Median Cross-sectional Area Research Articles

Nerve size correlates with clinical severity in Charcot-Marie-Tooth disease 1A.

Nerve cross-sectional area (CSA) is larger than normal in Charcot-Marie-Tooth disease 1A (CMT1A), although to a variable extent. We explored whether CSA is correlated with CMT clinical severity measured with neuropathy score version 2 (CMTNS2) and its examination subscore (CMTES2) in CMT1A. We assessed 56 patients with CMT1A (42 families). They underwent nerve conduction study (NCS) and nerve high-resolution ultrasound (HRUS) of the left median, ulnar, and fibular nerves. Univariate analysis showed NCS and HRUS variables to be significantly correlated with CMTNS2 and CMTES2 and with each other. Multivariate analysis showed that ulnar motor nerve conduction velocity (β: -0.19) and fibular compound muscle action potential amplitude (-1.50) significantly influenced CMTNS2 and that median forearm CSA significantly influenced CMTNS2 (β: 5.29) and CMTES2 (4.28). Nerve size is significantly associated with clinical scores in CMT1A, which suggests that it might represent a potential biomarker of CMT damage and progression.

Preoperative Ultrasound Assessment of Regional Lymph Nodes in Melanoma Patients Does not Provide Reliable Nodal Staging: Results From a Large Multicenter Trial.

To assess whether preoperative ultrasound (US) assessment of regional lymph nodes in patients who present with primary cutaneous melanoma provides accurate staging. It has been suggested that preoperative US could avoid the need for sentinel node (SN) biopsy, but in most single-institution reports, the sensitivity of preoperative US has been low. Preoperative US data and SNB results were analyzed for patients enrolled at 20 centers participating in the screening phase of the second Multicenter Selective Lymphadenectomy Trial. Excised SNs were histopathologically assessed and considered positive if any melanoma was seen. SNs were identified and removed from 2859 patients who had preoperative US evaluation. Among those patients, 548 had SN metastases. US was positive (abnormal) in 87 patients (3.0%). Among SN-positive patients, 39 (7.1%) had an abnormal US. When analyzed by lymph node basin, 3302 basins were evaluated, and 38 were true positive (1.2%). By basin, the sensitivity of US was 6.6% (95% confidence interval: 4.6-8.7) and the specificity 98.0% (95% CI: 97.5-98.5). Median cross-sectional area of all SN metastases was 0.13 mm2; in US true-positive nodes, it was 6.8 mm2. US sensitivity increased with increasing Breslow thickness of the primary melanoma (0% for ≤1 mm thickness, 11.9% for >4 mm thickness). US sensitivity was not significantly greater with higher trial center volume or with pre-US lymphoscintigraphy. In the MSLT-II screening phase population, SN tumor volume was usually too small to be reliably detected by US. For accurate nodal staging to guide the management of melanoma patients, US is not an effective substitute for SN biopsy.

P81-F Neuromuscular ultrasound as diagnostic tool and marker of disease progression in amyotrophic lateral sclerosis

Background Several methods have been proposed to diagnose and score disease severity in Amyotrophic Lateral Sclerosis (ALS) patients (pt.). Traditionally neurophysiological tests have been employed. The development of neuromuscular ultrasound (US) have provided a further useful tool. Our aim was to evaluate sonographic changes of muscles and nerve trunks to define diagnosis and assess ALS severity. Materials and methods 20 ALS pt. (15 m e 5 f, mean age: 63.9 + 9.5 yrs) were enrolled. All investigations were performed using an Esaote MyLabGamma device in conventional B-Mode. We evaluated the following muscles: sternocleidomastoid, diaphragm, biceps brachii/brachialis, forearm flexors, rectus femoris and anterior tibial; among the nerve, vagus, median, ulnar and sural. Results We found in all cases increased echogenicity with decreased muscle thickness and fasciculations; mean diaphragm rest thickness was reduced; changes in thickness during inspiration and expiration were also reduced and loss in the most severe cases. Median and Ulnar nerve cross-sectional area (CSA) resulted smaller; sural and vagal nerve resulted spared. ALS disease severity, measured using Functional Rating Scale (ALSFRS), correlated with quantitative ultrasound data. Conclusions neuromuscular ultrasound resulted a simple, fast and easy method, painless and risk-free, able to provide useful functional and structural information in ALS pt. Furthermore, diaphragm US may allow to point out concomitant respiratory failure. Moreover is desirable that US become an indispensable tool of the diagnostic armamentarium of the neuromuscular physician in pt. with ALS.

Trigeminal Nerve Atrophy Predicts Pain Recurrence After Gamma Knife Stereotactic Radiosurgery for Classical Trigeminal Neuralgia.

Trigeminal nerve atrophy and neurovascular compression (NVC) are frequently observed in classical trigeminal neuralgia (CTN). To determine whether nerve characteristics contribute to Gamma Knife (Elekta AB, Stockholm, Sweden) surgery (GKS) outcomes in unilateral CTN without previous surgery. From 2006 to 2012, 67 patients with unilateral CTN without previous surgery received GKS with a maximal dose of 90 Gy delivered to the trigeminal nerve juxta brainstem. Two evaluators, blinded to the side of pain, analyzed the magnetic resonance images before GKS to obtain the parameters, including nerve cross-sectional area (CSA), vessel type of NVC, and site of NVC along the nerve. Correlations of the parameters with pain relief (Barrow Neurological Institute [BNI] grades I-IIIb) and recurrence (BNI grades VI-V) were made by using Cox regression and Kaplan-Meier analyses. The median CSA of the symptomatic nerves was significantly smaller than that of the asymptomatic nerves (4.95 vs 5.9 mm2, P<.001). After adjustment for age and sex, larger nerve CSA was associated with lower initial pain relief (hazard ratio 0.81, P=.03) and lower pain recurrence after initial response (hazard ratio 0.58, P=.02). Patients with nerve atrophy (CSA of≤4.4 mm2 after receiver operating characteristic curve analysis) had a lower 5-yr probability of maintaining pain relief after initial response than those without nerve atrophy (65% vs 86%, P=.04). Trigeminal nerve atrophy may predict pain recurrence in patients with initial post-GKS relief of CTN. Arterial and proximal NVC are not predictive of GKS outcomes. Future studies are required to determine optimal treatments for long-term pain relief in patients with CTN and trigeminal nerve atrophy.

Quantitative magnetic resonance evaluation of the trigeminal nerve in familial dysautonomia.

Familial dysautonomia (FD) is a rare autosomal recessive disease that affects the development of sensory and autonomic neurons, including those in the cranial nerves. We aimed to determine whether conventional brain magnetic resonance imaging (MRI) could detect morphologic changes in the trigeminal nerves of these patients. Cross-sectional analysis of brain MRI of patients with genetically confirmed FD and age- and sex-matched controls. High-resolution 3D gradient-echo T1-weighted sequences were used to obtain measurements of the cisternal segment of the trigeminal nerves. Measurements were obtained using a two-reader consensus. Twenty pairs of trigeminal nerves were assessed in ten patients with FD and ten matched controls. The median (interquartile range) cross-sectional area of the trigeminal nerves in patients with FD was 3.5 (2.1)mm2, compared to 5.9 (2.0)mm2 in controls (P < 0.001). No association between trigeminal nerve area and age was found in patients or controls. Using conventional MRI, the caliber of the trigeminal nerves was significantly reduced bilaterally in patients with FD compared to controls, a finding that appears to be highly characteristic of this disorder. The lack of correlation between age and trigeminal nerve size supports arrested neuronal development rather than progressive atrophy.

Prospective Clinical Trial of Anti-CD19 CAR T Cells in Combination with Ibrutinib for the Treatment of Chronic Lymphocytic Leukemia Shows a High Response Rate

Prospective Clinical Trial of Anti-CD19 CAR T Cells in Combination with Ibrutinib for the Treatment of Chronic Lymphocytic Leukemia Shows a High Response Rate

Hybrid endoluminal stapled pyloroplasty: an alternative treatment option for gastric outlet obstruction syndrome.

Gastroparesis is a rapidly increasing problem with sometimes devastating consequences. While surgical treatments, particularly laparoscopic pyloroplasty, have recently gained popularity, they require general anesthesia, advanced skills, and can lead to leaks. Peroral pyloromyotomy is a less invasive alternative; however, this technique is technically demanding and not widely available. We describe a hybrid laparo-endoscopic collaborative approach using a novel gastric access device to allow endoluminal stapled pyloroplasty as an alternative treatment option for gastric outlet obstruction. Under general anesthesia, six pigs (mean weight 33kg) underwent endoscopic placement of intragastric ports using a technique similar to percutaneous endoscopic gastrostomy. A 5mm laparoscope was used for visualization. A functional lumen imagine probe was used to measure the cross-sectional area (CSA) and diameter of the pylorus before, after, and at 1week after intervention. Pyloroplasty was performed using a 5mm articulating laparoscopic stapler. Gastrotomies were closed by endoscopic clips, endoscopic suture, or combination. After 6-8days, a second evaluation was performed. At the end of the protocol, all animals were euthanized. Six pyloroplasties were performed. In all cases, this technique was effective in achieving significant pyloric dilatation. The median pre-pyloroplasty pyloric diameter (D) and cross-sectional area (CSA) were 8mm (4.9-11.6mm) and 58.6mm2 (19-107mm2), respectively. After the procedure, these values increased to 13.41mm (9.8-17.6mm) and 147.7mm2 (76-244mm2), respectively (p = 0.0152). No important intraoperative events were observed. Postoperatively, all animals did well, with adequate oral intake and no relevant complications. At follow-up endoscopy, all incisions were healed and the pylorus widely patent. Hybrid endoluminal stapled pyloroplasty is a feasible, safe, and effective alternative method for the treatment of gastric outlet obstruction syndrome.

Nerve ultrasound findings differentiate Charcot-Marie-Tooth disease (CMT) 1A from other demyelinating CMTs

ObjectiveUlnar/median motor nerve conduction velocity (MNCV) is ≤38 m/s in demyelinating Charcot-Marie-Tooth disease (CMT). Previous nerve high resolution ultrasound (HRUS) studies explored demyelinating CMT assuming it as a homogeneous genetic/pathological entity or focused on CMT1A. MethodsTo explore the spectrum of nerve HRUS findings in demyelinating CMTs, we recruited patients with CMT1A (N = 44), CMT1B (N = 9), CMTX (N = 8) and CMT4C (N = 4). They underwent nerve conduction study (NCS) and HRUS of the median, ulnar, peroneal nerve, and the brachial plexus. ResultsMedian, ulnar and peroneal MNCV significantly differed across CMT subtypes. Cross sectional area (CSA) was markedly and diffusely enlarged at all sites, except entrapment ones, in CMT1A, while it was slightly enlarged or within normal range in the other CMTs. No significant right-to-left difference was found. Age had limited effect on CSA. CSAs of some CMT1A patients largely overlapped with those of other demyelinating CMTs. A combination of three median CSA measures could separate CMT1A from other demyelinating CMTs. ConclusionsNerve HRUS findings are heterogeneous in demyelinating CMTs. SignificanceNerve HRUS may separate CMT1A from other demyelinating CMTs. The large demyelinating CMTs HRUS spectrum may be related to its pathophysiological variability.

Factors that affect ambulation in Charcot–Marie–Tooth patients

Charcot–Marie–Tooth (CMT) disease is the most common inherited peripheral neuropathy. Limited information on imaging in neuromuscular conditions is available and further less in Hispanic patients. Sonographic examination has been used to describe the pathology of the nerves in patients with CMT. The purpose of this study is to describe imaging of the nerves and muscles that affect ambulation using sonographic and evaluate their association with walking speed. Twenty-one patients previously diagnosed with a demyelinating form of CMT via genetic testing and/or electrodiagnostic study with family history of CMT were evaluated. Ultrasound (US) measurements of the common peroneal nerve (CPN), cross-sectional area (CSA) and anterior tibialis muscle (ATM) depth were performed. CPN compound motor action potential (CMAP) amplitude recording at the ATM was recorded. Later a 10-meter walk test and a Stair Climb test were performed. US evaluation showed significant increase in median and CPN CSA average when compared to reference data. Although not statistically significance there was a positive association between CMAP amplitude recording at the ATM and ATM depth in axial plane or size and ambulation velocity w/o AFO. This could be related to the fact that CPN with less pathology nerve conduction should be able to adequately supply the ATM, therefore better amplitude is obtained and less muscle atrophy is found. The negative association was found between CPN CSA and ambulation velocity w/o AFO not statistically significant. As the CPN increases in size, ambulation dysfunction is further observed in this population. To our knowledge no prior study has described the CPN and ATM with US, which are important components for ambulation in CMT. US is a sensitive and relatively accessible tools for evaluating this population. Future correlation of US findings and functional test is a potential field of research for future projects.

Sonographic assessment of carpal tunnel syndrome in diabetic patients with and without polyneuropathy.

The objective of this study is to determine whether the cross sectional area (CSA) measurement of the median nerve at the wrist differ between carpal tunnel syndrome (CTS) in diabetic patients with and without diabetic polyneuropathy (DPN).This study included 44 patients with type II diabete millitus (DM) with CTS, 32 patients with CTS and DPN, 46 patients with idiopathic CTS, and 42 healthy subjects. Ultrasonographic measurement of the CSA of the median nerve was made at the level of the wrist, together with nerve conduction studies.The median CSA at the wrist was significantly larger in all patient groups compared with healthy subjects. The median nerve CSA was significantly larger in diabetic patients with CTS than patients with idiopathic CTS. The median nerve CSA at wrist was significantly smaller in patients with CTS and DPN compared with diabetic patients with CTS only.The median nerve CSA at the wrist was larger in diabetic patients with CTS than patients with idiopathic CTS and CTS with DPN. Median nerve CSA can help to differentiate between diabetic patients with CTS with and without DPN.

Ultrasonographic reference values for the median nerve at the level of pronator teres muscle.

The purpose of this study was to investigate the ultrasonographic reference values for diameters and cross-sectional area (CSA) of the median nerve between the two heads of the pronator teres muscle in healthy population as well as to correlate the findings with height, weight, sex and age. Fifty-five healthy Caucasian volunteers (110 median nerves) were included in this study. The reference range (mean ± 2 standard deviations; 2.5th-97.5th quintiles) and the upper limit of side-to-side difference of the median nerve between the two heads of the pronator teres muscle were investigated using high-frequency ultrasound. The effects of age, sex, height, handedness, and body mass index (BMI) were examined. The mean age was 39.4 ± 10.6years (range 18-75years). The mean ± 2SD of the median CSA was 4.9-12.9mm2. The upper limit of normal side-to-side difference was 3.0mm2. The differences between genders and between the dominant and non-dominant hands were not significant. The mean antero-posterior and transverse diameters were 7.2 ± 1.5 and 10.7 ± 2.4mm, respectively. Significant correlations were observed between the dominant-side CSA and BMI (r = 0.33; p = 0.01) and age (r = 0.31; p = 0.02). The correlation between the CSA and height (r = 0.19; p = 0.16) was not significant. The measurements obtained in this study are of importance for examining median nerve entrapments in the forearm using high-frequency ultrasound. Age and BMI showed to be correlated with median nerve CSA; while gender and height were not.

Usefulness of ultrasound assessment of median nerve mobility in carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) is the most common peripheral compression neuropathy of the upper extremity. Recently, dynamic ultrasound (US) imaging has shown differences in median nerve mobility between the affected and unaffected sides in CTS. The present study was performed to compare the median nerve mobility between patients with CTS and healthy individuals, and to correlate median nerve mobility with the severity of CTS. A total of 101 patients (128 wrists) with CTS and 43 healthy individuals (70 wrists) were evaluated. Electrodiagnostic studies were initially conducted to determine the neurophysiological grading scale (NGS). The cross-sectional area (CSA) of the median nerve and the grade of median nerve mobility were measured using US. The mean grade of median nerve mobility in the CTS group (1.9) was significantly lower than that in the control group (2.6; P < 0.001). There were significant negative correlations between the grade of median nerve mobility and distal motor latency of the median nerve (r = -0.218, P = 0.015), NGS (r = -0.207, P = 0.020) and CSA of the median nerve (r = -0.196, P = 0.028). The grade of median nerve mobility was negatively correlated with the severity of CTS. US assessment of median nerve mobility may be useful in diagnosing and determining the severity of CTS.

Dialysis-Related Parameters Influence Remodeling in the Venous Part of the Native Arteriovenous Fistula

The aim of this study was to evaluate the association of hemodynamic parameters related to hemodialysis and antropometric parameters of patients with changes in the venous part of the arteriovenous fistula (AVF) at points of needling. Two hundred forty-two hemodialysis (HD) patients (60.3% men), with median age 65 (interquartile range [IQR] 56-75) years, on HD treatment for a median of 49 (IQR 20-88) months with functioning fistula were recruited for the study. The history of vascular access, comorbidity, antropometric (body mass index, body surface area, and body composition), and dialysis-related parameters were analyzed. The cross-sectional area of upper extremity vessels were measured using ultrasound and included 2 points: A (arterial point for blood aspiration) and V (venous point for returning the blood after purification). The difference between A and V (A-V) was calculated. The median cross-sectional area of A was larger than V (1.04 [IQR 0.58-1.7] vs. 0.74cm2 [IQR: 0.41-1.39], P<0.0001). The median difference between A and V (A-V) was 0.17cm2 and positively correlated with mean blood flow (Qb), effective Kt/V, and time of AVF use. Other analyzed factors had no influence on A-V. In the multivariate analysis, the independent factor increasing the difference (A-V) was mean blood flow measured during HD sessions. The needling and utilization of AVF for hemodialysis may affect vein anatomy, namely causing dilatation at the arterial point and narrowing at venous point of AVF. We suggest that blood pump velocity of the dialysis machine may have an impact on these changes, but practical importance of these findings has to be elucidated. The significance of (A-V) factor in the prognosis of fistula complications should be further studied and confirmed in the prospective trials.

Ultrasound assessment of peripheral nerve pathology in neurofibromatosis type 1 and 2.

The neurofibromatoses (NF) type 1 and 2 are hereditary tumor predisposition syndromes caused by germline mutations in the NF1 and NF2 tumor suppressor genes. In NF1 and 2, peripheral nerve tumors occur regularly. For further characterizing nerve ultrasound was performed in patients with NF1 and 2. Patients with established diagnosis of NF1 (n=27) and NF2 (n=10) were included. Ultrasound of peripheral nerves and cervical roots was performed during routine follow-up visits. Healthy volunteers were studied for comparison. In patients with NF1, median cross-sectional area (CSA) of most nerves was significantly increased compared to controls and to NF2 due to generalized plexiform tumors, which arose out of multiple fascicles in 23 of 27 patients (85%). These were often accompanied by cutaneous or subcutaneous neurofibromas. In NF2, the overall aspect of peripheral nerves consisted of localized schwannomas (80%) and, apart from that, normal nerve segments. Nerve ultrasound is able to visualize different nerve pathologies in NF1 and NF2. It is a precise and inexpensive screening method for peripheral nerve manifestation in neurofibromatosis and should be considered as the first choice screening imaging modality for all peripheral nerves within reach of non-invasive ultrasound techniques. Ultrasound patterns of peripheral nerve pathologies are described for the first time in a large cohort of patients with NF1 and NF2. It is a suitable screening tool and enables targeted MRI analysis.

Loss of muscle mass: a significant predictor of postoperative complications in acute diverticulitis

BackgroundSevere muscle mass depletion, sarcopenia, has been shown to be associated with poor operative outcomes. However, its impact on emergency abdominal operations remains unclear. The purpose of this study was to examine the association between low muscle mass (LMM) and outcomes after emergency operations for acute diverticulitis. Patients and methodsPatients ≥18 y requiring an emergency operation for acute diverticulitis between January 2007 and September 2014 were included. On preoperative computed tomography, the cross-sectional area (CSA) and transverse diameter (TVD) of the right and left psoas muscle were measured at the level of the third lumbar vertebral body. Sensitivity analysis was performed to determine appropriate CSA and TVD cutoff values defining low skeletal muscle mass. Clinical outcomes of patients with low muscle mass (LMM group) were compared with the non-LMM group. ResultsA total of 89 patients met our inclusion criteria. Median CSA and TVD were 794 mm2 and 24 mm, respectively. There was a strong correlation between the CSA and TVD (R2 = 0.84). In univariable analysis, significantly higher rates of postoperative major complications (63% versus 37%, P = 0.027) and surgical site infection (47% versus 19%, P = 0.008) were identified in the LMM group. After adjusting for clinically important covariates in a logistic regression model, patients with LMM were significantly associated with higher odds of major complications and surgical site infection. ConclusionsPreoperative assessment of the psoas muscle CSA and TVD on computed tomography can be a practical method for identifying patients at risk for postoperative complications.

Fluid signal changes around the knee on MRI are associated with increased volumes of subcutaneous fat: a case-control study.

BackgroundFluid in the subcutaneous fat is a common finding anterior to the knee on MRI. This may be caused by chronic low-grade shearing injuries in patients who are overweight. The purpose of this study was to determine if there is a difference in the amount of subcutaneous fat around the knee between patients with these appearances and controls.MethodsThis was a retrospective case-control study. Following a sample size calculation on pilot data, eighteen sequential patients demonstrating hyper-intense subcutaneous signal changes around the knee on fat-saturated T2-weighted MRI were identified from PACS (18 females, mean age 45, range 31–62). Age and gender-matched patients without abnormal T2 MR signal changes were selected. Two observers independently drew regions of interest representing cross-sectional areas of bone and fat. The location of T2 signal hyper-intense lesions was characterized by consensus.ResultsInter and intra-rater intraclass reproducibility was “excellent” (ICC > 0.8). The mean cross-sectional area of bone for patients with T2 hyper-intense lesions was 31.79cm2 (SD 2.57) and for controls 30.11cm2 (SD 3.20) which was not significantly different (p = 0.09). The median cross-sectional area of fat for the study group was 62.29cm2 (IQR 57.1–66.5) and for controls was 32.77cm2 (IQR 24.8–32.3) which was significantly different (p < 0.0001). Consensus agreement demonstrated all T2 hyper-intense lesions were anterior to the knee extensor mechanism.ConclusionSubcutaneous fluid around the knee is associated with an increased amount of subcutaneous fat, anterior to the knee extensor mechanism. This may be caused by shearing injuries in fat with reduced elasticity associated with metabolic syndrome.

EP 17. High-resolution ultrasound of the vagus nerve in healthy subjects

Background Over the last decade, examination of peripheral nerves with high-resolution ultrasound (HRUS) has been established as a useful diagnostic tool and now routinely complements electrophysiological studies in various diseases. Prerequisite for nerve HRUS are well-defined reference values. Notably, reference values for most cranial nerves and in particular the vagus nerve (VN) are variable ( Cartwright et al., 2008 , Lopez-Hernandez and Garcia-Escriva, 2014 ) and, overall, scarcely reported. Aim of this study was to assess age-related reference values for the VN and to examine interrater reliability. Herewith, we report preliminary results of the first training cohort. Methods Both VNs of 10 healthy subjects (6 female, median age 29 years) without history of cardiac disease, especially arrhythmia, were examined with HRUS using a 15 MHz ultrasound transducer (Esaote MyLab Five, probe LA435). Cross-sectional area (CSA) of each VN was assessed at 2 points: at the level of the distal common carotid artery before beginning of the bulb (proximal reading point) and at the level of the thyroid gland (distal reading point). Three ultrasound images at each reading point were recorded with subsequent assessment of CSA. Each subject was examined by 2 sonographers experienced in peripheral nerve ultrasound. Three-factorial (2 × 2 × 2) repeated measures ANOVA (ANOVArm) were performed with the factors GROUP (examiner 1, examiner 2), LEVEL (proximal, distal) and SIDE (right, left). Results Median CSA differed between the right and the left VN. This finding was supported by a significant ANOVArm that only revealed a significant main effect of SIDE (F = 14.630, p = 0.005). Median CSA of the VN at the proximal level was larger on the right (examiner 1/examiner 2: 2.8 ± 0.5 mm2 [mean ± SD]/2.6 ± 0.5 mm2) in comparison to the left side (2.3 ± 0.4 mm2/2.1 ± 0.4 mm2; p = 0.023 and p = 0.063, respectively; student t-test). At the distal level, median CSA of the right VN was also larger (2.7 ± 0.5 mm2/2.5 ± 0.6 mm2) than of the left VN (2.2 ± 0.5 mm2/1.9 ± 0.4 mm2; p = 0.021 and p = 0.012, respectively). Interrater reliability (intraclass correlation coefficient [ICC]) was moderate for the proximal (ICC 0.69, 95% confidence interval: 0.18–0.88) as well as for the distal (ICC 0.78, 95% confidence interval: 0.45–0.91) reading point. Sonographic assessment of the VN was found to be performed more easily at the level of the thyroid gland. Pulsating common carotid artery and the internal jugular vein in direct vicinity to VN represented significant technical problems interfering with VN sonography, Conclusion These preliminary findings point to a larger CSA of the right VN compared to the left VN, which emphasises the need for side-specific reference values. Interrater reliability was moderate for even experienced sonographers and may have to be improved by dedicated training.

The value of intravascular ultrasound in the treatment of central venous obstructions in hemodialysis patients.

Digital subtraction angiography (DSA) is the gold standard in diagnosis and treatment of central venous obstructions (CVOs) in hemodialysis access. However, growing data suggest that DSA might underestimate the degree and morphology of venous outflow stenosis. This could lead to inappropriate CVO management. Intravascular ultrasound (IVUS) has been shown to identify lesion characteristics remaining obscure with angiography. With the current study we suggest IVUS as an eminent imaging modality in CVO management. Twelve patients (8 male, mean age 62.4 ± 9 years) were analyzed for suspicion of symptomatic CVO. Both angiography and IVUS evaluation were performed to determine the degree of obstruction before and after PTA. Stent placement was indicated when significant residual stenosis (&gt;50% lumen reduction) was suspected. Conventional plain angiography determined 8 out of 12 central venous lesions significant. Secondary signs of obstruction, i.e., collateral filling, was present in all 12 cases. After PTA, persistent significant stenosis was observed in 3 out of 12 patients. IVUS showed significant lumen reduction in all 12 cases. Additionally, IVUS showed a median cross-sectional area of 24 ± 12 mm2 before PTA and 37 ± 23 mm2 after PTA (NS). Furthermore, IVUS showed signs of intraluminal fibrotic trabeculations in 9 patients. Stenting was performed in 10 patients with &gt;50% lumen reduction on IVUS after PTA. Conventional angiography seems unreliable to identify all significant aspects of a central venous outflow obstruction. Additional use of IVUS might aid in the decision-making process and select the optimal treatment strategy.

Correlation between median nerve conduction studies and ultrasonography in cases of carpal tunnel syndrome

Background Nerve conduction studies (NCS) have long been the only objective measure used to confirm the diagnosis of carpal tunnel syndrome (CTS), localize median nerve abnormalities, and exclude alternative diagnosis. Ultrasonography (US) can give information about the contents of carpal tunnel (CT) as well as aid in assessing the size of the median nerve (MN). Aim The aim of this study was to detect the relation between median NCS and cross-sectional area (CSA) of the MN measured using US in different grades of CTS. Patients and methods This study was a case–control, age-group matched, cross-sectional one. It included 60 wrists of 30 patients diagnosed with CTS and 60 wrists from 30 controls. Candidates were subjected to clinical assessment, median NCS, and measurement of CSA using US. Results There was a significant positive correlation between CSA of the MN at CT inlet and both motor and sensory responses latencies (r=0.638, P Conclusion US is highly correlated to NCS results in CTS. CSA of the MN at CT inlet measured using ultrasonography can be used as a screening tool for detection as well as discrimination of severe cases of CTS.

Characteristics of non-diabetic foot ulcers in Western Sydney, Australia.

BackgroundThere are few studies investigating the characteristics, risk factors and socioeconomic status of patients with non-diabetic foot ulcers. The aim of this study was to explore the characteristics of non-diabetic foot ulcers in a large tertiary referral outpatient hospital setting in Western Sydney, Australia.MethodsFrom 2011 to 2013, data from 202 patients with non-diabetic foot ulcers during their initial visit were retrospectively extracted for analysis from Westmead Hospital’s Foot Wound Clinic Registry. Data including demographics, socioeconomic status and foot ulcer characteristics were recorded on a standardised data collection form.ResultsDemographics and physical characteristics were: 54 % male, median age 78 years [interquartile range (IQR): 64–87], median body mass index (BMI) of 23.8 kg/m2 (IQR: 20–26.9), 35 % had loss of protective sensation and the median postcode score for socioeconomic status was 996 (IQR: 935–1034). Foot ulcer characteristics were: median cross-sectional area of 1.2 cm2 (IQR: 0.3–5.0), 30.5 % plantar and 27 % dorsal, 22.1 % University of Texas (UT) Wound Classification for Diabetic Foot Ulcers Grade of 1C-3C (with ischaemia).ConclusionsUnlike diabetic foot ulcers, non-diabetic foot ulcers largely affected older males and females. In accordance with diabetic foot ulcer characteristics, socioeconomic status was not related to non-diabetic foot ulcers in Western Sydney. Based on the findings of this study the epidemiological pattern of non-diabetic foot ulceration and its pathogenesis requires further investigation.