Strain Ratio Measurements of Patellar and Achilles Tendons With Different Reference Regions in Healthy Volunteers.

Strain ratio measurements of tendons vary because of the reference tissue selection. The main purpose of this study is to highlight, in detail, the numeric variability attributable to the use of various reference materials on strain ratio measurements of patellar and Achilles tendons. Measurements were performed at the proximal, middle and distal thirds of the patellar and Achilles tendons on the dominant site of healthy volunteers. A total of 3 references were used: the Hoffa's fat pad for the patellar tendon, the Kager's fat pad for the Achilles tendon, subcutaneous tissue and Aquaflex gel pads (Parker Laboratories, Fairfield, NJ, USA) for both tendons. Although the same methods were used by the same physician for each tendon site on repeated measurements, strain ratio values had numeric variability with various reference materials in each measurement. Therefore, comparison of numeric strain ratio results of various studies with various reference materials could confuse the clinical interpretations of these numeric data, and, using a reference material with standard stiffness like Aquaflex ultrasound gel pads, should be considered by verifying these results with further studies.

Diagnostic value of appendicular Doppler ultrasonography in acute appendicitis.

BACKGROUND: Acute appendicitis is one of the most common causes of acute abdominal pain prompting emergency department (ED) visits. It is critical for the physicians to promptly and accurately diagnose acute appendicitis. The present study aimed to evaluate the diagnostic efficacy of Doppler ultrasonography (USG) in patients with acute appendicitis and compare this new method with other commonly used radio-diagnostic tools. METHODS: All patients who were diagnosed with acute appendicitis at the Kecioren Training and Research Hospital ED and later underwent appendectomy between October 2012 and April 2013 were included in the study. Approval from the ethics committee was obtained for this prospective study. The patients' demographic information, physical examination findings, vital signs, Alvarado scores, and laboratory and radiological exam results were recorded. RESULTS: A total of 60 patients were enrolled in the study. In 46 of the 60 patients, diagnosis of acute appendicitis was confirmed by histopathology results, whereas 14 patients, diagnoses was not confirmed by lab tests. Doppler USG could detect 43 of the 46 patients as true positives, and it detected 2 of the 14 patients with negative lab results as false positives. For diagnosis of acute appendicitis, sensitivity of appendicular Doppler USG was 93%, specificity was 85%, accuracy was 91%, positive likelihood ratio was 6.5, and negative likelihood ratio was 0.08. CONCLUSION: Doppler imaging can offer a high level of diagnostic success in patients with acute appendicitis. Appendicular Doppler USG offers a rapid and easy application without the need to expose patients to contrast medium and is superior to both USG and computed tomography. Therefore, we recommend the use of appendicular Doppler imaging as the primary radiological exam in diagnosing acute appendicitis.

Effects of Cigarette Smoking on Elastographic Strain Ratio Measurements of Patellar and Achilles Tendons.

OBJECTIVES: The aim of this study was to explore the sonographic and elastographic properties of patellar and Achilles tendons in smoking and nonsmoking otherwise healthy adults. METHODS: We conducted a level 3 case-control analytical study. Smoking and nonsmoking volunteers (>18 years) without musculoskeletal system disorders were included in the study. Demographic characteristics and smoking habits (pack-years) were recorded. Proximal, middle, and distal third thicknesses of the patellar and Achilles tendons were measured by B-mode sonography. Strain ratio measurements of the same regions were measured by real-time ultrasound elastography. RESULTS: A total of 69 participants (57 male and 12 female; mean age ± SD, 35.5 ± 7.8 years) were evaluated in the study. Smoking (n = 35) and nonsmoking (n = 34) groups had no significant differences in terms of age, body mass index, sex, and activity level (all P > .05). Proximal, middle, and distal thirds of the patellar and Achilles tendons were significantly thinner in the smoking group (all P < .05). Furthermore, strain ratio measurements in the same regions were significantly lower in the smoking group (all P< .05). Patellar tendon thicknesses and strain ratios had negative correlations with the smoking amount (all P < .05). CONCLUSIONS: Thickness and strain ratio measurements of patellar and Achilles tendons were reduced (thinner and harder tendons) in smokers. Clinical implications of these morphologic and elastographic changes should be investigated in future studies.

Usefulness of transabdominal real-time sonoelastography in the evaluation of ovarian lesions: preliminary results.

OBJECTIVE: We aim to evaluate and describe the tissue elasticity characteristics of various ovarian lesions with sonoelastography. METHODS: 35 patients (age range 16-85 years; mean age 40.8 years) underwent sonoelastography and later MRI. Histopathological confirmation of all lesions was carried out, except eight of endometriomas and six of septated cysts which were confirmed on MRI and follow-up ultrasonography. Strain ratios and elastogram patterns were recorded. Lesions were classified into three groups (Group 1: cystic lesions, Group 2: benign tumours and Group 3: malignant lesions) and findings were compared between groups for both observers. Interobserver agreement was analyzed. Optimal cut-off values for strain ratios were achieved with receiver operating characteristic curve analysis. RESULTS: Ovarian endometriomas and complex cystic lesions were observed hard on elastograms with high strain ratios, and malignant lesions were observed mostly soft with very small strain ratios. Benign tumours had average tissue stiffness, observed harder than the malignant lesions, and strain ratios ranged from 4 to 14. The differences in patterns and strain ratios between groups were statistically significant (p < 0.05 for both observers). CONCLUSION: Our study revealed that malignant ovarian lesions have softer tissue property than benign lesions and cystic lesions in terms of elastogram patterns and strain ratios. ADVANCES IN KNOWLEDGE: Most ovarian lesions contain solid and cystic parts which make the malignant and benign lesions look similar on imaging modalities. Using real-time sonoelastography as an adjunct to other imaging modalities may improve the differentiation of malignant ovarian lesions from benign lesions.

Relationship of side dominance and ultrasonographic measurements of pronator quadratus muscle along with handgrip and pinch strength.

AIMS: We ascertained effects of hand dominance in both right and left-handed volunteers on the thickness and cross sectional area (CSA) of pronator quadratus (PQ) muscle as measured by the axial and sagittal views of ultrasound imaging. Secondly, we also aimed to document the extent of the relationship between the PQ measurements and handgrip. MATERIALS AND METHODS: Healthy adults from the volunteer medical staff were included in the study. Handedness was assessed via The Flinders Handedness survey. The sonographic appearance of the PQ was evaluated on sagittal and axial images for both hands. CSA of PQ muscle was digitally drawn and calculated on the axial plane. Handgrip was measured by using adjustable-handle dynamometer. RESULTS: Eighty-nine healthy volunteers were included (54 right and 35 left-handed). Significant difference was detected between dominant and non-dominant hands in CSA and muscle thickness in both right and left-handed volunteers (p<0.05). These measurements were correlated with the handgrip strength (p<0.05, r=0.55, and r=0.43 for right-handed volunteers, r=0.67 and r=0.48 for left-handed volunteers, respectively). There were also significantly high correlations between the measurements of CSA and PQ thickness of the corresponding extremity in both right-handed and left-handed volunteers (p<0.05). CONCLUSIONS: A statistically significant difference exists between dominant and non-dominant hands in CSA and muscle thickness measured by US in both right and left handed volunteers, and this is correlated with handgrip strength. Hand dominance should be considered to compare healthy and affected sites during US of PQ while investigating for occult fractures of distal forearm or PQ atrophy due to anterior interosseous nerve injury.

White matter alterations related to attention-deficit hyperactivity disorder and COMT val(158)met polymorphism: children with valine homozygote attention-deficit hyperactivity disorder have altered white matter connectivity in the right cingulum (cingulate gyrus).

INTRODUCTION: In this article, the COMT gene val(158)met polymorphism and attention-deficit hyperactivity disorder (ADHD)-related differences in diffusion-tensor-imaging-measured white matter (WM) structure in children with ADHD and controls were investigated. PATIENTS AND METHODS: A total of 71 children diagnosed with ADHD and 24 controls aged 8-15 years were recruited. Using diffusion tensor imaging, COMT polymorphism and ADHD-related WM alterations were investigated, and any interaction effect between the COMT polymorphism and ADHD was also examined. The effects of age, sex, and estimated total IQ were controlled by multivariate analysis of covariance (MANCOVA). RESULTS: First, an interaction between the COMT val(158)met polymorphism and ADHD in the right (R) cingulum (cingulate gyrus) (CGC) was found. According to this, valine (val) homozygote ADHD-diagnosed children had significantly lower fractional anisotropy (FA) and higher radial diffusivity (RD) in the R-CGC than ADHD-diagnosed methionine (met) carriers, and val homozygote controls had higher FA and lower RD in the R-CGC than val homozygote ADHD patients. Second, met carriers had higher FA and axial diffusivity in the left (L)-uncinate fasciculus and lower RD in the L-posterior corona radiata and L-posterior thalamic radiation (include optic radiation) than the val homozygotes, independent of ADHD diagnosis. Third, children with ADHD had lower FA in the L-CGC and R-retrolenticular part of the internal capsule than the controls, independent of the COMT polymorphism. CONCLUSION: Significant differences reported here may be evidence that the COMT gene val(158)met polymorphism variants, as well as ADHD, could affect brain development. ADHD and the COMT polymorphism might be interactively affecting WM development in the R-CGC to alter the WM connectivity in children with val homozygote ADHD.

Real-time elastography of patellar tendon in patients with auto-graft bone-tendon-bone anterior cruciate ligament reconstruction.

INTRODUCTION: Patellar tendon donor site has been previously evaluated in patients with auto-graft bone-tendon-bone (BTB) anterior cruciate ligament (ACL) reconstruction using either magnetic resonance imaging or B mode ultrasound. However, donor site patellar tendon strain ratio-reflecting structural features-has not been studied with US elastography. Here, we ascertain real-time elastography properties of patellar tendon donor site and clinical relevance of these properties in patients with auto-graft BTB ACL reconstruction in the postoperative period. METHODS: Patients who underwent ACL reconstruction using BTB autograft were evaluated. Demographic, operative and clinical data (severity of pain, Lysholm Knee score, sit to stand test, packages/year for smoking amount) were noted. Patellar tendons of the operated knees were evaluated by ultrasound (length and thickness) and sonoelastography (strain ratio). The healthy knees of the patients constituted the control group. RESULTS: Eighteen patients (17 M, 1 F; mean age 30.9 ± 7 years) were evaluated. Mean postoperative follow-up period was 22.1 ± 2.6 (range 18-26) months. Patellar tendons were shorter and thicker on the operated side when compared with the contralateral side (both p = 0.001). Patellar tendon strain ratios of the operated side were lower than the contralateral side (harder tendon on operated side). While there was no correlation between strain ratios and clinical variables (age, BMI, postoperative time, severity of pain, Lysholm score, all p values > 0.05), significant negative correlations were detected between strain ratios of proximal, middle and distal thirds of operated side and amount of smoking (p = 0.008, r = -0.607, p = 0.009, r = -0.598, p = 0.023, r = -0.533, respectively). CONCLUSION: Patellar tendons on the operated sides seemed to thicken and shorten with decreased strain ratios at the donor side compared to the healthy side at an average of 2-year follow-up in patients with ACL reconstruction using BTB autograft, and amount of smoking had negative relationship with strain ratio of donor patellar tendon.

The Effects of Smoking on Ultrasonographic Thickness and Elastosonographic Strain Ratio Measurements of Distal Femoral Cartilage.

Although adverse effects of smoking on bone health are all well known, data on how smoking interacts with cartilage structure in otherwise healthy individuals remains conflicting. Here, we ascertain the effects of cigarette smoking on sonoelastographic properties of distal femoral cartilage in asymptomatic adults. Demographic characteristics and smoking habits (packets/year) of healthy volunteers were recorded. Medial, intercondylar, and lateral distal femoral cartilage thicknesses and strain ratios on the dominant extremity were measured with ultrasonography (US) and real time US elastography. A total of 88 subjects (71 M, 17 F; aged 18-56 years, N = 43 smokers and N = 45 nonsmokers) were evaluated. Mean amount of cigarette smoking was 10.3 ± 8.9 (1-45) packets/year. Medial, intercondylar and lateral cartilage were thicker in smokers than nonsmokers (p = 0.002, p = 0.017, and p = 0.004, respectively). Medial distal femoral cartilage strain ratio was lower in smokers (p = 0.003). The amount of smoking was positively correlated with cartilage thicknesses and negatively correlated with medial cartilage strain ratios (p < 0.05). Femoral cartilage is thicker in smokers but has less strain ratio representing harder cartilage on the medial side. Future studies are needed to understand how these structural changes in the knee cartilage should be interpreted with regard to the development of knee osteoarthritis in smokers.

The Effect of Single Dose Methylphenidate on Neurometabolites according to COMT Gene Val158Met Polymorphism in the Patient with Attention Deficit Hyperactivity Disorder: A Study Using Magnetic Resonance Spectroscopy.

OBJECTIVE: Attention deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder. Thus, the present study aimed to determine the effects of a single dose of methylphenidate (Mph) on neurometabolite levels according to polymorphisms of the catechol-O-methyltransferase (COMT) gene. METHODS: This study evaluated the neurometabolite levels including N-acetylaspartate (NAA), creatine (Cr), and choline (Cho) of ADHD patients, before and after treatment with Mph (10 mg) according to the presence of COMT polymorphisms. The spectra were obtained from the dorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex (ACC), cerebellum, and striatum. RESULTS: The NAA levels of the val/val and val genotype carriers (val/val and val/met genotypes) increased in the DLPFC and ACC, respectively, following Mph treatment. The NAA/Cr ratio was lower in the DLPFC of val carriers than in the met/met genotype carriers prior to Mph administration. The Cho levels of the val/met genotype and val carriers increased in the striatum following Mph treatment. Following Mph treatment, the Cr levels of the met/met genotype carriers were higher than those of the val/met genotype and val carriers. Additionally, after Mph treatment, there was a significant increase in Cr levels in the DLPFC of the met/met genotype carriers but a significant decrease in such levels in the striatum of val/val genotype carriers. CONCLUSION: These findings suggest that polymorphisms of the COMT gene can account for individual differences in neurochemical responses to Mph among ADHD patients. Therefore, further studies are needed to fully characterize the effects of the Val158met polymorphism of the COMT gene on treatment outcomes in patients with ADHD.

Impaired Hemorheological Parameters and Increased Carotid Intima-Media Thickness in Children with Subclinical Hypothyroidism.

BACKGROUND: Subclinical hypothyroidism (SH) is defined as elevated serum thyroid-stimulating hormone (TSH) concentration associated with normal serum-free thyroxine levels. Effects of hypothyroidism on hemorheology had widely attracted the attention of researchers during the last decade. OBJECTIVE: The purpose of this study is to determine alterations in hemorheological parameters and carotid intima-media thickness (CIMT) in children with SH. METHODS: Fifty-three SH children and 31 healthy controls were enrolled. Erythrocyte deformability and aggregation were determined by an ektacytometer and plasma viscosity (PV) by a cone-plate rotational viscometer. CIMT was evaluated sonographically. RESULTS: Erythrocyte deformability of the SH group measured at 0.53 and 1.69-30 Pa was lower than that of the control group. The erythrocyte aggregation index, aggregation half time and PV were not different between the groups. However, the aggregation amplitude and mean corpuscular hemoglobin concentration were significantly higher in SH compared to the control group. There was a negative correlation between TSH and deformability values measured at 5.33-30.0 Pa. CIMT in patients with SH was significantly higher than in the control group (p = 0.001; SH = 0.48 ± 0.04 mm, control group = 0.43 ± 0.03 mm). CONCLUSION: Impaired hemorheology and increased CIMT are well-known risk factors for developing cardiovascular pathologies. The results of the current study suggest the treatment of children with SH in order to avoid early circulatory problems.

CT evaluation of medial clavicular epiphysis as a method of bone age determination in adolescents and young adults.

PURPOSE: We aimed to investigate the use of computed tomography (CT) staging of the medial clavicular epiphysis ossification in forensic bone age determination, and find a CT criterion to determine whether an individual is adult or not. METHODS: Chest CT and pulmonary CT angiography exams of 354 patients between 10 and 30 years of age (mean, 21.4 years) were retrospectively evaluated for epiphyseal ossification phase of the bilateral medial clavicles (708 clavicles) and compared with the sex and chronologic age of the individuals. The ossification phase of the medial clavicular epiphyses was classified from stage I to stage V using a modified staging system. RESULTS: Epiphyseal ossification center appeared from 11 to 21 years of age. Partial fusion occurred between 16 and 23 years of age. Complete fusion was first achieved at the ages of 18 and 19 years for male and female individuals, respectively. The probability of an individual being ≥18 years old was 70.8% in stage III A and 100% in stages III B, IV, and V in females and males. CONCLUSION: CT evaluation of the medial clavicular epiphysis is helpful in forensic age determination and stage III B can be used as a criterion to make the prediction that an individual is older than 18 years.

Chest X-rays in detecting injuries caused by blunt trauma.

BACKGROUND: The appropriate sequence of different imagings and indications of thoracic computed tomography (TCT) in evaluating chest trauma have not yet been clarified at present. The current study was undertaken to determine the value of chest X-ray (CXR) in detecting chest injuries in patients with blunt trauma. METHODS: A total of 447 patients with blunt thoracic trauma who had been admitted to the emergency department (ED) in the period of 2009-2013 were retrospectively reviewed. The patients met inclusion criteria (age>8 years, blunt injury to the chest, hemodynamically stable, and neurologically intact) and underwent both TCT and upright CXR in the ED. Radiological imagings were re-interpreted after they were collected from the hospital database by two skilled radiologists. RESULTS: Of the 447 patients, 309 (69.1%) were male. The mean age of the 447 patients was 39.5±19.2 (range 9 and 87 years). 158 (35.3%) patients were injured in motor vehicle accidents (MVA). CXR showed the highest sensitivity in detecting clavicle fractures [95%CI 78.3 (63.6-89)] but the lowest in pneuomediastinum [95%CI 11.8 (1.5-36.4)]. The specificity of CXR was close to 100% in detecting a wide array of entities. CONCLUSION: CXR remains to be the first choice in hemodynamically unstable patients with blunt chest trauma. Moreover, stable patients with normal CXR are candidates who should undergo TCT if significant injury has not been ruled out.

An evaluation of ocular elasticity using real-time ultrasound elastography in primary open-angle glaucoma.

OBJECTIVE: The aim of this study was to compare sonoelastographic findings in the retina-choroid-sclera (RCS) complex and vitreous in glaucomatous and healthy eyes. METHODS: For this cross-sectional comparative study, 20 patients with primary open-angle glaucoma and 20 healthy volunteers were recruited. Ultrasound elastography measurements were taken with a sonographic scanner of the RCS complex, anterior vitreous (AV), posterior vitreous (PV), retrobulbar fat tissue (RFT), optic disc (OD) and optic nerve (ON) in each eye. RESULTS: The elasticity index of the RCS complex, RFT, OD, ON, AV and PV was similar in both groups (p > 0.05), although the AV/PV strain ratio in the group of patients with glaucoma was significantly higher (p = 0.04). CONCLUSION: Glaucoma increases the AV/PV strain ratio. In providing reproducible and consistent values, the real-time elastography (RTE) technique may be helpful in elucidating the mechanisms of glaucoma in some aspects. ADVANCES IN KNOWLEDGE: This study can help to evaluate the elasticity of the RCS complex and vitreous in glaucomatous eyes with RTE.

Sonoelastographic evaluation of the distal femoral cartilage in patients with anterior cruciate ligament reconstruction.

OBJECTIVES: This study aims to evaluate sonoelastographic properties of the distal femoral cartilage in patients with anterior cruciate ligament (ACL) reconstruction. PATIENTS AND METHODS: Demographic characteristics and operative data of 28 patients (27 males, 1 female; mean age 31.7±7.1 years; range 22 to 48 years) with unilateral ACL reconstruction were evaluated. Reconstruction was performed with patellar tendon graft in 22 patients (78.6%) and hamstring tendon graft in six patients (21.4%). Lysholm knee score was used for functional evaluation and chair stand test was used for lower extremity strength. Medial, intercondylar, and lateral distal femoral cartilage thicknesses of operated knees and healthy knees were measured with B-mode ultrasound, while strain ratios were measured with real time sonoelastography. RESULTS: Postoperative mean follow-up duration was 20.4±9.8 months. Mean Lysholm knee and patient satisfaction scores were 88.0±8.5 and 8.2±1.8, respectively. Cartilage thicknesses were similar between operated and healthy knees (all p>0.05). Sonoelastographic strain ratio of medial distal femoral cartilage in operated knees was significantly higher (softer cartilage) (p=0.026). There was a negative correlation between strain ratio difference of medial cartilage of operated knees and lower extremity muscle strength (p=0.009, r= -0.487). CONCLUSION: While there was no difference for cartilage thickness between operated and healthy knees in B-mode ultrasound evaluation, detection of sonoelastographic strain ratio changes in medial distal femoral cartilage on the operated sides may indicate early structural changes following ACL reconstruction. Further studies are required to highlight the clinical effects of this relationship between the changes in cartilage structure and sonoelastography features.

Chest X-rays in detecting injuries caused by blunt trauma / 世界急诊医学杂志（英文）

BACKGROUND:The appropriate sequence of different imagings and indications of thoracic computed tomography (TCT) in evaluating chest trauma have not yet been clarified at present. The current study was undertaken to determine the value of chest X-ray (CXR) in detecting chest injuries in patients with blunt trauma. METHODS:A total of 447 patients with blunt thoracic trauma who had been admitted to the emergency department (ED) in the period of 2009–2013 were retrospectively reviewed. The patients met inclusion criteria (age>8 years, blunt injury to the chest, hemodynamically stable, and neurologically intact) and underwent both TCT and upright CXR in the ED. Radiological imagings were re-interpreted after they were collected from the hospital database by two skilled radiologists. RESULTS:Of the 447 patients, 309 (69.1％) were male. The mean age of the 447 patients was 39.5±19.2 (range 9 and 87 years). 158 (35.3％) patients were injured in motor vehicle accidents (MVA). CXR showed the highest sensitivity in detecting clavicle fractures [95％CI 78.3 (63.6–89)] but the lowest in pneuomediastinum [95％CI 11.8 (1.5–36.4)]. The specificity of CXR was close to 100％ in detecting a wide array of entities. CONCLUSION:CXR remains to be the first choice in hemodynamically unstable patients with blunt chest trauma. Moreover, stable patients with normal CXR are candidates who should undergo TCT if significant injury has not been ruled out.

The ultrasonographic evaluation of hemodynamic changes in patients with diabetic polyneuropathy after tarsal tunnel decompression.

BACKGROUND: Nerve decompression procedures have shown to have promising roles in patients with diabetic polyneuropathy. It is known that not only nerves but also arteries pass through the same compressed anatomical tunnels. The aim of the study is to reveal whether the surgical decompression procedures have a positive effect on hemodynamic and morphological parameters of the arterial structures passing through these anatomic tunnels. METHODS: Twenty-seven patients who underwent posterior and anterior tarsal tunnel release procedures were retrospectively scanned for preoperative and 3 months postoperative arterial Doppler ultrasound imaging. The preoperative and third month postoperative measurements were compared for flow pattern of artery, flow lumen diameter, pulsatility index (PI), resistance index (RI), and flow volumes by evaluating the hemodynamic and morphological parameters of dorsalis pedis (DPA) and tibialis posterior arteries (TPA). RESULTS: For TPA, mean PI values were 5.76 ± 2.78 preoperatively, 7.17 ± 3.08 postoperatively. Mean RI values were 0.94 ± 0.04 preoperatively and 0.89 ± 0.05 postoperatively. For DPA, mean PI values were 5.06 ± 2.14 preoperatively and 6.35 ± 2.31 postoperatively. Mean RI values were 0.93 ± 0.05 preoperatively and 0.86 ± 0.06 postoperatively. When the results are analyzed for both of the arteries, PI values were significantly increased; RI values were significantly decreased when the preoperative measurements were compared with the postoperative measurements (P < 0.05). CONCLUSION: According to these results, it can be suggested that the nerve release procedures have a positive effect on the hemodynamic and morphological parameters of the arteries as they pass through the anatomical tunnels as well as its positive effects on the neurological functions of the entrapped nerves.