Sensitive ultrasonic detection of dystrophic skeletal muscle in patients with duchenne muscular dystrophy using an entropy-based signal receiver

Quantitative assessment of pneumothorax by using Shannon entropy of lung ultrasound M-mode image and diaphragmatic excursion based on automated measurement

Background

Lung ultrasound (LUS) and diaphragm ultrasound (DUS) are the appropriate modalities for conservative observation to those patients who are with stable pneumothorax, as well as for the timely detection of life-threatening pneumothorax at any location, due to they are portable, real-time, relatively cost effective, and most important, without radiation exposure. The absence of lung sliding on LUS M-mode images and the abnormality of diaphragmatic excursion (DE) on DUS M-mode images are the most common and novel diagnostic criteria for pneumothorax, respectively. However, visual inspection of M-mode images remains subjective and quantitative analysis of LUS and DUS M-mode images are required.

Methods

Shannon entropy of LUS M-mode image (ShanEnLM) and DE based on the automated measurement (DEAM) are adapted to the objective pneumothorax diagnoses and the severity quantifications in this study. Mild, moderate, and severe pneumothoraces were induced in 24 male New Zealand rabbits through insufflation of room air (5, 10 and 15, and 25 and 40 mL/kg, respectively) into their pleural cavities. In vivo intercostal LUS and subcostal DUS M-mode images were acquired using a point-of-care system for estimating ShanEnLM and DEAM.

Results

ShanEnLM and DEAM as functions of air insufflation volumes exhibited U-shaped curves and were exponentially decreasing, respectively. Either ShanEnLM or DEAM had areas under the receiver operating characteristic curves [95% confidence interval (CI)] of 1.0000 (95% CI: 1.0000-1.0000), 0.9833 (95% CI: 0.9214-1.0000), and 0.9407 (95% CI: 0.8511-1.0000) for differentiating between normal and mild pneumothorax, mild and moderate pneumothoraces, and moderate and severe pneumothoraces, respectively.

Conclusions

Our findings imply that the combination of ShanEnLM and DEAM give the promising potential for pneumothorax quantitative diagnosis.

Draft Guidance for Industry Duchenne Muscular Dystrophy, Becker Muscular Dystrophy, and Related Dystrophinopathies - Developing Potential Treatments for the Entire Spectrum of Disease

Background

Duchenne muscular dystrophy (DMD) and related dystrophinopathies are neuromuscular conditions with great unmet medical needs that require the development of effective medical treatments.

Objective

To aid sponsors in clinical development of drugs and therapeutic biological products for treating DMD across the disease spectrum by integrating advancements, patient registries, natural history studies, and more into a comprehensive guidance.

Methods

This guidance emerged from collaboration between the FDA, the Duchenne community, and industry stakeholders. It entailed a structured approach, involving multiple committees and boards. From its inception in 2014, the guidance underwent revisions incorporating insights from gene therapy studies, cardiac function research, and innovative clinical trial designs.

Results

The guidance provides a deeper understanding of DMD and its variants, focusing on patient engagement, diagnostic criteria, natural history, biomarkers, and clinical trials. It underscores patient-focused drug development, the significance of dystrophin as a biomarker, and the pivotal role of magnetic resonance imaging in assessing disease progression. Additionally, the guidance addresses cardiomyopathy's prominence in DMD and the burgeoning field of gene therapy.

Conclusions

The updated guidance offers a comprehensive understanding of DMD, emphasizing patient-centric approaches, innovative trial designs, and the importance of biomarkers. The focus on cardiomyopathy and gene therapy signifies the evolving realm of DMD research. It acts as a crucial roadmap for sponsors, potentially leading to improved treatments for DMD.

Quantitative Assessment of Lung Ultrasound Grayscale Images Based on Shannon Entropy for the Detection of Pulmonary Aeration: An Animal Study

OBJECTIVE

Lung ultrasound (LUS) is a radiation-free, affordable, and bedside monitoring method that can detect changes in pulmonary aeration before hypoxic damage. However, visual scoring methods of LUS only enable subjective diagnosis. Therefore, quantitative analysis of LUS is necessary for obtaining objective information on pulmonary aeration. Because raw data are not always available in conventional ultrasound systems, Shannon entropy (ShanEn) of information theory without the requirement of raw data is valuable. In this study, we explored the feasibility of ShanEn estimated through grayscale histogram (GSH) analysis of LUS images for the quantification of pulmonary aeration.

METHODS

Different degrees of pulmonary aeration caused by edema was induced in 32 male New Zealand rabbits intravenously injected with 0.1 mL/kg saline (the control group) and 0.025, 0.05, and 0.1 mL/kg oleic acid (mild, moderate, and severe groups, respectively). In vivo grayscale LUS images were acquired using a commercial point-of-care ultrasound system for estimation of GSH and corresponding ShanEn. Both lungs of each rabbit were dissected, weighed, and dried to determine the wet weight-to-dry weight ratio (W/D) through gravimetry.

RESULTS

The determination coefficients of linear correlations between ShanEn and W/D increased from 0.0487 to 0.7477 with gain and dynamic range (DR). In contrast to visual scoring methods of pulmonary aeration that use median gain and low DR, ShanEn for quantifying pulmonary aeration requires high gain and DR.

CONCLUSION

The current findings indicate that ShanEn estimated through GSH analysis of LUS images acquired using conventional ultrasonic imaging systems has great potential to provide objective information on pulmonary aeration.

Quantitative Muscle Ultrasonography Using 2D Textural Analysis: A Novel Approach to Assess Skeletal Muscle Structure and Quality in Chronic Kidney Disease

Chronic kidney disease (CKD) is characterized by progressive reductions in skeletal muscle function and size. The concept of muscle quality is increasingly being used to assess muscle health, although the best means of assessment remains unidentified. The use of muscle echogenicity is limited by an inability to be compared across devices. Gray level of co-occurrence matrix (GLCM), a form of image texture analysis, may provide a measure of muscle quality, robust to scanner settings. This study aimed to identify GLCM values from skeletal muscle images in CKD and investigate their association with physical performance and strength (a surrogate of muscle function). Transverse images of the rectus femoris muscle were obtained using B-mode 2D ultrasound imaging. Texture analysis (GLCM) was performed using ImageJ. Five different GLCM features were quantified: energy or angular second moment (ASM), entropy, homogeneity, or inverse difference moment (IDM), correlation, and contrast. Physical function and strength were assessed using tests of handgrip strength, sit to stand-60, gait speed, incremental shuttle walk test, and timed up-and-go. Correlation coefficients between GLCM indices were compared to each objective functional measure. A total of 90 CKD patients (age 64.6 (10.9) years, 44% male, eGFR 33.8 (15.7) mL/minutes/1.73 m2) were included. Better muscle function was largely associated with those values suggestive of greater image texture homogeneity (i.e., greater ASM, correlation, and IDM, lower entropy and contrast). Entropy showed the greatest association across all the functional assessments (r = -.177). All GLCM parameters, a form of higher-order texture analysis, were associated with muscle function, although the largest association as seen with image entropy. Image homogeneity likely indicates lower muscle infiltration of fat and fibrosis. Texture analysis may provide a novel indicator of muscle quality that is robust to changes in scanner settings. Further research is needed to substantiate our findings.

The Quantitative Skeletal Muscle Ultrasonography in Elderly with Dynapenia but not Sarcopenia Using Texture Analysis

(1) Background: Dynapenia is defined as lower muscle strength alone. Only a few studies have investigated muscle quality in subjects with dynapenia. (2) Methods: The muscle quality, characterized by texture parameters of biceps brachii, triceps brachii, rectus femoris, and medial gastrocnemius muscles, were collected using ultrasonography. The risk of dynapenia was assessed by the multiple logistic regression model. (3) Results: There were a total of 36 participants (72.7 ± 5.8 yrs, 1:1 case-control matched). The values of texture parameters of autocorrelation (AUT) and sum variance (SVAR) in all four muscles were higher in the dynapenia group significantly (p < 0.05). AUT and SVAR had the significant associations for dynapenia in biceps (dds ratio[OR]:2.51, 95% CI = 1.25–5.07 for AUT; OR = 1.45, 95% CI:1.1–1.91 for SVAR), triceps (OR: 2.48, 95% CI = 1.60–5.3 for AUT; OR: 1.57, 95% CI = 1.08–2.28 for SVAR), and rectus femoris (OR: 1.58, 95% CI = 1.01–2.46 for AUT; OR: 1.2, 95% CI = 1.0–1.44 for SVAR). The areas under the receiver-operating curves of all texture parameters was between 0.84–0.94 after adjusting confounding factors. (4) Conclusions: The muscle quality in the dynapenia can be detected by the texture-feature quantitative ultrasound. Ultrasound measurement in the aging muscle might be promising, and further studies should validate its application in the context of dynapenia.

Resolution of Murine Toxic Hepatic Injury Quantified With Ultrasound Entropy Metrics

Image-based classification of liver disease generally lacks specificity for distinguishing between acute, resolvable injury and chronic irreversible injury. We propose that ultrasound radiofrequency data acquired in vivo from livers subjected to toxic drug injury can be analyzed with information theoretic detectors to derive entropy metrics, which classify a statistical distribution of pathologic scatterers that dissipate over time as livers heal. Here we exposed 38 C57BL/6 mice to carbon tetrachloride to cause liver damage, and imaged livers in vivo 1, 4, 8, 12 and 18 d after exposure with a broadband 15-MHz probe. Selected entropy metrics manifested monotonic recovery to normal values over time as livers healed, and were correlated directly with progressive restoration of liver architecture by histologic assessment (r² ≥ 0.95, p < 0.004). Thus, recovery of normal liver microarchitecture after toxic exposure can be delineated sensitively with entropy metrics.

Efficacy of Quantitative Muscle Ultrasound Using Texture-Feature Parametric Imaging in Detecting Pompe Disease in Children

Pompe disease is a hereditary neuromuscular disorder attributed to acid α-glucosidase deficiency, and accurately identifying this disease is essential. Our aim was to discriminate normal muscles from neuropathic muscles in children affected by Pompe disease using a texture-feature parametric imaging method that simultaneously considers microstructure and macrostructure. The study included 22 children aged 0.02-54 months with Pompe disease and six healthy children aged 2-12 months with normal muscles. For each subject, transverse ultrasound images of the bilateral rectus femoris and sartorius muscles were obtained. Gray-level co-occurrence matrix-based Haralick's features were used for constructing parametric images and identifying neuropathic muscles: autocorrelation (AUT), contrast, energy (ENE), entropy (ENT), maximum probability (MAXP), variance (VAR), and cluster prominence (CPR). Stepwise regression was used in feature selection. The Fisher linear discriminant analysis was used for combination of the selected features to distinguish between normal and pathological muscles. The VAR and CPR were the optimal feature set for classifying normal and pathological rectus femoris muscles, whereas the ENE, VAR, and CPR were the optimal feature set for distinguishing between normal and pathological sartorius muscles. The two feature sets were combined to discriminate between children with and without neuropathic muscles affected by Pompe disease, achieving an accuracy of 94.6%, a specificity of 100%, a sensitivity of 93.2%, and an area under the receiver operating characteristic curve of 0.98 ± 0.02. The CPR for the rectus femoris muscles and the AUT, ENT, MAXP, and VAR for the sartorius muscles exhibited statistically significant differences in distinguishing between the infantile-onset Pompe disease and late-onset Pompe disease groups (p < 0.05). Texture-feature parametric imaging can be used to quantify and map tissue structures in skeletal muscles and distinguish between pathological and normal muscles in children or newborns.

Normal values of abdominal muscles thickness in healthy children using ultrasonography

Abdominal muscles are one of the important elements to support the lumbar spine. Evaluation of muscle thickness using ultrasonography (US) is considered to be a source of information from muscles characteristics. The purpose of this study was to demonstrate normal reference data of abdominal muscles thickness and subcutaneous fat in adolescents using US. A random sample of 160 healthy adolescents (80 boys and 80 girls) at the age range of 15-18 years was recruited. Three abdominal muscles including Transversus Abdominis (TA), Internal Oblique (IO), External Oblique (EO) and subcutaneous fat (SF) were bilaterally measured using US. The range of normal values for TA muscle thickness was between 2.31 and 2.57 mm, for IO muscle thickness was between 4.02 and 5.15 mm and for EO muscle thickness was between 2.81 and 3.17 mm. The normal patterns of abdominal muscles were found as IO > EO > TA at both sides. Boys were taller, heavier with greater body mass index (BMI) and had larger abdominal muscles thickness than girls. A weak negative correlation was found between age and muscles size [r = (-0.06) - (-0.23), p < .05], but a significant positive correlation was found between BMI and muscle size (r = 0.21-0.68, p < .05). It seems that abdominal muscles thickness in adolescents followed the same pattern of muscle size in adults. BMI appeared to be the best predictor of muscle thickness. However, further studies are recommended to support the findings of the present study.

Performance Evaluations on Using Entropy of Ultrasound Log-Compressed Envelope Images for Hepatic Steatosis Assessment: An In Vivo Animal Study

Ultrasound B-mode imaging based on log-compressed envelope data has been widely applied to examine hepatic steatosis. Modeling raw backscattered signals returned from the liver parenchyma by using statistical distributions can provide additional information to assist in hepatic steatosis diagnosis. Since raw data are not always available in modern ultrasound systems, information entropy, which is a widely known nonmodel-based approach, may allow ultrasound backscattering analysis using B-scan for assessing hepatic steatosis. In this study, we explored the feasibility of using ultrasound entropy imaging constructed using log-compressed backscattered envelopes for assessing hepatic steatosis. Different stages of hepatic steatosis were induced in male Wistar rats fed with a methionine- and choline-deficient diet for 0 (i.e., normal control) and 1, 1.5, and 2 weeks (n = 48; 12 rats in each group). In vivo scanning of rat livers was performed using a commercial ultrasound machine (Model 3000, Terason, Burlington, MA, USA) equipped with a 7-MHz linear array transducer (Model 10L5, Terason) for ultrasound B-mode and entropy imaging based on uncompressed (H_E image) and log-compressed envelopes (H_B image), which were subsequently compared with histopathological examinations. Receiver operating characteristic (ROC) curve analysis and areas under the ROC curves (AUC) were used to assess diagnostic performance levels. The results showed that ultrasound entropy imaging can be used to assess hepatic steatosis. The AUCs obtained from H_E imaging for diagnosing different steatosis stages were 0.93 (≥mild), 0.89 (≥moderate), and 0.89 (≥severe), respectively. H_B imaging produced AUCs ranging from 0.74 (≥mild) to 0.84 (≥severe) as long as a higher number of bins was used to reconstruct the signal histogram for estimating entropy. The results indicated that entropy use enables ultrasound parametric imaging based on log-compressed envelope signals with great potential for diagnosing hepatic steatosis.

Acoustic firearm discharge detection and classification in an enclosed environment

Two different signal processing algorithms are described for detection and classification of acoustic signals generated by firearm discharges in small enclosed spaces. The first is based on the logarithm of the signal energy. The second is a joint entropy. The current study indicates that a system using both signal energy and joint entropy would be able to both detect weapon discharges and classify weapon type, in small spaces, with high statistical certainty.

Entropy vs. Energy Waveform Processing: A Comparison Based on the Heat Equation

Virtually all modern imaging devices collect electromagnetic or acoustic waves and use the energy carried by these waves to determine pixel values to create what is basically an “energy” picture. However, waves also carry “information”, as quantified by some form of entropy, and this may also be used to produce an “information” image. Numerous published studies have demonstrated the advantages of entropy, or “information imaging”, over conventional methods. The most sensitive information measure appears to be the joint entropy of the collected wave and a reference signal. The sensitivity of repeated experimental observations of a slowly-changing quantity may be defined as the mean variation (i.e., observed change) divided by mean variance (i.e., noise). Wiener integration permits computation of the required mean values and variances as solutions to the heat equation, permitting estimation of their relative magnitudes. There always exists a reference, such that joint entropy has larger variation and smaller variance than the corresponding quantities for signal energy, matching observations of several studies. Moreover, a general prescription for finding an “optimal” reference for the joint entropy emerges, which also has been validated in several studies.

Diagnostic ultrasound estimates of muscle mass and muscle quality discriminate between women with and without sarcopenia

Introduction: Age-related changes in muscle mass and muscle tissue composition contribute to diminished strength in older adults. The objectives of this study are to examine if an assessment method using mobile diagnostic ultrasound augments well-known determinants of lean body mass (LBM) to aid sarcopenia staging, and if a sonographic measure of muscle quality is associated with muscle performance.

Methods: Twenty community-dwelling female subjects participated in the study (age = 43.4 ± 20.9 years; BMI: 23.8, interquartile range: 8.5). Dual energy X-ray absorptiometry (DXA) and diagnostic ultrasound morphometry were used to estimate LBM. Muscle tissue quality was estimated via the echogenicity using grayscale histogram analysis. Peak force was measured with grip dynamometry and scaled for body size. Bivariate and multiple regression analyses were used to determine the association of the predictor variables with appendicular lean mass (aLM/ht²), and examine the relationship between scaled peak force values and muscle echogenicity. The sarcopenia LBM cut point value of 6.75 kg/m² determined participant assignment into the Normal LBM and Low LBM subgroups.

Results: The selected LBM predictor variables were body mass index (BMI), ultrasound morphometry, and age. Although BMI exhibited a significant positive relationship with aLM/ht² (adj. R² = 0.61, p < 0.001), the strength of association improved with the addition of ultrasound morphometry and age as predictor variables (adj. R² = 0.85, p < 0.001). Scaled peak force was associated with age and echogenicity (adj. R² = 0.53, p < 0.001), but not LBM. The Low LBM subgroup of women (n = 10) had higher scaled peak force, lower BMI, and lower echogenicity values in comparison to the Normal LBM subgroup (n = 10; p < 0.05).

Conclusions: Diagnostic ultrasound morphometry values are associated with LBM, and improve the BMI predictive model for aLM/ht² in women. In addition, ultrasound proxy measures of muscle quality are more strongly associated with strength than muscle mass within the study sample.

Application of ultrasonography in the assessment of skeletal muscles in children with and without neuromuscular disorders: a systematic review

The purpose of this study was to systematically review published studies (2000-2014) carried out on the application of ultrasonography (US) to evaluation of skeletal muscle size in children with and without neuromuscular disorders. Different databases including PubMed, Science Direct, OVID, MEDLINE, CINAHL, EMBASE, ProQuest and Google Scholar were searched. The key words used were: "children," "ultrasound," "skeletal muscles," "neuromuscular disease," "neurogenic disorders," "spina bifida," "myelomeningocele" and "reliability." Eighteen articles were found to be relevant. Eight studies applied US in combination with additional methods of assessment. Four of the 18 studies did not have a control group. Ten studies applied only US in the assessment of skeletal muscles in children with and without neuromuscular diseases. In 9 studies, there were children ranging widely in age, and in 3 studies US was used to determine normal values for skeletal muscles. According to the results of these 18 reviewed articles, US is an appropriate, reliable and highly predictive method for assessment of skeletal muscles in children.

Joint entropy of continuously differentiable ultrasonic waveforms

This study is based on an extension of the concept of joint entropy of two random variables to continuous functions, such as backscattered ultrasound. For two continuous random variables, X and Y, the joint probability density p(x,y) is ordinarily a continuous function of x and y that takes on values in a two dimensional region of the real plane. However, in the case where X=f(t) and Y=g(t) are both continuously differentiable functions, X and Y are concentrated exclusively on a curve, γ(t)=(f(t),g(t)), in the x,y plane. This concentration can only be represented using a mathematically "singular" object such as a (Schwartz) distribution. Its use for imaging requires a coarse-graining operation, which is described in this study. Subsequently, removal of the coarse-graining parameter is accomplished using the ergodic theorem. The resulting expression for joint entropy is applied to several data sets, showing the utility of the concept for both materials characterization and detection of targeted liquid nanoparticle ultrasonic contrast agents. In all cases, the sensitivity of these techniques matches or exceeds, sometimes by a factor of two, that demonstrated in previous studies that employed signal energy or alternate entropic quantities.

Quantitative ultrasound of skeletal muscle: reliable measurements of calibrated muscle backscatter from different ultrasound systems

Widespread implementation of quantitative muscle ultrasonography in assessing skeletal muscle pathology is limited by an inability to replicate results between different ultrasound systems. We have developed a measurement of skeletal muscle pathology, calibrated muscle backscatter (cMB), which should be reproducible between different ultrasound systems. We compared the reliability of grayscale and cMB measurements between different ultrasound systems, configurations and region-of-interest (ROI) sizes. cMB of skeletal muscle was reliably measured (intraclass correlation coefficient [ICC] ≤0.98) despite very dissimilar grayscale levels (ICC ≤0.54). cMB reliability was highest between systems using similar settings (ICC: 0.82-0.98) and was lowest when transducer type varied (ICC: 0.47-0.71). Reliability was better from ROIs spanning a narrow range of depths compared with larger ranges. cMB measurements are more reliable than grayscale between different ultrasound systems and configurations. Measuring cMB could improve widespread implementation of quantitative ultrasound in assessments of skeletal muscle pathology.

Use of smoothing splines for analysis of backscattered ultrasonic waveforms: application to monitoring of steroid treatment of dystrophic mice

Duchenne muscular dystrophy (DMD) is an X-linked genetic disease characterized by progressive weakness and wasting of skeletal and cardiac muscle; boys present with weakness by the age of 5 years and, if left untreated, are unable to walk without assistance by the age of 10 years. Therapy for DMD has been primarily palliative, with oral steroids emerging as a first-line approach even though this treatment has serious side-effects. Consequently, low-cost imaging technology suitable for improved diagnosis and treatment monitoring of DMD would be of great value, especially in remote and underserved areas. Previously, we reported use of the logarithm of the signal energy, log [E(f)], and a new method for ultrasound signal characterization using entropy, H(f), to monitor prednisolone treatment of skeletal muscle in a dystrophin-deficient mouse model. Three groups were studied: mdx mice treated with prednisolone, a control group of mdx mice treated with saline, and a control group of wild-type mice treated with saline. It was found that both log [E(f)] and H(f) were required to statistically differentiate the three groups. In the current study, we show that preprocessing of the raw ultrasound using optimal smoothing splines before computation of either log [E(f)] or a rapidly computable variant of Hf, denoted I(f,∞), permits delineation of all three groups by either metric alone. This opens the way to the ultimate goal of this study, which is identification and implementation of new diagnostically sensitive algorithms on the new generation of low-cost hand-held clinical ultrasonic imaging systems.

Paediatric musculoskeletal US beyond the hip joint

US is a technique particularly suited to the investigation of musculoskeletal disorders in children and adolescents. This review paper describes a range of clinical settings beyond the hip joint where US has a significant role to play, including sports injuries, infectious diseases, inflammatory and degenerative conditions, congenital and developmental disorders, acute trauma of bone and joints, and peripheral nerve injuries. In some circumstances, US can be regarded as the most effective means of diagnostic imaging, whereas in other instances, it is an alternative or supplement to other more comprehensive imaging modalities, like MRI and CT. Although MRI offers superior soft-tissue contrast resolution, US is low-cost, non-invasive and has higher spatial resolution and real-time capability for the assessment of musculoskeletal structures during joint movement and stress manoeuvres.

Quantitative ultrasound using backscatter analysis in Duchenne and Becker muscular dystrophy

Evaluation of ultrasound images of muscle with calibrated muscle backscatter (cMB) provides reproducible quantitative measurements of muscle pathology. Increased cMB is associated with greater muscle pathology. We used cMB to evaluate the severity of muscle pathology in 55 patients with Duchenne and Becker Muscular Dystrophy (D/BMD) compared to 77 controls. cMB was also compared to measurements of strength and function. cMB in DMD and BMD increased linearly with age and was higher than in controls when groups are compared. cMB increased twice as fast with age in DMD than in BMD. In DMD, cMB was higher with reduced function and strength. Ultrasound measurement of muscle pathology using cMB is a sensitive and objective quantitative technique for determining the severity of muscle pathology in dystrophinopathies. Longitudinal studies are required to determine the sensitivity of this measure to changes in pathology over time.

Quantitative muscle ultrasound in neuromuscular disorders using the parameters 'intensity', 'entropy', and 'fractal dimension'

BACKGROUND AND PURPOSE

Ultrasound is a useful non-invasive instrument in visualizing physiological and pathological morphology in skeletal muscle. Here, we evaluate the possibility that quantitative muscle ultrasound using the parameters 'intensity', 'entropy', and 'fractal dimension' is a feasible method to distinguish between dystrophic myopathies (DM), inflammatory myopathies (IM), and motor neuron disorders.

METHODS

Seven patients with IM, 12 patients with DM, nine patients with motor neuron diseases, and 24 healthy subjects underwent an identical ultrasound examination protocol, applied on gastrocnemius and tibialis anterior muscle. Analysis parameters were applied on grey scale images as well as on gradient images.

RESULTS

Statistical evaluation revealed no significant differences in the evaluated parameters for differentiation of the distinct disease groups. Compared with healthy controls however we found statistically significant differences between almost of all the investigated parameters, even in disease cases with clinically unaffected distal musculature.

CONCLUSION

The parameters are able to distinguish between healthy and affected musculature but not between distinct disease entities. Studies are needed to establish whether or not the parameters are helpful to monitor muscle involvement and disease progression in neuromuscular diseases.

Magnetic resonance imaging of the erector spinae muscles in Duchenne muscular dystrophy: implication for scoliotic deformities

Background

In Duchenne muscular dystrophy (DMD), the muscular degeneration often leads to the development of scoliosis. Our objective was to investigate how anatomical changes in back muscles can lead to scoliosis. Muscular volume and the level of fat infiltration in those muscles were thus evaluated, in non-scoliotic, pre-scoliotic and scoliotic patients. The overlying skin thickness over the apex level of scoliotic deformations was also measured to facilitate the interpretation of electromyographic signals when recorded on the skin surface.

Methods

In 8 DMD patients and two healthy controls with no known muscular deficiencies, magnetic resonance imaging (MRI) was used to measure continuously at 3 mm intervals the distribution of the erector spinae (ES) muscle in the T8-L4 region as well as fat infiltration in the muscle and overlying skin thickness: four patients were non-scoliotic (NS), two were pre-scoliotic (PS, Cobb angle < 15°) and two were scoliotic (S, Cobb angle ≥ 15°). For each subject, 63 images 3 mm thick of the ES muscle were obtained in the T8-L4 region on both sides of the spine. The pixel dimension was 0.39 × 0.39 mm. With a commercial software, on each 12 bits image, the ES contour on the left and on the right sides of the spine were manually determined as well as those of its constituents i.e., the iliocostalis (IL), the longissimus (LO) and the spinalis (SP) muscles. Following this segmentation, the surfaces within the contours were determined, the muscles volume were obtained, the amount of fat infiltration inside each muscle was evaluated and the overlying skin thickness measured.

Findings

The volume of the ES muscle of our S and PS patients was found smaller on the convex side relative to the concave one by 5.3 ± 0.7% and 2.8 ± 0.2% respectively. For the 4 NS patients, the volume difference of this muscle between right and left sides was 2.1 ± 1.5% and for the 2 controls, it was 1.4 ± 1.2%. Fat infiltration for the S and the PS patients was larger on the convex side than on the concave one (4.4 ± 1.6% and 4.5 ± 0.7% respectively) and the difference was more important near the apex. Infiltration was more important in the lateral IL muscle than in the medial SP and it was always larger near L2 than at any other spinal level. Fat infiltration was much more important in the ES for the DMD patients (49.9% ± 1.6%) than for the two controls (2.6 ± 0.8%). As for the overlying skin thickness measured near the deformity of the patients, it was larger on the concave than on the convex side: 14.8 ± 6.1 vs 13.5 ± 5.7 mm for the S and 10.3 ± 6.3 vs 9.8 ± 5.6 mm for the PS.

Interpretation

In DMD patients, our results indicate that a larger replacement of muscles fibers by fat infiltration on one side of the spine is a factor that can lead to the development of scoliosis. Efforts to slow such an infiltration on the most affected side of the spine could thus be beneficial to those patients by delaying the apparition of the scoliotic deformation. In addition to anatomical considerations, results obtained from the same patients but in experiments dealing with electromyography recordings, point to differences in the muscular contraction mechanisms and/or of the neural input to back muscles. This is similar to the adolescent idiopathic scoliosis (AIS) where a role of the nervous system in the development of the deformation has also been suggested.

Sensitive ultrasonic delineation of steroid treatment in living dystrophic mice with energy-based and entropy-based radio frequency signal processing

Duchenne muscular dystrophy is a severe wasting disease, involving replacement of necrotic muscle tissue by fibrous material and fatty infiltrates. One primary animal model of this human disease is the X chromosome-linked mdx strain of mice. The goals of the present work were to validate and quantify the capability of both energy and entropy metrics of radio-frequency ultrasonic backscatter to differentiate among normal, dystrophic, and steroid-treated skeletal muscle in the mdx model. Thirteen 12-month-old mice were blocked into three groups: 4 treated mdx-dystrophic that received daily subcutaneous steroid (prednisolone) treatment for 14 days, 4 positive-control mdx-dystrophic that received saline injections for 14 days, and 5 negative-control animals. Biceps muscle of each animal was imaged in vivo using a 40-MHz center frequency transducer in conjunction with a Vevo-660 ultrasound system. Radio-frequency data were acquired (1 GHz, 8 bits) corresponding to a sequence of transverse images, advancing the transducer from "shoulder" to "elbow" in 100-micron steps. Data were processed to generate both "integrated backscatter" (log energy), and "entropy" (information theoretic receiver, H(f)) representations. Analyses of the integrated-backscatter values delineated both treated-and untreated-mdx biceps from normal controls (p < 0.01). Complementary analyses of the entropy images differentiated the steroid-treated and positive-control mdx groups (p < 0.01). To our knowledge, this study represents the first reported use of quantitative ultrasonic characterization of skeletal muscle in mdx mice. Successful differentiation among dystrophic, steroid-treated, and normal tissues suggests the potential for local noninvasive monitoring of disease severity and therapeutic effects.