ABSTRACT Objective We aimed to share our experience in implementing a structured system for COVID-19 lung findings, elucidating key aspects of the lung ultrasound score to facilitate its standardized clinical use beyond the pandemic scenario. Methods Using a scoring system to classify the extent of lung involvement, we retrospectively analyzed the ultrasound reports performed in our institution according to COVID-RADS standardization. Results The study included 69 thoracic ultrasound exams, with 27 following the protocol. The majority of patients were female (52%), with ages ranging from 1 to 96 years and an average of 56 years. Classification according to COVID-RADS was as follows: 11.1% in category 0, 37% in category 1, 44.4% in category 2, and 7.4% in category 3. Ground-glass opacities on tomography correlated with higher COVID-RADS scores (categories 2 and 3) in 82% of cases. Ventilatory assessment revealed that 50% of cases in higher COVID-RADS categories (2 and 3) required second-line oxygen supplementation, while none of the cases in lower categories (0 and 1) utilized this support. Conclusion Lung ultrasound has been widely utilized as a diagnostic tool owing to its availability and simplicity of application. In the context of the pandemic emergency, a pressing need for a focused and easily applicable assessment arose. The structured reporting system, incorporating ultrasound findings for stratification, demonstrated ease of replicability. This system stands as a crucial tool for screening, predicting severity, and aiding in medical decisions, even in a non-pandemic context. COVID19 COVID 19 COVID-1 scenario involvement COVIDRADS RADS standardization 6 exams protocol 52%, 52 52% , (52%) 9 5 follows 111 11 11.1 0 37 444 44 4 44.4 74 7 7.4 3 Groundglass Ground glass 82 50 ( secondline second line supplementation support application emergency arose stratification replicability screening severity decisions nonpandemic non COVID1 COVID- (52% 11. 44. 7. 8 (52 (5

ABSTRACT Objective: Abdominal ultrasonography is widely used to evaluate suspected cases of appendicitis. Objective descriptions of the direct and indirect signs of appendicitis result in varied assessments of its likelihood. This study introduces the Appendix Imaging Reporting and Data System (APENDIC-RADS) to standardize the reporting of appendix ultrasound findings. Methods: This single-center retrospective study included consecutive patients of all ages who underwent abdominal ultrasonography for the investigation of acute appendicitis. The primary outcome was histopathological confirmation of acute appendicitis post-surgery. The imaging findings were classified into five categories: APENDIC-RADS 0, where the appendix cannot be visualized; APENDIC-RADS 1, indicating a normal appendix; APENDIC-RADS 2, describing an appendix that is likely normal but only partially visualized; APENDIC-RADS 3, appendicitis cannot be ruled out due to uncertain features and APENDIC-RADS 4, acute appendicitis. Results: A total of 747 patients were assessed for suspected acute appendicitis using ultrasonography. Of the diagnosed patients, 52% were male, primarily exhibiting symptoms such as nausea and/or vomiting (60%), right iliac fossa pain (54%), and sudden decompression in the right iliac fossa (24%). Stratification into APENDIC-RADS categories revealed a significant variation in the incidence of acute appendicitis, with incidence rates of 4.5% for category 0 and 0.7%, 2.2%, 11.5%, and 93.5% for categories 1 to 4, respectively (p<0.001). The APENDIC-RADS showed excellent discriminative ability, evidenced by an area under the receiver operating characteristic curve of 0.950 (95%CI=0.899-1). Conclusion: APENDIC-RADS categorization demonstrated excellent performance in standardizing the ultrasound-determined probability of acute appendicitis. Its implementation could improve physician communication and standardization of patient management. likelihood APENDICRADS APENDIC RADS (APENDIC-RADS Methods singlecenter single center postsurgery. postsurgery post surgery. surgery post-surgery visualized 2 3 4 Results 74 52 male andor or 60%, 60 60% , (60%) 54%, 54 54% (54%) 24%. 24 24% . (24%) 45 5 4.5 07 7 0.7% 22 2.2% 115 11 11.5% 935 93 93.5 p<0.001. p0001 p p<0.001 001 (p<0.001) ability 0950 950 0.95 95%CI=0.8991. 95CI08991 CI 95%CI=0.899 95 899 (95%CI=0.899-1) Conclusion ultrasounddetermined determined management 6 (60% (54% (24% 4. 0.7 2.2 11.5 9 93. p000 p<0.00 00 (p<0.001 095 0.9 8991 95%CI=0.8991 95CI0899 95%CI=0.89 89 (95%CI=0.899-1 (60 (54 (24 0. 2. 11. p00 p<0.0 (p<0.00 09 95CI089 95%CI=0.8 8 (95%CI=0.899- (6 (5 (2 p0 p<0. (p<0.0 95CI08 95%CI=0. (95%CI=0.899 ( p<0 (p<0. 95CI0 95%CI=0 (95%CI=0.89 p< (p<0 95CI 95%CI= (95%CI=0.8 (p< 95%CI (95%CI=0. (p (95%CI=0 (95%CI= (95%CI

ABSTRACT A 2-year-old female patient, admitted in the emergency room, presented diarrhea for 5 days and bloody stools in the last 24 hours. Physical examination revealed no significant findings. Ultrasound was initially performed, showing an elongated, well delimited and solid mass occupying since right hypocondrium until left iliac fossa, displacing adjacent structures. In sequence, magnetic resonance imaging was performed for confirmation of findings suggestive of omentum lipoma. After 1 week, the surgical resection was performed by videolaparoscopic acess. During 2-year follow-up, there was no sign of recurrence.

ABSTRACT Objective To stratify ultrasound samples in a pediatric population undergoing evaluation for acute appendicitis to examine the variability in cecal appendix diameter, in different age groups, and to determine whether there is a prevalent value for each age group. Methods A retrospective cross-sectional study with 196 children aged 0 to 15 years. Data were extracted from reports of ultrasound examinations carried out between 2008 and 2015. Children with sonographic diagnosis of appendicitis or other signs of periappendiceal inflammation were excluded. Results The evaluation of the anteroposterior measurement of the cecal appendix revealed a mean diameter of 4.14mm (standard deviation: 0.93mm; 95%CI: 3.86-4.14). Cecal appendix diameter did not differ significant between age groups. Conclusion Evaluation of the anteroposterior diameter of the cecal appendix in centimeters in a sample of 196 children aged 0 to15 years revealed a mean diameter of 4.14mm (standard deviation, 0.93mm. There were no significant differences in cecal appendix diameter following stratification by age. Results indicate a single value can be adopted for mean cecal appendix diameter in pediatric populations.

ABSTRACT Objective To determine whether the size of thyroid nodules in ACR-TIRADS ultrasound categories 3 and 4 is correlated with the Bethesda cytopathology classification. Methods Thyroid nodules (566) subclassified as ACR-TIRADS 3 or 4 were divided into three size categories according to American Thyroid Association guidelines. The frequency of different Bethesda categories in each size range within ACR-TIRADS 3 and 4 classifications was analyzed. Results Most nodules in both ACR-TIRADS classifications fell in the Bethesda 2 category, regardless of size (90.8% and 68.6%, ACR-TIRADS 3 and 4 respectively). The prevalence of Bethesda 6 nodules in the ACR-TIRADS 4 group was 14 times higher than in the ACR-TIRADS 3 group. There were no significant differences between nodule size and fine needle aspiration biopsy classification in any of the ACR-TIRADS categories. Conclusion Size does not appear to be an important criterion for indication of fine needle aspiration biopsy in thyroid nodules with a high suspicion of malignancy on ultrasound examination.

RESUMO Paciente de 34 anos, do sexo feminino, grávida, chega ao pronto-socorro com queixa de dor na fossa ilíaca direita piorando nos últimos 2 dias com suspeita de apendicite aguda. Foram solicitados exames laboratoriais, que estavam dentro dos limites de normalidade para aspectos infecciosos e inflamatórios. Exame de imagem também foi solicitado, sendo a ultrassonografia o método de escolha, que revelou gravidez em curso sem alterações e espessura da parede do apêndice sem sinais inflamatórios. Ainda com suspeita de apendicite aguda, foi realizada ressonância magnética, confirmando a hipótese de lipomatose do apêndice cecal.

ABSTRACT A 34-years-old pregnant woman admitted in the emergency unit complaining about worsening right iliac fossa pain for 2 days. Acute appendicitis was the suspected diagnosis. Laboratory exams were ordered and results were within normal limits for infectious and inflammatory aspects. Ultrasound scan revealed a pregnancy in course without alterations and a thickness of the appendix wall without inflammatory signs in the surrounding tissue. Because the suspicion of acute appendicitis remained, a magnetic resonance was done and confirmed the diagnosis of a cecal appendix lipomatosis.

RESUMO Objetivo: Avaliar os fatores anatômicos e a experiência do radiologista na detecção de massas renais sólidas na ultrassonografia. Métodos: Buscamos massas renais sólidas diagnosticadas em imagens seccionais, de 2007 a 2017, que também tivessem ultrassonografia prévia nos últimos 6 meses. As seguintes características foram avaliadas: tamanho do nódulo, lateralidade, localização e padrão de crescimento, índice de massa corporal do paciente e experiência do radiologista em ultrassonografia. Nos casos com ressecção cirúrgica, os laudos de patologia foram analisados. O teste t não pareado e o teste χ2 foram utilizados para avaliar as diferenças entre os subgrupos, usando R-statistics. A significância estatística foi estabelecida em p<0,05. Resultados: A pesquisa inicial de nódulos renais achados em imagens seccionais resultou em 428 lesões, com 266 exclusões. A coorte final incluiu 162 lesões e, destas, 108 (67%) foram detectadas corretamente na ultrassonografia (Grupo 1), e 54 (33%) não foram identificadas (Grupo 2). A comparação dos Grupos 1 e 2 mostrou índice de massa corporal (27,7 versus 27,1; p=0,496), tamanho (2,58cm versus 1,74cm; p=0,003), lateralidade (54% versus 59% no lado direito; p=0,832), localização (27% versus 22% no polo superior; p=0,869), padrão de crescimento (25% versus 28% endofítico; p=0,131) e experiência do radiologista (p=0,300). A histologia disponível para o Grupo 1 foi carcinoma renal de células claras (n=11), papilar (n=15), cromófobo (n=2), oncocitoma (n=1), e, para o Grupo 2, carcinoma renal de células claras (n=7), papilar (n=5), oncocitoma (n=2), angiomiolipoma, cromófobo e pielonefrite intersticial (n=1, cada). Conclusão: O tamanho foi o único parâmetro significativo relacionado à detecção de nódulos renais no ultrassom.

ABSTRACT Objective: To evaluate anatomic factors and radiologist's experience in the detection of solid renal masses on ultrasonography. Methods: We searched for solid renal masses diagnosed on cross-sectional imaging from 2007 to 2017 that also had previous ultrasonography from the past 6 months. The following features were evaluated: nodule size, laterality, location and growth pattern, patient body mass index and radiologist's experience in ultrasound. In surgically resected cases, pathologic reports were evaluated. Unpaired t test and χ2 test were used to evaluate differences among subgroups, using R-statistics. Statistical significance was set at p<0.05. Results: The initial search of renal nodules on cross-sectional imaging resulted in 428 lesions and 266 lesions were excluded. Final cohort included 162 lesions and, of those, 108 (67%) were correctly detected on ultrasonography (Group 1) and 54 (33%) were missed (Group 2). Comparison of Groups 1 and 2 were as follows, respectively: body mass index (27.7 versus 27.1; p=0.496), size (2.58cm versus 1.74cm; p=0.003), laterality (54% versus 59% right sided; p=0.832), location (27% versus 22% upper pole; p=0.869), growth pattern (25% versus 28% endophytic; p=0.131) and radiologist's experience (p=0.300). From surgically resected cases, histology available for Group 1 was clear cell (n=11), papillary (n=15), chromophobe (n=2) renal cell carcinoma, oncocytoma (n=1), and, for Group 2, clear cell (n=7), papillary (n=5) renal cell carcinoma, oncocytoma (n=2), angiomyolipoma, chromophobe renal cell carcinoma, and interstitial pyelonephritis (n=1, each). Conclusion: Size was the only significant parameter related to renal nodule detection on ultrasound.

RESUMO Objetivo: Avaliar o desempenho da ultrassonografia na avaliação dos ligamentos do cotovelo, comparando os achados com ressonância magnética. Métodos: Estudo prospectivo unicêntrico envolvendo 30 pacientes, sem alterações articulares nos cotovelos. Dois ultrassonografistas experientes avaliaram ambos os cotovelos de cada um dos pacientes, com 60 avaliações cada médico e 120 avaliações no total. As imagens de ressonância magnética foram obtidas em aparelhos 3 Tesla. Dois radiologistas experientes avaliaram as imagens, com total de 120 exames. Cada examinador deu uma nota subjetiva, de zero a 5, para os ligamentos avaliados; zero correspondeu a ligamento não identificado, e 5 a ligamento visualizado integralmente. Foi considerado nível de significância de 5%. Para cada par de medidas obtidas, construíram-se dispersões e parcelas de Bland-Altman. Resultados: Todos os ligamentos foram identificados pelos examinadores de ultrassonografia, recebendo pontuação 4 ou 5, em relação à sua visibilidade, e foram identificados pelos examinadores de ressonância magnética, com pontuação 5. Foram considerados intactos e saudáveis pelos quatro examinadores. As comparações entre ultrassonografia e ressonância magnética na avaliação dos ligamentos do cotovelo não demostraram diferenças significativas. Conclusão: Quando realizada por examinadores experientes, a ultrassonografia pode ser considerada semelhante à ressonância magnética na avaliação de ligamentos do cotovelo.

ABSTRACT Objective: To determine the value of ultrasonography in elbow ligament assessment compared to magnetic resonance imaging. Methods: A prospective single-center study involving 30 volunteers with no elbow joint changes. Two experienced ultrasound specialists evaluated both elbows of each volunteer, resulting in 60 evaluations per physician and totaling up 120 evaluations. Magnetic resonance images were obtained using a 3-Tesla machine and evaluated by two experienced radiologists, totaling up 120 exams. Each examiner assigned subjective, zero-to-5 scores to ligaments imaged, where zero corresponded to non-identified ligament and 5 to visualization of the entire ligament. The level of significance was set at 5%. Bland-Altman dispersions and plots were prepared for each pair of measurements obtained. Results: All ligaments were amenable to sonographic identification; scores of 4 or 5 were assigned by examiners based on ligament visibility. Ligaments could also be identified using magnetic resonance imaging and were assigned scores of 5 by examiners. All ligaments were described as intact and healthy by all four examiners. Comparative analysis of elbow ligament sonographic and magnetic resonance imaging findings did not differ significantly. Conclusion: Ultrasonography and magnetic resonance imaging can be considered equivalent modalities for elbow ligament assessment in the hands of experienced examiners.

Resumo As emergências envolvendo a região inguinal e o escroto são frequentes, derivadas de diferentes causas, e na maioria das vezes apresentam-se clinicamente de modo não específico e bastante dolorosas. Algumas destas condições apresentam elevado potencial de gravidade, sendo imperioso um diagnóstico rápido e preciso. A ultrassonografia é, indiscutivelmente, o método de escolha na avaliação inicial de todo o vasto leque de doenças nessas regiões, sendo rápido, de baixo custo e sem uso de radiação. Além da praticidade e acurácia do método, ideal para a prática em âmbito de pronto-atendimento, a experiência do examinador, o qual deve estar familiarizado com os principais achados de imagem, é fundamental para a precisão diagnóstica. Some-se a isto a necessidade de um relatório claro e assertivo, auxiliando o médico emergencista na terapêutica apropriada a cada caso, seja clínica ou cirúrgica. Procuramos trazer uma revisão baseada nos achados de imagem das principais afecções dolorosas inguinais e escrotais, discutindo os pontos-chaves para sua adequada caracterização.

Abstract Emergencies involving the inguinal region and scrotum are common and can be caused by a plethora of different causes. In most cases, such conditions have nonspecific symptoms and are quite painful. Some inguinoscrotal conditions have high complication rates. Early and accurate diagnosis is therefore imperative. Ultrasound is the method of choice for the initial evaluation of this vast range of conditions, because it is a rapid, ionizing radiation-free, low-cost method. Despite the practicality and accuracy of the method, which make it ideal for use in emergency care, the examiner should be experienced and should be familiarized with the ultrasound findings of the most common inguinoscrotal diseases. On the basis of that knowledge, the examiner should also be able to make an accurate, direct, precise report, helping the emergency room physician make decisions regarding the proper (clinical or surgical) management of each case. Here, we review most of the inguinoscrotal conditions, focusing on the imaging findings and discussing the critical points for the appropriate characterization of each condition.

RESUMO O exame ultrassonográfico do tórax avançou nas últimas décadas, sendo utilizado para o diagnóstico de inúmeras condições patológicas, e fornecendo informações qualitativas e quantitativas. Os pulmões aerados e o arcabouço ósseo do tórax representam barreira sonora para o estudo ultrassonográfico, gerando artefatos que, bem conhecidos, são utilizados como ferramentas diagnósticas. Eco pleural normal, linhas A, linhas B, linhas C, linhas E e Z (conhecidas como falsas linhas B) são artefatos com características peculiares. Os padrões de consolidação e de pneumotórax também são bem estabelecidos. Alguns protocolos têm sido utilizados no manuseio dos pacientes: Blue Protocol, Protocolo FALLS e Protocolo C.A.U.S.E são exemplos de três propostas que, por meio da associação entre os artefatos, permitem sugerir diagnósticos precisos. A ultrassonografia de tórax, aliada à radiografia de tórax, muitas vezes é suficiente para o diagnóstico e a conduta das afecções pulmonares e da parede torácica. Trata-se de ferramenta diagnóstica de grande valia para médicos radiologistas, emergencistas e intensivistas.

ABSTRACT Ultrasound examination of the chest has advanced in recent decades. This imaging modality is currently used to diagnose several pathological conditions and provides qualitative and quantitative information. Acoustic barriers represented by the aerated lungs and the bony framework of the chest generate well-described sonographic artifacts that can be used as diagnostic aids. The normal pleural line and A, B, C, E and Z lines (also known as false B lines) are artifacts with specific characteristics. Lung consolidation and pneumothorax sonographic patterns are also well established. Some scanning protocols have been used in patient management. The Blue, FALLS and C.A.U.S.E. protocols are examples of algorithms using artifact combinations to achieve accurate diagnoses. Combined chest ultrasonography and radiography are often sufficient to diagnose and manage lung and chest wall conditions. Chest ultrasonography is a highly valuable diagnostic tool for radiologists, emergency and intensive care physicians.

RESUMO Objetivo Apresentar a correlação entre o Thyroid Imaging Reporting and Data System (TI-RADS) e o sistema Bethesda, para relatar citopatologia em 1.000 nódulos tireoidianos. Métodos Estudo retrospectivo realizado no período de novembro de 2011 a fevereiro de 2014, que avaliou 1.000 nódulos tireoidianos de 906 pacientes submetidos a exame de ultrassonografia e à punção aspirativa por agulha fina. Resultados Observou-se associação significativa entre o TI-RADS e o resultado da classificação de Bethesda (p<0,001). A maioria dos indivíduos com TI-RADS 2 ou 3 teve resultado citológico Bethesda 2 (95,5% e 92,5%, respectivamente). Entre aqueles classificados TI-RADS 4C e 5, a maioria teve resultado Bethesda 6 (68,2% e 91,3%, respectivamente; p<0,001). A proporção de malignidades em TI-RADS 2 foi 0,8% e em TI-RADS 3 foi 1,7%. Entre TI-RADS 4A, foi de 16,0%, 43,2% em 4B, 72,7% em 4C e em 5 foi de 91,3% (p<0,001), mostrando clara associação entre o TI-RADS e os resultados da biópsia. Conclusão O TI-RADS é apropriado para avaliar nódulos da tireoide e evitar punção aspirativa por agulha fina desnecessária, além de auxiliar na decisão sobre quando este procedimento deve ser realizado.

ABSTRACT Objective To correlate the Thyroid Imaging Reporting and Data System (TI-RADS) and the Bethesda system in reporting cytopathology in 1,000 thyroid nodules. Methods A retrospective study conducted from November 2011 to February 2014 that evaluated 1,000 thyroid nodules of 906 patients who underwent ultrasound exam and fine needle aspiration. Results A significant association was found between the TI-RADS outcome and Bethesda classification (p<0.001). Most individuals with TI-RADS 2 or 3 had Bethesda 2 result (95.5% and 92.5%, respectively). Among those classified as TI-RADS 4C and 5, most presented Bethesda 6 (68.2% and 91.3%, respectively; p<0.001). The proportion of malignancies among TI-RADS 2 was 0.8%, and TI-RADS 3 was 1.7%. Among those classified as TI-RADS 4A, proportion of malignancies was 16.0%, 43.2% in 4B, 72.7% in 4C and 91.3% among TI-RADS 5 (p<0.001), showing clear association between TI-RADS and biopsy results. Conclusion The TI-RADS is appropriate to assess thyroid nodules and avoid unnecessary fine needle aspiration, as well as to assist in making decision about when this procedure should be performed.

OBJETIVO: Avaliar a eficácia da ultrassonografia com contraste de microbolhas no diagnóstico do carcinoma hepatocelular e comparar seus resultados com os de ressonância magnética e anatomia patológica. MÉTODOS: Foram avaliados 29 hepatopatas crônicos candidatos ao transplante pelo programa de transplante hepático do Hospital Israelita Albert Einstein. Esses pacientes foram submetidos a ressonância magnética, ultrassonografia com contraste de microbolhas e biópsia hepática excisional. RESULTADOS: Houve concordância ótima entre os resultados da ultrassonografia com contraste de microbolhas e aqueles da ressonância magnética. Notou-se concordância moderada entre os resultados obtidos pelos dois métodos, quando comparados com os resultados de anatomia patológica. CONCLUSÃO: A ultrassonografia com contraste de microbolhas mostrou-se um método tão acurado quanto a ressonância magnética na avaliação do carcinoma hepatocelular, resultado corroborado quando realizada a comparação conjunta dos dois métodos com a anatomia patológica.

OBJECTIVES: To evaluate the efficacy of microbubble contrast ultrasound in diagnosis of hepatocellular carcinoma and to compare its results with those of magnetic resonance and histopathology. METHODS: A total of 29 patients suffering from chronic liver diseases and awaiting liver transplants at Hospital Israelita Albert Einstein were subject to magnetic resonance, microbubble contrast ultrasound, and excision liver biopsies. RESULTS: Excellent agreement between magnetic resonance and microbubble contrast ultrasound was observed in this study. There was moderate agreement between both imaging methods and histopathology results. CONCLUSION: Microbubble contrast ultrasound was as accurate as magnetic resonance to evaluate hepatocellular carcinoma. These results were confirmed by comparing both methods to histopathological diagnosis.