Point-of-Care Ultrasonography for Hernia Reduction: A Case of Incarcerated Umbilical Hernia.

BACKGROUND: Manual reduction of an incarcerated hernia is used to avoid emergency surgery, which comes with risks of complications and death, especially in patients with severe comorbidities. However, there are no established procedures for hernia reduction. CASE REPORT: We present the case of an 82-year-old man with refractory ascites due to nephrotic syndrome and chronic heart failure who developed an incarcerated umbilical hernia. Color Doppler ultrasonography allowed us to detect clearly visible blood-flow signals in the incarcerated bowel and rule out necrosis, which is a contraindication for reduction. Several attempts at manual reduction failed; ultrasonography-guided reduction revealed that fluid collection within the hernia sac was blocking the manual pressure directly on the incarcerated bowel toward the hernia orifice. After sac paracentesis (draining the fluid from the sac), the incarcerated bowel became palpable, leading to a successful reduction. Four days later, once the patient was in a stable condition, an elective surgery was performed to prevent the recurrence of incarceration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We believe that this is a useful report on the use of point-of-care ultrasonography for incarcerated hernia from the initial assessment of bowel viability to reasonable hernia reduction through hernia sac paracentesis according to real-time observation. An approach based on visualization by ultrasonography, and not on the operator's experience, would be rational, and we believe that this approach will be feasible for emergency physicians, who are responsible for the initial treatment of incarcerated ventral hernia.

Endothelial dysfunction by flow-mediated dilation assessed ultrasonically in patients with Kawasaki Disease.

Kawasaki Disease (KD) is a febrile disorder seen in infants and young children. One of the most serious complications of the disease is coronary aneurysm. Endothelial dysfunction is considered to underlie the etiopathology of coronary aneurysm. Flow-mediated dilation (FMD), as assessed ultrasonically, is used to observe the endothelial function. The current paper summarizes, by providing a systematic review, the clinical studies that have examined endothelial dysfunction by determining the FMD ultrasonically in patients with KD. A PubMed-based search found eight articles published until 2013. Six studies reported the FMD level to be significantly lower in the patients with KD compared to controls, while two studies reported no significant difference in the FMD level between those with and without KD. Although patients with KD appeared to have endothelial dysfunction in the current summary, most reports have been associated with limitations, such as a small size and no prospective design for vascular outcomes. Further studies are therefore needed to draw definite conclusions regarding whether patients with KD suffer from endothelial dysfunction as determined by the FMD and/or whether this determination can be useful for understanding and managing vascular complications in these patients.

[Usefulness of POCUS in Orthopedic and Trauma Fields].

Recently, musculoskeletal ultrasonography has been becoming more common for diagnosis and treatment by ultrasound-guided intervention in the field of orthopedics. Because musculoskeletal ultrasound technology has rapidly advanced in recent years, and has many advantages, including no exposure to radiation, non-invasive, wide availability, cost-effectiveness, and the ability to be used in real-time in the general outpatient clinic. Traditional radiography was not able to detect soft tissue injury, but musculoskeletal ultrasonography enables the diagnosis of not only musculoskeletal disorders including soft tissue injury, but also fractures by dynamic examination. The first choice of diagnostic imaging should begin to shift to musculoskeletal ultra-sound from traditional radiography.

Coexistence of papillary thyroid cancer and Hashimoto thyroiditis in children: report of 3 cases.

This report documents 3 pediatric papillary thyroid carcinoma cases with associated Hashimoto thyroiditis. In all 3 cases, hypoechoic nodules accompanied by multiple echogenic spots were noted on sonography of the thyroid. Hashimoto thyroiditis was suspected on the basis of positive thyroid autoantibody test results and pathologic examinations of thyroidectomy specimens, which revealed chronic thyroiditis with lymphocytic infiltration as the background of papillary thyroid carcinoma development. The potential for papillary carcinoma development warrants close follow-up, and meticulous sonographic examinations must be performed in children with Hashimoto thyroiditis.

[Nationwide surveillance of parenteral antibiotics containing meropenem activities against clinically isolated strains in 2012].

The nationwide surveillance of antibacterial susceptibility to meropenem (MEPM) and other parenteral antibiotics against clinical isolates during 2012 in Japan was conducted. A total of 2985 strains including 955 strains of Gram-positive bacteria, 1782 strains of Gram-negative bacteria, and 248 strains of anaerobic bacteria obtained from 31 medical institutions were examined. The results were as follows; 1. MEPM was more active than the other carbapenem antibiotics tested against Gram-negative bacteria, especially against enterobacteriaceae and Haemophilus influenzae. MEPM was also active against most of the species tested in Gram-positive and anaerobic bacteria, except for multi-drug resistant strains including methicillin-resistant Staphylococcus aureus (MRSA). 2. Of all species tested, there were no species, which MIC90 of MEPM was more than 4-fold higher than those in our previous studies in 2009 or 2006. Therefore, the tendency to increase in antimicrobial resistance rates was not observed. 3. MEPM resistance against Pseudomonas aeruginosa was 17.8% (56/315 strains). Compared to our previous results, it was the lowest than that in 2006 and 2009. 4. Carbapenem-resistant Klebsiella pneumoniae, and multi-drug-resistant Acinetobacter species, which emerged in worldwide, were not observed. 5. The proportion of extended-spectrum beta-lactamase (ESBL) strains was 6.2% (59/951 strains) in enterobacteriaceae, which increased compared with that of our previous studies in 2009 or before. Whereas, the proportion of metallo-beta-lactamase strains was 1.6% (5/315 strains) in P. aeruginosa, which was stable. In conclusion, the results from this surveillance suggest that MEPM retains its potent and broad antibacterial activity and therefore is a clinically useful carbapenem for serious infections treatment at present, 17 years passed after available for commercial use in Japan.

[Ultrasonography in Large-Vessel Arteritis].

Vasculitides are a group of diseases in which inflammation occurs in various vascular walls of the whole body, and ischemic symptoms are caused by stenoses and occlusions of blood vessels. Various parts of blood vessels of the whole body are affected, and the clinical manifestations are diverse. In the Chapel Hill Consensus Conference (CHCC) 2012, vasculitides are classified into seven categories. Takayasu arteritis and giant cell arteritis are included in large-vessel vasculitis. Large-vessel arteritis is defined as vasculitis affecting the aorta and its major branches more often than other vasculitides, but any sized artery may be affected. Ultrasonography has been progressing rapidly, so we can easily depict vessels of the surface of the body, in 0.1-mm units, and indicate the blood flow noninvasively. Ultrasonography has been used for the diagnosis of and estimation of the treatment for large-vessel vasculitis, and its importance has been increasing.

Evaluation of skeletal muscle elasticity using color Doppler shear wave imaging.

PURPOSE: This study aimed to (1) assess the precision and reproducibility of color Doppler shear wave imaging (CD SWI) by comparing it with shear wave elastography (SWE) via elasticity phantom measurements, and (2) investigate the potential clinical applications of CD SWI in the upper limb muscles by assessing the reproducibility of skeletal muscle elasticity evaluations. METHODS: Four elastography phantoms of different stiffness (6.0-7.5 wt%) were used to assess the precision and reproducibility of CD SWI (compared with SWE) at depths. Typical upper limb muscles of 24 men were also assessed for this comparison. RESULTS: At superficial depths (0-2 cm), the phantom measurements obtained using CD SWI and SWE were similar at all levels of stiffness. Furthermore, both methods were highly reliable, with almost perfect intra- and inter-operator reliabilities. At greater depths (2-4 cm), measurements obtained using both methods were similar at all stiffness levels. Although standard deviations (SDs) of the phantom measurements obtained using both methods at lower stiffness were similar, those at higher stiffness were different. The SD of the CD SWI measurements was < 50% of that of the SWE measurements. However, both methods were highly reliable in the phantom test, with almost perfect intra- and inter-operator reliabilities. The intra- and inter-operator reliabilities of the shear wave velocity measurements for typical muscles of the upper limbs were also substantial in clinical settings. CONCLUSION: CD SWI is a valid method for measuring elasticity, with precision and reliability as high as those of SWE.

Oxidized lipoprotein(a) and cardio-ankle vascular index (CAVI) in hypertensive subjects.

While oxidized lipoprotein(a) (oxLp(a)) has been indicated to be involved in atherogenesis more than native lipoprotein(a) (Lp(a)), there is still a need to elucidate the associations among oxLp(a), hypertension, and atherosclerosis. The cardio-ankle vascular index (CAVI) is a recently developed index used to assess arterial stiffness that is independent of blood pressure components. The present study investigated the correlation between oxLp(a) and the CAVI among hypertensive subjects. Clinical data, including general atherosclerotic risk factors, in addition to Lp(a), oxLp(a), and the CAVI, were collected from 72 non-smoking, asymptomatic, and untreated female subjects (mean age: 64.3 years). Correlations between the CAVI and Lp(a) or oxLp(a) were examined in a hypertensive group (n = 34) and a non-hypertensive control group (n = 38). There was a significant and positive correlation between the CAVI and subject age in the control group, while there was a significant and positive correlation between the CAVI and subject age, systolic blood pressure, and oxLp(a) (r = 0.38, p < 0.05) in the hypertensive group. A stepwise multiple linear regression analysis identified the oxLp(a) to be correlated independently, significantly, and positively with the CAVI (ß = 0.30, p < 0.05) in the hypertensive group, while this correlation was not significant in the control group. These findings suggest that the oxidative modification of Lp(a) may be associated with arterial stiffness in hypertensive, but not non-hypertensive, female subjects.

Correlation between reactive oxygen metabolites & atherosclerotic risk factors in patients with type 2 diabetes mellitus.

BACKGROUND & OBJECTIVES: Oxidative stress plays important roles in the pathophysiology of type 2 diabetes mellitus (T2DM). The diacron reactive oxygen metabolites (d-ROMs) test has been used in the clinics. The present study was aimed to investigate the correlation of the oxidative stress status, as evaluated by the d-ROMs, with atherosclerotic risk factors in T2DM patients, in comparison to controls. METHODS: The study included 200 subjects (100 patients with T2DM and 100 controls; 86 males/114 females; mean age 59.0 yr). Clinical variables including the body mass index, blood pressure (BP), glucose and lipid panels, in addition to the d-ROMs, were measured. RESULTS: Patients with T2DM showed significantly higher d-ROMs levels than controls (322 ± 60 vs. 345 ± 64 U. Carr., P<0.05). A multiple linear regression analysis revealed that systolic BP (ß=0.26, P<0.05) and high-density lipoprotein cholesterol (HDL-C: ß= -0.30, P<0.05) were independently and significantly correlated with the d-ROMs levels in patients with T2DM, although these correlations were not significant in the controls. The gender-based analysis showed that systolic BP (ß = 0.44, P<0.05) and HDL-C (ß = -0.36, P<0.05) were independently and significantly correlated with the d-ROMs levels in females with T2DM, while there was a marginally significant correlation between HDL-C and the d-ROMs levels (ß = -0.36, P=0.06) in males with T2DM. INTERPRETATION & CONCLUSIONS: The present findings may reinforce the importance of BP control in female patients with T2DM, as well as the management of HDL-C in male and female patients with T2DM, under the linkage between oxidative stress and atherosclerosis.

Association between angiotensin II Type 2 receptor gene A/C3123 polymorphism and high-density lipoprotein cholesterol with hypertension in asymptomatic women.

OBJECTIVE: The present study investigated the association between the angiotensin II type 2 receptor (AT2R) gene adenine/cytosine (A/C)-3123 polymorphism and cardiometabolic variables in subjects with and without hypertension. METHODS: Cardiometabolic variables, in addition to genotyping by an allele-specific DNA assay, were measured in 161 asymptomatic community-dwelling Japanese women (age range 30-83 years). They were divided into hypertensive (n = 82, age 50-81 years) and nonhypertensive (n = 79, age 30-83 years) subjects. RESULTS: The A-allele carriers (n = 53) showed significantly lower high-density lipoprotein cholesterol (HDL-C) levels than the non-A-allele carriers (n = 26) among nonhypertensive subjects (1.45 ± 0.38 vs. 1.66 ± 0.33 mmol/l, p = 0.02). Even when multiple-adjusted analyses were performed, the HDL-C levels continued to differ significantly and independently of other variables, including the body mass index and insulin resistance index, between A-allele and non-A-allele carriers. However, this association was not observed among hypertensive subjects. CONCLUSION: The present study demonstrated that A-allele carriers had significantly lower HDL-C levels than did non-A-allele carries among nonhypertensive women, while this association was not observed among hypertensive women. This indicates that the A/C3124 polymorphism may be a marker associated with HDL metabolism by hypertension. This was a small study, so further research is warranted to confirm the observed association.

The effectiveness of "Protex" for disinfection of the ultrasound probe.

The aim of this study was to evaluate the effectiveness of "Protex" (Parker; Fairfield, NJ, USA) for disinfection of ultrasound probes. We examined bacterial contamination on ultrasound probes that were wiped with a plain paper towel, with a plain and an ethanol-soaked paper towel, or with a plain and Protex-soaked paper towel. The plain paper towel was used to remove the gel, and was contaminated by large numbers of bacteria, but the use of ethanol-soaked paper towels and that of paper towels soaked in Protex™ broad-spectrum disinfectant (Parker: Fairfield, NJ, USA) reduced those numbers markedly.

Ultrasonographic thyroid nodular findings in Japanese children.

PURPOSE: The Fukushima Health Management Survey conducted after the accident at the Fukushima Nuclear Power Plant included thyroid ultrasound examinations for children aged ≤18 years at the time of the accident. The purpose of this study was to investigate the frequency of thyroid nodular lesions detected using high-quality ultrasonography in a general population of Japanese children, in whom such data have not been previously characterized. METHODS: The current study investigated 4,365 free-living children aged between 3 and 18 years in three Japanese prefectures (Aomori, Yamanashi and Nagasaki). The same ultrasonography equipment as that used in the Fukushima Survey was employed to observe thyroid nodular lesions. The following categories of findings were used-'A', further examinations are not necessary; 'B', the presence of thyroid nodules with a diameter of ≥5.1 mm or thyroid cysts with a diameter of ≥20.1 mm; and 'C', immediate further examinations are required. As a sub-category of 'A', 'A1' was defined as the absence of nodules or cysts, and 'A2' was defined as the presence of thyroid nodules with a diameter of ≤5.0 mm or thyroid cysts with a diameter of ≤20.0 mm. RESULTS: Overall, 4,321 (99 %) of the total participants were classified with a status of 'A' and 44 (1 %) were classified with a status of 'B'. No participants were classified with a status of 'C'. A total of 56.5 % of the total participants was classified with a status of 'A2'. Thyroid nodules were identified in 1.6 % of the total participants and thyroid cysts were identified in 56.9 % of the participants. CONCLUSION: The current study provides data regarding the actual frequency of ultrasonographically detected thyroid nodular lesions among the Japanese children. These results would be useful for evaluating thyroid findings in Japanese children, although careful interpretation is required.

Acoustic radiation force impulse-induced lung hemorrhage: investigating the relationship with peak rarefactional pressure amplitude and mechanical index in rabbits.

PURPOSE: The safety of acoustic radiation force impulse (ARFI) elastography, which applies higher acoustic power with a longer pulse duration (PD) than conventional diagnostic ultrasound, is yet to be verified. We assessed the ARFI-induced lung injury risk and its relationship with peak rarefactional pressure amplitude (PRPA) and mechanical index (MI). METHODS: Eighteen and two rabbits were included in the ARFI (0.3-ms push pulses) and sham groups, respectively. A 5.2-MHz linear probe was applied to the subcostal area and aimed at both lungs through the liver for 30 ARFI emissions. The derated PRPA varied among the six ARFI groups-0.80 MPa, 1.13 MPa, 1.33 MPa, 1.70 MPa, 1.91 MPa, and 2.00 MPa, respectively. RESULTS: The occurrence of lung hemorrhage and the mean lesion area among all samples in the seven groups were 0/6, 0/6, 1/6 (1.7 mm2), 4/6 (8.0 mm2), 4/6 (11.2 mm2), 5/6 (23.8 mm2), and 0/4 (sham), respectively. Logistic regression analysis showed that derated PRPA was significantly associated with lung injury occurrence (odds ratio: 207, p < 0.01), with the threshold estimated to be 1.1 MPa (MI, 0.5). Spearman's rank correlation showed a positive correlation between derated PRPA and lesion area (r = 0.671, p < 0.01). CONCLUSION: This study demonstrated that the occurrence and severity of ARFI-induced lung hemorrhage increased with a rise in PRPA under clinical conditions in rabbits. This indicates a potential risk of lung injury due to ARFI elastography, especially when ARFI is unintentionally directed to the lungs during liver, heart, or breast examinations.

Prevalence of systemic and local risk factors for pulmonary non-tuberculous mycobacterial disease in Japan: a single-institution study.

Objective: To identify the prevalence of risk factors for pulmonary non-tuberculous mycobacterial (NTM) disease in a Japanese population. Patients and Methods: We reviewed 337 consecutive Japanese patients (210 women) with pulmonary NTM disease, including 225 patients with Mycobacterium avium complex (MAC) disease (95.8%) at our hospital during 2006-2017. We calculated the prevalence of risk factors reported in Western countries among mycobacterial species. Results: Pulmonary MAC disease cases comprised 78.2% of pulmonary NTM patients in their 40s, increasing to 100% at age ≥80 years. Body mass index (BMI) was <18.5 in approximately 40% of patients, which was significantly higher than the prevalence of underweight in the Japanese population. The percentage of male heavy smokers (Brinkman index ≥600) was 58.2% of pulmonary NTM disease and was high for all mycobacterial species. In pulmonary MAC disease, systemic factors were observed in the order of malignant tumors (other than lung cancer), diabetes, rheumatoid arthritis, and tuberculosis. Local factors were observed in the order of bronchiectasis, chronic obstructive pulmonary disease, lung cancer, and bronchial asthma. Conclusion: The risk factors reported in Western countries were relatively highly prevalent among Japanese pulmonary NTM disease patients. This observation may help elucidate disease onset mechanisms.

Spontaneous regression of lymphovascular invasion and metastasis of malignant melanoma: ultrasound findings.

This report presents a case of malignant melanoma in a 40-year-old male who underwent resection of the tumor in his right ankle. Eleven months after the resection, a subcutaneous mass was observed on his right femur. Ultrasound examination revealed a hypoechoic tubular structure in the right thigh, with a small amount of blood flow in the lesion. Using ultrasound and fine-needle aspiration, the patient was diagnosed with metastasis and lymphovascular invasion of malignant melanoma. Treatment with an immune checkpoint inhibitor was originally scheduled, but the lesion disappeared spontaneously after the fine-needle aspiration.

The Japan Society of Ultrasonics in Medicine guidelines on non-mass abnormalities of the breast.

It is possible to appropriately diagnose non-mass abnormalities by elucidating ultrasound non-mass abnormality findings and sharing the concept. If non-mass abnormalities can be diagnosed early, the number of curable cases could increase, leading to fewer breast cancer deaths. The Japan Society of Ultrasonics in Medicine (JSUM) Terminology/Diagnostic Criteria Committee has classified non-mass abnormalities into five subtypes: hypoechoic area in the mammary gland, abnormalities of the ducts, architectural distortion, multiple small cysts, and echogenic foci without a hypoechoic area. We herein define the findings for each of these subtypes and present a summary of the JSUM guidelines on non-mass abnormalities of the breast generated based on those findings.

The correlation between the cardio-ankle vascular index (CAVI) and serum amyloid A in asymptomatic Japanese subjects.

Chronic inflammation has received a great deal of attention due to the role it plays in cardiovascular disease (CVD). The cardio-ankle vascular index (CAVI) has recently been developed to evaluate arterial stiffness. This index is independent of blood pressure at the time that it is measured, making it a better measure for clinical studies on the prevention of CVD. Information on the association of serum amyloid A (SAA) with arterial stiffness in relatively healthy subjects is still scarce. The aim of the present study was to investigate the potential correlation between SAA and CAVI in asymptomatic Japanese subjects. In addition to SAA and CAVI, data on smoking status, body mass index, blood pressure, and serum/plasma biochemical indices such as glucose and total cholesterol were collected in 387 nonmedicated and CVD-free adult subjects during a health check examination (male/female 191/196, mean age 61.8 years). Among them, a randomly selected subgroup of 256 subjects (male/female 133/123, mean age 62.4 years) had a full dataset, including low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglyceride, and hemoglobin A1c. Among the whole population, CAVI levels were significantly higher in males than in females [mean 8.5 ± (SD 1.1) vs. 8.2 ± 1.1, p < 0.05], while SAA levels were slightly but nonsignificantly higher in females than in males [median 6.4 (interquartile range 4.0-9.3) µg/mL vs. 5.1 (3.5-8.4)]. In a multiple linear regression analysis, CAVI was weakly but significantly, independently, and positively correlated with SAA (ß-coefficient 0.200, p < 0.01). The results of the same analyses for the randomly selected subgroup were relatively similar to the findings for the whole population. SAA may be a positive inflammatory factor associated with arterial stiffness, and the clinical relevance and the biological mechanism for this relationship should be established in future studies.

The correlation between serum amyloid A and reactive oxygen metabolites in a young Mongolian population.

OBJECTIVE: Chronic inflammation and oxidative stress are associated with lifestyle-related diseases. Research into the pathophysiology of lifestyle-related diseases is important for Mongolian people. Our study investigated the correlation among the d-ROMs test (a measure of the total oxidant capacity of blood), serum amyloid A (SAA) and high-sensitivity C-reactive protein (hs-CRP) levels in a young Mongolian population. METHODS: The data, including anthropometric and biochemical markers, were collected from 78 Mongolian volunteers (male/female = 27/ 51, mean age 21 years). The correlation between the SAA and d-ROMs levels was examined, as well as the correlation between the hs-CRP and d-ROMs levels. RESULTS: The SAA levels were 3.2 microg/mL (median), hs-CRP .04 mg/dL (median) and d-ROMs 309 CARR U, respectively. There was a significant and positive correlation between the SAA and d-ROMs levels (r=.40, P<.01), in addition to a significant and positive correlation between the hs-CRP and d-ROMs levels (r = .32, P < .01). These significant correlations remained independent in a multiple linear regression analysis. A subgroup analysis by sex revealed the positive correlation between the SAA and d-ROMs levels to be greater, relative to that between the hs-CRP and d-ROMs levels, particularly in the female group. CONCLUSIONS: The coexistence of chronic inflammation and oxidative stress can be present even in young Mongolian people, suggesting that their coexistence may be a target of early prevention of lifestyle-related diseases. In addition, not only hs-CRP, but also SAA can be used to evaluate the relationship of oxidative stress in this population. Further studies are necessary to confirm the observed relationship.

Effect of ezetimibe on remnant-like particle cholesterol in subjects with metabolic syndrome.

OBJECTIVE: To investigate the influence of ezetimibe monotherapy on remnant-like particle cholesterol (RLP-C) in subjects with metabolic syndrome (MetS). MATERIALS AND METHODS: Ezetimibe (10 mg/daily) was prescribed over a 12-week period for hypercholesterolemic subjects divided into groups with MetS (n = 28; male/female = 13/15; mean age 67 years) and without MetS (n = 22; male/female = 9/13; mean age 66 years). In the pre- and post-treatment phases, BMI, blood pressure and fasting blood levels of glucose, lipid panels and RLP-C were measured. RESULTS: The group with MetS showed significantly higher RLP-C levels than the group without MetS [median level: 0.18 vs. 0.12 mmol/l (7.1 vs. 4.4 mg/dl), p < 0.01] in the pre-treatment phase. In the post-treatment phase, the low-density lipoprotein cholesterol levels were significantly reduced in both groups to a similar level (p < 0.001 in both), while there was a significantly greater reduction in RLP-C in the group with MetS than the group without MetS [median level: 0.12 vs. 0.11 mmol/l (4.8 vs. 4.1 mg/dl), p < 0.05]. This difference in RLP-C remained significant after adjusting for confounding factors. CONCLUSION: Ezetimibe monotherapy may be associated with a greater reduction in RLP-C levels in subjects with MetS than in those without MetS.

[Vascular function tests and new technology in the early phase of atherosclerosis].

The present topic of vascular function concerns how we detect the earliest arteriosclerotic changes. If we could diagnose the early phase of atherosclerosis, we would be able to intervene to prevent cardiovascular events caused by atherosclerosis. Recently, it became possible to examine vascular function non-invasively by pulse wave velocity (PWV), the augmentation index (AI) and flow-mediated dilatation (FMD) of the brachial artery induced by reactive hyperemia. Carotid ultrasonography is used to observe the morphological change and arterial stiffness of the carotid artery. This review focuses on the relation between arterial function tests and diseases, the method for measuring vascular function, and new technology for arterial stiffness.