Transverse View Research Articles

Aberran sağ subklavyen arter: Down sendromu ve konjenital kalp hastalığı için güçlü bir belirteç midir?

Amac: Fetal aberran sag subklavyen arter (ARSA) ile Down sendromu arasindaki iliski uzun zamandir bilinmektedir. Calismamizin amaci populasyonumuzdaki ARSA insidansini ve Down sendromu ve konjenital kalp hastaliklari (KKH) ile iliskisini belirlemektir. Gerec ve Yontem: 2015-2018 yillari arasinda ucuncu basamak merkezde prenatal tani icin 3150 gebeye fetal ekokardiyografi yapildi. ARSA varligi, fetal ekokardiyografi sirasinda transvers 3 damar trakea planinda renkli Doppler sonografide goruntulenmesi ile dogrulandi. Calismamizda ARSA'nin sikligi ve Down sendromu ile korelasyonu arastirildi. Bulgular: 3150 hasta arasinda 42 fetuste (% 1.3) ARSA, 36 fetuste (% 1.14) izole ARSA saptandi. Down sendromlu dokuz fetusten iki hastada (% 22.2) ARSA pozitifti. ARSA, KKH olan fetuslerden sadece birinde pozitifti (% 4.1). Izole ARSA'nin Down sendromu ve CHD icin pozitif olasilik oranlari sirasiyla 0.73 ve 3.81 idi. Sonuc: Olgu serimizde, prenatal ARSA'nin saptanmasi Down sendromu icin tek basina guclu bir marker gibi gorunmemektedir ve izole ARSA, KKH ile zayif bir iliski gostermektedir.

Comparison of Respiratory Variations of Subclavian Vein and Inferior Vena Cava in Hospitalized Patients with Kidney Disease.

BackgroundAccurate assessment of relative intravascular volume is critical for appropriate volume management of patients with kidney disease. Respiratory variations of inferior vena cava (IVC) diameter have been used and may correlate with those of subclavian vein (SCV) by bedside ultrasound. The purpose of this study was to assess the relationship between SCV and IVC respiratory variations by bedside ultrasound in a large group of hospitalized patients with acute and/or chronic kidney disease.MethodsWe compared 160 paired SCV and IVC bedside ultrasound studies from 102 semi-recumbent hospitalized adult patients with kidney disease. Patient encounters in which the SCV or IVC could not be clearly visualized were excluded. Collapsibility index=(Dmax–Dmin)/Dmax*100%; D=venous diameter.ResultsRelationships between SCV collapsibility index and IVC collapsibility index were not different for longitudinal and transverse views of the SCV. Correlation of SCV collapsibility index with IVC collapsibility index was 0.75 for mechanical ventilation (n=65, P<0.0001) and 0.67 for spontaneous breathing (n=95, P<0.0001). IVC collapsibility index cut-offs <20% for hypervolemia and >50% for hypovolemia corresponded to SCV collapsibility index cut-offs of <22% and >39%, respectively, for both mechanical ventilation and spontaneous breathing encounters. Using these cut-offs for SCV collapsibilities, assessment as hypervolemia versus not-hypervolemia had maximal sensitivity and specificity for predicting respective IVC collapsibility cut-offs of 88% for mechanical ventilation and 74% for spontaneous breathing, and assessment as hypovolemia versus not-hypovolemia had maximal sensitivity and specificity of 91% and 70%, respectively. Concordance, defined as agreement between assessment using SCV CI and assessment using IVC CI, was 85% for mechanical ventilation and 72% for spontaneous breathing when differentiating hypervolemia versus not-hypervolemia and was 89% and 71% respectively when differentiating hypovolemia versus not-hypovolemia.ConclusionAssessment using SCV collapsibility index in the semi-recumbent position has a reasonable concordance with assessment using IVC collapsibility index for both spontaneous breathing and mechanical ventilation, in a wide range of hospitalized patients with concurrent kidney disease, and may be a useful adjunct to assess relative intravascular volume in patients with kidney disease.

Ultrasound increases the success rate of spinal needle placement through the epidural needle during combined spinal-epidural anaesthesia: A randomised controlled study.

Combined spinal-epidural anaesthesia (CSEA) using a needle-through-needle technique is currently widely used. However, successful epidural needle placement does not mean a successful spinal needle placement during CSEA. Whether ultrasound assistance could increase the first-pass success rate of spinal needle placement for CSEA remains unknown. The aim of this study was to investigate if ultrasound assistance could increase the first-pass success rate of spinal needle placement through the epidural needle during CSEA performed by experienced anaesthesiologists in patients undergoing caesarean section. A prospective, randomised, double-blind study. Single centre, Department of Anaesthesiology, Shengjing Hospital, China Medical University, China, from June 2019 to September 2019. A total of 185 patients (aged 24 years to 52 years, American Society of Anesthesiologists grade (ASA) II-III, 38 to 40 weeks gestation) scheduled to undergo elective caesarean section under CSEA were enrolled. The patients were randomised to either an ultrasound group (patients received a preprocedural ultrasound scan, and the puncture site was identified by ultrasound imaging) and a palpation group (patients received a sham procedural ultrasound scan, and the puncture site was identified by conventional palpation). The primary outcome measure was the first-pass success rate for spinal needle placement through the epidural needle. Secondary outcome measures were total duration of CSEA, time required for successful epidural needle and spinal needle placement, number of epidural needle redirections and complications. Preprocedural ultrasound imaging significantly increased the first-pass success rate of spinal needle placement through the epidural needle compared with conventional palpation (93.8 vs. 68.8%, P < 0.001). Preprocedural ultrasound imaging also decreased the total duration of CSEA (186.9 ± 37.1 vs. 213 ± 60.4 s, P = 0.0015) and the time required for successful spinal needle placement (78.3 ± 22.9 vs. 100.1 ± 53.7 s, P < 0.01) compared with conventional palpation. Fewer patients in the ultrasound group needed epidural needle redirections during the spinal needle placement procedure than in the palpation group (four patients vs. 20 patients, P < 0.01). For experienced anaesthesiologists, preprocedural ultrasound imaging significantly increased the first-pass success rate of spinal needle placement through the epidural needle for obstetric patients undergoing caesarean section under CSEA. chictr.org.cn, identifier: ChiCTR1900024132.

S3440 A Rare but Serious Complication of Colonoscopy

INTRODUCTION: Reading View. Press Alt Shift A for accessibility help. Colonoscopy is the most widely used procedure for many colonic diseases. Hemorrhage and perforation are the most common complications. Splenic injury after colonoscopy is a very rare yet serious complication. Here we present a case followed by the review of literature. CASE DESCRIPTION/METHODS: Reading View. Press Alt Shift A for accessibility help. A 71-year-old woman presented with left lower abdominal pain after undergoing routine colonoscopy three days prior. She had history of right hemicolectomy for colonic carcinoma. Her exam showed tenderness in the left lower quadrant and epigastric area. Labs were significant for hemoglobin 10.7 g/dL (baseline 11 g/dL). CT abdomen revealed a 6.2 × 2.3 × 5.1 cm hematoma surrounding the lower pole of the spleen (Figure 1). She was managed conservatively with fluid resuscitation. CT angiography showed no active bleeding. Her hemoglobin remained stable and she did not require any surgical intervention. DISCUSSION: Reading View. Press Alt Shift A for accessibility help. Splenic injury is an under-reported complication of colonoscopy, with only 103 cases reported until 2012. The first ever case of splenic injury was reported in 1974 by Wherry and Zehner with the incidence of around 0.00005-0.017% and a mortality rate of 5%. Risk factors for splenic injury post-colonoscopy are previous surgical adhesions, as in our patient, IBD, difficult colonoscopy, rushing during the procedure and insufficient visualization due to poor bowel preparation. Splenic capsular avulsions and lacerations are caused either by direct injury during manipulation through the splenic flexure or during a difficult colonoscopy owing to transcolic pressure or looping of the instrument. Technical maneuvers during colonoscopy such as the alpha maneuver, straightening of the sigmoid loop, external pressure on the left hypochondrium also increase the risk. The most common symptom is left upper quadrant pain, with referred pain to the left shoulder known as the Kehr sign. Symptoms usually present within 24 hours. CT abdomen is the best imaging modality. Splenic injury post colonoscopy is treated either conservatively or through surgical intervention depending upon the hemodynamic status of patient and size of hematoma. Conservative management includes fluid resuscitation or blood product replacement. Surgical intervention is recommended for hemodynamic instability or Grades IV-V splenic lacerations.Figure 1.: CT scan abdomen and pelvis with intravenous contrast (Coronal view – right panel & Transverse view – left panel) showing spleen (blue arrows) and a 6.2 × 2.3 × 5.1 cm hematoma (green arrows).Figure 2.: CT scan abdomen and pelvis with intravenous contrast (Coronal view – right panel & Transverse view – left panel) showing spleen (blue arrows) and a 6.2 × 2.3 × 5.1 cm hematoma (green arrows).

VP04.15: Prenatal diagnosis and outcome of fetal cystic hygroma

To investigate the outcome of fetuses with cystic hygroma diagnosed at the first trimester from a general population in Crete. The study included pregnancies either referred to or admitted to our clinic in the General Hospital of Chania during the past decade, with a diagnosis of fetal cystic hygroma made between the 10th and 14th week. Diagnosis was made sonographically, with midsagittal and transverse views of the fetal neck demonstrating markedly increased nuchal translucency (> = 95th percentile for CRL), excessive nuchal fluid and septations, albeit with an intact spinal column and skull. Fetal karyotyping and genetic counselling were routinely offered to the parents. Pregnancy outcomes varied from miscarriage, elective termination, intrauterine death (at or above 22 weeks of gestation) to livebirth and/or neonatal death. 21 cases of fetal cystic hygroma were recorded. The mean sise of the defect was 7.3mm. Cardiac malformations were detected in 4 cases and micrognathia in one. Chromosomal abnormalities were present in 47.6% of cases, with 5 of them diagnosed as Down's syndrome. 6 pregnancies with normal karyotype resulted in livebirths, where no severe structural abnormalities were present. In total, an unfavourable outcome (miscarriage, elective termination, severe malformations) was recorded in 71,4% of the cases. Fetal cystic hygroma is a strong indicator of karyotype abnormalities and cardiac defects. The postnatal outcome of fetuses with cystic hygroma appears to be in relation to the presence of structural and/or chromosomal abnormalities.

S1672 A Case Description of Clostridium Glycolicum and Clostridium Paraputrificum Bacteremia From Complicated Diverticulitis

INTRODUCTION: Clostridium species are anaerobic gram-positive bacilli that can cause a broad range of invasive infections in humans, including bacteremia and intra-abdominal infections. Clostridium glycolicum and Clostridium paraputrificum in particular are infrequent isolates in bacteremia with incidence less than 1%. We describe a rare case of Clostridium paraputrificum and Clostridium glycolicum bacteremia resulting in septic shock secondary to a diverticular abscess. CASE DESCRIPTION/METHODS: A 66-year-old female was admitted with high fevers and seizure like activity. She had a history of Non-Hodgkin’s Lymphoma and breast cancer both of which were confirmed to be in remission. Prior to presentation, her husband had noticed the patient acting unusual and staring to the left with a fixed gaze. On arrival to the ER, she had a rectal temperature of 106.5F and needed vasopressor support. A computer tomography (CT) of the head showed no acute abnormalities and multiple lumbar punctures attempted were unsuccessful. She was empirically treated with levetiracetam/fosphenytoin for possible seizures and vancomycin/meropenem/metronidazole for sepsis. CT of the chest, abdomen and pelvis showed sigmoid diverticulitis with an adjacent small foci of gas which may have been a micro-perforation without fluid collections or pneumoperitoneum. Multiple blood cultures grew Clostridium glycolicum and Clostridium paraputrificum. Subsequent CT of abdomen and pelvis demonstrated a sigmoid diverticulitis with an adjacent abscess measuring 2.4 × 1.3 cm (Figure 1). She was treated with ceftriaxone and metronidazole for 3 weeks given her allergies to penicillin and ciprofloxacin. The patient is planned to have follow up imaging to check for resolution of the abscess. DISCUSSION: Presumably, the source of our patient's Clostridium bacteremia was the complicated diverticulitis given the imaging findings. Most species of Clostridium are considered to be harmless soil saprophytes but there are a few case reports of these strains causing bacteremia. Clostridium bacteremia in humans is usually caused by dissemination of gut colonizing strains due to disturbed host defenses locally or systemically. In our case, sigmoid diverticulitis could be considered a pre-disposing factor but given her past history she will need an outpatient work-up rule out malignancy. This case should heighten the awareness of these particular clostridium species as a clinically important organism and every effort should be made to investigate them further.Figure 1.: Transverse view of a computer tomography of the abdominal/pelvis showing an 2.4 × 1.3 cm abscess (blue arrow) on the anterior wall of the sigmoid colon with reactive thickening of the adjacent urinary bladder wall without evidence of a fistula.

S1705 A Rare Case of Bowel Perforation in a SARS-CoV-2 Patient

INTRODUCTION: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) patients commonly present with respiratory symptoms; however, the incidence of gastrointestinal symptoms is rising. We submit a case of cecal perforation in a SARS-CoV-2 infected patient, highlighting a life-threatening complication of the virus. CASE DESCRIPTION/METHODS: A 65-year-old with past medical history of atrial fibrillation on anticoagulation presents with fever and dyspnea. Initial observation showed an obese male on supplemental oxygen, with a benign abdominal exam. He tested SARS-CoV-2 positive and began Remdesivir therapy. While hospitalized, he had regular bowel movements but worsening abdominal distension and tenderness to palpation. CT of the abdomen revealed peritoneal free air signifying bowel perforation (Figure 1), which required emergent exploratory laparotomy and a right hemicolectomy. Biopsy of the perforation site showed acute inflammation and vascular congestion (Figure 2B). After an uneventful postoperative period, he was discharged. DISCUSSION: SARS-CoV-2 infection often arises with respiratory symptoms. However, as the pandemic ensues, gastrointestinal symptoms(GI) such as vomiting, abdominal pain and diarrhea, are emerging. Our case examines bowel perforation in a SARS-CoV-2 infected patient. The virus downregulates expression of the Angiotensin converting enzyme 2 (ACE2), found most abundantly in lung, intestinal and vascular tissue. Suppression in the intestinal tissue may cause an inflammatory response, thereby weakening the intestinal wall leading to bowel perforation.Similarly, the virus may induce complement-mediated inflammatory damage to the vascular endothelium and systemic coagulopathy causing vascular and microvascular thrombi formation. We postulate that by these mechanisms, SARS-CoV-2 begets intestinal ischemia and eventual bowel perforation. Our case also highlights a significant clinical issue regarding Remdesivir. In vitro, it inhibits Multi drug resistance associated protein 4 (MRP4), which partakes in cell proliferation. This may lead to reduced integrity of the epithelial barrier, causing bowel perforation. Further studies to elicit the adverse effects of Remdesivir are warranted.With few reports of bowel perforation in SARS-CoV-2 patients, our case magnifies potential GI symptoms and complications of this novel virus. Moreover, with growing Remdesivir use as a SARS-CoV-2 therapy, it is vital to investigate its adverse effects.Figure 1.: A. CT abdomen sagittal view- free intra-peritoneal air.Figure 2.: B. CT abdomen transverse view, with arrows showing irregular contour of bowel indicating area of perforation.Figure 3.: A. Sloughed epithelium, atrophic microcysts, hyalinization of lamina propria, acute inflammation. B. Marked surface injury, loss in atrophic crypts, hyalinization of lamina propria, residual glands appear more closely spaced, vascular congestion and acute inflammation.

S2331 A Case of Description: Extrapulmonary Small Cell Carcinoma Diagnosed With Endoscopic Ultrasonography

INTRODUCTION: Extrapulmonary small cell carcinomas (ESCCs) are considered to be a distinct clinicopathological entity that are extremely rare representing 2.5–4% of all small cell carcinoma (SCC) cases. Given the aggressive nature of the malignancy, patients often present late in the disease course with metastatic disease. We report a case of a young patient found to have ESCC presenting initially with atypical chest and epigastric pain with jaundice. CASE DESCRIPTION/METHODS: A 23-year-old male presented to an outside hospital with a 2-week history of intermittent chest pain radiating to the epigastric region. He also reported generalized pruritus and jaundice for four days. Social history was unremarkable and initial blood work was unremarkable except for hyperbilirubinemia. An ultrasound of the abdomen showed a hypoechoic mass in the porta hepatis measuring 2.0 × 2.5 × 2.4 cm. Contrast enhanced computer tomography (CT) imaging of the abdomen/pelvis confirmed the mass lesion with suggestion of an enlarged lymph node or early onset pancreatic adenocarcinoma. A subsequent endoscopic ultrasound (EUS) showed a poorly circumscribed hypoechoic mass in the porta hepatis (Figure 1) and fine needle biopsy (Figure 2) was performed which showed poorly differentiated small cell carcinoma. Patient had stent placement in common bile duct to relieve obstruction. Patient was then transferred to our intuition for further oncologic work up. At our hospital, the patient had a positron emission tomography with concurrently low dose CT scan which demonstrated multiple focal areas of uptake in lymph nodes with the largest being the porta hepatis node demonstrating a maximum SUV of 10.6 (Figure 3). An MRI of the head with contrast was negative for metastatic disease. The patient is planned to be treated with cisplatin plus etoposide for three to five cycles. DISCUSSION: Our case demonstrates the use of EUS to effectively and safely diagnose ESCC in a young patient with atypical chest pain and jaundice. The histopathology did not reveal the primary source. This case would be classified as SCC of unknown primary which is a type of ESCC. There are no randomized trials or prospective clinical studies on ESCC treatment and approach is based on extrapolation from experience with SCC of lung. As the outcomes have remained poor, further study may be beneficial to adequately define treatment strategies.Figure 1.: Endoscopic ultrasonography showing a 36.92 mm × 27.97 mm poorly circumscribed hypoechoic mass near the porta hepatis.Figure 2.: Endoscopic ultrasonography showing a fine needle biopsy (blue arrow) penetrating into hypoechoic mass.Figure 3.: Transverse view of positron emission tomography showing uptake in lymph node adjacent to the porta hepatis demonstrating a maximum SUV of 10.6.

Salivary gland ultrasound training: Improving anatomic identification in residents.

The aim of the study was to introduce and study the role of standardized views for ultrasound of the major salivary glands in resident learning and retention. Methods description and prospective case series. Five otolaryngology residents and two patient models were recruited for this study. The participants were timed on their identification of the submandibular gland, sublingual gland, and parotid gland and associated key anatomic structures. Participants were then timed again immediately after being presented a standardized view for each salivary gland: the longitudinal submandibular gland, transverse parotid gland, and submental transverse views. The same participants were then timed one month later to determine retention. A Wilcoxon signed-rank test was used to evaluate whether time to identification was equal pre- and post-standardized view instruction. There was a significant improvement from pre- to post-standardized view instruction in all glands, which was sustained one month later. Practically speaking, assessment times for all participants at the one-month measurement were reasonable, with averages of 71, 42, and 114s for the submandibular gland, sublingual gland, and parotid gland respectively. Standardized views provided otolaryngology ultrasonography learners with a reliable, fast, and memorable way to assess the salivary glands and their related structures. 4.

Point-of-care ultrasound for prompt diagnosis and treatment monitoring of acute epiglottitis.

A 72-year-old woman presented with a 1-day history of acute throat pain, hoarseness. On cervical ultrasonography (transverse view), the epiglottis was swollen with anterior-posterior diameter of 3.5 and 3.8mm at right and left edges, respectively. Laryngeal endoscopy showed marked swelling of the epiglottis, and acute epiglottitis was diagnosed.

Ultrasonography-guided botulinum toxin injection to the cricopharyngeus muscle: a case report and technical notes

Dysphagia associated with the cricopharyngeus muscle (CPm) dysfunction negatively influences the quality of life. This high-pressure region must relax and the lumen must open for smooth food passage. The CP muscle is therefore a common target of chemodenervation with botulinum toxin (BTX). Here we presented a patient with severe left lateral medullary syndrome and non-relaxation of the CPm. We described how to localize the CPm in the transverse and longitudinal views under ultrasonography and offered a video demonstrating ultrasonography-guided BTX injection. Ultrasonography-guided CPm injection with BTX may serve as a reliable, rapid, and effective choice for treatment of cricopharyngeal dysphagia.

Precision Medicine with 3D Ultrasound.

Introduction: Currently, B-mode ultrasound (US) is the primary imaging modality in diagnosing thyroid nodules (TNs). B-mode is a two-dimensional US (2D US) imaging display. Recent studies suggest a role for strain and shear wave elastography for evaluating TN as well. Three-dimensional US (3D-US) has the potential to enhance the diagnostic accuracy and precision for thyroid cancer (TC) detection.Materials and Methods: An experienced ultrasonographer (G.A.) evaluated the patient using the following techniques: B-mode, strain and shear wave elastography, and 3D-US followed by fine needle aspiration biopsy (FNAB). Laboratory measurements were performed at LabCorp. Informed consent was obtained.Case: A 28-year-old woman referred for hypothyroidism. Her primary doctor initiated levothyroxine 50 mcg daily 6 months prior. At the time of her visit, her thyroid stimulating hormone (TSH) was 2.8 (0.45–4.5 uIU/mL) and both thyroid peroxidase and thyroglobulin antibodies were elevated, suggestive of Hashimoto's thyroiditis. Her thyroid US showed a heterogeneous gland with an isoechoic TN in the right lobe measuring 7.7 × 6.3 × 7 mm. Strain elastography showed diffuse and patchy tissue stiffness throughout the gland, suggestive of tissue fibrosis caused by Hashimoto's thyroiditis. This study did not distinguish target TN from the surrounding tissue. Shear wave elastography of the TN revealed moderately increased stiffness compared with surrounding tissue. The shear wave velocity (SWV) measurement for the TN was 3.1 m/s. 3D-US examination demonstrated an isoechoic TN with irregular margins, and the volume was 0.119 cm3. FNAB of the TN was performed. Cytopathology was diagnostic for papillary thyroid cancer (PTC), Bethesda Category VI. Subsequent total thyroidectomy confirmed a 7 mm PTC with positive surgical margins caused by thyroid capsule invasion and no clear-cut evidence of extra-thyroid extension.Discussion: This case showcases the recent technological advances in TN imaging. Our objective is to provide an improved approach to TN management. The American College of Radiology Thyroid Imaging Reporting and Data System stratifies the malignancy risk of TN primarily based on the size and B-mode US features. This model does not recommend FNAB for any TN <10 mm regardless of malignancy risk.1 This is our observation that with 3D-US the size cutoff of TN might not be an issue as with B-mode or elastography. Irregularities of the TN can be seen with 3D-US with small and large nodules equally. The finding of irregular margins on 3D-US and consulting with the patient lead us to perform FNAB. Recent publications in the journal of VideoEndocrinology showed utilizations of 3D-US in diagnosing parathyroid adenomas and TNs. 3D-US technology improves view of the target lesion by adding a third dimension, coronal view, to the transverse and longitudinal views of B-mode US.2,3 B-mode imaging provides excellent view of TNs. However, it has a low sensitivity for predicting TC.4 Prospective TN studies have demonstrated that adding elastography to B-mode imaging improves sensitivity of US technology for detecting TC.5–10 In a prospective study with 707 TN, we showed that a single cutoff analysis for predicting malignancy in TNs, a maximum SWV of 3.54 m/s had the best sensitivity. The mean SWV for benign nodules was 2.71 m/s. The mean SWV for malignant nodules was 3.96 m/s.6 In this particular case strain and shear wave were not as helpful. The discrepancy between the two systems has been described in cases with severe Hashimoto's thyroiditis associated with tissue fibrosis.6 In our experience, the presence of autoimmune thyroid disease increases the risk for malignancy. Recent publications reported an association between differentiated TC and autoimmune thyroid disease and/or TSH when all Bethesda classifications were included.11–13Conclusion: 3D-US technology in conjunction with B-mode may improve diagnostic accuracy in detecting TC.No competing financial interests exist.Runtime of video: 2 mins 30 secs

First Trimester Ultrasound Evaluation of the Cleft Palate: Midsagittal, Axial or Coronal View-Which View is Best?

Abstract Objective First trimester evaluation of the palate is now gaining importance and the “maxillary gap sign” described in the midsagittal view and the retronasal triangle serves as a potential marker for detection of cleft palate (CP). The objective is to describe an ultrasound technique for evaluation of the palate in the axial view and to assess the utility of this view in assessing palatine clefts. Materials and methods The anatomical landmarks in sagittal, coronal and in axial view were evaluated in 17 cases of palatine clefts with known postnatal outcomes. Along with the midsagittal and coronal view, the alveolar ridge of the maxilla and the echogenic secondary palate was examined in the transverse view of the base of the skull at the level of the pharynx. Results Visualisation of the bony landmarks of the palate in all three planes was possible in all cases. Of the 17 cases, there were 7 unilateral Cleft Lips Palate (CLP), 5 bilateral CLP, 2 median CLP, 2 isolated CP and 1 atypical cleft. 2 cases of bilateral CLP showed no demonstrable maxillary gap in the midsagittal view (the vomer can often mimic the maxillary line). 2 cases showed a normal retronasal triangle (RNT) when the cleft was confined to the premaxilla alone. However, the axial view showed abnormal appearance in all 17 cases. Conclusion A combination of all three planes can be used as an effective screening tool but the axial view has more potential for detection of CP in first trimester. However, large scale prospective studies are needed to confirm this observation.

Three‐Dimensional Coronal Plane of the Uterus

Two-dimensional transvaginal and transabdominal ultrasound (US) examinations are the suggested methods for examining the uterus. Three-dimensional (3D) US, which is not compulsory by society guidelines, provides additional uterine views, reassuring users of pathologic conditions not evident on customary sagittal and transverse views. The 3D coronal plane is rarely seen by 2-dimensional US transducers, let alone in extremely retroverted or axial uteri. Ultrasound machines nowadays feature 3D US capability. Our experience is that the coronal uterine view is a problem solver, helping diagnostic abilities of pelvic imaging. We advocate its liberal use and its acquisition in every pelvic scan. In this Pictorial Essay we present examples to demonstrate its use.

Man with trauma following motorcycle crash.

A 56-year-old male presented to the emergency department (ED) following a frontal impact motorcycle accident. The patient was pale with persistent hypotension, tachypnea, and tachycardia along with bilateral lower limbs paralysis and a complete loss of sphincter functions. Patient was intubated, and transesophageal echocardiography performed by attending emergency physician at ED critical care bayshowed the transverse and longitudinal view of the descending aorta with hypoechoic, well-defined, crescent-shaped thickening of anterior aortic wall suggestive of intramural hematoma (Figures 1, 2; Supporting Information Videos S1 and S2). Computed tomography (CT) showed fracture T11 vertebra, intramural hematoma, and peri-aortic hematoma along the arch of the aorta extending down to upper abdominal aorta at the level of T12 (Figure 3). Traumatic thoracolumbar spine fracture with a concomitant blunt aortic injury is uncommon (1.4%) but potentially fatal.1 Most fractures associated with blunt traumatic aortic injury occurred at the level of T11–L2 vertebra (62%).1 ED transesophageal echocardiography is a potential new imaging adjunct in resuscitation.2-4 Even though the surface ultrasound has become an important bedside imaging tool in initial management of trauma patients in ED, its limitations include poor evaluation of vascular pathologies (ie, BTAI).5 The role of ED transesophageal echocardiography for the early detection of BTAI in hemodynamically unstable trauma patient was reported by Osman et al.6 The patient was managed conservatively and was discharged from spinal intensive care unit after day 10. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Development of a lumbosacral intervertebral cage prototype for dogs

ABSTRACT: Several surgical procedures aim to decompress and/or stabilize the lumbosacral (LS) joint of dogs; however, the lumbar interbody fusion technique, by using a cage combined with a bone graft, is the most indicated and used in human medicine. No specific implant is available for application to the canine lumbosacral joint. Thus, this study measured lumbosacral discs in large dogs, determined whether a human cage model could fit the dogs’ L7-S1 intervertebral space, and developed a LS cage prototype for dogs. Ten cadaveric lumbosacral spines from adult dog weighing 20-35kg were used. The dogs had died for reasons unrelated to this study. The vertebral body dimensions and the L7-S1 intervertebral space occupied by the intervertebral disc were measured by lateral and ventrodorsal radiographs and by computed tomography in the dorsal, sagittal, and transverse views. Measurements were also taken of the anatomical specimens in the sagittal and transverse planes. After measuring the intervertebral discs, the following mean measures were obtained for L7-S1 discs: height 12.23mm, dorsal thickness 3.3mm, central thickness 4mm, ventral thickness 5.5mm, and width 24.74mm. The human lumbar cage models from brands LDR, Baumer Orthopedics, Stryker, Synthes, and Vertebral Technologies, Inc. and cervical stabilization cages from the brands B-Braun and Stryker were evaluated and were found to be unsuitable for large dogs. Cervical human cages had measurements similar to those found in this study; however, due to their quadrangular shape, the possibility of being introduced surgically through the surgical accesses available for the articulation between L7-S1 in dogs without injuring the cauda equina or the L7 root is small. A cage model was then developed using 3D modelling software. It was designed for insertion via dorsal laminectomy in the lateral portions of the intervertebral space. To avoid cauda equina lesion, the implant model was developed to be placed laterally to the midline. The cage surface is serrated to prevent using the locking screw to fix it, thus avoiding further injury to nerve structures. The serrated surfaces are also designed to avoid cage migration and promote stability. The prototype allows graft placement in the surrounding intervertebral space, which is fundamental for fusion through integration between the cage and the endplates as well as for bone growth between and around the cage. It was also considered studies on humans showing that the lateral regions of the endplates support a more considerable load. Biomechanical and in vivo studies on the developed model are necessary to evaluate the actual degree of distraction, mobility and the long-term rate of fusion between L7 and S1 and its possible impact on the adjacent motor units, combined or not with dorsal fixation techniques.

Sonoanatomy of female reproductive organ of Sunda porcupine (Hystrix javanica).

The conventional anatomical study of specimens requires cutting processes which destruct the limited specimens. A non-destructive method, namely an ultrasonography, can be used to assess the anatomical organ information of those specimens. The aim of this research is to analyse the macroanatomy of the female reproductive organ in the Sunda porcupine (Hystrix javanica), using ultrasonographical imaging. In this study, four formaldehyde-fixed reproductive organ specimens of the Sunda porcupine were used. A 10-12MHz linear ultrasound transducer was utilized to provide an imaging format of both longitudinal and transversal views. Photographic images were then used as comparison with a sonographic image. The results show that the ultrasound image of the Sunda porcupine reproductive organ soft tissue was hypoechoic, the lumen and antrum follicles were anechoic, while atretic follicles and the mons pubis were hyperechoic. Generally, the size of the organ was not significantly different between photographical and ultrasonographical imaging (p>.05). In conclusion, ultrasound images can be utilized for anatomical studies of the Sunda porcupine reproductive organs without destructing the specimen.

“My Rapidly Growing Neck”

“My Rapidly Growing Neck”

A practical method for predicting patient-specific collision in radiotherapy.

PurposeTo develop a practical method for predicting patient‐specific collision during the treatment planning process.Materials and methodBased on geometry information of the accelerator gantry and the location of plan isocenter, the collision‐free space region could be determined. In this study, collision‐free space region was simplified as a cylinder. Radius of cylinder was equal to the distance from isocenter to the collimator cover. The collision‐free space was converted and imported into treatment planning system (TPS) in the form of region of interest (ROI) which was named as ROISS. Collision was viewed and evaluated on the fusion images of patient's CT and ROIs in TPS. If any points of patient's body or couch fell beyond the safety space, collision would occur. This method was implemented in the Pinnacle TPS. The impact of safety margin on accuracy was also discussed. Sixty‐five plans of clinical patients were chosen for the clinical validation.ResultsWhen the angle of couch is zero, the ROISS displays as a series of circles on the cross section of the patient's CT. When the couch angle is not zero, ROISS is a series of ellipses in the transverse view of patient's CT. The ROISS can be generated quickly within five seconds after a single mouse click in TPS. Adding safety margin is an effective measure in preventing collisions from being undetected. Safety margin could increase negative predictive value (NPV) of test cases. Accuracy obtained was 96.3% with the 3 cm safety margin with 100% true positive collision detection.ConclusionThis study provides a reliable, accurate, and fast collision prediction during the treatment planning process. Potential collisions can be discovered and prevented early before delivering. This method can integrate with the current clinical workflow without any additional required resources, and contribute to improvement in the safety and efficiency of the clinic.

Multi-instance Deep Learning of Ultrasound Imaging Data for Pattern Classification of Congenital Abnormalities of the Kidney and Urinary Tract in Children

OBJECTIVETo reliably and quickly diagnose children with posterior urethral valves (PUV), we developed a multi-instance deep learning method to automate image analysis. METHODSWe built a robust pattern classifier to distinguish 86 children with PUV from 71 children with mild unilateral hydronephrosis based on ultrasound images (3504 in sagittal view and 2558 in transverse view) obtained during routine clinical care. RESULTSThe multi-instance deep learning classifier performed better than classifiers built on either single sagittal images or single transverse images. Particularly, the deep learning classifiers built on single images in the sagittal view and single images in the transverse view obtained area under the receiver operating characteristic curve (AUC) values of 0.796 ± 0.064 and 0.815 ± 0.071, respectively. AUC values of the multi-instance deep learning classifiers built on images in the sagittal and transverse views with mean pooling operation were 0.949 ± 0.035 and 0.954 ± 0.033, respectively. The multi-instance deep learning classifiers built on images in both the sagittal and transverse views with a mean pooling operation obtained an AUC of 0.961 ± 0.026 with a classification rate of 0.925 ± 0.060, specificity of 0.986 ± 0.032, and sensitivity of 0.873 ± 0.120, respectively. Discriminative regions of the kidney located using classification activation mapping demonstrated that the deep learning techniques could identify meaningful anatomical features from ultrasound images. CONCLUSIONThe multi-instance deep learning method provides an automatic and accurate means to extract informative features from ultrasound images and discriminate infants with PUV from male children with unilateral hydronephrosis.