Diagnostic value of 12-zone lung ultrasound protocol for diagnosing COVID-19-associated pneumonia in outpatients

Introduction: In the SARS-CoV-2 pandemic, lung ultrasound can be of decisive importance for planning further treatment approach in patients with infection. There is still no clear priority for the choice of lung ultrasound protocol in an outpatient setting. Aim: The objective of the study was to evaluate the applicability of 12-zone protocol lung ultrasound for the diagnosis of COVID- 19 associated pneumonia in outpatients. Materials and methods: We examined 39 outpatients meeting the diagnostic criteria of COVID-19 infection (17 men and 22 women) aged 31–75 years (median 49 years). All patients underwent lung ultrasound immediately after chest computed tomography performed by a blinded specialist. Correlation analysis of the results of a quantitative assessment of the detected signs, assessment of the diagnostic significance of lung ultrasound for identifying signs of pneumonia were performed. Results: Pneumonia was diagnosed by computed tomography in 25 (64%; 95% CI 47–79) out of 39 patients. At the same time, ultrasound signs of interstitial abnormalities were detected in 31 patients. Multiple (narrow) B-lines, confluent (wide) B-lines, as well as areas of subpleural consolidation and “white lung” were the most common lung ultrasound abnormalities. When evaluating the method, the optimal sensitivity/ specificity ratio was obtained for a value of ≥2 points, the area under the curve = 0.970 (95% CI 0.858–0.999; p <0.0001). The score of lung ultrasound significantly correlated with computed tomography quantitative assessment (r = 0.928, p <0.001). Conclusion: Despite some limitations, lung ultrasound can be extremely useful in primary care settings, also in the case of a significant number of admitted patients, to detect features of COVID-19 associated pneumonia.

Sonography of tendon pathology in the hand and wrist

Traumatic and non-traumatic tendon lesions are common at the wrist and hand. For the diagnosis, therapy management, and long-term prognosis of tendon lesions, a detailed understanding of the complex anatomy and knowledge of typical injury patterns is crucial for both radiologists and clinicians. Improvements in high-resolution ultrasound are producing high quality images of the superficial tendinous and peritendinous structures. Thus, ultrasound is a valuable first-choice tool for visualizing traumatic, inflammatory, and degenerative conditions of the extensor and flexor tendons, particularly with the advantage of possible dynamic examination. The additional use of duplex-Doppler and power Doppler ultrasound imaging is recommended for detection of tenosynovitis in overuse injury, inflammatory disease, infection, and after traumatic conditions. In traumatic tendon injuries, knowing the precise injury zone is important for treatment decision-making. In cases of tendon rupture, the radiologist should report the tear type (i.e., complete or partial-thickness) and assess the degree of tendon retraction and associated avulsion injury, including the degree of fragment displacement. The function of intact flexor tendons may be impaired by thickening, strain, or rupture of corresponding annular pulleys. This review describes in detail the typical ultrasound imaging features of common pathologies of hand and wrist tendons, including annular pulley lesions.

Reliability of knee joint sonography in the evaluation of gouty arthritis

Objective: To determine the reliability of knee joint sonography in the evaluation of gouty arthritis. Methodology: A search of Google Scholar, PubMed, NCBI, MEDLINE, and Medscape databases, from 1988 up to 2020. The key search terms used were knee joint; knee joint ultrasound; gout; gouty arthritis, knee joint pain; sensitivity; specificity. The reviewer independently screened the titles and abstracts of the relevant articles and full text downloads to determine whether the inclusion or exclusion criteria were met. Results: In total, 103 articles were identified through the database search. In addition, 11 articles were identified through other sources. Then, screening was performed, and 9 articles were removed due to duplication. Further screening was done for 105 articles, and 27 articles were excluded due to insufficient information. Seventy-eight full-text articles were assessed for eligibility. A total of 13 full-text articles were excluded due to research performed on animals, as the study had been designed as a review of only human studies. Sixty-three studies were included that had a qualitative synthesis. Conclusion: The knee is a weight bearing joint and may be affected by a myriad of different pathological conditions, therefore a proper diagnosis is of prime importance for a proper management plan. Ultrasound is a non-invasive, radiation-free, and readily available modality that has high sensitivity and specificity in the evaluation of gouty arthritis.

Diagnostic value of shear wave velocity in polycystic ovarian syndrome

Aim: In polycystic ovarian syndrome, the ovaries become stiffer due to chronic anovulation. We aimed to compare tissue elasticity in terms of shear wave velocities measured using acoustic radiation force impulse imaging technique between the ovaries of polycystic ovarian syndrome women and non-polycystic ovarian syndrome women. Material and methods: The study was designed as a retrospective data analysis of women who underwent transvaginal ultrasound and acoustic radiation force impulse imaging in a university hospital between July 2014 and March 2015, for various reasons. There were 32 polycystic ovarian syndrome patients and 32 patients without a diagnosis of polycystic ovarian syndrome. Age, body mass index, fasting glucose levels, cycle day 3 follicle stimulating hormone, luteinizing hormone, thyroid stimulating hormone, prolactin, antimullerian hormone levels, and menstrual patterns with clinical hyperandrogenism were evaluated. On the menstrual cycle days 2–4, by performing a transvaginal ultrasound scan, the ovarian volumes and antral follicle counts in both ovaries were recorded for each woman. The ultrasound system was converted into the elastography mode, and acoustic radiation force impulse imaging was performed. Shear wave velocity (m/sec) was measured at least 5 times for each ovary, and the mean value was calculated for each polycystic ovarian syndrome and non-polycystic ovarian syndrome woman. Results: Age, body mass index, fasting glucose levels, cycle day 3 follicle stimulating hormone, luteinizing hormone, thyroid stimulating hormone, and prolactin levels were similar between the groups (p >0,05). Antimullerian hormone levels, antral follicle counts, and mean ovarian volumes were statistically different between the groups (p <0,05). Mean shear wave velocity values for both ovaries were 2.12 ± 0.82 (0.78–4.9) m/sec in the polycystic ovarian syndrome group, and 1.18 ± 0.41 (0.77–2.0) m/sec in the non-polycystic ovarian syndrome group, which was statistically significantly different (p = 0.016). Conclusion: In our study, we found significantly higher shear wave velocity levels in polycystic ovarian syndrome women than non-polycystic ovarian syndrome women, which indicates an impact of the condition on shear wave velocity. The increased acoustic frequencies cause a decreased response in time to transition, and motion becomes out of phase; in other words, scattered waves are faster in stiffer ovaries. Our results are thus compatible with the pathophysiology of the disease. Shear wave velocity is a beneficial tool for evaluating ovarian elasticity in polycystic ovarian syndrome patients in whom the levels are found to be significantly higher than non-polycystic ovarian syndrome women. In light of these findings, shear wave velocity is expected to be slower than polycystic ovarian syndrome levels in ovulatory women.

Ultrasonographic evaluation of the median nerve: normal and variant anatomy and appearance

The median nerve is a mixed sensory and motor nerve that innervates part of the flexor muscles in the anterior compartment of the forearm and muscles in the lateral part of the hand; palmar cutaneous and digital cutaneous nerves branch from the median nerve, which provides sensory innervation to the skin on the radial side of the palm. Also, the median nerve is an object of interest because neuropathy of the median nerve at the level of the carpal tunnel is the most common entrapment neuropathy which increases dramatically in patients with diabetes. Neuromuscular ultrasound provides extensive diagnostic information and has proved itself as a useful complementary test to electrodiagnostic examinations in cases involving median nerve neuropathy. It often happens that the cause of nerve entrapment and neuropathy are variants of several anatomical structures along the course of the median nerve. It is important to be aware and report such anatomical variations of the median nerve in order to avoid damaging the nerve during surgical treatment. Despite the frequently documented abnormalities in the pathway of the brachial plexus and the median nerve, the anatomical variations are unusual to see and are rarely reported. Moreover, there are variations that do not fit under any of the classifications described in the literature.

Comparative study of the reliability of ultrasound to confirm the position of endotracheal tube with cuff inflated with saline versus air

Aim: To compare the reliability of transtracheal ultrasound to confirm the endotracheal tube position with saline versus air inflated cuff. Methods: This was a prospective randomized cadaveric study. Four techniques were randomized: endotracheal tube in the trachea with air or saline inflated cuff, and endotracheal tube in the esophagus with air or saline inflated cuff. The investigator used the Mcgrath to randomly place the endotracheal tube in the trachea or in the esophagus with saline or air inflated cuff. During the first series of measurements, nine residents performed transtracheal ultrasound with linear transducer placed transversely at the suprasternal notch. They were recorded with a cut off fixed to 30 seconds, and a questionnaire was completed by the residents after each transtracheal ultrasound in order to report where the endotracheal tube is positioned according to them. The second series followed the same protocol and included three residents who had participated in the first series. The primary outcome was the success rate in determining the position of the endotracheal tube. Results: In the first series, the success rate was 46.5%. In the second series, the success rate was 72.9%. There was no significant difference between cuff inflated with saline and air (p = 1.00). The overall mean time required was 20.6 s (95% CI 13.0–28.2 s). Based on an empirical data set, transtracheal ultrasound had a sensitivity of 62.2%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 26.08%. Conclusion: This investigation shows that regardless of the contents of the endotracheal tube cuff, the use of transtracheal ultrasound to confirm the position of endotracheal tube reports disappointing results.

Intra-examiner and inter-examiner reliability of rehabilitative ultrasound imaging for lumbar multifidus and anterolateral abdominal muscles in females with recurrent low back pain: an observational, cross-sectional study

Aim: To examine the reliability of rehabilitative ultrasound imaging performed to measure the thickness of the transverse abdominis, internal oblique, external oblique, and lumbar multifidus muscles in females with recurrent low back pain. Material and methods: A sample of 15 women was recruited. Two independent examiners recorded the thickness of their deep abdominal and spinal muscles by rehabilitative ultrasound imaging. Imaging scans of the transverse abdominis, internal oblique, and external oblique muscles were performed in the supine position and in the midaxillary line, between the lower edge of the ribcage and the iliac crest. Imaging of the lumbar multifidus was done in the prone position and at the level of the L5/S1 zygapophyseal joints. Imaging scans were performed bilaterally in rest and contraction, three times by the first examiner (at baseline, after two hours, and one week later) and once by the second examiner. Results: Good to excellent within-session intra-rater (ICC = 0.76, 0.97), good to excellent between-session intra-rater reliability (ICC = 0.73, 0.93), and good to excellent inter-rater reliability (ICC = 0.73, 0.98) were obtained. Conclusions: The results showed that rehabilitative ultrasound imaging can be used as an excellent reliable instrument by one or two examiners to measure the thickness of the transverse abdominis, internal oblique, external oblique and lumbar multifidus muscles in females with recurrent low back pain.

Twinkle artifact in renal ultrasound, is it a solid point for the diagnosis of renal stone in children?

Background: Twinkle artifact, also known as color Doppler comet-tail artifact, occurs behind very strong, granular, and irregular reflecting interfaces such as crystals, stones, or calcification. This is visualized as a random mixture of red and blue pixels in the high-frequency shift spectrum located deep to the interface. Study results have suggested that the sonographic twinkling artifact may aid in the detection of renal stones with a variety of reference standard imaging modalities, including abdominal radiography, excretory urography, gray-scale sonography, and CT. Material and methods: Our retrospective observational study included children who had undergone abdomen/renal ultrasound for kidneys stones in our radiology department between 2013 and 2019. Presence of the twinkle artifact, and stone numbers and sizes were documented. CT examinations done <3 months prior to or after US were retrospectively assessed to confirm the presence of kidney stones as a reference standard. Results: Thirty-three abdominal renal US scans of 33 patients (21 males, 12 females) fulfilled the entry criteria. The interval between the US and CT was <3 months for all patients. The median overall age of the patients was 4 years (IQR: 3.125, range: 1– 165 months), The median number of days between the US and CT was 13 (IQR: 26, range: 0–81 days). US detected 33 hyperechoic foci suspected to be stones; 26 were confirmed as true positive (i.e. showed the twinkle artifact and were seen in CT), 4 were false positive (showed the twinkle artifact but were not seen in CT), and 3 were false negative (did not show the twinkle artifact but were seen in CT). The overall median stone size was 2 mm in the right kidney, and 5 mm in the left kidney (IQR: 6,11 mm), respectively. Twinkle artifact sensitivity was found to be 89.7% (95% CI 39.574%–90%). The twinkle artifact was assessed in all true-positive stones, determining a relatively high PPV of 26/29 (86.7%) for the twinkle artifact. The twinkle artifact was not dependent on stone size. Specificity for the twinkle artifact could not be calculated due to a lack of true negatives. Conclusion: The twinkle artifact is a sensitive US tool for detecting pediatric kidney and ureter stones, but with a small risk of false positive findings.

Antral follicle count and anti-Müllerian hormone level as predictors of ovarian hyperstimulation syndrome in women with polycystic ovarian syndrome undergoing controlled ovarian stimulation

Aim: To compare the rate of ovarian hyperstimulation syndrome in women with and without polycystic ovarian syndrome, and to determine the cut-off for the antral follicle count and the anti-Müllerian hormone level predictive of ovarian hyperstimulation syndrome in both groups. Methods: This was a prospective cohort study conducted in women aged 20–35 years who were undergoing controlled ovarian stimulation. The women were divided into those with polycystic ovarian syndrome and the controls on the basis of the Rotterdam criteria. The outcome of stimulation was recorded, and the ovarian response markers were compared in both groups. Results: Among 689 women included in the study, 276 (40.1%) had polycystic ovarian syndrome, and 476 (59.9%) were used as the controls. Ovarian hyperstimulation syndrome occurred in 19.6% of the cases, and in 7.7% of the controls (p <0.001). The conception rate was greater in the group of cases (52.5% vs. 16.5%, p = 0.001). Among the cases, the sensitivity and specificity for the prediction of hyper-response were 94.4% and 97.3% for AFC, and 92.6% and 93.7% for the anti-Müllerian hormone, at the cut-off values of ≥18 and ≥6.425 ng/ml, respectively. Among the controls, the sensitivity and specificity for the prediction of hyper-response were 93.8% and 97.1% for the antral follicle count, and 93.6% and 94.5% for the anti-Müllerian hormone, at the cut-off values of ≥10 and ≥3.95 ng/ml, respectively. Conclusion: Group-specific values should be used to identify and counsel women undergoing controlled ovarian stimulation. In light of available evidence, gynaecologists should be trained to perform ultrasound evaluation, determine the antral follicle count of their patients, and offer them appropriate counselling.

The ultrasonographic dynamic heel-rise test of the Achilles tendon

The treatment of Achilles tendon rupture attempts to restore the primary anatomical structure and principal biomechanical properties of the damaged tendon. Postoperative clinical assessment of the healing progression and function monitoring may be difficult and require experience. Diagnostic imaging (ultrasonography and magnetic resonance imaging) helps monitor the healing process. In the following paper, we propose a heel-rise test – a dynamic assessment of the Achilles tendon performed under direct observation and ultrasound monitoring to establish the tension of the Achilles tendon. The test allows for a simple assessment of tendon function and may be safely repeated at any postoperative stage. It may be performed by a physician, radiologist and physiotherapist to monitor the recovery process following Achilles tendon damage.