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Scheier E. Manual detorsion in pediatric testicular torsion: A narrative review of the literature. Urologia 2024; 91:628-631. [PMID: 38722164 DOI: 10.1177/03915603241229800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
Manual detorsion is infrequently performed in pediatric emergency medicine, particularly in centers with urology coverage. In no other emergency condition does an emergency physician not take immediate action to alleviate pain and damage, even if definitive care is close by. A small number of case reports exist in which pediatric emergency physicians have performed manual detorsion. This review the literature presents the case for routine manual detorsion prior to definitive orchiopexy.
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Affiliation(s)
- Eric Scheier
- Department of Pediatric Emergency, Kaplan Medical Center, Rehovot, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Liu Y, Shu S, Shi J, Li J. Multimodal ultrasound diagnosis of epididymo-orchitis with secondary testicular infarction: A case report. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:813-819. [PMID: 38624174 DOI: 10.1002/jcu.23692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/17/2024]
Abstract
We report a case of a 48-year-old man with testicular infarction caused by epididymo-orchitis (EO). Multimodal ultrasound showed extensive necrosis of the testis, and the patient underwent right orchiectomy. Postoperative pathology confirmed extensive necrosis of the testis. After 3 months of follow-up, the examination of scrotal ultrasound showed that the left testis and epididymis had no obvious abnormality.
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Affiliation(s)
- Yuexia Liu
- Department of Ultrasound, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Hospital of Chinese Medicine, Guangzhou, China
| | - Shengchun Shu
- Department of Ultrasound, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Hospital of Chinese Medicine, Guangzhou, China
| | - Jiayao Shi
- Department of Ultrasound, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Hospital of Chinese Medicine, Guangzhou, China
| | - Jinbing Li
- Department of Ultrasound, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Hospital of Chinese Medicine, Guangzhou, China
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Lee MS, Sweetnam-Holmes D, Soffer GP, Harel-Sterling M. Updates on the clinical integration of point-of-care ultrasound in pediatric emergency medicine. Curr Opin Pediatr 2024; 36:256-265. [PMID: 38411588 DOI: 10.1097/mop.0000000000001340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW There is expanding evidence for point-of-care ultrasound (POCUS) use in pediatric emergency medicine - this review highlights the benefits and challenges in the clinical integration of high-yield POCUS applications. Specifically, it will delve into POCUS applications during resuscitations, controversies of Focused Assessment with Sonography for Trauma (FAST) in pediatric trauma, POCUS-guided procedures, and examples of clinical pathways where POCUS can expedite definitive care. RECENT FINDINGS POCUS can enhance diagnostic accuracy and aid in management of pediatric patients in shock and help identify reversible causes during cardiac arrest. The use of the FAST in pediatric blunt abdominal trauma remains nuanced - its proper use requires an integration with clinical findings and an appreciation of its limitations. POCUS has been shown to enhance safety and efficacy of procedures such as nerve blocks, incision & drainage, and intravenous access. Integrating POCUS into pathways for conditions such as intussusception and testicular torsion expedites downstream care. SUMMARY POCUS enhances diagnostic efficiency and management in pediatric patients arriving at the ED with undifferentiated shock, cardiac arrest, or trauma. Additionally, POCUS improves procedural success and safety, and is integral to clinical pathways for expediting definitive care for various pediatric emergencies. Future research should continue to focus on the impact of POCUS on patient outcomes, ensuring user competency, and the expansion of POCUS into diverse settings.
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Affiliation(s)
- Michelle Sin Lee
- Pediatric Emergency Medicine, Hospital for Sick Children, Assistant Professor, University of Toronto, Toronto, ON, Canada
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Pyrgidis N, Apfelbeck M, Stredele R, Rodler S, Kidess M, Volz Y, Weinhold P, Stief CG, Marcon J, Schulz GB, Chaloupka M. The impact of health care on outcomes of suspected testicular torsion: results from the GRAND study. World J Urol 2024; 42:309. [PMID: 38722366 PMCID: PMC11082016 DOI: 10.1007/s00345-024-05015-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/20/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Suspicion of testicular torsion represents a urological emergency, necessitating immediate surgery. Comprehensive data on the current trends and perioperative outcomes regarding surgical exploration are sparse. Therefore, we utilized nationwide data on the prevalence and results of this surgery, aiming to provide evidence on this matter. METHODS We assessed the GeRmAn Nationwide inpatient Data (GRAND) from 2005 to 2021, provided by the Research Data Center of the Federal Bureau of Statistics. We performed multiple regression analyses to evaluate the perioperative outcomes (length of hospital stay, transfusion, and surgical wound infection) after surgical exploration due to suspected testicular torsion based on both the outcome of surgery (orchiectomy, detorsion with preservation of the testicle, and no testicular torsion) and on the department of operation (urological versus non-urological). RESULTS A total of 81,899 males underwent surgical exploration due to suspected testicular torsion in Germany from 2005 to 2021. Of them, 11,725 (14%) underwent orchiectomy, 30,765 (38%) detorsion with preservation of the testicle and subsequent orchidopexy, and 39,409 (48%) presented no testicular torsion. Orchiectomy was significantly associated with longer length of hospital stay (day difference of 1.4 days, 95%CI: 1.3-1.4, p < 0.001), higher odds of transfusion (1.8, 95% CI: 1.2-2.6, p = 0.002) and surgical wound infections (1.8, 95%CI: 1.4-2.3, p < 0.001) compared to no testicular torsion. The proportion of patients undergoing orchiectomy was significantly lower in urological departments (14%) versus non-urological departments (16%) and the proportion of patients undergoing preservation of testicle after detorsion was significantly higher in urological departments (38%) versus non-urological departments (37%), p < 0.001. Patients undergoing treatment in a urological department were discharged earlier and presented lower odds of transfusion and surgical wound infection (p < 0.001) compared to patients undergoing treatment in a non-urological department. CONCLUSIONS Nearly half of patients who underwent surgery for suspected testicular torsion did not have intraoperatively the condition confirmed. Patients treated in urological departments had significantly better perioperative outcomes compared to those treated in non-urological departments. Therefore, we advise to refer patients to urological treatment as early as possible.
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Affiliation(s)
- Nikolaos Pyrgidis
- Department of Urology, University Hospital, LMU Munich, Munich, Germany.
| | - Maria Apfelbeck
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Regina Stredele
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Severin Rodler
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Marc Kidess
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Yannic Volz
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Philipp Weinhold
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Christian G Stief
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Julian Marcon
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Gerald B Schulz
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Michael Chaloupka
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
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Alberti P, Bytyci J, Jindal J, Stephanou M, Thompson L, Tilahun Y, Ying Y, Killen A, Manirambona E, Niyukuri A, Lakhoo K, Ford K. Paediatric testicular torsion in low- and middle-income countries: an OxPLORE scoping study. Pediatr Surg Int 2024; 40:117. [PMID: 38695917 DOI: 10.1007/s00383-024-05704-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Literature on paediatric surgical conditions in low- and middle-income countries (LMICs) remains limited. As a common emergency, timely treatment of testicular torsion acts as a benchmark of adequate emergency service delivery in paediatric surgery. This scoping study aims to synthesise all existing literature on paediatric testicular torsion in LMICs. METHODS A database search was conducted by the OxPLORE global paediatric surgery research group to identify studies containing the terms 'testicular torsion' or 'acute scrotum' originating from LMICs. A thematic analysis was applied to the results of the search and the quality of evidence was appraised for all included articles. RESULTS This review included 17 studies with 1798 patients. All studies originated from middle-income countries and the majority (76%) had sample sizes smaller than 100 patients. All studies were appraised as providing less than adequate evidence. Included studies identified long delays to treatment and highlighted ongoing debates on the value of scoring systems and Doppler ultrasonography in diagnosing torsion. Major heterogeneity in surgical approaches to treatment of testicular torsion in children was also observed. CONCLUSIONS Literature on paediatric testicular torsion in LMICs is scarce and heterogeneous. Prospective, multi-centre research on the management of this common paediatric surgical emergency is urgently required.
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Affiliation(s)
- Piero Alberti
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Jola Bytyci
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Jessy Jindal
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Michael Stephanou
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Lucy Thompson
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Yedidiah Tilahun
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Yuxin Ying
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Annabel Killen
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Emery Manirambona
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Kokila Lakhoo
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Kathryn Ford
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
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Sugar BP, Thomas JM, Beutler BD, Clifford TG, Tchelepi H. Contrast-enhanced ultrasound (CEUS) for the characterization of intra-scrotal lesions. Eur J Radiol 2024; 175:111453. [PMID: 38598965 DOI: 10.1016/j.ejrad.2024.111453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/16/2024] [Accepted: 04/04/2024] [Indexed: 04/12/2024]
Abstract
Contrast-enhanced ultrasound (CEUS) has emerged as a promising imaging modality for the characterization of hepatic and renal lesions. However, there is a paucity of data describing the use of CEUS for the evaluation of intra-scrotal pathology. In the following review, we describe the clinical utility of CEUS for the characterization and differentiation of common and uncommon intra-scrotal conditions, including testicular torsion, infection, trauma, and benign and malignant intratesticular and extratesticular neoplasms. In addition, we outline key principles of CEUS and provide case examples from our institution.
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Affiliation(s)
- Benjamin P Sugar
- University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
| | - Jerry M Thomas
- University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
| | - Bryce D Beutler
- University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States.
| | - Thomas G Clifford
- University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, United States
| | - Hisham Tchelepi
- Los Angeles General Medical Center, Los Angeles, CA 90033, United States
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Hosokawa T, Tanami Y, Sato Y, Oguma E. Point-of-care ultrasonography for the diagnosis and manual detorsion of testicular torsion. J Med Ultrason (2001) 2024; 51:59-70. [PMID: 37863980 PMCID: PMC10937765 DOI: 10.1007/s10396-023-01374-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 10/22/2023]
Abstract
Testicular torsion is a urological emergency caused by the loss of testicular tissue due to ischemic damage. Rapid diagnosis and urgent treatment play a crucial role in the management of testicular torsion. Manual detorsion can be performed at the bedside, thereby reducing the duration of ischemia. Recent studies have reported the use of point-of-care ultrasonography for diagnosing testicular torsion; however, no review article has focused on the ultrasonographic findings pertaining to manual detorsion. This review describes the diagnosis of testicular torsion and the ultrasonographic indications for manual detorsion. Spermatic cord twisting or the whirlpool sign, absence of or decreased blood flow within the affected testis, abnormal testicular axis, abnormal echogenicity, and enlargement of the affected testis and epididymis due to ischemia are the sonographic findings associated with testicular torsion. The following findings are considered indications for manual detorsion: direction of testicular torsion, i.e., inner or outer direction (ultrasonographic accuracy of 70%), and the degree of spermatic cord twist. The following sonographic findings are used to determine whether the treatment was successful: presence of the whirlpool sign and the degree and extent of perfusion of the affected testis. Misdiagnosis of the direction of manual detorsion, a high degree of spermatic cord twisting and insufficient detorsion, testicular compartment syndrome, and testicular necrosis were found to result in treatment failure. The success of manual detorsion is determined based on the symptoms and sonographic findings. Subsequent surgical exploration is recommended in all cases, regardless of the success of manual detorsion.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777, Japan.
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, 1-2 Shintoshin Chuo-ku Saitama, Saitama, 330-8777, Japan
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Park JS, Kim D, Chun MK, Choi SJ, Lee JS, Ryu JM, Lee JY. Implementing Point-of-Care Ultrasound for Acute Scrotal Pain in the Pediatric Emergency Department: Screening Testicular Torsion and Patient Flow Analysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2757-2764. [PMID: 37555776 DOI: 10.1002/jum.16312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/29/2023] [Accepted: 07/24/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVES Testicular torsion (TT) is a pediatric surgical emergency that requires prompt treatment. This study investigated the feasibility of point-of-care ultrasound (POCUS) for diagnosing TT in the pediatric emergency department (ED). METHODS We retrospectively reviewed the medical records of patients, aged 18 years or younger, who visited a university-affiliated hospital pediatric ED with acute scrotal pain without trauma history and underwent diagnostic ultrasounds between January 2010 and October 2022. RESULTS This study included 731 patients (median age: 9 years), Of these, 315 (43%) were in the POCUS-performed group: 188 in the POCUS-only group, and 127 in the POCUS-and-RADUS group. The other 416 patients (56.9%) were in the RADUS-only group. In total, 45 patients (6.2%) were diagnosed with TT (19 in the POCUS-performed group and 26 in the RADUS-only group). The sensitivity, specificity, and positive and negative predictive values of POCUS for diagnosing TT were 94.7%, 92.9%, 46.2%, and 99.6%, respectively. The median time to perform POCUS was shorter than RADUS (23 versus 61 minutes, P < .001). The POCUS-performed group had a shorter ED length of stay than the RADUS-only group (93 versus 170 minutes, P < .001). Among the patients diagnosed with TT, performing POCUS first did not significantly delay the ED process, including time to operation (250 versus 205 minutes, P = .142). CONCLUSIONS For patients with acute scrotal pain, evaluation performed by pediatric emergency physicians using POCUS performs well in screening TT, and can decrease length of stay in the ED.
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Affiliation(s)
- Jun Sung Park
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dahyun Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Kyo Chun
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung Jun Choi
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong Seung Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Min Ryu
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Koyle MA. EDITORIAL COMMENT. Urology 2023; 180:233-234. [PMID: 37451911 DOI: 10.1016/j.urology.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Affiliation(s)
- Martin A Koyle
- Department of Surgery. Division of Urology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Urology, University of Minnesota, Minneapolis, MN.
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Lukosiute-Urboniene A, Nekrosius D, Dekeryte I, Kilda A, Malcius D. Clinical risk factors for testicular torsion and a warning against falsely reassuring ultrasound scans: a 10-year single-centre experience. Emerg Med J 2023; 40:134-139. [PMID: 36526335 DOI: 10.1136/emermed-2021-211946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 12/03/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND We sought to determine which demographic, clinical and ultrasonography characteristics are predictive of testicular torsion (TT) and to determine factors associated with time to treatment. METHODS We retrospectively reviewed all medical records of patients (0-17 years) with acute scrotal syndrome (ASS) who were treated in our hospital in Lithuania between 2011 and 2020. We extracted patients' demographic data, in-hospital time intervals, clinical, US and surgical findings. TT was determined at surgery or clinically after manual detorsion. Test characteristics of demographic, clinical and US findings for the diagnosis of TT versus other causes of ASS were determined. We performed a multivariate analysis to identify independent clinical predictors of torsion, and factors associated with surgical delay. RESULTS A search of medical records yielded 555 cases: 196 (35%) patients with TT and 359 (65%) patients with other ASS causes. Multivariate logistic regression analysis showed that age between 13 and 17 years (OR 8.39; 95% CI 5.12 to 13.76), duration of symptoms <7 hours (OR 3.41; 95% CI 2.03 to 5.72), palpated hard testis (OR 4.65; 95% CI 2.02 to 10.67), scrotal swelling (OR 2.37; 95% CI 1.31 to 4.30), nausea/vomiting (OR 4.37; 95% CI 2.03 to 9.43), abdominal pain (OR 2.38; 95% CI 1.27 to 4.45) were independent clinical predictors of TT. No testicular blood flow in Doppler US had a specificity of 98.2% and a positive predictive value of 94.6%. However, 75 (41.7%) patients with TT had normal testicular blood flow, yielding low sensitivity (58.3%) and negative predictive value of 81.3% for this US finding. In-hospital waiting time for surgery was longer in patients with TT with normal testicular blood flow by USS (195 min) compared with no blood flow (123 min), p<0.01. Higher orchiectomy rates were associated with longer duration of symptoms (p<0.001) and longer waiting time for USS (p=0.029) but not with false-negative US. CONCLUSIONS Pubertal age, symptoms duration of <7 hours, nausea/vomiting, palpated hard testis, abdominal pain and scrotal swelling are predictive factors for TT. Time lost between symptom onset and seeking medical care, and between arrival and US are associated with the need for orchiectomy. Preserved blood flow in USS does not rule out TT and may contribute to delays to surgery.
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Affiliation(s)
- Ausra Lukosiute-Urboniene
- Department of Pediatric Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Department of Pediatric Surgery, Lithuanian University of Health Sciences Hospital Kauno klinikos, Kaunas, Lithuania
| | - Deividas Nekrosius
- Department of Pediatric Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Department of Pediatric Surgery, Lithuanian University of Health Sciences Hospital Kauno klinikos, Kaunas, Lithuania
| | - Inga Dekeryte
- Department of Pediatric Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Department of Pediatric Surgery, Lithuanian University of Health Sciences Hospital Kauno klinikos, Kaunas, Lithuania
| | - Arturas Kilda
- Department of Pediatric Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Department of Pediatric Surgery, Lithuanian University of Health Sciences Hospital Kauno klinikos, Kaunas, Lithuania
| | - Dalius Malcius
- Department of Pediatric Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Department of Pediatric Surgery, Lithuanian University of Health Sciences Hospital Kauno klinikos, Kaunas, Lithuania
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