[Functional activity of autonomous adenoma in Germany]

BACKGROUND

The American (ATA) and the European Thyroid Association (ETA) recommend a thyroid scintiscan for the detection of a suspected autonomy only when serum thyrotropin (TSH) levels are low or suppressed. If ultrasound reveals a thyroid nodule > 1.0 cm and TSH is normal, a fine-needle biopsy is recommended without a preceding scintiscan as the next step. The aim of this prospective study was to evaluate the incidence of reduced or suppressed TSH in 100 autonomous adenoma > 1.0 cm and to clarify, if normal TSH does substantially exclude a focal autonomy. When the study was conducted no data of German patients were available.

PATIENTS AND METHODS

An unselected group of 496 patients with a nodular goiter was continuously screened by scintiscan in order to detect 100 autonomous adenoma > 1.0 cm for the study. The following investigations were carried out: ultrasound, scintiscan and laboratory tests (fT3, fT4, TSH, TPO-antibodies). The reference range of TSH was 0.4 to 4.0 µU/ml.

RESULTS

21% of patients (100/476) with a nodular goiter had a focal autonomy. 32 % (32/100) of autonomous adenoma revealed a reduced (< 0.4 µU/ml) or completely suppressed TSH, while in 68 % (68/100) normal TSH level were found.

CONCLUSION

In Germany autonomous adenoma are still frequent (21 % of all thyroid nodules). Most of them (68 %) reveal normal TSH levels. Our data demonstrate, that there is no relevant connection between TSH level and autonomous adenoma detected by scintiscan. In most cases, TSH is not able to discriminate, whether a nodule is autonomous or not. Biopsy of undetected autonomous nodules should not be performed, as they often show cytological features of follicular neoplasias. In thyroid nodules > 1.0 cm a scintiscan should routinely be performed in primary diagnostics to avoid unnecessary fine-needle biopsy of autonomous adenoma.

[Diabetes and rheumatism: is diabetes mellitus also an inflammatory disease?]

New studies have demonstrated similarities in the complex pathomechanisms of diabetes mellitus type 1 (T₁D) and rheumatic diseases and in particular rheumatoid arthritis (RA). Common HLA gene complex characteristics and polymorphisms of inflammatory cytokines, such as interleukin-1 (IL-1), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) play a special role in both disorders. The metabolic syndrome, associated with insulin resistance and diabetes mellitus type 2 (T₂D), often shows criteria of a subclinical chronic inflammation. New forms of therapy with monoclonal antibodies against TNF-α, IL-1 and IL-6 have improved the management of patients with RA. Cytokine-induced inflammation also seems to be important in the pathogenesis and progression of T₁D and T₂D. Whether a therapy with the same monoclonal antibodies established in RA could also be successful in diabetes still has to be investigated in further studies. Both RA and T₁D are autoimmune disorders and show a cumulative incidence with further autoimmune diseases.

Assessment of left ventricular volumes, ejection fraction and mass

Aim: We compared and delineated possible differences of model-based analysis of ECGgated SPECT using 99mTc-sestamibi (Tc- SPECT) with ECG-gated 18F-fluorodeoxyglucose- PET (FDG-PET) for determination of enddiastolic (EDV) and end-systolic (ESV) cardiac volumes, left ventricular ejection fraction (LVEF), and myocardial mass (LVMM). Patients, methods: 24 patients (21 men; age: 54 ± 12years) with coronary artery disease underwent Tc-SPECT and FDG-PET imaging for evaluation of myocardial perfusion and viability. By using model-based analysis EDV, ESV, LVEF and LVMM were calculated from short axis images of both Tc-SPECT and FDGPET. Results: Left ventricular volumes by Tc- SPECT and FDG-PET were 176 ± 60 ml and 181 ± 59 ml for EDV, and 97 ± 44 ml and 103 ± 45 ml for ESV respectively, LVEF was 47 ± 8% by Tc-SPECT and 45 ± 9% by FDG-PET. The LVMM was 214 ± 40 g (Tc-SPECT) and 202 ± 43 g (FDG-PET) (all p = NS, paired t-test). A significant correlation was observed between Tc-SPECT and FDG-PET imaging for calculation of EDV (r = 0.93), ESV (r = 0.93), LVEF (r = 0.83) and LVMM (r = 0.72). Conclusion: ECG-gated Tc-SPECT and FDG-PET using two tracers with different characteristics (perfusion versus metabolism) showed close agreement concerning measurements of left ventricular volumes, contractile function and myocardial mass by using a model-based analysis.

Dosing strategies for conversion of haemodialysis patients from short-acting erythropoiesis stimulating agents to once-monthly C.E.R.A.: experience from the MIRACEL study

AIMS

To analyse the impact of dosing decisions for continuous erythropoietin receptor activator (C.E.R.A.), a continuous erythropoietin receptor activator.

METHODS

This was a prospective, multicentre, single-arm study in haemodialysis patients receiving epoetin alfa/beta or darbepoetin alfa. After a 2-month screening phase, patients were converted to monthly C.E.R.A. using pre-filled syringes during a 5-month titration phase and a 2-month evaluation phase.

RESULTS

Four hundred and twenty-four eligible patients were converted to C.E.R.A. Mean Hb were 11.7 ± 0.7, 11.7 ± 0.8 and 11.5 ± 0.8 g/dl during screening, titration and evaluation, respectively. C.E.R.A. starting dose was 125 μg (n = 311) or 200 μg (n = 106), with corresponding final doses of 129 ± 61 μg and 203 ± 58 μg. The mean number of C.E.R.A. dose decreases and increases were 0.9 ± 1.0 and 1.1 ± 1.0 per patient, respectively. Hb rarely exceeded 12.5 g/dl after a C.E.R.A. dose increase (< 8%) and remained ≥ 11 g/dl after a dose reduction on approximately three-quarters of occasions. Among the 53 occasions where Hb decreased ≥ 2 g/dl between two consecutive visits, the previous dose had been withheld (n = 9), concomitant blood loss, coagulopathy or infection was present (n = 13), or iron parameters were low (n = 17). There were 104 adverse events/month during screening, and 45/month during the titration/evaluation phases. Serious adverse events occurred in 18.0 and 21.0 patients/month during the screening and titration/evaluation phases, respectively.

CONCLUSION

Switching haemodialysis patients from shorter-acting ESA to once-monthly C.E.R.A. using pre-filled syringes is straightforward, and Hb levels remain stable. Starting dose recommendations and dose changes correlated well with the clinical setting. Collateral factors such as infection or aggravating concomitant medical conditions should be taken into account.

Echo Doppler parameters predict response to cardiac resynchronization therapy

BACKGROUND

Cardiac resynchronization therapy (CRT) has been shown to reduce heart failure related morbidity and mortality. However, approximately 30% of patients do not respond to CRT. We investigated the usefulness of Echo Doppler parameters to predict reverse remodelling, functional improvement and mortality following CRT.

MATERIALS AND METHODS

Our population consists of 200 consecutive heart failure patients evaluated for ventricular dyssynchrony by echocardiography between February 1999 and May 2007 who subsequently received CRT. Patients were reassessed for signs of reverse remodelling after a mean follow-up of 10 months. Information on vital status was obtained from local registration authorities.

RESULTS

Three parameters significantly predicted reverse remodelling in the logistic regression analysis: the Q-to-E-wave-delay (QED) at a cutoff of 550 ms (odds ratio 4.5, P-value 0.001), the interventricular mechanical delay (IVMD) at a cutoff of 60 ms (odds ratio 2.4, P-value 0.02), and the aortic electromechanical delay (A-EMD) at a cutoff of 140 ms (odds ratio 2.9, P-value 0.004). Furthermore, the QED and the IVMD also predicted all-cause mortality (hazard ratio 0.36, P-value 0.02 and 0.21, P-value 0.004, respectively). Adjustment for confounders did not alter the results.

CONCLUSIONS

The QED and IVMD predict reverse remodelling and survival following CRT. These parameters are easy to obtain, provide valuable prognostic information, and should thus be measured in CRT candidates evaluated by echocardiography.