Ultrasound evaluation of varicoceles: guidelines and recommendations of the European Society of Urogenital Radiology Scrotal and Penile Imaging Working Group (ESUR-SPIWG) for detection, classification, and grading.

Varicoceles are relatively common particularly in asymptomatic men and are even more prevalent in subfertile men, representing the most common potentially correctable cause of male infertility. Ultrasound (US) is the imaging modality of choice for varicocele evaluation, but there is no widely accepted consensus on examination technique, diagnostic criteria, or classification. In view of this uncertainty, the guideline writing group (WG) of the European Society of Urogenital Radiology (ESUR) Scrotal and Penile Imaging Working Group (ESUR-SPIWG) undertook a literature review and assessment of the quality of relevant evidence. The group then produced evidence-based recommendations for varicocele US examination, interpretation, and classification by consensus agreement. The results are presented in the form of 15 clinical questions with a brief summary of the relevant evidence and the authorised recommendations from the SPIWG. This paper provides a short summary of the evidence evaluation and the complete recommendations.Key Points• Varicocele is a common clinical problem; it is highly prevalent amongst subfertile men and the most common potentially correctable cause of male infertility. • Ultrasound is the imaging modality of choice for varicocele assessment, but there is no generally agreed consensus on the US examination technique or the criteria that should be used for diagnosis, grading, and classification. • This paper summarises the recommendations of the ESUR-SPIWG for standardising the US assessment of varicoceles. This includes examination technique, image interpretation, classification, and reporting.

MRI of the scrotum: Recommendations of the ESUR Scrotal and Penile Imaging Working Group.

OBJECTIVES: The Scrotal and Penile Imaging Working Group (SPI-WG) appointed by the board of the European Society of Urogenital Radiology (ESUR) has produced recommendations for magnetic resonance imaging (MRI) of the scrotum. METHODS: The SPI-WG searched for original and review articles published before September 2016 using the Pubmed and Medline databases. Keywords used were 'magnetic resonance imaging', 'testis or testicle or testicular', 'scrotum', 'intratesticular', 'paratesticular', 'extratesticular' 'diffusion-weighted', 'dynamic MRI'. Consensus was obtained among the members of the subcommittee. The expert panel proposed recommendations using Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence. RESULTS: The recommended MRI protocol should include T1-, T2-weighted imaging, diffusion-weighted imaging and dynamic contrast-enhanced MRI. Scrotal MRI can be clinically applied for lesion characterisation (primary), including both intratesticular and paratesticular masses, differentiation between germ-cell and non-germ-cell neoplasms (evolving), characterisation of the histological type of testicular germ cell neoplasms (TGCNs, in selected cases), local staging of TGCNs (primary), acute scrotum (in selected cases), trauma (in selected cases) and undescended testes (primary). CONCLUSIONS: The ESUR SPI-WG produced this consensus paper in which the existing literature on MRI of the scrotum is reviewed. The recommendations for the optimal imaging technique and clinical indications are presented. KEY POINTS: • This report presents recommendations for magnetic resonance imaging (MRI) of the scrotum. • Imaging acquisition protocols and clinical indications are provided. • MRI is becoming established as a worthwhile second-line diagnostic tool for scrotal pathology.

Incidentally detected non-palpable testicular tumours in adults at scrotal ultrasound: impact of radiological findings on management Radiologic review and recommendations of the ESUR scrotal imaging subcommittee.

OBJECTIVES: The increasing detection of small testicular lesions by ultrasound (US) in adults can lead to unnecessary orchiectomies. This article describes their nature, reviews the available literature on this subject and illustrates some classical lesions. We also suggest recommendations to help characterization and management. METHODS: The ESUR scrotal imaging subcommittee searched for original and review articles published before May 2015 using the Pubmed and Medline databases. Key words used were 'testicular ultrasound', 'contrast-enhanced sonography', 'sonoelastography', 'magnetic resonance imaging', 'testis-sparing surgery', 'testis imaging', 'Leydig cell tumour', 'testicular cyst'. Consensus was obtained amongst the members of the subcommittee, urologist and medical oncologist. RESULTS: Simple cysts are frequent and benign, and do not require follow up or surgery. Incidentally discovered small solid testicular lesions detected are benign in up to 80 %, with Leydig cell tumours being the most frequent. However, the presence of microliths, macrocalcifications and hypoechoic areas surrounding the nodule are findings suggestive of malignant disease. CONCLUSION: Asymptomatic small testicular lesions found on ultrasound are mainly benign, but findings such as microliths or hypoechoic regions surrounding the nodules may indicate malignancy. Colour Doppler US remains the basic examination for characterization. The role of newer imaging modalities in characterization is evolving. KEY POINTS: • Characterization of testicular lesions is primarily based on US examination. • The role of MRI, sonoelastography, contrast-enhanced ultrasound is evolving. • Most small non-palpable testicular lesions seen on ultrasound are benign simple cysts. • Leydig cell tumours are the most frequent benign lesions. • Associated findings like microliths or hypoechoic regions may indicate malignancy.

Testicular microlithiasis imaging and follow-up: guidelines of the ESUR scrotal imaging subcommittee.

OBJECTIVES: The subcommittee on scrotal imaging, appointed by the board of the European Society of Urogenital Radiology (ESUR), have produced guidelines on imaging and follow-up in testicular microlithiasis (TML). METHODS: The authors and a superintendent university librarian independently performed a computer-assisted literature search of medical databases: MEDLINE and EMBASE. A further parallel literature search was made for the genetic conditions Klinefelter's syndrome and McCune-Albright syndrome. RESULTS: Proposed guidelines are: follow-up is not advised in patients with isolated TML in the absence of risk factors (see Key Points below); annual ultrasound (US) is advised for patients with risk factors, up to the age of 55; if TML is found with a testicular mass, urgent referral to a specialist centre is advised. CONCLUSION: Consensus opinion of the scrotal subcommittee of the ESUR is that the presence of TML alone in the absence of other risk factors is not an indication for regular scrotal US, further US screening or biopsy. US is recommended in the follow-up of patients at risk, where risk factors other than microlithiasis are present. Risk factors are discussed and the literature and recommended guidelines are presented in this article. KEY POINTS: • Follow up advised only in patients with TML and additional risk factors. • Annual US advised for patients with risk factors up to age 55. • If TML is found with testicular mass, urgent specialist referral advised. • Risk factors - personal/ family history of GCT, maldescent, orchidopexy, testicular atrophy.

Effect of 2.45 GHz Microwave Radiation on the Inner Ear: A Histopathological Study on 2.45 GHz Microwave Radiation and Cochlea.

BACKGROUND: The present study aims to determine the possible low dose-dependent adverse effects of 2.45 GHz microwave exposure and Wi-Fi frequency on the cochlea. METHODS: Twelve pregnant female rats (n=12) and their male newborns were exposed to Wi-Fi frequencies with varying electric field values of 0.6, 1.9, 5, 10 V/m, and 15 V/m during the 21-day gestation period and 45 days after birth, except for the control group. Auditory brainstem response testing was performed before exposure and sacrification. After removal of the cochlea, histopathological examination was conducted by immunohistochemistry methods using caspase (cysteine-aspartic proteases, cysteine aspartates, or cysteine-dependent aspartate-directed proteases)-3, -9, and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL). Kruskal-Wallis and Wilcoxon tests and multivariate analysis of variance were used. RESULTS: Auditory brainstem response thresholds in postexposure tests increased statistically significantly at 5 V/m and above doses. When the number of apoptotic cells was compared in immunohistochemistry examination, significant differences were found at 10 V/m and 15 V/m doses (F(5,15)=23.203, P=.001; Pillai's trace=1.912, η2=0.637). As the magnitude of the electric field increased, all histopathological indicators of apoptosis increased. The most significant effect was noted on caspase-9 staining (η2 c9=0.996), followed by caspase-3 (η2 c3=0.991), and TUNEL staining (η2 t=0.801). Caspase-3, caspase-9, and TUNEL-stained cell densities increased directly by increasing the electric field and power values. CONCLUSION: Apoptosis and immune activity in the cochlea depend on the electric field and power value. Even at low doses, the electromagnetic field in Wi-Fi frequency damages the inner ear and causes apoptosis.

Anatomical variations in branching pattern of arcus aorta: 64-slice CTA appearance.

PURPOSE: To review the 64-slice CTA (computed tomography angiography) appearance of anatomical variations in branching pattern of the arcus aorta, and to determine their prevalence in 1001 cases. MATERIALS AND METHODS: 1001 cases that underwent carotid CTA (performed by a 64-slice scanner) were included in the study. RESULTS: Seven types of aortic arch were found. In 853 cases (853/1001, 85.2 %) classical branching pattern of arcus aorta (three branches; TB, LCC, LS) was observed. Variations were present in 147 cases (147/1001, 14.7 %). One case (1/1001, 0.1 %) had right aortic arch. The most frequent variation was origination of LCC from TB (arch with 2 branches, TB with LCC and LS) which was observed in 78 cases (78/1001, 7.8 %). Origination of LV directly from the aortic arch (four branches; TB, LCC, LV, LS or TB, LCC, LS, LV) was observed in 51 cases (51/1001, 5.1 %). In two cases (2/1001, 0.2 %) truncus bicaroticus (3 branches; RS, common trunk for carotids, LS) was present. In seven cases (7/1001, 0.7 %) aortic arch had four branches in the order of RCC, RS, LCC and LS. In one case (1/1001, 0.1 %) left truncus brachiocephalicus (three branches; RS, RCC, LTB) was present. Seven cases (7/1001, 0.7 %) had aberrant RS (RCC, LCC, LS, RS). CONCLUSION: Variations in branching pattern of arcus aorta are not rare and being aware of them before surgical and interventional procedures of this region is important. CTA can depict the anatomical features of the aortic arch and is valuable as a road map.

Comparison of three methods for the estimation of pineal gland volume using magnetic resonance imaging.

Pineal gland is a very important neuroendocrine organ with many physiological functions such as regulating circadian rhythm. Radiologically, the pineal gland volume is clinically important because it is usually difficult to distinguish small pineal tumors via magnetic resonance imaging (MRI). Although many studies have estimated the pineal gland volume using different techniques, to the best of our knowledge, there has so far been no stereological work done on this subject. The objective of the current paper was to determine the pineal gland volume using stereological methods and by the region of interest (ROI) on MRI. In this paper, the pineal gland volumes were calculated in a total of 62 subjects (36 females, 26 males) who were free of any pineal lesions or tumors. The mean ± SD pineal gland volumes of the point-counting, planimetry, and ROI groups were 99.55 ± 51.34, 102.69 ± 40.39, and 104.33 ± 40.45 mm(3), respectively. No significant difference was found among the methods of calculating pineal gland volume (P > 0.05). From these results, it can be concluded that each technique is an unbiased, efficient, and reliable method, ideally suitable for in vivo examination of MRI data for pineal gland volume estimation.

Iatrogenic Vascular Injury Associated with Cervical Spine Surgery: A Systematic Literature Review.

BACKGROUND: Iatrogenic vascular injury is an uncommon complication of anterior and/or posterior surgical approaches to the cervical spine. Although the results of this injury may be life-threatening, mortality/morbidity can be reduced by an understanding of its mechanism and proper management. METHODS: We conducted a literature review to provide an update of this devastating complication in spine surgery. A total of 72 articles including 194 cases of vascular lesions following cervical spine surgery between 1962 and 2021 were analyzed. RESULTS: There were 53 female and 41 male cases (in addition to 100 cases with unreported sex) with ages ranging from 3 to 86 years. The vascular injuries were classified according to the spinal procedures, such as anterior or posterior cervical spine surgery. The interval between the symptom of the vascular injury and the surgical procedure ranged from 0 to 10 years. Only two-thirds of patients underwent intra- or postoperative imaging and the most frequently injured vessel was the vertebral artery (86.60%). Laceration was the most common lesion (41.24%), followed by pseudoaneurysm (16.49%) and dissection (5.67%). Vascular repair was performed in 114 patients. The mortality rate was 7.22%, and 18.04% of patients had 1 or more other complications. Most presumed causes of vascular lesions were by instrumentation/screw placement (31.44%) or drilling (20.61%). Sixteen patients had an anomalous artery. Direct microsurgical repair was achieved in only 15 cases. CONCLUSIONS: Despite increased anatomical knowledge and advanced imaging techniques, we need to consider the risk of vascular injury as a surgical complication in patients with cervical spine pathologies.

Comparison of three methods for the estimation of the pituitary gland volume using magnetic resonance imaging: a stereological study.

Stereological techniques using point counting and planimetry have been used to estimate pituitary gland volume. However, many studies have estimated pituitary gland volume by the mathematical approach the elliptic formula. The objective of the current study was to determine pituitary gland volume using stereological methods and elliptic formula on magnetic resonance imaging (MRI). In this study, pituitary gland volumes were estimated in a total of 28 subjects (22 females, 6 males,) who were free of any pituitary or neurological symptoms and signs. The mean ± SD pituitary gland volumes for the point counting, planimetry and elliptic formulae groups were 582.14 ± 140.16 mm³, 610.08 ± 133.17 mm³, and 432.82 ± 147.38 mm³, respectively. The mean CE for the pituitary gland volume estimates derived from the point counting technique was 8.07%. No significant difference was found between point counting and planimetric methods for the pituitary gland volume (P > 0.05). In addition, there was a 26.14 and 29.71% underestimation of pituitary volume as measured by the elliptic formula compared to the point counting and planimetric techniques, respectively. From these results, it can be concluded that stereological techniques are unbiased, efficient and reliable methods and are ideally suitable for in vivo examination of MRI data for pituitary gland volume estimation. Hence, we suggest that estimating pituitary gland volume using MRI study and stereology may be clinically relevant for pituitary surgeons for the investigation of the structure and function of the pituitary gland.

Follow-up sonographic results for Graf type 2A hips: association with risk factors for developmental dysplasia of the hip and instability.

OBJECTIVES: The purpose of the study was to evaluate the association of sonographic worsening in type 2a hips with risk factors of developmental dysplasia of the hip, stability of the hip, and initial sonographic findings. METHODS: Among infants who were referred for hip sonography between 2007 and 2009, 3450 were included in this study. Sonographic examinations were performed by combining the static Graf technique and the dynamic Harcke technique. The rate of sonographic worsening in type 2a hips and the relationship between sonographic worsening and risk factors for developmental dysplasia, instability of the hip, lateralization (right or left) of immaturity, and the presence of unilateral and bilateral immature hips were evaluated. RESULTS: Type 2a hips were observed in 529 infants (15.3%; 780 hips [11.3%]). Of these, in 36 cases (6.8%; 44 hips [5.6%]), the sonographic results worsened. Twenty-five of these 36 cases (32 of 44 hips) were diagnosed as type 2 b; in others, the dysplasia worsened, and 6 cases (7 hips) were classified as type 2 c, 3 cases (3 hips) as type D, and 2 cases (2 hips) as type 3. Instability, unilateral type 2a hips, and associated central nervous system anomalies were found to be independent predictors of sonographic worsening in type 2a hips. CONCLUSIONS: Type 2a hips may worsen sonographically at a rate of 5.6%; hence, sonographic follow-up is needed. Instability, central nervous system anomalies, and unilateral type 2a hips were found to be independent predictors of sonographic worsening. Our study shows that cases with these risk factors should be followed more carefully.

Fecal calprotectin concentration in celiac disease.

GOALS: We aimed to determine fecal calprotectin (FC) concentration and its relation with histopathologic findings of children with celiac disease (CD) and to observe the probable alterations under gluten-free diet (GFD). BACKGROUND: As FC is regarded as a marker of inflammation in the gastrointestinal tract, we hypothesized that it might be increased in untreated CD. STUDY: The study included 29 newly diagnosed patients with CD (mean age: 6.6+/-0.6 y) and sex and age-matched 10 healthy children. All of the children with CD admitted to the hospital were classical form who has chronic diarrhea and failure to thrive. The degree of mucosal damage was graded according to the modified Marsh criteria. FC concentration was determined by enzyme-linked immunosorbent assay method on admission and after 1 year of GFD. RESULTS: Mean FC concentration of children with CD on admission and of healthy children were 13.40+/-8.5 and 4.3+/-3.3 mg/L, respectively (P=0.004). FC concentration under GFD was 4.6+/-2.7 mg/L and there was a significant statistical difference between untreated patients and those under GFD for 1 year (P=0.001). There was no statistical difference between FC concentration of those under GFD and healthy children (P=0.8). Mean FC concentrations of children with total-villous atrophy and partial-villous atrophy were significantly different (13.8+/-9.3 mg/L vs. 3.7+/-1.8 mg/L, P=0.005). CONCLUSIONS: It was found that FC concentration is increased in childhood CD, related to the severity of histopathologic findings and responsive to GFD. The pathogenetic mechanism by which FC is increased in CD should be investigated in further studies.

Treatment results of chronic hepatitis B in children: a retrospective study.

In this retrospective study, we aimed to share our experience with different treatment modalities for chronic hepatitis B in a series of children. The study included 126 children (mean: 9.5 +/- 3.8 years). Normalization of alanine aminotransferase (ALT), loss of hepatitis B virus (HBV)-DNA and hepatitis B e antigen (HBeAg), and development of antibody to HBeAg (anti-HBe) altogether at the end of the treatment was considered as end of therapy response (ETR). Seroconversion ongoing one year after the cessation of therapy was considered as sustained response. Of the total children, 90 (71.4%) were treated, whereas the remaining were just followed-up. High-dose interferon (IFN)-alpha (10 MU/m2) alone, standard-dose IFN-alpha (6 MU/m2) plus lamivudine (4 mg/kg/d), high-dose IFN-alpha plus lamivudine, or lamivudine alone was used, IFN-alpha thrice weekly for six months, and lamivudine daily for one year. Of children who had completed their treatment, 34 (37.8%) achieved ETR. Sustained response rate was 36.7%. Response rates were different in the different treatment groups (p: 0.01). The highest response rate was observed in those who received standard-dose IFN-alpha plus lamivudine treatment (61.5%). Of children without treatment, one (2.8%) had anti-HBe seroconversion. Standard-dose IFN-alpha plus lamivudine treatment was found superior to the other treatment modalities. Predictors of ETR were similar to those found in previous studies.

Calcified or Ossified Chronic Subdural Hematoma: A Systematic Review of 114 Cases Reported During Last Century with a Demonstrative Case Report.

OBJECTIVE: Calcified or ossified chronic subdural hematoma (CSDH), characterized by slowly progressing neurologic symptoms, is a rarely seen entity that may remain asymptomatic for many years. Management of CSDH has improved dramatically in recent years as a result of advances in diagnostic tools, but there is still some controversy regarding the optimal treatment strategy. METHODS: In this systematic review, PRISMA guidelines were followed to query existing online databases between January 1930 and December 2018. We found a total of 88 articles containing 114 cases of calcified or ossified CSDH, comprising 83 patients operated on and 31 not operated on. RESULTS: In this study, there were 78 males and 29 females (7 with unreported gender) from 25 countries, ages ranging from 4 months to 86 years (mean, 33.7 years), with CSDH caused by head trauma in 33.3%, shunting for hydrocephalus in 27.2%, or after cranial surgery in 4.4%. The duration of symptoms ranged from acute onset to 20 years, with a mean of 24.1 months. Imaging techniques such as radiography, computed tomography, and magnetic resonance imaging were used, with pathologic confirmation of CSDH and complete recovery in 56.4% of patients. CONCLUSIONS: Incidence of calcified or ossified CSDH is high in certain countries, including the United States, Japan, and Turkey, with a steady increase in recent years. The therapy of choice is surgery in these patients and it should be considered in the differential diagnosis at presentation because of its infrequency and variable clinical manifestation, after shunting in children or head trauma in adults.

Iatrogenic Ureteral Injury as a Complication of Posterior or Lateral Lumbar Spine Surgery: A Systematic Review of the Literature.

OBJECTIVE: Iatrogenic ureteral injury associated with lumbar spine surgery is an uncommon but devastating complication with associated medicolegal implications. METHODS: We performed a systematic review of the English language literature published between 1954 and 2019, accessed through 4 popular databases. We found 44 articles (28 case reports, 9 case-based reviews, 4 case series, 1 original article, 1 case illustration, and 1 pictorial) containing 46 cases of ureteral injuries after posterior or lateral lumbar spine surgery. RESULTS: Except for 5 cases with insufficient data, 24 of the remaining 41 patients were female and 17 were male, with ages ranging from 16 years to 83 years. Excluding 4 cases without enough information, initial diagnoses of lumbar disc herniation (n = 33) or lumbar spinal stenosis (n = 4), spondylolisthesis (n = 3), degenerative disc disease (n = 1), and failed back surgery syndrome (n = 1) were reported from 18 countries; 54% of patients were from the United States, Japan, or Turkey. The interval from spinal surgery to restorative surgery ranged from <24 hours to 1 month to 1 year; in 48% of patients, it was >1 week, and 90% of patients recovered completely. Initial surgery was combined with vascular injury in 15% of patients. CONCLUSIONS: Ureteral injury associated with lumbar spine surgery is overreported in developed or developing countries. It should be considered in the differential diagnosis of any patient who presents with symptoms of acute abdomen after lumbar spine surgery, and patients who underwent restorative surgery had a good prognosis.

Ultrasound evaluation of varicoceles: systematic literature review and rationale of the ESUR-SPIWG Guidelines and Recommendations.

Although often asymptomatic and detected incidentally, varicocele is a relatively common problem in patients who seek medical attention for infertility problems. Ultrasound (US) is the imaging modality of choice for evaluation, but there is no consensus on the diagnostic criteria, classification, and examination technique. In view of this uncertainty, the Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG) undertook a systematic review of the available literature on this topic, to use as the basis for evidence-based guidelines and recommendations. This paper provides the results of the systematic review on which guidelines were constructed.

Multitechnique evaluation of renal hydatid disease.

OBJECTIVE: Hydatid involvement of the kidney accounts for only 2-4% of all cases of hydatid disease. The purpose of this article is to review the imaging features of hydatid disease of the kidney and thus show the role of radiography, excretory urography, sonography, CT, and MRI in the diagnosis of hydatidosis. CONCLUSION: The radiologist should be familiar with the imaging findings of hydatid disease because early diagnosis is important for more appropriate treatment.

Pineal gland calcification, lumbar intervertebral disc degeneration and abdominal aorta calcifying atherosclerosis correlate in low back pain subjects: A cross-sectional observational CT study.

The goal of this cross-sectional observational study was to assess the possible impact of pineal gland calcification upon the intervertebral disc degeneration and abdominal aorta atherosclerosis in subjects with low back pain, and to investigate the course of these processes with aging. The study was carried out on 81 (66 women and 15 men) subjects: younger than 45 years (group X, n=22), 45-65 years of age (group Y, n=45), and older than 65 years (group Z, n=14). In addition to clinical data, computed tomography (CT) scan of the brain as well as X-ray and CT examination of the lumbar spine were recorded in this study. The degree of disc degeneration and calcification rates of aortic wall and pineal gland were independently determined by two radiologists. Both ratio of calcified pineal gland and density of pineal calcification increased progressively with aging. Also, both the degree of aortic wall calcification and disc degeneration score increased with advancing age. On CT scan, a positive correlation between degree of aortic wall calcification and disc degeneration score was found (r=0.306, p<0.01). Importantly, there was a positive association between calcification of the pineal gland and degenerative disc disease in X-ray or CT study (r=0.378 and r=0.295, p<0.005 and p<0.01, respectively), as well as between abdominal aorta atherosclerosis and pineal calcification (r=0.634, p<0.001). Our findings suggest that there is a significant interaction between pineal gland calcification and lumbar intervertebral disc degeneration and also abdominal aorta atherosclerosis. However, further studies with a larger subject cohorts are needed.

Age-related changes in the incidence of pineal gland calcification in Turkey: A prospective multicenter CT study.

The goal of this cross-sectional observational study was to determine the incidence of pineal gland calcification (PGC), to investigate the interaction of PGC and aging, and to compare the incidence of PGC among the populations living in Turkey. In a prospective study the rate of PGC on CT scans of 1376 individuals in six referral centers from different regions of Turkey was investigated, with emphasis on effects of climatological parameters and aging on PGC. It was found that the incidence of PGC increased rapidly after first decade and the increase remains gradual thereafter, higher in males than in females for all age groups. There was a significant difference for incidence and degree of PGC between different clinics and between both sexes (p<0.001). In addition, there was a significant difference for the degree of PGC between the clinics in low altitude group and those in high altitude group (p<0.001 for each). Logistic regression analysis revealed that age, sex, altitude and intensity of sunlight exposure significantly affected the risk of PGC (odds ratios (OR) 1.335, 95% confidence intervals (CI) 1.261-1.414, p<0.001; OR 1.900, 95% CI 1.486-2.428, p<0.001; OR 0.715, 95% CI 0.517-0.990, p<0.05; OR 0.997, 95% CI 0.994-0.999, p<0.01, respectively). Furthermore, by multiple linear regression analysis, high altitude and increased intensity of sunlight exposure were found to affect the degree of PGC (beta=0.003, p<0.001). It is concluded that there is a close relationship between PGC and the aforementioned parameters, supporting a link between the development of PGC and these. This study provides some reference data for new clinical studies on the putative role of pineal gland in future.