Turkish Journal of Medical Sciences最新文献

Background/aim: Foot and ankle trauma represents a common reason for emergency department visits. While the majority of cases involve soft tissue injuries, radiographic imaging is frequently overutilized due to concerns about missed fractures, leading to increased costs and emergency department crowding. The Shetty test, a recently introduced clinical decision rule, may serve as a simpler alternative to established tools such as the Ottawa ankle rules. This study aimed to assess the diagnostic accuracy of the Shetty test and its potential role as a supportive tool within existing triage systems for patients presenting with foot and ankle trauma.

Materials and methods: In this cross-sectional study, 229 adult patients with isolated foot or ankle trauma were evaluated in the emergency department. All participants underwent the Shetty test and standard radiographic imaging. The Shetty test was performed by trained emergency physicians prior to imaging; a positive result was defined as an inability to apply downward pressure due to pain. Diagnostic accuracy metrics-including sensitivity, specificity, positive predictive value, and negative predictive value-were calculated using radiographic findings as the reference standard.

Results: Fractures were identified in 25.3% of cases. The Shetty test demonstrated a sensitivity of 77.6%, specificity of 60.8%, positive predictive value of 40.2%, and a high negative predictive value of 88.9%. Among patients with confirmed fractures, 77.6% had a positive test result. The test performed best in ruling out displaced and incomplete fractures, and results showed significant correlation with both physical findings and imaging outcomes.

Conclusion: The Shetty test exhibited moderate sensitivity and specificity, alongside a high negative predictive value, supporting its use as a reliable rule-out tool for foot and ankle fractures. Its simplicity, ease of application, and diagnostic potential make it a promising triage adjunct to optimize emergency department resource use. Prospective multicenter validation is warranted before broad clinical adoption.

Background/aim: Childhood-onset arthritis may result from various rheumatic diseases. This study aimed to systematically evaluate their distribution and characteristics in a large pediatric cohort.

Materials and methods: We retrospectively analyzed all pediatric patients who presented with arthritis to the pediatric rheumatology clinic between January 2000 and January 2023.

Results: A total of 1713 pediatric patients who presented with arthritis were included in this study (median age at diagnosis: 6.8 years; F/M = 1.2). Most of the patients (n = 859, 50.1%) had juvenile idiopathic arthritis (JIA) (especially oligoarticular JIA). Patients with familial Mediterranean fever, comprising 277 individuals (16.2%) presented with arthritis. The majority of them (n = 203, 73.3%) had short-lasting recurrent oligoarthritis (mostly monoarthritis) attacks. While arthritis was observed in 236 (13.8%) patients with vasculitis, immunoglobulin A vasculitis was the most common cause among them (n = 166, 70.3%). Most of the vasculitis patients had oligoarthritis (n = 221, 93.6%). Reactive arthritis was present in 147 patients (8.6%, mostly monoarthritis). Acute rheumatic fever was another cause of arthritis (4.7%, mostly polyarticular and migratory). Among autoimmune diseases (mostly systemic lupus erythematosus), arthritis was detected in 82 patients (4.8%, oligoarthritis or polyarthritis).

Conclusion: In our study, we focused on the rheumatic etiologies underlying childhood arthritis. Given the heterogeneity of etiologies, clinical evaluation should be comprehensive, considering systemic features beyond joint involvement.

Background/aim: This study evaluated the accuracy rates and response consistency of four different large language models (ChatGPT-4o, Gemini 2.0, Claude 3.5, and DeepSeek R1) in answering questions from the Emergency Medicine Fellowship Examination (YDUS), which was administered for the first time in Türkiye.

Materials and methods: In this observational study, 60 multiple-choice questions from the Emergency Medicine YDUS administered on 15 December 2024, were classified as knowledge-based (n = 26), visual content (n = 2), and case-based (n = 32). Each question was presented three times to the four large language models. The models' accuracy rates were evaluated according to overall accuracy, strict accuracy, and ideal accuracy criteria. Response consistency was measured using Fleiss' Kappa test.

Results: The ChatGPT-4o model was the most successful in terms of overall accuracy (90.0%), while DeepSeek R1 showed the lowest performance (76.7%). Claude 3.5 (83.3%) and Gemini 2.0 (80.0%) demonstrated moderate success. When analyzed by category, ChatGPT-4o achieved the highest success with 92.3% accuracy in knowledge-based questions and 90.6% in case-based questions. In terms of response consistency, the Claude 3.5 model (Fleiss' Kappa = 0.68) showed the highest consistency, while Gemini 2.0 (Fleiss' Kappa = 0.49) showed the lowest. Inconsistent hallucinations were more frequent in the Gemini 2.0 and DeepSeek R1 models, whereas persistent hallucinations were less common in the ChatGPT-4o and Claude 3.5 models.

Conclusion: Large language models can achieve high accuracy rates for knowledge and clinical reasoning questions in emergency medicine but show differences in terms of response consistency and hallucination tendency. While these models have significant potential for use in medical education and as clinical decision support systems (CDSS), they need further development to provide reliable, up-to-date, and accurate information.

Background/aim: Osteosarcoma is the most common primary malignant bone tumor in adolescents, and the evaluation of joint invasion with MRI is important for treatment planning. This study aimed to investigate the diagnostic value of MRI findings (direct and indirect) for joint invasion in patients diagnosed with osteosarcoma of the knee region.

Materials and methods: The MRI evaluations of 50 knee osteosarcoma patients who underwent surgical resection between 2006 and 2018 were reviewed retrospectively by two radiologists and an orthopedic oncologist. The presence of intrasynovial tumor tissue, intra-articular destruction of cartilage or bone, and invasion of the capsular and cruciate ligament insertions were evaluated as direct findings in the diagnosis of joint invasion on MRI. Indirect findings included tumor size, adjacent epiphyseal bone signal changes- bone marrow infiltration and edema, synovial contrast enhancement, and joint effusion. These findings were scored separately on a 5-point Likert scale and statistically compared with histopathologic results.

Results: The mean age of the patients was 22 years and the gender distribution was 21 females and 29 males. The best predictors for joint invasion were direct visualization of capsular insertion invasion (p < 0.05) and destruction of intraarticular bone (p < 0.05). MRI findings with statistically significant sensitivity and specificity: intrasynovial tumor tissue specificity 76%, sensitivity 58%; intra-articular cartilage destruction specificity 84%, sensitivity 56%; intra-articular bone destruction sensitivity 84%, specificity 48%; capsular insertion invasion sensitivity 92%, specificity 48%. Synovial effusion and contrast enhancement were the most sensitive indirect signs but lacked specificity.

Conclusion: Joint invasion by osteosarcoma can reliably be assessed on preoperative MR images with high sensitivity and specificity. Particularly direct visualization of intrasynovial tumor tissue, capsular insertion invasion, and destruction of intraarticular bone and cartilage, a combination of highly specific direct signs was valuable, while indirect signs were less predictive and specific.

Background/aim: Reports on the use of Janus kinase (JAK) inhibitors in the treatment of localized scleroderma are increasing in the literature. In this review, we examined the published studies regarding the use of JAK inhibitors in patients with localized scleroderma.

Materials and methods: We searched MEDLINE and Scopus for articles on patients with localized scleroderma treated with JAK inhibitors. The search included articles from the inception of these databases through August 1^st, 2024.

Results: Our literature search showed 11 articles describing 17 patients with localized scleroderma treated with JAK inhibitors. Generalized morphea (47.1%) was the most common type of localized scleroderma in patients treated with JAK inhibitors. The most frequently used JAK inhibitor was tofacitinib (64.7%). In some cases, baricitinib (17.6%) and ruxolitinib (17.6%) were also preferred. All JAK inhibitors were mainly preferred for the treatment of resistant/progressive skin disease in these patients (60.7%). The improvement rate associated with JAK inhibitors was 88.2%. Relapse occurred in 33.3% of patients treated with JAK inhibitors. Side effects were reported in 18.2% of patients: one patient was diagnosed to have diffuse large B-cell lymphoma (n = 1) while on tofacitinib.

Conclusion: JAK inhibitors could be considered as a therapeutic option, especially in patients with refractory localized scleroderma, but more extensive clinical trials are needed to clarify questions regarding their efficacy and safety data.

Background/aim: To evaluate the effect of hydroxychloroquine (HCQ) on disease activity and damage in patients with systemic lupus erythematosus (SLE) in whom HCQ had previously been discontinued due to retinal toxicity, and to examine and reevaluate toxicity findings through a detailed ophthalmological examination.

Materials and methods: Patients with SLE who had been on HCQ for at least 3 years after achieving lupus low disease activity state (LLDAS) following remission induction, and were followed up for at least 3 years after HCQ discontinuation due to retinal toxicity diagnosed by visual field testing, were analysed. Disease activity, the number and severity of flares and damage were recorded whilst on HCQ and after cessation. All patients were examined by two ophthalmologists using multimodal imaging techniques to further analyse toxicity.

Results: Sixty-one patients (age at diagnosis 33.4 ± 10.5, 88.5% female) were included. The percentage of visits maintaining LLDAS was significantly higher during HCQ treatment (p = 0.001). A significant number of patients experienced flares after HCQ discontinuation, with the mild-moderate type predominating (p = 0.006 and p = 0.026). Mean damage scores were higher at the end of the study period (p = 0.001). In the ophthalmologic examination (mean duration after drug cessation: 70.3 ± 52.3 months), signs of HCQ toxicity were not detected in 40 patients (65.6%), and HCQ was reinitiated for these patients. Of 21 (34.4%) patients who had visual field defects in reexamination, only five (8.2%) had typical retinal toxicity by multimodal imaging. Sixteen (26.2%) patients had macular atrophy due to other causes.

Conclusion: Hydroxychloroquine is effective in controlling disease activity and preventing damage in SLE, and the opportunity for remedication is valuable. More than half of the patients who could restart HCQ after reexamination show the importance of performing multimodal imaging to diagnose retinal toxicity and to distinguish macular pathologies with different aetiological background.

Background/aim: This study evaluates the use of a 3D-printed anatomical urinary system model (3D-AUSM) and a Virtual Reality RIRS Simulator (VRRS), for training in RIRS, based on real user feedback.

Materials and methods: The 3D-AUSM was created using cadaver CT and MRI scans, and the data was transferred to a VR environment for simulation. A total of 43 inexperienced urology trainees participated in the theoretical phase of the RIRS training program. Of these, 32 trainees (Group T) who passed a proficiency exam proceeded to the hands-on training phase with the 3D-AUSM and VRRS models. Additionally, 17 experienced surgeons (Group S) were included in the study for validation purposes. Skill scores and procedure times were recorded for both groups, and participants completed surveys to evaluate content, face, and construct validation of the models.

Results: Group S completed the procedures faster and achieved higher skill scores than Group T in both models. Group T, however, performed better with VRRS compared to 3D-AUSM. The most challenging steps for both groups were "exposing the intrarenal collecting system" and "relocating the stone". Both groups rated the models highly for content and face validation, though experienced surgeons gave lower overall satisfaction scores to VRRS compared to 3D-AUSM.

Conclusion: 3D-printed models and VR simulators are safe, cost-effective tools for developing essential surgical skills. While 3D-AUSM provides realistic anatomical feedback, VRRS offers unlimited practice opportunities. Both models are valuable in surgical education, promoting standardized, effective training.

Background/aim: The accuracy of pressure measurements with ManoScan™ high-resolution manometry (HRM) catheters decreases due to the development of pressure drift (PD) resulting from variations between room and body temperature. The corrective algorithm called thermal compensation (TC), added to the manometry software program by the manufacturer is used to prevent the development of PD. To date, no studies have demonstrated that PD leads to changes in manometry metrics and/or clinical diagnosis. The present study aims to demonstrate the impact of the TC algorithm on HRM metrics and final diagnosis.

Materials and methods: Records of 124 consecutive esophageal HRM studies with ManoScan™ HRM catheters were retrospectively reviewed. Manometry metrics and final diagnoses were compared by applying formal TC as recommended by the manufacturer (fTC group), without TC (nonTC group), and by performing TC at the 1st s (TC1 group), 5th s (TC5 group), and 10th s (TC10 group), respectively.

Results: Significant differences were observed in values of integrated relaxation pressure (IRP) and distal contractile integral (DCI), and the percentage of weak and intact peristalsis between the fTC group versus the TC1 and TC5 groups. In 28 of 85 studies in which IRP was normal and in 25 of 39 studies in which IRP > 15 mmHg, contrary IRP values were detected when TC was not performed or performed at a different time point than recommended. In the comparison of diagnoses, fewer esophagogastric junction outflow obstruction (EGJ-OO) and more normal esophageal motility (NEM) were diagnosed in the fTC group than in the nonTC group.

Conclusion: The omission of the TC or its application at an incorrect time point on esophageal manometry studies using the ManoScan™ HRM system can lead to inaccurate IRP measurements and diagnostic errors between NEM and EGJ-OO diagnoses.

Background/aim: Perioperative FLOT is considered the gold standard treatment for locally advanced gastric cancer. However, in the adjuvant setting, chemotherapy intolerance has brought de-escalation strategies to the forefront as an important area of research. This study aimed to compare the efficacy of adjuvant FLOT and FOLFOX regimens in enhancing survival outcomes in patients with locally advanced gastric cancer who underwent surgical resection following neoadjuvant FLOT treatment.

Materials and methods: Patients with locally advanced gastric cancer (cT2-4, N0-3) who received four cycles of neoadjuvant FLOT and subsequently underwent surgery at Ankara Bilkent City Hospital between January 2018 and September 2024 were retrospectively evaluated. Disease-free survival (DFS) and overall survival (OS) outcomes were compared to patients receiving adjuvant FOLFOX or FLOT. Clinical variables such as disease stage and response to neoadjuvant therapy were also analyzed to determine their impact on DFS and OS.

Results: The analysis included 171 patients, with a median age of 59 years and a median follow-up duration of 16.1 months. At 16 months, the DFS and OS rates were 66% and 82%, respectively. Of the 171 patients, 105 received adjuvant FLOT, 37 received FOLFOX, and 29 received no adjuvant therapy. Statistical analysis revealed no significant differences in DFS (HR: 0.63, 95% CI: 0.30-1.33, p = 0.229) or OS (HR: 0.76, 95% CI: 0.24-2.37, p = 0.635) between the FLOT and FOLFOX groups. However, the advanced disease stage and lack of pathological response to neoadjuvant FLOT were associated with decreased DFS and OS, highlighting these factors as potential prognostic indicators.

Conclusion: Among patients undergoing surgery after neoadjuvant FLOT, adjuvant FOLFOX showed comparable efficacy to FLOT, suggesting its potential as an alternative option, particularly for patients with deteriorated ECOG PS or those who developed chemotherapy intolerance postoperatively. These findings inform treatment strategies and optimize adjuvant therapy selection based on individual patient profiles.

[This corrects the article DOI: 10.55730/1300-0144.5990.].