Nirvikar Dahiya

Objective: To determine the proportion of cases of lower extremity symptoms attributable to underlying musculoskeletal ( MSK ) rather than thrombotic etiologies in emergency versus non‐emergency settings. Methods: We retrospectively reviewed all lower extremity Venous Doppler ultrasounds performed on emergency department ( ED ) and non‐ ED patients over a 1‐year period at a single institution. Using radiology report data mining software, keywords including tear, tendon, hematoma, and muscle were used to identify cases of MSK pathology of the lower leg. All reports were also reviewed for findings of venous thrombosis. Statistical significance between ED and non‐ ED patients for both incidental MSK pathology and venous thrombosis was assessed using chi‐squared tests. Results: A total of 5714 lower extremity Doppler ultrasounds were performed at a single institution during the 1‐year period, 1829 in the ED and 3885 in non‐ ED settings. Sixty‐nine of 1829 (3.8%) ED patients had incidental MSK pathology of the lower extremity compared to 53/3885 (1.4%) in the non‐ ED setting ( p < .001). Two hundred sixty‐seven of 1829 (14.5%) ED patients had evidence of venous thrombosis and/or chronic post‐thrombotic change. When combined with thrombotic pathology as positive cases, incidental MSK injury accounted for 69/336 (20.5%) of ED cases with positive sonographic findings. Conclusions: MSK pathology of the lower leg is significantly more likely to contribute to lower extremity symptoms in the ED compared to a non‐ ED setting. Therefore, a brief sonographic evaluation of the MSK apparatus may be beneficial in a subset of ED patients, particularly those with focal pain but no identifiable thrombotic etiology.

The sonographic diagnosis of acute cholecystitis presents challenges. In our practice, we enhance diagnostic accuracy by determining a patient’s risk of acute cholecystitis using four non-image parameters and five imaging parameters. The non-image risk assessment is based on patient age, sex, leukocytosis, and the presence of a sonographic Murphy sign. The imaging risk stratification is derived from evaluating gallbladder (GB) distention, GB wall thickness, GB contents, pericholecystic irregular collections, and hepatic artery peak systolic velocity (HAv). By applying a standardized scoring framework, patients are stratified into one of four diagnostic categories for acute cholecystitis: (1) practically excluded (< 1% probability); (2) reduced risk (< 10% probability); (3) elevated risk (25–30% probability); (4) substantially elevated risk (with three subgroups having 50%, 75%, and 90% probability). This review outlines the methodology of our approach, provides supporting data from published cohorts, and explains the macro-enabled Excel tool we use to streamline the analysis. This tool generates standardized report and impression statements that can be directly incorporated into radiology reporting templates. The approach promotes consistency in reporting, particularly amongst trainees formulating preliminary interpretations, and offers consistent evidence-based probability estimates to emergency department physicians and surgeons for clinical decision-making using a framework that eliminates indeterminate assessments. Graphical Abstract

Pancreas transplant is the standard treatment for restoring endocrine function and limiting complications from diabetes, and radiologists should understand the surgical techniques, normal imaging spectrum, and various complications associated with this surgical procedure.

Objectives: To combine sonographic Murphy sign (SMS) with clinical parameters to effectively stratify patients into risk groups for acute cholecystitis.Methods: Consecutive emergency department patients from April 1, 2019 to August 31, 2022 with possible acute cholecystitis were grouped using patient age, sex, and white blood cell count to determine the rate of acute cholecystitis found in subgroups. Three distinct clinical risk groups were established and then regrouped by prospective assessment of SMS into three non‐imaging risk groups. Differences in the rate of acute cholecystitis for clinical parameters, clinical risk groups, and non‐imaging risk groups were statistically analyzed.Results: Of 1231 patients (mean [SD] age, 51.2 [19.5]; 476 [38.7%] male), 156 had acute cholecystitis (mean [SD] age, 62.0 [15.4]; 85 [54.5%] male). Rates differed based on sex (9.4% female vs 17.9% male, P < .001), age group (1.8% for patients P < .001), and white blood cell count (23.1% elevated vs 6.6% not elevated; P < .001). The low, average, and high non‐imaging risk groups had acute cholecystitis rates of 1.8%, 14.0%, and 43.1%, respectively. Relative risk (95% CI) for the low non‐imaging group compared with others was 0.07 (0.04, 0.12; P < .001); relative risk for the high non‐imaging risk group compared with others was 7.05 (5.32, 9.43; P < .001).Conclusions: Sonographic Murphy sign assessment combined with patient age, sex, and white blood cell count effectively stratifies acute care patients into distinct acute cholecystitis risk groups.

Purpose Compare HAv to non-Doppler ultrasound observations for diagnosing acute cholecystitis in a large consecutive cohort of emergency department (ED) patients and establish a method to combine HAv assessment with non-Doppler observations for diagnosing acute cholecystitis. Methods Consecutive ED patients at one institution undergoing gallbladder (GB) ultrasound (US) for acute cholecystitis between 1/1/2020 and 8/31/2022 had assessments of GB diameter, GB wall thickness, GB contents, pericholecystic irregular collection, and hepatic artery peak systolic velocity (HAv). The non-Doppler observations were scored and summed. Non-Doppler risk categorization was based on rate of acute cholecystitis associated with summed scores. The impact of HAv stratification on the rate of acute cholecystitis in the non-Doppler risk categories was evaluated, with regrouping when subgroups had changes in the acute cholecystitis rate; the regrouping established the HAv-adjusted risk model. Receiver-operator curves for acute cholecystitis diagnosis for individual parameters, the non-Doppler risk categorization, and the HAv-adjusted risk model were compared using area-under-curve (AUC) calculations. Results Of the 885 patients in the study cohort, 117 (13.2%) had acute cholecystitis. The AUC for diagnosing acute cholecystitis using GB distention (83.8%, p < 0.001), GB wall thickness (79.1%, p < 0.001), and GB contents (75.0%, p 0.02) were higher than HAv (66.3%). HAv assessment adjusted risk for 195 patients. The non-Doppler risk categorization and the HAv-adjusted risk model had the same sensitivity (84.6%) and specificity (85.2%) for diagnosing acute cholecystitis, but the HAv-adjusted risk model showed higher AUC (91.3%, p 0.03) due to increased ability to exclude acute cholecystitis. Conclusions The diagnostic performance of HAv for acute cholecystitis was lower than other assessments. A categorization scheme based on summed points assigned to each non-Doppler observation was improved with HAv assessment. This risk categorization approach using formulaic integration of non-Doppler and Doppler assessments on ED patients allows radiologists to convey one of five levels of disease probability based solely on sonographic features ranging from effectively excluding acute cholecystitis to substantially elevating the chance the patient has the condition.

Ultrasound (US) is the imaging modality of choice for evaluation of superficial palpable lesions. A large proportion of these lesions have characteristic sonographic appearance and can be confidently diagnosed with US without the need for biopsy or other intervention. The Society of Radiologists in Ultrasound (SRU) recently published a Consensus Conference Statement on superficial soft tissue masses. The goal of this manuscript is (a) to serve as a sonographic pictorial review for palpable lesions based on the SRU statement, (b) present the typical sonographic features of palpable lesions that can be confidently diagnosed with US, and (c) provide an overview of other palpable lesions with a framework to interpret the US studies and advise on appropriate further management.

Purpose: To determine whether a 24 MHz transducer significantly improves sensitivity, specificity and accuracy in evaluating flexor tendon repair integrity compared with an 18 MHz transducer.Methods: One hundred and twelve cadaveric digits were randomised to an intact repair or simulated ‘failed’ repair, and to a two‐ or eight‐strand repair of a flexor digitorum profundus laceration. A blinded sonologist evaluated specimens in static mode using 18 and 24 MHz transducers. Gaps were remeasured after scanning, and final gap width recorded. McNemar's exact test calculated differences between sensitivity, specificity and accuracy, and chi‐squared test to compare sensitivity, specificity and accuracy between number of strands (2 vs. 8) and repair gap (≥4 mm).Results: The 24 MHz transducer had higher sensitivity (81 vs. 59%), lower specificity (67 vs. 70%) and higher overall accuracy (74 vs. 64%), than the 18 MHz transducer. The difference for sensitivity was significant (P = 0.011), but not differences for specificity and overall accuracy (P > 0.05). Pearson's correlation (r = 0.61) demonstrated a moderate‐to‐strong positive correlation between measured and true gap sizes. Increased number of suture strands (2 vs. 8) did not impair sensitivity, specificity nor accuracy.Discussion: Ultrasound may tend to overestimate gap width, and a slight risk that some intact repairs, or those with small, clinically insignificant gaps may undergo surgical exploration that may not be indicated.Conclusions: A 24 MHz transducer is a more sensitive and accurate transducer for assessing flexor tendon repair integrity and measuring small gaps.

Identifying, understanding, and correcting artifacts on contrast-enhanced US images, whether they are related to typical US artifacts or unique to contrast-enhanced imaging, can improve study quali... Contrast-enhanced US (CEUS), similar to other radiologic modalities, requires specific technical considerations and is subject to image artifacts. These artifacts may affect examination quality, ne...

Chronic venous insufficiency is a common condition caused by valvular incompetence and/or obstruction of the lower extremity venous system. Chronic venous insufficiency presents in a wide range of clinical presentations, ranging from mild pain or edema to the development of varicose veins and nonhealing venous ulcers. Doppler ultrasound is the preferred imaging modality in the assessment of this condition and provides both anatomical and functional information in a noninvasive, cost-effective, and radiation-free manner. Knowledge of the anatomy and nomenclature, pathophysiology, equipment requisites, scanning protocols, relevant findings, and reporting nuances is essential to the creation of an accurate and clinically actionable report. Evaluation of the superficial and deep venous system for degree and extent of reflux is necessary to establish the diagnosis and to institute appropriate treatment.

The Society of Radiologists in Ultrasound, or SRU, consensus conference provides management recommendations for extremely low risk, low risk, and indeterminate risk gallbladder polyps incidentally ... Gallbladder polyps (also known as polypoid lesions of the gallbladder) are a common incidental finding. The vast majority of gallbladder polyps smaller than 10 mm are not true neoplastic polyps but...