Professional Standards in Medical Ultrasound - EFSUMB Position Paper (Long Version) - General Aspects.

This first position paper of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on professional standards presents a common position across the different medical professions within EFSUMB regarding optimal standards for the performing and reporting of ultrasound examinations by any professional ultrasound operator. It describes general aspects of professionality that ensure procedure quality, effectiveness, efficiency, and sustainability in virtually all application fields of medical ultrasound. Recommendations are given related to safety and indication of ultrasound examinations, requirements for examination rooms, structured examination, systematic reporting of results, and management, communication and archiving of ultrasound data. The print version of this article is a short version. The long version is published online.

Professional Standards in Medical Ultrasound - EFSUMB Position Paper (Short Version) - General Aspects.

This first position paper of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on professional standards presents a common position across the different medical professions within EFSUMB regarding optimal standards for the performing and reporting of ultrasound examinations by any professional ultrasound operator. It describes general aspects of professionality that ensure procedure quality, effectiveness, efficiency, and sustainability in virtually all application fields of medical ultrasound. Recommendations are given related to safety and indication of ultrasound examinations, requirements for examination rooms, structured examination, systematic reporting of results, and management, communication and archiving of ultrasound data. The print version of this article is a short version. The long version is published online.

Assessment of the optic nerve, optic disc, and perineural area using shear-wave elastography in patients with multiple sclerosis.

PURPOSE: To observe and describe the stiffness changes of the optic nerve in the patients with multiple sclerosis (MS) with or without optic neuritis and healthy adults via shear wave elastography (SWE). METHODS: 70 optic nerves from 35 patients with MS and 60 optic nerves from 30 healthy subjects were included prospectively in the study. The optic nerve (ON), optic disc (OD), and perineural area were evaluated with SWE and optic nerve sheat diameter (ONSD) was measured by ultrasound. RESULTS: The mean age of patients was 39.68 ± 9.99 years. There was no statistically significant difference between the groups in terms of ONSD, SWE ON, SWE OD, and SWE perineural area levels (P > .05). In the MS group; No statistically significant difference was found between patients with and without optic neuritis for the mean age, gender distribution, duration of MS, types of MS, ONSD, SWE ON, SWE OD, SWE perineural area, and Expanded Disability Status Scale (EDSS) scores (P > .05). No statistically significant difference in terms of ONSD, SWE ON, SWE OD, and SWE perineural area between the MS patients with or without optic neuritis and the control group (P > .05). CONCLUSION: Shear wave elastography measurements of the optic nerve, optic disc, and perineural area do not contribute to the evaluation of optic neuritis in a patient with MS.

Ultrasound and contrast-enhanced ultrasound (CEUS) in infective liver lesions.

Infektiöse fokale Leberläsionen (FLL) treten in der klinischen Praxis häufig auf, wobei bakterielle Leberabszesse die Hälfte ausmachen. Eine genaue Diagnose der FLL ist für die Auswahl der am besten geeigneten Therapie und zur Vorbeugung von Komplikationen unerlässlich. Ziel der aktuellen Arbeit ist es, den Nutzen von Ultraschall und kontrastmittelverstärktem Ultraschall (CEUS) zur Erkennung und Charakterisierung infektiöser Leberläsionen zu beschreiben.

Assessment of Peripheral Nerves With Shear Wave Elastography in Type 1 Diabetic Adolescents Without Diabetic Peripheral Neuropathy.

OBJECTIVES: To investigate the utility of shear wave elastography (SWE) in detecting morphologic abnormalities of the median nerve and posterior tibial nerve in transverse and longitudinal axes in adolescents with type 1 diabetes mellitus (DM) without diabetic peripheral neuropathy (DPN). METHODS: The median nerves and posterior tibial nerves of 25 adolescents with diagnosis and follow-up of type 1 DM without DPN and 32 healthy volunteers were evaluated with SWE by 2 observers on the transverse and longitudinal axes. The cross-sectional area and thickness of the nerves and disease duration were noted, and probable associations of these parameters with SWE features were analyzed. Interobserver and intraobserver correlations were also examined. The statistical significance level was set at P < .05. RESULTS: Both the median nerve and posterior tibial nerve were smaller, thinner, and stiffer in the patient group for both observers on both axes. The disease duration weakly correlated with median nerve SWE features (r = 0.245-0391). The thickness and cross-sectional area had no correlations with SWE features. CONCLUSIONS: The median nerve and posterior tibial nerve in adolescents with type 1 DM without DPN have morphologic abnormalities that can be displayed by SWE regardless of the imaging axis. Shear wave elastography may have a potential role in subclinical DPN, but the reliability of the findings is not as high as desirable.

Role of iliac crest tangent in correct numbering of lumbosacral transitional vertebrae

Background/aim: The iliac crest tangent (ICT) has recently emerged as a reliable landmark to correctly number the lumbosacral transitional vertebrae (LSTV). We retrospectively evaluated the reproducibility and accuracy of the ICT as a landmark in subjects without disc degeneration. Materials and methods: Fifty-eight patients with LSTV [19 female, 41 (26­52) years] and 55 controls without LSTV [23 female, 40 (26­55) years] who had undergone spinal computed tomography were included. The ICT was drawn on the coronal images, with the cursor in the sagittal view set to the posterior ⅓ of the vertebral body located one level above the LSTV. When more than 1.25 vertebral body was counted below the ICT, the LSTV was considered as S1, otherwise it was considered as L5. The gold standard was counting the vertebrae craniocaudally. Results: The interobserver agreement was good for determining ICT level (Cohen's kappa = 0.78, P < 0.001). The rate of correct numbering by ICT in the LSTV group was significantly less than in the controls (43.1% vs. 96.4%, respectively, P < 0.001). Patients with sacralization had a significantly lower correct numbering rate than patients with lumbarization (33.3% vs. 63.2%, respectively, P = 0.03). Conclusion: ICT does not seem to be a reliable landmark for correct numbering of LSTV in patients with no intervertebral disc degeneration.

Shear Wave and Strain Elastographic Features of the Brachial Plexus in Healthy Adults: Reliability of the Findings-a Pilot Study.

OBJECTIVES: To determine the sonoelastographic findings for the normal brachial plexus via shear wave elastography (SWE) and strain elastography (SE) and the reliability of the measurements. METHODS: Thirty-nine healthy adult volunteers were included in the study. The brachial plexus was evaluated with SWE and SE at the interscalene region by 2 observers separately, and the observers were unaware of each other's outcomes. The elastic modulus (kilopascals), shear wave velocity (SWV, meters per second), and strain ratio were obtained. Elasticity patterns on SE were assessed as hard, intermediate, and soft. An intraclass correlation coefficient analysis was performed for determining the reliability of sonoelastographic findings. The correlation of sonoelastographic features with age and sex was investigated. RESULTS: The volunteers included 13 men and 26 women. The mean age of the participants ± SD was 36.2 ± 7.8 (range, 25-56) years. The mean elasticity modulus values of the brachial plexus for observers 1 and 2 were 17.03 (95% confidence interval [CI], 15.03, 19.03) and 13.83 (95% CI, 12.23, 15.43) kPa, respectively; the SWVs were 2.24 (95% CI, 2.12, 2.36) and 2.04 (95% CI, 1.93, 2.15) m/s; and the strain ratios were 1.20 (95% CI, 1.18, 1.25) 1.38 (95% CI, 1.22, 1.54). The elasticity pattern was mostly intermediate stiffness for both observers (n = 72 [92.3%]; n = 75 [96.1%]). The intraclass correlation coefficient was poor to moderate and statistically significant for the elastic modulus, SWV, and elasticity pattern (P < .05 for all parameters). The sonoelastographic characteristics of the brachial plexus had no correlation with age or sex. CONCLUSIONS: The reliability and reproducibility of sonoelastography of the brachial plexus are low, and the appropriateness of this technique in this manner is controversial.

Advantages of US in percutaneous dilatational tracheostomy: randomized controlled trial and review of the literature.

PURPOSE: To compare procedure times and complication rates of preincisional ultrasonographic (US) evaluation and perioperative US guidance in percutaneous dilatational tracheostomy ( PDT percutaneous dilatational tracheostomy ) with those of the current standard of care, PDT percutaneous dilatational tracheostomy performed without image guidance. MATERIALS AND METHODS: Between December 2007 and January 2011, 341 patients were included in this institutional review board-approved study after informed consent was obtained from the patients or their relatives. The patients were divided randomly into two groups. In group A (n = 166), the possible causes of complications, such as aberrations of tracheal, thyroidal, and vascular structures, were determined with US, and tracheal measurements were performed by using US. The clinician's initial considerations at physical examination were compared with the US findings. PDT percutaneous dilatational tracheostomy was subsequently performed with US guidance in suitable cases. In group B (n = 175), PDT percutaneous dilatational tracheostomy was performed solely on the basis of physical landmarks. The procedure times and complication rates were compared across groups by using the Fisher exact test. RESULTS: In group A, the puncture sites designated at the physical examination were reconsidered in 39 (23.8%) of 164 cases. The perioperative complication rates were slightly lower in group A (7.8% [12 of 154]) than in group B (15.0% [25 of 167]); however, the difference did not achieve statistical significance (P = .054). The mean procedure times for groups A and B were 24.09 minutes ± 8.05 (standard deviation) (range, 14-68 minutes) and 18.62 minutes ± 6.34 (range, 12-81 minutes), respectively (P = .001), and the numbers of patients in each group who required multiple puncture attempts were six (3.9%) of 154 and 23 (13.6%) of 169 (P = .003), respectively. CONCLUSION: The use of US guidance before and during PDT percutaneous dilatational tracheostomy could render the procedure easier and safer, with fewer complications but a slightly longer procedure time.

Splenic cysts: clues in sonographic differential diagnosis and a new role for twinkling artifact.

AIM: Our aim was to investigate the frequency of various splenic cysts, to define the sonographic differential diagnostic clues and to introduce the value of twinkling artefact in the diagnosis of epidermoid splenic cysts. MATERIAL AND METHODS: All the splenic cysts imaged by ultrasound in 3 university hospitals during the period of 2005 to 2022 were recorded, followed-up and analyzed. RESULTS: One hundred seventy-one patients with splenic cysts were detected and these were classified and 73% of the cysts were simple. Ten cysts were epidermoid cysts as proven by post-operative final histology. CONCLUSION: Cystic splenic lesions are rare. Most of them are small simple cysts. Epidermoid cysts are larger in volume, constitute 6% of the total and can be differentiated by the help of twinkling artefact by Doppler ultrasound.

Investigation of Childhood Pneumonia With Thoracic Ultrasound: A Comparison Between X-ray and Ultrasound.

ABSTRACT: Childhood pneumonia is a common entity, and chest x-rays are widely used as an initial diagnostic step. To avoid radiation exposure in the pediatric age group, we assessed whether the diagnostic accuracy of ultrasound (US) imaging is sufficient in the diagnosis. One hundred thirty-three children with pneumonia (72 girls/61 boys) were participated to study between 2019 and 2021. All participants had a chest x-ray. Radiologists who perform the US scans and interpret the x-rays were blinded to each other. A comparative analysis was also done to assess US findings on pneumonia for different age groups. We compare the diagnostic accuracy of US and x-rays by McNemar test and receiver operating characteristic curves. Intraclass correlation coefficient values were calculated for the assessment of interobserver agreement of x-ray evaluation. The participants' ages ranged from 1 month to 17 years and 8 months with a median age of 24 months (Q 1 : 8 and Q 3 : 66 months). Hospital stay lengths were longer, consolidation depths were greater, and presence of air bronchogram or pleural effusion was more frequent in school-age children. The proportion of consolidation seen on chest x-ray and transthoracic US scan was significantly different ( P < 0.001). The area under the curve was greater in the US than in the chest x-ray (area under the curve, 0.94 and 0.76 respectively). There was a good agreement between the 2 interpreters on chest x-ray assessment ( κ = 0.661). The thoracic US can be used as a safe and efficient imaging tool in the diagnosis of pediatric pneumonia.

Extraprostatic extension in multiparametric MRI; Is presurgical detection possible?

INTRODUCTION: Extraprostatic extension (EPE) is one of the important factors affecting the prognosis of prostate cancer (PCa). Therefore, preoperative evaluation of the presence of EPE is essential in multiparametric magnetic resonance imaging (mpMRI) examination. However, for the evaluation of mpMRI, objective criteria are needed to detect EPE, especially microscopic EPE. AIM: To evaluate the efficacy of 1.5T MRI using lesion length (LL) and tumor-capsule contact length (TCL) in detecting EPE in PCa. METHODS: A total of 110 patients who underwent radical prostatectomy due to PCa were enrolled. Preoperative MR images were evaluated retrospectively by two independent observers who did not know the histopathological results. The observers evaluated LL and TCL. The radiological findings, including lesion location, were verified using histopathological mapping. RESULTS: Multiparametric MRI examination of the prostate demonstrated low sensitivity (Observer 1; 40.4% and Observer 2; 40.4%) but high specificity (Observer 1; 96.6% and Observer 2; 84.5%), with significant differences for detecting EPE (Observer 1, P < 0.0001; Observer 2, P = 0.003). The increased PI-RADS score correlated positively with the increased EPE rate (P < 0.0001 for both observers). The mean LL and TCL values were statistically significantly higher in patients with EPE than in patients without EPE. The TCL was a significant parameter for EPE, with high sensitivity and low for both observers. For both observes the cutoff value of LL for EPE was 14.5 mm, and the cutoff value of TCL for EPE was 9.5 mm. Histopathological LL value (28 ± 12,3 mm) was higher than radiological LLs (Observer 1; 22,14 ± 10,15 mm and Observer 2; 19,06 ± 8,61). CONCLUSION: The results revealed that 1.5T MRI demonstrated low sensitivity and high specificity in detecting EPE. The LL and TCL may be indirectly beneficial in detecting EPE. Considering the radiological underestimation of LL may be helpful before PCa surgery.

Interobserver and Intraobserver Reliability in Sonoelastographic Assessment of Thyroid Nodules.

BACKGROUND: Thyroid ultrasonography is the first and perhaps most fundamental step for the radiological distinction of benign and malignant nodules. In this study, 2 radiologists reviewed the sonoelastographic and Doppler images of thyroid nodules and evaluated for the intraobserver and interobserver reliability. PURPOSE: We aimed to determine confusing nodule identifiers and sonographic features differently defined by observers. METHODS: A total of 157 nodules in 91 patients (male/female, 72:19) with ages ranging from 18 to 72 years old were included in the study. Ultrasonographic images and video clips of the nodules were obtained and presented to 2 reviewers unaware of the cytopathology results. Two observers defined the characteristics of the nodules based on previously determined criteria. Then, intraobserver and interobserver correlation coefficients were calculated for each subcategory. RESULTS: In the grayscale ultrasonographic examination, varying degrees from low to high interobserver correlation coefficients were obtained for different subcategories (between κ = 0.359 and κ = 0.821). In color Doppler examination, we obtained medium correlation coefficients ( κ = 0.493 and κ = 0.553). On the other hand, there was a high correlation coefficient in tissue compression elastography ( κ = 0.617 and κ = 0.638).According to our study results, elastographic pattern, shape of the nodule, presence of echogenic foci, and pathological lymph nodes are better predictors to determine the malignant potential of thyroid nodule with higher interobserver correlation. Therefore, these criteria may be used primarily for the evaluation of thyroid nodules. The intraobserver correlation coefficient was higher in the practitioner with longer experience, suggesting the importance of professional practice period on the decision-making process.

Bi-RADS category 3 nonpalpable breast masses on sonography: long-term results of a prospective cohort study.

PURPOSE: To determine the frequency of BI-RADS category 3 nonpalpable masses detected using only sonography (US) and the malignancy rate among these lesions. Second, to validate a proposed short-term follow-up regimen based on long-term observational results. METHODS: This prospective cohort study was conducted between September 2003 and April 2010. We conducted a 2-year short-term follow-up protocol composed of five US examinations at 3-month intervals for the first 6 months, and at 6-month intervals for the next 18 months, followed with age-appropriate screenings. Biopsy was recommended for the masses increasing in size and with changing imaging features. RESULTS: The frequency of category 3 nonpalpable masses detected only on US in 11,373 consecutive women was 5.3%. Of 562 lesions found in 451 women, 394 (70.1%) remained stable during the short-term and subsequent follow-up. Seventy-four (13.1%) masses showed interval regression and 79 (14.0%) showed interval progression. The malignancy rate was 0.3% (2 of 562), with about 85% of interval changes occurring within the first 2 years. The negative predictive value of US in the detection of cancer was 99.6% (95% CI, 98.7-99.9). The mean follow-up time was 65.5 ± 8.7 months. CONCLUSIONS: The frequency of BI-RADS 3 nonpalpable masses detected using sonography alone was 5.3%. During follow-up, the majority of interval changes occurred within the first 2 years. Because these masses have a very low malignancy rate, a 2-year follow-up instead of immediate biopsy is an appropriate option.

Patellofemoral Anatomical Measurements on MRI in Patient with Suprapatellar Fat Pad Edema and Mass Effect.

OBJECTIVE: To evaluate the impact of patellofemoral joint anatomical measurements of patients with anterior knee pain who were diagnosed with suprapatellar fat pad (SPFP) impingement syndrome (SP-FPIS) by magnetic resonance imaging (MRI). STUDY DESIGN: A prospective, descriptive study. PLACE AND DURATION OF STUDY: Goztepe Education and Research Hospital, between March 2015 and June 2019. METHODOLOGY: The study included 34 patients (Group 1) and 34 healthy volunteers (Group 2) who were referred to the radiology clinic with anterior knee pain; they underwent MRI and diagnosed with SP-FPIS. Twenty-three anatomical measurements such as SPFP cranio caudal length (CC), anteroposterior length (AP), oblique length (OBL), patellar length (PL), patellar tendon length (PTL), Insall Salvati Index (ISI), patellar cartilage distal-tibial tubercle (TT), patellar cartilage length (PCL), Modified Insall Salvati Index (MISI), patellotrochlear cartilage length (TCL), lateral trochlear inclination angle (LTI), etc. related to the morphological structure of SPFP and patellofemoral joint were evaluated and compared in both groups. RESULTS: The mean age of groups 1 and 2 was 45.62±10.87 and 41.47±11.98 years, respectively. There was a statistically significant difference in patients with SP-FPIS in PL, PT, TT, PC, MISI, TC, PTI, MF, PHY, PPI, MT, LTI, CC, AP, and OBL measurements compared with the control group (p<0.05). In the logistic regression analysis performed to evaluate the effect of statistically significant parameters on anterior knee pain, the probability of SP-FPIS increases 1.5 times as PTL increases among the groups, while the risk of SP-FPIS decreases 0.78 times as LTI decreases (p<0.05). CONCLUSION: There is a predisposing effect of PTL increase in SP-FPIS development, while LTI decrease has a protective effect. These results will guide future studies for the development and/or modification of treatment methods. KEY WORDS: Patellofemoral joint, Suprapatellar fat pad impingement syndrome, Anterior knee pain, Knee magnetic resonance imaging, Knee anatomy.

Cystic renal diseases: role of ultrasound. Part II, genetic cystic renal diseases.

Kidney cysts are quite common in adults. Though small simple renal cysts in an adult over 30-40 years of age are not too unusual, however, if the same cysts are seen in a child, and especially if there are additional findings, then several diagnostic possibilities may come to mind. The role of ultrasound, together with the help of intravenous contrast agents and Doppler mode, are very critical in describing the morphologic features and follow-up of the complex or multiple and bilateral renal cysts. These sonographic signs are occasionally specific for diagnosis, but in many cases sonographic clues should be evaluated together with the other genetic and clinical data to reach diagnosis.The first part of this pictorial essay included the introduction into the subject and the classification of non-genetic cystic renal diseases. The key features for the non-genetic cystic renal diseases are illustrated. In the second part, eye-catching features of genetic cystic renal diseases are demonstrated.

The role of intraoperative ultrasonography in detection of hepatic vein variations in living donor liver transplantation.

BACKGROUND: With advances in surgical techniques and immunosuppression, liver transplantation has become the most effective treatment of acute and chronic liver failures. Evaluation of vascular anatomy and detection of hepatic vascular variations prior to surgery, especially transplantation surgery, can help reduce complications in both the donor and the recipient. Intraoperative ultrasonography (IOUS) is known to be beneficial during planning of the transplantation surgery, and can help direct the surgery itself. OBJECTIVES: To our knowledge, there are no existing studies that evaluate the number and diameter of segment 5 and 8 branches that need to be anastomosed with IOUS. PATIENTS AND METHODS: In this study, considering surgical anatomical evaluation as the gold standard, IOUS findings were compared to computed tomography angiography (CTA) findings. 40 patients were included in the study. RESULTS: The average diameters of segment 8 branches that were anastomosed and not anastomosed were significantly different when measured by IOUS (p = 0.016); however, no such statistically significant difference was found in measurements made with CTA (p = 0.89). CONCLUSION: CTA is superior to IOUS in detecting segment 5 and 8 veins draining into the middle hepatic vein. However, IOUS is more accurate in predicting which vessels are going to be anastomosed. For a complete and accurate assessment, both imaging modalities should be used to complement each other, and their respective advantages and disadvantages should be known.

An intrathyroidal nodule consisting of papillary thyroid cancer and ectopic hyperechoic parathyroid adenoma: a case report.

A 53-year-old woman with fatigue lasting for 6 weeks and increased parathormone level underwent a neck ultrasound. It revealed a large, lobulated, solid intrathyroidal nodule consisting of hypoechoic component with microcalcifications and hy-perechoic component with vascularity on Doppler mode. There were also subcentimetric intrathyroidal hypo- and hyperechoic nodules. Upon the diagnosis of papillary thyroid cancer on fine-needle aspiration biopsy, a total thyroidectomy procedure was performed. In the histopathologic evaluation, the hypoechoic component was diagnosed as papillary thyroid cancer, while the hyperechoic component was diagnosed as ectopic parathyroid adenoma. Subcentimetric nodules were demonstrated as multi-foci of papillary thyroid cancer.

Imaging appearance of post umbilical venous catheter displacement: liver collections in children.

Umbilical venous catheters (UVCs) have become a part of routine perinatal care. In the case of its misplacement, extravasation into liver parenchyma might be observed and unusual findings might be detected and a suspicion of tumoral lesions emerges during the ultrasound examination. To avoid the unnecessary liver biopsies and catastrophic complications of UVC misplacement in the pediatric population, clinicians and radiologists must be familiar with the radiological findings. We aimed to present sonographic and computed tomographic images of liver collections resulting from UVC malposition.