Development of a machine learning-based fine-grained risk stratification system for thyroid nodules using predefined clinicoradiological features.

OBJECTIVE: We constructed and validated a machine learning-based malignancy risk estimation model using predefined clinicoradiological features, and evaluated its clinical utility for the management of thyroid nodules. METHODS: In total, 5708 benign (n = 4597) and malignant (n = 1111) thyroid nodules were collected from 5081 consecutive patients treated in 26 institutions. Seventeen experienced radiologists evaluated nodule characteristics on ultrasonographic images. Eight predictive models were used to stratify the thyroid nodules according to malignancy risk; model performance was assessed via nested 10-fold cross-validation. The best-performing algorithm was externally validated using data for 454 thyroid nodules from a tertiary hospital, then compared to the Thyroid Imaging Reporting and Data System (TIRADS)-based interpretations of radiologists (American College of Radiology, European and Korean TIRADS, and AACE/ACE/AME guidelines). RESULTS: The area under the receiver operating characteristic (AUROC) curves of the algorithms ranged from 0.773 to 0.862. The sensitivities, specificities, positive predictive values, and negative predictive values of the best-performing models were 74.1-76.6%, 80.9-83.4%, 49.2-51.9%, and 93.0-93.5%, respectively. For the external validation set, the ElasticNet values were 83.2%, 89.2%, 81.8%, and 90.1%, respectively. The corresponding TIRADS values were 66.5-85.0%, 61.3-80.8%, 45.9-72.1%, and 81.5-90.3%, respectively. The new model exhibited a significantly higher AUROC and specificity than did the TIRADS risk stratification, although its sensitivity was similar. CONCLUSION: We developed a reliable machine learning-based predictive model that demonstrated enhanced specificity when stratifying thyroid nodules according to malignancy risk. This system will contribute to improved personalized management of thyroid nodules. KEY POINTS: • The area under the receiver operating characteristic (AUROC) curve, sensitivity, and specificity of our model were 0.914, 83.2%, and 89.2%, respectively (derived using the validation dataset). • Compared to the TIRADS values, the AUROC and specificity are significantly higher, while the sensitivity is similar. • An interactive version of our AI algorithm is at http://tirads.cdss.co.kr .

Modification of Pediatric Sequential Organ Failure Assessment Score Using Acute Kidney Injury Diagnostic Criteria.

OBJECTIVES: To develop a modified pediatric Sequential Organ Failure Assessment score using the acute kidney injury diagnostic criteria and evaluate its performance in predicting mortality. DESIGN: A single-center retrospective study. SETTING: Fourteen-bed PICU in a tertiary care academic children's hospital. PATIENTS: Critically ill children admitted to the PICU between January 2017 and September 2019 with at least more than two serum creatinine measurements-one for baseline and the other within the first 48 hours of PICU admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 755 patients were included. Overall, 265 patients were diagnosed with acute kidney injury using the current acute kidney injury diagnostic criteria. The overall PICU mortality was 5.8%. Patients with acute kidney injury required more vasoactive-inotropic drugs and showed higher illness severity scores, including the Pediatric Risk of Mortality III, Pediatric Logistic Organ Dysfunction 2, pediatric Sequential Organ Failure Assessment, and modified pediatric Sequential Organ Failure Assessment scores, as well as higher PICU mortality than patients without acute kidney injury (p < 0.001). As acute kidney injury stages increase, PICU mortality also increased (p < 0.001). Based on multivariable logistic regression analysis adjusted for age and sex, the modified pediatric Sequential Organ Failure Assessment score was an independent prognostic factor of PICU mortality. The modified pediatric Sequential Organ Failure Assessment score showed better performance in predicting PICU mortality (area under the receiver operating characteristic curve, 0.821; 95% CI, 0.759-0.882) than other severity scores (area under the receiver operating characteristic curve [95% CI] of Pediatric Risk of Mortality III, Pediatric Logistic Organ Dysfunction 2, and pediatric Sequential Organ Failure Assessment scores: 0.788 [0.723-0.853], 0.735 [0.663-0.807], and 0.785 [0.718-0.853], respectively). CONCLUSIONS: Acute kidney injury is prevalent and associated with poor clinical outcomes in critically ill children. The modified pediatric Sequential Organ Failure Assessment score, based on the acute kidney injury diagnostic criteria, showed improved performance in predicting PICU mortality. The modified pediatric Sequential Organ Failure Assessment score could be a promising prognostic factor for critically ill children.

Radiofrequency Ablation of Benign Thyroid Nodules: Recommendations from the Asian Conference on Tumor Ablation Task Force - Secondary Publication.

Radiofrequency ablation (RFA) is a thermal ablation technique widely used for the management of benign thyroid nodules. To date, five academic societies in various countries have reported clinical practice guidelines, opinion statements, or recommendations regarding the use of thyroid RFA. However, despite some similarities, there are also differences among the guidelines, and a consensus is required regarding safe and effective treatment in Asian countries. Therefore, a task force was organized by the guideline committee of the Asian Conference on Tumor Ablation with the goal of devising recommendations for the clinical use of thyroid RFA. The recommendations in this article are based on a comprehensive analysis of the current literature and the consensus opinion of the task force members.

Application of deep learning to the diagnosis of cervical lymph node metastasis from thyroid cancer with CT: external validation and clinical utility for resident training.

PURPOSE: This study aimed to validate a deep learning model's diagnostic performance in using computed tomography (CT) to diagnose cervical lymph node metastasis (LNM) from thyroid cancer in a large clinical cohort and to evaluate the model's clinical utility for resident training. METHODS: The performance of eight deep learning models was validated using 3838 axial CT images from 698 consecutive patients with thyroid cancer who underwent preoperative CT imaging between January and August 2018 (3606 and 232 images from benign and malignant lymph nodes, respectively). Six trainees viewed the same patient images (n = 242), and their diagnostic performance and confidence level (5-point scale) were assessed before and after computer-aided diagnosis (CAD) was included. RESULTS: The overall area under the receiver operating characteristics (AUROC) of the eight deep learning algorithms was 0.846 (range 0.784-0.884). The best performing model was Xception, with an AUROC of 0.884. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of Xception were 82.8%, 80.2%, 83.0%, 83.0%, and 80.2%, respectively. After introducing the CAD system, underperforming trainees received more help from artificial intelligence than the higher performing trainees (p = 0.046), and overall confidence levels significantly increased from 3.90 to 4.30 (p < 0.001). CONCLUSION: The deep learning-based CAD system used in this study for CT diagnosis of cervical LNM from thyroid cancer was clinically validated with an AUROC of 0.884. This approach may serve as a training tool to help resident physicians to gain confidence in diagnosis. KEY POINTS: • A deep learning-based CAD system for CT diagnosis of cervical LNM from thyroid cancer was validated using data from a clinical cohort. The AUROC for the eight tested algorithms ranged from 0.784 to 0.884. • Of the eight models, the Xception algorithm was the best performing model for the external validation dataset with 0.884 AUROC. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 82.8%, 80.2%, 83.0%, 83.0%, and 80.2%, respectively. • The CAD system exhibited potential to improve diagnostic specificity and accuracy in underperforming trainees (3 of 6 trainees, 50.0%). This approach may have clinical utility as a training tool to help trainees to gain confidence in diagnoses.

Differentiation of salivary gland tumors through tumor heterogeneity: a comparison between pleomorphic adenoma and Warthin tumor using CT texture analysis.

PURPOSE: We compared the diagnostic performance of CT texture analysis in single-phase CT scan with that of conventional enhancement pattern analysis in a two-phase CT scan for discrimination of salivary gland tumors, Warthin tumor (WT) from pleomorphic adenoma (PA). METHODS: One hundred seventy-eight patients with PA and 84 patients with WT were selected and CT texture analysis was separately performed on early (40s) and delayed (180s) phases, after injection of the contrast agent, using commercially available software. The attenuation changes and enhancement patterns were visually and quantitatively assessed with Hounsfield units (HU). Differences between PAs and WTs were analyzed using χ2 test and independent t test. Diagnostic performance of texture parameters in single-phase CT was compared with that of dynamic enhancement pattern in two-phase CT using the McNemar test. RESULTS: Ratio of tumoral HU (delayed phase/early phase) was significantly higher in PAs compared with WTs (p < 0.001). Tumor heterogeneity parameters, standard deviation (SD) and entropy, were significantly lower in WTs regardless of the type of filter used (p ≤ 0.001). Mean with coarse filter (AUC = 0.944) on early phase scan and entropy with medium filter (AUC = 0.901) on delayed scan were best discriminators between PAs and WTs. Diagnostic accuracy of mean (90.5%) on early scan and entropy (84.7%) on delayed scan was not significantly different from the accuracy (89.3%) of conventional wash-out pattern for distinguishing WTs from PAs (p = 0.742, p = 0.088, respectively). CONCLUSION: Diagnostic performance of texture parameters was similar to that of quantitative enhancement pattern for differentiating WTs from PAs, with the advantage in lower radiation exposure.

Application of deep learning to the diagnosis of cervical lymph node metastasis from thyroid cancer with CT.

PURPOSE: To develop a deep learning-based computer-aided diagnosis (CAD) system for use in the CT diagnosis of cervical lymph node metastasis (LNM) in patients with thyroid cancer. METHODS: A total of 995 axial CT images that included benign (n = 647) and malignant (n = 348) lymph nodes were collected from 202 patients with thyroid cancer who underwent CT for surgical planning between July 2017 and January 2018. The datasets were randomly split into training (79.0%), validation (10.5%), and test (10.5%) datasets. Eight deep convolutional neural network (CNN) models were used to classify the images into metastatic or benign lymph nodes. Pretrained networks were used on the ImageNet and the best-performing algorithm was selected. Class-specific discriminative regions were visualized with attention heatmap using a global average pooling method. RESULTS: The area under the ROC curve (AUROC) for the tested algorithms ranged from 0.909 to 0.953. The sensitivity, specificity, and accuracy of the best-performing algorithm were all 90.4%, respectively. Attention heatmap highlighted important subregions for further clinical review. CONCLUSION: A deep learning-based CAD system could accurately classify cervical LNM in patients with thyroid cancer on preoperative CT with an AUROC of 0.953. Whether this approach has clinical utility will require evaluation in a clinical setting. KEY POINTS: • A deep learning-based CAD system could accurately classify cervical lymph node metastasis. The AUROC for the eight tested algorithms ranged from 0.909 to 0.953. • Of the eight models, the ResNet50 algorithm was the best-performing model for the validation dataset with 0.953 AUROC. The sensitivity, specificity, and accuracy of the ResNet50 model were all 90.4%, respectively, in the test dataset. • Based on its high accuracy of 90.4%, we consider that this model may be useful in a clinical setting to detect LNM on preoperative CT in patients with thyroid cancer.

Computer-aided diagnosis system for thyroid nodules on ultrasonography: diagnostic performance and reproducibility based on the experience level of operators.

PURPOSE: To evaluate the diagnostic performance and reproducibility of a computer-aided diagnosis (CAD) system for thyroid cancer diagnosis using ultrasonography (US) based on the operator's experience. MATERIALS AND METHODS: Between July 2016 and October 2016, 76 consecutive patients with 100 thyroid nodules (≥ 1.0 cm) were prospectively included. An experienced radiologist performed the US examinations with a real-time CAD system integrated into the US machine, and three operators with different levels of US experience (0-5 years) independently applied the CAD system. We compared the diagnostic performance of the CAD system based on the operators' experience and calculated the interobserver agreement for cancer diagnosis and in terms of each US descriptor. RESULTS: The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the CAD system were 88.6, 83.9, 81.3, 90.4, and 86.0%, respectively. The sensitivity and accuracy of the CAD system were not significantly different from those of the radiologist (p > 0.05), while the specificity was higher for the experienced radiologist (p = 0.016). For the less-experienced operators, the sensitivity was 68.8-73.8%, specificity 74.1-88.5%, PPV 68.9-73.3%, NPV 72.7-80.0%, and accuracy 71.0-75.0%. The less-experienced operators showed lower sensitivity and accuracy than those for the experienced radiologist. The interobserver agreement was substantial for the final diagnosis and each US descriptor, and moderate for the margin and composition. CONCLUSIONS: The CAD system may have a potential role in the thyroid cancer diagnosis. However, operator dependency still remains and needs improvement. KEY POINTS: • The sensitivity and accuracy of the CAD system did not differ significantly from those of the experienced radiologist (88.6% vs. 84.1%, p = 0.687; 86.0% vs. 91.0%, p = 0.267) while the specificity was significantly higher for the experienced radiologist (83.9% vs. 96.4%, p = 0.016). • However, the diagnostic performance varied according to the operator's experience (sensitivity 70.5-88.6%, accuracy 72.0-86.0%) and they were lower for the less-experienced operators than for the experienced radiologist. • The interobserver agreement was substantial for the final diagnosis and each US descriptor and moderate for the margin and composition.

Discrimination of HPV status using CT texture analysis: tumour heterogeneity in oropharyngeal squamous cell carcinomas.

PURPOSE: To evaluate the diagnostic performance of texture analysis for discriminating human papillomavirus (HPV) status in patients with oropharyngeal squamous cell carcinoma (OPSCC) in the primary tumours and metastatic lymph nodes. METHODS: Ninety-five patients with primary tumour and 91 with metastatic lymph nodes with confirmed HPV status, who underwent pretreatment contrast-enhanced CT (CECT), were included as the discovery population. CT texture analysis was performed using commercially available software. Differences between HPV-positive and HPV-negative groups were analysed using the χ2 test (or Mann-Whitney U test) and independent t test (or Fisher's exact test). ROC curve analysis was performed to discriminate HPV status according to heterogeneity parameters. Diagnostic accuracy was evaluated in the separate validation population (n = 36) from an outside hospital. RESULTS: HPV positivity was 52.6% for primary tumours and 56.0% for metastatic lymph nodes. The entropy and standard deviation (SD) values in the HPV-positive group were significantly lower. Entropy using the medium filter was the best discriminator between HPV-positive and HPV-negative primary OPSCCs (AUC, 0.85) and SD without the filter for metastatic lymph nodes (AUC, 0.82). Diagnostic accuracy of entropy for the primary tumour was 80.0% in the discovery group and 75.0% in the validation group. In cases of metastatic lymph node, the accuracy of SD was 79.1% and 78.8%, respectively. CONCLUSION: Significant differences were found in heterogeneity parameters from texture analysis of pretreatment CECT, according to HPV status. Texture analysis could be used as an adjunctive tool for diagnosis of HPV status in clinical practice.

US Fine-Needle Aspiration Biopsy for Thyroid Malignancy: Diagnostic Performance of Seven Society Guidelines Applied to 2000 Thyroid Nodules.

Purpose To compare the diagnostic performance of ultrasonography (US)-based fine-needle aspiration biopsy (FNAB) criteria from seven international societies in the detection of thyroid malignancy. Materials and Methods This study included a total of 2000 consecutive thyroid nodules (≥1 cm) in 1802 patients with final diagnoses from January 2010 to May 2011. US features of the thyroid nodules were retrospectively reviewed and were classified according to the categories defined by the seven international society guidelines. The diagnostic performance of US-based FNAB criteria in the detection of thyroid malignancy and unnecessary FNAB rates were calculated and compared by using a generalized estimating equation method. Results Of the 2000 thyroid nodules, 1546 (78.3%) were benign and 454 (22.7%) were malignant, with papillary carcinoma comprising 85.5% of all malignancies. The Korean Thyroid Association/Korean Society of Thyroid Radiology (KTA/KSThR) (94.5%), National Comprehensive Cancer Network (NCCN) (92.5%), and American Thyroid Association (ATA) (89.6%) guidelines were more sensitive than those of the American Association of Clinical Endocrinologists/American College of Endocrinology/Associazione Medici Endocrinologi (AACE/ACE/AME) (80.4%), American College of Radiology (ACR) (74.7%), French Society of Endocrinology (FSE) (72.7%), and Society of Radiology in Ultrasound (SRU) (70.9%) (P < .001), while the latter guidelines had higher specificity (P < .001). The rate of unnecessary FNAB was lowest with the ACR guidelines (25.3%), followed by the FSE (29.1%), AACE/ACE/AME (32.5%), SRU (45.2%), ATA (51.7%), NCCN (54.0%), and KTA/KSThR (56.9%) guidelines. Conclusion Because the diagnostic performance of US-based FNAB criteria varies according to the individual international society guidelines, clinicians should be aware of the strengths and weaknesses of US-based FNAB criteria in the management of thyroid nodules. © RSNA, 2018 Online supplemental material is available for this article.

Complications following ultrasound-guided core needle biopsy of thyroid nodules: a systematic review and meta-analysis.

OBJECTIVES: To identify the complication rate associated with US-guided core needle biopsy (CNB) of thyroid lesions using a systematic review and meta-analysis. METHODS: Ovid-MEDLINE and EMBASE databases were searched for studies on US-guided CNB of thyroid lesions from 1 January 1994-13 December 2016. A review of 393 potential papers identified 39 eligible papers including 14,818 patients. The pooled proportions of complications were assessed using random-effects modelling. Subgroup analysis was performed. Among-study heterogeneity was explored using χ2 statistic for pooled estimates and inconsistency index I2. Quality of the studies was evaluated using the Risk of Bias Assessment Tool for Nonrandomized Studies. RESULTS: The pooled proportion of overall complications after CNB of thyroid lesions was 1.11% (95% CI: 0.64-1.51, I2: 87.2%). The pooled proportion of major complications (0.06% [95% CI: 0.02-0.10], I2: 0.0%) was much lower than that of minor complications (1.08%[95% CI: 0.63-1.53], I2: 93.17%). Subgroup analysis revealed no significant differences between studies on Asian versus non-Asian groups (p=0.7769), radiologist versus non-radiologist groups (p=0.8607), nodule size <20 mm versus nodule size ≥20 mm (p=0.1591) groups, CNB versus CNB-plus-FNA groups (p=0.9281) and studies performed before and after 2012 (p=0.6251). The overall quality of the included studies was moderate with all of the studies satisfying five or more of the eight total domains. CONCLUSION: Various complications can occur after US-guided CNB of thyroid lesions. However, the procedure is safe, with a low complication rate. KEY POINTS: • Various complications occurred after CNB of thyroid lesions, but the pooled complication rate was low (1.11%, I 2 = 87.2%). • The pooled proportion of major complications (0.06%) was much lower than that of minor complications (1.08%). • There was no significant differences between studies on Asian vs. non-Asian groups, radiologist vs. non-radiologist groups, nodule size <20 mm vs. nodule size ≥20 mm groups, CNB vs. CNB-plus-FNA groups, or studies performed before 2012 vs. after 2012.

Elevated central venous pressure is associated with increased mortality in pediatric septic shock patients.

BACKGROUND: Central venous pressure (CVP) is an important factor affecting capillary blood flow, and it is associated with poor outcomes in adult septic shock patients. However, whether a similar association exists in pediatric patients remains unclear. METHODS: We retrospectively analyzed data from patients admitted to our pediatric intensive care unit (PICU) between February 2009 and July 2015. Patients were divided into two groups-survivors and nonsurvivors-according to 28-day mortality. The associations between (a) mortality and CVP at 6, 24, 48, and 72 h after initiating treatment for established septic shock was analyzed and (b) initial serum lactic acid levels and 6-h CVP. RESULTS: Two hundred twenty-six patients were included in this study, and the mortality rate was 29.6% (67 deaths, nonsurvivor group). Initial serum lactic acid levels, Pediatric Risk of Mortality (PRISM) III score, and Vasoactive-Inotropic Score (VIS) within 24 h after PICU admission were significantly higher in the nonsurvivors than in survivors (1.3 [0.9, 2.4] vs. 3.9 [1.6, 8.0] mmol/l, 11.0 [7.0, 15.0] vs. 17.0 [10.0, 21.5], 12.0 [7.0, 25.0] vs. 22.5 [8.0, 55.0], respectively with p-values < 0.001, < 0.001, and 0.009, respectively). In addition, compared to survivors, a greater percentage of nonsurvivors required mechanical ventilation (92.5% vs. 51.6%, p <  0.001) and showed a greater extent of fluid overload at 48 h after admission (3.9% vs. 1.9%, p = 0.006), along with higher 6-h CVP (10.0 [7.0, 16.0] vs. 8.0 [5.0, 11.0] mmHg, p <  0.001). Patient survival according to levels of CVP (CVP < 8 mmHg, CVP 8-12 mmHg, or CVP > 12 mmHg) showed that the CVP > 12-mmHg group had significantly greater mortality rates (50.0%, p = 0.002) than the other groups (21.3% and 27.5%). Furthermore, multivariate analysis identified significant associations of CVP > 12 mmHg, serum lactic acid levels, and the need for mechanical ventilation with mortality (OR: 2.74, 1.30, and 12.51, respectively; 95% CI: 1.11-6.72, 1.12-1.50, and 4.12-37.96, respectively). CONCLUSIONS: Elevated CVP is an independent risk factor for mortality in pediatric septic shock patients.

A rapid nuclear staining test using cationic dyes contributes to efficient STR analysis of telogen hair roots.

Telogen hairs presented in the crime scene are commonly encountered as trace evidence. However, short tandem repeat (STR) profiling of the hairs currently have low and limited use due to poor success rate. To increase the success rate of STR profiling of telogen hairs, we developed a rapid and cost-effective method to estimate the number of nuclei in the hair roots. Five cationic dyes, Methyl green (MG), Harris hematoxylin (HH), Methylene blue (MB), Toluidine blue (TB), and Safranin O (SO) were evaluated in this study. We conducted a screening test based on microscopy and the percentage of loss with nuclear DNA, in order to select the best dye. MG was selected based on its specific nuclei staining and low adverse effect on the hair-associated nuclear DNA. We examined 330 scalp and 100 pubic telogen hairs with MG. Stained hairs were classified into five groups and analyzed by STR. The fast staining method revealed 70% (head hair) and 33.4% (pubic hair) of full (30 alleles) and high partial (18-29 alleles) STR profiling proportion from the lowest nuclei count group (one to ten nuclei). The results of this study demonstrated a rapid, specific, nondestructive, and high yield DNA profiling method applicable for screening telogen hairs.

The effectiveness of anti-biofilm and anti-virulence properties of dihydrocelastrol and dihydrocelastryl diacetate in fighting against methicillin-resistant Staphylococcus aureus.

Human pathogens have readily been converted into multidrug-resistant pathogens, such as methicillin-resistant Staphylococcus aureus (MRSA), because of the long-term use of conventional antibiotics. In addition, the biofilms formed by S. aureus cells are especially problematic and are related to the persistence of chronic infections because they constitute a major mechanism of promoting tolerance to diverse antimicrobial agents. Hence, the inhibitions of biofilm formation and/or toxin production are accepted as alternative means of controlling S. aureus infections. The present study was aimed at identifying novel anti-biofilm and/or anti-virulence compounds in friedelane-based pentacyclic triterpenoids present in many edible and medicinal plants-and investigating them against MRSA strains. As a result, dihydrocelastrol and dihydrocelastryl diacetate were found to both inhibit the biofilm formation of, and to disrupt the preformed biofilms of, MRSA strains to an increasingly greater degree with increasing concentrations of each compound. Furthermore, these two triterpenoids also clearly inhibited the hemolytic activity of MRSA-and in-line with their anti-biofilm activities, rendered the cell more hydrophilic. Additionally, corroborating phenotypic results, transcriptional analyses showed that both dihydrocelastrol and dihydrocelastryl diacetate disturbed the expression of gene related to α-hemolysin (hla) and down-regulated the expressions of the crucial biofilm-associated genes (agrA, sarA, ica, RNAIII, and rbf) in MRSA. The findings of this study suggest that friedelane-based pentacyclic triterpenoids-especially dihydrocelastrol and dihydrocelastryl diacetate-have the potential to be candidates both for use in controlling biofilm-related infections and for use as important components of anti-virulence strategies for fighting against MRSA infection.

Complications following US-guided core-needle biopsy for thyroid lesions: a retrospective study of 6,169 consecutive patients with 6,687 thyroid nodules.

OBJECTIVES: To present the various complications of ultrasound (US)-guided core needle biopsy (CNB) of thyroid lesions in a large patient series. METHODS: From January 2008 to March 2013, 6,169 patients underwent US-guided CNB of 6,687 thyroid nodules at a single institution. We assessed the number and types of major and minor complications, and evaluated the factors associated with complications. RESULTS: Overall, 53 complications were observed in 50 patients (0.81 %), including 4 major and 49 minor complications. The major complications were massive haematoma (n = 2), pseudoaneurysm (n = 1) and voice change leading to disability that lasted for more than 30 days (n = 1). The minor complications were small to moderate haematoma (n = 42), carotid injury (n = 2), voice change that recovered within 30 days (n = 3), tracheal puncture (n = 1) and dysphagia (n = 1). Oedema (n = 12), vertebral puncture (n = 3) and vasovagal reaction (n = 1) were recorded as side effects. The presence of a coprocedure was the only significant factor associated with complications after thyroid CNB (P = 0.023). CONCLUSIONS: US-guided CNB of thyroid lesions was found in a large population to be a safe procedure with a low complication rate. KEY POINTS: • The complication rate after US-guided CNB for thyroid lesions was 0.81 % (50/6,169). • The rate of major complications was 0.06 % (4/6,169). • Vascular injury was the most common complication (47/6,169; 0.76 %). • None of the patients experienced permanent problems resulting from complications.

Factors Associated With Mortality in Continuous Renal Replacement Therapy for Pediatric Patients With Acute Kidney Injury.

OBJECTIVES: To analyze the epidemiology of pediatric acute kidney injury requiring continuous renal replacement therapy and identify prognostic factors affecting mortality rates. DESIGN: Retrospective analysis. SETTING: PICU of a tertiary medical center. PATIENTS: One hundred-twenty three children diagnosed with acute kidney injury requiring continuous renal replacement therapy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Vasoactive-Inotropic Score, arterial blood gas analysis, blood chemistry at continuous renal replacement therapy initiation, the extent of fluid overload 24 hours prior to continuous renal replacement therapy initiation, Pediatric Risk of Mortality III score at admission, and need for mechanical ventilation during continuous renal replacement therapy were compared in survivors and nonsurvivors. Out of 1,832 patient admissions, 185 patients (10.1%) developed acute kidney injury during the study period. Of these, 158 patients were treated with continuous renal replacement therapy, and finally, 123 patients were enrolled. Of the enrolled patients, 50 patients died, corresponding to a mortality rate of 40.6%. The survivor group and the nonsurvivor group were compared, and the following factors were associated with an increased risk of mortality: higher Pediatric Risk of Mortality III score at admission and Vasoactive-Inotropic Score when initiating continuous renal replacement therapy, increased fluid overload 24 hours before continuous renal replacement therapy initiation, and need for mechanical ventilation during continuous renal replacement therapy. The percentage of fluid overload difference between the survivors and the nonsurvivors was 1.2% ± 2.2% versus 4.1% ± 4.6%, respectively. Acidosis, elevated lactic acid and blood urea nitrogen, and lower serum creatinine level were laboratory parameters associated with increased mortality. On multivariate analysis, Vasoactive-Inotropic Score, need for mechanical ventilation, blood urea nitrogen, and creatinine level were statistically significant. (Odds ratio: 1.040, 6.096, 1.032, and 0.643, respectively.) CONCLUSIONS:: A higher Vasoactive-Inotropic Score, need for mechanical ventilation, elevated blood urea nitrogen, and lower creatinine level were associated with increased mortality in pediatric acute kidney injury patients who underwent continuous renal replacement therapy. Lower creatinine levels may be associated with increased mortality in the context of fluid overload, which is correlated with a reduced chance of survival.

Remarkable CT features of shock thyroid in traumatic and non-traumatic patients.

Shock thyroid is a part of the hypovolemic shock complex, which is a constellation of secondary computed tomographic (CT) findings that are observed in patients with hypovolemic shock. However, to the best of our knowledge, there has only been a single report on this condition, which described three cases associated with significant thoracoabdominal trauma. Here, we report four patients with profound hypotension who exhibited similar CT findings as those described in the initial report on shock thyroid, but with a more diverse clinical spectrum.

Initial clinical experience with BRAF(V600E) mutation analysis of core-needle biopsy specimens from thyroid nodules.

OBJECTIVE: The accurate diagnosis of thyroid nodules is important for making management decisions. The purpose of this study was to evaluate the feasibility of core-needle biopsy with BRAF(V600E) mutation analysis (CNB + BRAF(V600E) ) and to compare the clinical usefulness of CNB + BRAF(V600E) and fine-needle aspiration with BRAF(V600E) mutation analysis (FNA + BRAF(V600E) ) in the diagnosis of thyroid malignancy. DESIGN, PATIENTS AND MEASUREMENTS: The results of BRAF(V600E) mutation analyses of 820 nodules from 820 patients (153 men, 667 women; mean age, 51·1 years), who underwent CNB + BRAF(V600E) (n = 256) or FNA + BRAF(V600E) (n = 564) between January 2011 and March 2012 were retrospectively evaluated. The feasibility of CNB + BRAF(V600E) was assessed by comparing its rate of detection of BRAF(V600E) mutations and positive predictive value with those of FNA + BRAF(V600E) . The clinical usefulness of CNB + BRAF(V600E) was determined by comparing rates of inconclusive results, the additional value of BRAF(V600E) mutation analysis, diagnostic surgery and diagnostic performance with those of FNA + BRAF(V600E) . RESULTS: CNB + BRAF(V600E) and FNA + BRAF(V600E) had similar rates of BRAF(V600E) mutation detection (66·3% vs 64·4%, P = 0·883) and positive predictive value (100·0% vs 96·6%, P = 0·135). CNB + BRAF(V600E) had a significantly higher diagnostic accuracy rate (95·7% vs 85·9%, P < 0·001), and significantly lower rates of inconclusive results (8·2% vs 51·8%, P < 0·001), and diagnostic surgery (8·9% vs 22·3%, P = 0·006), than FNA + BRAF(V600E) . CONCLUSIONS: The greater diagnostic performance of CNB + BRAF(V600E) and its lower rate of inconclusive results than FNA + BRAF(V600E) suggest that CNB + BRAF(V600E) can reduce rates of preventable diagnostic surgery.

Core needle biopsy could reduce diagnostic surgery in patients with anaplastic thyroid cancer or thyroid lymphoma.

OBJECTIVE: To evaluate the diagnostic performance of fine needle aspiration (FNA) and core needle biopsy (CNB) in patients with anaplastic thyroid cancer (ATC) or thyroid lymphoma (TL). METHODS: Between January 2000 and March 2012, 104 patients were diagnosed with ATC or TL by means of ultrasound (US)-guided FNA, CNB, or surgery. This study ultimately included 99 patients with ATC (n = 59) or TL (n = 40). We evaluated the sensitivity and positive predictive value of FNA and CNB for the diagnosis of ATC and TL, and compared the rates of diagnostic surgery between FNA and CNB. RESULTS: FNA was used in 83 patients, and CNB was used in 32 patients initially (n = 16), after FNA results (n = 8), or simultaneously with FNA (n = 8). CNB achieved sensitivity of 87.5 % (28/32) and positive predictive value of 100.0 % (28/28) for the diagnosis of ATC and TL. The respective values for FNA were 50.6 % (40/79) and 90.9 % (40/44). The rate of diagnostic surgery was significantly lower after CNB (4/32, 12.5 %) than after FNA (28/79, 35.4 %) (p = 0.020). CONCLUSIONS: CNB was able to reduce unnecessary diagnostic surgery in patients with ATC or TL by virtue of its superior diagnostic sensitivity and positive predictive value compared to FNA. KEY POINTS: • Diagnostic sensitivity and PPV for CNB were 87.5 % and 100.0 %, respectively. • The respective values for FNA were 50.6 % and 91.0 % for ATC and TL. • Diagnostic surgery rates were reduced after CNB compared to FNA (p = 0.020).

Evaluation of Disseminated Intravascular Coagulation Scores in Critically Ill Pediatric Patients.

OBJECTIVES: Disseminated intravascular coagulation is a complex systemic thrombohemorrahgic disorder, which may contribute to organ failure. We aimed to compare the detection rate of the disseminated intravascular coagulation, early in the course of ICU admission, of the two disseminated intravascular coagulation scoring systems defined by International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine criteria and the prognostic value of disseminated intravascular coagulation scores in critically ill pediatric patients. DESIGN: Single-center retrospective observational study. SETTING: PICU in a tertiary care children's hospital. PATIENTS: Pediatric patients admitted in the PICU between January 2013 and December 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 191 patients were included. Among them, 15.7% and 29.8% of the patients were diagnosed with disseminated intravascular coagulation by International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine criteria, respectively. The diagnostic concordance rate between the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems was 52.6%. As the Pediatric Risk of Mortality III, the modified Sequential Organ Failure Assessment, and the Pediatric Multiple Organ Dysfunction Syndrome scores increased, the percentage of patients with disseminated intravascular coagulation increased stepwise. The disseminated intravascular coagulation scores correlated well with these severity scores. Overall, the 28-day mortality was 9.9%. There were significant differences in most variables consisting of the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems between survivor and nonsurvivors. Patients detected to have disseminated intravascular coagulation by the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems showed higher mortality than patients without disseminated intravascular coagulation. The areas under the receiver operating characteristic curve of the Japanese Association for Acute Medicine score and International Society on Thrombosis and Hemostasis score were 0.788 (95% CI, 0.675-0.900) and 0.716 (95% CI, 0.598-0.834), respectively. CONCLUSIONS: Both the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine scoring systems are useful for detection of the disseminated intravascular coagulation in critically ill pediatric patients. These scores correlate well with other severity scores, including Pediatric Risk of Mortality III, modified Sequential Organ Failure Assessment, and Pediatric Multiple Organ Dysfunction Syndrome. Disseminated intravascular coagulation scores are also significantly associated with 28-day mortality, suggesting that these could be promising prognostic factors.

Evaluation of Underlying Lymphocytic Thyroiditis With Histogram Analysis Using Grayscale Ultrasound Images.

OBJECTIVES: The purpose of this study was to evaluate diagnostic performance of histogram analysis using grayscale ultrasound (US) images in the diagnosis of lymphocytic thyroiditis. METHODS: Three radiologists reviewed a total of 505 US images and classified the images according to the presence/existence of lymphocytic thyroiditis. After 2 months, each reviewer repeated the process with the same 505 images in a randomly mixed order. The intraobserver and interobserver variability was analyzed with a generalized κ value. Four histogram parameters (mean value, standard deviation, skewness, and kurtosis) were obtained, and an index was calculated from principal component analysis. Diagnostic performances were compared. RESULTS: Of 505 patients, 125 (24.8%) had lymphocytic thyroiditis, and 380 (75.2%) had normal thyroid parenchyma on pathologic analysis. The κ value for intraobserver variance ranged from -0.002 to 0.781, and the overall κ values for interobserver variance were 0.570 and 0.214 in the first and second tests, respectively. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for the 3 reviewers versus the principal component analysis index were 28.0% to 83.2%, 43.7% to 82.6%, 53.5% to 79.0%, 24.6% to 56.2%, and 75.2% to 88.9% versus 58.4%, 72.4%, 68.9%, 41.0%, and 84.1%. CONCLUSIONS: Histogram analysis of grayscale US images provided confirmable and quantitative information about lymphocytic thyroiditis and was comparable with performers' assessments in diagnostic performance.