Comparison of ultrasound risk stratification systems for pediatric thyroid nodules.

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

Transversus Thoracic Muscle Plane Block For Postoperative Pain in Pediatric Cardiac Surgery: A Systematic Review And Meta-Analysis of Randomized And Observational Studies.

OBJECTIVES: Pediatric patients undergoing cardiac surgery usually experience significant surgical pain. Additionally, the effect of poor surgical analgesia creates a pain continuum that extends to the postoperative period. Transversus thoracic muscle plane block (TTMPB) is a novel plane block technique that can provide analgesia to the anterior chest wall. The analgesic role of TTMPB in pediatric cardiac surgery is still uncertain. A meta-analysis was conducted to determine the analgesic efficacy of this procedure. DESIGN AND SETTING: Systematic review and meta-analysis. PubMed, Embase, Web of Science, CENTRAL, WanFang Data, and the China National Knowledge Infrastructure were searched to November 2023, and the Grading of Recommendations Assessment, Development, and Evaluation approach was followed to evaluate the certainty of evidence. PARTICIPANTS: Eligible studies enrolled pediatric patients from 2 months to 12 years old scheduled to undergo cardiac surgery, and randomized them to receive a TTMPB or no block/sham block. MEASUREMENTS AND MAIN RESULTS: Six studies that enrolled 601 pediatric patients were included. Low-certainty evidence from randomized trials showed that, compared with no block or sham block, TTMPB in pediatric patients undergoing cardiac surgery may reduce postoperative modified objective pain score at 12 hours (weighted mean difference [WMD] -2.20, 95% CI -2.73 to -1.68) and 24 hours (WMD -1.76, 95% CI -2.09 to -1.42), intraoperative opioid consumption (WMD -3.83, 95% CI -5.90 to -1.76 µg/kg), postoperative opioid consumption (WMD -2.51, 95% CI -2.84 to -2.18 µg/kg), length of intensive care unit (ICU) stay (WMD -5.56, 95% CI -8.30 to -2.83 hours), and extubation time (WMD -2.13, 95% CI -4.21 to -0.05 hours). Retrospective studies provided very low certainty that the results were consistent with the randomized trials. CONCLUSION: Very low- to low-certainty evidence showed that TTMPB in pediatric patients undergoing cardiac surgery may reduce postoperative pain, opioid consumption, ICU length of stay, and extubation time.

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

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

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

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

Effect of the categorization method on the diagnostic performance of ultrasound risk stratification systems for thyroid nodules.

Objective: To evaluate whether the categorization methods of risk stratification systems (RSSs) is a decisive factor that influenced the diagnostic performances and unnecessary FNA rates in order to choose optimal RSS for the management of thyroid nodules. Methods: From July 2013 to January 2019, 2667 patients with 3944 thyroid nodules had undergone pathological diagnosis after thyroidectomy and/or US-guided FNA. US categories were assigned according to the six RSSs. The diagnostic performances and unnecessary FNA rates were calculated and compared according to the US-based final assessment categories and the unified size thresholds for biopsy proposed by ACR-TIRADS, respectively. Results: A total of 1781 (45.2%) thyroid nodules were diagnosed as malignant after thyroidectomy or biopsy. Significantly lowest specificity and accuracy, along with the highest unnecessary FNA rates were seen in EU-TIRADS for both US categories (47.9%, 70.2%, and 39.4%, respectively, all P < 0.05) and indications for FNA (54.2%, 50.0%, and 55.4%, respectively, all P < 0.05). Diagnostic performances for US-based final assessment categories exhibited similar accuracy for AI-TIRADS, Kwak-TIRADS, C-TIRADS, and ATA guidelines (78.0%, 77.8%, 77.9%, and 76.3%, respectively, all P > 0.05), while the lowest unnecessary FNA rate was seen in C-TIRADS (30.9%) and without significant differences to that of AI-TIRADS, Kwak-TIRADS, and ATA guideline (31.5%, 31.7%, and 33.6%, respectively, all P > 0.05). Diagnostic performance for US-FNA indications showed similar accuracy for ACR-TIRADS, Kwak-TIRADS, C-TIRADS and ATA guidelines (58.0%, 59.7%, 58.7%, and 57.1%, respectively, all P > 0.05). The highest accuracy and lowest unnecessary FNA rate were seen in AI-TIRADS (61.9%, 38.6%) and without significant differences to that of Kwak-TIRADS(59.7%, 42.9%) and C-TIRADS 58.7%, 43.9%, all P > 0.05). Conclusion: The different US categorization methods used by each RSS were not determinant influential factors in diagnostic performance and unnecessary FNA rate. For daily clinical practice, the score-based counting RSS was an optimal choice.

Transversus thoracic muscle plane block for pain during cardiac surgery: a systematic review and meta-analysis.

STUDY OBJECTIVE: The role of transversus thoracic muscle plane blocks (TTMPBs) during cardiac surgery is controversial. We conducted a systematic review to establish the effectiveness of this procedure. DESIGN: Systematic review. We searched PubMed, Embase, Web of Science, CENTRAL, WanFang Data, and the China National Knowledge Infrastructure to June 2022, and followed the GRADE approach to evaluate the certainty of evidence. STUDY ELIGIBILITY CRITERIA: Eligible studies enrolled adult patients scheduled to undergo cardiac surgery and randomized them to receive a TTMPB or no block/sham block. MAIN RESULTS: Nine trials that enrolled 454 participants were included. Compared to no block/sham block, moderate certainty evidence found that TTMPB probably reduces postoperative pain at rest at 12 h [weighted mean difference (WMD) -1.51 cm on a 10 cm visual analogue scale for pain, 95% CI -2.02 to -1.00; risk difference (RD) for achieving mild pain or less (≤3 cm), 41%, 95% CI 17-65) and 24 h (WMD -1.07 cm, 95% CI -1.83 to -0.32; RD 26%, 95% CI 9-37). Moderate certainty evidence also supported that TTMPB probably reduces pain during movement at 12 h (WMD -3.42 cm, 95% CI -4.47 to -2.37; RD 46%, 95% CI 12-80) and at 24 h (WMD -1.73 cm, 95% CI -3.24 to -0.21; RD 32%, 95% CI 5-59), intraoperative opioid use [WMD -28 milligram morphine equivalent (MME), 95% CI -42 to -15], postoperative opioid consumption (WMD -17 MME, 95% CI -29 to -5), postoperative nausea and vomiting (absolute risk difference 255 less per 1000 persons, 95% CI 140-314), and intensive care unit (ICU) length of stay (WMD -13 h, 95% CI -21 to -6). CONCLUSION: Moderate certainty evidence showed TTMPB during cardiac surgery probably reduces postoperative pain at rest and with movement, opioid consumption, ICU length of stay, and the incidence of nausea and vomiting.

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

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

The feasibility of decreasing the thresholds for biopsy in Kwak and C TIRADSs.

Objectives: To estimate the feasibility of decreasing the original thresholds for biopsy in the Kwak Thyroid Imaging Reporting and Data System (Kwak TIRADS) and Chinese Thyroid Imaging Reporting and Data System (C TIRADS). Methods: This retrospective study included 3,201 thyroid nodules from 2,146 patients with a pathological diagnosis. We lowered the original fine-needle aspiration (FNA) thresholds with the TR4a-TR5 in Kwak and C TIRADSs and calculated the ratio of additional benign-to-malignant nodules being biopsied (RABM). If the RABM is less than 1, the decreased FNA thresholds could be accepted and used to the modified TIRADSs (modified C and Kwak TIRADSs). Then, we estimated and compared the diagnostic performance between the modified TIRADS and the original TIRADS to determine if the decreased thresholds could be an effective strategy. Results: A total of 1,474 (46.0%) thyroid nodules were diagnosed as malignant after thyroidectomy. The TR4c-TR5 in Kwak TIRADS and TR4b-TR5 in C TIRADS had a rational RABM (RABM < 1). The modified Kwak TIRADS had higher sensitivity, a positive predictive value, a negative predictive value, lower specificity, an unnecessary biopsy rate, and a missed malignancy rate compared with the original Kwak TIRADS (94.1% vs. 42.6%, 59.4% vs. 44.6%, 89.9% vs. 52.8%, 45.0% vs. 54.9%, 40.6% vs. 55.4%, and 10.1% vs. 47.1%, respectively, P < 0.05 for all). Similar trends were seen in the modified C TIRADS versus the original C TIRADS (95.1% vs. 38.7%, 61.7% vs. 47.8%, 92.3% vs. 55.0%, 49.7% vs. 64.0%, 38.3% vs. 52.2%, and 7.7% vs. 44.9%, respectively, P < 0.05 for all). Conclusions: The biopsy of all nodules with TR4C-TR5 in the Kwak TIRADS and TR4B-TR5 in the C TIRADS might be an effective strategy. This paper contributes to the contradiction concerning whether to perform FNA for the nodules smaller than 10 mm.

Mulberry leaf extract improves intestinal barrier function and displays beneficial effects on colonic microbiota and microbial metabolism in weaned piglets.

BACKGROUND: Mulberry leaf extract (MLE) extracted from mulberry leaves is rich in a variety of bioactive ingredients and can be used as feed additives of weaned piglets. The present study was conducted to evaluate the effects of dietary MLE supplementation on intestinal barrier function, colon microbial numbers and microbial metabolites of weaned piglets. RESULTS: MLE supplementation increased the villus height and the villus height/crypt depth ratio in jejunum and ileum (P < 0.05), increased the mRNA expression of ZO-1, Claudin-1 and MUC-2 in the ileal mucosa (P < 0.05), and decreased the serum level of lipopolysaccharide (P < 0.01). Meanwhile, MLE reduced the mRNA expression of tumor necrosis factor-α and interleukin-1ß (P < 0.05) and increased secretory immunoglobulin A level in the ileal mucosa (P < 0.05). In addition, MLE increased the numbers of beneficial bacteria Bifidobacterium and Lactobacillus (P < 0.05) and decreased the number of potential pathogenic bacteria Escherichia coli (P < 0.05) in the colon. Correspondingly, MLE supplementation reduced the pH value of colonic digesta (P < 0.05) and altered the microbial fermentation pattern of the colon by increasing the concentrations of microbial metabolites derived from carbohydrates fermentation such as lactate, acetate, butyrate and total short-chain fatty acids (P < 0.05), and decreasing the concentrations of microbial metabolites derived from amino acid fermentation such as p-cresol, skatole, spermine, histamine and tryptamine (P < 0.05). CONCLUSION: MLE supplementation improved intestinal barrier function and displayed beneficial effects on colon microbes and microbial metabolism in weaned piglets. © 2022 Society of Chemical Industry.

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

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