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Objectives: This study aims to investigate whether pulsed electromagnetic field (PEMF) therapy in addition to a conventional rehabilitation program is effective on pain and functioning in patients with type 1 complex regional pain syndrome (CRPS-1) of the hand., Patients and Methods: Between March 2013 and January 2015, a total of 32 patients (16 males, 16 females; mean age: 50.1±13.1 years; range, 25 to 75 years) were included. The patients were randomly allocated into two groups. The control group (n=16) received a conventional rehabilitation program consisting of physical modalities, exercises, and occupational therapy, whereas the PEMF group (n=16) received additional PEMF (8 Hz, 3.2 mT) to the affected hand. The primary outcome measure was pain intensity using the Numeric Rating Scale (NRS). Secondary outcome measures were grip and pinch strength, hand edema, hand dexterity, and hand activities. All patients received 20 therapy sessions (five sessions/week, four weeks in total) and were evaluated before and after the therapy and at the first-month follow-up., Results: Both groups showed significant improvements in primary and secondary outcomes (p<0.05) after the therapy and at follow-up. When the groups were compared in terms of improvements in assessment parameters, no statistically significant difference was found between the two groups in any of the outcomes (p>0.05)., Conclusion: The PEMF in addition to conventional rehabilitation program did not provide additional benefit for pain and hand functions in CRPS-1. Future studies using different application parameters such as frequency, intensity, duration, and route may provide a better understanding of the role of PEMF in CRPS-1 treatment., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2022, Turkish Society of Physical Medicine and Rehabilitation.)

Introduction:  Sacrospinal anomalies that may accompany anorectal malformations may cause fecal and urinary incontinence despite proper anomaly treatment. The sacral ratio has been suggested in the determination of both the prognosis in terms of incontinence and the need for further examination for sacrospinal anomalies. The normal and clinically decisive values of sacral ratio are given differently in publications. We aimed to determine the distribution of the sacral ratio in children under 12 months and to develop the sacral ratio percentile card that will enable one to give an age-independent parametric result in clinical evaluations., Materials and Methods:  The files of patients under 1 year of age who had anteroposterior direct radiography including pelvis were reviewed retrospectively. Sacral ratio was studied for 360 patients, 30 patients per month. Percentile card was developed with LMS software and reference values were used as 1, 2, 3, 4, and 10%., Results:  The lowest sacral ratio value was 0.514 and the highest value was 0.936. There was no statistical difference between the mean sacral ratio of the cases when they were classified on a monthly basis ( p  = 0.191). Low percentile values were found slightly different at first 4 months of age., Conclusion:  Although the mean of sacral ratio does not change significantly during the first year of life, values that are considered pathological for patients are within different percentile limits depending on age. Instead of using sacral ratio with some clinically decisive values, we think that parametric evaluation with the help of the percentile card will increase its clinical value., Competing Interests: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article., (Thieme. All rights reserved.)

Background: Liver graft fibrosis affects long-term graft and patient survival in liver transplant recipients. Transient elastography and magnetic resonance elastography are widely used for the assessment of liver fibrosis in routine clinical practice, but are limited in liver transplant settings. The aims of the present study were to evaluate the accuracy of magnetic resonance elastography and transient elastograph in the assessment of liver fibrosis in liver transplant recipients, and to determine the recurrence rates of post-transplant hepatic steatosis and liver fibrosis., Methods: A total of 126 consecutive liver transplant recipients were included. Magnetic resonance elastography and transient elastography were performed for to measure liver stiffness., Results: The most common cause of liver transplantation was hepatitis B virus-induced cirrhosis (50%). The mean liver stiffness value with transient elastography was 6.1 ± 3.0 kPa, and the mean magnetic resonance elastography value was 2.7 ± 1.0 kPa. A significant positive correlation was found between magnetic resonance elastography and transient elastography in terms of liver stiffness measurement (r = 0.61, P < .001). Obesity and the underlying etiology of liver diseases did not have any significant negative effect on magnetic resonance elastography and transient elastography measurements. During the follow-up, the post-transplant recurrence rates of hepatic steatosis and hepatic fibrosis were 26% and 37%, respectively. The recurrence rates of post-transplant hepatic steatosis and liver fibrosis were slightly higher in recipients with non-alcoholic fatty liver disease-related cirrhosis than those with viral hepatitisrelated etiologies (44% vs 27%, P = .43; 44% vs 30%, P = .45, respectively)., Conclusion: Magnetic resonance elastography and transient elastography are accurate in assessing liver fibrosis in the liver transplant setting. Obesity and the underlying etiology of primary liver disease do not influence the measurements.

Aim: The aim of this study is to demonstrate our video training tool developed to teach and standardize complete mesocolic excision (CME) for right-sided colon cancer and also to present our long-term oncological outcomes., Method: Educational narrative videos were produced to demonstrate the technical steps of CME. First, a three-dimensional animation video was prepared. Then cadaveric dissections were recorded in a step-by-step fashion, following the sequences of open and minimally invasive surgery. These were followed by videos of real-life demonstrations of surgical procedures, enhanced by superimposed animations of key anatomical structures. In order to demonstrate the impact of this training module on outcomes of patients undergoing CME, we retrospectively queried data from before (2005-2010) and after (2011-2019) implementation of standardized CME in our practice., Results: A total of 180 consecutive patients underwent right hemicolectomy between 2005 and 2019. Fifty-four patients underwent surgery before and 126 patients after CME principles were elaborated and standardized. Of those patients who had surgery after the training module, 58 (46%) underwent open surgery and 68 (54%) underwent laparoscopic colectomy. Demographics, perioperative parameters and morbidity were comparable between the groups. The 5-year overall and disease-free survival rates were significantly improved after implementation of CME training (p = 0.059 and p = 0.041, respectively). Also, 5-year overall and disease-free survival rates for all patients were considerably better than our reported national outcomes., Conclusion: Our comprehensive step-by-step training video module for the CME technique demonstrates surgical anatomical planes and important vascular structures and variations. The video also helps standardization of the CME technique and should contribute to improved histopathological and oncological outcomes., (© 2021 Association of Coloproctology of Great Britain and Ireland.)

Aims: Familial Mediterranean fever (FMF) is an autosomal recessive disorder characterised by recurrent episodes of fever and serosal inflammation with elevated acute phase reactants. Assessing the severity of the disease may be useful in identifying colchicine-resistant patients. The aim of this study is to determine the disease severity of FMF patients according to the Pras, Mor, and International Severity Scoring System for Familial Mediterranean Fever (ISSF) scoring systems and to evaluate the consistency of these three systems., Methods: The medical records of patients with FMF were retrospectively reviewed. Demographic features, family history of FMF, clinical characteristics at disease onset, laboratory features, Mediterranean fever genetic mutations, treatment regimens, and disease courses were recorded., Results: A total of 205 patients (116 girls) were included in the study. The mean age of the patients was 13.3 ± 4.0 years. The Pras, Mor, and ISSF scores were inconsistent with each other, and there was poor fit between them (generalised Kappa: 0.140 ± 0.029; P < .001). In the receiver operating characteristic (ROC) analysis performed by accepting the clinician's opinion as the gold standard, the ISSF was found to be more sensitive and specific than the other two systems., Conclusion: Evaluation of disease severity according to the ISSF in paediatric patients is more sensitive and specific than the Pras and Mor scoring systems., (© 2021 John Wiley & Sons Ltd.)

Objective: To evaluate the effectiveness of radial extracorporeal shock wave therapy on ankle flexor spasticity in stroke survivors and to reveal changes in the fibroelastic components of muscle., Design: Randomized controlled trial., Setting: Inpatient neuro-rehabilitation clinic of a university hospital., Participants: Stroke patients with ankle flexor spasticity., Interventions: Patients were randomized to three groups; radial extracorporeal shock wave therapy, sham, or control. Active and sham therapy were administered two sessions/week for two weeks. All patients received conventional rehabilitation., Main Measures: The primary outcome was Modified Ashworth Scale. Secondary outcomes were the Tardieu Scale and elastic properties of plantar flexor muscles assessed by elastography (strain index). All assessments were performed before, immediately after the treatment, and four weeks later at follow-up., Results: Fifty-one participants were enrolled (active therapy n  = 17, sham n  = 17, control n  = 17). Modified Ashworth scores showed a significant decrease in the active therapy group (from 2.47 ± 0.72 to 1.41 ± 0.62) compared to sham (from 2.19 ± 1.05 to 2.06 ± 1.12) and control (from 2.06 ± 0.85 to 2.00 ± 0.73) groups immediately after the treatment ( P  < 0.001). Tardieu results were also in concordance ( P  < 0.001), however this effect was not preserved at follow-up. Elastic properties of the ankle flexors were improved in all groups at both assessments after the therapy showing significant decreases in strain index ( P  < 0.001). However, there was no difference among the groups in terms of improvement in elastography., Conclusion: Radial extracorporeal shock wave therapy has short-term anti-spastic effects on ankle flexor muscles when used as an adjunct to conventional rehabilitation.

Introduction: The importance of patient-reported outcome measures (PROMs) for rheumatoid arthritis (RA) clinical studies has been recognised for many years. The current study aims to describe the RA PROMs used over the past 20 years, and their performance metrics, to underpin appropriate tool selection., Methods: The study included a systematic search for PROMs that have been in use over the period 2000-2019, with detailed documentation of their psychometric properties, and a user-friendly presentation of the extensive evidence base., Results: 125 PROMs were identified with psychometric evidence available. The domains of pain, fatigue, emotional functions, mobility, physical functioning and work dominated, with self-efficacy and coping as personal factors. Domains such as stiffness and sleep were poorly served. The most frequently used PROMs included the Health Assessment Questionnaire Disability Index (HAQ), the Short Form 36 (SF-36), the EuroQoL and the Modified HAQ which, between them, appeared in more than 3500 papers. Strong psychometric evidence was found for the HAQ, and the SF-36 Physical Functioning and Vitality (fatigue) domains. Otherwise, all domains except stiffness, sleep, education and health utility, had at least one PROM with moderate level of psychometric evidence., Conclusion: There is a broad range of PROMs for measuring RA outcomes, but the quality of psychometric evidence varies widely. This work identifies gaps in key RA domains according to the biopsychosocial model., Competing Interests: Competing interests: PGC has done consultancies or speakers bureaus for AbbVie, Bristol Myers Squibb, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, GlaxoSmithKline, Novartis, Pfizer, Roche, Samumed and Stryker. All other authors declare no competing interests., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Purpose: To evaluate the association of visceral adiposity measured on computed tomography (CT) in preoperative period with lymph node (LN) metastasis and overall survival in gastric adenocarcinoma patients., Methods: Preoperative CT scans of 246 gastric adenocarcinoma patients who did not receive neoadjuvant chemoradiotherapy were evaluated. Visceral fat area (VFA), subcutaneous fat area (SFA) and Total fat area (TFA), VFA/TFA ratio were quantified by CT. VFA/TFA > 29% was defined as visceral obesity. The differentiation, t-stage, n-stage and the number of harvested-metastatic LNs were noted. The maximum thickness of tumor and localization were recorded from CT. Chi-square, Student's t-test, multiple Cox regression, Spearman's correlation coefficient, and Kaplan-Meier algorithm were performed., Results: The overall survival (OS) rates and N-stage were not different significantly between viscerally obese and non-obese group (p = 0.994, p = 0.325). The number of metastatic LNs were weakly inversely correlated with VFA (r = -0.144, p = 0.024). Univariate analysis revealed no significant association between visceral obesity and OS or LN metastasis (p = 0.377, p = 0.736). In multivariate analyses, OS was significantly associated with poorly differentiation (HR = 1.72, 95% CI =1.04-2.84, p = 0.035), higher pathologic T and N stage (T4 vs T1 + T2 HR = 2.67, 95% CI =1.18-6.04, p = 0.019; T3 vs T1 + T2 HR = 1.98, 95% CI = 0.90-4.33, p = 0.089; N3b vs N0 HR = 2.97, 95% CI1.45-6.0, p = 0.003; N3 (3a+ 3b) vs N0 HR = 2.24 95% CI =1.15-4.36, p = 0.018)., Conclusion: Visceral obesity may not be a prognostic factor in resectable gastric adenocarcinoma patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: This study aims to develop measurement tools for assessing patients' functional status with rheumatoid arthritis (RA) in terms of upper and lower extremity function and to evaluate the tools' construct validities with classical and modern psychometric approaches., Patients and Methods: Between April 2010 and April 2012, a total of 300 patients with RA (77 males, 223 females; mean age: 52.3±11.5 years; range, 18 to 82 years) who answered items from a range of widely used instruments were included. After examining initial dimensionality with exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and Rasch analysis were used to evaluate the tools' construct validities. The data-model fit was evaluated with goodness-of-fit (GoF) statistics in CFA, while the tools were examined in terms of item and person fit, unidimensionality and differential item functioning (DIF) from the perspective of Rasch analysis., Results: According to EFA, two dimensions were identified and named as "self-care-mobility-household activities related to lower extremity" and "self-care-mobility-household activities related to upper extremity" taking into account the factor loadings and the clinical classifications. While the clinical classification was tested with CFA, all items were loaded on their pre-defined dimensions with the factor loadings of ≥0.40 and GoF statistics were within the acceptable ranges. When the "self-care-mobility-household activities related to upper extremity" and "self-care-mobility-household activities related to lower extremity" tools were evaluated via the Rasch analysis, both tools were found to fit the Rasch model expectations, with a mean item fit statistics of -0.528 logit (standard deviation [SD]: 1.365) and -0.213 (SD: 1.168; mean person fit statistics of -0.412 logit (SD: 1.160) and -0.303 logit (SD: 0.859), respectively., Conclusion: For the evaluation of a scale's construct validity, it is recommended to use the Rasch analysis in tandem with factor analytic methods, as the Rasch analysis explores a scale's construct validity in terms of item and person fit, DIF and unidimensionality which is the only aspect of the factor analysis., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2021, Turkish Society of Physical Medicine and Rehabilitation.)

Purpose: To evaluate the agreement between observers using Greulich-Pyle (GP) and Gilsanz-Ratib (GR) methods, between four specialities (radiology, pediatrics, pediatric endocrinology and pediatric radiology) and between observers and automated tool in the bone age estimation., Materials and Methods: A total of 99 observers participated in this questionnaire-based study. BoneXpert was used for the automated tool. Experienced, senior, and junior observers were defined by their experience, and the bone age determined by experienced observers was regarded as the ground truth. Agreement between observers was evaluated using the coefficient of variance (CV) and intraclass correlation coefficient (ICC), and they were reevaluated after adding BoneXpert to the observers. Agreement of BoneXpert, the senior, and the junior observers was also evaluated using the root-mean-square-error (RMSE) values and Blant Altman method by comparing with the ground truth., Results: The CV ranged from 4.98% to 22.08%. The ICC were 0.980 for GP, 0.980 for GP and BoneXpert, 0.973 for GR, and 0.976 for GR and BoneXpert, and the ICC between four specialities ranged form 0.963 to 0.990. BoneXpert tool had the lowest RMSE values (0.504 years for GP atlas)., Conclusion: Automated bone age estimation showed comparable results with GP and GR methods and its utilization may decrease inter-observer variability.

Background and Goals: The aims of the present study were to investigate the natural history of cirrhosis and to determine trends in the etiology of cirrhosis., Methods: Between January 2001 and January 2018, a total of 1,341 patients had been diagnosed with cirrhosis and were included., Results: A total of 898 cirrhotic patients, who were followed up for at least 6 months were included into the analysis. The median age was 54 years. The median Child-Pugh and MELD scores were 7.5 and 11, respectively. Ascites (51%) was the most common causes of decompensation. Chronic viral hepatitis was the most frequent cause of cirrhosis (58%). Hepatitis B virus (HBV) infection was the main etiology (34%), followed by hepatitis C virus (HCV) infection (18%). Among 129 patients with cryptogenic cirrhosis (CC), 60 had metabolic abnormalities. If these 60 patients with CC were considered to have nonalcoholic fatty liver disease (NAFLD)-related cirrhosis, the proportion of NAFLD-related cirrhosis increased from 1.8 to 8.0%. At admission, 74 patients (8%) had been diagnosed with hepatocellular carcinoma (HCC). A new HCC developed in 80 patients during the follow-up period. The probability of developing HCC was 3.9% at 12 months. Logistic regression analysis showed that the development of HCC was significantly associated with older age (p < 0.001), male gender (p < 0.001), viral etiology (p = 0.026), and baseline high aspartate aminotransferase level (p = 0.01). Overall, 104 cirrhotic patients died., Conclusion: HBV and HCV remain the leading causes of etiology in cirrhosis and HCC. However, NAFLD-related cirrhosis is recognized as a growing burden., (© 2020 S. Karger AG, Basel.)

Objectives: To develop a common reference metric of functioning, incorporating generic and health condition-specific disability instruments, and to test whether this reference metric is invariant across 2 health conditions., Design: Psychometric study using secondary data analysis. Firstly, the International Classification of Functioning, Disability and Health (ICF) Linking Rules were used to examine the concept equivalence between the World Health Organization Disability Assessment Schedule (WHODAS 2.0), Health Assessment Questionnaire (HAQ) and Functional Independence Measure (FIMTM). Secondly, a scale-bank was developed using a reference metric approach to test-equating, based on the Rasch measurement model., Participants: Secondary analysis was performed on data from 487 people; 61.4% with rheumatoid arthritis and 38.6% with stroke., Results: Three sub-domains of the WHODAS 2.0 and all items of the HAQ and FIMTM motor mapped on to the ICF chapters d4 Mobility, d5 Self-care and d6 Domestic life. Test-equating of these scales resulted in good model fit, indicating that a scale bank and associated reference metric across these 3 instruments could be created., Conclusion: This study provides a transformation table to enable direct comparisons among instruments measuring physical functioning commonly used in rheumatoid arthritis (HAQ) and stroke (FIMTM motor scale), as well as in people with disability in general (WHODAS 2.0).

Background and Aim: The present study aims to investigate the role of genetic variability of the PNPLA3 gene (adiponectin) in predisposition to non-alcoholic fatty liver disease (NAFLD) by comparing NAFLD patients to healthy controls and to investigate any impact of the PNPLA3 genetic variability on the natural course of the disease., Materials and Methods: This cohort consisted of 174 patients with biopsy-proven NAFLD and 151 healthy controls. DNA was extracted from peripheral blood and the rs738409 C>G single nucleotide polymorphism was assessed using PCR-DNA sequencing., Results: The frequency distribution of the GG genotype was significantly higher in NAFLD patients than in controls (p=0.01). In patients with NAFLD, the GG genotype was associated with lower platelet counts (p=0.001), the presence of steatohepatitis (p=0.04) and hepatic fibrosis (p=0.016). After adjustment for age, gender, obesity, and diabetes mellitus, the GG genotype was an independent predictor of significant hepatic fibrosis (adjusted odds ratio =3.031 p=0.012). From the baseline to sequential liver biopsies, the progression of NAS in NAFLD patients was slightly higher in the GG genotype than that of CC and GG genotypes (p=0.18)., Conclusion: The PNPLA3 GG genotype is a predisposing factor for the development of hepatic steatosis in NAFLD patients and related to a more severe liver disease., Competing Interests: The authors have no conflict of interest to declare., (© Copyright 2020 by Hepatology Forum.)

OBJECTIVE. Many T1 mapping sequences and measurement methods have been reported in the literature. To obtain accurate results, the most appropriate T1 and T2 mapping sequences and postprocessing methods should be used. The aim of the present study is to compare the T1 and T2 mapping sequences and measurement methods used to diagnose acute myocarditis. MATERIALS AND METHODS. Fourteen patients with an interval of 7 days or less between symptom onset and MRI examination were included in the study. The control group consisted of 22 healthy individuals. T1 mapping images acquired using four different methods (modified Look-Locker inversion recovery [MOLLI] 3[3]3[3]5, MOLLI 3[2]3[2]5, MOLLI 5[3]3 heart rate-corrected, and MOLLI 5[3]3 heart rate-uncorrected sequences) and T2 mapping images obtained using two different methods (FLASH and true fast imaging with steady-state precession) in the area from the short axis through the basal slice were retrospectively evaluated. RESULTS. The mean T1 and T2 values were significantly higher in the patient group than in the control group for all sequences in SAX measurements and segmental measurements (segments 1, 4, 5, and 6). Measurements from segments 2 and 3 were not statistically significant between patient and control groups. The segment with the highest AUC value of T1 and T2 mapping values was the inferior segment, followed by the inferolateral segment. The highest diagnostic performance for short-axis measurements was obtained using the MOLLI 3(2)3(2)5 sequence (AUC value = 0.902). CONCLUSION. According to the results of this study and many other studies, pathologic changes in the myocardium can be detected by native T1 and T2 mapping. The accuracy of mapping methods will increase with increased knowledge of the advantages and disadvantages of currently used sequences and measurement methods.

Purpose: We aimed to assess the diagnostic performance of transluminal attenuation difference (TAD) in predicting the severity of internal carotid artery (ICA) stenosis., Methods: The study cohort consisted of 48 patients with <50% stenosis, 50%-69% stenosis, 70%-99% stenosis, and 51 controls without plaque development in ICA. A total of 143 measurements were performed through right and left internal and common carotid arteries. The TAD ratio was calculated as the difference between the mean attenuation values of the common carotid artery (CCA) and ICA, divided by the MAV of the CCA, multiplied by 100., Results: TAD ratio was significantly higher in severe (>70%) stenosis compared with control arteries and low-moderate stenosis. A TAD ratio cutoff of 4.5 predicted 70%-99% stenosis with a sensitivity of 100% and specificity of 93%. The inter- and intraobserver agreements in TAD measurements were almost perfect (ICC, 0.89-0.86)., Conclusion: Assessment of TAD ratio predicts the degree of stenosis in concordance with NASCET system.

Objective: To assess the usefulness of a single-phase contrast-enhanced CT to differentiate subtypes of neuroendocrine tumour (NET) liver metastases and to evaluate the correlation between CT features and Ga-68 DOTATATE positron emission tomography/CT (PET/CT) findings., Methods: Between December 2017 and April 2019 patients with liver metastases of neuroendocrine tumours who underwent CT and Ga-68 DOTATATE PET/CT were enrolled in the study. All patients involved in the study had undergone a standardised single-phase contrast-enhanced CT. Whole body PET/CT images were obtained with a combined PET/CT scanner. All CT images were retrospectively analysed by two radiologists. Enhancement patterns of lesions were assessed. For quantitative examination; CT attenuation values of metastatic lesions, liver parenchyma and aorta were measured using a freehand ROI and tumour-to-liver ratio [T-L = (Tumour-Liver) / Liver] and tumour-to-aorta ratio [T-A = (Tumour-Aorta) / Aorta] were calculated. The lesion with the highest Ga-68 DOTATATE uptake in the liver was used for calculations. The metabolic tumour volume (MTV), maximum standardised uptake value (SUV max ) and SUV mean were calculated for the target liver lesion., Results: A total of 137 NET liver metastases divided into in three groups: 49 (35.7%) pancreatic, 60 (44.5%) gastroenteric and 26 (18.9%) lung NET liver metastases were analysed. Gastroenteric NET metastases often showed heterogeneous enhancement which was significantly higher than in the pancreas and lung NET liver metastases ( p < 0.001). 96.72% ( n = 59) of the gastroenteric NET liver metastases were hypoattenuating whereas the most frequent presentation for the pancreatic group was hyperattenuation (63.26%, n = 31). The difference in enhancement patterns of the liver metastases was statistically significant ( p < 0.001) with respect to the location of the primary tumour. For quantitative analysis; tumour CT values were significantly different between the groups ( p < 0.001). The T-L ratio was statistically different between gastroenteric and pancreatic NET liver metastases and pancreatic and lung NET groups ( p < 0.001). The T-A ratio was significantly higher in the pancreatic NET metastases ( p < 0.001). SUV max , SUV mean and MTV values, however, were not significantly different between the subgroups. There was a weak positive correlation between T-L ratio and SUV mean values., Conclusion: We noticed statistically significant differences in both qualitative and quantitative CT features between histologic subgroups of neuroendocrine tumour liver metastases at a single phase contrast-enhanced CT., Advances in Knowledge: Our study will be the first in the literature which extensively focus on assessing the CT features of liver metastases of NETs at a single phase CT and Ga-68DOTATATE PET/CT. As the different histological subtypes of NET liver metastases exhibit different clinical outcomes, these features might help to identify the primary tumour to provide optimal treatment.

Introduction: The aim of the study was to assess the clinical features and outcome parameters of children with vesicoureteral reflux (VUR) based on gender and VUR grade., Population and Methods: Patients with VUR who were seen during routine follow-up visits at Ankara University Children's Hospital between January 2014-January 2015 were included in this retrospective study. Patient demographics, clinical course, laboratory investigations, imaging were noted., Results: Two hundred and twenty patients were recruited. Mean age at the time of diagnosis was 3,17 ± 3,08 years. Boys were diagnosed at younger ages as compared to girls (2.00 ± 2,59 vs. 3,81 ± 3.15, p < 0.001). Urinary tract infection (UTI) was the most common presentation. The second presentation form was antenatal hydronephrosis (AHN) which was more common in males (25.6 %, p < 0.001). Twenty-two percent of the patients had grade 1-2, 51 % grade 3 and 27 % grade 4-5 reflux. Patients with grade 4-5 reflux had more abnormal ultrasound (US) and Tech 99m dimercaptosuccinic acid scintigraphy (DMSA) findings and surgery was performed more frequently in this group (p < 0.001). In males, grade 4-5 reflux (43.6 % vs. 18.3 %), abnormal US (77 % vs. 54 %) and DMSA (77 % vs. 59 %) findings were more frequent (p < 0.05). In girls higher rates of UTIs, lower urinary tract dysfunction (LUTD) and spontaneous reflux resolution were seen (p < 0.05)., Conclusions: Despite younger age at diagnosis, spontaneous resolution was found lower in boys and they had more frequent AHN, more severe reflux, and radiological abnormalities., Competing Interests: The authors report no conflicts of interest in this work., (Sociedad Argentina de Pediatría.)

Objectives: Endogenous hyperthyroidism accelerates bone turnover and shortens the normal bone remodeling cycle, which results in reduced bone density. It is estimated that suppressive levothyroxine (LT4) therapy also decreases bone density. The aim of this study was to define risk factors for osteoporosis development in patients under thyrotropin-stimulating hormone (TSH) suppressive treatment for differentiated thyroid cancer (DTC)., Methods: Patients with a diagnosis of low or intermediate risk group DTC according to the American Thyroid Association 2015 guidelines and who have been receiving LT4 suppression therapy and were physically fit to undergo femur and lumbar vertebra bone density study were included in the study. Patients lacking information on demographic data, medical history, preoperative thyroid hormone status, or routine follow-up data were excluded from the study. A study form consisting of patient information on possible risk factors for osteoporosis such as gender, age, menopausal status, smoking, family history of osteoporosis, preoperative thyroid hormone status, postoperative hypoparathyroidism history, mean serum TSH levels, and duration of TSH suppression was created and filled out for each participant. Bone mineral densitometries of the femur and lumbar vertebrae were measured along with serum vitamin D and parathyroid hormone levels., Results: During TSH suppression (mean 7.2±4.5 years, range: 1-26), osteoporosis was detected in 89 (9.6%) patients. The mean time to develop osteoporosis was significantly different in patients with or without a family history of osteoporosis (15.3±0.4 versus 20.3±0.6 years; p=0.002). Similarly, the mean time to develop osteoporosis for was found to be significantly shorter in postmenopausal patients than that for premenopausal women (18.6±0.7 versus 20.4±0.4 years; p<0.001). Male gender (p<0.001), a family history of osteoporosis (p=0.001) and menopausal state (p<0.001) were identified as independent predictive factors for developing osteoporosis., Conclusion: Postmenopausal women, men, and patients with a family history who receive TSH-suppression treatment have a tendency to develop osteoporosis.

Purpose: To assess and compare the multiphasic computed tomography (CT) features of neuroendocrine tumor (NET) liver metastases and to investigate the possibility to predict the histologic subtype of the primary tumor., Materials and Methods: Between January 2013 and December 2017 patients with biopsy proven NET with at least one liver metastasis who underwent multiphasic CT were enrolled in this study. All cases were acquired using a standardized multiphasic liver CT protocol, arterial, portal, and hepatic venous phases were obtained. Images were retrospectively analyzed in consensus by two abdominal radiologists blinded to clinical data and histologic subtype. The size, number, and location of lesions were noted. Enhancement patterns of each lesion on arterial, portal, and hepatic venous phases were assessed. For quantitative analysis, CT attenuation of tumors, liver parenchyma, and aorta were measured using a circular region of interest (ROI) on arterial, portal, and hepatic venous phases for reflecting the blood supply of the tumor. Tumor-to-aorta and tumor-to-liver ratio were calculated in all three phases. Differences between subtypes of NET liver metastases were studied using ROC analysis of clustered data., Results: A total of 255 neuroendocrine tumor liver metastases divided into 101 (39.6%) pancreatic, 60 (23.5%) gastroenteric and 94 (36.8%) lung NET liver metastases were analyzed. Contrast enhancement of lesions was homogeneous in 78% of patients (n = 199), which was significantly more frequent in patients with pancreatic group than in those with gastroenteric origin (n = 90, 89.1% vs. n = 28, 46.7%; p < 0.001). Gastroenteric NET metastases frequently showed heterogeneous enhancement, which was significantly higher than in the other two groups (50% vs. 3% and 2%). With respect to the location of the primary tumor, the difference in enhancement patterns of the liver lesions was statistically significant (p < 0.001). Pancreatic NET metastases were mostly hyperdense on arterial images and isodense on portal and hepatic venous phase images (79.2%, n = 80). Gastroenteric NET metastases were mostly hyperdense on arterial phase images and hypodense on portal and hepatic venous phase images (n = 28, 46.7%). The most frequent pattern for lung NET metastases was hypoattenuation on all three phase images (n = 44, 46.8%). ROC analysis of clustered data revealed statistically significant differences between pancreatic NET liver metastases, gastroenteric NET liver metastases, and lung NET liver metastases in terms of tumor-to-aorta (T-A) ratio and tumor-to-liver (T-L) ratio (p < 0.001)., Conclusion: We observed statistically significant differences in multiphasic CT features (enhancement pattern, T-A ratio, and T-L ratio) between histologic subtypes of NET liver metastases. As the difference in histological subtypes of NET liver metastases results in a different prognosis and different management strategy, these CT features might help to identify the primary tumor when it is not known to ensure accurate tumor staging and to provide optimal treatment.

Background: Familial Mediterranean fever (FMF) is the most common hereditary monogenic autoinflammatory disease caused by mutations in the MEFV gene. It is controversial whether E148Q alteration is an insignificant variant or a disease-causing mutation. The aim of this study was to evaluate the clinical features and disease severity of FMF patients carrying E148Q mutation., Methods: Files of FMF patients were retrospectively evaluated. Patients with at least one E148Q mutation were included to the study. The clinical characteristics and disease severity of the patients who were carrying only E148Q mutation were compared with the patients who were compound heterozygous for E148Q and homozygous for M694V mutation., Results: The study group comprised 33 patients who were homozygous or heterozygous for E148Q; 34 with compound heterozygous E148Q mutations and 86 patients who had homozygous M694V mutation. Patients who had only E148Q mutation were found to have the oldest mean age of disease onset and lowest mean disease severity score. Attack frequency and colchicine doses were lower in patients with only E148Q mutation as compared with the other two groups. The frequency of clinical findings such as fever, abdominal pain, arthralgia, and arthritis among the three groups was similar., Conclusion: Familial Mediterranean fever patients with only E148Q mutation are presenting with late-onset and milder disease course despite having similar clinical findings as compared with patients who had other mutations. Finally, we imply that E148Q is a mutation and colchicine treatment should be given., (© 2019 The Authors. Journal of Clinical Laboratory Analysis Published by Wiley Periodicals, Inc.)

Introduction: Patient-reported outcome measures (PROM) or self-completed questionnaires have been used to report outcomes in osteoarthritis (OA) for over 35 years. Choices will always need to be made about what should be measured and, if relevant, what would be the most appropriate PROM to use. The current study aims to describe the available PROMs used in OA and their performance quality, so that informed choices can be made about the most appropriate PROM for a particular task., Methods: The study included a systematic search for PROMs that have been in use over 17 years (period 2000-2016), and to catalogue their psychometric properties, and to present the evidence in a user-friendly fashion., Results: 78 PROMs were identified with psychometric evidence available. The domains of pain, self-care, mobility and work dominated, whereas domains such as cleaning and laundry and leisure, together with psychological and contextual factors, were poorly served. The most frequently used PROMs included the Western Ontario McMaster Osteoarthritis Index, the Short Form 36 and the Knee Disability and Osteoarthritis Outcome Score which, between them, appeared in more than 4000 papers. Most domains had at least one PROM with the highest level of psychometric evidence., Conclusion: A broad range of PROMs are available for measuring OA outcomes. Some have good psychometric evidence, others not so. Some important psychological areas such as self-efficacy were poorly served. The study provides a current baseline for what is available, and identifies the shortfall in key domains if the full biopsychosocial model is to be explored., Competing Interests: Competing interests: None declared.

Objectives: Familial Mediterranean fever (FMF) is characterized by recurrent, self-limited attacks of fever with serositis involving the peritoneum, pleura and joints. Fatigue is a common problem in many pediatric rheumatic diseases; however, has not been evaluated systematically in FMF patients. Accordingly, the aim of this study was to evaluate fatigue and its possible allied factors in patients with FMF., Methods: Patients with FMF, aged between 10 and 21 years, were assessed by completed validated fatigue questionnaire (Checklist Individual Strength-20). As a control group, patients with chronic rheumatic diseases and healthy children without any chronic disease were included., Results: The study group comprised 111 patients with FMF, 54 with other chronic rheumatic diseases and 79 healthy subjects. While the CIS-20 total score and subscale scores (including subjective experience of fatigue) were similar between patients with FMF and those with other chronic rheumatic diseases (p > .05); both groups had significantly higher scores when compared with healthy subjects (p < .05). FMF patients with musculoskeletal complaints had significantly higher scores of subjective experiences of fatigue when compared to those without those complaints., Conclusions: Fatigue is a common but unrecognized complaint in patients with FMF. Familial Mediterranean fever seems to be a chronic disease with inter attack ongoing complaints.

Background: This study aims to identify the prognostic factors for stage I lung adenocarcinoma and to evaluate the surgical management of subsolid nodules., Methods: The study included 133 patients (90 males, 43 females; mean age 64.9 years; range, 29 to 82 years) who had undergone operation in our clinic for stage I lung adenocarcinoma between January 2007 and December 2015. Clinical, radiological and pathological data were retrospectively evaluated and their effects on recurrence and survival were examined by Kaplan-Meier and Cox regression analyses., Results: Comparing the histopathological tumor types according to the pathological tumors size, we determined that the prevalence of invasive adenocarcinoma significantly increased with increasing tumor size (p<0.001). For all nodules, a tumor disappearance rate lower than 25% negatively influenced disease-free survival and a maximum standardized uptake value higher than 5.6 negatively influenced overall survival (p=0.027 for both). The grouping, which was performed considering the maximum standardized uptake value 5.6 as the cut-off value, was an independent prognostic factor for overall survival (hazard ratio: 5.973, 95% confidence interval: 1.186-30.073, p=0.03). Five-year overall survival rate was statistically significantly higher in patients who underwent wedge resection or segmentectomy for subsolid nodules compared to those who underwent lobectomy (100% vs. 79.3%, p=0.044)., Conclusion: Sublobar resections can be safely performed in subsolid nodules smaller than 2 cm in diameter with tumor disappearance rate ≥25% and maximum standardized uptake value ≤5.6., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2018, Turkish Society of Cardiovascular Surgery.)

Objectives: This study aims to report the assessment of the Turkish League Against Rheumatism (TLAR) expert panel on the compliance and adaptation of the European League Against Rheumatism (EULAR) 2016 recommendations for the management of rheumatoid arthritis (RA) in Turkey., Patients and Methods: The EULAR 2016 recommendations for the treatment of RA were voted by 27 specialists experienced in this field with regard to participation rate for each recommendation and significance of items. Afterwards, each recommendation was brought forward for discussion and any alteration gaining ≥70% approval was accepted. Also, Turkish version of each item was rearranged. Last version of the recommendations was then revoted to determine the level of agreement. Levels of agreement of the two voting rounds were compared with Wilcoxon signed-rank test. In case of significant difference, the item with higher level of agreement was accepted. In case of no difference, the changed item was selected., Results: Four overarching principles and 12 recommendations were assessed among which three overarching principles and one recommendation were changed. The changed overarching principles emphasized the importance of physical medicine and rehabilitation specialists as well as rheumatologists for the care of RA patients in Turkey. An alteration was made in the eighth recommendation on treatment of active RA patients with unfavorable prognostic indicators after failure of three conventional disease modifying anti-rheumatic drugs. Remaining principles were accepted as the same although some alterations were suggested but could not find adequate support to reach significance., Conclusion: Expert opinion of the TLAR for the treatment of RA was composed for practices in Turkish rheumatology and/or physical medicine and rehabilitation clinics., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Purpose: To assess the prevalence of ectopic thyroidal thymus tissue detected by sonography (US) in children and to analyze the US features., Methods: We retrospectively reviewed images of 216 children who had undergone a thyroid or neck US examination from February 2015 to June 2015. Lesions within or adjacent to the thyroid gland that showed echopatterns consistent with thymic tissue were diagnosed as ectopic thyroidal thymus tissue. Lesions were reviewed according to their side, location, level, size, shape, echo pattern, internal content, and vascularization., Results: A total of 216 children (119 girls, 97 boys) with a mean ± SD age of 8.6 ± 5.2 years were enrolled the study.Thirty children (13girls, 17 boys) (13.9%) had 35 lesions compatible with ectopic thyroidal thymus tissue.Nine children had intrathyroidal (4.2%) and 21 children had extrathyroidal (9.7%) ectopic thymus tissue.The mean ± SD ages of the children with and without ectopic thyroidal thymus tissue were 6.0 ± 3.6 years and 9.1 ± 5.2 years, respectively (P = .002). Twenty-five of the lesions were extrathyroidal and 10 were intrathyroidal. All extrathyroidal and most (8/9) intrathyroidal ectopic thymuses had fusiform shape with well demarcated contours. Ectopic thymuses were located either in the midportion (n = 23) or lower portion of the neck (n = 12). Both extrathyroidal and intrathyroidal ectopic thymuses showed typical hypoechoic (n = 22/25, n = 9/10, respectively) or hyperechoic (n = 3/25, n = 1/10, respectively) echo patterns with internal linear and punctate echoes., Conclusions: Ectopic thyroidal thymic tissue is common in children. Radiologists should be vigilant about the unique US features of ectopic thyroidal thymus, including a hypo- and hyper-echoic echo pattern with multiple linear and punctate echoes, a fusiform shape, well-demarcated contours, and middle or low-lying location to differentiate it from other neck or thyroid lesions., (© 2018 Wiley Periodicals, Inc.)

Owing to an error in typesetting, the name of the author Atilla Halil Elhan was rendered wrongly. The original publication has now been corrected in this respect.

Background: Thiol/disulphide homeostasis plays a critical role in numerous intracellular enzymatic pathways including antioxidant defense and detoxification. This study was designed to investigate the impact of thiol/disulfide homeostasis in adolescent patients with recently diagnosed primary hypertension (HT) using a novel and automated method., Methods: Native thiol/disulphide levels were measured by a novel spectrophotometric method (Cobasc 501, Roche Diagnostics, Mannheim, Germany) in 30 patients with primary HT together with 30 healthy controls., Results: The levels of native thiol, total thiol, and native thiol/total thiol ratios were significantly lower, while the disulphide level, disulphide/native thiol, and disulphide/total thiol ratios were significantly higher in patients with primary HT compared with the control group. There were significant positive correlations between 24-h mean systolic and diastolic blood pressure and disulphide levels, disulphide/native thiol, and disulphide/total thiol ratios. A multiple linear regression model showed that a disulphide/native thiol ratio above 5 and family history of HT are independent predictors of HT., Conclusions: Our study showed that dynamic thiol/disulphide homeostasis shifted towards disulphide formation in adolescent patients with primary HT. Understanding the role of thiol/disulfide homeostasis in primary HT might provide new therapeutic intervention strategies for patients.

Objectives: This study aims to evaluate whether items in the Turkish version of the Nottingham Health Profile (NHP) function differently according to age, sex, and duration of pain using the Mixed Rasch Model (MRM)., Patients and Methods: The NHP data of patients with low back pain from a previous study was analyzed. To analyze differential item functioning (DIF) within the items of the NHP, the MRM was used. Age, sex, and duration of pain were considered factors which could cause DIF. The most powerful factor to define latent classes derived from the MRM was estimated using the Rasch tree method., Results: The two-class mixture version of the nominal response model was identified as the best fitting model for the physical mobility, sleep, and social isolation sections. For the physical mobility dimension, some items showed DIF by age and for the social isolation dimension some items showed DIF by sex. For the sleep dimension, latent classes were unable to be explained by age, sex, and duration of pain. Items in other dimensions of the NHP were DIF-free and no items showed DIF according to age, sex, and duration of pain., Conclusion: The results of this study may shed light on explaining the different response behavior of patients on the items of the NHP. Age and sex were found to be variables affecting item responses of NHP. Contrary to expectations, duration of pain did not cause DIF for any item. From the perspective of DIF, it can be concluded that NHP scale is a robust scale in terms of validity., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Purpose: To determine the sonographic appearances of the endochondral ossification process of the thyroid cartilage in children., Methods: Thyroid cartilage sonography (US) of 420 children was performed with a high-resolution linear-array transducer. Right and left laminae of the thyroid cartilage, including the inferior horns, were examined. Ossification foci were evaluated for their presence, location, shape, size, echo pattern, and number., Results: Four hundred nineteen children, 239 girls and 180 boys, were enrolled in the study with a mean age of 109.8 ± 60.7 months. Ossification foci were found in 167 children (39.9%). First ossification focus detection age was 72 months in girls and 79 months in boys. On both laminae, the most frequent appearance of the ossification focus was hypoechoic (right: 94.8%, left: 93.5%). Prevalence and number of ossification foci increased with age in each sex. The shape of the ossification foci in both laminae was generally nonexpansile (right: 92.9%, left: 93.5%)., Conclusion: Endochondral ossification process of the thyroid cartilage begins in the first decade with extracellular matrix changes, which can be detected as hypoechoic foci by US. These foci can be expansile, and radiologists should be aware of this entity to avoid misdiagnosing them as abnormal masses., (© 2017 Wiley Periodicals, Inc.)

Çullas-İlarslan NE, Günay F, İleri DT, Elhan AH, Ertem M, Arsan S. Investigation of the frequency of iron insufficiency among infants in a population in which routine iron supplementation is implemented. Turk J Pediatr 2018; 60: 22-31. Iron deficiency anemia (IDA) represents the most common cause of anemia worldwide. Because of potential irreversible neurodevelopmental impairment, its prevention during infancy is essential. We aimed to investigate the frequency of iron insufficiency among infants in a population which routine iron supplementation is implemented; and to examine related risks. A total of 501 infants, aged 9-15 months, were screened with complete blood count and serum ferritin. Infants were divided into two groups. [Group 1 (iron insufficient), [Group 1a: Iron deficiency (ID), Group 1b: IDA (IDA)], Group 2 (Iron sufficient (IS)]. Anemia was recognized in 122 (24.3%) infants. Microcytosis was observed in 110 (90.2%) of anemic infants. Group 2 accounted for 49.5% (n=248) whereas 152 (30.3%) and 101 (20.2%) infants belonged to Groups 1a and 1b, respectively. Multiple logistic regression analysis showed that male gender (OR=1.53; 95%CI 1.07 and 2.17), receiving > 500 ml/day cow`s milk (OR=2.77; 95%CI 0.87 and 8.83) and incompliance to iron supplementation (OR=2.51; 95%CI 1.75 and 3.60) were distinctive characteristics of Group 1 while prevalence of iron insufficiency was higher in infants consuming less formula (OR=3.10; 95%CI 2.00 and 4.80). The most frequent reasons for incompliance were consideration of supplementation as unnecessary (n=69, 31.1%) and neglection (n= 59, 26.6%). Our study demonstrated a high frequency of iron insufficiency among infants in a setting utilizing national iron supplementation and `incompliance` to iron as the most evident risk factor for iron insufficiency. Effective counseling of families by health care providers concerning importance of compliance to iron prophylaxis is essential for prevention of iron insufficiency. We also suggest screening of infants for ID as well as IDA in settings with high frequency of iron insufficiency.

Aim: This study aimed to explore the potential of an inclusive and fully integrated measurement system for the Activities component of the International Classification of Functioning, Disability and Health (ICF), incorporating four classical scales, including the Health Assessment Questionnaire (HAQ), and a Computerized Adaptive Testing (CAT)., Methods: Three hundred patients with rheumatoid arthritis (RA) answered relevant questions from four questionnaires. Rasch analysis was performed to create an item bank using this item pool. A further 100 RA patients were recruited for a CAT application. Both real and simulated CATs were applied and the agreement between these CAT-based scores and 'paper-pencil' scores was evaluated with intraclass correlation coefficient (ICC). Anchoring strategies were used to obtain a direct translation from the item bank common metric to the HAQ score., Results: Mean age of 300 patients was 52.3 ± 11.7 years; disease duration was 11.3 ± 8.0 years; 74.7% were women. After testing for the assumptions of Rasch analysis, a 28-item Activities item bank was created. The agreement between CAT-based scores and paper-pencil scores were high (ICC = 0.993). Using those HAQ items in the item bank as anchoring items, another Rasch analysis was performed with HAQ-8 scores as separate items together with anchoring items. Finally a conversion table of the item bank common metric to the HAQ scores was created., Conclusion: A fully integrated and inclusive health assessment system, illustrating the Activities component of the ICF, was built to assess RA patients. Raw score to metric conversions and vice versa were available, giving access to the metric by a simple look-up table., (© 2015 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd.)

Background: Although tacrolimus is one of the essential drugs used for the prevention of rejection in kidney recipients, target trough levels are not well established. In this study, we aimed to investigate the association between average tacrolimus trough levels (TTLs) of the first month after transplantation and biopsy-proven acute rejection (BPAR) during the first 12 months after transplant., Methods: A total of 274 patients who underwent kidney-alone transplantation between 2002 and 2014 were enrolled in the study. Average TTLs of the first month were assessed by means of receiver operating characteristic (ROC) curve analysis to discriminate patients with and those without BPAR. Univariate and multivariate Cox proportional hazards models were used to determine the effect of average TTLs of the first month on BPAR., Results: According to ROC curve analysis, the highest area under the curve (AUC) was obtained from 8 ng/mL (AUC = 0.73 ± 0.11; 95% confidence interval [CI], 0.62-0.84). Forty-two (31.8%) of the 132 patients with average TTLs <8 ng/mL and 13 (9.1%) of 142 patients with ≥8 ng/mL had BPAR during the first 12 months after transplant (P < .001). In univariable analysis, average TTLs of the first month <8 ng/mL were associated with higher risk of BPAR (P < .001), and the significance remained in Cox multivariable analysis (hazard ratio, 2.79; 95% CI, 1.76-3.82; P = .001). No significant differences were observed in the glomerular filtration rate, cytomegalovirus, BK viremia, or BK nephropathy between groups at post-transplant month 12., Conclusions: Keeping the average TTLs of the first month after transplantation at ≥8 ng/mL not only prevents BPAR occurrence but also minimizes the toxic effects of the use of a single-trough level., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: We aimed to evaluate the diagnostic accuracy and safety of computed tomography (CT)-guided biopsy of pulmonary lesions with fine needle aspiration (FNA) using non-coaxial technique., Methods: We analyzed 442 patients who underwent CT-guided lung biopsy with FNA and non-coaxial technique to determine the diagnostic outcomes, complication rates, and independent risk factors for diagnostic failure and pneumothorax., Results: Diagnostic accuracy, sensitivity, and specificity were 97.6%, 97.3%, and 100%, respectively. Age and >35 mm lesion size were significant risk factors for diagnostic failure. The rates of pneumothorax and chest tube placement were 19% and 2.9%, respectively. Middle and lower lobe location, lesion to pleura distance >7.5 mm, and >45° needle trajectory angle were significant risk factors for pneumothorax., Conclusion: CT-guided FNA of pulmonary lesions with non-coaxial technique is a safe and reliable method with a relatively low pneumothorax rate and an acceptably high diagnostic accuracy.

Background: Hysterectomy might adversely affect pelvic floor functions and result in many different symptoms, such as urinary and anal incontinence, obstructed defecation, and constipation., Objective: The aim of this prospective study was to evaluate the influence of hysterectomy on pelvic floor disorders., Design: This was a prospective and longitudinal study., Settings: The study was conducted at the Ankara University Department of Surgery and the Dr Zekai Tahir Burak Women's Health Research and Education Hospital between September 2008 and March 2011., Patients: The study was performed on patients who underwent hysterectomy for benign pathologies., Main Outcome Measures: A questionnaire about urinary incontinence (International Continence Society scoring), anal incontinence, constipation, and obstructed defecation (Rome criteria and constipation severity score), along with an extensive obstetric history, was administered preoperatively and postoperatively annually for 4 years., Results: Patients (N = 327) who had completed each of the 4 annual postoperative follow-ups were included in this study. Compared with the preoperative observations, the occurrence of each symptom was significantly increased at each of the follow-up years (p < 0.001). Over the 4 postoperative years, the frequencies for constipation (n = 245) were 7.8%, 8.2%, 8.6%, and 5.3%; those for obstructed defecation (n = 269) were 4.5%, 5.2%, 4.1%, and 3.0%; those for anal incontinence (n = 252) were 4.8%, 6.3%, 6.0%, and 5.2%, and those for urinary incontinence (n = 99) were 12.1%, 12.1%, 11.1%, and 13.1%. In addition, patients who had no preoperative symptom (n = 70) from any of the selected symptoms showed a postoperative occurrence of at least 1 of these symptoms of 15.8%, 14.3%, 11.4%, and 8.6% for the postoperative years 1, 2, 3, and 4., Limitations: Although the study had several limitations, no comparison with a control population was the most important one., Conclusions: Hysterectomy for benign gynecologic pathologies had a significant negative impact on pelvic floor functions in patients who had no previous symptoms.

Objective: Mastalgia is often ignored by physicians although it is the most common breast-related complaint among women. The effectiveness of exercise therapy for mastalgia is unclear. The aim of this study is to investigate the effects of exercise on mastalgia., Methods: A randomized controlled trial was conducted with twenty women with complaints of mastalgia fulfilling the inclusion and exclusion criteria. Patients were randomly assigned to the control group and to the exercise group. Sports brassiere, refraining from caffeine- and methylxanthine-containing foods, and simple analgesics were recommended for two groups. In the exercise group, an exercise program was conducted three times a week for 6 weeks. Participants in both groups were evaluated for breast pain and using the Short-Form Health Survey (SF-36) questionnaire before and six weeks after study. Serum cytokine levels were also collected and analyzed., Results: No significant differences were detected with respect to age, body mass index, menopausal status, psychiatric condition, and existence of unexplained pain syndromes between the groups. Total breast pain scores were similar in both groups. The sensory component of breast pain questionnaire and visual analogue scale values significantly improved via exercise in only exercise group (p = 0.012 and p = 0.016). There was no significant difference between groups in serum levels of cytokines. SF-36 subscale scores for general health and social functioning significantly improved in the control group and scores for role physical, bodily pain, and social functioning improved in exercise group., Conclusions: Based on our preliminary findings, exercise treatment is beneficial for patients with mastalgia and it can be suggested by clinicians.

Background: Minimally invasive procedures may be an alternative to surgical excisions for pilonidal disease., Objective: The aim of the study was to compare phenol injection versus excision with open healing technique., Design: This is a prospective randomized study (ACTRN12612000868886)., Settings: This study was conducted at the Ankara University and Ufuk University Departments of Surgery., Patients: One hundred forty patients were randomly assigned to phenol injection (n = 70) or excision with open healing (n = 70)., Main Outcome Measures: The primary end point of the study was the time to complete wound healing. Secondary end points were visual analog scale pain score, painkiller intake, time to resume daily activities, recurrence rate, Short Form 36 Health Survey, and Nottingham Health Profile at 3 weeks after surgery., Results: Time to complete wound healing (16.2 ± 8.7 versus 40.1 ± 9.7 days) was significantly in favor of the phenol injection group (p < 0.001). The median operation time was 14.0 ± 3.8 minutes in the phenol group versus 49.0 ± 24.2 minutes in the excision with open healing group (p <  0.001). The time to resume daily activities (pain-free mobilization and defecation) was 0.8 ± 2.8 and 16.2 ± 12.6 hours after phenol injection and 9.3 ± 10.0 and 22.5 ± 15.1 hours after the excision with open healing treatment (p <  0.001, p = 0.008). Visual analog pain score at 48 hours and painkiller intake within 48 hours were significantly in favor of the phenol injection group. At the mean follow-up of 39.2 ± 9.0 months after surgery, no differences were seen in the recurrence rate between the treatment arms (13 recurrences in phenol vs 9 in excision with open healing; p = not significant). Short Form 36 and Nottingham Health Profile scores at 3 weeks after surgery were also in favor of phenol injection., Limitations: The present study was not double blinded, and a history of abscess drainage was significantly higher in the surgery group., Conclusions: Based on the results, we conclude that phenol injection is as effective as the excision with open healing technique.

Aims: In this study, the authors aimed to identify prognostic factors after selective internal radiation therapy (SIRT) for colorectal cancer (CRC) liver metastasis., Methods: Forty-nine (28 male, 21 female; mean age: 64.6 ± 10.8) patients who received SIRT for CRC liver metastasis were studied. Effects of number (<5 vs. ≥5), maximum dimension, and standardized uptake value (SUV) of liver metastases, liver tumor load (<25% vs. 26%-50% vs. 51%-75%), presence of extrahepatic disease, and metabolic early response on overall survival were analyzed., Results: Mean follow-up time was 44.1 ± 27.5 months. Overall survival time was calculated as 10.03 ± 1.61 (95% CI; 6.86-13.20) months. SUV (0.004) of liver metastases, early metabolic response (p = 0.015), and presence of extrahepatic metastasis (p = 0.001) were identified as significant factors influencing overall survival. The hazard ratio was 1:2.3 for the presence of extrahepatic metastasis and 1:2.7 for the absence of early metabolic response., Conclusion: These findings suggest that patients with CRC liver metastasis who have lower SUV at presentation and early metabolic response have better outcomes after SIRT.

Objective: Noonan syndrome (NS) is a multisystem disorder, and short stature is its most striking manifestation. Optimal growth hormone (GH) treatment for NS is still controversial. In this study, using a nationwide registration system, we aimed to evaluate the growth characteristics and the clinical features of NS patients in Turkey and their growth response to GH treatment., Methods: Children and adolescents with a diagnosis of NS were included inthe study. Laboratory assessment including standard GH stimulation test results were evaluated. Height increment of patients with or without GH treatment were analyzed after three years of therapy., Results: A total of 124 NS patients from different centers were entered in the web-based system. Short stature and typical face appearance were the most frequently encountered diagnostic features of our patients. Of the 84 patients who were followed long-term, 47 hadreceived recombinant human GH (rhGH). In this group of 47 patients, height standard deviation score (HSDS) increased from -3.62±1.14 to -2.85±0.96 after three years of therapy, indicating significant differences from the patients who did not receive GH treatment. PTPN11 gene was analyzed in 61 patients, and 64% of these patients were found to have a mutation. HSDS at admission was similar in patients with or without PTPN11 gene mutation., Conclusion: A diagnosis of NS should be kept in mind in all patients with short stature showing systemic clinical findings. GH therapy is effective for improvement of short stature especially in the first two years of treatment. Further studies are needed for optimisation of GH therapy and evaluation of final height data in NS patients.

Familial Mediterranean fever (FMF) is an autosomal recessive disease, characterised by recurrent, self-limited attacks of fever with serositis. Recently, it was shown that patients with early disease onset during childhood period had more severe disease. The aim of this study was to describe the demographic, clinical and genetic features of FMF patients who had late-onset disease during childhood period and to compare them to those with earlier onset patients. Files of patients who had been seen in our department between January 2013 and January 2014 were retrospectively evaluated. Patients were divided into two groups according to age of disease onset (group I, ≤8 years; group II, >8 years), and clinical findings were compared between the two groups. The study group comprised 317 FMF patients. There were 267 patients in group I and 50 patients in Group II. Median attack frequency was 24/year in group I and 12/year in group II (p < 0.05). Fever and M694V homozygosity were less frequently detected in group II (p = 0.003 and p = 0.022). Median delay in diagnosis was 24 months in group I and 12 months in group II (p = 0.002). Disease severity scores and final colchicine dosages were lower in group II (p < 0.001 and p = 0.003). Only a small number of FMF patients had disease onset at older ages in childhood period. It seems that FMF patients with late-onset disease have milder illness. However, more readily expression of their clinical findings in older ages yields earlier diagnosis in this group.

Background: Many imaging methods have been defined for quantification of hepatic steatosis in non-alcoholic fatty liver disease (NAFLD). However, studies comparing the efficiency of magnetic resonance imaging-proton density fat fraction (MRI-PDFF), magnetic resonance spectroscopy (MRS), and liver histology for quantification of liver fat content are limited., Purpose: To compare the efficiency of MRI-PDFF and MRS in the quantification of liver fat content in individuals with NAFLD., Material and Methods: A total of 19 NAFLD patients underwent MRI-PDFF, MRS, and liver biopsy for quantification of liver fat content. The MR examinations were performed on a 1.5 HDx MRI system. The MRI protocol included T1-independent volumetric multi-echo gradient-echo imaging with T2* correction and spectral fat modeling and MRS with STEAM technique., Results: A close correlation was observed between liver MRI-PDFF- and histology- determined steatosis (r = 0.743, P < 0.001) and between liver MRS- and histology-determined steatosis (r = 0.712, P < 0.001), with no superiority between them (ƶ = 0.19, P = 0.849). For quantification of hepatic steatosis, a high correlation was observed between the two MRI methods (r = 0.986, P < 0.001). MRI-PDFF and MRS accurately differentiated moderate/severe steatosis from mild/no hepatic steatosis (P = 0.007 and 0.013, respectively), with no superiority between them (AUCMRI-PDFF = 0.881 ± 0.0856 versus AUCMRS = 0.857 ± 0.0924, P = 0.461)., Conclusion: Both MRI-PDFF and MRS can be used for accurate quantification of hepatic steatosis., (© The Foundation Acta Radiologica 2015.)

Aim: To report patient and procedure-related factors affecting the angiographic and clinical outcome in patients treated with the Silk device., Material and Methods: All patients with intracranial aneurysms in whom treatment was attempted with the Silk flow diverter by our neurovascular team between October 2010 and November 2013 were included consecutively. The data was analyzed by an independent stroke neurologist not involved in the treatment of the patients., Results: A total of 96 patients (64 female) with ages range from 3 to 78 were included in this study. We found that 54 of the patients were asymptomatic and 42 of them symptomatic, while 21 had a prior history of subarachnoid hemorrhage (SAH). Mean aneurysm size was 10.2 mm (range 2 to 40 mm). 2 patients died due to consequences of SAH. 3 patients developed visual decline on the follow-up, 2 of these were procedure-related. Symptomatic thromboembolic events were noted in 7 cases. Patients with aneurysms smaller than 13 mm had significantly less complications and higher occlusion rates. The complication rate was significantly high in patients admitted with symptoms. Adjunctive coiling had no impact on outcome., Conclusion: Safety and efficacy of flow diversion in this series was closely related to aneurysm size and presenting symptoms. A size cut-off for safety and efficacy has not been reported before and will be useful not only for future studies but also for patient counseling in daily practice. The futility of adjunctive coiling in this series calls for reappraisal of the current recommendations for this specific device.

Background/aims: There are many controversies regarding the best approach for evaluating children after their first febrile urinary tract infection (UTI). The aim of this study was to define the clinical, laboratory, and radiological features of patients with their first febrile UTI and to investigate the factors that might predict the presence of vesicoureteral reflux (VUR) and renal scarring., Methods: The files of patients who were followed due to their first febrile UTI between 2008 and 2013 were retrospectively reviewed (n = 300). Patients were divided into groups based on their age, the resistance state of microorganisms, the presence of VUR, and scarring on Tc99m dimercaptosuccinic acid scintigraphy. The chi-square test and Mann-Whitney U test were used for analysis., Results: The median age at the first febrile UTI was 11 months and girls constituted 77% of the patient population. VUR and renal scarring were detected in 30.9 and 19.4% of the patients, respectively. C-reactive protein levels and the presence of renal scarring were significantly higher in patients with VUR (p < 0.05). Abnormal ultrasonography findings, VUR and recurrent UTIs were significantly higher in patients with renal scars (p < 0.001). In multivariate analysis, we did not detect any factor that might predict the presence of VUR and renal scarring., Conclusion: A majority of children had their first febrile UTI at a young age. Although we could not find any factor that might predict the VUR and scar risk in patients with their first febrile UTI, an abnormal renal scan at 6 months after infection was closely related with the presence of VUR and recurrent UTIs., (© 2016 S. Karger AG, Basel.)

Purpose: The purpose of the present study was to determine liver, pancreas, kidney, and vertebral fat deposition in NAFLD patients by proton density fat fraction (PDFF) using magnetic resonance imaging (MRI) and to evaluate the relationships among them., Methods: A total of 41 biopsy-proven NAFLD patients underwent MRI-PDFF with IDEAL-IQ. MRI protocol included T1-independent volumetric multi-echo gradient-echo imaging with T2* correction and spectral fat modeling. The MR examinations were performed on a 1.5 HDx MRI system. MRI-PDFF measurements were obtained from liver, pancreas, renal cortex and sinus, and vertebral body. Liver biopsy specimens were retrieved from the archives and evaluated by one pathologist according to NASH CRN., Results: The median age of the patients was 47 years. The median interval between liver biopsy and MRI examination was 16 days. Mean liver, pancreas, renal cortex, renal sinus, T12 and L1 vertebral body MRI-PDFFs were 18.7%, 5.7%, 1.7%, 51%, 43.2%, and 43.5%, respectively. No correlation between either liver MRI-PDFF or histological steatosis, and other organ MRI-PDFFs was observed. A good correlation between pancreas and vertebral body MRI-PDFFs, and pancreas and renal sinus MRI-PDFFs was observed. Diabetic patients had higher average pancreas MRI-PDFF compared to non-diabetics (12.2%, vs., 4.8%; P = 0.028)., Conclusions: Pancreas and vertebral body MRI-PDFF is well correlated in NAFLD patients and both of them are higher in diabetic patients which may explain increased bone fractures in diabetics. MRI-PDFF can be used to demonstrate fat fractions of different organs and tissues and to understand fat metabolism.

The aim of this study was to determine the long-term efficacy of entecavir (ETV) and tenofovir disoproxil fumarate (TDF) on the natural course of disease in chronic hepatitis B patients (CHB) with/without cirrhosis in clinical practice. A total of 355 treatment-naïve CHB patients were enrolled into the study. The primary outcome measure was viral suppression as defined by serum HBV DNA level <20 IU/mL. A secondary outcome measure was to determine the development of Hepatocellular carcinoma (HCC). Virological and biochemical responses were similar between the two treatment groups over time. The presence of cirrhosis and hepatitis B e antigen (HBeAg) positivity did not appear to impact viral suppression. The cumulative probability of HBeAg loss was 41% at 4 years of therapy. Hepatitis B surface antigen (HBsAg) loss occurred in four patients. Model for End-Stage Liver Disease score was significantly improved from baseline to week 48 and 96 under antiviral therapy (P = 0.013, P = 0.01). HCC was diagnosed in 17 patients (4.8%). The cumulative probability of the development of HCC was 3.3% at 1 year and 7.3% at 4 years of therapy. The development of HCC was independently associated with older age (P = 0.031) and the presence of cirrhosis (P = 0.004). Serum creatinine levels and creatinine clearance remained stable over time. ETV and TDF effectively maintained virological and biochemical responses in long-term follow-up of CHB patients with/without cirrhosis. HCC may still develop, although at a lower rate, and is more likely to develop in patients with cirrhosis, especially in older patients., (© 2014 John Wiley & Sons Ltd.)

Gastric Cancer is one of the most common malignancies worldwide and the second most common cause of cancer-related mortality. Previous studies revealed several genetic alterations specific to gastric cancer. In this study, we aimed to investigate the diagnostic and prognostic significance of the expression levels of the glypican 5 and glypican 6 genes ( GPC5 and GPC6 , respectively) in gastric cancer. For this purpose, GPC5 and GPC6 expression was quantitatively determined by quantitative polymerase chain reaction method in normal gastric mucosa and intestinal type gastric adenocarcinoma samples from 35 patients. The expression levels of GPC5 and GPC6 were compared between normal and tumor tissues. Additionally, the association of the expression levels in tumor tissues with several clinicopathological parameters was evaluated. Although GPC5 was not expressed in any of the samples, the expression of GPC6 , which was detected in both groups, was found to be significantly higher in tumor tissues compared to that in normal samples (P=0.039). However, there was no statistically significant association between GPC6 expression and any of the clinicopathological parameters investigated (P>0.05). Our findings suggested that an increase in GPC6 expression levels may be implicated in gastric cancer development, but not in cancer progression.

The Ankylosing Spondylitis Work Instability Scale (AS-WIS) is a recently developed 20-item measure to assess work instability in AS. This study aimed to adapt the AS-WIS to Turkish and to test its reliability and validity. After the translation process, 132 AS patients were assessed by the AS-WIS, Bath AS Disease Activity Index, Bath AS Functional Index and the AS Quality of Life Questionnaire. Reliability was tested by internal consistency, person separation index (PSI) and intra-class correlation coefficient (ICC); internal construct validity by Rasch analysis; external construct validity by associations with comparator scales and cross-cultural validity by comparison with the original UK data. Reliability of the Turkish AS-WIS was good with Cronbach's α and PSI of 0.88 and test-retest ICC of 0.91. Data showed good fit to Rasch model [mean item fit: -0.477 (SD 1.047), Chi-square interaction: 60.9 (df = 40, p = 0.018)]. There was no differential item functioning by age, gender, disease duration or work type. The scale was strictly unidimensional. 51 % of the patients were at moderate risk, and 9 % were at high risk of having to give up their work. External construct validity was confirmed by expected correlations with comparator scales, and a clear gradient of disease activity and functional status across increasing levels of risk. Cross-cultural validity showed some differences in item locations, but this cancelled out at the test level. Turkish version of the AS-WIS is reliable, valid and available for use in routine clinical setting to identify patients who are at risk of having to give up their current job.

Background: Febrile neutropenia (FN) is a life-threatening condition that requires urgent management in the emergency department (ED). Recent progress in the treatment of neutropenic fever has underscored the importance of risk stratification. In this study, we aimed to determine independent factors for prediction of poor outcomes in patients with FN., Material and Methods: We retrospectively evaluated 200 chemotherapy-induced febrile neutropenic patients who visited the ED. Upon arrival at the ED, clinical data, including sex, age, vital signs, underlying systemic diseases, laboratory test results, estimated GFR, blood cultures, CRP, radiologic examinations, and Multinational Association of Supportive Care in Cancer (MASCC) score of all febrile neutropenic patients were obtained. Outcomes were categorized as "poor" if serious complications during hospitalization, including death, occurred., Results: The platelet count <50 000 cells/mm3 (OR 3.90, 95% CI 1.62-9.43), pulmonary infiltration (OR 3.45, 95% CI 1.48-8.07), hypoproteinemia <6 g/dl (OR 3.30, 95% CI 1.27-8.56), respiratory rate >24/min (OR 8.75, 95% CI 2.18-35.13), and MASCC score <21 (OR 9.20, 95% CI 3.98-21.26) were determined as independent risk factors for the prediction of death. The platelet count <50 000 cells/mm3 (OR 3.93, 95% CI 1.42-10.92), serum CRP >50 mg/dl (OR 3.80, 95% CI 1.68-8.61), hypoproteinemia (OR 7.81, 95% CI 3.43-17.78), eGFR ≤90 ML/min/1.73 m2 (OR 3.06, 95% CI 1.13-8.26), and MASCC score <21 (OR 3.45, 95% CI 1.53-7.79) were determined as independent risk factors for the prediction of poor clinical outcomes of FN patients. Platelet count, protein level, respiratory rate, pulmonary infiltration, CRP, MASCC score, and eGFR were shown to have a significant association with outcome., Conclusions: The results of our study may help emergency medicine physicians to prevent serious complications with proper use of simple independent risk factors besides MASCC score.

Objectives: The aims of this study were to explore whether the demographic and clinical features of paediatric familial Mediterranean fever (FMF) patients with different colchicine response vary or not and to determine whether colchicine response can be predicted in FMF patients., Methods: Files of patients who have been on colchicine therapy for at least 6 months were retrospectively evaluated. Patients were divided into two groups: group I included patients with no attacks after colchicine and group II comprised patients with ongoing attacks. Thereafter group II was further divided into two groups according to the reduction rate of attack frequency: group IIA (>50%) and group IIB (≤50%)., Results: The study group comprised 221 FMF patients (116 females, 105 males). There were 131 patients in group I and 90 patients in group II (54 in group IIA and 36 in group IIB). Leg pain and M694V homozygosity were more frequent in group II (P < 0.05). Final colchicine doses, disease severity scores and number of patients with elevated acute phase reactant levels (attack-free period) were significantly higher and colchicine compliance was lower in group II when compared with group I (P < 0.05). Erysipelas-like erythema (ELE), leg pain and protracted arthritis/protracted febrile myalgia/vasculitis were more frequently detected in group IIB (P < 0.05)., Conclusion: Colchicine response is excellent in the majority of FMF patients, however, colchicine unresponsiveness cannot be predicted easily at onset. More rarely encountered clinical findings such as ELE, leg pain and protracted complaints and M694V homozygosity may be a clue for less colchicine response., (© The Author 2014. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: To determine the utility of sequential MRI-estimated proton density fat fraction (MRI-PDFF) for quantification of the longitudinal changes in liver fat content in individuals with nonalcoholic fatty liver disease (NAFLD)., Methods: A total of 18 consecutive individuals (M/F: 10/8, mean age: 47.7±9.8 years) diagnosed with NAFLD, who underwent sequential PDFF calculations for the quantification of hepatic steatosis at two different time points, were included in the study. All patients underwent T1-independent volumetric multi-echo gradient-echo imaging with T2* correction and spectral fat modeling., Results: A close correlation for quantification of hepatic steatosis between the initial MRI-PDFF and liver biopsy was observed (rs=0.758, p<0.001). The median interval between two sequential MRI-PDFF measurements was 184 days. From baseline to the end of the follow-up period, serum GGT level and homeostasis model assessment score were significantly improved (p=0.015, p=0.006, respectively), whereas BMI, serum AST, and ALT levels were slightly decreased. MRI-PDFFs were significantly improved (p=0.004). A good correlation between two sequential MRI-PDFF calculations was observed (rs=0.714, p=0.001). With linear regression analyses, only delta serum ALT levels had a significant effect on delta MRI-PDFF calculations (r2=38.6%, p=0.006). At least 5.9% improvement in MRI-PDFF is needed to achieve a normalized abnormal ALT level. The improvement of MRI-PDFF score was associated with the improvement of biochemical parameters in patients who had improvement in delta MRI-PDFF (p<0.05)., Conclusions: MRI-PDFF can be used for the quantification of the longitudinal changes of hepatic steatosis. The changes in serum ALT levels significantly reflected changes in MRI-PDFF in patients with NAFLD.