The Role of Superb Microvascular Imaging and Shear Wave Elastography in Differentiation of Thyroid Nodules from Intrathyroidal Ectopic Thymus in Children.

BACKGROUND: Ectopic thymus could be located intrathyroidal, therefore fine ultrasound details are useful for this differentiation. AIM: To investigate differences in stiffness and vascularity properties among thyroid nodules and intrathyroidal ectopic thymus (IET) by obtaining quantitative data in children. PATIENTS AND METHODS: Twenty-seven thyroid nodules and 20 IET in children were evaluated in terms of vascularity index (VI) via superb microvascular imaging (SMI) and stiffness by shear wave elastography (SWE). Differences in the volume, VI, and SWE parameters of the lesions were assessed by using the Mann-Whitney U test. Association of the age, lesion volume, SWE, and VI parameters was investigated by using Spearman's correlation analysis. The optimal cut-off values for stiffness and vascularity in the differentiation of nodules from IET were calculated with ROC analysis. RESULTS: The median (range) age of the participants with thyroid nodules and IET were 15.6 (10-18) years and 8.8 (3-14) years, respectively. The medians (range) VI of the IET and thyroid nodules were 4.7 (0.2-16) % and 23.8 (7.5-40)%, respectively. The median SWE values were 7.6 (4.4-9.5) kPa and 15.58 (8.5-23.4) kPa for IET and nodules, respectively. There have been highly significant differences among medians of volume, SWE, and VI values of the lesions. Significant positive correlations were found between VI and SWE parameters (p=0.001, r=0.64), and volume with VI (p=0.018, r=0.34) and SWE (p:0.001, r= 0.5). The diagnostic accuracies were 93%, 91% with the cut-off values as 9.2 kPa, 13% for the SWE and SMI, respectively. IETs were found to be less vascular and less stiff than thyroid nodules. CONCLUSIONS: IETs could be easily and confidently differentiated from nodules using SWE and SMI quantifications. This discrimination prompts the reduction of unnecessary interventional procedures.

Heart and Aorta Anomalies in Turner Syndrome and Relation with Karyotype.

OBJECTIVES: Turner Syndrome (TS) is associated with a high risk of cardiac anomalies and cardiovascular disease. We aimed to evaluate patients with TS (n=33) for cardiac and aortic pathology using thorax magnetic resonance angiography (MRA). SUBJECTS AND METHODS: Clinical findings, karyotypes, echocardiogram (ECHO) findings and thorax MRA results were evaluated. Aortic dimensions were measured and standard Z scores of aortic diameters along with aortic size index (ASI) were calculated. RESULTS: Mean age of the patients was 13.7±3.4 years. MRA revealed cardiovascular pathology in 10 patients (30%). CoA (n=4), aberrant right subclavian artery (n=3), dilatation of the ascending aorta (n=1), tortuosity of the descending aorta (n=1) and fusiform dilatation of the left subclavian artery (n=1) were found. Two of the four patients with CoA found on MRA were detected with ECHO. Mean diameter of the sinotubular junction was found to be elevated [mean±SD: 2.4±1.5]. Z scores for the diameters of the isthmus, ascending aorta and descending aorta were in normal ranges. 45,X patients were found to have significantly higher ASI values than non 45,X patients (p=0.036). CONCLUSION: Our findings indicate that patients with TS should be evaluated with MR imaging studies in addition to ECHO to reveal additional subtle cardiac and vascular anomalies. CoA which is very distally located or which has mild nature may not be seen by ECHO. The increase in ASI observed in 45,X patients may herald the development of life-threatening complications. Therefore, frequent follow-up is warranted in these patients.

The efficacy of maxillary and mandibular nerve blockade using electrical nerve stimulation for guidance.

BACKGROUND: In oral and maxillofacial surgical procedures, sometimes conventional loco-regional anesthesia techniques could be insufficient in daily clinical practice. The aim of this study was to evaluate the efficacy of analgesia using electrical nerve stimulation (ENS) for maxillary or mandibular nerve blockade, in comparison with conventional loco-regional anesthesia techniques. METHODS: The study comprised 52 patients who were attending the department for advanced surgery of the upper and lower jaw. Patients were randomly divided into 2 groups: ENS and Local group. The predictor variable was the anesthesia technique (ENS and Local groups). The outcome variables were patient assessed pain levels (VAS scores) and total anesthetic dose. RESULTS: Both the administered anesthetic dose and patient-assessed pain levels were significantly lower in the ENS group than in the Local group, despite there being no difference in age, sex or any hemodynamic parameters between the groups. CONCLUSIONS: Maxillary and mandibular nerve blockade is more efficient with ENS guidance, with lower amounts of anesthetic required, compared to conventional loco-regional anesthesia.

THE ROLE OF THYROID FINE-NEEDLE ASPIRATION CYTOLOGY IN THE TREATMENT AND FOLLOW-UP OF THYROID NODULES IN THE PEDIATRIC POPULATION.

OBJECTIVE: Thyroid fine-needle aspiration (FNA) and cytology is a reliable diagnostic method used in the assessment of malignancy when evaluating thyroid nodules, in conjunction with clinical and ultrasonographic findings. The aim of this study is to compare clinical, ultrasonographic, cytological and histopathological findings in children who underwent thyroid FNA. METHODS: Subjects comprised 80 patients (52 female) aged 13.7±2.8 years at the time of FNA who where evaluated for thyroid nodules. Clinical, ultrasonographic and cytological findings of patients were evaluated retrospectively. RESULTS: Autoimmune thyroiditis was present in 30% and history of radiotherapy to the head or neck in 10%. The cytological diagnosis of patients included: inadequate or hemorrhagic sample in 10%; benign in 42.5%; atypia or follicular lesion of undetermined significance (AUS/FLUS) in 15%; suspicion of follicular neoplasia (SFN) in 7.5%; suspicion of malignancy (SM) in 8.8%; and malignant in 16.3%. Thirty-seven patients underwent thyroidectomy. Malignancy rates for histopathologic follow-up were 75%, 85.7% and 100% for SFN, SM and malignant categories, respectively. Only one benign and two AUS/FLUS FNAs were found to be malignant on histopathological examination. Among patients who had received radioiodinetherapy, 87.5% had malignancy. In this study, the sensitivity of FNA was 96%, specificity 50%, positive predictive value 90.9%, negative predictive value 75%, and diagnostic value of FNA was 89.2%. CONCLUSION: Thyroid FNA results were highly compatible with histopathological examination. Sensitivity, positive predictive value and diagnostic value of FNA were high.

Assessment of paediatric Hashimoto's thyroiditis using superb microvascular imaging.

AIM: To evaluate the role of superb microvascular imaging along with greyscale and Doppler imaging for thyroid gland evaluation in Hashimoto's thyroiditis (HT) versus control subjects. MATERIALS AND METHODS: The study included 33 healthy volunteers with normal ultrasound and laboratory findings and 70 patients with HT based on laboratory and sonographic findings who were undergoing follow-up and receiving medical treatment. HT patients were classified based on the modification of the scheme proposed by Sostre and Reyes that incorporates the extent of hypoechoic foci or patchy infiltration as grade A (foci involving <50% of the gland) and B (foci involving >50% of the gland). Thyroid volume, mean resistive indices, peak-systolic and end-diastolic velocities based on Doppler imaging, and vascularity index via superb microvascular imaging were obtained using a Canon Aplio 500 ultrasound device using a linear 10-14 MHz transducer. RESULTS: Patients with HT had significantly higher median thyroid volume and peak-systolic velocities (7.32 ml and 19 cm/s, respectively) compared to control subjects (4.62 ml and 16 cm/s, respectively). HT patients had significantly higher median vascularity index (VI; 13.5%) compared to control subjects (7.95%). A significant fair positive correlation with VI and anti-thyroglobulin antibody levels (r=0.356, p<0.05) and significant moderate positive correlation with VI and anti-thyroid peroxidase antibody levels (r=0.503, p<0.05) were found. In HT diagnosis, the optimal VI cut-off value was 10.58% with a sensitivity and specificity of 67.1% and 90%, respectively. CONCLUSION: Superb microvascular imaging appears to allow assessment of subtle vascularity changes in early HT stages that cannot be detected by Doppler parameters. This technique demonstrates excellent visualization of the microvascular structures and quantitative assessment based on a novel parameter such as VI.

Coeliac trunk and common hepatic artery variations in children: an analysis with computed tomography angiography.

BACKGROUND: Understanding the coeliac trunk (CeT) and hepatic artery anatomy is important not only in preventing iatrogenic injuries but also in planning surgical procedures in children. Therefore, the aim of this study is to analyse the prevalence of CeT and common hepatic artery (CHA) variations in the paediatric population. MATERIALS AND METHODS: One hundred and seventy-four children who underwent abdominal multidetector computed tomography (MDCT) angiography, either because of trauma or liver transplantation, were analysed retrospectively. The patterns of CeT, CHA and their variant branches were revealed and compared with previous studies involving adults. RESULTS: A total of 157 (90.2%) of the 174 patients had normal CeT anatomy, whereas 17 (9.8%) had variations. Five types of CeT variations were identified according to Song's classification in which 'hepatosplenic trunk + left gastric artery + superior mesenteric artery' was the most prevalent. One hundred-twelve (64.4%) of the 174 patients had normal CHA anatomy; however, 62 (35.6%) had variations. Six types of CHA variations were identified according to Michel's and Hiatt's classification. The most common was 'replaced left hepatic artery originating from left gastric artery'. CONCLUSIONS: The prevalences of CeT and hepatic artery variations are high in children, as they are in older patients. Awareness of these variations is important in terms of avoiding iatrogenic injury and in promoting surgical procedure planning for liver transplantation or abdominal tumour surgery.

Outcome of Otologic Symptoms after Temporomandibular Joint Arthrocentesis.

The objectives of this study were to determine the prevalence of otologic complaints in patients with temporomandibular joint (TMJ) closed lock (CL), and to evaluate the efficacy of arthrocentesis in temporomandibular disorder (TMD) patients with otologic symptoms. Fifty-seven patients with TMJ CL were included in this study. The pre-treatment evaluations included assessment of the maximum mouth opening (MMO); pain level in palpation of the affected TMJ; pain level with function; and otologic complaints, including otalgia, tinnitus, vertigo, and hearing loss. Arthrocentesis treatment was performed for all the patients, and post-treatment data were recorded 1 month later. Before arthrocentesis and lavage, the mean MMO was 24.67 ± 4.61 mm; the mean tenderness score was 7.02 ± 1.09; and the mean score for pain in function was 6.86 ± 1.31. Following TMJ arthrocentesis and lavage, the mean MMO was 39.81 mm ± 4.56 mm; the mean tenderness score was 2.37 ± 0.65; and the mean score for pain in function was 2.45 ± 0.69. Seventeen (29.82%) patients reported at least 1 otologic complaint, 17 (29.82%) patients reported otalgia, and 8 (14.04%) patients reported tinnitus. Vertigo was noted in 5 (8.77%) patients. Complaints of hearing loss were not noted in any of the patients. After treatment, 14 patients no longer complained of otalgia, 5 patients no longer complained of tinnitus, and 2 patients no longer complained of vertigo. This represented a significant improvement in the patients' condition, especially in patients with otalgia (P < 0.0006). As evident from the results of this study, arthrocentesis procedures reduce both TMD symptoms and otologic complaints.

The use of stentless valves for root replacement during repair of ascending aortic aneurysms with aortic valve regurgitation.

BACKGROUND: Early and mid-term results of stentless valves for the treatment of ascending aortic aneurysm (AAA) were evaluated in a retrospective manner. MATERIAL AND METHODS: During a four-year period, 26 patients with ascending aortic aneurysms and aortic valve insufficiency underwent a total root replacement procedure using a stentless "Freestyle" valve (Medtronic Inc., Minneapolis MN). Mean age was 71 +/- 4 years (range 66 to 79 years). Eight patients were in NYHA Class 2, 13 in Class 3, and 5 in Class 4. Cardiopulmonary bypass (CPB) was begun with femoral artery-right atrium (two-stage) cannulation in all cases but four, in which the right axillary artery was used. Myocardial protection was established by retrograde, cold-blood cardioplegia and direct antegrade blood cardioplegia from the right coronary ostium. The left ventricle outflow tract was constructed by using 2-0 ticron sutures and incorporating a pericardial strip in between. Coronary buttons were sewn to the xenograft with 6-0 polypropylene sutures. Meanwhile, the patient was cooled down to 18 degrees nasopharyngeal temperature and the distal anastomosis with the proximal arch was performed with a Dacron graft under total circulatory arrest (TCA), using 4-0 polypropylene sutures. During rewarming, the connection between the Freestyle valve and the Dacron graft was performed. RESULTS: Ischemic time was 91 +/- 11 minutes and TCA time was 9 +/- 4 minutes. Operative mortality was zero, and there was one 30-day mortality (3.8%). At discharge, all 25 patients had a functional valve with low transvalvular gradients. Patients were followed for a mean period of 15 months, with one patient being lost to follow-up and one patient dying of non-cardiac causes. Follow-up was 97% complete, and echocardiographic control during the follow-up period revealed competent valves with gradients comparable to those at discharge. Two patients were screened with electron beam tomography (EBT) three years after the operation and there was no sign of wall or leaflet calcification. At the end of the 15 months (mean) follow-up, the functional capacity of the patients had improved significantly (p <0.05). CONCLUSIONS: Our early results suggest that use of the Freestyle valve in conjunction with a Dacron tube graft can be a good alternative for patients over 65 years of age who present with ascending aortic aneurysm with aortic valve insufficiency.

Does off-pump coronary artery bypass surgery reduce mortality in high risk patients?

BACKGROUND: The aim of this retrospective study was to compare outcome in two groups of patients who were classified according to their risk groups and underwent coronary revascularization with or without cardiopulmonary bypass. MATERIAL AND METHODS: Between January 1996 and July 2000, 480 cases that underwent coronary artery bypass surgery (CABG) were included in a retrospective nonrandomized manner for study. Group 1 included 210 patients who were revascularized using off-pump techniques. Octopus 2 and 3 (Medtronic, Inc., Minneapolis, MN) were used for tissue stabilization. Group 2 included 270 cases who underwent CABG using CPB. Emergency cases, combined operations, reoperations, and patients in cardiogenic shock were excluded. Demographic variables were comparable between two the groups. Using the Allegheny Clinic Risk Scoring Scale [Magovern 1996], patients in both groups were scored as low, moderate, and high risk. In Group 1, 37 % of patients consisted of high risk patients while Group 2 had 14% (p < 0.05). Student's t-test and chi-square test were used for statistical analysis and alfa < 0.05 was considered significant. RESULTS: Mortality was 1.4% in Group 1 and 1.5% in Group 2 (p = ns). Mean anastomosis per patient was 2.6 +/- 0.6 in Group 1 and 3.2 +/- 0.5 in Group 2 (p < 0.05). Patients in Group 1 needed less blood transfusions and less inotropic support postoperatively (p < 0.05). There were also fewer minor neurological events (p < 0.05) and pulmonary complications (Type 2) in Group 1. Atrial fibrillation rate, infection, and major neurological deficit (Type 1) were similar in both groups. Mortality was less among Group 1 high risk patients (3.9 %) in comparison to Group 2 high risk patients (7.9 %), but this did not reach statistical significance. CONCLUSIONS: In low or moderate risk patients, CABG can be performed safely with or without CPB. In high risk patients with several comorbidities, off-pump CABG seems to be a safe and efficient method that can improve outcome.

Immobilization of alpha-amylase into photographic gelatin by chemical cross-linking.

alpha-Amylase was immobilized into photographic gelatin by chemical cross-linking with chromium (III) acetate and chromium (III) sulphate. Cellulose triacetate film strips, enabled simple handling when coated with an alpha-amylase-gelatin mixture, accomplishing a high degree of durability during consecutive immersions into reaction media. The optimum conditions for pH, substrate concentration, temperature, incubation time and storing conditions of free and immobilized alpha-amylase were determined. The effect of use number on activity and the effect of resting on reuse number were also determined. Photographic gelatin was found to be a very efficient natural polymer, due to its extraordinary diffusion characteristics for immobilization as a carrier.

A psychosomatic investigation of Behçet's disease.

The psychiatric investigation of 55 Behçet patients through a psychoanalytically oriented interview and the application of the Rorschach test revealed that psychosocial stress factors were predominant prior to the onset of the disease. The personality structures, according to the Rorschach findings, were generally pathological with a weak ego, regressive tendencies, disturbed body image, high anxiety, difficulties in social adaptation and evaluation of realities as well as incapacity of an adequate expression and handling of affects and emotions. The stressful life events, as well as disturbed personality structures seen in these patients are common to most psychosomatic manifestations. Considering the recent research emphasizing the effects of immune mechanisms in the etiology of this disease, together with the relationship of autonomic system functions with immune reactions as also with psychological stress situations, it is discussed whether psychosocial stress and weak personality structures can be assumed to be one of the possible effective factors in the etiopathogenesis of this disease, at least as precipitating agents.