The value of ultrasonography in detecting early arthropathic changes and contribution to the clinical approach in patients of hemophilia.

PURPOSE\AIM: Hemophilia affects the blood clotting process, is a genetic disease characterized by recurrent bleeding. The hemophilia early arthropathy detection with ultrasound (HEAD-US) procedure and scoring method were designed for the detection of early changes in affected joints of patients. In this article, it was aimed to detect early arthropathic changes in the joints of hemophilia patients with the HEAD US scoring system and to investigate its clinical contribution. It was aimed to investigate the effectiveness of HEAD-US scoring in showing early joint damage in subclinical hemophilia cases and its contribution to treatment. METHODS: The present study included 50 hemophilia patients who were admitted to Departments of Pediatric and Adult Hematology for routine follow-up. During routine follow-up controls, patients were scored by physical examination and HJHS 2.1 and by ultrasonography and HEAD US. Statistical tests were used to analyze joint health status and the results of US examination in the patient group. RESULTS: A total of 294 joints (elbow n = 100, knee n = 94, ankle n = 100) were evaluated by ultrasonography. The mean HJHS and HEAD-US scores of the patients were 14.94 ± 15.18 and 15.6 ± 12.6, respectively. CONCLUSIONS: HEAD-US is accepted to be more sensitive than HJHS in detecting early signs of arthropathy. Detection of early abnormalities by ultrasonography will enable the development of individualized treatment protocols and to the prevention of arthropathy development.

Hepatic and splenic sonographic and sonoelastographic findings in pulmonary arterial hypertension.

PURPOSE: The aim of this study was to evaluate the associations of sonographic and sonoelastographic parameters with clinical cardiac parameters, as well as to assess their value in predicting survival in patients with pulmonary arterial hypertension (PAH). METHODS: Thirty-six patients with PAH and normal liver function were prospectively enrolled in this prospective study along with 26 healthy controls, all of whom underwent ultrasound and point shear wave elastography examinations. Additionally, the portal vein pulsatility index (PVPI), inferior vena cava collapsibility index, and clinical cardiac variables were obtained in PAH patients. The values of hepatic (LVs) and splenic shear wave velocity (SVs) were compared between PAH patients and controls. The relationships between all sonographic and clinical parameters in the PAH patients were analyzed. Furthermore, their prognostic value in predicting survival was investigated. RESULTS: LVs values in PAH patients (median, 1.62 m/s) were significantly higher than in controls (median, 0.99 m/s), while no significant difference was observed in SVs values. Patients with higher grades of tricuspid regurgitation (TR) had significantly different values of PVPI (P=0.010) and sonoelastographic parameters (P<0.001 for LVs and P=0.004 for SVs) compared to those with less severe TR. Tricuspid annular plane systolic excursion values were the only investigated parameter found to be associated with survival (hazard ratio, 0.814; 95% confidence interval, 0.694 to 0.954; P=0.011). CONCLUSION: Our results demonstrated a direct association between cardiac congestion (i.e., the severity of TR) and liver stiffness, which should be kept in mind during the assessment of fibrosis in patients with PAH.

Acoustic Radiation Force Impulse Elastography May Predict Acute Rejection in Kidney Transplantation.

BACKGROUND: Allograft biopsy that is done as indicated by clinical and laboratory clues about graft rejection provides a definitive diagnosis. Noninvasive methods that may be useful for predicting or diagnosing rejection are important for early diagnosis of possible rejection. PURPOSE: The aim of this study is to investigate the relationship between changes in shear wave velocity (SWV) values and renal allograft kidney biopsy findings. MATERIAL AND METHODS: Thirty-four end-stage renal failure patients who underwent living donor renal transplantation between January 2015 and July 2015 were enrolled in this prospective cohort study. Implantation, sixth-month protocol, and biopsies that were performed with suspicion of acute rejection were evaluated with renal Doppler ultrasound and elastography findings of recipients' preimplantation donor ultrasonography findings. RESULTS: Comparison of renal ultrasound and elastography findings of 2 groups revealed a significant elevation in the resistive index (0.81 vs 0.63, P = .005) and pulsatility index (2.08 vs 1.20, P = .008) values in the rejection group, and no significant difference in the SWV values between the 2 groups. Delta (Δ)-SWV was calculated using the difference between acute rejection values and preimplantation, implantation, and sixth-month values showed a positive correlation between acute rejection (Δ-sixth month, r = 0.498, P = .030), tubulitis (Δ-pretransplant, r = 0.509, P = .037), and inflammation (Δ-pretransplant, r = 0.657, P = .004) scores. However, there were no correlations between Δ-SWV values and glomerulitis and peritubular capillaritis score. CONCLUSION: Changes in SWV may predict acute rejection in kidney transplantation patients if the reference measurements were done at a more stable time after the transplantation.

A 5 years follow-up for ischemic cardiac outcomes in patients with carotid artery calcification on panoramic radiographs confirmed by doppler ultrasonography in Turkish population.

OBJECTIVE: To evaluate the diagnostic accuracy of digital panoramic radiograph (DPR) for detection of carotid artery calcification (CAC) confirmed by Doppler Ultrasonography (DUSG) and to clarify the relationship between between CAC identified by DPR and cardiovascular events through a 5 year follow-up period. METHODS: Of 3600 consecutive patients examined, 158 patients presented with CAC as detected by DPR. The final study group was composed of 96 patients who had CAC confirmed by DUSG or CT angiogram. The control group was composed of 62 patients who has normal DUSG. The end point of the study was the occurrence of any cardiovascular event. RESULTS: 72 (75%) of the 96 patients with CAC confirmed by DUSG (16 patients had significant stenosis) had bilateral and 24 (25%) had unilateral CAS as detected by DUSG. There was a low agreement between the examination results with a κ value of 0.488 (p < 0.005) for calcification. Study data revealed that smoking, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM) and diastolic hypertension were significantly more common in patients with CAC than the control group (p < 0.05). During the follow-up period, 13 subjects had myocardial infarction and 1 subject died; in the control group, 1 patient died after MI and 1 patient died of a non-cardiac event. CONCLUSION: Patients with CAC detectable by DPR concomitant with COPD, DM, smoking or diastolic hypertension are more likely to suffer from vascular events. Therefore, patients with detectable carotid plaque in DPR require referral to a cardiovascular surgery clinic for further investigations.

Increase in interventricular septum thickness may be the first sign of cardiovascular change in kidney donors.

BACKGROUND: Because of the inadequate number of deceased kidney donors, living kidney donation remains an important issue for kidney transplantation. Previous studies have shown that living donation does not differ life expectancy and progression to end-stage renal disease compared with the normal population. In this study, we investigated short-term cardiovascular changes after donor nephrectomy. METHODS: Thirty-four patients who underwent donor nephrectomy between January 2015 and July 2015 at Ege University Renal Transplantation Unit were included in the study. Arterial stiffness, multifrequency bioimpedance analysis, renal ARFI elastography, and echocardiography performed prior to the donor nephrectomy and 6 months after nephrectomy. RESULTS: A total of 34 kidney donors were enrolled in this study. Twenty donors were female (59%) and 14 donors were male (41%). The pathological evaluation of donor kidneys using implantation renal biopsy sample revealed mean Karpinski Renal Score of 1.5 and the mean glomerulosclerosis ratio was 5% for all donated kidneys. Arterial stiffness, systolic and diastolic blood pressure measures, body fluid composition, and left atrial size did not change significantly during the follow-up. However, interventricular septum thickness of donors increased by 1 mm during a 6-month period (9.6 mm vs 10.6 mm, P = .002). CONCLUSION: We observed an increase in interventricular septum thickness in kidney donors during a 6-month follow-up. In order to evaluate the net effect of this change on donor morbidity, prospective studies investigating an increased number of donors with long-term follow-up should be needed.

An Association Study Between Gene Polymorphisms of Folic Acid Metabolism Enzymes and Biochemical and Hormonal Parameters in Acromegaly.

AIM: Folate metabolism is fundamental to several biological functions and required for cell replication, division, and survival. The mammalian folic acid cycle is highly complex and the enzymes, methylenetetrahydrofolate reductase (MTHFR), methionine synthase (MTR), and methionine synthase reductase (MTRR), have crucial roles in this metabolic pathway. The common polymorphisms of the MTHFR (C677T and A1298C), MTRR (A66G), and MTR (A2756G) enzymes are well documented as folate deficiency-related disorders, but their roles have not been examined in acromegalic patients. The aim of this study was to compare the genotypic distribution of these gene polymorphisms between patients with acromegaly and controls and explore whether these polymorphisms were associated with biochemical and hormonal parameters in acromegaly. We examined 91 acromegaly patients and 112 healthy subjects who were compared in terms of age and gender. Blood specimens of the subjects were collected in tubes containing ethylenediaminetetraacetic acid. Genomic DNA was isolated from peripheral blood leukocytes and genotyping of the MTHFR (C677T and A1298C) gene polymorphisms was assessed by melting temperature analyses after real-time polymerase chain reaction (PCR), whereas MTRR A66G and MTR A2756G gene polymorphism analyses were performed by PCR/restriction fragment length polymorphism from the isolated DNA of the subjects. RESULTS: MTHFR-677TT genotype frequency was significantly higher in the acromegaly group than the control group (p=0.017), and a significant increase was found in fibrinogen (p=0.032) levels in 677TT-carrying acromegaly patients. MTRR-66AA genotype was significantly higher in the control group than the acromegaly group (p=0.004). Total cholesterol (p=0.048) and C-reactive protein (p=0.046) levels decreased significantly in 66AA genotypes. Although MTR-2756AG genotype frequency was not different between the control and acromegaly groups, 2756AG genotype-carrying individuals have higher left carotid intima-media thickness levels within the patient group. CONCLUSION: Our results suggest that polymorphisms of the genes encoding the folic acid metabolism enzymes affect biochemical parameters in acromegaly and this may result in predispositions to some complications associated with folate metabolism and acromegaly.

Should subtotal thyroidectomy be abandoned in multinodular goiter patients from endemic regions requiring surgery?

The most convenient surgical procedure for benign thyroid diseases is still controversial. The aim of this study is to determine the recurrence rate and risk factors for recurrence after different thyroidectomy procedures in multinodular goiter patients. Patients were separated into two groups according to the detection of a recurrent nodule or not after thyroidectomy. Of the 748 patients, 216 (29%) had recurrence, while 532 had no recurrent nodule. The difference between surgical procedures described as subtotal (ST), near total (NT) and total thyroidectomy (TT) was statistically significant. Transient hypoparathyroidism was significantly higher in NT and TT, when compared to ST patients (P < 0.05). Young age, bilateral multinodular goiter and insufficient surgery are risk factors affecting recurrence for benign nodular thyroid disease. Currently, subtotal procedures should be discontinued and total or near total procedures should be preferred. Meanwhile, the probability of a higher risk of hypoparathyroidism should be kept in mind.

Does Apolipoprotein E genotype affect cardiovascular risk in subjects with acromegaly?

Acromegaly is a syndrome that results when the pituitary gland produces excess growth hormone after epiphyseal closure at puberty. Usually, subjects with acromegaly exhibit a 2- to 3-fold higher mortality rate from diseases that are associated with cardiovascular complications when compared to the normal population. In this study, we therefore aimed to evaluate whether a well-established cardiovascular risk factor, the Apolipoprotein E (Apo E) genotype, contributes to increased risk of cardiovascular complications in subjects with acromegaly. A total of 102 unrelated acromegaly subjects were prospectively included into this case-control association study and constituted our study group. The study group was comparable by age and gender with 200 unrelated healthy subjects constituting our control group. Genomic DNA was isolated from the peripheral blood leukocytes of all subjects and Apo E genotype (codon 112/158) was assessed by melting temperature analyses after using a real-time PCR protocol. The Apolipoprotein E4 allele was found at a significantly higher frequency in the study group when compared with the control group (P = 0.032). Subjects with the E2 allele, on the other hand, had significantly increased values in body mass index (P = 0.004), waist circumference (P = 0.001), C-reactive protein (CRP) (P < 0.001), and left-side carotid intima media thickness (P = 0.025). The Apolipoprotein E2 genotype might contribute to increased risk of cardiovascular complications in subjects with acromegaly since it is concurrently present with other cardiovascular risk factors such as the left-side carotid intima media thickness and CRP.

Duplex ultrasound evaluation of endoluminally treated aortic aneurysms with emphasis on diameter measurement: A comparison with computed tomography.

PURPOSE: The aim of this study was to determine the accuracy of color Doppler ultrasound (CDUS) for endoleak detection and measurement of the aneurysm diameter after endovascular aortic aneurysm repair. METHODS: Forty-eight CDUS and computed tomographic angiography (CTA) examinations performed concurrently on 29 patients who were treated with endovascular stent grafts for abdominal aortic aneurysms were included in the study. CTA and CDUS findings were retrospectively compared for aneurysm diameter, patency of the graft, and the presence of leaks in the aneurysm's lumen (the so-called "endoleaks"). RESULTS: The stent graft was patent in all patients. Including the follow-up examinations, endoleaks were detected in a total of 17 CTA studies. The sensitivity, specificity, and positive and negative predictive values for CDUS compared with CTA as the gold standard were 100%, 96%, 94.4%, and 100%, respectively. Kappa statistics showed a high level of agreement between CDUS ant CTA examinations (χ = 0.95). The aneurysm diameters measured with CDUS and CTA were significantly different, but within 5 mm of each other in 83% of patients. CONCLUSIONS: Provided that a strict CDUS protocol including spectral analysis of perigraft flow is used, CDUS is comparable to CTA for endoleak detection and measurement of the aneurysm diameter.

Methylenetetrahydrofolate reductase C677T gene polymorphism in Turkish patients with polycystic ovary syndrome.

Higher Levels of Hcy are associated with several clinical conditions, among them non-insulin-dependent diabetes mellitus, endometrial dysplasia and hypertension with insulin resistance, and polycystic ovary syndrome. The purpose of this study was to investigate the serum homocystein levels and other metabolic parameters in relationship with the MTHFR C677T gene polymorphism in patients with PCOS. Our study included 86 young women with PCOS constituting the study group and 70 healthy women constituting the control group. Homocystein levels, metabolic, and hormonal parameters were measured, and genetic analysis of the MTHFR C677T gene polymorphism was performed in all the subjects. A statistically significant difference was observed in mean homocystein levels between patients with PCOS when compared to the control group. The MTHFR 677 CC genotypes had significantly higher proportions in the control group compared to the PCOS patients (χ(2) = 21.381, P < 0.001). Our data show that homocystein levels were higher than normal subjects in patients with PCOS and that the MTHFR C677T gene polymorphism does not influence homocystein levels of patients with PCOS.

The relationship of the Fas 670 A/G gene polymorphism with cardiovascular risk factors in polycystic ovary syndrome (PCOS) patients.

AIMS: Apoptosis has been shown in cardiac cells under divergent physiological and pathological conditions. Apoptosis plays a key role in the pathogenesis of cardiac diseases. We aimed to evaluate the relation between Fas 670 A/G gene polymorphism in polycystic ovary syndrome (PCOS) patients carrying a potential risk for developing cardiovascular disease (CVD). MATERIALS AND METHODS: Ninety-one patients with PCOS and 100 cases of healthy control people were included in this study. PCOS was defined by the Rotterdam PCOS consensus criteria. The evaluation of genotype for Fas 670 A/G gene polymorphism was performed by using PCR-RFLP method. RESULTS: The evaluation of Fas genotype and gene allele frequency did not show statistically significant difference between patient and control groups. Both in PCOS patients and control groups, there were no statistically significant differences among A/A, A/G, and G/G. CONCLUSIONS: We found no relation between the cardiovascular risk factors and Fas 670 A/G gene polymorphism in women with PCOS and healthy subjects. Our results in risk factors of CVD can probably be explained by the fact that metabolic parameters and endothelial systems of the patients may not be affected yet in this short period of time.

Multiseptate gallbladder in a child with recurrent abdominal pain.

Multiseptate gallbladder, a rare congenital anomaly, can present with recurrent abdominal pain. Ultrasonography is the preferred imaging technique in patients with abdominal pain, especially for the evaluation of the gallbladder. We present the sonographic appearance of a multiseptate gallbladder.

Pancreatic arteriovenous malformation: a rare manifestation of hereditary hemorrhagic telangiectasia.

We present Doppler ultrasound, computed tomography and angiography findings of a rare pancreatic arteriovenous malformation associated with hereditary hemorrhagic telangiectasia.

Role of contrast-enhanced 3D magnetic resonance portography in evaluating portal venous system compared with color Doppler ultrasonography.

AIM: The purpose of this study was to evaluate the capability of contrast-enhanced three-dimensional (3D) MR portography in detecting abnormal findings associated with the portal venous system compared with the results of color Doppler ultrasonography (CDUS). MATERIALS AND METHODS: MR portography findings were retrospectively compared with the results of CDUS examinations in 161 patients, who were suspected of having portal venous system abnormalities. Portal venous vessels were divided into main 5 groups including the main portal vein, its left and right intrahepatic branches, splenic vein and superior mesenteric vein. Imaging findings were classified as normal, occluded, or partially thrombosed. Results of clinical and imaging follow-up examinations including CDUS, MR portography or angiography, if available, were used as a proof of final diagnosis. The potential sites of varicose veins and collateral vessels were also examined by both imaging methods. RESULTS: Vascular abnormalities were identified in 79 of 161 patients. There was a statistically significant agreement between the results of MR portography and CDUS in evaluating portal venous system (kappa = 0.871, P < 0.05). The sensitivity of MR portography was slightly superior to CDUS in detecting partially thrombosis and occlusion in the main portal venous vessels. In addition, MR portograms were superior to CDUS in the management of patients with portal hypertension by identifying portosystemic collaterals more adequately, and clearly demonstrated portal venous vessels that cannot be visualized at CDUS. CONCLUSION: Results of present study indicates that contrast-enhanced 3D MR portography is well suited and superior to CDUS in the management of patients with portal hypertension.

The progesterone receptor PROGINS polymorphism is not related to oxidative stress factors in women with polycystic ovary syndrome.

BACKGROUND: Women with PCOS have been reported to be at increased risk of a number of gynaecological neoplasias, including endometrial, breast, and ovarian cancer. Studies of the possible association of genetic variation in progesterone receptor polymorphism with risk of ovarian and breast cancer have concentrated on a variant known as PROGINS. METHODS: Ninety-five young women with PCOS and 99 healthy control women were included in our study. All subjects underwent venous blood drawing for complete hormonal assays, lipid profile, glucose, insulin and PROGINS polymorphism genetic study. RESULTS: In PROGINS polymorphism results; in both control and the patient groups T1/T1 has been detected in high levels. But for genotype (p = 0.178) and allele (p = 0.555) frequencies both of the groups give similar results. Statistically significant difference has been detected on serum FSH levels for T1/T1 genotype according to T2/T2 genotype. CONCLUSION: No relation has been detected between the inflammatory and oxidative stress factors, and PROGINS polymorphism alleles. This may be because the PCOS patients are young and their BMI means are normal and their CIMT and oxidative stress markers are like healthy women.

Ultrasound evaluation of fetal chromosome disorders.

Prenatal diagnosis of chromosomal disorders requires an invasive test in women regarded as being at high risk after screening. There is extensive evidence that effective screening for major chromosomal abnormalities can be provided in the first and second trimesters of pregnancy. With the association of some biochemical markers, it is possible to identify about 90% of chromosomal abnormalities. In this article, we aimed to review the important ultrasonographic markers of chromosomal abnormalities, including nuchal translucency, nasal bone, and nuchal skinfold thickness, based on the data available in the literature.

Does obesity prevent the needle from reaching muscle in intramuscular injections?

AIM: This paper is a report of a study to measure subcutaneous tissue thickness at the dorsogluteal and ventrogluteal sites and to determine optimal needle length for dorsogluteal and ventrogluteal intramuscular injections in adults with a body mass index of more than 24.9 kg/m2. BACKGROUND: Problems can arise if drugs designed to be absorbed from muscle are only delivered into subcutaneous tissue. Increasing obesity in all developed and many developing countries makes this an increasing concern. METHOD: Ultrasound measurements were made of the subcutaneous tissue of overweight, obese and extremely obese people at the dorsogluteal and ventrogluteal sites with the probe held at a 90 degrees angle to the plane of the injection site. Subcutaneous tissue thickness was measured in 119 adults whose body mass index was >or=25 kg/m2. The data were collected in 2005-2006. RESULTS: Mean subcutaneous tissue thickness at the dorsogluteal site was 34.5 mm for overweight adults, 40.2 mm for obese adults and 51.4 mm for extremely obese adults, and at the ventrogluteal site was 38.2 mm for overweight adults, 43.1 mm for obese adults and 53.8 mm for extremely obese adults. CONCLUSION: Intramuscular injections administered at the dorsogluteal site in 98% of women and 37% of men, and at the ventrogluteal site in 97% of women and 57% of men, would not reach the muscles of the buttock. A needle longer that 1.5 inches should be used in women whose body mass index is more than 24.9 kg/m2, the dorsogluteal site may be used in all overweight and obese men, and the ventrogluteal site may be used in overweight men only.

Comparison between allogenic and autologous vascular conduits in the drainage of anterior sector in right living donor liver transplantation.

Congestion of the anterior sector may lead to graft failure in right lobe grafts. Selective drainage of the prominent segment 5 and/or 8 veins is proposed to overcome this problem. Different vascular conduits may be used during drainage of the anterior sector. In this study, we evaluated the efficiency of the vascular conduits. Between June 1999 and December 2005, 190 patients underwent living donor right lobe liver transplantation and reconstruction of segment 5 and/or 8 veins was performed in 48 patients (25.2%). Two groups were formed according to the types of vascular conduits. Cryopreserved cadaveric iliac artery (n = 28) and cryopreserved cadaveric iliac vein (n = 8) were used in group A. In group B, recipient saphenous vein (n = 6), recipient umbilical vein (n = 5) and recipient collateral omental vein (n = 1) were used for reconstruction. The graft-recipient weight ratio, mean duration of anhepatic phase and MELD scores between two groups were not significantly different. All of the conduits were found to be patent just after reperfusion and in the early postoperative period by Doppler ultrasonography. In follow-up period of 1 year, four (11%) patients died in group A, two patients (16%) in group B. One of these patients died because of sepsis started from the saphenous vein incision site. None of the patients dying in the two groups were lost due to venous outflow problems. This study proves the efficacy of drainage of segment 5 and/or 8 veins using cryopreserved cadaveric vascular conduits. Every effort should be employed to store cadaveric iliac vessels, otherwise, whole other additive surgical intervention to ensure vascular conduit may lead uninvited serious complication.

Acute mesenteric ischemia: endovascular therapy.

Acute mesenteric ischemia (AMI) is an abdominal emergency with a high mortality. Prompt revascularization can prevent intestinal infarction and reduce mortality. We report three cases of acute occlusive mesenteric ischemia without signs of intestinal necrosis, which were successfully managed with endovascular interventions. Mechanical thrombus fragmentation was performed and underlying chronic stenoses were treated with stent implantation. All the patients had pain relief immediately after the procedure, and none of them required surgery for bowel resection. The patients remained symptom free during a follow-up of 12-16 months. We suggest that endovascular treatment is a feasible option in patients with AMI and can prevent intestinal infarction.

Vascular complications after liver transplantation: evaluation with Doppler US.

PURPOSE: To demonstrate the spectral and color Doppler ultrasonography (US) findings that would indicate vascular complications after liver transplantation and to report our single center results of vascular complications detected in liver transplant recipients. MATERIALS AND METHODS: Our study was consisted of 326 patients who underwent liver transplantation procedures between November 1997 and May 2004. The records of all patients were reviewed retrospectively for the details of each patient's post-transplant Doppler US examinations, visceral angiographic examinations, and/or surgical procedures. Doppler US findings were correlated with angiographic results or surgery. Sensitivity and specificity of Doppler US parameters for the diagnosis of vascular complications of the hepatic artery, portal vein, and hepatic veins were calculated. RESULTS: Vascular complications occurred in 47 patients (14%). Eight instances of vascular complications were detected intraoperatively by Doppler US at the time of transplantation. For hepatic artery complications, use of a Doppler US criteria resulted in a sensitivity and a specificity of 92% and 97%, respectively. Doppler US parameters also resulted in a sensitivity and a specificity of 100% in detecting portal vein complications, and resulted in a sensitivity of 99% and a specificity of 100% in detecting hepatic vein complications. CONCLUSION: Although it is clear that Doppler US evaluation is an effective choice for diagnosing vascular complications after liver transplantation, we also observed that Doppler US examination plays an important role in detecting vascular complications intraoperatively and improving the patient's chance for a successful outcome.