Analysis and Comparison of the Malignant Thyroid Nodules Not Recommended for Biopsy in ACR TIRADS and AI TIRADS With a Large Sample of Surgical Series.

OBJECTIVE: To determine if the artificial intelligence-based Thyroid Imaging, Reporting and Data System (AI TIRADS) would perform better than the American College of Radiology (ACR) TIRADS in monitoring malignant thyroid nodules not recommended for biopsy using follow-up thresholds. METHODS: A total of 3499 thyroid nodules with surgical histopathology and ultrasound features were retrospectively reviewed and categorized using ACR TIRADS and AI TIRADS. The recommendations for biopsy and follow-up divided nodules into three groups 1) fine needle aspiration (FNA), 2) follow-up ultrasound, and 3) no further evaluation. RESULTS: Of the total 1608 malignant nodules in this study, 974 malignant nodules would not be biopsied in ACR TIRADS compared with 967 in AI TIRADS. While 60.0% (584/974) of these non-biopsied malignancies could be followed-up by ultrasound in ACR TIRADS and 62.8% (607/967) in AI TIRADS. For the malignancies of no further evaluation, 97.4% (380/390) were sized <10 mm in ACR TIRADS and 93.3% (336/360) in AI TIRADS. Compared with ACR TIRADS, AI TIRADS had lower unnecessary FNA rate and missing cancer rate (41.0% vs 47.8% and 22.8% vs 27.5%, P < .05, respectively) while having higher specificity and AUC as well as lower sensitivity (65.0% vs 57.9%, 0.895 vs 0.881, and 96.1% vs 97.8%, all P < .05). CONCLUSIONS: Using the follow-up thresholds, more than half of the malignancies not being biopsied were monitored by ultrasound in both ACR TIRADS and AI TIRADS, and AI TIRADS had lower missing cancer rate. More than 90% of malignancies recommended for no further evaluation were <10 mm in diameter.

Autologous wound margin point columnar full-thickness skin grafting combined with negative pressure wound therapy improves wound healing in refractory diabetic foot ulcers.

Diabetic lower extremity ulcers (DLEUs) are a severe complication of diabetes mellitus (DM) and are difficult to heal. This study aimed to explore the efficacy of autologous point columnar full-thickness skin graft taken from the ulcer wound margin combined with negative pressure wound therapy (NPWT) in refractory DLEUs. This is a prospective cohort study. A total of 40 inpatients with refractory DLEUs were recruited in the Diabetes Foot Center of Guangxi Zhuang Autonomous Region People's Hospital from October 2019 to November 2021. According to the doctors' professional suggestions and the patients' personal wishes, these enrolled patients were divided into two groups based on different topical wound management: the graft group (n = 18) and the conventional wound therapeutic (CWT) group (n = 22). The efficacy evaluations included the time to complete re-epithelialization of the wound and healing speed within 14 days of graft treatment or after 14 days of graft treatment in the two groups. Before the treatment, the graft group had a significantly larger ulcer area than the CWT group [27.22 (15.28, 46.59) versus 10.92 (7.00, 24.93) cm2 , P < .01]. However, the time to complete wound re-epithelialization in the graft group was shorter than in the CWT group [58.22 ± 30.60 versus 86.09 ± 49.54 d, P < .05]. Meanwhile, the healing speed in graft group was markedly faster than in CWT group, whether within 14 days [0.60 (0.40, 0.92) versus 0.16 (0.07, 0.34) cm2 /d, P < .01] or after 14 days of graft treatment [0.57 (0.45, 0.91) versus 0.13 (0.08, 0.27) cm2 /d, P < .01]. However, the total treatment cost in the graft group was lower than in the CWT group [419.59 ± 137.20 versus 663.97 ± 497.02 $, P < .05]. The novel treatment modality of autologous full-thickness skin graft taken from the ulcer wound margin combined with NPWT has hereby proposed for the first time, and is a safe, effective, and reliable method with a good performance-to-cost ratio to promote wound healing and shorten the healing time for DLEUs.

Multimodal ultrasound imaging: A method to improve the accuracy of diagnosing thyroid TI-RADS 4 nodules.

Thyroid nodule is a common and frequently occurring disease in the neck in recent years, and ultrasound has become the preferred imaging diagnosis method for thyroid nodule due to its advantages of noninvasive, nonradiation, real-time, and repeatable. The thyroid imaging, reporting and data system (TI-RADS) classification standard scores suspicious nodules that are difficult to determine benign and malignant as grade 4, and further pathological puncture is recommended clinically, which may lead to a large number of unnecessary biopsies and operations. Including conventional ultrasound, ACR TI-RADS, shear wave elastography, super microvascular imaging, contrast enhanced ultrasound, "firefly," artificial intelligence, and multimodal ultrasound imaging used in combination. In order to identify the most clinically significant malignant tumors when reducing invasive operations. This article reviews the application and research progress of multimodal ultrasound imaging in the diagnosis of TI-RADS 4 thyroid nodules.

A combination of risk stratification systems for thyroid nodules and cervical lymph nodes may improve the diagnosis and management of thyroid nodules.

Introduction: To assess the performance of the European Thyroid Association Thyroid Imaging and Reporting Data System (EU-TIRADS) and the Korean Thyroid Imaging Reporting and Data System (K-TIRADS), which combine risk stratification systems for thyroid nodules (TN-RSS) and cervical lymph nodes (LN-RSS) in diagnosing malignant and metastatic thyroid cancer in a single referral center. Methods: We retrospectively analyzed 2,055 consecutive patients who underwent thyroidectomy or fine-needle aspiration (FNA) from January 2021 to December 2022. TNs and LNs were categorized according to the ultrasonography (US) features of EU-TIRADS and K-TIRADS, respectively. The diagnostic performance and postponed malignancy rate (PMR) were compared with those of EU-TIRADS and K-TIRADS. PMR was defined as the number of patients with malignant nodules not recommended for biopsy among patients with cervical LN metastasis. Results: According to the EU-TIRADS and K-TIRADS, for TN-RSS alone, there were no significant differences in sensitivity, specificity, accuracy, unnecessary FNA rate (UFR), missed malignancy rate (MMR), and PMR between the two TIRADSs (29.0% vs. 28.8%, 50.5% vs. 51.1%, 32.3% vs. 32.2%, 23.6% vs. 23.5%, 88.6% vs. 88.5%, and 54.2% vs. 54.5%, P > 0.05 for all). Combining the LN-RSS increased the diagnostic accuracy (42.7% vs. 32.3% in EU-TIRADS; 38.8% vs. 32.2% in K-TIRADS) and decreased the PMR (54.2% vs. 33.9% in EU-TIRADS; 54.5% vs. 39.3% in K-TIRADS). EU-TIRADS had higher sensitivity and accuracy and lower PMR than K-TIRADS (41.3% vs. 36.7%, 42.7% vs. 38.8%,33.9% vs. 39.3%, P < 0.05 for all). Conclusions: A combination of TN-RSS and LN-RSS for the management of thyroid nodules may be associated with a reduction in PMR, with enhanced sensitivity and accuracy for thyroid cancers in EU-TIRADS and K-TIRADS. These results may offer a new direction for the detection of aggressive thyroid cancers.

An economically efficient strategy for diagnosing atypia of undetermined significance or follicular lesion of undetermined significance thyroid nodules with ultrasound-based risk stratification systems and BRAFV600E testing.

Background: The management of thyroid nodules classified as atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) has been a subject of ongoing debate. Therefore, the aim of this study was to investigate a cost-effective approach for managing these nodules by combining BRAFV600E mutation analysis with the guidelines provided by the American Thyroid Association (ATA) or the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TIRADS). Methods: This study included 762 AUS/FLUS nodules in 551 patients with a postoperative pathology. A preoperative BRAFV600E gene test and an evaluation using the ATA guidelines and ACR-TIRADS were performed. Two combined diagnostic approaches were employed: In method 1, all nodules underwent BRAFV600E gene testing, and nodules testing positive for BRAFV600E or for risk stratification systems (RSSs) were diagnosed as malignant, while those with negative results in both tests were considered benign. In method 2 (modified combination method), nodules were reclassified into low-risk (category 2 and 3 in the ATA guidelines and ACR-TIRADS), medium-risk (category 4), and high-risk (category 5) groups based on the malignancy rate of the RSSs. BRAFV600E gene testing was applied only with the medium-risk group. Nodules with positive BRAFV600E mutation were upgraded to the high-risk group, while negative cases remained in the medium-risk group. Results: Both malignancy rates and positive BRAFV600E mutation rates increased with the increase in RSS category (P<0.001). The combination of ACR with BRAFV600E gene testing significantly improved the area under the curve (AUC) compared to the use of ACR or BRAFV600E alone (the AUCs for ACR combined with BRAFV600E, modified ACR combined with BRAFV600E, ACR alone, and BRAFV600E alone were 0.875, 0.878, 0.832, and 0.839, respectively; P<0.05 for both combinations vs. ACR or BRAFV600E alone). Similarly, ATA combined with BRAFV600E showed significant improvements in AUC compared to ATA alone (the AUCs for ATA combined with BRAFV600E, modified ATA combined with BRAFV600E, and ATA alone were 0.851, 0.846, 0.809, respectively; P<0.001 for both combination methods vs. ATA alone), but there was no significant difference observed compared to using BRAFV600E alone (P=0.450 and P=0.680 for both combination methods vs. BRAFV600E). Notably, the AUC of ACR combined with BRAFV600E was greater than that of ATA combined with BRAFV600E (P=0.047 and P=0.007 for both combination methods, respectively). There were no significant differences in diagnostic performance between the two combination approaches (P=0.428 for ACR combined with BRAFV600E and P=0.314 for ATA combined with BRAFV600E). Performing BRAFV600E gene testing only on the medium-risk groups (modified combination method) significantly reduced the rate of BRAFV600E gene testing (P<0.001) without increasing the false-negative rate (P=0.818 and P=0.394 for ACR and ATA, respectively). Conclusions: Incorporating the BRAFV600E gene test exclusively for nodules in the medium-risk group significantly improved diagnostic efficacy, reduced the utilization of gene tests, and maintained a consistent false-negative rate.

Comparison of ultrasound risk stratification systems for pediatric thyroid nodules.

Background: There is currently insufficient data to validate adult-based US risk stratification systems (RSSs) for the identification of malignant thyroid nodules in a pediatric population. Methods: From October 2016 and May 2023, 173 thyroid nodules of pediatric patients (age ≤ 18 years) with definitive pathology results and ultrasound (US) examination within 1 month before surgery or fine-needle aspiration (FNA) biopsy in our institution were enrolled in this study. The clinical and US characteristics of these nodules were retrospectively reviewed and categorized according to the ACR-TIRADS, C-TIRADS, and ATA guidelines. The diagnostic performance of US-based FNA criteria (original and simulating) of the three guidelines in thyroid cancer detection was estimated. Results: The three RSSs had similar AUC according to the categories(0.849-0.852, all P > 0.05). When combined with the original FNA criteria of the three RSSs to manage the nodules, the FNA rate of ACR-TIRADS and C-TIRADS were significantly less than ATA guidelines (53.18% vs. 64.63%, P < 0.05, and 52.60% vs. 64.63%, P < 0.05). The missed malignancy rate (MMR) and unnecessary FNA rate (UFR) of ATA guidelines (50.00%, 35.85%) was highest among the three RSSs, followed by the C-TIRADS (37.80%, 19.57%) and the ACR-TIRADS (37.04%, 19.57%). When nodules < 1 cm with the highest category in each RSS biopsied, that is when using the simulating FNA thresholds, the MMR was reduced overall (all P < 0.001), without a change in the UFR (all P > 0.05). All the three RSSs showed a substantial improvement in accuracy and malignant detection rate (all P < 0.05). Conclusion: The ACR-TIRADS, C-TIRADS, and ATA guidelines showed high missed malignancy rates when using their original recommended FNA criteria. When nodules < 1 cm with the highest category in each RSS biopsied, the missed malignancy rate of each RSS was decreased. Decreasing the FNA thresholds for highly suspicious malignant nodules may therefore be an effective means of managing malignant thyroid nodules in pediatric patients.

Study on the Occurrence Characteristics of the Remaining Oil in Sandstone Reservoirs with Different Permeability after Polymer Flooding.

After polymer flooding, the heterogeneity between different layers intensifies, forming intricate seepage channels and fluid diversions, which results in decreased circulation efficiency and lower recovery rates, leaving a significant amount of residual oil trapped within the reservoir. Understanding the characteristics of residual oil occurrence is crucial for enhancing oil recovery post-polymer flooding. This study focused on sandstone reservoirs with varying permeability in the Saertu block of the Daqing oilfield. Using cryosectioning and laser scanning confocal microscopy, the occurrence characteristics of the residual oil in these sandstone reservoirs post-polymer flooding were investigated. Additionally, micro-CT and scanning electron microscopy were employed to analyze the impact of the pore structure on the distribution characteristics of the residual oil. The results indicate that laser scanning confocal images reveal that post-polymer flooding, the residual oil in high- and low-permeability sandstone reservoirs predominantly exists in a bound state (average > 47%), mostly as particle-adsorbed oil. In contrast, the residual oil in medium-permeability reservoirs is primarily in a free state (average > 49%), mostly as intergranular-adsorbed oil. In high-permeability sandstone reservoirs, heavy oil components are mainly in a particle-adsorbed form; in medium-permeability sandstone reservoirs, residual oil predominantly consists of heavy components, with most light components occurring in a clustered form; in low-permeability sandstone reservoirs, clustered residual oil exists in a balanced coexistence of light and heavy components, while the heavy components primarily exist in a particle-adsorbed form. Post-polymer flooding, the large pore-throat structure in high-permeability sandstone reservoirs results in effective displacement and less free residual oil; medium-permeability sandstone reservoirs, with medium-large pores and throats, have preferential channels and fine particles blocking the throats, leading to some unswept pores and more free residual oil; low-permeability sandstone reservoirs, with small pores and throats, exhibit weak displacement forces and poor mobility, resulting in more bound residual oil. The distribution and content of clay particles and clay minerals, along with the complex microscopic pore structure, are the main factors causing the differences in the residual oil occurrence states in sandstones with varying permeability.

A comprehensive comparative assessment of eight risk stratification systems for thyroid nodules in the elderly population.

Objective: This study aims to investigate the diagnostic value of eight risk stratification systems (RSSs) for thyroid nodules in the elderly and explore the reasons in comparison with a younger group. Methods: Cases of thyroid nodules that underwent ultrasound examination with thyroidectomy or fine-needle aspiration (FNA) at our hospital between August 2013 and March 2023 were collected. The patients were categorized into two groups: an elderly group (aged ≥60) and a younger group (aged <60). Eight RSSs were applied to evaluate these nodules respectively. Results: The malignant rate in the elderly group was significantly lower than that in the younger group (28.2% vs. 49.6%, P=0.000). There were statistically significant differences in nodule diameter, multiplicity, composition, echogenicity, orientation, margin, and echogenic foci between the elderly and younger groups (P<0.05). Among the eight RSSs evaluated in elderly adults, the artificial intelligence-based Thyroid Imaging Reporting and Data System (AI TIRADS) demonstrated the highest overall diagnostic efficacy, but with relatively high unnecessary FNA rate (UFR) and missed cancer rate (MCR) of 55.0% and 51.3%, respectively. By modifying the size thresholds, the new AI TI-RADS achieved the lowest UFR and MCR while maintaining nearly the lowest FNA rate (FNAR) among all the RSSs (P=0.172, 0.162, compared to the ACR and original AI, respectively, but P<0.05 compared to the other six RSSs). Conclusion: Among the eight RSS systems, AI demonstrated higher diagnostic efficacy in the elderly population. However, the size thresholds for FNA needed to be adjusted.

Diagnostic and therapeutic performances of three score-based Thyroid Imaging Reporting and Data Systems after application of equal size thresholds.

Background: The aim of this study was to explore the diagnostic and therapeutic performances of the artificial intelligence (AI), American College of Radiology (ACR), and Kwak Thyroid Imaging Reporting and Data Systems (TIRADSs) using the size thresholds for fine needle aspiration (FNA) and follow-up defined in the ACR TIRADS. Methods: This retrospective study included 3,833 consecutive thyroid nodules identified in 2,590 patients from January 2010 to August 2017. Ultrasound (US) features were reviewed using the 2017 white paper of the ACR TIRADS. US categories were assigned according to the ACR/AI and Kwak TIRADS. We applied the thresholds for FNA and follow-up defined in the ACR TIRADS to the Kwak TIRADS. The diagnostic and therapeutic performances were calculated and compared using the McNemar or DeLong methods. Results: The AI TIRADS had higher specificity, accuracy, and area under the curve (AUC) than did the ACR and Kwak TIRADS (specificity: 64.6% vs. 57.4% and 52.69%; accuracy: 78.5% vs. 75.4% and 73.0%; AUC: 88.2% vs. 86.6% and 86.0%; all P values <0.05). Meanwhile, the AI TIRADS had a lower FNA rate (FNAR), unnecessary FNA rate (UFR), and follow-up rate (FUR) than did the ACR and Kwak TIRADS using the size thresholds of the ACR TIRADS (specificity: 30.9% vs. 34.4% and 36.9%; accuracy: 41.1% vs. 47.8% and 48.7%; AUC: 34.2% vs. 37.7% and 41.0%; all P values <0.05). In addition, the Kwak TIRADS incorporating the size thresholds of the ACR TIRADS was almost similar to the ACR TIRADS in diagnostic and therapeutical performance. Conclusions: The ACR TIRADS can be simplified, which potentially enhances its diagnostic and therapeutic performance. The method of score-based TIRADS (counting in the Kwak TIRADS and weighting in the ACR and AI TIRADS) might not determine the diagnostic and therapeutic performances of the TIRADS. Thus, we propose choosing a straightforward and practical TIRADS in daily practice.

Autologous Bone Marrow Mononuclear Cell Transplantation Delays Progression of Carotid Atherosclerosis in Rabbits.

Bone marrow mononuclear cells (BMMNCs) can counteract oxidative stress and inhibit the inflammatory response in focal ischemic stroke models. However, the effect of BMMNC transplantation on carotid atherosclerosis needs to be determined. The carotid atherosclerotic plaque model was established in New Zealand White rabbits by balloon injury and 8 weeks of high-fat diet. Rabbits were randomized to receive an intravenous injection of autologous bromodeoxyuridine (BrdU)-labeled BMMNCs or an equal volume of phosphate-buffered saline. Plaques were evaluated for expression of proinflammatory and anti-inflammatory cytokines, anti-oxidant proteins, and markers of cell death. BMMNCs migrated into atherosclerotic plaque on the first day after cell transplantation. BMMNC-treated rabbits had smaller plaques and more collagen deposition than did the vehicle-treated controls on day 28 (p < 0.05). BMMNC treatment significantly increased endothelial nitric oxide synthase and the anti-oxidant enzymes glutathione peroxidase and superoxide dismutase in plaques compared to vehicle treatment on day 7. BMMNC-treated rabbits also had lower levels of cleaved caspase-3 expression; lower levels of proinflammatory cytokines interleukin-1ß, tumor necrosis factor alpha, and matrix metalloproteinase 9; and higher levels of insulin-like growth factor-1 and its receptor (p < 0.05). Autologous BMMNC transplantation can suppress the process of atherosclerotic plaque formation and is associated with enhanced anti-oxidative effect, reduced levels of inflammatory cytokines and cleaved caspase-3, and increased expression of insulin-like growth factor-1 and its receptor. BMMNC transplantation represents a novel approach for the treatment of carotid atherosclerosis.