A Nomogram for Predicting Venous Thromboembolism in Critically Ill Patients with Primary Intracerebral Hemorrhage.

OBJECTIVE: To develop and validate a nomogram for predicting the risk of venous thromboembolism in critically ill patients with primary intracerebral hemorrhage. METHODS: Patients ≥18 years old with primary intracerebral hemorrhage were screened within 24 hours of onset from January 2019 to April 2021. Univariate and multivariate logistic regression analyses were performed to screen out independent predictors that were significantly associated with venous thromboembolism. A nomogram was constructed based on the results of a multivariate regression analysis. Discrimination and calibration were used to evaluate performance of the nomogram. A decision curve analysis was used to assess its clinical utility. RESULTS: This study enrolled 369 patients. The nomogram included 3 predictors from the regression analysis: D-dimer, National Institutes of Health Stroke Scale score, and Glasgow Coma Scale score on admission. The area under the receiver operating characteristic curve was 0.794, indicating good discrimination of the nomogram. The nomogram demonstrated calibration curves with slight deviation from the ideal predictions. Decision curve analysis showed that the prediction nomogram was clinically useful. CONCLUSIONS: This nomogram comprising D-dimer, National Institutes of Health Stroke Scale score and Glasgow Coma Scale score on admission can accurately predict the risk of venous thromboembolism in critically ill patients with intracerebral hemorrhage.

Historical trends for the standards in scrotal ultrasonography: What was, what is and what will be normal.

BACKGROUND: Ultrasonography is the gold standard imaging method for scrotal investigation. Colour Doppler ultrasonography, contrast-enhanced ultrasonography and sonoelastography allow sonographers to assess size, echotexture, vascular features and stiffness of the scrotal organs and abnormalities. Scrotal ultrasonography has been used to investigate male reproductive health, scrotal pain, masses and trauma. However, ultrasonography thresholds/classifications used to distinguish normal and pathologic features of the scrotal organs have changed over time, and have not yet been fully standardized. OBJECTIVES: To evaluate historical trends for the standards in scrotal ultrasonography: what was, what is and what will be normal. METHODS: An extensive Medline search was performed identifying the most relevant studies in the English language from inception to date. RESULTS: We provide here (i) a brief overview of the history of ultrasonography, (ii) current indications for scrotal ultrasonography and (iii) previous and current normal values, cut-offs and classifications of the main colour-Doppler ultrasonography parameters/characteristics of the scrotal organs, as derived from recent guidelines and evidence-based studies. In addition, we report recommendations and the clinical utility of contrast-enhanced ultrasonography and sonoelastography. Finally, we discuss critical issues needing further evidence and future directions to fill in the current gaps. DISCUSSION: Several studies on scrotal ultrasonography are available. However, guidelines/recommendations dealing with specific ultrasonography applications have been published only in recent years. More recently, the European Academy of Andrology published evidence-based scrotal colour-Doppler ultrasonography reference ranges/normative parameters derived from a cohort of healthy, fertile men. In addition, a standardization of the methodology to evaluate qualitative and quantitative colour-Doppler ultrasonography parameters was reported. Other international societies reported indications, methodological standards, clinical utility and limitations of contrast-enhanced ultrasonography and sonoelastography. CONCLUSIONS: To date, colour-Doppler ultrasonography normative values for the scrotal organs are available. However, a wide international consensus on assessment and classification of several ultrasonography parameters is still lacking. An alignment of the world societies on these issues is advocated.

Advanced Ultrasound Techniques for Pediatric Imaging.

Ultrasound has become a useful tool in the workup of pediatric patients because of the highly convenient, cost-effective, and safe nature of the examination. With rapid advancements in anatomic and functional ultrasound techniques over the recent years, the diagnostic and interventional utility of ultrasound has risen tremendously. Advanced ultrasound techniques constitute a suite of new technologies that employ microbubbles to provide contrast and enhance flow visualization, elastography to measure tissue stiffness, ultrafast Doppler to deliver high spatiotemporal resolution of flow, three- and four-dimensional technique to generate accurate spatiotemporal representation of anatomy, and high-frequency imaging to delineate anatomic structures at a resolution down to 30 µm. Application of these techniques can enhance the diagnosis of organ injury, viable tumor, and vascular pathologies at bedside. This has significant clinical implications in pediatric patients who are not easy candidates for lengthy MRI or radiation-requiring examination, and are also in need of a highly sensitive bedside technique for therapeutic guidance. To best use the currently available, advanced ultrasound techniques for pediatric patients, it is necessary to understand the diagnostic utility of each technique. In this review, we will educate the readers of emerging ultrasound techniques and their respective clinical applications.

Papel de la ecografía doppler color en el diagnóstico de granuloma aséptico facial idiopático / Role of Color Doppler Ultrasound in the Diagnosis of Idiopathic Facial Aseptic Granuloma

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Ampliando el espectro ecográfico de las anomalías vasculares / Broadening the Sonographic Spectrum of Vascular Anomalies

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Transcranial Color-Coded Duplex in Acute Encephalitis: Current Status and Future Prospects.

BACKGROUP AND PURPOSE: There are limited data regarding the diagnostic yield of transcranial color-coded Doppler (TCCD) in acute encephalitis. We present our preliminary observations of consecutive ultrasound evaluations in 2 patients with acute encephalitis and we review the possible diagnostic role of TCCD in such cases. METHODS: We describe two cases of acute encephalitis that presented with aphasia and confusion and underwent repeat TCCD evaluation at baseline and after 48 hours in both patients. We also critically review the current literature regarding potential TCCD applications in acute central nervous system infections. RESULTS: Serial TCCD evaluations revealed the following triad of abnormal findings in both patients: (i) elevated pulsatility index (PI) in the left middle cerebral artery (M1 MCA) at baseline (>1.2), (ii) increased PI in left M1 MCA by >25% in comparison to right M1 MCA, and (iii) decrease in PI in left M1 MCA by >25% at the follow-up evaluation at 48 hours. The decrease in PI in left M1 MCA coincided with symptom improvement in both patients. DISCUSSION: The focal transient increase in left M1 MCA PI may be attributed to focally increased intracranial pressure or peripheral vasospasm of distal left MCA branches. Since there are limited reports in the literature concerning TCCD evaluation of patients with central nervous system infections, our preliminary findings require independent confirmation in a larger series of patients.

Utilidad de la ecografía en el diagnóstico de lesiones torácicas periféricas realizadas en una unidad de técnicas de neumología / Benefit of Chest Ultrasonography in the Diagnosis of Peripheral Thoracic Lesions in an Interventional Pulmonology Unit

Introducción y objetivos: La ecografía como guía en la punción percutánea de lesiones torácicas periféricas (LTP) ofrece ventajas frente a otras técnicas de imagen. La mayoría de los estudios con esta técnica han sido comunicados por radiólogos intervencionistas. El objetivo de este estudio ha sido analizar la rentabilidad diagnóstica de la punción percutánea guiada por ecografía en una unidad de técnicas de neumología. Metodología: Estudio retrospectivo de 58 pacientes con LTP puncionadas con visualización ecográfica en tiempo real, entre el 1 de marzo de 2011 y el 1 de septiembre de 2014. Los resultados fueron divididos en 3 categorías diagnósticas: maligna, benigna y no diagnóstica (ND); esta última incluye los resultados de benignidad no específica (SD) y los de muestra insuficiente para diagnóstico (MID). Resultados: Se obtuvo: resultado maligno en 34 (58,6%) de los procedimientos, resultado benigno en 13 (22,4%) y ND en 11 (19%) (SD en 5 [8,6%] y MID en 6 [10,3%]). En 5 de los casos ND el resultado final fue de malignidad y en 4 de ellos se tratada de una MID. La sensibilidad diagnóstica obtenida fue del 75,6%, el valor predictivo negativo del 54,2%, y la especificidad y el valor predictivo positivo del 100%, con una rentabilidad diagnóstica del 81%. Cuando se excluyeron los casos con MID los valores fueron del 87,2%, 72,3%, 100% y 100%, respectivamente, con una rentabilidad diagnóstica del 90,4%. No hubo complicaciones graves con la técnica. Conclusiones: La punción percutánea bajo guía ecográfica en LTP realizada por neumólogos intervencionistas es una técnica segura y con una alta rentabilidad diagnóstica

Introduction and objectives: The use of ultrasound in peripheral thoracic lesions offers advantages over other radiological guiding methods. This diagnostic procedure has been applied in most studies published by radiologists. Our aim was to determine the diagnostic efficacy of percutaneous ultrasound-guided punctures and biopsies of peripheral thoracic lesions performed by pulmonologists. Methodology: A retrospective analysis of 58 patients who underwent real-time ultrasound-guided transthoracic punctures and biopsy of peripheral thoracic lesions between March 2011 and September 2014 in the pulmonology department of our hospital. Cases were classified into the following diagnostic categories: malignant, benign and non-diagnostic (non-specific benign without evidence of malignancy and insufficient specimen). Results: A conclusive diagnosis was obtained in 47 procedures (81%), of which 13 (22.4%) were specific benign lesions and 34 (58.6%) cancers. In the remaining 11 (19%) patients, a non-diagnostic result was obtained [non-specific benign in 5 cases (8.6%) and insufficient specimen in 6 (10.3%)]. Sensitivity was 75.6%, negative predictive value was 54.2%, specificity and positive predictive value were 100%, and diagnostic accuracy was 81%. Excluding procedures with insufficient specimens, the results were 87.2%, 72.3%, 100%, 100% and 90.4% respectively. There were no serious complications. Conclusions: Percutaneous ultrasound-guided puncture and biopsy in the diagnosis of peripheral thoracic lesions performed by pulmonologists is a safe procedure with high diagnostic accuracy. We achieved similar results to those previously obtained by radiologists

Retrobulbar Spot Sign Predicts Thrombolytic Treatment Effects and Etiology in Central Retinal Artery Occlusion.

BACKGROUND AND PURPOSE: Transorbital sonography may help establish diagnosis of central retinal artery occlusion (CRAO). Next to Doppler sonographic proof of CRAO, an intra-arterial spot sign can be detected in some cases. We hypothesized that it reflects calcified components. It may be associated with embolization from atherosclerotic plaques and may negatively influence thrombolysis. METHODS: Prospective monocenter study of 46 patients with ophthalmologically confirmed CRAO. Systemic tissue-type plasminogen activator thrombolysis was performed when appropriate. All patients received etiologic workup. RESULTS: CRAO was confirmed by Doppler in all patients. Fifty-nine percent of patients with arterio-arterial embolization were spot sign-positive compared with 20% from cardiac source (P<0.05) and none with vasculitis. Eleven patients underwent thrombolysis. Clinically relevant visual improvement was only found in absence of a spot sign (P<0.05). CONCLUSIONS: Transbulbar ultrasound is valuable for initial diagnosis and diagnostic workup of CRAO. In the light of inconsistent results of previous thrombolysis trials, ultrasound may identify patients more likely to benefit from thrombolytic treatment.

Past, present and future ultrasonographic techniques for analyzing ovarian masses.

Ultrasonography is today the method of choice for distinguishing between benign and malignant adnexal pathologies. Using pattern recognition several types of tumors can be recognized according to their characteristic appearance on gray-scale imaging. Color Doppler imaging should be used only to perform a semiquantitative color score or evaluate the flow location. International Ovarian Tumor Analysis group had standardized definitions characterizing adnexal masses and suggested the use of 'simple rules' in premenopausal women. Recently, the use of 3D vascular indices has been proposed but its potential use in clinical practice is debated. Also computerized aided diagnosis algorithms showed encouraging results to be confirmed in the future.

Solución del caso 45. Sarcoidosis con afectación testicular / Solution to case 45. Sarcoidosis with testicular involvement

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Tomosíntesis. Un avance cualitativo en el diagnóstico de patología mamaria / Tomosynthesis: a qualitative advance in the diagnosis of breast disease

La mamografía es la técnica de imagen indicada en el cribado de patología tumoral de mama asintomática. Es una técnica sensible en la valoración de lesiones malignas, que se manifiestan como nódulos espiculados, distorsiones arquitecturales y asimetrías. Sin embargo, en algunos parénquimas mamarios estas lesiones pueden pasar desapercibidas, debido a que poseen una densidad mamaria alta, BIRADS 3-4, con abundante tejido fibroglandular, que pueden ocultar los signos de malignidad. Para ello nace la tomosíntesis, que mediante la realización de varias incidencias a baja dosis con distintos ángulos elimina la superposición de tejido normal y es una herramienta de gran ayuda en el diagnóstico de la patología mamaria(AU)

Mammography is the imaging modality indicated in the screening of asymptomatic breast tumors. This technique is sensitive in the evaluation of malignant lesions, which manifest as speculated nodules, architectural distortions and asymmetries. However, in some breast parenchymas these lesions may be missed due to higher breast density (BIRADS 3-4), with abundant glandular tissue that can mask the signs of malignancy. Tomosynthesis was developed to identify these lesions. By performing several low-dose mammograms at different angles of incidence, this technique eliminates overlapping normal tissue and is helpful in the diagnosis of breast disease(AU)

Current clinical practice in postoperative endovascular aneurysm repair imaging surveillance.

PURPOSE: To investigate the current clinical practice in postoperative endovascular aneurysm repair (EVAR) imaging surveillance. MATERIALS AND METHODS: Corresponding authors of EVAR publications during the years 2006-2011 and subscribers to an endovascular journal were invited to complete a 27-question online survey related to institutional demographics, standard post-EVAR imaging surveillance, and imaging protocols in special circumstances (eg, renal insufficiency). RESULTS: The survey was completed by 515 of 9,631 physicians performing EVAR from 52 countries. Of respondents, 65.3% were affiliated with experienced centers where EVAR has been performed for > 10 years or with > 50 EVAR procedures performed per year. Computed tomography (CT) angiography was the modality used most often for standard surveillance with a maximum time interval between studies of 12 months in 78.8% of centers out to 5 years. Experienced centers were more likely to delay follow-up imaging to 1 year after an unremarkable initial post-EVAR imaging study (P < .001), to extend surveillance intervals > 12 months (P = .043), and to use ultrasound (P < .01) for surveillance. After the detection of a type II endoleak, CT angiography was favored for follow-up by 59.4% of the respondents. Experienced centers were more likely to favor ultrasound (P = .006) and to schedule this follow-up examination later (after 6-12 months, P < .001). Of respondents, 62.8% used a glomerular filtration rate threshold of < 30 mL/min for not performing contrast-enhanced CT scan. In patients with renal insufficiency, most respondents performed ultrasound with or without a concomitant noncontrast CT scan. CONCLUSIONS: CT is the most frequently used method of long-term surveillance after EVAR. Use of ultrasound for long-term surveillance, extension of follow-up time intervals, or both were most often reported in experienced centers.

El artefacto de centelleo en la caracterización de los cálculos urinarios / Role of twinkling artifact in characterization of urinary calculi

Introducción: La caracterización de los cálculos renales está cada vez cobrando mayor importancia como paso previo a la toma de decisiones terapéuticas tales como la nefrolitotomía percutánea (NLP) y la litotricia extracorpórea por ondas de choque (LEOC). En algunos estudios se ha publicado que el artefacto de centelleo (artefacto de ecografía de flujo en color) puede ser de utilidad en la detección de piedras en el riñón. En este estudio se pretende dilucidar si la presencia o ausencia del artefacto de centelleo tendría alguna relación con la composición química de los cálculos. Material y método: En un estudio prospectivo se incluyó a pacientes con cálculos renales de ≥ 0,5cm. Se examinó a 70 pacientes mediante rayos X, pielografía intravenosa, tomografía computarizada sin contraste y ecografía doppler espectral y a color. El artefacto se consideró de grado 1 si sólo ocupaba una parte de la sombra acústica, considerándose de grado 2 si ocupaba la totalidad de la sombra. Se trató a los pacientes con cálculos de menos de 2cm con LEOC, y a aquellos con piedras de mayor tamaño se les derivó a tratamiento con NLP. Resultados: No se detectó artefacto alguno (grado 0) en 11 sujetos, detectándose el grado 1 en 25 y el grado 2 en 24. Se encontró una relación significativa entre el aumento en artefactos de centelleo y tamaño del cálculo (p<0,001). Al analizar la relación entre composición de los cálculos y artefacto de centelleo se detectó el artefacto en prácticamente todas las piedras de oxalato de calcio —dihidrato y fosfato de calcio, mientras que en el caso de los cálculos de oxalato de calcio— monohidrato y ácido úrico se detectó el artefacto únicamente en algo más de la mitad de ellos. En el grupo LEOC se observó que, al aumentar el grado del artefacto de centelleo, descendía el número de sesiones de LEOC necesario (p<0,001). En el grupo NLP se encontró el artefacto de centelleo en todos los pacientes (100%) con piedras de superficie irregular. Conclusión: La irregularidad de la superficie lítica es el factor más influyente en la formación del artefacto de centelleo en piedras de riñón. Dicho artefacto puede tener utilidad a la hora de prever la predisposición a la fragmentación de los cálculos en pacientes derivados a tratamiento con aplicación de LEOC. Podría pronosticarse que aquellos casos en los que el tamaño de la piedra fuese de más de 2cm y no se detectase artefacto de centelleo serían de oxalato de calcio - monohidrato, que es una de las piedras con mayor predisposición a la fragmentación (AU)

Introduction: Stone characterization is becoming important before decision of treatment such as percutaneous nephrolithotomy (PCNL) and extracorporeal shock wave lithotripsy (ESWL). Some studies have reported that the twinkling artifact (color-flow ultrasonography artifact) may be useful to detect urinary stones. This study aims to determine whether the presence or absence of the twinkling artifact is correlated with the chemical composition of the stones. Material and method: Patients with renal stones > 0.5cm were included in a prospective study. Sixty patients were examined with x-ray film, intravenous pyelography, non-contrast computerized tomography, and color and spectral doppler ultrasonography. The artifact was considered grade 1 when occupied only one portion of the acoustic shadowing and when the artifact occupied the entire acoustic shadowing was considered grade 2. Patients with stones smaller than 2cm were treated with SWL and patients with stones larger than 2cm were treated with PCNL. Results: No artifact (grade 0) was detected in 11 subjects, grade 1 in 25 and grade 2 in 24. Significant relationship was found between the increase in twinkling artifact and stone size (p<0.001). When the relation between the composition of the stones and the twinkling artifact was analyzed, artifact was detected nearly in all of the calcium oxalate dihydrate and calcium phosphate stones; whereas the artifact was detected in more than half of the calcium oxalate monohydrate and uric acid stones. In ESWL group it was observed that as the grade of the twinkling artifact increases, the number of required ESWL sessions decreases (p<0.001). In PCNL group twinkling artifact was found in all of the patients (100%) with roughly surfaced stones. Conclusion: The roughness of stone surface is the most important factor in terms of formation of the twinkling artifact in kidney stones. This artifact can be of use in anticipating the breakability of the stones of those patients to be treated with applied ESWL. One might anticipate that cases where the size of the stone is larger than 2cm but no twinkling artifact is detected are calcium oxalate monohydrate, which is one of the stones with highest level of breakability (AU)

Ultrasonography in kidney transplantation: values and new developments.

Renal transplant is performed on patients with end-stage renal disease. Gray-scale renal sonography combined with color Doppler has become the main noninvasive imaging method for evaluating a kidney transplant, as it provides information about the kidney anatomy and its vascular flow. In this article, we discuss the utility of sonography in renal transplants and describe the ultrasound findings in early and chronic graft pathology. Also, we explain new developments in ultrasound imaging with contrast media and its utility in renal transplantation, proposing that contrast-enhanced sonography be incorporated as a method to evaluate graft status because of its capability to evaluate cortical capillary blood flow.

Ultrasound of the small joints of the hands and feet: current status.

The aim of this article was to review the current status of ultrasound imaging of patients with rheumatological disorders of the hands and feet. Ultrasound machines with high-resolution surface probes are readily available in most radiology departments and can be used to address important clinical questions posed by the rheumatologist and sports and rehabilitation physician. There is increasing evidence that ultrasound detects synovitis that is silent to clinical examination. Detection and classification of synovitis and the early detection of bone erosions are important in clinical decision making. Ultrasound has many advantages over other imaging techniques with which it is compared, particularly magnetic resonance. The ability to carry out a rapid assessment of many widely spaced joints, coupled with clinical correlation, the ability to move and stress musculoskeletal structures and the use of ultrasound to guide therapy accurately are principal amongst these. The use of colour flow Doppler studies provides a measure of neovascularisation within the synovial lining of joints and tendons, and within tendons themselves, that is not available with other imaging techniques. Disadvantages compared to MRI include small field of view, poor image presentation, and difficulty in demonstrating cartilage and deep joints in their entirety. Contrast-enhanced magnetic resonance provides a better measure of capillary permeability and extracellular fluid than does ultrasound. The ability to image simultaneously multiple small joints in the hands and feet and their enhancement characteristics cannot be matched with ultrasound, though future developments in 3-D ultrasound may narrow this gap. Magnetic resonance provides a more uniform and reproducible image for long-term follow-up studies.

Emergency pediatric imaging: current status and update.

Imaging has undergone a major revolution. Many procedures performed 20 years ago are no longer performed and new ones have expanded our ability to diagnose previously hidden conditions and also our knowledge of these conditions. This communication deals both with modern imaging and how it is affecting our evaluation of certain diseases but yet underscores that plain film findings still are important and should not be cast by the wayside in favor of more modern cross sectional imaging.