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.

A combination of non-invasive tests for the detection of significant fibrosis in patients with metabolic dysfunction-associated steatotic liver disease is not superior to magnetic resonance elastography alone.

OBJECTIVES: The aims of the present study were to investigate a combination of magnetic resonance elastography (MRE) and vibration-controlled transient elastography (VCTE) or MRE and fibrosis score 4 (FIB-4) in the detection of significant fibrosis in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). METHODS: Between November 5, 2021, and March 4, 2022, a total of 119 consecutive patients with MASLD were included. Liver stiffness was measured using liver biopsy, MRE, VCTE, and FIB-4. Data were collected from outpatient visit charts. Significant fibrosis was defined as ≥ stage 2 fibrosis. RESULTS: All 119 MASLD patients were Caucasian, and their median age was 55 years. MRE, VCTE, and FIB-4 demonstrated significant accuracy in the detection of significant fibrosis with an area under the ROC curve (AUC) of 0.848 ± 0.036 (p < 0.001), 0.632 ± 0.052 (p = 0.012), and 0.664 ± 0.051 (p = 0.001), respectively. However, the diagnostic performance of MRE was superior compared to that of VCTE (AUC difference: 0.216 ± 0.053, p < 0.001) and FIB-4 (AUC difference: 0.184 ± 0.058, p = 0.001). With logistic regression analysis, it was determined that when compared to MRE alone, a combination of MRE and TE (p = 0.880) or MRE and FIB-4 (p = 0.455) were not superior for detecting significant fibrosis. CONCLUSIONS: MRE alone is an accurate and non-invasive method for the identification of MASLD patients with significant fibrosis. CLINICAL RELEVANCE STATEMENT: Magnetic resonance elastography alone accurately detects significant fibrosis in patients with metabolic dysfunction-associated steatotic liver disease. KEY POINTS: • In routine clinical practice, several non-invasive biochemical-based biomarkers and imaging methods are widely used to assess liver fibrosis in patients with metabolic dysfunction-associated steatotic liver disease. • Magnetic resonance elastography (MRE) is more accurate than vibration-controlled transient elastography (VCTE) or fibrosis score 4 (FIB-4) for assessing liver fibrosis and identifying significant fibrosis in patients with metabolic dysfunction-associated steatotic liver disease. • The combination of MRE and VCTE or MRE and FIB-4 was not superior to MRE alone.

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.

Does the power of the laser devices matter for a successful HoLEP procedure? A prospective comparative study.

BACKGROUND: The objectives of this prospective study were to evaluate the efficiency, safety and applicability of medium-power (MP) holmium laser devices in the endoscopic enucleation of the enlarged prostate (HoLEP) compared with high-power (HP) laser devices. METHODS: From October 2019 to July 2020, a total of 120 consecutive patients planned for HoLEP were divided randomly into two groups formed in terms of the power of the device used. While patients in group 1 were treated with a MP device (50 W) at 39.6 W (2.2 J/18 Hz), patients in group 2 were treated with HP (100 W) device at 42 W (1.2 J/35 Hz). Preoperative patient characteristics, perioperative measures and 3-month functional outcomes were evaluated in both groups with an emphasis on enucleation efficiency (EE) and haemoglobin decrease in a comparative manner. RESULTS: All patients underwent successful HoLEP surgery with no severe perioperative and postoperative complications. No statistically significant differences were observed in terms of preoperative patient characteristics and perioperative measures in the two groups. The median EE values in groups 1 and 2 were 1.15 (interquartile range [IQR]: 0.33-2.2) and 1.11 (IQR: 0.4-2.8), respectively (P = .775). Haemoglobin decrease values in groups 1 and 2 were 1.3 (IQR: 0.1-4) and 1.4 (IQR: 0.4-3.1), respectively (P = .736). There was no difference in terms of either catheterisation time or hospital stay in the groups. In the model created to predict haemoglobin decrease, only biopsy was detected to be the independent predictive factor among the data from laser device, biopsy and antithrombotic use. Functional outcomes markedly improved in all patients without any statistically significant difference between the groups in the 3-month follow-up. CONCLUSION: Our comparative study indicated that HoLEP can be performed safely and effectively with MP laser devices without any technical difficulties and with comparable results achieved in HP laser devices.

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.

[Burden of Pneumococcal Meningitis and Bacteremia, Serotype Distribution and Antibiotic Resistance in Healthy Children After Conjugated Pneumococcal Vaccine Implementation: Single Center Experience]. / Saglikli Çocuklarda Konjuge Pnömokok Asisi Uygulamasi Sonrasi Pnömokokal Menenjit ve Bakteriyemi Hastalik Yükü, Serotip Dagilimi ve Antibiyotik Direnci: Tek Merkez Deneyimi.

In Turkey, the seven-valent pneumococcal conjugated vaccine (PCV7) was included in the childhood national immunization programme in April 2008 and was replaced by the 13-valent pneumococcal conjugated vaccine (PCV13) in April 2011. In this retrospective, single-center study, it was aimed to determine the serotype distribution and antimicrobial resistance in Streptococcus pneumoniae isolates of pediatric patients with invasive pneumococcal disease (IPD) after the introduction of PVC7 and PVC13. Fifty pediatric patients diagnosed with meningitis and sepsis/bacteremia between October 2009 and October 2019 were included in the study. The pediatric patient group consisted of previously healthy patients diagnosed with meningitis and sepsis/bacteremia with S.pneumoniae isolated in their blood or cerebrospinal fluids. Patients with pneumonia-associated bacteremia and empyema were not included in the study. Serotyping of the isolates was performed by Quellung reaction using specific antisera (Statens Serum Institute, Denmark) and antibiotic (penicillin and ceftriaxone) susceptibility was determined by antibiotic gradient method based on Clinical Laboratory Standards Institute (CLSI) criteria. Of the children, 29 (58%) were boys and 21 (42%) were girls. The median age of the patients was 19 months (1 month-18 year). When the children under the age of five were evaluated, it was found that 30 (79%) patients were diagnosed with occult bacteremia/sepsis and 8 (21%) with meningitis. The overall annual incidence rate of IPD among the healthy children aged <5 years decreased significantly from 9.35/100000 to 0.83/100000 (p< 0.001). Serotype identification was determined for 44 of 50 pneumococcal isolates . However, since six patients with underlying disease were not included in the evaluation, the remaining 38 isolates were found to be one of the serotypes included in PCV7 and PCV13 at a rate of 28.9% (n= 11) and 44.7% (n= 17), respectively. While the rate of PCV13 serotypes seen in the PCV7 period was 81.8%, this rate decreased to 29.6% within eight years after PCV13 administration. The rate of non-vaccine serotypes was determined as 54.5% in PCV7 period and 70.3% in PCV13 period. The rate of non-vaccine serotypes in patients under 5 years was 60% in the period of PCV7 and 75% in the period of PCV13. The proportion of non-vaccine serotypes has increased over time. However, this difference was not statistically significant (p> 0.05). The most common serotypes detected in isolates were 19F, 23F, 7F, 31 and 24B. According to the minimum inhibitory concentration values of the isolates recovered from patients with meningitis, penicillin and ceftriaxone resistance rates were found as 43.9% and 9.8%, respectively. In conclusion, our study showed that there was a 91.1% decrease in the incidence of IPD in healthy children aged under five years after the implementation of PCV7 and PCV13. It was determined that while the rate of serotypes in vaccine content decreased, there was an increase in non-vaccine serotypes. In addition no significant change was observed in antibiotic resistance rates over the years.

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.

The Impact of Arterial Phase on the Detection of Cervical Lymph Node Metastasis From Papillary Thyroid Carcinoma: A Quantitative Evaluation on Multiphasic Computed Tomography.

OBJECTIVE: The purpose of this study was to assess the diagnostic performance of multiphasic computed tomography (CT) in the discrimination of metastatic lymph nodes (LNs) of papillary thyroid cancer by using quantitative parameters. METHODS: This study enrolled 272 pathologically proven metastatic and benign LNs. Multiphasic CT was utilized by using nonenhanced, arterial (25-second delay), and venous (80-second delay) phases. Mean tissue attenuation values (MAVs) of metastatic and benign LNs were measured, and normalized MAV (common carotid artery and paraspinal muscle) and wash-in and wash-out percentages were also calculated. RESULTS: The arterial phase showed the highest diagnostic performance in differentiation (area under the curve ± standard error, 0.97 ± 0.02; 95% confidence interval, 0.94-1.0; P < 0.001). Cutoff values for MAVs, normalized MAVs, and wash-in and wash-out percentages to predict metastatic LNs were calculated as 109 HU, 0.33, 1.93, 122.5, and -5.6 (sensitivity: 93.4%, 93.3%, 90.4%, 94.1%, and 97.8%, and specificity: 99.3%, 90.4%, 98.5%, 92.6%, and 99.3%, respectively). CONCLUSIONS: Early-phase enhanced CT and the use of quantitative parameters derived from multiphasic CT improve the detection of cervical lymph node metastasis from papillary thyroid cancer.

Clinical Features and HSCT Outcome for SCID in Turkey.

Severe combined immunodeficiency (SCID) is the most serious PID, characterized by T cell lymphopenia and lack of antigen-specific T cell and B cell immune responses, inevitably leading to death within the first year of life if hematopoietic stem cell transplantation (HSCT) is not performed. PURPOSE AND METHODS: Since SCID is a common type of PID with an estimated incidence of 1/10.000 in Turkey, a retrospective analysis of HSCT characteristics, survival, immune recovery, and the major clinical features of SCID prior to HSCT is the aim of this multi-transplant center-based analysis. RESULTS: A total of 234 SCID patients transplanted between the years 1994 and 2014 were included in the study. Median age at diagnosis was 5 months, at transplantation, 7 months, B- phenotype and RAGs were the most common defects among others. Immune phenotype did not seem to have an effect on survival rate (p > 0.05), Immunoglobulin (Ig) requirement following HSCT did not differ between B+ and B- phenotypes (p > 0.05). Overall survival rate was 65.7% over a period of 20 years. It increased from 54% (1994-2004) to 69% (p = 0.052) during the last 10 years (2005-2014). Ten-year survival after HSCT has improved over time although the difference was not significant. Infection at the time of transplantation (p = 0.006), mismatched related donor (MMRD) (haploidentical parents), and matched unrelated donor (MUD) donor transplants p < 0.001 were the most important factors, significantly affecting the outcome. CONCLUSIONS: This is the first multicenter study with the largest data obtained from transplanted SCID patients in Turkey. Early diagnosis with newborn screening (NBS) together with emerging referrals, treatment by transplantation centers, and specialized teams are mandatory in countries with high parental consanguinity such as Turkey.

Clinical features and disease severity of Turkish FMF children carrying E148Q mutation.

BACKGROUND: Familial Mediterranean fever (FMF) is the most common hereditary monogenic autoinflammatory disease caused by mutations in the MEFV gene. It is controversial whether E148Q alteration is an insignificant variant or a disease-causing mutation. The aim of this study was to evaluate the clinical features and disease severity of FMF patients carrying E148Q mutation. METHODS: Files of FMF patients were retrospectively evaluated. Patients with at least one E148Q mutation were included to the study. The clinical characteristics and disease severity of the patients who were carrying only E148Q mutation were compared with the patients who were compound heterozygous for E148Q and homozygous for M694V mutation. RESULTS: The study group comprised 33 patients who were homozygous or heterozygous for E148Q; 34 with compound heterozygous E148Q mutations and 86 patients who had homozygous M694V mutation. Patients who had only E148Q mutation were found to have the oldest mean age of disease onset and lowest mean disease severity score. Attack frequency and colchicine doses were lower in patients with only E148Q mutation as compared with the other two groups. The frequency of clinical findings such as fever, abdominal pain, arthralgia, and arthritis among the three groups was similar. CONCLUSION: Familial Mediterranean fever patients with only E148Q mutation are presenting with late-onset and milder disease course despite having similar clinical findings as compared with patients who had other mutations. Finally, we imply that E148Q is a mutation and colchicine treatment should be given.

Evaluation of Extramural Venous Invasion by Diffusion-Weighted Magnetic Resonance Imaging and Computed Tomography in Rectal Adenocarcinoma.

PURPOSE: The aim of this study is to evaluate the diagnostic contribution of diffusion-weighted magnetic resonance imaging (MRI) and computed tomography (CT) to distinguish extramural venous invasion (EMVI) in rectal adenocarcinoma. MATERIALS AND METHODS: Fifty-eight patients who had been diagnosed with rectal adenocarcinoma (30 patients with EMVI and 28 patients without EMVI) were enrolled in the study. Apparent diffusion coefficient (ADC) values of the tumour and the EMVI (+) vein, the lengths of the tumours were measured on MRI. The diameters of the superior rectal vein (SRV)-inferior mesenteric vein (IMV) and distant metastatic spread were evaluated on CT. The ability of these findings to detect EMVI was assessed using receiver operating characteristic (ROC) analysis. Pathology was accepted as the reference test for EMVI. RESULTS: Mean diameters of the SRV (4.9 ± 0.9 mm vs 3.7 ± 0.8 mm) and IMV (6.9 ± 0.8 mm vs 5.4 ± 0.9 mm) were significantly larger (P < .001) and tumour ADC values were significantly lower (0.926 ± 0.281 × 10-3 mm2/s vs 1.026 ± 0.246 × 10-3 mm2/s; P = .032) in EMVI (+) patients. Diameters of 3.95 mm for the SRV (area under the curve [AUC] ± standard error [SE]: 0.851 ± 0.051, P < .001, sensitivity: 93.3%, specificity: 67.9%) and 5.95 mm for the IMV (AUC ± SE: 0.893 ± 0.040, P < .001, sensitivity: 93.3%, specificity: 71.4%) and an ADC value of 0.929 × 10-3 mm2/s (AUC ± SE: 0.664 ± 0.072, P = .032 sensitivity: 76.7%, specificity: 57.1%) were found to be cutoff values, determined by ROC analysis, for detection of EMVI. Distant metastases were significantly more prevalent in EMVI (+) patients (P < .001). CONCLUSION: The measurement of ADC values and SRV-IMV diameters seems to have contribution for diagnosis of EMVI in rectal adenocarcinoma. EMVI (+) patients appear to have higher risks of distant metastases at diagnosis.

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.