Is FDG-PET/CT used correctly in the combined approach for nodal staging in NSCLC patients?

BACKGROUND: The most widely accepted approach nowadays in nodal staging of non-small cell lung cancer (NSCLC) is the combined use of 18-Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) and endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA). However, this approach may not be sufficient, especially for early stages. AIMS: Our aim was to assess whether more satisfactory results can be obtained with standardized uptake value maximum lymph node/standardized uptake value mean mediastinal blood pool (SUVmax LN/SUVmean MBP), SUVmax LN/Primary tumor, or a novel cut-off value to SUVmax in this special group. SUBJECTS AND METHODS: Patients with diagnosed NSCLC and underwent FDG-PET/CT were reviewed retrospectively. 168 LNs of 52 early stage NSCLC patients were evaluated. The LNs identified in surgery/pathology reports were found in the FDG-PET/CT images. Anatomic and metabolic parameters were measured. Statistical analysis was performed by using of MedCalc Statistical Software. RESULTS: Regardless of LNs size; sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of SUVmax >2.5 were 91.5%, 65.9%, 58.2%, and 95.1%, respectively. Optimum cut-off value of SUVmax was >4.0. Sensitivity, specificity, PPV, and NPV were found as 81.0%, 90.0%, 81.0%, and 90.0% respectively. Optimum cut-off value of SUVmax LN/SUVmean MBP was >1.71. Sensitivity, specificity, PPV, and NPV were found as 94.7%, 80.0%, 71.1%, and 96.7%, respectively. Optimum cut-off value of SUVmax LN/Primary tumor was >0.28. Sensitivity, specificity, PPV, and NPV were found as 81.1%, 85.1%, 72.9% and 90.1%, respectively. CONCLUSION: SUVmax LN/SUVmean MBP >1.71 has higher PPV than currently used, with similar NPV and sensitivity. This can provide increase in the accuracy of combined approach. In this way, faster nodal staging/treatment decisions, cost savings for healthcare system and time saving of medical professionals can be obtained.

Criticality in tailoring the treatment for tracheoesophageal fistulas in children.

OBJECTIVE: Tracheo-oesophageal fistula (TOF) is a rare pathology. It can be congenital and concurrent with other congenital anomalies such as oesophageal atresia, laryngeal and tracheal agenesis, or it can be acquired. The purpose of this study was to analyse various management strategies and their outcomes in infants and children with TOF and identify potential areas for standardisation of the fistula repair procedures. METHODS: At a single institution, a retrospective analysis of infants and children with congenital or acquired TOF between 2013 and 2019 was performed. Thirteen patients were identified. Data collection included: patient demography, associated congenital anomalies, details of fistula at the time of endoscopy, surgical approach and intra-operative findings, need for additional intervention(s), and outcomes. RESULTS: Thirteen patients underwent endoscopic or open surgeries for correction of TOF. The TOF was congenital in ten patients and acquired in three patients. Eight patients had associated aero-digestive comorbidities, and six patients had systemic comorbidities. Three patients underwent endoscopic procedures and nine patients underwent an open TOF repair. One patient had tracheal agenesis and was not offered any treatment. Two patients required multiple endoscopic interventions for recurrent TOFs. Among four patients with prior tracheostomy, three were decannulated and one awaits decannulation. Conclusion Appropriate case selection and surgical ergonomics are essential for patients with TOF to avoid recurrences. Preoperative endoscopy to obtain precise details regarding associated laryngotracheal lesions and demographics of the fistula is crucial.

Meta-analytic comparison of robotic and transoral laser surgical procedures in supraglottic carcinoma.

OBJECTIVE: To assess published reports of oncological surgical success rates in patients who underwent transoral laser supraglottic surgery and robotic surgery for supraglottic cancer. METHODS: A systematic review of the literature was conducted and a meta-analysis of published data was performed. PubMed, Sage, Medline and Cochrane data sources were investigated. Overall survival rates, disease-specific survival rates, additional treatments and recurrence rates were investigated to determine the success of the surgical procedures. RESULTS: The meta-analysis included 24 studies; 1617 studies were excluded. There were no statistically significant differences between the transoral laser supraglottic surgery and transoral robotic supraglottic surgery groups in terms of overall survival (77.0 per cent and 82.4 per cent respectively) and disease-specific survival (75.8 per cent and 87.0 per cent respectively). There was recurrence in 164 out of 832 patients (19.7 per cent) in the transoral laser supraglottic surgery group and in only 6 out of 66 patients (9 per cent) in the transoral robotic supraglottic surgery group. CONCLUSION: Transoral laser surgery and robotic surgery appear to have comparable and acceptable oncological success rates.

The utility of susceptibility-weighted imaging to evaluate the extent of iron accumulation in the choroid plexus of patients with ß-thalassaemia major.

AIM: To assess iron accumulation in the choroid plexus of ß-thalassaemia patients using fast spin echo (FSE) T2-weighted, gradient echo (GRE) T2*-weighted, susceptibility-weighted imaging (SWI) and compare the results. MATERIALS AND METHODS: Eighteen patients with transfusion-dependent ß-thalassaemia and the control group underwent magnetic resonance imaging (MRI) examinations. Signal intensities were separately evaluated using a "number of hypointensity in the choroid plexus" (NHICP) grading system on axial FSE T2-weighted, GRE T2*-weighted, and SWI images. The NHICP grading system scores were compared using the chi-squared test. Spearman's correlation analysis was used to explore relationships between the variables and NHICP grading system scores. RESULTS: The sensitivity of each technique was calculated: FSE T2-weighted imaging=0.17, GRE T2*-weighted imaging=0.48, and SWI=0.81. Three-sample test for equality of proportions showed that chi-squared=74.85, df=2, p<0.0001. All of the FSE T2-weighted, GRE T2*-weighted, and SWI images differed significantly in terms of their capacity to reveal iron accumulation in the choroid plexus. Of the three methods, SWI was the most sensitive. CONCLUSIONS: SWI is useful for revealing iron deposition in the brains of ß-thalassaemia patients, especially those in the early stages of disease, and it can be used to predict disease prognosis. The present study contributes to an understanding of the important role played by the choroid plexus in brain iron metabolism.

Relationship between betatrophin levels and metabolic parameters in patients with polycystic ovary syndrome.

To evaluate the status of serum betatrophin levels and potential relations between metabolic parameters and betatrophin levels in patients with polycystic ovary syndrome. We included patients newly diagnosed with PCOS in our study. Fifty-seven female patients (30 patients with PCOS and 27 healthy control subjects) were enrolled in this study. Serum betatrophin levels were measured using a betatrophin enzyme-linked immunosorbent assay kit. Insulin resistance was calculated using the homeostasis model of the assessment-insulin resistance index formula. The betatrophin level was 1538,85 ng/L in the patient group and 2440,46 ng/L in the control group, and the difference was statistically significant (p=0.003). A significantly negative correlation was found between betatrophin level and insulin, HOMA-IR, and BMI. Betatrophin levels in patients with PCOS are lower than those without PCOS and inversely related to insulin resistance.

Impact of unilateral carbon dioxide laser posterior transverse cordotomy on vocal and aerodynamic parameters in bilateral vocal fold paralysis.

OBJECTIVES: Carbon dioxide laser posterior transverse cordotomy is a common option for bilateral vocal fold paralysis. This study prospectively evaluated aerodynamic and acoustic effects of unilateral carbon dioxide laser posterior transverse cordotomy in bilateral vocal fold paralysis patients. METHODS: The study comprised 11 bilateral vocal fold paralysis patients (9 females, 2 males), with a mean age of 46.6 ± 14.1 years. All patients were treated by laser posterior transverse cordotomy. Pre-operative and two-month post-operative assessments were conducted, including: dyspnoea scales, maximum phonation time measurement, spirometry and bicycle ergometry. RESULTS: All subjective and objective aerodynamic parameters showed statistically significant improvements between the pre- and post-operative period. Objective spirometric and ergometric parameters showed a significant increase post-operatively. The changes in objective voice parameters (fundamental frequency (f0), jitter, shimmer, soft phonation index and noise-to-harmonic ratio) were statistically non-significant; however, there was a significant improvement in subjective voice parameters post-operatively, as assessed by the voice handicap index and grade-roughness-breathiness-asthenia-strain scale (p = 0.026 and p = 0.018 respectively). CONCLUSION: Unilateral carbon dioxide laser posterior transverse cordotomy is an effective procedure that results in improved dyspnoea and aerodynamic performance with some worsening of voice parameters.

Effects of fine-needle aspiration biopsy (FNAB) nodule depth on pain score.

PURPOSE: Fine-needle aspiration biopsy (FNAB) of the thyroid is generally a well-tolerated procedure associated with weak levels of pain. However, pain may be very intense in some patients. The cause for the pain in these patients has not been identified. The hypothesis of this study is that there is a likely relationship between pain level and nodule depth during FNAB. MATERIALS AND METHODS: Included in the study were 98 patients with euthyroid nodular goiter who underwent FNAB. When ultrasound guided thyroid fine-needle aspiration biopsy was performed findings such as the distance of the nodule to the skin, the size of the nodule, visual analogue scale (VAS) score values were recorded. FINDINGS: The distance of nodule to skin and nodule size was measured, respectively, as 10.7 ± 2.8 mm and 21.7 ± 8.6 mm. Mean VAS score was 36 ± 16. FNAB-related pain was correlated with the nodule depth (r = 0.43, p < 0.001). In the logistic regression analysis, we also found that high VAS score class was effected by only nodule depth (B = -1.619; OR 1.287; CI 1.057-1.565, p < 0.05). CONCLUSION: Our results show that pain increased significantly during FNAB in patients who had more deeply situated nodules. Local anesthetic methods may be recommended for these patients.

Are small adrenal incidentalomas solely a radiological finding?

OBJECTIVE: The criterium defining the threshold size of adrenal incidentaloma (AI) is a size greater than 1 cm diameter. However, data concerning AI≤1 cm in diameter is scant. The aim of this study was to evaluate the function of adrenal masses≤1 cm and to compare them with adrenal masses>1 cm. MATERIALS AND METHODS: The study included 130 consecutive patients with AI (38 and 92 AI at ≤ 1 cm and > 1 cm, respectively). The patients were evaluated according to demographic and hormonal characteristics. RESULTS: The prevalence of SCS was 5.3 and 12% in AI≤1 cm and > 1 cm diameter, respectively. Hyperaldosteronism was found only in patients with > 1 cm AI. Pheochromocytoma were not found in either group. Patients with > 1 cm AI had a higher prevalence of SCS and primary hyperaldosteronism than patients with ≤ 1 cm AI, but the difference was not significant. The prevalence of diabetes and hypertension was high both in non-functional AI with ≤ 1 cm and > 1 cm patients and showed no significant difference between the 2 groups. CONCLUSION: Our study is the first to focus on the clinical and hormonal characteristics of patients with ≤ 1 cm AI. Those with AI≤1 cm harboured SCS, as was the case for AI>1 cm. Similar to AI>1 cm, non-functional AI≤1 cm also had a higher prevalence of diabetes and hypertension.

Airway and Respiration Parameters Improve Following Vocal Fold Medialization: A Prospective Study.

OBJECTIVES/HYPOTHESIS: Laryngeal medialization procedures such as injection laryngoplasty (IL) and thyroplasty type 1 (TT1) are standard techniques for the treatment of glottic insufficiency related to unilateral vocal fold paralysis (UVFP). These procedures reliably improve the voice and may also improve swallowing function. Despite the association of laryngeal paralysis with airway regulation, there is little published on the effect of UVFP and its surgical treatment on respiration. The aim of this prospective study was to evaluate the aerodynamic outcomes of UVFP patients before and after vocal fold medialization, either by IL or TT1. METHODS: Consecutive patients with dysphonia due to UVFP were included in this prospective study between 2012 and 2014. Nineteen patients were investigated (5 females, 14 males) with a mean age of 37.05 ± 17.8 years. Eight patients were treated by IL while 11 patients received TT1. The patients were subjected to Modified Medical Research Council (MMRC) and Borg dyspnea scales, maximum phonation time (MPT) measurement, spirometry, and cycle ergometry, pre- and postoperatively at 2 months. RESULTS: There was a statistically significant increase in MPT from 5.5 ± 3 seconds to 11.2 ± 4.9 seconds postoperatively (P < .001). The MMRC and Borg dyspnea scales also showed significant improvement postoperatively (P < .001, P = .006, respectively). The change in spirometric parameters (peak expiratory flow, forced expiratory volume in 1 second, forced vital capacity, and peak inspiratory flow) were nonsignificant, while there was a significant improvement in cycle ergometry test postoperatively (P = .018). CONCLUSION: Laryngeal medialization procedures such as IL and TT1 improve UVFP patients' respiration-related quality of life and aerodynamic performance with no significant changes in spirometry.

Enoxaparin-induced unilateral hemotympanum.

Hemotympanum is defined as the presence of blood in the middle ear cavity. It is commonly associated with skull fractures. Spontaneous hemotympanum secondary to anticoagulant therapy is extremely rare. Herein, we report the first case of a 51-year-old woman with right spontaneous hemotympanum related to the use of enoxaparin. Complete resolution of signs and symptoms was accomplished by conservative management. Close follow-up is important to assure resolution and reduce long-term sequelae. The use of anticoagulants should be considered in the differential diagnosis of hemotympanum. This is also a good case for clinicians to be mindful about hemorrhagic complications of anticoagulant treatment.

The importance of education in diabetic foot care of patients with diabetic neuropathy.

OBJECTIVE: Our aim is to research the effect of the knowledge and routine gained from the diabetic foot (DF) care education program given to patients with Type 2 Diabetes Mellitus (DM) with diabetic neuropathy. MATERIALS AND METHOD: A total of 104 patients with Type 2 DM and diabetic neuropathy participated in a survey to evaluate standards of DF care, and knowledge of and behavior relating to personal care. The difference in knowledge and personal care between the group who had received education on diabetes and the group who had not was researched. RESULTS: A total of 42.3% of patients reported receiving education about diabetes. The education for Type 2 DM patients increased the frequency of attending yearly check-ups (p:0.028), and helped develop the habit of having doctors check their feet (p:0.004). When comparing the daily practice of those who had received education about DF care with those who had not, positive effects of education were seen in all questions evaluating foot care, nail care and choice of shoe. The statistical analysis proved that the educated group were significantly better in terms of foot care such as using moisturizer (p:0.002) and using insoles (p:0.042). CONCLUSION: Our study reveal that educating diabetic patients about foot care is an effective method to develop their knowledge. However we observed that this education is not provided to all diabetic patients. We believe that every diabetic patient should receive education from the moment of diagnosis and repeated education during check-ups by doctors will increase effectiveness.

Diagnostic value of prostatic specific antigen in hirsute women.

Determination of prostatic specific antigen (PSA) in female tissues has become available recently. The expression of PSA gene is under androgenic regulation. Therefore, hyperandrogenemic states, such as polycystic ovary syndrome (PCOS), are expected to be presented with the higher levels of PSA. The current study aimed at evaluating PSA levels in hirsute women presumed to have PCOS or idiopatic hirsutism (IH). Thirty-three patients with PCOS, 40 patients with IH, and 20 healthy control subjects were enrolled in the study. Beside basal hormonal evaluation, total PSA (tPSA), and free PSA (fPSA) were determined in all subjects. Average level of tPSA was the highest in PCOS patients (0.099+/-0.267 ng/ml) when compared with IH and control subjects (p<0.05 and p<0.001, respectively). Besides, mean fPSA levels were found to be significantly higher in patients with PCOS than healthy controls (0.033+/-0.070 vs 0.010+/-0.001 ng/ml; p<0.05). Both total and free PSA levels were found to be higher in 73 hirsute women than in control subjects (p<0.01 and p<0.05, respectively). Women with hyperandrogenemia tended to have higher tPSA than women without hyperandrogenemia (p<0.01). PSA is likely to be used to discriminate hyperandrogenemic hirsutism. If more sensitive assays become available, PSA might be used as a diagnostic criteria for hirsutism and even for some diseases which have hirsutism as a component.

Localized pigmented villonodular synovitis of the knee.

Localized pigmented villonodular synovitis (PVNS) of the knee is a rare, idiopathic condition presenting with symptoms that can be confused with various other intra-articular pathologies. The condition is usually monoarticular, the knee being most commonly affected. If totally excised, complete cure can be achieved and recurrence is very rarely reported. In this report, we present 4 cases of patients with different symptomatology but all with PVNS of the knee who underwent arthroscopic treatment. At short-term follow-up, all patients had complete recovery of their symptoms with no apparent recurrence.

Rice bodies of synovial origin in the knee joint.

Rice bodies are free corpuscles of synovial origin with a cartilage-like appearance that may reach hundreds in number in the intra-articular space. Rheumatologic or infectious pathologies that may produce synovial hypertrophy play a major role in the etiology. Already recognized by rheumatologists, this entity is rarely reported in orthopaedic literature. Numerous particles in the size and form of rice bodies were noted in the knee joint of an 11-year-old patient who underwent arthroscopic drainage and partial synovectomy. Histopathologic examination showed that some of the rice bodies consisted only of fibrin and some of them included a collagenous nucleus surrounded by a fibrin layer. No evidence of recurrence was observed by orthopaedic and rheumatologic evaluations within 2.5 years after the arthroscopic procedure.

Strength of different meniscus suturing techniques.

We measured and compared the primary stabilities of five different meniscal suturing techniques. The techniques tested were horizontal mattress, vertical mattress, knot-end, vertical, and vertical loop. Twenty bovine medial menisci were cut to simulate peripheral longitudinal tears and repaired with one of the five suture techniques. Then the two parts of the meniscus were pulled using the Instron Tensometer until failure occurred. Knot-end techniques gave inferior results (mean ultimate failure strength 64 +/- 5 N) compared with the other techniques. Vertical mattress failed at 130 +/- 3 N, vertical loop at 128 +/- 4.5 N, horizontal mattress at 98 +/- 5 N and vertical suturing at 136 +/- 2.7 N. This study shows the superior mechanical characteristic of the vertical suturing technique.

Open traumatic posterior dislocation of the hip. A case report.

A case of open traumatic posterior dislocation of the hip is presented. The femoral head and neck were completely out of the skin and there were accompanying fractures of the acetabular floor, the ischial ramus and the greater trochanter. To our knowledge, such a case has not been reported previously and this, together with its interesting mechanism, has led us to report the case. It was followed for 18 months and roentgenographic and 99mtechnetium sulphur colloid scanning studies showed avascular necrosis and osteoarthritis.