Cytokine expression profiles in children and adolescents with tic disorders.

The etiology of tic disorders (TDs) is not precisely known, although several lines of evidence suggest involvement of the immune system in pathogenesis. Here, we aimed to determine the expression levels of pro-inflammatory and anti-inflammatory cytokines in children with TD and compare them with those of healthy controls. Furthermore, we also evaluated their association with clinical variables in the TD group. Within the study period, 88 children with tic disorders and 111 healthy control children were enrolled. Most children with tic disorders were diagnosed with Tourette's disorder (n = 47, 53.4%) or persistent motor tic disorder (n = 39, 44.3%), while the remainder (n = 2, 2.3%) were diagnosed with persistent vocal tic disorder. We found that children with tic disorders had significantly elevated levels of IL-1ß, TNF-α, IL-6 and IL-4 expression, while we detected lower expression levels of IL-17 in children with tic disorders. Our findings provide a molecular landscape of cytokine expression in children with TD, which may suggest a proinflammatory state not affected by the presence of comorbidity and symptom severity. Delineating the contribution of alterations in the immune system to the pathogenesis of tic disorders may pave the way for better therapeutic interventions.

Examining cognitive disengagement syndrome in a psychiatric outpatient sample: Psychometric support and associations with internalizing symptoms and sleep problems.

OBJECTIVE: The internal (structural) and external validity of a self-report measure of cognitive disengagement syndrome (CDS, formerly sluggish cognitive tempo) relative to a self-report measure of attention-deficit/hyperactivity disorder-inattention (ADHD-IN) was evaluated with adults from university outpatient psychiatric clinics in Turkey. METHODS: A total of 274 outpatients (75.9% women; ages 18-64 years; Mage = 31.06; SDage = 10.84; 50.4% anxiety disorders; 41.6% depressive disorders; 2.9% ADHD; 1.5% sleep disorders; 0.7% eating disorders; 2.9% no mental disorder) completed self-report measures of CDS, ADHD-IN, ADHD-hyperactivity/impulsivity (HI), sleep problems, depression, and stress. RESULTS: All 15 CDS symptoms measured by the Adult Concentration Inventory (ACI) showed convergent (moderate to high loadings on the CDS factor) and discriminant (loading close to zero on the ADHD-IN factor) validity. CDS also showed stronger first-order and unique associations than ADHD-IN with sleep problems, depression, anxiety, and stress, whereas ADHD-IN showed stronger first-order and unique associations than CDS with ADHD-HI. CONCLUSION: This is the first study to provide support for the scores from this 15 item self-report measure of CDS by the ACI in a clinical sample of adults, with findings consistent with previous studies examining parent and teacher rating scale measures with the same 15 CDS symptoms. These findings provide additional support for usefulness of these 15 CDS symptoms as measured by the ACI to study CDS across various cultures.

functional outcome in late adolescence/early adulthood of patients with autism spectrum disorder and its relationships with parental burnout and depression: A preliminary multi-center, cross-sectional study.

The aim of this study is to determine the functioning of adults with autism spectrum disorders (ASDs) diagnosed in childhood and depression and burnout levels among their parents. A total of 261 adults with ASDs and their parents were recruited for the study. Both parents completed the Beck Depression and Maslach Burnout Inventories and reported the functioning of their adult offspring with ASDs. Only 5.4 % of our sample reported "good" or "very good" outcomes. The most common psychiatric comorbidities were intellectual disabilities and attention-deficit/hyperactivity disorder. Maternal burnout and depression scores were significantly elevated compared to those of fathers. There is an undeniable urgent need for more research to identify the needs of adults and families suffering from ASD. Modifications for those with ASD may have to be made for support in workplaces, achieving driving licenses, using public transportation and attendance at tertiary education.

Prevalence and Factors Affecting the Use of Antipsychotics and Antipsychotic Polypharmacy in a Child and Adolescent Psychiatry Inpatient Service.

Objective: We aimed to examine the antipsychotics used by patients hospitalized in the child and youth inpatient service providing tertiary care to investigate whether there is a difference between admission and discharge, polypharmacy, which antipsychotics are used, and which psychotropics are used concomitant with antipsychotics. Methods: Research data were collected retrospectively from all children and adolescents hospitalized in a child and adolescent psychiatry inpatient service in a university hospital in a 4-year period (2015-2019). The sociodemographic and clinical characteristics of the patients, the antipsychotics they used at admission and discharge, the other psychotropics concomitantly used with antipsychotics, and the side effects associated with antipsychotics during hospitalization were collected from the files of the 363 patients. Results: Patients on antipsychotics increased 12.1% from hospitalization to discharge. Antipsychotic polypharmacy increased from 16.2% at admission to 30.7% at discharge. Logistic regression analysis was performed to investigate the factors affecting antipsychotic and antipsychotic polypharmacy. Self-harm, aggression/violence, and extended hospitalization were factors associated with increased antipsychotic use. Psychotic symptoms, psychotic disorder, and extended hospitalization were factors associated with an increase in antipsychotic polypharmacy. Conclusions: Understanding the factors that may cause antipsychotic use and polypharmacy in inpatient services in children and adolescents may prevent unnecessary drug use and long-term side effects that may occur due to these drugs.

Caregiver's reports of their children's psychological symptoms after the start of the COVID-19 pandemic and caregiver's perceived stress in Turkey.

PURPOSE: There is limited information about Turkish children's mental health during the COVID-19 outbreak. Here, in a Turkish community sample, we investigate the psychological symptoms in primary school children after the start of the COVID-19 outbreak according to caregivers and the caregivers' perceived stress levels. MATERIALS AND METHODS: The sample was randomly selected from the primary schools in Denizli, Turkey. Denizli is a large city and the total population is around one-million. The study was conducted online. The caregivers responded to a sociodemographic and daily life during pandemic questionnaire and psychological symptoms screening form (which evaluated whether the children had any newly developed symptoms after the start of the COVID-19 outbreak) and the Perceived Stress Scale (PSS). One-thousand-seven-hundred-ninety-seven people were included in the study. Data was collected between 3 July and 31 August 2020. RESULTS: Symptoms such as anhedonia, gets angry easily, fidgets around, sleeping problems, impulsivity, appetite problems, restlessness or nervousness, and feels sad can be seen more frequently than other symptoms in children. Caregivers' PSS scores were higher in mothers than fathers. An association was found between the PSS scores of the caregivers and all psychological symptoms questioned in the study for children, except for encopresis. Lower education level of the father, lower family income, having a child with a psychiatric disease, impaired sibling relationship, and impaired functionality at home were risk factors for higher caregivers' PSS scores. CONCLUSION: It may be beneficial to take supportive measures in terms of protecting children's mental health.

Traumatic Effects of the COVID-19 Outbreak in Middle School Students and Caregivers.

OBJECTIVE: To investigate the traumatic effects of the COVID-19 pandemic on middle-school students and their parents. METHODS: This epidemiological cross-sectional study was conducted with middle-school students in Denizli. A questionnaire consisting of the IES-R, CRIES-13 and a sociodemographic data form was delivered online. A total of 1059 participants who fully completed the questionnaire were included for analysis. RESULTS: The IES-R total and subdimension scores and the CRIES-13 scores were found to be significantly higher in families with an income level of ≤2,500 TL. The CRIES-13 scores of children were found to be significantly higher in divorced families. No statistically significant difference was determined between the IES-R total and subdimension scores of the parents who were healthcare workers and the CRIES-13 scale scores of their children. CONCLUSION: A statistically significant, positive, moderate relationship was found between the IES-R scale total and subdimension scores of parents and the CRIES-13 scale scores of children. A low socioeconomic level was seen to increase the prevalence of anxiety in adults and adolescents. The children of divorced families were found to be at higher risk of PTSD. Successful management of mental health symptoms in parents will reflect positively on the mental health status of their children.

High Depression Symptoms and Burnout Levels Among Parents of Children with Autism Spectrum Disorders: A Multi-Center, Cross-Sectional, Case-Control Study.

The diagnosis of autism spectrum disorder (ASD) in a child affects family processes, increases parenting stress and marital conflicts, and may lead to parental psychopathology. It may also affect the prognosis for their children. The aim of this study is to determine depression and burnout levels as well as their predictors among parents of children with ASD compared with those of healthy children. We also sought to evaluate rate of complementary and alternative medicine (CAM) interventions among parents and explore the associations of this phenomenon in an exploratory fashion. 145 children with ASD and 127 control children were enrolled along with their mothers and fathers. Beck Depression Inventory and Maslach Burnout Inventory were used to evaluate parents' depression symptoms and burnout levels. Symptoms of children with ASDs were evaluated according to the Childhood Autism Rating Scale by the clinicians. Family, child and CAM variables were screened by means of a sociodemographic data form. Descriptive, bivariate and correlation analyses were used in statistical evaluations. Predictors of burnout were evaluated with multiple regression analysis. Burnout and depression levels among parents of children with ASD were significantly elevated compared to controls. Burnout levels of mothers were significantly elevated compared to fathers while depression scores of fathers were significantly elevated compared to mothers. Maternal burnout was significantly predicted by presence of functional speech in child while paternal burnout was significantly predicted by paternal vocation. Maternal depression was associated with paternal depression, lack of speech in child and attendance of child to special education services. Paternal depression was associated with autistic symptom severity and maternal depression. More than half the parents sought CAM interventions. Education level did not affect search for CAM interventions while both maternal and paternal psychopathology and presence of epilepsy among children increased use of CAM methods. Psychological support should be provided to both mothers and fathers of a child receiving a diagnosis of ASD. Addressing parents' burnout and stress levels and facilitating their negotiation of knowledge on etiology and treatments for ASD may be beneficial for the family unit as a whole.

Cytokine expression profiles in Autism spectrum disorder: A multi-center study from Turkey.

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder characterized by impairments in communication and social interaction as well as restricted interests and repetitive behaviors. The pathogenesis of ASD is not completely understood, but a growing body of research has demonstrated that the immune response may be a contributing factor in the etiology and/ or ontogeny of ASD. The aim of this study was to determine the expression levels of IL-1ß, IL-1α, IL-4, IL-6, IL-17, TNF-α and TGF-ß in peripheral blood mononuclear cells of children with ASD and healthy controls in order to determine the contributions of cytokines to ASD. Within the study timeframe, 195 children with ASDs (80.5% male) and 162 controls (73.6% male) were enrolled. Most children with ASD had a comorbid disorder (n = 114, 58.5%), with the most common diagnoses as Intellectual Developmental Disorder (IDD, n = 64, 32.8%) and ADHD (n = 64, 32.8%). The majority of children with ASD had severe autistic symptoms as evaluated via Childhood Autism Rating Scale (CARS, n = 130, 64.6%). The mean CARS score in the ASD sample was 40.8 (S.D. = 7.6). The patients with ASD were found to have significantly higher levels of IL-6 (p < 0.001) and significantly lower levels of IL-17 (p < 0.05, all Bonferroni corrected). Treatment tended to affect IL-4 levels. Lastly, discriminant function analysis (DFA) revealed that a combination of IL-6, IL-17 and IL-1α correctly classified 56.6% of cases. Despite extensive immunological evidence suggesting immune system aberrations, further research is required to clarify the relationship between immune profiles and ASD symptoms.

Novel inflammatory targets for immunotherapies in pediatric patients with trichotillomania.

Immune dysregulation may be important in the etiology of obsessive-compulsive and related disordersandbody-focusedrepetitivebehaviors, such as Trichotillomania (TTM). The role of inflammation and inflammatory markers in TTM has received relatively little attention. This study was aimed to determine the expression levels of inflammatory markers (i.e. IL-1ß, IL-1α, IL-4, IL-6, IL-17, TNF-α and TGF-ß) in peripheral blood mononuclear cells of children with TTM and healthy controls and to evaluate their association with clinical variables. Seventy-seven patients with TTM and 107 healthy controls were enrolled in the study. Peripheral blood was collected in standardized conditions. The mean age of patients and controls did not differ significantly (10.8 ± 4.4 and 12.0 ± 3.2 years; respectively). The majority of patients with TTM and controls were females (n = 55, 71.4 % and n = 55, 51.4 %; respectively); with a greater preponderance of females among TTM. Patients with TTM had significantly elevated expression levels of TNF-α, IL-6 and IL-17 compared to controls. However, the expression level of IL-4 was significantly reduced in TTM patients compared to controls. Accordingly, we found a pro-inflammatory state in TTM and those findings may suggest novel treatment options for TTM and further, cross-disciplinary studies focusing on neuro- inflammation in TTM conducted on larger samples are needed.

The prevalence and comorbidity rates of specific learning disorder among primary school children in Turkey.

Purpose: The aim of the present study was to investigate the prevalence of specific learning disorder (SLD), comorbid disorders, and risk factors in primary school children for the first time in two-stage design in Turkey.Materials and methods: Participants were 1041 pupils in 28 primary schools and aged from 7 to 11. The Mathematics, Reading, Writing Assessment Scale (MOYA) teacher and parent forms were used in the screening stage and parents and teachers of each child completed MOYA. Ninety-five children were screen positive and eighty-three of these children participated in the interview. SLD diagnoses were based on DSM V criteria. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL) was used for the comorbid psychiatric disorders.Results and conclusions: The prevalence rate of the SLD was 6.6%, impairment in reading was 4%, in mathematics was 3.6%, and in written expression was 1.8%. About 62.75% of children with SLD had one or more comorbid diagnoses. ADHD was the most common comorbid mental disorder in SLD (54.9%). SLD prevalence was higher among males. The prevalence of SLD in primary school children in Turkey is consistent with previous studies.

The Prevalence and Comorbidity Rates of ADHD Among School-Age Children in Turkey.

Objective: The aim of the present study was to explore the prevalence and comorbidity rates of ADHD in a community sample of school-age children. Method: Participants were 1,508 children aged 6 to 14 years. Parents and teachers of each child completed the Turgay Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) Disruptive Behavior Disorders Rating Scale (T-DSM-IV-S). Screen-positive cases were interviewed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). Diagnoses were based on DSM-IV criteria. Results: The prevalence rate of ADHD was 8%. Children from extended families had extremely high rates (46.4%) of ADHD. Sixty percent of children with ADHD had one or more comorbid diagnoses. The most common comorbidities were learning disorders (35.7%) and oppositional defiant disorder (22.6%). Conclusion: The prevalence and comorbidity rates of ADHD in school-age children in Turkey are similar to those found in previous studies in other countries.

Brain-Derived Neurotrophic Factor Gene Val66Met Polymorphism Is a Risk Factor for Attention-Deficit Hyperactivity Disorder in a Turkish Sample.

OBJECTIVE: Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that negatively affects different areas of life. We aimed to evaluate the associations between the Val66Met polymorphism of brain-derived neurotrophic factor (BDNF) and ADHD and to assess the effect of the BDNF polymorphism on the neurocognitive profile and clinical symptomatology in ADHD. METHODS: Two hundred one ADHD cases and 99 typically developing subjects (TD) between the ages of 8 and 15 years were involved in the study. All subjects were evaluated using a complete neuropsychological battery, Child Behavior Checklist, the Teacher's Report Form (TRF) and the DSM-IV Disruptive Behavior Disorders Rating Scale-teacher and parent forms. RESULTS: The GG genotype was significantly more frequent in the patients with ADHD than in the TD controls, and the GG genotype was also significantly more frequent in the ADHD-combined (ADHD-C) subtype patients than in the TDs. However, there were no significant associations of the BDNF polymorphism with the ADHD subtypes or neurocognitive profiles of the patients. The teacher-assessed hyperactivity and inattention symptom count and the total score were higher, and the appropriately behaving subtest score of the TRF was lower in the GG genotypes than in the GA and AA (i.e., the A-containing) genotypes. CONCLUSION: We found a positive association between the BDNF gene Val66Met polymorphism and ADHD, and this association was observed specifically in the ADHD-C subtype and not the ADHD-predominantly inattentive subtype. Our findings support that the Val66Met polymorphism of BDNF gene might be involved in the pathogenesis of ADHD. Furthermore Val66Met polymorphism of BDNF gene may be more closely associated with hyperactivity rather than inattention.

The impact of synapsin III gene on the neurometabolite level alterations after single-dose methylphenidate in attention-deficit hyperactivity disorder patients.

OBJECTIVE: To investigate the neurometabolite level changes according to synapsin III gene rs133945G>A and rs133946C>G polymorphisms by using magnetic resonance spectroscopy (MRS) in patients with attention-deficit hyperactivity disorder (ADHD). METHODS: Fifty-seven adults diagnosed with ADHD were recruited for the study. The participants were examined by single-voxel (1)H MRS when medication naïve and 30 minutes after oral administration of 10 mg methylphenidate (Mph). Those who had been on a stimulant discontinued the medication 48 hours before MRS imaging. Spectra were taken from the anterior cingulate cortex, dorsolateral prefrontal cortex, striatum, and cerebellum, and N-acetylaspartate (NAA), choline, and creatine levels were examined. For genotyping of the synapsin III gene polymorphisms, DNA was isolated from peripheral blood leukocytes. The effects of age, sex, and ADHD subtypes were controlled in the analyses. RESULTS: After a single dose of Mph, choline levels increased significantly in the striatum of rs133945G>A polymorphism-GG genotypes (P=0.020) and NAA levels rose in the anterior cingulate cortex of rs133946C>G polymorphism-CG genotypes (P=0.014). Both rs133945G>A and rs133946C>G polymorphisms were found to statistically significantly affect the alteration of NAA levels in response to Mph in dorsolateral prefrontal cortex with two-way repeated measure of analysis of variance. Post hoc comparisons revealed a significant difference between CG and GG genotypes of rs133946C>G polymorphisms after Bonferroni adjustment (P=0.016). CONCLUSION: Synapsin III gene polymorphisms may be affecting the changes in neurometabolite levels in response to Mph in adult ADHD patients. Future studies are needed to confirm our findings.

White matter alterations related to attention-deficit hyperactivity disorder and COMT val(158)met polymorphism: children with valine homozygote attention-deficit hyperactivity disorder have altered white matter connectivity in the right cingulum (cingulate gyrus).

INTRODUCTION: In this article, the COMT gene val(158)met polymorphism and attention-deficit hyperactivity disorder (ADHD)-related differences in diffusion-tensor-imaging-measured white matter (WM) structure in children with ADHD and controls were investigated. PATIENTS AND METHODS: A total of 71 children diagnosed with ADHD and 24 controls aged 8-15 years were recruited. Using diffusion tensor imaging, COMT polymorphism and ADHD-related WM alterations were investigated, and any interaction effect between the COMT polymorphism and ADHD was also examined. The effects of age, sex, and estimated total IQ were controlled by multivariate analysis of covariance (MANCOVA). RESULTS: First, an interaction between the COMT val(158)met polymorphism and ADHD in the right (R) cingulum (cingulate gyrus) (CGC) was found. According to this, valine (val) homozygote ADHD-diagnosed children had significantly lower fractional anisotropy (FA) and higher radial diffusivity (RD) in the R-CGC than ADHD-diagnosed methionine (met) carriers, and val homozygote controls had higher FA and lower RD in the R-CGC than val homozygote ADHD patients. Second, met carriers had higher FA and axial diffusivity in the left (L)-uncinate fasciculus and lower RD in the L-posterior corona radiata and L-posterior thalamic radiation (include optic radiation) than the val homozygotes, independent of ADHD diagnosis. Third, children with ADHD had lower FA in the L-CGC and R-retrolenticular part of the internal capsule than the controls, independent of the COMT polymorphism. CONCLUSION: Significant differences reported here may be evidence that the COMT gene val(158)met polymorphism variants, as well as ADHD, could affect brain development. ADHD and the COMT polymorphism might be interactively affecting WM development in the R-CGC to alter the WM connectivity in children with val homozygote ADHD.

The Effect of Single Dose Methylphenidate on Neurometabolites according to COMT Gene Val158Met Polymorphism in the Patient with Attention Deficit Hyperactivity Disorder: A Study Using Magnetic Resonance Spectroscopy.

OBJECTIVE: Attention deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder. Thus, the present study aimed to determine the effects of a single dose of methylphenidate (Mph) on neurometabolite levels according to polymorphisms of the catechol-O-methyltransferase (COMT) gene. METHODS: This study evaluated the neurometabolite levels including N-acetylaspartate (NAA), creatine (Cr), and choline (Cho) of ADHD patients, before and after treatment with Mph (10 mg) according to the presence of COMT polymorphisms. The spectra were obtained from the dorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex (ACC), cerebellum, and striatum. RESULTS: The NAA levels of the val/val and val genotype carriers (val/val and val/met genotypes) increased in the DLPFC and ACC, respectively, following Mph treatment. The NAA/Cr ratio was lower in the DLPFC of val carriers than in the met/met genotype carriers prior to Mph administration. The Cho levels of the val/met genotype and val carriers increased in the striatum following Mph treatment. Following Mph treatment, the Cr levels of the met/met genotype carriers were higher than those of the val/met genotype and val carriers. Additionally, after Mph treatment, there was a significant increase in Cr levels in the DLPFC of the met/met genotype carriers but a significant decrease in such levels in the striatum of val/val genotype carriers. CONCLUSION: These findings suggest that polymorphisms of the COMT gene can account for individual differences in neurochemical responses to Mph among ADHD patients. Therefore, further studies are needed to fully characterize the effects of the Val158met polymorphism of the COMT gene on treatment outcomes in patients with ADHD.

Increased urinary 6-hydroxymelatoninsulfate levels in attention deficit hyperactivity disorder diagnosed children and adolescent.

There are some studies in attention deficit hyperactivity disorder (ADHD) which note altered circadian rhythms, suggesting abnormalities in melatonin physiology. In order to better characterize the possible melatonin alteration in ADHD, in this study we aimed to detect daytime, nighttime and 24 h levels of 6-hydroxymelatoninsulfate (6-OH MS) in the patients diagnosed with ADHD. Twenty-seven patients between 6 and 16 years-old, who had been diagnosed initially with ADHD, but without other physical and psychiatric disease history and who had not taken psychotropic pharmacotherapy for six months, plus 28 healthy volunteer controls, were included in the study. Urine samples were collected during the whole 24 h cycle, daytime and nighttime separately to assess the time-dependent excretion of the 6-OH MS, which is the main urine metabolite of melatonin. The Enzyme-Linked Immunosorbent Assay (ELISA) method was used for measuring the urine 6-OH MS level. Daytime (15.4 (8.9-24.8) ng/ml vs 6.9 (2.5-15.9) ng/ml, p=0.002), nighttime (102.9 (65.3-197.7) ng/ml vs 61.5 (37.2-114.4) ng/ml, p=0.012) and 24 h (54.1 (34.6-83.9) ng/ml vs 27.3 (14.3-48.9) ng/ml, p=0.000) 6-OH MS levels median (25p-75p) were found to be significantly higher in the ADHD group. After adjustment for age and sex, there was a statistically significant difference between the ADHD group (59.8 ± 4.9) and control group (33.8 ± 4.8) in 24-h 6-OH MS levels (F(1, 51)=13.673, p=.001, partial η2=.211). There was no relationship between 6-OH MS levels and Conners Parent Rating Scale short form subscale scores for the ADHD group. These findings indicate that melatonin production is increased in ADHD cases. Further research is needed to determine and thereby understand the mechanisms underlying the higher melatonin production, to assess the impact of altered melatonin on the pathophysiology of ADHD.

Knowledge, attitude and behaviour of boys and parents about circumcision.

AIM: To determine the knowledge, attitude and behaviour of parents and previously circumcised early adolescent boys about circumcision. METHODS: Half of the boys attending the sixth class of the primary school in our city centre and their parents were included in this cross-sectional, descriptive study. Questionnaires were prepared by the authors, which include 38 questions for parents and 25 questions for boys. RESULTS: Sixty-six per cent of the students were circumcised at the age of 7 years and above, 26% between three and 6 years and 8% below 3 years of age. Forty-two per cent of boys were circumcised by a traditional circumciser and 64% were circumcised at home. Main reasons of circumcision for parents were religious purposes (79%) and health issues (51%). When the boys were asked about their thoughts during circumcision, they mostly stated that 'it was necessary to become a man' (58%) and 'it would hurt much' (50%). Thirty-eight per cent of boys were frightened during circumcision and 46% were worried. Boys circumcised in the 7 years and above age group were most content about their age of circumcision. CONCLUSIONS: We consider that it is reasonable to wait up to an age at which the child could understand and participate in the decision of the concept and timing of circumcision.

A Rare Presentation of Xanthogranulomatous Cholecystitis as Bouveret's Syndrome.

The purpose of this paper is to present sonographic and CT imaging findings of xanthogranulomatous cholecystitis (XGC) presented as Bouveret's syndrome, a very rare cause of gastric obstruction. While the patient's physical examination, upper GI endoscopy, and radiological findings all pointed to Bouveret's syndrome, CT differential diagnosis suggested either XGC or gallbladder carcinoma, and the final diagnosis was done histopathologically. Our paper aims to increase awareness in radiologically diagnosing XGC cases by introducing the possibility of existence of Bouveret's syndrome.