Spontaneous uterine rupture with amniotic sac protrusion during the third trimester of a unicornuate uterus pregnancy: A rate case report

RATIONALE

Uterine rupture is an obstetrical emergency associated with severe maternal and fetal mortality. It is rare in the unscarred uterus of a primipara.

PATIENT CONCERNS

A 25-year-old woman in her 38th week of gestation presented with slight abdominal pain of sudden onset 10 hours before. An emergency cesarean section was done. After surgery, the patient and the infant survived.

DIAGNOSES

With slight abdominal pain of clinical signs, ultrasound examination showed that the amniotic sac was found in the peritoneal cavity with a rupture of the uterine fundus.

INTERVENTIONS

Uterine repair and right salpingectomy.

OUTCOMES

After surgery, the patient and the infant survived. The newborn weighed 2600 g and had an Apgar score of 10 points per minute. Forty-two days after delivery, the uterus recovered well.

LESSONS

Spontaneous uterine rupture should be considered in patients even without acute pain, regardless of gestational age, and pregnancy with abdominal cystic mass should consider the possibility of uterine rupture.

Accuracy of Thoracic Ultrasonography for the Diagnosis of Pediatric Pneumonia: A Systematic Review and Meta-Analysis

As an emerging imaging technique, thoracic ultrasonography (TUS) is increasingly utilized in the diagnosis of lung diseases in children and newborns, especially in emergency and critical settings. This systematic review aimed to estimate the diagnostic accuracy of TUS in childhood pneumonia. We searched Embase, PubMed, and Web of Science for studies until July 2023 using both TUS and chest radiography (CR) for the diagnosis of pediatric pneumonia. Two researchers independently screened the literature based on the inclusion and exclusion criteria, collected the results, and assessed the risk of bias using the Diagnostic Accuracy Study Quality Assessment (QUADAS) tool. A total of 26 articles met our inclusion criteria and were included in the final analysis, including 22 prospective studies and four retrospective studies. The StataMP 14.0 software was used for the analysis of the study. The overall pooled sensitivity was 0.95 [95% confidence intervals (CI), 0.92-0.97] and the specificity was 0.94 [95% CI, 0.88-0.97], depicting a good diagnostic accuracy. Our results indicated that TUS was an effective imaging modality for detecting pediatric pneumonia. It is a potential alternative to CXR and a follow-up for pediatric pneumonia due to its simplicity, versatility, low cost, and lack of radiation hazards.

The diagnostic accuracy of ultrasonography over manual aspiration for gastric reserve volume estimation in critically ill patients

BACKGROUND

Although gastric reserve volume (GRV) is a surrogate marker of gastrointestinal dysfunction and feeding intolerance, there is ambiguity in its estimation due to problems associated with its measurement. Introduction of point-of-care ultrasound as a tool for anesthetists kindled interest in its use for GRV estimation.

METHODS

In this prospective observational study, we recruited 57 critically ill patients and analyzed 586 samples of GRV obtained by both ultrasonography (USG) and manual aspiration.

RESULTS

The analysis showed that USG-guided GRV was significantly correlated (r=0.788, P<0.001) and in positive agreement with manual aspiration based on Bland-Altman plot, with a mean difference of 8.50±14.84 (95% confidence interval, 7.389-9.798). The upper and lower limits of agreement were 37.7 and -20.5, respectively, within the ±1.96 standard deviation (P<0.001). The respective sensitivity and positive predictive value, specificity and negative predictive value, and area under the curve of USG for feeding intolerance were 66.67%, 98.15%, and 0.82%, with 96.49% diagnostic accuracy.

CONCLUSIONS

Ultrasonographic estimation of GRV was positively, significantly correlated and in agreement with the manual aspiration method and estimated feeding intolerance earlier. Routine use of gastric USG could avoid clinical situations where feeding status is unclear and there is high risk of aspiration and could become a standard practice of critical care.

Value Of Anteroposterior-To-Transverse Ratio in Ultrasonic Diagnosis of Thyroid Nodule in Different Locations

PURPOSE

To investigate the value of anteroposterior-to-transverse ratio (ATR) and the effect on features of nodules in ultrasound (US) diagnosis of thyroid nodules in different locations.  Methods: The nodules were divided into three groups according to the different nodule location: isthmus group; upper and lower poles of bilobed thyroid group; and the middle of the bilobed thyroid group. The diameters of the nodules were recorded, and ATR of the nodule was calculated on the transverse and longitudinal sections. The transverse and the longitudinal sections of ATR of thyroid nodules in different groups were compared.  Result: The transverse section of ATR was significantly different among the three groups (p = 0.001). In addition, there are significant differences in many US features among three groups, including nodule composition, thyroid parenchyma, morphology, echogenicity, shape, calcifications, vascularity, nodule ACR TI-RADS and histopathologic (all p < 0.05). In the group of upper and lower poles of bilobed thyroid, significant difference was found between the transverse and the longitudinal section of ATR (p = 0.019). The cut-off values of transverse section and longitudinal section of ATR were 0.967 and 0.750, respectively.  Conclusion: The transverse section of ATR at different location of thyroid may be a predictor for malignancy with clinical diagnostic significance.

Ultrasonographic misdiagnosis of multicystic mesothelioma of the omentum: A case report

RATIONALE

Multicystic Mesothelioma (MM) is very rare and preoperative diagnosis is difficult.

PATIENT CONCERNS

We report a case of a 34-year-old man with solid abdominal cystic echo mass. Physical examination showed that the patient had a flat and soft abdomen without tenderness or rebound pain, no fluid wave tremor, and no obvious abdominal mass was touched. The patient complained of repeated abdominal distention with nausea for 5 days. Sonographic examination suspected pseudomyxoma peritoneum.

DIAGNOSIS

Conventional ultrasound examination showed a cystic solid echo mass in the right abdominal cavity of the patient, with uneven internal echo and honeycomb change, and clear boundary with surrounding organs. Color Doppler suggested that the blood flow in the mass was not obvious. Contrast-enhanced computed tomography of the abdomen revealed hypodensity foci in hepatic and renal crypts and right paracolic sulcus.

INTERVENTIONS

Laparoscopic resection of the mass was performed, and the postoperative pathological findings were polycystic mesothelioma (greater omentum).

OUTCOMES

After mass resection, all laboratory tests and abdominal ultrasound were normal, and abdominal distension and nausea disappeared.

LESSONS

Improved ultrasound diagnosis of MM is useful for clinical decision-making.

High-resolution ultrasonography of gingival biomarkers for periodontal diagnosis in healthy and diseased subjects

OBJECTIVE

To determine the capacity of ultrasonographic image-based measurements of gingival height and alveolar bone level for monitoring periodontal health and disease.

METHODS

Sixteen subjects were recruited from patients scheduled to receive dental care and classified as periodontally healthy (n = 10) or diseased (n = 6) according to clinical guidelines. A 40-MHz ultrasound system was used to measure gingival recession, gingival height, alveolar bone level, and gingival thickness from 66 teeth for comparison to probing measurements of pocket depth and clinical attachment level. Interexaminer variability and comparison between ultrasound measurements and probing measurements was performed via Bland-Altman analysis.

RESULTS

Gingival recession and its risk in non-recessed patients could be determined via measurement of the supra- and subgingival cementoenamel junction relative to the gingival margin. Interexaminer bias for ultrasound image analysis was negligible (<0.10 mm) for imaged gingival height (iGH) and 0.45 mm for imaged alveolar bone level (iABL). Diseased subjects had significantly higher imaging measurements (iGH, iABL) and clinical measurements (probing pocket depth, clinical attachment level) than healthy subjects (p < 0.05). Subtraction of the average biologic width from iGH resulted in 83% agreement (≤1 mm difference) between iGH and probing pocket depth measurements.

CONCLUSIONS

Ultrasonography has an equivalent diagnostic capacity as gold-standard physical probing for periodontal metrics while offering more detailed anatomical information.

The dynamic enhanced characterization with low mechanical index gray-scale harmonic imaging inflammatory pseudotumor of liver compared with hepatic VX2 tumor and normal liver

BACKGROUND

Inflammatory pseudotumor of the liver (IPTL) is misdiagnosed usually as a malignant tumor based on the imaging findings. Differential diagnosis should be established to avoid hepatic resection. At imaging, IPTL has been misdiagnosed usually as hepatocellular carcinoma (HCC). It is usually found firstly using conventional ultrasonic examination, which cannot give a definitive diagnosis. Because of its atypical clinical presentation and radiological appearance, a presumptive diagnosis of malignancy is frequently made. With the development of ultrasound systems and ultrasound contrast agents (UCA), contrast-enhanced ultrasound is widely used in diagnosing focal lesions of the liver.

OBJECTIVES

To delineate the hemodynamic features of IPTL compared with hepatic VX2 tumor and normal liver using contrast-enhanced ultrasound.

MATERIAL AND METHODS

Freund's complete adjuvant (FCA) was injected using a modified method into the desirable portion of the liver in rabbits. Two weeks after the injection, solitary IPTLs were formed (which was proved with pathological examination). Ten rabbits with IPTL, 10 rabbits with VX2 carcinoma and 10 healthy rabbits were studied using contrast-enhanced ultrasound with bolus injection of SonoVueTM through the peripheral vein. Corresponding parameters such as time to enhancement (ET), time to peak intensity (PIT), time to ascent (AT), and time to lighten (LT) were measured with wash-in/wash-out curve.

RESULTS

Contrast-enhanced imaging clearly delineated the dynamic enhancement of the lesions and liver parenchyma during the whole phase. Inflammatory pseudotumor of the liver showed the same enhanced features as the liver parenchyma. In VX2 tumors, hyperechoic enhancement in arterial phase and hypoechoic enhancement was observed in the portal and delayed phase compared with the surrounding hepatic parenchyma. The normal liver showed whole of liver parenchyma enhanced in portal phase.

CONCLUSIONS

The study showed that contrast-enhanced ultrasound provided useful information about perfusion in IPTL and VX2 carcinoma. Contrast-enhanced ultrasound is a useful technique in the differential diagnosis of focal liver lesions if combined with time-intensity curve.

The diagnostic value of the ultrasound gray scale ratio for different sizes of thyroid nodules

At present, hypoechogenicity, as one of the clinically relevant features associated with suspicion of malignant thyroid disease, is affected by the variability of modules and the experience of sonographers, thus leading to unsatisfying results. We propose the ultrasound gray scale ratio (UGSR) to obtain an objective, numerical estimate of the echogenicity degree in different‐sized thyroid nodules, and we then evaluate its diagnostic efficacy in differentiating benign and malignant thyroid lesions. In total, 553 ultrasound images of thyroid nodules from one kind of ultrasonographic scanner were analyzed, among which 281 were papillary thyroid carcinomas (PTCs) and 272 were nodular goiters (NGs). The UGSR of the PTCs, NGs, and surrounding normal thyroid tissue was measured by image analysis software. The best cut‐off value for distinguishing various sizes of PTCs and NGs was determined by receiver operating characteristic (ROC) curve analysis. As the UGSR increased, the sensitivity of the diagnosing PTCs decreased, and the specificity increased. When the maximum Jordan index was 0.611, the best cut‐off value was 0.692, and the corresponding sensitivity and specificity of diagnosing PTCs were 87.9% and 73.2%, respectively. For the analysis of subgroups of different tumor sizes, as the size of thyroid nodules increased from 0.3 to 2 cm, the sensitivity of the diagnosis of PTCs decreased from 97.5% to 58.8%, and the specificity increased from 72.4% to 90.9%. These results strongly suggest that the UGSR is an appropriate objective, numerical method for estimating the echogenicity degree and has various diagnostic efficacies in different‐sized thyroid nodules. Thus, the UGSR can be used as an additional ultrasound parameter in the diagnosis of different‐sized PTCs and NGs.

The Use of Ultrasound as a Tool to Evaluate Pulmonary Disease in Cystic Fibrosis

BACKGROUND

Lung ultrasound is an examination that allows the assessment of pulmonary involvement by analyzing artifacts. Our primary aim was to correlate our lung ultrasound findings with pulmonary function and the modified Bhalla score in patients with cystic fibrosis.

METHODS

Subjects with cystic fibrosis were evaluated based on the results of lung ultrasound, pulmonary function exams (ie, spirometry before and after the use of a bronchodilator and S_pO2 ), and the modified Bhalla score. The partial correlation set by age between lung ultrasound, pulmonary function, and modified Bhalla score was carried out. Lung ultrasound was graded according to a new score, ranging from 0 to 36, with a higher score being associated with a greater degree of involvement. We performed Bland-Altman and linear regression analysis to identify bias between lung ultrasound and modified Bhalla score. Alpha = 0.05.

RESULTS

18 subjects with cystic fibrosis were included. In partial correlation controlled by age, we observed significant ultrasound score values with weight (partial correlation = -0.579), body mass index (partial correlation = -0.609), S_pO2 (partial correlation = -0.728), FVC% (pre-bronchodilator: partial correlation = -0.538; post-bronchodilator: partial correlation = -0.560), FEV₁% (pre-bronchodilator: partial correlation = -0.536; post-bronchodilator: partial correlation = -0.546), and modified Bhalla score (partial correlation = 0.607). We did not identify bias between lung ultrasound and modified Bhalla score measured by z-score.

CONCLUSIONS

Lung ultrasound seems to be effective and corroborates with high-resolution computed tomography when evaluated by the modified Bhalla score. At the same time, lung ultrasound had significant correlation with pulmonary function and nutritional status.

Placenta membranacea: an anormaly of the placenta: Three case reports

RATIONALE

The placenta membranacea (PM) is a rare type of placental abnormality, which is associated with placenta previa, antepartum hemorrhage (APH), postpartum hemorrhage (PPH), chorioamnionitis, fetal growth restriction (FGR), preterm birth even stillbirth. The purpose of this case report is to summarize the characteristics and analyze the relevant factors of PM.

PATIENTS CONCERNS

Repetitive B-ultrasound of the first patient demonstrated a thin placenta covering the most part of uterine wall, which completely covers the internal cervical ostium for 22 weeks. B-ultrasound of the second patient showed placenta partially covering the internal cervical ostium and fetus small for gestation age for 23 days. The third patient complained of abdominal pain and vaginal discharge for 1 day.

DIAGNOSES

Diagnosis of PM is based on Doppler ultrasound apparatus, and confirmed by pathology.

INTERVENTIONS AND OUTCOMES

In the first patient, elective cesarean section was performed. The second patient required termination of pregnancy due to poor postnatal outcome. The third patient underwent intrauterine fetal death. Of these 3 cases, one delivered a term fetus by cesarean section complicated with placenta previa and placenta accreta, one terminated the pregnancy because of serious fetal growth retardation, and the other underwent intrauterine fetal death.

LESSONS

High-resolution color Doppler ultrasound apparatus can improve the diagnostic accuracy, and close antenatal surveillance followed by proper arrangement of delivery may improve neonatal outcomes.

Effect of head circumference in combination with facial profile line on ultrasonic diagnosis of microcephaly

Objective: Recently, microcephaly has usually been misdiagnosed only by ultrasound via measurement of head circumference (HC). Therefore, the aim of this study is to find another diagnostic index to supplement the original diagnostic method of microcephaly, to improve the detection rate of fetal microcephaly and to reduce the misdiagnosis rate.Methods: We retrospectively analyzed 123 pregnant women from February 2012 to January 2017 with fetal HC less than two standard deviations (SD). The facial profile line (FPL) was determined by ultrasonography. The first method (M1) was only used HC to determine whether the fetus was microcephaly, the second one (M2) was to combine HC and FPL for the diagnosis of microcephaly. Results were classified into five orderly categories by experienced sonographers. ROC curve was drawn to evaluate the diagnostic effect.Results: Among the pregnant women, 14 cases of fetal head circumference were less than 3SD, 109 were -2SD < HC≤ -3SD. A total of 12 cases were confirmed of microcephaly by magnetic resonance imaging (MRI) or postnatal, 10 cases of HC were less than 3SD, 2 were -2SD < HC≤ -3SD. The area under the ROC curve for M1 and M2 were 0.751 and 0.983 respectively.Conclusion: The HC in combination with FPL can be used to evaluate the fetal HC and forehead development quickly, and to improve the sensitivity and specificity of diagnosing fetal microcephaly.

Lung ultrasound compared to chest X-ray for diagnosis of pediatric pneumonia: A meta-analysis

OBJECTIVE

Although a clinical diagnosis, the standard initial imaging modality for patients with concern for pediatric community acquired pneumonia (pCAP) is a chest x-ray (CXR), which has a relatively high false negative rate, exposes patients to ionizing radiation, and may not be available in resource limited settings. The primary objective of this meta-analysis is to evaluate the accuracy of lung ultrasound (LUS) compared to CXR for the diagnosis of pCAP.

METHODS

Data were collected via a systematic review of PubMed, EMBASE, and Web of Science with dates up to August 2017. Keywords and search terms were generated for pneumonia, lung ultrasound, and pediatric population. Two independent investigators screened abstracts for inclusion. PRISMA was used for selecting appropriate studies. QUADAS was applied to these studies to assess quality for inclusion into the meta-analysis. We collected data from included studies and calculated sensitivity, specificity, positive predictive value, and negative predictive values of CXR and LUS for the diagnosis of pCAP.

RESULTS

Twelve studies including 1510 patients were selected for data extraction. LUS had a sensitivity of 95.5% (93.6-97.1) and specificity of 95.3% (91.1-98.3). CXR had a sensitivity of 86.8% (83.3-90.0) and specificity of 98.2% (95.7-99.6). Variations between the studies included ultrasound findings diagnostic of pneumonia, study setting (inpatient vs emergency department) and inclusion of CXR in the reference standard for pneumonia.

CONCLUSIONS

In our meta-analysis, lung ultrasound had significantly better sensitivity with similar specificity when compared to chest x-ray for the diagnosis of pediatric community acquired pneumonia.

Ultrasonic features of papillary thyroid microcarcinoma coexisting with a thyroid abnormality

The present study aimed to investigate the value of ultrasonography in the diagnosis of papillary thyroid microcarcinoma (PTMC) coexisting with a thyroid abnormality, and to improve the accuracy of PTMC diagnosis. The ultrasonic features of 38 PTMC nodules coexisting with a thyroid abnormality and 56 thyroid benign nodules, obtained by surgical resection and confirmed by pathological analysis, were retrospectively analyzed. All masses were ≤ 1.0 cm in diameter. Ultrasonic features that were analyzed included the shape, aspect ratio, boundary, margin, echo, uniformity, presence or absence of microcalcification and enlargement of the lymph nodes, as well as the blood flow of the nodules. Furthermore, the sensitivity, specificity and accuracy of ultrasonography for the diagnosis of PTMC were obtained. The following ultrasonic features of thyroid nodules were significantly (P<0.05) associated with PTMC coexisting with a thyroid abnormality: An irregular shape; an aspect ratio of ≥ 1; an unclear boundary; blurred margins; internal heterogeneous hypoechogenicity; and microcalcification. Therefore, thyroid nodules with these ultrasonic characteristics coexisting with a thyroid abnormality may be suspected as malignant PTMC. The present study demonstrated that ultrasound-guided biopsies are necessary to prevent misdiagnosis of PTMC. The sensitivities of enlarged neck lymph nodes and abundant blood flow are so low that they may be considered as references for the differentiation of PTMC from benign nodules.

The reliability of ultrasonography in developmental dysplasia of the hip: How reliable is it in different hands?

BACKGROUND

Developmental dysplasia of the hip (DDH) is the most common skeletal dysplasia. Two principal methods used in early diagnosis of DDH are clinical examination and ultrasonographic investigation. Dogruel et al. found a low specificity of clinical examination in patients with DDH. Additionally, Kamath et al. stated that ultrasonography performed by a radiologist in routine clinical practice is more reliable than physical examination performed by the average clinician. In clinical practice, the application and assessment of hip ultrasonography are completed by a single person. This assessment determines the followup of the patient. Thus, hip ultrasonography performed on the same person by different individuals under the same conditions will yield a more accurate assessment of the reliability of ultrasonographic assessment of DDH. Although inter-observer reliability was high in many previous studies of ultrasound image evaluation, reliability rates vary among studies of the application of ultrasonography.

MATERIALS AND METHODS

Inter-examiner reliability of hip ultrasonography was analyzed among four investigators who separately evaluated 100 hips (50 infants). The obtained bone structure angles α, cartilage structure angles β, and distribution of hip types were compared among the investigators. All infants were brought to the hospital for a healthy child followup examination, according to the country's health policy. Babies between 0 and 6 months were included in the study. Babies with any neuromuscular disorders, neural tube defects or any type of genetic anomalies were excluded from the study. The study was explained to the families of all infants and written informed consent was obtained.

RESULTS

There was a significant difference in the hip type determined by the investigators with respect to α and β angles (P < 0.01, P < 0.01, P = 0.002). The average alpha measurements of the first orthopedist, second orthopedist, first radiologist, and second radiologist were 67.38 ± 6.24, 65.60 ± 5.84, 65.44 ± 4.59, and 62.59 ± 4.50, respectively. The average beta measurements of the first orthopedist, second orthopedist, first radiologist, and second radiologist were 53.85 ± 8.86, 50.74 ± 7.80, 44.77 ± 6.30, and 44.39 ± 5.81, respectively. Agreement among the results obtained by the clinicians was investigated in dual comparisons. The relative agreement according to the alpha angle ranged from 3.6% to 44.5%, and the relative concordance according to the beta angle ranged from 0.9% to 45.3%. Agreement regarding hip typing was determined to range from 19.1% to 42.6%.

CONCLUSION

Sonographic evaluation of the hip appears to vary depending on the investigator.

Intravascular ultrasonic imaging

Because conventional imaging methods are inadequate for evaluating human coronary arteries in vivo, an intravascular ultrasonic imaging catheter was developed that allows the arterial wall to be studied in cross-section from within the artery. The catheter incorporates a mechanically rotating 20-MHz transducer, which is designed so that the ringdown occurs within the catheter and imaging is permitted up to the catheter's surface. The device rotates at 1800-rpm within a plastic sleeve and provides real-time cross-sectional images at 30 frames/sec. Preliminary experimental and clinical studies indicate that the intravascular ultrasonic imaging catheter could play a valuable role in providing preoperative information concerning arterial wall thickness and tissue characteristics, in distinguishing normal from diseased arterial wall structures during therapeutic intervention, and in assessing the results of intervention.