Do Ultrasound Based Quantitative Hepatic Fat Content Measurements Have Differences Between Respiratory Phases?

RATIONALE AND OBJECTIVES: The recently developed ultrasound based tools using attenuation coefficient (AC) and scatter distribution coefficient (SDC) values can be used to quantify hepatic fat content in patients with non-alcoholic fatty liver disease (NAFLD). However, currently the impact of respiratory phase on these measurements is not known. The purpose of this study is to compare AC and SDC measurements acquired at peak inspiration and end expiration phases. MATERIALS AND METHODS: AC and SDC measurements were obtained in 50 patients with NAFLD. Tissue Attenuation Imaging (TAI) and Tissue Scatter Distribution Imaging (TSI) tools were utilized to measure AC and SDC values, respectively. Five measurements were performed at respiratory phases using TAI and TSI tools and the median values were noted. Subgroup analyses were performed and Wilcoxon signed rank test was used for comparison of the measurements. RESULTS: The median values of the AC measurements at peak inspiration and end expiration phases were 0.87 dB/cm/MHz and 0.89 dB/cm/MHz, respectively. The median values of the SDC measurements at peak inspiration and end expiration phases were 97.91 and 96.62, respectively. There were no statistically significant differences in AC and SDC measurements between the respiratory phases except for AC measurements in BMI <30 kg/m2 subgroup. CONCLUSION: Our results revealed that respiratory phases have no impact on SDC measurements. However, while the AC measurements in BMI ≥30 kg/m2 subgroup showed no significant difference, there was a significant difference in AC measurements in BMI <30 kg/m2 subgroup between the respiratory phases.

Interobserver Variability in Ultrasound-Based Liver Fat Quantification.

OBJECTIVES: To assess interobserver variability in ultrasound-based quantitative liver fat content measurements and to determine how much time these quantitative ultrasound (QUS) techniques require. METHODS: One hundred patients with known or suspected of having nonalcoholic fatty liver disease were included in this prospective study. Two observers who were blinded to each other measurements performed tissue attenuation imaging (TAI) and tissue scatter distribution imaging (TSI) techniques independently. Both observers assessed hepatic steatosis visually and obtained 5 measurements for each QUS technique and the median values of the measurements were recorded. Spearman's correlation test was used to assess the correlation between QUS measurements and visual hepatic stetaosis grades. Intraclass correlation coefficient (ICC) test was used to assess interobserver variability in QUS measurements. RESULTS: The median values of TAI measurements for the observers 1 and 2 were 0.75 and 0.74 dB/cm/MHz, respectively. The median values of TSI measurements for the observers 1 and 2 were 93.53 and 92.58, respectively. The interobserver agreement in TAI (ICC: 0.970) and TSI (ICC: 0.938) measurements were excellent. The mean of the required time period for TAI technique were 55.1 ± 7.8 and 59.9 ± 6.6 seconds for the observers 1 and 2, respectively. The mean of the required time period for TSI technique were 49.1 ± 5.8 and 54.1 ± 5.4 seconds for the observers 1 and 2, respectively. CONCLUSION: The current study revealed that both TAI and TSI techniques are highly reproducible and can be implemented into daily practice with little additional time requirement.

Hepatic Fat Quantification With Novel Ultrasound Based Techniques: A Diagnostic Performance Study Using Magnetic Resonance Imaging Proton Density Fat Fraction as Reference Standard.

Purpose: To assess the diagnostic performances of novel Tissue attenuation imaging (TAI) and Tissue scatter distribution imaging (TSI) tools in quantification of liver fat content using magnetic resonance imaging proton density fat fraction (MRI PDFF) as reference standard. Methods: Eighty consecutive patients with known or suspected non-alcoholic fatty liver disease (NAFLD) who volunteered to participate in the study comprised the study cohort. All patients underwent MRI PDFF scan and quantitative ultrasound (QUS) imaging using TAI and TSI tools. The cutoff values of ≥5%, ≥16.3% and ≥21.7% on MRI PDFF were used for mild, moderate and severe steatosis, respectively. Area under the Receiver operating characteristic (AUROC) curves were used to assess the diagnostic performance of TAI and TSI in detecting different grades of hepatic steatosis. Results: The AUROCs of TAI and TSI tools in detecting hepatosteatosis (MRI PDFF ≥5%), were 0.95 [95% Confidence Interval (CI): 0.91-0.99] (P < 0.001) and 0.96 (95% CI: 0.93-0.99) (P < 0.001), respectively. In distinguishing between different grades of steatosis, the values of 0.75, 0.86 and 0.96 dB/cm/MHz have 88%, 88% and 100% sensitivity, respectively, for TAI tool; and the values of 92.44, 96.64 and 99.45 have 90%, 92% and 91.7% sensitivity, respectively, for TSI tool. Conclusion: TAI and TSI tools accurately quantify liver fat content and can be used for the assessment and grading of hepatosteatosis in patients with known or suspected NAFLD.

Evaluation of Diaphragm Thickness and Stiffness Using Ultrasound and Shear-Wave Elastography.

ABSTRACT: The purposes of this study are to measure the thickness and stiffness of diaphragm in association with the respiratory cyclus and to assess the reproducibility of these measurements. Forty individuals who are volunteered for participating diaphragm evaluation were included in the study. Two radiologists with 14 and 15 years of experiences in abdominal ultrasound performed all examinations independently. Furthermore, 8 chronic obstructive pulmonary disease (COPD) patients were examined by only the first radiologist. Gray scale and shear-wave elastography imaging of only the right hemidiaphragm of all participants were performed. Thickness and stiffness of diaphragm were measured at the peak inspiration and end expiration phases. Intraclass correlation coefficients test was used to assess the interobserver agreement. The thickness and stiffness of diaphragm significantly increased with inspiration (P < 0.001). The mean ± SD stiffness of diaphragm in peak inspiration and end expiration phases was 51.84 ± 16.83 kPa and 38.49 ± 9.42 kPa, respectively, for the first radiologist and 49.61 ± 13.83 kPa and 37.52 ± 10.71 kPa, respectively, for the second radiologist. Intraclass correlation coefficient values for diaphragm stiffness were 0.667 and 0.736 in peak inspiration and end expiration phases, respectively. In COPD patients, there was no significant difference between stiffness measurements of respiratory phases. In conclusion, the current study revealed that diaphragm thickness and stiffness increase at inspiration, and these measurements are slightly more reproducible at the end of expiration. However, diaphragm stiffness changes between respiratory phases may not be valid for COPD patients, and this may be related to loss of force-generating capacity of diaphragm in COPD patients.

Evaluation of common carotid artery in type 1 diabetes mellitus patients through speckle tracking carotid strain ultrasonography.

PURPOSE: We aimed to evaluate the effectiveness of speckle tracking carotid strain (STCS) technique, which enables measurement of arterial stiffness and strain parameters, in the detection of early atherosclerotic findings in type 1 diabetes mellitus (T1DM). METHODS: We prospectively enrolled 30 T1DM patients and 30 age- and sex-matched control participants with no history of cardiovascular disease. All study population underwent carotid ultrasonography. Radial and circumferential movement of the common carotid artery (CCA) in the transverse plane as the well as the radial movement of the CCA in the longitudinal plane were calculated automatically by using the STCS method. In addition, the strain (%), strain rate (per second), and peak circumferential and radial displacements (mm) were calculated. Arterial stiffness parameters, such as elastic modulus, distensibility, arterial compliance, and ß-stiffness index, were calculated using the radial measurements. The mean value of the carotid intima media thickness (CIMT) was calculated semi-automatically for each CCA, in the longitudinal plane. We also analyzed the patients' overall body composition. RESULTS: T1DM and control groups were compared in terms of strain and stiffness parameters and no statistically significant difference was found (p > 0.05). CIMT was higher in diabetic patients than in the control group (p = 0.039). In both groups, age was correlated with all arterial stiffness and strain parameters (p < 0.05). The duration of diabetes was also correlated with ß-stiffness index, distensibility, and elastic modulus in the longitudinal plane (p < 0.05). In the diabetic group, abdominal fat ratio, whole body fat ratio, and fat mass were correlated with radial and circumferential displacement and strain parameters in transverse plane, and radial displacement in longitudinal plane (p < 0.05, for each). Diabetic patients were divided into subgroups according to the presence of nephropathy and dyslipidemia. Although no significant difference was found between the groups in terms of CIMT, patients with nephropathy had higher values for transverse and longitudinal elastic modulus, pulse-wave velocity, and longitudinal ß-stiffness index, as well as lower values for longitudinal arterial compliance and distensibility, compared with patients without nephropathy (p < 0.05). Also, patients with dyslipidemia had higher longitudinal ß-stiffness and elastic modulus values compared with patients without dyslipidemia (p < 0.05). CONCLUSION: STCS ultrasonography is an effective, easy, and noninvasive method for evaluating the arterial elasticity. It may provide an early assessment of atherosclerosis in patients with T1DM, especially in the presence of nephropathy and dyslipidemia; thus, together with CIMT measurement, it may be used more frequently to detect subclinical damage and stratify atherosclerosis.

Shear Wave Elastography Evaluation of Meniscus Degeneration with Magnetic Resonance Imaging Correlation.

RATIONALE AND OBJECTIVES: The objective of the study was to assess the diagnostic efficiency of shear wave elastography in the grading of meniscal degeneration compared to magnetic resonance imaging (MRI) as a reference standard. MATERIALS AND METHODS: Fifty patients were included in the study (who had bilateral knee MRI). Tissue elasticity was measured in the coronal plane from the meniscus body in kilopascal. Nonparametric testing (Mann-Whitney U) was utilized to assess the differences between mean elasticity of the meniscus tissue, gender. The inter-intraobserver agreement was determined by the intraclass correlation coefficient. The correlations between the mean elasticity of the meniscus versus age, height, and body mass index were calculated via the "Pearson Correlation Coefficient Test." The relationship between MRI meniscal degeneration grading and elastography elasticity module was determined via the "Spearman Correlation Test." A p value less than 0.05 was considered statistically significant. RESULTS: Inter-intraobserver intraclass correlation coefficient of the lateral and medial meniscus mean stiffness values were good or excellent (>0.8). A statistically significant increase in stiffness of meniscus tissue was observed with an increase in age (p = 0.003 for medial menisci, 0.006 for lateral menisci). Tissue stiffness was higher in the medial meniscus than the lateral meniscus (p < 0.001). A positive correlation was observed between the MRI meniscal degeneration grade and tissue stiffness (p < 0.05). Additionally, mean stiffness values from lateral and medial menisci were higher in the group with degeneration (p < 0.0001). CONCLUSION: Meniscus stiffness is increased with aging. There was a statistically significant positive correlation between meniscal stiffness and degeneration grading in MRI.

The evaluation of the use of 2D shear-wave ultrasound elastography in differentiation of clinically insignificant and significant liver fibrosis in pediatric age group.

OBJECTIVE: To determine the accuracy of 2D shear-wave elastography (2D-SWE) in pediatric age group patients in differentiating clinically insignificant and significant liver fibrosis using METAVIR fibrosis scoring system as the gold standard. INTRODUCTION: Liver biopsy has long been the gold standard in liver fibrosis diagnosis. However, due to probable complications and sampling variabilities, the need for more accurate and non-invasive techniques has increased. 2D-SWE is a non-invasive technique used in the evaluation of liver stiffness and utilized more and more in routine clinical practice with recent advances and researches. MATERIALS AND METHODS: In this retrospective single-center study, we included 46 pediatric age group patients who had a liver parenchymal biopsy and 2D-SWE evaluation regardless of etiology. For 2D-SWE, the LOGIQ E9 system (GE Medical Systems, Wisconsin, USA) and, for histopathological evaluation, METAVIR fibrosis scoring system were utilized. Patients were further subgrouped as clinically insignificant (METAVIR Score F0-1) and significant (METAVIR Score F2-4). The Kolmogorov-Smirnov and Mann-Whitney U tests were employed for statistical analysis. The diagnostic accuracy of 2D-SWE was assessed, and cutoff values were set by ROC curve analysis. RESULTS: kPa values were statistically different between clinically significant and insignificant fibrosis patient groups (p < 0.001). kPa value of 8.92 was designated as the best cutoff value according to the Youden Index. CONCLUSION: 2D-SWE is one of the non-invasive techniques in the evaluation of liver fibrosis. Our findings suggest that 2D-SWE accurately differentiate clinically insignificant and significant liver fibrosis.

The effectiveness of RENAL nephrometry score in ablated renal tumors via radiofrequency ablation or cryoablation

Background/aim: This study aimed to evaluate the clinical efficacy of radiofrequency ablation (RFA) and cryotherapy and to scrutinize the therapeutic success of the RENAL (radius, exophytic/endophytic, nearness to collecting system, anterior/posterior, and location) nephrometry score in terms of possible complications and the predictive status of oncological results. Materials and methods: Forty-five patients with biopsy-proven renal cell carcinomas (32 males, 13 females) treated with RFA and cryotherapy were included. Patients were 22­90 years old (average: 59.2 years). Statistical analyses were performed using SPSS for Windows. Results: A total of 79 lesions with dimensions varying between 0.9 and 4.5 cm (average: 2.2 cm) were ablated. Complete ablation was achieved for 72 (91.1%) lesions. Six repeat RFA sessions were applied for 4 (5%) lesions with residue/recurrence. The average RENAL nephrometry scores of lesions that underwent complete ablation and those that developed residue/recurrence were 6.3 and 7.7, respectively. The average recurrence-free survival time was 34.8 months (range: 3­55 months), while it was 44.6 months (range: 6­55 months) for cryotherapy and 28.6 months (range: 3­50 months) for RFA. Conclusion: Ablative therapies are minimally invasive and effective methods for treating small renal tumors. RENAL nephrometry scoring is a valuable system for standardizing renal tumors and evaluating the success of ablative therapies, possible complications, and oncological results.

Assessment of brachial artery reactivity, carotid intima-media thickness, and adhesion molecules in pediatric solid tumor patients treated with anthracyclines.

The aim of this study was to determine subclinical atherosclerosis and endothelial functional disturbance with measurement of carotid intima-media thickness (IMT), brachial artery reactivity (BAR), and levels of serum adhesion molecules in children with solid tumors who were treated with anthracyclines and are actually in complete remission. Fifty patients who were in remission and 30 healthy children were included in the study. Mean ages of patient and control groups were 13.5 ± 4.7 years (range: 3-23 years) and 12.00 ± 4.3 years (range: 4-21 years), respectively. The patients were divided into 3 groups according to cumulative doxorubicin dose: Group 1, ≤100 mg/m(2); Group 2, 101-299 mg/m(2); Group 3, ≥300 mg/m(2). The BAR and carotid IMT were measured in order to determine the endothelial function. The serum adhesion molecule levels in our patients and controls were also measured. The BAR of the patients with cumulative anthracycline dose ≥300 mg/m(2) was significantly lower than the patients with cumulative anthracycline dose ≤100 mg/m(2) and healthy controls (P =.005 and P =.003, respectively). Also, there was a negative correlation between brachial artery reactivity and increasing cumulative anthracycline dose (r = -.287, P =.044). We also found significant difference between the mean carotid IMT of the patients and the healthy children (P =.041). No statistically significant difference was detected between the serum levels of sICAM-1 (soluble intercellular adhesion molecule-1), sVCAM-1 (soluble vascular cell adhesion molecule-1), sE-selectin of the patients and controls. The use of anthracyclines in pediatric patients with cancer could result in increase of the carotid IMT and endothelial dysfunction.

Intraocular pressure and superior ophthalmic vein blood flow velocity in Graves' orbitopathy: relation with the clinical features.

BACKGROUND: The aim of this study is to evaluate the association of intraocular pressure (IOP) and superior ophthalmic vein blood flow velocity (SOV-BFV) with the clinical features of Graves' orbitopathy. METHODS: During the 2002-2007 period, 66 eyes of 34 Graves' orbitopathy cases were classified as mild, moderate and severe orbital disease, and evaluated according to their clinical features as: i)type 1 vs type 2 cases, and ii) cases with or without dysthyroid optic neuropathy. In all patients, a full ophthalmic examination including IOP and Hertel measurements was performed. SOV-BFV was analyzed with color Doppler sonography. RESULTS: The Hertel value, IOP in primary and upgaze position were higher, and SOV-BFV was lower in moderate and severe Graves' orbitopathy cases that showed statistical significance from mild cases, and controls (p = 0.001). Moderate and severe Graves' orbitopathy cases showed comparable Hertel measures and IOP in primary and upgaze position (p = 0.39); however, SOV-BFV was significantly lower in severe cases when compared to moderate cases (p = 0.001).This study demonstrated statistically significant negative correlation between IOP in both primary (r = 0.43,p = 0.008) and upgaze position (r = 0.51,p = 0.002), and SOV-BFV. Additionally, statistically significant positive correlation was detected between Hertel values and SOV-BFV(r = 0.402,p = 0.007).There was a statistical difference between type 1 and 2 cases in Hertel values(p = 0.006), IOP in upgaze position (p = 0.026) and SOV-BFV (p = 0.003). SOV-BFV of the eyes showing dysthyroid optic neuropathy was statistically lower than eyes without dysthyroid optic neuropathy (p = 0.006). CONCLUSIONS: IOP and SOV-BFV have significant association with the clinical features of Graves' orbitopathy. The decrease in SOV-BFV increases the severity of Graves' orbitopathy, and may have a role in the clinical course of dysthyroid optic neuropathy.

Granulocytic sarcoma after stem cell transplantation in a child with biphenotypic leukemia.

Granulocytic sarcoma is an extramedullary tumor composed of leukemic blasts. Isolated granulocytic sarcoma has rarely been reported in children with leukemia undergoing allogeneic stem cell transplantation. We report a case of isolated granulocytic sarcoma arising from the pleura in an 11-year-old girl who was previously treated for biphenotypic leukemia with allogeneic stem cell transplantation. Complete resolution of the tumor was achieved after two inductions with MRC 12 protocol; however, she died of sepsis during the neutropenic period. The unusual presentation, immunophenotypic differences at diagnosis and relapse, and the management options are discussed.