Elastography in the assessment of sentinel lymph nodes prior to dissection

Objective

Breast cancer starts as a local tumor but can become metastatic and spread via the lymph nodes. When the pre-operative assessment of the axillary lymph nodes is negative patients generally undergo sentinel node biopsy (SNB), followed by a secondary surgical axillary lymph node dissection (ALND) if the SNB is positive. The extemporaneous anatomo-pathological analysis of the sentinel lymph node enables metastases to be detected and an ALND at the same time of the SNB. The goal of this study was to evaluate the added value of ShearWave Elastography (SWE), compared with the conventional pre-operative assessment, in the screening of sentinel lymph nodes with a high metastatic risk, which could then benefit from an extemporaneous anatomo-pathological analysis.

Patients and methods

Women undergoing breast surgery with SNB were prospectively enrolled. Before surgery, they underwent ultrasound and elastography imaging of axillary lymph nodes using the SuperSonic Imagine device and its ShearWave™ elastography mode (SWE™). The results obtained were compared to the immunohistochemical results for the removed lymph nodes.

Results

65 patients were enrolled. From the 103 lymph nodes examined by elastography and the 185 lymph nodes removed we were able to pair 81; 70 were healthy and 11 were malignant. The stiffness measurements (mean and maximal values) were significantly different between the healthy and metastatic lymph nodes, (p < 0.05). The areas under the ROC curves were 0.76 (95% confidence interval (CI): 0.58–0.94) and 0.75 (95%CI: 0.55–0.95) for the mean and the maximal stiffness, respectively.

Conclusion

These encouraging results show a correlation between the metastatic risk of lymph nodes and their increased mean stiffness. Elasticity variables and potential thresholds that seem to predict the metastatic status of axillary lymph nodes were identified. If confirmed by further larger studies, these results could be useful in clinical practice for the identification of lymph nodes at high metastatic risk that could benefit from a intra-operative analysis to reduce the number of secondary surgical procedures.     

Comparison of the T2 Relaxation Time of the Temporomandibular Joint Articular Disk between Patients with Temporomandibular Disorders and Asymptomatic Volunteers

BACKGROUND AND PURPOSE:T2 relaxation time is a quantitative MR imaging parameter used to detect degenerated cartilage in the knee and lumbar intervertebral disks. We measured the T2 relaxation time of the articular disk of the temporomandibular joint in patients with temporomandibular disorders and asymptomatic volunteers to demonstrate an association between T2 relaxation time and temporomandibular disorder MR imaging findings.MATERIALS AND METHODS:One hundred forty-four patients with temporomandibular disorders and 17 volunteers were enrolled in this study. An 8-echo spin-echo sequence for measuring the T2 relaxation times was performed in the closed mouth position, and the T2 relaxation time of the entire articular disk was measured. Patients were classified according to the articular disk location and function, articular disk configuration, presence of joint effusion, osteoarthritis, and bone marrow abnormalities.RESULTS:The T2 relaxation time of the entire articular disk was 29.3 ± 3.8 ms in the volunteer group and 30.7 ± 5.1 ms in the patient group (P = .177). When subgroups were analyzed, however, the T2 relaxation times of the entire articular disk in the anterior disk displacement without reduction group, the marked or extensive joint effusion group, the osteoarthritis-positive group, and the bone marrow abnormality–positive group were significantly longer than those in the volunteer group (P < .05).CONCLUSIONS:The T2 relaxation times of the articular disk of the temporomandibular joint in patients with progressive temporomandibular disorders were longer than those of healthy volunteers.

Disorders of the temporomandibular joint (TMJ) are characterized by intra-articular positional and/or structural abnormalities.¹ MR imaging is the preferred imaging technique for diagnosing temporomandibular disorders (TMD).² It has been reported that the diagnostic accuracy of MR imaging for the assessment of the articular disk position and articular disk formation is 95% and for the assessment of osseous changes is 93% in postmortem examinations.³ Numerous studies of TMD by using MR imaging have reported qualitative and morphologic evaluations, because the most important subgroup of articular abnormalities in patients with TMD includes different forms of articular disk displacement and deformation of the articular disk, either with normal bony joint components or accompanied by degenerative joint diseases such as osteoarthritis.⁴ Other MR imaging findings of TMD, including joint effusion and bone marrow abnormalities, have also been evaluated qualitatively and morphologically.^5,6The T2 relaxation time is a quantitative MR imaging parameter derived from multiecho spin-echo sequences. Measuring the T2 relaxation times by using MR imaging has been reported to detect degenerated cartilage in the knee and lumbar intervertebral disk.^7–11 The T2 relaxation time of the articular disk of the TMJ in healthy volunteers has been previously described by using a 3T MR imaging system,¹² but the T2 relaxation time of the articular disk of the TMJ in patients with TMD has not been reported, to our knowledge.We hypothesized that the T2 relaxation time of the articular disk of the TMJ correlates with the qualitative and morphologic variations in the pathology of the TMJ. The aims of this study were to measure the T2 relaxation time of the articular disk of the TMJ in patients with TMD and asymptomatic volunteers to demonstrate any association between T2 relaxation time and MR image findings of TMD.     

Thermographic characterization of masticatory muscle regions in volunteers with and without myogenous temporomandibular disorder: preliminary results

Objectives:

This study aims to conduct a non-invasive measurement of the cutaneous temperature of selected masticatory muscle regions of volunteers with and without myogenous temporomandibular disorder (TMD), using infrared thermography.

Methods:

23 females (10 myogenous TMD volunteers and 13 controls) were recruited and studied. The temperature at the surface of the facial area over the anterior temporalis and masseter muscles was assessed by medical thermography, using regional lateral views and clinical examination.

Results:

The temperature levels measured at the masseter and anterior temporalis muscle regions in myogenous TMD volunteers (32.85 ± 0.85 and 34.37 ± 0.64 ºC, respectively) were significantly lower (p < 0.05) than those measured in controls (33.49 ± 0.92 and 34.78 ± 0.44 ºC, respectively). Medical infrared imaging indicated a mean difference of 1.4 ºC between the masseter and anterior temporalis regions. Analysis of the comparison between the absolute and normalized mean temperatures was performed using the pairwise comparison of receiver operating characteristic curves, and no statistically significant difference was observed (p > 0.05). The sensitivity and specificity of the thermographic assessment for the masseter region was of 70% and 73%, respectively and for the anterior temporalis region was of 80% and 62%, respectively.

Conclusions:

This method of evaluating masticatory muscle regions of this preliminary study seems to indicate that it can be used as an aid in complimentary diagnosing of TMDs.     

Stiffness of the iliotibial band and associated muscles in runner’s knee: Assessing the effects of physiotherapy through ultrasound shear wave elastography

ObjectivesTo test the hypothesis that Iliotibial Band Syndrome (ITBS) is caused by excessive iliotibial band (ITB) tension, promoted by hip abductor and external rotator weakness, and evaluate the influence of 6 weeks of physiotherapy on ITB stiffness.DesignInterventional study with control group.SettingClinical.Participants14 recreational runners with ITBS and 14 healthy controls of both sexes.Main outcome measuresUltrasound shear wave elastography, hip muscle strength, visual analog scale pain, subjective lower extremity function.ResultsNo statistical differences in ITB tension between legs as well as between patients suffering from ITBS and healthy controls were detected. Results showed significant strength deficits in hip abduction, adduction as well as external and internal rotation. Following six weeks of physiotherapy, hip muscle strength (all directions but abduction), pain and lower extremity function were significantly improved. ITB stiffness, however, was found to be increased compared to baseline measurements.ConclusionShear wave elastography data suggest that ITB tension is not increased in the affected legs of runners with ITBS compared to the healthy leg or a physical active control group, respectively. Current approaches to the conservative management of ITBS appear ineffective in lowering ITB tone.     

Diffusion Tensor Imaging of the Lateral Pterygoid Muscle in Patients with Temporomandibular Joint Disorders and Healthy Volunteers

ObjectiveThis study aimed to explore the feasibility of functional evaluation of the lateral pterygoid muscle (LPM) using diffusion tensor imaging (DTI) in patients with temporomandibular joint disorders (TMDs).Materials and MethodsA total of 119 patients with TMD (23 male and 96 female; mean age ± standard deviation, 41 ± 15 years; 58 bilateral and 61 unilateral involvements for a total of 177 joints) and 20 healthy volunteers (9 male and 11 female; 40 ± 13 years; 40 joints) were included in this prospective study. Based on DTI of the jaw in the resting state, the diffusion parameters, apparent diffusion coefficient (ADC), fractional anisotropy (FA), λ1, λ2, and λ3 of the superior and inferior heads of the LPM (SHLPM and IHLPM) were measured. Patients with TMD with normal disc position (ND), anterior disc displacement with reduction (ADWR), and anterior disc displacement without reduction (ADWOR) were compared.ResultsPatients with TMD overall, and ADWR and ADWOR subgroups had significantly higher ADC, λ1, λ2, and λ3 in both the SHLPM and IHLPM than those in volunteers (p < 0.05 for all), whereas the ND subgroup only had significantly higher ADC and λ1 (p < 0.001). Meanwhile, significant differences in FA in the SHLPM and IHLPM were found between volunteers and ADWOR (p = 0.014 and p = 0.037, respectively). Among the three TMD subgroups, except for λ3 and FA in the ADWR subgroup, ADWR and ADWOR subgroups had significantly higher ADC, λ1, λ2, and λ3 and lower FA than those in the ND group (p < 0.050). There was no significant difference in diffusion variables between ADWR and ADWOR. In ADWOR, the osteoarthritis group had significantly higher λ3 and lower FA values in the IHLPM than those in the non-osteoarthritis group.ConclusionDTI successfully detected functional changes in the LPM in patients with TMD. The unsynchronized diffusivity changes in the LPM in different subgroups of TMD signified the possibility of using diffusion parameters as indicators to identify the severity of LPM hyperfunction at various stages of TMD.     

A systematic review to investigate the effectiveness and acceptability of interventions for moist desquamation in radiotherapy patients

AimTo systematically review the currently available high quality evidence evaluating treatments for moist desquamation in radiotherapy patients.DesignSystematic literature review.MethodsElectronic databases, websites, reference lists, key journals and conference proceedings were searched. Attempts were also made to uncover unpublished material. Relevant studies proceeded to data extraction and quality assessment.ResultsTwenty studies were found; 10 were eligible for inclusion. Although many studies were small, none had unacceptably poor quality. No meta-analysis was undertaken as the studies were not homogenous in their interventions or methods. No convincing evidence for any intervention was found.ConclusionDespite being recommended by many guidelines (College of Radiographers Summary of Intervention for Acute Radiotherapy Induced Skin Reactions in Cancer Patients (London, 2001); NHS Quality Improvement Scotland Best Practice Statement: Skincare of Patients Receiving Radiotherapy (Edinburgh, 2004)); there is mixed evidence concerning the use of hydrogels and hydrocolloid dressings. However, improved patient comfort was sometimes seen, which is arguably equally important. There was limited evidence to support other interventions. Further research is urgently needed.     

Non-invasive biomechanical characterization of intervertebral discs by shear wave ultrasound elastography: a feasibility study

Objectives

Although magnetic resonance is widely spread to assess qualitatively disc morphology, a simple method to determine reliably intervertebral disc status is still lacking. Shear wave elastography is a novel technique that allows quantitative evaluation of soft-tissues’ mechanical properties. The aim of this study was to assess preliminary the feasibility and reliability of mechanical characterization of cervical intervertebral discs by elastography and to provide first reference values for asymptomatic subjects.

Methods

Elastographic measurements were performed to determine shear wave speed (SWS) in C6-C7 or C7-T1 disc of 47 subjects; repeatability and inter-operator reproducibility were assessed.

Results

Global average shear wave speed (SWS) was 3.0?±?0.4 m/s; measurement repeatability and inter-user reproducibility were 7 and 10 %, respectively. SWS was correlated with both subject’s age (p?=?1.3?×?10^?5) and body mass index (p?=?0.008).

Conclusions

Shear wave elastography in intervertebral discs proved reliable and allowed stratification of subjects according to age and BMI. Applications could be relevant, for instance, in early detection of disc degeneration or in follow-up after trauma; these results open the way to larger cohort studies to define the place of this technique in routine intervertebral disc assessment.

Key Points

? A simple method to obtain objectively intervertebral disc status is still lacking ? Shear wave elastography was applied in vivo to assess intervertebral discs ? Elastography showed promising results in biomechanical disc evaluation ? Elastography could be relevant in clinical routine for intervertebral disc assessment     

Anticipatory postural adjustment during gait initiation in multiple sclerosis patients: A systematic review

BackgroundMultiple sclerosis (MS) causes balance and walking disorders. Gait initiation is the complex transition between standing and walking and is characterized by two distinct phases: the anticipatory postural adjustment (APA) phase followed by the execution of the first step phase.Research aimTo determine alterations in the APA during gait initiation in patients with MS.MethodsA systematic search was conducted in May 2018. The search was carried out by the use of the following databases: PubMed, Web of Science and the Cochrane Library. The following keywords were used: MS, gait initiation, step initiation, and postural adjustment(s). Outcomes of interest were the variables generally used to assess APA, including electromyography, force-plate data, or video-based data, duration of APA, and length of first step. The Ottawa scale was used to assess the quality of the studies.ResultsEight case-control studies were included; one was a transverse study. A total of 215 MS patients and 116 healthy subjects were included with ages ranging from 22 to 76 years old. In MS patients, Expanded Disability Status Scale (EDSS) scores ranged from 0 to 7. APA CoP displacements were smaller in the anteroposterior axis. Four studies evaluated muscle activation during APA. The latencies of all muscles were delayed, and smaller magnitudes of muscle activity during APA were found, even in the early stage of disease. The first step was shorter in MS patients than in healthy patients. No previous study has reported joint movement or trunk inclination during gait initiation.SignificanceThis review illustrates the gap in knowledge of APA alterations in MS patients. APA assessment in the early stage of MS could be an interesting measure to characterize balance, dynamic control and risk of fall for such patients.     

Breast disease: clinical application of US elastography for diagnosis

PURPOSE: To evaluate the diagnostic performance of real-time freehand elastography by using the extended combined autocorrelation method (CAM) to differentiate benign from malignant breast lesions, with pathologic diagnosis as the reference standard. MATERIALS AND METHODS: This study was approved by the University of Tsukuba Human Subjects Institutional Review Board; all patients gave informed consent. Conventional ultrasonography (US) and real-time US elastography with CAM were performed in 111 women (mean age, 49.4 years; age range, 27-91 years) who had breast lesions (59 benign, 52 malignant). Elasticity images were assigned an elasticity score according to the degree and distribution of strain induced by light compression. The area under the curve and cutoff point, both of which were obtained by using a receiver operating characteristic curve analysis, were used to assess diagnostic performance. Mean scores were examined by using a Student t test. Sensitivity, specificity, and accuracy were compared by using the standard proportion difference test or the Delta-equivalent test. RESULTS: For elasticity score, the mean +/- standard deviation was 4.2 +/- 0.9 for malignant lesions and 2.1 +/- 1.0 for benign lesions (P < .001). When a cutoff point of between 3 and 4 was used, elastography had 86.5% sensitivity, 89.8% specificity, and 88.3% accuracy. When a best cutoff point of between 4 and 5 was used, conventional US had 71.2% sensitivity, 96.6% specificity, and 84.7% accuracy. Elastography had higher sensitivity than conventional US (P < .05). By using equivalence bands for noninferiority or equivalence, it was shown that the specificity of elastography was not inferior to that of conventional US and that the accuracy of elastography was equivalent to that of conventional US. CONCLUSION: For assessing breast lesions, US elastography with the proposed imaging classification, which was simple compared with that of the Breast Imaging Recording and Data System classification, had almost the same diagnostic performance as conventional US.     

Comparison of point and two-dimensional shear wave elastography of the spleen in healthy subjects

BACKGROUNDFew systematic comparative studies of the different methods of physical elastography of the spleen are currently available.AIMTo compare point shear wave and two-dimensional elastography of the spleen considering the anatomical location (upper, hilar, and lower pole).METHODSAs part of a prospective clinical study, healthy volunteers were examined for splenic elasticity using four different ultrasound devices between May 2015 and April 2017. The devices used for point shear wave elastography were from Siemens (S 3000) and Philips (Epiq 7), and those used for two-dimensional shear wave elastography were from GE (Logiq E9) and Toshiba (Aplio 500). In addition, two different software versions (5.0 and 6.0) were evaluated for the Toshiba ultrasound device (Aplio 500). The study consisted of three arms: A, B, and C.RESULTSIn study arm A, 200 subjects were evaluated (78 males and 122 females, mean age 27.9 ± 8.1 years). In study arm B, 113 subjects were evaluated (38 men and 75 women, mean age 26.0 ± 6.3 years). In study arm C, 44 subjects were enrolled. A significant correlation of the shear wave velocities at the upper third of the spleen (r = 0.33088, P < 0.0001) was demonstrated only for the Philips Epiq 7 device compared to the Siemens Acuson S 3000. In comparisons of the other ultrasound devices (GE, Siemens, Toshiba), no comparable results could be obtained for any anatomical position of the spleen. The influencing factors age, gender, and body mass index did not show a clear correlation with the measured shear wave velocities.CONCLUSIONThe absolute values of the shear wave elastography measurements of the spleen and the two different elastography methods are not comparable between different manufacturers or models.     

Effects of pre-sleep protein consumption on muscle-related outcomes — A systematic review

ObjectivesThe timing of protein intake over the day on muscle mass and strength gains have received interest in the literature. Thus, the aim of this systematic review is to analyze clinical studies that evaluated the acute effects of pre-sleep protein consumption on overnight muscle protein synthesis and the chronic effects on muscle mass and strength.DesignsSystematic review.MethodsA literature search was conducted up to June 2020 according to PRISMA statement and nine articles were included to analyze.ResultsThe consumption of 20–40 g of casein approximately 30 min before sleep stimulates whole-body protein synthesis rates over a subsequent overnight period in young and elderly men (preceded or not by resistance exercise, respectively). In addition, pre-sleep protein consumption can augment the muscle adaptive response (muscle fiber cross-sectional area, strength and muscle mass) during 10–12 weeks of resistance exercise in young, but not in elderly men.ConclusionsBased on current evidence, the consumption of 20–40 g of casein approximately 30 min before sleep improves protein synthetic response during an overnight recovery period in healthy young adult men, with possible positive effects on muscle mass and strength following prolonged resistance exercise. In elderly, despite the initial evidence regarding the pre-sleep protein enhances overnight muscle protein synthesis rates, the current available evidence is limited precluding to conclude about the chronic effects on skeletal muscle mass or strength. These conclusions need to be taken with caution due to uneven protein intakes between experimental groups. Therefore, more data are needed before further considering pre-sleep protein as an effective nutritional intervention.     

Ultrasound elastography: How can it help in differentiating breast lesions?

Introduction

Elastography is considered a non-invasive imaging modality which determines the tumors according to their stiffness. Strain images representing the stiffness of the lesions compared to that of the surrounding normal tissue.

Deep facial infections of odontogenic origin: CT assessment of pathways of space involvement.

PURPOSEWe investigated the pathways of spread of odontogenic infection in the facial and neck spaces.METHODSCT scans of 45 patients with extensive spread of odontogenic infection into the facial and neck spaces were analyzed to document pathways of spread.RESULTSOdontogenic infections arising in the mandible first spread upward, into the masseter and/or medial pterygoid muscles in the masticator space, and downward, into the sublingual and/or submandibular spaces, and then spread into the spaces or muscles adjacent to one or more of these locations. Infections from the masseter muscle spread into the parotid space to involve the temporalis and lateral pterygoid muscles. Infections from the medial pterygoid muscle spread into the parapharyngeal space to involve the lateral pterygoid muscle. Infections in the maxilla did not spread downward; instead, they tended to spread upward and superficially into the temporal and/or masseter spaces and deeply involve the lateral and/or medial pterygoid muscles in the medial masticator space.CONCLUSIONCT may be useful to depict the extent of infection and to plan treatment of extensive odontogenic infection, which can be life threatening when therapy is ineffective.     

Concomitant osteochondral lesions of the talus affect the stair descent biomechanics of patients with chronic ankle instability: A pilot study

BackgroundPrevious studies on the kinematics of patients with chronic ankle instability (CAI) that did not incorporate MRI and arthroscopic assessment could not differentiate between patients with CAI without osteochondral lesion of the talus (OLT) and patients with CAI and OLT and have thus presented contradictory results.Research questionThis study aimed to investigate the kinematic and electromyographic differences between patients with and without OLT.MethodsSixteen subjects with CAI (eight without OLT and eight with OLT confirmed through MRI and arthroscopic assessment) and eight healthy subjects underwent gait analysis in a stair descent setting. The three groups’ patient-reported outcomes; ankle joint range of motion in flexion, inversion and rotation; and muscle activation of the peroneus, tibialis anterior, and gastrocnemius during a gait cycle were analyzed and compared. A curve analysis, namely, one-dimensional statistical parametric mapping, was performed to compare the dynamic ankle kinematics and muscle activation curves over the entire normalized time series.ResultsThe patients with and without OLT had no difference in patient-reported outcomes. The maximal ankle plantarflexion of the patients without OLT and the healthy subjects was significantly larger than that of patients with OLT (p = 0.005). The maximal ankle internal rotation of patients without OLT was significantly larger than that of patients with OLT (p = 0.048). The peroneal activation during 0–6% of the gait cycle of patients with OLT was reduced compared with the healthy subjects.SignificancePatients with CAI and OLT and patients with CAI without OLT have no difference in patient-reported outcomes, but patients with OLT can be differentiated using the post-initial-contact peroneal activation deficit and the restriction of ankle plantarflexion and internal rotation during stair descent. These variables can be utilized to monitor the function of patients with CAI and their possibility of developing OLT.     

Clinical application of breast elastography: State of the art

Breast elastography is a new sonographic imaging technique for the characterization of focal breast lesions in addition to conventional ultrasonography (US) and mammography. Elastography provides a non-invasive evaluation of the stiffness of a lesion. Two different technical approaches are available for clinical use: free-hand elastography (USE) and shear wave elastography (SWE). Initial results of these techniques in clinical trials suggest that elastography substantially improves the US capability in differentiating benign from malignant breast lesions, thus reducing the number of breast biopsies in benign nodules. This review paper, based on an extensive literature search, highlights the basics of breast elastography, including main technical features, how to do suggestions, limit and pitfalls, and presents the results of major clinical studies.     

Elastosonography in the diagnosis of the nodular breast lesions: preliminary report

PURPOSE: To assess the diagnostic accuracy of elastography in characterising nodular breast lesions. MATERIALS AND METHODS: A total of 82 patients who received mammographic, ultrasonographic and elastographic evaluation in a single session at two Italian centres (Dept of Radiology, Az. Ospedali Riuniti, Ancona, and Ospedale Valduce, Como, Italy) between January and August 2004 according to identical protocols exhibited 91 nodules that were subjected to cytological/histological examination. Lesions were classified and scored and the sensitivity and specificity of elastography calculated. RESULTS: Overall sensitivity and specificity were 79% and 89%, respectively. However, sensitivity was 86% and 65% and specificity 100% and 62% for lesions < 2 cm and > 2 cm in diameter, respectively. Despite the small sample and the fact that it does not include the full range of cell types, tumour cell composition seemed to affect accuracy. CONCLUSIONS: Elastography is easy and rapid to perform. Larger studies are needed to establish semiological patterns; despite the small patient sample, these data provide an interesting contribution.     

Intrinsic foot muscle hardness is related to dynamic postural stability after landing in healthy young men

BackgroundThe human foot has competent mechanisms for supporting weight and adapting movement to various surfaces; in particular, the toe flexor muscles aid in supporting the foot arches and may be important contributors to postural stability. However, the role of intrinsic foot muscle morphology and structure in the postural control system remains unclear, and the relationship between them is not well known.Research questionAre intrinsic foot muscle morphology and toe flexor strength related to static and dynamic postural stability in healthy young men?.MethodsA total of 27 healthy men aged 19–27 years participated in this study. intrinsic foot muscle morphology included muscle hardness and thickness. Cross-sectional area was measured by ultrasonography at an ankle dorsiflexion angle of 0°. The hardness of the abductor hallucis (AbH), flexor hallucis brevis, and flexor digitorum brevis (FDB) muscles was measured using ultrasound real-time tissue elastography. Static postural stability during single-leg standing on a single force platform with closed eyes was assessed for the right leg. In the assessment of dynamic postural stability, the subjects jumped and landed on single-leg onto a force platform and the dynamic postural stability index (DPSI) was measured.ResultsFDB muscle thickness showed a positive correlation with anteroposterior stability index (APSI) (r = 0.398, p = 0.040). AbH muscle hardness was negatively correlated with APSI (r = −0.407, p = 0.035); whereas FDB muscle hardness was positively correlated with DPSI (r = 0.534, p = 0.004), vertical stability index (r = 0.545, p = 0.003), and maximum vertical ground reaction force (r = 0.447, p = 0.020). Multiple regression with forced entry revealed that only DPSI was significantly correlated with FDB muscle hardness (p = 0.003).SignificanceThe results indicated that intrinsic foot muscle hardness plays an important role in dynamic postural control among healthy young men, which may enable a more rapid muscular response to changes in condition during jump landing and better performance in balance tasks.     

Acoustic radiation force impulse tissue characterization of the anterior talofibular ligament: a promising noninvasive approach in ankle imaging

Objectives: The anterior talofibular ligament (ATFL) is the most frequently injured ligament during inversion strains of the ankle. The purpose of this study was to evaluate the feasibility of acoustic radiation force impulse (ARFI) elastography and to determine the in vivo mechanical properties of the ATFL in healthy athletes.

Methods: Sixty healthy athletes (32 female, 28 male; 28.9 ± 2.1 years) were recruited from the medical and sports faculty. ARFI values, represented as shear wave velocities (SWVs) as well as conventional ultrasound were obtained for the ATFL in neutral ankle position. A clinical assessment was performed in which the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score and the functional ankle ability measure (FAAM) were collected. Interobserver and intraobserver reliability (repeated sessions and repeated days) were assessed using an intra class correlation coefficient (ICC) and typical error (TE) calculation in absolute (TE) and relative units as coefficient of the variation (CV).

Results: SWV values of the ATFL had an average velocity of 1.79 ± 0.20 m/s for all participants, with an average of 1.72 ± 0.36 m/s for females and 1.85 ± 0.31 m/s for males. The interobserver and intraobserver reliability revealed an ICC of 0.902 and 0.933 (TE of 0.67 (CV: 5.2%) and 0.52 (CV: 3.84%)), respectively. FAAM and AOFAS revealed the best possible scores.

Conclusion: ARFI seems to be a valuable diagnostic modality and represents a promising imaging marker for the assessment and monitoring of ankle ligaments in the context of acute and chronic ankle instabilities; ARFI could also be used to investigate loading or sport dependent adaptions.     

Strain wave elastography for evaluation of renal parenchyma in chronic kidney disease

Objective:

Chronic kidney disease (CKD) is an important and costly health problem in developed countries and has a tendency to progress to end-stage renal disease regardless of the aetiology. This progress ends in interstitial fibrosis, which decreases the elasticity of tissue. Elastography is a developing technique to assess tissue elasticity. The aim of this study was to determine the difference of strain index (SI) value of renal parenchyma between patients with CKD and healthy individuals. In addition, SI differences of inter-stages were studied.

Methods:

Toshiba (Toshiba Medical Systems Corporation, Otawara, Japan) Aplio™ 500 ultrasound device and 3.5- to 5.0-MHz convex probe were used for the elastography examinations.

Results:

A total of 58 patients with CKD from nephrology and endocrinology clinics (30 males and 28 females; mean age, 56.14 ± 11.60 years) and 40 normal healthy individuals (19 males and 21 females; mean age, 51.70 ± 11.71 years) were included in this prospective study. The mean SI of normal healthy individuals and patients with CKD (regardless of stages) was 0.42 ± 0.30 and 1.81 ± 0.88, respectively (p < 0.001). SI values were not statistically significant among the CKD stages (except CKD Stages 1 and 3). The area under the receiver operating characteristic curve was 0.956 for SI. The optimal cut-off value for the prediction of CKD was 0.935 (sensitivity, 88% and specificity, 95%).

Conclusion:

SI value of sonoelastography can be used to differentiate patients with CKD and healthy individuals. Sonoelastography is an acceptable technique to approach patients with CKD, but we have not shown that it can reliably differentiate different stages.

Advances in knowledge:

Determining a cut-off SI value between normal and diseased renal parenchyma can help in the diagnosis of CKD.Chronic kidney disease (CKD) is an important and costly health problem in developed countries.^1–3 The survival rates of patients treated with dialysis for 1, 2, 5 and 10 years are 80%, 67%, 40% and 18%, respectively.^4,5CKD is defined as kidney damage of a duration of 3 months or more caused by structural or functional abnormalities with or without a decreased glomerular filtration rate (GFR) by The Kidney Disease Outcomes Quality Initiative™ (KDOQI) guidelines.⁴ CKD is categorized into five stages (Stages 1–5) according to the GFR based on the US National Kidney Foundation and the KDOQI guidelines.^3,4CKD has a tendency to end-stage renal disease (ESRD) regardless of the aetiology. CKD progresses to some histological changes such as progressive glomerulosclerosis, vascular sclerosis and tubulointerstitial injury, which encompass tubular atrophy and interstitial fibrosis.¹ Fibrosis decreases the elasticity of tissue.⁶ If we can detect the elasticity difference between normal parenchyma and CKD parenchyma, this may support the diagnosis of CKD.Elastography is a developing technique to assess tissue elasticity. It is a software that can be integrated to the ultrasonography machines.^1,7,8 There are different elastography techniques.^8,9 Strain wave elastography, acoustic radiation force impulse (ARFI) imaging, shear wave elastography (SWE) and transient elastography are the different techniques. Strain wave elastography was introduced to clinical use earlier than other image-based elastography techniques, and there are studies in the literature concerning its use in different areas such as the breast, prostate, liver, pancreas, thyroid, lymph nodes and kidney.ARFI technique is a variant of strain wave elastography, which is stimulated by an internal ultrasound pulse rather than applying external pressure to the tissue, supplying quantitative data about the stiffness of the tissue.¹⁰ A limitation of this technique is that it cannot be used in the presence of ascites.SWE is a technique that does not require external pressure on the tissue and supplies quantitative data. On the other hand, the production of shear waves needs a particular deepness, and the use of SWE is limited in superficial tissue.¹⁰ Also, it cannot be used in the presence of ascites.Transient elastography, also known as vibration elastography, is a type of SWE that uses equipment applying external pressure on the tissue and is mostly used in the liver.¹⁰ However, it cannot supply sonographic image and thus cannot be used in focal liver lesions.⁹Significant results on studies related to renal parenchymal evaluation have been obtained by using ultrasonography–elastography. However, further studies using all these ultrasonography–elastography techniques are required in order to demonstrate whether they display different results or which technique is better on the kidneys. To highlight this topic, in this study we used strain wave elastography that had already been integrated into the ultrasonography machine in our clinic.The aim of this study was to determine the difference in strain index (SI) values of renal parenchyma between patients with CKD and healthy individuals, and SI values of CKD inter-stages were also studied.