[Preliminary Application of Contrast-Enhanced Ultrasound in the Treatment of Diabetic Ulcers].

Objective: To investigate the role of contrast-enhanced ultrasound (CEUS) in the treatment of diabetic ulcers. Methods: The clinical data of 27 diabetic patients, who underwent CEUS examination of their ulcers in our hospital between April 2021 and July 2022 were collected. Among them, 26 patients suffered from diabetic foot ulcers, 5 of whom underwent amputation during hospitalization, and one patient suffered from hip ulcer. The 27 patients' mean age was (64.08±12.57) years. Fasting blood glucose levels of the patients were 3.36-34.61 mmol/L, with a mean of (10.62±8.77) mmol/L. Their glycosylated hemoglobin levels were 5.80%-10.70%, with an average of 7.96%±1.50%. Philips EPIQ7 ultrasound system with L9-3 linear probe of 3-9 MHz was used. First, the patients' ulcers were examined with conventional ultrasound to observe for abnormal echo. Then, 2.4 mL SonoVue (Bracco, Italy), a contrast agent, was injected intravenously through the elbow to look for effusion/pus, sinus tract, or dead space in the lesion area, and images were acquired. Results: Among the 27 patients, except for 5 with amputation stumps, 22 patients had wound areas ranging from 0.16 cm 2 to 215 cm 2, all being accompanied by sinus tract formation. Ten patients underwent ultrasound examination during their treatment. The positive rate of the results of conventional ultrasound was 50% (5/10) for identifying effusion/pus and pseudoaneurysm in the deep area of ulcers, while the positive rate of CEUS results was 100% (10/10). In addition to the lesions found by conventional ultrasound, CEUS also found large sinus tracts or dead spaces in the deep surface of ulcers in 5 additional patients. Of the 27 patients, 17 underwent ultrasound examination of the healing status of sinus tracts and dead spaces in the deep areas of ulcers before discharge. No sinus tracts in the deep areas of the ulcers were found by conventional ultrasound. However, relatively small dead spaces or sinus tracts in the deep areas of the ulcers were found in 10 patients by CEUS. Conventional ultrasound and CEUS found that 1 patient had a small amount of fluid in the amputation stump. In the remaining 6 patients, no deep sinus tracts in the ulcers were found by either conventional ultrasound or CUES, and the ulcers healed completely. Conclusion: By examining microvascular perfusion in diabetic wounds with CEUS, we can observe the extent of sinus tracts during treatment and whether the sinus tracts have healed or whether there are still dead spaces before patient discharge, which provides support for clinical decision-making concerning the treatment of diabetic ulcers.

Intravascular Fasciitis of the Jugular Vein Mimicking Thrombosis and Sarcoma: A Case Report.

Background: Intravascular fasciitis is a rare disease that is a reactive proliferative lesion of myofibroblasts. There are rare reports that intravascular fasciitis has invaded the jugular vein as seen in this case. Case Presentation: A 41-year-old female presented with right neck dull pain for 20 days. The appearance of the subcutaneous mass was oval, pink hyaline, well-demarcated, and measuring ~5 mm in diameter. Microscopically, the mass was composed of spindle cells arranged in intersecting fascicles. Immunohistochemical stains showed that the spindle cells were positive for smooth muscle actin and negative for S-100, Desmin, MyoD1, and elastin stains. The nuclei of the spindle cells were relatively uniform, and mitotic activity was observed. The overall morphological and immunohistochemical features are consistent with intravascular fasciitis. Conclusion: Due to the rapid growth and vascular invasion, intravascular fasciitis created a high risk of misdiagnosing it as a sarcoma or thrombosis. Reporting this uncommon case, we raise awareness of this non-neoplastic lesion, and careful, light microscopic examination combined with immunohistochemical staining aids in the diagnosis of intravascular fasciitis.

[Successful Treatment of Refractory Ischemic Diabetic Foot Ulcers by Combination Therapy of Autologous Platelet-rich Gel and Topical ß Adrenergic Receptor Blocker: a Case Report].

HISTORY AND CLINICAL FINDINGS: A 76 year-old woman with 8-year history of diabetes mellitus and hypertension was admitted with gangrene of left great toe, 3rd, 4th and 5th toes. Twenty months ago, She started to receive hemodialysis due to end-stage renal disease. She did not have any history of reactive airway disease nor bradycardia that would contraindicate the use of topical beta-blocker. The X-ray of left lower limb and foot showed calcification of left superficial femoral artery, popliteal artery, anterior tibial artery, posterior tibial artery, dorsal foot artery and digital artery, as well as osteolytic destruction at distal end of metatarsal bone, and lateral dislocation of the 4th and 5th toes. Color Doppler ultrasound of bilateral lower extremity arteries showed obvious calcification of bilateral superficial femoral arteries, thrombosis of left popliteal artery, severe stenosis of left anterior tibial artery, occlusion of left posterior tibial artery, right anterior tibial artery and posterior tibial artery. Computed tomographic angiography (CTA) of bilateral lower limb arteries revealed moderate stenosis of left superficial femoral artery, occlusion of left popliteal artery, left posterior tibial artery and dorsal pedal artery, occulusion of right posterior tibial artery, but right dorsal pedal artery was visible. DIAGNOSIS, TREATMENT AND FOLLOW-UP: Diagnosis of diabetic foot (left, grade 4) and diabetic lower extremity arterial occlusion (left, stage 4) was made. Based on multidisciplinary team (MDT) discussion, the patient was unable to undergo vascular bypass surgery, and left lower extermity amputation also was not suitable because of right atrial thrombosis. Therefore, conservative treatment was recommended. The specific scheme used clopidogrel for antiplatelet agglutination, Low Molecular Weight Heparin (Clexane) and warfarin for anticoagulation, lipo-alprostadil for vasodilation, as well as local debridement and ultrasonic debridement. The treatments were given for up to 9 weeks, but with no significant clinical response. So the patient was treated with vacuum-assisted closure and autologous platelet-rich gel therapy for the next 7 weeks, then applied with 1 drop of timolol maleate 0.5% ophthalmic solution per cm 2 wound area every other day for another 6 weeks, the wound rapidly healed and re-epithelialized basically. The follow-up for 5 weeks showed that the wound healed completely without any discomfort. No side effect was found.

[Effects of GLP-1 Agonist Exenatide on Cardiac Diastolic Function and Vascular Endothelial Function in Diabetic Patients].

OBJECTIVE: To study the protective effect of glucagon-like peptide-1 (GLP-1) on the left ventricular diastolic function and endothelial function in patients with type 2 diabetes. METHODS: 27 patients with type 2 diabetes were randomly divided into two groups: GLP-1 treated group and insulin treated group. Patients in the GLP-1 group were given GLP-1 analogue and metformin hydrochloride. Patients in the insulin group were given insulin and metformin hydrochloride. The outcomes of treatments were measured by fasting plasma glucose (FBG) fasting lipid profile, glycosylated hemoglobin (HbA1c), blood pressure and general clinical features. High resolution Doppler ultrasound was performed to detect mitral early diastolic rapid filling (E-wave), atrial contraction late filling (A-wave), E/A ratio, early diastolic mitral annular velocity (e), late diastolic mitral annular velocity (a), e/a ratio, endothelium-dependent vasodilatation (EDV) mediated by brachial arterial blood flow, and endothelium-independent vasodilatation (EIV) mediated by nitroglycerin. RESULTS: The levels of FBG and HbA1c decreased significantly in both groups after treatments (P < 0.05). Patients in the GLP-1 group showed improved e, e/a ratio, and E/e ratio after treatments (P < 0.05), but no significant changed in E, A, and E/A ratio (P > 0.05). By contrast, patients in the insulin group showed no significant changes in e, a, E, A, E/A ratio, e/a ratio and E/e ratio after treatments (P > 0.05). EDV increased significantly after treatments in both groups (P < 0.05). A higher level of post-treatment EDV was found in patients in the GLP-1 group compared with those in the insulin group. No significant changes in EIV were found in both groups. CONCLUSION: GLP-1 may be able to mitigate the left ventricular diastolic dysfunction and improve endothelial function of patients with type 2 diabetes. Our findings suggest that GLP-1 has the potential to prevent or delay cardiovascular complications in patients with type 2 diabetes. Further studies are needed.

[Ultrasound diagnosis of scrotal wall sarcoma].

OBJECTIVE: To study the ultrasound imaging characteristics of scrotum sarcoma. METHODS: Retrospective analyses of the ultrasound and clinical data of 9 patients with scrotum sarcoma were performed. RESULTS: Of the 9 patients, 5 had scrotum rhabdomyosarcoma, which included 2 cases of alveolus rhabdomyosarcoma and 3 cases of embryonic rhabdomyosarcoma (including 2 embryonic rhabdomyosarcoma of the tunica dartos in the scrotum). Their ultrasound imaging showed single or multiple hypoechoic mass located in the scrotum with distinct boundary and vascularity within the tumor. The other 4 patients had scrotum liposarcoma. The ultrasound imaging of 2 cases of scrotum liposarcoma displayed slightly hyperecho mass, while the other 2 cases displayed hyperecho and hypoechoic heterogeneous echo pattern. All of the mass had identifiable boundary and increased blood vessels. CONCLUSION: Scrotum sarcoma is a rare malignant tumor of male genitalia. Scrotum ultrasound is useful for differentiating it from testicular tumor. The pathological feature of the tumor can be speculated according to the echo pattern and increased blood flow in the tumor.

[Association of glycaemic variability and carotid intima-media thickness in patients with type 2 diabetes mellitus].

OBJECTIVE: To investigate the relationship between blood glucose fluctuations and carotid intima-media thickness (CIMT) in type 2 diabetic patients. METHODS: 64 patients with type 2 diabetes mellitus (T2DM) in the Department of Endocrinology and Metabolism, West China Hospital from July 2009 to March 2012 were recruited in this study. The CIMT were measured bilaterally with high-resolution ultrasonography. The glucose excursions were assessed by the following parameters obtained from the continuous glucose monitoring system (CGMS) for 72 h: mean blood glucose (MBG) and its standard deviation (SD), mean amplitude of glycemic excursion (MAGE), mean of daily differences (MODD). Glycosylated hemoglobin (HbAlc), triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c), and low-density lipoprotein cholesterol (LDL-c) of the participants were also determined. According to the levels of CIMT, 64 diabetic patients were classified into two groups: diabetes mellitus without atherosclerosis (A group, n = 37) and diabetes mellitus with atherosclerosis (B group, n = 27). The relationship between the parameters of glycaemic variability and CIMT was examined. RESULTS: (1) There were no differences between A group and B group with regard to gender composition, course of diabetes, body mass index (BMI), diabetic chronic complications, family history of diabetes, smoking, alcohol drinking, diastolic blood pressure (DBP), TG, TC, HDL-c, SD and MAGE (P > 0.05). A group had younger age and lower levels of systolic blood pressure (SBP), LN(LDL-c) and LN (MODD) than B group (P < 0.05). (2) Pearson correlation analyses showed that CIMT was positively correlated with age (r = 0.370, P = 0.005), LN (LDL-c) (r = 0.325, P = 0.009), SD (r = 0.251, P = 0.045) and LN (MODD) (r = 0.346, P = 0.005). (3) Age, smoking, LN (LDL-c) and LN (MODD) were identified as predictors for CIMT in the multiple linear regression analysis. CONCLUSION: Glucose excursions may contribute to the development of atherosclerosis in patients with type 2 diabetes, which is independent from HbA1c levels.

[The ultrasound image characteristics of lower extremities arteries in diabetic foot].

OBJECTIVE: To identify the ultrasound image characteristics of lower limb arteries in diabetic feet. METHODS: 189 patients with diabetic feet were recruited in this study. 375 lower limbs of the patients were classified into grade I-IV according to their Fontaine classifications and accepted Color Doppler Ultrasound examinations. Of the 375 lower limbs, 210 were classified as level I, 46 as level II, 43 as level III and 76 as level IV. The degree of artery stenosis was categorized into < or = 50% reduction in diameter, 51%-99% reduction in diameter and complete occlusion. The lesion characteristics of common femoral arteries, superficial femoral arteries, popliteal arteries, anterior tibial arteries, posterior tibial arteries, peroneal arteries and dorsalis pedis arteries were analyzed. The ultrasound scores of lower limbs arterial diseases were compared in the patients with different levels of Fontaine classifications. RESULTS: The incidence of plagues in lower extremities arteries was 97.60% (366/375). Most plaques (97.60%, 366/375) were distributed in crus arteries and the majority of plaques (59.47%, 223/375) were serious. The incidence of PAD was 63.73% (239/375). Crus vasculars involvement was more serious. The levels of Fontaine classifications of the lower limb arteries were associated with ultrasound vascular disease severity scores. The higher grade had higher scores. The lower limbs with at least one occlusive blood vessel in the patients with Fontaine grade I reached 30%. CONCLUSION: The Ultrasound image is an important screening tool for PAD in diabetic feet. It can estimate the type of plaques, the seriousness of artery diseases and the location of lesions. Because up to 30% diabetic feet with Fontaine I classifications have at least one occlusive blood vessel, the clinical manifestations do not provide enough evidence for the diagnosis of PAD.

[Surgical treatment of sinus tract in diabetic foot with adjacent pedicle fascia flap and arthrodesis].

OBJECTIVE: To study the therapeutic effect of adjacent pedicle fascia flap filling and arthrodesis in the regional management of sinus tract in diabetic foot. METHODS: From February 2007 to August 2010, 6 patients suffering diabetic foot with sinus tract were included. There were 4 male and 2 female patients, aged 47 to 68 (averaging 58.3 +/- 6.7). One case had the entrance of sinus tract in the heel, and its base located deep in the calcaneus. Three cases had the sinus tract in the vola or dorsum of the foot, in which 1 with a perforating tract connecting the vola and the dorsum. Another 2 cases were in the toes, both located around joints. Under the effective treatments of anti-infection, anti-coagulation and control of blood sugar, blood pressure as well as blood lipid level, the patients were subjected to surgical treatments of sinus tract, the sinuses in the heel, sole and dorsum of the feet were filled up with facial flap, and those in the toes were eliminated using arthrodesis. RESULTS: All the 6 patients received rational debridement. Four patients were treated with adjacent fascia flap filling, the other two were treated with arthrodesis. The sinus tracts healed 14-20 d after surgery in all patients. One patient developed skin necrosis at the edge of the incision in the dorsum of the foot and another whose sinus located in the toe suffered inflammation and exudation. Both patients recovered after dressing replacement, antiseptic therapy and blood sugar regulation for a period of time. CONCLUSION: Appropriately designed pedicle fascia flap can provide satisfactory healing for sinus in the heel, vola and dorsum, and arthrodesis is a safe and effective way for that in the toes. Rational debridement is the key prerequisite for healing of sinus tract in diabetic foot.

[Study on the parameter optimization for therapeutic ultrasound mediated microbubble destruction enhancs gene transfection in rat muscle in vivo].

OBJECTIVE: To search for the most suitable gene transfection conditions for rat muscle in vivo by therapertic ultrasound-mediated microbubble destruction (UMMD). METHODS: A mixture of microbubbles and enhanced green flurescence protein (EGFP) plasmids was injected into rat tibialis anterior muscle and the muscels treated with ultrasound irradiation by different output intensity, duty cycle and irradiation time of therapeutic ultrasound. The transfection efficiency was demonstrated by the EGFP expression results under fluorescent staining and immunohistochemical staining. And the most favorable ultrasound conditions as well as local intra-muscle and intravenous injection methods were selected based on the best transfection efficiency and the least muscle damage under HE staining. The rats were divided into four groups: 1) ultrasound + microbubbles + plasmid; 2) microbubble + plasmid; 3) ultrasound + plasmid; 4) plasmid only. The favorable ultrasound conditions and injection method were selected out on the basis of above steps. EGFP expression was observed in the tibialis anterior muscle of each group. The rats were sacrificed in groups at 5 days after they underwent ultrasound irradiation, the EGFP expression in muscle was observed after fluorescent and immunohistochemical stainingand the muscle damage was also observed under HE staining. RESULTS: The most favorable conditions consisted of a 1-MHz therapeutic ultrasound irradiation applied for 3 min, a power output of 2 W/cm2 and a 20% duty cycle. Under these conditions, the muscle showed significant EGFP expression, and the muscle was not significantly damaged. The EGFP expression induced by the local intra-muscle injection was more significantly increased than that induced by the intravenous injection. Among the four groups, the EGFP expression under fluorescence staining and immunohistochemical staining in the muscle of the ultrasound + microbubbles + plasmid group was significantly higher than that of the other three groups, and the microbubbles + plasmid group was higer than that of the other two groups (P<0.05). No muscle damage caused by the ultrasound and microbubbles was detected under HE staining. CONCLUSION: Under the optimal transfection conditions, the therapeutic ultrasound-mediated microbubble destruction method can significantly enhance the in vivo gene transfection efficiency of rat muscle and found no damage to the muscle. Thus, these conditions can be used as part of a safe and effective non-viral gene transfection procedure for gene therapy.

Characterization and diagnostic confidence of contrast-enhanced ultrasound for solid renal tumors.

The objective was to determine whether contrast-enhanced ultrasound (CEUS) could improve the diagnostic confidence of solid renal masses. CEUS examinations were performed on 51 patients with renal tumors. Histologic findings from surgical specimens (n = 24) or magnetic resonance imaging follow-up (n = 27) were used as reference procedures for definitive diagnosis. Diffuse heterogeneous/homogeneous enhancement and quick peripheralnodularenhancement were found to be characteristic patterns in renal cell carcinoma (RCC). Dotlike or diffuse heterogeneous/homogeneous enhancement and slow peripheral nodular enhancement were observed as typical enhancement patterns in angiomyolipoma. The results show that CEUS combined with conventional ultrasound significantly improves diagnostic confidence. The sensitivity for RCC diagnosis with this imaging approach was 86% and the specificity was 93%. Both positive and negative predictive values of detection were 90% and the overall accuracy was 90%.

Can contrast-enhanced ultrasound evaluate the severity of acute pancreatitis?

OBJECTIVES: To investigate the ability of contrast-enhanced ultrasound (CEUS) in the assessment of acute pancreatitis (AP), as well as its diagnostic accuracy in the evaluation of the severity of pancreatitis. METHODS: A prospective double-blind study was carried out in 33 AP patients from May 2007 to January 2008. Each patient underwent both CEUS and contrast-enhanced computed tomography (CECT) with the time interval between two examinations less than 72 h. Using CECT as gold standard, the ability of CEUS to diagnose pancreatic necrosis as well as peripancreatic effusion and/or complications, and its diagnostic value in the evaluation of the severity of pancreatitis, were investigated. Balthazar's grading system was used to measure CT and ultrasound severity indices (CTSI and USSI), and the correlation between CTSI and USSI was tested by Spearman's rank correlation coefficient. RESULTS: A strong correlation between CTSI and USSI was found (r = 0.92, P < 0.01).The sensitivity, specificity, accuracy, positive and negative predictive value of CEUS in the diagnosis of pancreatic parenchyma necrosis were 90, 95, 94, 90 and 95%, in the diagnosis of peripancreatic effusion and/or complications were 83, 100, 93, 100 and 91%, and in the diagnosis of severe pancreatitis were 97, 67, 94, 97 and 67%, respectively. CONCLUSIONS: CEUS has shown to be of clinical value in the assessment of pancreatic necrosis as well as peripancreatic complications in AP and has a high diagnostic accuracy in the evaluation of the severity of pancreatitis. Further studies are needed to add it to the diagnostic algorithm for acute pancreatitis.

[Destruction of synovial pannus of antigen-induced arthritis by ultrasonic cavitation in rabbits].

OBJECTIVE: To optimize the conditions of ultrasonic irradiation and microbubble of ultrasound cavitation on destruction of synovial pannus of antigen-induced arthritis (AIA) in rabbits. METHODS: Antigen-induced arthritis was successfully induced on bilateral knee joints of 85 rabbits. Each 10 AIA rabbits were divided into two groups to compare various peak negative pressures, different ultrasonic pulse durations, various pulse repetition frequencies, different irradiance duration, different dosages of microbubble contrast agents, different ultrasonic irradiance times. With intravenous infusion of Sonovue to the rabbits, ultrasonic irradiance was performed on the right knee joint using the above condition of ultrasound cavitation. At the day 1 after ultrasonic irradiance, MRI and pathological examination were employed to evaluate the optimal conditions. RESULTS: The optimal parameters and conditions for ultrasonic irradiance included intermittent ultrasonic application (in 6 s intervals), 0.6 mL/kg of microbubble contrast agent, 4.6 MPa of ultrasonic peak negative pressure, 100 cycles of pulse duration, 50 Hz of pulse repetition frequency, 5 min of ultrasonic duration, 0.6 mL/kg of dosages of microbubble contrast agents and multi-sessional ultrasonic irradiance. After the ultrasonic irradiance, the thickness of right knee synovium measured by MRI was thinner than that of left knee and synovial necrosis was confirmed by the pathological finding. CONCLUSION: Under optimal ultrasonic irradiation and microbubble conditions, ultrasonic cavitation could destroy synovial pannus of AIA in rabbits.

Postoperative complications in patients with portal vein thrombosis after liver transplantation: evaluation with Doppler ultrasonography.

AIM: To study the postoperative complications in patients with preoperative portal vein thrombosis (PVT) undergoing liver transplantation (LT) and to evaluate the complications with Doppler ultrasonography. METHODS: Retrospective studies were performed on 284 patients undergoing LT (286 LT) with respect to pre- and postoperative clinical data and Doppler ultrasonography. According to the presence and grade of preoperative PVT, 286 LTs were divided into three groups: complete PVT (c-PVT), partial PVT (p-PVT) and non-PVT, with 22, 30 and 234 LTs, respectively. Analyses were carried out to compare the incidence of early postoperative complications. RESULTS: PVT, inferior vena cava (IVC) thrombosis, hepatic artery thrombosis (HAT) and biliary complications were found postoperatively. All complications were detected by routine Doppler ultrasonography and diagnoses made by ultrasound were confirmed by clinical data or/and other imaging studies. Nine out of 286 LTs had postoperative PVT. The incidence of the c-PVT group was 22.7%, which was higher than that of the p-PVT group (3.3%, P < 0.05) and non-PVT group (1.3%, P < 0.005). No difference was found between the p-PVT and non-PVT groups (P > 0.25). Of the 9 cases with postoperative PVT, recanalizations were achieved in 7 cases after anticoagulation under the guidance of ultrasound, 1 case received portal vein thrombectomy and 1 case died of acute injection. Ten LTs had postoperative IVC thrombosis. The c-PVT group had a higher incidence of IVC thrombosis than the non-PVT group (9.1% vs 2.6%, P < 0.05); no significant difference was found between either the c-PVT and p-PVT groups (9.1% vs 6.7%, P > 0.5) or between the p-PVT and non-PVT groups (P > 0.25). Nine cases with IVC thrombosis were cured by anticoagulation under the guidance of ultrasound, and 1 case gained natural cure without any medical treatment after 2 mo. HAT was found in 2 non-PVT cases, giving a rate of 0.7% among 286 LTs. Biliary complications were seen in 12 LTs. The incidence of biliary complications in the c-PVT, p-PVT and non-PVT groups was 9.1%, 3.3% and 4.3%, respectively (P > 0.25 for all), among which 2 stenosis led retransplantations and others were controlled by relative therapy. CONCLUSION: C-PVT patients tend to have a higher incidence of PVT and IVC thrombosis than non-PVT patients after LT. The incidence of postoperative complications in p-PVT patients does not differ from that of non-PVT patients. A relatively low incidence of HAT was seen in our study. Doppler ultrasonography is a convenient and efficient method for detecting posttransplant complications and plays an important role in guiding treatment.