Should there be a paradigm shift for the evaluation of isthmic thyroid nodules?

PURPOSE: Although the thyroid isthmus seems like a rudimentary structure that connects bilateral lobes, it is an undiscovered area that needs to be explored. Currently, the data is evolving that the increase in the risk of malignancy is higher in the isthmic nodules, and extrathyroidal extensions and lymph node metastases are more common in isthmic-derived malignant thyroid nodules. Therefore, we aimed to compare the malignancy rate of isthmic and lobar nodules, the ultrasonographic features of isthmic and lobar nodules, and presence of lymph node metastases, distant metastases, and extrathyroidal invasions in malignant isthmic nodules. METHODS: In this retrospective study, we enrolled patients between the ages of 18-80 years, who had thyroid nodule/nodules cytology and/or pathology results from January 2009 to November 2022. 9504 nodules were selected for the analysis of US findings, cytopathology results, and malignancy rates. RESULTS: A mean ± SD age of 55.3 ± 13.0 years with a female to male ratio of [7618 (80.2%)/1886(19.8%)] were included in the study. 962 of the nodules were at isthmic localization; whereas 8542 nodules were at lobar localization. 1188 nodules were resulted as malignant from histopathological evaluation. Of the 1188 malignant nodules, 986 nodules were (83.0%) PTC, 114 nodules (9.6%) were FTC, 55 nodules were (4.6%) MTC, 16 nodules 1.3% were Hurtle cell carcinoma, 8 nodules (0.7%) were anaplastic thyroid carcinoma, and 9 nodules (0.8%) were thyroid tumors of uncertain malignant potential (TT-UMP). 156 of the malignant nodules (13.1%) were located in the isthmus, whereas the majority of the malignant nodules (n = 1032, 86.9%) were located at the lobar parts (right or left) of the thyroid. When the metastasis patterns of isthmic and lobar thyroid cancers were examined, no significant relationship was found between isthmic and lobar cancers in terms of capsule invasion (p = 0.435), muscle invasion (p = 0.294), and lymph node metastasis (p = 0.633). A significant relation was found between nodule localization (isthmus-upper-middle and lower lobes) and malignancy (p < 0.001). In our logistic regression analysis, isthmic and upper pole nodule localizations, age and TI-RADS were evaluated as independent risk factors for malignancy (p < 0.001 for all factors). CONCLUSION: We recommend nodule localization has to be considered an additional risk factor when performing a Fine Needle Aspiration Biopsy for the increased malignancy risk in this localization.

Short-Course Radiotherapy Followed by Consolidation Chemotherapy Is Safe and Effective in Locally Advanced Rectal Cancer: Comparative Short-term Results of Multicenter Propensity Score Case-Matched Study.

BACKGROUND: Consolidation chemotherapy strategies have demonstrated improved pathological complete response and tumor downstaging rates for patients diagnosed with rectal cancer. OBJECTIVE: This study aimed to compare perioperative outcomes and pathological complete response rates among different neoadjuvant treatment strategies in patients undergoing total mesorectal excision for locally advanced rectal cancer. DESIGN: Propensity score case-matched study. SETTING: High-volume tertiary care centers. PATIENTS: Consecutive patients undergoing curative total mesorectal excision between January 2014 and June 2021 were queried. INTERVENTIONS: Patients were divided into 3 groups: long-course chemoradiation therapy with (N = 128) or without (N = 164) consolidation chemotherapy or short-course radiotherapy (N = 53) followed by consolidation chemotherapy. MAIN OUTCOME MEASURES: Demographics, preoperative tumor characteristics, histopathologic outcomes, and postoperative complication rates were reviewed and compared. Propensity score match analysis was conducted. RESULTS: A total of 345 patients (mean age: 58 ± 12 years; female: 36%) met the study inclusion criteria. Time interval from neoadjuvant treatment until surgery was longer for patients receiving consolidation chemotherapy ( p < 0.001). Pathological complete response rates were comparable among patients receiving long-course chemoradiation therapy (20.3%) and short-course radiotherapy with consolidation chemotherapy (20.8%) compared to long-course chemoradiation therapy alone (14.6%) ( p = 0.36). After the propensity score case-matched analysis, 48 patients in the long-course chemoradiation therapy with consolidation chemotherapy group were matched to 48 patients in the short-course radiotherapy with consolidation chemotherapy group. Groups were comparable with respect to age, sex, clinical stage, tumor location, type of surgical approach, and technique. Pathological complete response rate was comparable between the groups (20.8% and 18.8%, p = 0.99). LIMITATIONS: Study was limited by its retrospective nature. CONCLUSIONS: Among recent neoadjuvant treatment modalities, pathological complete response rates, and short-term clinical outcomes were comparable. Short-course radiotherapy with consolidation chemotherapy is safe and effective as long-course chemoradiation therapy as in a short-term period. See Video Abstract at http://links.lww.com/DCR/C174 . LA RADIOTERAPIA DE CORTA DURACIN SEGUIDA DE QUIMIOTERAPIA DE CONSOLIDACIN ES SEGURA Y EFICAZ EN EL CNCER DE RECTO LOCALMENTE AVANZADO RESULTADOS COMPARATIVOS A CORTO PLAZO DEL ESTUDIO MULTICNTRICO DE CASOS EMPAREJADOS POR PUNTAJE DE PROPENSION: ANTECEDENTES: Las estrategias de quimioterapia de consolidación han demostrado una mejor respuesta patológica completa y tasas de reducción del estadio del tumor para pacientes diagnosticados con cáncer de recto.OBJETIVO: Comparar los resultados perioperatorios y las tasas de respuesta patológica completa entre diferentes estrategias de tratamiento neoadyuvante en pacientes sometidos a escisión mesorrectal total por cáncer de recto localmente avanzado.DISEÑO: Estudio de casos emparejados por puntaje de propensión.ENTORNO CLINICO: Centros de atención terciaria de alto volumen.PACIENTES: Pacientes consecutivos sometidos a escisión mesorrectal total curativa por cáncer de recto localmente avanzado entre enero de 2014 y junio de 2021.INTERVENCIONES: Los pacientes se dividieron en tres grupos según la modalidad de tratamiento neoadyuvante: quimiorradioterapia de ciclo largo con (N = 128) o sin (N = 164) quimioterapia de consolidación o radioterapia de ciclo corto (N = 53) seguida de quimioterapia de consolidación.PRINCIPALES MEDIDAS DE RESULTADO: El punto final primario fue la respuesta patológica completa. Se revisaron y compararon los datos demográficos, las características preoperatorias del tumor, los resultados histopatológicos y las tasas de complicaciones posoperatorias entre los grupos de estudio. Se realizó un análisis de casos emparejados por puntaje de propensión.RESULTADOS: Un total de 345 pacientes (edad media de 58 ± 12 años y mujeres: 36%) cumplieron los criterios de inclusión del estudio. El intervalo de tiempo desde el tratamiento neoadyuvante hasta la cirugía fue mayor para los pacientes que recibieron quimioterapia de consolidación ( p < 0,001). Las tasas de respuesta patológica completa fueron comparables entre los pacientes que recibieron quimiorradioterapia de larga duración con quimioterapia de consolidación (20,3 %) y radioterapia de corta duración con quimioterapia de consolidación (20,8%) en comparación con la quimiorradiación de larga duración sola (14,6%) ( p = 0,36). Después del análisis de casos emparejados por puntaje de propensión, 48 pacientes en el grupo de quimiorradioterapia de ciclo largo con quimioterapia de consolidación se emparejaron con 48 pacientes en el grupo de radioterapia de ciclo corto con quimioterapia de consolidación. Los grupos fueron comparables con respecto a la edad, sexo, estadio clínico, ubicación del tumor, tipo de abordaje quirúrgico y la técnica. La tasa de respuesta patológica completa fue comparable entre los grupos (20,8% y 18,8%, p = 0,99). La morbilidad postoperatoria a los 30 días y las tasas de fuga anastomótica fueron similares.LIMITACIONES: El estudio estuvo limitado por su naturaleza retrospectiva.CONCLUSIONES: Entre las modalidades de tratamiento neoadyuvante recientes, las tasas de respuesta patológica completa y los resultados clínicos a corto plazo fueron comparables. La radioterapia de corta duración con quimioterapia de consolidación es segura y eficaz como terapia de quimiorradioterapia de larga duración en un período corto. Consulte Video Resumen en http://links.lww.com/DCR/C174 . (Traducción-Dr. Fidel Ruiz Healy ).

Lumbrical muscle enhancement on MRI and its association with rheumatoid arthritis.

OBJECTIVE: To investigate the significance of lumbrical muscle enhancement (LME) on magnetic resonance imaging (MRI) in rheumatoid arthritis (RA). MATERIALS AND METHODS: Blinded to the diagnoses, contrast-enhanced bilateral hand MRIs of patients with suspected early RA between 2014 and 2019 were reviewed by two observers for the presence and degree (weak/strong) of LME. The presence of other inflammatory findings was also noted. The patients were then stratified into RA (n = 41), control (n = 31), and other arthritides groups(n = 28) based on their final diagnoses in the hospital records within the following 12 months. Categorical variables were compared by chi-square test or Fisher's exact test. Differences among the groups were evaluated by one-way ANOVA or Kruskal-Wallis tests. When the p-value from the Kruskal-Wallis test was statistically significant, multiple comparison test was used to identify group differences. Correlations between LME and flexor tenosynovitis were evaluated by Spearman rank correlation test. The agreement between two observers was assessed by Cohen's Kappa (κ) statistic. P-value < 0.05 was considered as statistically significant. RESULTS: There were 100 patients (88 females) with mean age of 47.2 ± 11.2. There were no significant differences for age or sex between groups (p = 0.17, p = 0.84, respectively). RA patients showed significantly more frequent (p < 0.001) and stronger LME (p = 0.001). There were no correlations between LME and flexor tenosynovitis (p > 0.05). Interrater agreement for the degree of LME on right and left sides was substantial (κ = 0.74, κ = 0.67, respectively). CONCLUSION: RA patients demonstrated significantly more frequent and stronger LME with substantial interrater agreement. LME could constitute a subtle radiological clue for early RA.

Evaluation of the Validity and Reliability of ANKUTRIAGE, a New Decision Support System in Pediatric Emergency Triage.

BACKGROUND: The intensity of emergency services is an increasing health problem all over the world, necessitating an effective triage system. The aim of this study was to evaluate the validity and reliability of the "ANKUTRIAGE" in children. METHODS: This prospective, longitudinal study was carried out at a pediatric emergency department. ANKUTRIAGE, a 5-level computer-aided triage decision support system, was developed. Patients younger than 18 years who do not need emergency intervention, who had complete vital sign measurements, who gave consent for the study, and who were admitted to the emergency service during working hours with trained personnel were included. For validity, agreement between the urgency levels determined by ANKUTRIAGE and the reference triage systems: Pediatric Canadian Triage and Acuity Scale and Emergency Severity Index, was evaluated. In addition, the association of urgency levels with clinical outcomes was studied. To assess reliability, patients were evaluated by 2 blinded healthcare professionals using ANKUTRIAGE and a quadratic weighted κ was estimated. RESULTS: A total of 1232 children with a median age of 4.00 years were included. ANKUTRIAGE acuity levels significantly correlated with the number of resources used, the number of patients undergoing life-saving procedures, pediatric intensive care unit, and overall hospitalization rates, respectively ( P < 0.001, P < 0.001, P < 0.001, P < 0.001). The agreement of ANKUTRIAGE with Pediatric Canadian Triage and Acuity Scale was found to be 0.94 (95% confidence interval [CI], 0.93-0.94), with an Emergency Severity Index of 0.75 (95% CI, 0.70-0.80). The interrater agreement between 2 evaluators who used ANKUTRIAGE reflected as excellent consistency 0.92 (95% CI, 0.89-0.95; κ > 0.8). CONCLUSIONS: ANKUTRIAGE demonstrated high agreement with clinical outcomes and with proven triage systems and reflected high reliability between users. ANKUTRIAGE will enable a more standardized and practical triage, especially in crowded pediatric emergency departments and in situations where triage is performed by health professionals with different experience and professions.

Can Serum Thyroglobulin Levels Help to Identify the Involved Neck Compartment of Differentiated Thyroid Carcinoma?

We aimed to evaluate the predictive ability of serum thyroglobulin (Tg) levels on the localization of the metastatic lymph node compartments in locoregional metastases of papillary thyroid cancer (PTC). This retrospective study included 143 patients who underwent neck dissections for a total of 172 for persistent/recurrent locoregional PTC. They were grouped according to the localization of lymph node metastasis (LNM): Central (C-LNM), Lateral (L-LNM), both central and lateral LNM (C+L LNM). To confirm that the Tg cutoff discriminated LNM localizations, the sample was categorized as suppressed (<0.1 mU/l) or non-suppressed (>0.1 mU/l) according to TSH and ROC analysis. Mixed-effects models were used to investigate the effect of LNM localization on Tg levels and to eliminate the confounding effects of TSH, tumor burden (defined as the number and the largest diameter of LNM), and RAI. Mean Tg levels were 1.43 µg/l for C-LNM (n=47), 3.7 µg/l for L-LNM (n=99), and 8.60 µg/l for C+L LNM (n=26). Independent of TSH, tumor burden and RAI, the mean Tg levels of L-LNM and C+L LNM groups were not significantly different, while that of C-LNM was significantly lower than those of L-LNM and C+L LNM. To discriminate C-LNM from L-LNM and C+L LNM in patients with TSH>0.1 mU/l, the optimal cutoff for Tg was 1.05 µg/l (sensitivity=74.7%, specificity=70.4%, PPV=87.7%). L-LNM increases serum Tg levels more than C-LNM in persistent/recurrent locoregional nodal disease of PTC. Tg above 1.05 µg/l may indicate lateral LNM. Tg may be an important marker for the localization of LNM in the neck.

Evaluation of the early cervical structural change in patients with non-radiographic axial spondyloarthropathy.

In this double-blind, controlled, cross-sectional study, we compared structural changes in the cervical vertebrae of patients with nonradiographic axial spondyloarthropathy (nr-axSpA), patients with ankylosing spondylitis (AS), and a control group. We used the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) to determine whether the involvement of the cervical spine occurs earlier and is more severe than that of the lumbar spine in axial spondyloarthropathy (axSpA). A statistically significant difference was found in the total mSASSS between the AS and nr-axSpA groups (p = 0.038), but not in the cervical and lumbar mSASSS. Although the duration of the symptoms was shorter in the nr-axSpA group than in the AS group, no statistically significant difference was found in the cervical mSASSS between the AS and nr-axSpA groups. In both the AS and nr-axSpA groups, the cervical mSASSS values were found to be higher than the lumbar mSASSS values for the majority of the patients (82.8 and 89.5%, respectively). This may indicate that structural changes in the cervical spine occur during an early period of axSpA.

Natural History of Cirrhosis: Changing Trends in Etiology Over the Years.

BACKGROUND AND GOALS: The aims of the present study were to investigate the natural history of cirrhosis and to determine trends in the etiology of cirrhosis. METHODS: Between January 2001 and January 2018, a total of 1,341 patients had been diagnosed with cirrhosis and were included. RESULTS: A total of 898 cirrhotic patients, who were followed up for at least 6 months were included into the analysis. The median age was 54 years. The median Child-Pugh and MELD scores were 7.5 and 11, respectively. Ascites (51%) was the most common causes of decompensation. Chronic viral hepatitis was the most frequent cause of cirrhosis (58%). Hepatitis B virus (HBV) infection was the main etiology (34%), followed by hepatitis C virus (HCV) infection (18%). Among 129 patients with cryptogenic cirrhosis (CC), 60 had metabolic abnormalities. If these 60 patients with CC were considered to have nonalcoholic fatty liver disease (NAFLD)-related cirrhosis, the proportion of NAFLD-related cirrhosis increased from 1.8 to 8.0%. At admission, 74 patients (8%) had been diagnosed with hepatocellular carcinoma (HCC). A new HCC developed in 80 patients during the follow-up period. The probability of developing HCC was 3.9% at 12 months. Logistic regression analysis showed that the development of HCC was significantly associated with older age (p < 0.001), male gender (p < 0.001), viral etiology (p = 0.026), and baseline high aspartate aminotransferase level (p = 0.01). Overall, 104 cirrhotic patients died. CONCLUSION: HBV and HCV remain the leading causes of etiology in cirrhosis and HCC. However, NAFLD-related cirrhosis is recognized as a growing burden.

Computer-based multimodal training module facilitates standardization of complete mesocolic excision technique for right-sided colon cancer: Long-term oncological outcomes.

AIM: The aim of this study is to demonstrate our video training tool developed to teach and standardize complete mesocolic excision (CME) for right-sided colon cancer and also to present our long-term oncological outcomes. METHOD: Educational narrative videos were produced to demonstrate the technical steps of CME. First, a three-dimensional animation video was prepared. Then cadaveric dissections were recorded in a step-by-step fashion, following the sequences of open and minimally invasive surgery. These were followed by videos of real-life demonstrations of surgical procedures, enhanced by superimposed animations of key anatomical structures. In order to demonstrate the impact of this training module on outcomes of patients undergoing CME, we retrospectively queried data from before (2005-2010) and after (2011-2019) implementation of standardized CME in our practice. RESULTS: A total of 180 consecutive patients underwent right hemicolectomy between 2005 and 2019. Fifty-four patients underwent surgery before and 126 patients after CME principles were elaborated and standardized. Of those patients who had surgery after the training module, 58 (46%) underwent open surgery and 68 (54%) underwent laparoscopic colectomy. Demographics, perioperative parameters and morbidity were comparable between the groups. The 5-year overall and disease-free survival rates were significantly improved after implementation of CME training (p = 0.059 and p = 0.041, respectively). Also, 5-year overall and disease-free survival rates for all patients were considerably better than our reported national outcomes. CONCLUSION: Our comprehensive step-by-step training video module for the CME technique demonstrates surgical anatomical planes and important vascular structures and variations. The video also helps standardization of the CME technique and should contribute to improved histopathological and oncological outcomes.

Is the performance of the international severity scoring system for familial mediterranean fever in children better than other scoring systems?

AIMS: Familial Mediterranean fever (FMF) is an autosomal recessive disorder characterised by recurrent episodes of fever and serosal inflammation with elevated acute phase reactants. Assessing the severity of the disease may be useful in identifying colchicine-resistant patients. The aim of this study is to determine the disease severity of FMF patients according to the Pras, Mor, and International Severity Scoring System for Familial Mediterranean Fever (ISSF) scoring systems and to evaluate the consistency of these three systems. METHODS: The medical records of patients with FMF were retrospectively reviewed. Demographic features, family history of FMF, clinical characteristics at disease onset, laboratory features, Mediterranean fever genetic mutations, treatment regimens, and disease courses were recorded. RESULTS: A total of 205 patients (116 girls) were included in the study. The mean age of the patients was 13.3 ± 4.0 years. The Pras, Mor, and ISSF scores were inconsistent with each other, and there was poor fit between them (generalised Kappa: 0.140 ± 0.029; P < .001). In the receiver operating characteristic (ROC) analysis performed by accepting the clinician's opinion as the gold standard, the ISSF was found to be more sensitive and specific than the other two systems. CONCLUSION: Evaluation of disease severity according to the ISSF in paediatric patients is more sensitive and specific than the Pras and Mor scoring systems.

Does extracorporeal shock wave therapy decrease spasticity of ankle plantar flexor muscles in patients with stroke: A randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of radial extracorporeal shock wave therapy on ankle flexor spasticity in stroke survivors and to reveal changes in the fibroelastic components of muscle. DESIGN: Randomized controlled trial. SETTING: Inpatient neuro-rehabilitation clinic of a university hospital. PARTICIPANTS: Stroke patients with ankle flexor spasticity. INTERVENTIONS: Patients were randomized to three groups; radial extracorporeal shock wave therapy, sham, or control. Active and sham therapy were administered two sessions/week for two weeks. All patients received conventional rehabilitation. MAIN MEASURES: The primary outcome was Modified Ashworth Scale. Secondary outcomes were the Tardieu Scale and elastic properties of plantar flexor muscles assessed by elastography (strain index). All assessments were performed before, immediately after the treatment, and four weeks later at follow-up. RESULTS: Fifty-one participants were enrolled (active therapy n = 17, sham n = 17, control n = 17). Modified Ashworth scores showed a significant decrease in the active therapy group (from 2.47 ± 0.72 to 1.41 ± 0.62) compared to sham (from 2.19 ± 1.05 to 2.06 ± 1.12) and control (from 2.06 ± 0.85 to 2.00 ± 0.73) groups immediately after the treatment (P < 0.001). Tardieu results were also in concordance (P < 0.001), however this effect was not preserved at follow-up. Elastic properties of the ankle flexors were improved in all groups at both assessments after the therapy showing significant decreases in strain index (P < 0.001). However, there was no difference among the groups in terms of improvement in elastography. CONCLUSION: Radial extracorporeal shock wave therapy has short-term anti-spastic effects on ankle flexor muscles when used as an adjunct to conventional rehabilitation.

Diagnostic Accuracy of Mapping Techniques and Postprocessing Methods for Acute Myocarditis.

OBJECTIVE. Many T1 mapping sequences and measurement methods have been reported in the literature. To obtain accurate results, the most appropriate T1 and T2 mapping sequences and postprocessing methods should be used. The aim of the present study is to compare the T1 and T2 mapping sequences and measurement methods used to diagnose acute myocarditis. MATERIALS AND METHODS. Fourteen patients with an interval of 7 days or less between symptom onset and MRI examination were included in the study. The control group consisted of 22 healthy individuals. T1 mapping images acquired using four different methods (modified Look-Locker inversion recovery [MOLLI] 3[3]3[3]5, MOLLI 3[2]3[2]5, MOLLI 5[3]3 heart rate-corrected, and MOLLI 5[3]3 heart rate-uncorrected sequences) and T2 mapping images obtained using two different methods (FLASH and true fast imaging with steady-state precession) in the area from the short axis through the basal slice were retrospectively evaluated. RESULTS. The mean T1 and T2 values were significantly higher in the patient group than in the control group for all sequences in SAX measurements and segmental measurements (segments 1, 4, 5, and 6). Measurements from segments 2 and 3 were not statistically significant between patient and control groups. The segment with the highest AUC value of T1 and T2 mapping values was the inferior segment, followed by the inferolateral segment. The highest diagnostic performance for short-axis measurements was obtained using the MOLLI 3(2)3(2)5 sequence (AUC value = 0.902). CONCLUSION. According to the results of this study and many other studies, pathologic changes in the myocardium can be detected by native T1 and T2 mapping. The accuracy of mapping methods will increase with increased knowledge of the advantages and disadvantages of currently used sequences and measurement methods.

Evaluation of the level of dynamic thiol/disulphide homeostasis in adolescent patients with newly diagnosed primary hypertension.

BACKGROUND: Thiol/disulphide homeostasis plays a critical role in numerous intracellular enzymatic pathways including antioxidant defense and detoxification. This study was designed to investigate the impact of thiol/disulfide homeostasis in adolescent patients with recently diagnosed primary hypertension (HT) using a novel and automated method. METHODS: Native thiol/disulphide levels were measured by a novel spectrophotometric method (Cobasc 501, Roche Diagnostics, Mannheim, Germany) in 30 patients with primary HT together with 30 healthy controls. RESULTS: The levels of native thiol, total thiol, and native thiol/total thiol ratios were significantly lower, while the disulphide level, disulphide/native thiol, and disulphide/total thiol ratios were significantly higher in patients with primary HT compared with the control group. There were significant positive correlations between 24-h mean systolic and diastolic blood pressure and disulphide levels, disulphide/native thiol, and disulphide/total thiol ratios. A multiple linear regression model showed that a disulphide/native thiol ratio above 5 and family history of HT are independent predictors of HT. CONCLUSIONS: Our study showed that dynamic thiol/disulphide homeostasis shifted towards disulphide formation in adolescent patients with primary HT. Understanding the role of thiol/disulfide homeostasis in primary HT might provide new therapeutic intervention strategies for patients.

Publisher Correction: Evaluation of the level of dynamic thiol/disulphide homeostasis in adolescent patients with newly diagnosed primary hypertension.

Owing to an error in typesetting, the name of the author Atilla Halil Elhan was rendered wrongly. The original publication has now been corrected in this respect.

Prevalence and sonographic features of ectopic thyroidal thymus in children: A retrospective analysis.

PURPOSE: To assess the prevalence of ectopic thyroidal thymus tissue detected by sonography (US) in children and to analyze the US features. METHODS: We retrospectively reviewed images of 216 children who had undergone a thyroid or neck US examination from February 2015 to June 2015. Lesions within or adjacent to the thyroid gland that showed echopatterns consistent with thymic tissue were diagnosed as ectopic thyroidal thymus tissue. Lesions were reviewed according to their side, location, level, size, shape, echo pattern, internal content, and vascularization. RESULTS: A total of 216 children (119 girls, 97 boys) with a mean ± SD age of 8.6 ± 5.2 years were enrolled the study.Thirty children (13girls, 17 boys) (13.9%) had 35 lesions compatible with ectopic thyroidal thymus tissue.Nine children had intrathyroidal (4.2%) and 21 children had extrathyroidal (9.7%) ectopic thymus tissue.The mean ± SD ages of the children with and without ectopic thyroidal thymus tissue were 6.0 ± 3.6 years and 9.1 ± 5.2 years, respectively (P = .002). Twenty-five of the lesions were extrathyroidal and 10 were intrathyroidal. All extrathyroidal and most (8/9) intrathyroidal ectopic thymuses had fusiform shape with well demarcated contours. Ectopic thymuses were located either in the midportion (n = 23) or lower portion of the neck (n = 12). Both extrathyroidal and intrathyroidal ectopic thymuses showed typical hypoechoic (n = 22/25, n = 9/10, respectively) or hyperechoic (n = 3/25, n = 1/10, respectively) echo patterns with internal linear and punctate echoes. CONCLUSIONS: Ectopic thyroidal thymic tissue is common in children. Radiologists should be vigilant about the unique US features of ectopic thyroidal thymus, including a hypo- and hyper-echoic echo pattern with multiple linear and punctate echoes, a fusiform shape, well-demarcated contours, and middle or low-lying location to differentiate it from other neck or thyroid lesions.

Sonographic evaluation of the endochondral ossification process of the thyroid cartilage in children.

PURPOSE: To determine the sonographic appearances of the endochondral ossification process of the thyroid cartilage in children. METHODS: Thyroid cartilage sonography (US) of 420 children was performed with a high-resolution linear-array transducer. Right and left laminae of the thyroid cartilage, including the inferior horns, were examined. Ossification foci were evaluated for their presence, location, shape, size, echo pattern, and number. RESULTS: Four hundred nineteen children, 239 girls and 180 boys, were enrolled in the study with a mean age of 109.8 ± 60.7 months. Ossification foci were found in 167 children (39.9%). First ossification focus detection age was 72 months in girls and 79 months in boys. On both laminae, the most frequent appearance of the ossification focus was hypoechoic (right: 94.8%, left: 93.5%). Prevalence and number of ossification foci increased with age in each sex. The shape of the ossification foci in both laminae was generally nonexpansile (right: 92.9%, left: 93.5%). CONCLUSION: Endochondral ossification process of the thyroid cartilage begins in the first decade with extracellular matrix changes, which can be detected as hypoechoic foci by US. These foci can be expansile, and radiologists should be aware of this entity to avoid misdiagnosing them as abnormal masses.

Effects of Hysterectomy on Pelvic Floor Disorders: A Longitudinal Study.

BACKGROUND: Hysterectomy might adversely affect pelvic floor functions and result in many different symptoms, such as urinary and anal incontinence, obstructed defecation, and constipation. OBJECTIVE: The aim of this prospective study was to evaluate the influence of hysterectomy on pelvic floor disorders. DESIGN: This was a prospective and longitudinal study. SETTINGS: The study was conducted at the Ankara University Department of Surgery and the Dr Zekai Tahir Burak Women's Health Research and Education Hospital between September 2008 and March 2011. PATIENTS: The study was performed on patients who underwent hysterectomy for benign pathologies. MAIN OUTCOME MEASURES: A questionnaire about urinary incontinence (International Continence Society scoring), anal incontinence, constipation, and obstructed defecation (Rome criteria and constipation severity score), along with an extensive obstetric history, was administered preoperatively and postoperatively annually for 4 years. RESULTS: Patients (N = 327) who had completed each of the 4 annual postoperative follow-ups were included in this study. Compared with the preoperative observations, the occurrence of each symptom was significantly increased at each of the follow-up years (p < 0.001). Over the 4 postoperative years, the frequencies for constipation (n = 245) were 7.8%, 8.2%, 8.6%, and 5.3%; those for obstructed defecation (n = 269) were 4.5%, 5.2%, 4.1%, and 3.0%; those for anal incontinence (n = 252) were 4.8%, 6.3%, 6.0%, and 5.2%, and those for urinary incontinence (n = 99) were 12.1%, 12.1%, 11.1%, and 13.1%. In addition, patients who had no preoperative symptom (n = 70) from any of the selected symptoms showed a postoperative occurrence of at least 1 of these symptoms of 15.8%, 14.3%, 11.4%, and 8.6% for the postoperative years 1, 2, 3, and 4. LIMITATIONS: Although the study had several limitations, no comparison with a control population was the most important one. CONCLUSIONS: Hysterectomy for benign gynecologic pathologies had a significant negative impact on pelvic floor functions in patients who had no previous symptoms.

Phenol Injection Versus Excision With Open Healing in Pilonidal Disease: A Prospective Randomized Trial.

BACKGROUND: Minimally invasive procedures may be an alternative to surgical excisions for pilonidal disease. OBJECTIVE: The aim of the study was to compare phenol injection versus excision with open healing technique. DESIGN: This is a prospective randomized study (ACTRN12612000868886). SETTINGS: This study was conducted at the Ankara University and Ufuk University Departments of Surgery. PATIENTS: One hundred forty patients were randomly assigned to phenol injection (n = 70) or excision with open healing (n = 70). MAIN OUTCOME MEASURES: The primary end point of the study was the time to complete wound healing. Secondary end points were visual analog scale pain score, painkiller intake, time to resume daily activities, recurrence rate, Short Form 36 Health Survey, and Nottingham Health Profile at 3 weeks after surgery. RESULTS: Time to complete wound healing (16.2 ± 8.7 versus 40.1 ± 9.7 days) was significantly in favor of the phenol injection group (p < 0.001). The median operation time was 14.0 ± 3.8 minutes in the phenol group versus 49.0 ± 24.2 minutes in the excision with open healing group (p < 0.001). The time to resume daily activities (pain-free mobilization and defecation) was 0.8 ± 2.8 and 16.2 ± 12.6 hours after phenol injection and 9.3 ± 10.0 and 22.5 ± 15.1 hours after the excision with open healing treatment (p < 0.001, p = 0.008). Visual analog pain score at 48 hours and painkiller intake within 48 hours were significantly in favor of the phenol injection group. At the mean follow-up of 39.2 ± 9.0 months after surgery, no differences were seen in the recurrence rate between the treatment arms (13 recurrences in phenol vs 9 in excision with open healing; p = not significant). Short Form 36 and Nottingham Health Profile scores at 3 weeks after surgery were also in favor of phenol injection. LIMITATIONS: The present study was not double blinded, and a history of abscess drainage was significantly higher in the surgery group. CONCLUSIONS: Based on the results, we conclude that phenol injection is as effective as the excision with open healing technique.

A comparison of liver fat content as determined by magnetic resonance imaging-proton density fat fraction and MRS versus liver histology in non-alcoholic fatty liver disease.

BACKGROUND: Many imaging methods have been defined for quantification of hepatic steatosis in non-alcoholic fatty liver disease (NAFLD). However, studies comparing the efficiency of magnetic resonance imaging-proton density fat fraction (MRI-PDFF), magnetic resonance spectroscopy (MRS), and liver histology for quantification of liver fat content are limited. PURPOSE: To compare the efficiency of MRI-PDFF and MRS in the quantification of liver fat content in individuals with NAFLD. MATERIAL AND METHODS: A total of 19 NAFLD patients underwent MRI-PDFF, MRS, and liver biopsy for quantification of liver fat content. The MR examinations were performed on a 1.5 HDx MRI system. The MRI protocol included T1-independent volumetric multi-echo gradient-echo imaging with T2* correction and spectral fat modeling and MRS with STEAM technique. RESULTS: A close correlation was observed between liver MRI-PDFF- and histology- determined steatosis (r = 0.743, P < 0.001) and between liver MRS- and histology-determined steatosis (r = 0.712, P < 0.001), with no superiority between them (ƶ = 0.19, P = 0.849). For quantification of hepatic steatosis, a high correlation was observed between the two MRI methods (r = 0.986, P < 0.001). MRI-PDFF and MRS accurately differentiated moderate/severe steatosis from mild/no hepatic steatosis (P = 0.007 and 0.013, respectively), with no superiority between them (AUCMRI-PDFF = 0.881 ± 0.0856 versus AUCMRS = 0.857 ± 0.0924, P = 0.461). CONCLUSION: Both MRI-PDFF and MRS can be used for accurate quantification of hepatic steatosis.

Quantification of liver, pancreas, kidney, and vertebral body MRI-PDFF in non-alcoholic fatty liver disease.

PURPOSE: The purpose of the present study was to determine liver, pancreas, kidney, and vertebral fat deposition in NAFLD patients by proton density fat fraction (PDFF) using magnetic resonance imaging (MRI) and to evaluate the relationships among them. METHODS: A total of 41 biopsy-proven NAFLD patients underwent MRI-PDFF with IDEAL-IQ. MRI protocol included T1-independent volumetric multi-echo gradient-echo imaging with T2* correction and spectral fat modeling. The MR examinations were performed on a 1.5 HDx MRI system. MRI-PDFF measurements were obtained from liver, pancreas, renal cortex and sinus, and vertebral body. Liver biopsy specimens were retrieved from the archives and evaluated by one pathologist according to NASH CRN. RESULTS: The median age of the patients was 47 years. The median interval between liver biopsy and MRI examination was 16 days. Mean liver, pancreas, renal cortex, renal sinus, T12 and L1 vertebral body MRI-PDFFs were 18.7%, 5.7%, 1.7%, 51%, 43.2%, and 43.5%, respectively. No correlation between either liver MRI-PDFF or histological steatosis, and other organ MRI-PDFFs was observed. A good correlation between pancreas and vertebral body MRI-PDFFs, and pancreas and renal sinus MRI-PDFFs was observed. Diabetic patients had higher average pancreas MRI-PDFF compared to non-diabetics (12.2%, vs., 4.8%; P = 0.028). CONCLUSIONS: Pancreas and vertebral body MRI-PDFF is well correlated in NAFLD patients and both of them are higher in diabetic patients which may explain increased bone fractures in diabetics. MRI-PDFF can be used to demonstrate fat fractions of different organs and tissues and to understand fat metabolism.

Impact of sequential proton density fat fraction for quantification of hepatic steatosis in nonalcoholic fatty liver disease.

OBJECTIVE: To determine the utility of sequential MRI-estimated proton density fat fraction (MRI-PDFF) for quantification of the longitudinal changes in liver fat content in individuals with nonalcoholic fatty liver disease (NAFLD). METHODS: A total of 18 consecutive individuals (M/F: 10/8, mean age: 47.7±9.8 years) diagnosed with NAFLD, who underwent sequential PDFF calculations for the quantification of hepatic steatosis at two different time points, were included in the study. All patients underwent T1-independent volumetric multi-echo gradient-echo imaging with T2* correction and spectral fat modeling. RESULTS: A close correlation for quantification of hepatic steatosis between the initial MRI-PDFF and liver biopsy was observed (rs=0.758, p<0.001). The median interval between two sequential MRI-PDFF measurements was 184 days. From baseline to the end of the follow-up period, serum GGT level and homeostasis model assessment score were significantly improved (p=0.015, p=0.006, respectively), whereas BMI, serum AST, and ALT levels were slightly decreased. MRI-PDFFs were significantly improved (p=0.004). A good correlation between two sequential MRI-PDFF calculations was observed (rs=0.714, p=0.001). With linear regression analyses, only delta serum ALT levels had a significant effect on delta MRI-PDFF calculations (r2=38.6%, p=0.006). At least 5.9% improvement in MRI-PDFF is needed to achieve a normalized abnormal ALT level. The improvement of MRI-PDFF score was associated with the improvement of biochemical parameters in patients who had improvement in delta MRI-PDFF (p<0.05). CONCLUSIONS: MRI-PDFF can be used for the quantification of the longitudinal changes of hepatic steatosis. The changes in serum ALT levels significantly reflected changes in MRI-PDFF in patients with NAFLD.