with massive blood transfusion support, and an alive female baby—with a birth body weight of 2485 g, and Apgar score of 9 at the 1 st minute and 10 at the 5 th minute—was born. The intraoperative blood loss was 7000 mL, and no postoperative hemorrhage or other complication occurred. Conclusion Ultrasonography remains the main tool for diagnosis of morbid adherent placenta with several typical clues, including abnormal vasculature, increased size and numbers of vascular sinus, absence of uterovesicle border or retroplacental hypoechoic zone, and invaded placenta insertion on myometrium. Proper planning prior to the operation and detailed counseling may be necessary, as well as hysterectomy; massive bleeding with transfusion remained the most seen complication.

Uterine artery embolization is the most common treatment for uterine vascular abnormalities. Herein, we report the successful use of dilation and evacuation as a treatment for uterine artery pseudoaneurysm. A 36-year-old woman complained of vaginal bleeding after an uncomplicated vaginal delivery. Ultrasonography showed a 12.8-mm anechoic area inside the uterus. Color Doppler revealed a to-and-fro sign, indicating an arteriovenous malformation. A blood test showed a low level of human chorionic gonadotropin. Therefore, a diagnosis of early uterine artery pseudoaneurysm following spontaneous delivery was suspected. Under monitoring with transabdominal color Doppler sonography, intrauterine balloon tamponade induced complete disappearance of abnormal blood flow. With bleeding determined to be under control with balloon tamponade, dilation and evacuation was performed. The patient had a favorable postoperative course.

Objective The thyroid gland is an important endocrine gland. A nomogram of thyroid gland size in a Bangladeshi population is prepared in this study. Methods In the present prospective, cross-sectional study, a nomogram of thyroid gland size was constructed using a linear parameter. Measurements were made of the anterioposterior diameter of the two lobes and the isthmus of the thyroid gland, and the results compared with results from Western studies. Thyroid size was also determined in pregnant women and similar comparisons were made. High-resolution ultrasonography was used for scanning purposes. Results Mean, standard deviations, and 95% confidence intervals of the measurements were derived from the data of 711 individuals. The mean size of the right lobe of the male participants was 12.73 ± 2.21 mm and of the left lobe 12.36 ± 2.53 mm. The mean size of the right lobe of the female participants was 12.31 ± 2.03 mm and of the left lobe 10.88 ± 2.04 mm. The mean size of the isthmus of the studied men was 3.17 ± 0.69 mm and was 3.09 ± 0.73 mm for the women studied. The mean values of pregnant women were also derived. Statistically significant differences were determined between the right and left lobes within the groups and between two groups. A table of the unknown thyroid pathologies detected during the study, found in 71 individuals or 9.08% of all participants, was also prepared. Conclusion These nomograms will aid in differentiating normal from abnormal measurements of thyroid glands in the Bangladeshi population. This study also presents the prevalence of unknown thyroid diseases in normal Bangladeshi population.

Carpal tunnel syndrome is common, and open carpal tunnel release remains the treatment of choice for cases refractive to conservative treatment. However, up to 25% of postrelease patients remain symptomatic. Our case illustrates how ultrasound examination can visualize the movements of the contents of the carpal tunnel and reveal additional pathologies. A 42-year-old patient with previous bilateral open carpal tunnel release surgeries presented with recurrent symptoms of bilateral hand tingling sensation starting months after the first operation. Under real-time sonographic exam, the median nerve (MN) changed shape and migrated inferiorly when the patient extended her third finger, suggesting that the perineurium of the MN was adherent to the tendon sheath of the third flexor digitorum superficialis tendon. The patient opted to continue conservative treatment but unfortunately did not improve. Recurrent inflammation and fibrosis may have led to the adhesion of the flexor tendons to the MN which was only apparent on real-time evaluation of the displacement of the MN on ultrasound examination. We suggest that the observation of the displacement of the MN during active finger movement can be integrated into the examination of carpal tunnel syndrome patients both before and after surgical intervention and herein include an easy to follow protocol for such examinations.

The hospitalized cases and mortality from alcoholic liver disease (ALD) are increasing in Taiwan and worldwide. Meanwhile, the Asia–Pacific region also has a high prevalence of hepatitis B virus (HBV) and hepatocellular carcinoma (HCC). The Taiwanese have the highest percentage of aldehyde dehydrogenase 2 (ALDH2) deficiency and the lowest amount of alcohol consumption. Based on the histological changes, ALD is clinically classified as steatosis, alcoholic hepatitis, alcoholic fibrosis, alcoholic cirrhosis, and alcoholic hepatitis on cirrhosis. Patients with overt alcoholic hepatitis often develop marked hepatomegaly, audible hepatic arterial bruit, mild leukocytosis, and mild fever. Patients having alcoholic cirrhosis had much more serious complications and mortality. It is clinically important to identify hepatic fibrosis and cirrhosis earlier for early management. Active assessments for esophageal varices and ascites may help the diagnosis of cirrhosis. Sonography is helpful for exanimating features of cirrhosis including portal hypertension, ascites, increased hepatic portal flow, and collaterals. Synergistic damage of viral hepatitis on ALD patients lead to rapid progression to cirrhosis and HCC. Distinct from the Western population, 30% of Taiwanese alcoholics had concomitant chronic HBV regardless of the different histologic categories. Patient groups with combined alcoholics and HBV had fewer platelet counts and much more cirrhosis with Ishak Stage 5–6 fibrosis. The annual incidences of HCC were significantly higher in alcoholic cirrhotic patients having concomitant HBV infection than those with only HBV infection or alcoholism alone. Antiviral nucleotide and nucleoside analogs therapy reduces the prevalence of HCC to a similar level to those ALD patients without active HBV.

Necrotizing acute pancreatitis is the most severe form of pancreatitis, and it is a potentially life-threatening condition. Its diagnosis and severity are based on radiological signs. Although computed tomography is the most used imaging tool, ultrasound can be a quick and useful technique in emergency and intensive care scenarios. The use of abdominal ultrasound is generally limited to ruling out cholecystitis. Bowel gas can limit the accuracy of pancreatic imaging. When the pancreas is visualized, ultrasound can reveal pancreatic enlargement, echotextural changes, and peripancreatic fluid. We present a patient with necrotizing pancreatitis who developed peritonitis due to ileal perforation, where the use of ultrasound as a bedside imaging technique was very useful.

An amniotic sheet is a septation in the amniotic cavity with a perforation that allows amniotic fluid to pass through. Although the incidence of abnormal placental implantation is higher in such cases, the management recommendations remain unclear. We report a case of an amniotic sheet with a hammock-like placenta located in the center of the uterine cavity. A 25-year-old woman with a history of two dilation and curettage procedures was found to have an amniotic cavity separated by a septum that contained part of the placenta. At gestational Week 32, magnetic resonance images revealed that the placenta was attached from the anterior to posterior uterine walls and resembled a hammock hanging in the center of the uterus. Subsequently, continuous intravenous administration of ritodrine hydrochloride and magnesium sulfate were given. The pregnancy was extended to Week 36. Elective cesarean section was performed, and a 3212-g female infant was delivered. Thus, owing to the risk of umbilical cord complications and placental injury secondary to premature rupture of membranes, aggressive and careful perinatal management is required in such cases.

Background Our aim in this study was to determine the ability of ultrasonography (US) to assess and classify the degree of subcutaneous edema caused by infusion via peripheral intravenous catheter, compared to assessment by the Infusion Nurses Society infiltration scale. Methods This prospective study included 64 adult patients who underwent infusion via peripheral intravenous catheter. All patients underwent US imaging of the subcutaneous tissue just after the insertion of indwelling catheters and just before catheter removal. The grade of swelling was then assessed using the infiltration scale. Subcutaneous edema and edema thickness were analyzed on transverse US images, and the edema was classified as normal, mild, or severe. The relationship between US-determined subcutaneous edema and that determined by using the infiltration scale was evaluated. Results Among the 64 patients, US images of the subcutaneous edema were classified into three groups: normal in 15 patients, mild subcutaneous edema in 41 patients, and severe subcutaneous edema in eight patients. Thus, US classification of subcutaneous edema could provide more detailed information than the infiltration scale. Conclusion The results of the present study suggest that US imaging of subcutaneous tissue could help classify the degree of subcutaneous edema.

Background: To obtain the learning curve in determining fetal sex with the first trimester ultrasound scan. Methods: A prospective study was conducted on 400 pregnant patients to determine the fetal sex by ultrasound scan between 11–13+6 weeks of gestation. A midsagittal plane of the fetus was obtained by two sonographers who were newly trained for measuring nuchal translucency. It would be assigned as male if the fetal phallus was in the cranial direction and assigned as female if in caudal direction. The baby sex was confirmed after delivery. The accuracy of each sonographer was analyzed after every 50 ultrasound scans performed. Results: Nearly all the patients requested to be informed about the fetal sex during ultrasound. The accuracy in determining fetal sex by the two sonographers increased with the number of ultrasound scans performed. The two sonographers achieved an accuracy rate of 71.4–78% after 200 ultrasound scans performed. Among different factors which may affect the accuracy in determining fetal sex with ultrasound, a gestational age less than 12 weeks had a significantly lower accuracy than those more than 12 weeks, and male fetuses had significantly higher accuracy than female fetuses. A logistic regression model showed that these two factors remained significant in the equation (p

Background Point-of-care-ultrasound (POC-US) is an increasingly popular tool in the assessment of a wide variety of emergency department patients. In this case report we discuss how POC-US aided in the diagnosis and treatment of inferior shoulder dislocation, a rare presentation of a common emergency department complaint. Case Report A 69-year-old female presented to the emergency department with severe shoulder pain after a ground level fall. Her arm was held overhead with her shoulder trapped in abduction. POC-US confirmed the diagnosis of inferior shoulder dislocation, guided glenohumeral intraarticular anesthesia, and confirmed successful reduction. Why an emergency physician should be aware of this: POC-US is a useful tool for the emergency physician when confronted with shoulder dislocation. US not only confirms the dislocation, but also differentiates between anterior versus posterior versus inferior dislocation. POC-US can guide the placement of intraarticular lidocaine for anesthesia which then potentially reduces time, expense, and risk of procedural sedation. Finally, POC-US may reduce failed reductions by providing immediate visual confirmation and in the case of reductions performed under sedation, may prevent the need for repeat sedation.

Acute cholecystitis is a common etiology of acute right upper quadrant pain in patients presenting to the emergency department (ED). The use of ED-focused right upper quadrant ultrasound (RUQ US) is becoming more widely utilized to evaluate abdominal pain thought to be hepatobiliary in nature. We describe a case series of two patients with acute cholecystitis detected by serial ED-focused RUQ US. Case 1: A woman presented to the ED with epigastric pain of acute onset. She was initially found to have a mild leukocytosis and cholelithiasis detected by ED-focused RUQ US. Seventy-five minutes later, the patient had a repeat bedside ultrasound by the same sonographer that showed visual evidence of acute cholecystitis that was later confirmed by surgical pathology. She was treated operatively. Case 2: A man with known cholelithiasis presents to the ED with acute-onset RUQ pain. Initial RUQ ultrasound performed by the Department of Radiology (University of Colorado Hospital) was equivocal, showing cholelithiasis with a mildly thickened wall and no pericholecystic fluid. A repeat ED-focused RUQ ultrasound 5 hours later showed increased wall thickness and pericholecystic fluid. The patient was subsequently taken for same-day cholecystectomy. This case series demonstrates the dynamic and progressive nature of acute cholecystitis detected by ED-focused RUQ US. It also highlights how serial bedside ultrasonography can reduce harm, appropriately triage patients with hepatobiliary disease and lead to reductions in overall morbidity.

Background Point-of-care ultrasound has become an essential skill in the armory of modern physicians. The South African point-of-care ultrasound curriculum reflects that of the United Kingdom by including five module applications, namely, extended focused assessment of sonography in trauma (eFAST), abdominal aorta aneurysm, central and peripheral venous access, focused emergency echocardiography in resuscitation (FEER), and deep venous thrombosis (DVT). A recent descriptive study demonstrated marked discrepancies between the current five point-of-care ultrasound curriculum application modules trained and the disease burden faced by doctors within Cape Town Emergency Centers during their daily clinical practice. The motivation for conducting this study is to extend the study location beyond Cape Town. The objective was to establish whether the clinical practice exposure of South African certified point-of-care ultrasound providers reflects the current curriculum content. Methods An online survey was conducted. All South African certified emergency medicine point-of-care ultrasound providers were eligible for inclusion. Cases with incomplete data and providers practicing outside South Africa were excluded. Summary statistics were used to describe all variables. Results Forty-four providers completed the survey (52.4% response rate), but only 37 responses were analyzed [currently working outside South Africa ( n = 5); incomplete responses ( n = 2)]. Most respondents were female ( n = 20, 54.1%); aged > 35 years ( n = 22, 59.5%); working in the Western Cape Province ( n = 29, 78.4%); and emergency medicine specialists ( n = 22, 59.5%). The eFAST (35.9%), DVT (24.4%), and FEER (14.3%) application modules were the most frequently used. The top five modules selected that best match the participants' perceived burden of disease were eFAST (89.2%), DVT (86.5%), FEER (64.9%), first-trimester pregnancy (56.8%), and focused assessment with sonography for human immunodeficiency virus/tuberculosis (43.2%). Most respondents ( n = 27, 73%) indicated that the curriculum should be expanded to include more than five application modules. Conclusions This study indicates a mismatch between the current point-of-care ultrasound curriculum and the clinical burden of disease experienced. Disease burden, disease impact, technical difficulty of ultrasound applications, and logistical barriers need to be incorporated when considering a change in the curriculum to make it more appropriate for the South African setting.

Spontaneous intrahepatic porto-systemic shunts (IHPSS) can be disclosed with ultrasound (US) and color Doppler ultrasound (CDU). However, direct evidence of the shunt on US or CDU may not be convincing. In this report we demonstrate the presence of IHPSS by ultrasonic contrast portography with intravenous injection of microbubble-based contrast agent (MBCA). With this technique, the MBCA was depicted to enter the hepatic vein through the shunt, and then flowed into the inferior vena cava.

Radiofrequency ablation (RFA) is a minimally invasive technique, used with ultrasound or computed tomography guidance, which can produce tissue coagulation necrosis in various kinds of tumors in the human body. In the past 10 years, numerous studies about RFA in benign thyroid nodules have been published. Reviewing these studies, we noticed that the effectiveness of ablation was higher when it was performed with the "moving-shot technique" via an internally cooled electrode. A consensus statement published from the Korean Society of Radiology also suggested the moving-shot technique as a standard ablation procedure for benign thyroid nodule ablation in Korea. In Taiwan, most symptomatic benign nodules are currently treated with surgical removal. RFA for mass lesions is primarily performed for the treatment of metastatic hepatic tumors. In our case, we have attempted to introduce RFA for benign thyroid nodules in Taiwan. Because endocrinologists in Taiwan were not familiar with this technique, we adopted a stepwise approach in learning how to perform RFA. We conducted ex vivo animal ablation exercises to gain experience in setting the radiofrequency generator for the right ablation mode and appropriate power output. The thyroid nodule volume reduction rate after 1 year of follow up was approximately 50% in this case. The most important thing we learned from this trial is that we confirmed the safety of thyroid nodule ablation. To the best of our knowledge, this is the first reported study of RFA of a thyroid nodule in Taiwan.

Background: High intensity focused ultrasound ablation is a new technique for the treatment of uterine fibroids. Its efficacy is influenced by the blood perfusion of the fibroids. Oxytocin is a promising drug which may decrease the blood flow to the fibroids. In this study, the alterations of blood flow to the uterine fibroids were observed using contrast-enhanced sonography (CEUS) before and after the use of parenteral oxytocin. Methods: A total of 40 women with 42 fibroids (mean ± standard deviation, 5.8 ± 1.9 cm; range, 3.1–12.9 cm) underwent CEUS before and after intravenous infusion of oxytocin at 0.1 U/min. The CEUS time-intensity curves were drawn, the maximum signal intensity, the time-to-peak intensity and mean transit time of the fibroids were measured to observe the changes of perfusion after the use of oxytocin. Results: After the use of oxytocin, the wash-in of microbubbles was significantly slowed down on CEUS in all patients. The maximum signal intensity of the fibroids decreased significantly and the time-to-peak intensity and mean transit time of the fibroids were prolonged significantly after the use of oxytocin in all patients (p

Background To investigate the relevance of two-dimensional (2D) endoanal ultrasonic (EAUS) assessment of anal sphincter and puborectalis morphology by comparison to functional measures derived from patient symptoms and anorectal physiology. Methods Thirty women (mean age 44 years, mean parity 2) with anal incontinence underwent 2D EAUS, anorectal pull-through manometry, anorectal electosensitivity and sensation to rectal distension, pelvic floor dynamometry, and completed Wexner incontinence scores. EAUS images were reported blind to physiological assessments by a single experienced observer. The external and internal sphincters, and puborectalis were measured and scored for integrity and atrophy, and correlated with symptom load (Wexner score) and physiological data. Results The mean Wexner score was 10 (range 1–20). The puborectalis could not be accurately measured in 12 patients (44%) on EAUS. Anal squeeze pressure correlated with integrity of the external sphincter ( r = −0.4, p = 0.02) but not integrity or atrophy of the puborectalis. There were no other significant correlations between EAUS features and patient symptom load or anorectal physiology ( r range, −0.42–0.26, p > 0.05). Conclusion Two-dimensional EAUS can define sphincter integrity, has a limited role for assessment of muscular quality but is not useful for assessment of the puborectalis.

Nontuberculous mycobacteria tenosynovitis is a rare clinical condition that commonly affects the hand and wrist. It is also a condition that is difficult to diagnose through clinical and roentgenological methods. In this study, a case of nontuberculous mycobacterial tenosynovitis infected by Mycobacterium marinum , which can be easily misdiagnosed, was reported and its imaging findings discussed.

Cardiac chamber collapse secondary to extrapericardial causes is rare. Focused cardiac ultrasound (FoCUS) in the emergency department can rapidly yield important clinical information and guide management in patients presenting with dyspnea, hypotension, or other cardiopulmonary complaints of uncertain etiology. We report a case of newly-diagnosed cirrhosis with massive ascites and large pleural effusions that distorted normal cardiac anatomy and venous return, in which FoCUS was essential in differentiating underlying pathology of this sick patient and guiding therapy.

Testicular cancer is one of the most common cancers diagnosed in young men. Frequent sites of metastasis include the retroperitoneum, lungs, liver, brain, and bone. Intra-cardiac metastasis has also been described. An 18-year-old boy with a history of mixed testicular germ cell tumor presented to our institution for surgical resection of his metastatic disease. Intraoperative transesophageal echocardiography during his surgery confirmed a tumor thrombus into the left atrium coming from the left pulmonary vein. We report a case of metastatic testicular cancer with rare tumor extension from the left inferior pulmonary vein into the left atrium. Perioperative transesophageal echocardiography was necessary to aid intraoperative diagnosis and confirmation of the intracardiac tumor, providing data to guide surgical strategy.

We describe a case of left-sided pneumocardium, identified by transesophageal echocardiography, following needle thoracostomy in a tertiary intensive care unit (ICU). Bilateral needle thoracostomy was performed during a cardiac arrest. Intracardiac arrest echocardiography demonstrated pneumocardium immediately following the procedure, with air in the left atrium (LA) and left ventricle (LV). This previously unreported consequence of needle decompression contributes to a growing body of literature that questions the value of this intervention.

Embolization of uterine arteriovenous malformations is usually performed angiographically via transfemoral arterial approach. In this report, ultrasound guided transcutaneous embolization of a uterine arteriovenous malformation, using color Doppler, was successfully performed in one patient with intractable vaginal bleeding. There were no complications following the procedure, and complete cessation of blood flow in the uterine arteriovenous malformation was achieved. This technique may be an alternative treatment option for recurrent heavy vaginal bleeding secondary to uterine arteriovenous malformation.

In 1809, Johann Friedrich Meckel the Younger described the most common congenital small bowel anomaly, which was named after him; however, the radiologic manifestations and interventional guidelines related to this entity are still limited to a few large-scale case series as well as proposed therapeutic protocols for the general population. Despite the fact that this entity is more commonly found within the first decade of life, imaging and management protocols remain controversial in the pediatric population, particularly within the asymptomatic group. We present an article depicting the radiologic and histologic findings in a series of Meckel's diverticulum within the pediatric population seen within our institution. We present this series to underscore the importance of high clinical suspicion in the early diagnosis and management of Meckel's diverticulum and to examine further the radiologic and therapeutic protocols within the pediatric population based on our local experience.

The role of sonoelastography in diagnosing cancerous masses has increased since the advent of elastography as an ultrasound modality. Its ability to display differences in the mechanical properties of cancerous masses compared to normal surrounding tissue has shown benefit in increasing the accuracy of diagnosing malignant breast and thyroid masses and has shown early potential in accomplishing better targeted prostate biopsies. To date, the literature is limited in the number of studies describing the use of sonoelastography for testicular masses. We describe a 34-year-old man who presented with an incidental finding of an impalpable hypoechoic testicular mass on grayscale ultrasound during an infertility work-up. Sonoelastography was performed displaying intermediate testicular elastic properties. Upon frozen section of the mass during surgical exploration, classic testicular seminoma was diagnosed and subsequent radical orchiectomy was performed. We would like to use this atypical presentation of testicular seminoma to review the potential role of elastography for diagnosing testicular cancer.

Purpose Transcranial color-coded sonography (TCCS) noninvasively assesses physiologic and pathologic intracranial blood flow especially in non-Caucasians who have high prevalence of intracranial steno-occlusive arterial disease. However, a higher temporal bone window failure (WF) rate is found in non-Caucasians and thus limits the utilization of TCCS. This study was performed to explore the associated factors of temporal bone WF in Taiwanese patients. Methods Between January 2014 and June 2014, 355 consecutive patients who received TCCS examination during their hospitalization at neurological ward were enrolled in this study, including 218 men and 137 women. Patients were classified into two groups, one with no or insufficient temporal bone window and the other with good temporal bone window for identification of middle, anterior, and posterior cerebral arteries via transtemporal approach. Age, sex, and conventional vascular risk factors in each group were compared. Results It was found that 28.8% of the patients had no or insufficient temporal bone window. Among them, 20.3% had complete bilateral temporal bone WF. For all factors studied, older age and female sex were significantly associated with no or insufficient temporal bone window. Conclusion The failure rate of temporal bone window was considered high as compared to Western countries but, not surprisingly, age and sex remained the significant factors. Introducing echo contrast agents during the TCCS examination might help to increase the success rate of TCCS examination and provide useful information to clinicians.

BackgroundThe main outcome of virus-related hepatitis is progression to liver fibrosis. Therefore, early diagnosis is very important in the treatment and management of patients. Although liver biopsy is the gold standard test for assessment of liver fibrosis, it is expensive and has some disadvantages such as sampling errors, interobserver variability, and a significant mortality and morbidity rate. Moreover, this method is invasive and has side effects, especially if it needs repeated sampling. In order to come up with a reliable noninvasive modality in place of biopsy, we studied the value of grayscale ultrasonography (US) and Doppler ultrasonography (DS) for the diagnosis of liver fibrosis in patients with chronic viral hepatitis.Patients and methodsSixty patients, 43 with chronic hepatitis B and 17 with chronic hepatitis C, were enrolled in this study. Grayscale US and DS were performed for all patients in the week prior to liver biopsy. Ultrasonographic findings were recorded according to a US scoring system, and they were compared with histological findings after liver biopsy.ResultsA total of 35 male (mean age: 36.1 ± 10.1 years) and 25 female (mean age: 36.1 ± 10.4 years) patients were studied. Forty-three patients had chronic hepatitis B and the others had chronic hepatitis C. The overall grayscale US score was abnormal (ranged from 1 to 7) in 63.3% of patients and normal (0) in the other patients. The mean portal vein velocity ranged from 8.1 cm/s to 31.7 cm/s (mean: 17.1 ± 5.1 cm/s). The right hepatic vein diameter ranged from 2.8 mm to 8 mm (mean: 5.1 ± 1.2 mm). The total DS score was abnormal (1 or 2) in 66.7% of patients. Quantitative US parameters that were related more significantly to the histopathological staging scores of liver fibrosis were mean portal vein velocity, right hepatic vein diameter, and gallbladder wall thickness. The total grayscale US score, DS score, and accumulation of US and DS scores (US–DS score) were significantly different between patients with liver fibrosis and those without fibrosis (p = 0.03, p = 0.03, and p

ObjectiveThis paper aims to discuss the evaluation of the therapeutic effect of contrast-enhanced ultrasonography (CEUS) in radiofrequency ablation (RFA) for liver cancer and its application value.MethodsA total of 80 patients (120 hepatic malignant tumor lesions) were treated using RFA, and CEUS was conducted on the liver before and after the treatment. Sixty-five patients (85/120 tumor lesions) had primary hepatic carcinoma and 11 (30/120 tumor lesions) had metastatic hepatic carcinoma (6 cases of 15 lesions had colorectal carcinoma, 3 cases of 8 lesions had lung carcinoma, and 2 cases of 7 lesions had gastric carcinoma). Four patients (5 lesions) had recurrence. Prior to the treatment, CEUS accurately guided the RFA of lesions, and after the treatment, the accuracy of CEUS was compared with conventional ultrasonography and enhanced computed tomography (CT).ResultsAfter the RFA, there were two cases of bile leakage, two cases of bleeding, and three cases of hydrothorax, and 20 cases had fever. In the CEUS performed after the operation, 114 of the 120 lesions (94.6%) were not filled with contrast agent in the arterial phase, venous phase, and delayed phase, indicating that the tumor lesions were totally inactivated. In the remaining six lesions, the arterial phase was enhanced partially on the edge, indicating suspected partial residues of tumor lesions. The final diagnosis was based on the aforementioned two kinds of imaging examinations in combination with the level of tumor markers, needle biopsy, and follow-up visits of over 1 month. Based on the therapeutic effects on the tumor after the operation with the final diagnosis as the standards, the accuracy of CEUS was 94.6%, whereas that of contrast-enhanced CT (CECT) and conventional ultrasonography was 93.4% and 60.5%, respectively. A comparative analysis was performed, which indicated that the difference between CEUS and conventional ultrasonography was of statistical significance (χ2 = 5.42, p 0.05).ConclusionCEUS has important value of clinical application both prior to and after RFA operations. Prior to the operation, CEUS can accurately guide the RFA treatment, whereas after the operation, CEUS is an important method to evaluate the inactivation after the treatment, and can be an important means for follow-up visits for partial treatment of hepatic carcinoma.

Objective This study was conducted to determine the accuracy of estimated fetal weight (EFW) by ultrasound, compared with birth weight (BW), in Bangladesh. Methods This is a prospective, cross-sectional study on well-dated singleton fetuses. The accuracy of weight-prediction formula is determined by assessing how well the formula works in a group of fetuses scanned close to delivery. Results of previous studies were compared with those of this study. Results A total of 73 infants were included in the analysis to determine the accuracy of EFW. The mean absolute difference between ultrasound EFW and BW was −64.5 (±218.5) g, and the mean relative difference or the mean percentage error of fetal weight estimation was −1.4% (±7.6%). Conclusion Ultrasound is a reliable modality for estimating fetal weight in a Bangladeshi population using the head circumference, femur length, and abdominal circumference formula of Hadlock.

Background The diagnosis of brain death (BD) is complex. For this reason, we aimed to evaluate the accuracy of power mode transcranial Doppler (PMD-TCD) in diagnosing BD. Patients and methods Patients admitted to an intensive care unit between December 2003 and January 2012 were included in this study if they were in a structural coma, had no craniectomy, and were evaluated blind by a neurologist using PMD-TCD. The diagnosis of BD was based on an evaluation that took into consideration the absence of sedative drugs, a median blood pressure >60 mmHg, a body temperature >35°C, and the absence of brainstem reflexes. A neurosonologist followed a protocol using PMD-TCD that considered the examination as positive for brain circulatory arrest given the presence of reverberating, small systolic peaks or the disappearance of a previous signal present in both middle cerebral arteries and intracranial vertebral arteries. Results A total of 74 patients were evaluated. In 61 (82.4%) patients the interval between both evaluations was less than 1 hour. The sensitivity and specificity for the diagnosis of BD with PMD-TCD were 100% and 98%, respectively. The positive and negative likelihood ratios for BD were 45 and 0, respectively. Conclusion PMD-TCD is accurate for the diagnosis of BD.

ObjectiveThe aim of this study was to identify the role of transvaginal color Doppler and gray-scale ultrasonography findings in managing first- and second-trimester miscarriges.MethodsA prospective interventional study was conducted from March 2009 to April 2010 in our center in which 77 women with first- and second-trimester abortion were recruited. All women were evaluated by transvaginal grayscale and color Doppler ultrasonography. Blood flow within the endometrium was measured using color Doppler. Pulsed Doppler was performed to evaluate blood flow impedance by calculating the resistance index (RI).ResultsForty-six patients underwent dilation and curettage of which 67.4% were proven to have retained products of conception (RPOC). Thirty-one patients were followed up through expectant management. Endometrial thickness (ET) was greater in the group with RPOC (p 10 mm. The combination of vascular pattern and endometrial echogenic mass was the most sensitive and specific ultrasonographic feature for detecting RPOC (88%; 95% confidence intervals: 79–95).ConclusionTransvaginal color Doppler ultrasonography can be used to verify the presence of RPOC after spontaneous miscarriges.

Cloacal exstrophy is a rare congenital disorder that may lead to mortality and morbidity. Although the prenatal diagnosis of cloacal exstrophy can be made by a midtrimester ultrasound, it is difficult to differentiate it from a simple omphalocele that can be corrected completely by surgery without morbidity. We reported a case with cloacal exstrophy and reviewed previous literature on differentiating it from an omphalocele. A 33-year-old, pregnant female visited our outpatient center for prenatal care at the 22 nd gestational week. The midtrimester ultrasound showed fetal anomalies including a protruding mass from umbilicus, absence of bladder, ambiguous genitalia, and bilateral renal hydronephrosis. The parents received prenatal genetic counseling and decided to continue the pregnancy. A female baby was delivered at the 37 th gestational week via vaginal delivery, and cloacal exstrophy without omphalocele was diagnosed. Cloacal exstrophy is a complicated congenital disorder that should be differentiated from a simple omphalocele. Prenatal counseling and postnatal care in a tertiary medical center are important for parents and the fetus, respectively.

It is uncommon to diagnose fetal hepatic hemangioma during the antenatal period. We describe herein two patients with a giant hepatic hemangioma detected antenatally, both with perinatal complications. In Case 1, a fetal intra-abdominal mass, measuring 63 mm × 50 mm × 74 mm, was observed below the right lobe of the liver, and the presumptive antenatal diagnosis of hepatic hemangioma was made at 37 weeks of gestation. Antenatal imaging suggested an intratumoral hemorrhage, but postnatal clinical findings refuted this diagnosis. However, progressive thrombocytopenia and coagulopathy were noted just after birth, resulting in the diagnosis of Kasabach–Merritt syndrome. In Case 2, our ultrasound examination performed at 40 weeks of gestation revealed a mixed solid and cystic hepatic tumor, measuring 99 mm × 54 mm. Further, antenatal sonography revealed cardiomegaly, increased descending-aorta velocity, atrioventricular valvular regurgitation, and a dilated inferior vena cava, suggesting high-output cardiac insufficiency. Giant hepatic hemangiomas can lead to severe complications such as cardiac insufficiency and Kasabach–Merritt syndrome, and these complications may occur during the fetal or early neonatal period. Detailed prenatal evaluation using fetal imaging and cord-blood sampling is important to determine proper antenatal management of patients with giant hepatic hemangiomas and to allow for prompt postnatal treatment.

A brief history of the affiliation process of the ultrasound society of Taiwan to the Asian Federation of Societies for Ultrasound in Medicine and Biology and the World Federation for Ultrasound in Medicine and Biology is described. Although such an affiliation sounds very easy today, it required complicated and delicate negotiations and moderations in those difficult days (from 1986 to 1991). This was a typical past example of how politics was brought into the field of medical ultrasound. As some of the people involved have already passed away, a record of the hidden history might be needful and brought up from the viewpoint of the mediator.

Background Thyroid nodules are often incidentally detected during physical examination, Doppler ultrasound of carotid artery, and other imaging modalities and there are many controversies about the management of these incidentalomas. We focused on incidental thyroid lesions during carotid ultrasound and evaluated their importance and suspected malignant features. Patients and methods The thyroid gland was evaluated for any nodule(s) following carotid Doppler ultrasound in 290 patients. If there was an abnormal finding in the thyroid ultrasound, the patient was referred to an endocrinologist and after clinical and laboratory evaluation, fine-needle aspiration (FNA) biopsy was done if required. Results We found an abnormal thyroid in 63 (21.8%) patients and 57 (19.6%) of patients had incidental thyroid nodules; these were mainly in women and older patients. Based on size and ultrasound findings of the nodules, 28 (44.4% of abnormal thyroids) patients were referred for fine-needle aspiration biopsy and 15 patients agreed with this procedure. Aspiration cytology showed two nondiagnostic samples (13.3%), 10 benign lesions (66.6%), two follicular cell lesions (13.3%), and one (6.6%) Hurthle cell neoplasm lesion. Conclusion Thyroid evaluation during carotid ultrasound has little benefits.

Background Maternal mortality ratio (MMR) in India is 200/100,000 live births, many of which are preventable. To reduce MMR, the Government of India has set up basic obstetric ultrasonography facilities in primary health centers. This service was introduced in a nurse-run, low-risk antenatal and delivery service in an urban health center. This report documents the benefit of prenatal ultrasound in an urban health center. Methods This is a retrospective observational study carried out in an urban health center of a tertiary medical college and hospital, which provides health services to the economically disadvantaged urban population. The urban health center runs a nurse-led low-risk antenatal and delivery service. All consecutive antenatal ultrasounds from March 2012 to February 2013 were analyzed. Routine obstetric ultrasound was done for all women at their booking visit. Crown-rump length was measured if the first visit was prior to 13 weeks of gestation. If they presented after 13 weeks of gestation, biparietal diameter and femur length were measured to confirm gestational age. Results A total of 715 obstetric ultrasounds were performed during the period from 2012 to 2013. Among the 715 ultrasounds, 71.6% were for estimation of gestational age and 15.7% were for amniotic fluid index estimation for fetal surveillance. Among the dating ultrasounds performed, 48.6% were for primigravida women and 51.4% were for multigravida women. Discrepancies were identified in the expected date of confinement by the last menstrual period in 26% of the dating ultrasounds and 4.2% of women were identified to have a missed abortion at booking visit. Conclusion Maternal morbidity and mortality can be reduced by early detection of missed abortion, placenta previa, twin pregnancy, and molar pregnancy by routine obstetric ultrasound at booking visit. Routine obstetric ultrasound at the first and second trimesters had obvious benefits in confirming the expected date of delivery in a community where remembering the last menstrual period was not a priority. Introduction of this procedure helped in appropriate management of post-term pregnancies.

The blood–brain barrier is a specialized protective structure in the central nervous system, which is critical for maintaining brain homeostasis and low permeability to control the passage of molecules from the circulation into the brain parenchyma and the efflux from the brain. However, the blood–brain barrier also hinders the transportation of therapeutic agents and contrast agents from the blood into brain tissue, lowering treatment efficiency. Recently, focused ultrasound sonication with microbubbles has been proved to transiently open the blood–brain barrier, allowing the penetration of administered agents or drugs into the brain. In this article, we review the current state of this drug delivery technique, its application in preclinical brain disease models, and treatment planning for this novel technique.

Hypereosinophilic syndrome (HES), or Löeffler's endocarditis, is a heterogenous group of disorders marked by the sustained overproduction of eosinophils involving different organ systems. Cardiac involvement, recognized as endocardial thickening and left ventricular (LV) mural thrombi, is the major cause for morbidity and mortality. Herein, we present a case with idiopathic HES complicated with severe cardiac involvement, who was treated successfully with corticosteroids. Echocardiography is pivotal in diagnosis and follow-up.

Background Ultrasonography (US) is being increasingly used in clinical practice to detect rotator cuff tears (RCTs) in patients with rheumatoid arthritis (RA) who have shoulder pain. The major aim of this study was to determine the diagnostic utility of US and magnetic resonance imaging (MRI) for detecting RCTs in patients with RA who have persistent shoulder pain. Patients and methods With standardized procedures, US and MRI examinations of the shoulder were performed in 36 patients with RA who had persistent shoulder pain prior to arthroscopic intervention. Within 1 month after US and MRI examination, arthroscopic repair was performed. Arthroscopic findings were used as the gold standard for the diagnosis of RCTs. Results Full-thickness RCTs in 28 patients with RA (77.8%) and partial-thickness RCTs in eight patients (22.2%) were identified using arthroscopic inspection. With arthroscopic findings as the gold standard, the sensitivity and accuracy of US in detecting full-thickness RCTs were 92.9% and 89%, respectively, whereas those for MRI were 96.4% and 90%, respectively. In detecting partial-thickness RCTs, the sensitivity and accuracy were 62.5% and 75.0%, respectively, for US, in contrast with 87.5% and 88%, respectively, for MRI. The overall agreement between US and MRI was 89.3% in detecting full-thickness RCTs and 75.0% in detecting partial-thickness RCTs. US demonstrated levels of sensitivity similar to that of MRI in detecting posterior recess synovitis, tenosynovitis, and subacromial-subdeltoid bursitis. Conclusion With a good agreement with MRI, US was shown to be a highly sensitive and accurate imaging modality in detecting full-thickness RCTs for patients with RA who have shoulder pain, but appeared to have lower sensitivity in detecting partial-thickness RCTs compared with MRI.

BackgroundThe purpose of this study was to evaluate the efficacy of ultrasound (US) for the diagnosis of acute appendicitis in children.Patients and methodsWe reviewed all sonograms for acute appendicitis in children suspected of having appendicitis from January 2009 to December 2012. Sonographic findings were positive when the largest axial diameters were >6 mm. The sonograms that were unable to find the appendix were classified into an other group and were considered separately. Sonographic findings were compared with surgical pathological findings or discharge diagnoses in cases of no surgery. Subgroup analysis in the surgical group, including patient age (

This report discusses a new development in the use of ultrasound microbubble contrast agents on transdermal drug delivery. The medium surrounding the microbubbles at the optimum concentration from liquid to gel can be modified and it can still achieve the same enhancement for transdermal drug permeation as liquid medium. It was also found that under the same ultrasound power density, microbubbles of larger particle sizes can extend the penetration depths of dye at the phantom surface.