Diagnostic value of qualitative and quantitative enhancement parameters on contrast-enhanced mammography

PURPOSE

To determine whether qualitative and quantitative enhancement parameters obtained from contrast-enhanced mammography (CEM) can be used in predicting malignancy.

METHODS

After review board approval, consecutive 136 suspicious lesions with definite diagnosis were retrospectively analyzed on CEM. Acquisition was routinely started with craniocaudal view and ended with mediolateral oblique view of the affected breast. Lesion conspicuity (low, moderate, high), internal enhancement pattern (homogeneous, heterogeneous, rim), contrast-to-noise ratio (CNR), percentage of signal difference (PSD) and relative enhancement from early to late view were analyzed. PSD and relative enhancements were used to determine patterns of descending, steady or ascending enhancements. Receiver operating characteristic analysis, Cohen's kappa statistics and Spearman correlation tests were used.

RESULTS

There were 29 benign and 107 malignant lesions. 64% of the malignant lesions exhibited high conspicuity compared to 14% of the benign lesions (P < 0.001). CNR values were higher in malignant lesions compared to benign ones (P ≤ 0.004). CNR from early view yielded 82% sensitivity, 72% specificity and PSD yielded 79% sensitivity, 65% specificity. Descending pattern and rim enhancement observed in 44% and 21% of breast cancers, respectively, and both provided 96% positive predictive value for malignancy.

CONCLUSION

Diagnostic accuracy of quantitative parameters was higher than that of qualitative parameters. High CNR, rim enhancement, and descending pattern were features commonly seen in malignant lesions, while low CNR, homogeneous enhancement, and ascending pattern were commonly seen in benign lesions.

Evaluation of the height of the corpus callosum body region in fetal meningomyelocele malformation

PURPOSE

To investigate height of the corpus callosum (CC) in order to describe the corpus callosum anomalies in fetuses with meningomyelocele (MMC) and compare these findings with the corpus callosum of healthy fetuses.

METHODS

In this study, fetal MRI examinations were performed on 44 fetal MMC malformation cases. As the control group, 34 fetal MRI examinations, which were anatomically normal, were evaluated retrospectively. In the study group, lateral ventricle diameter, the level and diameter of the MMC defect, and CC height were measured. In the control group, CC height and lateral ventricular diameter were measured.

RESULTS

The mean CC body height was 1.36 mm in the study group, and 2.48 mm in the control group. The height of the CC body region of the study population was inclined to be thinner compared with the control population (p<0.001).

CONCLUSIONS

The fact that the height of the CC body region was found to be thinner in fetal MRI in cases of MMC compared with normal fetuses suggests that various callosal anomalies are uncertain, investigation of additional callosal anomalies may be beneficial in the decision for the continuation of pregnancy, and termination or intrauterine surgery in cases with MMC. Further large case group studies are needed.

Outcomes of high-risk breast lesions diagnosed using image-guided core needle biopsy: results from a multicenter retrospective study

PURPOSE

The clinical management of high-risk lesions using image-guided biopsy is challenging. This study aimed to evaluate the rates at which such lesions were upgraded to malignancy and identify possible predictive factors for upgrading high-risk lesions.

METHODS

This retrospective multicenter analysis included 1.343 patients diagnosed with high-risk lesions using an image-guided core needle or vacuum-assisted biopsy (VAB). Only patients managed using an excisional biopsy or with at least one year of documented radiological follow-up were included. For each, the Breast Imaging Reporting and Data System (BI-RADS) category, number of samples, needle thickness, and lesion size were correlated with malignancy upgrade rates in different histologic subtypes. Pearson's chi-squared test, the Fisher-Freeman-Halton test, and Fisher's exact test were used for the statistical analyses.

RESULTS

The overall upgrade rate was 20.6%, with the highest rates in the subtypes of intraductal papilloma (IP) with atypia (44.7%; 55/123), followed by atypical ductal hyperplasia (ADH) (38.4%; 144/375), lobular neoplasia (LN) (12.7%; 7/55), papilloma without atypia (9.4%; 58/611), flat epithelial atypia (FEA) (8.7%; 10/114), and radial scars (RSs) (4.6%; 3/65). There was a significant relationship between the upgrade rate and BI-RADS category, number of samples, and lesion size Lesion size was the most predictive factor for an upgrade in all subtypes.

CONCLUSION

ADH and atypical IP showed considerable upgrade rates to malignancy, requiring surgical excision. The LN, IP without atypia, pure FEA, and RS subtypes showed lower malignancy rates when the BI-RADS category was lower and in smaller lesions that had been adequately sampled using VAB. After being discussed in a multidisciplinary meeting, these cases could be managed with follow-up instead of excision.

High-resolution diffusion-weighted imaging compared with conventional diffusion-weighted imaging and dynamic contrast-enhanced magnetic resonance imaging with regard to image quality and assessment of breast cancer morphology

PURPOSE

To evaluate the image quality and tumor morphology depiction ability of high resolution (HR) diffusion- weighted imaging (f-DWI) in comparison to conventional DWI (c-DWI) and dynamic contrast- enhanced magnetic resonance imaging (DCE-MRI) in the primary breast cancer setting.

METHODS

The f-DWI, c-DWI, and DCE-MRIs of 160 malignant breast masses were evaluated retrospectively by two independent radiologists. Data on image quality [sharpness, distortion, and perceived signalto- noise ratio (SNR)], apparent diffusion coefficient (ADC) value, lesion size, and tumor morphology (shape, margin, and internal pattern) obtained on f-DWI, c-DWI, and DCE-MRI were compared. Consistency between the readers and imaging methods for morphological parameters was analyzed.

RESULTS

The ADC values measured on f-DWI were significantly lower than those measured on c-DWI for both readers (P < 0.001 for each), whereas mean lesion size was significantly larger in c-DWI than in f-DWI and DCE-MRI for both readers (P < 0.001 for each). Higher consistency values were obtained for f-DWI compared with c-DWI when correlated with DCE-MRI for each morphological parameter. The least distorted images were obtained using DCE-MRI compared with c-DWI and f-DWI for both readers, whereas the highest distortion scores were obtained using c-DWI. Sharpness and perceived SNR scores were rated as significantly higher for f-DWI and DCE-MRI images compared with c-DWI by both readers (P < 0.001 for all). The concordance between c-DWI and DCE-MRI was fair to slight (κ = 0.15 to 0.41), whereas concordance between f-DWI and DCE-MRI was significantly better (κ = 0.68 to 0.87) for each reader and for all morphological parameters (P < 0.001). The highest concordance between the readers was achieved in margin assessment (κ = 0.87 to 0.89) regardless of the MRI method, followed by shape and internal pattern parameters (κ = 0.63 to 0.79).

CONCLUSION

The results demonstrated that f-DWI produces higher-quality images than c-DWI, enabling the morphological features to be identified in similar detail to that offered by HR DCE-MRI. Accordingly, f-DWI, as a method that highly correlates with DCE in determining the morphological characteristics of breast cancers, seems to have potential in the evaluation of breast tumors in patients for whom the use of contrast media is contraindicated.

Effect of udder type on udder traits, milk yield and some physicochemical characteristics of milk in Awassi ewes

In this study, it was aimed to determine the effects of udder type on milk yield, udder and teat traits, and some physicochemical properties of milk in 54 Awassi ewe aged 3-4 years. In this study, Type-3 udder, which was reported to be prevalent in breeded Awassi ewes. Type-4, Type-5, and Type-6 udders were not detected in ewes. The lactation period, lactation, and the daily average milk yield values were calculated as 208.33 days, 138.59 liters, and 659.49 ml, respectively. The 90th day of lactation measurements were as follows: udder circumference (44.58 ± 0.51 cm), udder width (13.20 ± 0.36 cm), udder depth (17.66 ± 0.58 cm), udder volume (881.25 ± 37.41 ml), teat length-right (3.84 ± 0.15 cm), teat length-left (3.64 ± 0.17 cm), teat diameter-right (2.07 ± 0.14 cm). The values of the physicochemical characteristics of milk generally showed an increase from the beginning to the middle periods of lactation and then decreased. In conclusion, udder type had no significant effect on the lactation period, milk yield, udder and teat characteristics and the physicochemical properties of milk in Awassi ewes. New studies are required in the determination of the yield and other characteristics of ewes in Turkey. 

Is group C really needed as a separate group from D in COPD? A single-center cross-sectional study

INTRODUCTION

GOLD 2017 report proposed that the combined COPD assessment should be done according only to symptom burden and exacerbation history in the previous year.

OBJECTIVE

This study aims to investigate the change in the COPD groups after the GOLD 2017 revision and also to discuss the evaluation of group C and D as a single group after the GOLD 2019 report.

METHOD

The study was designed as a cross-sectional. 251 stable COPD patients admitted to our out-patient clinic; aged ≥40 years, at least one-year diagnosis of COPD and ≥10 pack-year smoking history were consecutively recruited for the study.

RESULTS

In GOLD 2017, a significant difference was found between the distribution of all groups compared to GOLD 2011 (P = 0,001). 31 patients included in group C were reclassified into group A and 37 patients in group D were reclassified into group B. The FEV₁ values of group A and B patients were significantly low and group C and D patients had had exacerbations in more frequently the previous year in GOLD 2017 compared to GOLD 2011.

CONCLUSION

After the GOLD 2017 revision, the rate of group C patients decreased even more compared to GOLD 2011 and the group C and D may be considered as a single group in terms of the treatment recommendations with the GOLD 2019 revision. We think that future prospective studies are needed to support this suggestion.

The role of low keV virtual monochromatic imaging in increasing the conspicuity of primary breast cancer in dual-energy spectral thoracic CT examination for staging purposes

Background

The additive value of dual-energy spectral computerized tomography (DESCT) in breast cancer imaging is still unknown.

Purpose

To investigate the role of DESCT in improving the conspicuity of primary breast cancer.

Material and Methods

Twenty-nine patients who were histopathologically diagnosed with breast cancer and underwent DESCT for staging of lung metastasis were evaluated retrospectively. The visual conspicuity of breast cancer was scored by two readers separately in reconstructed virtual monochromatic images obtained at 40, 60, 80, and 100 keV. A circular region of interest slightly smaller than the maximum contrasted portion of the primary breast cancer was manually placed. Iodine enhancement (HU) and iodine content (mg/mL) values of tumor, normal breast tissue and pectoral muscle, and contrast-to-noise values of images at four different energy levels were calculated.

Results

The lesion conspicuity score peaked at 40-keV series for both readers and was significantly higher than those at other energy levels (all P < 0.001). Lesion iodine enhancement was highest at 40-keV virtual monochromatic image reconstructions ( P < 0.001). The iodine content was significantly higher in tumor than normal breast tissue, and pectoral muscle ( P < 0.001). The highest contrast-to-noise value was obtained at 60 keV (4.0 ± 2.5), followed by 40 keV (3.9 ± 2.2), without a significant difference ( P = 0.33).

Conclusion

The conspicuity of primary breast cancer was significantly higher in low keV virtual monochromatic images obtained by DESCT. This gives us hope that DESCT may play an effective role in detecting incidental breast lesions. It also raises the question of whether quantitative values obtained by DESCT can be used for characterization of primary breast lesion.

Value of tomography in detecting breast masses and discriminating malign and benign lesions

Objectives

The main purpose of the present study was to determine the effectivity of computerized tomography (CT) in detecting breast masses and discriminating masses as malignant or benign.

Material and Methods

After having received the institutional local ethics committee approval, an experienced radiologist who did not participate in the study created a patient pool by searching our health center's Pathology department database between 2010 and 2018. The group created consisted of dense and non-dense breast types equally and included approximately similar percentages of benign and malignant breast mass sizes. Finally, 70 subjects were included: 30 females with definite malign, 20 with definite benign breast masses, and 20 without any breast pathology based on mammography and ultrasonography results, who were considered as the control group. Three experienced Radiologists (R1, R2, R3) who were not aware of the final diagnosis evaluated all images independently. Radiologist performance was assessed by calculating the area under the receiver operating characteristic curve (AUC) and interobserver reliability values were estimated by intraclass correlation coefficient (ICC) analysis.

Results

The diagnostic accuracy suitability of CT according to BI-RADS scores for R1, R2 and R3 were found as p <0.001, p <0.001 and p <0.001, respectively. There were significant interobserver reliability rates between all investigators (p= 0.0001).

Conclusion

CT may be used as a valuable diagnostic tool in discriminating breast masses with further training in widely varying appearances of normal breast tissues leading to false positive findings.

Diagnostic value of 3D power Doppler ultrasound in the characterization of thyroid nodules

Background/aim

This study aimed to evaluate the diagnostic value of vascular indices obtained using 3D power Doppler ultrasound (3D PDUS) in differentiation of benign and malignant thyroid nodules.

Materials and methods

Sixty-seven patients (56 female, 11 male, mean age 44.6) with 81 thyroid nodules exhibiting mixed (peripheral and central) vascularization patterns, with the largest diameter between 10 and 30 mm, were prospectively evaluated using 3D PDUS. Nodule volume, vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were calculated using the Virtual Organ Computer-aided Analysis (VOCAL) software, and these indices were then compared with regard to the cytohistopathology-based diagnosis. The optimum cutoff values for the differentiation of benign and malignant nodules were identified, and diagnostic efficacy was calculated using receiver operating characteristic (ROC) analysis.

Results

Fifty-six of the 81 nodules included in this study were diagnosed as benign and 25 as malignant. Vascular indices in malignant nodules were significantly higher than those in benign nodules (P < 0.05). In benign nodules, the mean VI was 11.61 ± 6.88, mean FI was 39.75 ± 3.93, and mean VFI was 4.82 ± 2.94, compared to 18.64 ± 12.81, 41.82 ± 4.43, and 8.17 ± 6.37, respectively, in malignant nodules. The area under the curves (AUCs) was calculated as 0.68, 0.61, and 0.67 for VI, FI, and VFI, respectively. At optimal cutoff values of 10.2 for VI, 40.8 for FI, and 5.5 for VFI, the sensitivity and specificity were 72%/55.4%, 68%/57.1%, and 68%/67.9%, respectively.

Conclusion

3D PDUS can be useful in the characterization of thyroid nodules.

Neurocognitive Functions in Infants with Malnutrition; Relation with Long-chain Polyunsaturated Fatty Acids, Micronutrients Levels and Magnetic Resonance Spectroscopy

PURPOSE

Malnutrition may influence neurocognitive development in children by directly affecting the brain structural development, or indirectly by affecting the children's cognition experience. Malnutrition alters the cell numbers, cell migration, synaptogenesis, and neurotransmission due to inadequate availability of necessary micronutrients to support cell growth. We aimed to analyze neurocognitive development in infants with malnutrition and its association with long chain polyunsaturated fatty acids (LC-PUFA), micronutrients levels and magnetic resonance spectroscopy (MRS) findings.

METHODS

The study included two groups; group 1, infants with malnutrition (n=24), group 2; healthy infants (n=21). Peripheral blood was obtained from the participants for studying micronutrients and LC-PUFA levels. The neurocognitive development was analyzed by the use of an Ankara Developmental Screening Inventory test. MRS were performed on all infants.

RESULTS

All parameters of neurocognitive development and serum calcium (9.6±0.9 mg/dL vs. 10.4±0.3 mg/dL, p<0.05) and magnesium (2.02±0.27 mg/dL vs. 2.2±0.14 mg/dL, p<0.05) levels were noted as being low in infants with marked malnutrition. No difference was found in LC-PUFA levels between healthy and malnourished infants. Thalamic choline/creatine levels were significantly high in infants with malnutrition (1.33±0.22 vs. 1.18±0.22, p<0.05). Total neurocognitive development in infants was positively correlated with serum calcium levels (p<0.05, r=0.381).

CONCLUSION

Calcium supplementation may improve neurocognitive development in malnourished infants.

Assessment of breast mass morphology with diffusion-weighted MRI: Beyond apparent diffusion coefficient

BACKGROUND

Diffusion-weighted imaging (DWI) is a noncontrast-enhanced MRI technique. There are new promising studies on the use of DWI as a part of the enhanced or unenhanced abbreviated breast MRI protocols.

PURPOSE

To evaluate the ability of breast DWI in the assessment of mass morphology and determine the contribution of this morphologic evaluation in their characterization.

STUDY TYPE

Retrospective.

POPULATION

In all, 213 consecutive women were breast MR imaged and had a later confirmed diagnosis.

FIELD STRENGTH/SEQUENCE

Breast dynamic contrast-enhanced-MRI (DCE-MRI) and DWI at 1.5T.

ASSESSMENT

After Institutional Review Board approval, two radiologists first independently, and later in consensus, evaluated the visibility and morphology of the 143 malignant, 70 benign masses on DWI and DCE-MRI in separate sessions, blindly. Shape, margin, and internal pattern of the masses were evaluated according to BI-RADS lexicon. Apparent diffusion coefficient (ADC) and tumor size were measured by one radiologist.

STATISTICAL TESTS

Consistency between imaging methods and readers was evaluated with Cohen's kappa statistics. Multivariate analysis was applied to find the best predictors of malignancy.

RESULTS

Tumor visibility on DWI was high to moderate in at least 88% of cases. Consistency between DWI and DCE-MRI was substantial (kappa ≥0.757) for shape and margin and moderate (kappa = 0.505) for internal pattern. Interobserver agreement was substantial to moderate for all morphologic parameters (kappa ≥0.596). Morphology evaluated on DWI provided 83-84% accuracy in discriminating malignant from benign masses. ADC alone provided 90-91% accuracy. Both morphologic parameters and ADC were significantly associated with malignancy on multivariate analysis and provided 91-93% accuracy.

DATA CONCLUSION

DWI might be used not only for ADC evaluation but also for the morphological evaluation of breast masses to characterize them.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;48:1668-1677.

Multislice/multidetector-row computed tomography findings of a rare coronary anomaly: the first septal perforator branch originating from the left main coronary artery

Multislice/multidetector-row computed tomography (MDCT) is now widely used for noninvasive assessment of coronary arteries, and it may sometimes reveal coronary anomalies. Detection of such anomalies may be relevant both during follow-up and for planning cardiac or coronary surgical/interventional procedures. These anomalies may be missed unless carefully sought. In this paper, we present the MDCT images of a first septal perforator branch originating from the left main coronary artery, which represents an extremely rare coronary anomaly. To the best of our knowledge, this is the first case in the literature where MDCT images are presented.

Association between the plasma levels of IMA and coronary atherosclerotic plaque burden and ischemic burden in early phase of non-ST-segment-elevation acute coronary syndromes

OBJECTIVE

Ischemia-modified albumin (IMA), a novel biochemical marker, is known to reflect ischemia in early phases of acute coronary syndrome (ACS). In the present study, we evaluated the role of IMA on the prediction of coronary atherosclerotic plaque burden and ischemic burden in patients with non-ST-segment-elevation acute coronary syndromes (NSTEACS).

PATIENTS AND METHODS

Ninety-six consecutive NSTEACS patients presented within the first three hours of symptom onset were prospectively enrolled in this study. Blood samples were collected in the first 30 min of admission for IMA measurement. Serum levels of IMA were analyzed using the rapid and colorimetric method and reported in absorbance units (ABSU). Coronary plaque burden was assessed by using angiographic Gensini score (GS). In addition, patients were divided into large (LIBG) and small ischemic burden (SIBG) groups based on angiography findings.

RESULTS

Patients were dichotomized into two groups according to median GS as follows; with GS ≤ 44 and GS > 44, respectively. Mean IMA was significantly higher in GS > 44 group as compared to GS ≤ 44 group (0.746 ± 0.15 vs. 0.550 ± 0.12 ABSU, p < 0.001). The GS was positively correlated with the levels of IMA (r = 0.673, p < 0.001). IMA was significantly higher in LIBG as compared to SIBG (0.745 ± 0.16 vs. 0.570 ± 0.13 ABSU, p < 0.001).

CONCLUSIONS

IMA measurement in early phases of NSTEACS may give predictive information about ischemic burden and coronary atherosclerotic plaque burden; thus, may be useful in decision-making about treatment options in these patients.

Somatic SNPs of the BRCA2 gene at the fragments encoding RAD51 binding sites of canine mammary tumors

Mammary tumors are the most common tumor type both in women and in female dogs. In women, heritable breast cancers have been linked mutations in the breast cancer susceptibility gene BRCA2 and it contains eight BRC repeats in exon 11 that bind to RAD51. In this study, we investigated the sequence variations of BRC1-BRC8 and C-terminus of canine BRCA2 gene. From a total of 64 canine patients with mammary tumors, 31 mammary tumors with benign and malign carcinomas and the 3 normal mammary glands were used for the study. In this study, 19 SNPs of exon 11 of BRCA2 in canine mammary tumors were detected for the first time. The c.2383A>C (T1425P) SNP was found to be the most probable disease-associated nsSNP. Our findings suggest that T1425P variation in BRC3 to be the most probable disease-associated nsSNP and may affect RAD51 binding strength.

The management of adnexal masses in premenopausal patients: a ten-year retrospective study at a single center

PURPOSE OF INVESTIGATION

To distinguish adnexal masses as benign and malignant, and to thereby identity the suitable surgical method for these masses, in premenopausal women, by retrospectively evaluating over a ten-year period, the diagnostic parameters, such as serum CA 125 and transvaginal ultrasonography (TVS), in combination with the presence of ascites in the abdomen.

MATERIALS AND METHODS

The study was conducted with 255 premenopausal patients diagnosed with adnexal masses who had been admitted to the Gaziantep University Faculty of Medicine, Clinic of Gynecology and Obstetrics, between January 2003 and January 2013. Data collected from these patients included age, menopausal state, information regarding the presence of ascites, ultrasound findings, and serum CA 125 levels.

RESULTS

The mean age of the women included in the study was 32.79 ± 8.11 (range: 18-51) years. Based on the criteria mentioned above, 152 patients were treated by laparoscopy based on a strong suspicion of benign mass, while 103 patients were treated by laparotomy, based on a strong suspicion of malignant mass. CA 125 values did not have a significant effect on malignancy risk. Based on the TVS results, three malignant masses were reported postoperatively in the patient group strongly suspected to have benign masses, while five benign masses were reported postoperatively in the patient group strongly suspected to have malignant masses.An evaluation of the present diagnostic method showed that the TVS has a positive predictive value (PPV) of 94.19% in identifying malignant masses, and a negative predictive value (NPV) of 98.22% in identifying benign masses.

CONCLUSION

TVS and CA 125, along with an evaluation of menopausal status and ascites, can be an effective approach for diagnosing adnexal masses, and also for determining the proper surgical method to follow.

Can unenhanced breast MRI be used to decrease negative biopsy rates?

PURPOSE

We aimed to determine whether low-risk breast masses can be effectively managed with unenhanced magnetic resonance imaging (MRI) combining T2-weighted sequences with diffusion-weighted imaging (DWI) instead of immediate biopsy to decrease negative biopsy rates.

METHODS

After institutional review board and patient approvals, 141 consecutive women with 156 low-risk breast masses, who underwent unenhanced MRI and later on received a final diagnosis, were included in the study. There were 72 BI-RADS 3 masses in women with relative risk factors and 84 BI-RADS 4A masses, all referred for biopsy. Apparent diffusion coefficient (ADC) cutoff was 0.90×10-3 mm2/s. According to ADC values and T2-weighted imaging characteristics, masses were classified as either malignant or benign. Unenhanced MRI results were compared with final diagnoses obtained by histopathology or imaging surveillance, and diagnostic values were calculated.

RESULTS

Of 156 masses, 112 underwent biopsy. Four malignancies were diagnosed, three of which having ADC values lower than the cutoff. In women who rejected the biopsy, masses were stable during a follow-up of at least two years (n=44). MRI revealed 91% specificity and 99% negative predictive value (NPV) for detection of breast cancer.

CONCLUSION

Combination of T2-weighted imaging with DWI is a feasible method to further characterize breast masses with a low probability of malignancy. With the use of unenhanced MRI instead of immediate biopsy, it might be possible to decrease negative biopsy rates of low-risk breast masses.

The determinants of defensive medicine in Italian hospitals: The impact of being a second victim

BACKGROUND

Defensive medicine affects healthcare systems worldwide. The concerns and perception about medical liability could lead practitioners to practise defensive medicine. Second victim is a healthcare worker involved in an unanticipated adverse patient event. The role of being second victim and the other possible determinants for defensive medicine is mostly unclear.

OBJECTIVE

To study the condition of being second victim as a possible determinants of defensive medicine among Italian hospital physicians.

DESIGN, SETTING AND PARTICIPANTS

A secondary analysis of the database of the national survey study on the prevalence and the costs of defensive medicine in Italy that was carried out between April 2014 and June 2014 in 55 Italian hospitals was performed for this study. The demographic section of the questionnaire was selected including the physician's age, gender, specialty, activity volume, grade and the variable being a second victim after an adverse event.

RESULTS

A total sample of 1313 physicians (87.5% response rate) was used in the data analyses. Characteristics of the participants included a mean age 49.2 of years and 19.4 average years of experience. The most prominent predictor for practising defensive medicine was the physicians' experience of being a second victim after an adverse event (OR=1.88; 95%CI, 1.38-2.57). Other determinants included age, years of experience, activity volume and risk of specialty.

CONCLUSIONS

Malpractice reform, effective support to second victims in hospitals together with a systematic use of evidence-based clinical guidelines, emerged as possible recommendations for reducing defensive medicine.

Leukoencephalopathy with thalamus and brainstem involvement and high lactate caused by novel mutations in the EARS2 gene in two siblings

Leukoencephalopathy with thalamus and brainstem involvement, and high lactate (LTBL) is a recently identified disease related to mutations in the EARS2 gene encoding glutamyl-tRNA synthetase. We report clinical and radiological findings for two siblings with new pathogenic mutations in the EARS2 gene. Both patients showed symptoms of mild-type disease, but there were clinical differences between the two siblings. While the older brother had hypotonia and delayed developmental milestones, the younger brother had seizures and spasticity in the lower extremities. Brain magnetic resonance imaging (MRI) findings were quite similar for the two siblings. MRI findings were specific to LTBL. MRI lesions of the older sibling had regressed over time. Clinical and radiological improvement, as in the previously reported patients with LTBL, may be an important clue for diagnosis.

Role of 3D power Doppler ultrasound in the further characterization of suspicious breast masses

PURPOSE

To investigate effectiveness of vascular indices obtained with 3D power Doppler ultrasound in the further characterization of breast masses and prevention of unnecessary biopsies.

MATERIALS AND METHODS

Between April 2013 and March 2014, 109 patients (age range, 17-85 years; mean age, 47 years) with 117 radiologically or clinically suspicious breast masses were prospectively evaluated with 3DPDUS before biopsy. Mass volume (MV), vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were calculated using Virtual Organ Computer-aided Analysis (VOCAL) software and they were correlated with the final diagnosis. Cutoff values of vascular indices were determinated and diagnostic efficacy was calculated with receiver operating curve (ROC) analysis.

RESULTS

All vascular indices, age of patients and tumor volume were significantly lower in benign masses compared with malignant ones (p<0.001). AUCs were 0.872, 0.867 and 0.789 for VI, VFI and FI, respectively. The diagnostic efficacy of VI (for cutoff 1.1; 83% sensitivity, 82% specificity and 82% accuracy) and VFI (for cutoff 0.4; 80% sensitivity, 83% specificity and 80% accuracy) were significantly higher than FI (for cutoff 33,9; 73% sensitivity, 69% specificity and 71% accuracy). It was found that with the use of vascular indices of 3DPDUS in the further characterization of suspicious breast masses between 24% to 37% of unnecessary biopsies could have been avoided.

CONCLUSION

The vascular indices obtained with 3DPDUS seem reliable in the further characterization of suspicious breast masses and might be used to decrease unnecessary biopsies.

Umbilical venous catheter complications in newborns: a 6-year single-center experience

OBJECTIVE

Umbilical venous catheter (UVC) insertion is frequently performed in critically ill neonates. Various mild or serious complications of umbilical venous catheterization can be observed associated with this procedure. In this study, newborns that have undergone UVC and developed complications were evaluated.

METHODS

This retrospective observational study was carried out in newborns that have undergone UVC and developed complications were evaluated between June 2008 and November 2014.

RESULTS

Umbilical venous catheter were inserted to 974 (22.4%) newborn and followed for 7402/catheter days. UVC-related complications developed at 198 patients (20.3%). The most common UVC-related complications were malposition (n = 189), catheter-related bloodstream infection (n = 6) and remnant of catheter in the umbilicus (n = 3), respectively. Remnant of catheter in the umbilicus was removed by pediatric surgeon. Except one patient, all patients were discharged.

CONCLUSION

Although UVC is a common and easy vascular access, this process is not without complications. UVC may be inappropriate position because the catheter is inserted by the pediatrician without imaging guidance and may occasionally be associated with complications. Inappropriate positioning of the catheter may observe during the follow-up and maintained care. Therefore, newborns particularly in premature and very low birth-weight newborn should be followed in terms of catheter complications during insertion, following and just after removing of the catheter.

Is Sinusitis Innocent?--Unilateral Subdural Empyema in an Immunocompetent Child

Subdural empyema related to Streptococcus constellatus is extremely rare in an immunocompetent child, and also there is no reported case along with Staphylococcus lugdunensis infection. Although Streptococcus constellatus has been determined as a co-pathogen with anerobic bacteria in many infections, it has not been reported in combination with Staphylococcus lugdunensis. The authors describe a case of previously healthy 16-y-old child with unilateral subdural empyema due to these bacteria. Sinusitis was the only predisposing factor in the index case. The authors propose that some cases of culture-negative intracranial infections may be due to these infectious agents. Therefore, these agents should be considered as causes of intracranial infection in persistent complaints such as fever and headache after sinusitis in children. It is important to treat them with effective antibiotics and early surgical intervention for favorable outcome, because fatal cases were reported due to Streptococcus constellatus infections.

Relationship between exhaled leukotriene and 8-isoprostane levels and asthma severity, asthma control level, and asthma control test score

OBJECTIVE

Exhaled breath condensate (EBC) is a completely non-invasive method for the collection of airway secretions to measure intense inflammation in the airways of asthmatics. It has been shown that the childhood asthma control test (c-ACT) is a good tool for use in the evaluation of asthmatics. Whether the c-ACT score and asthma control level correlate with the airway inflammation is not well known. We aimed to evaluate the relationship between exhaled cysteinyl leukotrienes (Cys-LTs) and 8-isoprostane levels and asthma severity, asthma control level and c-ACT score in asthmatic children.

METHODS

Thirty asthmatic children were evaluated with c-ACT score and pulmonary function tests. Asthma severity and asthma control level were assessed according to GINA. EBC was collected and Cys-LTs and 8-isoprostane concentrations were determined using a specific immunoassay kit.

RESULTS

Exhaled 8-isoprostane level in patients with moderate persistent asthma [114 (55-146)pg/ml] was higher than in the mild persistent group [52 (21-91)pg/ml] (p=0.05, Mann-Whitney U [MWU]). EBC 8-isoprostane in children with 1-4 asthma exacerbations/year [52 (16-80)pg/ml] was significantly lower than in children with >4 asthma exacerbations/year [114 (57-129)pg/ml] (p<0.05, MWU). No significant relation was determined between exhaled 8-isoprostane and Cys-LTs levels and c-ACT score and asthma control level. Exhaled 8-isoprostane correlated negatively with bronchodilator response (p=0.015, r=-0.45).

CONCLUSIONS

Exhaled 8-isoprostane, as an oxidative stress specifier, was found to be increased in relation with asthma exacerbation frequency and oxidative stress increases with the severity of asthma. In contrast to asthma severity level, c-ACT score and asthma control level may not reflect airway inflammation.

Nonfunctional islet cell tumor of the pancreas in a patient with tuberous sclerosis: a case report with literature review

Islet cell tumors (ICTs) are rare tumors of the pancreas. Association of this type of tumor with tuberous sclerosis is extremely rare. Only 13 cases of pancreatic ICT with tuberous sclerosis have so far been documented in the literature. However, awareness of the association of tuberous sclerosis and ICT is important for early diagnosis and appropriate treatment of this condition. This article presents the case of a 63-year-old female with angiomyolipoma (AML) of the kidney and liver, calcified subependymal nodules and a large mass in the pancreas, which was proven to be an ICT on histopathological examination.

Zwolle risk score predicts contrast-induced acute kidney injury in STEMI patients undergoing PCI

OBJECTIVE

Contrast-induced acute kidney injury (CI-AKI) is a common complication in patients with acute ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). The Mehran risk score was defined originally in elective PCI and may be predictive of CI-AKI. The aim of the present study was to investigate whether the Zwolle score predicts CI-AKI in patients with acute STEMI undergoing primary PCI.

PATIENTS AND METHODS

We analyzed the data of 314 consecutive patients (mean age 56.3 ± 11.4 years) with acute STEMI undergoing primary PCI. The study population was divided into two groups according to CI-AKI development. The Mehran score, Zwolle score, baseline characteristics, and in-hospital outcomes were recorded.

RESULTS

Patients with CI-AKI had higher Mehran and Zwolle scores. In a receiver operating characteristic (ROC) curve analysis, high area under the curve (AUC) values were determined for Zwolle and Mehran scores (0.85 and 0.79, respectively) for CI-AKI development. A Zwolle score greater than  2 predicted CI-AKI with a sensitivity of 76.3 % and a specificity of 75.4 %. A Mehran score greater than 5 predicted CI-AKI with a sensitivity of 71.1 % and a specificity of 73.6 %.

CONCLUSION

Zwolle score predicts CI-AKI slightly better than the Mehran score in patients with STEMI undergoing primary PCI. This simple score can be used at the catheterization laboratory for risk stratification for the development of CI-AKI.

Metabolic syndrome and long-term cardiovascular outcomes in NSTEMI with unstable angina

BACKGROUND AND AIM

Metabolic syndrome (MS) is associated with cardiovascular mortality and morbidity in patients with acute coronary syndrome. The purpose of this study was to evaluate the impact of MS on long-term clinical outcomes in patients with pure non-ST segment myocardial infarction (NSTEMI) or unstable angina pectoris (USAP).

METHODS AND RESULTS

We prospectively enrolled 310 consecutive NSTEMI/USAP patients (74 females; mean age, 59.3 ± 11.9 years). The study population was divided into two groups: MS(+) and MS(-). The clinical outcomes of the patients were followed for up to 3 years. Increased 3-year cardiovascular mortality and reinfarction were observed in the MS(+) group, as compared to the MS(-) group (15 vs. 3.4%, p = 0.001, and 22.2 vs. 8.3%, p = 0.001, respectively). Hospitalization rates for heart failure and stroke were not significantly different between the two groups on follow-up. By a Cox multivariate analysis, a significant association was noted between MS and the adjusted risk of 3-year cardiovascular mortality (odds ratio 3.4, 95% confidence interval, 1.24-9.1, p = 0.02).

CONCLUSION

These results suggest that MS is associated with an increased risk of 3-year cardiovascular mortality and reinfarction in patients with NSTEMI/USAP.

Polymorphism of sheep POU1F1 gene exon 6 and 3'UTR region and their association with milk production traits

The purpose of the study was to detect the AluI and DdeI polymorphisms within POU1F1 gene exon 6 and 3'UTR region in Turkish sheep breeds, and their association with milk productive traits. Jugular blood samples were collected from 50 Sakiz, 50 White Karaman, and 50 Awassi sheep using EDTA as an anticoagulant. PCR-RFLP and sequencing analysis were performed to investigate possible polymorphisms in the exon 6 and 3' flanking region of the sheep POU1F1 gene. The PCR products were digested with restriction endonuclease AluI and DdeI, and biallelic polymorphism was found with restriction endonuclease AluI and two genotypes (TT (296 bp and 173 bp) and CC (235 bp, 173 bp and 61 bp)) were detected. White Karaman and Awassi breeds did not show polymorphisms for AluI restriction sites. No polymorphism at the DdeI cleavage sites was detected in the three sheep breeds. Significant statistical results were found in milk yield ((***)P0.001), fat ((***)P0.001) and lactose ((*)P0.05) values with TT and CC genotypes, however no significant association of TT and CC genotypes with protein values was detected (P>0.05) and individuals with genotype TT had a superior milk yield in Sakiz sheep breeds. As sequence results, seven variation points were determined for exon 6 (g.185T>C) and 3'UTR (g.220G>A, g.229C>T, g.248C>T, g.250A>T, g.255T>C, g.258C>T) of the sheep POU1F1 gene. We have reported here for the first time single nucleotide polymorphisms of the POU1F1 gene for both exon 6 and 3'UTR and its effects on milk traits in Turkish sheep breeds were evaluated.

Diagnostic performance of using effervescent powder for detection and grading of esophageal varices by multi-detector computed tomography

PURPOSE

To investigate the effect of using effervescent powder (EP) on the efficacy of multi-detector computed tomography (MDCT) in detection and grading of esophageal varices in cirrhotic patients by considering endoscopy as the gold standard.

MATERIALS AND METHODS

Ninety-two cirrhotic patients undergoing biphasic liver MDCT followed by upper gastrointestinal endoscopy within 4 weeks of MDCT were prospectively evaluated. The patients were divided into two groups before MDCT. The first group (n=50) received effervescent powder (EP) before and during MDCT procedure and the second group did not receive (n=42). The presence, size and grade of the esophageal varices were evaluated. MDCT findings were compared with endoscopic results. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of MDCT with EP and without EP were calculated and compared. Correlations between the grades of the varices for each group based on MDCT imaging and endoscopic grading were also evaluated.

RESULTS

The sensitivity, specificity, accuracy, PPV, and NPV of MDCT were 100%, 88%, 96%, 94%, and 100%, respectively, in the EP group, whereas they were 76%, 67%, 74%, 89%, and 43%, respectively, in the non-EP group. Correlations between the grades of the esophageal varices on MDCT and endoscopy were significant in both groups (r=0.94, p<0.001 for EP group and r=0.70, p<0.001 for non-EP group).

CONCLUSION

During periodic CT scanning of cirrhotic patients, use of EP increases the success rate of MDCT for detection and grading of esophageal varices.

A new echocardiographic parameter of arterial stiffness in end-stage renal disease

BACKGROUND

Cardiovascular disease is the leading cause of death among patients with end-stage renal disease (ESRD). Arterial stiffness is an independent predictive parameter of overall and cardiovascular mortality in these patients. However, the defined procedures for the measurement of arterial stiffness are time consuming and not practical in daily practice.

METHODS

The study population included 50 patients with ESRD who were treated with hemodialysis (HD; n=23) or peritoneal dialysis (PD; n=27) and 70 age- and sex-matched control subjects. Aortofemoral pulse wave velocity (PWV), carotid intima-media thickness (CIMT), and color M-mode propagation velocity of the descending aorta (aortic propagation velocity, APV) were measured.

RESULTS

Compared to the control group, the patients with ESRD had significantly lower APV (46.4 ± 12.4 vs. 58.5 ± 8.5, p < 0.01) and higher PWV (10.5 ± 2.5 vs. 9.2 ± 1.2, p < 0.01) and CIMT (0.66 ± 0.15 vs. 0.43 ± 0.06, p < 0.01) measurements. There were significant correlations between APV and CIMT (r = - 0.769, p < 0.001), APV and PWV (r = - 0.682, p < 0.001), and PWV and CIMT (r = 0.564, p < 0.001). There were no significant differences in APV and PWV between the PD and HD patients.

CONCLUSION

Arterial stiffness is an important indicator of atherosclerosis and arterial aging in patients with ESRD. The measurement of APV is an easy and practical new echocardiographic method and may be used to identify arterial stiffness in these patients.

The very low density lipoprotein receptor-associated pontocerebellar hypoplasia and dysmorphic features in three Turkish patients

Pontocerebellar hypoplasia consists of a rare heterogeneous group of congenital neurodevelopmental disorders characterized by hypoplasia and atrophy of the cerebellar cortex, dentate and pontine nuclei, and inferior olives. The very low density lipoprotein receptor protein is an integral part of the reelin signaling pathway, which guides neuroblast migration in the cerebral cortex and cerebellum. Mutations in this receptor cause nonprogressive cerebellar ataxia, mental retardation, and cerebellar hypoplasia. In this report, we present 3 patients from 2 different families displaying very low density lipoprotein receptor-associated pontocerebellar hypoplasia, cortical dysplasia, mental retardation, and bipedal gait. One of the siblings has also displayed dysmorphic features, as we previously reported before the identification of the genetic defect in this family.

Comparison of pre-emptive tonsillar lodge infiltration with ropivacaine versus intravenous tramadol in pediatric tonsillectomies: a randomized placebo-controlled study

OBJECTIVE

To investigate the placebo controlled effect of pre-emptive local infiltration of ropivacaine and intravenous tramadol in postoperative pain and nausea-vomiting in pediatric tonsillectomy cases.

METHODS

90 children at ASA I-II physical status, who are between 2 and 9 years old, underwent tonsillectomy were included to the study. Patients were randomized into one of three study groups. Group I was i.v. saline group (placebo group), Group II was preemptive 1.5 ml 0.75% ropivakain to the tonsil lodge and Group III was preemptive 1mg/kg i.v. tramadol. Hemodynamic parameters and synchronized Maunuksela pain scores were evaluated in the post anesthetic care unit.

RESULTS

There was no difference in age, weight, sex and hemodynamic parameters of children included to the study groups. Postoperative nausea vomiting was significantly lower in Group II and pain scores at resting and swallowing are significantly lower than the other study groups. Maunuksela pain scores at 2nd, 3rd, 6th and 9th hours while resting were significantly lower in Group II compared with Groups I and III (p<0.001). The comparison of scores between groups I and III were similar. Maunuksela pain scores during swallowing were significantly lower in Group II compared with Group I and III at 2nd, 3rd, 6th, 9th, 12th, 21st and 24th hours postoperatively (p<0.001). While comparing Maunuksela pain scores of Groups I and III, significantly lower scores are determined at 2nd and 24th hours in Group III (p<0.001). Analgesic needs were significantly low in Group II at postoperative period (150 ± 30 mg paracetamol) (p<0.05). It was similar in Groups I and III (Group I: 400 ± 40 mg, Group III: 360 ± 40 mg paracetamol).

CONCLUSION

This study showed that peritonsillar ropivacaine infiltration might produce an effective postoperative analgesia probably due to a preventing effect on sensitization of the pain pathways.

Multiple relapses in extramedullary localization of acute lymphoblastic leukemia

Extramedullary relapses of acute lymphoblastic leukemia in children and young adults are rare and in most cases are usually related to the central nervous system or testes. We describe a case of a 25-year-old man with an acute lymphoblastic leukemia with multiple extramedullary relapses in the testes, gallbladder, breast, parotid gland and eye at various times (Fig. 5, Ref. 21).

Pontocerebellar hypoplasia associated with nevoid hyperpigmentation and dysmorphic findings: a new subtype?

Pontocerebellar hypoplasia consists of a rare heterogeneous group of congenital neurodevelopmental disorders characterized by hypoplasia and atrophy of the cerebellar cortex, dentate and pontine nuclei, and inferior olives. Lineer nevoid hyperpigmentation is a rare skin condition characterized by whorls and streaks of hyperpigmented macules in a reticulate pattern along Blaschko's lines. Herein we present a three year-old male patient with pontocerebellar hypoplasia associated with nevoid hyperpigmentation on the upper part of the body. Besides he has some dysmorphic features including microcephaly, triangular chin, long philtrum, long hand fingers, flexion contracture in all of the distal phalanges of both hands, and strabismus.