Relationships among Bone Metabolic Markers, Body Fat Composition and Carotid Intima-Media Thickness in Premenopausal Obese Women.

Osteocalcin (OC) is inversely related to body fat distribution and fasting glucose levels. We sought to observe the effect of OC on fat distribution and subclinical atherosclerosis as measured by carotid intima-media thickness (CIMT) in premenopausal obese women. In this prospective observational study, totally, 73 premenopausal obese women (aged 17-55 years) and 53 healthy women (aged 20-50 years) with normal weight were included as controls. Anthropometric measurements, total fat and fat ratio, insulin, fasting blood glucose, and OC levels were estimated. Ultrasonography was used to assess fat distribution, and fat thickness was measured in 4 regions. Subcutaneous fat (SCF), visceral fat (VF), and preperitoneal fat (PPF) thicknesses were considerably higher in obese subjects (p<0.01) than healthy controls, while OC levels were significantly lower. No correlation was observed between OC levels and SCF, VF, or PPF. In a multiple regression analysis, OC was significantly positively associated with SCF (p=0.04, Beta=0.284). No associations were observed between OC levels and VF, PPF, or CIMT. A significant association was observed between parathyroid hormone (PTH) and VF (p=0.021, Beta=0.284), and vitamin D levels were inversely associated with VF (p=0.002, r=-0.366). OC levels were lower in premenopausal obese women than normal-weight healthy controls, but OC exhibited no correlation with VF or PPF, and only a weak positive association with SCF. Additionally, VF was positively correlated with PTH and inversely correlated with vitamin D. These results suggest that OC may be an early indicator of lipid accumulation in te subcutaneous area and development of atherosclerosis.

Evaluation of the chest computed tomography and hemogram data in patients with COVID-19: the importance of thymus

Background/aim: To investigate the relationship between imaging findings and peripheral blood cell counts of COVID-19 patients and the degree of thymus fat involution of these patients. Materials and methods: Computed tomography (CT) images of 87 patients with COVID-19 positive through RT-PCR testing were evaluated retrospectively by two radiologists. Ground glass densities and other signs of viral pneumonia were recorded, lung involvement was scored quantitatively. The patients thymus fat involution was graded on CT. Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratios (PLR), lymphocyte and platelet counts were calculated. Imaging findings and degrees of thymus fat involution were compared with laboratory data. Results: Quantitative scoring of lung involvement was calculated at mean 6.63 ± 4.70 (1­23) for observer 1 and mean 6.55 ± 4.65 (1­23) for observer 2 (K = 0.824­1.000). Statistical significance was determined between the increase in age and the increase in scores of lung findings (p = 0.003). Lymphocyte count (p = 0.0001) and PLR (p = 0.001) were significantly lower in patients with severe CT involvement. A statistically significantcorrelation was found between increased thymus fat component and presence of COVID-19 lung involvement in CT (r = 0.461). Conclusion: The severity of imaging findings for COVID-19 patients significantly correlates with the degree of fat involution in patients' thymus tissue.

Diffusion-Weighted Imaging and Color Doppler Ultrasound in Evaluation of Partial Testicular Torsion in Rat Model.

BACKGROUND: To evaluate the utility of histogram analysis of apparent diffusion coefficient (ADC) in the diagnosis of incomplete testicular torsion. MATERIAL/METHODS: Fourteen Wistar albino rats were randomly allocated into two groups. In group 1 (control), left testicles were kept outside for 45 seconds and then replaced, whereas left testicles were twisted by 360° in group 2. Four hours later, DWI was performed. After that, magnetic resonance imaging (MRI) and testicular color Doppler ultrasound (CDU) were performed by two radiologists who looked for the presence or absence of blood flow. ADC measurements were carried out by two radiologists who were blinded to each other's measurements. After CDU, testes were surgically removed and a pathological examination was performed after four hours of torsion. Comparisons of minimum, mean, and maximum ADC values in testicles were performed with the Wilcoxon test. P value of 0.05 or less was considered as statistically significant. Inter-observer agreement was also analyzed. RESULTS: In the torsion group, minimum ADC values for left testicles were significantly lower than for the control group (p<0.05), regardless of the observer. Inter-observer agreement for measurements of ADCmin and ADCmax values was substantial, with an ICC score of 0.751 and 0.774, respectively (95% CI). Inter-observer agreement for the measurement of ADCmean value was excellent, with an ICC score of 0.844 (95% CI). The pathological examination revealed mild interstitial edema and closely packed seminiferous tubules in the left testes, indicating reversible damage in the torsion group. CONCLUSIONS: On the pathological examination, all left testes in the torsion group were recoverable after four hours of torsion. Minimum ADC values can be used as an auxiliary method in the diagnosis of partial testicular torsion. Comparing minimum ADC values between the affected and non-affected testicles can be a useful tool in the early diagnosis of incomplete testicular torsion.

Association of real-time sonoelastography findings with clinical parameters in lateral epicondylitis.

The objective of this study was to investigate the role of real-time sonoelastography (RTSE) in patients with lateral epicondylitis (LE) and whether it is associated with clinical parameters. Seventeen patients with unilateral LE were enrolled in the study. The healthy elbows of the participants constituted the control group. Using B-mode ultrasound, color Doppler ultrasound, and RTSE, we prospectively examined 34 common extensor tendon elbows of 17 patients. Both color scales and strain ratio were used for evaluating RTSE images. Two radiologists evaluated the RTSE images separately. Elbow pain was scored on a 100-mm visual analog scale (VAS). Symptom duration and the presence of nocturnal pain were questioned. Quick disabilities of arm shoulder and hand (DASH) Questionnaire was applied to assess the pain, function, and disability. Nottingham health profile (NHP) was used to determine and quantify perceived health problems. Both color scales and strain ratios of the affected tendon portions were significantly different from that of healthy tendons (p < 0.001). There was no significant association between NHP, VAS, Quick DASH scores, and color scales and strain ratio. Strain ratio of the medial portion of the affected tendon was significantly correlated with symptom duration (rho = -0.61 p = 0.010) and nocturnal pain (rho = 0.522 p = 0.031). Interobserver agreement was substantial for color scales (κ = 0.74, p = 0.001) and strain ratio (ICC = 0.61, p = 0.031). RTSE may facilitate differentiation between healthy and affected elbows as a feasible and practical supplementary method with substantial interobserver agreement. RTSE was superior to B-mode ultrasound and color Doppler ultrasound in discriminating tendons with LE. Strain ratio of the medial portion of the tendon is associated moderately with nocturnal pain and symptom duration. No other associations were present between RTSE findings and clinical or functional parameters.

Role of Strain Elastography in the Evaluation of Testicular Torsion: An Experimental Study.

OBJECTIVES: To evaluate the utility of real-time strain elastography in experimentally induced testicular torsion at different degrees and torsion hours. METHODS: Thirty-one Wistar albino rats were divided into 4 torsion groups by twisting left testes (group I, sham operated; group II, 360°; group III, 720°; and group IV, 1080°). Elastography was applied at the 8th and 24th hours of torsion. Elasticity patterns (pattern 1, soft testis; pattern 2, moderately soft testis; pattern 3, predominantly hard testis; and pattern 4, almost entirely hard testis) and strain ratios were recorded. Histopathologic evaluation was done at the 24th hour. Interobserver agreement was analyzed. RESULTS: Changes in elastographic patterns and strain ratios among groups II, III, and IV were statistically significant at both hours as determined by both radiologists (P < .01). Elastographic patterns changed from 2 to 3 in groups II and III to 4 in group III between the 8th and 24th hours (P < .05), but in group IV, patterns were reversed, and pattern 1 was observed at both hours. Pathologically severe necrosis (grade 4) was seen in left testes in group IV. In the other groups, pathologic grading in the left testes was as follows: mostly grade 1 in groups I and II and mostly grade 2 in group III. Elastography showed that right testes were affected in group IV, with significant differences in elastographic patterns and strain ratios (P < .01). Interobserver agreement for elastographic patterns in right testes was substantial at the 8th hour (κ = 0.72) and otherwise excellent (κ = 0.81-0.85). Concordance of strain ratios between observers was excellent for right and left testes at the 8th and 24th hours (intraclass correlation coefficients, 0.990 at the 8th hour and 0.987 at the 24th hour). CONCLUSIONS: Our results show that real-time strain elastography can be a complementary method in the evaluation of testicular tissue in testicular torsion and can guide surgeons in their surgical approach.

Pylephlebitis Complicating Acute Appendicitis: Prompt Diagnosis with Contrast-Enhanced Computed Tomography.

BACKGROUND: Pylephlebitis, a rare complication of abdominal infections, is a septic thrombophlebitis of the portal venous system with high rates of morbidity and mortality. CASE REPORT: We present a case of pylephlebitis complicating acute appendicitis and report the utility of a computed tomography scan in the diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The prompt diagnosis and appropriate treatment of pylephlebitis are crucial to reduce morbidity and mortality, but clinical presentation is often nonspecific. A computed tomography scan is instrumental in the early diagnosis of pylephlebitis because it readily reveals the thrombus in the mesenteric or portal vein in the setting of acute appendicitis. Early and aggressive treatment with broad-spectrum antibiotics is necessary, and anticoagulation therapy can also be used to prevent bowel ischemia.

Evaluation of Free Breathing Versus Breath Hold Diffusion Weighted Imaging in Terms Apparent Diffusion Coefficient (ADC) and Signal-to-Noise Ratio (SNR) Values for Solid Abdominal Organs.

BACKGROUND: Our aim was to compare the apparent diffusion coefficient (ADC) values of normal abdominal parenchymal organs and signal-to-noise ratio (SNR) measurements in the same patients with breath hold (BH) and free breathing (FB) diffusion weighted imaging (DWI). MATERIAL/METHODS: Forty-eight patients underwent both BH and FB DWI. Spherical region of interest (ROI) was placed on the right hepatic lobe, spleen, pancreas, and renal cortices. ADC values were calculated for each organ on each sequence using an automated software. Image noise, defined as the standard deviation (SD) of the signal intensities in the most artifact-free area of the image background was measured by placing the largest possible ROI on either the left or the right side of the body outside the object in the recorded field of view. SNR was calculated using the formula: SNR=signal intensity (SI)(organ)/standard deviation (SD)(noise). RESULTS: There were no statistically significant differences in ADC values of the abdominal organs between BH and FB DWI sequences (p>0.05). There were statistically significant differences between SNR values of organs on BH and FB DWIs. SNRs were found to be better on FB DWI than BH DWI (p<0.001). CONCLUSIONS: Free breathing DWI technique reduces image noise and increases SNR for abdominal examinations. Free breathing technique is therefore preferable to BH DWI in the evaluation of abdominal organs by DWI.

CT of Hepatic Sarcoidosis: Small Nodular Lesions Simulating Metastatic Disease.

BACKGROUND: Sarcoidosis is a multisystemic inflammatory disease of unknown origin. The lymphoid system and the lungs are the most commonly involved organs. The frequency of signs or symptoms of hepatic involvement is very low. CASE REPORT: We present a case of symptomatic granulomatous liver disease secondary to sarcoidosis, mimicking a metastatic disease on ultrasonography and CT. CONCLUSIONS: Hepatic involvement in sarcoidosis might be a perplexing diagnostic problem. The decisive CT finding with respect to the differential diagnosis was the absence of a mass effect and intact vascular architecture around the lesions.

Inflammatory Myofibroblastic Tumor of the Lung: Unusual Imaging Findings of Three Cases.

BACKGROUND: Inflammatory myofibroblastic tumor (IMT), also known as inflammatory pseudotumor, is a benign disorder composed of fibrous tissues, myofibroblasts and inflammatory cell proliferation with obscure etiology. Although it is the most common lung tumor in children, it is seen rarely in adults constituting less than 1% of adult lung tumors. CASE REPORTS: In this report, we present different and rare CT manifestations of three adult patients with lung IMT. CONCLUSIONS: In conclusion, IMT is a rare lung tumor in adults and may simulate malignancy. It should be considered in the differential diagnosis when a large mass with lobulated contour or harboring coarse calcification is observed.

The value of multimodal ultrasonography in the evaluation of late presenting testicular torsion in a rat experimental model.

OBJECTIVE: To evaluate the value of multimodal ultrasonography (US) in a rat experimental torsion model after 6 h of torsion with different degrees. METHODS: Twenty-one male rats were divided into three groups. Left testes of the rats were twisted around their vascular pedicle 360 degrees in group 1, 720 degrees in group 2, and 1080 degrees in group 3 and intact right testes of the rats were accepted as control group. Grey-scale US, superb microvascular imaging (SMI), colour Doppler ultrasonography (CDUS), strain elastography (SE), and two-dimensional (2-D) shear wave elastography (SWE) examinations were applied 6 h after torsion procedure and testes were removed for pathological evaluation. RESULTS: Short-axis dimensions and volumes of the torsion side were higher than control testes. Lengths of the testes in the 3rd torsion group were smaller than the testes in groups 1 and 2 (P < 0.002). SMI was better than CDUS in recognizing blood flow in testicular tissue. Strain ratios were higher in group 1 and decreased with the increasing torsion degree. Emean and standard deviation (SD) measurements increased in the torsion side. Pathologically the mean testicular damage scores were statistically significant between torsion and control testes in all groups. CONCLUSION: Our results showed that short-axis and volume measurements, SMI, 2D-SWE, and SE are effective in the evaluation and diagnosis of testicular torsion (TT). ADVANCES IN KNOWLEDGE: Evaluation of affected testis and intact testis with multiparametric US in late presenting TT cases is more reliable than being dependent on a single sonographic modality.

Pancreatic injury due to blunt trauma on CT: does retropancreatic fat tissue reduce the severity of pancreatic injury?

BACKGROUND: Pancreatic injuries from blunt abdominal trauma have a high mortality rate, often accompanied by injuries to adjacent organs. This study aims to investigate the relationship between the size of retropancreatic adipose tissue and the severity of pancreatic and adjacent organ injuries in patients with pancreatic trauma. METHODS: We retrospectively screened computed tomography (CT) images of 34 patients (25 males, nine females, aged 13-69 years) and 34 controls (28 males, six females, aged 15-66 years) who suffered blunt abdominal trauma. The area of adipose tissue located posterior to the pancreatic body was measured in the axial plane for all subjects. The severity of pancreatic injury was assessed in terms of the injury site, the retropancreatic adipose tissue area, and the degree of other organ injuries. RESULTS: Pancreatic injuries were located in the head for 16 patients (23.5%), in the body for four patients (5.9%), and in the tail for 14 patients (20.6%). The retropancreatic fat area was found to be significantly smaller in patients with pancreatic trauma compared to controls (p<0.0001). Furthermore, the ratio of the retropancreatic fat area to the vertebral corpus area differed significantly between patients with and without pancreatic injuries (p=0.014). CONCLUSION: Retropancreatic adipose tissue protects the pancreatic body from the impacts of blunt abdominal trauma. An increased amount of retropancreatic adipose tissue is associated with a reduced rate of pancreatic injury.

Evaluation of abdominal computed tomography findings in patients with COVID-19: a multicenter study

PURPOSE: To evaluate the frequency of abdominal computed tomography (CT) findings in patients with coronavirus disease-2019 (COVID-19) and interrogate the relationship between abdominal CT findings and patient demographic features, clinical findings, and laboratory test results as well as the CT atherosclerosis score in the abdominal aorta. METHODS: This study was designed as a multicenter retrospective study. The abdominal CT findings of 1.181 patients with positive abdominal symptoms from 26 tertiary medical centers with a positive polymerase chain-reaction test for severe acute respiratory syndrome coronavirus 2 were reviewed. The frequency of ischemic and non-ischemic CT findings as well as the association between CT findings, clinical features, and abdominal aortic calcific atherosclerosis score (AA-CAS) were recorded. RESULTS: Ischemic and non-ischemic abdominal CT findings were detected in 240 (20.3%) and 328 (27.7%) patients, respectively. In 147 patients (12.4%), intra-abdominal malignancy was present. The most frequent ischemic abdominal CT findings were bowel wall thickening (n = 120; 10.2%) and perivascular infiltration (n = 40; 3.4%). As for non-ischemic findings, colitis (n = 91; 7.7%) and small bowel inflammation (n = 73; 6.2%) constituted the most frequent disease processes. The duration of hospital stay was found to be higher in patients with abdominal CT findings than in patients without any positive findings (13.8 ± 13 vs. 10.4 ± 12.8 days, P < 0.001). The frequency of abdominal CT findings was significantly higher in patients who did not survive the infection than in patients who were discharged after recovery (41.7% vs. 27.4%, P < 0.001). Increased AA-CAS was found to be associated with a higher risk of ischemic conditions in abdominal CT examinations. CONCLUSION: Abdominal symptoms in patients with COVID-19 are usually associated with positive CT findings. The presence of ischemic findings on CT correlates with poor COVID-19 outcomes. A high AA-CAS is associated with abdominal ischemic findings in patients with COVID-19.

A Hypertrophic Spinal Pachymeningitis Patient With Factor V Leiden (G1691A), MTHFR C677T, MTHFR A1298C, PAI-1 4G-5G, Glycoprotein IIIa L33P Gene Mutations.

Hypertrophic pachymeningitis (HP) is a rare clinical entity of diverse etiology, characterized by a chronic inflammation that causes dura thickening. Reports of Idiopathic hypertrophic cranial pachymeningitis (IHCP) were related to infections, trauma, tumors, and rheumatologic conditions. It was first described by Charcot and Joffroy regarding spinal meninges in 1869. HP has three stages; progressive radicular symptoms begin first, then muscle weakness and atrophy start. Findings such as paraplegia, loss of bladder and bowel control, and respiratory distress caused by intercostal and diaphragmatic denervation are considered the third stage of the disease. Especially in the cranial form of the disease, nerve ischemia and various cranial neuropathic findings may occur. Factor V Leiden (G1691A), MTHFR C677T, MTHFR A1298C, and PAI-1 4G-5G gene mutation analysis were measured with an ABI Prism. In this case report, the authors present a case of hypertrophic mutations pachymeningitis with Factor V Leiden (G1691A), MTHFR C677T, MTHFR A1298C, PAI-1 4G-5G, Glycoprotein IIIa L33P gene. In conclusion, we report a case of HP with Factor V Leiden (G1691A), MTHFR C677T, MTHFR A1298C, PAI-1 4G-5G, and Glycoprotein IIIa L33P gene mutations. We emphasize that the identification of pachymeningitis can be easily bypassed with the application of limited laboratory techniques. As in this case report, we think that these mutations should be analyzed in patients diagnosed with pachymeningitis.

The Effect of Continuing Chemotherapy after Chemoradiotherapy during the Time to Surgery on Tumor Response and Survival for Local Advanced Rectal Cancer.

Aim: The current standard treatment of locally advanced rectal carcinoma is total mesorectal excision and postoperative adjuvant chemotherapy after neoadjuvant concurrent chemoradiotherapy (NCRT). Many studies have shown that pathological complete response (pCR) is an important prognostic factor for patients receiving NCRT. Many studies have therefore been conducted to increase pCR rates by changing the perioperative treatment strategies. Prolonging the chemotherapy time may be a reasonable way to increase the effectiveness of NCRT, pCR, and survival rates. We investigated whether neoadjuvant consolidation chemotherapy had an effect on tumor response and survival. Methods: The data of 163 patients diagnosed with locally advanced rectal carcinoma were evaluated. The data of 107 patients (Group 1) who were radiologically T3-T4 and/or N+ and received chemotherapy after NCRT until their operations were compared with the data of 56 patients (Group 2) who were operated after NCRT. Results: Group 1 patients had tumor and node downstaging. Their pCR was found significantly higher than in Group 2 (p = 0.005). In Group 1 patients with T3, pCR was significantly higher than for those with T4. The elapsed time between NCRT and surgery was significantly longer in patients with pCR (respectively, p = 0.012 and p = 0.008). Conclusion: Neoadjuvant consolidation chemotherapy after NCRT is a safe approach that can lead to higher pathological complete response rates. The time until surgery with neoadjuvant consolidation chemotherapy may provide the chance to follow the patient without surgery in addition to increasing pCR.

Diagnostic Performance of Radiology Residents in Thoracic CT Imaging in Emergency Radiology During The COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, the workload of all radiologists and radiology residents, as well as other clinical physicians, has increased. INTRODUCTION: This study aims to determine the diagnostic performance of radiology residents, who effectively contribute to the diagnosis of COVID-19. METHODS: The thoracic Computed Tomography (CT) images of 135 patients aged 20-83 diagnosed with COVID-19 were evaluated retrospectively by five radiology residents and a radiologist with 10 years of experience. The diagnostic performance of the radiology residents in evaluating COVID-19 was assessed according to their year of residency and the patients' age and gender. Receiver Operating Characteristic (ROC) curve analysis was performed to determine the sensitivity and specificity of radiology residents. RESULTS: The radiology residents' performance in determining COVID-19 using CT findings was evaluated as follows: sensitivity 97.22%, specificity 88.89%, positive predictive value 90.91%, negative predictive value 96.55%, and accuracy 93.33%. According to the year of residency, the sensitivity and specificity of the radiology residents in determining COVID-19 using CT images were between 92.3% and 100%, and 71.43% and 100%, respectively. CONCLUSION: The high sensitivity and specificity of radiology residents in evaluating thoracic CT images for COVID-19 diagnosis indicate that radiologists are as important as clinical physicians in the diagnosis of COVID-19.

Efficiency of Fat Suppression in T1-Weighted Inner Ear Magnetic Resonance Imaging: Multipoint Dixon Method Versus Hybrid Techniques.

BACKGROUND: Temporal bone is a region where fat suppression is difficult due to the inhomogeneity of various structures with different molecular properties. INTRODUCTION: We aimed to determine the most effective fat suppression sequence in order to increase the visibility of the inner ear region. MATERIALS AND METHODS: The hybrid techniques and T1-Weighted mDIXON images of 40 patients with Magnetic Resonance (MR) imaging of the inner ear were prospectively compared by two experienced radiologists in terms of fat suppression efficacy. In all fat-suppressed sequences, the Signal to Noise Ratio (SNR), the spinal cord signal intensity / mean fat signal intensity ratio and spinal cord signal to noise ratio were calculated. The suppression efficacy of MR techniques for fat areas in the inner ear was visually graded. RESULTS: Qualitative assessment of image quality due to fat suppression in the inner ear was made; the Dixon technique performed significantly better than SPAIR and SPIR techniques (p<0.0001). The mean signal intensity of the inner ear fat and SNR for the Dixon technique were significantly lower than that for SPIR and SPAIR techniques (p<0.0001). Inter-observer agreement regarding the assessment of the inner ear fat, mean signal intensity values and mean SNR values for fat suppression techniques was significant. CONCLUSION: The Dixon technique exhibited higher image quality and fat suppression efficiency than the hybrid techniques in the MR imaging of the inner ear.

Diagnosis of Sarcopenia in Head and Neck Computed Tomography: Cervical Muscle Mass as a Strong Indicator of Sarcopenia.

OBJECTIVES: Patients with head and neck cancer (HNC) have a high risk of sarcopenia, which is associated with poor prognosis. Skeletal-muscle area and index at the third lumbar (L3) vertebra level (L3MA and L3MI) are recommended for the detection of sarcopenia. However, L3 level is not included in many imaging protocols and there are no data for optimal levels and cutoffs for the diagnosis of sarcopenia in head and neck computed tomography (HNCT) scans. Our aim was to assess the relationship between cervical paravertebral muscle values and L3MI and to investigate optimal level to diagnose sarcopenia on HNCTs. METHODS: Patients with HNC (n=159) who underwent positron emission tomography-CT for tumor staging were retrospectively analyzed. On CT images, paravertebral and sternocleidomastoid muscle areas at second (C2), third (C3), and fourth (C4) cervical vertebrae levels (C2MA, C3MA, C4MA, SCMA) and L3MA were measured. Cross-sectional areas were normalized for stature (muscle area/height square) and muscle index (C2MI, C3MI, C4MI, SCMI, L3MI) values were obtained. Spearman correlation and linear regression analyses were used for assessing correlations. To calculate the diagnostic performance of SCMI, C2MI, C3MI, and C4MI for the diagnosis of sarcopenia with respect to the cutoffs of L3MI, receiver operating characteristic (ROC) analysis was used. RESULTS: Males had significantly higher muscle areas than females. Although C2MI, C3MI, C4MI, and SCMI values all showed very strong and significant correlation with L3MI (P<0.001). According to the ROC analysis, the best discriminative for sarcopenia was C3MI in males (area under curve [AUC], 0.967) and SCMI in females (AUC, 0.898). CONCLUSION: C2MI, C3MI, C4MI, and SCMI values can be used as alternatives for the diagnosis of sarcopenia in routine HNCT examinations.