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Background Thyroid nodules (TN) are commonly present in the general population and are usually pathologically benign. An initial diagnosis with fine‐needle aspiration (FNA) cytopathology could help clinical decision‐making with fewer complications. As the previous studies suggest surgical procedures for >4 cm TNs, we aimed to investigate the accuracy of preoperative FNA cytology to predict malignancy risk in these nodules in a sample of the Iranian population. Methods Patients with ≥4 cm TNs who had preoperative FNA cytology, underwent nodulectomy and had a histopathological report were included. Each patient's preoperative demographic, ultrasonographic, and cytology data were gathered. After surgery, resected samples were assessed pathologically and diagnosed as benign or malignant. Finally, data were analyzed to evaluate the presurgical accuracy of the FNA cytology. Results We identified 41 (51.25%) patients with malignant legions among our study population (N = 80). The pathology reports were indeterminate in 3 patients with follicular neoplasm. Bethesda scores were substantially higher in patients with malignancy. The sensitivity, specificity, and false‐negative rate of FNA cytology reports using the Bethesda system were 73.7%, 74.2%, and 26.3%, respectively. There was no association between malignancy and TNs' size, neither their volume nor their highest diameter. Conclusion FNA cytology is not as sensitive and specific in nodules>4 cm as in smaller ones. However, it can still be used alongside other diagnostic procedures in malignancy screening. Clinicians should make more complex decisions considering various influential factors to avoid missing malignant lesions and reduce diverse probable complications of highly invasive diagnostic surgery. Further prospective research on >4 cm TNs and their multiple features' association with malignancy is required for more precise judgment.

Background and aim Altered level of consciousness(LOC) is a common complaint in patients admitted to the emergency department(ED). Altered LOC occurs with various causes. Emergent diagnosis and treatment of patients with altered LOC are vital to prevent irreversible brain damage. In this study, we aimed to acquire a better vision of non-traumatic altered LOC’s prevalent etiologies. The association between patients’ initial condition and survival was also assessed. Methods This prospective cohort study enrolled 1000 patients with altered LOC referred to two tertiary hospitals in 2020 and 2021. Patients with ALOC who had GCS < 14, and a final diagnosis, were included and followed for a month. We also collected all initial data gathered by ED triage and investigated the association of these entities with survival and their distribution among different final diagnoses. Results We studied 1000 patients. 52.4% of the population consisted of males. The mean age was 59.85 ± 16.06. Sepsis(38.3%) was the most common etiology, followed by: stroke(9.2%), heart failure(8%), myocardial infarction(7.3%), meningitis(7.2%), hepatic encephalopathy(6.5%) and alcohol intoxication(5.8%). Deceased patients had higher pulse rates(P = .030) and lower blood glucose(P = .049) and blood pressure(P = .001) at admission. Prior history of stroke(P = .003) and hyperlipidemia(P = .012) were associated with reduced survival odds. Conclusion Our data reveal high one-month mortality(56%) in patients with altered LOC. Also, patients with hyperlipidemia and a history of previous stroke seem to have worse outcomes. Due to this high mortality rate, patients with altered LOC should be treated intensively and prioritized, especially in crowded EDs.

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