Convolutional Neural Network to Stratify the Malignancy Risk of Thyroid Nodules: Diagnostic Performance Compared with the American College of Radiology Thyroid Imaging Reporting and Data System Implemented by Experienced Radiologists.

BACKGROUND AND PURPOSE: Comparison of the diagnostic performance for thyroid cancer on ultrasound between a convolutional neural network and visual assessment by radiologists has been inconsistent. Thus, we aimed to evaluate the diagnostic performance of the convolutional neural network compared with the American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS) for the diagnosis of thyroid cancer using ultrasound images. MATERIALS AND METHODS: From March 2019 to September 2019, seven hundred sixty thyroid nodules (≥10 mm) in 757 patients were diagnosed as benign or malignant through fine-needle aspiration, core needle biopsy, or an operation. Experienced radiologists assessed the sonographic descriptors of the nodules, and 1 of 5 American College of Radiology TI-RADS categories was assigned. The convolutional neural network provided malignancy risk percentages for nodules based on sonographic images. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated with cutoff values using the Youden index and compared between the convolutional neural network and the American College of Radiology TI-RADS. Areas under the receiver operating characteristic curve were also compared. RESULTS: Of 760 nodules, 176 (23.2%) were malignant. At an optimal threshold derived from the Youden index, sensitivity and negative predictive values were higher with the convolutional neural network than with the American College of Radiology TI-RADS (81.8% versus 73.9%, P = .009; 94.0% versus 92.2%, P = .046). Specificity, accuracy, and positive predictive values were lower with the convolutional neural network than with the American College of Radiology TI-RADS (86.1% versus 93.7%, P < .001; 85.1% versus 89.1%, P = .003; and 64.0% versus 77.8%, P < .001). The area under the curve of the convolutional neural network was higher than that of the American College of Radiology TI-RADS (0.917 versus 0.891, P = .017). CONCLUSIONS: The convolutional neural network provided diagnostic performance comparable with that of the American College of Radiology TI-RADS categories assigned by experienced radiologists.

Additional malignant breast lesions detected on second-look US after breast MRI vs. additional malignant lesions detected on initial US in breast cancer patients: comparison of US characteristics.

PURPOSE: The purpose of our study was to review and compare the US findings of synchronous malignant breast lesions other than the index cancer additionally detected on second-look US with those detected on initial US, and therefore to determine differing characteristics that may aid in diagnosis and essentially improve the performance of the initial US examination. MATERIALS AND METHODS: A retrospective review of 39 mammographically occult synchronous malignant lesions other than the index cancer from 38 patients was performed (21 lesions: detected on second-look US, 18 lesions: detected on initial US). All patients underwent initial mammography, bilateral whole breast US (BWBU) and breast MRI, and all lesions were confirmed pathologically by biopsy or preoperative localization. RESULTS: Additional malignant breast lesions detected on both initial US and second-look US tended to be subtle and often did not show classic malignant findings. Second-look US lesions (median, 7.0 mm; range, 3 - 22 mm) tended to be smaller than initial US lesions (median, 9.0 mm; range 3 - 45 mm), although the difference was not statistically significant (p = 0.134). Second-look US lesions also showed no posterior acoustic features (p = 0.037) and a significantly higher proportion of lesions with circumscribed or indistinct margins compared to initial US lesions (p = 0.042). Second-look US lesions were significantly subareolar or relatively far (> 5 cm) from the nipple than initial US lesions (p = 0.048). CONCLUSION: Second-look US lesions showed more subtle findings of posterior acoustic features and margins, and tended to be subareolar or relatively far from the nipple compared to initial US lesions. However, both groups showed subtle US findings and there was no significant difference in other features.

Screening for hepatitis B, C and non-alcoholic fatty liver disease: a survey of community-based physicians.

BACKGROUND: Screening guidelines for hepatitis B (HBV) and hepatitis C viruses (HCV) as well as a position statement for non-alcoholic fatty liver disease (NAFLD) have been put forth by different sources, but awareness of these guidelines and their impact on the physician practices have not been assessed. AIM: To assess the attitudes of primary care physicians (PCPs), gastroenterologists (GEs) and hepatologists (HEPs) regarding screening for HBV, HCV and NAFLD. DESIGN: A survey questionnaire was sent to community-based PCPs and GEs to assess issues related to HBV, HCV and NAFLD. The same questionnaire was sent to hepatologists (HEPs). The questionnaire contained 10 items related to demographic and practice patterns of these physicians, 35 items related to HBV, 35 items related to HCV and 29 items related to NAFLD. RESULTS: A total of 214 physicians (103 PCPs, 59 GEs and 52 HEPs) completed the survey. A majority of PCPs, GEs and HEPs agreed on most screening issues for these causes of liver disease. Nevertheless, within group comparison of physicians (guideline aware versus guideline unaware) showed significant differences in accurate response between those who were aware of guidelines and those who were not aware. CONCLUSIONS: A large percentage of PCPs and GEs were unaware of official guidelines for viral hepatitis B and hepatitis C. Those aware of guidelines were more likely to screen appropriately and avoid unnecessary testing. More needs to be done to assess awareness and the impact implementation of guidelines in hepatology.

Mechanisms underlying the sensitivity of neurons in the lateral superior olive to interaural intensity differences.

The initial processing of interaural intensity differences (IIDs), the major cue to the azimuthal location of high-frequency sounds in mammals, is carried out by neurons in the lateral superior olivary nucleus (LSO) that receive excitatory input from the ipsilateral ear and inhibitory input from the contralateral ear (IE neurons). The "latency" hypothesis asserts that it is the effects of intensity differences on the latency, and hence the relative timing, of the synaptic inputs to these neurons that is the basis of their sensitivity to IIDs, while other models assign the major role to changes in the relative amplitude of the inputs. To test the latency hypothesis and to determine the contributions of changes in the relative timing and amplitude of synaptic inputs to the IID sensitivity of LSO neurons, a method was developed of generating sets of stimuli that produced either the same changes in the relative timing of inputs without any change in their amplitude (equivalent interaural time difference stimuli) or the same differences in amplitude without any difference in timing (delay-cancelled IID stimuli) as a given range of IIDs. Data were obtained from a sample of IE neurons in the LSO of anesthetized rats using these stimulus paradigms and click and tone-burst stimuli. For click stimuli, the IID sensitivity of a small proportion of neurons was explained entirely by sensitivity to differences in input timing, but the sensitivity of most neurons reflected either sensitivity to the relative amplitude of inputs or to the joint operation of both factors. In neurons whose sensitivity was tested at a number of different absolute sound pressure levels (SPLs), the relative contributions of the two factors tended to differ at different SPLs. The IID sensitivity of onset responses to tone stimuli could be classified into the same three categories but was explained for a larger proportion of neurons by sensitivity to differences in input timing. The IID sensitivity of the late response component of neurons with sustained responses to tones in all cases reflected sensitivity to the relative amplitude of the inputs. The results confirm the contribution of changes in latency produced by intensity changes to the IID sensitivity of the onset responses of many IE neurons in LSO but require rejection of the strong form of the latency hypothesis, which asserts that this factor alone accounts for such sensitivity.

Maternal and fetal inherited thrombophilias are not related to the development of severe preeclampsia.

OBJECTIVE: Thrombotic vascular disease may predispose patients to the development of preeclampsia. The purpose of this study was to determine whether maternal or fetal genotype frequencies of the inherited thrombophilic gene mutations (factor V Leiden, methylenetetrahydrofolate, and prothrombin) are altered in severe preeclampsia. STUDY DESIGN: We performed a prospective cross-sectional study to compare the maternal and fetal genotype frequencies of factor V Leiden, methylenetetrahydrofolate, and prothrombin. One hundred ten patients with severe preeclampsia were matched for gestational age to 97 normotensive pregnancies. Umbilical cord blood was obtained from 92 control patients and 75 patients with preeclampsia. Deoxyribonucleic acid was extracted from leukocytes and polymerase chain reaction was performed. Polymerase chain reaction products were digested with the appropriate restriction enzyme and fractionated by gel electrophoresis. Genotype frequencies were calculated. Statistical significance was determined by the chi(2) test. RESULTS: There were no significant differences between patients with severe preeclampsia and control patients regarding frequency of maternal factor V Leiden G/506/A mutation (4.4% vs 4.3%; P =.96), methylenetetrahydrofolate CC/667/TT mutation (9.6% vs 6.3%; P =.54), or prothrombin G/20210/A mutation (0% vs 1.1%; P =.92). In addition, no statistical difference could be found between fetal thrombophilias and the development of preeclampsia. Findings were similar in both white (n = 47) and African American (n = 63) preeclamptic subsets. Moreover, there was no association between any of the maternal or fetal genetic polymorphisms and the incidence of hemolysis, elevated liver enzymes, and low platelet count syndrome (n = 21); eclampsia (n = 12); or intrauterine growth restriction (n = 9). CONCLUSION: Inherited thrombophilias are not associated with severe preeclampsia.

Lack of association of severe preeclampsia with maternal and fetal mutant alleles for tumor necrosis factor alpha and lymphotoxin alpha genes and plasma tumor necrosis factor alpha levels.

OBJECTIVE: The purpose of this study was to determine whether the increased frequency of mutant alleles of the gene for tumor necrosis factor alpha and elevated maternal and fetal plasma levels of tumor necrosis factor alpha were associated with severe preeclampsia. STUDY DESIGN: We performed a prospective cross-sectional study involving 112 patients with severe preeclampsia matched for gestational age with 106 normotensive pregnant women. Deoxyribonucleic acid for restriction fragment length polymorphism analysis was extracted from maternal and fetal blood. Two mutations associated with the gene for tumor necrosis factor alpha were assayed by polymerase chain reaction. Polymerase chain reaction products were digested with the restriction enzyme Ncol and then fractionated by gel electrophoresis. Genotypic frequencies were calculated. Maternal and fetal plasma tumor necrosis factor alpha levels were assayed by the dual monoclonal antibody sandwich enzyme-linked immunosorbent assay technique. The chi2 test, the Fisher exact test, the Student t test, and the Mann-Whitney test were performed to calculate statistical significance. RESULTS: The differences in the genotypic frequencies of the two loci were not significant in either maternal or fetal samples between control women and women with pregnancies complicated by severe preeclampsia. There was no statistical difference in median maternal plasma levels of tumor necrosis factor alpha between control subjects (0.0 pg/mL) and patients with severe preeclampsia (2.5 pg/mL; P =.36). Unexpectedly, fetal plasma tumor necrosis factor alpha levels were found to be significantly elevated in control women (18.4 pg/mL) relative to women with severe preeclampsia (9.1 pg/mL; P <.0001). CONCLUSION: Neither the genotypic frequencies for tumor necrosis factor alpha mutant alleles nor maternal tumor necrosis factor alpha plasma levels were increased in patients with severe preeclampsia.

Hypercoagulable state mutation analysis in white patients with early first-trimester recurrent pregnancy loss.

OBJECTIVE: Antiphospholipid antibodies (APA) and other coagulation abnormalities have been associated with an increased risk of venous, arterial, and placental thrombosis and recurrent pregnancy loss (RPL). Factor V Leiden (a point mutation [1691G-->A] in the factor V gene), the prothrombin 20210G-->A mutation, and homozygosity for a common polymorphism in the methylene tetrahydrofolate reductase (MTHFR) gene (677C-->T) have been associated with arterial and venous thrombosis and arterial occlusive disease. We explored an association between these markers of thrombophilic states and RPL. DESIGN: Prospective case-control evaluation. SETTING: University-associated private practice. PATIENT(S): Fifty nonpregnant women with three or more pregnancy losses and 50 healthy, nonpregnant controls. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Anticardiolipin and antiphosphatidylserine antibodies were detected in serum by ELISA. Polymerase chain reaction was performed to identify the factor V Leiden (1691G-->A) mutation, the thermobile MTHFR (677C-->T) mutation, and the prothrombin 20210G-->A mutation. RESULT(S): The following were identified by restriction fragment-linked polymorphism analyses: 1 (2%) factor V Leiden heterozygosity; 1 (2%) prothrombin 20210G-->A heterozygosity; and 4 (8%) thermolabile MTHFR homozygosity. None of these mutation frequencies in women with RPL were statistically significantly different from controls. CONCLUSION(S): These data suggest that factor V Leiden, thermolabile MTHFR (677C-->T), and prothrombin 20210G-->A are not found at an increased frequency in women with a history of early RPL.

Factor V Leiden and other hypercoagulable state mutations are not associated with osteonecrosis during or after treatment for pediatric malignancy.

OBJECTIVE: Osteonecrosis (ON) is a debilitating complication of cancer treatment in children and is usually associated with systemic steroid therapy. Defects of coagulation may be important in the pathogenesis of ON. This study evaluated the prevalence of factor V Leiden (FVL, 1691G-->A), the most common inherited thrombophilic state, the prothrombin 20210G-->A polymorphism, and the thermolabile methylene tetrahydrofolate reductase (MTHFR, 677C-->T) variant in a group of children in whom ON developed during or after treatment for cancer. STUDY DESIGN: Children in whom ON developed during cancer treatment at St Jude Children's Research Hospital were studied (n = 24). Genomic DNA was isolated, and polymerase chain reaction was performed to identify the FVL, prothrombin 20210, and thermolabile MTHFR mutations. RESULTS: Sixteen of 24 patients had acute lymphoblastic leukemia. The mean age at ON diagnosis was 14.4 +/- 3. 7 years. The mean interval between cancer diagnosis and ON diagnosis was 27 +/- 21 months. Twenty-two patients had received steroids for a mean duration of 24 +/- 15 weeks before having development of ON. No patient had a history of thrombosis. Five (21%) patients had a family history of thrombosis. Genetic analysis revealed 0 (0%) of 24 FVL, 1 (4.5%) of 22 prothrombin 20210, and 3 (13.6%) of 22 thermolabile MTHFR. None of these mutation frequencies was significantly different from our control frequencies or published values. CONCLUSIONS: Although procoagulant abnormalities in general and FVL in particular have been detected in a significant number of patients with ON of the jaw and Legg-Perthes disease, we did not identify an increased prevalence of FVL or other hypercoagulable state mutations in a cohort of children with ON that developed during or after treatment for a variety of cancers.

Alternative splicing of exons 29 and 30 in the neurofibromatosis type 1 gene.

Alternative splicing of exons 29 and 30 of the human neurofibromatosis type 1 (NF1) gene was detected by reverse transcription/polymerase chain reaction (RT-PCR). Three different isoforms that omitted either one or both exons were identified (ex29-, ex30-, and ex29/30-). The alternatively spliced transcripts exhibited tissue-specific differences, with the ex30- variant apparent only in brain. All three isoforms altered the reading frame and introduced a stop codon in the adjacent downstream exon. Alternative splicing of this region of the NF1 gene also was detected in RNA from rats, although only the ex30- variant was observed. RNA from mice revealed only constitutive expression in this region of the NF1 gene. This study adds a new site of alternative processing to the complex expression of NF1.

Neurofibromatosis type 1 (NF1): a protein truncation assay yielding identification of mutations in 73% of patients.

Neurofibromatosis type 1 (NF1) is caused by mutations in a tumour suppressor gene located on chromosome 17 (17q11.2). Disease causing mutations are dispersed throughout the gene, which spans 350 kilobases and includes 59 exons. A common consequence of NF1 mutations is introduction of a premature stop codon, and the majority of mutant genes encode truncated forms of neurofibromin. We used a protein truncation assay to screen for mutations in 15 NF1 patients and obtained positive results in 11 of them (73%). Sequencing of cDNA and genomic DNA yielded identification of 10 different mutations, including four splicing errors, three small deletions, two nonsense mutations, and one small insertion. Nine mutations were predicted to cause premature termination of translation, while one mutation caused in frame deletion as a result ofexon skipping. In one other case involving abnormal splicing, five different aberrantly spliced transcripts were detected. One germline nonsense mutation (R1306X, 3916C>T) corresponded to the same base change that occurs by mRNA editing in normal subjects. The second nonsense mutation (R2496X) was the sole germline mutation that has been previously described. The subjects studied represented typically affected NF1 patients and no correlations between genotype and phenotype were apparent. A high incidence of ocular hypertelorism was observed.

Cloning and characterization of the promoter for the liver isoform of the rat carnitine palmitoyltransferase I (L-CPT I) gene.

Carnitine palmitoyltransferase I (CPTI) catalyses the transfer of long chain fatty acids to carnitine for translocation across the mitochondrial inner membrane. The cDNAs of two isoforms of CPT I, termed the hepatic and muscle isoforms, have been cloned. Expression of the hepatic CPT I gene (L-CPT I) is subject to developmental, hormonal and tissue specific regulation. We have cloned the promoter of the L-CPTI gene from a rat genomic library. In the L-CPTI gene, there are two exons 5' to the exon containing the ATG that initiates translation. Exon 1 and the 5' end of exon 2 contain sequences that were not previously described in the rat L-CPTI cDNA. There is an alternatively spliced form of the L-CPTI mRNA in which exon 2 is skipped. The proximal promoter of the L-CPTI gene is extremely GC rich and does not contain a TATA box. There are several putative Sp1 binding sites near the transcriptional start site. A 190 base pair fragment of the promoter can efficiently drive transcription of luciferase and CAT (chloramphenicol acetyltransferase) reporter genes transiently transfected into HepG2 cells. Sequences in both the first intron and the promoter contribute to basal expression. Our results provide the foundation for further studies into the regulation of L-CPTI gene expression.

Sex chromosome markers: characterization using fluorescence in situ hybridization and review of the literature.

Fluorescence in situ hybridization (FISH) using biotin labeled X- and Y-chromosome DNA probes was utilized in the analysis of 23 sex chromosome-derived markers. Specimens were obtained through prenatal diagnosis, because of a presumptive diagnosis of Ullrich-Turner syndrome, mental retardation, and minor anomalies or ambiguous genitalia; three were spontaneous abortuses. Twelve markers were derived from the X chromosome and eleven from the Y chromosome; this demonstrates successfully the value and necessity of FISH utilizing DNA probes in the identification of sex chromosome markers. Both fresh and older slides, some of which had been previously G-banded, were used in these determinations. We have also reviewed the literature on sex chromosome markers identified using FISH.

A jumping Robertsonian translocation: a molecular and cytogenetic study.

We report a patient with mosaicism for two different Robertsonian translocations, both involving chromosome 21. She carries an unbalanced cell line with an i(21q) and a balanced cell line with a rob(21q22q). She is phenotypically normal but has two children who inherited the i(21q) and have Down syndrome. We demonstrate that both abnormal chromosomes are dicentric and that the proband's 21/21 rearrangement is an isochromosome formed from a maternally derived chromosome 21. We propose a model in which the i(21q) is the progenitor rearrangement in the proband, which subsequently participated in a nonreciprocal rearrangement characteristic of a jumping translocation. In addition, we review other cases of constitutional mosaicism involving jumping translocations.

Risk of fetal mosaicism when placental mosaicism is diagnosed by chorionic villus sampling.

OBJECTIVE: Our purpose was to determine the risk of fetal mosaicism when placental mosaicism is found on chorionic villus sampling. STUDY DESIGN: We present a case of mosaic trisomy 22 detected on chorionic villus sampling and subsequently found in the fetus. A review of comprehensive chorionic villus sampling studies with emphasis on follow-up for fetal mosaicism was conducted. RESULTS: Among 13 studies reviewed, 469 cases of placental mosaicism are presented; fetal mosaicism was found in 50 (10.7%). Factors associated with fetal mosaicism are (1) mosaicism on mesenchymal core culture and (2) type of chromosome abnormality involved--specifically, marker chromosomes (26.7%) and common autosomal trisomies (19.0%). Amniocentesis predicted fetal genotype in 93% to 100% of cases of placental mosaicism, depending on the cell type in which mosaicism was diagnosed. CONCLUSIONS: Although mosaicism is usually confined to the placenta, the fetus is involved in about 10% cases. Patients should be counseled about this risk and the accuracy of follow-up amniocentesis.

Double non-disjunction in maternal meiosis II giving rise to a fetus with 48,XXX,+21.

We describe a prenatally detected case of double trisomy involving chromosome 21 and the X chromosome (48,XXX,+21) along with determination of the segregation errors responsible for the double aneuploidy. The patient was ascertained as a result of an abnormal maternal serum analyte screen showing an increased risk for fetal Down's syndrome. Following determination of the abnormal karyotype, pregnancy termination was elected. Microsatellite polymorphisms and cytogenetic heteromorphisms were used to determine that both aneuploidies arose as a result of non-disjunction in maternal meiosis II. These results support hypotheses that a segregation defect at a cellular level may cause non-disjunction involving more than one chromosome.

A family study describing second cousins with cystic fibrosis and no common ancestor who is a carrier.

We describe an extended pedigree in which second cousins are affected with cystic fibrosis (CF). Since the degree of relationship of the affected subjects is 1/32, common descent of one CF mutation was expected when the DNA laboratory undertook mutation analysis. Mutation testing showed that each CF mutation was introduced into the family by random mating and not by descent through a common ancestor. Implications for pedigree analysis and DNA testing are discussed.

Responses of neurons in the inferior colliculus of the rat to interaural time and intensity differences in transient stimuli: Implications for the latency hypotheses.

Although the sensitivity to interaural intensity differences (IIDs) of neurons receiving excitatory - inhibitory binaural input (EI neurons) has been examined in numerous studies, the mechanisms underlying this sensitivity remain unclear. According to the 'latency hypotheses' neuronal sensitivity to IIDs reflects sensitivity to differences in the timing of ipsilateral and contralateral inputs that are produced as a consequence of the effects of intensity upon latency. If the latency hypothesis is correct, a neuron's responses over any given IID range should be predicted by its responses to the interaural time differences (ITDs) that are 'equivalent' to the IIDs tested, in the sense that they produce the same changes in the relative timing of inputs. This prediction from the latency hypotheses were examined by determining the sensitivity of EI neurons in the inferior colliculus of anesthetized rats to IIDs and ITDs in click stimuli, under conditions that allowed 'equivalent' ITDs to be estimated. In approximately 10% of the 41 neurons tested, the IID-sensitivity function was a perfect or near-perfect match to the equivalent-ITD function, indicating that IID sensitivity could be entirely accounted for in terms of sensitivity to intensity-produced neural time differences, as asserted by the latency hypothesis. For the majority of neurons, however, sensitivity to equivalent ITDs accounted only partially for the characteristics of the IID-sensitivity function; other features of the function in these cases appeared to reflect the operation of an additional factor, most probably the relative magnitude of the inputs from the two ears. Although the conclusions are qualified by the fact that one of the assumptions on which the estimation of equivalent ITDs was based was probably not satisfied for some neurons, the results suggest that intensity-produced changes in both the magnitude and the timing of excitatory and inhibitory inputs shape the IID sensitivity of most EI neurons.

Primary structure of the 5 S subunit of transcarboxylase as deduced from the genomic DNA sequence.

Transcarboxylase from Propionibacterium shermanii is a complex biotin-containing enzyme composed of 30 polypeptides of three different types. It is composed of six dimeric outer subunits associated with a central cylindrical hexameric subunit through 12 biotinyl subunits; three outer subunits on each face of the central hexamer. Each outer dimer is termed a 5 S subunit which associates with two biotinyl subunits. The enzyme catalyzes a two-step reaction in which methylmalonyl-CoA and pyruvate form propionyl-CoA and oxalacetate, the 5 S subunit specifically catalyzing one of these reactions. We report here the cloning, sequencing and expression of the monomer of the 5 S subunit. The gene was identified by matching amino acid sequences derived from isolated authentic 5 S peptides with the deduced sequence of an open reading frame present on a cloned P. shermanii genomic fragment known to contain the gene encoding the 1.3 S biotinyl subunit. The cloned 5 S gene encodes a protein of 519 amino acids, M(r) 57,793. The deduced sequence shows regions of extensive homology with that of pyruvate carboxylase and oxalacetate decarboxylase, two enzymes which catalyze the same or reverse reaction. A fragment was subcloned into pUC19 in an orientation such that the 5 S open reading frame could be expressed from the lac promoter of the vector. Crude extracts prepared from these cells contained an immunoreactive band on Western blots which co-migrated with authentic 5 S and were fully active in catalyzing the 5 S partial reaction. We conclude that we have cloned, sequenced and expressed the monomer of the 5 S subunit and that the expressed product is catalytically active.