Patel, Maitray D

US is a valuable tool for assessing ovarian and adnexal lesions but is an operator-dependent modality, and it is crucial to optimize US technique to enhance O-RADS accuracy for reliable characterization and malignancy risk assessment.

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

Objectives Evaluate the value of ultrasound specialist assessment of ovarian masses over 50 mm with sonograms interpreted as possible hemorrhagic ovarian cysts (HOC). Methods Retrospective review of consecutive endovaginal pelvic US reports of premenopausal women at one organization identified adnexal masses over 50 mm maximum diameter designated as possibly being HOC (large HOC). Four ultrasound specialists reviewed studies, scoring two assessments as true or false: 1) US features are most consistent with either an ovarian hemorrhagic cyst (HOC) or endometrioma; 2) If assessment 1 was true, the mass meets O‐RADS criteria of classic HOC except for size. Results A total of 457 of 51,305 women (0.9%) had reports indicating possible large HOC. For 366 patients with established outcomes, 225 (61.5%) had a large HOC (87.1% ≤ 70 mm). Assessment 1 was true for 318 patients; outcomes showed 224 (70.4%) HOC, 89 (28.0%) endometriomas, 4 (1.3%) TOAs, and 1 (0.3%) cystadenoma. Assessment 1 was false for 48 patients; outcomes showed 1 (2.1%) HOC, 1 (2.1%) endometrioma, 6 (12.5%) other non‐neoplastic cysts, 33 (68.8%) benign neoplasms, 5 (10.4%) borderline tumors, and 2 (4.2%) high‐grade malignancies. The decrease in neoplasms and malignancies with true assessment 1 was significant ( p < .001). Assessment 2 was true for 190 patients (180 [94.7%] HOC, 9 [4.7%] endometrioma, 1 [0.5%] cystadenoma), false for 128 patients (44 [34.4%] HOC, 80 [62.5%] endometrioma, and 4 [3.1%] TOA) ( p < .001), and not applicable for 48 patients. Conclusions Ultrasound specialist review of adnexal masses designated as a possible large HOC adds value since over 10% are neoplasms (nearly 2% malignant). Ultrasound specialist assessment can expedite additional imaging or intervention when necessary and obviate follow‐up when HOC features are typical.

ObjectivesTo combine sonographic Murphy sign (SMS) with clinical parameters to effectively stratify patients into risk groups for acute cholecystitis.MethodsConsecutive emergency department patients from April 1, 2019 to August 31, 2022 with possible acute cholecystitis were grouped using patient age, sex, and white blood cell count to determine the rate of acute cholecystitis found in subgroups. Three distinct clinical risk groups were established and then regrouped by prospective assessment of SMS into three non‐imaging risk groups. Differences in the rate of acute cholecystitis for clinical parameters, clinical risk groups, and non‐imaging risk groups were statistically analyzed.ResultsOf 1231 patients (mean [SD] age, 51.2 [19.5]; 476 [38.7%] male), 156 had acute cholecystitis (mean [SD] age, 62.0 [15.4]; 85 [54.5%] male). Rates differed based on sex (9.4% female vs 17.9% male, P < .001), age group (1.8% for patients <30 years, 9.0% for patients 30–59 years, 22.3% for patients ≥60 years; P < .001), and white blood cell count (23.1% elevated vs 6.6% not elevated; P < .001). The low, average, and high non‐imaging risk groups had acute cholecystitis rates of 1.8%, 14.0%, and 43.1%, respectively. Relative risk (95% CI) for the low non‐imaging group compared with others was 0.07 (0.04, 0.12; P < .001); relative risk for the high non‐imaging risk group compared with others was 7.05 (5.32, 9.43; P < .001).ConclusionsSonographic Murphy sign assessment combined with patient age, sex, and white blood cell count effectively stratifies acute care patients into distinct acute cholecystitis risk groups.

Peripheral arterial and venous examinations are performed regularly in vascular labs and interpreted by physicians of different specialities. Many vascular examinations have nonvascular pathology that is either inadvertently imaged by the sonographer or imaged with intent as it relates to patient's symptoms. It is prudent for every reader of vascular studies to be acquainted with the sonographic appearance of these non‐vascular lesions to enable appropriate and optimal interpretation that has a direct bearing on patient's clinical care. Our review includes a discussion of the nonvascular pathologies like lymph nodes, soft tissue edema, soft tissue fluid collections, musculotendinous injuries, soft tissue masses, and joint and bursal pathologies that may be encountered during interpretation of vascular exams. The pictorial essay includes a discussion of their sonographic appearances and pitfalls in interpretation. Multiple illustrative examples and sonographic images of the non‐vascular pathologies found during interpretation of vascular studies have been utilized to highlight their appearances.

ObjectiveWe evaluated the performance of ACR TI‐RADS when points for lobulated margins are applied only when the margins meet a quantified measure of margin microlobulation and not applied when nodules only demonstrate macrolobulation.MethodsWe retrospectively reviewed ultrasound and pathology records (May 01, 2018 to July 31, 2020) to find all thyroid nodules at one institution characterized as having lobulated margins using the ACR TI‐RADS lexicon and subsequently undergoing fine needle aspiration (FNA). Nodule margins were evaluated to note the presence or absence of microlobulation, quantitatively defined as a protrusion with a base <2.5 mm in length. The impact to detection of malignant nodules and avoidance of benign FNA when margin points for lobulation were added only when microlobulated was analyzed.Results58 of 516 thyroid nodules undergoing US‐guided FNA were classified as lobulated, comprising the study population. 21 (36.2%) had microlobulated margins, with 12 of the 21 (57.1%) being malignant. Comparatively, of the 37 nodules showing only macrolobulated margins without microlobulation, only 2 (5.4%) were malignant (P < .0001). For 53 nodules ≥10 mm, 15 (28.3%) benign nodules would not have met size criteria for FNA had points for margins not been applied when only showing macrolobulation, whereas all 10 malignant nodules would still have been sampled.ConclusionAdding two points to the ACR TI‐RADS score for lobulated thyroid nodules should only apply when microlobulations are present.