Ultrasound shear wave elastography and liver fibrosis: A Prospective Multicenter Study

Exploring Biomarkers in Nonalcoholic Fatty Liver Disease Among Individuals With Type 2 Diabetes Mellitus

Integrating biomarkers into a comprehensive strategy is crucial for precise patient management, especially considering the significant healthcare costs associated with diseases. Current studies emphasize the urgent need for a paradigm shift in conceptualizing nonalcoholic fatty liver disease (NAFLD), now renamed metabolic dysfunction-associated steatotic liver disease (MASLD). Biomarkers are emerging as indispensable tools for accurate diagnosis, risk stratification, and monitoring disease progression. This review classifies biomarkers into conventional and novel categories, such as lipids, insulin resistance, hepatic function, and cutting-edge imaging/omics, and evaluates their potential to transform the approach to MASLD among individuals with type 2 diabetes mellitus (T2D). It focuses on the critical role of biomarkers in early MASLD detection, enhancing predictive accuracy, and discerning responses to interventions (pharmacological or lifestyle modifications). Amid this discussion, the complexities of the relationship between T2D and MASLD are explored, considering factors like age, gender, genetics, ethnicity, and socioeconomic background. Biomarkers enhance the effectiveness of interventions and support global initiatives to reduce the burden of MASLD, thereby improving public health outcomes. This review recognizes the promising potential of biomarkers for diagnostic precision while candidly addressing the challenges in implementing these advancements in clinical practice. The transformative role of biomarkers emerges as a central theme, promising to reshape our understanding of disease trajectories, prognosis, and the customization of personalized therapeutic strategies for improved patient outcomes. From a future perspective, identifying early-stage biomarkers, understanding environmental impact through exposomes, and applying a multiomics approach may reveal additional insight into MASLD development.

How I treat sickle cell disease with gene therapy

ABSTRACT

In 2023, 2 different gene therapies were approved for individuals with severe sickle cell disease (SCD). The small number of patients treated on the pivotal clinical trials that led to these approvals have experienced dramatic short-term reductions in the occurrence of painful vaso-occlusive crises, but the long-term safety and efficacy of these genetic therapies are yet to be ascertained. Several challenges and treatment-related concerns have emerged in regard to administering these therapies in clinical practice. This article discusses the selection and preparation of individuals with SCD who wish to receive autologous gene therapy, as well as the salient features of the care needed to support them through a long and arduous treatment process. I specifically focus on postinfusion care, as it relates to immune monitoring and infection prevention. Compared with allogeneic hematopoietic cell transplantation, delivering autologous gene therapy to an individual with SCD has distinct nuances that require awareness and special interventions. Using clinical vignettes derived from real-life patients, I provide perspectives on the complex decision-making process for gene therapy for SCD based on currently available data and make recommendations for evaluating and supporting these patients.

The association between renal medullary and cortical fibrosis, stiffness, and concentrating capacity: an observational, single-center cross-sectional study

BACKGROUND

Fibrosis is a common final pathway leading to end-stage renal failure. As the renal medulla and cortex contain different nephron segments, we analyzed the factors associated with the progression of renal medullary and cortical fibrosis.

METHODS

A total of 120 patients who underwent renal biopsy at Kawashima Hospital between May 2019 and October 2022 were enrolled in this retrospective study. Renal medullary and cortical fibrosis and stiffness were evaluated using Masson's trichrome staining and shear wave elastography, respectively. Maximum urine osmolality in the Fishberg concentration test was also examined.

RESULTS

Medullary fibrosis was positively correlated with cortical fibrosis (p < 0.0001) and log-converted urinary β2-microglobulin (MG) (log urinary β2-MG) (p = 0.022) and negatively correlated with estimated glomerular filtration rate (eGFR) (p = 0.0002). Cortical fibrosis also correlated with log urinary β2-MG, eGFR, and maximum urine osmolality. Multivariate analysis revealed that cortical fibrosis levels (odds ratio [OR]: 1.063) and medullary stiffness (OR: 1.089) were significantly associated with medullar fibrosis (≧45%). The severe fibrosis group with both medullary fibrosis (≧45%) and cortical fibrosis (≧25%) had lower eGFR and maximum urine osmolality values and higher urinary β2-MG levels than the other groups.

CONCLUSIONS

Patients with disorders involving both renal medullary and cortical fibrosis had decreased maximum urine osmolality but had no abnormalities in the urinary concentrating capacities with either condition. Renal medullary and cortical fibrosis were positively correlated with urinary β2-MG, but not with urinary N-acetyl-beta-D-glucosaminidase.

Non-Invasive Ultrasound Diagnostic Techniques for Steatotic Liver Disease and Focal Liver Lesions: 2D, Colour Doppler, 3D, Two-Dimensional Shear Wave Elastography (2D-SWE), and Ultrasound-Guided Attenuation Parameter (UGAP)

We conducted a comprehensive literature review to evaluate the efficacy of combining two-dimensional shear wave elastography (2D-SWE) and ultrasound-guided attenuation parameter (UGAP) in assessing the risk of progressive metabolic dysfunction-associated steatohepatitis (MASH). This narrative review explores the applications of liver ultrasound in diagnosing metabolic liver diseases, focusing on recent advancements in diagnostic techniques for steatotic liver disease (SLD). Liver ultrasound can detect a spectrum of SLD manifestations, from metabolic dysfunction-associated liver disease (MASLD) to fibrosis and cirrhosis. It is also possible to identify inflammation, hepatitis, hepatocellular carcinoma (HCC), and various other liver lesions. Innovative ultrasound applications, including elastography and UGAP, can significantly enhance the diagnostic capabilities of ultrasound in accurately interpreting liver diseases. Understanding the pathogenesis of liver diseases requires a thorough analysis of their etiology and progression in order to develop sound diagnostic and therapeutic approaches. Chronic liver diseases (CLD) vary in origin, with MASLD affecting approximately 20-25% of the general population. The insidious progression of CLD from inflammation to fibrosis and cirrhosis underscores the need for effective early detection methods. This review aims to highlight the evolving role of non-invasive ultrasound-based diagnostic tests in the early detection and staging of liver diseases. By synthesizing current evidence, we aim to provide an updated perspective on the utility of advanced ultrasound techniques in redefining the diagnostic landscape for metabolic liver diseases.

The relationship between liver stiffness by two-dimensional shear wave elastography and iron overload status in transfusion-dependent patients

Increased liver stiffness (LS) can be result of increased liver iron concentration (LIC) which may not yet be reflected in the liver fibrotic status. The objective of our study was to examine relationship between hemochromatosis, LS, and serum ferritin level in transfusion-dependent patients. We recruited all 70 transfusion-dependent patients, whose median age was 15, referred for evaluating LIC status by magnetic resonance imaging (MRI) followed by two-dimensional ultrasonography shear wave elastography (2D-SWE). Thalassemia beta affected the majority of the patients. The optimal cut point for prediction of severe hemochromatosis using median SWE (kPa) and SWV (m/s) was ≥ 7.0 kPa and ≥ 1.54 m/s, respectively, with sensitivity of 0.76 (95% confidence interval [CI] 0.55, 0.91) and, specificity of 0.69 (95%CI 0.53, 0.82). When combing the optimal cut point of SWE (kPa) at ≥ 7.0 and serum ferritin ≥ 4123 ng/mL, the sensitivity increased to 0.84 (95%CI 0.64, 0.95) with specificity of 0.67 (95%CI 0.50, 0.80), positive predictive value (PPV) of 0.60 (95%CI 0.42, 0.76), and negative predictive value (NPV) of 0.88 (95%CI 0.71, 0.96). Simultaneous tests of 2D-SWE and serum ferritin for prediction of severe hemochromatosis showed the highest sensitivity of 84% (95%CI 0.64-0.95), as compared to 2D-SWE alone at 76% (95%CI 0.55, 0.91) or serum ferritin alone at 44% (95%CI 0.24-0.65). We recommend measuring both 2D-SWE and serum ferritin in short interval follow up patients. Adding 2D-SWE to management guideline will help in deciding for aggressive adjustment of iron chelating medication and increased awareness of patients having severe hemochromatosis.

Comparing the effect of FUAS and myomectomy on the elasticity of myometrium around targeted uterine fibroid

BACKGROUND

Focused ultrasound ablation surgery (FUAS) has been widely employed to treat patients with uterine fibroid (UF). This study aimed to estimate myometrial stiffness changes in patients who received FUAS for UFs or myomectomy (ME) and compare the recovery of surrounding myometrium between FUAS and ME groups. Our results may provide more evidence for guiding the proper conception timing in patients with UF.

METHODS

This study enrolled 173 patients from May 2022 to August 2023. Shear wave elastography (SWE) was used to dynamically monitor myometrial elasticity changes in patients before and after surgery. Moreover, our study monitored and analyzed the stiffness changes in the targeted fibroid after FUAS, as well as in the myometrium around after FUAS or ME.

RESULTS

The stiffness of the myometrium around the resected fibroid was significantly higher than at the preoperative level until 6 months. Conversely, the stiffness of the surrounding myometrium was only temporarily increased 1 day after FUAS. The comparison between FUAS and ME groups regarding the stiffness of the surrounding myometrium showed that nonsignificant differences were detected between the two groups before the treatment. The stiffness of the surrounding myometrium in the ME group was statistically significantly higher than that of the FUAS group 1 day as well as 1, 3, and 6 months after the treatment, respectively.

CONCLUSION

The FUAS had less impact on the surrounding myometrium than the ME, which may be more conducive to the recovery of myometrial elasticity in patients with UF.

Projected Healthcare System Cost Burden of Metabolic Dysfunction-Associated Steatotic Liver Disease in Canada

Background and Aims

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common cause of chronic liver disease worldwide. The current and projected cost of treating individuals with MASLD in Canada remains unknown. Our objective was to calculate the projected liver-specific and total health-care costs for people living with MASLD in Canada from 2020 to 2050.

Methods

The health-care usage of a cohort of patients diagnosed with MASLD in Calgary, Alberta was calculated using administrative data. Liver-specific encounters were identified and the average costs per year per patient were calculated. Projected costs were calculated by multiplying the average cost per patient within each health state by the projected prevalence of each health state.

Results

There were 6358 patients in the cohort. The annual average liver-specific cost per patient was $7.02 for F0/F1, $35.30 for F2, $60.46 for F3, and $72.55 for F4. The projected Canada-wide liver-specific cost was $85.5 million in 2020 and was expected to increase by $51 million by 2050. The average annual total health-care cost per patient was $397.90 for F0/F1, $781.53 for F2, $2881.84 for F3, and $1598.82 for F4. Thus, the projected Canada-wide total health-care cost was $3.76 billion in 2020 and was expected to increase by almost $2 billion by 2050.

Conclusion

These estimates underscore the need for a MASLD framework that focuses on both prevention and innovative care models to change the predicted trajectory of health-care costs.

Endoscopic Ultrasound-based Shear Wave Elastography for Detection of Advanced Liver Disease

BACKGROUND AND AIMS

Endoscopic ultrasound shear wave elastography (EUS-SWE) is a novel modality for liver stiffness measurement. The aims of this study are to evaluate the performance and reliability of EUS-SWE for detecting advanced liver disease in a prospective cohort.

METHODS

EUS-SWE measurements were prospectively obtained from patients undergoing EUS between August 2020 and March 2023. Liver stiffness measurements were compared between patients with and without advanced liver disease (ALD), defined as stage ≥3, to determine diagnostic accuracy for advanced fibrosis and portal hypertension. Logistic regression was performed to identify variables that impact the reliability of EUS-SWE readings. Select patients underwent paired magnetic resonance elastography (MRE) for liver fibrosis correlation.

RESULTS

Patients with ALD demonstrated higher liver stiffness compared to healthy controls (left lobe: 17.6 vs. 12.7 kPa, P<0.001; median right lobe: 24.8 vs. 11.0 kPa, P<0.001). The area under the receiver operator characteristic (AUROC) for the detection of ALD was 0.73 and 0.80 for left and right lobe measurements, respectively. General anesthesia was associated with reliable EUS-SWE liver readings (odds ratio: 2.73, 95% CI: 1.07-7.39, P=0.040). Left lobe measurements correlated significantly with MRE with an increase of 0.11 kPa (95% CI: 0.05-0.17 kPA) for every 1 kPa increase on EUS-SWE. D.

CONCLUSIONS

SWE is a promising technology that can readily be incorporated into standard EUS examinations for the assessment of ALD.

Quantitative measurements of radiation-induced fibrosis for head and neck cancer: A narrative review

Objectives

To provide a comprehensive summary of the different modalities available to measure soft tissue fibrosis after radiotherapy in head and neck cancer patients.

Data Sources

PubMed, Scopus, and Web of Sciences.

Review Methods

A search was conducted using a list of medical subject headings and terms related to head and neck oncology, radiation fibrosis, and quantitative measurements, including bioimpedance, MRI, and ultrasound. Original research related to quantitative measurement of neck fibrosis post-radiotherapy was included without time constraints, while reviews, case reports, non-English texts, and inaccessible studies were excluded. Discrepancies during the review were resolved by discussing with the senior author until consensus was reached.

Results

A total of 284 articles were identified and underwent title and abstract screening. Seventeen articles had met our criteria for full-text review based on relevance, of which nine had met our inclusion criteria. Young's modulus (YM) and viscoelasticity measures have demonstrated efficacy in quantifying neck fibrosis, with fibrotic tissues displaying significantly higher YM values and altered viscoelastic properties such as increased stiffness rate-sensitivity and prolonged stress-relaxation post-radiation. Intravoxel incoherent motion offers detailed insights into tissue changes by assessing the diffusion of water molecules and blood perfusion, thereby differentiating fibrosed from healthy tissues. Shear wave elastography has proven to be an effective technique for quantifying radiation-induced fibrosis in the head and neck region by measuring shear wave velocity.

Conclusion

There are various modalities to measure radiation-induced fibrosis, each with its unique strengths and limitations. Providers should be aware of these implications and decide on methodologies based on their specific clinical workflow.

Level of Evidence

Step 5.

Comparison of resistive index and shear-wave elastography in the evaluation of chronic kidney allograft dysfunction

BACKGROUND

Detection of early chronic changes in the kidney allograft is important for timely intervention and long-term survival. Conventional and novel ultrasound-based investigations are being increasingly used for this purpose with variable results.

AIM

To compare the diagnostic performance of resistive index (RI) and shear wave elastography (SWE) in the diagnosis of chronic fibrosing changes of kidney allograft with histopathological results.

METHODS

This is a cross-sectional and comparative study. A total of 154 kidney transplant recipients were included in this study, which was conducted at the Departments of Transplantation and Radiology, Sindh Institute of Urology and Transplan tation, Karachi, Pakistan, from August 2022 to February 2023. All consecutive patients with increased serum creatinine levels and reduced glomerular filtration rate (GFR) after three months of transplantation were enrolled in this study. SWE and RI were performed and the findings of these were evaluated against the kidney allograft biopsy results to determine their diagnostic utility.

RESULTS

The mean age of all patients was 35.32 ± 11.08 years. Among these, 126 (81.8%) were males and 28 (18.2%) were females. The mean serum creatinine in all patients was 2.86 ± 1.68 mg/dL and the mean estimated GFR was 35.38 ± 17.27 mL/min/1.73 m2. Kidney allograft biopsy results showed chronic changes in 55 (37.66%) biopsies. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of SWE for the detection of chronic allograft damage were 93.10%, 96.87%%, 94.73%, and 95.87%, respectively, and the diagnostic accuracy was 95.45%. For RI, the sensitivity, specificity, PPV, and NPV were 76.92%, 83.33%, 70.17%, and 87.62%, respectively, and the diagnostic accuracy was 81.16%.

CONCLUSION

The results from this study show that SWE is more sensitive and specific as compared to RI in the evaluation of chronic allograft damage. It can be of great help during the routine follow-up of kidney transplant recipients for screening and early detection of chronic changes and selecting patients for allograft biopsy.

Proposal of a Novel Serological Algorithm Combining FIB-4 and Serum M2BPGi for Advanced Fibrosis in Nonalcoholic Fatty Liver Disease

Background/Aims

Noninvasive methods have become increasingly critical in the diagnosis of fibrosis in chronic liver diseases. Herein, we compared the diagnostic performance of serum Mac2 binding protein glycosylation isomer (M2BPGi) and other serological panels for fibrosis in patients with nonalcoholic fatty liver disease (NAFLD) and proposed an improved two-step diagnostic algorithm for advanced fibrosis.

Methods

We enrolled 231 patients diagnosed with NAFLD who underwent a liver biopsy. We subsequently evaluated the diagnostic performance of serological panels, including serum M2BPGi, a fibrosis index based on four factors (FIB-4), aspartate aminotransferase-to-platelet ratio index (APRI), and NAFLD fibrosis score (NFS), in predicting the stage of liver fibrosis. We then constructed a two-step algorithm to better differentiate advanced fibrosis.

Results

The areas under the receiver operating characteristic curves of serum M2BPGi, FIB-4, APRI, and NFS for advanced fibrosis (≥F3) were 0.823, 0.858, 0.779, and 0.827, respectively. To reduce the performance of unnecessary liver biopsy, we propose a two-step algorithm using FIB-4 as an initial diagnostic tool and serum M2BPGi (≥0.6) as an additional diagnostic method for patients classified as intermediate (23%). Using the proposed algorithm, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 0.812, 0.814, 0.814, 0.600, and 0.927, respectively.

Conclusions

Serum M2BPGi is a simple and effective test for advanced fibrosis in patients with NAFLD. Application of the two-step algorithm based on FIB-4 and M2BPGi proposed here can improve diagnostic performance and reduce unnecessary tests, making diagnosis easily accessible, especially in primary medical centers.

Hematopoietic cell transplantation and gene therapy for Diamond-Blackfan anemia: state of the art and science

Diamond-Blackfan anemia (DBA) is one of the most common inherited causes of bone marrow failure in children. DBA typically presents with isolated erythroid hypoplasia and anemia in infants. Congenital anomalies are seen in 50% of the patients. Over time, many patients experience panhematopoietic defects resulting in immunodeficiency and multilineage hematopoietic cytopenias. Additionally, DBA is associated with increased risk of myelodysplastic syndrome, acute myeloid leukemia and solid organ cancers. As a prototypical ribosomopathy, DBA is caused by heterozygous loss-of-function mutations or deletions in over 20 ribosomal protein genes, with RPS19 being involved in 25% of patients. Corticosteroids are the only effective initial pharmacotherapy offered to transfusion-dependent patients aged 1 year or older. However, despite good initial response, only ~20-30% remain steroid-responsive while the majority of the remaining patients will require life-long red blood cell transfusions. Despite continuous chelation, iron overload and related toxicities pose a significant morbidity problem. Allogeneic hematopoietic cell transplantation (HCT) performed to completely replace the dysfunctional hematopoietic stem and progenitor cells is a curative option associated with potentially uncontrollable risks. Advances in HLA-typing, conditioning regimens, infection management, and graft-versus-host-disease prophylaxis have led to improved transplant outcomes in DBA patients, though survival is suboptimal for adolescents and adults with long transfusion-history and patients lacking well-matched donors. Additionally, many patients lack a suitable donor. To address this gap and to mitigate the risk of graft-versus-host disease, several groups are working towards developing autologous genetic therapies to provide another curative option for DBA patients across the whole age spectrum. In this review, we summarize the results of HCT studies and review advances and potential future directions in hematopoietic stem cell-based therapies for DBA.

Usefulness of two-dimensional shear wave elastography in the assessment of non-alcoholic fatty liver disease in children and adolescents

Two-dimensional shear wave elastography (2D-SWE) evaluates liver stiffness using a non-invasive method, but studies in the paediatric population are rare. This study evaluated the role of 2D-SWE in the diagnosis and severity of paediatric non-alcoholic fatty liver disease (NAFLD). In total, 131 patients with NAFLD and 25 healthy controls were enrolled in this study. The diagnosis and severity of NAFLD were initially assessed using the ultrasound fatty liver index (US-FLI), and all participants underwent 2D-SWE. US-FLI semi-quantitatively measures the severity of NAFLD on a scale of 2-8. The assessment of liver stiffness measurement (LSM) by 2D-SWE is presented in kilopascals (kPa). The NAFLD group was characterised by significantly higher LSM (4.40 ± 0.90 kPa) than the control group (3.76 ± 0.28 kPa) (P < 0.001). 2D-SWE significantly correlated with age, height, weight, body mass index, glucose, aspartate aminotransferase, alanine aminotransferase, high-density lipoprotein cholesterol, US-FLI, and triglyceride-glucose index (P < 0.001). In the receiver operating characteristic curve analysis, the area under the curve of LSM for predicting US-FLI ≥ 2 and ≥ 6 was 0.784 (P < 0.001) and 0.819 (P < 0.001), respectively. In conclusion, we suggest that 2D-SWE can be used as a non-invasive diagnostic tool for diagnosing and assessing the severity of paediatric NAFLD.

Optical force estimation for interactions between tool and soft tissues

Robotic assistance in minimally invasive surgery offers numerous advantages for both patient and surgeon. However, the lack of force feedback in robotic surgery is a major limitation, and accurately estimating tool-tissue interaction forces remains a challenge. Image-based force estimation offers a promising solution without the need to integrate sensors into surgical tools. In this indirect approach, interaction forces are derived from the observed deformation, with learning-based methods improving accuracy and real-time capability. However, the relationship between deformation and force is determined by the stiffness of the tissue. Consequently, both deformation and local tissue properties must be observed for an approach applicable to heterogeneous tissue. In this work, we use optical coherence tomography, which can combine the detection of tissue deformation with shear wave elastography in a single modality. We present a multi-input deep learning network for processing of local elasticity estimates and volumetric image data. Our results demonstrate that accounting for elastic properties is critical for accurate image-based force estimation across different tissue types and properties. Joint processing of local elasticity information yields the best performance throughout our phantom study. Furthermore, we test our approach on soft tissue samples that were not present during training and show that generalization to other tissue properties is possible.

Can Tissue Stiffness Measured Using Shear-Wave Elastography Represent Lymphedema in Breast Cancer?

Background: Lymphedema causes skin and subcutaneous fibrosis. However, quantitative methods for estimating the severity of fibrosis due to lymphedema have not been established. We evaluated skin stiffness using shear-wave elastography (SWE) and aimed to identify stiffness-associated factors in patients with breast cancer-related lymphedema (BCRL). Methods and Results: Thirty-six women (mean age, 57.5 ± 1.78 years; range, 39-77 years) were retrospectively recruited for this study. The mid-arm and mid-forearm circumferences were measured. The percentage differences in arm and forearm circumferences were used as an indicator of the severity of lymphedema at the time of SWE measurement and the measurement taken when the symptoms were most severe. Not subcutaneous tissues but cutaneous tissues of the affected arm and forearm showed a significant increase in shear-wave velocity (SWV) compared with those of the unaffected side. However, SWV was not correlated with the severity of lymphedema as a percentage difference when symptoms were most severe. Body mass index and lymphedema duration showed no significant correlation with the SWV of cutaneous tissues on the affected upper extremities. Conclusions: SWE can adequately estimate cutaneous fibrosis between the affected and unaffected limbs in patients with BCRL. However, evaluation of subcutaneous fibrosis is limited. Therefore, SWE can be an effective tool for evaluating cutaneous fibrosis in patients with BCRL.

Ultrasound shear-wave elastography applicability in estimation of post-mortem time

Introduction

Post-mortem rigidity of the tissues is one of the basic principles in forensic medicine to estimate the time of death. Qualitative methods to determine the stiffness of the corpse may have some limitations. Methods that provide quantitative values may be useful. We intended to evaluate the applicability of ultrasound shear-wave elastography of the tissues to estimate the post-mortem interval (PMI).

Methods

For 80 corpses, shear-wave elastography of the liver, sartorius muscle, testis, thyroid and parotid was performed before autopsy. Based on the forensic reports as the reference method to define post-mortem interval, the corpses were divided into four groups: group 0 (PMI < 24 hours), group 1 (PMI ≥24 hours and <48 hours), group 2 (PMI ≥ 48 hours and <72 hours), and group 3 (PMI ≥ 72 hours). There were 24, 38, 13, and 5 corpses, respectively, in groups 0, 1, 2, and 3.

Results

A significant rise in the elasticity values in comparison to elasticity of normal tissues in live adults was seen very early in the post-mortem period. Between-group comparisons showed that a significant difference in the liver elasticity was present among the groups. The mean (SD) liver elasticity was 10.29 (±0.83) in group 0, 14.98 (±1.56) in group 1, 12.49 (±1.09) in group 2, and 15.64 (±1.68) kilopascals (kPa) in group 3 (P = 0.035). Nevertheless, elasticity measurements in other tissues were not helpful in distinguishing post-mortem interval groups.

Conclusion

It is possible to use liver quantitative shear-wave elastography to estimate the time of death.

Noninvasive imaging of hepatic dysfunction: A state-of-the-art review

Hepatic dysfunction represents a wide spectrum of pathological changes, which can be frequently found in hepatitis, cholestasis, metabolic diseases, and focal liver lesions. As hepatic dysfunction is often clinically silent until advanced stages, there remains an unmet need to identify affected patients at early stages to enable individualized intervention which can improve prognosis. Passive liver function tests include biochemical parameters and clinical grading systems (e.g., the Child-Pugh score and Model for End-Stage Liver Disease score). Despite widely used and readily available, these approaches provide indirect and limited information regarding hepatic function. Dynamic quantitative tests of liver function are based on clearance capacity tests such as the indocyanine green (ICG) clearance test. However, controversial results have been reported for the ICG clearance test in relation with clinical outcome and the accuracy is easily affected by various factors. Imaging techniques, including ultrasound, computed tomography, and magnetic resonance imaging, allow morphological and functional assessment of the entire hepatobiliary system, hence demonstrating great potential in evaluating hepatic dysfunction noninvasively. In this article, we provide a state-of-the-art summary of noninvasive imaging modalities for hepatic dysfunction assessment along the pathophysiological track, with special emphasis on the imaging modality comparison and selection for each clinical scenario.

Arterial Stiffness Assessment in Healthy Participants Using Shear Wave Elastography

BACKGROUND

Arterial stiffness is an important biomarker for cardiovascular disease. Shear wave elastography (SWE) provides quantitative estimates of tissue stiffness.

OBJECTIVE

This study aimed to provide reference values for arterial wall, assessing the suitability of SWE to quantify elasticity of the common carotid artery (CCA) and evaluating inter- and intra-observer reproducibility.

METHODS

A Supersonic Aixplorer ultrasound system with L15-4 probe was used to scan longitudinal sections of the CCA. Young's modulus (YM) was measured within 2-mm regions of interest. Reproducibility was assessed within a subgroup of 16 participants by two operators (one novice and one experienced) during two sessions >one week apart.

RESULTS

This study involves seventy-three participants with a mean age of 40±10 years and body mass index of 26 ±6 kg/m2. YM estimates were 59 kPa ±19 in men and 56 kPa ±12 in women. The average YM of the CCA walls was 58 kPa ±15 (57 ±15 kPa for the anterior wall and 58 ±20 kPa for the posterior wall, p=0.75). There was no significant difference in the mean of YM estimates of the CCA between the observers (observer: one 51 ±14 kPa and observer two: 55 ±17 kPa [p=0.46]). inter- and intra-observer reproducibility was fair to good (Intra-class correlations, ranging from 0.46 to 0.71). Inter-frame variability was 28%.

CONCLUSION

In healthy individuals, SWE provided an estimate of YM of the CCA (58 kPa) with fair to good reproducibility. This study demonstrated the potential of using SWE for assessing biomechanical properties of blood vessels.

Intriguing findings of liver fibrosis following COVID-19

Background

Studies on a new coronavirus disease (COVID-19) show the elevation of liver enzymes and liver fibrosis index (FIB-4) independently on pre-existing liver diseases. It points to increased liver fibrogenesis during acute COVID-19 with possible long-term consequences. This study aimed to assess liver fibrosis in COVID-19 patients by serum hyaluronic acid (HA) and FIB-4.

Methods

The study included the acute COVID-19 group (66 patients, 50% females, mean age 58.3 ± 14.6), the post-COVID group (58 patients in 3–6 months after the recovery, 47% females, mean age 41.2 ± 13.4), and a control group (17 people, 47% females, mean age 42.8 ± 11.0). Ultrasound elastography was performed in the post-COVID and control groups.

Results

Sixty-five percent of the acute COVID-19 group had increased FIB-4 (> 1.45), and 38% of patients had FIB-4 ≥ 3.25. After matching by demographics, 52% of acute COVID-19 and 5% of the post-COVID group had FIB-4 > 1.45, and 29% and 2% of patients had FIB-4 ≥ 3.25, respectively. Increased serum HA (≥ 75 ng/ml) was observed in 54% of the acute COVID-19 and 15% of the post-COVID group. In the acute COVID-19 group, HA positively correlated with FIB-4, AST, ALT, LDH, IL-6, and ferritin and negatively with blood oxygen saturation. In the post-COVID group, HA did not correlate with FIB-4, but it was positively associated with higher liver stiffness and ALT.

Conclusion

More than half of acute COVID-19 patients had increased serum HA and FIB-4 related to liver function tests, inflammatory markers, and blood oxygen saturation. It provides evidence for the induction of liver fibrosis by multiple factors during acute COVID-19. Findings also indicate possible liver fibrosis in about 5% of the post-COVID group.

Ultrasonic technologies in imaging and drug delivery

Ultrasonic technologies show great promise for diagnostic imaging and drug delivery in theranostic applications. The development of functional and molecular ultrasound imaging is based on the technical breakthrough of high frame-rate ultrasound. The evolution of shear wave elastography, high-frequency ultrasound imaging, ultrasound contrast imaging, and super-resolution blood flow imaging are described in this review. Recently, the therapeutic potential of the interaction of ultrasound with microbubble cavitation or droplet vaporization has become recognized. Microbubbles and phase-change droplets not only provide effective contrast media, but also show great therapeutic potential. Interaction with ultrasound induces unique and distinguishable biophysical features in microbubbles and droplets that promote drug loading and delivery. In particular, this approach demonstrates potential for central nervous system applications. Here, we systemically review the technological developments of theranostic ultrasound including novel ultrasound imaging techniques, the synergetic use of ultrasound with microbubbles and droplets, and microbubble/droplet drug-loading strategies for anticancer applications and disease modulation. These advancements have transformed ultrasound from a purely diagnostic utility into a promising theranostic tool.

Association of shear-wave elastography with clinical outcomes post-liver transplantation

PURPOSE

Two-dimensional shear-wave elastography (2D-SWE) assessment of liver stiffness has the advantage of being obtained during conventional ultrasound. Liver-stiffness values on 2D-SWE for grafted livers are unknown, as are their potential link to post-transplantation morbidity. This study was undertaken to determine liver-stiffness values on 2D-SWE for grafted livers without complications, and examine relationships between liver-stiffness values on 2D-SWE and early post-operative arterial or biliary complications.

METHODS

In our facility, all liver-transplant recipients are entered in a comprehensive surgical database, where donor, procedure and recipient characteristics are described. All patients underwent systematic 2D-SWE assessment. Potential relationships were analyzed between liver-stiffness findings and donor, procedure and recipient characteristics, and follow-up events, including death, arterial or biliary complications, graft removal and allograft-dysfunction scores.

RESULTS

Liver-stiffness values on 2D-SWE of 337 ultrasound examinations from 165 liver-transplant recipients were collected retrospectively. Median time from transplantation to 2D-SWE examination was 149 days, with median follow-up at 36 months. The mean±SD stiffness value for grafts without complications was 7.3±2.3kPa; it was significantly higher during the first 90 days (8.2±2.5kPa) post-transplant than after 1year (7.0±2.4kPa) (P=0.01). Patients with biliary complications during the first-year post-transplantation had significantly higher mean liver-stiffness values on 2D-SWE than those without, respectively: 9.8±7.0 vs 7.5±1.8kPa (P=0.01).

CONCLUSIONS

Post-transplantation patients without complications had stiffer livers than the general population, with higher values during the first 90 days after surgery. Liver-stiffness values on 2D-SWE were significantly higher for patients with biliary, but not arterial, complications.

The Value of Real-Time Shear Wave Elastography before and after Rehabilitation of Upper Limb Spasm in Stroke Patients

Objective

Our goal was to evaluate the efficacy of muscle spasm before and after rehabilitation by comparing shear wave propagation velocity (SWV) and Young's modulus (YM) in the normal and spastic biceps brachii in stroke patients.

Methods

A study of 60 stroke patients with upper limb spasm was performed; these patients were admitted from April 2018 to September 2019. The modified Ashworth scale (MAS) scores of the spastic biceps brachii before and after rehabilitation treatment were compared. SWV and YM on the spastic and normal biceps brachii before rehabilitation treatment, SWV and YM on the spastic and normal biceps brachii after rehabilitation treatment, and SWV and YM on the spastic biceps brachii before and after rehabilitation treatment were compared. Whether SWV and YM on the spastic biceps brachii are related to MAS was compared.

Results

There was a statistically significant difference in SWV and YM between the normal and spastic biceps brachii before (P < 0.01) and after (P < 0.05) the rehabilitation treatment. There was no statistically significant difference in SWV and YM in the normal biceps brachii before and after the rehabilitation treatment (P > 0.05). There was a statistically significant difference in SWV and YM in the spastic biceps brachii before and after the rehabilitation treatment (P < 0.01). SWV and FM of the spastic biceps brachii are correlated with MAS before and after rehabilitation treatment, and the correlation coefficient for SWV was 0.563 and 0.605 for YM (P < 0.05).

Conclusion

SWE can be used as a means of assessment before and after rehabilitation treatment.

The Use of Two-Dimensional Shear Wave Elastography in People with Obesity for the Assessment of Liver Fibrosis in Non-Alcoholic Fatty Liver Disease

Obesity is associated with significant comorbidities, including non-alcoholic fatty liver disease (NAFLD). Given its potential to progress to advanced liver disease, monitoring the extent and progress of liver fibrosis and assessing its fibrosis stage are essential. Although liver biopsy is considered to be the gold standard for liver fibrosis staging, it is an invasive procedure with risk of complications. Considering the rising prevalence of obesity and NAFLD globally, developing non-invasive diagnostic methods is a priority. Transient elastography (TE) is increasingly being used to assess the severity of liver disease. However, in the presence of severe obesity, the increased thickness of subcutaneous adipose tissue and changes in anatomy may affect its diagnostic accuracy. Two-dimensional shear wave elastography (2D-SWE) assesses the liver stiffness in real time along with simultaneous anatomic B-mode ultrasound imaging and allows selection of the region of interest. This would suggest that 2D-SWE has several advantages over TE in patients with severe obesity. The purpose of this review is to examine the current literature addressing the use of 2D-SWE in the assessment of liver fibrosis in patients with NAFLD. This review also examines the evidence on the use of 2D-SWE in patients with obesity and NAFLD and compares it to TE as a novel and non-invasive method of assessing liver fibrosis.

Shear wave elastography accurately detects chronic changes in renal histopathology

AIM

Renal biopsy is the gold standard for the histological characterization of chronic kidney disease (CKD), of which renal fibrosis is a dominant component, affecting its stiffness. The aim of this study was to investigate the correlation between kidney stiffness obtained by shear wave elastography (SWE) and renal histological fibrosis.

METHODS

Shear wave elastography assessments were performed in 75 CKD patients who underwent renal biopsy. The SWE-derived estimates of the tissue Young's modulus (YM), given as kilopascals (kPa), were measured. YM was correlated to patients' renal histological scores, broadly categorized into glomerular, tubulointerstitial and vascular scores.

RESULTS

Young's modulus correlates significantly with tubulointerstitial score (ρ = 0.442, P < .001) and glomerular score (ρ = 0.375, P = .001). Patients with no glomerular sclerosis showed lower mean YM measurements compared to those with glomerular sclerosis. The mean YM increased as the percentage of interstitial fibrosis and tubular atrophy increased. The area under the receiver operating characteristic curve (ROC) for SWE in differentiating between mildly and moderately impaired kidneys was 0.702.

CONCLUSION

Shear wave elastography accurately detects chronic renal damage resulting from glomerular sclerosis, interstitial fibrosis and tubular atrophy, using the optimal cut-off YM value of ≥5.81 kPa.

Ultrasound Shear Wave Elastography to Assess Tissue Mechanical Properties in Somatic Dysfunction: A Feasibility Study

CONTEXT

Diagnosis of somatic dysfunction is based on subjective palpatory osteopathic assessments. This subjectivity has posed a challenge for researchers in studying osteopathic medicine. The development and use of radiological imaging techniques to objectively confirm or quantify muscle tissue stiffness associated with somatic dysfunction could be of benefit in osteopathic clinical practice, training, and further research.

OBJECTIVES

To investigate the feasibility of ultrasound shear wave elastography (SWE) to quantify muscle tissue stiffness in somatic dysfunction before and after osteopathic manipulative treatment (OMT).

METHODS

In this prospective study, we assessed lumbar spine somatic dysfunction in 20 adult patients before and after a single OMT session using standard osteopathic palpatory assessments by osteopathic physician faculty members in the Department of Osteopathic Principle and Practice at Rocky Vista University College of Osteopathic Medicine (Utah campus). Shear wave velocity (SWV, m/s) was measured in lumbar paraspinal muscle tissue using a commercial ultrasonography scanner on all participants immediately before and after OMT. In this study, OMT techniques targeted the iliocostalis lumborum and included the articulatory technique, balanced ligamentous tension, facilitated positional release, high-velocity, low-amplitude technique, muscle energy, myofascial release, and the Still technique at the discretion of the osteopathic physician. The difference in SWV between muscle tissues with and without dysfunction, and differences in SWV of dysfunctional tissue before and after OMT were examined using unpaired and paired t tests, as appropriate. The correlation between SWV measurements and osteopathic assessments was examined by the Spearman rank correlation. Intra- and interobserver reliability was analyzed using intraclass correlation coefficient.

RESULTS

The difference in SWV between muscle tissues with and without somatic dysfunction was significant before OMT (mean [SD], 1.93 [0.44] vs 1.69 [0.19]; P=.03) and was not significant after OMT (mean [SD], 1.69 [0.19] vs 1.53 [0.31]; P=.05). The difference in SWV in the same tissue with somatic dysfunction before and after OMT was significant (mean [SD], 1.93 [0.44] vs 1.52 [0.3]; P<.001). The SWV value highly correlated with manual osteopathic assessments (r=0.72). Intra- and interobserver reliability for performing SWE in somatic dysfunction was good (intraclass correlation coefficient >0.80).

CONCLUSIONS

The results of this study show that ultrasound SWE can objectively assess muscle tissue stiffness for diagnosis of somatic dysfunctions and for muscle tissue stiffness changes after OMT.

Role of shear wave elastography in the evaluation of the treatment and prognosis of supraspinatus tendinitis

BACKGROUND

Supraspinatus tendinitis recurs easily after treatment. One of the main reasons is the lack of objective tools for the efficacy evaluation. Shear wave elastography (SWE) can quantitatively analyze the tissue elasticity of region of interest by measuring the Young’s modulus (YM) value.

AIM

To explore the role of SWE in the efficacy and prognostic evaluation of supraspinatus tendinitis.

METHODS

Eighty-seven patients with supraspinatus tendinitis treated in Jiading District Central Hospital Affiliated Shanghai University of Medicine and Health Sciences were recruited. Another 30 healthy volunteers were enrolled as the control group. The visual analogue scale (VAS) and Constant-Murley Score (CMS) were recorded before treatment. All participants were scanned by SWE scan, and the YM value of the region of interest were recorded. Spearman correlation analysis was performed on YM values with VAS and CMS. Univariate repeated measures analysis of variance was used to calculate the changing trend of VAS, CMS and SWE under different treatment courses. After treatment, the patients were further grouped based on who achieved significantly effective and curative treatment. The patients in the continued treatment group continued to receive treatment according to the YM value, and the remaining patients who stopped receiving treatment were included in the stopped treatment group. All patients were followed up for 1 year, and the difference in recurrence rates between the continued treatment group and the stopped treatment group were compared.

RESULTS

The SWE images of supraspinatus muscle in healthy volunteers were mainly blue, while those of patients with supraspinatus tendinitis showed regional red and green areas. The average YM value of the supraspinatus muscle in healthy volunteers was 26.12 ± 4.03 kPa. The average YM value of patients with supraspinatus muscle was greater than that of healthy volunteers (average YM = 60.61 ± 11.53 kPa, t = 26.344, P < 0.001). The YM value was positively correlated with VAS (r = 0.564, P < 0.001) and negatively correlated with CMS (r = -0.411, P < 0.001). The changes of VAS and CMS were the most obvious in course 1 and then decreased gradually. The degree of change in YM values was similar in different courses. After a 1-year follow-up, the cumulative relapse-free rate in the continued treatment group was 91.43%, which was significantly higher than that in the stopped treatment group (64.71%, X² = 7.379, P = 0.007).

CONCLUSION

SWE can objectively indicate the severity of supraspinatus tendinitis. Using the YM value as a criterion for curative effect may reduce the recurrence rate.

Deep residual nets model for staging liver fibrosis on plain CT images

PURPOSE

The early diagnosis of liver fibrosis is crucial for the prevention of liver cirrhosis and liver cancer. As gold standard for staging liver fibrosis, liver biopsy is an invasive procedure that carries the risk of serious complications. The aim of this study was to evaluate the performance of the residual neural network (ResNet), a non-invasive methods, for staging liver fibrosis using plain CT images.

METHODS

This retrospective study involved 347 patients subjected to liver CT scanning and liver biopsy. For each patient, we selected three axial images adjacent to the puncture location in the eighth or ninth inter-space on the right side. After processing and enhancement (rotation, translation, and amplification), these images were used as input data for the ResNet model. The model used a fivefold cross-validation method. In each fold, the images of approximately 80% of the total sample size (278 patients) were used for training the ResNet model, the other 20% (69 patients) were used for testing the trained network, with the liver biopsy pathology results as gold standard. The proportion of patients in each fibrosis stage was equal for training and test groups. The final result was the mean of the fivefold cross-validation in the test group. The performance of the ResNet model was evaluated for the test group by receiver operating characteristic (ROC) analysis.

RESULTS

For the ResNet model, the area under the ROC curve (AUC) for assessing cirrhosis (F4), advanced fibrosis (F3 or higher), significant fibrosis (F2 or higher), and mild fibrosis (F1 or higher) was 0.97, 0.94, 0.90, and 0.91, respectively.

CONCLUSIONS

The ResNet model analysis of plain CT images exhibited high diagnostic efficiency for liver fibrosis staging. As a convenient, fast, and economical non-invasive diagnostic method, the ResNet model can be used to assist radiologists and clinicians in liver fibrosis evaluations.

Diagnostic Accuracy of Shear Wave Elastography as a Non-invasive Biomarker of High-Risk Non-alcoholic Steatohepatitis in Patients with Non-alcoholic Fatty Liver Disease

In this study, we evaluated the diagnostic accuracy of shear wave elastography (SWE) for differentiating high-risk non-alcoholic steatohepatitis (hrNASH) from non-alcoholic fatty liver and low-risk non-alcoholic steatohepatitis (NASH). Patients with non-alcoholic fatty liver disease scheduled for liver biopsy underwent pre-biopsy SWE. Ten SWE measurements were obtained. Biopsy samples were reviewed using the NASH Clinical Research Network Scoring System and patients with hrNASH were identified. Receiver operating characteristic curves for SWE-based hrNASH diagnosis were charted. One hundred sixteen adult patients underwent liver biopsy at our institution for the evaluation of non-alcoholic fatty liver disease. The area under the receiver operating characteristic curve of SWE for hrNASH diagnosis was 0.73 (95% confidence interval: 0.61-0.84, p < 0.001). The Youden index-based optimal stiffness cutoff value for hrNASH diagnosis was calculated as 8.4 kPa (1.67 m/s), with a sensitivity of 77% and specificity of 66%. SWE may be useful for the detection of NASH patients at risk of long-term liver-specific morbidity and mortality.

Viscoelastic Biomarkers of Ex Vivo Liver Samples via Torsional Wave Elastography

The clinical ultrasound community demands mechanisms to obtain the viscoelastic biomarkers of soft tissue in order to quantify the tissue condition and to be able to track its consistency. Torsional Wave Elastography (TWE) is an emerging technique proposed for interrogating soft tissue mechanical viscoelastic constants. Torsional waves are a particular configuration of shear waves, which propagate asymmetrically in-depth and are radially transmitted by a disc and received by a ring. This configuration is shown to be particularly efficient in minimizing spurious p-waves components and is sensitive to mechanical constants, especially in cylinder-shaped organs. The objective of this work was to validate (TWE) technique against Shear Wave Elasticity Imaging (SWEI) technique through the determination of shear wave velocity, shear moduli, and viscosity of ex vivo chicken liver samples and tissue mimicking hydrogel phantoms. The results of shear moduli for ex vivo liver tissue vary 1.69–4.0kPa using TWE technique and 1.32–4.48kPa using SWEI technique for a range of frequencies from 200 to 800Hz. Kelvin–Voigt viscoelastic parameters reported values of μ = 1.51kPa and η = 0.54Pa·s using TWE and μ = 1.02kPa and η = 0.63Pa·s using SWEI. Preliminary results show that the proposed technique successfully allows reconstructing shear wave velocity, shear moduli, and viscosity mechanical biomarkers from the propagated torsional wave, establishing a proof of principle and warranting further studies.

The effect of regions-of-interest and elasticity modulus selection on differentiating benign and malignant cervical lymph nodes with shear wave elastography

OBJECTIVE

Imaging diagnosis of cervical lymphadenopathy has conventionally used ultrasonography. Shear wave elastography (SWE) is a recent ultrasound technological advancement that has shown promise in the important medical problem of differentiating between benign and malignant cervical lymph nodes based on quantitative measurements of elasticity modulus. However, widely varying elasticity modulus metrics and regions-of-interest (ROIs) were used in existing studies, leading to inconsistent findings and results that are hard to compare with each other.

METHODS

Using a large dataset of 264 cervical lymph nodes from 200 patients, we designed a study comparing three elasticity modulus metrics (Emax, Emean, and standard deviation-SD) with three different ROIs to evaluate the effect of such selections. The metric values were compared between the benign and malignant node groups. The different ROI and metric selections were also compared through receiver operating characteristics curve analysis.

RESULTS

For all ROIs, all metric values were significantly different between the two groups, indicting their diagnostic potential. This was confirmed by the ≥0.80 area under the curve (AUC) values achieved with these metrics. Different ROIs had no effect on Emax, whereas all ROIs achieved high performance at 0.88 AUC. For Emean, the smallest ROI focusing on the area of the highest elasticity achieved the best diagnostic performance. In contrast, the larger ROIs achieved higher performances for SD.

CONCLUSIONS

This study illustrated the effect of elasticity modulus and ROI selection on the diagnostic performance of SWE on cervical lymphadenopathy. These new findings help guide relevant future studies and clinical applications of this important quantitative imaging modality.

Detecting liver fibrosis using a machine learning-based approach to the quantification of the heart-induced deformation in tagged MR images

Liver disease causes millions of deaths per year worldwide, and approximately half of these cases are due to cirrhosis, which is an advanced stage of liver fibrosis that can be accompanied by liver failure and portal hypertension. Early detection of liver fibrosis helps in improving its treatment and prevents its progression to cirrhosis. In this work, we present a novel noninvasive method to detect liver fibrosis from tagged MRI images using a machine learning-based approach. Specifically, coronal and sagittal tagged MRI imaging are analyzed separately to capture cardiac-induced deformation of the liver. The liver is manually delineated and a novel image feature, namely, the histogram of the peak strain (HPS) value, is computed from the segmented liver region and is used to classify the liver as being either normal or fibrotic. Classification is achieved using a support vector machine algorithm. The in vivo study included 15 healthy volunteers (10 males; age range 30-45 years) and 22 patients (15 males; age range 25-50 years) with liver fibrosis verified and graded by transient elastography, and 10 patients only had a liver biopsy and were diagnosed with a score of F3-F4. The proposed method demonstrates the usefulness and efficiency of extracting the HPS features from the sagittal slices for patients with moderate fibrosis. Cross-validation of the method showed an accuracy of 83.7% (specificity = 86.6%, sensitivity = 81.8%).

The Propagation Display Method Improves the Reproducibility of Pancreatic Shear Wave Elastography

Evaluation of the pancreatic elastic modulus (PEM) using shear wave elastography (SWE) requires at least 5 measurements to ensure reproducibility. The aim of this study was to evaluate improvement in reproducibility of SWE, using the propagation display method in normal pancreas ([NP] phase 1) and to examine the differences in PEM between NP and chronic pancreatitis (CP), intraductal papillary mucinous neoplasm (IPMN) and autoimmune pancreatitis ([AIP] phase 2). In phase 1, the measurement success rate, median PEM in repeated measurements and appropriate number of SWE measurements were determined in 109 cases with NP. In phase 2, PEM was measured in CP (n = 10), IPMN (n = 31) and AIP (n = 5), using the required number of SWE measurements determined in phase 1. In phase 1, the measurement success rate was 93.9% (92/109 cases). The median PEM for NP was 14.6 kPa and the appropriate number of SWE measurements was at least 3. In phase 2, the median PEMs in CP, IPMN and AIP were 19.6, 18.1 and 17.2 kPa, respectively, with significant differences between NP and CP (p = 0.0133) and between NP and IPMN (p = 0.0436). Use of the propagation display method in SWE improves the reproducibility of measurement of PEM.

Assessment of carotid plaque hardness in patients with fatty liver by shear wave elastography: Correlation with blood lipid levels

BACKGROUND

Ultrasound plays an important role in carotid plaque screening, density structure determination, and stability evaluation. Shear wave elastography (SWE), as a new method of ultrasonic elastography, can quantitatively evaluate the elastic hardness of biological tissues by analyzing the propagation velocity of shear wave. Therefore, quantitative analysis of hardness characteristics of different types of carotid plaques by SWE can provide a valuable reference for clinical evaluation of plaque stability.

AIM

To determine the hardness of different types of carotid plaques in patients with fatty liver by SWE, and to explore the correlation between the hardness and blood lipid levels.

Methods

Clinical data of 130 fatty liver patients with single carotid plaque were retrospectively analyzed. According to the echo of plaque under conventional ultrasound, the patients were divided into three groups: soft plaque group (40 cases), mixed plaque group (52 cases), and hard plaque group (38 cases). All plaques were examined by SWE. The mean Young's modulus (mean YM) of each plaque was measured and its correlation with low density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C) levels was analyzed.

Results

The mean YM and HDL-C levels in the hard plaque group were significantly higher than those in the mixed plaque group and soft plaque group (P < 0.05). The mean YM and HDL-C levels in the mixed plaque group were significantly higher than those in the soft plaque group (P < 0.05). The LDL-C level in the hard plaque group was significantly lower than that in the mixed plaque group and soft plaque group (P < 0.05). The LDL-C level in the mixed plaque group was significantly lower than that in the soft plaque group (P < 0.05). The mean YM of carotid plaque was negatively correlated with LDL-C (r = -0.71, P < 0.05), and positively correlated with HDL-C (r = 0.75, P < 0.05).

Conclusion

SWE can quantitatively evaluate the hardness of different types of carotid plaques, and the mean YM is correlated with blood lipids levels. SWE can provide elastic hardness information for clinical evaluation of plaque stability.

Wavelet-based Computationally-Efficient Computer-Aided Characterization of Liver Steatosis using Conventional B-mode Ultrasound Images

Hepatic steatosis occurs when lipids accumulate in the liver leading to steatohepatitis, which can evolve into cirrhosis and consequently may end with hepatocellular carcinoma. Several automatic classification algorithms have been proposed to detect liver diseases. However, some algorithms are manufacturer-dependent, while others require extensive calculations and consequently prolonged computational time. This may limit the development of real-time and manufacturer-independent computer-aided detection of liver steatosis. This work demonstrates the feasibility of a computationally-efficient and manufacturer-independent wavelet-based computer-aided liver steatosis detection system using conventional B-mode ultrasound (US) imaging. Seven features were extracted from the approximation part of the second-level wavelet packet transform (WPT) of US images. The proposed technique was tested on two datasets of ex-vivo mice livers with and without gelatin embedding, in addition to a third dataset of in-vivo human livers acquired using two different US machines. Using the gelatin-embedded mice liver dataset, the technique exhibited 98.8% accuracy, 97.8% sensitivity, and 100% specificity, and the frame classification time was reduced from 0.4814 s using original US images to 0.1444 s after WPT preprocessing. When the other mice liver dataset was used, the technique showed 85.74% accuracy, 84.4% sensitivity, and 88.5% specificity, and the frame classification time was reduced from 0.5612s to 0.2903 s. Using human liver image data, the best classifier exhibited 92.5% accuracy, 93.0% sensitivity, 91.0% specificity, and the classification time was reduced from 0.660 s to 0.146 s. This technique can be useful for developing computationally-efficient and manufacturer-independent noninvasive CAD systems for fatty liver detection.

Non-invasive Quantitative Assessment of Muscle Force Based on Ultrasonic Shear Wave Elastography

The objective of this study was to investigate the feasibility of using shear wave elastography (SWE) to indirectly measure passive muscle force and to examine the effects of muscle mass and scan angle. We measured the Young's moduli of 24 specimens from six muscles of four swine at different passive muscle loads under different scan angles (0°, 30°, 60° and 90°) using SWE. Highly linear relationships between Young's modulus E and passive muscle force F were found for all 24 muscle specimens at 0^o scan angle with coefficients of determination R² ranging from 0.984 to 0.999. The results indicate that the muscle mass has no significant effect on the muscle E-F relationship, whereas E-F linearity decreases disproportionately with increased scan angle. These findings suggest that SWE, when carefully applied, can provide a highly reliable tool to measure muscle Young's modulus, and could be used to assess the muscle force quantitatively.

Diagnostic Performance of Shear Wave Elastography in Patients With Autoimmune Liver Disease

OBJECTIVES

To assess performance of shear wave elastography for evaluation of fibrosis and the histologic stage in patients with autoimmune liver disease (ALD) and to validate previously established advanced fibrosis cutoff values in this cohort.

METHODS

Shear wave elastography was performed on patients with ALD with an Aixplorer ultrasound system (SuperSonic Imagine, Aix-en-Provence, France) using an SC6-1 transducer. The median estimated tissue Young modulus was calculated from sets of 8 to 10 elastograms. A blinded, subspecialty-trained pathologist reviewed biopsy specimens. The METAVIR classification was used to stage liver fibrosis and necroinflammation. Steatosis was graded from 0 to 4+. The Kendall τ-b correlation test was performed to identify the correlation between the estimated tissue Young modulus and fibrosis, steatosis, and the necroinflammatory score. The Spearman correlation test was performed to identify the correlation between the estimated tissue Young modulus and clinical data. The diagnostic performance of shear wave elastography for differentiating METAVIR stage F2 or higher from F0 and F1 fibrosis was evaluated by a receiver operating characteristic (ROC) curve analysis.

RESULTS

Fifty-one patients with ALD were analyzed. The estimated tissue Young modulus was positively correlated with the fibrosis stage and necroinflammation score (r = 0.386; P < .001; r = 0.338; P = .002, respectively) but not steatosis (r = -0.091; P = .527). Serum aspartate aminotransferase, alanine aminotransferase, and total bilirubin values were positively correlated with the estimated tissue Young modulus (r = 0.501; P < .001; r = 0.44; P = .001; r = 0.291; P = .038). The serum albumin value was negatively correlated (r = -0.309; P = .033). The area under the ROC curve was 0.781 (95% confidence interval, 0.641-0.921) for distinguishing F2 or greater fibrosis from F0 and F1 fibrosis. Based on the ROC curve, an optimal cutoff value of 9.15 kPa was identified (sensitivity, 83.3%; specificity, 72.7%).

CONCLUSIONS

Shear wave elastography is a novel noninvasive adjunct to liver biopsy in evaluation and staging of patients with ALD, showing the potential for serial evaluations of disease progression and treatment responses.

The role of imaging in prediction of post-hepatectomy liver failure

Post-hepatectomy liver failure (PHLF) is not only a leading cause of mortality but also a leading cause of life-threatening complications in patients undergoing liver resection. The ability to accurately detect the emergence of PHLF represents a crucially important step. Currently, PHLF can be predicted by a comprehensive evaluation of biological, clinical, and anatomical parameters. With the development of new technologies, imaging methods including elastography, diffusion-weighted magnetic resonance imaging, and gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid-enhanced MRI play a more significant role in the pre-operative prediction and assessment of PHLF. In this review, we summarize the mainstream studies, with the aim of evaluating the role of imaging and improving the clinical value of existing scoring systems for predicting PHLF.

Liver fibrosis detection and staging: a comparative study of T1ρ MR imaging and 2D real-time shear-wave elastography

Purpose

To compare the results of T1ρ MR imaging and 2D real-time shear-wave elastography (SWE) for liver fibrosis detection and staging.

Methods

Twenty-nine rabbit models of CCl₄-induced liver fibrosis were established and six untreated rabbits served as controls. T1ρ MR imaging and 2D real-time SWE examination were performed at 2, 4, 6, 8, 10, and 12 weeks. T1ρ values and liver stiffness (LS) values were measured. Fibrosis was staged according to the METAVIR scoring system. Correlation test was performed among T1ρ values, LS values, and fibrosis stage. Receiver operating characteristic (ROC) analysis was performed for assessing diagnostic performance of T1ρ and SWE in detection of no fibrosis (F0), substantial fibrosis (≥ F2), severe fibrosis (≥ F3), and cirrhosis (F4).

Results

There was moderate positive correlation between fibrosis stage and T1ρ values (r = 0.566; 95% CI 0.291–0.754; P < 0.0001), and LS value (r = 0.726; 95% CI 0.521–0.851; P = 0.003). T1ρ values showed moderate positive correlations with LS values [r = 0.693; 95% confidence interval (CI) 0.472–0.832; P < 0.0001]. Areas Under ROC (AUROCs) were 0.861 (95% CI 0.705–0.953) for SWE and 0.856 (95% CI 0.698–0.950) for T1ρ (P = 0.940), 0.906 (95% CI 0.762–0.978) for SWE and 0.849 (95% CI 0.691–0.946) for T1ρ (P = 0.414), 0.870 (95% CI 0.716–0.958) for SWE and 0.799 (95% CI 0.632–0.913) for T1ρ (P = 0.422), and 0.846 (95% CI 0.687–0.944) for SWE and 0.692 (95% CI 0.517–0.835) for T1ρ (P = 0.137), when diagnosing liver fibrosis with ≥ F1, ≥ F2, ≥ F3, and F4, respectively. There was moderate positive correlation between inflammatory activity and T1ρ values (r = 0.520; 95% CI 0.158–0.807; P = 0.013).

Conclusion

T1ρ imaging has potential for liver fibrosis detection and staging with good diagnostic capability similar to that of ultrasonography elastography.

Shear wave elastography in the evaluation of renal parenchymal stiffness in patients with chronic kidney disease

OBJECTIVE

To investigate the use of shear wave elastography (SWE)-derived estimates of Young's modulus (YM) as an indicator to detect abnormal renal tissue diagnosed by estimated glomerular filtration rate (eGFR).

METHODS

The study comprised 106 chronic kidney disease (CKD) patients and 203 control subjects. Conventional ultrasound was performed to measure the kidney length and cortical thickness. SWE imaging was performed to measure renal parenchymal stiffness. Diagnostic performance of SWE and conventional ultrasound were correlated with serum creatinine, urea levels and eGFR.

RESULTS

Pearson's correlation coefficient revealed a negative correlation between YM measurements and eGFR (r = -0.576, p < 0.0001). Positive correlations between YM measurements and age (r = 0.321, p < 0.05), serum creatinine (r = 0.375, p < 0.0001) and urea (r = 0.287, p < 0.0001) were also observed. The area under the receiver operating characteristic curve for SWE (0.87) was superior to conventional ultrasound alone (0.35-0.37). The cut-off value of less or equal to 4.31 kPa suggested a non-diseased kidney (80.3% sensitivity, 79.5% specificity).

CONCLUSION

SWE was superior to renal length and cortical thickness in detecting CKD. A value of 4.31 kPa or less showed good accuracy in determining whether a kidney was diseased or not. Advances in knowledge: On SWE, CKD patients show greater renal parenchymal stiffness than non-CKD patients. Determining a cut-off value between normal and diseased renal parenchyma may help in early non-invasive detection and management of CKD.

Non-invasive assessments for liver fibrosis: The crystal ball we long for

Non-invasive assessment of liver fibrosis has been one of the most rapidly advancing fields in hepatology in the last decade. Progressive liver fibrosis results in cirrhosis, hepatocellular carcinoma (HCC), and various liver-related complications in essentially all chronic liver diseases. Assessment of liver fibrosis allows clinicians to determine the prognosis, need of treatment, disease progression, and response to treatment in patients with chronic liver disease. Liver biopsy has been the gold standard in last few decades and most adopted diagnostic tool in clinical trials. Nonetheless, it is impractical to apply the test in a large number of patients or to do it serially. Hence, various non-invasive assessments have been developed and adopted in some international management guidelines. Liver stiffness measurement (LSM) with transient elastography is one of the most widely validated non-invasive assessments for liver fibrosis. It is an accurate and reproducible method to predict advanced fibrosis in chronic hepatitis B. Using transient elastography, it is possible to perform repeated liver fibrosis assessments on a large number of asymptomatic patients. The key challenge of his tool is the confounding effect of alanine aminotransferase (ALT) level, such that decrease in LSM may only reflect ALT normalization, hence not accurate enough to indicate regression of liver fibrosis. This may be partially handled by combining LSM with a serum-based formula, which is independent of ALT such as the Forns index and enhanced liver fibrosis test. An LSM-based HCC risk score is useful to prioritize patients for HCC surveillance.

Quantitative Evaluation of Denervated Muscle Atrophy with Shear Wave Ultrasound Elastography and a Comparison with the Histopathologic Parameters in an Animal Model

This study explored the efficacy of shear wave ultrasound elastography (SWUE) for quantitative evaluation of denervated muscle atrophy in a rabbit model. The elastic modulus of the triceps surae muscle was measured with SWUE and compared with histopathologic parameters at baseline and at various post-denervation times (2, 4 and 8 wk) with 10 animals in each group. Our results revealed that the elastic modulus of denervated muscle was significantly lower at 2 wk but higher at 8 wk compared with that at the baseline (p <0.05), and no significant difference was found between the elastic modulus at 4 wk and that at the baseline (p > 0.05). The wet-weight ratio and the muscle fiber cross-sectional area of the denervated muscle decreased gradually during the 8 wk post-denervation together with a gradual increase of the collagen fiber area (p <0.05). In conclusion, SWUE was useful for quantitative evaluation of muscle denervation. The decreased elastic modulus might be an early sign of denervated muscle atrophy.

Reproducibility of shear wave elastography (SWE) in patients with chronic liver disease

The presence of significant fibrosis is an indicator for liver disease staging and prognosis. The aim of the study was to determine reproducibility of real-time shear wave elastography using a hepatic biopsy as the reference standard to identify patients with chronic liver disease. Forty patients with chronic liver disease and 12 normal subjects received shear wave elastography performed by skilled operators. Interoperator reproducibility was studied in 29 patients. Fibrosis was evaluated using the Metavir score. The median and range shear wave elastography values in chronic liver disease subjects were 6.15 kPa and 3.14-16.7 kPa and were 4.49 kPa and 2.92-7.32 kPa in normal subjects, respectively. With respect to fibrosis detected by liver biopsy, shear wave elastography did not change significantly between F0 and F1 (p = 0.334), F1 and F2 (p = 0.611), or F3 and F4 (0.327); a significant difference was observed between the F0-F2 and F3-F4 groups (p = 0.002). SWE also correlated with inflammatory activity (Rs = 0.443, p = 0.0023) and ALT levels (Rs = 0.287, p = 0.0804). Age, sex and body mass index did not affect shear wave elastography measurements. Using receiver operator characteristic curves, two threshold values for shear wave elastography were identified: 5.62 kPa for patients with fibrosis (≥F2; sensitivity 80%, specificity 69.4%, and accuracy 77%) and 7.04 kPa for patients with severe fibrosis (≥F3; sensitivity 88.9%, specificity 81%, and accuracy 89%). Overall interobserver agreement was excellent and was analysed using an interclass correlation coefficient (0.94; CI 0.87-0.97).This study shows that shear wave elastography executed by skilled operators can be performed on almost all chronic liver disease patients with high reproducibility. It is not influenced by age, sex or body mass index, identifies severely fibrotic patients and is also related to inflammatory activity.

Comparison of the effectiveness of ultrasound elastography with that of conventional ultrasound for differential diagnosis of thyroid lesions with suspicious ultrasound features

Ultrasound elastography (USE) has been used for quantitative imaging since the early 1990s. The aim of the present study was to compare the effectiveness of USE with that of conventional ultrasound in the differential diagnosis of benign vs. malignant thyroid nodules. USE was performed on 150 thyroid nodules in 123 patients. USE demonstrated a lower grade of elasticity (grade I/II) in 86% of benign nodules and a decreased strain ratio (2.30±1.01) compared with malignant nodules. USE of malignant nodules exhibited a higher grade of elasticity (grade III/IV) in 90% of nodules and an increased strain ratio (6.39±2.50). The results of the present study indicate that USE and strain ratio may be useful in the differential diagnosis of thyroid nodules.