Effects of Obesity on Axillary Lymph Node Structure: Association of Hilar Fat Deposition and Alterations in Cortex Width.

Introduction: This study aims to evaluate the effects of obesity on the structure of axillary lymph nodes in women with no evidence of breast or axilla pathology. Method: In this prospective study, we documented the body mass index of 204 women who were referred for screening mammography. Two radiologists have independently viewed the mammograms to find the largest axillary lymph node and reported its dimensions. Independent sample T-test was used to evaluate the association of the above indices with participants' body mass index. Associations between indices were investigated using multiple regression analyses. Results: All measurements of axillary lymph nodes and hilo-cortical ratio were significantly increased with increasing body mass index (p<0.001), except for cortex width (p=0.15). There were strong associations (p < 0.001) between increasing hilum length and increasing lymph node length (R²=0.90), increasing hilum width and increasing lymph node width (R²=0.85), and increasing hilum width and decreasing cortex width (R²=0.12). There was no association between cortex width and lymph node width (R²=0.0001). Inter-rater reliability ranged from 0.49 to 0.70. Conclusion: Our study demonstrated that axillary lymph nodes with a bigger hilum width had a smaller cortex width in obese but apparently normal population. Considering the important role of axillary lymph node cortex in their immune function, this may be a cause for immune dysfunction of axillary lymph nodes in obesity and explain the worse prognosis of breast cancer in obese women. The limited number of participants, the 2-dimensional nature of mammograms and the difficulty of measuring the dimensions of axillary lymph nodes using mammography were important limitations of this study. Implications for practice: Obesity may result in structural change and dysfunction of axillary lymph nodes. Dysfunction of axillary lymph nodes may have a role in worse prognosis of breast cancer in obese patients.

Diagnostic value of shear wave sonoelastography in differentiation of benign from malignant thyroid nodules.

PURPOSE: To study the efficacy of shear wave elastography (SWE), using both qualitative and quantitative methods, alone and in conjunction with other B-mode features. METHOD: 117 patients with 123 nodules were studied both by conventional ultrasonography and SWE. Size, echogenicity, margins, internal calcification (micro- or macro-calcification), composition, shape and color Doppler were assessed for each nodule. The elasticity was assessed both qualitatively and quantitatively. Velocity in the ROI (Region of Interest) was calculated in the stiffest portions for 3 times, and maximum and mean velocity were obtained. ROC curve was analyzed to calculate the best cut-off value of the SWV (Shear Wave Velocity). Univariate logistic regression was used to examine the maximum and mean SWV as discrete variables and the results were compared to key variables of conventional US (Ultrasound) features. RESULT: 123 nodules in 117 patients were evaluated. Poor margins, hypoechogenicity, micro-calcification, color Doppler grades III and IV, color map grades IV and V, maximum and minimum velocity had significant correlation with malignancy. The highest Nagelkerke R2 belonged to maximum and mean velocity (R2 = 41.2 and 39 respectively) which propose them as the strongest predictors of malignancy. The best cut-off point for differentiation of benign from malignant nodules was 3.63 m/s for maximum velocity (sensitivity of 90 %, specificity of 78.2 %,) and 3.44 m/s for mean velocity (sensitivity of 90 %, specificity of 76.4 %). CONCLUSION: The Real-time SWE is a promising test for the preoperative malignancy risk stratification of patients and maximum velocity has the strongest predictive value for both conventional and elastography variables.

Proximal Tibiofibular Joint Inclination Angle and Associated Meniscal Tear in Patients with Discoid Lateral Meniscus.

Background and objectives:Discoid lateral meniscus (DLM) is the most common congenital variant of a meniscus with a high prevalence meniscal tear due to abnormal shape and behavior. The proximal tibiofibular joint (PTFJ) has an important role during knee extension and ankle dorsiflexion. The aim of this research is to study the association between PTFJ morphology in MRI and DLM and its pathologies as compared with the normal lateral meniscus in Iranian population. Materials and methods:Totally, 1729 MRI scans were reviewed, and 69 scans were selected based on inclusion/exclusion criteria. A group of aged-matched control patients without DLM were also included in this study. MRI scans were studied for DLM, meniscal tear and PTFJ inclination angle (horizontal or oblique). Findings were compared with those of patients without DLM. Results:The frequency of horizontal-type PTFJ was significantly higher in the DLM group than in the control group. We also found a strong association (p value=0.018) between horizontal-type PTFJ and meniscal tear as compared with oblique-type in patients with DLM. Conclusion:Horizontal-type PTFJ is more prevalent in patients with DLM. The meniscal tear is also more frequently seen in patients with DLM and horizontal-type PTFJ. Larger prospective studies are needed to confirm these results.

Evidence-based prevention and treatment of osteoporosis after spinal cord injury: a systematic review.

PURPOSE: Spinal cord injury (SCI) results in accelerated bone mineral density (BMD) loss and disorganization of trabecular bone architecture. The mechanisms underlying post-SCI osteoporosis are complex and different from other types of osteoporosis. Findings of studies investigating efficacy of pharmacological or rehabilitative interventions in SCI-related osteoporosis are controversial. The aim of this study was to review the literature pertaining to prevention and evidence-based treatments of SCI-related osteoporosis. METHODS: In this systematic review, MEDLINE, EMBASE, PubMed, and the Cochrane Library were used to identify papers from 1946 to December 31, 2015. The search strategy involved the following keywords: spinal cord injury, osteoporosis, and bone loss. RESULTS: Finally, 56 studies were included according to the inclusion criteria. Only 16 randomized controlled trials (involving 368 patients) were found. We found following evidences for effectiveness of bisphosphonates in prevention of BMD loss in acute SCI: very low-quality evidence for clodronate and etidronate, low-quality evidence for alendronate, and moderate-quality evidence for zoledronic acid. Low-quality evidence showed no effectiveness for tiludronate. In chronic SCI cases, we found low-quality evidence for effectiveness of vitamin D3 analogs combined with 1-alpha vitamin D2. However, low-quality inconsistent evidence exists for alendronate. For non-pharmacologic interventions, very low-quality evidence exists for effectiveness of standing with or without treadmill walking in acute SCI. Other low-quality evidences indicated that electrical stimulation, tilt-table standing, and ultrasound provide no significant effects. Very low-quality evidence did not show any benefit for low-intensity (3 days per week) cycling with functional electrical stimulator in chronic SCI. CONCLUSIONS: No recommendations can be made from this review, regarding overall low quality of evidence as a result of high risk of bias, low sample size in most of the studies, and notable heterogeneity in type of intervention, outcome measurement, and duration of treatment. Therefore, future high-quality RCT studies with higher sample sizes and more homogeneity are strongly recommended to provide high-quality evidence and make applicable recommendations for prevention and treatment of SCI-related bone loss.

Does the normal four steps weight-bearing rule predict the need for radiography in cases of blunt ankle trauma?

Background: Ankle injuries are one of the most common complaints of patients presenting to emergency departments (ED). The Ottawa ankle rules (OAR) was introduced to help physicians to decide who may require x-ray for blunt injuries. The present study aimed at validating the four steps weight-bearing rule of OAR as a sole criterion. Methods: This prospective observational study was conducted on 214 patients with acute ankle injury who referred to 3 emergency departments over a 7-months period in 2008. Main outcome measures of this survey included the sensitivity, specificity, positive and negative predictive values, and the likelihood ratios (positive and negative) of the four steps weight-bearing rule. Results: In this study, 34 fractures were found among the patients. The decision rule had a sensitivity of 0.88 and specificity of 0.61 in detecting all midfoot and ankle fractures. Application of this rule by emergency medicine residents resulted in a 47% reduction in the use of midfoot and ankle radiography. Conclusion: Applying a four steps weight-bearing rule as a sole criterion to detect ankle fractures is not as accurate and sensitive as OAR. Solitary application of this rule may lead to an increasing number of missed fractures compared with OAR.

Developing SNOMED-CT for decision making and data gathering: a software prototype for low back pain.

The issue of medical errors is currently a global concern which places a heavy financial and emotional burden on communities. A clinical decision support system (CDSS) is an electronic system designed to support clinical decision making. Considering the increasing importance and use of Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT), we developed SNOMED-CT to implement it more efficiently in making smart history taking, decisions to perform lab tests and imaging, diagnosis and recommendations. To evaluate these capabilities in real clinical problems, a new CDSS was compiled, aimed at supporting decisions on patients with a chief complaint of low back pain (LBP). A number of LBP differential diagnoses as well as some recommended indications and contraindications published by guidelines, were inputted to the database. Future software based on this model would help physicians to do necessary assessments and recommendations and might improve patients' safety.

Preventing motor vehicle crashes related spine injuries in children.

BACKGROUND: Spinal cord injury (SCI) is a devastating event that results in permanent disability for injured children. Among all etiologies of SCI, motor vehicle crashes (MVCs) are the leading cause and account for 29% of all traumatic SCIs in children. We tried to evaluate types and mechanisms of MVC-related spinal column and spinal cord injuries, risk factors, safety issues and legislation. DATA SOURCES: A literature review was performed using PubMed from 1966 to 12th April 2010 with the following key words: children OR pediatric, spine, injury OR trauma, restraint, seat belt, motor vehicle, road OR traffic, collision OR crash, safety. Cross referencing of discovered articles was also performed. RESULTS: Risk factors for MVC-related SCI include single vehicle crashes, vehicle rollover, and ejection of the passenger from the vehicle. Any anatomic region of the spinal cord may be injured as a result of MVC and may vary according to the type of accident and restraint system usage. Increasing use of three-point seat belts, which are more protective than isolated lap seat belts, has decreased the incidence of MVC-related SCI. There is evidence that airbag use without seatbelt use is associated with an increased risk of cervical spine fractures with or without SCI. Vehicle designers need to give more attention to the prevention of vehicle rollover and to improve occupant protection when rollover occurs. CONCLUSIONS: MVC is a common cause of SCI in children; therefore, paying attention to risk factors and modes of prevention is important. As MVC-related SCI can lead to permanent disability, prevention and education play an important role in decreasing childrens' morbidity and mortality. Making behavior, roads and vehicles safer can significantly reduce MVC-related SCI in children.