Ultrasound and 12 cases of Toothpick MisEating in 2008-2018

NHÂN 12 CA NUỐT TĂM XỈA RĂNG: VAI TRÒ SIÊU ÂM CHẨN ĐOÁN

 LÝ VĂN PHÁI, LÊ VĂN TÀI, PHẠM THỊ THANH XUÂN, LÊ THỊ THANH THẢO, LÊ TỰ PHÚC, LÊ THANH LIÊM, PHAN THANH HẢI

Nuốt phải tăm xỉa răng không phải dễ chẩn đoán. Y văn có 134 ca đã báo cáo với CT là phương tiện phát hiện trước can thiệp, một số siêu âm có thể thấy được, và trong đó 35% trường hợp  bỏ sót.

Tại Medic từ 2008 đến nay có 12 trường hợp [01 ca ở nữ] nuốt phải tăm xỉa răng được phát hiện  chủ yếu bằng siêu âm [11/12 ca] và CT xác chẩn:

-          2 ca xuyên tá tràng D2 và D3, 1 ca CT không xác định được.

-          2 ca xuyên dạ dày, 1 xuyên dính gan T, 1 xuyên tới nhánh T tĩnh mạch cửa và tạo huyết khối trong tĩnh mạch cửa.

-          2 ca xuyên dạ dày qua túi mật.

-          1 ca xuyên  đại tràng sigma.

-          1 ca xuyên thực quản  ra tuyến giáp sau uống cà phê [nữ].

-          2 ca trong mạc nối lớn gây áp xe thành bụng rốn P và áp xe thành bụng hố chậu T.

-          1 ca trong mạc nối lớn thượng vị.

-          1 ca siêu âm không thấy, CT phát hiện.

     6 ca lấy tăm qua mổ, 3 ca rút tăm qua nội soi tiêu hoá và 3 ca theo dõi điều trị nội khoa 2 tuần. Lâm sàng sau can thiệp hết đau, sinh hoạt bình thừơng, không có biến chứng.
  Hình ảnh siêu âm của tăm  xỉa răng= cấu trúc dạng dài, echo dày trung bình, không có bóng lưng sau. Nếu xuyên thành ống tiêu hóa thì thấy cả 2 đầu ở 2 bên vách ống tiêu hóa, với đầu tận tự do hoặc cắm vào cơ quan lân cận. Nếu thấy ngoại vật trong mạc nối lớn thì ngoại vật đã ra khỏi ống tiêu hóa để vào trong ổ phúc mạc hoặc sau phúc mạc.

 

    Thường bệnh nhân không nhớ đã nuốt phải tăm lúc nào. Không có bệnh nhân có rối loạn tâm thần như y văn. Thói quen ngậm tăm hầu như không có ghi nhận. Tập quán cho tăm vào ly bia của Đài loan đã được báo cáo không có ở Việt nam.  Siêu âm Medic phát hiện nhờ thấy ngoại vật xuyên thành ống tiêu hóa ở các trường hợp đau bụng khu trú. Phân biệt tăm xỉa răng [dày] với xương cá [mảnh hơn] vẫn là thách thức của bác sĩ siêu âm.

ULTRASOUND  DETECTED TOOTHPICK  INGESTION 

NGUYEN THIEN HUNG,  LY VAN PHAI, LE VAN TAI,  PHAM THI THANH XUAN, LE THI THANH THAO, LE TU PHUC,  LE THANH LIEM, PHAN THANH HAI.

MEDIC MEDICAL CENTER, HCMC, VIETNAM

Toothpick ingestion is hard to reveal by ultrasound. In literature  there are 134 published cases   in which CT takes main role of imaging modalities  and still 35% of cases in misdiagnosing.

     In MEDIC CENTER, there are 12 cases of toothpick ingestion which were detected    by ultrasound (11/12 cases) and CT confirmed later since 2008.

·        2 cases of perforation of D2 and D3, one case CT missed.

·        2 cases of perforation of stomach in which is comes to left lobe of liver and cases thrombus in left portal vein.

·        2 cases of perforation of stomach coming to gallbladder.

·        1 case of perforation sigmoid colon.

·        1 case of perforation of esophagus coming to thyroid after coffee drinking in a female patient.

·        2 cases in great epiploon induced abdominal wall abscesses in near umbilicus and in left lower quadrant.

·        1 case in great omentum in epigastric region.

·        1 case CT detected and ultrasound missed.

Invasive retrieval of toothpick infections by surgery for 6 cases, by endoscopy with  3 cases and  3 cases only medical treatments in 2 weeks.
All of cases remain well without complications.

Ultrasound findings of toothpick ingestion= line structure, mediate hyperechoic, no posterior shadowing. In case of perforation of digestive tube, one could be shown both 2 ends in 2 sides of digestive tube wall, with liberal end or with end in adjacent organ. In case toothpick is shown in epiploon then it is out of digestive tube and coming to peritoneal sac or retroperitoneal space.

Patients nearly could not remember when they ingested toothpick. There are no patient with psychological problem in all cases. No patient with bad habit of holding toothpick in mouth. Ultrasound detected toothpick ingestion in cases of local abdominal pain with foreign bodies perforating digestive tube wall. But different diagnosis toothpick (thickening) from fishbone is still challenging for sonologist.

NHÂN 5 CA XƯƠNG CÁ TẠO ÁPXE Ở CỔ VÀ Ổ BỤNG.

Gồm 5 ca, trong đó có 1 ca từ bệnh viện Bình an Kiên giang [ca 313], hóc xương gây áp xe vùng cổ, 

còn lại 1 ca trong tuyến bọt dưới hàm và 3 ca trong ổ bụng tại Medic Hòa Hảo, với 1 ca áp xe trước gan T trì hoãn 2 tháng gây viêm phúc mạc, 2 ca còn lại gây ápxe gan P  và  1 ca  xuyên túi mật qua gan.

Ca mới nhất = Xương cá gây viêm phúc mạc sau siêu âm 2 tháng.

Bnh nữ 43 tuổi, siêu âm 19-5 =ápxe trước gan T nghi có ngoại vật (bs Võ thị ThanhThảo), được CT xác chẩn có ngoại vật xương cá 25mm [bs Trần Lãm], siêu âm lần 2 (13/6) = ápxe trước gan T nghi có ngoại vật, hình ảnh  không thay đổi so với lần trước, [bs Lê thị Thanh Thảo], hội chẩn ngày7/7 với  bs GĐ chuyển bv Bình dân, cho về không mổ , sáng nay 16/7 mổ viêm phúc mạc tại bv Bình dân, ngoại vật là xương cá.

Hình ảnh siêu âm xương cá trong ổ ápxe là cấu trúc dạng đừơng, echo dày, dài, mảnh, không có bóng lưng sau. Siêu âm có thể phát hiện ngoại vật xương cá trong ổ ápxe tùy thuộc vào kỹ năng người khám, vị trí ổ ápxe, thể trạng bệnh nhân [bụng to, béo phì... khó khám].

Ca 265=

https://www.ultrasoundmedicvn.com/2014/07/case-265-fish-bone-intragallbladder-dr.html

Ca 313=

https://www.ultrasoundmedicvn.com/2015/05/case-313-fish-bone-appearing-in-neck-dr.html

 Case 387= LIVER ABSCESS dueto FISHBONE

. 

https://www.ultrasoundmedicvn.com/2016/07/case-387-liver-abscess-due-to-fishbone.

US features help define thyroid nodules in children

By AuntMinnie.com staff writers

May 3, 2018 -- Certain ultrasound characteristics can help clinicians identify malignant thyroid nodules in children, according to a study published online May 1 in Radiology

A team led by Dr. Danielle Richman of Brigham and Women's Hospital used data from 404 thyroid nodules in 314 patients (age range: 2-18 years) between January 2004 and July 2017. All nodules received ultrasound-guided fine-needle biopsy; the researchers recorded age, sex, background appearance of the thyroid gland for each patient, sonographic characteristics, and pathologic diagnosis for each nodule.

Of all the nodules, 77 (19.1%) were malignant, and most of these were papillary thyroid carcinoma (88.3%). The likelihood of malignancy did not differ by patient sex or puberty status, Richman and colleagues found. The cancer rate in children with a solitary nodule was higher than in those with multiple nodules (29.4% versus 14.2%, p = 0.003).

The researchers also identified a number of sonographic characteristics associated with malignant nodules, such as larger size, solid parenchyma, taller-than-wide shape, presence of speckled calcifications, lack of a smooth margin, and presence of abnormal lymph nodes.

"In children with thyroid nodules ... [these characteristics] raise concern for malignancy," they concluded.

Automated 3D US effective for diagnosing hip dysplasia

By Kate Madden Yee, AuntMinnie.com staff writer

April 30, 2018 -- Automated 3D ultrasound is just as effective as 2D ultrasound for diagnosing developmental dysplasia of the hip (DDH) in infants: In fact, it reduces the number of studies characterized as borderline by more than two-thirds, according to research published online April 24 in Radiology.

The study's findings suggest that automated 3D ultrasound could serve as an even more effective tool for diagnosing this condition -- which, if untreated, can cause long-term damage, wrote the team led by Dornoosh Zonoobi, PhD, from the University of Alberta in Edmonton, Canada.

"Three-dimensional ultrasound has potential advantages in feasibility in a screening setting for hip dysplasia because the 3D indexes of dysplasia are calculated automatically from surface models generated with minimal user input, or potentially completely automatically calculated by using deep-learning tools," the researchers wrote.

Developmental hip dysplasia in infants is associated with premature osteoarthritis later in life, and it is the cause of 30% of hip arthroplasties in patients younger than 60. The condition is usually treated in infants with a harness, and a prompt and accurate diagnosis reduces its negative long-term effects. 2D ultrasound has long been used to identify DDH, but it has limitations, including operator variability and overdiagnosis.

3D ultrasound overcomes these limitations because it offers a more complete view of hip geometry than 2D ultrasound and also because it is automated, Zonoobi and colleagues wrote. The modality was first suggested for the diagnosis of DDH in the 1990s, but only recently has transducer technology evolved enough to make the use of 3D ultrasound for this application feasible.

For their study, Zonoobi and colleagues added 3D ultrasound to conventional 2D ultrasound exams of 1,728 infants (mean age, 67 days) to evaluate the children for DDH; the exams were performed between January 2013 and December 2016. Custom software automatically calculated measures such as 3D posterior and anterior alpha angle and osculating circle radius. Of the infants imaged, 1,347 were normal, 140 were borderline for the condition, and 241 were dysplastic.

The researchers found that 3D ultrasound helped correctly categorize 97.5% of the dysplastic and 99.4% of the normal hips, and no dysplastic hips were categorized as normal. 3D ultrasound provided a correct diagnosis in 69.3% of cases categorized as borderline at initial 2D ultrasound. The modality also reduced the number of borderline diagnoses to 39, compared with 140 with 2D ultrasound.

The study results justify generalized implementation of 3D ultrasound for DDH diagnosis in clinical settings, Dr. Diego Jaramillo of Nicklaus Children's Hospital in Miami wrote in an editorial that accompanied the study.

Spinal Pain in Space and US

By Kate Madden Yee, AuntMinnie.com staff writer

April 26, 2018 -- Astronauts armed with a compact ultrasound system successfully performed scans on each other while on the International Space Station. The scans were part of a study to assess spinal changes during long-term spaceflight that could lead to back pain, researchers wrote in the April issue of the Journal of Ultrasound in Medicine.

A group from Henry Ford Hospital worked with NASA to train astronauts on the International Space Station to use ultrasound for imaging the spines of their colleagues during flight. The researchers found that it was feasible to teach these novice users to use ultrasound effectively for this purpose. In addition, the data collected could help in the development of countermeasures to protect astronauts' spines during spaceflight, as well as the creation of protocols for treating injury once the astronauts have returned.

"Focused ultrasound monitoring of the spine for longitudinal changes during long-duration spaceflight may influence additional strategies or nutrition/drug therapies to reduce disk degeneration," lead author Kathleen Garcia and colleagues wrote. "[Our] study demonstrates a potential role for ultrasound in evaluating spinal integrity and alterations in the extreme environment of space."

Aches and pains

Starting with the Apollo program and continuing into the International Space Station era, moderate to severe back pain has been a common medical complaint among astronauts, corresponding author Dr. Scott Dulchavsky, PhD, told AuntMinnie.com.

"When there's no gravity, the spine loosens, making it less stable and putting stress on muscles and ligaments," he said. "The spine can actually elongate by as much as three inches, and that puts astronauts at higher risk of problems when they return."

MRI and CT are the clinical standards for spinal imaging, but they aren't available in space. Ultrasound can be carried on space vehicles thanks to its compact size, but a framework for imaging spinal structures in space hasn't been clearly formulated, Garcia's team wrote.

Dr. Scott Dulchavsky, PhD, from Henry Ford Hospital.

To address this problem, the researchers developed an ultrasound protocol for spaceflight, and they investigated whether astronauts on the International Space Station could effectively perform ultrasound assessments of the lumbar and cervical regions of the spine. Seven astronauts participated in the study and served as both ultrasound operators and research subjects; two additional crew members were trained as backup operators. The exams were read remotely, and the researchers then compared these in-flight results with preflight and postflight MRI and ultrasound exams (J Ultrasound Med, April 2018, Vol. 37:4, pp. 987-999).

The astronauts were trained six months before their mission via an online program that included a review of spinal anatomy, procedure demonstrations, equipment setup orientation, and a software review, as well as a one-hour, hands-on session during which they alternated between patient and operator roles. The exams were conducted with GE Healthcare's Vivid q device, a laptop-sized ultrasound scanner. The astronauts were assisted remotely by experts at NASA's Lyndon B. Johnson Space Center in Houston.

When the astronauts underwent the exams, they were placed supine on a medical restraint system on board the space station. To evaluate the effects of a lack of gravity on the spine over time, each study participant had three in-flight ultrasounds: one at day 30, one at day 90, and one at day 150.

The astronauts easily obtained high-quality images of the lumbar and cervical vertebrae, the researchers found. Overall success rates for image acquisition were 95% in the lumbar spine and 90% in the cervical spine. In addition, there was "no appreciable difference in success rates for either image acquisition or image quality between expert operators and astronaut crew members in the lumbar and cervical regions," they wrote.

The study findings fill in a data gap, according to Garcia and colleagues.

"Given the previous void of in-flight spinal imaging capabilities in space, to our knowledge, this study represents the first attempt to monitor microgravity-associated acute changes to the spine while they are occurring," they wrote.

Greater purpose

One of the benefits of this kind of research is that the findings can influence healthcare on Earth, according to Dulchavsky.

"By putting smart people into constrained environments like space, we can find solutions to health problems that can be used beyond the space station," he said. "Our work here found not only that nonphysicians can be trained to effectively use imaging devices, but it also pointed to further research on exercise and dietary regimens that could help keep the spine healthy in patients on Earth."

As the U.S. sets its sights on sending astronauts on longer missions -- such as to Mars -- understanding how the human body is affected by space is crucial, Garcia and colleagues wrote.

"As the duration of space missions continues to increase, [ultrasound's utility] will only gain importance in monitoring crew health and diagnosing disorders," the group concluded. "Further investigations should be performed to corroborate this imaging technique and to create a larger database related to in-flight spinal disorders during long-duration spaceflights.

PROTOCOLS for SHOCK

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PROTOCOLS FOR SHOCK

Shock is a major morbidity in emergency and critical care and is also one of the important prognostic factors affecting  in-hospital mortality [1]. Timely diagnosis and treatment of shock reduce the length of stay (LOS) and mortality rate at the emergency department (ED). The early use of the point of care ultrasound (POCUS) can reduce the diagnostic time as well as increase the accuracy of diagnosis [2]. The first protocol Undifferentiated hypotension protocol (UHP) was release on 2001, [3]; and more than 15 subsequent protocols were developed [4].

Future and discussion

Most currently available protocols are focused on diagnosis.Blanco et al. suggested that an ultrasound scan should also assess the efficacy of treatment [5]. For example, the use of velocity time integral (VTI) of LVOT to measure the responses to fluid and inotropic agent to help further management.

Point of care ultrasound is a powerful tool in emergency setting. The emergency ultrasound procedures for shock can reduce the LOS at the emergency department.

Therefore, POCUS is an essential skill for personnels in the emergency department and critical care units.

PROTOCOLS for SHOCK