Positive Ultrasound Examination Research Articles

Neonatal Proximal Humerus Osteomyelitis: A Case Report and Literature Review

Objective − This case report was written with the purpose of educating neonatal caregivers with regard to the early detection of osteomyelitis in order to start treatment quickly and avoid the devastating consequences later with lifelong disability.Case Report − We present a 20-day-old newborn with a lack of spontaneous movement of the right arm, which first occurred 5 days prior. The newborn was diagnosed with Erb’s palsy, and physiotherapy was started. Upon re-examination, he did not move his right arm, his shoulder was slightly swollen, he was afebrile, and C-reactive protein was elevated. The initial radiographic finding was normal, but the ultrasound evaluation found evidence of proximal humerus osteomyelitis. Over the next two days, the condition did not improve despite the included therapy (vancomycin and amikacin). Then, joint drainage surgery was performed. The radiographic finding upon discharge showed significant destruction of the proximal humerus and shoulder joint. At the age of 12 months, the range of motion in the affected shoulder joint was less than in the left.Conclusion − Regular arm mobility in the early postpartum days, pseudoparalysis on examination, a swollen and raised shoulder, pain during passive movements, a positive ultrasound examination, and a high level of C-reactive protein are data that can reliably indicate the onset of osteomyelitis of the proximal humerus and help in the differential diagnosis between osteomyelitis and Erb’s palsy. The lack of timely diagnosis of osteomyelitis and the delayed inclusion of therapy can lead to late consequences, such as significant destruction of the proximal humerus and the shoulder joint.

Extended ultrasound examination identifies more large vessel involvement in patients with giant cell arteritis.

To compare limited with a more extended ultrasound examination (anteromedial ultrasound, A2-ultrasound) to detect large vessel (LV) involvement in patients with newly diagnosed GCA. Patients with new-onset GCA were included at the time of diagnosis. All patients were examined using limited ultrasound (ultrasound of the axillary artery as visualized in the axilla) and an extended A2-ultrasound method (which also includes the carotid, vertebral, subclavian and proximal axillary arteries), in addition to temporal artery ultrasound. One hundred and thirty-three patients were included in the study. All patients fulfilled the criteria according to a proposed extension of the 1990 ACR classification criteria for GCA and had a positive ultrasound examination at diagnosis. Ninety-three of the 133 GCA patients (69.9%) had LV involvement when examined by extended A2-ultrasound, compared with only 56 patients (42.1%) by limited ultrasound (P < 0.001). Twelve patients (9.0%) had vasculitis of the vertebral arteries as the only LVs involved. Five patients (3.8%) would have been missed as having GCA if only limited ultrasound was performed. Forty patients (30.0%) had isolated cranial GCA, 21 patients (15.8%) had isolated large vessel GCA and 72 patients (54.1%) had mixed-GCA. Extended A2-ultrasound examination identified more patients with LV involvement than the limited ultrasound method. However, extended A2-ultrasound requires high expertise and high-end equipment and should be performed by ultrasonographers with adequate training.

Analysis of clinical characteristics of 126 children with recurrent intussusception

Objective: To analyze and summarize the clinical features in children with recurrent intussusception. Methods: This retrospective cohort study collected the clinical data of 126 children with recurrent intussusception who were admitted to the Children's Hospital of Zhejiang University School of Medicine due to "abdominal pain, paroxysmal crying, vomiting, bloody stools" from January 1, 2015 to November 30, 2019. The clinical manifestations of recurrent intussusception between ≤3 years old group and >3 years old group were compared, the etiology and age characteristics of pathologic lead points (PLP) were analyzed, and the clinical characteristics of PLP group and non-PLP group were also compared. The χ2 test and Mann-Whitney U test were used to compare the differences between groups. Results: A total of 126 children with recurrent intussusception were included, of whom 76 were males and 50 were females, with the age of 2.9 (1.7, 5.1) years. The proportion of children aged more than 1 year was 87.3% (110/126), and 48.4% (61/126) more than 3 years. Clinical manifestations mostly lacked the typical triad of symptoms. The percentage of paroxysmal crying in ≤ 3 years old group was significantly higher than that in >3 years old group (52.3% (34/65) vs. 24.6% (15/61), χ2=10.17, P=0.001), while the percentage of abdominal pain was significantly lower than that in the >3 years old group (46.1% (30/65) vs. 75.4% (46/61), χ2=11.25, P=0.001). The rate of positive ultrasound examination was 17.5% (22/126), and 63.6% (14/22) of them were diagnosed. The positive rate of CT examination was 4/13, of which 2 cases were diagnosed. In this study, 37 children were diagnosed with PLP by colonoscopy, laparoscopy or laparotomy, and 89 children were found without PLP. The positive rate of PLP in >3 years old group was significantly higher than that in ≤3 years old group (37.7% (23/61) vs. 21.5% (14/65), χ2=3.96, P=0.046). Meckel's diverticulum and juvenile polyp were the main contributors of PLP in ≤3 years old group, accounting for 7/14 and 3/14 respectively, while lymphoma and juvenile polyp accounted for 34.8% (8/23) and 26.1% (6/23), respectively in >3 years old group. Compared with non-PLP group, PLP group had higher age (5.2 (1.6, 6.7) vs. 2.7 (1.8, 4.2) years, Z=-2.26, P=0.01). However, there were no significant differences in gender and recurrence frequency between the two groups (both P>0.05). Conclusions: Recurrent intussusception is more common in children more than 1 year old, and has a wide spectrum of non-specific clinical presentations. Imaging examinations can be used to identify PLP. The most recurrent intussusception is idiopathic, but the presence of PLP should be alerted for, such as Meckel's diverticulum, lymphoma and juvenile polyp. Colonoscopy sometimes is necessary, surgical exploration and treatment should be carried out in time.

Spatial analysis of the geographical distribution of thyroid cancer cases from the first-round thyroid ultrasound examination in Fukushima Prefecture

Following the Fukushima Daiichi Nuclear Power Plant (FNPP) accident on 11 March 2011, there have been concerns regarding the health impacts of the ensuing radioactive environmental contamination, which was spatially heterogeneous. This study aimed to assess the geographical variability of thyroid cancer prevalence among children and adolescents in Fukushima Prefecture. We computed the sex- and age-standardised prevalence ratio using 115 diagnosed or suspected thyroid cancer cases among approximately 300,000 examinees at the first-round ultrasound examination during 2011–2015 from 59 municipalities in the prefecture, under the Fukushima Health Management Survey. We applied flexibly shaped spatial scan statistics and the maximised excess events test on the dataset to detect locally anomalous high-prevalence regions. We also conducted Poisson regression with selected regional indicators. Furthermore, approximately 200 examinees showed positive ultrasound examination results but did not undergo confirmatory testing; thus, we employed simulation-based sensitivity tests to evaluate the possible effect of such undiagnosed cases in the statistical analysis. In conclusion, this study found no significant spatial anomalies/clusters or geographic trends of thyroid cancer prevalence among the ultrasound examinees, indicating that the thyroid cancer cases detected are unlikely to be attributable to regional factors, including radiation exposure resulting from the FNPP accident.

Baseline Shoulder Ultrasonography Is Not a Predictive Marker of Response to Glucocorticoids in Patients with Polymyalgia Rheumatica: A 12-month Followup Study

In this study, we evaluated whether ultrasound (US) subdeltoid bursitis (SB) and/or biceps tenosynovitis (BT) presence at baseline could represent a predictive marker of response to standard therapy after 12 months of followup, and whether a positive US examination could highlight the need of higher maintenance dosage of glucocorticoids (GC) at 6 and 12 months in patients with polymyalgia rheumatica (PMR). Sixty-six consecutive patients with PMR underwent bilateral shoulder US evaluations before starting therapy and after 12 months of followup. Absence of girdle pain and morning stiffness (clinical remission) and laboratory variables were evaluated. After diagnosis, all patients were treated with prednisone. At baseline, SB and/or BT were present in 46 patients (70%), of whom 33 (72%) became negative while 13 (28%) remained positive at the 12-month US evaluation. All patients rapidly achieved a clinical remission, and at 6 months 26 (39%) also achieved a laboratory variable normalization. According to US positivity at baseline, no difference was found in remission or relapse rate after 12 months. Thirty patients (46%) at 6 months and 7 (11%) at 12 months were still taking more than 5 mg/day of prednisone. According to the US pattern at baseline, no difference was found in the mean GC dose at 6 and 12 months. In patients with PMR, the presence of SB and/or BT on US at diagnosis is not a predictive marker of GC response or of a higher GC dosage to maintain remission in a 12-month prospective followup study.

Imaging Acute Appendicitis: State of the Art

The goal of this review is to present the state of the art in imaging tests for the diagnosis of acute appendicitis. Relevant publications regarding performance and advantages/disadvantages of imaging modalities for the diagnosis of appendicitis in different clinical situations were reviewed. Articles were extracted from a computerized database (MEDLINE) with the following activated limits: Humans, English, core clinical journals, and published in the last five years. Reference lists of relevant studies were checked manually to identify additional, related articles. Ultrasound (US) examination should be the first imaging test performed, particularly among the pediatric and young adult populations, who represent the main targets for appendicitis, as well as in pregnant patients. A positive US examination for appendicitis or an alternative diagnosis of possible gastrointestinal or urological origin, or a negative US, either showing a normal appendix or presenting low clinical suspicion of appendicitis, should lead to a final diagnosis. A negative or indeterminate examination with a strong clinical suspicion of appendicitis should be followed by a computed tomography (CT) scan or alternatively, a magnetic resonanace imaging (MRI) scan in a pregnant patient. A second US examination in a patient with persistent symptoms, especially if the first one was performed by a less experienced imaging professional, is a valid alternative to a CT.

Authors' Response

To the Editor: We would like to thank Dr Scholz et al for their commentary regarding our Image of the Month in March 2010 (1), which highlights the use of ultrasound in the diagnosis of intussusception. We agree that abdominal ultrasound is useful for diagnosis in cases of suspected intussusception, specifically ileocolic variations. Dr Scholz and colleagues also describe limitations of other imaging modalities (eg, computed tomography [CT]), as well as therapeutic options for reduction. We applaud the German approach of broad training in ultrasound for pediatric residents and gastroenterology fellows. However, we also note several logistical issues that may limit the feasibility of ultrasound training as a requirement in the United States. Our case focused on intussusception as a presenting feature of celiac disease. Our patient's initial presentation was a distended and tender abdomen with bilious emesis and an abdominal film suggestive of obstruction. We agree that if a standard ileocolic intussusception was suspected from the presentation, CT scan and laparoscopy would not have been performed initially. In a 4-year-old patient such as ours, appendicitis is more common than ileocolic intussusception, and in the setting of obstruction, this diagnosis was pursued. In our case, the multiple intussusceptions were not identified on CT imaging. We submit that even if they had been visualized, the presentation of bilious emesis and small bowel obstruction would have prompted exploratory laparoscopy. There was no clinical indication that the intussusceptions were transient in nature. Although we agree that typical ileocolic intussusception can be generally reduced by contrast enema, the 6 multiple ileoileal intussuceptions seen in our patient would not have been reduced in this manner as effectively. Instead, intussusceptions caused by pathological lead points often require operative reduction. The majority of the literature in this area is directed at ileocolic intussusception rather than small bowel intussusceptions (SBI), but subsets of data related to ileoileal intussusception can be extracted. Saxena and Höllwarth (2) reported 25.2% of patients with intussusception were SBI, and 14.3% had surgery, with 10.7% requiring bowel resections. Compared with ileocolic intussusceptions, pneumatic reduction was less successful in SBI (85.7% vs 91%). Harrington et al (3) propose that plain film suggestive of small bowel obstruction is a relative contraindication for enema reduction. They report that >50% of children older than age 2 years experienced a failed attempt at hydrostatic reduction, and 5 of 6 with bowel obstruction had proximal lesions (3). There is a paucity of data on the management of multiple simultaneous SBI, as in our case. In a series of 112 positive ultrasound examinations for ileocolic intussusceptions, 8 of 15 were falsely positive and later diagnosed with ileoileal intussusception (4). These data may suggest that even if ultrasound is positive, management may be altered in a significant number of patients (5). In conclusion, we maintain that a variety of diagnostic options are available in the diagnosis and treatment of SBI, and clinical information and initial imaging are likely to direct subsequent steps in diagnosis and treatment. Our case primarily suggests the importance of evaluating for potential underlying celiac disease in cases of SBI in which pathological lead points, such as polyps or lymphoma, are not identified as the cause of intussusception, regardless of the means by which reduction is achieved.

Second‐trimester genetic sonogram for detection of fetal chromosomal abnormalities in a community‐based antenatal testing unit

To evaluate the efficacy of the second-trimester genetic sonogram for the detection of Down syndrome and other chromosomal abnormalities in a community-based antenatal testing unit. This was a retrospective study using data from two community hospital antenatal ultrasound units. Six hundred and sixty fetal ultrasound examinations in both at-risk (n = 581) and low-risk (n = 79) pregnancies were performed from 15 + 0 to 22 + 6 weeks' gestation and all cases were verified for outcome data. The sonographic detection of a major congenital anomaly or a sonographic marker (increased nuchal skinfold, short humerus, short femur, echogenic bowel, pyelectasis, echogenic intracardiac focus, absence or hypoplasia of fifth mid phalanx or choroid plexus cyst) was recorded. The entire group of 660 ultrasound examinations as well as subgroups with and without non-ultrasound risk factors for a fetal chromosomal abnormality were analyzed to determine the sensitivity, specificity, positive and negative predictive values and positive likelihood ratio for the detection of Down syndrome and other fetal chromosomal abnormalities. There were 32 (4.85%) chromosomal abnormalities in our study population. Twelve (3.75%) of these were Down syndrome, of which eight (66.6%) had a positive ultrasound examination in the second trimester. Six of seven (85.7%) of the trisomy 18 fetuses, 2/2 of the trisomy 13 fetuses and 2/3 of the non-mosaic 45,X fetuses had positive sonograms. The overall detection rate for chromosomal abnormalities was 20/32 (sensitivity, 62.5%; specificity, 80.7%; negative predictive value, 97.7%; positive predictive value, 14.2%; positive likelihood ratio, 3.24). Major structural defects and sonographic markers, excluding hypoplastic fifth digit and choroid plexus cyst, occurred significantly more frequently in Down syndrome cases compared with normal ones. In a community-based antenatal testing unit we have demonstrated a detection rate for fetal Down syndrome with the second-trimester genetic sonogram that is comparable to the range of sensitivities reported by larger centers involving primarily high-risk patients. However, only 12 of the 32 fetal chromosomal abnormalities that we encountered were Down syndrome.

A prospective evaluation of ultrasonography for the diagnosis of penetrating torso injury.

Ultrasound (US) is commonly used for the diagnosis of hemoperitoneum after blunt abdominal trauma, but the value of US as an aid for identification of operative lesions after penetrating trauma is not well documented. The purpose of this investigation was to determine the accuracy of US for the evaluation of penetrating torso trauma and to assess the impact of this information on patient management. We conducted a prospective cohort observational study of consecutive penetrating torso patients at a Level I trauma center. During the 6-month trial period, 177 victims of penetrating torso trauma were assessed by our trauma teams. Ninety-two patients had stab wounds, 84 patients had gunshot wounds, and 1 patient had a puncture wound. All 28 patients with positive US examination had an exploratory laparotomy or thoracotomy (one patient had more than one procedure), resulting in 26 therapeutic operations. There were 149 negative US examinations, but in this group, 36 patients underwent laparotomy or thoracotomy, and 28 had therapeutic operations. The overall accuracy of the US examination was therefore 85%, the sensitivity was 48%, and the specificity was 98%. There were only three patients who had their initial management altered by a positive US examination. The US examination lacks sensitivity to be used alone in determining operative intervention after gunshot or stab wounds. Rarely does US information contribute to the management of patients with penetrating abdominal injuries.

Predicting the need for laparotomy in pediatric trauma patients on the basis of the ultrasound score.

It is possible to quantify the amount of hemoperitoneum seen on focused assessment with sonography for trauma (FAST) using a simple scoring system that had previously been shown to correlate with the need for subsequent laparotomy in adults. A score of 3 or greater was shown to be highly accurate in predicting the need for laparotomy. We hypothesized that this scoring system might also predict the need for laparotomy in pediatric trauma patients. We retrospectively reviewed all records for patients 15 years and younger who underwent FAST after blunt trauma. A "positive" ultrasound examination was defined as one containing free intraperitoneal fluid with or without solid organ injury. The ultrasound score (USS) was defined as the depth of the deepest pocket of fluid collection measured in centimeters plus the number of additional spaces where fluid was seen. Thirty-eight (19.6%) of 193 patients who had FAST performed had positive ultrasound examinations. Thirty-seven patients with complete records were analyzed. There were no differences between patients with a USS < or = 3.0 and those with a USS > 3.0 in terms of admission pulse, Glasgow Coma Scale score, Injury Severity Score, or the proportion of patients who were initially hypotensive. One of 22 patients with a USS < or = 3.0 required therapeutic laparotomy versus 8 of 15 patients with a USS > 3.0 ( = 0.002). For a USS > 3.0, sensitivity, specificity, and accuracy in predicting therapeutic laparotomy were 89%, 75%, and 78%, respectively. Ultrasound quantification of hemoperitoneum by a simple scoring system may serve as a useful adjunct to traditional clinical parameters in predicting the need for subsequent laparotomy in pediatric patients. Prospective validation with a larger study is required.

The value of colour duplex imaging in suspected proximal deep vein thrombosis of the leg

Objectives: To establish the accuracy and identify advantages and disadvantages of colour duplex imaging compared with venography in the diagnosis of symptomatic proximal deep vein thrombosis (DVT) in our centre. Design: Prospective study over a 15 month period. Patients: 34 patients with 35 DVT suspected lower limbs were studied. They were first studied with colour duplex ultrasonography and the findings compared with contrast venography of the suspect limb. Results: 17 venograms were positive for DVT and ultrasound was positive in all. There was one false positive ultrasound examination. Sensitivity and specificity for detection of proximal DVT was 100% and 94.4% respectively. Venography resulted in complications in 6 patients (phlebitis 4, skin ulceration 2). Additional diagnoses were possible with sonography (calf haematoma 1, calf neoplasm 1, deep venous reflux 2 and superficial venous reflux 5). Conclusion: Colour coded duplex sonography is highly accurate and safe in detecting femoropopliteal thrombosis. Venography should be reserved only for duplex inconclusive situations.

Transabdominal ultrasonography as the primary investigation in patients with suspected crohn's disease or recurrence: A prospective study

Traditionally, patients with suspected or known and possible recurrent Crohn's disease have been investigated by small bowel barium radiology, which incurs a relatively high radiation dose. Despite patient selection a significant number have a normal barium examination. A prospective study was performed to evaluate the use of transabdominal ultrasound as the initial investigation in these two groups. One hundred and twenty-seven patients were examined, including 31 with a previous history of Crohn's disease. In the known Crohn's disease group there were 14 true positive ultrasound examinations and eight true negative, with six false positive and three false negative examinations. In the 96 patients not previously known to have Crohn's disease, there were 18 true positive and 70 true negative examinations, with two false positive and six false negative examinations. The overall sensitivity for ultrasound was 78% with a specificity of 91%. A significant learning curve was apparent in the early stages of study; in the last 64 patients the sensitivity was increased to 87%. These data support the use of ultrasound as the initial investigation in patients with suspected Crohn's disease or recurrence, prior to consideration for small bowel barium radiology, to reduce the large number of unnecessary small bowel barium examinations currently being performed.

Pyloric stenosis associated with malrotation

Three cases of pyloric stenosis associated with malrotation are presented. In one case, the diagnosis was made synchronously, and in two cases, pyloric stenosis was noted following correction of malrotation. All three patients underwent pyloromyotomy and Ladd's procedure. These cases differ from the few reported hereditary cases of pyloric stenosis associated with malrotation, which have congenitally shortened bowel, functional obstruction, and poor prognosis. The unusual finding of pyloric stenosis and malrotation occurring together in the first patient was diagnosed with upper gastrointestinal series, obtained because of a high index of suspicion despite a palpable pyloric tumor and positive ultrasound examination. The second and third cases illustrate that vomiting following Ladd's procedure may be due to pyloric stenosis. When clinical findings do not support the presumed diagnosis, further investigation prior to operation is recommended so that rare concommitant pathology can be corrected.

A Prospective Study of Ultrasonography in the Diagnosis of Appendicitis

The diagnosis of appendicitis is frequently difficult. We studied prospectively the diagnostic accuracy and clinical impact of abdominal ultrasonography in 111 consecutive patients thought to have appendicitis. Ultrasonography was performed with small high-resolution, linear-array transducers, with the abdomen compressed to displace or compress bowel and fat. Among 52 patients later shown in surgery to have appendicitis, ultrasonography was unequivocally positive in 39 (sensitivity, 75 percent). Of 31 patients in whom appendicitis was definitely excluded, none had a positive ultrasound examination (specificity, 100 percent). The sensitivity in those with a perforated appendix (28.5 percent) was much lower than in those with acute nonperforating appendicitis (80.5 percent) or appendiceal mass (89 percent), but the low sensitivity did not influence clinical management, since the need for surgery in patients with a perforated appendix was clinically obvious. Ultrasonography resulted in changes in the proposed management in 29 of the 111 patients (26 percent). It also led to the correct diagnosis in the 16 patients who were found to have a disease other than appendicitis. We conclude that ultrasonography is a useful aid in the diagnosis of appendicitis.

The accuracy of ultrasound in the detection of cirrhosis of the liver.

The association of high amplitude echoes returned from the liver and cirrhosis is well recognized. There have been no reports in the literature as to the overall incidence of this finding in the clinical situation. We report our experience in a series of 67 patients with proven cirrhosis who had liver biopsy and an ultrasound examination within three months of one another. In 43 patients cirrhosis was suggested by recognition of a bright liver echo pattern. In 23 patients the liver echo pattern was normal, although additional relevant information was shown in half of this group. The detailed pathology has been analysed in an attempt to account for the false negative examinations, revealing a strong trend for cases of micronodular cirrhosis to give positive ultrasound examinations and macronodular cirrhosis negative examinations.