Medical Ultrasound

Application of ultrasound liver elastography to the diagnosis and monitoring of liver disease Jing-Houng Wang Journal of Medical Ultrasound 2019 27(1):1-2

Reliability of ultrasound for the detection of rheumatoid arthritis Rabia Hassan, Sobia Hussain, Raham Bacha, Syed Amir Gillani, Sajid Shaheen Malik Journal of Medical Ultrasound 2019 27(1):3-12 The aim of this review article was to investigate the pooled sensitivity and specificity of musculoskeletal ultrasound (MSUS) for the detection of synovitis and early bone erosion in the small joint in rheumatoid arthritis (RA). In addition, investigate the pooled sensitivity and specificity of Power Doppler ultrasonography (PDUS) for the detection of synovial hypervascularity in small joints in RA. A systematic literature search of PubMed, Wiley online library, Google Scholar, Research gate, E-book, BioMed Central, the Journal of Rheumatology and Springer Link were investigated from 2001 to 2017. Original researches related to the article written in English including RA, synovitis, bone erosion, grayscale, and PDUS were included in this study. The sample size, study design, sensitivity, and specificity were analyzed. The review summarizes the value of MSUS for the detection of RA as it is the first choice of modality. Results show the acceptable reliability of US for the diagnosis of early bone erosions, synovitis, and synovial hypervascularity.

Relation of color doppler twinkling artifact and scale or pulse repetition frequency Raham Bacha, Syed Amir Gilani, Iqra Manzoor Journal of Medical Ultrasound 2019 27(1):13-18 Objective: The aim of this study is to determine the effect of scale/pulse repetition frequency (PRF) on the appearance of color Doppler twinkling artifact. Materials and Methods: We commenced this cross-sectional study for 20 months from November 2014 to July 2016. During routine ultrasound examination, we observed multiple case of twinkling artifact produced by renal stones, calcifications in the thyroid nodules, bony fragments and intestinal gases, etc., We observed twinkling artifact with low- and high-PRF settings in 500 different structures. A total of 500 other structures were included wherein there was no Doppler twinkling artifact produced by them, with usual optimum PRF settings. These structures were also evaluated with low- and high-PRF to determine the effect of PRF on twinkling artifact effectively. All the patients were examined according to the AIUM guideline for appropriate examination protocol. Data were collected from the observation of twinkling artifact with low- and high-PRF/scale and evaluated with the help of IBM SPSS 24 package, the results were summarized as follow. Results: Change in scale/PRF could not affect the twinkling artifact. The twinkling artifact observed with low-PRF was the same as seen with high-PRF. There was a significant agreement between low- and high-PRF in the production of color twinkling artifact. The kappa value of agreement was estimated as 0.96, whereas the Pearson's correlation was significant with the value of 0.001. Same twinkling artifact was created with low- and high-PRF, with no significant variation. Conclusion: Twinkling artifact is independent of PRF/Scale.

Correlational study of nonalcoholic fatty liver disease diagnosed by ultrasonography with lipid profile and body mass index in adult nepalese population Umesh P Khanal, Bigyan Paudel, Ghanshyam Gurung, Yong-Sin Hu, Chiung-Wen Kuo Journal of Medical Ultrasound 2019 27(1):19-25 Objective: The purpose of this study was to categorize patients into different grades of nonalcoholic fatty liver disease (NAFLD) by ultrasonography and to compare the findings with their serum lipid profile. Materials and Methods: Descriptive, cross-sectional study design was used. One hundred and nine patients without a history of alcohol consumption of age more than 16 years attending general health checkup were selected at Tribhuvan University Teaching Hospital, Maharajganj, Kathmandu, as per the exclusion and inclusion criteria. Ultrasound scanning of the patients was done and their liver size, as well as grading of fatty liver, was done. Data were collected in predesigned pro forma and were analyzed using Statistical Package for the Social Sciences (SPSS) 16.0, IBM (SPSS Inc., Chicago, IL). Results: In this study, the mean age of fatty liver in males was found to be 44.3 years and in females was found to be 51.9 years. 22.9% of patients with NAFLD had increased liver size. Significant association with increasing grades of fatty liver was found with increasing levels of cholesterol (P = 0.028), low-density lipoprotein (LDL) (P = 0.017), liver size (P = 0.001), and body mass index (BMI) (P = 0.045) in patients diagnosed with NAFLD. No significant association with increasing grades of fatty liver was found with increasing levels of triglyceride (P = 0.32) and high-density lipoprotein (P = 0.25). Conclusion: Ultrasound is a safe and first-line modality for the evaluation of fatty liver and its grading. Increasing grades of fatty liver had significant association with increasing levels of cholesterol LDL, increasing liver size, and BMI of patients.

Comparison of strain elastography, shear wave elastography, and conventional ultrasound in diagnosing thyroid nodules Li-Jen Liao, Huan-Wen Chen, Wan-Lun Hsu, Yung-Sheng Chen Journal of Medical Ultrasound 2019 27(1):26-32 Objective: The purpose of this study is to compare the diagnostic performances of strain elastography (SE), shear wave elastography (SWE), and traditional ultrasound (US) features in diagnosing thyroid nodules. Subjects and Methods: This study included 185 adult patients with thyroid nodules who underwent conventional gray-scale US, SE, and SWE. SE was scored using a four-pattern elastographic scoring (ES) system. SWE values were presented as mean SWE values and standard derivation using Young's modules. The optimal cutoff values of the mean SWE values for predicting malignancy were determined using receiver operating characteristic (ROC) curve analysis. We used logistic regression models to test elastography as a novel significant predictor for the diagnosis of malignant nodules. The diagnostic performance of elastography parameters was compared with a traditional trained model. Results: Malignant thyroid nodules were stiffer for SE (ES patterns 1 and 2/3 and 4) and mean SWE values (4/17; 51.0 ± 24.4 kPa) than for benign nodules (114/50; 33.1 ± 25.2 kPa) (P < 0.01). In ROC curve analyses, a mean SWE value of 32 kPa was the optimal cutoff point, with diagnostic performance measures of 81% sensitivity, 65% specificity, a 23% positive predictive value (PPV), and 96% negative predictive value (NPV). In multivariate logistic regression, the mean SWE value (≥32 kPa) was an independent predictor for malignancy (odds ratio: 16.8; 95% confidence interval [CI]: 3.6–78.3). However, after the addition of SE and SWE to traditional US features, the C-statistic was not significantly increased compared to the traditional model (0.88, 95% CI: 0.81–0.94 vs. 0.91, 0.85–0.97, P = 0.4). Conclusion: In this study, we confirmed SWE as an independent predictor for malignant thyroid nodules. However, in comparing the new extended elastography model to our previous prediction model, the new extended model showed no significant difference in the diagnostic performance.

A longitudinal study of the 28 joints of disease activity score by ultrasonographical examination in rheumatoid arthritis patients Rabab Hussin Ali, Osama Sayed Daifallah, Hanan Sayed M. Abozaid, Esam Mohmad Abu Alfadl, Sahar Abdel-Rahman Elsayed Journal of Medical Ultrasound 2019 27(1):33-39 Background: The damaging effect of rheumatoid arthritis (RA) on cartilage, bone, ligaments, and tendons has raised the importance of the disease activity and severity assessment to enable therapeutic decisions and to evaluate disease outcome. Aim: The aim is to compare the clinical examination of the Disease Activity Score (DAS)-28 with the musculoskeletal ultrasonography (US) examination in RA patients. Moreover, finding if we can use ultrasonographical results as a tool for predicting subsequent radiological damage. Patients and Methods: It is a longitudinal study included 60 adult RA patients. Patients were under assessment at baseline, 6 months, and 12 months from the recruitment time. Twenty-eight joints of DAS were assessed for tenderness and swelling. US gray scale (GS) and US power Doppler (PD) score also was done at each visit. Results: DAS-28, with its parameters, is positively and highly significantly correlated to synovitis severity both by US GS and US-PD score along the study follow-up visits. There was highly significant difference between the number of 28 swollen and tender joints by clinical examination with both US GS and US-PD. Linear regression analysis to predict the number of swollen and tender joints after 12 months showed significance between US PD with swollen and tender joints' numbers. The correlation was positive and significant between Larsen score at 12 months with GS US and PD US assessment, but linear regression analysis was only significant for Larsen score with only GS US. Conclusion: GS US and PD is a sensitive and reliable noninvasive method complementary to standard clinical assessment and could be a tool for predicting subsequent joints' damage.

Consistency of the sonographic image (double contour sign) in patients with gout after ambulation Angel Checa Journal of Medical Ultrasound 2019 27(1):40-42 The aim of this study was to know whether or not any crystal shedding occurs after ambulation in patients with gout and how it affects the consistency of the sonographic image of crystal deposition on hyaline cartilage. A total of 18 consecutive patients (29 knees), 11 with early gout (17 knees) and seven with chondrocalcinosis (12 knees), were prospectively scanned by ultrasound. Examination at rest and after ambulation was performed in each patient. Crystal aggregates were measured in a transverse view. Crystal shedding after ambulation was noted in two patients (two knees) with gout. However, crystal deposits on the surface of the articular cartilage in gout kept invariable size. In patients with chondrocalcinosis, crystal shedding by ambulation was absent. The conclusion of this study is that the size of crystal deposits on the hyaline cartilage in gout and chondrocalcinosis assessed by ultrasound is not modifiable by ambulation.

IgG4-related disease presenting as cervical lymphadenopathy Po-Hsuan Wu, Yu-Chen Chang, Li-Jen Liao Journal of Medical Ultrasound 2019 27(1):43-46 Cervical lymph node enlargement as the first and sole manifestation of IgG4-related disease (IgG4-RD) is rare and is often difficult to distinguish from lymphoma. Here, we report a case of a 63-year-old man initially presenting with bilateral posterior neck masses. Ultrasonography revealed multiple matted, ovoid, homogenous, hypoechoic, and enlarged lymph nodes below the right parotid gland. In addition, there was heterogeneous echotexture with small and indistinct hypoechoic nodules over bilateral parotid and submandibular glands which suggested sclerosing sialadenitis. Pathology of the tissues obtained by core needle biopsy revealed reactive hyperplasia, but a diagnosis of lymphoma could not be excluded. Subsequently, excisional biopsy and serological tests were done. The diagnosis of IgG4-RD was confirmed due to marked elevation of serum IgG4 levels and pathological evidence of IgG+ and IgG4+ plasma cell infiltration in the lymph node specimen. The patient's neck masses subsided gradually after 1 week of oral steroid therapy. The differential diagnosis of IgG4-RD should always be considered when sclerosing sialadenitis is presented with cervical lymphadenopathy.

Early detection of superior mesenteric artery dissection by ultrasound: Two case reports Chun-Yen Huang, Jen-Tang Sun, Wan-Ching Lien Journal of Medical Ultrasound 2019 27(1):47-49 Superior mesenteric artery (SMA) dissection is a rare disease. Most of the cases are diagnosed through contrast-enhanced computed tomography. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, evidence is limited regarding the use of bedside ultrasound for diagnosing SMA dissection, which is a known risk factor for aortic dissection. We present two case reports: one case of isolated SMA dissection and one case of SMA dissection complicated with aortic dissection. Both cases were initially diagnosed through bedside ultrasound and confirmed through contrast-enhanced computed tomography.

Soft-tissue sarcoma masquerading as a haematoma Mark Charnock Journal of Medical Ultrasound 2019 27(1):50-53 Sarcomas commonly occur in the buttock and thigh, although the clinical presentation varies with no specific symptoms other than a painless lump. This case study reports on a soft-tissue sarcoma that was initially thought to be a haematoma on ultrasound, despite being rescanned 6 weeks later. The patient presented back to their general practitioner 8 months later with the subsequent ultrasound showing an irregular and hypervascular soft-tissue mass. Further imaging and ultrasound-guided biopsy led to a surgical excision of a myxofibrosarcoma. This case demonstrates the difficulty of differentiating between a haematoma and sarcoma, especially in patients presenting with a history of trauma.