Carotid intima media thickness evaluation by ultrasound comparison amongst healthy, diabetic and hypertensive Pakistani patients.

OBJECTIVE: To compare carotid Intima media thickness and atherosclerosis burden amongst healthy, diabetic and hypertensive Pakistani patients. METHODS: A cross-sectional study was carried out at the Department of radiology and family medicine, Aga Khan University Hospital Karachi from April 2014 to July 2015. Bilateral carotid ultrasound was done in 133 healthy adults, 65 hypertensive, 31 type-2 diabetic and 37 hypertensive with type-2 diabetes patients. Normal adults were matched for age and gender. Mean intimal media thickness was measured for common and internal carotid arteries. Presence or absence of atherosclerotic plaque was also identified. Height, weight, ethnicity, socioeconomic status and other risk factors were also assessed. Ultrasound findings were compared between healthy and diseased patients through statistical tests. RESULTS: A total of 266 patients participated (Controls=133, Hypertensive=65, Diabetic=31, and Diabetes with Hypertension=37). There was no significant difference in the baseline characteristics between the four patients' groups for age (p>0.05) and gender (p>0.05). The mean carotid intima media thickenss of right common carotid artery was significantly higher in patients with diabetes along with hypertension as compared to the control group (p=0.03). For (RICA) Right Internal Carotid Artery, (LCCA) Left Common Carotid Artery and (LICA) Left Internal Carotid Artery, there was a significantly higher thickness among patients with hypertension as compared to the control group with p=0.011, p=0.002, and p=0.039 respectively. CONCLUSIONS: Increased CIMT is most likely associated with underlying chronic diseases. Ultrasound is a non-invasive, easily available and useful modality for early detection and prevention of vascular atherosclerosis.

An online method for diagnosis of difficult TB cases for developing countries.

Optimal use of limited human, technical and financial resources is a major concern for tuberculosis (TB) control in developing nations. Further impediments include a lack of trained physicians, and logistical difficulties in arranging face-to-face (f-2-f) TB Diagnostic Committee (TBDC) consultations. Use of e-Health for virtual TBDCs (Internet and "iPath"), to address such issues is being studied in the Philippines and Pakistan. In Pakistan, radiological diagnosis of 88 sputum smear negative but suspected TB patients has been compared with the 'gold standards' (TB culture, and 2-month clinical follow up). Of 88 diagnostic decisions made by primary physicians at the spoke site and electronic TBDC (e-TBDC) at hub site, there was agreement in 71 cases and disagreement on 17 cases. The turn-around time (TAT; patient registration at spoke site for f-2-f diagnosis to receiving the electronic diagnosis), averaged 34.6 hours; ranging 9 minutes to 289.2 hours. Average TAT at the rural site (59.15 hours) was more than the urban site (15.9 hours). Comparison of e-TBDC and f-2-f diagnosis with the gold standards showed only slight differences. Using culture as the gold standard, e-TBDC decisions showed greater accuracy (sensitivity - 32.4%) as compared to f-2-f (27.6%); using 2-month clinical follow-up as the gold standard, f-2-f diagnosis showed slightly better improvement in patient symptoms and weight as compared to e-TBDC. In Philippines "iPath" was trialed and demonstrated that e-TBDCs have potential. Such groups could review cases, diagnose, and write comments remotely, reducing the diagnosis and treatment delay compared to usual care.

Accuracy of MRI Pelvis in the Diagnosis of Ovarian Endometrioma: Using Histopathology as Gold Standard.

Background Endometriosis is defined as the ectopic presence of endometrial mucosa at locations other than the uterine cavity. It results in significant morbidity and is a leading cause of infertility as well. Magnetic resonance imaging (MRI) is establishing its role in the diagnosis of endometriosis and its complications. The objective of this study was to assess the accuracy of MRI in the diagnosis of ovarian endometriosis using histopathology as the gold standard. Materials and methods All patients presenting with clinical complaints and suspicion of endometriosis, undergoing MRI followed by surgical resection and confirmation by histopathology, were included in the study. Data were analyzed on a predefined proforma and parameters of accuracy were calculated. Results  A total of 170 patients were included in this study, having a mean age of 36.8 years with a standard deviation of 10.4 years. The mean parity for included subjects was 2.25, with a standard deviation of 1.3. Overall, the sensitivity of MRI was 86.7% and the specificity was 81.9%. The positive predictive value (PPV) of MRI was 83.3%, while the negative predictive value (NPV) was 81.9%. Overall, the diagnostic accuracy of MRI was 84.7%. Conclusion The accuracy of MRI in the diagnosis of endometriosis was found to be acceptable and comparable to most of the worldwide published literature. The routine use of MRI for diagnosis and preoperative planning is justified by the results of this study.

Detection of cervical spine trauma: Are 3-dimensional reconstructed images as accurate as multiplanar computer tomography?

INTRODUCTION: This study was conducted to assess the diagnostic accuracy of three-dimensional computed tomography (3D-CT) in detection of cervical spine injuries in symptomatic post-trauma patients using multiplanar computed tomography (MP-CT) as reference standard. APPROACH: This cross-sectional study was conducted at Aga Khan University from July 2016 to January 2017. Patients were included using a non-probability, consecutive sampling. MP-CT and 3D- CT images were obtained and evaluated by a senior radiologist to identify cervical spine injuries. RESULTS: 205 patients were included in the study. For fractures, 3D-CT images had sensitivity of 71%, specificity of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 96.8% and diagnostic accuracy of 97%. For dislocations, 3D-CT reported sensitivity of 83.34%, specificity of 100%, positive predictive value of 100% and negative predictive value of 99.5% and diagnostic accuracy of 99.5%. CONCLUSION: 3D-CT has good diagnostic accuracy for injuries of the cervical spine but must be reviewed simultaneously with multiplanar CT images.

Direct observation of procedural skills in radiology.

OBJECTIVE: The purpose of this perspective is to describe the reliability and feasibility of methods such as direct observation of procedural skills and multisource feedback in assessment of the performance of radiology residents. CONCLUSION: Workplace-based assessments such as direct observation of procedural skills have a role in the formative assessment of radiology residents. They can be used to evaluate residents' performance, provide feedback, and identify areas for improving performance and filling in identified gaps.

Safety of Percutaneous Transhepatic Biliary Stenting in Patients with Obstructive Jaundice.

OBJECTIVE: To determine the safety of percutaneous transhepatic biliary stenting (PTBS) in patients with obstructive jaundice. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Department of Radiology, The Aga Khan University Hospital Karachi, Pakistan, from February 2012 to April 2013. METHODOLOGY: Patients with obstructive jaundice due to any cause referred for percutaneous transhepatic biliary stenting were included in the study. Patients were excluded if they had undergone previous ERCP, had guided transhepatic biliary stenting, previous percutaneous transhepatic biliary stenting and were lost to follow-up. Follow-up was taken at a 2, 4 and 6 week interval and clinical outcome was assessed as the difference between the bilirubin levels at base line and 6 weeks after PTBS, which was measured using Freidman's test. RESULTS: A total of 102 patients were included; 59 (58%) were males and 43 (42%) were females. The age ranged from 21 to 89 years. A total of 30 patients experienced complications making an overall complication rate of 29.4%; 20 experienced minor and 10 experienced major complications. Pain was the most frequent minor complication (n=15 patients, 14.7%) followed by biliary leakage, fever and cholangitis. Major complications included death in 10 (10%) patients followed by biliary peritonitis and septicemia. CONCLUSION: PTBS achieved satisfactory palliation with a low complication rate in patients with obstructive jaundice.

Periosteal desmoid.

Periosteal desmoid is a benign tumor like reactive fibrous lesion developed by repeated micro trauma. We describe the case of a 14 year old boy with pain in his right knee who underwent plain radiography followed by radionuclide bone scan. The final diagnosis was that of periosteal desmoid.

Carotid Intima Media Thickness Percentiles for Pakistani Population.

Carotid artery intima media thickness estimation is a well-established way of cardio vascular disease evaluation. The purpose of this cross-sectional study was to develop normal carotid intima media thickness percentile values for a Pakistani cohort. Data was collected at the Departments of Radiology and Family Medicine, The Aga Khan University Hospital, Karachi, from April 2014 to August 2015. High frequency ultrasound of carotid was done in 257 patients [97 male (38%), 160 female (62%)] without any known carotid artery disease. Reference ranges (90% range between 5th and 95th centiles) were constructed for each common carotid and internal carotid artery measurement and displayed in graph form. The mean difference was found in left common carotid artery (0.55 ±0.13) and left internal carotid artery thickness (0.50 ±0.10) significant at p=0.031 and p=0.014, respectively. The IMTpercentile graphs developed in this study for internal and common carotid arteries are exclusive for this population and can be used to assess vascular health from ultrasound measurements.

Role of focused appendiceal computed tomography in clinically equivocal acute appendicitis.

OBJECTIVE: To determine the accuracy of FACT (focused appendiceal computed tomography) in evaluation of acute appendicitis. METHODS: The study was conducted in Aga Khan University Hospital, Karachi, over a period of one year. Sixty-three patients with clinically equivocal acute appendicitis underwent thin-section non-enhanced helical CT. Axial scans were obtained in a single breath hold from L2 vertebral level to the pubic symphysis with 5-mm collimation and a pitch of 1.5. All scans were obtained without oral, intravenous, or rectal contrast material. Criteria for diagnosis of acute appendicitis included an enlarged appendix (>6 mm diameter) and periappendiceal inflammation. Final diagnoses were established with the results of surgical or clinical follow-up. RESULTS: There were 21 true-positive diagnoses, 38 true-negative diagnoses, no false-positive diagnoses, and 2 false-negative diagnoses, which yielded a sensitivity of 91% and a specificity of 100%. CONCLUSION: Non-enhanced FACT is a highly accurate problem solving technique in clinically equivocal cases of acute appendicitis.

Evaluation of erectile dysfunction with color Doppler sonography.

OBJECTIVE: To assess the role of Color Doppler Sonography in the evaluation of erectile dysfunction. METHODS: A cross-sectional study was conducted at the Radiology Department, Aga Khan University Hospital Karachi from 5-6-2002 to 2-9-2003. All consecutive patients presenting with erectile dysfunction and undergoing penile color Doppler evaluation with injection PGE1 20 mcg were included in this study. RESULTS: A total of 70 patients with an age range of 24-70 years (mean 41 +/- 12.25 years) were included in the study. A normal response was noted in 45 (psychogenic) cases. Vasculogenic causes were observed in 23 patients, 12 with arterial insufficiency and 11 with venous leak. Peyronie's disease was diagnosed in 2 patients. CONCLUSION: Color Doppler evaluation of erectile dysfunction is an effective method for differentiating psychogenic and vasculogenic causes of erectile dysfunction.

Multiple parameters in the diagnosis of ectopic pregnancy.

OBJECTIVE: To determine the role of emergency ultrasound examination in the diagnosis and management of ectopic pregnancy. METHODS: A descriptive study done at the Radiology Department, Aga Khan University Hospital, Karachi from January 1999 to December 2000 using observational facts by non-probability convenient sampling method. Seventy one patients who presented with acute symptoms in early pregnancy, were subjected to emergency pelvic ultrasound. Both transabdominal and transvaginal ultrasound were done in 52 patients while in 19 patients only transabdominal ultrasound was performed. Serum Beta hCG levels, of all patients were greater than 1500 iu/ml. RESULTS: Ultrasound correctly identified ectopic pregnancy in 71 patients. Ultrasound diagnosis included live embryo in six patients, adnexal mass with pelvic fluid in 54 patients, extrauterine gestational sac in 4 patients and pelvic fluid without adnexal mass in 7 patients. There was no indeterminate ultrasound scan, resulting in 100% specificity and sensitivity. CONCLUSION: The use of multiple parameters in the diagnosis of ectopic pregnancy resulted in 100% sensitivity and specificity.

Cerebral deep venous thrombosis: case report and literature review.

The case of a 28 years old woman presenting with headache, drowsiness and vomiting of a short duration, is presented. She was diagnosed as deep cerebral venous thrombosis on the basis of MRI findings. Treatment with heparin gave completed recovery.

Role of computed tomography in acute pancreatitis and its complications among age groups.

OBJECTIVE: To determine value of CT scan in diagnosis of acute pancreatitis, its complications and to correlate with severity among different age groups. METHODS: The study was carried out from August 2001 to August 2002 at the Radiology Department, Aga Khan University Hospital. A total of 40 patients (33 male and 7 female) with age range from 16-71 years were divided in three groups. Group I was less than 40 years (12 patients), Group II was between 40-60 years (17 patients), and Group III was more than 60 years (11 patients). CT scans were assessed for pancreatic necrosis and its complications. CT Severity Index (CTSI) was calculated according to Balthazar's method. RESULTS: In 17 patients with mild pancreatitis, 5 had necrosis involving one-third of pancreas. In 13 patients with severe pancreatitis, 8 had necrosis involving more than half of the pancreas and 5 had necrosis involving half of the pancreas. No significant correlation was demonstrated between moderate pancreatitis and degree of necrosis. Thirty patients had complications, 8 had mild CTSI, 9 had moderate CTSI and 13 patients had severe CTSI. CONCLUSION: The study demonstrated a relationship between CTSI and severity of pancreatic damage and incidence of complications.

Ultrasound differentiation of benign versus malignant solid breast masses.

OBJECTIVE: To determine the reliability of ultrasonographic features in differentiating benign from malignant solid breast masses. DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Radiology Department, Aga Khan University Hospital, Karachi from July 2000 to June 2002. SUBJECTS AND METHODS: One hundred solid breast masses in females with a tissue diagnosis available were reviewed. Two radiologists reviewed the sonographic features of masses without knowledge of clinical history or histologic examination results. Ultrasound features were corrected later with histologic features to determine the reliability of the former in benign or malignant nature of nodules. RESULTS: Ultrasound features that most reliably characterize masses as benign were a round or oval shape, circumscribed margins and a width to antero-posterior (AP) dimension ratio greater than 1.4. Features that characterized masses as malignant included irregular shape, spiculated margins and width to antero-posterior (AP) dimension ratio of 1.4 or less. If these three most reliable criteria had been strictly applied by the primary reporting radiologist, the overall cancer biopsy yield would have increased. CONCLUSION: The data confirms that certain ultrasound features can help differentiate benign from malignant masses. However, practice and interpreter variability should be further explored before these criteria are applied to defer biopsy of solid masses.

Accuracy of magnetic resonance imaging in the knee.

OBJECTIVE: To determine the accuracy of magnetic resonance imaging (MRI) in the assessment of various knee disorders in comparison with arthroscopic findings and pathologic diagnosis. DESIGN: A retrospective and comparative study. PLACE AND DURATION OF STUDY: Radiology Department, Aga Khan University Hospital, Karachi, from 01-12-1996 to 30-06-2000. PATIENTS AND METHODS: Fifty-six subjects (36 males and 20 females), included in this study, had abnormal findings on MRI, which were correlated with arthroscopic findings in 50 cases and pathological diagnosis in 6 cases. Plain X-rays were available in all cases. RESULTS: The sensitivity, specificity and accuracy for MRI of the menisci and cruciate ligaments were as follows: medial meniscus pathologies 87% sensitivity, 94% specificity and 92% accuracy; lateral meniscus pathologies 92% sensitivity, 89% specificity and 90% accuracy; anterior cruciate ligament injuries 95% sensitivity, 96% specificity and 96% accuracy and posterior cruciate ligament injuries 100% sensitivity, 98% specificity and 98% accuracy. Pathological diagnosis was available in 6 cases. MR imaging suggested the diagnosis of tuberculosis and metastases as well as mapped out the extent of osteogenic sarcoma, fibromatoses and rhabdomyosarcoma. CONCLUSION: This study confirms that MR imaging of the knee is highly sensitive, specific, and accurate.

Magnetic resonance imaging in the diagnosis and local staging of primary bone tumors.

OBJECTIVE: To evaluate relationship of magnetic resonance (MR) imaging in the diagnosis and local staging of primary bone tumors with histopathological and surgical outcome. DESIGN: Cross-sectional comparative study. PLACE AND DURATION OF STUDY: Radiology Department, The Aga Khan University Hospital, Karachi from December 1999 to March 2002. SUBJECTS AND METHODS: Thirty patients suspected of having primary bone tumors were selected. MRI scans were evaluated for local staging including intramedullary tumor length, cortical, soft tissue, neuro-vascular, joint and epiphyseal involvement. MR staging was compared with surgical and pathological staging and MR diagnosis with histopathological diagnosis considering benign and malignant tumors and specific diagnosis. RESULTS: The study included 30 patients with age ranging from 5 - 75 years (mean 30.1 years). Twenty-three patients had malignant and 7 benign tumors. On MRI, 25 tumors were characterized as malignant and 2 tumors were false positive for malignancy. CONCLUSION: MR imaging proved to be accurate in local staging of bone tumors and determination of the extent of disease in benign tumors.

Ultrasound in the diagnosis and management of intrauterine growth retardation.

OBJECTIVE: To evaluate the value of ultrasound in the diagnosis and management strategies of intrauterine growth retardation. DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: Radiology Department, Aga Khan University Hospital, Karachi, from April 1998 to August 1999. PATIENTS AND METHODS: The study population comprised of 206 subjects evaluated for suspected intrauterine growth retardation. Grey scale as well as Doppler ultrasound findings were evaluated and compared against post-natal outcome. RESULTS: One hundred and eight out of 206 subjects showed positive imaging results with 40 false positive and 20 false negative subjects. The sensitivity, specificity, positive predictive and negative predictive values were 77.8%, 66.1%, 55.6%, and 45.1% respectively. Forty subjects showed false positive results on imaging (low biophysical profile score and Grey scale biometry discrepancy) while 20 of the subjects showed false negative results (normal on US imaging) when compared with postnatal neonatal body weight criteria. Twenty-two subjects had oligohydramnios with amniotic fluid index below 5 percentile for their respective gestational ages (20%) out of 108. CONCLUSION: Obstetric and Doppler ultrasound is an accurate method for diagnosis and management of fetal growth retardation.

Mesenteric panniculitis.

Mesenteric panniculitis is a rare condition of unknown etiology that causes inflammation of the adipose tissue in the mesentery. We describe a case in which mesenteric panniculitis was diagnosed on the basis of imaging and resolved spontaneously.

Unenhanced helical CT scan for the investigation of acute ureteral colic.

Unenhanced helical CT is presently considered a superior imaging technique for investigating acute urinary colic compared to intravenous urography and ultrasound. It was introduced in Pakistan around the year 2000 and is in the process of being acknowledged as the first line investigation in emergency departments. We have discussed the advantages and the disadvantages of the technique, and have compared it with other imaging modalities.

Damage control laparotomy for exsanguinating penetrating abdominal trauma.

Damage control, defined as initial control of haemorrhage and contamination with intra-peritoneal packing and rapid closure, allows the resuscitation to normal physiology in the intensive care unit and subsequent definitive re-exploration. A case of penetrating abdominal trauma with extensive hepatic, interior vena cava and pancreatico-duodenal injuries, was managed on the principles of damage control on the first laparotomy and definitive procedure of pancreaticoduodenectomy was delayed and performed after 48 hours.