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Current thyroid cancer trends in the United States, Association between screening and the thyroid cancer epidemic in South Korea: evidence from a nationwide study, 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer, Thyroid ultrasound and the increase in diagnosis of low-risk thyroid cancer, Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology, Ultrasonography diagnosis and imaging-based management of thyroid nodules: revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations, European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults: the EU-TIRADS, Multiinstitutional analysis of thyroid nodule risk stratification using the American College of Radiology Thyroid Imaging Reporting and Data System, The Bethesda System for reporting thyroid cytopathology: a meta-analysis, The role of repeat fine needle aspiration in managing indeterminate thyroid nodules, The indeterminate thyroid fine-needle aspiration: experience from an academic center using terminology similar to that proposed in the 2007 National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. The test that really lets you see a nodule up close is a CT scan. PPV was poor (20%), NPV was no better than random selection, and accuracy was worse than random selection (65% vs 85%). official website and that any information you provide is encrypted Risk of Malignancy in Thyroid Nodules Using the American - PubMed You can then get a more thorough medical evaluation, including a biopsy, which is a small sample of tissue from the nodule to look at under the microscope. FNA, fine-needle aspiration; US, ultrasound; CEUS, contrast-enhanced, A 38-year-old woman with a nodule in the right-lobe of her thyroid gland., A 35-year-old woman with a nodule in the left-lobe of her thyroid gland., The ROC curves of C-TIRADS, CEUS, and CEUS-TIRADS of 228 nodules in the. Your health care provider will examine your neck to feel for changes in your thyroid, such as a lump (nodule) in the thyroid. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. The chance of finding cancer is 1 in 20, whereas the chance of testing resulting in an unnecessary operation is around 1 in 7. The ACR-TIRADS guidelines also provide easy-to-follow management recommendations that have understandably generated momentum. If the nodule got a score of 2 in the CEUS schedule, the CEUS-TIRADS category remained the same as before. Thyroid surgery, Microvascular reconstruction, Neck surgery, Reconstructive surgery, Facial reconstruction, Parathyroid. Friedrich-Rust M, Meyer G, Dauth N et-al. Until a well-designed validation study is completed, the performance of TIRADS in the real world is unknown. It would be unfair to add these clinical factors to only the TIRADS arm or only to the clinical comparator arm, and they would cancel out if added to both arms, hence they were omitted. 4b - Suspicious nodules (10-50% risk of malignancy) Score of 2. TIRADS can be welcomed as an objective way to classify thyroid nodules into groups of differing (but as yet unquantifiable) relative risk of thyroid cancer. TIRADS Management Guidelines in the Investigation of Thyroid Nodules Become a Gold Supporter and see no third-party ads. Unauthorized use of these marks is strictly prohibited. So just using ACR TIRADS as a rule-out test could be expected to leave 99% of undiagnosed cancers amongst the remaining 75% of the population, in whom the investigation and management remains unresolved. The specificity of TIRADS is high (89%) but, perhaps surprisingly, is similar to randomly selecting of 1 in 10 nodules for FNA (90%). ", the doctor would like to answer as follows: With the information you provided, you have a homophonic nucleus in the right lobe. Thyroid nodules could be classified into one of 10 ultrasound patterns, which had a corresponding TI-RADS category. A 35-year-old woman with a nodule in the left-lobe of her thyroid gland. Thyroid nodules - Symptoms and causes - Mayo Clinic The sensitivity, specificity, and accuracy of C-TIRADS were 93.1%, 55.3%, and 74.6% respectively. If the proportions of patients in the different TR groups in the ACR TIRADs data set is similar to the real-world population, then the prevalence of thyroid cancer in the TR3 and TR4 groups is lower than in the overall population of patients with thyroid nodules. Using TIRADS as a rule-out cancer test would be the finding that a nodule is TR1 or TR2 and hence has a low risk of cancer, compared with being TR3-5. Methods: Thyroid nodules (566) subclassified as ACR-TIRADS 3 or 4 were divided into three size categories according to American Thyroid Association guidelines. We first estimate the performance of ACR TIRADS guidelines recommended approach to the initial decision to perform FNA, by using TR1 or TR2 as a rule-out test, or using TR5 as a rule-in test because applying TIRADS at the extremes of pretest cancer risk (TR1 and TR2 for lowest risk, and TR5 for highest risk), is most likely to perform best. ectomy, Parotid gland surgery, Transoral laser microsurgery, Transoral robotic surgery, Oral surgery, Parotid gland tumor, Skin cancer, Tonsil cancer, Throat cancer, Salivary gland tumor, Salivary gland cancer, Thyroid nodule, Head and neck cancer, Laryngeal cancer, Tongue . Bastin S, Bolland MJ, Croxson MS. Role of Ultrasound in the Assessment of Nodular Thyroid Disease. doi: 10.1111/j.1754-9485.2009.02060.x In: Thyroid 26.1 (2016), pp. Risk Stratification of Thyroid Nodules Using the Thyroid Imaging Now you can go out and get yourself a thyroid nodule. The implication is that US has enabled increased detection of thyroid cancers that are less clinically important [11-13]. The site is secure. Given that a proportion of thyroid cancers are clinically inconsequential, the challenge is finding a test that can effectively rule-in or rule-out important thyroid cancer (ie, those cancers that will go on to cause morbidity or mortality). The Value of Chinese Thyroid Imaging Report and Data System Combined With Contrast-Enhanced Ultrasound Scoring in Differential Diagnosis of Benign and Malignant Thyroid Nodules. A minority of these nodules are cancers. Second, we then apply TIRADS across all 5 nodule categories to give an idea how TIRADS is likely to perform overall. Russ G, Royer B, Bigorgne C et-al. Sometimes a physician may refer you to a specialist (doctor) at a clinic that specializes in thyroid cancer. A negative result with a highly sensitive test is valuable for ruling out the disease. And because thyroid cancer is often diagnosed in a persons late 30s or 40s, most of us are often diagnosed after the symptoms have already begun. In addition, changes in nomenclature such as the recent classification change to noninvasive follicular thyroid neoplasm with papillary-like nuclear features would result in a lower rate of thyroid cancer if previous studies were reported using todays pathological criteria. That particular test is covered by insurance and is relatively cheap. Full data including 95% confidence intervals are given elsewhere [25]. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Among the 228 C-TIRADS 4 nodules, 69 were determined as C-TIRADS 4a, 114 were C-TIRADS 4b, and 45 were C-TIRADS 4c. Methodologically, the change in the ACR-TIRADS model should now undergo a new study using a new training data set (to avoid replicating any bias), before then undergoing a validation study. Second, the proportion of patients in the different ACR TIRADS (TR) categories may, or may not, reflect the real-world population (Table 1). This is likely an underestimate of the number of scans needed, given that not all nodules that are TR1 or TR2 will have purely TR1 or TR2 nodules on their scan. Malignancy Predictors, Bethesda and TI-RADS Scores Correlated With Therefore, taking results from this data set and assuming they would apply to the real-world population raises concerns. 24;8 (10): e77927. What does highly suspicious thyroid nodule mean? Those working in this field would gratefully welcome a diagnostic modality that can improve the current uncertainty. We then compare the diagnosis performance of C-TIRADS, CEUS, and CEUS-TIRADS by sensitivity, specificity, and accuracy. By CEUS-TIRADS diagnostic model combining CEUS with C-TIRADS, a total of 127 cases were determined as malignancy (111 were malignant and 16 were benign) and 101 were diagnosed as benign ones (5 were malignant and 96 were benign). A meta-analysis, This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (, Mitoguardin2 is Associated with Hyperandrogenism and Regulates Steroidogenesis in Human Ovarian Granulosa Cells, Factors Associated with Diabetes Distress among Patients with Poorly Controlled Type 2 Diabetes, Serum adiponectin and leptin is not related to skeletal muscle morphology and function in young women, Association Between Metabolic Syndrome Inflammatory Biomarkers and COVID-19 Severity, Long-term outcome of body composition, ectopic lipid and insulin resistance changes with surgical treatment of acromegaly, Volume 7, Issue 4, April 2023 (In Progress), The Journal of Clinical Endocrinology & Metabolism, https://www.uptodate.com/contents/diagnostic-approach-to-and-treatment-of-thyroid-nodules, https://doi.org/10.6084/m9.figshare.11640168.v, http://creativecommons.org/licenses/by-nc-nd/4.0/, Receive exclusive offers and updates from Oxford Academic, 1 in 10 nodules having FNA, assuming pretest probability of cancer of 5%, Negative test being TR1 or TR2; positive test meaning TR3, TR4, or TR5, Positive test meaning TR5; negative test meaning TR1-4, Positive test meaning TR5, TR4 above size cutoff and TR3 above size cutoff; negative test meaning TR1, TR2, TR3 Below Size Cutoff or TR4 below size cutoff, Positive Test Meaning TR5, TR4 Above Size Cutoff and TR3 Above Size Cutoff; negative test meaning TR1, TR2, TR3 below size threshold or TR4 below size cutoff. Performing FNA on TR5 nodules is a relatively effective way of finding thyroid cancers. With the question "Evaluate treatment results for thyroid disease Tirads 3, Tirads 4? To find 16 TR5 nodules requires 100 people to be scanned (assuming for illustrative purposes 1 nodule per scan). The test may cycle back between being used on training and validation data sets to allow for improvements and retesting. Learn how t. Therefore, 60% of patients are in the middle groups (TR3 and TR4), where the US features are less discriminatory. Its not something that happens every day, but every day. The system is sometimes referred to as TI-RADS Kwak 6. As it turns out, its also very accurate and detailed. Results: The financial cost depends on the health system involved, but as an example, in New Zealand where health care costs are modest by international standards in the developed world, compared with randomly selecting 1 in 10 nodules for FNA, using ACR TIRADS would result in approximately NZ$140,000 spent for every additional patient correctly reassured that he or she does not have thyroid cancer [25]. TI-RADS: Diagnostically valid, high reproducibility in ID'ing malignant Ultrasound (US) risk-stratification systems for investigation of thyroid nodules may not be as useful as anticipated. The authors proposed the following criteria, based on French Endocrine Society guidelines, for when to proceed with fine needle aspiration biopsy: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. If one decides to FNA every TR5 nodule, from the original ACR TIRADS data set, 34% were found to be cancerous, but note that this data set likely has double the prevalence of thyroid cancer compared with the real-world population. Bookshelf Cawood T, Mackay GR, Hunt PJ, OShea D, Skehan S, Ma Y. Russ G, Bigorgne C, Royer B, Rouxel A, Bienvenu-Perrard M. Yoon JH, Lee HS, Kim EK, Moon HJ, Kwak JY. Department of Endocrinology, Christchurch Hospital. Applying ACR-TIRADS across all nodule categories did not perform well, with sensitivity and specificity between 60% and 80% and overall accuracy worse than random selection (65% vs 85%). Objective: To determine whether the size of thyroid nodules in ACR-TIRADS ultrasound categories 3 and 4 is correlated with the Bethesda cytopathology classification. -, Lee JH, Shin SW. Overdiagnosis and Screening for Thyroid Cancer in Korea. Prospective evaluation of thyroid imaging reporting and data system on 4550 nodules with and without elastography. Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference. With the right blood tests, you can see if you have a thyroid nodule, and if so, you can treat it with radioactive iodine. Tom James Cawood, Georgia Rose Mackay, Penny Jane Hunt, Donal OShea, Stephen Skehan, Yi Ma, TIRADS Management Guidelines in the Investigation of Thyroid Nodules; Illustrating the Concerns, Costs, and Performance, Journal of the Endocrine Society, Volume 4, Issue 4, April 2020, bvaa031, https://doi.org/10.1210/jendso/bvaa031. Summary Test Performance of Random Selection of 1 in 10 Nodules for FNA, Compared with ACR-TIRADS. Authors 3. These cutoffs are somewhat arbitrary, with conflicting data as to what degree, if any, size is a discriminatory factor. Endocrinol. The US follow-up is mainly recommended for the smaller TR3 and TR4 nodules, and the prevalence of thyroid cancer in these groups in a real-world population with overall cancer risk of 5% is low, likely<3%. Perhaps the most relevant positive study is from Korea, which found in a TR4 group the cancer rate was no different between nodules measuring between 1-2 cm (22.3%) and those 2-3 cm (23.5%), but the rate did increase above 3 cm (40%) [24]. The flow chart of the study. Thyroid Nodule Characterization: How to Assess the Malignancy Risk. 5. A robust validation study is required before the performance and cost-benefit outcomes of any of the TIRADS systems can be known. The CEUS-TIRADS category was 4a. The diagnostic schedule of CEUS could get better diagnostic performance than US in the differentiation of thyroid nodules. EU-TIRADS 2 category comprises benign nodules with a risk of malignancy close to 0%, presented on sonography as pure/anechoic cysts ( Figure 1A) or entirely spongiform nodules ( Figure 1B ). TI-RADS - Thyroid Imaging Reporting and Data System The equation was as follows: z = -2.862 + 0.581X1- 0.481X2- 1.435X3+ 1.178X4+ 1.405X5+ 0.700X6+ 0.460X7+ 0.648X8- 1.715X9+ 0.463X10+ 1.964X11+ 1.739X12. Such a study should also measure any unintended harm, such as financial costs and unnecessary operations, and compare this to any current or gold standard practice against which it is proposed to add value. Thyroid nodules are a common finding, especially in iodine-deficient regions. If your doctor is not sure what to do with your nodule, lets say its just a very small, non-cancerous, nodule, you may need to go to an endocrinologist. Mao S, Zhao LP, Li XH, Sun YF, Su H, Zhang Y, Li KL, Fan DC, Zhang MY, Sun ZG, Wang SC. Approach to Bethesda system category III thyroid nodules - PubMed This is a specialist doctor who specializes in the treatment and diagnosis of thyroid cancer. published a simplified TI-RADS that was prospectively validated 5. The key next step for any of the TIRADS systems, and for any similar proposed test system including artificial intelligence [30-32], is to perform a well-designed prospective validation study to measure the test performance in the population upon which it is intended for use. Those wishing to continue down the investigative route could then have US, using TIRADS or ATA guidelines or other measures to offer some relative risk-stratification. Accessibility In a clinical setting, this would typically be an unselected sample of the test population, for example a consecutive series of all patients with a thyroid nodule presenting to a clinic, ideally across multiple centers. 8600 Rockville Pike In the case of thyroid nodules, there are further challenges. The gender bias (92% female) and cancer prevalence (10%) of the data set suggests it may not accurately reflect the intended test population. Frontiers | Differentiation of Thyroid Nodules (C-TIRADS 4) by The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. So, for 100 scans, if FNA is done on all TR5 nodules, this will find one-half of the cancers and so will miss one-half of the cancers. Thyroid nodules - Diagnosis and treatment - Mayo Clinic The authors suggested, as with BI-RADS, that biopsy candidates were those nodules categorized as TI-RADS category 4 or 5, meaning demonstrating at least one suspicious sonographic feature. Thyroid Cancer: Diagnosis, Treatment and Follow-Up | IntechOpen 19 (11): 1257-64. In 2013, Russ et al. MeSH Multivariate factors logistic analysis was performed and a CEUS diagnostic schedule was established. As noted previously, we intentionally chose the clinical comparator to be relatively poor and not a fair reflection of real-world practice, to make it clearer to what degree ACR TIRADS adds value. [Clinical Application of the 2021 Korean Thyroid Imaging Reporting and Federal government websites often end in .gov or .mil. This data set was a subset of data obtained for a previous study and there are no clear details of the inclusion and exclusion criteria, including criteria for FNA. National Library of Medicine Thyroid radiology practice has an important clinical role in the diagnosis and non-surgical treatment of patients with thyroid nodules, and should be performed according to standard practice guidelines for proper and effective clinical care. -, Zhou J, Yin L, Wei X, Zhang S, Song Y, Luo B, et al. Because the data set prevalence of thyroid cancer was 10%, compared with the generally accepted lower real-world prevalence of 5%, one can reasonably assume that the actual cancer rate in the ACR TIRADS categories in the real world would likely be one-half that quoted from the ACR TIRADS data set, which we illustrate in the following section. Im on a treatment plan with my oncologist, my doctor, and Im about to start my next round of treatments. The health benefit from this is debatable and the financial costs significant. Would you like email updates of new search results? It is important to validate this classification in different centres. Cheng H, Zhuo SS, Rong X, Qi TY, Sun HG, Xiao X, Zhang W, Cao HY, Zhu LH, Wang L. Int J Endocrinol. Treatment of patients with the left lobe of the thyroid gland, tirads 3 The Thyroid Imaging Reporting and Data System (TI-RADS) of the American College of Radiology (ACR) was designed in 2017 with the intent to decrease biopsies of benign nodules and improve overall . tirads 4 thyroid nodule treatment - Investigative Signal Clinical Application of C-TIRADS Category and Contrast-Enhanced Ultrasound in Differential Diagnosis of Solid Thyroid Nodules Measuring 1 cm. A normal finding in Finland. TR5 in the data set made up 16% of nodules, in which one-half of the thyroid cancers (183/343) were found. The area under the curve was 0.803. At best, only a minority of the 3% of cancers would show on follow-up imaging features suspicious for thyroid cancer that correctly predict malignancy. Because we have a lot of people who have been put in a position where they dont have the proper education to be able to learn what were going through, we have to take this time and go through it as normal. The risk of malignancy was derived from thyroid ultrasound (TUS) features. Well, there you have it. Thyroid nodules are common, affecting around one-half of the population and become increasingly common with advancing age [1, 2]. The process of validation of CEUS-TIRADS model. 283 (2): 560-569. Kwak JY, Han KH, Yoon JH et-al. ACR TI-RADS FAQ : RADS - Reporting and Data Systems Support 2009;94 (5): 1748-51. Ultrasonographic scoring systems such as the Thyroid Imaging Reporting and Data System (TIRADS) are helpful in differentiating between benign and malignant thyroid nodules by offering a risk stratification model. Diagnostic approach to and treatment of thyroid nodules We realize that such factors may increase an individuals pretest probability of cancer and clinical decision-making would change accordingly (eg, proceeding directly to FNA), but we here ascribe no additional diagnostic value to avoid overestimating the performance of the clinical comparator. doi: 10.1007/s12020-020-02441-y eCollection 2022. This allows patients with a TR1 or TR2 nodule to be reassured that they have a low risk of thyroid cancer, rather than a mixture of nodules (not just TR1 or TR2) not being able to be reassured. The category definitions were similar to BI-RADS, based on the risk of malignancy depending on the presence of suspicious ultrasound features: The following features were considered suspicious: The study included only nodules 1 cm in greatest dimension. See this image and copyright information in PMC. The TIRADS reporting algorithm is a significant advance with clearly defined objective sonographic features that are simple to apply in practice. Results: Among the 228 C-TIRADS 4 nodules, 69 were determined as C-TIRADS 4a, 114 were C-TIRADS 4b, and 45 were C-TIRADS 4c. doi: 10.1016/S0140-6736(14)62242-X Thyroid imaging reporting and data system (TI-RADS)refers to any of several risk stratification systems for thyroid lesions, usually based on ultrasound features, with a structure modelled off BI-RADS. J. Clin. Here at the University of Florida, we are currently recruiting endocrinologists to work with us to help people with thyroid nodules. Such data should be included in guidelines, particularly if clinicians wish to provide evidence-based guidance and to obtain truly informed consent for any action that may have negative consequences. A thyroid nodule is an unusual lump (growth) of cells on your thyroid gland. The sensitivity, specificity, and accuracy of CEUS were 78.7%, 87.5%, and 83.3% respectively. In ACR TI-RADS, points in five feature categories are summed to determine a risk level from TR1 to TR5 . Any additional test has to perform exceptionally well to surpass this clinicians 95% negative predictive performance, without generating false positive results and consequential harm. If one accepts that the pretest probability of a patient presenting with a thyroid nodule having an important thyroid cancer is 5%, then clinicians who tell every patient they see that they do not have important thyroid cancer will be correct 95% of the time. Thyroid nodules are solid or fluid-filled lumps that form within your thyroid, a small gland located at the base of your neck, just above your breastbone. Required fields are marked *. 4. Thyroid Tirads 4: Thyroid lesions with suspicious signs of malignancy. The common first step when you have a thyroid nodule is to go to your health care provider and get a referral. It is this proportion of patients that often go on to diagnostic hemithyroidectomies, from which approximately 20% are cancers [12, 17, 21], meaning the majority (80%) end up with ultimately unnecessary operations. Methods: The performance of any diagnostic test in this group has to be truly exceptional to outperform random selection and accurately rule in or rule out thyroid cancer in the TR3 or TR4 groups. Among thyroid nodules detected during life, the often quoted figure for malignancy prevalence is 5% [5-8], with UptoDate quoting 4% to 6.5% in nonsurgical series [9], and it is likely that only a proportion of these cancers will be clinically significant (ie, go on to cause ill-health). (2017) Radiology. The 2 examples provide a range of performance within which the real test performance is likely to be, with the second example likely to provide TIRADS with a more favorable test performance than in the real world. The other one-half of the cancers that are missed by only doing FNA of TR5 nodules will mainly be in the TR3 and TR4 groups (that make up 60% of the population), and these groups will have a 3% to 8% chance of cancer, depending upon whether the population prevalence of thyroid cancer in those being tested is 5% or 10%. Clipboard, Search History, and several other advanced features are temporarily unavailable. What percentage of TR4 nodules are cancerous? - TimesMojo The CEUS-TIRADS combining CEUS analysis with C-TIRADS could make up for the deficient sensibility of C-TIRADS, showing a better diagnostic performance than US and CEUS. They will want to know what to do with your nodule and what tests to take. The first time Tirads 3 after cytology is benign, but you do not say how many mm and after 3 months of re-examination, it was . Later arrival time, hypo-enhancement, heterogeneous enhancement, centripetal enhancement, and rapid washout were risk factors of malignancy in multivariate analysis. With the right blood tests, you can see if you have a thyroid nodule, and if so, you can treat it with radioactive iodine. For example, a previous meta-analysis of more than 25,000 FNAs showed 33% were in these groups [17]. Epub 2021 Oct 28. This equates to 2-3 cancers if one assumes a thyroid cancer prevalence of 5% in the real world. We assessed a hypothetical clinical comparator where 1 in 10 nodules are randomly selected for fine needle aspiration (FNA), assuming a pretest probability of clinically important thyroid cancer of 5%. The summary of test performance of random selection, ACR TIRADS as a rule-out test, ACR TIRADS as a rule-in test, and ACR TIRADS applied across all TIRADS categories are detailed in Table 2, and the full data, definitions, and calculations are given elsewhere [25]. This study has many limitations. Now, the first step in T3N treatment is usually a blood test. Other limitations include the various assumptions we have made and that we applied ACR TIRADS to the same data set upon which is was developed. I have some serious news about my thyroid nodules today. The true test performance can only be established once the optimized test has been applied to 1 or more validation data sets and compared with the existing gold standard test. A total of 228 thyroid nodules (C-TIRADS 4) were estimated by CEUS. J. Endocrinol. {"url":"/signup-modal-props.json?lang=us"}, Jha P, Weerakkody Y, Bell D, et al. If you do 100 (or more) US scans on patients with a thyroid nodule and apply the ACR TIRADS management guidelines for FNA, this results in costs and morbidity from the resultant FNAs and the indeterminate results that are then considered for diagnostic hemithyroidectomy. If a guideline indicates that FNA is recommended, it can be difficult to oppose this based on other factors. Given that ACR TIRADS test performance is at its worst in the TR3 and TR4 groups, then the cost-effectiveness of TIRADS will also be at its worst in these groups, in particular because of the false-positive TIRADS results. Lin JD, Chao TC, Huang BY, Chen ST, Chang HY, Hsueh C. Bongiovanni M, Crippa S, Baloch Z, et al.