Can Subclinical Atherosclerosis Be Assessed More Precisely in Behçet Syndrome Patients by Using a Particular Cutoff Value for Carotid Intima Media Thickness?

OBJECTIVE: Behçet syndrome (BS) is a multisystemic chronic vasculitic disease. Among previous studies, although there are some that showed increased risk of subclinical atherosclerosis in BS, there are also others that showed the opposite. The objective of this study is to evaluate subclinical atherosclerosis in BS by using the cutoff value for intima-media thickness in the 2013 European Society of Cardiology/European Society of Hypertension guideline. METHODS: We conducted a cross-sectional analysis of 100 BS patients and 30 healthy volunteers at a single center in a 4-month period. All ultrasound scans were performed in a blind manner to the clinical assessment, and they were carried out by the same researcher by a B-mode ultrasonography. RESULT: When we grouped the patients based on the presence of subclinical atherosclerosis, the frequency of subclinical atherosclerosis in the BS patients was found to be higher than that in the healthy controls (32% and 7%, respectively; p = 0.006). When a cutoff is used for carotid intima-media thickness, increased atherosclerosis risk is observed in BS patients with vascular involvement (p = 0.043). CONCLUSIONS: Although higher inflammation and increased atherosclerosis in vascular BS patients were expected, this situation was not supported much in previous studies. We think that this may have been caused by mere comparison of numerical data, and usage of a cutoff value could be more significant in distinguishing what is normal and what is abnormal as in several medical parameters.

Warfarin is associated with the risk of vascular calcification in abdominal aorta in hemodialysis patients: a multicenter case-control study.

BACKGROUND: Vascular calcifications (VCs), recognized risk factor for increased mortality, are highly prevalent in hemodialysis (HD) patients. We aimed to investigate the relation between VC and warfarin use with plain radiography. METHODS: VCs were assessed using Adragao (radial and digital) and Kauppila (aortic) scores in 76 HD patients from six centers. Out of a total 711 HD patients, there were 32 (4.5%) who had been treated with warfarin for at least 1 year, and we included 44 control patients. RESULTS: Of the patients, 47% were females, the mean age was 66 ± 9 years, 23% were diabetics, the mean dialysis vintage was 68 ± 38 months. In warfarin group, median Kauppila score was higher than in control group [11 vs 6.5, (25%-75% percentile, 5 vs. 15), p = 0.032] and the percentage of the patients with a Kauppila score of >6 was higher, as well (76.6% vs. 50%; p = 0.029). Median Adragao score was not significantly different between the two groups [7 vs. 6, (%25,%75 percentile 6 vs. 8), p = 0.17]. Logistic regression analysis revealed that warfarin treatment was independently associated with Kauppila scores of >6 (OR 3.60, 95% CI 1.18-10.9, p = 0.024). DISCUSSION: In this study, we found that warfarin is associated to vascular calcifications, especially in aorta of HD patients.

Deep Convolutional Neural Network-Aided Detection of Portal Hypertension in Patients With Cirrhosis.

BACKGROUND & AIMS: Noninvasive and accurate methods are needed to identify patients with clinically significant portal hypertension (CSPH). We investigated the ability of deep convolutional neural network (CNN) analysis of computed tomography (CT) or magnetic resonance (MR) to identify patients with CSPH. METHODS: We collected liver and spleen images from patients who underwent contrast-enhanced CT or MR analysis within 14 days of transjugular catheterization for hepatic venous pressure gradient measurement. The CT cohort comprised participants with cirrhosis in the CHESS1701 study, performed at 4 university hospitals in China from August 2016 through September 2017. The MR cohort comprised participants with cirrhosis in the CHESS1802 study, performed at 8 university hospitals in China and 1 in Turkey from December 2018 through April 2019. Patients with CSPH were identified as those with a hepatic venous pressure gradient of 10 mm Hg or higher. In total, we analyzed 10,014 liver images and 899 spleen images collected from 679 participants who underwent CT analysis, and 45,554 liver and spleen images from 271 participants who underwent MR analysis. For each cohort, participants were shuffled and then sampled randomly and equiprobably for 6 times into training, validation, and test data sets (ratio, 3:1:1). Therefore, a total of 6 deep CNN models for each cohort were developed for identification of CSPH. RESULTS: The CT-based CNN analysis identified patients with CSPH with an area under the receiver operating characteristic curve (AUC) value of 0.998 in the training set (95% CI, 0.996-1.000), an AUC of 0.912 in the validation set (95% CI, 0.854-0.971), and an AUC of 0.933 (95% CI, 0.883-0.984) in the test data sets. The MR-based CNN analysis identified patients with CSPH with an AUC of 1.000 in the training set (95% CI, 0.999-1.000), an AUC of 0.924 in the validation set (95% CI, 0.833-1.000), and an AUC of 0.940 in the test data set (95% CI, 0.880-0.999). When the model development procedures were repeated 6 times, AUC values for all CNN analyses were 0.888 or greater, with no significant differences between rounds (P > .05). CONCLUSIONS: We developed a deep CNN to analyze CT or MR images of liver and spleen from patients with cirrhosis that identifies patients with CSPH with an AUC value of 0.9. This provides a noninvasive and rapid method for detection of CSPH (ClincialTrials.gov numbers: NCT03138915 and NCT03766880).

Stage I-laparoscopy partial ALPPS procedure for perihilar cholangiocarcinoma.

The treatment for perihilar cholangiocarcinoma (PHC) is a challenge for the surgeon requiring complex resections with a reported perioperative mortality rate between 15% and 48%. In PHC patients with future liver remnant (FLR) less than 30%, it is advised that hepatectomy can be safely performed after the FLR is modified. Associating Liver Partition and Portal vein ligation for Staged Hepatectomy (ALPPS) procedure is criticized heavily due to its high morbidity and mortality rate in this setting. Hereby, we are reporting a modification of ALPPS procedure for PHC. Clinical presentation, preoperative work-up as well as operation and postoperative course of two cases were described in detail. Both patients were jaundiced preoperatively, stage 1 partial-ALPPS procedures were performed laparoscopically, there was sufficient remnant hypertrophy during the interval stage and there was no posthepatectomy liver failure after the second stage (Supporting Information Video). We have followed patients with a mean follow up of 35 months without any recurrence. Here we describe the key technical aspects of this approach that are discussed in three parts: minimally invasive first stage, biliary drainage of both FLR, and deportalized liver at first stage and biliary reconstruction at the second stage. This technique, in selected patients, can extend the indication of ALPPS procedure for PHC with preoperative jaundice.

Extended left hepatectomy for intrahepatic cholangiocarcinoma: hepatic vein reconstruction with in-situ hypothermic perfusion and extracorporeal membrane oxygenation.

BACKGROUND: Liver resection for intrahepatic cholangiocarcinoma (ICC) with invasion of the inferior vena cava (IVC) and hepatic veins (HV) is a challenging procedure. CASE PRESENTATION: We report a case of a 63-year-old woman with a 6-cm, centrally located liver mass. Her biochemistry results were normal except for a Ca19-9 level of 1199 U/ml. The liver biopsy was consistent with ICC and 60% macrosteatosis. Abdominal CT scans revealed a large central mass invading the left HV, middle HV and right HV, infringing on their junction with the vena cava. An operation was planned using a 3-dimensional (3D) computer simulation model using dedicated software. We also describe a novel veno-portal-venous extracorporeal membrane oxygenation (VPV-ECMO) support with in-situ hypothermic perfusion (IHP) during this procedure. We aimed to perform an extended left hepatectomy and reconstruct 3 right HV orifices with an interposition jump graft to the IVC with total vascular exclusion (TVE) and IHP A supplemental video describing the preoperative planning, the operative procedure with the postoperative follow-up in detail is presented. After the patient was discharged, she developed a hepatic venous outflow obstruction 3 months postoperatively, which was effectively managed with hepatic venous stenting by interventional radiology. She is currently symptom free and without tumour recurrence at the 1-year follow-up. CONCLUSIONS: This report demonstrates that extended left hepatectomy for IHC with IHP and VPV-ECMO is safe and feasible under the supervision of a highly experienced team.

Real-Time Sonoelastography of Parotid Gland Tumors.

OBJECTIVES: We sought to determine the performance of real-time sonoelastography in the differential diagnosis of parotid gland tumors. METHODS: Between April, 2014, and June, 2015, 54 parotid gland masses were examined by ultrasound and strain sonoelastography in 46 patients. Real-time sonoelastography using the elasticity score (E-index), which gives an absolute value between 0 (softest) and 6 (hardest), was performed. Demographic characteristics, histopathologic examination, and difference in elasticity scores between benign and malignant masses were evaluated. RESULTS: The mean age of the patients was 60.01 ± 2.97 years, and 56.52% of the patients were male (n = 26). Among the 54 parotid gland masses, 44 (81.5%) were benign and 10 (18.5%) were malignant tumors, 63% (n = 34) of the lesions being on the right side. The diagnoses as benign tumors consisted of Warthin tumor (n = 18, 33.3%), pleomorphic adenoma (n = 8, 14.8%) and other benign tumors (n = 18, 33.3%). The mean elasticity score and the size of all tumors were 2.87 ± 0.96 and 23.68 ± 12.38 mm, respectively. The mean elasticity score for benign tumors was 2.75 ± 0.95, and for malignant tumors it was 3.44 ± 0.85 (P = .034). CONCLUSIONS: According to our results, real-time strain sonoelastography seems to have additional value over routine sonographic evaluation of parotid gland tumors in the differential diagnosis of benign and malignant parotid masses. However, with a small sample of malignant cases and appreciable overlap of the stiffness of benign and malignant masses, caution must be applied because the findings may not be representative of all patients with a parotid gland tumor.

Intranodal Palisaded Myofibroblastoma: Radiological and Cytological Overview.

BACKGROUND: Intranodal palisaded myofibroblastoma is a benign and very rare mesenchymal neoplasm of the lymph nodes originating from differentiated smooth muscle cells and myofibroblasts. CASE REPORT: We report a case of intranodal palisaded myofibroblastoma in an 84-year-old woman with Parkinson's disease that presented as a left inguinal mass. The diagnosis was made using ultrasound-guided fine needle aspiration biopsy and consequent cytopathological examination that included immunohistochemical analysis. Herein, we discuss the presentation of a rare intranodal palisaded myofibroblastoma with emphasis on its ultrasonographic and cytopathologic features. CONCLUSIONS: Intranodal palisaded myofibroblastoma should be considered in the differential diagnosis of inguinal lymphadenopathy and the diagnosis is possible with cytopathologic exam and immunohistochemical analysis using ultrasound-guided FNA biopsy, guiding the clinician to nodal excision rather than aggressive measures.

Effect of carotid artery stenting on ophthalmic artery flow patterns.

OBJECTIVES: The purpose of this study was to assess the effect of carotid artery stenting on ophthalmic artery blood flow using transorbital color and spectral Doppler sonography and review the changes in relation to cerebral hemodynamics. METHODS: Twenty-eight consecutive patients with severe internal carotid artery stenosis (≥ 70%) who were scheduled for carotid stenting were included. Ophthalmic artery Doppler sonography was performed bilaterally before and after stenting. The flow direction, peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility index (PI), and resistive index in the ophthalmic artery were recorded. RESULTS: Twenty male and 8 female patients with 10 right-sided and 18 left-sided stenoses were studied. The mean overall carotid stenosis ratio ± SD was 87.3% ± 9.9%. After stenting in the ophthalmic artery ipsilateral to the stenosis, significant increases in the PSV (-3.87 ± 48.81 to 46.70 ± 25.33 cm/s; P < .001), and EDV (-3.02 ± 16.31 to 11.24 ± 7.37 cm/s; P < .001) were detected, and the increase in the PI approached significance (1.40 ± 0.59 to 1.62 ± 0.52; P = .055). A change in the flow direction from retrograde to antegrade was noted in 11 patients (39%) after stenting, and in 1 patient with no detectable flow, reconstitution of flow was observed. Increases in the PSV and EDV (P= .03 for ΔEDV) were more pronounced in symptomatic patients than asymptomatic patients after stenting. CONCLUSIONS: Substantially decreased ophthalmic artery velocity and retrograde flow are suggestive of high-grade carotid artery stenosis (≳90%). Stenting improves ophthalmic artery perfusion and positively changes cerebral hemodynamics in high-grade carotid artery stenosis, especially in symptomatic patients, which can be monitored with ophthalmic artery Doppler sonography.

Ultrasonographic and histopathological investigation of the effect of N-acetylcysteine on doxorubicin-induced ovarian and uterine toxicity in rats.

BACKGROUND: This study aimed to investigate the mitigating effect of N-acetylcysteine (NAC) on doxorubicin (DOX)-induced ovarian and uterine toxicity in rats using laboratory tests, ultrasonographic (US) imaging, and histopathology analysis. METHODS: Forty-eight rats were divided into six groups (n = 8) as follows: Group A (control) (0.5 mL saline administered intraperitoneally [IP]), Group B (a single 10 mg/kg dose of DOX administered IP on day 1), Group C (a single 10 mg/kg dose of DOX administered IP 24 h before sacrifice), Group D (100 mg/kg of NAC administered IP for 21 days), Group E ( a single 10 mg/kg dose of DOX administered IP on day 1 and 100 mg/kg of NAC administered IP for 21 days), and Group F (100 mg/kg of NAC administered IP for 21 days and a single 10 mg/kg dose of DOX administered IP 24 h before sacrifice). The ovaries were examined using B-mode US on days 1, 14, and 21, and the histopathological examinations of the ovaries and the uterus were undertaken after sacrifice on day 22. RESULTS: Histomorphological analyses showed that ovarian weight decreased after DOX administration in Group B but not in Group E. US revealed a transient increase in ovarian size in Group B and E, reverting to baseline levels over time, as well as a progressive increase in peritoneal fluid in Groups B and E. Group B exhibited a significant decrease in the thickness of the endometrium and myometrium and uterine cornual length, which was not observed in Group E. Histopathological examination showed that DOX caused a decline in follicular count, especially in primordial, secondary, and Graafian follicles, and resulted in follicular atresia, predominantly in Group B. Destructive degeneration/necrosis and vascular changes were most prominently seen in the corpus luteum of Groups C and B. In NAC-treated rats (Groups E and F), although germ cell damage was present, atretic follicles and vascular changes, such as hyperemia and congestion, were reduced. The anti-müllerian hormone (AMH) level was the highest in Group F. CONCLUSIONS: NAC, an antioxidant, attenuated DOX-induced gonadotoxicity in rats.

Effects of edaravone on testicular torsion-detorsion injury in rats.

BACKGROUND AND OBJECTIVE: This study aimed to assess the protective ability of edaravone on testicular torsion-detorsion injury in rats. METHODS: Eighteen adult male Sprague-Dawley rats were randomly divided into three groups: Sham group (control, n = 6); testicular torsion/detorsion (T/D group, n = 6) and T/D+edaravone (T/D+E group, n = 6). The spermatic cords of rats of the T/D group and the T/D+E group were rotated 720° in a clockwise direction and maintained for 120 min in this torsion position. Around 90 min after the torsion, edaravone at a dose of 10 mg/kg dissolved in saline was administered IP to the T/D+E group. The testicle was counter-rotated to its normal position to allow reperfusion for 4 h. Left testes of each animal were excised 240 min after beginning of reperfusion. Oxidative stress markers (TAS, TOS, SOD, and MDA) and apoptotic pathways (Caspase 3, Caspase 8, Caspase 9, Bcl-2, and Bax,) were assessed by ELISA methods. Also, testicles were subjected to the histopathologic and ultrasound examinations. RESULTS: Ultrasound imaging showed that edaravone reduced the surface area and increased vascularization in testicles with T/D (p < 0.0001, p < 0.05, respectively). Edaravone pretreatment markedly decreased the levels of MDA, TOS, Bcl-2, Bax, Caspase 3, Caspase 8, and Caspase 9 (p < 0.0001). Also, it increased significantly TAS levels (p < 0.0001) and reduced insignificantly SOD activity. Histopathologic examinations demonstrated that edaravone significantly attenuated the histological damage caused by T/D in testicles. CONCLUSION: Taken together, the findings indicate that pretreatment of edaravone has protective effect against testicular T/D injury.

High frequency of kidney and urinary tract anomalies in asymptomatic first-degree relatives of patients with CAKUT.

BACKGROUND: Congenital anomalies of the kidney and urinary tract (CAKUT) commonly cause chronic kidney disease in children. While most CAKUT cases are sporadic, observed familial clustering suggests that the pathogenesis is influenced by genetic factors. METHODS: The purpose of the present study is to determine the frequency of the kidney and urinary tract anomalies in asymptomatic first-degree relatives of patients with CAKUT. A total of 218 index patients and their families followed at an academic hospital in Ankara, Turkey, were enrolled in the study. RESULTS: Family histories revealed at least one other member with a known kidney or urinary tract disease in 50% and CAKUT in 22.9% of the families. All asymptomatic first-degree relatives of 180 index patients were screened for kidney and urinary tract anomalies using ultrasound. New anomalies were diagnosed in 116 asymptomatic first-degree relatives (23%) in 87 families (48.3%). When family histories and ultrasound findings of 180 index patients were evaluated together, 129 first-degree relatives in 92 families (51.1%) had CAKUT. CONCLUSIONS: This study suggests that genetic mechanisms might be very important in the pathogenesis of apparently sporadic CAKUT. Identification of the underlying gene mutations will provide further insights into the knowledge of the kidney and urinary tract development and pathogenesis of CAKUT.

Ultrasound anatomy of the brachial plexus nerves in the neurovascular bundle at the axilla in patients undergoing upper-extremity block anesthesia.

PURPOSE: Familiarity with the localization of the nerves in the neurovascular bundle that constitutes the axillary segment of the brachial plexus (BP) is important when applying ultrasound (US)-guided block anesthesia. Therefore in this study we aimed to delineate the anatomy of the median, radial, and ulnar nerves of the BP at the axilla with US and electrical stimulation. MATERIALS AND METHODS: The study included 60 patients who were scheduled to undergo upper-arm surgery with axillary block anesthesia. Prior to anesthesia, ulnar, radial, and median nerves were localized with US using a 12-h quadrant identification system that placed the axillary artery (AA) in the middle. The nerves were then functionally tested using a neurostimulator. RESULTS: The radial nerve was mainly located in the 4-6 o'clock arc (posterior and posteromedial to AA) in 50 (83 %) of patients. Ulnar nerve was mainly at the 12-3 o'clock arc (anteromedial to AA) in 51 (85 %) of patients. Ulnar nerve showed a second peak at 9-10 o'clock quadrant (anterolateral to AA) in 11 % (7) of patients. Median nerve location was most common in the 12 and 9 o'clock arc (anterior and anterolateral to AA) in 53 (88 %) of the patients. CONCLUSIONS: Ultrasound is a useful tool for depicting BP anatomy in the axillary fossa prior to block anesthesia. Median, ulnar, and radial nerves form a highly consistent triangular pattern around the axillary artery that is easily recognizable with US.

Palpation tests versus impingement tests in Neer stage I and II subacromial impingement syndrome.

PURPOSE: Using sonographic findings to test the diagnostic accuracy of impingement versus tendon palpation tests in Neer stage I and II subacromial impingement syndrome cases and examine their clinical potential. METHODS: Neer and Hawkins impingement tests and rotator cuff tendon palpation tests followed by bilateral shoulder sonography were conducted on 69 patients with a clinical diagnosis of unilateral subacromial impingement. RESULTS: The Neer and Hawkins tests had 74 and 62 % accuracy (sensitivity 80 and 67 %, and specificity 52 and 47 %, respectively) in comparison to 79 and 62 % accuracy rates for supraspinatus and biceps tendon palpation tests (sensitivity 92 and 41 %, and specificity 41 and 48 %, respectively). Overall, the palpation tests scored better than impingement tests in the diagnosis of Neer stage I and II subacromial impingement syndrome. No tendinosis or tear was noted in patients with negative findings in the supraspinatus palpation tests (sensitivity 100 %, specificity 21 %). CONCLUSION: Palpation tests for supraspinatus and biceps tendons have a slightly higher accuracy than the impingement tests, and if tenderness does not exist then supraspinatus tendinopathy can be ruled out. These findings warrant the use of palpation tests in a routine physical examination for tendinopathy. LEVEL OF EVIDENCE: I.

Sonographic assessment of acute changes in plaque size and echogenicity and in intima-media thickness of carotid arteries after neck radiation therapy.

BACKGROUND: Ultrasonic assessment of acute changes in carotid artery walls before and after neck radiation therapy (RT). METHODS: Fifty cancer patients scheduled for curative neck irradiation were included and underwent sonographic examination of carotid arteries, with assessment of intima-media thickness (IMT) and plaque size and echogenicity before and immediately after completion of RT. RESULTS: IMT was linearly correlated with age and before RT (r = 0.267, p = 0.007) and increased after RT (0.68 ± 0.11 versus 0.87 ± 0.16, p < 0.001), without correlation with total RT dose and protocol. New plaques (six hypoechoic, one hyperechoic, and one calcified) were found in eight patients after RT, while 17 of the 44 plaques that were present before RT increased in size, and 8 soft and 1 dense plaques in nine patients became calcified. CONCLUSIONS: Radiation in the acute phase not only increases the IMT but also causes new plaque formation and changes in plaque size and echogenicity.

Can Anti-embolism Stockings Cause Common Peroneal Nerve Palsy Following Total Hip Arthroplasty Via Anterior Approach? A Case Report.

We present a patient who had a common peroneal nerve palsy complication due to anti-embolism stocking compression following total hip arthroplasty (THA) surgery performed via the anterior approach (AA). The patient was a 17-year-old underweight female and have experienced bilateral hip pain for the last 3 years. Pelvic X-rays revealed bilateral osteonecrosis of the femoral head and THA surgery for the left hip via the AA was done. Common peroneal palsy developed due to anti-embolism stocking compression on the first postoperative day, which was confirmed by ultrasonography (USG). The common peroneal nerve returned to full function in the third postoperative month with complete healing and the patient was followed up for 3 years. Several etiologic factors have been reported as the cause of the common peroneal nerve palsy following THA surgery. Common peroneal palsy caused by anti-embolism stocking as in our case is an etiologic factor to be considered by arthroplasty surgeons.

Elastography and Doppler May Bring a New Perspective to TIRADS, Altering Conventional Ultrasonography Dominance.

RATIONALE AND OBJECTIVES: The main aim of ultrasonography (US) examining thyroid nodules is to differentiate malignant nodules from benign nodules. Several professional societies and groups of investigators have defined guidelines such as Thyroid Imaging Reporting and Data System (TIRADS) to provide the standardized language and approach to thyroid nodules. This study is aimed to investigate the compatibility of such classification systems with the pathological diagnosis of nodules and evaluate the contribution of the Shear-wave elastography (SWE) and Doppler ultrasonography (DUS) findings. MATERIALS AND METHODS: This is a prospective study. Patients with thyroid US exams between December 2017 and April 2019 were included. In the study, eligible 210 nodules from 210 patients were enrolled. For stratification, the conventional B-mode US, SWE and DUS were performed. According to Kwak, American College of Radiology (ACR), and European (EU)-TIRADS, Nodules were classified separately, and a new scoring system whose the criteria was put defined in the study has developed. RESULTS: For SWE; Emean cut-off value was 33 kPa with a sensitivity and specificity of 95,6% (95% CI: 0,85-0,98) and 95% (95% CI:0,90-0,97) respectively (p <0.001). For spectral DUS; resistivity index (RI) cut-off value was 0.64 with a sensitivity and specificity of 73,3% (95% CI:0,59-0,83) and 80% (95% CI:0,73-0,85) respectively (p <0.001). Kwak TIRADS, American College of Radiology TIRADS, EU-TIRADS, and new system were compared by ROC curve analysis. The new system has the highest sensitivity, specificity, PPV, NPV, accuracy, and AUC compared to others. CONCLUSIONS: The new scoring system has shown that SWE and DUS findings may alter the categorization in TIRADS and increase sensitivity and specificity.