Our experience with liver and spleen elastography in the prediction of oesophageal varices.

Background: Variceal bleeding is an important cause of mortality in patients with chronic liver disease (CLD). The gold standard for detection and grading of oesophageal varices (EV) is upper gastrointestinal endoscopy. However, it is expensive, time-consuming and invasive. Objectives: This study aimed to find any association between splenic shear wave velocity (SWV) measured by acoustic radiation force imaging (ARFI) and the presence of EV. Method: The quasi-experimental study included 50 patients with CLD and 50 subjects without CLD as the control group. Both underwent upper abdominal ultrasonography followed by elastographic assessment on a Siemens Acuson S2000TM ultrasound system. A comparison of the findings was made between the control and patient groups. Results: Both groups had similar hepatic size while patients with CLD had larger splenic size and area (p < 0.05). The CLD patients had higher mean hepatic and splenic SWV compared with the control group (p < 0.05). The mean splenic size and splenic SWV were higher in patients with varices than in those without varices (p < 0.05). Conclusion: Chronic liver disease causes significant increase in liver and splenic stiffness with splenic SWV values being higher for patients with varices emphasising the role of elastography as a non-invasive predictor for the presence of EVs. Splenic SWV had the highest sensitivity and specificity, which was augmented by a combination of hepatic and splenic SWV. Thus, splenic SWV alone or in combination with hepatic SWV is a useful technique for prediction of the presence of EVs. Contribution: This study aims to find an alternative non-invasive and cost-effective technique for screening of EV.

Venous Malformation in the Breast: Imaging Features to Avoid Unnecessary Biopsies or Surgery.

Venous malformations are now categorised under the broad heading of slow flow vascular malformations. They comprise abnormally dilated venous channels that fail to involute. These may be superficial or deep in location. We describe two cases of venous malformation in breast. Both the patients presented with focal pain in one breast. On mammography, they appeared as equal density well circumscribed soft tissue masses. No sonographic correlate was found on initial ultrasound examination. Subsequent ultrasonography performed by an experienced radiologist with minimal probe pressure revealed dilated veins. On the basis of imaging findings, the diagnosis of venous malformation was established.

Temporal Evolution of Signal Alterations in the Deep Gray Nuclei in term Neonates With Hypoxic-Ischemic Brain Injury: A Comprehensive Review.

The deep gray nuclei are paired interconnected gray nuclei comprising the basal ganglia and thalami. Injury to the deep gray nuclei secondary to hypoxic-ischemic injury is associated with poor short- and long-term clinical outcomes. The signal changes following hypoxic-ischemic injury are dynamic and evolve over a period of time from injury to resolution. Radiologically relevant events following hypoxic-ischemic injury include the onset of anaerobic metabolism immediately following hypoxic-ischemic injury, increase in cytotoxic edema followed by its resolution, and the onset and progression of neuronal necrosis and gliosis. Appearance of lactate peak on proton spectroscopy is the initial radiologic evidence of hypoxic-ischemic injury. Diffusion-weighted imaging has the highest prognostic value and pseudo-normalizes following 1 week of hypoxic-ischemic injury. Recommended timing for magnetic resonance imaging (MRI) is between 4 and 7 days. MR imaging performed between 1 and 6 months underestimates the extent of injury because radiologic changes are subtle. This review provides a detailed timeline of radiologic abnormalities in the deep gray nuclei following hypoxic-ischemic injury.

Biological approaches for E-waste management: A green-go to boost circular economy.

E-waste is a pressing situation on human due to its complex composition. Although E-waste on one hand has some toxic components but at the same time, it would be a promising business sector. Recycling of E-waste to mine-out valuable metals and other components has opened a chance of business and hence a way towards transformation of linear economy to circular one. Chemical, physical and traditional technologies are holding the position in E-waste recycling sector but sustainability with respect to cost and environmental issues is a major concern associated with these technologies. In order to overcome these gaps, lucrative, environment friendly and sustainable technologies need to be implied. Biological approaches could be a green and clean approach to handle E-waste through sustainable and cost-effective means by considering socio-economic and environmental aspects. This review elaborates biological approaches for E-waste management and advancements in expanse. The novelty covers the environmental and socio-economic impacts of E-waste, solution and further scope of biological approaches, further research and development need in this contour to come up with sustainable recycling process.

Lung Ultrasound: A Complementary Imaging Tool for Chest X-Ray in the Evaluation of Dyspnea.

The present study was designed to evaluate the spectrum of imaging findings seen on chest ultrasonography in patients presenting with dyspnea and verify the concordance between chest X-ray and chest ultrasound. Methods Fifty-three patients presenting with dyspnea were included in this study. Patients with known/suspected cardiac disease were excluded from the study. All patients underwent chest X-ray and chest ultrasound, reported by two different investigators. The concordance was analyzed using Cohen's kappa value with a ' p -value' less than 0.05 considered statistically significant. Results Among the fifty-three patients with dyspnea, five diagnostic pathologies were evaluated. Concordance between lung ultrasound and chest X-ray for diagnosis of pneumonia, pneumothorax, acute exacerbation of COPD/severe asthma, and diffuse alveolar interstitial syndrome was found to be high with Cohen's kappa value > 0.8 ( p < 0.01). Ultrasound was able to correctly diagnose more cases of pneumothorax and pulmonary edema compared with chest X-ray with sensitivity and negative predictive value of 100%. Chest X-ray was found to be superior in correctly diagnosing COPD. The difference was, however, not statistically significant. Similarly, no statistically significant difference could be inferred between the diagnostic value of ultrasound and Chest X-ray in the diagnosis of pneumonia or pleural effusion. Conclusions A high concordance was noted between ultrasound and chest X-ray for diagnosis of all pathologies studied ( p < 0.01), the highest noted in pneumonia/pleural effusion and diffuse interstitial syndrome (κ = 0.9). Hence, ultrasound may be considered a complimentary imaging modality for Chest-X-ray in the evaluation of dyspnea.

Can Sublingual Nitrate Improve Visualization of Lower Limb Arteries on Computed Tomography Angiography?

OBJECTIVE: The aim of the study is to evaluate the role of sublingual nitrate in improving vessel visualization on peripheral computed tomography angiography (CTA). METHODS: Fifty patients clinically diagnosed with peripheral arterial disease of the lower limb were prospectively included in this study: Twenty-five underwent CTA after sublingual nitrate administration (nitrate group) and 25 without (non-nitrate group). Two blinded observers qualitatively and quantitatively assessed the data thus generated. The mean luminal diameter, intraluminal attenuation, site, and percentage of stenosis were evaluated in all segments. Assessment of collateral visualization at sites of significant stenosis was also done. RESULTS: Patients in the nitrate and non-nitrate groups were similar in age and sex characteristics ( P > 0.05).On subjective evaluation, there was significantly improved visualization of the femoropopliteal and tibioperoneal vasculature of the lower limb in the nitrate group compared with the non-nitrate group ( P < 0.05). Quantitative evaluation showed a statistically significant difference in the measured arterial diameters for all evaluated segments in the nitrate group versus the non-nitrate group ( P < 0.05). Intra-arterial attenuation was significantly greater for all segments in the nitrate group resulting in better contrast opacification in these studies. Collateral visualization around segments with more than 50% stenosis/occlusion was also better in the nitrate group. CONCLUSIONS: Our study suggests that nitrate administration before peripheral vascular CTA can improve visualization, especially in the distal segments by increasing the vessel diameter and intraluminal attenuation along with better delineation of the collateral circulation around stenotic areas. It may also improve the number of evaluable segments of vasculature in these angiographic studies.

Magnetic resonance imaging of rhino-orbito-cerebral mucormycosis: a pictorial review.

Rhino-orbito-cerebral mucormycosis is a potentially fatal disease requiring early magnetic resonance imaging (MRI) for disease evaluation and timely detection of intracranial complications. Angio-invasive nature leading to necrosis and infarction is the hallmark of mucormycosis. The disease follows a fulminant course extending from the paranasal sinuses to involve the orbit, deep neck spaces, skull base, facial bones, and intracranial compartment. Loss of vision either due to direct extension into the orbit or optic nerve infarction adds to disease morbidity. Prompt MRI using dedicated sequences can help in assessing the exact disease extent including early osseous and intracranial changes, which aid in precise disease management.

Tuberculoma - a great mimicker: can diffusion tensor imaging and tractography help?

BACKGROUND: Central nervous system (CNS) tuberculomas often mimic tumors on conventional imaging, differentiation of which may not be possible without invasive tissue sampling. Diffusion tensor imaging (DTI), owing to its unrivalled property of characterizing molecular diffusion, may help in better lesion characterization and tractography may help understand the pattern of white matter involvement by tuberculomas. PURPOSE: To estimate qualitative and quantitative diffusion tensor changes in brain tuberculomas and to evaluate patterns of white matter involvement using 3D tractography. MATERIAL AND METHODS: Thirty patients with brain tuberculomas were evaluated on a 3-T magnetic resonance scanner. Diffusion tensor images were acquired along 20 non-colinear encoding directions with two b-values (b = 0, b = 1000). Regions of interest (ROIs) were drawn on quantitative fractional anisotropy (FA) and apparent diffusion coefficient (ADC) maps in the center of the tuberculoma and perilesional area. Similar ROIs were placed in contralateral hemispheres for comparison. Tractography maps were also generated. RESULTS: Mean FA in the center and perilesional area of tuberculomas were 0.098 ± 0.041 and 0.311 ± 0.135, respectively. ADC values in corresponding regions were 0.920 ± 0.272 ×10-3 mm2/s and 1.157 ± 0.277 ×10-3 mm2/s. These values were significantly different compared to contralateral similar brain parenchyma. Tractography revealed interruption of white fibers in the center with deviation of fibers at the periphery in the majority of tuberculomas with none showing infiltration of white matter described in tumors. CONCLUSION: Significant qualitative as well as quantitative DTI changes were seen in tuberculoma and perilesional areas compared to contralateral hemisphere with tractography showing a pattern different from that described in tumors. These findings may help to differentiate tuberculomas from infiltrating tumors.

Lung ultrasound for evaluation of dyspnea: a pictorial review.

Lung ultrasound is based on the analysis of ultrasound artifacts generated by the pleura and air within the lungs. In recent years, lung ultrasound has emerged as an important alternative for quick evaluation of the patient at the bedside. Several techniques and protocols for performing lung ultrasound have been described in the literature, with the most popular one being the Bedside Lung Ultrasound in Emergency (BLUE) protocol which can be utilized to diagnose the cause of acute dyspnea at the bedside. We attempt to provide a simplified approach to understanding the physics behind the artifacts used in lung ultrasound, the imaging techniques, and the application of the BLUE protocol to diagnose the commonly presenting causes of acute dyspnea.

Role of Ultrasonography and Inflammatory Markers in Predicting Complicated Appendicitis.

Aim: The aim is to compare the diagnostic accuracy of laboratory investigations and ultrasonography (USG) in distinguishing complicated appendicitis (C-AA) from uncomplicated appendicitis (UC-AA). Materials and Methods: Forty-six children who underwent appendicectomy at our center between November 2018 and July 2020 were included. Based on intraoperative findings, they were divided into two groups - complicated (perforated, gangrenous, or associated with fecal peritonitis; n = 18) and UC-AA (n = 28). USG findings and inflammatory markers were compared in both groups at admission. Results: At admission, the mean values for total leukocyte count (TLC) (16090.56 vs. 11739.29 per mm3), high sensitivity C-reactive protein (hsCRP) (35.8 vs. 31.62 mg/L), and procalcitonin (PCT) (3.83 vs. 1.41 ng/mL) were significantly higher in C-AA. Visualization of a blind tubular aperistaltic structure was the only sonographic sign showing statistical significance - significantly lower in C-AA (50% vs. 90%). Independent predictors of C-AA were - duration of symptoms >48 h (odds ratio [OR] 6.3), free fluid/loculated collection in right iliac fossa (OR 3.75), TLC >11000/mm3 (OR 3.6), hsCRP >35 mg/L (OR 6.0), PCT >0.6 ng/mL (OR 4.02), and nonvisualization of appendix on USG (OR 8.33). Biochemical factors were sensitive (89%) and specific (55%) in differentiating C-AA from UC-AA but the addition of sonological parameters significantly improved the specificity of predicting complicated AA to 61% (P = 0.0036). Conclusion: Combining laboratory data with sonological findings significantly improves the predictive value for differentiating C-AA from UC-AA and can help decide operative approach and prognosticating.

Evaluation of the plantar fascia in patients with diabetes mellitus: the role of sonoelastography.

Purpose: It has been postulated that hyperglycaemic non-enzymatic glycation of proteins with subsequent accumulation of glycosylated end-products in tissues like the plantar fascia (PF) contributes to the development of foot ulcers in diabetics. The present study evaluates the spectrum of sonoelastographic findings in the plantar fascia in patients with type 2 diabetes mellitus (DM). Material and methods: A total of 81 patients and 32 healthy volunteers were included in the study. PF thickness was registered 1 cm distal to the attachment at the calcaneus. Greyscale ultrasonographic examination was followed by strain elastography of the PF based on which PF were qualitatively categorized into 3 grades (hard, intermediate, soft) depending on their predominant colour. Results: Patients were found to have thicker PF than healthy volunteers (p < 0.0001). Grade 2 (intermediate elasticity) PF was the most common type seen in both groups (48.44% of healthy volunteers and 57.25% of patients). However, a greater number of patients (36.64%) had grade 3, i.e. soft PF as compared to healthy volunteers (9.38%). Conclusions: To conclude, there is thickening and softening of the PF in patients with type 2 DM, supporting the hypo-thesis that diabetes-induced changes occur in the tissues of the foot.

Nasopharyngeal Carcinoma With Bilateral Breast Metastasis: A Report of an Elusive Case.

Nasopharyngeal carcinoma is a prevalent head and neck cancer, especially in Southeast Asia. Although its potential for distant metastasis is well established, metastasis to the breast has seldom been reported. To the best of our knowledge, this is the fourth report of a case of nasopharyngeal carcinoma metastasizing to bilateral breasts. A 35-year-old patient presented with left nasal obstruction, epistaxis, and a palpable mass in her left breast, without any cervical or axillary lymph nodal enlargement. Radiological examination with contrast-enhanced computed tomography scan and magnetic resonance and imaging of breast revealed the presence of enhancing mass lesions in bilateral breasts. Histopathology of the nasal mass was suggestive of undifferentiated nasopharyngeal carcinoma. Breast fine needle aspiration revealed an abundance of metastatic squamous cells. Immunohistochemistry examination was positive for chromogranin A, synaptophysin, and cluster of differentiation-56, confirming the diagnosis of a primary nasopharyngeal malignancy metastasizing to bilateral breasts. Differentiation between metastatic disease and a coexisting second primary is imperative for planning appropriate treatment and defining the further outcomes.

The role of chronic disease in the disparity of influenza incidence and severity between indigenous and non-indigenous Australian peoples during the 2009 influenza pandemic.

BACKGROUND: The 2009 H1N1 influenza pandemic (influenza A(H1N1)pdm09) disproportionately impacted Indigenous peoples. Indigenous Australians are also affected by a health gap in chronic disease prevalence. We hypothesised that the disparity in influenza incidence and severity was accounted for by higher chronic disease prevalence. METHODS: We analysed influenza data from Western Australia, South Australia, the Northern Territory, and Queensland. We calculated population prevalence of chronic diseases in Indigenous and non-Indigenous Australian populations using nationally-collected health survey data. We compared influenza case notifications, hospitalisations, intensive care admissions, and deaths reported amongst the total population of Indigenous and non-Indigenous Australians ≥ 15 years. We accessed age-specific influenza data reported to the Australian Department of Health during the 2009 'swine flu' pandemic, stratified by Indigenous status and the presence of one of five chronic conditions: chronic lower respiratory conditions, diabetes mellitus, obesity, renal disease, and cardiac disease. We calculated age-standardised Indigenous: non-Indigenous rate ratios and confidence intervals. FINDINGS: Chronic diseases were more prevalent in Indigenous Australians. Rates of influenza diagnoses were higher in Indigenous Australians and more frequent across all indices of severity. In those with chronic conditions, Indigenous: non-Indigenous influenza notification rate ratios were no lower than in the total population; in many instances they were higher. Rate ratios remained above 1·0 at all levels of severity. However, once infected (reflected in notifications), there was no evidence of a further increase in risk of severe outcomes (hospitalisations, ICU admissions, deaths) amongst Indigenous Australians compared to non-Indigenous Australians with a chronic disease. INTERPRETATION: Higher rates of influenza infection was observed amongst those Indigenous compared to non-Indigenous Australians, and this difference was preserved amongst those with a chronic condition. However, there was no further increase in prevalence of more severe influenza outcomes amongst Indigenous Australians with a chronic condition. This suggests that the prevalence of chronic disease, rather than Indigenous status, affected influenza severity. Other factors may be important, including presence of multiple morbidities, as well as social and cultural determinants of health.

Cerebrospinal Fluid Flow Analysis in Tuberculous Meningitis Using Phase Contrast Technique on 3 Tesla MRI: A New Paradigm and Our Initial Experience.

Background: Phase-contrast magnetic resonance imaging (PC-MRI) has been used for studying cerebrospinal fluid (CSF) dynamics in various CSF related disorders at aqueduct of Sylvius. Objective: To analyze the CSF flow dynamics qualitatively and quantitatively using PC-MRI across the aqueduct of Sylvius in diagnosed patients of tuberculous meningitis. Methods: Thirty patients, clinically diagnosed with tuberculous meningitis and mean age of 24 years (range: 12-60 years) were taken up to study the changes in CSF flow dynamics using PC-MRI with retrospective cardiac gating. Thirty age and sex matched healthy volunteers were also included for comparison and reference values. Flow quantification was done by through-plane scans acquired in the axial plane perpendicular to the aqueduct. For qualitative examination, in-plane phase contrast scans were acquired in the mid-sagittal plane. Encoding velocity was kept in craniocaudal direction. Calculated parameters were peak velocity (cm/s), average velocity (cm/s), average flow (mL/s), net forward volume (mL), and stroke volume (µL). Results: Qualitatively, loss of normal sinusoidal waveform of CSF flow was noted in two cases of hydrocephalus with exaggerated flows. Quantitatively, CSF flow parameters showed marked numerical difference in tuberculous meningitis patients with hydrocephalus on comparison with healthy volunteers and with cases without hydrocephalus. Conclusion: PC-MRI is a sensitive technique to analyze altered CSF flow dynamics in tuberculous meningitis patients. This is a useful adjunct in imaging these patients to extract both the qualitative and quantitative information about CSF flow for comprehensive evaluation.

Diffusion-weighted magnetic resonance imaging of abdominal tuberculosis: a new take on an old disease.

Abdominal tuberculosis is a major cause of mortality and morbidity in developing countries also re-emerging in western world due to the AIDS epidemic and population migration. Large proportion of the patients are young and hence radiation exposure is of concern. In addition, in some patients, contrast may be contraindicated or repeat studies may be required, where MR especially DWI may be useful. The aim of the study is to describe MRI features in abdominal tuberculosis including DWI in the involved bowel, lymphadenopathy, omental, and peritoneal thickening. Nodes being especially easy to appreciate on DWI, thus DWI in conjunction with routine noncontrast MR sequence can be useful technique to identify abdominal tubercular lesions in patients with contraindication to contrast.

Cervical extension of pancreatic pseudocyst: An unusual cause of neck stiffness and dysphagia.

Pancreatic pseudocyst is a common complication that can occur following acute or chronic pancreatitis. Commonly, they are peripancreatic in location. Rarely, they can extend to the mediastinum, and further extension to the neck is even rarer. A 55-year-old man who presented with neck stiffness and dysphagia and on imaging, was found to have a cystic lesion in the neck. Aspiration of the lesion revealed raised amylase levels suggestive of a pancreatic pseudocyst.

The role of "penumbra sign" and diffusion-weighted imaging in adnexal masses: do they provide a clue in differentiating tubo-ovarian abscess from ovarian malignancy?

PURPOSE: To evaluate the role of "penumbra sign", diffusion-weighted imaging (DWI), and the apparent diffusion coefficient (ADC) value in differentiating tubo-ovarian abscess (TOA) from ovarian malignancy. MATERIAL AND METHODS: Thirty-six patients with 50 adnexal masses (tubo-ovarian abscess, n = 24; ovarian malignancy, n = 26), who underwent magnetic resonance imaging (MRI) with DWI, were retrospectively evaluated. "Penumbra sign" (hyperintense rim on T1W images), diffusion restriction, and mean apparent diffusion coefficient (ADC) values from cystic (c-ADC) and solid (s-ADC) components were evaluated for all the masses. RESULTS: "Penumbra sign" on T1W images was significantly more common in the TOA group (n = 21, 87.5%) than in the ovarian malignancy group (n = 2, 7.7%) (p < 0.001). Similarly, diffusion restriction in the cystic component was more frequent in the TOA group (n = 24, 100% vs. n = 2, 10.5%; p < 0.001). In contrast, diffusion restriction in the solid component was more common in the ovarian malignancy group (n = 5, 20.8% vs. n = 26, 100%; p < 0.001). The mean c-ADC value was significantly lower in TOAs (p < 0.001). A c-ADC value of 1.31 × 10-3 mm2/s may be an optimal cut-off in distinguishing TOAs from ovarian malignancies. Conversely, the mean s-ADC value was significantly lower in the ovarian malignancy group (p < 0.001). An s-ADC value of 0.869 × 10-3 mm2/s may be an optimal cut-off in differentiating ovarian malignancies from TOAs (p < 0.001). ROC curve analysis showed that c-ADC values had a higher diagnostic accuracy than s-ADC values. CONCLUSIONS: "Penumbra sign" on T1W images, diffusion characteristics, and ADC values provide important clues in addition to conventional MR imaging features in differentiating TOA from ovarian malignancy.

Bilateral Submandibular Gland Aplasia: An Unusual Cause of Sublingual Swelling-The Role of Imaging in Patient Management.

There are very limited reports of aplasia of bilateral submandibular glands. We report the case of a 55-year-old male who presented with nontender palpable sublingual masses. On computed tomography and magnetic resonance imaging, bilateral submandibular gland aplasia and compensatory hypertrophy of bilateral parotid and sublingual glands were seen with herniation of hypertrophied sublingual glands through the bilateral mylohyoid muscles presenting as palpable sublingual region masses. Additional finding of bilateral accessory parotid glands was also noted. Prolapsed hypertrophied sublingual glands should be considered in patients presenting with bilateral sublingual masses to avoid unnecessary invasive procedures. We suggest radiological evaluation of such cases prior to any intervention.

Meandering pulmonary vein: A case report.

Anomalies of the pulmonary venous circulation are extremely uncommon. We report a case of an anomalous unilateral single pulmonary vein also referred to as a meandering pulmonary vein. A single large tortuous pulmonary vein was seen on the right side draining into the left atrium with associated ipsilateral absence of the middle lobe bronchus and interlobar fissures. This is considered a variant of the classical scimitar syndrome. The venous anatomy was depicted with considerable accuracy using multidetector computed tomography (MDCT) non-invasively.

Sonoelastographic Evaluation of the Achilles Tendon in Patients With Type 2 Diabetes Mellitus.

Diabetic foot is one of the dreaded complications of diabetes mellitus (DM). Alterations of the Achilles tendon (AT) may contribute to development of foot ulcers in diabetic patients. We evaluated the sonoelastographic abnormalities of the AT in 61 healthy volunteers and 81 patients with type 2 DM. The patients were further divided into those with and without peripheral neuropathy (PN). The AT thickness was measured in the proximal, middle and distal portions. Alterations in echo pattern were noted. The patients were found to have thicker tendons than the healthy volunteers (p < 0.01). Alterations in the echo pattern of the AT were more common in patients compared with healthy volunteers (p < 0.01). The shear wave velocity in the distal one-third of the AT was measured using shear wave elasticity imaging. Mean shear wave velocity values obtained were lower in patients compared with healthy volunteers (p < 0.001). No significant difference was found in the sonoelastographic findings of the AT in patients with and without PN. We conclude that there is softening, thickening and alterations in echo pattern of the AT in the form of hypoechogenicity, loss of fibrillar pattern and calcification at insertion in patients with type 2 DM, and these alterations could occur independent of onset of PN.