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Background: Radiofrequency (RF) is a therapeutic modality for reducing the volume of large benign thyroid nodules. If thermal therapies are interpreted as an alternative strategy to surgery, critical issues in their use are represented by the extent of nodule reduction and by the durability of nodule reduction over a long period of time., Objective: To assess the ability of machine learning to discriminate nodules with volume reduction rate (VRR) < or ≥50% at 12 months following RF treatment., Methods: A machine learning model was trained with a dataset of 402 cytologically benign thyroid nodules subjected to RF at six Italian Institutions. The model was trained with the following variables: baseline nodule volume, echostructure, macrocalcalcifications, vascularity, and 12-month VRR., Results: After training, the model could distinguish between nodules having VRR <50% from those having VRR ≥50% in 85% of cases (accuracy: 0.85; 95% confidence interval [CI]: 0.80-0.90; sensitivity: 0.70; 95% CI: 0.62-0.75; specificity: 0.99; 95% CI: 0.98-1.0; positive predictive value: 0.95; 95% CI: 0.92-0.98; negative predictive value: 0.95; 95% CI: 0.92-0.98)., Conclusions: This study demonstrates that a machine learning model can reliably identify those nodules that will have VRR < or ≥50% at 12 months after one RF treatment session. Predicting which nodules will be poor or good responders represents valuable data that may help physicians and patients decide on the best treatment option between thermal ablation and surgery or in predicting if more than one session might be necessary to obtain a significant volume reduction., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2019 by European Thyroid Association Published by S. Karger AG, Basel.)

Background The purpose of this study was to confirm the generalisation of radiofrequency ablation (RFA) in the treatment of benign thyroid nodules (BTN) and to look for a correlation between final shrinkage and some ultrasound (US) findings in a large Italian population data set. Methods This prospective study included 337 patients with solid cold BTN from six Italian institutions. Nodule volume, US pattern, thyroid function, symptom/cosmetic scores and complications were evaluated before treatment and at 6 and 12 months. The primary outcome was to find a correlation between basal volume and US pattern of the nodules and final shrinkage. The secondary outcome was to confirm the efficacy and safety of RFA in a large data set. Results The median basal volume was 20.7 mL, and this significantly decreased after RFA at 6 months (7.3 mL (-63.5%), P < 0.001) and at 12 months (6 mL (-70%), P vs 6 months = 0.009). A significant correlation was found for US structure (a spongiform pattern showing a 76% reduction vs 67 and 66% of mix and solid patterns respectively, P < 0.01) as well as for vascularity (intense peripheral and intranodal patterns showing 71 vs 68 and 67% of weak peripheral and intranodal and peripheral patterns respectively, P < 0.03), but not for macrocalcifications. A slight inverse correlation was found between nodule basal volume and shrinkage (Spearman: -0.23). Mean symptoms/cosmetic scores were significantly reduced. No major complications were encountered. Conclusions This multicentre study validated the efficacy and safety of RFA for treating BTN and showed a clear correlation between final shrinkage and some common US findings.

Background: Interest has grown into the use of multidetector computed tomography (CT) and magnetic resonance imaging as an adjunct or alternative to the invasive autopsy. We sought to investigate these possibilities in postmortem CT scan using an innovative virtual autopsy approach., Methods: Twenty-five postmortem cases were scanned with the Philips Brilliance CT-64 and then underwent traditional autopsy. The images were interpreted by two blinded forensic pathologists assisted by a radiologist with the INFOPSY ® Digital Autopsy Software System which provides three-dimensional images in Digital Imaging and Communications in Medicine format. Diagnostic validity of virtual autopsy (accuracy rate, sensitivity, specificity, and predictive values) and concordance between the two forensic pathologists (kappa intraobserver coefficients) were determined., Results: The causes of death at traditional autopsies were hemorrhage due to traumatic injuries ( n = 8), respiratory failure (5), asphyxia due to drowning (4), asphyxia due to hanging or strangulation (2), heart failure (2), nontraumatic hemorrhage (1), and severe burns (1). In two cases, the cause of death could not be ascertained. In 15/23 (65%) cases, the cause of death diagnosed after virtual autopsy matched the diagnosis reported after traditional autopsy. In 8/23 cases (35%), traditional autopsy was necessary to establish the cause of death. Digital data provided relevant information for inferring both cause and manner of death in nine traumatic cases. The validity of virtual autopsy as a diagnostic tool was higher for traumatic deaths than other causes of death (accuracy 84%, sensitivity 82%, and specificity 86%). The concordance between the two forensic pathologists was almost perfect (>0.80)., Conclusions: Our experience supports the use of virtual autopsy in postmortem investigations as an alternative diagnostic practice and does suggest a potential role as a screening test among traumatic deaths., Competing Interests: There are no conflicts of interest.

In immunocompromised patients, Aspergillus infections are important causes of morbidity and mortality. We describe a patient with cryoglobulinemic vasculitis who developed disseminated invasive aspergillosis with thyrotoxicosis caused by Aspergillus fumigatus. The diagnosis was based upon radiological, microbiological and pathological findings. The patient was treated successfully with voriconazole and caspofungin treatment followed by total thyroidectomy. We provide an overview of published reports on Aspergillus thyroiditis with an emphasis on therapeutic approaches.

Temporary tracheal balloons have been shown to improve lung growth in fetuses with severe congenital diaphragmatic hernia. Fetoscopic Endoluminal Tracheal Occlusion (FETO) is performed at 26-28 weeks gestation, and then is removed in utero at 34 weeks gestation at highly specialized centers. In case of preterm labor at a hospital without a specialized team, a number of techniques have been used to remove the balloon, sometimes with death of the newborn. We have successfully performed an ultrasound-guided approach to puncture and remove the tracheal balloon in a premature infant in an emergency setting at birth. After that she was treated for congenital diaphragmatic hernia at our Newborn Intensive Care Unit.

Accessory spleen torsion is very rare condition especially in children. The aim of this study is to report the conservative treatment option. In April 2009 we observed a 10-year-old child affected by hereditary spherocytosis who reported acute abdominal pain without fever or vomiting. At hospitalization all blood tests were within normal value. Abdominal ultrasounds showed an increase in spleen volume and a solid round-shaped hypoechogenic formation with hyperechogenic areas in the lower pole without vascolarisation on color-Doppler scan. These findings suggested torsion of the accessory spleen. We opted for a conservative approach: analgesics on demand and antibiotics. After a week symptoms resolved spontaneously and patient was discharged in good health conditions. Follow-up ultrasound scans were performed at one week, three-six months and one year after hospitalization and showed a progressive reduction of the dimensions of the solid round-shaped formation. Accessory spleen torsion needs to be added to the differential diagnosis of cases of acute abdomen in children. Ultrasounds with eco-color-Doppler scans seem to be the best option for the diagnosis of such condition in the pediatric age since other diagnostic methods are more invasive and require sedation of patients. Once accessory spleen torsion is correctly diagnosed it is possible to opt for its conservative treatment.

Purpose: This study evaluated the usefulness of multidetector computed tomography (MDCT) in the postmortem diagnosis of death by drowning in fresh water by measuring the difference of blood density within the cardiac chambers., Materials and Methods: Twenty-two corpses including six cases of fresh-water drowning (group A) and 16 deaths by other causes (group B), among which were also different forms of mechanical asphyxia other than drowning, underwent MDCT and conventional autopsy. Blood density within the right and left heart chambers, the aorta and the pulmonary trunk was measured and values compared between groups and within each group between heart chambers., Results: Blood density in all cardiac chambers was lower in group A than in group B. The difference was statistically significant within the left atrium and ventricle and was significantly lower in the left than in the right heart chambers in group A only., Conclusions: MDCT, together with conventional autopsy, may contribute to the diagnosis of drowning, by measuring blood density in the heart chambers.

Developmental cysts are very rare lesions occurring in the retrorectal space, and include epidermoid, dermoid, tailgut cysts and teratomas. There is little information on their natural history and biologic behavior, although a recent paper reported a greater incidence of malignant transformation than previously thought. The diagnosis requires high-resolution imaging, and complete surgical excision is the treatment of choice. In this paper we analyzed short- and long-term results of surgical excision of six retrorectal developmental cysts observed at our institution over a period of 11 years. All patients were women, three were referred with an infected perineal fistula/pelvic abscess after having undergone drainage surgery elsewhere. In these three patients, excision was attempted through a trans-perineal approach, which was technically demanding and ultimately incomplete because of the intense surrounding inflammation. Multiple re-interventions were required for tumor recurrence, and two of them still present an occasional perineal discharge. In the other three patients, a trans-perineal or trans-anal route was employed according to tumor location, without any recurrence at a median follow-up of 118.5 months. Final pathologic diagnosis included five tailgut cysts and one teratoma. This paper shows that the treatment of developmental cysts may be very challenging, especially when they are associated with a concomitant fistula/abscess and are not correctly diagnosed at presentation. In our experience, healing was finally achieved in four patients out of six. All the lesions were benign, and no malignant transformation was observed during follow-up, even in tumors partially resected.

Objectives: To assess the role and efficacy of aspiration alone in the treatment of hydroceles occurring after varicocelectomy. Hydroceles represent one of the most common complications related to varicocelectomy at any age., Methods: From September 1990 to 2008 at our department, a total of 453 varicocelectomies were performed. Inclusion and exclusion criteria were created. The patients with postoperative hydrocele formation were followed up every 3 months. Aspiration was suggested and then performed after 2 consecutive follow-up visits showing an enlarged hydrocele. In compliance with the protocol implemented at our institution, the clinicians performed >or=3 aspirations before suggesting surgical treatment., Results: A total of 256 patients were considered for the present study. All patients underwent laparoscopic varicocelectomy, and 31 (11%) developed postoperative hydrocele. Of the 31 patients, 9 (29%) underwent surgical hydrocelectomy after 3 aspirations, 7 (22.5%) had spontaneous resolution of the hydrocele, and 15 (48.5%) were treated with aspiration only. The success rate of aspiration seemed to be related only to the aspirated fluid volume, with <50 mL/aspiration guaranteeing spontaneous resolution in 60% of patients (P <.05)., Conclusions: The results of our study have shown that the management of postoperative hydrocele formation should be conservative for almost 18-24 months, with a minimum of 3 aspirations, if necessary. If confirmed by additional studies, the volume of fluid aspirated from hydroceles could be used as an early indicator of the need for surgery.

Aim: Clinical diagnosis of appendicitis in children is often difficult. The aim of this study was to evaluate the usefulness of ultrasound with graded compressed technique in cases with suspected appendicitis., Methods: A radiological classification of appendicitis was formulated associated with the surgical/histological degree. Afterwards, 92 patients with suspected appendicitis enrolled in this study were prospectively evaluated and managed to follow a new protocol based on the clinical and radiological experiences. In this study, the ultrasonography was considered positive when the diameter of the wall of the appendix was larger than 7 mm and vascularization was increased or absent., Results: Of these 92 patients, 54 patients underwent surgery while 38 were treated conservatively. Of the treated group, 12 patients had a perforated appendicitis, 3 had a gangrenous appendicitis, 36 patients demonstrated a phlegmonous appendix while 3 patients had a catarrhal appendix. Blood cell counts and CRP levels were significantly higher in patients with appendicitis (P<0.05) and WBC and CRP levels were higher for patients with perforated appendicitis compared with patients with simple appendicitis (P<0.05). A CRP value higher than 17 mg/dL was a strong predictor for the presence of infection. Three patients of the conservative group underwent surgery later for recurrent abdominal pain (within 2 weeks); two had a catarrhal appendix while one patient had a normal appendix (confirmed by histology), Conclusions: Patients with suspected appendicitis could be managed with ultrasound, suggesting an early approach. The selection of patients for surgery prevent complication and unnecessary surgery.

Background: Psoriasis is associated with a form of spondyloarthropathy in 10-30% of cases. A major feature of psoriatic arthritis is enthesitis. In some patients with psoriasis the presence of enthesitis could be underdiagnosed., Objective: To investigate the presence of lower limbs entheseal abnormalities in patients with chronic plaque psoriasis without signs and symptoms of psoriatic arthritis., Methods: Thirty patients with psoriasis and 30 controls underwent ultrasonographic evaluation of Achilles, quadriceps, patellar entheses and plantar aponeurosis. Ultrasonographic findings were scored according to the Glasgow Ultrasound Enthesitis Scoring System (GUESS)., Results: Mean GUESS score was significantly higher in patients with psoriasis as compared with controls: 7.9 (0.6) vs 2.9 (0.3); p<0.0001. In particular, the thickness of all tendons examined was significant higher in cases than in controls (p<0.0001), as well as the number of enthesophytes in all sites examined. In both cases and controls, the GUESS score was directly correlated with age (r = 0.22; p = 0.008), body mass index (r = 0.23, p = 0.0067) and waist circumference (r = 0.17; p = 0.02). In contrast, the GUESS score was not correlated with the duration and severity of psoriasis according to the Psoriasis Area and Severity Index (r = 0.03; p = 0.8) and body surface area involvement (r = 0.07; p = 0.6)., Conclusions: Entheseal abnormalities can be documented by ultrasonography in clinically asymptomatic patients with psoriasis. These findings could be related to a subclinical entheseal psoriatic inflammation. We suggest close follow-up of patients with psoriasis with entheseal abnormalities for early diagnosis of psoriatic arthritis.

Purpose: The aim of this study was to evaluate the sensitivity of ultrasonography, integrating standard ultrasound and arthrosonography after injecting a saline solution into the glenohumeral cavity in cases of suspected rotator cuff tears., Materials and Methods: We prospectively examined 40 patients awaiting shoulder arthroscopy for suspected or diagnosed tears of the rotator cuff. A radiologist, unaware of the pre-operative diagnosis, performed an ultrasound scan on all the patients before and after the injection of saline solution into the glenohumeral cavity. The parameters considered were presence or absence of a rotator cuff injury; type of injury according to Snyder and its extent along the longitudinal and transverse planes; presence or absence of effusion into the articular cavity; subacromial/subdeltoid bursal distension. All the patients underwent arthroscopy either the same day or the day after the ultrasound examination., Results: Standard sonography showed 26 complete rotator cuff tears (type C according to Snyder), 2 partial tears (type B according to Snyder) and 12 intact rotator cuffs. Arthrosonography detected 31 complete rotator cuff tears (type C according to Snyder), 1 partial tear (type B according to Snyder) and 8 intact rotator cuffs.Arthroscopy identified 32 complete rotator cuff tears (type C according to Snyder), 1 partial tear (type B according to Snyder) and 8 intact rotator cuffs. Analysis of the results shows that, taking arthroscopy as the gold standard, the sensitivity of normal sonography is 81.2%, whereas that of arthrosonography is 96.8% (p < 0.05)., Conclusions: On the basis of the data obtained in this study, standard sonography, integrated with the injection of a saline solution into the glenohumeral cavity, considerably increases the diagnostic sensitivity for rotator cuff tears. The authors suggest that arthrosonography can be used in the event of suspected rotator cuff tears, when MRI is contraindicated.

Background: Tuberous sclerosis is a protean, genetically determined disease that may involve any organ or tissue and lead to a great number of symptoms and clinical features., Objective: Diagnosis can be very difficult in cases with incomplete manifestations (formes fruste) lacking the classic signs of the disease., Materials and Methods: We report a case fulfilling the diagnostic criteria for tuberous sclerosis (shagreen patches, hypomelanotic macules, renal cysts and angiomyolipomas, and "migration tracts" in the cerebral white matter) in association with a giant intracranial aneurysm, but lacking mental retardation, epilepsy and facial angiofibroma., Results: Fourteen other cases of tuberous sclerosis and intracranial aneurysms, all but one without any clear sign of polycystic kidney disease, were found in the literature., Conclusion: We suggest that vascular dysplasias in general and aneurysms (mainly intracranial) in particular can be added to the other non-primary diagnostic features for the clinical diagnosis of tuberous sclerosis.

A notchlike bone defect in the basiocciput due to a prominent fossa navicularis was incidentally discovered in a patient referred for radiologic evaluation of sinusitis. MR images showed that the osseous defect was filled with lymphoid tissue of the pharyngeal tonsil. The occurrence of this anatomic variant is discussed, with reference to ancient anatomic works.

The purpose of this study was to show a gradient of possible bilateral activation for movements of the non-dominant vs. dominant hand, as well as for areas involved in complex vs. simple hand movements. A standard 1.5 T magnetic resonance imaging (MRI) system has been utilized to localize the cortical motor hand areas, using the blood oxygen level dependent contrast (BOLDc) technique and single-section fast low-angle shot (FLASH) imaging. Ten normal right-handed subjects volunteered for the study. The motor tasks consisted of simple (flexion-extension) finger movements of either hand, and complex movements (finger-to-thumb opposition in a repeating, pre-planned sequence) of the non-dominant hand. Simple movements caused contralateral activation of the primary motor area (MA); ipsilateral activation was observed for the non-dominant hand only. Supplementary motor area (SMA) was also activated, with a clear contralateral prevalence. The ratio of bilateral activation of MA did not change with complex movements of the non-dominant hand, while SMA as well as lateral premotor area were largely bilaterally activated in this task. In conclusion, the ipsilateral MA is activated for movements--even simple--performed with the non-dominant hand. There is widespread functional activity, involving both contralateral and ipsilateral SMA, for complex movements.