Unveiling the potential of strain elastography in perihilar cholangiocarcinoma biopsies.

PURPOSE: This study was conducted to investigate the effectiveness of strain elastography in guiding precise and sufficient tissue sampling for perihilar cholangiocarcinoma (CCA) biopsies. METHODS: Our retrospective analysis included 23 liver biopsies conducted between March 2019 and July 2022 for suspected perihilar CCA. An experienced radiologist performed the biopsies via an ultrasound machine with elastography configuration. Tissue stiffness color maps were used for guiding when the biopsies were performed. Strain index value calculations were made by radiologists on recorded images. RESULTS: Patient demographics revealed a mean age of 65.17 ± 9.25 years, with a gender distribution of six females and 17 males. Gray-scale examinations unveiled diverse echogenic characteristics in liver lesions. Elastography-guided biopsies demonstrated no need for repeats, while gray-scale biopsies necessitated re-biopsy in four patients, resulting in cholangiocarcinoma diagnosis (P = 0.037). Strain index values showcased strong inter- and intra-observer agreements (P < 0.001). Notably, no post-biopsy complications emerged in either study group. CONCLUSION: The diagnostic advantage of elastography, particularly in enhancing accuracy in challenging isoechoic lesions, was demonstrated, although the substantial overlap between strain index values of benign and malignant liver masses limits clinical usefulness of this technique.

Use of dose-volume histograms for metabolic response prediction in hepatocellular carcinoma patients undergoing transarterial radioembolization with Y-90 resin microspheres.

INTRODUCTION: Voxel-based dosimetry offers improved outcomes in the treatment of hepatocellular carcinoma (HCC) with transarterial radioembolization (TARE) using glass microspheres. However, the adaptation of voxel-based dosimetry to resin-based microspheres has been poorly studied, and the prognostic relevance of heterogeneous dose distribution remains unclear. This study aims to explore the use of dose-volume histograms for resin microspheres and to determine thresholds for objective metabolic response in HCC patients treated with resin-based TARE. METHODS: We retrospectively reviewed HCC patients who underwent TARE with Y-90-loaded resin microspheres in our institution between January 2021 and December 2022. Voxel-based dosimetry was performed on post-treatment Y-90 PET/CT images to extract parameters including mean dose absorbed by the tumor (mTD), the percentage of the targeted tumor volume (pTV), and the minimum doses absorbed by consecutive percentages within the tumor volume (D10, D25, D50, D75, D90). Assessment of metabolic response was done according to PERCIST criteria with F-18 FDG PET/CT imaging at 8-12 weeks after the treatment. RESULTS: This study included 35 lesions targeted with 22 TARE sessions in 19 patients (15 males, 4 females, mean age 60 ± 13 years). Objective metabolic response was achieved in 43% of the lesions (n = 15). Responsive lesions had significantly higher mTD, pTV, and D25-D90 values (all p < 0.05). Optimal cut-off values for mTD, pTV, and D50 were 94.6 Gy (sensitivity 73%, specificity 70%, AUC 0.72), 94% (sensitivity 73%, specificity 55%, AUC 0.64), and 91 Gy (sensitivity 80%, specificity 80%, AUC 0.80), respectively. CONCLUSION: Parameters derived from dose-volume histograms could offer valuable insights for predicting objective metabolic response in HCC patients treated with resin-based TARE. If verified with larger prospective cohorts, these parameters could enhance the precision of dose distribution and potentially optimize treatment outcomes.

Effects of Focal Cerebellar Injury on Fracture Healing and Oxidative Stress in Rat Model: An Experimental Animal Study.

AIM: To examine the effect of cerebellar damage on the process of fracture healing. MATERIAL AND METHODS: A total of forty-two male rats were selected at random and subsequently allocated into three distinct groups. The experimentals were divided into two subgroups within each group, with the intention of sacrificing them during the third and sixth weeks. Group 1 had isolated femoral fracture, Group 2 had femoral fracture after craniotomy, and Group 3 had femoral fracture accompanying cerebellar injury after craniotomy. Left femoral fractures in rats in all groups were treated using an intramedullary Kirschner wire. Radiological, histological, and biochemical evaluations were conducted at 3 and 6 weeks to assess the processes of fracture healing. To determine the effects of fracture healing and cerebellar injury on oxidant-antioxidant systems, catalase (CAT), malondialdehyde, superoxide dismutase (SOD), and glutathione peroxidase (GPx) activities were measured. RESULTS: Between the time frame of 3 to 6 weeks, Group 3 had higher radiography scores, alkaline phosphatase levels, callus/ diaphyse ratio, callus improvement, and bone mineral density in comparison to the other groups. The activity of SOD was found to be statistically negligible in all groups, suggesting that SOD does not have a substantial impact on fracture healing in cerebellar injury. However, notable increases in the activity of GPx and CAT enzymes were observed, showing their considerable involvement in the process of fracture healing. CONCLUSION: Cerebellar injury reduces the oxidative stress in the fracture area and contributes positively to fracture healing by means of radiologically, biochemically and histopathologically.

Lung ultrasound score in the decision of patent ductus arteriosus closure in neonates.

PURPOSE: We aimed to investigate the role of lung ultrasound (LUS) score in the closure of hemodynamically insignificant patent ductus arteriosus (PDA) and the clinical findings of the patients before and after closure. METHODS: The study groups (107 preterm neonates under 34 gestational weeks) were classified as hemodynamically significant PDA (group 1), hemodynamically insignificant PDA with closure therapy (group 2), hemodynamically insignificant PDA without closure therapy (group 3), and no PDA group (group 4) based on the echocardiography. 6- and 10-region LUS scores were compared for each group. RESULTS: There was a significant difference between groups 1 and 3 on first, third, and seventh days. In contrast, groups 1 and 2 had similar LUS scores on the first, third, and seventh days. There was a negative correlation between LUS scores on the first and third days and gestational age, birth weight, the first- and fifth-minute APGAR scores, and there was a positive correlation between aortic root to left atrium ratio, and PDA diameter/weight ratio. CONCLUSION: We observed that LUS scores in patients with hemodynamically insignificant PDA treated with closure therapy were similar to in patients with hemodynamically significant PDA. Thus, LUS score can have role in PDA closure in preterm neonates. However, more comprehensive studies are needed.

Long-term effect of indomethacin on a rat model of neonatal hypoxia ischemic encephalopathy through behavioral tests.

BACKGROUND: Many medical experts prescribe indomethacin because of its anti-inflammatory, analgesic, tocolytic, and duct closure effects. This article presents an evaluation of the enduring impact of indomethacin on neonatal rats with hypoxic-ischemic (HI) insults, employing behavioral tests as a method of assessment. METHODS: The experiment was conducted on male Wistar-Albino rats weighing 10 to 15 g, aged between seven and 10 days. The rats were divided into three groups using a random allocation method as follows: hypoxic ischemic encephalopathy (HIE) group, HIE treated with indomethacin group (INDO), and Sham group. A left common carotid artery ligation and hypoxia model was applied in both the HIE and INDO groups. The INDO group was treated with 4 mg/kg intraperitoneal indomethacin every 24 h for 3 days, while the Sham and HIE groups were given dimethylsulfoxide (DMSO). After 72 h, five rats from each group were sacrificed and brain tissue samples were stained with 2,3,5-Triphenyltetrazolium chloride (TCC) for infarct-volume measurement. Seven rats from each group were taken to the behavioral laboratory in the sixth postnatal week (PND42) and six from each group were sacrificed for the Evans blue (EB) experiment for blood-brain barrier (BBB) integrity evaluation. The open field (OF) test and Morris water maze (MWM) tests were performed. After behavioral tests, brain tissue were obtained and stained with TCC to assess the infarct volume. RESULTS: The significant increase in the time spent in the central area and the frequency of crossing to the center in the INDO group compared with the HIE group indicated that indomethacin decreased anxiety-like behavior (p < 0.001, p < 0.05). However, the MWM test revealed that indomethacin did not positively affect learning and memory performance (p > 0.05). Additionally, indomethacin significantly reduced infarct volume and neuropathological grading in adolescence (p < 0.05), although not statistically significant in the early period. Moreover, the EB experiment demonstrated that indomethacin effectively increased BBB integrity (p < 0.05). CONCLUSIONS: In this study, we have shown for the first time that indomethacin treatment can reduce levels of anxiety-like behavior and enhance levels of exploratory behavior in a neonatal rat model with HIE. It is necessary to determine whether nonsteroidal anti-inflammatory agents, such as indomethacin, should be used for adjuvant therapy in newborns with HIE.

A Prospective Randomized Trial: Does Full Weight Bearing Improve Functional Outcomes in Elderly Patients With Proximal Intramedullary Nailing After an Intertrochanteric Femur Fracture?

Introduction This study aimed to compare the functional outcomes and degree of independence in activities of daily living in patients aged >65 years who were treated with a proximal femoral nail (PFN) after an intertrochanteric femur fracture (ITFF) and underwent full and partial load-bearing in the early stage. Methods Overall, 133 patients who were hospitalized for ITFF and treated with PFN between August 2018 and March 2021 were randomly assigned to two groups. During the follow-up period, 45 patients who underwent partial load bearing (Group 1) and 40 patients who underwent full load bearing (Group 2) were prospectively evaluated. The Harris hip score was used for functional evaluation, and the Barthel index was used to evaluate the degree of independence in activities of daily living. Results The mean age of the patients included in the study was 76.67 ± 8.62 years. Regarding the comparison among groups in terms of age, sex, direction of fracture, reduction quality, fracture type, tip-apex distance, and surgical risk, there was no statistically significant difference between the two groups (p ≥ 0.05). Moreover, regarding the comparison in terms of calcium, phosphate, alkaline phosphatase, vitamin D, and keratin levels, which affect bone metabolism, no statistical difference was observed (p ≥ 0.05). We found that the mean Harris hip score was significantly higher in Group 1 than in Group 2 (Group 1: 76.82 ± 12.48; Group 2: 67.80 ± 15.34; p = 0.004). Moreover, 73.3% (n=33) and 42.5% (n=17) of patients in Groups 1 and 2 were fully independent or mildly dependent, respectively. We also found that the independence status was significantly better in Group 1 (p = 0.004). Conclusion Mobilization of older patients treated with PFN after ITFF using partial load-bearing protocols in the early postoperative period positively impacts hip function and the ability to perform activities of daily living independently.

Comparison of the complications and long-term results of heparin-coated and non-heparin-coated symmetric-tip hemodialysis catheters.

BACKGROUND: Tunneled catheters are effectively used in patients receiving chronic dialysis due to end-stage renal disease. However, the dysfunction of catheters caused by infection or thrombus requires repetitive procedures. In this study, we aimed to compare the long-term results of heparin-coated and non-heparin-coated tunneled dialysis catheters. METHOD: The study included a total of 161 patients who underwent tunneled dialysis catheter placement. Heparin-coated and non-heparin-coated tunneled catheters were placed in 81 and 80 patients, respectively. Of all the patients, 89 (55.3%) were male and 72 (44.7%) were female. The mean age of the patients was 64.3 ± 15.3 years. The patients were followed up for 12 months. RESULTS: Catheter infection developed in 10 (6.2%) of the cases, of which seven (70%) resolved with antibiotic therapy and the remaining three (30%) required catheter replacement. There was no significant difference between the groups in terms of the catheter infection rate (p = 0.84). Fibrin sheaths developed in nine (5.5%) patients. Fibrin sheath development was found to be significantly higher in the non-heparin-coated catheters (p = 0.017). There was no significant difference in fibrin sheath formation between the patients with and without systemic antiaggregant use (p = 0.864). The mean catheter durability time was determined to be 11 months in both groups (p = 0.704). Catheter survival was similar in heparin-coated and non-heparin coated catheters. CONCLUSION: This study showed that the rate of fibrin sheath development was significantly lower in heparin-coated tunneled catheters than non-heparin-coated catheters. There was no significant difference between the two catheters in terms of the rates of infection and mechanical complications.

Smith c/b ratio and teardrop figure measurements; Can it be used in the follow-up of patients who underwent salter innominate osteotomy?

BACKGROUND: This study aimed to investigate the effectiveness of radiological parameters used in the follow-up of patients who underwent salter innominate osteotomy (SIO) for the treatment of developmental dysplasia of the hip. METHODS: Acetabular index, c/b ratio, teardrop width, femoral head teardrop distance (TDD), and acetabular teardrop angle were measured on anteroposterior pelvic radiographs of patients who underwent SIO between 2017 and 2020. The patients were divided into 2 groups according to their preoperative Tönnis stage. Twenty-five (51%) hips of 23 patients with Tönnis stage 2 were classified into group 1, and 24 (49%) of 17 patients with Tönnis stages 3 and 4 were classified into group 2. Changes in radiologic parameters over time and between the groups were statistically evaluated. RESULTS: The study included 49 hips of 40 patients (37 female and 3 male). The age at surgery was 26.53 (18-53) months. After a mean follow-up period of 33.7 ± 12.8 months, there was no statistically significant difference between Groups 1 and 2 in terms of clinical, radiological and femoral head avascular necrosis results (P = .591, P = 956, P = .492). The changes in radiological parameters over time and between groups were statistically significant. (P < .001). Only the TDD and c/b ratio were significantly different between groups 1 and 2 (P = .002 and P < .001, respectively). CONCLUSION: In our study, along with acetabular index, the c/b ratio, teardrop width, TDD, and acetabular teardrop angle significantly changed after SIO and could be used as a guide for patient follow-up.

The Impacts of Clozapine Use on the Risk and Outcomes of COVID-19 Disease in Patients with Schizophrenia.

Introduction: Clozapine may affect the outcome of severe COVID-19 infection due to its anti-inflammatory and immunosuppressant effects. This study aimed to investigate whether the risk of COVID-19 changed in schizophrenic patients using clozapine and to compare patients using clozapine with other antipsychotics in terms of COVID-19 severity. Methods: A total of 732 patients who were registered and followed up with a diagnosis of schizophrenia were included in the study. These patients' sociodemographic data, smoking status, medications, comorbidities, COVID-19 PCR results, and COVID-19 outcomes (inpatient care admission, intensive care unit admission, death) were retrospectively analyzed. Results: Of the 732 patients included in our study, 177 were using clozapine. Ninety-six of 732 patients were diagnosed with COVID-19, and 34 of these were being treated with clozapine. We found that clozapine use was an independent risk factor for COVID-19 positivity (OR=1.81 95% CI=1.13-2.90), inpatient care admission (OR=3.01, 95% CI=1.12-8.06). Conclusion: In our study, clozapine use was associated with an increased risk of COVID-19 positivity and inpatient care admission; however, it was not associated with ICU admission or death. Due to the frequent follow-up of patients using clozapine and the effects of clozapine on immunity, the frequency and/or identification of COVID-19 may be increased in these patients. Clozapine toxicity, granulocytopenia or agranulocytosis during the COVID-19 infection may have increased these patients' hospitalisation frequency.

Gemcitabine-associated digital necrosis in metastatic breast cancer.

INTRODUCTION: Gemcitabine is a nucleoside analog antimetabolite used in various malignancies, including metastatic breast cancer. Objective response rates in its use as a single agent in the treatment of metastatic breast cancer are not to be underestimated. Cutaneous, hematological, pulmonary, and vascular side effects are well-known side effects. Venous thromboembolism may occur with antineoplastics, such as platinum compounds. Arterial thromboembolism is rare in cancer, almost rare with chemotherapy. Here, we present a metastatic breast cancer patient who had digital necrosis due to arterial occlusion with gemcitabine monotherapy. CASE REPORT: A 54-year-old metastatic breast cancer female patient had digital ischemia and necrosis in the left hand's fifth finger after the second course of single-agent gemcitabine as the fourth line setting. Gemcitabine was discontinued, and medical treatment was started. Thrombus was detected in the left subclavian artery digital angiography. Balloon angioplasty and stenting were applied. However, digital amputation had to be performed since tissue necrosis had not regressed despite radiological interventions and medical treatment. MANAGEMENT AND OUTCOME: Gemcitabine was discontinued. Low molecular weight heparin and acetylsalicylic acid were started. The distal phalanx was amputated due to necrosis during follow-up. Gemcitabine was permanently stopped. DISCUSSION: Gemcitabine-related vascular events, including arterial thrombosis, may also occur in cancer patients, especially those with higher tumor burden. Therefore, predisposing factors for hypercoagulability and vascular occlusion should be questioned in more detail even before starting antineoplastics which are known to have a lower risk for thrombosis, such as gemcitabine monotherapy.

Mutation Spectrum of ß-Thalassemia in Some Ethnic Groups of North Maharashtra, India.

Beta-thalassemia is the most common inherited single-gene disorder in the world, caused by more than 200 known mutations in the HBB gene. In India, the average prevalence of ß-thalassemia carriers is 3-4%. Several ethnic groups have a much higher prevalence, about 8% in the tribal groups, according to the 2011 census. The study's main goal is to identify common ß-thalassemia mutations and the frequencies of different haplotypes in various communities in North Maharashtra. Nashik district had the highest prevalence of ß-thalassemia (34%), followed by Ahmednagar (29%), Jalgaon (16%), Dhule (14%), and Nandurbar (7.0%). Prevalence of ß-thalassemia was highest in the schedule caste community (SC) (48%), followed by (17%) in Muslims, (14%) in other backward classes (OBC), (13%) in Schedule Tribe (ST), and (8.0%) in the general population The six most common ß-thalassemia mutations detected in this study are IVS 1 > 5 (G→C), Cd 15(G→A), Cd 41/41 (-TCTT), Cd 8/9(+G), IVS 1 > 1(G→T) and Cap + 1(A > G). Among these mutations, IVS 1 > 5 (G > C) was the most common type of mutation found in ß-thalassemia patients in the North Maharashtra population. Type-I haplotype was the most prevalent among all communities. Nashik and Ahmednagar districts were highly affected by ß-thalassemia. Among different ethnic groups, the SC and Muslim communities were the worst affected with a higher proportion of ß-thalassemia and increased frequency of mutations.

Comparison of two surgical techniques for Lisfranc injuries; closed reduction and fixation versus primary partial arthrodesis.

BACKGROUND: This study reviewed the outcomes of Lisfranc injuries treated by primary partial arthrodesis (PPA) or closed re-duction and internal fixation (CRIF). METHODS: A retrospective review was made of patients who underwent PPA or CRIF for a Lisfranc injury after low-energy trauma, and follow-up was assessed according to radiographic, and clinical outcomes. A total of 45 patients with a median age of 38 years were followed up for an average of 47 months. RESULTS: The average American orthopaedic foot and ankle society (AOFAS) score was 83.6 points in the PPA group and 86.2 points in CRIF group (p>0.05). The mean pain score was 32.9 in the PPA group, 33.7 in the CRIF group (p>0.05). Secondary surgery for symptomatic hardware was required in 78% of the CRIF group and in 42% of the PPA group (p<0.05). CONCLUSION: Treatment of low-energy Lisfranc injuries with either PPA or closed reduction and fixation produced good clinical and radiological outcomes. The total AOFAS scores were comparable between two groups. However, the function and pain scores were seen to improve more with closed reduction and fixation while there was a greater requirement for secondary surgery in the CRIF group.

Percutaneous treatment of giant hydatid cysts: a single-center experience of 58 cysts.

PURPOSE: The aim of this study is to evaluate the efficacy of percutaneous treatment in hydatid cysts (HCs) with at least one diameter larger than 10 cm. MATERIALS AND METHODS: 58 CE1 or CE3a HCs with at least one diameter larger than 10 cm which were treated with catheterization between September 2016 and December 2021 were retrospectively analyzed. RESULTS: Mean age was 40 ± 17.7 (18-80). Majority of HCs were in the liver (89.6%). Median follow-up was 28 months. Technical success rate was 100%; however, a second procedure was needed in 13 cysts due to recollection (n = 4), infection (n = 6), and recurrence (n = 3). CONCLUSIONS: Giant HCs can be effectively treated with catheterization with low complication rates.

Etiology of genetic muscle disorders induced by mutations in fast and slow skeletal MyBP-C paralogs.

Skeletal muscle, a highly complex muscle type in the eukaryotic system, is characterized by different muscle subtypes and functions associated with specific myosin isoforms. As a result, skeletal muscle is the target of numerous diseases, including distal arthrogryposes (DAs). Clinically, DAs are a distinct disorder characterized by variation in the presence of contractures in two or more distal limb joints without neurological issues. DAs are inherited, and up to 40% of patients with this condition have mutations in genes that encode sarcomeric protein, including myosin heavy chains, troponins, and tropomyosin, as well as myosin binding protein-C (MYBPC). Our research group and others are actively studying the specific role of MYBPC in skeletal muscles. The MYBPC family of proteins plays a critical role in the contraction of striated muscles. More specifically, three paralogs of the MYBPC gene exist, and these are named after their predominant expression in slow-skeletal, fast-skeletal, and cardiac muscle as sMyBP-C, fMyBP-C, and cMyBP-C, respectively, and encoded by the MYBPC1, MYBPC2, and MYBPC3 genes, respectively. Although the physiology of various types of skeletal muscle diseases is well defined, the molecular mechanism underlying the pathological regulation of DAs remains to be elucidated. In this review article, we aim to highlight recent discoveries involving the role of skeletal muscle-specific sMyBP-C and fMyBP-C as well as their expression profile, localization in the sarcomere, and potential role(s) in regulating muscle contractility. Thus, this review provides an overall summary of MYBPC skeletal paralogs, their potential roles in skeletal muscle function, and future research directions.

Contribution of Multilevel Transformainal Lumbar Interbody Fusion Surgery to Restoration of Lumbar Lordosis in Patients with Degenerative Spine: Comparison of Long and Short Level Fusion.

AIM: To investigate the effect of multilevel transforaminal lumbar interbody fusion (TLIF) procedures in lumbar degenerative spine conditions on the restoration of lumbar lordosis (LL) in patients with short- and long-level fusion, and to examine the associated radiological results. MATERIAL AND METHODS: This retrospective study reviewed patients with degenerative spinal diseases who underwent lumbar fusion using a multilevel TLIF procedure. Patients with three or fewer segments involved in fusion were assigned to the shortlevel fusion group and those with more than three segments involved in fusion were assigned to the long-level fusion group. The anteroposterior and lateral spine radiographs of the patients were used to measure LL, distal lumbar lordosis and radiological parameters. RESULTS: The study included 47 patients who met the inclusion criteria, with a mean age of 60.4 ± 12.2 years. The mean follow-up time of our patients was 18.3 ± 11 months. Thirty-five (74.5%) patients were women and 12 (25.5%) were men. Overall, 12 patients underwent 3-level and 35 patients underwent 2-level TLIF. Long-level fusion was performed in 24 patients and short-level fusion was performed in 23 patients. CONCLUSION: Multilevel TLIF can be used to correct spinopelvic alignment when applied with the appropriate indications and techniques in patients with degenerative spinal disorders. Multilevel TLIF is associated with substantial improvements in LL, distal lumbar lordosis, and SVA (sagittal vertical axis). It also helps to correct the correlation between PI and LL.

Evaluation of pupil diameter for pain assessment in interventional headache management.

OBJECTIVES: Pain is a subjective experience. Besides, sensory, affective and behavioral responses, and autonomic response are part of pain response to noxious stimuli. Evaluation of pupil diameter by pupillometry has been used as an alternative method for pain assessment. In algologic procedures like interventional headache management have not been addressed in the literature. Herein, we investigated changes in pupil diameter during interventional headache management as an objective method for pain assessment. METHODS: Demographic data of the patients were collected before the bilateral major occipital nerve blockage (MONB) procedure. Numeric rating score (NRS) and pupil diameter measurements by pupillometer were recorded before MONB. Standard MONB procedure was applied to all patients. Pain assessment and pupillary diameter measurements were obtained after nerve blockage. RESULTS: Twenty-eight patients were included in this study. Mean age was 41.03+-12.63 years. There is no difference between the hemodynamic parameters before and after the procedure. Post-procedure NRS and pupil diameter values were significantly lower than pre-procedure values. There was a positive correlation between changes in NRS scores and changes in the right and left pupil diameters. CONCLUSION: There was a significant correlation between NRS score and pupil diameter in patients who underwent MONB. Monitoring of pupil diameter can be used for pain assessment during headache treatment. Evaluation of pupil diameter is a new approach in pain palliation. Future research is needed to study the effect of other parameters, that is, gender, age, origin of pain, acute, and chronic pain on pupil diameter and to evaluate its application in different algological procedures.

Prolonged Bleeding After Dental Extraction Due to Decreased Serum Level of Von Willebrand Factor Caused by Untreated Profound Hypothyroidism.

BACKGROUND: Delayed diagnosis of hypothyroidism may result in atypical presentations. Here, we report a case with decreased serum level and activity of von Willebrand factor due to untreated profound hypothyroidism. OBSERVATION: A 9-year-old girl, presented with prolonged gingival bleeding after dental extraction. Clinical findings of the case were consistent with hypothyroidism, and the laboratory workup results revealed decreased serum level and activity of von Willebrand factor associated with profound hypothyroidism. Restoration of euthyroidism normalized the coagulation parameters. CONCLUSION: Delayed diagnosis of hypothyroidism may lead to atypical presentations such as bleeding diathesis. Profound hypothyroidism should be considered in the differential diagnosis of acquired von Willebrand disease to avoid undue treatment.

Complete Recovery After Immunosuppressive Treatment Change in a Patient With Posttransplant Lymphoproliferative Disorder.

Posttransplant lymphoproliferative diseases are a rare but important cause of morbidity and mortality secondary to immunosuppression after solid-organ or bone marrow transplant. Generally, posttransplant lymphoproliferative diseases develop in the first 2 years after transplant, when immunosuppressive therapy is the most intense. Change or reduction in immunosup - pressive treatment is an option for treatment of posttransplant lymphoproliferative diseases. We evaluated the treatment of a patient with posttransplant lymphoproliferative disease after liver transplant. A 64-year-old man underwent liver transplant from a living donor (the patient's son) in 2011 to treat hepatocellular cancer secondary to chronic hepatitis B. Tacrolimus and mycophenolate mofetil were used for immunosuppression through 9 years after liver transplant. In the abdominal computed tomography performed in response to abdominal pain during follow-up in March 2019, multiple solid lesions were observed. A liver biopsy revealed posttransplant lymphoproliferative disease with diffuse large B-cell lymphoma. Fluorine-18 positron emission tomography/computed tomography imaging of the patient showed no pathology in favor of primary lymphoproliferative disease. Mycophenolate mofetil and tacrolimus treatment was changed to everolimus. In the follow-up dynamic magnetic resonance imaging examination that was performed at 3 months after treatment change, we observed that the lesion at liver segment 6 had regressed to 30 mm and several lesions with similar features were observed in the right lobe of the liver. Additional liver biopsy results were compatible with complete remission. The patient's clinical symptoms had fully regressed at 18 months after the diagnosis of PTLD, at the time of this writing. Ongoing radiological and clinical follow-up has shown complete remission. Change from calcineurin treatment to treatment with an inhibitor of the mechanistic target of rapamycin may be an essential and new option for treatment of posttransplant lymphoproliferative disease after liver transplant.

D-dimer may aid in the diagnosis of pediatric musculoskeletal infections: a prospective study.

Musculoskeletal infections, including septic arthritis, osteomyelitis, and soft tissue infections, are critical morbidity factors for children and adolescents. This study investigated the role of D-dimer levels for diagnosing childhood musculoskeletal infections. This single-center prospective study was initiated in April 2020 following approval from the local ethics committee. The study included 54 children, divided into the infection group ( n = 21), comprising patients who underwent surgical treatment for childhood musculoskeletal infections and had macroscopically visible purulent discharge during surgery, and the control group ( n = 33), comprising healthy children. In the infection group, the mean values of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), plasma D-dimer, and white blood cell (WBC) were 39.42 ± 27.00 mm/h, 101.50 ± 76.90 mg/l, 2.34 ± 2.59 mg/l, and 15.55 ± 6.86 × 10 9 /l, respectively. On comparison, the infection group showed higher levels of WBC, CRP, ESR, D-dimer, and neutrophil-to-lymphocyte ratio than the control group. When the D-dimer cutoff value of 0.43 mg/l was taken, it was observed that it had 95.2% sensitivity and 81.8% specificity. The area under curve (AUC) of the above-mentioned parameters calculated via receiver operating characteristic curves showed CRP levels as the optimum predictor of childhood musculoskeletal infections, followed by the ESR, plasma D-dimer, and WBC levels in descending order (AUC: 0.999, 0.997, 0.986, and 0.935, respectively). D-dimer is another test, which in combination with other conventional established tests (CRP and ESR) can be helpful in diagnosis of pediatric infection. We recommend the addition of D-Dimer to ESR, CRP, and WBC as a first-line investigation in cases with suspected pediatric musculoskeletal infections.