Role of qualitative contrast-enhanced ultrasound in the diagnosis of malignant breast lesions.

Background: Carcinoma breast is the commonest cancer among women. Various authors have studied breast cancer with Contrast-Enhanced Ultrasound (CEUS) with promising results. Despite promising results, the additional cost of post-processing software limits its availability. In this study, we evaluated the utility of CEUS in differentiating malignant from benign breast lesions on regular ultrasound equipment without the use of dedicated software. Methods: We performed CEUS in 121 women with 121 breast lesions. CEUS was done by creating a custom preset on existing ultrasound equipment with the help of an application specialist authorized by the vendor. Lesions were evaluated qualitatively without the use of any commercial software. The pattern of enhancement i.e. homogenous, heterogeneous, peripheral, or no enhancement, and the number of penetrating vessels i.e., few or multiple were recorded. Results were compared with histopathological diagnosis. Results: There were a total of 121 breast lesions. The study showed sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 86.67 %, 54.10 %, 65 %, and 80.49% respectively for differentiating benign vs malignant lesions on the basis of the pattern of contrast enhancement. Using penetrating vessels for differentiating malignant lesions from benign lesions, the sensitivity, specificity, PPV, and NPV were found to be 64%, 67.86%, 78.05%, and 51.35% respectively. Conclusion: CEUS is useful in differentiating malignant from benign breast lesions. It can be easily performed by creating a custom preset on standard ultrasound equipment without the use of expensive software.

Abdominal and Chest Ultrasonography: A predictor for disease progression in nonsevere dengue.

Background: Dengue is one of the most rapidly spreading arboviral infections in the world. Ultrasound is well established in abdomino-thoracic evaluation of patients with dengue infection. The aim of this study was to explore the role of ultrasound in predicting occurrence of severe infection in dengue patients and in predicting deterioration in patients with nonsevere dengue. Methods: The serologically proven dengue patients who reported to hospital during the study period were divided into three categories based on the dengue infection severity score. Ultrasound findings of abdomen and chest in these patients were noted in the initial, as well as follow-up scans and inferences drawn. Results: 61% belonged to the category of Dengue Fever, 35% were in Dengue Hemorrhagic Fever category, and 4% had Dengue Shock Syndrome. Positive ultrasound findings were seen to be significantly higher in patients with severe dengue. Logistic regression analysis revealed the presence of pericholecystic fluid to be significantly associated with the severe disease, while the presence of gall bladder wall edema, ascites, and any ultrasound finding were significantly associated with the disease progression. The odds of a patient with severe dengue having gall bladder wall edema, ascites, or any ultrasound finding were 2.74, 2.04, and 2.619 times, respectively. Conclusion: Our study indicates that positive findings on ultrasound are significantly higher in severe dengue and also that ultrasound can be reliably used to identify the patients with nonsevere dengue who are likely to progress to severe dengue.

Artificial intelligence and the radiologist: the future in the Armed Forces Medical Services.

Artificial intelligence (AI) involves computational networks (neural networks) that simulate human intelligence. The incorporation of AI in radiology will help in dealing with the tedious, repetitive, time-consuming job of detecting relevant findings in diagnostic imaging and segmenting the detected images into smaller data. It would also help in identifying details that are oblivious to the human eye. AI will have an immense impact in populations with deficiency of radiologists and in screening programmes. By correlating imaging data from millions of patients and their clinico-demographic-therapy-morbidity-mortality profiles, AI could lead to identification of new imaging biomarkers. This would change therapy and direct new research. However, issues of standardisation, transparency, ethics, regulations, training, accreditation and safety are the challenges ahead. The Armed Forces Medical Services has widely dispersed units, medical echelons and roles ranging from small field units to large static tertiary care centres. They can incorporate AI-enabled radiological services to subserve small remotely located hospitals and detachments without posted radiologists and ease the load of radiologists in larger hospitals. Early widespread incorporation of information technology and enabled services in our hospitals, adequate funding, regular upgradation of software and hardware, dedicated trained manpower to manage the information technology services and train staff, and cyber security are issues that need to be addressed.

Rifled carotid: Internal carotid artery thrombosis from prolonged carrying of a military rifle.

BACKGROUND: Traumatic carotid artery thrombosis is uncommon and it usually results from penetrating injuries and less commonly secondary to blunt trauma. It can lead to delayed clinical presentation, which leads to delay in the diagnosis. Soldiers in combat scenario also can present with such an illness, which results from varied modes of injuries. Our case illustrates an unusual cause of carotid thrombosis. CASE PRESENTATION: Our patient is a 37-year-old soldier who developed neck pain and headache following a 5 km training run with rifle on the shoulder and subsequently developed left upper limb weakness and evaluation revealed extracranial right internal carotid thrombosis. He was managed with anticoagulants and antiplatelets with complete resolution of the thrombosis and complete recovery of the weakness. CONCLUSION: Blunt trauma to the neck in the form of carrying a rifle for a prolonged duration can result in injury to the carotid vessels leading to delayed neurological presentation. Educating the troops regarding such a mode of illness will prevent such a catastrophic nature of vascular injury resulting in ischaemic stroke.

Bell's Palsy-Tertiary Ischemia: An Etiological Factor in Residual Facial Palsy.

The facial nerve is unique among the motor nerves. It has long and tortuous course through the temporal bone and within the Fallopian canal. Because of this it is more prone to paralysis than any other nerve in the body. The most frequent type of facial palsy is Bell's palsy. This is an acute idiopathic lower motor neuron palsy of the facial nerve which does not normally progress and which is most usually unilateral and self limiting,: the majority of cases remit within 4-6 months and nearly always remission is complete by 1 year. In those cases that do not recover it is my contention that this is caused by Either the progression, or after effects, of secondary ischemia: tertiary ischemia. In turn this causes thickening of the facial nerve sheath with a fibrous band or bands forming with resultant strangulation and compression of the nerve, which hampers its recovery. In such cases facial nerve decompression with slitting of the sheath and cutting of any fibrous bands would be the preferred management when allied with aggressive medical therapy.

Nonpalpable intrauterine device threads: Is it a cause for worry?

BACKGROUND: Intrauterine contraceptive device is a popular and effective method of contraception. It can be inserted either as an interval procedure or after abortion or delivery. Threads are attached to the vertical limb so that the user can find out the location of the device. Sometimes the threads are not palpable by the user; this study was conducted to find out the reasons for inability to palpate the threads. METHODS AND RESULTS: The retrospective study was conducted over a period of eight years; 110 female patients who complained of inability to feel the threads were included in the study. In most of the cases the device was in the right place. In four cases the device could not be felt on uterine sounding; this could have been due to subendometrial placement of the device. There was no case of perforation by the device. CONCLUSION: Inability to feel the threads is a common complaint by the patients who are using intrauterine contraceptive device. In most of the cases the device was in correct position and could be localized by clinical examination. Ultrasonography can help in localization of the device; if used at the time of insertion it can confirm proper insertion and location of the device. This will reassure the client and the health care providers.

Transitioning to intravitreal aflibercept following a previous treat-and-extend dosing regimen in neovascular age-related macular degeneration: 24-month results.

PURPOSE: To evaluate frequency of injections, visual and anatomical outcomes of neovascular age-related macular degeneration (nAMD) patients transitioned to intravitreal aflibercept after failure to extend treatment interval beyond 8 weeks with prior intravitreal bevacizumab or ranibizumab. METHODS: Retrospective review of patients with nAMD switched to aflibercept following ≥ 6 prior intravitreal ranibizumab or bevacizumab injections at 4-8-week intervals. Three monthly aflibercept injections were given followed by a treat-and-extend dosing regimen. RESULTS: Twenty-one eyes of 18 patients who had received a mean of 23.8 ± 18.8 (mean ± SD; range 6-62) prior ranibizumab or bevacizumab injections were included. Over a mean follow-up of 24 months after the transition, 9.2 ± 2.9 (range 4-21) aflibercept injections were required. Interval between aflibercept injections increased to 57.3 days (range 35-133 days), as compared with 37 ± 6.1 days (range 29-54 days) with the prior agents (P = 0.01). Mean best-corrected visual acuity was preserved (0.42 ± 0.31 vs 0.42 ± 0.23 logMAR; P = 0.2). Mean OCT central subfoveal thickness (292.1 ± 83.2 µm to 283.6 ± 78.6 µm; P = 0.4) and mean macular volume (7.9 ± 0.95 mm(3) to 7.67 ± 0.94 mm(3); P = 0.16) remained stable. CONCLUSION: Patients requiring treatment more frequently than every 8 weeks with ranibizumab and bevacizumab were transitioned to > 8-week treatment interval with aflibercept while maintaining the anatomic and visual gains.

Visual and anatomical outcomes following intravitreal aflibercept in eyes with recalcitrant neovascular age-related macular degeneration: 12-month results.

PURPOSE: To describe the efficacy of intravitreal aflibercept on 12-month visual and anatomical outcomes in patients with neovascular age-related macular degeneration (AMD) recalcitrant to prior monthly intravitreal bevacizumab or ranibizumab. METHODS: Non-comparative case series of 21 eyes of 21 AMD patients with evidence of persistent exudation (intraretinal fluid/cysts, or subretinal fluid (SRF), or both) on spectral domain OCT despite ≥6 prior intravitreal 0.5 mg ranibizumab or 1.25 mg bevacizumab (mean 29.8±17.1 injections) over 31.6±17.4 months who were transitioned to aflibercept. RESULTS: At baseline, best-corrected visual acuity (BCVA) was 0.42±0.28 logarithm of minimum-angle of resolution (logMAR), central foveal thickness (CFT) was 329.38±102.67 µm and macular volume (MV) was 7.71±1.32 mm(3). After 12 months of aflibercept (mean 10.2±1.2 injections), BCVA was 0.40±0.28 logMAR (P=0.5), CFT decreased to 292.71±91.35 µm (P=0.038) and MV improved to 7.33±1.27 mm(3) (P=0.003). In a subset of 15 eyes with a persistent fibrovascular or serous pigment epithelial detachment (PED), mean baseline PED greatest basal diameter (GBD) was 2350.9±1067.6 µm and mean maximal height (MH) was 288.7±175.9 µm. At 12 months, GBD improved to 1896.3±782.3 µm (P=0.028), while MH decreased to 248.27±146.2 µm (P=0.002). CONCLUSION: In patients with recalcitrant AMD, aflibercept led to anatomic improvement at 12 months, reduction in proportion of eyes with SRF and reduction in PED, while preserving visual acuity.

Comparison of Scheimpflug imaging and spectral domain anterior segment optical coherence tomography for detection of narrow anterior chamber angles.

PURPOSE: To compare the performance of anterior chamber volume (ACV) and anterior chamber depth (ACD) obtained using Scheimpflug imaging with angle opening distance (AOD500) and trabecular-iris space area (TISA500) obtained using spectral domain anterior segment optical coherence tomography (SD-ASOCT) in detecting narrow angles classified using gonioscopy. METHODS: In this prospective, cross-sectional observational study, 265 eyes of 265 consecutive patients underwent sequential Scheimpflug imaging, SD-ASOCT imaging, and gonioscopy. Correlations between gonioscopy grading, ACV, ACD, AOD500, and TISA500 were evaluated. Area under receiver operating characteristic curve (AUC), sensitivity, specificity, and likelihood ratios (LRs) were calculated to assess the performance of ACV, ACD, AOD500, and TISA500 in detecting narrow angles (defined as Shaffer grade ≤1 in all quadrants). SD-ASOCT images were obtained at the nasal and temporal quadrants only. RESULTS: Twenty-eight eyes (10.6%) were classified as narrow angles on gonioscopy. ACV correlated with gonioscopy grading (P<0.001) for temporal (r=0.204), superior (r=0.251), nasal (r=0.213), and inferior (r=0.236) quadrants. ACV correlated with TISA500 for nasal (r=0.135, P=0.029) and temporal (P=0.160, P=0.009) quadrants and also with AOD500 for nasal (r=0.498, P<0.001) and temporal (r=0.517, P<0.001) quadrants. For detection of narrow angles, ACV (AUC=0.935; 95% confidence interval (CI) =0.898-0.961) performed similar to ACD (AUC=0.88, P=0.06) and significantly better than AOD500 nasal (AUC=0.761, P=0.001), AOD500 temporal (AUC=0.808, P<0.001), TISA500 nasal (AUC=0.756, P<0.001), and TISA500 temporal (AUC=0.738, P<0.001). Using a cutoff of 113 mm(3), ACV had 90% sensitivity and 88% specificity for detecting narrow angles. Positive and negative LRs for ACV were 8.63 (95% CI=7.4-10.0) and 0.11 (95% CI=0.03-0.4), respectively. CONCLUSIONS: ACV measurements using Scheimpflug imaging outperformed AOD500 and TISA500 using SD-ASOCT for detecting narrow angles.

Artificial neural network-based glaucoma diagnosis using retinal nerve fiber layer analysis.

PURPOSE: To develop, train, and test an artificial neural network (ANN) for differentiating among normal subjects, primary open angle glaucoma (POAG) suspects, and persons with POAG in Asian-Indian eyes using inputs from clinical parameters, optical coherence tomography (OCT), visual fields, and GDx nerve fiber analyzer. METHODS: One hundred eyes were classified using optic disc examination and perimetry into normal (n=35), POAG suspects (n=30), and POAG (n=35). EasyNN-plus simulator was used to develop an ANN model with inputs including age, sex, myopia, intraocular pressure (IOP), optic nerve head, and retinal nerve fiber layer (RNFL) parameters on OCT, Octopus 30-2 full threshold visual field, and GDx parameters. RESULTS: With two outputs (POAG or normal), specificity was 80% and sensitivity was 93.3%. Ninety percent of POAG suspects were labeled as abnormal in this analysis. ANN assigned the highest importance to Smax/Imax RNFL on OCT followed by cup-area (OCT) and other RNFL parameters (OCT) for two outputs. With three outputs (normal, POAG, and POAG suspect), ANN gave an overall classification rate of 65%, specificity of 60%, and sensitivity of 71.4% with a target error rate of the training set at 1%. The parameters for three outputs, in decreasing order of relative importance, were Savg, vertical cup-disc ratio, cup-volume, and cup-area on OCT. CONCLUSIONS: An ANN taking varied diagnostic imaging inputs was able to separate POAG eyes from normal subjects and POAG suspects. The network had reasonable sensitivity with three outputs; however, it had a tendency to mislabel POAG suspects as POAG.

Posterior capsule rupture following closed globe injury: Scheimpflug imaging, pathogenesis, and management.

PURPOSE: To report the Scheimpflug and clinical findings in a case of pediatric posterior capsule rupture due to blunt ocular trauma. METHODS: Interventional case report. Analysis of Scheimpflug findings and review of literature. RESULTS: An 11-year-old boy presented 2 days after blunt trauma to the left eye with a slingshot. On examination his best-corrected visual acuity (BCVA) was 20/20 in the right eye and 20/400 in the left. Slitlamp examination (left eye) revealed a Vossius ring, traumatic cataract, and traumatic posterior capsular rupture (TPCR).The contour of the posterior bulge corresponded to the edges of the TPCR. Scheimpflug imaging (Pentacam 70700: Oculus, Wetzlar, Germany) confirmed traumatic cataract in region of TPCR evidenced by increased lens density at cortex-vitreous interface, absence of vitreous prolapse into the anterior chamber, and the amount of residual nucleus. The extent of the TPCR in the greatest and least dimensions was documented before and after intraocular lens (IOL) implantation. Intraoperatively, TPCR was evident and phacoemulsification with IOL implant was performed. Postoperatively, his BCVA improved to 20/20 in the left eye with a well-centered in-thebag IOL as found on slit lamp and Scheimpflug images. CONCLUSIONS: This report highlights the use of Scheimpflug imaging in isolated posterior capsule rupture following closed globe injury, to visualize and quantify the size of posterior capsule rupture and its role in management.

Canal wall down tympanomastoidectomy: the 'on-disease' approach for retraction pockets and cholesteatoma.

It is well known that cholesteatoma is three-dimensional; hence, we feel that its surgical management requires a three-dimensional approach in order to achieve the best curative and functional results. Retraction pockets are undeniably caused by chronic and recurrent eustachian tube obstruction. However, we found that the presence of a large mastoid antrum was an important, additional aetiological factor in the formation of a retraction pocket and its progression to cholesteatoma formation, with bone destruction and subsequent complications. Canal wall down tympanomastoidectomy--the 'on-disease' approach--is an innovative, three-dimensional technique based on universally accepted surgical principles. We modified the technique to ensure complete exposure and thereby eradication of the disease, with a resultant small cavity. Working in a three-dimensional field, we began drilling at the posterior meatal wall, lowering it while simultaneously widening the cavity as the mastoid was drilled to reach the antrum and the aditus. The bridge was lowered and the incus removed to completely expose the entire disease. The facial ridge was debulked and the temporalis fascia graft placed so as to simplify the middle-ear cleft. We present a comprehensive report of this technique, based upon 600 patients studied retrospectively over a five-year period. After one-year follow up, 546 patients had a dry, healed cavity. Canal wall down tympanomastoidectomy performed by the on-disease approach ensures complete eradication of the disease, with excellent curative as well as functional results.