Quantitative ultrasound (QUS) in the evaluation of liver steatosis: data reliability in different respiratory phases and body positions.

Liver steatosis is the most common chronic liver disease and affects 10-24% of the general population. As the grade of disease can range from fat infiltration to steatohepatitis and cirrhosis, an early diagnosis is needed to set the most appropriate therapy. Innovative noninvasive radiological techniques have been developed through MRI and US. MRI-PDFF is the reference standard, but it is not so widely diffused due to its cost. For this reason, ultrasound tools have been validated to study liver parenchyma. The qualitative assessment of the brightness of liver parenchyma has now been supported by quantitative values of attenuation and scattering to make the analysis objective and reproducible. We aim to demonstrate the reliability of quantitative ultrasound in assessing liver fat and to confirm the inter-operator reliability in different respiratory phases. We enrolled 45 patients examined during normal breathing at rest, peak inspiration, peak expiration, and semi-sitting position. The highest inter-operator agreement in both attenuation and scattering parameters was achieved at peak inspiration and peak expiration, followed by semi-sitting position. In conclusion, this technology also allows to monitor uncompliant patients, as it grants high reliability and reproducibility in different body position and respiratory phases.

Multimodality ultrasound assessment of the spleen: Normal appearances and emergency abnormalities.

This paper summarizes the main splenic emergencies and their ultrasonographic findings to orient appropriate patient management. US requires minimal preparation time and allows to examine the parenchyma and to detect intraperitoneal fluid collections, which may be indirect evidence of solid organ injuries. In this paper, we analyze the role of B-mode, Doppler and Contrast-Enhanced Ultrasound in the diagnosis of splenic emergencies, with a particular focus on splenic infarction, infection, traumatic injuries and vascular splenic anomalies.

The Role of Ultrasound in Chronic Intestinal Diseases in Pediatric Patients.

Chronic inflammatory bowel diseases (IBD) are chronic disorders of the gastrointestinal tract, with an increasing incidence in pediatric populations. Ultrasound of the intestinal wall represents the first-line imaging technique in children since it is a noninvasive method, is free of ionizing radiation, and is inexpensive. Furthermore, the absence of intestinal wall thickening has a good negative predictive value for IBD, which is greater for Crohn's disease than for ulcerative colitis. Ultrasound is used for the diagnosis of disease, for the differential diagnosis in IBD, in the follow-up of known IBD, in the definition of the site and extent of the disease, for the diagnosis of intestinal complications, for the evaluation of disease activity, in the definition of prognostic parameters, and in the post-operative follow-up.

Omental Infarction: An Underrecognized Cause of Right-Sided Acute Abdominal Pain in Children.

OBJECTIVE: To evaluate the prevalence of omental infarction (OI) in children with suspected appendicitis, the role of ultrasonography (US) in its diagnosis and management and the efficacy of conservative management. METHODS: Consecutive children with suspected acute appendicitis were prospectively enrolled. Ultrasonography was performed at baseline, during follow-up, before the discharge, and at 15-day intervals until US findings of OI disappeared. All children with a diagnosis of OI were treated conservatively. RESULTS: One hundred ninety-nine children (91 male; age range, 3-15 years) were evaluated. Eighty-four patients had acute appendicitis. Omental infarctions were found in 14 children (8 male; mean age, 9.8 ± 2.6 years), with an incidence of 7%. Ultrasonography depicted an echogenic mass consistent with OI in all children. Ultrasonography detected in 8 patients a normal-looking appendix, whereas in other 6 patients, it identified neither appendix nor indirect signs of acute appendicitis. A normal appendix has been detected by US during follow-up in 2 of these 6 patients. During follow-up, US finding of OI disappeared in all cases and no signs of acute appendicitis or other disease occurred. All 14 OIs were treated conservatively, with no reported complications. CONCLUSIONS: Omental infarction is an underestimated cause of abdominal pain in children accounting for 7% of patients with suspected appendicitis. Ultrasonography is a useful method for the diagnoses and to guide clinical management of OI. Conservative therapy is a safe option for the management of OI.

The role of point of care ultrasound in radiology department: update and prospective. A statement of Italian college ultrasound.

Ultrasound, in its new point-of-care conception, has been called the stethoscope of the future. Goal-directed bedside ultrasound examination, performed by a healthcare provider to answer a specific diagnostic question or guide an invasive procedure, is currently revolutionizing medical practice. It is used by various specialties in multiple clinical contexts for procedural, diagnostic, and screening applications. Point-of-care ultrasound is also a strategic technique in clinical radiology; it brings the radiologist closer to the patient (in interaction and understanding) like interventional and angiography procedures and, as an integrative imaging modality, is a vital radiological tool for decision-making in many situations. In this commentary, we present our observations on the use of ultrasound, in a sincere appeal to refrain from omitting ultrasound as a diagnostic technique in this era of deep professional change, in which radiologists must return to being a true clinical semiologist.

Ultrasound, shear-wave elastography, and magnetic resonance imaging in native liver survivor patients with biliary atresia after Kasai portoenterostomy: correlation with medical outcome after treatment.

BACKGROUND: Biliary atresia (BA) is a rare obliterative cholangiopathy and Kasai portoenterostomy (KP) represents its first-line treatment; clinical and laboratory parameters together with abdominal ultrasound (US) are usually performed during the follow-up. Shear-wave elastography (SWE) is able to evaluate liver parenchyma stiffness; magnetic resonance imaging (MRI) has also been proposed to study these patients. PURPOSE: To correlate US, SWE, and MRI imaging findings with medical outcome in patients with BA who are native liver survivors after KP. MATERIAL AND METHODS: We retrospectively enrolled 24 patients. They were divided in two groups based on "ideal" (n = 15) or "non-ideal" (n = 9) medical outcome. US, SWE, and MRI exams were analyzed qualitatively and quantitatively for imaging signs suggestive of chronic liver disease (CLD). RESULTS: Significant differences were found in terms of liver surface (P = 0.007) and morphology (P = 0.013), portal vein diameter (P = 0.012) and spleen size (P = 0.002) by US, liver signal intensity (P = 0.013), portal vein diameter (P = 0.010), presence of portosystemic collaterals (P = 0.042), and spleen size (P = 0.001) by MRI. The evaluation of portal vein diameter (moderate, κ = 0.44), of portosystemic collaterals (good, κ = 0.78), and spleen size (very good, κ = 0.92) showed the best agreement between US and MRI. A significant (P = 0.01) difference in liver parenchyma stiffness by SWE was also found between the two groups (cut-off = 9.6 kPa, sensitivity = 55.6%, specificity = 100%, area under the ROC curve = 0.82). CONCLUSION: US, SWE, and MRI findings correlate with the medical outcome in native liver survivor patients with BA treated with KP.

The lung ultrasound: facts or artifacts? In the era of COVID-19 outbreak.

Ultrasound is the most disruptive innovation in intensive care life, above all in this time, with a high diagnostic value when applied appropriately. In recent years, point-of-care lung ultrasound has gained significant popularity as a diagnostic tool in the acutely dyspnoeic patients. In the era of Sars-CoV-2 outbreak, lung ultrasound seems to be strongly adapting to the follow-up for lung involvement of patients with ascertaining infections, till to be used, in our opinion emblematically, as a screening test in suspected patients at the emergency triage or at home medical visit. In this brief review, we discuss the lung ultrasound dichotomy, certainties and uncertainties, describing its potential role in validated clinical contexts, as a clinical-dependent exam, its limits and pitfalls in a generic and off-label clinical context, as a virtual anatomical-dependent exam, and its effects on the clinical management of patients with COVID-19.

Case report: horse or zebra, ascites or pseudo-ascites? Care for pictural details!

BACKGROUND: Pseudo-ascites is a very rare condition in children and remains a challenging diagnosis. Targeted imaging may be helpful, but a high index of clinical suspicion is often necessary to guide the investigations, as pseudo-ascites may efficiently mimic true ascites. To date, still many cases of pseudo-ascites suffer diagnostic and therapeutic delay, and some are only diagnosed during surgical exploration. We report the case of a patient with a late laparoscopic diagnosis of pseudo-ascites. We retrospectively review our patient's imaging findings and suggest new characteristic features which may help differentiate pseudo-ascites from true ascites. CASE PRESENTATION: A 7-month-old infant was referred for a progressive abdominal distention. Physical examination and initial ultra-sonographic findings evoked free ascites. An extensive diagnostic workup was then performed and was negative for hepatic, renal, cardiac, intestinal, pancreatic, inflammatory or infectious diseases, malignancy and congenital metabolic disorders. Pseudo-ascites was evoked and dedicated ultra-sonographic and magnetic resonance studies were repeated but could not confirm this diagnosis. Symptomatic diuretic treatment with spironolactone and furosemide was then started. A temporary and limited effect was noted but, with time, repeated paracenteses were necessary as the abdominal distention progressed causing discomfort and breathing difficulty. Last, because the patient's quality of life deteriorated, a peritoneal-venous shunting was proposed; as the operation started with a diagnostic laparoscopy, a benign giant cystic mesenteric lymphangioma was identified and totally excised. The resolution of symptoms was immediate and the patient remained symptom-free throughout the subsequent observation period that lasted more than 1 year. CONCLUSIONS: Increased awareness about pseudo-ascites is necessary, as the diagnosis is often overlooked, and treatment delayed. Targeted imaging may be helpful, as some specific, although not pathognomonic, features exist which may aid in the diagnosis.

Clinical significance and sonographic evolution of enlarged abdominal lymph nodes in children.

AIM: Paediatric evidence about the clinical implications of enlarged abdominal lymph nodes (EALN) is not univocal. The main purpose of our study was to evaluate the clinical significance and the morphological evolution of enlarged abdominal nodes in children with recurrent abdominal pain. METHODS: All children with recurrent abdominal pain diagnosed with EALN were enrolled at the involved centres between September 2017 and June 2018. Number, size, localisation, shape and architecture of nodes were accurately recorded along with clinical and laboratory data at enrolment and after three and six months. RESULTS: A total of 38 children were enrolled. After the six-month study period, 58% of them had lymph nodes reduced in size, 13% had unchanged lymph nodes, and 29% had lymph nodes increased in size. Overall, we observed a gradual, albeit slight reduction in the average size of enlarged nodes over the six-month period. The extent of size changes was not correlated with any clinical parameter. CONCLUSION: Our data suggest that EALN are a non-specific finding, which is not worth a change in the diagnostic and therapeutic management of children with abdominal pain.

Urate-Lowering Agents in Asymptomatic Hyperuricemia: Role of Urine Sediment Analysis and Musculoskeletal Ultrasound.

Current urate-lowering therapy (ULT) includes three direct acting drugs (allopurinol, febuxostat, Rasburicase) and at least four 'indirect' drugs with other important targets (canagliflozin, losartan, fenofibrate and sevelamer). Moreover, the alcalinization of urines using bicarbonate can be used to dissolve urate crystals and the clinician may discontinue several drugs are known to increase serum levels of uric acid, such as diuretics, aspirin, cyclosporine, theophylline, mycophenolate and ACE inhibitors. While there is a consensus to start ULT in cases of symptomatic hyperuricemia (gout, urate-nephrolithiasis), the very frequent conditions of asymptomatic hyperuricemia remains a major conundrum. The effect of asymptomatic hyperuricemia on kidney function has had fluctuating positions over decades. The conflicting results might indicate: (i) the presence of counterbalancing positive and negative effects on kidney function of both serum uric acid and urate-lowering agents, (ii) the presence of a subpopulation of patients, as yet unidentified, which could truly benefit from a urate-lowering therapy. Therefore, today the treatment of asymptomatic hyperuricemia is not recommended nor excluded by current guidelines. Here we suggest that a possible guide for the treatment of asymptomatic hyperuricemia might be the presence of urate crystals in the urine sediment and/or signs of asymptomatic articular damage by urates, identified by musculo-skeletal ultrasound. Moreover, a watchful analysis of the trend in creatinine/eGFR, proteinuria or urate levels might also guide the clinician. Initiation of ULT and follow-up in cases of asymptomatic hyperuricemia should consider urine sediment analysis, musculoskeletal ultrasound and trends in creatinine, proteinuria and serum urate levels.

Lung Ultrasound for Diagnosing Pneumothorax in the Critically Ill Neonate.

OBJECTIVES: To evaluate the accuracy of lung ultrasound for the diagnosis of pneumothorax in the sudden decompensating patient. STUDY DESIGN: In an international, prospective study, sudden decompensation was defined as a prolonged significant desaturation (oxygen saturation <65% for more than 40 seconds) and bradycardia or sudden increase of oxygen requirement by at least 50% in less than 10 minutes with a final fraction of inspired oxygen ≥0.7 to keep stable saturations. All eligible patients had an ultrasound scan before undergoing a chest radiograph, which was the reference standard. RESULTS: Forty-two infants (birth weight = 1531 ± 812 g; gestational age = 31 ± 3.5 weeks) were enrolled in 6 centers; pneumothorax was detected in 26 (62%). Lung ultrasound accuracy in diagnosing pneumothorax was as follows: sensitivity 100%, specificity 100%, positive predictive value 100%, and negative predictive value 100%. Clinical evaluation of pneumothorax showed sensitivity 84%, specificity 56%, positive predictive value 76%, and negative predictive value 69%. After sudden decompensation, a lung ultrasound scan was performed in an average time of 5.3 ± 5.6 minutes vs 19 ± 11.7 minutes required for a chest radiography. Emergency drainage was performed after an ultrasound scan but before radiography in 9 cases. CONCLUSIONS: Lung ultrasound shows high accuracy in detecting pneumothorax in the critical infant, outperforming clinical evaluation and reducing time to imaging diagnosis and drainage.

Ultrasonographic diagnosis of midgut volvulus with malrotation in children.

OBJECTIVES: Midgut volvulus with malrotation is typical in newborns. We present our experience to emphasize the importance of suspecting midgut volvulus as a cause of abdominal pain also beyond infancy, particularly in relation to malrotation, and the relevance of ultrasonographic (US) signs in its diagnosis. METHODS: A total of 34 patients (10 boys, 24 girls; ages between 1 day and 12 years) diagnosed as having malrotation or malrotation with volvulus, surgically confirmed, between 2006 and 2013 were retrospectively selected among all of the patients referred to our institution for acute abdomen and bilious vomiting. All of them underwent US and color Doppler examination before surgery. The US examinations were performed with 6 to 10 MHz microconvex and 7.5 to 10 Mhz linear transducer. The transducer was placed under xiphoid, and, with axial projection, the presence of anatomic position reversed between superior mesenteric vein (SMV) and superior mesenteric artery (SMA), as a sign of malrotation, and the presence of "whirlpool sign" (WS) (wrapping of the SMV and the mesentery around the SMA), as a sign of midgut volvulus, were evaluated. RESULTS: In 27 of these 34 patients, midgut volvulus was present; 7 patients had intestinal malrotation. In 2 of 7 (28%) patients with malrotation, SMA and SMV were inverted. Among the patients with volvulus, 2 showed reversed vessel position and 22 patients presented the WS in association with SMA/SMV inversion (22/27, 81%). CONCLUSIONS: Midgut volvulus with malrotation can appear beyond the neonatal age group as demonstrated in our case. The WS sign is sufficiently sensitive for its diagnosis and should be routinely researched at all ages of pediatric population. Anatomic inversion between SMV and SMA seems to be not enough sensitive in isolated malrotation diagnosis.

Idiopathic scrotal hematoma simulating a testicular torsion, in association with cryptorchidism: US findings.

BACKGROUND: An acute scrotum concerns endoscrotal organs (testicles, spermatic cord, tunica vaginalis) and is characterized by pain, swelling and hyperemia of the hemi-scrotum. It represents one of the most common surgical emergencies in children often caused by testicular torsion; the diagnosis is mostly clinical but must be supported by ultrasonographic examination of the scrotal region in association with a colour Doppler study of the spermatic cord vessels and glandular parenchyma. An idiopathic scrotal hematoma is a very rare condition that can simulate it. CASE REPORT: A 3-day-old full-term baby, otherwise in good health, showed swelling and pain of the left inguinal-scrotal region. A testicular torsion was suspected, so the baby underwent an ultrasound examination of the testis and spermatic cord that showed a left scrotal hematoma with superior displacement of the didymus; the right testicle was located in the internal inguinal canal. Surgical intervention confirmed the sonographic diagnosis of left testicular hematoma and of the right cryptorchidism. CONCLUSIONS: Although testicular torsion is the most frequent cause of acute scrotum, the possibility of a persistent idiopathic scrotal haematoma and/or haematoma secondary to a trauma of the inguino-scrotal region, must be always taken into account. US diagnosis can avoid unnecessary emergency surgical treatment, required in case of testicular torsion.

Future Perspectives on Radiomics in Acute Liver Injury and Liver Trauma.

Background: Acute liver injury occurs most frequently due to trauma, but it can also occur because of sepsis or drug-induced injury. This review aims to analyze artificial intelligence (AI)'s ability to detect and quantify liver injured areas in adults and pediatric patients. Methods: A literature analysis was performed on the PubMed Dataset. We selected original articles published from 2018 to 2023 and cohorts with ≥10 adults or pediatric patients. Results: Six studies counting 564 patients were collected, including 170 (30%) children and 394 adults. Four (66%) articles reported AI application after liver trauma, one (17%) after sepsis, and one (17%) due to chemotherapy. In five (83%) studies, Computed Tomography was performed, while in one (17%), FAST-UltraSound was performed. The studies reported a high diagnostic performance; in particular, three studies reported a specificity rate > 80%. Conclusions: Radiomics models seem reliable and applicable to clinical practice in patients affected by acute liver injury. Further studies are required to achieve larger validation cohorts.

Volvulus of a wandering spleen in a pediatric patient.

Wandering spleen is a rare condition in children that is often caused by the loss or weakening of the splenic ligaments. Its clinical presentation is variable; 64% of children with wandering spleen have splenic torsion as a complication. A 13-year-old boy who had been showing abdominal pain in the hypogastric region accompanied by vomit and an enormous tumefaction in the suprapubic region came to our observation. Considering the ovoid morphology at ultrasound exam, the echostructure and the marked reduction of parenchymal vascularization, suspicion for torsion of an ectopic spleen arose. Ultrasound evaluation has a primary role in the diagnosis of a suspected wandering spleen and, to avoid potentially life-threatening complications, immediate surgery is often times required.

Musculoskeletal disorders in padel: from biomechanics to sonography.

Padel is a racket sport, combining high-frequency and low-intensity athletic gestures, that has been gaining growing scientific interest in recent years. Musculoskeletal injuries are very common among padel players with an incidence rate of 3 per 1000 h of training and 8 per 1000 matches. To the best of our knowledge, a comprehensive collection describing the most common sonographic findings in padel players with musculoskeletal injuries is lacking in the pertinent literature. In this sense, starting from the biomechanical features of padel-specific gestures we have reported the ultrasonographic patterns of most frequent injuries involving the upper limb, the trunk, and the lower limb. Indeed, comprehensive knowledge of the biomechanical and clinical features of musculoskeletal injuries in padel is paramount to accurately perform a detailed ultrasound examination of the affected anatomical site. So, the present investigation aims to provide a practical guide, simple and ready-to-use in daily practice, to optimize the sonographic assessment of padel players by combining it with the clinical findings and the biomechanical features of athletic gestures.

Stool consistency, but not frequency, correlates with total gastrointestinal transit time in children.

OBJECTIVES: To evaluate the correlation between stool characteristics (consistency and frequency) and gut transit time in children and to determine whether the Bristol Stool Form Scale is a reliable method of assessing intestinal transit rate in children. STUDY DESIGN: From March 2011 to March 2012, 44 children (25 boys and 19 girls, mean age 7.8 years) with a diagnosis of functional constipation and 36 healthy, nonconstipated children (17 boys and 19 girls, mean age 7.6 years) were enrolled. All participants maintained a 1-week stool diary, recording the time and date of every bowel movement and stool form, and then completed a validated questionnaire on functional constipation according to Rome III criteria. Whole gut transit time (WGTT) was then assessed using the radiopaque markers test. RESULTS: There was a significant correlation between stool form and WGTT in both constipated and nonconstipated children (correlation coefficient -0.84, P<.001). By contrast, there was no correlation between either stool frequency and WGTT or stool frequency and stool form. Multivariate logistic regression analysis, using WGTT as a dependent variable, showed that the sole variable significantly associated with WGTT was stool form (regression coefficient 2.9, OR 18.4, 95% CI 5.4-62.5, P<.001). CONCLUSION: In this prospective, observational, case-control study, we show that stool form, as measured by the Bristol Stool Form Scale, rather than stool frequency, correlates with WGTT in both constipated and nonconstipated children.

How the preoperative ultrasound examination and BFI of the cervical lymph nodes modify the therapeutic treatment in patients with papillary thyroid cancer.

BACKGROUND: Ultrasound is considered the best diagnostic method for the detection of metastatic cervical lymph nodes (LNs) in patients with papillary thyroid carcinoma (PTC). According to current guidelines, all patients undergoing thyroidectomy for malignancy should undergo preoperative neck ultrasound of the thyroid and central and lateral neck LNs, followed by fine needle aspiration of suspicious LNs. Cervical LN involvement determenes the extent of surgery. Complete surgical resection disease at the initial operation decreases likelihood of future surgery for recurrent disease and may impact survival. We use a new technique, B-flow imaging (BFI), recently used for evaluation of thyroid nodules, to estimate the presence of BFI twinkling signs (BFI-TS), within metastatic LNs in patients with PTC. METHODS: Between September 2006 and December 2012, 304 patients with known PTC were examined for preoperative sonographic evaluation with gray-scale US, color Doppler US and BFI. Only 157 with at least one metastatic LN were included in our study. All patients included underwent surgery, and the final diagnosis was based on the results of histologic examination of the resected specimens. The following LN characteristics were evaluated: LN shape, abnormal echogenicity, the absent of hilum, calcifications, cystic appearance, peripheral vascularization and the presence of BFI-TS. RESULTS: A total of 767 LNs were analyzed. 329 out of 767 were metastatic, according to the histopathologic findings. BFI-TS, showed 99.5% specificity and 81,5% sensitivity. We detected BFI-TS in 6 metastatic LNs that were negative to the other conventional US features. CONCLUSIONS: Our results indicate that the BFI-TS has a diagnostic accuracy higher than the other conventional sonographic signs. Our findings suggest that BFI can be helpful in the selection of suspicious neck LNs that should be examined at cytologic examination or open biopsy for accurate preoperative staging and individual therapy selection.

[Repair of a root perforation by using MTA: a case report]. / Supporto radiografico nel trattamento della riparazione di una perforazione endodontica con l'uso di MTA.

Root perforations are accidental events that may occur during the treatment, causing tissue inflammation and alveolar bone loss of integrity of the periodontium. In such cases, the radiological evidence is fundamental in the formulation of the diagnosis, in the choice of therapy (surgical or non-surgical) and finally for the assessment of prognosis of the dental element. In non-surgical treatment of endodontic lesions, the material used for the repair of the defect root should have biocompatibility, antibacterial activity, ability to induce healing of periodontal tissues and radiopacity. The Mineral Trioxide Aggregate (MTA) is a silicate-based cement introduced in dental clinical practice with good radiopacity, biocompatibility and bone induction. This article describes the use of MTA in endodontic repair of a perforation of the middle third root and the success of non-surgical treatment was dimonstrated radiographicaly.

The role of Lung Ultrasound in the diagnosis of SARS-COV-2 disease in pregnant women.

AIM: To evaluate the role of lung ultrasound (LUS) in recognizing lung abnormalities in pregnant women affected by COVID-19 pneumonia. MATERIALS AND METHODS: An observational study analyzing LUS patterns in 60 consecutively enrolled pregnant women affected by COVID-19 infection was performed. LUS was performed by using a standardized protocol by Soldati et al. The scoring system of LUS findings ranged from 0 to 3 in increasing alteration severity. The highest score obtained from each landmark was reported and the sum of the 12 zones examined was calculated. RESULTS: Patients were divided into two groups: 26 (43.3%) patients with respiratory symptoms and 32 (53.3%) patients without respiratory symptoms; 2 patients were asymptomatic (3.3%). Among the patients with respiratory symptoms 3 (12.5%) had dyspnea that required a mild Oxygen therapy. A significant correlation was found between respiratory symptoms and LUS score (p < 0.001) and between gestational weeks and respiratory symptoms (p = 0.023). Regression analysis showed that age and respiratory symptoms were risk factors for highest LUS score (p < 0.005). DISCUSSION: LUS can affect the clinical decision course and can help in stratifying patients according to its findings. The lack of ionizing radiation and its repeatability makes it a reliable diagnostic tool in the management of pregnant women.