Application of Point-of-care Cardiac Ultrasonography in COVID-19 Infection: Lessons Learned from the Early Experience.

The outbreak of the SARS-CoV-2 infection, also known as coronavirus disease 2019 (COVID-19), was formally defined a pandemic by the World Health Organization (WHO) in March 2020, and is still a global health issue. Since there is a high prevalence of acute cardiac injury in patients with COVID-19 infection, point-of-care cardiac ultrasound (PoCCUS) may be used for longitudinal monitoring of patients infected with COVID-19. However, there is still limited experience on the application of PoCCUS in the COVID-19 pandemic. Within the point of care setting in our system, focused cardiac US exams were performed with specific imaging protocols on the basis of suspicion of a specific disease, such as ruling out tamponade or thrombotic complications. Our preliminary experience shows that PoCCUS helps distinguish the causes of dyspnea in febrile patients. The COVID-19 infection may play a role in unmasking or exacerbating underlying chronic cardiovascular conditions, especially in patients with inadequate past history. In hospitalized patients with COVID-19, CURB-65 score for pneumonia severity and raised D-dimer were significantly associated with deep vein thrombosis (DVT). COVID-19 patients with DVT had worse prognosis, and patients with lower leg edema deserve further evaluation by using point-of-care ultrasound for the lower legs and heart. In COVID-19 patients with arrhythmia, PoCCUS used by experienced hands may reveal abnormal right ventricle (RV) functional parameters and lead to a more comprehensive cardiac US study. When there is suspicion of cardiac disease, PoCCUS can be done first, and if information is inadequate, limited transthoracic echocardiography (TTE), and critical care echocardiography (CCE) can be followed. Ultrasound practitioners should follow the standard precautions for COVID-19 as outlined by the Centers for Disease Control and Prevention to prevent transmission of infection, regardless of suspected or confirmed COVID-19.

Percutaneous ethanol ablation of intrahepatic arterial pseudoaneurysm: A case report.

Hepatic arterial pseudoaneurysm is a rare but potentially fatal condition that requires prompt management. We report a case of hepatic arterial pseudoaneurysm developed after radiofrequency ablation of a hepatocellular carcinoma. The patient was successfully treated with percutaneous absolute ethanol injection under ultrasound guidance. Follow-up studies with ultrasound and computed tomography for 2 years after treatment revealed no evidence of local recurrence of hepatocellular carcinoma and of the pseudoaneurysm.

Safety of Perfluorobutane (Sonazoid) in Characterizing Focal Liver Lesions.

BACKGROUND: The purpose of this study was to report the safety of perfluorobutane (Sonazoid) as a vascular-phase imaging agent in characterizing focal liver lesions (FLLs). MATERIALS AND METHODS: From May 2014 to April 2015, a total of 54 individuals who received Sonazoid contrast-enhanced ultrasound (CEUS) were enrolled at 5 hospitals of 4 medical centers. All individuals were included in safety evaluation. A prospective study to evaluate the adverse effect (AE) incidences after intravenous administration of Sonazoid. RESULTS: Sonazoid was well tolerated. Treatment-emergent adverse events (TEAEs) representing AE were recorded for 13 (24.1%) patients. The most common AE was abdominal pain (9.3%), followed by heart rate irregularity (5.6%). The majority of these patients (69.2%) experienced TEAEs that were mild in intensity. Sonazoid causes no significant AEs after intravenous injection. The only noteworthy AEs are related to tolerable myalgia (3.7%), abdominal pain (1.9%), and headache (1.9%). None of the 54 patients showed serious adverse effects. CONCLUSION: Sonazoid shows good safety and tolerance of intravenous use during CEUS of the liver for evaluation of FLLs.

Shoulder joint synovial chondromatosis presenting as multiple axillary masses: A case report.

Synovial chondromatosis is a rare, benign, proliferative cartilaginous lesion arising from the synovial tissue, tenosynovium, or bursal lining. We describe the case of a patient who initially presented with multiple axillary masses. Breast ultrasound (US) was requested due to the concern of a breast tumor with axillary lymph node metastases. US study was helpful and provided adequate information to suggest the diagnosis.

A comparison of central nervous system involvement in patients with classical Fabry disease or the later-onset subtype with the IVS4+919G>A mutation.

BACKGROUND: Patients with the later-onset IVS4+919G>A (IVS4) Fabry mutation are known to have positive central nervous system involvement compared with age- and sex-matched controls. This study compares central nervous system manifestations in patients with the IVS4 mutation or classical Fabry mutations. METHODS: This was a retrospective analysis of magnetic resonance imaging (MRI) data from Taiwanese patients enrolled in the Fabry Outcome Survey (sponsored by Shire; data extracted March 2015). RESULTS: Twenty-five IVS4 (19 males) and 12 (four males) classical Fabry patients underwent MRI at a median (range) age of 60.7 (45.0-70.4) and 43.0 (18.0-61.4) years, respectively. All patients received agalsidase alfa enzyme replacement therapy; two (16.7%) classical Fabry patients underwent MRI before treatment start. The pulvinar sign occurred in eight (32.0%; seven males) IVS4 and six (50.0%; three males) classical Fabry patients. Infarction occurred in eight (32.0%) IVS4 and four (33.3%) classical Fabry patients. Fazekas scores of 0, 1, 2, and 3 were found for 15 (60.0%), seven (28.0%), two (8.0%), and one (4.0%) of the IVS4 patients and for six (50.0%), four (33.3%), two (16.7%), and 0 classical Fabry patients, respectively. Abnormal height bifurcation of the basilar artery was observed in 40.0% of IVS4 and 58.3% of classical Fabry patients; abnormal laterality was observed in 4.0% of IVS4 and 16.7% of classical Fabry patients. Median (range) basilar artery diameter was 2.7 (1.4-4.0) mm in IVS4 and 3.2 (2.3-4.7) mm in classical Fabry patients (P = 0.0293); vascular stenosis was noted in 8.3% of IVS4 patients but in no classical Fabry patients. CONCLUSIONS: A similar range of MRI findings was found for both IVS4 and classical Fabry patients. Notably, basilar artery diameter was larger in classical Fabry patients than IVS4 patients.

Solitary fibrous tumor of the breast: A case report and review of the literature.

Solitary fibrous tumor (SFT) is an uncommon neoplasm of mesenchymal origin, which can be benign or malignant. Most SFTs develop from the pleura, but they can also be found in other sites. There are only few reports of SFT occurring in the breast. We herein report such a rare case. Sonography demonstrated an ovoid lesion mimicking a fibroadenoma, whereas color Doppler imaging showed marked internal vascularity. A brief literature review on imaging features of SFTs is added. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:350-354, 2017.

Left Ulnar Artery Pseudoaneurysm and Left Hand Swelling Simulated by Elephantiasis in a Patient with Neurofibromatosis Type 1.

Elephantiasis is a condition featured by gross enlargement of body parts to massive proportions. Neurofibromatosis type 1 (NF1) is a multisystem genetic disorder. Vascular anomaly is one among the complications of NF1. We report a case of NF1 who had a left hand vascular pseudoaneurysm with left hand swelling mimicking elephantiasis. The characteristics of sonography make it an excellent imaging modality to investigate this sort of superficial vascular lesion.

Right-Sided Colonic Diverticulitis: Clinical Features, Sonographic Appearances, and Management.

PURPOSE: This study aims to evaluate patients with right-sided colonic diverticulitis detected at ultrasonography (US). METHODS: We retrospectively analyzed 14 patients. Demographic data, clinical features, and US images were documented. RESULTS: In the 14 patients, clinical manifestations included right lower abdominal tenderness (93%), leukocytosis (57.1%), and fever (28.6%). Diverticulitis occurred in cecum and ascending colon with a similar frequency (35.7%). US features included diverticular wall thickening (50%), surrounding echogenic fat (50%), intradiverticular echogenic material (50%), adjacent lymph node enlargement (21.4%), intradiverticularor peridiverticular fluid collection (28.6%), and color flow signals on or surrounding the diverticula (14.3%). Two (14.2%) patients suffered from recurrence. Two (14.3%) patients had abscess formation, and one (7.1%) patient had diverticulum perforation. Most (85.7%) patients received conservative treatment only. One (7.1%) patient received computed tomography-guided drainage due to diverticulum perforation and pocket of abscess formation. One patient underwent surgery due to recurrent diverticulitis-related fistula. CONCLUSION: Common US features of diverticulitis include diverticular wall thickening, surrounding echogenic fat, and intradiverticular echogenic material. Proper recognizing of these features helps in differentiating diverticulitis from appendicitis and may obviate an unnecessary emergent surgery.

Type I Choledochal Cyst Complicated With Acute Hemorrhagic Pancreatitis: A Case Report.

Choledochal cysts rarely present with acute pancreatitis. We report a patient with type I choledochal cyst(s) who had concomitant acute frank hemorrhagic pancreatitis. A 14-year-old male noted with a history of recurrent abdominal pain, fever and jaundice. Ultrasonography (US) of abdomen at the Emergency Department depicted distended gall bladder with wall thickening. Apparently dilated intrahepatic ducts (IHDs) and fusiform dilatation of the common bile duct (CBD), and mild dilatation of the pancreatic duct were also noted, suggesting a type I choledochal cyst( ). Computed tomography (CT) demonstrated calcifications in the uncinate process of the pancreas in addition to the similar findings on US. He subsequently underwent choledochal cyst excision with a Roux-en-Y hepaticojejunostomy. After surgical treatment, he has been doing well for 3 years.

Epidermoid cyst of the testis: An atypical sonographic appearance.

Epidermoid cysts are rare. They represent the most common benign tumor of the testis. The sonographic appearances of testicular epidermoid cysts usually include avascular, mostly lamellated, heterogeneous internal echotexture, with hypoechoic and hyperechoic concentric rings, accounting for the typical onion-ring appearance. On MRI, epidermoid cysts show a low-signal-intensity center, with internal concentric rings of alternating high- and low-signal intensity on T2-weighted images, which correlates with the onion-ring appearance. We report a patient with testicular epidermoid cyst with atypical ultrasound and MRI appearances that led to the erroneous initial diagnosis of "burned-out" tumor. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:448-451, 2016.

Thyroid metastasis from breast cancer presenting with diffuse microcalcifications on sonography: a case report.

Microcalcifications are frequently associated with papillary thyroid cancers. Metastatic nodules from extrathyroid malignancies may mimic primary thyroid neoplasm on sonography, but do not present with microcalcifications. We report the case of a 45-year-old woman with a history of invasive ductal carcinomas of bilateral breasts, status post surgery and neoadjuvant chemotherapy. Four years after surgery, thyroid sonography revealed diffuse microcalcifications without nodular component. Core needle biopsy confirmed thyroid metastasis from primary breast cancer.

Long-term secular trend of skeletal maturation of Taiwanese children between agricultural (1960s) and contemporary (after 2000s) generations using the Tanner-Whitehouse 3 (TW3) method.

BACKGROUND: The Tanner-Whitehouse (TW) method is one of the well-known techniques in determining the bone age. OBJECTIVE: According to the objectivity of TW3, the secular trend was investigated to discover whether the skeletal maturation of Taiwanese children between two generations was different. SUBJECTS AND METHODS: The large-scale database of Taiwan was collected. The first group, called mid-1960s, included 265 boys and 295 girls in the agricultural generation (between 1966 and 1967). The second group, called mid-2000s, includes 114 boys and 616 girls in the contemporary generation (after 2000s). The bone age was determined by three radiologists using the carpals-only system of the TW3 method and by two physicians using the Greulich and Pyle method. A comparison of the means (independent-samples t-test) was applied by examining the difference of the children's skeletal maturation between the two generations in the same chronological age. The significant difference was considered while the p-value was 0.05 or less (95% confidence interval). RESULTS: A significant difference of the mean bone age (by, on average, three radiologists using the TW3 method) between the mid-1960s and mid-2000s in the same gender and chronological age was presented by the independent-samples t-test (p<0.001 with 95% confidence interval), and the bone age, determined by the TW3 method, of the mid-2000s group was higher than that of the mid-1960s group. This scenario corresponded with the children's bone age determined by pediatricians. Besides, it deserved to notice that the bone age of boys in the mid-2000s was larger than that of the girls in the mid-1960s. Furthermore, by comparing the environmental condition, we suspect that the difference of bone age of children between the two generations was attributed to the discrepancy in nutrition and socioeconomic variation during the four decades in Taiwan. CONCLUSION: The study presents that the secular trend of skeletal maturation of children in the mid-2000s is faster than that in the mid-1960s.

Stochastic region competition algorithm for Doppler sonography segmentation.

PURPOSE: A probabilistic image segmentation algorithm called stochastic region competition is proposed for performing Doppler sonography segmentation. METHODS: The image segmentation is conducted by maximizing a posteriori that models histogram likelihood, gradient likelihood, and a spatial prior. The optimization is done by a modified expectation and maximization (EM) method that aims to improve computation efficiency and avoid local optima. RESULTS: The algorithm was tested on 155 color Doppler sonograms and compared with manual delineations. The qualitative assessment shows that our algorithm is able to segment mass lesions under the condition of low image quality and the interference of the color-encoded Doppler information. The quantitative assessment analysis shows that the average distance between the algorithm-generated boundaries and manual delineations is statistically comparable to the variability of manual delineations. The ratio of the overlapping area between the algorithm-generated boundaries and manual delineations is also comparable to that between different sets of manual delineations. A reproductivity test was conducted to confirm that the result is statistically reproducible. CONCLUSIONS: The algorithm can be used to perform Doppler sonography segmentation and to replace the tedious manual delineation task in clinical application.

Interrelationship of carpal angle and bone age in children of different generations: a retrospective study.

BACKGROUND: Carpal angle measurement is one of the anthropometrical methods to evaluate the maturation of children. OBJECTIVE: To discuss the relationship between bone age and carpal angle in the maturation of children of two different generations. SUBJECTS AND METHODS: The first group (mid-1960s group) includes 521 Taiwanese children, 196 boys and 325 girls, growing during the agricultural period (between 1966 and 1967). The second group (mid-2000s group) includes 326 children, 74 boys and 252 girls, growing during the mid-2000s. The bone age of both groups was assessed by two leading physicians, and the carpal angle was measured by two senior radiologists. The Mann-Whitney U-test was used to compare the relationship of carpal angle and bone age among eras, sexes, and chronological ages. RESULTS: According to the same chronological age and sexes, the carpal angle of those in the mid-2000s group was larger than that of the mid-1960s group. In addition, in the same chronological age, the results also show that the mean carpal angle of girls in both generations was larger than that of boys. However, it is notable that the carpal angle of boys in the mid-2000s group is larger than that of girls in the mid-1960s group. Furthermore, by comparing the environmental condition, we suspect that the differences between carpal angles of both generation children are caused by the great changes in socioeconomic and nutrition status in Taiwan. CONCLUSION: The study presents a quantitative comparison of carpal angle between two generations of Taiwanese. The preliminary result indicates that the carpal angle for the mid-2000s group is larger than that for the mid-1960s groups.

Simplified radius, ulna, and short bone-age assessment procedure using grouped-Tanner-Whitehouse method.

BACKGROUND: The Tanner-Whitehouse III (TW3) method is popular for assessing children's bone age, but it is time-consuming in clinical settings; to simplify this, a grouped-TW algorithm (GTA) was developed. METHODS: A total of 534 left-hand roentgenograms of subjects aged 2-15 years, including 270 training and 264 testing datasets, were evaluated by a senior pediatrician. Next, GTA was used to choose the appropriate candidate of radius, ulna, and short bones and to classify the bones into three groups by data mining. Group 1 was composed of the maturity pattern of the radius and the middle phalange of the third and fifth digits and three weights were obtained by data mining, yielding a result similar to that of TW3. Subsequently, new bone-age assessment tables were constructed for boys and girls by linear regression and fuzzy logic. In addition, the Bland-Altman plot was utilized to compare accuracy between the GTA, the Greulich-Pyle (GP), and the TW3 method. RESULTS: The relative accuracy between the GTA and the TW3 was 96.2% in boys and 95% in girls, with an error of 1 year, while that between the assessment results of the GP and TW3 was about 87%, with an error of 1 year. However, even if the three weights were not optimally processed, GTA yielded a marginal result with an accuracy of 78.2% in boys and 79.6% in girls. CONCLUSIONS: GTA can efficiently simplify the complexity of the TW3 method, while maintaining almost the same accuracy. The relative accuracy between the assessment results of GTA and GP can also be marginal.

Computer-aided US diagnosis of breast lesions by using cell-based contour grouping.

PURPOSE: To develop a computer-aided diagnostic algorithm with automatic boundary delineation for differential diagnosis of benign and malignant breast lesions at ultrasonography (US) and investigate the effect of boundary quality on the performance of a computer-aided diagnostic algorithm. MATERIALS AND METHODS: This was an institutional review board-approved retrospective study with waiver of informed consent. A cell-based contour grouping (CBCG) segmentation algorithm was used to delineate the lesion boundaries automatically. Seven morphologic features were extracted. The classifier was a logistic regression function. Five hundred twenty breast US scans were obtained from 520 subjects (age range, 15-89 years), including 275 benign (mean size, 15 mm; range, 5-35 mm) and 245 malignant (mean size, 18 mm; range, 8-29 mm) lesions. The newly developed computer-aided diagnostic algorithm was evaluated on the basis of boundary quality and differentiation performance. The segmentation algorithms and features in two conventional computer-aided diagnostic algorithms were used for comparative study. RESULTS: The CBCG-generated boundaries were shown to be comparable with the manually delineated boundaries. The area under the receiver operating characteristic curve (AUC) and differentiation accuracy were 0.968 +/- 0.010 and 93.1% +/- 0.7, respectively, for all 520 breast lesions. At the 5% significance level, the newly developed algorithm was shown to be superior to the use of the boundaries and features of the two conventional computer-aided diagnostic algorithms in terms of AUC (0.974 +/- 0.007 versus 0.890 +/- 0.008 and 0.788 +/- 0.024, respectively). CONCLUSION: The newly developed computer-aided diagnostic algorithm that used a CBCG segmentation method to measure boundaries achieved a high differentiation performance.

Intensity inhomogeneity correction for the breast sonogram: constrained fuzzy cell-based bipartitioning and polynomial surface modeling.

PURPOSE: To develop an intensity inhomogeneity algorithm for breast sonograms in order to assist visual identification and automatic delineation of lesion boundaries. METHODS: The proposed algorithm was composed of two essential ideas. One was decomposing the region of interest (ROI) into foreground and background regions by a cell-based segmentation algorithm, called constrained fuzzy cell-based bipartition-EM (CFCB-EM) algorithm. The CFCB-EM algorithm deformed the contour in a fuzzy cell-based deformation fashion with the cell structures derived by the fuzzy cell competition (FCC) algorithm as the deformation unit and the boundary estimated by the normalized cut (NC) algorithm as the reference contour. The other was modeling the intensity inhomogeneity in an ROI as a spatially variant normal distribution with a constant variance and spatially variant means, which formed a polynomial surface of order n. The proposed algorithm was formulated as a nested EM algorithm comprising the outer-layer EM algorithm, i.e., the intensity inhomogeneity correction-EM (IIC-EM) algorithm, and the inner-layer EM algorithm, i.e., the CFCB-EM algorithm. The E step of the IIC-EM algorithm was to provide a reasonably good bipartition separating the ROI into foreground and background regions, which included three major component algorithms, namely, the FCC, the NC, and the CFCB-EM. The M step of the IIC-EM algorithm was to estimate and correct the intensity inhomogeneity field by least-squared fitting the intensity inhomogeneity to an nth order polynomial surface. Forty-nine breast sonograms with intensity inhomogeneity, each from a different subject, were randomly selected for performance analysis. Three assessments were carried out to evaluate the effectiveness of the proposed algorithm. RESULTS: Based on the visual evaluation of two experienced radiologists, in the first assessment, 46 out of 49 breast lesions were considered to have better contrasts on the inhomogeneity-corrected images by both radiologists. The interrater reliability for the radiologists was found to be kappa = 0.479 (p = 0.001). In the second assessment, the mean gradients of the low-gradient boundary points before and after correction of the intensity inhomogeneity were compared by the paired t-test, yielding a p-value of 0.000, which suggested the proposed intensity inhomogeneity algorithm may enhance the mean gradient of the low-gradient boundary points. By using the paired t-test, the third assessment further showed that the Chan and Vese level set method could derive a much better lesion boundary on the inhomogeneity-corrected image than on the original image (p = 0.000). CONCLUSIONS: The proposed intensity inhomogeneity correction algorithm could not only augment the visibility of lesion boundary but also improve the segmentation result on a breast sonogram.

ACCOMP: Augmented cell competition algorithm for breast lesion demarcation in sonography.

PURPOSE: Fully automatic and high-quality demarcation of sonographical breast lesions remains a far-reaching goal. This article aims to develop an image segmentation algorithm that provides quality delineation of breast lesions in sonography with a simple and friendly semiautomatic scheme. METHODS: A data-driven image segmentation algorithm, named as augmented cell competition (ACCOMP) algorithm, is developed to delineate breast lesion boundaries in ultrasound images. Inspired by visual perceptual experience and Gestalt principles, the ACCOMP algorithm is constituted of two major processes, i.e., cell competition and cell-based contour grouping. The cell competition process drives cells, i.e., the catchment basins generated by a two-pass watershed transformation, to merge and split into prominent components. A prominent component is defined as a relatively large and homogeneous region circumscribed by a perceivable boundary. Based on the prominent component tessellation, cell-based contour grouping process seeks the best closed subsets of edges in the prominent component structure as the desirable boundary candidates. Finally, five boundary candidates with respect to five devised boundary cost functions are suggested by the ACCOMP algorithm for user selection. To evaluate the efficacy of the ACCOMP algorithm on breast lesions with complicated echogenicity and shapes, 324 breast sonograms, including 199 benign and 125 malignant lesions, are adopted as testing data. The boundaries generated by the ACCOMP algorithm are compared to manual delineations, which were confirmed by four experienced medical doctors. Four assessment metrics, including the modified Williams index, percentage statistic, overlapping ratio, and difference ratio, are employed to see if the ACCOMP-generated boundaries are comparable to manual delineations. A comparative study is also conducted by implementing two pixel-based segmentation algorithms. The same four assessment metrics are employed to evaluate the boundaries generated by two conventional pixel-based algorithms based on the same set of manual delineations. RESULTS: The ACCOMP-generated boundaries are shown to be comparable to the manual delineations. Particularly, the modified Williams indices of the boundaries generated by the ACCOMP algorithm and the first and second pixel-based algorithms are 1.069 +/- 0.024, 0.935 +/- 0.024, and 0.579 +/- 0.013, respectively. If the modified Williams index is greater than or equal to 1, the average distance between the computer-generated boundaries and manual delineations is deemed to be comparable to that between the manual delineations. CONCLUSIONS: The boundaries derived by the ACCOMP algorithm are shown to reasonably demarcate sonographic breast lesions, especially for the cases with complicated echogenicity and shapes. It suggests that the ACCOMP-generated boundaries can potentially serve as the basis for further morphological or quantitative analysis.

Glomus tumor in the stomach.

Gastric glomus tumor is rare and most commonly described as a solitary, well-defined, submucosal lesion in the antrum with non-specific clinical manifestations. We report this case with representative image findings, correlate with clinical presentations and pathologic demonstrations that can help to early detect and distinguish it from other malignant tumors such as gastrointestinal stromal tumor.

Testicular microlithiasis: analysis of prevalence and associated testicular cancer in Taiwanese men.

PURPOSE: To determine the incidence of testicular microlithiasis (TM) in Taiwanese males who were referred for scrotal sonography (US) and to evaluate the association between TM and cancer, with state-of-the-art equipment. METHODS: This retrospective study included 513 males who underwent scrotal US in a period of 7 months. The US images and charts of each patient were reviewed to determine the presence of TM and note relevant clinical information. RESULTS: The data for all 513 patients were analyzed. Their age was 0-91 years (mean, 54.3 years). The overall incidence of TM was 14.4% (74/513); 6.2% (32/513) had classic TM, and 8.2% had limited TM. The incidence of testicular cancer in this population was 1.6% (8/513). Six of eight (75%) patients who had testicular cancer at presentation had classic TM or limited TM. There was a significant difference (P < 0.01) between the rate of malignancy in subjects with TM (6/74) and that in subjects without TM (2/439). CONCLUSION: The incidence of TM in Taiwanese people may be higher than previously reported, which may be due to the difference in methodology and increased awareness of the US findings. Although there was a significant difference in the rate of malignancy in males with TM compared with those without TM, the question remains whether TM independently increases the risk of testicular malignancy.