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Clinical Application of Ultrasound Tomography in Diagnosis of Musculoskeletal Diseases
Cong Wei, MD, Hui Zhang, PhD, Tao Ying, MD, Bing Hu, MD, Yini Chen, MD, Hongtao Li, MD, Qiude Zhang, PhD, Mingyue Ding, PhD, Jie Chen, MD, Ming Yuchi, PhD, Yuanyi Zheng, MD
Advanced Ultrasound in Diagnosis and Therapy    2024, 8 (1): 7-14.   DOI: 10.37015/AUDT.2024.230060
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Objective To evaluate the feasibility and capability of UT in detecting musculoskeletal system lesions in the limbs and to explore its image quality.

Materials and Methods The Institutional Review Board has approved this prospective single-center study. This study included participants with various musculoskeletal and neurologic disorders in the limbs who provided written consent from October 2022 to April 2023. In addition to other radiological examinations (X-rays, CT, or MRI) and conventional handheld ultrasound scans requested by clinicians based on the conditions, each participant also underwent UT scanning using our developed limb ultrasound imaging system during the same period. Four radiologists and ultrasound physicians with more than five years of experience in musculoskeletal diagnostics analyzed the two-dimensional and three-dimensional images of the examination area.

Results Overall, 50 participants were evaluated (mean age, 36 years ± 18 [SD]; 26 males). The conditions included musculoskeletal tumors (n = 10), postoperative follow-up of musculoskeletal tumors (n = 20), peripheral nerve disorders in the limbs (n = 10) and postoperative pain in orthopedic surgery (n = 10). In all UT images, the region of interest was completely displayed, and internal structures such as muscles and nerves were clearly visible. Compared to conventional ultrasound images, the reconstructed three-dimensional images intuitively displayed the relationship between the lesions and surrounding tissues. Furthermore, UT did not exhibit metal artifacts when observing soft tissues around metallic implants, providing more comprehensive soft tissue information and more intuitive stereoscopic images.

Conclusion Clinical results of the UT system have demonstrated its feasibility as an automated and standardized imaging technique for musculoskeletal imaging, providing a new imaging modality for the diagnosis of musculoskeletal diseases in the human body.

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Diagnostic Utility of Superb Microvascular Imaging of ultrasound Examinations to Evaluate Hepatic Ischemia-reperfusion Injury
Guoying Zhang, MD, Ying Tang, BS, Mingyang Wang, MD, Weina Kong, MD
Advanced Ultrasound in Diagnosis and Therapy    2024, 8 (1): 15-21.   DOI: 10.37015/AUDT.2024.230010
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Objective To investigate the effectiveness of SMI in evaluating hepatic IRI and detecting its therapy response.

Methods Thirty rats were randomly divided into sham (n = 12), IRI (n = 12), and andrographolide pretreatment (n = 6) groups. SMI, pathological, and biochemical examinations were conducted for the sham and IRI groups at 4 (n = 6) and 24 h (n = 6) after reperfusion, respectively. Two ultrasonologists measured the vascular index (VI). The interobserver agreement was evaluated using the intraclass correlation coefficient (ICC). The rat liver parameters, including Suzuki's score, alanine aminotransferase (ALT), and aspartate aminotransferase (AST), were obtained at different time steps in each group. For the andrographolide pretreatment group, data were obtained at 24 h after reperfusion to further verify the advantage of VI. Parameters were analyzed for correlations and compared between each group at 4 and 24 h.

Results The ICC between two ultrasonologists who measured the VI was 0.912 (95%CI: 0.889-0.940). Suzuki's score and VI were negatively correlated (r = -0.504, P = 0.012). Compared with the sham group, the IRI group showed a significant decrease in the VI at 4 and 24 h after reperfusion [(24.78 ± 3.23) versus (20.22 ± 2.55); (22.67 ± 1.36) versus (19.27 ± 2.23), P < 0.05)]. The VI in the andrographolide pretreatment group was higher than that in the IRI group [(21.90 ± 1.47) versus (19.27 ± 2.23), P <0.05].

Conclusions The VI on SMI can be used as a noninvasive and sensitive index to evaluate hepatic IRI and detect its therapeutic response.

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Identification of Differently Expressed miRNAs and Genes between Benign Prostatic Hyperplasia and Prostate Cancer
Yuqing Huang, MD, Cui Lei, BS, Xinyu Zhao, PhD, Jing Xiao, PhD, Xian-Quan Shi, PhD
Advanced Ultrasound in Diagnosis and Therapy    2024, 8 (1): 22-28.   DOI: 10.37015/AUDT.2024.230044
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Objective MicroRNAs (miRNAs) play important roles in various diseases’ development and progression. The aim of this study is to identify the differently expressed miRNAs (DEmiRNAs) and differently expressed genes (DEGs) between BPH and PCa.

Methods Selecting BPH and PCa tissues from GEO database (GSE118038 as test dataset; GSE30994 as validation dataset), we identified DEmiRNAs and DEGs between BPH and PCa using GEO2R online tool and “Deseq2” R package. We applied random forest method to select hub DEmiRNAs, combining age and BMI, to establish a nomogram model for BPH detection. Finally, GO and KEGG enrichment analyses were conducted to explore the underlying mechanisms and pathways of DEmiRNAs in BPH.

Results We found 26 DEmiRNAs between BPH and PCa, of which 21 DEmiRNAs were up-regulated and 5 DEmiRNAs were down-regulated. Via forest random method, we selected miR-636, miR-324-3p, miR-210-3p and miR-3615 as hub DEmiRNAs in BPH. Combing these four hub DEmiRNAs, age and BMI, we established a nomogram model to distinguish BPH from PCa. Through “miRWalk” online tool, we targeted 499 hub DEGs between BPH and PCa, and found most of genes enriched in muscle system process, muscle contraction, contractile fiber, myofibril, actin binding, passive transmembrane transporter activity, focal adhesion, axon guidance.

Conclusion Our results suggested that miR-636, miR-324-3p, miR-210-3p and miR-3615 might the hub DEmiRNAs between BPH and PCa, which may play a crucial role to distinguish BPH from PCa.

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A Non-Invasive Follicular Thyroid Cancer Risk Prediction System Based on Deep Hybrid Multi-feature Fusion Network
Yalin Wu, PhD, Qiaoli Ge, MM, Linyang Yan, PhD, Desheng Sun, MD
Advanced Ultrasound in Diagnosis and Therapy    2023, 7 (4): 373-380.   DOI: 10.37015/AUDT.2023.230023
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Objective A non-invasive assessment of the risk of benign and malignant follicular thyroid cancer is invaluable in the choice of treatment options. The extraction and fusion of multidimensional features from ultrasound images of follicular thyroid cancer is decisive in improving the accuracy of identifying benign and malignant thyroid cancer. This paper presents a non-invasive preoperative benign and malignant risk assessment system for follicular thyroid cancer, based on the proposed deep feature extraction and fusion of ultrasound images of follicular thyroid cancer.

Methods First, this study uses a convolution neural network (CNN) to obtain a global feature map of the image, and the fusion of global features cropped to local features to identify tumor images. Secondly, this tumour image is also extracted by googleNet and ResNet respectively to extract features and recognize the image. Finally, we employ an averaging algorithm to obtain the final recognition results.

Results The experimental results show that the method proposed in this study achieved 89.95% accuracy, 88.46% sensitivity, 91.30% specificity and an AUC value of 96.69% in the local dataset obtained from Peking University Shenzhen Hospital, all of which are far superior to other models.

Conclusion In this study, a non-invasive risk prediction system is proposed for ultrasound images of thyroid follicular tumours. We solve the problem of unbalanced sample distribution by means of an image enhancement algorithm. In order to obtain enough features to differentiate ultrasound images, a three-branched feature extraction network was designed in this study, and a balance of sensitivity and specificity is ensured by an averaging algorithm.

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Ultrasonographic Identification of Muscle Atrophy in Hamstring Muscles after Anterior Cruciate Ligament Repair among Soccer Players: A Case-control Study
Sebastián Eustaquio Martín Pérez, MSc, Raúl Hernández García, PT, Alberto Brito Lorenzo, PT, Carlos Daniel Sabater Cruz, PT, Mario Herrera Pérez, PhD, Fidel Rodríguez Hernández, PhD, Kristin Briem, PhD, Isidro Miguel Martín Pérez, MD
Advanced Ultrasound in Diagnosis and Therapy    2023, 7 (4): 381-389.   DOI: 10.37015/AUDT.2023.230036
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Objectives To measure the CSA of the HST musculature measured with ultrasonography in soccer players undergoing ACLR and compare limb differences with healthy controls.

Methods A case-control study was performed with patients after anterior cruciate ligament repair (ACLR) and healthy controls in which cross-sectional areas (CSA) obtained using a model TE7 ultrasound machine (MINDRAY ®, USA) in B mode (4.2 to 13 MHz) with a multifrequency linear array transducer (L12-4S). Three CSA images were taken of the semitendinosus muscle (ST) and the long head of the biceps femoris (BFlh), at a distance of 30% and 70% of the ischial tuberosity insertion. Mean differences between groups were analyzed using SPSS v.20 (IBM®, USA), and statistical analyses were performed using non-parametric techniques to determine differences between groups (Student's t-test) and Cohen's correlation coefficient to quantify effect size.

Results 14 ACLR operated 17 ± 5.4 months ago and 12 healthy controls (W = 6; M = 20M; 24.5 ± 3.92 years; BMI = 25.1 ± 2.32 kg/m2) were recruited. There were differences between groups in CSA-ST70 (Post-ACLR = 1.43 ± 1.029 cm2 vs Control 2.65 ± 0.664 cm2, T Student = -3.68, 95% CI [-Inf, -0.648], P < 0. 001, ES = -1.418), but not in CSA-ST30 (Post-ACLR = 8.42 ± 1.596 cm2 vs Control 9.16 ± 0.945 cm2, T Student = -1.535; 95% CI [-Inf, -0.0793], P = 0. 068, ES = -0.5607), CSA-BFlh30 (Post-ACLR = 8.79 ± 1.47 cm2 vs Control 8.87 ± 2.312 cm2, T Student = -0.123; 95% CI [-Inf, 1.1049], P = 0.452, ES = -0. 049) or CSA-BFlh70 (Post-ACLR = 6.91 ± 1.011 cm2 vs Control 7.01 ± 1.453 cm2, T Student = -0.214; 95% CI [-Inf, 0.6795], P = 0.416, ES = -0.0783).

Conclusion Ultrasound measurement of the CSA can be an image marker to identify muscle weakness or atrophy that predicts functional loss early.

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Evaluation of the Effect of Age on Median Nerve Cross-sectional Area: A Cross-sectional Study
Seyed Mansoor Rayegani, MD, Masume Bayat, MD
Advanced Ultrasound in Diagnosis and Therapy    2023, 7 (4): 390-393.   DOI: 10.37015/AUDT.2023.220047
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Objective This cross-sectional study was designed considering disagreements on the normal range of Median Nerve Cross-Sectional Area (MNCSA) and its association with age.

Methods In this cross-sectional descriptive study, the upper limbs of 98 healthy subjects (46 men and 52 women) were assessed bilaterally by sonography, and MNCSA was measured at the distal wrist crease.

Results Mean MNCSA values for subjects older and younger than 40 were 11.25 mm2 and 10.21 mm2, respectively. The results showed that the MNCSA significantly increased after 40 years of age.

Conclusion According to the present study's findings, advances in age can increase the MNCSA and affect the diagnostic accuracy of MNCSA measurement in CTS diagnosis.

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The Value of VTTQ Combined with B-mode US for Distinguishing Benign from Malignant Breast Masses by Comparing with SE: A Clinical Research
Lujing Li, MD, Zuofeng Xu, MD
Advanced Ultrasound in Diagnosis and Therapy    2023, 7 (4): 394-400.   DOI: 10.37015/AUDT.2023.220041
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Objective The purpose of this study was to compare the diagnostic performance of virtual touch tissue quantification (VTTQ) combined with B-mode ultrasonograpgy (US), strain elastography (SE) combined with B-mode US and B-mode US alone in differentiating the properties of breast lesions.

Methods A retrospective database was queried for 283 healthy subjects and 100 consecutive patients with 130 breast lesions. All the cases were examined by B-mode US, VTTQ and SE. Histological diagnosis was used as the reference standard. The area under the receiver operating curve (AUC) values of each data set was compared.

Results Twenty-two lesions were determined as malignant and 108 as benign. The best cutoff point of VTTQ was 7.82 m/s. The AUC of B-mode US combined with VTTQ or SE was greater than that of B-mode US alone (0.913 or 0.918 vs. 0.797) (P = 0.007 and 0.012).

Conclusion Both VTTQ and SE could give help to B-mode US in distinguishing benign from malignant breast lesions about elastography values. There was no difference between them.

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Point of Care Ultrasound Training in Military Medical Student Curriculum
Bradley Havins, MD, Michael Nguyen, MS, Ryan Becker, MS, Chusila Lee, MS, Siri Magadi, MS, Choi Heesun, DO
Advanced Ultrasound in Diagnosis and Therapy    2023, 7 (4): 401-404.   DOI: 10.37015/AUDT.2023.230003
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Objective VaveHealth is a company that developed an app-based POCUS (Point of Care Ultrasound) education platform. Our objective is to provide educators with insights into novel approaches to medical education by comparing the platform to PowerPoint-based education, the standard and current technique used to instruct medical students in the United States.

Methods We used a non-inferiority study to assess if the app-based platform was not less efficacious than the current standard of PowerPoint-based education. Thirty-three military medical students were provided with app-based or PowerPoint-based education for instructions on performing a focused assessment with sonography for trauma (FAST exam). Physicians evaluated each image and assigned a score from 1-5. The final scores were the average of all views. In addition, a two-sample t-test of the final scores and each view of the FAST was used to measure whether the VaveHealth platform was non-inferior to a PowerPoint-based model.

Results Overall, the VaveHealth group had lower average scores on each view and a lower average total score. There was no statistically significant difference in overall scores (VaveHealth = 7.65, PowerPoint = 9.04, P = 0.07). Subgroup analysis showed no statistically significant difference in student performance in the views of the splenorenal recess (VaveHealth score = 1.60, PowerPoint score = 1.65, P = 0.42), hepatorenal recess (VaveHealth score = 2.45, PowerPoint score = 3.00, P = 0.11), and suprapubic (VaveHealth score = 2.10, PowerPoint score = 2.46, P = 0.23) regions. In the subxiphoid region, students in the VaveHealth had a statistically significantly lower average score (VaveHealth score = 1.70, PowerPoint score = 2.08, P = 0.04).

Conclusion VaveHealth education is not a viable alternative to traditional PowerPoint education for POCUS training based on the lower raw scores and statistically significantly lower scores on one of the views of the FAST exam.

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Ultrasound-Guided Attenuation Parameter May Replace B-mode Ultrasound in Diagnosing Nonalcoholic Fatty Liver Disease
Bo Jiang, MD, Yiman Du, MD, Xiang Fei, MD, Jianing Zhu, MD, Lianhua Zhu, MD, Qiuyang Li, MD, Yukun Luo, MD, PhD
Advanced Ultrasound in Diagnosis and Therapy    2023, 7 (3): 260-266.   DOI: 10.37015/AUDT.2023.220037
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Objective: To compare the diagnostic sensitivity and consistency of ultrasound-guided attenuation parameter (UGAP) with B-mode ultrasound in nonalcoholic fatty liver disease (NAFLD) patients, and explored their correlation with clinical indicators.
Methods: Patients suspected of NAFLD from July to November 2021 were enrolled in this prospective study. After performing the B-mode ultrasound and UGAP examination, all patients were divided into four groups according to the grade of NAFLD obtained by two modalities, respectively. The diagnostic agreement of the two modalities were evaluated, and the diagnostic sensitivity was compared by the McNemar test. The correlation between clinical indicators and the attenuation coefficient (AC) of UGAP was analyzed by linear regression.
Results: The intraclass correlation coefficient of UGAP was 0.958 (95%CI: 0.943,0.970), while the kappa value of B-mode ultrasound grading was 0.799 (95%CI: 0.686, 0.912). The diagnostic sensitivity of UGAP was higher than that of B-mode ultrasound (99.0% vs. 32%, P < 0.001). BMI and TG can be distinguished in different grades of NAFLD diagnosed by B-mode ultrasound, while BMI, ALT, HDL, and Apo A can be distinguished in different grades of NAFLD diagnosed by UGAP. BMI (r = 0.502, P < 0.001), ALT (r = 0. 396, P < 0.001), TG (r = 0.418, P < 0.001), HDL (r = -0. 359, P < 0.001) and Apo A (r = -0.228, P = 0.020) were linearly correlated with the AC value of UGAP.
Conclusions: Compared with the B-mode ultrasound, UGAP had a higher sensitivity and consistency in diagnosing NAFLD, and correlated well with some laboratory indicators, which may be more valuable in screening and diagnosis of NAFLD.

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Localization of Nonpalpable Breast Lumps by Ultrasound Local Coordinates and Skin Inking: A Randomized Controlled Trial
Leila Bayani, MD, Donya Goodarzi, BS, Reza Mardani, MD, Bita Eslami, PhD, Sadaf Alipour, MD
Advanced Ultrasound in Diagnosis and Therapy    2023, 7 (3): 267-271.   DOI: 10.37015/AUDT.2023.220033
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Background and Purpose: Surgery of ultrasound-detected non-palpable breast lesions should be guided by ultrasound. Commonly radiologists localize the lesion under ultrasound preoperatively, which necessitates the availability of a localization device and may involve a substantial cost. We performed a study to prospectively assess the feasibility of ultrasound-guided localization without any special device.
Methods: Women with non-palpable benign breast masses were assigned to the “guide wire insertion” (GWI) or the “local coordinates and skin inking” (LOCSI) groups. In both groups, the tumor was marked as a shadow on the skin by the radiologist under ultrasound. In the GWI group, a guidewire was inserted, and in the LOCSI group, the local coordinates of the lesion relative to the skin and the nipple as well as its clockwise placement were reported.
Results: Overall, 29 cases were included in the study, 11 in the GWI and 18 in the LOCSI groups. In all cases, the specimen was correctly excised. The weights of the resected specimens were significantly higher with GWI; LOCSI prevented excessive tissue extraction. Clinicians reported LOCSI as “very easy” more frequently, and surgery took less time.
Conclusions: Overall, our study showed that LOCSI was feasible and can be a suitable method in areas with limited resources. We propose similar studies with a larger sample size, inclusion of malignant cases for margin assessment, and estimation of the cost-effectiveness of the technique.

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Lung Nodule Classification in CT Images Using Improved DenseNet
Xiuping Men, PhD, Vladimir Y. Mariano, PhD, Aihua Duan, PhD, Xiaoyan Shi, PhD
Advanced Ultrasound in Diagnosis and Therapy    2023, 7 (3): 272-278.   DOI: 10.37015/AUDT.2022.220018
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Objective: Computed tomography (CT) imaging of the chest is an effective diagnostic tool assisting physicians in making a diagnosis. This study aimed to propose a new convolutional neural network for classifying the lung nodules of the patient through chest CT scan data to determine whether the patient has related disease genes.
Methods: We proposed a DenseNet-based neural network structure that uses multi-scale convolutional kernels to obtain features of different receptive fields, which are fed into a DenseNet containing four improved DenseBlocks, followed by a classification module to obtain the model output, i.e., whether a lung nodule contains a cancer gene. We conducted classification experiments on a CT scan dataset containing 465 training samples and 117 test samples.
Results: The results showed that DenseNet was better than ResNet in terms of classification, whereas ResNet was better than VGG, which was consistent with the findings of previous studies. However, because these models were more complex, they suffered from overfitting problems. Among all of the models used in this paper, our proposed network achieved the best results in terms of accuracy, F1 score, and sensitivity without an over fitting. The accuracy was 72.0%, sensitivity was 78%, and F1 score was 68%.
Conclusion: The proposed DenseNet neural network can improve and assist medical imaging diagnostic physicians in the initial diagnosis of lung nodules.

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Comparison of Sonographic Quantitative Assessment of Splenomegaly in Thalassemia Patients Receiving Whole Blood and Packed Red Cell Transfusions
Muhammad Arif Afridi, MS , Raham Bacha, PhD , Nadeem Ullah, BS , Syed Muhammad Yousaf Farooq, PhD , Malik Mairaj Khalid, BS , Imran Khan, BS , Ashfaq Ahmad, Mujahid Sher, PhD
Advanced Ultrasound in Diagnosis and Therapy    2023, 7 (3): 279-284.   DOI: 10.37015/AUDT.2023.220039
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Objective: An observational cross-sectional study to assess sonographic splenomegaly quantitatively in thalassemia patients grouped with respect to transfusion given whole blood vs packed red cells.
Methods: A study was conducted among 330 patients equally divided into two groups, undergoing an abdominal ultrasound examination with a transducer frequency ranging from 3-5 MHz during the period December 2021 to August 2022. An independent t-test was applied to compare the splenic volume in thalassemia patients given whole blood transfusions versus packed red cells transfusions, and Cohen's d was used to indicate the standardized difference between two ultrasound splenic volume means.
Results: The mean splenic volume of the patients who received whole blood cells was 320.62 ± 219.05 cm3, which is greater than the patients who received packed red cells, whose mean was 60.72 ± 58.72 cm3, The splenomegaly was quantitatively assessed in six age groups ranging from 1 to 3 years, 4 to 6 years, 7 to 9 years, 10 to 12 years, 13 to 15 years, and 16-18 years and mean splenic volume in each age group was compared to those receiving whole blood or packed red cells transfusion. there is a statistically significant difference between both transfusion receiving groups, having a larger Cohen’s d size effect of 1.62.
Conclusion: Ultrasound is a reliable imaging modality for assessing splenic volume and linear parameters of the spleen with greater splenomegaly in thalassemia patients with whole blood transfusions than those with packed red cells when quantitatively assessed according to relevant age groups. Thalassemia patients should be transfused packed red cells to delay splenomegaly, that should be assessed sonographically.

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Rapid Screening of Carotid Plaque in Cloud Handheld Ultrasound System Based on 5G and AI Technology
Wenjun Zhang, MD, Mi Zhou, PhD, Qingguo Meng, MD, Lin Zhang, MS, Xin Liu, MS, Paul Liu, PhD, Dong Liu, PhD
Advanced Ultrasound in Diagnosis and Therapy    2023, 7 (2): 152-157.   DOI: 10.37015/AUDT.2023.230018
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Objective: To evaluate the real-time accuracy of cloud handheld ultrasound system using AI technology in screening carotid plaque.

Methods: 2627 ultrasound images of the carotid artery are collected using the cloud handheld system. Bounding boxes of carotid plaques are labeled by qualified sonographers, and the dataset is trained using a lightweight YOLOv3 model. An additional and separate 390 images are collected and tested using the evaluation metrics average recall (AR), average precision (AP), and frames per second (FPS) for quantifying classification performance and time consumption.

Results: We use a plaque grading definition with a thickness of 1.2-1.5 mm defined as small plaque, 1.5-3 mm as medium plaque, and more than 3 mm thick as large plaque. Our model achieves APIoU=0.50 with 96.5%, with APlarge is 79.9%, APmedium is 90.7%, APsmall is 93.5%; ARIoU=0.50 is 64.5%, where ARlarge is 60.6%, ARmedium is 58.3%, ARsmall is 70.8%, and FPS is 33.3.

Conclusion: We establish a framework for data set construction, model selection, training, and testing of carotid ultrasound images and verify the effectiveness of real-time AI technology in the automatic detection of carotid artery plaque.

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Predicting Malignancy in Sonographic Features of Thyroid Nodules Using Convolutional Neural Networks ResNet50 Model
Jingfang Dong, MD, Jianyun Wang, MD, Xiangzhu Wang, MD
Advanced Ultrasound in Diagnosis and Therapy    2023, 7 (1): 16-22.   DOI: 10.37015/AUDT.2023.220023
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Objective To predict sonographic features of malignancy in thyroid nodules by using convolutional neural networks (CNNs) ResNet50 model.

Methods A cohort of 461 patients having sonographic thyroid nodules with histology diagnosis were randomly split into training set (70%), validation set (15%) and testing set (15%). Labeled sonographic patterns of thyroid nodules were used to train CNNs ResNet50 in training set, where algorithm pipelines were used to explicitly delineate structures of interest using segmentation algorithms to measure predefined characteristics of these structures as to be predictive and to use these features to train models that predict the malignancy in thyroid nodules. The prognostic accuracy of ResNet50 model was evaluated on validation set and compared with the individual sonographic specialists in testing set. Accuracy, sensitivity, specificity, and efficiency of ResNet50 model was measured using receiver operating characteristic (ROC) curve.

Results Measurements showed the evaluation indexes of ResNet50 model were as follows: accuracy: 94.39%, sensitivity: 92.45%, specificity: 96.30%, efficiency: 96.08%, F1 value: 94.23%, and AUC: 93.40%. The prognostic accuracy and other indexes of ResNet50 model was not subordinate compared to sonographic specialists (P < 0.05).

Conclusion These results highlight the emerging role of deep learning techniques including CNNs in precision medicine and suggest an expanding utility for computational analysis of sonographic images in the future practice. This study showed a computational approach can be used for learning sonographic features of thyroid nodules using ResNet50 model to combine the power of adaptive machine learning and algorithms with traditional sonographic assessment.

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Application of Ultrasound-guided Stellate Ganglion Block in Treatment of Allergic Rhinitis
Chunyao Liu, BS, Huiwen Li, MS, Yajiang Zhang, MS, Ji Liu, BS, Jingru Yang, MS, Wei Li, MS, Jin Gao, BS, Rong Wu, MD
Advanced Ultrasound in Diagnosis and Therapy    2023, 7 (1): 23-27.   DOI: 10.37015/AUDT.2023.220008
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Objectives To assess the clinical efficacy and safety of ultrasound-guided stellate ganglion block in the treatment of allergic rhinitis.

Methods Sixty patients with allergic rhinitis were selected as study subjects and were treated with stellate ganglion blocking. We observed the appearance and time of the patient's Horner syndrome, and compared the patient's clinical symptom scores before and after one month treatment, and calculated the clinical efficacy and overall effective rate.

Results After ultrasound-guided stellate ganglion blocking treatment, 97% of patients occurred Horner syndrome within 2 minutes. The scores of sneezing, runny nose, nasal itching, and nasal congestion significantly reduced at one month after treatment compared with those before treatment, in which there was statistically significant difference (P<0.05). The clinical efficacy rate also reached 96.7% after procedures. No serious complications occurred in this study.

Conclusions Ultrasound-guided stellate ganglion block can significantly improve the clinical symptoms and the life quality for patients with allergic rhinitis, and it is worthy of extensive clinical application.

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Using S-Detect to Improve Breast Ultrasound: The Different Combined Strategies Based on Radiologist Experience
Ying Zhu, MD, Xiaohong Jia, MD, Yijie Dong, MD, Juan Liu, MD, Yilai Chen, MD, Congcong Yuan, MD, Weiwei Zhan, MD, Jianqiao Zhou, MD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (4): 180-187.   DOI: 10.37015/AUDT.2022.220007
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Objective: To investigate the best combined method of S-Detect, a computer-aided diagnosis (CAD) system, with breast ultrasound (US) according to radiologists’ experience.

Methods: From March 2019 to June 2019, 259 breast masses in 255 women were included in this study. Ultrasonographic images of the target masses were prospectively analyzed by radiologists and CAD. Three combined methods, including method 1 [selective downgrading combination for Breast Imaging Reporting and Data System (BI-RADS) 4a lesions], method 2 (selective upgrading combination for BI-RADS 3 lesions) and method 3 (selective upgrading or downgrading combination for BI-RADS 3 or 4a lesions), were applied to interpret the CAD results. The sensitivity, specificity, the area under the receiver operating characteristic curve (AUC) of experienced or inexperienced radiologists before and after adding CAD results were compared using the histopathological results as a reference standard.

Results: In identifying breast malignancy, the AUC for CAD was similar to that of experienced radiologists (P= 0.410), but higher than that of inexperienced radiologists (P= 0.003). When combining CAD with experienced radiologists based on method 1 and combining CAD results with inexperienced radiologists based on method 3, the AUCs were significantly improved (P= 0.024 and 0.003, respectively) compared to US alone, with significantly increased specificity (P< 0.001 for both) and no significantly decreased sensitivity (P> 0.05 for both).

Conclusion: The combination of CAD system and conventional ultrasound can improve ultrasound diagnostic performance in determining breast malignancy. The method 1 and method 3 combinations are respectively recommended for experienced and inexperienced radiologists when CAD is combined with conventional breast ultrasound.

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Graphene Oxide/Polylactic Acid Microbubbles for Efficient Removal of Lead Ions from Aqueous Solution
Meng Han, MD, Ruirui Kang, MD, Juanjuan Chen, MD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (4): 188-194.   DOI: 10.37015/AUDT.2022.210030
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Objective: Heavy metal pollution has become one of the environmental contamination problems in today's world. Adsorption materials can effectively remove heavy metal ions from the water. There are some shortcomings for traditional adsorbents, such as difficult separation after adsorption, long separation time, and may cause secondary pollution in the environment without recycling. The aim of this study was to seek new materials with effective ways to absorb heavy metal ions in the water.

Methods: A new kind of adsorption material consisted of polylactic acid (PLA) microbubble and graphene oxide (GO) (i.e., PLA@GO microbubbles) was fabricated which can combine by electrostatic adsorption with the assistance of PAH. The influence of the initial concentration of heavy metal of lead ion, pH value, and absorption time on the adsorption effect of PLA@GO microbubbles was tested in this study.

Results: Graphene oxide modified on PLA microbubble has huge specific surface area and various functional groups, which can adsorb heavy metal ions in water. The resulting PLA@GO microbubble showed a homogeneous spherical structure with a size of 500-1.5 μm, which was suitable for its effective separation from water. The optimal dosage of PLA@GO microbubbles was 10 mg, the pH value of the solution was 5.0, and the adsorption time was 20 minutes which correlates to 75 mg/L of leadions.

Conclusion: The characteristics of the PLA@GO microbubbles showed a strong adsorption capacity, high adsorption efficiency, and a shorter balance time which provided an environment-friendly new material to remove heavy metal ions from water.

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Performance of Elastography, Color Doppler and B Mode Ultrasound to Differentiate Fibroadenomas from Phyllodes Tumors
Lynda Aoudia, Amal Kouchkar, Salah Eddine Bendib
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (4): 195-203.   DOI: 10.37015/AUDT.2022.220003
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Objective: To evaluate and compare the diagnostic performance of B-mode ultrasound (B-mode US), strain elastography (SE), color Doppler ultrasound (color Doppler US) and the combination of these modalities in differentiation between fibroadenomas and phyllodes tumors.

Methods: This retrospective study included 220 breast lesions, between January 2016 and January 2018. B-mode US, strain elastography, and color Doppler US were realized to evaluate each lesion. The results of three modalities were compared between the B-mode US and the combination of B-mode US, elastography, and color Doppler US: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating characteristic curve (AUC). The pathological findings were used as the reference standard.

Results: Among 220 breast masses, 189 of the lesions were fibroadenomas, 31 were phyllodes tumors. Addition of strain elastography and color Doppler US to B-mode US increased the specificity from 27.5% (95% confidence interval [CI]: 21.15%, 33.88%) to 95.24% (95% CI: 92.20%, 98.27%; P < 0.001); PPV from 16.46% (95% CI: 10.79%,22.14%) to 60.87% (95% CI: 40.92%, 80.82%; P < 0.001) and AUC from 0.584 (95% CI: 0.481, 0.687) to 0.886 (95% CI: 0.824, 0.948; P < 0.001).

Conclusion: The combination B-mode US, strain elastography and color Doppler US increase the diagnostic performance in distinguishing fibroadenomas from phyllodes tumors.

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Contrast-enhanced Ultrasound for Evaluation of Active Needle Tract Bleeding during Thermal Ablation of Liver Cancer
Huolin Ye, MD, Qiannan Huang, MD, Qingjing Zeng, MD, Xuqi He, MD, Erjiao Xu, MD, Yinglin Long, MD, Kai Li, MD, Rongqin Zheng, MD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (3): 104-111.   DOI: 10.37015/AUDT.2021.210019
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Objective: To investigate the accuracy of contrast-enhanced ultrasound (CEUS) in the diagnosis and localization of active needle-tract bleeding (ANTB) during thermal ablation for liver cancer.

Methods: Between June 2013 and December 2018, liver cancer patients with poor coagulation function or suspected needle-tract bleeding during ablation were enrolled in the study. Conventional US and CEUS were applied to detect ANTB and the bleeding sites, and sequentially abdominal paracentesis drainage (APD) was used as the gold standard for the diagnosis of ANTB. Thermal ablation guided by conventional US or CEUS was used to stop the bleeding.

Results: Among the 77 enrolled patients, 21 patients (27.3%, 21/77) had ANTB. In total, four (19.0%) and 21 (100%) cases of ANTB were diagnosed by colour Doppler US and CEUS, respectively. The sensitivity, specificity and accuracy of colour Doppler US for diagnosing ANTB were 19.0%, 100% and 77.6%, respectively. The sensitivity, specificity, and accuracy of CEUS for diagnosing ANTB were 100%, 100% and 100%, respectively. The sensitivity of CEUS to diagnose ANTB was significantly higher than that of colour Doppler US (P < 0.001). All cases of ANTB were arterial bleeding and were stopped by thermal ablation under the guidance of colour Doppler US or CEUS.

Conclusion: Compared to colour Doppler US, CEUS could detect ANTB with significantly higher sensitivity and accurately guide needle-tract ablation during thermal ablation of liver cancer.

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Role of Lung Ultrasound in Diagnosing and Differentiating Transient Tachypnea of Newborn and Respiratory Distress Syndrome in Preterm Neonates
Srinivasan S, MD, Neeti Aggarwal, MD, Sushma Makhaik, MD, Anupam Jhobta, MD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (3): 112-118.   DOI: 10.37015/AUDT.2022.210034
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Objective: Transient tachypnea of newborn (TTN) and respiratory distress syndrome (RDS) are the most common causes of respiratory distress among preterm neonates. The aim of this study was to evaluate the accuracy of lung ultrasonography (LUS) for diagnosing and differentiating TTN and RDS in preterm neonates.

Methods: This was a prospective single center study. From January 2020 to June 2021 a total of 114 preterm neonates who were admitted to neonatal intensive care unit (NICU) with symptoms of respiratory distress within 6 hours of birth were subjected to clinical examination, laboratory testing, chest x-ray (AP and lateral view’s) and LUS. Their clinical course was closely monitored. On the basis of final diagnosis made on day three of admission they were divided into two groups, 37 diagnosed with TTN and 61 with RDS. Patients diagnosed with other conditions including neonatal pneumonia, meconium aspiration syndrome etc. were excluded from analysis. LUS findings in RDS and TTN were analyzed and compared to each other.

Results: Pulmonary edema manifesting as alveolo-interstitial syndrome, double lung point and less commonly as white out lungs in absence of consolidation had a 100% sensitivity and specificity in diagnosing TTN. A combination of three signs of consolidation with air or fluid bronchograms, white out lungs and absent spared areas has a 100% sensitivity and specificity for diagnosing RDS. Double lung point was seen only in infants suffering from TTN while consolidation with air or fluid bronchograms was only seen in cases of RDS.

Conclusion: Lung ultrasound can accurately diagnose and reliably differentiate TTN and RDS in preterm neonates. Hence LUS can become an initial screening tool in NICU.

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Ultrasound and Color Doppler Flow Imaging of Paratesticular Leiomyoma
Nianyu Xue, MM, Yaya Chen, MD, Guoyao Wang, BS, Shengmin Zhang, BS
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (3): 119-121.   DOI: 10.37015/AUDT.2021.210022
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Objective: In this paper, we retrospectively analyzed the ultrasonographic features of paratesticular leiomyoma to help doctors correctly diagnose the disease before operation and guide surgical treatment.

Methods: From 2013 to 2020, 16 cases of paratesticular leiomyomas confirmed by pathology in our hospital were retrospectively analyzed. The retrospective analysis included the ultrasound and color Doppler flow imaging (CDFI) of paratesticular leiomyoma which were evaluated by two experienced radiologists based on the features of ultrasound images of lesions.

Results: All the 16 paratesticular leiomyoma presented as hypoechoic masses with a clear boundary and round shape. The echotexture of 6 large leiomyomas showed a typical vortex appearance. In the remaining 10 small leiomyomas, thin cord-like hyper-echogenic appearance was found. Color Doppler flow imaging showed that the blood flow signal within a large leiomyoma mass (n = 1) was significantly higher than that of surrounding testis while the blood flow signals of the smaller leiomyomas (n = 5) had significantly less flow signals compared with the testis. The remaining leiomyoma masses (n = 10) had similar flow signals to the testicular blood flow.

Conclusion: Sonography can be used to detect testicular tumors and to differentiate extratesticular from intratesticular masses. The ultrasound features of paratesticular leiomyoma included hypo- and hyperechoic mass, a round or typical vortex shape as well as various vascularity based on the size of the tumors.

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Follicular Thyroid Neoplasmon Conventional and Contrast-enhanced Ultrasound
Xuehong Diao, MD, Lin Chen, MD, Bo Yu, MS, Jiamei Jin, MS, Jia Zhan, MD, Yue Chen, BS
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (2): 48-57.   DOI: 10.37015/AUDT.2022.210026
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Objective: The aim of this study was to identify features of follicular thyroid neoplasm by conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS) based on morphological and pathological correlations and make diagnostic strategy for predicting malignancy.

Methods: Conventional US and CEUS were performed in 21 follicular thyroid cancers (FTCs) and 35 follicular adenomas (FAs) that were pathologically approved. Sonographic features were retrospectively reviewed, and diagnostic performance were analyzed using pathology as reference standard.

Results: The most useful character in diagnosis of FTC by conventional US was round shape (OR=6.6), followed by absent of halo sign (Odds ratio, OR = 4.79) and calcification (OR = 3.875). Among all CEUS morphological and blow flow findings, incomplete rim enhancement pattern (OR = 19.2) and the presence of perfusion defects (OR = 5.454) were the most effective features to discriminate between FTC and FA. Based on the five discriminatory parameters, a diagnostic criterion was established to assess the risk of FTC. The sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and accuracy for predicting malignancy were 81.0 %, 80 %, 70.8 %, 87.5 % and 80.4%, respectively.

Conclusions: CEUS provided additional sonographic features which is helpful for predicting potentially malignancy of follicular thyroid neoplasm.

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Ultrasonographic Features of Intrathyroidal Thymic Carcinoma: Review and Analysis of 10 Cases
Yanhai Wang, MD, Hua Yang, MD, Hanqing Liu, MD, Xiaoli Luo, MD, Luying Liu, BS, Pingting Zhou, BS
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (2): 58-63.   DOI: 10.37015/AUDT.2022.220013
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ObjectiveIntrathyroidal thymic carcinoma (ITTC) is a rare epithelial tumor of the thyroid gland. Since ITTC is rare, its imaging findings have not been well defined. In the present study, we studied the US appearance of ITTC by analyzing ten cases retrospectively.

Methods Patients were identified by searching the surgical pathology records at our hospital. There were three male and seven female patients ranging in age from 40 to 79 years. The ultrasound (US) features were evaluated, and the relevant clinical data were combined with the fine needle aspiration (FNA) results from previous publications.

Results The average length of the nodules was 48 mm. Of all ten nodules, half were located in the right lobe of the thyroid, and half were located in the left lobe, either immediately adjacent to the lower lobe or within the lower part of the thyroid lobe. All nodules manifested with a completely solid composition and heterogeneous hypoechoic echogenicity. Three nodules had striped hyperechogenicity within the nodule. All nodules had irregular margins. Seven had a horizontal shape, and three had a vertical shape. Four nodules manifested with mainly peripheral vascularity, two nodules showed mainly central vascularity, and three had mixed vascularity. The vascularity of one remaining nodule was unknown. Cervical lymph node metastasis was detected in two cases by US examination. According to previous literature, FNA cytology revealed atypical type of thyroid cancer, poorly differentiated carcinoma, or a high-grade malignant thyroid neoplasm without further definitive classification.

ConclusionA large cancer-like nodule located within the lower thyroid in middle-aged people, combined with an atypical type of thyroid cancer after FNA, indicated that ITTC should be considered.

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Etiologies and Adverse Outcomes of Fetuses with Short Femur Length Based on Proportion and Percentile Categorization
Jianan Li, BS, Hong Xu, MD, Mei Shen, BS, Shiyu Li, BS, Longxia Wang, MD, Yanping Lu, MD, Qiuyang Li, MD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (1): 7-13.   DOI: 10.37015/AUDT.2021.210015
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Objective: To compare the etiologies and adverse outcomes of pregnancies with short fetal femur length (FL) categorized based on relative proportion and percentile placement.
Methods: Fetuses (n = 254) with short FL measured by ultrasound were classified into four groups: severe and disproportionate short FL (group A); severe and proportionate short FL (group B); mild and disproportionate short FL (group C); mild and proportionate short FL (group D). Etiologies and outcomes of pregnancies were compared between groups.
Results: A larger percentage of skeletal dysplasia occurred in group A (28.57%) than in the other three groups (group B: 1.85%; group C: 4.08%; group D: 0). Groups A and B also had higher rates (group A: 40.82%, group B:33.33%) of fetal growth restriction (FGR) than groups C and D (group C: 4.08%; group D:3.92%). No difference in chromosomal and genetic anomalies was detected among groups (P = 0.307); however, the rate of chromosomal and genetic testing in group A was higher than in group D (P = 0.001). Group A (57.14%) had a significantly lower rate of live birth than the other three groups, and group D (98.04%) had a higher live birth rate than groups B (87.04%) and C (83.67%). Considering only living fetuses, higher rates of preterm birth (P < 0.001), low birth weight (LBW) (P < 0.001), neonatal intensive care unit (NICU) admission or pediatric hospital referral (P = 0.004), Apgar score (1 min/5 min) ≤7 (P < 0.001) and fetal distress or neonatal asphyxia (P = 0.004) were found in group A compared to group D.
Conclusion: Fetuses with severe and disproportionate short FL should be flagged for possible skeletal dysplasia. Fetuses with severe short FL should be watched for FGR prenatally. Invasive prenatal tests are recommended for fetuses with severe and disproportionate FL but not recommended for those with mild and proportionate short FL. Outcomes of fetuses with severe and disproportionate short FL were worse than that of fetuses with mild and proportionate short FL.

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Shear Wave Dispersion Imaging for Measuring Carotid Elasticity and Viscosity
Zhaojun Li, MD, PhD, Cuiqin Shen, MS, Qingqing Chen, MB, Lei Sha, MB, Xianghong Luo, MD, PhD, Lianfang Du, MD, PhD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (1): 14-21.   DOI: 10.37015/AUDT.2021.200071
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Objective: To assess the viscoelasticity of the carotid artery using shear wave dispersion Imaging and to determine the relevant factors.
Methods: Ninety volunteers were recruited and divided into elder group and young group. Shear wave dispersion (SWD) imaging was applied to measure carotid viscoelasticity. The other arterial parameters, including arterial pulse wave velocity (PWV), inner diameter (CD), intima-medium thickness (CIMT), peak systolic velocity (PSV), mean flow velocity (MFV), and velocity time integral (VTI) of the common carotid artery (CCA) were also recorded by using ultrasound measurement.
Results: Measurements showed the SWD were lower, while CD, CIMT and PWV were higher in the elder group than those of young group. However, SWD was negatively correlated with VTI, and PSV respectively (r = -0.492 and -0.533, all P < 0.05). SWD was also positively correlated with MFV (r = 0.354, P < 0.05). In elder group, SWD was negatively correlated with PSV and PWV, respectively (r = -0.372 and -0.422, all P < 0.05) while in young group, SWD positively correlated with CD, CIMT and MFV (r = 0.531, 0.462 and 0.479 respectively, and all P < 0.05).
Conclusion: SWD imaging shown relationship with ultrasound parameters of carotid artery and has a potential for assessment of arterial viscoelasticity.

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Comparison of Diagnostic Efficacy of US, CT, and MRI for Pancreatic Intraductal Papillary Mucinous Neoplasms
Yue Yu, MM, Ling Zhang, MM, Bangwei Zeng, MM, Zhikui Chen, PhD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (4): 291-297.   DOI: 10.37015/AUDT.2021.210008
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Objective: Imaging modalities for pancreatic intraductal papillary mucinous neoplasm (IPMN) often provide a large amount of information, and an adequate comparison of their diagnostic efficacies cannot be made by simply referring to the diagnostic accuracy rates. The aim of the study was to apply a novel scoring system to evaluate the pancreatic IPMN diagnostic efficacy of transabdominal ultrasound (TAUS), computed tomography (CT), and magnetic resonance imaging (MRI).

Methods: The clinical and diagnostic imaging data of 42 patients with pancreatic IPMN diagnosed at Fujian Medical University Union Hospital between January 2014 and November 2020 were retrospectively analyzed. We applied our scoring system for the quantitative, location, and qualitative diagnosis of each imaging modality, and the diagnostic efficacy was determined.

Results: The mean rank scores of quantitative diagnosis for MRI, CT, and TAUS were 53, 48.96, and 48.54, respectively (P = 0.267). The mean rank scores of location diagnosis for these three methods were 51.72, 49.58, and 48.97, respectively (P = 0.752). The mean rank scores of qualitative diagnosis for MRI, CT, and TAUS were 59.69, 41.08, and 51.18, respectively; the difference was statistically significant (P = 0.015).

Conclusions: The novel scoring system could comprehensively and accurately evaluate the diagnostic efficacy of TAUS, CT, and MRI for pancreatic IPMN. MRI had the highest quantitative, localization, qualitative, and comprehensive diagnostic efficacy.

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Quantitative Evaluation of Cirrhosis by Geometrical Characteristics of Hepatic Capsule Based on High-frequency Ultrasound Imaging: an Experimental Study
Jialin Song, MS, Xiang Liu, MD, Jianquan Zhang, MD, Jiaqi Zhao, MD, Lulu Zhao, MS
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (4): 298-303.   DOI: 10.37015/AUDT.2021.200073
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Objective: To explore the feasibility of quantitative evaluation of cirrhosis by geometrical characteristics of hepatic capsule based on high-frequency ultrasound imaging.

Methods: Rabbits with models of cirrhosis were established and then were divided into four groups: control, 6-week, 12-week and 18-week groups. Two-dimensional high-frequency ultrasound images of hepatic capsule of all rabbits were collected to obtain hepatic capsual contours and key points refltected shapes of these contours (shape control points) which were approximated by the principle of vertical gradient maximization under the manual supervision. Subsequently, the number of continuous segments of the contour line, the mean value and variance of angles between adjacent seed points were extracted to evaluate the continuity and smoothness of the contour line of the hepatic capsule.

Results: With aggravating cirrhosis, the number of segments required to make the sum of lengths of continuous segments reach up to 80% of the total width of the imaging section was gradually increased. The differences between the control group and 18-week group (P = 0.025) as well as between 6-week group and 18-week group (P = 0.004) were statistically significant. Similarly, the mean value and variance of the angles were also gradually increased, and the differences between the control group and the 6-week (P = 0.015, P = 0.036), 12-week (P < 0.001, P = 0.002) and 18-week groups (P = 0.023, P < 0.001) were statistically significant. In addition, the difference in variance of angles between the 6-week group and 18-week group (P = 0.030) was statistically significant.

Conclusion: Sonographic analysis of geometrical characteristics of the hepatic capsule could be used to partially indicate the presence of early-stage cirrhosis, which could provide a quantitative method for non-invasive assessment of cirrhosis.

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Evaluation of Features of Adrenal Adenomas and Nonadenomas Using Dynamic Contrast-Enhanced CT Biomarkers
Xifu Wang, MD, Xizhong Dong, BS, Tingting Huang, MS, Jie Meng, BS, Yuanxun Kuang, MS, Jiwen Kang, BS, Renju Bai, MD, Zhaojun Li, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (4): 304-312.   DOI: 10.37015/AUDT.2021.210020
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Objective: To investigate the correlation between the DCE-CT imaging biomarkers and histological biomarkers of tumor angiogenesis in adrenal adenomas and non-adenomas for the enhancement mechanism of DCE-CT.

Methods: Forty-two patients with 45 adrenal masses including 27 adenomas and 18 non-adenomas diagnosed pathologically were enrolled in this study. The features of DCE-CT (imaging biomarkers) and tumor angiogenesis (histological biomarkers) in adrenal masses were evaluated, and their correlations were explored.

Results: The enhanced features of DCE-CT in adrenal masses were classified: rapid washout group and slow washout group. Type A and C of time density (TD) curves, relative washout rate (Washr) ≥34%, and absolute washout rate (Washa) ≥43% belonged to the rapid group. In contrast, type B, D and E, Washr <34%, and Washa <43% belonged to the slow group. There was significant difference between the biomarkers of DCE-CT in adrenal masses. The rapid group was mainly found in adenomas, whereas the slow was mainly present in nonadenomas. The tumor angiogenesis, histological biomarkers, including microvessel density (MVD), vascular endothelial growth factor (VEGF), and microvascular ultrastructures demonstrated significant difference between the rapid and the slow washout group revealed by DCE-CT. The MVD and VEGF expression in rapid group were remarkably higher than those in slow group. Meanwhile, the tumor angiogenesis was also significantly different between adenomas and nonadenomas. The MVD and VEGF expression were also significantly higher in adenomas than those in nonadenomas. Furthermore, different microvascular ultrastructures were identified between adenomas and nonadenomas, which were in accordance with those between the rapid and the slow group. Microvascular ultrastructures in adrenal adenomas and/or the rapid group showed regular lumens and nonstenosis; more pinocytotic vesicles and fenestrations of endothelium; widening of the intercellular space; uniform thinning and better integrity of basal membrane; regular and uniform thinning, along with less stroma of extra vessel space. In comparison, opposite microvascular ultrastructures, in adrenal nonadenomas and/or the slow group.

Conclusion: The close correlation of DCE-CT imaging biomarkers and histological biomarkers of tumor angiogenesis was found between adrenal adenomas and nonadenomas. Tumor angiogenesis in adrenal adenomas and nonadenomas were shown the different enhancement characteristics at DCE-CT.

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A New-Designed Microwave Ablation System: Testing in ex vivo and in vivo Liver Model
Danni He, MS, Qiao Ji, MD, Huitong Lin, MD, Xuankun Liang, MM, Lujing Li, MM, Fengping Liang, MM, Xianxiang Wang, MM, Kun Yuan, MS, Zuofeng Xu, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (1): 39-46.   DOI: 10.37015/AUDT.2021.200014
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Objective: The present study aimed to determine the efficacy and safety of a newly designed microwave ablation (MWA) system in ex vivo and in vivo liver model.
Methods: A new MWA system (HRMW-01, Hengrui Medical, Guangzhou, China) was tested on porcine liver ex vivo with different parameter settings (50-70 W for 5-20 min). Ablation volums were measured on the gross specimens. In an in vivo study, MWA was performed at 60 W for 5 min in canine liver. Ablation volumes were identified and measured using contrast-enhanced ultrasound (CEUS) 1 w after the ablation. All animals underwent routine hematological, biochemical, and coagulation tests before ablation at 1 d and 1 w after ablation. For comparison, radiofrequency ablation (RFA) was performed using a Cool-tip system (Valleylab, Boulder, CO, USA) with an automated power setting for 12 min in both ex vivo and in vivo studies.
Results: In ex vivo studies, the mean volumes of MWA coagulation ranged from 27.8 ± 7.3 cm3 to 144.6 ± 35.9 cm 3 and increased with ablation duration and power output. MWA was prone to creating larger volume but less spherical ablation shape than RFA (P < 0.05). In in vivo studies, MWA created larger ablation volumes with shorter ablation time compared to RFA (P < 0.05). Laboratory data showed significantly higher alanine aminotransferase and aspartate aminotransferase levels 1 d after ablation than based line levels (P < 0.05) while the levels decreased close to pre-ablation levels 1 w after ablation (P > 0.05).
Conclusion: The newly designed MWA system is safe and more efficient than a commonly used RFA system. However, further clinical studies are warranted.

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Evaluating the Curative Effect of Ultrasound-guided Sclerotherapy with Foam Lauromacrogol for Uterine Fibroids
Juan Gao, MS, Yanggui Xie, MS, Bo Liang, MD, Xiaoqin Qian, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (1): 32-38.   DOI: 10.37015/AUDT.2021.190030
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Objective: To evaluate the curative effect of lauromacrogol foam sclerotherapy of uterine fibroids via transvaginal ultrasound-guided injection.
Methods: Thirty premenopausal women with a total of thirty-one uterine fibroids were recruited consecutively and underwent transvaginal 3D-Power Doppler Angiography (PDA) at 0, 1, 3, and 6 months. Written informed consent was obtained from all of the patients. The changes in the fibroid 3D volume and relationships between the fibroid location and blood supply were analyzed. The relief of clinical symptoms and improvement in health-related quality of life (HRQL) were evaluated using the uterine fibroid symptom and quality-of-life (UFS-QOL) questionnaire before and after treatment for 6 months; adverse events were also assessed.
Results: The mean baseline volumes ± SD were 61.2 ± 71.5 cm3 (range, 4.1 cm3 - 340.4 cm3) for the dominant fibroid. The mean values of percentage reduction in fibroid volume at 1, 3 and 6 months were 23.9% (range, 5.2% - 42.1%; 95%CI, 20.6% - 27.3%), 43.4% (range, 21.8% - 67.4%; 95%CI, 39.0% - 47.8%), and 60.0% (range, 31.8% - 83.2%; 95%CI, 55.2% - 64.9%), respectively, and the reduction was correlated with the location and blood supply. Additionally, the blood flow to the fibroids was markedly decreased. The clinical symptoms were greatly alleviated or even completely resolved, and the HRQL was notably improved (P < 0.001). Mild abdominal pain, paleness, vomiting, and cold sweat were most commonly reported adverse effects.
Conclusion: Ultrasound-guided sclerotherapy of uterine fibroids with foam lauromacrogol is a simple, safe and useful method with a wide application prospect.

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Comparative Features of Carotid and Cerebral Hemodynamics between Adult Rhesus Macaques and Humans
Yumei Liu, MD, PhD, Yang Hua, MD, Jingzhi Li, MD, PhD, Yunlu Tao, MD, Di Wu, MD, PhD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (1): 26-31.   DOI: 10.37015/AUDT.2021.200027
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Objective: Although rhesus macaques and human beings share many fundamental biological characteristics, including underlying genes and physiological processes, the similarity and difference of cerebrovascular hemodynamic have not been well investigated. We aimed to examine and compare the intracranial and extracranial hemodynamics between these two species.
Methods: A total of 10 adult male rhesus and 20 age-matched healthy men were recruited in this study. The somatometric measurements (BMI, HR, and BP) and ultrasonography examinations (carotid arteries and middle cerebral artery) were performed on both groups.
Results: We found a few similarities in somatometric measurements (BMI, waist-hip ratio and mean artery pressure), mean velocity ratios of internal carotid artery (ICA)/external carotid artery (ECA) and ICA/vertebral artery (VA), and the resistance index both in ICA and ECA between rhesus macaques and humans. However, faster HR (103 ± 12 vs. 73 ± 14 beat/min, P < 0.01), higher pulse pressure (89.5 ± 8.9 vs. 48.1 ± 6.3 mmHg, P < 0.01), smaller diameter ratio of bilateral ICA/ECAdia (P < 0.01), elevated middle cerebral artery pulsatility index (P < 0.01) and higher cerebrovascular resistance (2.42 ± 0.59 vs. 1.54 ± 0.35, P < 0.01) were found in rhesus when compared with humans.
Conclusions: This study leads to a better understanding of cerebral neuroanatomy in rhesus macaques, and it has several important implications for future cerebrovascular translational researches.

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Liver and Spleen Stiffness Measurements by Sound Touch Elastography and Sound Touch Quantification
Jian Zheng, MD, Manli Wu, MD, Qingjuan Wang, MD, Rizhen Gu, MD, Xiaohong Yao, MD, Yuansen Chen, MD, Jing Huang, MD, Lexiang Long, MD, Rongqin Zheng, MD
Advanced Ultrasound in Diagnosis and Therapy    2020, 4 (4): 315-321.   DOI: 10.37015/AUDT.2020.190038
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Objective: To evaluate the technical success rate and reproducibility of sound touch elastography (STE) and sound touch quantification (STQ) in liver and spleen stiffness measurement and the reference ranges of normal liver and spleen stiffness. We also compared with a previous validated acoustic radiation force impulse (ARFI) technique.
Methods: Two hundred and fifty-three healthy adults and 40 chronic hepatitis B patients were recruited. All patients underwent liver and spleen stiffness measurements using STE, STQ, and ARFI. A hundred and five patients (36 patients with chronic hepatitis and 69 healthy adults) were examined twice, by two trained sonographers who are familiar with STE and STQ techniques independently. Another 36 healthy adults were examined twice by ARFI imaging. The technical success rates and reproducibility were evaluated.
Results: The success rates of STE, STQ, and ARFI were 96.5%, 95.1%, and 94.8% in liver, and 87.5%, 84.0%, and 78.0% in spleen, respectively. The inter-observer reproducibility of STE, STQ and ARFI were 0.914, 0.896, and 0.845 in liver, and 0.629, 0.601, and 0.543 in spleen, respectively. When the thickness of spleen was greater than 30mm, the reproducibility was 0.704 in STE and 0.668 in STQ. The normal ranges of liver stiffness were 5.80-6.04 kPa measured by STE and 5.87-6.13 kPa measured by STQ, and normal spleen stiffness ranged from 14.83-15.54 kPa measured by STE and 15.85-16.62 kPa measured by STQ.
Conclusion: Our study showed STE and STQ in liver and spleen stiffness measurement had a high success rate with good reproducibility, which were comparable to ARFI. The inter-observer reproducibility of spleen was barely satisfactory, but was good when the thickness of spleen was greater than 30mm.

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Real-Time Tissue Elastography: A Noninvasive Technique to Evaluate Liver Damage after Brain Death in Animal Mode
Ningning Niu, MD, Ying Tang, MD, Jingwen Zhao, MD
Advanced Ultrasound in Diagnosis and Therapy    2020, 4 (4): 322-328.   DOI: 10.37015/AUDT.2020.190028
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Objective: Using brain-dead donors to obtain organs for transplant is an effective way to overcome the shortage of organ donors. The purpose of this study is to investigate ultrasound flow imaging and elastography as a simple, feasible, accurate and effective method for evaluation of liver damage after brain death using an animal model.
Methods: We established a brain-death model using 15 pigs. Brain death was induced by progressively increasing the intracranial pressure, and the brain-death state was maintained for 9 hours. Spectral Doppler imaging and elastography was used to evaluate hepatic hemodynamic parameters and tissue stiffness over the period of brain death.
Results: Electron microscopy of the liver over the progress of brain death revealed gradual mitochondrial swelling (with rupture), expansion of the endoplasmic reticulum, and increased collagen in the extracellular matrix. Spectral Doppler imagin demonstrated that the HA-RI increased over time, which had statistically significant difference between the Bef-BD measurement and measurements at 3, 6, and 9 hours after brain death. Real time elastography of the liver revealed a gradual decrease of the mean relative strain value (MEAN) over the time, and a gradual increase in standard deviation of the relative strain value, complexity of low strain area, and skewness, suggesting that brain-death induced liver damage increases with time. The ROC curves showed that MEAN had the highest sensitivity, specificity, and accuracy for assessing liver injury.
Conclusion: Hepatic tissue damage induced by brain death increased over time. The HA-RI and liver stiffness index changes can be assessed by Doppler ultrasound and elastographic imaging. Our results showed that elastography is a useful method to evaluate liver damage after brain death.

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Transthoracic Echocardiography for Evaluation of an Intrapulmonary Artery Mass
Ting Sun, MD, Guoliang Lu, MD, Jian Fang, MD, Shaobo Xie, MD
Advanced Ultrasound in Diagnosis and Therapy    2020, 4 (4): 329-334.   DOI: 10.37015/AUDT.2020.190022
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Objective: Intrapulmonary artery mass is rare and prone to be misdiagnosed. The purpose of this study was to retrospectively review the evaluation of intrapulmonary artery masses by ultrasound imaging, summarize their characteristics, and suggest a standardized approach for clinical management.
Methods: Sixteen patients were enrolled in the study. Transthoracic echocardiography (TTE) showed a mass attached to the major pulmonary artery (MPA) trunk, straddling the bilateral pulmonary arteries or pulmonary valve (PV). The masses were diagnosed based on the site of the attachment, shape, size, mobility, and other morphological characteristics on ultrasound imaging examination. The pathological data were collected and analyzed from medical records.
Results: TTE images showed that the intrapulmonary artery mass was most frequently located in the MPA trunk. Eight patients had a pathological diagnosis and underwent complete mass resection. Five patients were suspected as having pulmonary thromboembolism (PTE) and were prescribed anticoagulation therapy, after which the masses decreased or disappeared on follow-up TTE. Three patients with suspected metastatic tumors died during hospitalization and had no pathological data. The 16 patients had the following distribution of diagnoses: thrombus (32%; 5/16), vegetations (12%; 2/16), primary benign lesions (12%; 2/16), primary malignant tumors (19%; 3/16), and metastatic tumors (25%; 4/16).
Conclusion: The majority of intrapulmonary artery masses were thrombi or primary pulmonary artery sarcomas. Primary tumors are much more common than metastatic tumors in the intrapulmonary artery.

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Identification of Key Genes Between Lung Adenocarcinoma and Lung Squamous Cell Carcinoma by Bioinformatics Analysis
Jinru Xue, MS, Yu Yang, MS, Bo Jiang, MD, Linxue Qian, MD, Xian-Quan Shi, PhD
Advanced Ultrasound in Diagnosis and Therapy    2020, 4 (4): 335-342.   DOI: 10.37015/AUDT.2020.200011
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Objective: To explore differentially expressed genes (DEGs) between lung adenocarcinoma (LUAD) and lung squamous cell carcinoma (LUSC).
Methods: Based on GEO database, we used R software to identify the DEGs and conducted the bioinformatics analysis to explore the molecular mechanisms of DEGs and constructed PPI network to find the key DEGs. Then we assessed the effect of the eligible key DEGs on survival in LUAD by Kaplan-Meier plotter online tool.
Results: GSE10245 was downloaded from the GEO database, which contained a total of 58 tissue samples, including 18 LUSC and 40 LUAD. We identified 784 DEGs between LUAD and LUSC. DEGs were enriched in statistical significant GO annotation 201 items and KEGG pathways 17 items. By constructed PPI network, we obtained 10 hub genes. Of which, five genes were significantly correlated with the overall survival of LUAD.
Conclusions: P2RY1, CHRM3, LPAR3, NMU, and S1PR5 may be the potential prognostic markers and therapeutic targets for LUAD.

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Absent Blood Flow in the Testis on Color Doppler Ultrasound: The Causes, Differential Diagnosis and Clinical Value
Shun-Ping Chen, MD, Bin Chen, MD
Advanced Ultrasound in Diagnosis and Therapy    2020, 4 (3): 223-229.   DOI: 10.37015/AUDT.2020.190035
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Objectives: To investigate the causes, differential diagnosis, and clinical significance of absent blood flow (ABF) in the testis detected by color Doppler ultrasound (CDU) in acute scrotum.
Methods: A total of 263 patients with ABF in the testis detected by CDU in our hospital were reviewed retrospectively. However, only 111 patients who underwent surgery were included in this study. The ultrasonographic features of the testis and paratesticular tissue were analyzed. The surgical or surgical-pathologic results were taken as the reference standard to determine the causes of ABF in the testis.
Results: The causes of ABF in the testis were testicular torsion (n = 98, torsion group) and non-testicular torsion related diseases (n = 13, non-torsion group, including 8 testicular rupture, 3 epididymitis-orchitis combination with testicular necrosis, and 2 tumors). Tunica albuginea of the testis, diffuse enlarged epididymis, whirlpool sign, and internal echo of the testis were the better parameters for diagnosing the causes of ABF in the testis detected by CDU. And the accuracies of these approaches were 93.7%, 91%, 83.8%, and 81.1%, respectively. Whirlpool sign had a 100% positive predictive value (PPV), and disrupted tunica albuginea of the testis and diffuse enlarged epididymis each had 100% specificity for predicting testicular torsion. When the ultrasonographic findings were combined with these methods to determine the causes, the accuracy was 96.4% (107/111).
Conclusion: ABF in the testis detected by CDU is not always indicative of testicular torsion in acute scrotum; Analyzing ultrasound findings of the testis and paratesticular tissue can help with differential diagnosis of the causes of ABF in the testis and guide clinical decision-making.

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Automated Machine Learning in the Sonographic Diagnosis of Non-alcoholic Fatty Liver Disease
Sriharsha Gummadi, MD, Nirmal Patel, Haresh Naringrekar, MD, Laurence Needleman, MD, Andrej Lyshchik, MD PhD, Patrick O’Kane, MD, Jesse Civan, MD, John R Eisenbrey, PhD
Advanced Ultrasound in Diagnosis and Therapy    2020, 4 (3): 176-182.   DOI: 10.37015/AUDT.2020.200008
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Objective: This study evaluated the performance of automated machine-learning to diagnose non-alcoholic fatty liver disease (NAFLD) by ultrasound and compared these findings to radiologist performance.
Methods: 96 patients with histologic (33) or proton density fat fraction MRI (63) diagnosis of NAFLD and 100 patients without evidence of NAFLD were retrospectively identified. The “Fatty Liver” label included 96 patients with 405 images and the “Not Fatty Liver” label included 100 patients with 500 images. These 905 images made up a “Comprehensive Image” group. A “Radiology Selected Image” group was then created by selecting only images considered diagnostic by a blinded radiologist, resulting in 649 images. Cloud AutoML Visionbeta (Google LLC, Mountain View, CA) was used for machine learning. The models were evaluated against three blinded radiologists.
Results: The “Comprehensive Image” group model demonstrated a sensitivity of 88.6% (73.3-96.8%) and a specificity of 95.3% (84.2-99.4%). Radiologist performance on this image group included a sensitivity of 81.0% (74.3-87.6%) and specificity of 86.0% (72.6-99.5%). The model’s overall accuracy was 92.3% (84.0-97.1%), compared with mean individual performance (83.8%, 78.4-89.1%). The “Radiology Selected Image” group model demonstrated a sensitivity of 88.6% (73.3 - 96.8%) and specificity of 87.9% (71.8-96.6%). Mean radiologist sensitivity was 92.4% (86.9-97.9%) and specificity was 91.9% (83.4-100%). The model’s overall accuracy was 88.2% (78.1-94.8%) which was comparable to the individual radiologist performance (92.2%, 90.1-94.2%) and consensus performance (95.6%, 87.6-99.1%).
Conclusions: An automated machine-learning algorithm may accurately detect NAFLD on ultrasound.

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Quantitative Analysis of Textural Features Extracted from Sonograms of Biceps under Different Physiological States
Lanting Jia, MD, Jiaqi Zhao, MD, Qi Xu, PhD, Qian Pan, MD, Jianquan Zhang, MD
Advanced Ultrasound in Diagnosis and Therapy    2020, 4 (3): 183-188.   DOI: 10.37015/AUDT.2020.190024
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Objective: To quantitatively analyze the difference of texture features of skeletal muscle in high-frequency ultrasound images under different physiological states using the multiscale decomposition method of ultrasound echo intensity interface reflections.
Methods: High frequency ultrasound images of the biceps brachii in different physiological states were collected from 20 healthy volunteers. In offline state, eight texture parameters including mean of texture gray scale (Mean), standard variance (SDev) of gray scale, number of blobs (NOB) of texture density, irregularity (IRGL) of texture primitive shape, mean size of blobs (SOB) of texture primitive, homogeneity of distribution (HOD) of texture uniformity, directionality of texture distribution (DOD), and periodicity of texture distribution (POD) were extracted by MATLAB software and compared and analyzed statistically.
Results: With the use of high frequency ultrasound, all healthy volunteers' biceps brachii showed isoechoic muscle bundles, organized arrangement of muscle fibers, and distinct and intact texture of structure. In different physiological states of biceps brachii of the same gender group, the NOB and the Mean showed statistically differences (P < 0.05). In the relaxation state of biceps brachii between different gender groups, the average SOB and the DOD showed statistically differences (P < 0.05). In the load state of biceps brachii between different genders, the NOB and the Mean showed statistically differences (P < 0.05).
Conclusions: The ultrasonic image changes of muscle fibers under different physiological states can be identified by quantitative texture characteristic parameters, providing more information for clinical computer-aided diagnosis of skeletal muscle injury.

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Use of Contrast-Enhanced Ultrasound for Detecting the Disease Activity of the Carotid Artery in Takayasu Arteritis
Chaolun Li, MD, Lingying Ma, MD, Linjin Huang, MD, Hong Han, MD, Lingdi Jiang, MD, Wenping Wang, MD
Advanced Ultrasound in Diagnosis and Therapy    2020, 4 (3): 189-194.   DOI: 10.37015/AUDT.2020.200010
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Objective: To investigate whether contrast-enhanced ultrasound (CEUS) is helpful for assessing the disease activity of Takayasu arteritis (TA).
Methods: Eighty-four patients with TA were examined with ultrasound (US) and CEUS. Intima-media thickness (IMT) of both sides of the common carotid artery was measured for each patient. Semiquantitative analyses of contrast enhancement within the arterial wall were performed with a visual interpretation scale. Disease activity was determined by one experienced physician based on Physician Global Assessment criteria.
Results: Carotid CEUS revealed that 6 arteries showed no enhancement (7.1%, 6/84) while 78 arteries showed homogeneous enhancement within the thickened wall (92.9%, 78/84). Grade 1 enhancement was noted in 40 patients, and grade 2 in 38 patients. IMT of the active group was significantly thicker than that of the inactive group (2.4 ± 0.9 mm vs. 1.8 ± 0.5 mm, P = 0.001) on B-mode US, and slightly correlated with ESR (r = 0.344, P < 0.05) and CRP (r = 0.261, P < 0.05). Grade 2 enhancement was observed more in the active patients (61.7% vs. 41.3%, P = 0.001) on CEUS.
Conclusions: CEUS is a convenient and non-invasive imaging modality that is useful for evaluating disease activity in TA patients by assessing the vascularization within the carotid wall.

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A Novel Two-dimensional Quantitative Shear Wave Elastography Mode for Differential Diagnosis of Benign and Malignant Thyroid Nodules
Ying Zhang, MD, Yifeng Zhang, MD, Hanxiang Wang, MD, Anqi Zhu, MD, Hui Shi, MD
Advanced Ultrasound in Diagnosis and Therapy    2020, 4 (3): 195-203.   DOI: 10.37015/AUDT.2020.190039
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Background: To evaluate the diagnostic performance of a novel two-dimensional quantitative shear wave elastography (SWE) of virtual touch tissue imaging quantification (VTIQ) in the differential diagnosis between benign and malignant thyroid nodules.
Methods: Two hundred and six solid thyroid nodules were included in this prospective study. Conventional ultrasound and VTIQ examinations were performed. The diagnostic performances of US, VTIQ, and the combination of the two methods were compared. The usefulness of VTIQ in different size of nodules was also assessed.
Results: There were 113 benign nodules and 93 malignant nodules on fine needle aspiration (FNA) or histology. The shear wave velocities (SWVs) in malignant nodules were all significantly higher than those in benign nodules (SWV max: 4.01 ± 1.72 m/s vs 3.25 ± 1.01 m/s, SWV min: 2.87 ± 0.69 m/s vs 2.46 ± 0.67 m/s, SWV mean: 3.33 ± 0.89 m/s vs 2.85 ± 0.81 m/s, SWV median: 3.31 ± 0.88 m/s vs 2.82 ± 0.77 m/s, all P value < 0.001). After combined VTIQ with ultrasound, the diagnostic performances improved compared with ultrasound alone or VTIQ alone. As for lesions of different sizes, areas under curve (AUC) for the largest diameter of nodules ≤ 1.0 cm was 0.711, which was lower than that for the largest diameter of the nodules > 1.0 cm (AUC was 0.862) (P < 0.05). Conventional ultrasound features such as halo sign and microcalcification were predictors for lymphatic metastasis in malignant thyroid nodules (P < 0.05).
Conclusions: VTIQ is a new method for measuring stiffness of thyroid lesions qualitatively. The diagnostic performance of combined using VTIQ and conventional ultrasound was better than that of using either alone. Malignant thyroid nodules with conventional ultrasound features such as halo sign and microcalcification were more likely to have lymphatic metastasis. The evaluation of small thyroid lesions remained a difficult problem.

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