Diagnosing thyroid nodules : Strain elastography, shear wave elastography, and conventional ultrasound

Comparison of strain elastography, shear wave elastography, and conventional ultrasound in diagnosing thyroid nodules
Li-Jen Liao, Huan-Wen Chen, Wan-Lun Hsu, Yung-Sheng Chen

Journal of Medical Ultrasound 2019 27(1):26-32

Objective: The purpose of this study is to compare the diagnostic performances of strain elastography (SE), shear wave elastography (SWE), and traditional ultrasound (US) features in diagnosing thyroid nodules. Subjects and Methods: This study included 185 adult patients with thyroid nodules who underwent conventional gray-scale US, SE, and SWE. SE was scored using a four-pattern elastographic scoring (ES) system. SWE values were presented as mean SWE values and standard derivation using Young's modules. The optimal cutoff values of the mean SWE values for predicting malignancy were determined using receiver operating characteristic (ROC) curve analysis. We used logistic regression models to test elastography as a novel significant predictor for the diagnosis of malignant nodules. The diagnostic performance of elastography parameters was compared with a traditional trained model. Results: Malignant thyroid nodules were stiffer for SE (ES patterns 1 and 2/3 and 4) and mean SWE values (4/17; 51.0 ± 24.4 kPa) than for benign nodules (114/50; 33.1 ± 25.2 kPa) (P < 0.01). In ROC curve analyses, a mean SWE value of 32 kPa was the optimal cutoff point, with diagnostic performance measures of 81% sensitivity, 65% specificity, a 23% positive predictive value (PPV), and 96% negative predictive value (NPV). In multivariate logistic regression, the mean SWE value (≥32 kPa) was an independent predictor for malignancy (odds ratio: 16.8; 95% confidence interval [CI]: 3.6–78.3). However, after the addition of SE and SWE to traditional US features, the C-statistic was not significantly increased compared to the traditional model (0.88, 95% CI: 0.81–0.94 vs. 0.91, 0.85–0.97, P = 0.4). Conclusion: In this study, we confirmed SWE as an independent predictor for malignant thyroid nodules. However, in comparing the new extended elastography model to our previous prediction model, the new extended model showed no significant difference in the diagnostic performance.

The damaging effect of rheumatoid arthritis (RA) on cartilage, bone, ligaments, and tendons.The Disease Activity Score (DAS)-28 with the musculoskeletal ultrasonography (US) examination

A longitudinal study of the 28 joints of disease activity score by ultrasonographical examination in rheumatoid arthritis patients
Rabab Hussin Ali, Osama Sayed Daifallah, Hanan Sayed M. Abozaid, Esam Mohmad Abu Alfadl, Sahar Abdel-Rahman Elsayed

Journal of Medical Ultrasound 2019 27(1):33-39

Background: The damaging effect of rheumatoid arthritis (RA) on cartilage, bone, ligaments, and tendons has raised the importance of the disease activity and severity assessment to enable therapeutic decisions and to evaluate disease outcome. Aim: The aim is to compare the clinical examination of the Disease Activity Score (DAS)-28 with the musculoskeletal ultrasonography (US) examination in RA patients. Moreover, finding if we can use ultrasonographical results as a tool for predicting subsequent radiological damage. Patients and Methods: It is a longitudinal study included 60 adult RA patients. Patients were under assessment at baseline, 6 months, and 12 months from the recruitment time. Twenty-eight joints of DAS were assessed for tenderness and swelling. US gray scale (GS) and US power Doppler (PD) score also was done at each visit. Results: DAS-28, with its parameters, is positively and highly significantly correlated to synovitis severity both by US GS and US-PD score along the study follow-up visits. There was highly significant difference between the number of 28 swollen and tender joints by clinical examination with both US GS and US-PD. Linear regression analysis to predict the number of swollen and tender joints after 12 months showed significance between US PD with swollen and tender joints' numbers. The correlation was positive and significant between Larsen score at 12 months with GS US and PD US assessment, but linear regression analysis was only significant for Larsen score with only GS US. Conclusion: GS US and PD is a sensitive and reliable noninvasive method complementary to standard clinical assessment and could be a tool for predicting subsequent joints' damage.

Otolaryngology

Transdermal lidocaine as treatment for chronic subjective tinnitus: A pilot study Publication date: Available online 18 March 2019 Source: American Journal of Otolaryngology Author(s): Daniel C. O'Brien, Aaron D. Robinson, Nancy Wang, Rodney Diaz Abstract Objective To assess the efficacy of transdermal lidocaine as a treatment for chronic subjective tinnitus as measured by the Tinnitus Functional Index (TFI). Study design Pilot, prospective efficacy trial. Setting Tertiary care hospital. Patients Men and women, over the age of 18 with chronic subjective tinnitus for >6 months. Intervention Daily application of commercially available transdermal lidocaine patch. Outcome measure Change in the TFI. Results The average pre-treatment TFI score was 56.2. After 1 month the average TFI decreased to 41 (p < 0.05). The scores dropped to 34 and 35 after 2 and 3 months of treatment respectively. Despite improvement in symptoms of tinnitus, most patients did not continue the study after the first month, dropping out due to the size, discomfort, and appearance of the lidocaine patch, failure to follow-up and lack of perceived benefit from treatment. Conclusions In this preliminary study, 5% transdermal lidocaine appears to be a potential treatment for chronic subjective tinnitus. The majority of subjects who completed 1 month of treatment had clinically significantly improved tinnitus. These findings are confounded however by the small sample size and significant drop out rate.

Mild hypothermia is associated with improved outcomes in patients undergoing microvascular head and neck reconstruction Publication date: Available online 16 March 2019 Source: American Journal of Otolaryngology Author(s): Benjamin M. Laitman, Yue Ma, Bryan Hill, Marita Teng, Eric Genden, Samuel DeMaria, Brett A. Miles Abstract Objective Microvascular free tissue transfer has become the standard for reconstruction for large defects. With long operative times and an increased surface area exposed, transient hypothermia is common, but it is unclear how this impacts surgical outcomes. This study evaluated the impact of core body temperature on free tissue flap outcomes in patients undergoing microvascular reconstruction. Study design Retrospective data analysis. Setting Mount Sinai Hospital; NYC, NY; 2007–2016. Subjects and methods Demographic information, mean/minimum/maximum body temperatures, and the presence of flap complications (venous thrombosis, arterial insufficiency, flap death, wound infection/dehiscence, fistula, chyle leak, hematoma/seroma) of 519 free tissue transfer patients were documented. Binomial logistic regression was used to examine associations between the presence of flap complications and mean temperature. Statistical analysis used SPSS, with p-values ≤0.05 deemed statistically significant. Results 393 soft-tissue and 125 osteocutaneous flaps were included. 19.8% (n = 103) patients had the presence of ≥1 flap complication, while 80.2% (n = 416) did not. Average temperature for all patients was 36.12 ± 0.84 °C, with minimum at 34.43 ± 0.97 °C and maximum at 37.24 ± 1.23 °C. After controlling for several factors including: tumor stage, radiation, diabetes, BMI, age, sex, and flap type, there was a significant association between flap complications and mean intraoperative temperature (Exp(B) = 1.559, p = 0.004). Conclusion Higher intraoperative temperatures were associated with worse outcomes. A mild relative hypothermia may improve flap outcomes in this population. This represents the largest study to date evaluating the impact of intraoperative temperature on free tissue transfer outcomes.

Non-recurrent laryngeal nerve in thyroid surgery: Frequency, anatomical variations according to a new classification and surgery consideration Publication date: Available online 12 March 2019 Source: American Journal of Otolaryngology Author(s): Quang Van Le, Quoc Ngo Duy, Quy Xuan Ngo Abstract Background Iatrogenic injury to the recurrent laryngeal nerve (RLN) is one of the most concerning problems of thyroid surgery. The non-recurrent laryngeal nerve (NRLN) is a rare variation of the RLN. Objectives We aimed to identify the proportion of NRLN (during thyroidectomy), introduce a new details classification and recommend some surgical considerations. Materials and methods From May 2017 to September 2018, our hospital carried out 2462 thyroid operations. We reported the NRLN rate and distinguished NRLN into three types: (a) Type 1: descending – NRLN runs downward to the cricothyroid joint; (b) Type 2: vertical – NRLN runs vertically to the cricothyroid joint; (c) Type 3: ascending – NRLN runs upward to the cricothyroid joint. Results Overall, right-side NRLN had an incidence rate of 0.74% (16 out of 2158 total right thyroid surgeries). However, we did not detect any patient with left-sided NRLN. 12.5% of our patients had type 1, 25% had type 2 and 62.5% had type 3. All 16 patients with NRLN were treated without any complications or injury and some considerations for surgeons were mentioned on how to avoid injury of the NRLN. Conclusion Despite NRLN occurrence being rare, the injury probability during surgery can reach up to 12.9% if correct procedures were not carried out. Here, we introduce a new details classification and information with which they can make appropriate surgical considerations to avoid nerve injury in thyroid surgery.

Angiolymphoid hyperplasia with eosinophilia of the external ear Publication date: Available online 12 March 2019 Source: American Journal of Otolaryngology Author(s): Brian C. Deutsch, Zachary G. Schwam, Vivian Z. Kaul, George B. Wanna Abstract Herein we present the rare case of angiolymphoid hyperplasia with eosinophilia of the external ear treated by surgical resection and full-thickness skin graft. Current diagnosis and management options are reviewed.

Thyroid cancer in patients undergoing surgery for hyperthyroidism Publication date: Available online 11 March 2019 Source: American Journal of Otolaryngology Author(s): Yogesh More, Aly Bernard Khalil, Huda Mustafa, Manjiri Gupte, Musa al abbadi, Doua Elamin, Luay Aziz, Shaikh Irfan Basha

Seed and soil? - Pharyngeal Merkel cell carcinoma after radiotherapy for laryngeal squamous cell carcinoma Publication date: Available online 9 March 2019 Source: American Journal of Otolaryngology Author(s): Monica K. Rossi, D. Anand Rajan Kanagasabapathy, Henry T. Hoffman Abstract Merkel cell carcinoma (MCC) is a neuroendocrine cutaneous malignancy that may present as metastatic disease without a known primary site but, most commonly originates in the sun-exposed skin of the head, neck, and extremities. We present a 66-year-old male treated with chemo-radiation for T3N2cM0 laryngeal squamous cell carcinoma (SCCa) six years before he was diagnosed with MCC isolated to the radiated laryngopharynx. Mucosal MCC is rare and radiation-induced MCC has been hypothesized to occur in previously radiated tissue but, never before to the laryngopharynx. Implications regarding cancer biology and management is focused with discussion on relevant advances in pathologic assessment and immunotherapy.

A systematic review of the nasal septal turbinate: An overlooked surgical target Publication date: Available online 4 March 2019 Source: American Journal of Otolaryngology Author(s): William J. Moss, Farhoud Faraji, Aria Jafari, Adam S. DeConde Abstract Objective The nasal septal turbinate (NST) is a conspicuous structure located in the anterior nasal cavity that impacts the internal nasal valve. Its structure and function is often thought to be poorly characterized, and it is rarely addressed surgically. The authors perform a systematic review in an attempt to synthesize what has been learned of this structure and to evaluate its potential as a treatment target. Methods A query of the Medline, Embase, Web of Science and Cochrane databases was undertaken in search of studies evaluating the NST. This qualitative systematic review was performed in accordance with PRISMA guidelines. Study quality and risk of bias were assessed with established criteria. Results Of the initial 1069 hits from the four databases, 16 articles were ultimately included in the review, which varied in quality and risk of bias. The included articles consisted predominantly of radiographic and histopathologic studies. Four studies evaluated NST treatment outcomes. The NST represents a fusiform-shaped region of erectile tissue, similar in structure and function to that of the turbinates. Preliminary treatment outcomes suggest the NST represents an important surgical target in nasal airway surgery. Conclusion When evaluating nasal obstruction patients, surgeons should assess the NST and consider addressing it surgically.

The role of doxycycline in the management of chronic rhinosinusitis with nasal polyps Publication date: Available online 4 March 2019 Source: American Journal of Otolaryngology Author(s): Arjun K. Parasher, Sarah M. Kidwai, Neeraja Konuthula, Erden Goljo, Stephanie Pan, Alok T. Saini, Anthony Del Signore, Alfred Marc Iloreta, Satish Govindaraj, Benjamin D. Malkin Abstract Introduction Many theories on the pathophysiology of chronic rhinosinusitis with nasal polyposis (CRSwNP) exist. The most effective management of CRSwNP has not been elucidated. Doxycycline, which has anti-inflammatory and anti-bacterial properties, has shown durable effects; however, its efficacy in combination with standard therapy has not been examined. We hypothesized that its addition to the standard anti-inflammatory regimen would improve patient outcomes. Methods We performed a double-blind, placebo-controlled trial at a tertiary level institution. Patients with moderate or severe CRSwNP were randomized into two groups, each receiving a 20-day course of oral corticosteroids and doxycycline or placebo. The 22-item Sinonasal Outcome Test (SNOT-22), nasal polyp scores, and visual analog scale (VAS) scores were recorded at the initial, 3-, 8- and 12-week visits. Results 49 patients were enrolled, 24 in the experimental and 25 in the placebo group with 3 moderate disease patients in each group. There were 12 dropouts in the treatment group and 14 in the placebo group. The most common reasons for dropout were severe CRS and asthma exacerbations. There was no significant difference in SNOT-22 scores, nasal polyp scores, and VAS scores between the two arms. Conclusions Non-surgical management of patients with CRSwNP remains challenging. Our conclusions are limited given the high dropout rate and thus, limited sample size with inadequate power. This study is important, however, because a high dropout rate of mostly severe disease patients may illustrate that this patient population may not be optimally managed with medical therapy alone.

Sensorineural hearing loss and volatile organic compound metabolites in urine Publication date: Available online 4 March 2019 Source: American Journal of Otolaryngology Author(s): Charles Pudrith, William N. Dudley Abstract Purpose Oxidative stress in the auditory system contributes to acquired sensorineural hearing loss. Systemic oxidative stress, which may predict auditory oxidative stress, can be assessed by measuring volatile organic compound metabolite concentrations in urine. The purpose of this retrospective study was to determine if hearing decreased in those with higher concentrations of urinary volatile organic compound metabolites. Materials and methods Audiometric, demographic, and metabolite concentration data were downloaded from the 2011–2012 cycle of the U.S. National Health and Nutritional Examination Survey. Participants were first grouped by reported noise exposure. For each metabolite, an analysis of covariance was used to look for differences in age-adjusted hearing loss among urinary volatile organic compound metabolite concentration groups. Participants were grouped into quartiles based on concentration for each metabolite separately because many individuals were at the lower limit of concentration detection for several metabolites, leading to a non-normal distribution. Results Age-adjusted high-frequency pure-tone thresholds were significantly (FDR < 0.05) increased by about 3 to 4 dB in high concentration quartile groups for five metabolites. All five metabolites were glutathione-dependent mercapturic acids. The parent compounds of these metabolites included acrylonitrile, 1,3 butadiene, styrene, acrylamide, and N,N-dimethylformamide. Significant associations were only found in those with no reported noise exposure. Conclusions Urinary metabolites may help to explain susceptibility to oxidative stress-induced hearing loss.

Is otitis media with effusion associated with oxidative stress? Evaluation of thiol/disulfide homeostasis Publication date: March–April 2019 Source: American Journal of Otolaryngology, Volume 40, Issue 2 Author(s): Eda Şimşek, Cemile Koca Bicer, Muhammed Recai Mazlumoğlu, Soner Sertan Kara, Ozcan Erel, Ayşe Çarlıoğlu Abstract Background We evaluated the relationship between otitis media with effusion and thiol/disulfide homeostasis using a novel marker of oxidative stress. Methods The study group consisted of 30 patients (mean age 8.33 ± 3.30 years) with bilateral otitis media with effusion admitted to our hospital. The control group consisted of 35 (mean age 7.40 ± 3.97 years) age-, sex-, and body mass index-matched healthy subjects. Thiol/disulfide homeostasis was measured using a newly developed method. Results Native and total thiol levels were lower in the study than the control group (native thiols 421.37 ± 72 μmol/L vs. 464.46 ± 46.42 μmol/L, p < 0.05; total thiols 468.42 ± 77.89 μmol/L vs. 501.32 ± 50.30 μmol/L, respectively). Disulfide levels and the disulfide/native thiol and disulfide/total thiol ratios were higher in the study group (disulfides 23.56 ± 4.68 μmol/L vs. 18.43 ± 4.94 μmol/L; disulfide/native thiol ratio 5.65 ± 1.05 vs. 3.97 ± 1.03%; disulfide/total thiol ratio 5.06 ± 0.83 vs. 3.66 ± 0.88%, respectively). Conclusion Oxidative stress may be the major cause of the increase in oxidized thiols in patients with bilateral otitis media with effusion, however, this relationship requires further investigation.

Early detection of superior mesenteric artery dissection by ultrasound

: Two case reports
Chun-Yen Huang, Jen-Tang Sun, Wan-Ching Lien

Journal of Medical Ultrasound 2019 27(1):47-49

Superior mesenteric artery (SMA) dissection is a rare disease. Most of the cases are diagnosed through contrast-enhanced computed tomography. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, evidence is limited regarding the use of bedside ultrasound for diagnosing SMA dissection, which is a known risk factor for aortic dissection. We present two case reports: one case of isolated SMA dissection and one case of SMA dissection complicated with aortic dissection. Both cases were initially diagnosed through bedside ultrasound and confirmed through contrast-enhanced computed tomography.

Haematoma OR ...?

Soft-tissue sarcoma masquerading as a haematoma
Mark Charnock

Journal of Medical Ultrasound 2019 27(1):50-53

Sarcomas commonly occur in the buttock and thigh, although the clinical presentation varies with no specific symptoms other than a painless lump. This case study reports on a soft-tissue sarcoma that was initially thought to be a haematoma on ultrasound, despite being rescanned 6 weeks later. The patient presented back to their general practitioner 8 months later with the subsequent ultrasound showing an irregular and hypervascular soft-tissue mass. Further imaging and ultrasound-guided biopsy led to a surgical excision of a myxofibrosarcoma. This case demonstrates the difficulty of differentiating between a haematoma and sarcoma, especially in patients presenting with a history of trauma.

Cervical lymphadenopathy

IgG4-related disease presenting as cervical lymphadenopathy
Po-Hsuan Wu, Yu-Chen Chang, Li-Jen Liao

Journal of Medical Ultrasound 2019 27(1):43-46

Cervical lymph node enlargement as the first and sole manifestation of IgG4-related disease (IgG4-RD) is rare and is often difficult to distinguish from lymphoma. Here, we report a case of a 63-year-old man initially presenting with bilateral posterior neck masses. Ultrasonography revealed multiple matted, ovoid, homogenous, hypoechoic, and enlarged lymph nodes below the right parotid gland. In addition, there was heterogeneous echotexture with small and indistinct hypoechoic nodules over bilateral parotid and submandibular glands which suggested sclerosing sialadenitis. Pathology of the tissues obtained by core needle biopsy revealed reactive hyperplasia, but a diagnosis of lymphoma could not be excluded. Subsequently, excisional biopsy and serological tests were done. The diagnosis of IgG4-RD was confirmed due to marked elevation of serum IgG4 levels and pathological evidence of IgG+ and IgG4+ plasma cell infiltration in the lymph node specimen. The patient's neck masses subsided gradually after 1 week of oral steroid therapy. The differential diagnosis of IgG4-RD should always be considered when sclerosing sialadenitis is presented with cervical lymphadenopathy.

Medical Ultrasound

Application of ultrasound liver elastography to the diagnosis and monitoring of liver disease Jing-Houng Wang Journal of Medical Ultrasound 2019 27(1):1-2

Reliability of ultrasound for the detection of rheumatoid arthritis Rabia Hassan, Sobia Hussain, Raham Bacha, Syed Amir Gillani, Sajid Shaheen Malik Journal of Medical Ultrasound 2019 27(1):3-12 The aim of this review article was to investigate the pooled sensitivity and specificity of musculoskeletal ultrasound (MSUS) for the detection of synovitis and early bone erosion in the small joint in rheumatoid arthritis (RA). In addition, investigate the pooled sensitivity and specificity of Power Doppler ultrasonography (PDUS) for the detection of synovial hypervascularity in small joints in RA. A systematic literature search of PubMed, Wiley online library, Google Scholar, Research gate, E-book, BioMed Central, the Journal of Rheumatology and Springer Link were investigated from 2001 to 2017. Original researches related to the article written in English including RA, synovitis, bone erosion, grayscale, and PDUS were included in this study. The sample size, study design, sensitivity, and specificity were analyzed. The review summarizes the value of MSUS for the detection of RA as it is the first choice of modality. Results show the acceptable reliability of US for the diagnosis of early bone erosions, synovitis, and synovial hypervascularity.

Relation of color doppler twinkling artifact and scale or pulse repetition frequency Raham Bacha, Syed Amir Gilani, Iqra Manzoor Journal of Medical Ultrasound 2019 27(1):13-18 Objective: The aim of this study is to determine the effect of scale/pulse repetition frequency (PRF) on the appearance of color Doppler twinkling artifact. Materials and Methods: We commenced this cross-sectional study for 20 months from November 2014 to July 2016. During routine ultrasound examination, we observed multiple case of twinkling artifact produced by renal stones, calcifications in the thyroid nodules, bony fragments and intestinal gases, etc., We observed twinkling artifact with low- and high-PRF settings in 500 different structures. A total of 500 other structures were included wherein there was no Doppler twinkling artifact produced by them, with usual optimum PRF settings. These structures were also evaluated with low- and high-PRF to determine the effect of PRF on twinkling artifact effectively. All the patients were examined according to the AIUM guideline for appropriate examination protocol. Data were collected from the observation of twinkling artifact with low- and high-PRF/scale and evaluated with the help of IBM SPSS 24 package, the results were summarized as follow. Results: Change in scale/PRF could not affect the twinkling artifact. The twinkling artifact observed with low-PRF was the same as seen with high-PRF. There was a significant agreement between low- and high-PRF in the production of color twinkling artifact. The kappa value of agreement was estimated as 0.96, whereas the Pearson's correlation was significant with the value of 0.001. Same twinkling artifact was created with low- and high-PRF, with no significant variation. Conclusion: Twinkling artifact is independent of PRF/Scale.

Correlational study of nonalcoholic fatty liver disease diagnosed by ultrasonography with lipid profile and body mass index in adult nepalese population Umesh P Khanal, Bigyan Paudel, Ghanshyam Gurung, Yong-Sin Hu, Chiung-Wen Kuo Journal of Medical Ultrasound 2019 27(1):19-25 Objective: The purpose of this study was to categorize patients into different grades of nonalcoholic fatty liver disease (NAFLD) by ultrasonography and to compare the findings with their serum lipid profile. Materials and Methods: Descriptive, cross-sectional study design was used. One hundred and nine patients without a history of alcohol consumption of age more than 16 years attending general health checkup were selected at Tribhuvan University Teaching Hospital, Maharajganj, Kathmandu, as per the exclusion and inclusion criteria. Ultrasound scanning of the patients was done and their liver size, as well as grading of fatty liver, was done. Data were collected in predesigned pro forma and were analyzed using Statistical Package for the Social Sciences (SPSS) 16.0, IBM (SPSS Inc., Chicago, IL). Results: In this study, the mean age of fatty liver in males was found to be 44.3 years and in females was found to be 51.9 years. 22.9% of patients with NAFLD had increased liver size. Significant association with increasing grades of fatty liver was found with increasing levels of cholesterol (P = 0.028), low-density lipoprotein (LDL) (P = 0.017), liver size (P = 0.001), and body mass index (BMI) (P = 0.045) in patients diagnosed with NAFLD. No significant association with increasing grades of fatty liver was found with increasing levels of triglyceride (P = 0.32) and high-density lipoprotein (P = 0.25). Conclusion: Ultrasound is a safe and first-line modality for the evaluation of fatty liver and its grading. Increasing grades of fatty liver had significant association with increasing levels of cholesterol LDL, increasing liver size, and BMI of patients.

Comparison of strain elastography, shear wave elastography, and conventional ultrasound in diagnosing thyroid nodules Li-Jen Liao, Huan-Wen Chen, Wan-Lun Hsu, Yung-Sheng Chen Journal of Medical Ultrasound 2019 27(1):26-32 Objective: The purpose of this study is to compare the diagnostic performances of strain elastography (SE), shear wave elastography (SWE), and traditional ultrasound (US) features in diagnosing thyroid nodules. Subjects and Methods: This study included 185 adult patients with thyroid nodules who underwent conventional gray-scale US, SE, and SWE. SE was scored using a four-pattern elastographic scoring (ES) system. SWE values were presented as mean SWE values and standard derivation using Young's modules. The optimal cutoff values of the mean SWE values for predicting malignancy were determined using receiver operating characteristic (ROC) curve analysis. We used logistic regression models to test elastography as a novel significant predictor for the diagnosis of malignant nodules. The diagnostic performance of elastography parameters was compared with a traditional trained model. Results: Malignant thyroid nodules were stiffer for SE (ES patterns 1 and 2/3 and 4) and mean SWE values (4/17; 51.0 ± 24.4 kPa) than for benign nodules (114/50; 33.1 ± 25.2 kPa) (P < 0.01). In ROC curve analyses, a mean SWE value of 32 kPa was the optimal cutoff point, with diagnostic performance measures of 81% sensitivity, 65% specificity, a 23% positive predictive value (PPV), and 96% negative predictive value (NPV). In multivariate logistic regression, the mean SWE value (≥32 kPa) was an independent predictor for malignancy (odds ratio: 16.8; 95% confidence interval [CI]: 3.6–78.3). However, after the addition of SE and SWE to traditional US features, the C-statistic was not significantly increased compared to the traditional model (0.88, 95% CI: 0.81–0.94 vs. 0.91, 0.85–0.97, P = 0.4). Conclusion: In this study, we confirmed SWE as an independent predictor for malignant thyroid nodules. However, in comparing the new extended elastography model to our previous prediction model, the new extended model showed no significant difference in the diagnostic performance.

A longitudinal study of the 28 joints of disease activity score by ultrasonographical examination in rheumatoid arthritis patients Rabab Hussin Ali, Osama Sayed Daifallah, Hanan Sayed M. Abozaid, Esam Mohmad Abu Alfadl, Sahar Abdel-Rahman Elsayed Journal of Medical Ultrasound 2019 27(1):33-39 Background: The damaging effect of rheumatoid arthritis (RA) on cartilage, bone, ligaments, and tendons has raised the importance of the disease activity and severity assessment to enable therapeutic decisions and to evaluate disease outcome. Aim: The aim is to compare the clinical examination of the Disease Activity Score (DAS)-28 with the musculoskeletal ultrasonography (US) examination in RA patients. Moreover, finding if we can use ultrasonographical results as a tool for predicting subsequent radiological damage. Patients and Methods: It is a longitudinal study included 60 adult RA patients. Patients were under assessment at baseline, 6 months, and 12 months from the recruitment time. Twenty-eight joints of DAS were assessed for tenderness and swelling. US gray scale (GS) and US power Doppler (PD) score also was done at each visit. Results: DAS-28, with its parameters, is positively and highly significantly correlated to synovitis severity both by US GS and US-PD score along the study follow-up visits. There was highly significant difference between the number of 28 swollen and tender joints by clinical examination with both US GS and US-PD. Linear regression analysis to predict the number of swollen and tender joints after 12 months showed significance between US PD with swollen and tender joints' numbers. The correlation was positive and significant between Larsen score at 12 months with GS US and PD US assessment, but linear regression analysis was only significant for Larsen score with only GS US. Conclusion: GS US and PD is a sensitive and reliable noninvasive method complementary to standard clinical assessment and could be a tool for predicting subsequent joints' damage.

Consistency of the sonographic image (double contour sign) in patients with gout after ambulation Angel Checa Journal of Medical Ultrasound 2019 27(1):40-42 The aim of this study was to know whether or not any crystal shedding occurs after ambulation in patients with gout and how it affects the consistency of the sonographic image of crystal deposition on hyaline cartilage. A total of 18 consecutive patients (29 knees), 11 with early gout (17 knees) and seven with chondrocalcinosis (12 knees), were prospectively scanned by ultrasound. Examination at rest and after ambulation was performed in each patient. Crystal aggregates were measured in a transverse view. Crystal shedding after ambulation was noted in two patients (two knees) with gout. However, crystal deposits on the surface of the articular cartilage in gout kept invariable size. In patients with chondrocalcinosis, crystal shedding by ambulation was absent. The conclusion of this study is that the size of crystal deposits on the hyaline cartilage in gout and chondrocalcinosis assessed by ultrasound is not modifiable by ambulation.

IgG4-related disease presenting as cervical lymphadenopathy Po-Hsuan Wu, Yu-Chen Chang, Li-Jen Liao Journal of Medical Ultrasound 2019 27(1):43-46 Cervical lymph node enlargement as the first and sole manifestation of IgG4-related disease (IgG4-RD) is rare and is often difficult to distinguish from lymphoma. Here, we report a case of a 63-year-old man initially presenting with bilateral posterior neck masses. Ultrasonography revealed multiple matted, ovoid, homogenous, hypoechoic, and enlarged lymph nodes below the right parotid gland. In addition, there was heterogeneous echotexture with small and indistinct hypoechoic nodules over bilateral parotid and submandibular glands which suggested sclerosing sialadenitis. Pathology of the tissues obtained by core needle biopsy revealed reactive hyperplasia, but a diagnosis of lymphoma could not be excluded. Subsequently, excisional biopsy and serological tests were done. The diagnosis of IgG4-RD was confirmed due to marked elevation of serum IgG4 levels and pathological evidence of IgG+ and IgG4+ plasma cell infiltration in the lymph node specimen. The patient's neck masses subsided gradually after 1 week of oral steroid therapy. The differential diagnosis of IgG4-RD should always be considered when sclerosing sialadenitis is presented with cervical lymphadenopathy.

Early detection of superior mesenteric artery dissection by ultrasound: Two case reports Chun-Yen Huang, Jen-Tang Sun, Wan-Ching Lien Journal of Medical Ultrasound 2019 27(1):47-49 Superior mesenteric artery (SMA) dissection is a rare disease. Most of the cases are diagnosed through contrast-enhanced computed tomography. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, evidence is limited regarding the use of bedside ultrasound for diagnosing SMA dissection, which is a known risk factor for aortic dissection. We present two case reports: one case of isolated SMA dissection and one case of SMA dissection complicated with aortic dissection. Both cases were initially diagnosed through bedside ultrasound and confirmed through contrast-enhanced computed tomography.

Soft-tissue sarcoma masquerading as a haematoma Mark Charnock Journal of Medical Ultrasound 2019 27(1):50-53 Sarcomas commonly occur in the buttock and thigh, although the clinical presentation varies with no specific symptoms other than a painless lump. This case study reports on a soft-tissue sarcoma that was initially thought to be a haematoma on ultrasound, despite being rescanned 6 weeks later. The patient presented back to their general practitioner 8 months later with the subsequent ultrasound showing an irregular and hypervascular soft-tissue mass. Further imaging and ultrasound-guided biopsy led to a surgical excision of a myxofibrosarcoma. This case demonstrates the difficulty of differentiating between a haematoma and sarcoma, especially in patients presenting with a history of trauma.