The Role of 4D-CT for Pre-Operative Localization in Patients with Primary Hyperparathyroidism with Negative Ultrasonography and/or Sestamibi SPECT/CT.

Objectives: The major cause of primary hyperparathyroidism (pHPT) is parathyroid adenoma. Today, minimally invasive parathyroidectomy (MIP) has become the standard treatment for patients in whom the pathological gland can be localized with pre-operative imaging methods. In this study, we aimed to evaluate the role of 4D-CT in pre-operative localization in patients with pHPT who are negative for ultrasonography (USG) and/or sestamibi single-photon emission computed tomography/CT (SPECT/CT) and will undergo primary surgery. Methods: Patients whom were operated between 2018 and 2023 were included to this study. 4D-CT results of patients with one- or two-negative USG and SPECT/CT results were evaluated retrospectively. Results: In this study, 19 patients (5 men and 14 women) with a mean age of 57.1±8.5 years were evaluated. Pathology results were consistent with parathyroid adenoma in 18 patients (94.7%) and parathyroid hyperplasia in 1 patient (5.3%). USG was negative in six patients, SPECT/CT was negative in 14 patients, and both were negative in four patients. In 4D-CT, positive images were detected in 15 patients and these results were finalized as true positive in 14 patients and false positive in 1 patient. The sensitivity of 4D-CT was 82.4% (95% CI: 60.4-95.3%), positive predictive value was 93.3% (95% CI: 73.8-99.6%), accuracy was 78.9%, and localization rate was 73.7%. In 14 (73.7%) patients, the pathological glands were removed by MIP. Conclusion: In approximately 75% of patients with negative USG and/or SPECT/CT, the pathological gland can be localized with 4D-CT and MIP can be applied in these patients.

Management of Thyroid Nodules.

Thyroid nodules are common and the prevalence varies between 4 and 7% by palpation and 19-68% by high-resolution USG. Most thyroid nodules are benign, and the malignancy rate varies between 7 and 15% of patients. Thyroid nodules are detected incidentally during clinical examination or, more often, during imaging studies performed for another reason. All detected thyroid nodules should be evaluated clinically. The main test in evaluating thyroid function is thyroid stimulating hormone (TSH). If the serum TSH level is below the normal reference range, a radionuclide thyroid scan should be performed to determine whether the nodule is hyperfunctioning. If the serum TSH level is normal or high, ultrasonography (US) should be performed to evaluate the nodule. US is the most sensitive imaging method in the evaluation of thyroid nodules. Computed tomography (CT) and magnetic resonance imaging are not routinely used in the initial evaluation of thyroid nodules. There are many risk classification systems according to the USG characteristics of thyroid nodules, and the most widely used in clinical practice are the American Thyroid Association guideline and the American College of Radiology Thyroid Imaging Reporting and Data System. Fine needle aspiration biopsy (FNAB) is the gold standard method in the evaluation of nodules with indication according to USG risk class. In the cytological evaluation of FNAB, the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is the most frequently applied cytological classification. TBSRTC is a simplified, 6-category reporting system and was updated in 2023. The application of molecular tests to FNAB specimens, especially those diagnosed with Bethesda III and IV, is increasing to reduce the need for diagnostic surgery. Especially in Bethesda III and IV nodules, different methods are applied in the treatment of nodules according to the malignancy risk of each category, these are follow-up, surgical treatment, radioactive iodine treatment, and non-surgical ablation methods.

Assessment of Health-Related Quality of Life in Patients with Idiopathic Hirsutism Compared to Patients with Polycystic Ovary Syndrome.

Objective: Hirsutism affects 5-15% of women of reproductive age. Health-related quality of life (HQOL) is a multidimensional assessment of well-being that considers the physical, social, and emotional aspects associated with a specific disease. The aim of this study is to evaluate HQOL in patients diagnosed with idiopathic hirsutism (IH) and compare it with patients diagnosed with polycystic ovary syndrome (PCOS). Methods: This cross-sectional observational study was performed on 183 female individuals, consisting of 51 patients diagnosed with idiopathic hirsutism, 76 patients diagnosed with PCOS, and 56 healthy volunteers. Participants with a history of neuropsychiatric disorders, under 18 and over 45 years of age, during pregnancy and lactation, with any chronic disease that could interfere with diagnostic laboratory tests, and who had previously been treated for IH or PCOS were excluded from the study. Demographic, anthropometric, laboratory, and clinical data on the cases were recorded. The Short Form-36 (SF-36) questionnaire, the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI) were administered in a face-to-face interview by related authors involved in the study. Results: The mean age, level of education, lifestyle, and marital status of all three groups were similar. There were no significant differences in body mass index (BMI) or waist circumference between the groups. Mean modified Ferriman-Gallwey (mFG) scores were similar in the IH and PCOS groups. In the IH patients, the general health and mental health domains of the SF-36 questionnaire scores were significantly lower than in the control group (p<0.001 and p=0.026, respectively). When the SF-36 questionnaire scores were compared between the IH and PCOS groups, the general health and role emotional domains were significantly lower in the PCOS group (p=0.013 and p<0.001, respectively), and the other domains were similar. All SF-36 questionnaire domains were significantly and negatively correlated with BMI and waist circumference measurements in IH patients. Both BDI and BAI scores were significantly and positively correlated with BMI (r=0.348, p<0.001, and r=0.162, p=0.012, respectively) and waist circumference (r=0.326, p<0.001, and r=0.344, p<0.001, respectively). Six out of eight domains of the SF-36 QOL scores were significantly and negatively correlated with the mFG scores. Conclusion: Patients diagnosed with IH have impaired HQOL, similar to patients diagnosed with PCOS. Improving HQOL should be a goal when deciding on a management approach for hirsutism, which is one of the most common reasons for referral to endocrinology and dermatology outpatient clinics.

Interobserver Variability of Ultrasound Features Based on American College of Radiology Thyroid Imaging Reporting and Data System Lexicon in American College of Radiology Thyroid Imaging Reporting and Data System System: A Single-Center Study With Radiologists and Radiology Residents.

ABSTRACT: The aim of this study is to evaluate the variability of selecting the ultrasound features used in American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS) and in assigning the ACR-TIRADS level in a single center among radiologists and radiology residents. The study cohort consisted of 108 thyroid nodules in 102 patients who had definite cytology results after thyroid fine needle aspiration biopsy (Bethesda category II, VI) or surgery. Seven observers including 3 radiologists and 4 radiology residents evaluated the nodules according to 5 ultrasound feature categories. The evaluation process was performed after a joint meeting session, in which the "white papers" of the ACR-TIRADS committee were discussed regarding the thyroid ultrasound reporting lexicon, and final TIRADS system. Variability of ultrasound features and assigning ACR-TIRADS level was measured using Fleiss kappa statistics. Agreement for ultrasound features was "substantial" to "almost perfect" among all observers, with composition (κ = 0.86), macrocalcification (κ = 0.89) and peripheral calcification (κ = 0.92) at the highest level of agreement. The level of agreement for large comet tail artifacts and punctate echogenic foci was "moderate" in residents, whereas in radiologists, that level was "substantial." The agreement for assigning ACR-TIRADS level was moderate in resident as well as in radiologist subgroup. Agreement of thyroid ultrasound features was "substantial to almost perfect" among all observers. Although the level of agreement among resident group decreased to "moderate" level, ACR-TIRADS is a useful system in thyroid nodule management.

Comparison of lung ultrasound and other volumetric methods in peritoneal dialysis patients.

ABSTRACT: Although many alternative methods are present, maintaining ideal volume status in peritoneal dialysis (PD) patients still rely on clinical evaluation due to lack of an evidence-based method. Lung ultrasound (LUS) is a new method for evaluation of hidden congestion in this group.LUS findings and its relationship with other volumetric methods are investigated in this observational cross-sectional study.In this observational cross sectional study, LUS was performed to all PD patients and compared with symptoms of hypervolemia, physical examination, vascular endothelial growth factor-C (VEGF-C), and N-terminal pro-brain natriuretic peptide levels, chest radiography, echocardiography, bioelectrical impedance analysis.Data of 21 PD patients were evaluated. There was correlation between number of B lines and VEGF-C levels (r = 0.447, P = .042), daily urine output (r = 0.582, P = .007) and left ventricle mass index (r = -0.456, P = .038). Correlations with all other parameters were not significant. Daily urine output and VEGF-C levels were significantly different when B lines were grouped into 2 according to the median level (P < .05 for all).This is the widest spectrum study looking for LUS findings and other volumetric parameters in a small PD cohort. LUS might be useful to evaluate hidden hypervolemia. Its correlation with VEGF-C level is a novel finding.

Evaluation of Carotid Artery Intima-Media Thickness as a Cardiovascular Risk Factor in Patients With Polycystic Ovary Syndrome.

Introduction The purpose of this study is to assess cardiovascular risk factors in patients diagnosed with polycystic ovary syndrome (PCOS) by comparing dyslipidemia, insulin sensitivity, hyperhomocysteinemia, carotid artery intima-media thickness (CIMT) between women diagnosed with PCOS and healthy subjects. Materials and Methods Hundred women diagnosed with PCOS aged between 18 and 35 years and who applied to tertiary center gynecology clinic were included in the study. Hundred women who applied for menstrual irregularity to the same outpatient clinic with no systemic diseases, who were not under medical treatment for any condition, were included in the control group. Physical examination, hormone profile tests on the second day of the patients' menstrual cycle, pelvic, and neck ultrasonography to evaluate CIMT were performed for all patients. CIMT values were compared with biochemical, hormonal, and anthropometric values. Sensitivity, specificity, Pearson correlation coefficient, mean, and standard deviation were calculated. Results In the PCOS group, there was no statistically significant difference in homeostatic model assessment for insulin resistance (HOMA-IR) (<2.5 and >2.5) among all parameters. When we evaluate body mass index (BMI) (<30 and >30) for this PCOS group patients, a very highly significant difference (p < 0.001) between waist-hip ratio and hemoglobin A1c (HbA1c) was established statistically, and there was a significant difference (p < 0,05) between waist-hip ratio and luteinizing hormone (LH). After this statistical analysis, dehydroepiandrostenedione sulfate (DHEAS), free androgen index (FAI), LH, low-density lipoprotein (LDL), Ferriman-Gallwey score (FGS), homocysteine, mean CIMT, and waist to hip ratio were significantly different in the two groups (p < 0.01). The difference between HbA1c and cholesterol high-density lipoprotein (HDL) was significant (p < 0.05). Conclusion As a result, in the PCOS group, when compared to the healthy subjects, dyslipidemia, HbA1c, waist to hip ratio, and CIMT were significantly different. It might be suitable to perform an ultrasound for CIMT in patients with higher Ferriman-Gallwey (FG) score.

Giant parathyroid adenoma associated with severe hypercalcemia in an adolescent patient.

BACKGROUND: The objective of this study is to bring attention to the importance of differential diagnosis in adolescent patients with skeletal involvement and hypercalcemia. CASE: A 17-year-old male patient with a complaint of severe leg pain was admitted to our hospital. Seven months before he had a fracture of his distal humerus after falling on to his left shoulder and was treated conservatively. Five months previously, he had a rupture of his quadriceps tendon. Magnetic resonance imaging (MRI) was performed for the quadriceps tendon rupture and was evaluated as polyostotic fibrous dysplasia (PFD). Doctors decided to operate for the ruptured tendon but they detected severe hypercalcemia in the pre-operative blood tests and noticed that the main disease was primary hyper-parathyroidisim (PHPT) which was caused by a giant parathyroid adenoma. Conclusions Giant parathyroid adenoma can present in adolescent patients with multiple bone lesions and severe hypercalcemia. PHPT should be considered in the differential diagnosis of pathological bone fractures and benign bone tumors in every age. This may prevent patients from miss or delayed diagnosis of PHPT.

Sonographic scoring of solid thyroid nodules: effects of nodule size and suspicious cervical lymph node / Escore ultrassonográfico de nódulos sólidos de tireoide: efeitos do tamanho do nódulo e de linfonodo cervical suspeito

Abstract Introduction Ultrasound is the most frequently used imaging method to evaluate thyroid nodules. Sonographic characteristics of thyroid nodules which are concerning for malignancy are important to define the need for fine needle aspiration biopsy or open surgery. Objective To evaluate malignancy risk of solid thyroid nodules through sonographic scoring. The effects of nodule size ≥2 cm and associated pathologic cervical lymph node in scoring were examined in addition to generally excepted suspicious features. Methods Medical data of 123 patients underwent thyroid surgery were reviewed, and 89 patients (58 females, 31 males) were included in the study. The presence and absence of each suspicious sonographic feature of thyroid nodules were scored as 1 and 0, respectively. Total ultrasound score was obtained by adding the positive ultrasound findings. Differently from the literature, nodule size ≥2 cm and associated pathologic cervical node were added in scoring criteria. The diagnostic performance of nodule characteristics for malignancy and the effect of total US score to discriminate malignant and benign disease were calculated. Results A significant relationship was found between malignancy and hypoechogenity, border irregularity, intranodular vascularity, and microcalcification (p < 0.05). Pathologic cervical node was observed predominantly in association with malignant nodules. Positive predictive value of suspicious cervical node for malignancy was 67%, similar to microcalcification. Nodule size ≥2 cm was not distinctive for diagnosis of malignancy. The number of suspicious sonographic features obtained with receiver operating characteristic analysis to discriminate between malignant and benign disease was three. Conclusion Sonographic scoring of thyroid nodules is an effective method for predicting malignancy. The authors suggest including associated pathologic node in the scoring criteria. Further studies with larger cohorts will provide more evidence about its importance in sonographic scoring.

Resumo Introdução A ultrassonografia é o método imagiológico mais frequentemente usado na avaliação de nódulos tireoidianos. As características ultrassonográficas dos nódulos tireoidianos que dizem respeito à malignidade são importantes para a definição da necessidade de uma biópsia por aspiração com agulha fina ou uma cirurgia aberta. Objetivo Avaliar o risco de malignidade de nódulos tireoidianos sólidos por meio de escore ultrassonográfico, verificar os efeitos de nódulos ≥ 2 cm, em associação com linfonodo cervical patológico, além de características suspeitas geralmente omitidas. Método Foram revisados dados médicos de 123 pacientes tratados com cirurgia da tireoide. Foram incluídos no estudo 89 pacientes (58 mulheres, 31 homens). Presença e ausência de cada característica ultrassonográfica suspeita de nódulo tireoidiano receberam pontuações de 1 e 0, respectivamente. O escore ultrassonográfico total foi obtido pela soma dos achados ultrassonográficos positivos. Diferentemente da literatura, nódulos ≥ 2 cm e nodo cervical patológico associado foram acrescentados nos critérios de pontuação. Foram calculados o valor diagnóstico das características dos nódulos para malignidade e o efeito do escore ultrassonográfico total na diferenciação entre doença maligna vs. benigna. Resultados Foi encontrada uma associação significante entre malignidade e hipoecogenicidade, irregularidade das margens, vascularidade intranodular e microcalcificação (p < 0,05). Nodo cervical patológico foi observado predominantemente em associação com nódulos malignos. O valor preditivo positivo de nodo cervical suspeito para malignidade foi de 67%, similar ao achado para microcalcificação. Diâmetro de nódulo ≥ 2 cm não foi fator diferenciador para diagnóstico de malignidade. O número de características ultrassonográficas suspeitas obtido com a análise da curva de características de operação do receptor (receiver operating characteristic, ROC) para discriminação entre doença maligna vs. benigna foi igual a 3. Conclusão O escore ultrassonográfico dos nódulos tireoidianos é método efetivo para predição de malignidade. Sugerimos a inclusão de nódulo patológico associado aos critérios de pontuação. Futuros estudos com coortes maiores proporcionarão mais evidências sobre sua importância no escore ultrassonográfico.

Sonographic scoring of solid thyroid nodules: effects of nodule size and suspicious cervical lymph node.

INTRODUCTION: Ultrasound is the most frequently used imaging method to evaluate thyroid nodules. Sonographic characteristics of thyroid nodules which are concerning for malignancy are important to define the need for fine needle aspiration biopsy or open surgery. OBJECTIVE: To evaluate malignancy risk of solid thyroid nodules through sonographic scoring. The effects of nodule size ≥2cm and associated pathologic cervical lymph node in scoring were examined in addition to generally excepted suspicious features. METHODS: Medical data of 123 patients underwent thyroid surgery were reviewed, and 89 patients (58 females, 31 males) were included in the study. The presence and absence of each suspicious sonographic feature of thyroid nodules were scored as 1 and 0, respectively. Total ultrasound score was obtained by adding the positive ultrasound findings. Differently from the literature, nodule size ≥2cm and associated pathologic cervical node were added in scoring criteria. The diagnostic performance of nodule characteristics for malignancy and the effect of total US score to discriminate malignant and benign disease were calculated. RESULTS: A significant relationship was found between malignancy and hypoechogenity, border irregularity, intranodular vascularity, and microcalcification (p<0.05). Pathologic cervical node was observed predominantly in association with malignant nodules. Positive predictive value of suspicious cervical node for malignancy was 67%, similar to microcalcification. Nodule size ≥2cm was not distinctive for diagnosis of malignancy. The number of suspicious sonographic features obtained with receiver operating characteristic analysis to discriminate between malignant and benign disease was three. CONCLUSION: Sonographic scoring of thyroid nodules is an effective method for predicting malignancy. The authors suggest including associated pathologic node in the scoring criteria. Further studies with larger cohorts will provide more evidence about its importance in sonographic scoring.

A Rare Presentation of Autonomously Functioning Papillary Thyroid Cancer: Malignancy in Marine-Lenhart Syndrome Nodule.

Objective. Marine-Lenhart Syndrome (MLS) is defined as concomitant occurrence of autonomously functioning thyroid nodule (AFTN) with Graves' disease (GD). Malignancy in a functional nodule is rare. We aimed to present an extremely rare case of papillary thyroid cancer in a MLS nodule with lateral lymph node metastases. Case. A 43-year-old male presented with hyperthyroidism and Graves' ophthalmopathy. On Tc99m pertechnetate scintigraphy, a hyperactive nodule in the left upper thyroid pole was detected and the remaining tissue showed a mildly increased uptake. The ultrasonography demonstrated 15.5 × 13.5 × 12 mm sized hypoechoic nodule in the left upper pole of the thyroid and round lymph nodes on the left side of the neck. Fine needle aspiration biopsy (FNAB) of the nodule and lymph node revealed cytological findings consistent with papillary cancer. Total thyroidectomy with central and left modified radical neck dissection was performed. On pathologic examination, two foci of micropapillary cancer were detected. The skip metastases were present in three lymph nodes on the neck. Conclusion. AFTN can be seen rarely in association with GD. It is not possible to exclude malignancy due to the clinical and imaging findings. In the presence of suspicious clinical and sonographic features, FNAB should be performed.

IS BIOCHEMICAL ASSESSMENT OF PHEOCHROMOCYTOMA NECESSARY IN ADRENAL INCIDENTALOMAS WITH MAGNETIC RESONANCE IMAGING FEATURES NOT SUGGESTIVE OF PHEOCHROMOCYTOMA?

OBJECTIVE: Currently, it is unclear whether pheochromocytomas can be ruled out based on low intensity on T2-weighted sequences and signal loss on out-of-phase magnetic resonance imaging (MRI) sequences. Hence, in this study, we investigated whether biochemical screening for pheochromocytoma in patients with adrenal incidentalomas (AIs) showing MRI features not suggesting pheochromocytoma would prove beneficial. METHODS: We performed MRI for 300 AIs in 278 consecutive patients. All patients were screened for pheochromocytoma with plasma metanephrine and normetanephrine. Patients with high plasma levels of metanephrine and/or normetanephrine were also assessed for pheochromocytoma by urinary metanephrines. RESULTS: Hyperintensity was detected on T2-weighted MRI sequences in 28 (9.3%) of the 300 AIs. Among these 28 incidentalomas, pheochromocytoma was diagnosed in 13 (46.4%) of the cases by histopathologic analysis. Hyperintensity on T2-weighted MRI was significantly higher in pheochromocytomas compared to the remaining AIs (P<.001). All 13 pheochromocytomas were characterized by hyperintensity on T2-weighted sequences and the absence of signal loss on out-of-phase MRI sequences. Pheochromocytoma was not detected in any of the 272 AIs that appeared hypointense or isointense on T2-weighted MRI sequences or in the 250 cases with signal loss on out-of-phase sequences. CONCLUSION: The results of this study suggest that AIs that appear hypointense or isointense on T2-weighted MRI sequences and those with signal loss on out-of-phase sequences may not require routine biochemical screening for pheochromocytoma. Further studies including a higher number of pheochromocytomas are required to confirm our results.

Doppler ultrasound diagnosis of an unusual variant of median arcuate ligament syndrome: concomitant involvement of celiac and superior mesenteric arteries. A case report.

Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome is a rare condition characterized by chronic mesenteric ischemia, secondary to the compression of the celiac artery by the median arcuate ligament. Occasionally, in addition to the celiac artery, the superior mesenteric artery may be partially compressed by the median arcuate ligament. We report a case with complaints of chronic abdominal pain from compression of both the celiac artery and the superior mesenteric artery due to MALS, which was primarily detected by Doppler ultrasound. The diagnosis was confirmed with CT-angiography.

Ectopic cervical thymus as a rare cause of pediatric neck mass: the role of ultrasound and MRI in the diagnosis. Case report.

Ectopic cervical thymus (ECT) is an uncommon cause for cervical mass in the pediatric age group. Ultrasound and magnetic resonance imaging findings of the mass (located along the thymic descent pathway along the thymopharyngeal tract and has identical echostructure and signal intensities to the native thymus in the superior mediastinum) would lead to the diagnosis. The diagnosis is confirmed by fine needle aspiration biopsy or histopathology after resection. The management of ECT is a conservative follow up, except in symptomatic cases with tracheal compression and histologically confirmed neoplasia where surgery is indicated. We present the case of ECT presenting as a left upper neck mass in a 12 year old girl.

Effects of totally extraperitoneal (TEP) and Lichtenstein hernia repair on testicular blood flow and volume.

BACKGROUND: Laparoscopic totally extraperitoneal hernia repair (TEP) has been compared with the open technique in several studies in terms of technical properties and perioperative outcomes. There are few studies that compare the long-term effects of each technique on testicular structure and function on the side of the hernia repair. The objective of this study is to investigate the effects at 6 months of the TEP and the Lichtenstein technique on testicular volume and arterial flow by the use of Doppler ultrasonography. METHODS: A total of 148 men with a unilateral hernia were randomized prospectively to undergo TEP or Lichtenstein repair. In both groups, unilateral resistive indices, pulsatile indices of capsular and intratesticular artery flow, and testicular volume (in milliliters) were measured preoperatively and 6 months postoperatively by the use of grayscale and color Doppler ultrasonography (CDUS). The primary outcomes of the study were postoperative findings from history, physical examination, and CDUS measurements at 6 months postoperatively. Demographics, clinical and operative data, CDUS measurements, and recurrence patterns were analyzed. RESULTS: Of 148 procedures, 134 cases consisting of 64 TEP and 70 Lichtenstein repairs were evaluated. Pre- and postoperative CDUS findings, rates of complications, and recurrence in both groups did not show any difference. Operative time was greater with a Lichtenstein repair (36 vs 30 minutes; P = .01). CONCLUSION: Complications and recurrence rates and effects on testicular perfusion and testicular volume in both laparoscopic and open techniques are similar, whereas the laparoscopic approach has shorter operative time than open hernia repair.

Diffusion tensor imaging of cysts, hemangiomas, and metastases of the liver.

BACKGROUND: Although diffusion-weighted magnetic resonance imaging imaging (DW-MRI) is commonly used to characterize hepatic lesions, the literature is sparse about the use of MR diffusion tensor imaging (DTI) in this regard. By using DTI, one is able to obtain not only apparent diffusion coefficients (ADCs) but also fractional anisotropy (Fa) values. PURPOSE: To evaluate DTI using ADC and Fa values in the imaging of hepatic cysts, hemangiomas, and metastases. MATERIAL AND METHODS: Sixty-six patients with 77 lesions were examined with DTI. There were 32 metastases, 13 cysts, and 32 hemangiomas. Two radiologists performed ADC and Fa measurements. Inter-observer agreement was evaluated using Bland-Altman plots. ADCs and Fa values were correlated using Pearson correlation. The differences were compared using ANOVA and Tukey tests. A ROC analysis was applied; sensitivities and specificities were calculated. RESULTS: The inter-observer agreement was very good. The correlation between ADC and Fa was negative, weak, and significant (r = -0.36). The mean ADC value of cysts (3.30 ± 0.8 × 10(-3) mm(2)/s) was significantly higher than that of hemangiomas (2.23 ± 0.5 × 10(-3) mm(2)/s) and metastases (1.62 ± 0.4 × 10(-3) mm(2)/s). The mean Fa value of cysts (0.2 ± 0.05) was significantly lower than hemangiomas (0.37 ± 0.1) and metastases (0.46 ± 0.1). The Az values for discriminating metastases from benign hepatic lesions for ADC and Fa value were 0.885 and 0.731, respectively. The sensitivity and specificity of ADC and Fa were 87.5% and 84.4%, and 78.1% and 57.8%, respectively. The Az value for discriminating cysts from hemangiomas for Fa was 0.96. The sensitivity and specificity were 90.6% and 92.3%, respectively. CONCLUSION: Fa values may play a supportive role in the imaging of liver lesions. Whereas metastases tend to have low ADCs and high Fa values, cysts have high ADCs and low Fa values and hemangiomas have high ADCs and high Fa values.

The Diagnostic Utility of Color Doppler Ultrasonography, Tc-99m Pertechnetate Uptake, and TSH-Receptor Antibody for Differential Diagnosis of Graves' Disease and Silent Thyroiditis: A Comparative Study.

OBJECTIVE: The differential diagnosis of Graves disease (GD) and silent thyroiditis (ST) is important for the selection of appropriate treatment. To date, no study has compared the diagnostic utility of color Doppler ultrasonography (CDUSG), Tc-99m (technetium-99m) pertechnetate uptake, and thyroid-stimulating hormone (TSH)-receptor antibody (TRAb) for the differential diagnosis of these two conditions. In the present study, we compared the diagnostic utility of inferior thyroid artery (ITA) peak systolic and end diastolic velocities (PSV and EDV) measured by CDUSG, Tc-99m pertechnetate uptake, and TRAb for differential diagnosis of GD and ST. METHODS: A total of 150 subjects with GD, 79 with ST, and 71 healthy euthyroid controls were included in the study. Diagnoses of GD and ST were made according to patient signs and symptoms, physical examination findings, the results of TRAb and Tc-99m pertechnetate uptake, and follow-up findings. All subjects underwent CDUSG for the quantitative measurement of ITA blood-flow velocities. RESULTS: The mean ITA-PSV and EDV in patients with GD were significantly higher than in ST patients. In receiver operating characteristic analysis, the sensitivity/specificity of the 30 and 13.2 cm/s cutoff values of the mean ITA-PSV and EDV for discrimination of GD from ST were 95.3/94.9% and 89.3/88.6%, respectively. The sensitivity/specificity of the 1.0 international unit (IU)/L and 3% cutoff values of the TRAb and Tc-99m pertechnetate uptake analyses were 93.0/91.0% and 90.7/89.9%, respectively. CONCLUSION: The measurement of ITA-PSV by CDUSG is a useful diagnostic tool and is a complementary method to the TRAb and Tc-99m pertechnetate uptake methods for differential diagnosis of GD and ST.

FGF-23 associated with the progression of coronary artery calcification in hemodialysis patients.

BACKGROUND: Disordered mineral metabolism is implicated in the pathogenesis of vascular calcification in hemodialysis (HD) patients. Fibroblast growth factor 23 (FGF-23) is the main regulator of phosphate metabolism. In this prospective study, we aimed to investigate the association of serum FGF-23 with progression of coronary artery calcification in HD patients. METHODS: Seventy-four HD patients (36 male/38 female, mean age: 52 ± 14 years) were included. Serum FGF-23 levels were measured by ELISA. Coronary artery calcification score (CACS) was measured twice with one year interval. Patients were grouped as progressive (PG) (36 patients-48%) and non-progressive (NPG). RESULTS: Age, serum phosphorus, baseline and first year CACS were found to be significantly higher in the PG compared to NPG group. Serum FGF-23 levels were significantly higher in PG [155 (80-468) vs 147 (82-234), p = 0.04]. Patients were divided into two groups according to baseline CACS (low group, CACS ≤ 30; high group, CACS > 30). Serum FGF-23 levels were significantly correlated with the progression of CACS (ΔCACS) in the low baseline CACS group (r = 0.51, p = 0.006), but this association was not found in high baseline CACS group (r = 0.11, p = 0.44). In logistic regression analysis for predicting the PG patients; serum FGF-23, phosphorus levels and baseline CACS were retained as significant factors in the model. CONCLUSIONS: Serum FGF-23 was found to be related to progression of CACS independent of serum phosphorus levels. FGF-23 may play a major role in the progression of vascular calcification especially at the early stages of calcification process in HD patients.

Ultrasonographic diagnosis of median arcuate ligament syndrome: a report of two cases.

The compression of the proximal part of the celiac trunk by median arcuate ligament of the diaphragm during expiration is defined as median arcuate ligament syndrome. It is a rare cause of chronic mesenteric ischemia. We report two cases with this syndrome, primarily diagnosed by Doppler ultrasound. The diagnosis was confirmed with digital substraction and computed tomography angiography in both cases. The role of ultrasound in the diagnostic work up of this syndrome is discussed with regard to the recent literature.

Osteoprotegerin/RANKL axis and progression of coronary artery calcification in hemodialysis patients.

BACKGROUND AND OBJECTIVES: Vascular calcification is associated with increased cardiovascular mortality in chronic hemodialysis patients. This prospective study investigated the relationship between serum osteoprotegerin, receptor activator of NF-κB ligand, inflammatory markers, and progression of coronary artery calcification score. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Seventy-eight hemodialysis patients were enrolled. Serum IL-1ß, IL-6, TNF-α, osteoprotegerin, receptor activator of NF-κB, fetuin A, and bone alkaline phosphatase were measured by ELISA. Coronary artery calcification score was measured two times with 1-year intervals, and patients were classified as progressive or nonprogressive. RESULTS: Baseline and first-year serum osteoprotegerin levels were significantly higher in the progressive than nonprogressive group (17.39±9.67 versus 12.90±6.59 pmol/L, P=0.02; 35.17±18.35 versus 24±11.65 pmol/L, P=0.002, respectively). The ratio of serum osteoprotegerin to receptor activator of NF-κB ligand at 1 year was significantly higher in the progressive group (0.26 [0.15-0.46] versus 0.18 [0.12-0.28], P=0.004). Serum osteoprotegerin levels were significantly correlated with coronary artery calcification score at both baseline (r=0.36, P=0.001) and 1 year (r=0.36, P=0.001). Importantly, progression in coronary artery calcification score significantly correlated with change in serum osteoprotegerin levels (r=0.39, P=0.001). In addition, serum receptor activator of NF-κB ligand levels were significantly inversely correlated with coronary artery calcification scores at both baseline (r=-0.29, P=0.01) and 1 year (r=-0.29, P=0.001). In linear regression analysis for predicting coronary artery calcification score progression, only baseline coronary artery calcification score and change in osteoprotegerin were retained as significant factors in the model. CONCLUSIONS: Baseline coronary artery calcification score and serum osteoprotegerin levels were significantly associated with progression of coronary artery calcification score in hemodialysis patients.

The diagnostic efficiency of ultrasound in characterization for thyroid nodules: how many criteria are required to predict malignancy?

OBJECTIVE: The purpose of this study was to define the criteria for use in differentiating benign and malignant nodules with the help of the receiver operating characteristic analysis and to increase the objective diagnostic accuracy of ultrasonography. MATERIALS AND METHODS: A total of 363 patients (307 women, 56 men) with 363 nodules (22 malignant and 341 benign nodules) were included in the study. The presence and absence of each US feature of the evaluated nodule - shape taller than wide, irregular margin, hypoechogenicity, microcalcification, and intranodular vascularity - were scored 1 and 0, respectively. The total ultrasound score was obtained by the summing up of each positive ultrasound findings for malignancy. The effect of the total US score in the discrimination of benign and malignant nodules was analysed using ROC analysis. RESULTS: The cut off values of US score at maximum sensitivity and specificity for nodules larger and smaller than one centimeter were two (Az: 0.783) and three (Az: 0.935), respectively. For nodules greater than one centimeter, the calculated diagnostic performances including sensitivity, specificity, positive predictive value and negative predictive value, and accuracy were 62.5%, 91.5%, 30.3%, 97.7%, and 89,9%, respectively. For nodules smaller or equal to one centimeter; the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 83.3%, 94.9%, 62.5%, 98.2% and 93.8%, respectively. CONCLUSION: Using ultraound, thyroid nodules can be characterized effectively. The number of the US features used in this distinction varies in respect to the nodule size.