Doppler Signal Research Articles

A Novel Doppler Flowmetry Shaft for Postoperative Monitoring after Head and Neck Reconstructive Surgery.

Doppler flowmetry is one of the most popular methods of monitoring Doppler signals during reconstructive surgery of the body surface. However, because of the thick and straight structure of the shaft, it is difficult to perform in areas with limited space, such as the oral cavity. We used a new type of Doppler flowmetry shaft to postoperatively monitor the flap in the oral cavity. Compared with conventional Doppler flowmetry, the new type uses a thinner metal probe shaft that can easily be inserted in narrow and limited spaces, such as the oral cavity. Additionally, the tip of the metal probe is gently bent, thereby allowing the Doppler tip to be placed perpendicular to the surface of the skin flap. We used this new type of Doppler flowmetry shaft for 30 patients after head and neck reconstruction using free flap transfer because Doppler signals were difficult to hear using conventional Doppler flowmetry. For all 30 patients, the new Doppler flowmetry shaft was able to monitor free flaps. Vascular thrombosis or vascular spasm occurred in three patients; two patients had inadequate arterial flow caused by vasospasm and arterial thrombus, and one patient had a venous thrombus. These three patients required re-exploration, and all flaps survived. This new type of Doppler flowmetry is simple and noninvasive. Furthermore, it can easily be performed by nonphysician medical personnel, and is useful for monitoring patients after head and neck reconstructive surgery.

Ultrasound characteristics of soft tissues near sacroiliac joints and in the lumbar region of patients with ankylosing spondylitis.

To investigate the musculoskeletal morphomechanical properties (i.e., the thickness and elastic modulus) and the total count of power Doppler signals near the sacroiliac joints in patients with ankylosing spondylitis (AS) and non-AS individuals. Twenty participants with AS [median age (interquartile range): 31.7 (11.04) years] and 19 controls [36.3 (10.5) years] with no AS history were recruited. Bilateral ultrasound image acquisition was performed, including the short posterior sacroiliac ligament, interosseous sacroiliac ligament, long posterior sacroiliac ligament, iliolumbar ligament, proximal piriformis muscle, and sacrotuberous ligament. The intraclass correlation coefficients (ICC) of ultrasound parameters, laboratory test results of human leukocyte antigen B27, C-reactive protein, and erythrocyte sedimentation rate, and self-reported physical and disease activity scores were also obtained. The ligaments and piriformis muscle were thicker and stiffer (greater elastic modulus) in participants with AS than in non-AS participants (all p<0.01). The measurements showed good or excellent reliability (all ICC(3,1) >0.85). The numbers of power Doppler signals detected in the iliolumbar ligament, proximal piriformis muscle, and sacrotuberous ligament were higher in participants with AS than in non-AS participants (all p<0.001). A correlation was identified between disease duration and the elastic modulus of the piriformis muscle (r=0.640, p=0.003). We conclude that the ligaments and proximal piriformis muscle of AS participants have increased thickness, elastic modulus, and power Doppler signal than those of non-AS individuals. These reliable findings may serve as potential markers for the early diagnosis of AS and for assessing medication effects.

Investigation of the Pre- and Co-Seismic Ionospheric Effects from the 6 February 2023 M7.8 Turkey Earthquake by a Doppler Ionosonde

During the catastrophic M7.8 earthquake in Turkey on 6 February 2023, anomalous effects were revealed in the ionosphere associated with various propagation mechanisms of seismogenic disturbance from the lithosphere up to the height of the ionosphere. Seventeen minutes after the main shock, a co-seismic disturbance was detected by a Doppler ionosonde on an inclined, 3010 km long, two-hop radio path “Kuwait—Institute of Ionosphere (Almaty)”. An appearance of acoustic waves at the height of 232 km in the ionosphere was fixed 568 s after arrival of the surface Rayleigh wave to the sub-ionospheric point, and such a delay agrees with the calculated propagation time of a vertically moving acoustic wave. The disturbance lasted 160 s, and its double amplitude was above 2 Hz, which noticeably exceeds the background fluctuation of Doppler frequency. The best coincidence between the waveforms of the Doppler signal and of the surface seismic wave was observed over the duration of the two leading periods, with correlation coefficients of 0.86 and 0.79, correspondingly. Pre-seismic effects in the ionosphere were revealed 8 days before the main shock both in the variations of the Doppler frequency and of the critical frequency f0F2. The probable origination mechanism of the pre-seismic ionospheric disturbances above the region of the earthquake preparation determined by the Dobrovolsky radius may be considered in accordance with the concept of lithospheric–atmospheric–ionospheric coupling.

Reliable measurement methods for the isovolumic relaxation time: comparisons of dual gate Doppler and seven other methods

PurposeIsovolumic relaxation time (IVRT) is a useful indicator of diastolic dysfunction. However, a measurement method for IVRT has not been established. The Dual Gate Doppler method, which can record two separate pulse-wave Doppler signals simultaneously using two sample gates, may be ideal for measuring IVRT. This study aimed to evaluate the accuracy of IVRT measured using conventional methods versus that measured using the Dual Gate Doppler method.MethodsA total of 104 patients (mean age 58 ± 21 years, 48 women) were examined using ultrasound equipment with Dual Gate Doppler at our hospital. In addition to Dual Gate Doppler method, IVRTs were measured using seven different methods: pulsed Doppler (PW method), continuous wave Doppler (CW method), and other methods. The IVRT values obtained using the Dual Gate Doppler method were compared with those measured using other methods.ResultsAll IVRTs measured using conventional methods showed a strong correlation with the that measured using the Dual Gate Doppler method. However, there were slight deifferences among the IVRTs depending on the method. The PW method and the PW time difference method using only the PW showed small statistical bias and were not complicated. The IVRT measured using the CW method was significantly longer than that measured using the Dual Gate Doppler method.ConclusionsAmong the conventional methods, the PW method was the simplest and most practical method for measuring the IVRT in any conditions as arrhythmias. It is important to recognize the characteristics of IVRTs based on the measurement method.

Ultrasound abnormalities of the major salivary glands in Egyptian patients with systemic sclerosis

Introduction/objectivessystemic sclerosis (SSc) is an autoimmune disorder with multiple organs destruction. This study aimed to identify the ultrasonographic changes of major salivary glands in Egyptian scleroderma patients and to detect their association to different disease manifestations.MethodsForty-seven SSc patients and 43 apparent healthy volunteers were enrolled. Demographics, inflammatory markers, and autoimmune status were recorded. Ultrasound evaluation of salivary glands was performed. Salivary gland changes’ associations were statistically examined with SSc susceptibility and disease manifestations.ResultsThirty-one SSc patients exhibited glandular pathology (p < 0.0001), compared to controls. Of these abnormalities, SSc patients showed a total parotid gray scale of 2, total submandibular gray scale of 2, total glandular gray scale of 4, and total glandular Doppler signal of 1 at p < 0.0001, compared to the control group. Patients with SSc and glandular pathology had a higher prevalence of arthritis (p = 0.029) and ESR (p = 0.002) than those with normal glandular ultrasound. Significant associations were reported between gray scale ultrasound (GSUS) of total parotid (odds ratio “OR” = 0.4), total submandibular (OR = 0.36), and total glandular (OR = 0.53) with susceptibility to SSc at p < 0.0001. Total glandular GSUS (p = 0.039) and total submandibular power Doppler (p = 0.044) correlated with the SSc duration. Total parotid GSUS (p = 0.008) and total glandular GSUS (p < 0.0001) correlated with Schirmer’s test.ConclusionsMajor salivary glands are affected in SSc. Hence, scanning these glands with ultrasound is an additive tool besides the current practice.Key Points• Major salivary gland changes, observed by ultrasonography, are new findings in Egyptian SSc patients.• Ultrasound changes of major salivary glands are associated with inflammatory markers and clinical manifestations of SSc.• Scleroderma ultrasonography scans of the main salivary glands could be added to the routine work.

Correlation of ultrasound features with Bcl-2 protein expression in basal cell carcinomas (BCCs).

The expression of the Bcl-2 protein is frequently observed in basal cell carcinomas (BCCs), making it a significant biological marker and potential therapeutic target. Skin ultrasonography offers a noninvasive means of obtaining anatomical information about cutaneous tumors. The purpose of this study was to investigate the correlation between ultrasound features and Bcl-2 expression in BCCs, to provide a reference for developing pharmacological treatment plans. According to the Bcl-2 protein expression, 74 BCCs confirmed by surgical pathology were divided into high Bcl-2 expression BCCs (HB-BCCs) and low Bcl-2 expression BCCs (LB-BCCs). Preoperative lesion ultrasound features were analyzed retrospectively based on Liang's criteria, which included the following features: shape, surface, keratinization, base, infiltration level, internal echogenicity, distribution of hyperechoic spots, posterior echogenic changes, internal Doppler signal, and lesion size (maximum diameter and infiltration depth). The differences of two groups were compared using a chi-square test or a paired t-test. Based on ultrasound features, cystic areas were more frequent in LB-BCCs (χ2 = 7.015, P = .008). Furthermore, LB-BCCs exhibited greater infiltration depth than HB-BCCs (4.86 ± 2.12 mm vs. 2.72 ± 1.40 mm, P = .000), had a higher propensity to infiltrate the subcutaneous tissue (χ2 = 12.422, P = .002), and displayed a more abundant internal Doppler signal within the lesions (χ2 = 24.696, P = .000). Conversely, maximum diameter of the lesions, shape, surface, keratinization, base, hyperechoic spots distribution, and posterior echogenic changes of the lesions did not differ significantly between the two groups. Ultrasound features are correlated with Bcl-2 protein expression level in BCCs. LB-BCCs show greater infiltration depth, subcutaneous infiltration, more cystic changes and more abundant internal Doppler signal than HB-BCCs, which may suggest a potential basis for drug selection in BCC chemotherapy.

Mid-Systolic Notching of the Pulmonary Valve Doppler Signal is Highly Associated with Pulmonary Hypertension.

Mid-systolic notching (MSN) of the pulmonary valve Doppler signal represents a reflected systolic pressure wave from the pulmonary vasculature and is often seen in pulmonary hypertension (PH). We hypothesize that MSN is associated with a higher pulmonary vascular resistance (PVR) and mean pulmonary artery pressure (mPAP), and a diagnosis of PH in pediatric patients. This was a retrospective study of patients ≤ 18years who had an echocardiogram obtained ≤ 30days before catheterization for suspected PH. MSN was defined as an indentation in the initial two thirds of the systolic Doppler signal. PH was defined as mPAP > 20mmHg and PVR ≥ 3.0 Wu m2. Subgroups (MSN vs. normal) were compared. Receiver operator characteristic determined a continuous variable's discriminatory ability for a diagnosis of PH. Reproducibility of MSN was assessed. In total, 90 patients (73 with congenital heart disease) were included, of which 36 had MSN and 54 were normal. MSN patients were more likely to have PH, and had significantly higher mPAP, PVR, and lower pulmonary stroke volume. The presence of MSN had good discriminatory ability for PH diagnosis. The presence of MSN had high specificity (96%) for PH, whereas sensitivity was lower (54%). Reproducibility was 100% for MSN. MSN is a simple, highly reproducible echocardiographic metric associated with higher mPAP and PVR. When present, there is a high likelihood a diagnosis of PH confirmed by catheterization. Incorporation of MSN into imaging protocols may be useful. MSN appears worthy of further investigation in pediatric patients with suspected PH.

Prediction of Response to Treatment Using Doppler Signal Positivity Measured by Ultrasound in Rheumatoid Arthritis: A Proof-of-Concept Study.

Prediction of Response to Treatment Using Doppler Signal Positivity Measured by Ultrasound in Rheumatoid Arthritis: A Proof-of-Concept Study.

Identifying Acoustic Wave Sources on the Sun. II. Improved Filter Techniques for Source Wavefield Seismology

In this paper, we refine a previously developed acoustic source filter, improving its reliability and extending its capabilities. We demonstrate how to fine-tune the filter to meet observational constraints and focus on specific wave-front speeds. This refinement enables discrimination of acoustic source depths and tracking of local source wave fronts, thereby facilitating ultralocal helioseismology. By utilizing the photospheric Doppler signal from a subsurface source in a MURaM simulation, we demonstrate that robust ultralocal three-dimensional helioseismic inversions for the granular flows and the local sound speed to depths of at least 80 km below the photosphere are possible. The capabilities of the National Science Foundation’s new Daniel K. Inouye Solar Telescope will enable such measurements of the real Sun.

Large Photospheric Doppler Shift in Solar Active Region 12673. I. Field-aligned Flows

Delta (δ) sunspots sometimes host fast photospheric flows along the central magnetic polarity inversion line (PIL). Here we study the strong Doppler shift signature in the central penumbral light bridge of solar active region NOAA 12673. Observations from the Helioseismic and Magnetic Imager (HMI) indicate highly sheared and strong magnetic fields. Large Doppler shifts up to 3.2 km s−1 appeared during the formation of the light bridge and persisted for about 16 hr. A new velocity estimator, called DAVE4VMwDV, reveals fast converging and shearing motion along the PIL from HMI vector magnetograms, and recovers the observed Doppler signal much better than an old version of the algorithm. The inferred velocity vectors are largely (anti-)parallel to the inclined magnetic fields, suggesting that the observed Doppler shift contains a significant contribution from the projected field-aligned flows. High-resolution observations from the Hinode/Spectro-Polarimeter further exhibit a clear correlation between the Doppler velocity and the cosine of the magnetic inclination, which is in agreement with HMI results and consistent with a field-aligned flow of about 9.6 km s−1. The complex Stokes profiles suggest significant gradients of physical variables along the line of sight. We discuss the implications on the δ-spot magnetic structure and the flow-driving mechanism.

The Relationship Between Sarcopenic Obesity and Knee Osteoarthritis: The SARCOB Study.

To investigate whether sarcopenic obesity may contribute to knee osteoarthritis or not. In this study, we assessed 140 community-dwelling adult patients. Their demographic data were recorded along with comorbidities. Anterior mid-thigh muscle thickness in the axial plane was measured on the dominant leg using ultrasound midway between the anterior superior iliac spine and the upper end of patella in millimeter. Then, the sonographic thigh adjustment ratio was calcu- lated by dividing this thickness by body mass index. ISarcoPRM algorithm was used for the diagnosis of sarcopenia. Kellgren-Lawrence grading was used for knee osteoarthritis . Functional evaluation was performed using chair stand test, gait speed, and grip strength. There were 50 patients with knee osteoarthritis and 90 age- and gender-similar control sub- jects. When compared with controls, anterior thigh muscle thickness, gait speed, and grip strength were found to be similar between the groups, whereas body mass index and chair stand test val- ues were higher in the knee osteoarthritis group (both P < .05). In addition, sarcopenic obesity was observed in 12 (13.3%) of control subjects and in 14 (28%) of osteoarthritis patients. When age, gen- der, exercise, smoking, and body composition type (i.e., nonsarcopenic nonobese, sarcopenic only, obese only, and sarcopenic obesity) were taken into binary logistic regression analyses, only sarcope- nic obesity [relative risk ratio = 2.705 (95% CI: 1.079-6.779)] was independently related with the knee osteoarthritis (P < .05). Our preliminary study has shown that neither sarcopenia nor obesity but sarcopenic obe- sity seems to be independently related to the knee osteoarthritis. Further longitudinal studies with larger samples are required for investigating the effects of obesity and sarcopenia on the develop- ment of knee osteoarthritis.

Renal artery aneurism and renal autotransplantation: review of surgical technique, preoperative complementary examinations and postoperative follow-up protocol

Introduction: Renal artery aneurysm (RAA) is a rare pathology; however, its incidental diagnosis is increasingly frequent due to the increasing use of imaging techniques. Complex (hilar) RAAs, dependent on the distal renal artery and its branches, constitute a subset of RAAs that present a therapeutic challenge due to their anatomical location and may require extracorporeal arterial repair and autotransplantation. Material and methods: A bibliographic review is carried out to homogenize the management of this pathology, analyzing the indications for surgical treatment, the recommended surgical technique step by step, as well as post-surgical monitoring. Two clinical cases of RAA treated in our center by hand-assisted laparoscopic nephrectomy, ex vivo bench repair and renal autotransplantation are presented. Results: In both cases, a postoperative Doppler ultrasound of the graft was performed 24 hours later, in which a renal graft was observed in the iliac fossa, of normal size and cortical thickness within normality with normal color Doppler signal, and spectral curves without alterations. Both patients presented oligoanuric acute renal failure (injury) during the immediate postoperative period (first 24 hours) with complete resolution at discharge, which occurred on the 11th and 12th postoperative day, respectively. In both patients a diuretic renogram with MAG3 was performed. In case 1, it was performed the third postoperative month and a slightly ectatic right kidney was observed with less perfusion and parenchymal incorporation of the radiotracer, with a reduction in relative renal function (39.47%) and MAG3 clearance (indeterminate renographic pattern). In this patient, a CT scan with the excretory phase was performed simultaneously, in which a grafted right kidney was seen at the level of the right iliac fossa with good contrast elimination in the excretory phase bilaterally and symmetrically. A small non-perfused area is observed in the upper pole. In the second patient, the renogram was performed on the 14th postoperative day, finding the morphofunctional study of the graft within normal parameters without detecting areas of hypoperfusion. The levels of creatinine and glomerular filtration were, respectively, in the first case: 0.86mg/dl and 90.19ml/min/1.73m2 preoperatively and 0.83mg/dl and 90.96ml/min/ 1.73m2 per postoperative month. In the second case, the values were: preoperatively creatinine of 0.66mg/dl and glomerular filtration rate of 97.96ml/min/1.73m2 and 0.81mg/dl and 89ml/min/1.73m2 one month postoperatively. Conclusion: After reviewing the literature, there is no consensus regarding the imaging techniques to be performed after renal autotransplantation and the optimal time frames for performing these for the evaluation of the postoperative graft. There is also no homogeneity in the imaging techniques to be performed in the preoperative assessment. In our experience, open ex vivo surgical repair of complex distal hilar RAAs has been successful with low morbidity and mortality and an acceptable rate of preservation of renal function.

LEO Satellite Localization of Receiver in Motion Using Signal Frequency of Arrival

This study presents a localization algorithm for moving the receiver based on LEO satellite downlink Doppler signals. This algorithm could provide an alternative to pseudo-range based GNSS. Considering the asynchrony between satellites and the existence of a relative clock skew, we used sequential measurements at multiple receiving moments to obtain a sufficient number of observations. And we performed motion offset compensation for the receiver position and velocity at different moments. Simulation results show that the algorithm can achieve good localization accuracy.

Sonographic diagnosis and evaluation in patients with superficial radial arteries.

The superficial radial artery (SRA) is a rare congenital anomaly in the forearm. However, it can be detected incidentally via trauma, intraoperative findings, angiography, or ultrasonography. In addition, intra-arterial infusion of intravenous medications and difficulties in radial artery catheterization may occur in cases of the SRA. Between December 2016 and July 2020, anomalous branches of radial arteries were found incidentally in nine patients at the preoperative visit and identified during ultrasound-guided radial artery puncture in 21 patients when radial artery catheterization using the palpation method proved difficult. Ultrasound examinations were performed for diagnosis and evaluation of these 30 patients. All anomalous branches of the radial artery were SRAs; 11 (37%), 13 (43%), 6 (20%) were present on the right side, on the left side, and bilaterally, respectively. All SRAs ran close to the cephalic vein. The vascular diameters of the radial arteries were the smallest in the radial artery distal to the SRA bifurcation (followed by in the SRA) and the largest in the radial artery proximal to the bifurcation (p < .001). In two cases, color Doppler study revealed that both the blood flow and color Doppler signal of the SRA disappeared with compression of the radial artery proximal to the SRA bifurcation. Because the SRA runs very close to the cephalic vein, a tourniquet applied to the arm may easily lead to intravenous catheter misplacement into the SRA. In addition, the small radial artery distal to the SRA bifurcation causes difficulty in radial artery catheterization. Furthermore, SRA cases may have falsely normal Allen's test results. Therefore, the authors recommend that the SRA must be identified before vascular puncture for safe vascular catheterization in the forearm.

Ultrasound Assessment of Entheseal Sites and Anterior Chest Wall in Ankylosing Spondylitis: A Cross-Sectional Study.

The study was designed to evaluate entheseal sites and anterior chest wall (ACW) of patients with ankylosing spondylitis (AS) using ultrasound (US) and investigate the correlation between disease activity and US score. This prospective cross-sectional study included 104 patients with AS and 50 control subjects. Each patient underwent US scanning of 23 entheses and 11 sites of the ACW. The US features, including hypoechogenicity, thickness, erosion, calcification, bursitis, and Doppler signal, were evaluated. Disease activity was assessed based on C reactive protein (CRP), erythrocyte sedimentation rate (ESR), disease activity score-C reactive protein (ASDAS-CRP), and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). The most commonly involved entheses on US were the Achilles tendon (AT) and quadriceps tendon (QT). The most involved site of ACW was the sternoclavicular joint (SCJ). Compared with the control group, significant differences were observed in the AS group in the rates of US enthesitis and ACW in AT (P = .01), SCJ (P = .00), and costochondral joint (CCJ) (P = .01). Patients with high or very high disease activity had a higher erosion score (P = .02). The erosion score was weakly positively associated with CRP, ESR, BASDAI, ASDAS-CRP, and ASDAS-ESR (correlation coefficient: 0.22-0.45). The most commonly involved entheseal sites on US were AT and QT, while the site of ACW was SCJ. The US assessment of AS should take the ACW into account. High disease activity might indicate erosion in AS.

Ultrasound diagnostics in the assessment of traumatic peripheral nerve damage in combat trauma

BACKGROUND: Traumatic peripheral nerve damage is a significant clinical and social problem, which is characterized by a high level of disability in young patients.&#x0D; AIM: To assess the diagnostic efficiency of ultrasound in the diagnosis of peripheral nerve damage in combat trauma.&#x0D; METHODS: A total of 163 patients (362 peripheral nerves) were examined. The duration of traumatic nerve damage was 2273 days. All patients were men aged 2048 years. Ultrasound was performed with 717 MHz linear transducers on an ACUSSON S2000 device using standard technique in B-mode, in longitudinal and transverse scanning planes, with the use of Doppler techniques. Statistical analysis was conducted to assess diagnostic efficiency. Calculation of operational (sensitivity and specificity) and integral (accuracy) characteristics was performed by the qualitative assessment of the reference method (surgical intervention) and the method under study (ultrasound).&#x0D; RESULTS: Peripheral nerve damage resulted from combat trauma. In 120 (73.6%) cases, injuries of the limbs were accompanied by injuries of the osteoarticular apparatus and vessels. A total of 274 (75.7%) nerves had signs of traumatic damage. Multiple nerve injuries were observed in 95 (58.3%) people. Nerves of the upper extremities were damaged more frequently (185 [67.5%]) compared to nerves of the lower extremities (89 [32.5%]). Contusional structural changes were observed in 181 (66%) nerves. Impairment of anatomical integrity was diagnosed in 46 (16.8%) nerves, while complete impairment was found in 29 (10.6%) cases with the presence of diastasis between the nerve ends. Early after injury, a wound canal and hematomas were visualized near the nerve. In 4 cases, a foreign body of metallic density was visualized in the nerve sheath. After 3 weeks from the moment of injury, terminal neuromas were observed. The neuroma sizes for the proximal and distal ends were 0.50.3 to 1.60.6 cm and 0.40.2 to 1.30.6 cm (avascular), respectively. Adjacent sections of the nerve over 35 cm were thickened and characterized by echo structure, however, with thickening of all fasciculi and blood flow observed along the periphery of the nerve. Marginal nerve damage was observed in 17 (6.2%) people. In case of marginal neuroma, a significant nerve thickening of 1.43.2 times over a short distance (from 0.4 cm to 1.5 cm) with loss of bundle differentiation of the part of the nerve, pronounced decrease in echogenicity, and absence of Doppler signal was detected. Nerve compression in 47 cases (17.1%) was accompanied by 1.22.3 times thickening of nerve trunks, indistinct contours, decreased echogenicity, and significant changes in the nerve structure. Compression was due to cicatricial changes, hematomas, foreign bodies, bone fragments, and in 2 cases spokes from external fixation devices. A total of 106 patients underwent surgery.&#x0D; CONCLUSIONS: The ultrasound sensitivity and specificity were 96% and 67%, respectively. The peculiarities of the examination included extensive soft tissue defects and external fixation devices, which significantly complicated the examination. The diagnostic accuracy was 91%. A pronounced cicatricial process (70%) was the main cause of false-positive (6.6%) and false-negative (2.8%) results.

Sclerodermic hand: a retrospective study on the role of ultrasonography in the detection of subclinical joint involvement.

The inflammatory involvement of joints and tendons is common in Systemic Sclerosis (SSc). Ultrasonography (US) is a non-invasive tool commonly applied for the assessment of the main inflammatory arthropathies and could be also used in identifying pathological features in SSc patients, even without clinical evidence of joint complaint. So, the aim of this study was to assess the prevalence of US pathological features in a cohort of SSc patients and assessed the role of US in the detection of subclinical joint involvement. In this retrospective study, we collected data about the prevalence of US pathological features at the level of hands and wrists in a cohort of patients with a definite diagnosis of SSc,submitted to an ultrasound examination of hands and wrists according to the clinician's opinion, with or without joint involvement symptoms,in order to assess the US ability in detecting subclinical inflammatory signs in SSc patients. In total, 47.5% of patients reported at least one US pathological feature. The most common was synovial hypertrophy (62.1%). Other assessed lesions were effusion (48%), tenosynovitis (37.9%), power Doppler (PD) signal (31.0%), and erosions (0.7%). Effusion and PD signal appeared significantly higher in symptomatic patients, with a p<0.01 and p=0.045, respectively. In this cohort of SSc subjects, almost the half of the US-positive patients were clinically asymptomatic. Therefore, the application of US could be useful to detect the musculoskeletal involvement of SSc patients, a potential markers of disease severity. Further studies are required to assess the role of US in monitoring SSc patients. Key Points • The inflammatory involvement of joints and/or tendons is common in systemic sclerosis (SSc) but could be partially covered by other disease features. • Among the diagnostic methods able to increase the sensitivity of the musculoskeletal evaluation, Ultrasonography (US) is one of the most promising to reveal subclinical inflammation and predict the joint damage progression. • We retrospectively investigated the prevalence of US pathological features in a cohort of SSc patients, with or without symptoms of joint involvement, assessingthe role of US in the detection of subclinical joint involvement. • We found that joint and tendon involvement, a potential marker of disease severity, is common in SSc.

DSA-Based 2D Perfusion Measurements in Delayed Cerebral Ischemia to Estimate the Clinical Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage: A Technical Feasibility Study.

(1) Background: To predict clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH) and delayed cerebral ischemia (DCI) by assessment of the cerebral perfusion using a 2D perfusion angiography (2DPA) time-contrast agent (CA) concentration model. (2) Methods: Digital subtraction angiography (DSA) data sets of n = 26 subjects were acquired and post-processed focusing on changes in contrast density using a time-concentration model at three time points: (i) initial presentation with SAH (T0); (ii) vasospasm-associated acute clinical impairment (T1); and (iii) directly after endovascular treatment (T2) of SAH-associated large vessel vasospasm (LVV), which resulted in n = 78 data sets. Maximum slope (MS in SI/ms), time-to-peak (TTP in ms), and maximum amplitude of a CA bolus (dSI) were measured in brain parenchyma using regions of interest (ROIs). First, acquired parameters were standardized to the arterial input function (AIF) and then statistically analyzed as mean values. Additionally, data were clustered into two subsets consisting of patients with regredient or with stable/progredient symptoms (or Doppler signals) after endovascular treatment (n = 10 vs. n = 16). (3) Results: Perfusion parameters (MS, TTP, and dSI) differed significantly between T0 and T1 (p = 0.003 each). Significant changes between T1 and T2 were only detectable for MS (0.041 ± 0.016 vs. 0.059 ± 0.026; p = 0.011) in patients with regredient symptoms at T2 (0.04 ± 0.012 vs. 0.066 ± 0.031; p = 0.004). For dSI, there were significant differences between T0 and T2 (5095.8 ± 2541.9 vs. 3012.3 ± 968.3; p = 0.001), especially for those with stable symptoms at T2 (5685.4 ± 2967.2 vs. 3102.8 ± 1033.2; p = 0.02). Multiple linear regression analysis revealed that a) the difference in MS between T1 and T2 and b) patient's age (R = 0.6; R2 = 0.34; p = 0.009) strongly predict the modified Rankin Scale (mRS) at discharge. (4) Conclusions: 2DPA allows the direct measurement of treatment effects in SAH associated DCI and may be used to predict outcomes in these critically ill patients.

Diastolic Left Main Coronary Artery Flow Reversal

In patients undergoing percutaneous cardiac interventions, perioperative transesophageal echocardiography is used routinely, often revealing an unusual pathology that was not previously detected with transthoracic echocardiography. In this e-challenge, the authors present a patient undergoing percutaneous transcatheter aortic valve replacement, with preprocedural transesophageal echocardiography revealing an abnormal color Doppler signal near the left main coronary artery during diastole.

A case of life-threatening hematuria.

A 66-year-old male with a past medical history of hypertension and benign prostatic hypertrophy, not on anticoagulation, presented with difficulty voiding and hematuria. He was seen at an outside hospital earlier in the day and received a straight catheterization for urinary retention, he was prescribed antibiotics for a urinary infection, and he was discharged home. Subsequently, after discharge, he developed hematuria with inability to void, prompting a visit to our emergency department (ED). On arrival, the patient was uncomfortable appearing, tachycardic with a heart rate of 116 beats per minute and a blood pressure of 114/67 mm Hg. His lower abdomen was tender to palpation. A point-of-care ultrasound (POCUS) of the bladder was performed. The ultrasound demonstrated a distended-appearing bladder containing a large area of layering mixed echogenicity with intrinsic turbulent Doppler signal (Video 1). The patient had a three-way Foley catheter placed in the ED for continuous bladder irrigation. He had a computerized tomography (CT) angiography of the abdomen and pelvis that did not reveal any active hemorrhage. He also had a CT urogram. Initially, the hematuria improved, however, following the abnormal ultrasound Doppler images, the patient was admitted to the urology service. Although he was admitted, his hemoglobin declined from 12 to 7.9 g/dL, and he suffered a cardiac arrest. The reason for the arrest was presumed to be from hemorrhagic shock. There was return of spontaneous circulation after initiation of massive transfusion protocol. He underwent cystoscopy showing an enlarged median prostate lobe with active extravasation, requiring embolization of the prostatic artery by interventional radiology (IR). Hematuria and urinary obstruction are common causes of ED visits with multiple underlying etiologies.1 Emergency physicians are tasked with the challenge of determining which patients can be managed as outpatients. In this case, gross hematuria from an actively bleeding prostate led to the hemorrhagic shock requiring multiple transfusions and need for IR embolization. The most common etiologies of prostatic hematuria are benign prostatic hyperplasia, iatrogenic urologic trauma, prostate cancer, and radiation therapy.2 In this patient, POCUS showed turbulent Doppler flow within the bladder (Figure 1A), which was concerning for active bleeding, and ultimately led to the patient's admission and emergent urologic consultation. Additionally, the POCUS also showed layering mixed echogenicities seen within the distended bladder, indicating a clot at various stages (Figure 1B). This case illustrates the importance of considering POCUS in patients with urinary retention and hematuria, especially in the setting of recent catheter placement.