Interdisiplinary and intraobserver reliability of the Greulich-Pyle method among Turkish children.

OBJECTIVES: Greulich-Pyle (GP) is one of the most used method for bone age determination (BAD) in various orthopedic, pediatric, radiological, and forensic situations. We aimed to investigate the inter- and intra-observer reliability of the GP method between the most relevant disciplines and its applicability to the Turkish population. METHODS: One-hundred and eighty (90 boys, 90 girls) patients with a chronological age younger than 18 (mean 9.33) were included. X-rays mixed by the blinded investigator were evaluated by two orthopedists, two radiologists, and two pediatric endocrinologists to determine skeletal age according to the GP atlas. A month later the process was repeated. As a statistical method, Paired t-test was used for comparison, an Intraclass Correlation Coefficients test was used for reliability and a 95 % confidence interval was determined. Results were classified according to Landis-Koch. RESULTS: All results were consistent with chronological age (p<0.001), according to the investigators' evaluations compared with chronological age. At the initial evaluation, the interobserver reliability of the method was 0.999 (excellent); at the second evaluation, the interobserver reliability was 0.997 (excellent). The intra-observer reliability of the method was 'excellent' in all observers. When results were separately evaluated by gender, excellent intraobserver correlation and excellent correlation with chronological age were found among all researchers (>0.9). When X-rays were divided into three groups based on age ranges and evaluated, 'moderate' and 'good' correlations with chronological age were obtained during the peripubertal period. CONCLUSIONS: The GP method used in skeletal age determination has excellent inter- and intra-observer reliability. During the peripubertal period, potential discrepancies in bone age assessments should be kept in mind. This method can be used safely and reproducibly by the relevant specialists.

The evaluation of bone mineral density in patients with nonalcoholic fatty liver disease.

BACKGROUND AND AIM: Nonalcoholic fatty liver diseases (NAFLD) are a clinical spectrum of disorders, of which nonalcoholic steatohepatitis (NASH) is the most strongly associated with inflammation. Inflammation is a known risk factor for low bone mass in the body. The primary goal of the present study was to evaluate the association between bone mineral density and liver function in patients with NASH. MATERIALS AND METHODS: Consenting patients with a diagnosis of NAFLD were included in the study. Extent of fatty change was graded based on ultrasonographic appearance (Grade 1, mild; Grade 2, moderate; Grade 3, severe). Bone mineral density was measured using the dual-energy x-ray absorptiometry method. ALT and hs-CRP were considered as noninvasive marker of NASH. According to ALT levels, patients were divided into two subgroups. RESULTS: A total of 102 patients with NAFLD and 54 healthy controls participated in the study. None of the patients with NAFLD had an abnormal bone mineral density. Furthermore, there was no difference between groups with regard to serum vitamin D levels. A subgroup analysis revealed that female patients with elevated serum ALT level had significantly lower bone mineral densities and higher hsCRP levels than female patients with normal ALT levels. The difference in vitamin D levels and body mass indices between the same subgroups was statistically insignificant. CONCLUSIONS: Simple steatosis of the liver does not affect bone mineral density. However, in a subgroup of patients with NAFLD, the presence of elevated serum ALT and hs-CRP levels, which are suggestive of NASH, was associated with lower bone mineral densities. Better understanding of the biological basis and the complex interactions between NAFLD and bone mass may help guide the clinical management of bone diseases associated with inflammation of the liver.

Dynamic Doppler evaluation of the hand arteries to distinguish between primary and secondary raynaud phenomenon.

OBJECTIVE: The objective of our study was to use Doppler sonography to detect the flow characteristics and parameters of the hand arteries that are needed to distinguish between primary Raynaud phenomenon (RP) and secondary RP. SUBJECTS AND METHODS: The diameter, resistive index (RI), and flow volume of the digital, ulnar, and radial arteries of patients with primary RP and those with secondary RP were measured at rest and after cold provocation. The flow starting time in the digital artery and the flow normalizing time of all three arteries were also recorded after cold provocation. RESULTS: At baseline and after cold provocation, the diameters of the radial and digital arteries and the flow volumes of the three arteries were less in patients with secondary RP than in primary RP patients. In primary RP and secondary RP, the flow normalizing times (mean ± SD) were 9.8 ± 3.88 and 25.88 ± 7.14 minutes, respectively, in the radial artery; 11.3 ± 7.43 and 32.15 ± 12.57 minutes in the ulnar artery; and 12.22 ± 6.82 and 32.67 ± 10.76 minutes in the digital artery. A flow normalizing time cutoff in the radial artery of 17 minutes yielded a sensitivity of 90% and specificity of 100%. A flow normalizing time cutoff in the ulnar artery of 23 minutes yielded a sensitivity and specificity of 71% and 100%, respectively. A flow normalizing time cutoff in the digital artery of 23 minutes yielded a sensitivity and specificity of 82.6% and 98%, respectively. The flow starting time of the digital artery was 3.80 ± 3.27 minutes in primary RP and 16.78 ± 9.97 minutes in secondary RP (p < 0.0001). The flow starting time cutoff of the digital artery was 7 minutes (sensitivity, 82.6%; specificity, 95.7%). CONCLUSION: The diameter of the radial and distal arteries; flow volume; and flow volume normalizing time of the digital, ulnar, and radial arteries' flow starting time in the digital artery may be helpful in distinguishing between primary RP and secondary RP with high sensitivity and specificity values. These parameters may also facilitate objective follow-up of treatment. The noninvasive nature of Doppler sonography is an additional advantage, and there is no need for extra hardware or software.