CSA Ratio Research Articles

Effects of Triazole Antifungal Agents on the Plasma Concentration and Dosage of Cyclosporin in Patients with Aplastic Anaemia

Objectives. This study aimed to investigate the effects of different triazole antifungal agents on the blood concentration and dosage of cyclosporine (CsA) in patients with aplastic anaemia (AA). Methods. This retrospective study enrolled AA patients who received CsA and triazole antifungal agents simultaneously between January 2018 and December 2022. The ratio of CsA blood concentration (ng/mL) to dosage (mg/day) (C/D) co-administration with and without azoles was compared. The effects of different triazole antifungal agents on blood concentrations and dosages of CsA were analysed. Results. The mean C/D ratio of CsA increased 1.97 times when co-administered with posaconazole (POS), while the mean C/D ratio of CsA increased 1.76 times when co-administered with fluconazole (FCZ). Compared with CsA monotherapy, there was a significant difference in CsA concentrations among patients with azoles (P<0.05). The mean dose of CsA decreased was 0.26 (−0.25—1.05) mg/kg/day and 0.18 (−0.50—0.69) mg/kg/day when co-administered with POS and FCZ, respectively. There is a wide interindividual variability in the magnitude of drug interaction between azoles and CsA. Conclusions. Although azoles increased CsA concentration, a wide individual variability was found in the patients with CsA C/D ratio. Therefore, the CsA dose should be adjusted by closely monitoring the blood levels of CsA co-administered with triazole antifungal agents. In addition, we observed that POS had a greater effect on the blood concentration of CsA than FCZ. When adjusting the dose of CsA in clinical practice, the blood concentration of CsA and the type of co-administered triazole antifungal agents should be considered.

Optimal Cut-Off Value for Detecting Breast Cancer-Related Lymphedema Using Ultrasonography.

Background: We previously devised an ultrasonographic evaluation to calculate subcutaneous tissue cross-sectional area (△CSA). The reliability and accuracy of this method were demonstrated in healthy individuals and in patients with lymphedema. The purpose of this study was to estimate the optimal cut-off value of the ratio of the △CSA of the involved side (lesion side) to the contralateral side for detecting breast cancer-related lymphedema (BCRL) using ultrasonography. Methods and Results: Ultrasonographic measurements were performed 290 times in 150 patients. BCRLD was defined as a confirmed difference of >2 cm in arm circumference. BCRL confirmed by a clinician (BCRLC) was defined as the patient group that included not only BCRLD but also patients with subcutaneous thickening and abnormal findings on lymphoscintigraphy, even if the difference in arm circumference was <2 cm. The △CSAs of both upper arms and forearms were calculated by measuring the thickness of the subcutaneous tissue at four locations using ultrasonography (superior, medial, inferior, lateral) at 10 cm above the elbow and 10 cm below the elbow. With a 1.35 △CSA ratio as the cut-off value for detecting BCRLD, the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were 0.88, 0.87, and 0.95, respectively. With a 1.20 △CSA ratio as the cut-off value for detecting BCRLC, the sensitivity, specificity, and AUC were 0.92, 0.89, and 0.97, respectively. Conclusions: Our findings suggest that a 1.20 △CSA ratio as determined using ultrasonography, corresponding to a tape measurement of 1.05 cm, can be considered as a diagnostic criterion for lymphedema.

Magnetic resonance image segmentation of the compressed spinal cord in patients with degenerative cervical myelopathy using convolutional neural networks.

Spinal cord segmentation is the first step in atlas-based spinal cord image analysis, but segmentation of compressed spinal cords from patients with degenerative cervical myelopathy is challenging. We applied convolutional neural network models to segment the spinal cord from T2-weighted axial magnetic resonance images of DCM patients. Furthermore, we assessed the correlation between the cross-sectional area segmented by this network and the neurological symptoms of the patients. The CNN architecture was built using U-Net and DeepLabv3 + and PyTorch. The CNN was trained on 2762 axial slices from 174 patients, and an additional 517 axial slices from 33 patients were held out for validation and 777 axial slices from 46 patients for testing. The performance of the CNN was evaluated on a test dataset with Dice coefficients as the outcome measure. The ratio of CSA at the maximum compression level to CSA at the C2 level, as segmented by the CNN, was calculated. The correlation between the spinal cord CSA ratio and the Japanese Orthopaedic Association score in DCM patients from the test dataset was investigated using Spearman's rank correlation coefficient. The best Dice coefficient was achieved when U-Net was used as the architecture and EfficientNet-b7 as the model for transfer learning. Spearman's rs between the spinal cord CSA ratio and the JOA score of DCM patients was 0.38 (p = 0.007), showing a weak correlation. Using deep learning with magnetic resonance images of deformed spinal cords as training data, we were able to segment compressed spinal cords of DCM patients with a high concordance with expert manual segmentation. In addition, the spinal cord CSA ratio was weakly, but significantly, correlated with neurological symptoms. Our study demonstrated the first steps needed to implement automated atlas-based analysis of DCM patients.

A study on the applicability of scoria gravel an alternative base course material through blending with marble waste aggregate

This study aims to evaluate the applicability of Scoria gravel as an alternative base course material in flexible pavements through blending with marble waste aggregate (MWA) by modifying the physical and mechanical engineering properties of scoria. Non-Probabilistic sampling techniques and experimental methods were used. To achieve the objectives of the study, the laboratory tests were passed in three steps. First, the Engineering properties of materials were independently tested; the result proves the marginality of scoria gravel. Second, scoria gravel was mechanically stabilized by 20% percentages by weight increments of MWA. The obtained engineering properties test results at 20:80 Scoria to MWA mix ratios are 2.56%, 21.38%, 18.59%, 19.27%, 17.45%, 13.77%, Non-Plastic, 1.21%, and 73.4%, for Specific Gravity, Aggregate Crushing Value, Aggregate Impact Value, Loss Angeles Abrasion, Flakiness Index, Elongation Index, Atterberg's limit, Water Absorption, and California Bearing Ratio (CBR) respectively. These test results fulfilled the ERA standard specification for GB2 and GB3 base course materials. However, the CBR test results showed a failure to meet the standard spécification. Thus, 20:80 Scoria to MWA percentage by weight ratio was selected as a control mixture. So, Crushed Stone Aggregate was added at 5% percentage by weight to improve the CBR of scoria gravel. Therefore, the CBR value of 82.13% attained the ERA standard Specification limit for base course materials at 15:60:25 percentages by weight ratio of scoria gravel, MWA, and CSA respectively. Finally, Based on this study it was recommended to use scoria gravel as an alternative base course construction material, when it was found abundantly near construction vicinity.

A Novel Ultrasonographic Anthropometric-Independent Measurement of Median Nerve Swelling in Carpal Tunnel Syndrome: The "Nerve/Tendon Ratio" (NTR).

There is little consensus on ultrasound (US) normative values of cross-sectional area of median nerve (MN-CSA) in carpal tunnel syndrome (CTS) because of its dependency on anthropometric parameters. We aim to propose a novel anthropometric-independent US parameter: MN-CSA/flexor radialis carpi CSA (FCR-CSA) ratio ("Nerve Tendon Ratio", NTR), in the diagnosis of clinically and electrodiagnostic (EDS)-defined CTS. 74 wrists of 49 patients with clinically defined CTS underwent EDS (scored by the 1-5 Padua Scale of electrophysiological severity, PS) and US of carpal tunnel with measurement of MN-CSA (at the carpal tunnel inlet), FCR-CSA (over scaphoid tubercle) and its ratio (NTR, expressed as a percentage). US normality values and intra-operator agreement were assessed in 33 healthy volunteers. In controls, the mean MN-CSA was 5.81 mm2, NTR 64.2%. In 74 clinical CTS, the mean MN-CSA was 12.1 mm2, NTR 117%. In severe CTS (PS &gt; 3), the mean MN-CSA was 15.9 mm2, NTR 148%. In CTS, both MN-CSA and NTR correlated with sensitive conduction velocity (SCV) (p &lt; 0.001), distal motor latency (DML) (p &lt; 0.001) and PS (p &lt; 0.001), with a slight superiority of NTR vs. MN-CSA when controlled for height, wrist circumference and weight. In CTS filtered for anthropometric extremes, only NTR maintained a correlation with SCV (p = 0.023), DML (p = 0.016) and PS (p = 0.009). Diagnostic cut-offs were obtained with a binomial regression analysis. In those patients with a clinical diagnosis of CTS, the cut-off of MN-CSA (AUROC: 0.983) was 8 mm2 (9 mm2 with highest positive predictive value, PPV), while for NTR (AUROC: 0.987), the cut-off was 83% (100% with highest PPV). In patients with EDS findings of severe CTS (PS &gt; 3), the MN-CSA (AUROC: 0.876) cut-off was 12.3 mm2 (15.3 mm2 with highest PPV), while for NTR (AUROC: 0.858) it was 116.2% (146.0% with highest PPV). NTR can be simply and quickly calculated, and it can be used in anthropometric extremes.

Ultrasonic and Electrophysiological Evaluation of Carpal Tunnel Syndrome in Diabetic and Non-diabetic Subjects

Background: Carpal tunnel syndrome (CTS) is the most prevalent upper-limb entrapped neuropathy. A nerve conduction study (NCS) is the simplest method for identifying CTS when combined with a satisfactory clinical assessment and physical assessment. Ultrasound is a beneficial non-traumatic screening approach for CTS and there is a relationship between the NCS tests and the measures of CSA by ultrasound. Objective: to assess whether or not sonographic observations of the median nerve seems to be varied amongst DM and non-DM CTS individual. Patients and methods: The total of 50 non-DM Individuals with CTS and 50 DM individuals with CTS have been included in this study. All individuals were submitted to full medical assessment NCS testing the hands and sonogram US for assessment of cross-sectional area CSA and wrist forearm ratio (WFR). Results: Total 100 affected wrists with CTS are classified as 30 (60.0%) wrists with mild disease, 11 (22.0%) wrists that demonstrated moderate disease and 9 (18.0%) wrists had a severe disease in diabetic CTS patients and 23 (46.0%) wrist mild disease, 20 (40.0%)wrist show moderate disease, 7 (14.0%) wrist had a severe disease in non-diabetic CTS patient. The mean of the median nerve CSA was (0.14+0.03), (0.15+0.04) in diabetic and non-diabetic CTS individuals, respectively with no significant difference between the two groups. In contrast, the wrist-forearm ratio demonstrates a significant difference between the two groups. Conclusion: The CSA of the median nerve is greater in CTS wrists through both DM and non-DM individuals with no significant difference. The mean wrist-forearm ratio was less in diabetic patients than in non-diabetic with a significant difference. Pairing NCS with US imaging gives effective assessment methods for the CTS hands in individuals with and without diabetes.

Assessment of clinical, imaging, surgical risk factors for subsequent fracture following vertebral augmentation in osteoporotic patients.

Currently, the risk factors for subsequent fracture following vertebral augmentation remain incomplete and controversial. To provide clinicians with accurate information for developing a preventive strategy, we carried out a comprehensive evaluation of previously controversial and unexplored risk factors. We retrospectively reviewed patients with osteoporotic vertebral compression fracture in lumbar spine who received vertebral augmentation between January 2019 and December 2020. Based on whether refracture occurred, patients were assigned to refracture and non-refracture group. The clinical characteristics, imaging parameters (severity of vertebral compression, spinal sagittal alignment, degeneration of paraspinal muscles), and surgical indicators (cement distribution and leakage, correction of spinal sagittal alignment) were collected and analyzed. There were 128 patients and 16 patients in non-refracture and refracture group. The incidence of previous fracture, multiple fractures, and cement leakage were notably higher, relative cross-sectional area of psoas (r-CSAPS) was significantly smaller, CSA ratio, fatty infiltration of erector spinae plus multifidus (FIES+MF), FIPS, postoperative lumbar lordosis (post-LL), correction of body angel (BA), and LL were significantly greater in refracture group. Binary logistic regression analysis revealed previous fracture, cement leakage, post-LL, and correction of BA were independent risk factors. According to the ROC curve, correction of BA showed the highest prediction accuracy, and the critical value was 3.45°. The occurrence of subsequent fracture might be the consequence of multiple factors. Previous fracture, cement leakage, post-LL, and correction of BA were identified as independent risk factors. Furthermore, the correction of BA should not exceed 3.45°, especially in patients with risk factors.

Why the patients with Hirayama disease have abnormal cervical sagittal alignment? A radiological measurement analysis of posterior cervical extensors

PurposeTo explore the relationship between the strength of posterior cervical extensors (PCEs) and cervical sagittal alignment in Hirayama disease (HD) patients.MethodsWe analyzed the (magnetic resonance imaging) MRI T2WI and X-rays of 60 HD patients who visited Huashan Hospital from June 2017 to February 2020. Symptoms of these patients include adolescent onset, manifestation of unilateral upper limb muscle weakness and muscle atrophy of the forearm and hand. MRI images were used to measure (the cross-sectional area) CSA of cervical PCEs. The ratio of muscle CSA to vertebral body areas at the same level is defined as R-CSA. Cervical sagittal alignment includes the C2–7 Cobb angle, T1 slope and C2–7 sagittal vertical axis (SVA). The geometric center of the C3–6 vertebral body was determined using the line connecting the C2 inferior endplate and the C7 upper endplate. When located behind the line, it is defined as a “local kyphotic deformity.” The number of vertebral bodies involved in kyphotic deformity was determined by measuring the local kyphosis angle (LKA). Spearman correlation analysis (α = 0.05) was used to determine the relationship between R-CSA and sagittal parameters. ROC curves were used to analyze the sensitivity and specificity of relevant variables.ResultsSpearman correlation test revealed that R-CSA negatively correlated with T1S (S = 0.34, r = 0.34, p = 0.01) and LKA (S = 0.44, r = 0.5, p = 0.01), but did not correlate with the C2-C7 Cobb angle (S = 0.20, p = 0.12) or C2-C7 SVA (S = − 0.17, p = 0.46). (p < 0.05). ROC curve analysis showed that the areas under the curve (AUCs) of the T1 slope and LKA was 0.6696 and 0.7646, respectively. T1 slope, cutoff value: 17.2°; sensitivity: 0.5806; specificity: 0.7241; p < 0.05. LKA: cutoff value: − 14°; sensitivity: 1; specificity: 0.5333; p < 0.05.ConclusionsIn patients with Hirayama disease, the strength of posterior cervical extensors and cervical sagittal alignment are closely related. The local kyphosis angle can be used as a reference for the strength of posterior cervical extensors. These results indicate the weakness of PCEs, which may predispose the cervical spine of HD patients to a less stable situation. Therefore, patients with Hirayama disease should strengthen the exercise of the PCEs.

Different degeneration patterns of paraspinal muscles in degenerative lumbar diseases: a MRI analysis of 154 patients

Study designA retrospective study.ObjectiveTo evaluate the different degeneration patterns of paraspinal muscles in degenerative lumbar diseases and their correlation with lumbar spine degeneration severity.Summary of background dataThe degeneration characteristics of different paraspinal muscles in degenerative lumbar diseases remain unclear.Methods78 patients diagnosed with single-level degenerative lumbar spondylolisthesis (DLS) and 76 patients with degenerative lumbar kyphosis (DLK) were included as DLS and DLK groups. Paraspinal muscle parameters of psoas major (PS), erector spinae (ES) and multifidus muscle (MF) were measured, including fatty infiltration (FI) and relative cross-sectional area (rCSA), namely the ratio of the paraspinal muscle CSA to the CSA of the vertebrae of the same segment. Sagittal parameters including lumbar lordosis (LL) and sagittal vertical axis (SVA) were measured. The paraspinal muscle parameters and ES/MF rCSA ratio were compared between the two groups. Paraspinal muscles parameters including rCSA and FI were also compared between each segments from L1 to L5 in both DLS and DLK groups. In order to determine the influence of sagittal spinal alignment on paraspinal muscle parameters, correlation analysis was conducted between the MF, ES, PS rCSA and FI and the LL in DLS and DLK group.ResultMF atrophy is more significant in DLS patients compared with DLK. Also, MF fatty infiltration in the lower lumbar spine of DLS patients was greater compared to DLK patients. DLK patients showed more significant atrophy of ES and heavier ES fatty infiltration. MF FI was significantly different between all adjacent segments in both DLS and DLK groups. In DLS group, ES FI was significantly different between L2/L3 to L3/L4 and L4/L5 to L5/S1, while in DLK group, the difference of ES FI between all adjacent segments was not significant, and ES FI was found negatively correlated with LL.ConclusionsParaspinal muscles show different degeneration patterns in degenerative lumbar diseases. MF degeneration is segmental in both DLS and DLK patients, while ES degenerated diffusely in DLK patients and correlated with the severity of kyphosis. MF degeneration is more significant in the DLS group, while ES degeneration is more significant in DLK patients. MF is the stabilizer of the lumbar spine segments, while the ES tends to maintain the spinal sagittal balance.

Diagnostic value of median nerve shear wave ultrasound elastography in diagnosis and differentiation of carpal tunnel syndrome severity

BackgroundCarpal tunnel syndrome (CTS) is the commonest type of peripheral nerve entrapment syndromes. The study aimed at evaluation of diagnostic value of median nerve stiffness measured by shear wave ultrasound elastography for diagnosis and differentiation of CTS severity, correlated to electrophysiological studies. This case–control study involved 40 patients (56 wrists) with CTS of different severity and 40 controls (40 wrists). All participants underwent electrophysiological study to assess the CTS severity, high-resolution conventional B-mode ultrasound to assess cross-sectional area “CSA” of median nerve at carpal tunnel, ratio of median nerve CSA at carpal tunnel and forearm, and shear wave ultrasound elastography with measurement of median nerve mean stiffness and correlation to electrophysiological results as the reference standard.ResultsMean median nerve stiffness by shear wave US elastography was increased in patients with CTS compared to controls and across the different CTS severity groups (P value < 0.001 & 0.001, respectively). The cutoff value by ROC curve analysis for median nerve stiffness to differentiate between patients with CTS and control group was 65.4 kPa (P value < 0.001, 94.6% sensitivity, 97.3% specificity). Higher diagnostic accuracy was noted with the combination of shear wave elastography and conventional B-mode US with improved AUC (B-mode + shear wave; 0.962, P value < 0.001).ConclusionsShear wave ultrasound elastography of median nerve was able to discriminate different severity subgroups of CTS with high sensitivity, while conventional US couldn’t. The diagnostic accuracy of CTS was improved when combined high-resolution conventional B-mode US and complementary shear wave ultrasound elastography.

Utilization of Carbide Slag by Wet Grinding as an Accelerator in Calcium Sulfoaluminate Cement.

In this study, wet-ground carbide slag (i.e., WGCS) was utilized as an accelerator in calcium sulfoaluminate cement (CSA) for obtaining considerably faster setting processes for some special engineering processes such as plugging projects and rapid repair engineering. The WGCS–CSA system was designed, in which the replacement ratio of CSA by carbide slag was chosen as 4%, 8% and 12%. The setting time and compressive strength were measured, and the mechanism of the system hydration was studied in detail by means of calorimetry, XRD, thermogravimetry (TG) and SEM. The results showed that WGCS shortened the setting time of cement and significantly augmented the early strength. The addition of 8% of WGCS contributed to increasing the 2-h compressive strength from 4.2 MPa to 32.9 MPa. The decrease in the setting time and the increase in the initial strength were mainly attributed to the high initial pH value of the liquid phase and the high content of calcium ions in WGCS. Both these factors contributed to the ettringite formation and, at the same time, to the transformation of the morphology at a later time. Such results testify that WGCS can be used as an accelerator in the CSA system and also that it provides a novel approach to the reutilization of carbide slag.

Diagnostic utility of median nerve CSA to ulnar nerve CSA ratio in the diagnosis of mild idiopathic carpal tunnel syndrome

BackgroundUltrasonography (US) measurement of median nerve cross-sectional area (m-CSA) at pisiform is increasingly utilized in identification of carpal tunnel syndrome (CTS), but there is still no agreement about the ideal cut-off value to employ. The aim of the study was to explore whether the median CSA to ulnar CSA ratio at the level of pisiform may yield a more accurate diagnosis of CTS. The study included 50 patients with mild idiopathic CTS (ICTS), assessed clinically and by nerve conduction studies, and 50 matched controls. M-CSA, median nerve flattening ratio and swelling ratio (m-SR), palmer bowing, and median CSA to ulnar CSA ratio (m-CAS:u-CSA) were measured for patients and controls. The cutoff values for the US parameters for the diagnosis of ICTS were evaluated.ResultsCompared to the control group, the ICTS group had significantly higher m-CSA (p < 0.001), higher m-CSA:u-CSA ratio (p < 0.001), higher m-SR (p = 0.012, and higher palmar bowing (p < 0.001). Use of m-CSA cutoff value of 11.78 mm2 and CSA:u-CSA ratio cut-off point of 2.97 yielded the greatest sensitivity and specificity for the diagnosis of ICTS.ConclusionThe m-CSA:u-CSA ratio is slightly superior to the m-CSA in the diagnosis of CTS in terms of sensitivity and specificity.

Role of High-Resolution Ultrasonography in Evaluation of Median Nerve and Thickness of Flexor Retinaculum in Patients with Hypothyroidism

Objectives: To determine the role of high resolution ultrasonography in evaluation of cross sectional area, maximum nerve fascicle thickness and thickness/width ratio of the median nerve and flexor retinaculum thickness in patients with hypothyroidism and to correlate it with the healthy volunteers. Material and Methods: A prospective study was conducted from February 2018 to October 2019 on 62 patients which included 32 clinically proven cases of hypothyroidism and 30 healthy volunteers. High resolution ultrasonography was performed using high frequency linear probes. Results: The most affected parameter was cross sectional area of median nerve at three levels, inlet/outlet ratio of CSA of the median nerve and thickness of flexor retinaculum in hypothyroidism patients in correlation with healthy volunteers. These parameters showed statistically significant p values. Maximum nerve fascicle thickness and thickness/width ratio of the median nerve showed no statistical significance in hypothyroid patients in correlation with healthy volunteers. Conclusion: High-resolution ultrasonography plays an important role in evaluating the changes occuring in cross sectional area of the median nerve, its inlet/outlet CSA ratio and flexor retinaculum thickness in hypothyroidism patients as correlated with the healthy volunteers.

Combined Sensory Index Test versus Diagnostic Ultrasonography in Early Detection of Carpal Tunnel Syndrome

Abstract Objectives to evaluate combined sensory index test (CSI) versus diagnostic ultrasonography in early detection of carpal tunnel syndrome. Patients and Methods case control cross sectional study was performed on twenty patients with symptoms and signs suggestive of carpal tunnel syndrome with duration 1 to 4 months and twenty apparently healthy volunteers included as a control group. All patients and controls were assessed and underwent ultrasound of the wrist and electrophysiological testing. Data from patients and control groups were compared to determine the diagnostic relations in patients with CTS. Results This study include 20 Patient with ages ranged from 25 to 45 with mean±SD (36.8±6.1) years with symptoms and signs suggestive of carpal tunnel syndrome with duration 1 to 4 months. The control group ages ranged from 25 to 45 with mean±SD (57.63±6.41) years. Our results revealed that CSI ranged from (0.7-1.9ms) with mean ± SD (1.36± 0.366) in CTS group and ranged from (0.2-0.8ms) with mean ±SD (0.59± 0.187) in control group (P &amp;lt; 0.001), cutoff point was &amp;gt; 0.8ms with sensitivity 85%, specificity 100% and accuracy 97.5%. Our diagnostic ultrasound results revealed that Inlet Outlet Ratio of CSA of median nerve ranged from (1-1.6) with mean ± SD (1.26 ± 0.226) in CTS group and from (0.7-1.1) with mean ± SD (0.92 ± 0.134) in control group (P &amp;lt; 0.001) with sensitivity was 80%, specificity 70% and accuracy 85%. By combination of both electrodiagnostic test (CSI) and diagnostic ultrasound (IOR) in early detection of CTS, our results revealed highly statistically significant difference between patient and control groups (P &amp;lt; 0.001) with sensitivity 100%, specificity 70%, and accuracy 85%. Conclusion Combined sensory index (CSI) is indicated in suspected cases of CTS with positive symptoms and negative signs. US is not an alternative diagnostic tool to electrodiagnostic tests but they are complementary.

Shearwave Elastography in the Differentiation of Carpal Tunnel Syndrome Severity.

There is emerging evidence that ultrasound elastography may provide additional diagnostic information in peripheral neuropathies. To investigate the use of ultrasound elastography to evaluate median nerve stiffness in patients with carpal tunnel syndrome (CTS), as well as the relationship between the elastographic stiffness and electrophysiological severity. Case control study. Tertiary hospital outpatient neurophysiology clinic. Twenty eight patients (47 wrists) with CTS and 25 control patients (25 wrists). None. Ultrasound parameters (median nerve cross-sectional area [CSA] at carpal tunnel, ratio of median nerve CSA at carpal tunnel and forearm), shearwave elastography parameter (median nerve stiffness), and electrophysiological severity of carpal tunnel syndrome. In patients with CTS, median nerve stiffness by ultrasound elastography was increased between the different severity groups (control 83.5 ± 24.8, EDx negative CTS 84.2 ± 46.4, mild 117.7 ± 79.3, moderate 144.0 ± 71.1, severe 196.6 ± 48.4). The control versus moderate and severe subgroup was statistically significant. In total, this study has demonstrated that ultrasound elastography was able to discriminate the severity of CTS whereas conventional ultrasound parameters did not.

Optical Coherence Tomography for the Early Detection of Coronary Vascular Changes in Children and Adolescents After Cardiac Transplantation: Findings From the International Pediatric OCT Registry

ObjectivesThis study sought to describe the initial findings from the International Pediatric Optical Coherence Tomography (OCT) registry in pediatric heart transplant recipients. BackgroundCardiac allograft vasculopathy (CAV) is a common cause of late graft failure and mortality in pediatric heart transplant recipients. Early diagnosis may improve outcomes. OCT is a high-resolution intravascular imaging technique that has the potential to identify CAV earlier than angiography. MethodsOCT and angiography of the coronary arteries were performed in pediatric heart transplant recipients at participating centers. Demographics, clinical data, medications, episodes of rejection, and angiographically confirmed CAV were collected for each case. OCT and angiography images were analyzed in a central core imaging laboratory. Intimal thickness and intima/media cross sectional area (I/M CSA) ratios were calculated for each case. Intimal thickness ≥0.25 mm was defined as abnormal and ≥0.4 mm as severe intima thickening. I/M CSA ratio of ≥1 was defined as abnormal. OCT findings were compared to angiographic findings for each case. ResultsAcross 3 centers, 110 cases were analyzed from 76 patients. Intimal thickening was present in 26 of 110 cases. Eleven of these cases had severe intima thickening (≥0.4 mm) and notably, angiography results were normal in 8 cases. All 5 cases with a median I/M CSA ratio of ≥2 had normal angiography. The maximal intima thickness was ≥0.25 mm in 24% and ≥0.4 mm in 10% of cases. Median I/M CSA ratio was ≥1 for 80% of cases. I/M CSA ratio was significantly higher in cases with concurrent CAV (p = 0.03). Maximal intima thickness was significantly greater in cases with current or previous rejection (p = 0.01). I/M CSA ratio was significantly lower in patients treated with statins (p = 0.01). OCT findings alone prompted a change to medical management in 17% of cases. ConclusionsOCT provides important insights into coronary vascular changes not detected by angiography in pediatric transplant recipients. The use of OCT for pediatric heart transplant recipients should be further investigated, given its potential to impact the management of CAV.

Dibenzylamine substituted cyclotetraphosphazenes: Synthesis, characterization and their stereogenic properties

In this study, octachlorocyclotetraphosphazene, (1) and mono-spiro-1,3-propanedioxycyclotetraphosphazene, (2) were reacted with dibenzylamine to obtain cyclotetraphosphazenes having one and two stereogenic centres and to investigate the stereogenic properties of them. The reactions of compound 1 with bulky reagent, dibenzylamine might progress to until the tetrakis stage of chlorine replacement occurs and further substitutions by dibenzyamine do not occur. The structures of the products (3, 4, 5a, 5b, 6a, 6b, 7a and 7b) were determined by elemental and mass analyses, 1H and 31P NMR spectroscopies and for compounds 3, 4 and 5a where suitable single crystals were obtained, the structures were characterised by X-ray crystallography. The stereogenic properties of compound 3 which has one stereogenic centre and compound 5b which has two stereogenic centres were investigated by 31P NMR spectroscopy on the addition of a chiral solvating agent. It was found that 31P NMR/CSA method did not lead to the expected separation of the signals of enantiomers (3, 5b), even molar ratio of CSA:compound is up to 100:1 for dibenzylamine derivatives of cyclotetraphosphazene . Hence X-ray crystallography (for 3) and chiral HPLC method (for 5b) were used in order to determine their stereogenic properties.

OPTICAL COHERENCE TOMOGRAPHY IN CHILDREN: DEVELOPMENT OF A PROTOCOL FOR THE STANDARDIZED QUANTITATIVE ANALYSIS OF CORONARY ARTERIES

Optical coherence tomography (OCT) is a high-resolution intravascular imaging technique that has shown promise for the early detection of intimal thickening of coronary arteries in pediatric heart transplant recipients. The potential utility of OCT as a diagnostic and/or prognostic tool is currently unclear due to a lack of a standardized approach to analyse OCT images in this population. We established the OCT Core Imaging Laboratory at BC Children’s Hospital to develop a standardized protocol for the quantitative analysis of OCT images. Our study population included n=30 pediatric cardiac transplant recipients who had OCT imaging of the coronary arteries performed as part of standard of care at BC Children’s Hospital (St Jude Medical, now Abbott). We deemed a ‘pullback’ analyzable if ≥10mm of the segment was of good image quality (defined as ≥75% of cross-section visible without artifact). We evenly selected 10-20 cross-sectional frames ≥1 mm apart, avoiding bifurcations. Using the device-manufacturer’s software, we applied digital planimetry to trace the lumen-intima border, the internal elastic lamina, and the external elastic lamina for each cross-sectional frame. Cross-sectional areas (CSA, mm2) were derived for the lumen, the intima and the media; maximal intimal thickness (mm) was defined as the widest point between the circular markers for the intima and media. We calculated the intima/media (I/M) CSA ratio. For each pullback, we derived summary values from cross-sectional frames for relevant variables as means, medians, 95th percentile (p95) and maximal values. We performed inter-rater and intra-rater reliability analyses by intra-class correlation coefficients and Bland-Atman Analyses. Overall, 82% of analyzable pullbacks met inclusion criteria for our protocol (≥10-20 frames, ≥1 mm apart), resulting in 67 pullbacks from 28 patients analysed. The right coronary artery was most frequently imaged (58%), and more often met inclusion criteria for quantitative analyses (85% vs. 82% overall). Mean vs. median and max vs. p95 summary statistics yielded very similar values for I/M CSA and maximal intimal thickness (all ICC>0.98; difference < 3%), suggesting our protocol provides robust summary values. We registered excellent inter-rater and intra-rater reliability for I/M CSA and maximal intimal thickness (all ICC>0.95; difference < 5%). We provide a systematically developed and rigorously tested protocol for the quantitative analysis of OCT images in children. The novel application of OCT to a pediatric population requires expert image analysis and has the potential to improve the care of pediatric transplant patients who are at risk of structural coronary changes.

Acute non-contact anterior cruciate ligament tears are associated with relatively increased vastus medialis to semimembranosus cross-sectional area ratio: a case-control retrospective MR study.

Hamstring muscle deficiency is increasingly recognized as a risk factor for anterior cruciate ligament (ACL) tears. The purpose of this study is to evaluate the vastus medialis to semimembranosus cross-sectional area (VM:SM CSA) ratio on magnetic resonance imaging (MRI) in patients with ACL tears compared to controls. One hundred knee MRIs of acute ACL tear patients and 100 age-, sex-, and side-matched controls were included. Mechanism of injury, contact versus non-contact, was determined for each ACL tear subject. The VM:SM CSA was measured on individual axial slices with a novel method using image-processing software. One reader measured all 200 knees and the second reader measured 50 knees at random to assess inter-reader variability. The intraclass correlation coefficient (ICC) was calculated to evaluate for correlation between readers. T-tests were performed to evaluate for differences in VM:SM CSA ratios between the ACL tear group and control group. The ICC for agreement between the two readers was 0.991 (95% confidence interval 0.984-0.995). Acute ACL tear patients have an increased VM:SM CSA ratio compared to controls (1.44 vs. 1.28; p=0.005). Non-contact acute ACL tear patients have an increased VM:SM CSA ratio compared to controls (1.48 vs. 1.20; p=0.003), whereas contact acute ACL tear patients do not (1.23 vs. 1.26; p=0.762). Acute non-contact ACL tears are associated with increased VM:SM CSA ratios, which may imply a relative deficiency in hamstring strength. This study also demonstrates a novel method of measuring the relative CSA of muscles on MRI.

Cyclosporine Use in Epidermal Necrolysis Is Associated with an Important Mortality Reduction: Evidence from Three Different Approaches

Several immunomodulatory agents are used in the treatment of epidermal necrolysis, but evidence of their efficacy is limited. The Autonomous Community of Madrid has two reference burn units to which all patients with epidermal necrolysis are referred. One burn unit has mostly used cyclosporine (CsA), and the other has used non-CsA therapies (mainly high-dose intravenous immunoglobulin). The allocation of patients to one or the other burn unit was mainly based on proximity, resembling a random assignment. Thus, we took advantage of this "natural experiment" to estimate the mortality risk ratio (MRR) of CsA (n= 26) compared with non-CsA (n= 16) treatment using hospital as an instrumental variable over the period from 2001 to 2015. We also computed the observed versus expected (O/E) MRR in a case series of 49 CsA-treated patients (including 23 patients from other regions treated in Madrid), and using the Score for Toxic Epidermal Necrolysis (i.e., SCORTEN) scale to estimate the expected values. The instrumental variable-based MRR of CsA versus non-CsA was 0.09 (95% confidence interval= 0.00-0.49). The O/E analysis also showed a reduction in mortality risk (MRROE= 0.42; 95% confidence interval= 0.14-0.99). We identified five other case series of CsA-treated patients providing MRROE and meta-analyzed their results. The pooled MRROE (including from this study) was 0.41 (95% confidence interval= 0.21-0.80). All three approaches consistently show that CsA reduces the mortality in epidermal necrolysis patients.