[Ultrasound in the assessment of muscle mass. The GLIM (Global Leadership Initiative on Malnutrition) criteria called into question (I)]. / Ecografía en la valoración de la masa muscular. Criterios GLIM (Global Leadership Initiative on Malnutrition) a cuestión (I).

Introduction: Ultrasound in the assessment of muscle mass. The GLIM (Global Leadership Initiative on Malnutrition) criteria called into question (I).

Introducción: Ecografía en la valoración de la masa muscular. Criterios GLIM (Global Leadership Initiative on Malnutrition) a cuestión (I).

[Ultrasound in the assessment of muscle mass. The GLIM (Global Leadership Initiative on Malnutrition) criteria called into question (II)]. / Ecografía en la valoración de la masa muscular. Criterios GLIM (Global Leadership Initiative on Malnutrition) a cuestión (II).

Introduction: Ultrasound in the assessment of muscle mass. The GLIM (Global Leadership Initiative on Malnutrition) criteria called into question (II).

Introducción: Ecografía en la valoración de la masa muscular. Criterios GLIM (Global Leadership Initiative on Malnutrition) a cuestión (II).

Evaluation of the use of muscle condition score and ultrasonographic measurements for assessment of muscle mass in dogs.

OBJECTIVE: To evaluate repeatability and reproducibility of muscle condition score (MCS) in dogs with various degrees of muscle loss; to compare MCS, muscle ultrasonographic measurements, and quantitative magnetic resonance (QMR) measurements; and to identify cutoff values for ultrasonographic measurements of muscle that can be used to identify dogs with cachexia and sarcopenia. ANIMALS: 40 dogs of various age, body condition score (BCS), and MCS. PROCEDURES: A prospective cross-sectional study was conducted. Body weight, BCS, QMR measurements, thoracic radiographic measurements, and muscle ultrasonographic measurements were assessed once in each dog. The MCS for each dog was assessed 3 separate times by 4 separate raters. RESULTS: For the MCS, overall κ for interrater agreement was 0.50 and overall κ for intrarater agreement ranged from 0.59 to 0.77. For both interrater and intrarater agreement, κ coefficients were higher for dogs with normal muscle mass and severe muscle loss and lower for dogs with mild and moderate muscle loss. The MCS was significantly correlated with age (r = -0.62), vertebral epaxial muscle score (VEMS; r = 0.71), forelimb epaxial muscle score (FLEMS; r = 0.58), and BCS (r = 0.73), and VEMS was significantly correlated (r = 0.84) with FLEMS. Cutoff values for identification of mild muscle loss determined by use of VEMS and FLEMS were 1.124 and 1.666, respectively. CONCLUSIONS AND CLINICAL RELEVANCE: MCS had substantial repeatability and moderate reproducibility for assessment of muscle mass in dogs. Prospective studies of MCS, VEMS, and FLEMS for assessment of muscle mass in dogs are warranted.

Non-invasive Assessment of Changes in Muscle Injury by Ultrasound Shear Wave Elastography: An Experimental Study in Contusion Model.

The present study investigated the potential of ultrasound shear wave elastography (SWE) in assessment of muscle stiffness in muscle injury. SWE was performed on the injured muscle in 30 New Zealand rabbits that were randomly assigned to three groups: the contusion group, which was not treated with an efficient therapeutic strategy after muscle injury; the treatment group, which was treated with a therapeutic scheme after muscle injury; and the healthy group, which was not injured and served as a control. Both the mean Young's modulus (Emean) and the maximum Young's modulus (Emax) were obtained pre-injury and 0.5, 1, 3, 5, 7, 14 and 28 d post-injury. At these time points, a rabbit in each group was randomly selected for biopsy for histopathological observation as well as comparison with Young's modulus. Eventually, all muscle tissues were collected for histologic analysis of collagen fiber formation. The contusion group had the highest Young's modulus, followed by the treatment group and then the healthy group (p < 0.05). In both the contusion and treatment groups, Emean and Emax gradually increased within 1-3 d after injury, followed by a gradual decrease. Compared with the healthy group, histopathologic analysis of the contusion and treatment groups revealed the myofibril destruction process, inflammatory reaction and myofibril regeneration. The amount of collagen fibers in the contusion group was maximal compared with the treated and healthy groups (p = 0.001 and p < 0.001, respectively). There were more collagen fibers in the treatment group than in the healthy group (p = 0.003). The abundance of collagen fibers was positively correlated with the value of Young's modulus (Emean: r = 0.706, p < 0.001; Emax: r = 0.761, p < 0.001). Thus, SWE can be used to detect pathologic changes in injured muscle and to monitor therapeutic effects.

Assessment of Paraspinal Muscle Cross-sectional Area After Lumbar Decompression: Minimally Invasive Versus Open Approaches.

STUDY DESIGN: A retrospective, blinded analysis of imaging studies. SUMMARY OF BACKGROUND DATA: To evaluate changes in paraspinal muscle cross-sectional area (CSA) after surgical treatment for lumbar stenosis and to compare these changes between minimally invasive and standard open approaches. The open approach to lumbar stenosis is effective, but it involves retraction and resection of muscle from the spinous process, which can result in ischemia and denervation of paraspinal musculature and may lead to muscle atrophy and pain. OBJECTIVE: It is hypothesized that the microendoscopic decompression of stenosis (MEDS) technique will better preserve the paraspinal muscles compared with the open procedure. MATERIALS AND METHODS: A total of 18 patients underwent a 1-level posterior decompression for lumbar stenosis, (9 open, 9 MEDS). Lumbar magnetic resonance imaging was obtained before surgery and after surgery (open approach average 16.3 mo; MEDS average 16.6 mo). CSA of paraspinal muscles were averaged over the distance of the surgical site. RESULTS: The mean age of patients treated with the open and MEDS approaches were 55.2 and 66.4 years, respectively (P=0.07). Paraspinal muscle CSA decreased by an average of 5.4% (SD=10.6%; range, -24.5% to +7.7%) in patients treated with the open approach and increased by an average of 9.9% (SD=14.4%; range, -9.8% to +33.1%) in patients treated with MEDS (P=0.02). For the open approach, changes in CSA did not differ significantly between the left and right sides for erector spinae (P=0.35) or multifidus muscles (P=0.90). After the MEDS approach there were no significant differences between the dilated and contralateral sides with regard to change in CSA for erector spinae (P=0.85) or multifidus muscles (P=0.95). CONCLUSIONS: Compared with the open approach for lumbar stenosis, MEDS had significantly less negative impact on the paraspinal muscle CSA. Previous reports have documented negative effects of paraspinal muscle injury, including weakness, disability, and pain. Collectively, these data suggest that the MEDS approach for lumbar decompression is less destructive to the paraspinous muscles than the open approach and may facilitate better clinical outcomes.

Acute myonecrosis on MRI: etiologies in an oncological cohort and assessment of interobserver variability.

OBJECTIVE: To determine the etiologies of myonecrosis in oncology patients and to assess interobserver variability in interpreting its MRI features. MATERIALS AND METHODS: Pathology records in our tertiary cancer hospital were searched for proven myonecrosis, and MRIs of affected regions in those patients were identified. MRI reports that suggested myonecrosis were also identified. Each MRI was reviewed independently by 2 out of 6 readers to assess anatomical site, size, and signal intensities of muscle changes, and the presence of the previously reported stipple sign (enhancing foci within a region defined by rim enhancement). The stipple sign was assessed again, weeks after a training session. Cohen kappa and percentage agreement were calculated. Medical records were reviewed for contemporaneous causes of myonecrosis. RESULTS: MRI reports in 73 patients suggested the diagnosis of myonecrosis; pathological proof was available in another 2. Myonecrosis was frequently associated with radiotherapy (n = 34 patients, 45 %); less frequent causes included intraoperative immobilization, trauma, therapeutic embolization, ablation therapy, exercise, and diabetes. Myonecrosis usually involved the lower extremity, the pelvis, and the upper extremity; mean size was 13.0 cm. The stipple sign was observed in 55-100 % of patients at first assessment (κ = 0.09-0.42; 60-80 % agreement) and 55-100 % at second (κ = 0.0-0.58; 72-90 % agreement). Enhancement surrounded myonecrosis in 55-100 % patients (κ = 0.03-0.32; 58-70 % agreement). CONCLUSION: Myonecrosis in oncology patients usually occurred after radiotherapy, and less commonly after intraoperative immobilization, trauma, therapeutic embolization, ablation therapy, exercise, or diabetes. Although interobserver variability for MRI features of myonecrosis exists (even after focused training), a combination of findings facilitates diagnosis and conservative management.

Ultrasonographic Assessment of Diaphragm Function in Critically Ill Subjects.

The majority of patients admitted to the ICU require mechanical ventilation as a part of their process of care. However, mechanical ventilation itself or the underlying disease can lead to dysfunction of the diaphragm, a condition that may contribute to the failure of weaning from mechanical ventilation. However, extended time on the ventilator increases health-care costs and greatly increases patient morbidity and mortality. Nevertheless, symptoms and signs of muscle disease in a bedridden (or bed rest-only) ICU patient are often difficult to assess because of concomitant confounding factors. Conventional assessment of diaphragm function lacks specific, noninvasive, time-saving, and easily performed bedside tools or requires patient cooperation. Recently, the use of ultrasound has raised great interest as a simple, noninvasive method of quantification of diaphragm contractile activity. In this review, we discuss the physiology and the relevant pathophysiology of diaphragm function, and we summarize the recent findings concerning the evaluation of its (dys)function in critically ill patients, with a special focus on the role of ultrasounds. We describe how to assess diaphragm excursion and diaphragm thickening during breathing and the meaning of these measurements under spontaneous or mechanical ventilation as well as the reference values in health and disease. The spread of ultrasonographic assessment of diaphragm function may possibly result in timely identification of patients with diaphragm dysfunction and to a potential improvement in the assessment of recovery from diaphragm weakness.

Reliability of contrast-enhanced ultrasound for the assessment of muscle perfusion in health and peripheral arterial disease.

We investigated the reliability of contrast-enhanced ultrasound (CEUS) in assessing calf muscle microvascular perfusion in health and disease. Response to a post-occlusive reactive hyperaemia test was repeated on two occasions >48 h apart in healthy young (28 ± 7 y) and elderly controls (70 ± 5 y), and in peripheral arterial disease patients (PAD, 69 ± 7 y; n = 10, 9 and 8 respectively). Overall, within-individual reliability was poor (coefficient of variation [CV] range: 15-87%); the most reliable parameter was time to peak (TTP, 15-48% CV). Nevertheless, TTP was twice as long in elderly controls and PAD compared to young (19.3 ± 10.4 and 22.0 ± 8.6 vs. 8.9 ± 6.2 s respectively; p < 0.01), and area under the curve for contrast intensity post-occlusion (a reflection of blood volume) was ∼50% lower in elderly controls (p < 0.01 versus PAD and young). Thus, CEUS assessment of muscle perfusion during reactive hyperaemia demonstrated poor reliability, yet still distinguished differences between PAD patients, elderly and young controls.

99mTc-sestamibi thigh SPECT/CT imaging for assessment of myopathy in cerebrotendinous xanthomatosis with histopathological and immunohistochemical correlation.

PURPOSE: The aim of this study was to determine the effectiveness of using Tc-sestamibi thigh SPECT/CT imaging for evaluating myopathy in cerebrotendinous xanthomatosis (CTX). PATIENTS AND METHODS: Four genetically proven CTX patients (Family I, Cases I-1 and I-2; Family II, Cases II-1 and II-2) were included. They all underwent muscle biopsies for histopathologic and ultrastructural studies. Immunohistochemical staining for vinculin expression was also performed. Tc-sestamibi thigh SPECT/CT imaging was conducted on all 4 CTX patients, and both visual interpretation and muscle-to-background (M/B) ratio count were applied for assessment. Correlation analysis of the imaging findings and results of the ultrastructural and immunohistochemical studies was done. RESULTS: In the Tc-sestamibi thigh SPECT/CT imaging study, all 4 CTX cases had abnormal scores of visual interpretation and M/B ratios. The ultrastructural features of the skeletal muscle of the 4 CTX cases showed mitochondrial and membrane system abnormalities, with increased depositions of metabolites. They also had abnormal increases in vinculin expression after immunohistochemical staining of the skeletal muscle. CONCLUSIONS: This is the first report on the use of Tc-sestamibi thigh SPECT/CT imaging to assess the mitochondrial status of CTX. The imaging findings may have a correlation with the ultrastructural and immunohistochemical findings on skeletal muscle. Although the Tc-sestamibi thigh SPECT/CT imaging is not specific for CTX, this noninvasive in vivo assessment can be an important tool for the detection and follow-up study of skeletal muscle involvement in CTX.

Sonoelastography as a diagnostic tool in the assessment of musculoskeletal alterations: a systematic review.

UNLABELLED: Elasticity imaging is a relatively new ultrasound-based technique for investigating musculoskeletal injury. Sonoelastography (SEL), the most commonly used technique, allows determination of the elastic properties of tissue by applying pressure. PURPOSE: To critically evaluate the literature regarding the use of SEL in the diagnosis of tendon and muscle alterations. MATERIALS AND METHODS: This review includes a systematic literature search performed on major electronic databases. Eight articles were included. The GRADE approach was used to evaluate the quality of evidence presented in the included articles and the strength of their recommendations. RESULTS: The results on human tendon disorders showed that the SEL findings correlated extremely well with conventional ultrasound (US) findings as well as with magnetic resonance imaging (MRI) and clinical examination. In some articles SEL was found to be even more sensitive than conventional ultrasound and in addition capable of identifying subclinical alterations that conventional ultrasound could not. For skeletal muscle, a close correlation between SEL and US and MRI was found, although there is only one article on the topic. SEL was found to be able to distinguish between healthy and diseased muscles and was potentially more sensitive in identifying early dystrophic changes than US or MRI. CONCLUSION: Based on this critical evaluation of the literature, SEL seems to be at least as feasible as US and MRI for assessing tendon alterations and able to identify subclinical tendon alterations not visible with conventional US.  The findings in the reviewed articles suggest that SEL could become a supplementary imaging technique in the assessment of musculoskeletal alterations, potentially superior to US and MRI. Until more studies are available, SEL has to be viewed as an experimental examination without sufficient supporting evidence to be used as a routine examination equivalent to US and MRI.

Visual assessment of segmental muscle ultrasound images in spina bifida aperta.

In spina bifida aperta (SBA), spinal MRI provides a surrogate marker to estimate muscle damage caudal to the myelomeningocele (MMC). This muscle damage by the MMC can be quantified by intra-individual comparison of muscle ultrasound density (MUD) caudal versus cranial to the MMC (dMUD = [MUD(caudal-to-the-MMC)] - [MUD(cranial-to-the-MMC)]). Quantitative dMUD assessment requires time, equipment and expertise, whereas it could also be visually determined by differences in muscle echodensity caudal vs. cranial to the MMC (visual-dMUD). If visual and quantitative dMUD correspond, visual dMUD assessment could provide a clinical screening parameter. In 100 SBA muscle ultrasound recordings of patients with various MMC levels, we aimed to compare quantitative dMUD (dMUD = [MUD(calf-muscle/S1)] - [MUD(quadriceps-muscle/L2-L4)]) with visual dMUD assessments by 20 different observers. Results indicate that quantitative dMUD can be visually detected (sensitivity 86%; specificity 57%), implicating that visual dMUD screening could provide a quick, clinical screening tool for muscle impairment by the MMC.

An assessment of between-recti distance and divarication in patients with and without abdominal aortic aneurysm.

INTRODUCTION: The study assessed whether there is a greater incidence of divarication of the recti and whether between-recti distance is greater in patients with abdominal aortic aneurysm (AAA). PATIENTS AND METHODS: The study consisted of two parts: a radiological and a clinical assessment. All patients with a confirmed AAA on computerised tomography were included and compared with patients in whom AAA was excluded with imaging. Between-recti distance was measured using a computerised image viewer and clinical divarication was assessed by a surgical registrar or consultant. RESULTS: In the radiological part of the study, 108 patients with AAA were compared with 84 with colorectal cancer. Median between-recti distance was 38 mm (range, 25-59 mm) in the AAA group and 27 mm (range, 20-44.5 mm) in the non-AAA group (P=0.006). AAA diameter did not correlate with between-recti distance. The clinical study included 50 patients (25 AAA). The groups were well matched, with only a greater incidence of diabetes in the AAA group (20% vs 0%; P=0.018). AAA patients were more likely to have clinically detected divarication of the recti (76% vs 36%; P=0.004). CONCLUSIONS: Patients with AAA have greater radiological and clinical evidence of divarication. It is suggested that patients with divarication be screened for AAA.

Assessment of pelvic floor muscle function in women with and without low back pain using transabdominal ultrasound.

Pelvic floor muscle (PFM) dysfunction has been recently associated with the development of low back pain (LBP). Transabdominal ultrasound imaging has been established as an appropriate method for visualizing and measuring PFM function. No study has directly evaluated PFM function in individuals with and without LBP. The purpose of this study was to investigate the PFM function in women with and without LBP using transabdominal ultrasound. Convenience sample of 40 non-pregnant female participated in the study. Subjects were categorized into two groups: with LBP (n = 20) and without LBP (n = 20). The amount of bladder base movement on ultrasound (normalized to body mass index) was measured in all subjects and considered as an indicator of PFM function. Statistical analysis (Independent t-test) revealed significant difference in transabdominal ultrasound measurements for PFM function between the two groups (P = 0.04, 95% CI of difference: 0.002-0.27). The results of this study indicate PFM dysfunction in individuals with LBP compared to those without LBP. The results could be beneficial to clinicians when assessing and prescribing therapeutic exercises for patients with LBP.

Quantitative assessment of fatty degeneration in rotator cuff muscles determined with computed tomography.

OBJECTIVES: Reliable assessment of fatty degeneration of rotator cuff muscles is desirable to predict the outcome of shoulder surgery. Currently used qualitative assessments are limited by relatively high inter- and intraobserver variability. It was hypothesized that a quantitative measurement of muscle density using computed tomography (CT) was more reliable and reproducible. MATERIALS AND METHODS: Thirty shoulders from patients with rheumatoid arthritis were analyzed using parasagittal multiplanar reconstructions acquired from a 16-slice CT scanner. Three observers visually rated the severity of fatty degeneration and independently outlined the rotator cuff muscles, after which the mean density was calculated. Inter- and intraobserver agreement on both measurements was expressed by the interclass correlation coefficient (ICC) and the standard deviation of the differences (SDD) between the measurements. RESULTS: A strong correlation was found between the quantitative measure and the visual rating (R2 = 0.94; P < 0.0001). The SDD in muscle density did not exceed 2.3 Hounsfield units, and the mean rotator cuff ICC (0.98) was substantially greater than that of the visual rating (0.63). CONCLUSIONS: This study describes a reproducible method to quantify fatty degeneration of the rotator cuff muscles in CT images, with a higher interobserver agreement than the visual score, and may prove a reliable tool to evaluate the quality of the rotator cuff muscles.

MR imaging versus alternative imaging techniques.

MR imaging is the method of choice in evaluating a large number of soft-tissue abnormalities; however, it has certain draw-backs, some of which may make other imaging methods more suitable. MR imaging is more expensive than alternative imaging methods; it may not be affordable for screening purposes and for diagnoses obtainable by less expensive imaging methods. In addition, immediate scheduling is not always possible for MR imaging, and an MR scanner may not be available close to the patient's home, which may be important for imaging follow-up. These factors support the use of other imaging modalities, with sonography frequently being the appropriate choice. In some situations, mainly in the presence of certain biomedical implants and devices, MR imaging is contraindicated. Additionally, under some circumstances patient access may be difficult during MR imaging; sonography and CT therefore are preferable (as for imaging guided biopsy). Moreover, some artifacts, such as motion artifacts, may have less relevance in other imaging methods (such as sonography), which may be important in noncooperative patients and children. MR imaging may not be specific in tumors and infection; this deficiency is shared with most alternative imaging methods, with the exception of scintigraphy in selected indications. Lastly, standard radiography and CT commonly are superior to MR imaging in diagnosing calcification and abnormalities of cortical bone. Consequently, in selected cases and for screening purposes, methods other than MR imaging should be considered for depicting soft-tissue structures.

CT muscle imaging and the clinical assessment of neuromuscular disease.

Twenty patients with neurogenic disorders, polymyositis, or muscular dystrophies were assessed clinically and by CT imaging of limb, limb girdle, and trunk muscles, using a standard protocol. On each side of these patients 26 movements were graded by the MRC scale, and 20 muscles were assessed by CT imaging. The clinical and CT findings could be compared, in a blind evaluation, in 10 muscles on each side. A quantitative assessment of the CT muscle images were also made. The CT images showed striking abnormalities, even in many muscles of normal strength by clinical testing. Asymmetrical involvement of muscles was found in all the disorders studied, even when not suspected on clinical examination. Muscles in patients with muscular dystrophy were more abnormal than those in patients with neurogenic disorders. In polymyositis the attenuation values were intermediate to the other two groups. A "washed-out" appearance with very low attenuation values was very suggestive of muscular dystrophy. Involvement of paraspinal and rectus abdominis muscles was uncommon in neurogenic disorders. The gracilis muscle was relatively resistant to degeneration. CT imaging can enhance the clinical assessment of patients with neuromuscular disease, often revealing unexpected abnormalities.

[Echographic assessment of the hand: normal anatomy and pathologic patterns]. / Studio ecografico della mano: anatomia normale e quadri patologici.

Ultrasonography (US) can ben used to study the hand thanks to small-parts probes whose frequency ranges 7.5 MHz to 20 MHz. Due to the complex hand anatomy, the clinician often needs further data relative to periskeletal soft tissues and vessels, which are provided by color Doppler US. Our personal series included 465 patients and a group of 20 healthy volunteers. A silicon pad was used to ensure max. adhesion to probe surface, given the uneven surface of the examined structures. Besides normal anatomic patterns, US demonstrated pathologic features in tendons, sheaths and muscles. As for tendons, stenosing and hypertrophic-exudative tenosynovites were depicted, as well as cysts and ruptures. As for muscles, the main findings were ruptures and, rarely, tumors. Relative to joints, arthrogenous ganglia and rheumatism were observed. Finally, the carpal tunnel syndrome was accurately investigated, where US revealed tenovaginalitis with sheath thickening and deformed and compressed median nerve in the carpal tunnel. Also the benign and malignant masses whose primary location is the nervous tissue are easily demonstrated on US, their typical shape being ovalar. To conclude, US proved extremely accurate in all the surgical patients, exhibiting 100% sensitivity in all of them; its specificity ranged from 84% for tendons, to 81% for muscles, 79% for nervous tissues and finally 82% for joint disorders.