Power Doppler Ultrasonography Research Articles

Power-doppler ultrasonography is an accurate tool for early pregnancy detection in donkeys

Early detection of pregnancy could enhance the reproductive efficiency of donkeys, as the species has a wide range for the first detection of the embryonic vesicle (EV) via B-mode ultrasonography. This study aimed to assess the uterine blood flow of jennies as an early indirect pregnancy diagnostic test. We hypothesized that uterine blood flow is increased, thus, serving as an early pregnancy diagnostic tool. Jennies (n=52) were bred with fresh semen from a fertile jack, and nine jennies were not bred and served as controls; ovulation (Day-0) was confirmed at 12h intervals for all jennies. Power-doppler and B-mode ultrasonography were performed on Days 7 to 10 to assess the uterine horn blood flow and identification of EV, respectively; the latter was repeated on Day 15. Uterine horn blood flow was evaluated using spot meter techniques, measuring mean pixel intensity. Progesterone concentrations were determined with RIA on Days 7 to 10. Data were assessed for normality with Shapiro- Wilk's test and mixed models. Receiving operating curve was used to determine the cut off value for uterine blood flow. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for blood flow on Days 7 to 10 were calculated to identify pregnant jennies and confirmed on Day 15. Significance was set as P≤0.05 and tendency as 0.05<P<0.1. Of 52 bred jennies, 29 (53%) were confirmed pregnant on Day 15. B-modeultrasonography identified 17.2% (5/29) of the EVs on Day 9 and 48.3% (14/29) on Day 10; no EVs were identified on Days 7 to 8. Pregnant jennies (n=29) had greater uterine blood flow in comparison with non-pregnant jennies (144.8±1.5 vs. 139.2±1.3 pixels/unit, n=32) (P=0.007), with an SD of the difference of 6.3 pixels/unit (p=0.008). There was no effect of time (P=0.48) or group x time interaction between (P=0.70) for uterine blood flow. Progesterone concentrations did not change within Days 7 to 10 (P=0.81), and there was no group x time interaction (P=0.49). Progesterone tended to be greater in pregnant than non-pregnant jennies (P=0.07). There was no effect of time (P=0.79), group (P=0.77), or group x time interaction (P=0.92) for uterine horns. Sensitivity from Days-7-to-10 were 86%, 82%, 60%, and 62%, respectively. In contrast, specificity for Days 7 to 10 was 80%, 88%, 78%, and 75%, respectively. The PPV and NPV for Days 7 to 10 were 81% and 85%; 75% and 20%; 35% and 33%; and 30% and 27%; respectively. In conclusion, this study demonstrated the efficacy of power-doppler-ultrasonography as a sensitive and specific tool for early indirect detection of pregnancy in donkeys, whereas standard B-mode first detected a small percentage of pregnancies on Days 9 to 10. Power-doppler could facilitate the breeding management of donkeys, such as timing the induction of luteolysis in non-pregnant jennies at Days 7 to 10 post-ovulation.

Impact of ovulation inducers on ovarian artery in mares: pulsatility and resistivity indexes

A failure of vascular development in reproductive organs may be the cause of several dysfunctions during the estrous cycle and gestation. Therefore, it is important to evaluate the in vivo influences of ovarian vaso- irrigation on ovulation. The ovarian follicles need an adequate blood supply for oxygen, nutrients, and hormones, besides eliminating CO2 and other metabolites (Bruno et al. Animal Reproduction. 2009; 6, 2:371-379). Transrectal ultrasonography (US) with color, power, and spectral Doppler US has been used to study blood flow and ovarian perfusion in mares (Acosta et al. Biology of Reproduction. 2004b; 71, 2: 502-507). Studies have shown a daily increase in vascularization of the wall of the dominant follicle as it approaches the day of ovulation (Gastal et al. Animal Reproduction Science. 2007; 102, 3-4: 314-321); However, a few hours before ovulation, an abrupt decrease in blood perfusion of the follicular wall has been detected (Ginther et al. Journal of Equine Veterinary Science. 2007a; 27, 1: 20-27). The drugs most used as ovulation inducers in horses are human chorionic gonadotropin (hCG) and analogues of gonadotropin-releasing hormone (GnRH), such as deslorelin (Chavatte & Palmer Equine Veterinary Education. 1998; 10, 26-30). Using different ovulation inducers, this study aimed to evaluate changes in ovarian arteryblood flow after induction of ovulation in mares with follicles ≥ 35mm diameter. Twenty-eight estrous cycles were followed, randomly and equally distributed: GI: control mares without treatment; GII: 1000 IU IV of hCG; GIII: 750µl IV of deslorelin; GIV: 250µg IM of hysterelin. The ovarian artery pulsatility and resistivity indexes (PI and RI) were measured. Thereafter, estrous cycles were followed every 12 hours from time 0 (induction) until ovulation using B-mode US and spectral mode Doppler US of ovarian arteries. Statistical analysis was performed with ANOVA, a p-value of <0.05 was considered significant. No statistical difference was found in PI between groups (p=0.1297) of at the different evaluation times. When the times of analysis were compared separately between the groups, no statistical difference was found between 0h (p= 0.7092), 12h (p= 0.5148), 24h (p=0.2642), and 36h (p=0.582). Similarly, the RI did not differ between the groups analyzed (p= 0.1397), regardless of the time of evaluation, nor between the timepoints analyzed separately between 0h (p= 0.5049), 12h (p= 0.7334), 24h (p=0.3589) and 36h (p=0.1621). It can be concluded that although an increase in vascularization of the wall of the dominant follicle occurred, the PI and RI of the ovarian artery were not influenced by any ovulation inducer of the pre-ovulatory follicles.

Using 2D/3D ultrasound observation of endometrial thickness, endometrial volume, and blood flow changes to predict the outcome of frozen embryo transfer cycles: a prospective study.

Endometrial thickness (EMT) and blood flow are commonly used indicators of endometrial receptivity. However, the results of single ultrasound examination studies differ. Therefore, we used 3-dimensional (3D) ultrasound to study the influence of changes in EMT, endometrial volume, and endometrial blood flow on frozen embryo transfer cycles. This was a prospective cross-sectional study. Women who underwent in vitro fertilization (IVF) at Dalian Women and Children's Medical Group and met the inclusion criteria were enrolled between September 2020 and July 2021. Ultrasound examinations were performed in patients who underwent frozen embryo transfer cycles on the day of progesterone administration, the third day after progesterone administration, and the day of embryo transplantation. Two-dimensional ultrasound was used to record EMT, 3D ultrasound was used to record endometrial volume, and 3D power Doppler ultrasound imaging was used to record the following endometrial blood flow parameters: vascular index, flow index, and vascular flow index. Changes in the 3 inspections of the EMT, volume, vascular index, flow index, and vascular flow index and 2 inspections of estrogen levels were categorized as "declining" or "nondeclining". The relationship between changes in a certain indicator and the IVF outcome was analyzed by univariate analysis and multifactorial stepwise logistic regression. In total, 133 patients were enrolled in this study, 48 were excluded, and 85 were included in the statistical analysis. Among these 85 patients, 61 were pregnant (71%), 47 had a clinical pregnancy (55%), and 39 had an ongoing pregnancy (45%). The results showed that if the first change in endometrial volume was nondeclining, the outcomes of clinical and ongoing pregnancies were more likely to be unfavorable (P=0.03, P=0.01). Additionally, if the second change in endometrial volume on the day of embryo transplantation was nondeclining, the outcome of an ongoing pregnancy was more likely to be favorable (P=0.03). The changes in endometrial volume was a factor helpful in predicting the IVF outcome, whereas the changes in EMT and endometrial blood flow analyses were not helpful in predicting IVF outcome.

Changes of placental three-dimensional power Doppler ultrasonography in third trimester among hypertensive disorders complicating pregnancy and its predictive value for pregnant outcomes.

Hypertensive disorders complicating pregnancy (HDCP) represent a systemic condition specific to pregnant women. Three-dimensional (3D) power Doppler ultrasonography is a technique that utilizes erythrocyte density, scattered intensity, or energy distribution in the bloodstream for imaging purposes. This study aimed to compare the changes in 3D power Doppler ultrasonography parameters in late pregnancy between patients with HDCP and those without HDCP, and to evaluate the predictive value of these parameters for pregnancy outcomes in patients with HDCP. The study included 160 pregnant women diagnosed with HDCP and 100 pregnant women without HDCP, who served as the control group. 3D power Doppler ultrasonography was performed, and the values of the vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were measured. In the HDCP group, the VI, FI, and VFI were all lower than those observed in patients without HDCP. In HDCP patients with positive outcomes, these three parameters were higher than those recorded in patients with negative outcomes. The area under the predicted curve (AUC) for VI, FI, VFI, and the combination of these three parameters were 0.69, 0.63, 0.66, and 0.75, respectively. The parameters of 3D power Doppler ultrasonography can reflect the perfusion status of the placenta and predict the outcome of pregnancy in patients with HDCP. By monitoring these relevant hemodynamic parameters, valuable information can be provided for the clinical diagnosis, objective evaluation, and treatment of HDCP.

OA16 Identification of surrogate serum proteomic biomarkers associated with ultrasound power Doppler in psoriatic arthritis

Abstract Background/Aims An area of key unmet need in psoriatic arthritis (PsA) is the identification of biomarker(s) which predict those likely to respond to a specific therapy; in order to achieve that, an objective measure of disease activity would be ideal. Ultrasound power Doppler (PD) is a semi-quantitative measure of inflammation. However, ultrasound is time-consuming and requires specific expertise, whereas a blood-based surrogate biomarker of PD would be easier to apply clinically, and could serve as an objective outcome measure of response. Our aim is to identify proteomic biomarkers associated with PD in PsA patients. Methods Twenty-six patients with PsA (fulfilling CASPAR criteria) were recruited prospectively. All underwent 66-joint ultrasound examination and presence of PD was recorded. There were 7 patients without PD(-) and 19 with PD(+) detectable in at least 1 joint. Proteomics data for 1,073 proteins were generated using sequential window acquisition of all theoretical fragment ion spectra mass spectrometry (SWATH MS). Proteins with high levels of missing data were filtered (&amp;gt;30%) followed by random forest analysis. Differentially expressed proteins (DEPs) based on PD status were identified. Protein-protein interaction network analysis was performed using the search tool for retrieval of interacting genes (STRING), Kyoto Encyclopedia of Genes and Genomes (KEGG) and gene ontology (GO). Results Following pre-processing, 553 proteins were available for analysis. Seventeen DEPs were identified (p-values &amp;lt;0.05) (Table 1). Among these, ERAP2, an enzyme involved in MHC-I ligand processing and a known risk factor for inflammatory diseases, had the largest fold change (-0.64 95%CI -1.20 to -0.07, p = 0.03). Network analysis revealed that the 17 DEPs were significantly enriched (p &amp;lt; 0.001) in the PD+ group. KEGG pathway analysis identified the association of the DEPs in leukocyte transendothelial migration (strength 1.5 FDR=0.04). GO analysis of the DEPs revealed involvement in immunoglobulin receptor binding (strength 2.28 FDR=0.03). Conclusion We identified several potential serum proteomic biomarkers correlated with disease activity, as assessed by the presence of PD, in PsA; these provide insights into the biological mechanisms underlying synovitis in PsA. Validation in a larger cohort and functional studies are required to determine the role of these proteins in mediating inflammation in PsA. Disclosure R.M. Hum: None. N. Nair: None. S.F. Ling: None. A. Barton: None. P. Ho: None. D. Plant: None.

P146 Pragmatic Biologic Tapering Combining Clinical and Ultrasound Assessment in Patients with Rheumatoid Arthritis in Routine Clinical Practice - Predictors of Failure from a Regional Centre in UK

Abstract Background/Aims Tapering biologic therapies in patients with rheumatoid arthritis (RA) is evolving. Our primary objective was to combine clinical and ultrasound assessment in selecting patients with RA for tapering biologic therapies. The secondary objectives were to identify predictors for failure and cost savings. Methods RA patients on biologics in sustained clinical remission (defined as DAS 28 &amp;lt; 2.6) in the previous year and imaging remission (defined as Power Doppler US of small joints of hands not significant) were included. The patients were seen in a multidisciplinary clinic with an advanced pharmacy practitioner between April 2019 and March 2022. They were advised to lengthen the interval of their biologics gradually and were followed quarterly till September 2022. Failure was defined as reverting to previous regime at any point during follow up. Independent predictors of failure were identified with Cox multiple regression analysis SPSS v29.0 (IBM 2022). Results Biologics were tapered in 184 patients including 129 on anti-cytokine therapy (abatacept 13, adalimumab 35, certolizumab 31, etanercept 18, golimumab 8, infliximab 4, tocilizumab 20) and 55 on rituximab. The mean age of the cohort was 63.8±11.7 years and there were 72.3% females. The mean duration of RA was 15.2 ± 7.9 years and baseline DAS28 before taper was 1.93±1.04 years. Concomitant DMARDs were used in 53.8%. Anti-cytokine therapy:Over 287.9 patient-years follow up (mean follow up duration: 26.8 ± 14.1 months), taper failure occurred in 36 (27.9%) patients in a mean time of 12.0 ± 8.1 months. There was no statistically significant difference in failure rate between different agents. A 50% dose reduction could be achieved in 65 (50.4%) patients with the mean time to achieve it of 10.4 ±9.1 months. Thirteen (10.1%) patients stopped biologics completely. Current smoking [HR:3.67 95%CI:1.50-9.00, p:0.04] and higher DAS28 at initiation of taper [HR:1.93 95%CI:1.11-3.36, p:0.020] were predictive of taper failure. All but 3 of the 36 patients who failed taper, responded on reverting to their previous treatment regime. Anti B-cell therapy:The 55 patients on Rituximab were tapered to a lower dose or had their interval lengthened. Over 98.6 patient-years follow up (mean follow up: 21.5 ± 11.3 months). Mean dose reduction achieved was 62.2 ± 19.9 %. Mean interval between RTX infusions was 12.9 ± 6.4 months. We have managed to save nearly £800,000 over the 3 years with tapering of biologics in this cohort of RA patients compared to the standard dose. Conclusion Successful tapering of biologic therapies in patients with rheumatoid arthritis is feasible and safe in majority of patients who are in clinical and imaging remission. Current smoking and baseline high DAS28 predicted taper failure for anti-cytokine biologics. This can be safely managed by reverting to the original dosing in most patients. Disclosure H. Muhammed VK: None. A. Yau: None. G. Hirsch: None. T. Sheeran: None. S. Venkatachalam: None.

P132 A late and rapid increase in ultrasound joint inflammation occurs when anti-CCP positive at-risk individuals with subclinical synovitis progress to inflammatory arthritis

Abstract Background/Aims Anti-CCP positive individuals with musculoskeletal (MSK) symptoms and subclinical synovitis on ultrasound (US) are at high risk of developing inflammatory arthritis (IA). Treatment initiation in these individuals is not accepted practice as they do not have clinical synovitis. We aimed to determine whether imaging characteristics change when individuals with pre-RA progress to IA in order to inform the optimal window of opportunity for therapeutic interventions. Methods Anti-CCP+ at-risk individuals with MSK symptoms from the Leeds CCP cohort were selected for having US subclinical synovitis [Grey scale (GS)≥1 and Power Doppler (PD)≥1] prior to IA development and an US scan performed at clinical synovitis onset. The US protocol included the metacarpophalangeal joints (MCPJs), proximal interphalangeal joints (PIPJs), wrists, elbows, knees, second-fifth metatarsophalangeal joints (MTPJs), extensor carpi ulnaris (ECU) and finger flexor tendons (FFTs). US PD and GS synovitis were scored semi-quantitatively (0-3) according to EULAR/OMERACT. At patient level, total GS and PD scores were compared between scans. Change on US in the joints that became clinically swollen was also assessed. Wilcoxon signed-rank tests were conducted for comparisons. Results Forty-six CCP2+ at-risk individuals were identified (Table). The median US scan interval was 3.5 months (IQR 1.25-8.75). At patient level the overall burden of PD in the joints increased at IA progression, trending towards significance [3 (IQR 1.25-5) vs 4 (IQR 2-7.25) p = 0.063]. Overall burden of GS did not increase. There was an increase in PD in the MCPJs [0 (IQR 0-2) vs 1.5 (IQR0-3) p = 0.008] and MCP and wrist joints combined [1 (IQR 0.25-3) vs 2 (IQR 1.25-4.75) p = 0.002]. GS at the elbows also significantly increased. At joint level PD [1 (IQR(0-2) vs 2 (IQR 0-3) p = 0.036] increased in joints swollen at progression and GS increased with a trend towards significance. Non-swollen joints did not change. Conclusion A marked increase in US joint inflammation is seen when CCP+ at-risk individuals with subclinical synovitis on US progress from pre-RA to clinical arthritis. This is particularly evident in the MCPJs, wrist joints and joints that become clinically swollen. Intervening when at-risk individuals have subclinical synovitis may represent a window of opportunity to prevent the rapid increase in joint inflammation which accompanies the onset of joint swelling. Disclosure K. Harnden: None. A. Di Matteo: None. D. Esperança Almeida: None. E. De Lorenzis: None. L. Duquenne: None. L. Garcia-Montoya: None. J. Nam: None. P. Emery: None. K. Mankia: None.

P173 Evaluating disease activity in established psoriatic arthritis with ultrasound

Abstract Background/Aims Early diagnosis, tight disease activity control and a treat-to-target approach are now recognised as critical factors that improve the outcome of patients with psoriatic arthritis (PsA). The traditional method used to assess disease activity is clinical examination (CE) by counting the number of tender and swollen joints. Ultrasound (US) has proven its superiority over CE for assessing the presence of synovitis in some studies. We aimed to identify the frequency and location of subclinical synovitis in a cohort of PsA patients with established disease. Methods Patients with established PsA were recruited. All gave informed, written consent and local ethical approval was obtained. All patients had a standard CE including 68/66 tender/swollen joint count. Grayscale (GS) and power doppler (PD) US of a standard set of 44 joints was performed using a GE logiq-P9 machine utilising 6-15-MHz and 8-18-MHz linear transducers. GS and PD were scored on a 0-3 semiquantitative scale for each joint. The presence of US active joints was defined as a GS-score ≥2 and/or PD-score ≥1. Results 78 patients were enrolled; 46/78 were female with a median age = 61 years (range 41-80). Median duration of PsA disease = 31.5 years (range 41-80), 40/78 were on bDMARDs and 27/78 on csDMARDs. The median TJC = 2 (range of 0-6) and mean CRP = 3.2 (SD 3.5). The most common sites for subclinical synovitis were wrists, knees, and metatarsophalangeal joints (see Table 1). 36 patients (46.2%) achieved a clinical state of minimal disease activity (MDA). 11 patients in MDA (30.5%) had a PD-score of &amp;gt; 1, suggesting they did not achieve minimal ultrasound disease activity (MUDA). Conclusion These data demonstrate that a proportion of established PsA patients deemed to have MDA actually have sonographic evidence of active disease. A previous study showed that PD-synovitis in PsA patients in clinical remission was a strong predictor of disease flare. It is unclear if subclinical synovitis in PsA is linked to radiographic progression. Combining CE and sonographic evaluation is an attractive approach to identifying subclinical disease. However, a validated ultrasound composite index, which includes the key joint areas frequently affected in PsA, is needed. Disclosure S. Sundanum: None. H. Darcy: None. P. Gallagher: None. F. Young: None. L. O'Neill: None. D. Veale: None.

P072 Significant functional impairment and disability in individuals with psoriatic arthritis and Achilles tendon pain

Abstract Background/Aims Enthesitis is a hallmark clinical feature of psoriatic arthritis (PsA) with the most commonly affected site being the Achilles tendon (AT) insertion into the posterior calcaneum. There is overlap in the clinical and ultrasound (US) pathological presentation of Achilles enthesitis and Achilles tendinopathy, however their treatment guidelines differ significantly. AT pain in PsA is complex, with the potential interplay of mechanobiology and inflammation. The aim of this study was to assess the structure and function of the AT in individuals with PsA to inform the future development of a non-pharmacological intervention. Methods A single-centre, cross-sectional observational study was conducted. People with PsA with (PsA+AT) and without (PsA-AT) AT pain were age and sex-matched with healthy controls (n = 11 per group). AT structure and function were assessed by clinical examination (Leeds Enthesitis Index and AT tendinopathy tests), B-mode and Power Doppler (PD) US, the Victorian Institute of Sports Assessment - Achilles (VISA-A) questionnaire, the bilateral heel raise test and 10-metre walk test (10MWT). Patient-reported outcome measures were used to evaluate local and global disease activity, impact, and quality of life. Group membership associations and between-group differences for domains of interest were evaluated using Pearson’s Chi-squared, one-way ANOVA, Mann-Whitney or Kruskal-Wallis tests. Results All groups were comparable in terms of sex, age and BMI. PsA disease duration was longer in the PsA-AT group (mean [SD], 20.1 years [13.1]) compared to the PsA+AT group (7.4 [6.3]). Structural changes at the enthesis on US were detected in all groups; however inflammatory features were significantly more prevalent in the PsA+AT group (p&amp;lt;0.001). PD signal was only detected in the PsA+AT group. Mid-portion and myotendinous AT pathology, including diffuse thickening, altered echogenicity and partial tears were also present, irrespective of the presence of enthesitis. PsAID-12 and HAQ-DI scores were significantly worse in the PsA+AT compared to the PsA-AT group (p=0.018 and p=0.001, respectively). The PsA+AT group walked slower (mean=17.89 seconds for 10MWT) compared to the PsA-AT group (12.23) and controls (11.55), could perform significantly less heel raises until the point of fatigue (PsA+AT mean=19.45, PsA-AT=39.18, controls=51.55, p=0.007) and had significantly worse VISA-A scores (PsA+AT mean=33, PsA-AT=71, controls=92, p&amp;lt;0.001), indicative of impaired AT function. In the PsA+AT group, AT pain was persistent and disabling despite pharmacological management in line with current guidelines and &amp;lt;30% had received treatment from podiatry or physiotherapy services. Conclusion People with PsA and AT pain exhibit severe functional limitations as demonstrated by the bilateral heel raise test, 10MWT and VISA-A scores. The diversity of US imaging features detected, and the inconsistencies in treatment provided, highlights an opportunity to develop individualised non-pharmacological management strategies stratified by US features and performance-based testing. Disclosure A. Patience: None. M.P. Steultjens: None. S. Siebert: None. G.J. Hendry: None.

Ultrasonographic Evaluation of Entheseal Fibrocartilage in Patients with Psoriatic Arthritis, Athletes and Healthy Controls: A Comparison Study

Consecutive PsA patients attending our unit were asked to participate. HCs and agonist athletes were enrolled as a control group. A bilateral PDUS evaluation of Achilles tendons was performed in order to evaluate the EF in all patients and controls. In total, 30 PsA patients, 40 athletes and 20 HCs were enrolled. The median (IQR) EF thickness among the PsA patients, athletes and HCs was 0.035 cm (0.028-0.04) cm, 0.036 (0.025-0.043) cm and 0.030 (0.020-0.038) cm, respectively (p = 0.05 between PsA patients and HCs). The intra-reader reliability was excellent [ICC (95% CI) of 0.91 (0.88-0.95)] and the inter-reader reliability was good (0.80 (0.71-0.86). The assessment of EF was feasible, with a mean time of 2 min. No correlations were found with disease activity indices in PsA patients. The assessment of EF is a feasible and reproducible test and may be explored as a potential imaging biomarker.

Three-dimensional Power Doppler Ultrasonography Evaluation of Maternal Orbital Perfusion in Pregnancies with Gestational Diabetes Mellitus

Three-dimensional Power Doppler Ultrasonography Evaluation of Maternal Orbital Perfusion in Pregnancies with Gestational Diabetes Mellitus

Role of color Doppler ultrasonography in predicting the viability of bowel loops in children with intussusception

Abstract Background: Intussusception mainly affects infants and toddlers, though it can affect any age of the pediatric population. Intussusception has been successfully diagnosed using B-mode ultrasonography. Once, hydrostatic or pneumatic intussusception reduction under image guidance was used to treat these children. But this needs a critical assessment of the preserved bowel viability before the procedure. There are several criteria based on ultrasonography for predicting bowel reducibility during hydrostatic or pneumatic reduction. Our study aimed to demonstrate the role of color Doppler ultrasound in predicting the viability of the intestine in children with intussusception. Materials and Methods: Thirty children under 14 years of age with clinical symptoms suggestive of intussusception were evaluated on color Doppler and power Doppler ultrasonography to predict the viability of bowel loops in children with intussusception. The compression technique was used for graded compression, and the patients were followed for clinical/surgical outcomes. Sensitivity, specificity, positive predictive value, negative predictive value, the strength of agreement of trapped fluid, vascularity at apex, and power Doppler for predicting viability of bowel loops were statistically analyzed. Results: In 17 (56.67%) children, vascularity at the apex of the intussusceptum loop was absent. Vascularity at the apex was present in only 13 of 30 patients (43.33%). On the final clinical/surgical outcome, 17 (56.67%) of patients had necrosis of the bowel loop. Bowel loops were viable in only 13 of 30 patients (43.33%). Of patients who had viability of bowel loops, 76.92% of patients did not have trapped fluid. If the trapped fluid was absent, there was a 100.00% probability of viability of bowel loops; if trapped fluid was present, there was an 85.00% chance of necrosis. Among patients who had necrosis, 100.00% of patients had trapped fluid. In predicting bowel loops’ viability, vascularity’s sensitivity and specificity at the apex on color Doppler were maximum: sensitivity 100% (75.29%–100.00%) and specificity 100% (80.49%–100.00%). In predicting the viability of bowel loops, the sensitivity and specificity of power Doppler at the apex of the intussusceptum loop were maximum: sensitivity 100% (75.29%–100.00%) and specificity 100% (80.49%–100.00%) each. Excellent agreement was seen between final diagnosis and vascularity at the apex with kappa 1 and P value &lt;0.0001. Among 17 patients diagnosed with bowel necrosis, 17 had similar findings in vascularity at the apex. Among 13 patients diagnosed with viable bowel loops, 13 had similar vascularity findings at the apex. The concordance rate was 100.00%, and the discordance rate was 0.00% between the final diagnosis and vascularity at the apex. Conclusion: The presence or absence of blood flow in the intussusceptum loop on color Doppler sonography and power Doppler is a promising predictor of bowel viability. Trapped fluid within the intussusceptum loop emphasizes the possibility of no spontaneous resolution of intussusception. Color Doppler ultrasonography, which detects blood flow in the invaginated bowel, seems to be the most valuable diagnostic modality for predicting the likelihood of bowel reduction.

How are rheumatologists from Argentina managing patients with arthralgias suspicious for progressing to rheumatoid arthritis?

Patients with arthralgias who could be at risk of progressing to rheumatoid arthritis (RA) represent a clinical challenge. Recommendations for their management and treatment are lacking. The purpose of the present study was to determine how Argentinean rheumatologists deal with these patients. We developed an anonymous ad hoc survey which was sent to 522 Argentinean rheumatologists. The RA study group of our Argentinean Rheumatology National Society assisted in forwarding the surveys to its members via the internet (e-mail or WhatsApp). The findings of the collected data are presented as descriptive statistics. The questionnaires were completed by 255 rheumatologists (overall response rate of 48.9%), and 97.6% confirmed that their practices had received medical consultations to rule out RA in patients with arthralgias. Ultrasound (US) was the method of first choice (93.7%) as part of the evaluation of these patients. For those in whom US power Doppler signal was present in at least one joint, 93.7% of the participants would start treatment and methotrexate was the first choice (58.1%). In patients with tenosynovitis but no synovitis on US, most rheumatologists would start treatment (89.4%), being NSAIDs the drug of first choice (52.3%). Argentinean rheumatologists evaluate patients with imminent RA and treat them based on their clinical judgment and findings from the US evaluation of affected joints; the drug of first choice for these patients among these rheumatologists was methotrexate. Despite published data of recent clinical trials, recommendations for the management and treatment of these patients are necessary.

Exercise induced muscle blood flow is decreased in Charcot-Marie-Tooth disease type 1 polyneuropathy: a power Doppler analysis.

Intramuscular blood flow increases during physical activity and may be quantified immediately following exercise using power Doppler sonography. Post-exercise intramuscular blood flow is reduced in patients with muscular dystrophy, associated with disease severity and degenerative changes. It is not known if intramuscular blood flow is reduced in patients with neuropathy, nor if it correlates with muscle strength and structural changes. The aim was to determine whether blood flow is reduced in patients with polyneuropathy due to Charcot-Marie-Tooth disease type 1 (CMT1) and to compare more affected distal to less affected proximal muscles. This was a cross-sectional study including 21 healthy volunteers and 17 CMT patients. Power Doppler ultrasound was used to quantify post-exercise intramuscular blood flow in distal (gastrocnemius) and proximal (elbow flexor) muscles. Intramuscular blood flow was compared to muscle echo intensity, muscle strength, disease severity score, patient age and electromyography. Polyneuropathy patients showed reduced post-exercise blood flow in both gastrocnemius and elbow flexors compared to controls. A more prominent reduction was seen in the gastrocnemius (2.51% vs. 10.34%, p< 0.0001) than in elbow flexors (4.48% vs. 7.03%, p< 0.0001). Gastrocnemius intramuscular blood flow correlated with muscle strength, disease severity and age. Receiver operating characteristic analysis showed that quantification of intramuscular blood flow was superior to echo intensity for detecting impairment in the gastrocnemius (area under the curve 0.962 vs. 0.738, p= 0.0126). Post-exercise intramuscular blood flow is reduced in CMT1 polyneuropathy. This reduction is present in both impaired distal and minimally affected proximal muscles, indicating it as an early marker of muscle impairment due to neuropathy.

A power Doppler ultrasound method for improving intraoperative tip localization for visually obstructed needles in interstitial prostate brachytherapy.

High-dose-rate (HDR) interstitial brachytherapy (BT) is a common treatment technique for localized intermediate to high-risk prostate cancer. Transrectal ultrasound (US) imaging is typically used for guiding needle insertion, including localization of the needle tip which is critical for treatment planning. However, image artifacts can limit needle tip visibility in standard brightness (B)-mode US, potentially leading to dose delivery that deviates from the planned dose. To improve intraoperative tip visualization in visually obstructed needles, we propose a power Doppler (PD) US method which utilizes a novel wireless mechanical oscillator, validated in phantom experiments and clinical HDR-BT cases as part of a feasibility clinical trial. Our wireless oscillator contains a DC motor housed in a 3D printed case and is powered by rechargeable battery allowing the device to be operated by one person with no additional equipment required in the operating room. The oscillator end-piece features a cylindrical shape designed for BT applications to fit on top of the commonly used cylindrical needle mandrins. Phantom validation was completed using tissue-equivalent agar phantoms with the clinical US system and both plastic and metal needles. Our PD method was tested using a needle implant pattern matching a standard HDR-BT procedure as well as an implant pattern designed to maximize needle shadowing artifacts. Needle tip localization accuracy was assessed using the clinical method based on ideal reference needles as well as a comparison to computed tomography (CT) as a gold standard. Clinical validation was completed in five patients who underwent standard HDR-BT as part of a feasibility clinical trial. Needle tips positions were identified using B-mode US and PD US with perturbation from our wireless oscillator. Absolute mean±standard deviation tip error for B-mode alone, PD alone, and B-mode combined with PD was respectively: 0.3±0.3mm, 0.6±0.5mm, and 0.4±0.2mm for the mock HDR-BT needle implant; 0.8±1.7mm, 0.4±0.6mm, and 0.3±0.5mm for the explicit shadowing implant with plastic needles; and 0.5±0.2mm, 0.5±0.3mm, and 0.6±0.2mm for the explicit shadowing implant with metal needles. The total mean absolute tip error for all five patients in the feasibility clinical trial was 0.9±0.7mm using B-mode US alone and 0.8±0.5mm when including PD US, with increased benefit observed for needles classified as visually obstructed. Our proposed PD needle tip localization method is easy to implement and requires no modifications or additions to the standard clinical equipment or workflow. We have demonstrated decreased tip localization error and variation for visually obstructed needles in both phantom and clinical cases, including providing the ability to visualize needles previously not visible using B-mode US alone. This method has the potential to improve needle visualization in challenging cases without burdening the clinical workflow, potentially improving treatment accuracy in HDR-BT and more broadly in any minimally invasive needle-based procedure.

Value of Hands Ultrasonography in the Differential Diagnosis Between Psoriatic Arthritis and Rheumatoid Arthritis.

Psoriatic arthritis (PsA) can mimic rheumatoid arthritis (RA) at an early stage, especially when psoriasis is lacking. In the absence of specific radiological and immunological markers, the differential diagnosis between these two diseases can be challenging. We aimed to determine whether hands ultrasonography (US) may be useful in the differential diagnosis between PsA and RA. We conducted a cross-sectional study including patients with PsA and RA. All wrists and small joints of the hands were examined using gray-scale and Power Doppler US. The evaluated US lesions were: synovitis, tenosynovitis of extensor carpi ulnaris, extensor communis and flexor tendons, enthesitis of extensor tendons at distal interphalangeal joints, peritendon inflammation of extensor tendons, and soft tissue edema. Six hundred joints in 20 PsA patients and 900 joints in 30 RA patients were assessed. Extensor enthesitis was significantly more observed in PsA compared with RA (39.4 vs 26.3%, P=.006) with a significant higher frequency of enthesophytes and calcifications (P=.022 and P=.002, respectively). Peritendon inflammation of extensor digitorum tendons was observed in 13% of metacarpophalangeal joints in PsA patients versus 3% in RA patients with a significant difference (P < .001). Soft tissue edema was exclusively observed in PsA (1.5 vs 0%, P=.033). Power Doppler synovitis was significantly more frequent in RA (9.2 vs 5%, P=.002). Extensor carpi ulnaris tenosynovitis was significantly more frequent in RA (18.3 vs 2.5%, P=.017). Extrasynovial US findings may be helpful to distinguish PsA from RA especially in patients with immunonegative polyarthritis and no evidence of psoriasis.

Psoriatic Arthritis: Differential Features at the Time of Clinical Presentation in a Large Cohort of Patients with Polyarthralgia.

Most patients with psoriatic arthritis begin with cutaneous psoriasis, which is why all early detection strategies are based on screening in the dermatological consultation and referral to a rheu matologist. However, there are cases of patients who consult initially for musculoskeletal symptoms, mostly joint pain, regardless of family and/or personal history of psoriasis. This study aimed to esti mate the frequency of psoriatic arthritis in a cohort of patients who consulted for polyarthralgia and to determine the differential features, at the time of clinical presentation, in relation to both patients with final diagnosis other than psoriatic arthritis and patients with diagnosis of rheumatoid arthritis. Consecutive patients with polyarthralgia (including arthralgia of the hands) were included. Clinical examination, laboratory tests, ultrasound with power Doppler of both hands, and radiography of both hands and feet were performed at baseline. All patients were followed up and the definitive diagnosis of psoriatic arthritis was established. A total of 1055 were included, 88 (8.3%) ended with diagnosis of psoriatic arthritis. Diagnosis of psoriatic arthritis was positively associated with a family history of psoriasis (odds ratio=4.14), pso riasis (odds ratio=78.94), radiographic erosions (odds ratio=5.74), and ultrasound with at least 1 joint with positive power Doppler (odds ratio=7.11). In comparison with rheumatoid arthritis patients, diagnosis of psoriatic arthritis was positively associated with psoriasis (odds ratio=433.42) and family history of psoriasis (odds ratio=41.63). On the other hand, it was negatively associated with positivity, for both rheumatoid factor (odds ratio=0.03) and anti-cyclic citrullinated peptide antibodies (odds ratio=0.06). The frequency of psoriatic arthritis was 8.3% and was associated with a personal and/or family history of psoriasis, radiographic erosions, and inflammatory involvement by Power Doppler Ultrasound (PDUS). In comparison with rheumatoid arthritis patients, psoriatic arthritis was associated with a personal and/or family history of psoriasis, while the presence of both rheumatoid factor and/ or anti-cyclic citrullinated peptide antibodies was shown to be a protective factor for the diagnosis of psoriatic arthritis.

The Temporal Associations of B-Mode and Power-Doppler Ultrasonography, and Ovarian Steroid Changes of the Periovulatory Follicle and Corpus Luteum During Luteogenesis and Luteolysis in Jennies.

This study aimed to determine the associations between B-mode and Power-doppler ultrasonography and ovarian steroids of the periovulatory follicle and respective corpus luteum (CL) during luteogenesis and luteolysis in jennies. Twenty-four periovulatory follicles/estrus of correspondent one inter-ovulatory interval (n=12 jennies) were assessed in the study. B-mode ultrasonography and teasing were carried out once day until the detection of a periovulatory follicle (≥28 mm, uterine edema, and signs of estrus). Thereafter, jennies were monitored at 4-hour-intervals by B-mode and Power-doppler ultrasonography. Closer to ovulation, jennies were hourly checked. Each CL was checked daily from luteogenesis to luteolysis. Plasma concentrations of estradiol and progesterone were assessed daily with chemiluminescence immunoassay. Granulosa echogenicity and thickness increased from -36 hour to -1 hour before ovulation in 70% of follicles (P < .05) and were strongly associated with impending ovulation (r=0.80 and r=0.70, respectively). The follicular-wall blood flow increased from -72 to -24 hour pre-ovulation, while the estradiol concentration declined from 42 pg/mL by -72 hour to 31.6 pg/mL by 24 hour before ovulation (P < .05). The vascularization of the periovulatory follicle decreased from 62% (-36 hour) to 37% (-1 hour) before ovulation (P < .05). The CL vascularization and progesterone concentration gradually increased, reaching the peak at 11- and 10-day after the ovulation, respectively (P < .05). The CL vascularization started to decline 3 day before luteolysis, while progesterone concentrations started to drop 4 day before luteolysis (P < .05). In conclusion, the structural changes of the periovulatory follicle detected on B-mode and Power-doppler can be used to detect impending ovulation in donkeys; however, Power-doppler, but not B-mode ultrasonography, can be used to assess CL function in jennies.

Assessment of First-Trimester Utero-Placental Vascular Morphology by 3D Power Doppler Ultrasound Image Analysis Using a Skeletonization Algorithm: The Rotterdam Periconception Cohort

ABSTRACT Abnormal uteroplacental vascular development is one of the primary causes of the major disorders of pregnancy. Identification of this aberrant development in the preconception stage and in the first trimester, when measures to prevent complications are most effective, remains a challenge. Recent advances in offline imaging processing and Doppler techniques have allowed ultrasonographic analysis of placental volume (PV) and uteroplacental vascular volume (uPVV) in the first trimester. The ability of ultrasound to assess specific vascular morphology is not fully understood. The aim of this study was to investigate morphologic development of the first-trimester human uteroplacental vasculature in vivo using 3-dimensional power Doppler ultrasound and advanced image processing to generate the uteroplacental vascular skeleton (uPVS). Data were obtained from the VIRTUAL Placenta study, an ongoing observational study including adult women carrying a singleton pregnancy at less than 10-week gestational age (GA). At least 2 study visits were scheduled in the first trimester, at 7, 9, and 11 weeks' GA. The image quality of ultrasound scans was scored on a 4-point scale ranging between 0 (optimal) and 3 (unusable), and PV was measured using VOCAL software. The uPVV was measured using a virtual reality desktop system with the V-scope volume-rendering application. A skeletonization algorithm was then applied to the uPVV segmentation to generate the uPVS, and 7 morphological uPVS characteristics were used to determine the density of vascular branching within the placenta. A total of 214 women from the VIRTUAL cohort were eligible for inclusion, and 81% of all ultrasound data were of sufficient quality for generation of the uPVS. The distribution of endpoints, vessel points, bifurcation points, and crossing points in the uPVS and the distribution of uPVS characteristics per cm3 uPVV show consistent morphologic patterns throughout the first trimester. Moderate to strong positive correlations between uPVS characteristics and PV and strong positive correlations between uPVS characteristics and uPVV were identified. All uPVS characteristics increased significantly through the first trimester, except for uPVS average length, which remained constant between 7, 9, and 11 weeks' GA. When stratifying for placenta-related complications among the cohort, no significant differences in the uPVS characteristics were seen at 7 weeks' GA (n = 94). However, at 9 weeks (n = 170), there were significantly fewer number of vessel points (P = 0.040), bifurcation points (P = 0.050), crossing points (P = 0.020), and a shorter total network length (P = 0.023) among pregnancies with placenta-related complications. At 11 weeks' GA (n = 129), uPVS average vascular thickness was significantly lower in pregnancies with placenta-related complications (P = 0.007), but no other uPVS differences were observed. At 11 weeks' GA, pregnancies with placenta-related complications were found to have an increased density of vascular branching in the uPVV. The results of this study demonstrate a quantitative morphologic analysis of the human uteroplacental vasculature in the first trimester of pregnancy and key differences in the vascular morphology between pregnancies with and without placenta-related complications.

Artefact Indicator for Flow‐based Temporal Interpolation of Power Doppler Ultrasound

AbstractPower Doppler ultrasound is a sonography technique to detect and visualise blood circulation. Its acquired image sequences suffer from poor temporal resolution and artefacts caused by aliasing, noise, large displacements, shearings or out‐of‐plane movements. These pitfalls distort flow fields and have unforeseen consequences on flow‐based temporal interpolations. We propose a method to detect artefacts caused by such distorted flow fields and to improve the visual quality by replacing regions with detected artefacts by locally better results. This is demonstrated on real data.