Emergency Ultrasound in Trauma Patients: Beware of Pitfalls and Artifacts!

BackgroundUltrasonography (US) is highly dependent on operators’ skills. It is not only a matter of correct scan techniques; there are anatomical structures and variants, as well as artifacts, which can produce images difficult to interpret and which, if not properly understood, can be causes of errors.ObjectivesThis paper will review relatively common US pitfalls and artifacts that can be encountered in trauma patients and will offer tips to recognize and avoid them.DiscussionNormal anatomical structures and anatomical variants can mimic fluid collections or perisplenic lesions. Examination along multiple scan planes, real-time observation of movements or repetition of the study after the patient has drunk some fluid or after placing a finger on her/his body wall can help proper identification. The term artifact in US imaging refers to display phenomena not properly representing the imaged structures. This can result in images suggesting fracture lines within organs or at their borders, lung consolidations, or pleural effusions, and abdominal fluid collections. Their knowledge is the first step to recognize them; then, use of multiple scan planes or repetition of the study after voiding or changes of equipment setting can make them disappear or clarify their nature.ConclusionWe present possible anatomic pitfalls and artifacts that may affect correct interpretation of US images in patients with abdominal trauma and suggest how to avoid or to clarify them during the examination. Knowing their existence, their appearances, and the reasons why they are produced is important for proper use of this diagnostic technique.     

Endoscopic ultrasound-guided fine-needle aspiration cytology for diagnosis above and below the diaphragm

Endosonography ultrasound (EUS) is a minimally invasive technology using a high-frequency ultrasound transducer that is incorporated into the tip of a conventional endoscope. This technique permits high-resolution imaging of the gastrointestinal wall and structures in its vicinity, as well as real-time endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA). This is a review of the literature on EUS-guided FNA of the mediastinal and abdominal lymph nodes, the pancreas, intramural gastrointestinal masses, and other miscellaneous organs and body cavities. EUS-guided FNA is a recently developed procedure that has established itself as a safe, highly accurate, and clinically useful modality.     

腹式呼吸配合穴位按摩减轻妇科腹腔镜患者腹胀的效果观察

目的探讨腹式呼吸配合穴位按摩减轻妇科腹腔镜术后患者腹胀的效果。方法将180例妇科腹腔镜术后腹胀患者随机分为对照组和观察组,每组各90例,对照组给予常规围手术期护理,观察组在此基础上采用腹式呼吸配合穴位(包括足三里、上巨墟、下巨墟、内关穴)按摩,减轻患者术后腹胀。观察两组患者术后3d内腹胀程度及肠功能恢复情况。结果观察组患者术后3 d内腹胀程度明显轻于对照组,肠蠕动恢复时间和肛门排气时间明显短于对照组(均P0.01)。结论腹式呼吸配合穴位按摩能有效减轻妇科腹腔镜术后患者腹胀,促进患者胃肠功能尽早恢复。     

Contrast-enhanced CT and MR imaging of renal vessels

In the evaluation of renal vessels, the accepted diagnostic gold standard digital subtraction angiography is now being challenged by state of the art CT and MR imaging. Currently in many centers, cross-sectional imaging modalities are being used as a first line diagnostic tool to evaluate arterial and venous system of the kidneys and conventional angiography has been reserved only for therapeutic intervention. CT and MR imaging display not only the lumen of the vessel as in conventional angiography, but also allow the visualization of the vessel wall, renal parenchyma, collecting system, and other adjacent soft tissue structures. Therefore, CT and MRI have each become a one-stop shop for a thorough evaluation of kidneys. In this pictorial essay, we reviewed normal anatomical variants and wide range of pathologies involving renal arteries and veins with illustrated contrast-enhanced CT and MR imaging samples.     

Myofeedback: a new method of teaching breathing exercises in emphysematous patients.

The diaphragm of the emphysematous patient is low and limited in its excursions, producing an increased functional residual capacity and decreased pulmonary ventilation. This report describes our experiences with a new technique for 1) the training of abdominal-diaphragmatic (A-D) breathing and 2) the relaxation of accessory respiratory muscles in emphysematous patients. Abdominal muscle contraction during expiration has been shown to increase diaphragmatic excursions and, hence, pulmonary ventilation. Use of this technique has been limited, however, because of the difficulty in learning this breathing pattern. Through continuous audio and visual feedback of myoelectric potentials (myofeedback) from abdominal muscles, 12 patients learned A-D breathing. The lower rectus abdominis muscle was found to be the most suitable muscle for obtaining the myoelectric potentials. Similarly, by providing the patients with myofeedback from their accessory muscles, they decreased the use of these muscles, thus increasing their respiratory efficiency. With myofeedback, patients appear to learn new breathing patterns effectively and in fewer sessions than with conventional procedures.     

Causes and risk factors for development of mitral valve prolapse

Mitral prolapse is a common valvular anomaly. Mechanisms of prolapse formation are studied with the use of modern investigation methods. Primary prolapse results from congenital structural defects of intracardiac formations (papillary muscles, trabecules, chordae) of the left ventricle, as well as associated microcirculatory disorders. Genetically caused rearrangement of fibrillar structures of the extracellular matrix of connective tissue (myxomatous degeneration) is observed in half of the patients with primary mitral prolapse. Concerning secondary prolapse of the leaflets, some mechanisms are singled out and a large group of diseases is described.     

Stability, continence and breathing: The role of fascia following pregnancy and delivery

Pregnancy-related pelvic girdle pain (PRPGP) has a prevalence of approximately 45% during pregnancy and 20–25% in the early postpartum period. Most women become pain free in the first 12 weeks after delivery, however, 5–7% do not. In a large postpartum study of prevalence for urinary incontinence (UI) [Wilson, P.D., Herbison, P., Glazener, C., McGee, M., MacArthur, C., 2002. Obstetric practice and urinary incontinence 5–7 years after delivery. ICS Proceedings of the Neurourology and Urodynamics, vol. 21(4), pp. 284–300] found that 45% of women experienced UI at 7 years postpartum and that 27% who were initially incontinent in the early postpartum period regained continence, while 31% who were continent became incontinent. It is apparent that for some women, something happens during pregnancy and delivery that impacts the function of the abdominal canister either immediately, or over time.Current evidence suggests that the muscles and fascia of the lumbopelvic region play a significant role in musculoskeletal function as well as continence and respiration. The combined prevalence of lumbopelvic pain, incontinence and breathing disorders is slowly being understood. It is also clear that synergistic function of all trunk muscles is required for loads to be transferred effectively through the lumbopelvic region during multiple tasks of varying load, predictability and perceived threat. Optimal strategies for transferring loads will balance control of movement while maintaining optimal joint axes, maintain sufficient intra-abdominal pressure without compromising the organs (preserve continence, prevent prolapse or herniation) and support efficient respiration. Non-optimal strategies for posture, movement and/or breathing create failed load transfer which can lead to pain, incontinence and/or breathing disorders.Individual or combined impairments in multiple systems including the articular, neural, myofascial and/or visceral can lead to non-optimal strategies during single or multiple tasks. Biomechanical aspects of the myofascial piece of the clinical puzzle as it pertains to the abdominal canister during pregnancy and delivery, in particular trauma to the linea alba and endopelvic fascia and/or the consequence of postpartum non-optimal strategies for load transfer, is the focus of the first two parts of this paper. A possible physiological explanation for fascial changes secondary to altered breathing behaviour during pregnancy is presented in the third part. A case study will be presented at the end of this paper to illustrate the clinical reasoning necessary to discern whether conservative treatment or surgery is necessary for restoration of function of the abdominal canister in a woman with postpartum diastasis rectus abdominis (DRA).     

Intra-abdominal pressure and trunk muscle activity during lifting. IV. The causal factors of the intra-abdominal pressure rise

The intra-abdominal pressure (IAP) has been regarded as important for stabilization and relief of the lumbar spine when exposed to heavy loads, such as when lifting. Previous trials, however, have failed to increase the IAP by abdominal muscle training. Twenty healthy subjects, 20 low-back patients and 10 weight-lifters, were tested with various breathing techniques in order to elucidate the causal factors of the IAP rise during lifting and the effects respiration. Those with high IAP and low IAP as well as those with great variations in IAP underwent an extended program. The intra-abdominal and intrathoracic pressures and the EMG of the oblique abdominal, the erector spinae and--in some cases--the puborectalis muscles, were recorded. The transdiaphragmatic pressure was calculated both during lifting and during the Mueller manoeuvre. The IAP rise during lifting seems to be correlated to a good coordination between the muscles surrounding the abdominal cavity. Of these, the diaphragm seems to be the most important for the IAP level. Closure of the glottis seems to help the diaphragm to maintain the IAP rise, otherwise the respiration type seems to be less important for the IAP during lifting.     

The Abdominal Circulatory Pump

Blood in the splanchnic vasculature can be transferred to the extremities. We quantified such blood shifts in normal subjects by measuring trunk volume by optoelectronic plethysmography, simultaneously with changes in body volume by whole body plethysmography during contractions of the diaphragm and abdominal muscles. Trunk volume changes with blood shifts, but body volume does not so that the blood volume shifted between trunk and extremities (Vbs) is the difference between changes in trunk and body volume. This is so because both trunk and body volume change identically with breathing and gas expansion or compression. During tidal breathing Vbs was 50–75 ml with an ejection fraction of 4–6% and an output of 750–1500 ml/min. Step increases in abdominal pressure resulted in rapid emptying presumably from the liver with a time constant of 0.61±0.1SE sec. followed by slower flow from non-hepatic viscera. The filling time constant was 0.57±0.09SE sec. Splanchnic emptying shifted up to 650 ml blood. With emptying, the increased hepatic vein flow increases the blood pressure at its entry into the inferior vena cava (IVC) and abolishes the pressure gradient producing flow between the femoral vein and the IVC inducing blood pooling in the legs. The findings are important for exercise because the larger the Vbs the greater the perfusion of locomotor muscles. During asystolic cardiac arrest we calculate that appropriate timing of abdominal compression could produce an output of 6 L/min. so that the abdominal circulatory pump might act as an auxiliary heart.     

Respiratory Muscle Blood Flow Distribution during Expiratory Resistance

When work load on the respiratory system is increased the relative increase in blood flow to each of the muscles of breathing provides an index of how the augmented effort of breathing is partitioned among the different muscles. We have used a radio-active microsphere technique to measure blood flow to each of the muscles of respiration in supine dogs during unobstructed respiration and breathing against graded expiratory threshold loads. 79% of the augmented flow went to expiratory muscles; of this increased flow to expiratory muscles 74% went to abdominal wall muscles and 26% to internal intercostals. In our earlier studies of hyperventilation induced by CO₂ rebreathing where expiratory work loads were low, 44% of the increase in flow went to expiratory muscles; of this, only 39% went to abdominal wall muscles and 61% to internal intercostals. During inspiratory resistance which produced small increases in expiratory work, 27% of the increase in blood flow went to expiratory muscles; of this, only 37% went to abdominal wall muscles and 63% to internal intercostals. These results suggest that the internal intercostals are predominantly used for expiration when expiratory work loads are low, whereas the abdominal wall muscles are predominantly used when loads are high.     

Faszienforschung: Quo vadis?

Although the fascia has been studied for a long time, science has only recently begun to pay more attention to the exploration of this network in our bodies. The essential role the fascia plays for body perception and the mobility of body structures is now being explored.After a brief look at the fascia as a specialized connective tissue, we introduce six of the most important current research areas. These are sports science, myofascial pain research, evolutionary biology, molecular biology, biomechanics, and functional anatomy.The abundance of research areas demonstrates our growing understanding of fascial connective tissues and suggests hope for new clinical approaches, such as in the treatment of lower back pain and in cancer research.     

Atmung, Ventilation, Atembewegung

Manual medicine investigates and treats reversible dysfunctions in the human locomotor system.Observation of movements of inspiration and expiration provides evidence about the mobility of the thoracic spine and thorax. This paper gives an overview of the mechanics and physiology of ventilation and regulation of external respiration. Links between movements of breathing and mobility of inner organs, blood flow, and trunk muscles are shown. We emphasize aspects of manual medicine.     

Brainstem White Matter Tracts and the Control of Eye Movements

This article summarizes the anatomy of brainstem tracts and cranial nerves as depicted by magnetic resonance imaging, with special emphasis on the structures that are involved in the control of eye movement. It discusses the anatomical structures that can be observed on conventional magnetic resonance images as well as structures that can only be observed using more advanced imaging techniques such as diffusion tensor imaging and tractography. The basic mechanisms of various kinds of ophthalmoplegia are also discussed.     

Primary hydatid disease in adductor muscles

Primary muscular Echinococcus infection is very rare without involvement of thoracic and abdominal organs. In this case a 31-year-old man who had a growing mass in the postero-medial part of his right thigh was examined. The mass was diagnosed as hydatid cyst using ultrasound, magnetic resonance imaging (MRI) and serological tests. It was removed surgically and there has been no recurrence one year after the surgery. The MRI imaging characteristics may differ depending on the life cycle stage of the parasite. In this case report, we discuss the imaging characteristics of the muscular hydatid cyst with special emphasis on the MRI findings. In regions where hydatidosis is endemic, a mass found in body muscles should be considered as a muscular hydatid cyst.     

Tissue Deformation Index as a Reliable Measure of Lateral Abdominal Muscle Activation on M‐Mode Sonography

The aim of this article is to present a novel method of evaluating the activity of lateral abdominal muscles using M‐mode sonography. The method leads to calculation of the tissue deformation index, representing the percent change in lateral abdominal muscle thickness over time. The objectives of this study were as follows: (1) to establish the mean tissue deformation index values for individual lateral abdominal muscles; and (2) to establish the reliability of the tissue deformation index. In a group of 34 healthy young volunteers (mean age, 24.03 years; body mass, 68.89 kg; body height, 174.25 cm), the reflex response of the lateral abdominal muscles to postural perturbation in the form of rapid arm abduction was recorded in 2 series, with 6 repetitions each, and the tissue deformation index was calculated. The mean tissue deformation index values formed a gradient, increasing from deep to superficial lateral abdominal muscles: 0.06%/ms for transversus abdominis, 0.11%/ms for oblique internal, and 0.16 for oblique external muscles. The tissue deformation index values differed significantly among individual lateral abdominal muscles (all paired comparisons, P < .001). Three repeated measurements are sufficient to achieve good intra‐rater reliability of the tissue deformation index (intraclass correlation coefficient, > 0.8).     

Ultrasonic imaging of normal intrauterine fetal anatomy.

With the advent and subsequent refinement of gray scale compound scanning, we are now able to obtain in utero a more detailed look at the size, shape position, and anatomical relationships between the internal organs and vasular structures within the body of a fetus. It is now possible to visualize fetal intracranial structures, lungs, myocardium and valvular structures, liver, spleen, stomach, abdominal aorta, portal venous system, gall bladder, umbilical vein, kidneys, urinary bladder, and genitalia. Fetal extremities, including individual phalanges, are better visualized with gray scale than with bistable sonography.     

Pitfalls in diagnostic imaging and assessment of benign asbestos-related thoracic diseases

The recognition of asbestos-related diseases of the lung and/or pleura as an occupational disease is of psychosocial, medical and legal importance to the insured person. Radiological imaging is an essential part of the assessment and requires an increasingly high level of competence in the field of radiological diagnosis of pneumoconiosis in interdisciplinary collaboration with occupational medicine and pneumonology. The chest radiogram remains an integral part of basic diagnostic procedures in asbestos-related diseases of the lungs and/or pleura. Its importance lies in the detection of extended pleural changes as well as substantial fibrosis. The inherent low sensitivity and specificity of projection radiography is taken into account by the increasing use of multi-slice high resolution (HR) CT (in low dose technique). Radiological pitfalls in pleural plaque assessment with respect to plain chest X-ray concern all structures that superimpose on the pleural circumference, particularly the anatomical layers of the chest wall (extra-pleural fatty tissue, muscles, thoracic skeleton) as well as other pulmonary findings that can only be reliably assigned using CT. Even if state-of the-art CT is applied, asymmetries and abnormal expression of anatomical structures and variants (e. g. muscles and blood vessels) can lead to false-positive findings. The interstitial fibrosis of asbestosis, manifested as usual interstitial pneumonia (UIP) is non-pathognomonic for asbestosis. Therefore, parietal pleural thickening as a coincident finding to UIP is considered as being the main feature and a highly suggestive indicator of asbestosis in patients with a history of asbestos exposure.     

Fetal diffusion imaging: pearls and solutions

ABSTRACT: Recently, diffusion-weighted (DWI) magnetic resonance imaging of the fetus has evolved from a basic research application to an important diagnostic imaging tool in fetal magnetic resonance imaging. Although technically challenging and still plagued with several sources of artifacts, DWI can add clinically important information, which cannot be provided by any other prenatal imaging modality. Its potential to noninvasively probe tissue structures on the basis of Brownian molecular motion enables the detection of early changes associated with acute fetal diseases, as well as structural alterations of functionally diverse compartments of different fetal organs. In this article, the current clinical applications of fetal brain and body DWI are outlined, as well as its current limitations.     

Does Intercostal Stretch Alter Breathing Pattern and Respiratory Muscle Activity in Conscious Adults?

The effects of intercostal (IC) stretch on breathing patterns and respiratory muscle activity were monitored in nine healthy subjects. Tidal volume (V_t), breathing frequency (F_b), and inspiratory (T_i) and expiratory (T_e) durations were determined from a pneumotachometer. Peak amplitudes and burst durations of activity in the diaphragm, parasternal ICs and external abdominal oblique muscles were determined from surface EMGs.The third and eighth IC spaces were stretched in phase with inspiration or expiration when supine and 60° semi recumbent. V_t increased and T_i and T_e were prolonged, resulting in a decreased F_b, independent of site of stretch, phase of breathing, or body position, during IC stretch compared to controls.Peak amplitudes and burst durations of diaphragmatic EMG and burst durations of parasternal ICs were greater when the third and eighth IC spaces were stretched during inspiration compared to controls. Peak amplitudes of parasternal ICs increased only when the third IC space was stretched during inspiration. When applied during expiration, IC stretch increased only parasternal activity in the supine position. Intercostal stretch applied in phase with inspiration resulted in a slower, deeper breathing pattern with increased activity of the diaphragm and parasternal IC muscles. IC stretch may alter breathing sufficiently to improve gas exchange in some patients with pulmonary disorders.     

Management of patellofemoral problems

Patellofemoral pain is often a challenge for the physiotherapist, because of its complex aetiology. Physiotherapists with their understanding of soft tissue structure and muscle function are well positioned to effectively manage most patellofemoral problems by improving the extensibility and mobility of tight structures and improving the timing of the elongated muscles. This will involve recognising the biomechanical factors contributing to the symptoms, adequately explaining to the patient the cause of the symptoms and teaching the patient how to manage the symptoms. Specific training of certain muscles with accurate feedback to change the timing of these muscles during functional and sporting activities will be required if this problem is not to recur.