Effect of hypothyrodism's medication (T4) on implant osstointegration: A case series and literature search

INTRODUCTION

Hypothyroidism reduces the recruitment, maturation, and activity of bone cells, decreasing bone resorption and formation. Several investigations have reported that T4 replacement therapy is associated with a significant decrease in bone mineral density in various skeletal parts, while others have failed to corroborate these results. The present study describes both a literature review and our own experience with dental implants in patients with hypothyroidism undergoing T4 replacement therapy.

CASE PRESENTATION

The study included two parts: a literature review and case series. The literature review included 12 articles documenting the success rate of osseointegrated dental implants in patients with hypothyroidism. The clinical cases were chosen from King Saud University Dental College, Riyadh. The patients' identity was only available to the main researcher. The inclusion criteria for the clinical cases were: T4-treated hypothyroidism, age 20-60 years, and use of dental implants with a follow-up period of 6-12 months after loading. The exclusion criteria were: any other medical condition alongside hypothyroidism, syndromic hypothyroidism, pregnancy, current smoking, bruxism, and hypothyroidism caused by surgical excision combined with radiotherapy. The following parameters were assessed: insertion torque (IT), crestal bone height (CBH), mesial bone width (MBW), and distal bone width (DBW) at different time points, probing depth, and signs of infection.

DISCUSSION

Seventeen dental implants placed in patients with T4-treated hypothyroidism showed median IT success (42.4 N⋅cm; range: 35-45 N⋅cm). The median crestal bone loss was measured at 6-12 months after loading was 0.6 mm (range: 0.5-0.7. mm). Conversely, the median bone loss differences in MBW and DBW at 6-12 months after loading were 0.3 mm and 0.2 mm, respectively.

CONCLUSION

After a 1-year follow-up, patients with T4-treated hypothyroidism who had received dental implants fulfilled the criteria for successful implants.

Robotic surgery for clinical T4 rectal cancer: short- and long-term outcomes

BACKGROUND

The optimal surgical approach for clinical T4 (cT4) rectal cancer is unknown. This study was conducted to clarify short- and long-term outcomes of robotic surgery for cT4 rectal cancer.

METHODS

In our retrospective cohort study, we enrolled patients who underwent robotic surgery for cT4 rectal cancer within 15 cm from the anal verge between 2011 and 2018. The short- and long-term outcomes were evaluated.

RESULTS

Of a total of 122 eligible patients, 70 (57%) had cT4a tumors and 52 (43%) had cT4b tumors. Thirty-five patients (29%) had distant metastasis and 21 (17%) underwent preoperative chemoradiotherapy. Thirty-four patients (28%) underwent combined resection of adjacent organs and 43 (35%) underwent lateral lymph node dissection. The median operative time was 288 min and the median blood loss was 11 ml. No patients required conversion to open surgery. The incidences of postoperative complications of grades II, III, and IV or more according to the Clavien-Dindo classification were 17.2%, 3.5%, and 0%, respectively. Seventy-three patients (60%) had pathological T4 tumors, and the incidence of positive resection margins was 4.9%. The median follow-up time was 42.9 months. The 3-year overall survival, disease-free survival, and cumulative local recurrence rates were 87.5%, 70.4%, and 4.0%, respectively.

CONCLUSIONS

The short- and long-term outcomes of robotic surgery for cT4 rectal cancer were favorable. Robotic surgery is considered to be a useful approach for cT4 rectal cancer.

[Catatonic walks with Emil Kraepelin, Aloys Alzheimer, Henry Aloysius Cotton and others]

Die Betriebsausflüge von Emil Kraepelins Königlich Psychiatrischer Klinik wurden unter den Mitarbeitern als „katatone Wanderungen“ bezeichnet. Im Jahr 1906 nahm eine erstaunliche Zahl deutscher und internationaler Gäste daran teil, Nicolas Achucarro, Henry Cotton, Eduard Flatau, Smith Ely Jelliffe, Gaetano Perusini, Edward Scripture, Maurycy Urstein und andere. Viele von Kraepelins Kollegen waren inspiriert von seinen Ideen und getrieben von wissenschaftlichem Enthusiasmus, der neben fachlichen Fortschritten in der Nervenheilkunde zu ganz unterschiedlichen Ergebnissen führte, von der Zahn- und Bauchchirurgie zu Psychoanalyse und Evidenz-basierter Medizin; von Rassenhygiene und Nationalismus zur Präsidentschaft des kommunistischen Rumänien.

Outcomes of neoadjuvant chemoradiotherapy followed by radical resection for T4 colorectal cancer

BACKGROUND

Patients with clinical T4 colorectal cancer (CRC) have a poor prognosis because of compromised surgical margins. Neoadjuvant therapy may be effective in downstaging tumors, thereby rendering possible radical resection with clear margins.

AIM

To evaluate tumor downsizing and resection with clear margins in T4 CRC patients undergoing neoadjuvant concurrent chemoradiotherapy followed by surgery.

METHODS

This study retrospectively included 86 eligible patients with clinical T4 CRC who underwent neoadjuvant concurrent chemoradiotherapy followed by radical resection. Neoadjuvant therapy consisted of radiation therapy at a dose of 45-50.4 Gy and chemotherapy agents, either FOLFOX or capecitabine. A circumferential resection margin (CRM) of < 1 mm was considered to be a positive margin. We defined pathological complete response (pCR) as the absence of any malignant cells in a specimen, including the primary tumor and lymph nodes. A multivariate logistic regression model was used to identify independent predictive factors for pCR.

RESULTS

For 86 patients who underwent neoadjuvant chemoradiotherapy and surgery, the rate of pCR was 14%, and the R0 resection rate was 91.9%. Of the 61 patients with rectal cancer, 7 (11.5%) achieved pCR and 5 (8.2%) had positive CRMs. Of the 25 patients with colon cancer, 5 (20%) achieved pCR and 2 (8%) had positive CRMs. We observed that the FOLFOX regimen was an independent predictor of pCR (P = 0.046). After a median follow-up of 47 mo, the estimated 5-year overall survival (OS) and disease-free survival (DFS) rates were 70.8% and 61.4%, respectively. Multivariate analysis revealed that a tumor with a negative resection margin was associated with improved DFS (P = 0.014) and OS (P = 0.001). Patients who achieved pCR exhibited longer DFS (P = 0.042) and OS (P = 0.003) than those who did not.

CONCLUSION

Neoadjuvant concurrent chemoradiotherapy engenders favorable pCR and R0 resection rates among patients with T4 CRC. The R0 resection rate and pCR are independent prognostic factors for patients with T4 CRC.

Classification of Thyroid Dysfunction in Pregnant Women Differs by Analytical Method and Type of Thyroid Function Test

CONTEXT

Physiological alterations challenge the assessment of maternal thyroid function in pregnancy. It remains uncertain how the reference ranges vary by week of pregnancy, and how the classification of disease varies by analytical method and type of thyroid function test.

DESIGN

Serum samples from Danish pregnant women (n = 6282) were used for the measurement of thyrotropin (TSH), total and free thyroxine (T4), total and free 3,5,3'-triiodothyronine (T3), and T-uptake using "Method A" (Cobas 8000, Roche Diagnostics). TSH and free T4 were also measured using "Method B" (ADVIA Centaur XP, Siemens Healthineers).

MAIN OUTCOME MEASURES

Pregnancy week- and method-specific reference ranges were established among thyroid antibody-negative women (n = 4612). The reference ranges were used to classify maternal thyroid function, and results were compared by analytical method and type of thyroid function test.

RESULTS

The reference ranges for TSH showed a gradual decrease during pregnancy weeks 4 to 14, a gradual increase was observed for total T4, total T3, and T-uptake, whereas free T4 and free T3 showed less variation. When TSH and free T4 were used, Method A classified 935 (14.9%) with abnormal thyroid function, Method B a total of 903 (14.4%), and the methods agreed on 554 individuals. When TSH and total T4 were used, 947 (15.1%) were classified with abnormal thyroid function, and classifications by either total T4 or free T4 agreed on 584 individuals.

CONCLUSIONS

Even when pregnancy week- and method-specific reference ranges were established, the classification of maternal thyroid dysfunction varied considerably by analytical method and type of thyroid function test.

Surgical resection of T4 colon cancers: an NCDB propensity score-matched analysis of open, laparoscopic, and robotic approaches

Historically, T4 tumors of the colon have been a contraindication to minimally invasive resection. The purpose of this study was to conduct a National Cancer Database analysis to compare the outcomes after curative treatment for T4 colon cancer between robotic, laparoscopic, and open approaches. The US National Cancer Database was queried for patients with T4 adenocarcinoma of the colon who underwent curative resection. Groups were separated based on approach (open, laparoscopic, robotic). One to one nearest neighbor propensity score matching (PSM) ± 1% caliper was performed across surgical approach cohorts to balance potential confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze primary outcome of survival. Secondary outcomes were analyzed by way of logistic regression. Inclusion criteria and PSM identified 876 cases per treatment approach (n = 2628). PSM provided adequate discrimination between treatment cohorts (0.6 < AUC < 0.8) and potential confounding covariates did not significantly differ between cohorts (all respective P > 0.05). Patients who underwent a robotic approach had lower odds of conversion to laparotomy compared to the laparoscopic cohort (P < 0.0001). Laparoscopic and robotic approaches were associated with increased odds of > 12 lymph nodes examined, decreased odds of positive margins, and decreased odds of 30-day readmission, 30-day mortality, and 90-day mortality compared to the open approach. Cox-proportional hazards regression showed that both robotic and laparoscopic approaches were significantly associated with decreased mortality hazards relative to open. Both laparoscopic and robotic-assisted surgeries achieved improved oncologic outcomes and survival compared to open resection of T4 cancers. A robotic-assisted approach was significantly associated with a lower conversion rate compared to the laparoscopic approach. This case-matched study demonstrates safety of using minimally invasive techniques in T4 cancers.

Minimally invasive surgery for T4 colon cancer is associated with better outcomes compared to open surgery in the National Cancer Database

Minimally invasive surgery (MIS) is favored for T1-T3 colon cancer resection due to improved short and long-term outcomes. Recommendations regarding T4 cancers remain controversial due to a paucity of clinical trials or large datasets assessing outcomes. We aim to compare outcomes for pT4 colon cancer patients treated with MIS or open surgery (OS) in the National Cancer Database (NCDB). We analyzed adults having MIS or OS for stage II or III pT4 colon cancers between 2010 and 2014 using propensity-score matching, Cox and logistic regression modeling. Of 21 998 T4 patients, 7532 (34.2%) underwent MIS, 14 466 (65.8%) OS and 22.3% were MIS converted to OS. After propensity score matching, 5624 patients in each cohort were included. MIS was associated with improved postoperative mortality (3.4 vs. 7.2%, p > .001), surgical margins, optimal lymph node harvest, adjuvant chemotherapy use and 5-year survival (46% vs. 41%, P < .001). MIS was associated with improved short and long term outcomes for T4 colon cancers compared to OS on multivariate analysis. Based on these findings, well selected pT4 colon cancers can be considered appropriate for MIS however, prospective clinical trials are needed to better define the role of MIS in T4b colon cancer.

Genotyping and phylogenic study of Acanthamoeba isolates from human keratitis and swimming pool water samples in Iran

Objective

Acanthamoeba keratitis cause severe corneal infection and lead to poor vision and blindness. This disease is caused by a unicellular amphizoic protozoon called Acanthamoeba spp. that present in different environments. This study aimed to represent the existence and genotyping of Acanthamoeba spp. in patients with keratitis and swimming pool water (SPW) in Tehran Province, Central Iran.

Methods

In this descriptive study, 56 clinical samples were collected from patients with keratitis and 30 water samples were collected from different swimming pools in Tehran Province. All samples were examined based on the morphological and molecular techniques. The genotypes were determined by sequencing the partial of 18S rRNA gene.

Results

Of 56 clinical (corneal) and 30 environmental (SPW) samples, 30.3% and 40.0% were positive for Acanthamoeba spp., respectively. According to sequencing analysis, 94.1% of amoebic keratitis isolates were belonged to T4 genotype and only one (5.8%) isolate was belonged to T11 genotype. All genotypes were detected from SPW samples were identified as T4 genotype.

Conclusion

According to our results, use of contact lens and swimming in pool poses the major risk factor for amoebic keratitis in the studied area (Tehran). Moreover, T4 genotype was the predominant genotype of human keratitis and swimming pool samples there. Consequently, essential and practical measures are urgently needed to prevent subjects against this ocular seriously disease.

We All Know We Need Them, We Hope They Are Coming, But When?

A number of mechanisms modify thyroid hormone (TH) signaling at the cellular level. To restore TH signaling in patients with hypothyroidism or in patients with the syndrome of TH resistance, it is necessary to quantify the action of THs in a tissue-specific manner. The development of biomarkers that are tissue-specific and respond to TH is a significant first step toward understanding and possibly modifying TH signaling in health and disease states.

T4 cervical esophageal cancer cured with modern chemoradiotherapy: A case report

BACKGROUND

T4 esophageal cancer portends a poor prognosis, particularly when it is complicated by a tracheoesophageal fistula (TEF) either resulting from disease or occurring as a complication of treatment. Patients with TEF that occurs during treatment are commonly treated with palliative intent because fistula-associated treatment complications such as aspiration pneumonia and mediastinitis are associated with high morbidity and mortality. To date, there is no clear evidence on the optimal treatment of T4 esophageal cancer, particularly when a TEF formation occurs.

CASE SUMMARY

A 67-year-old gentleman who presented with dysphagia and weight loss. Endoscopy and imaging revealed a T4N1M0 cervical esophageal squamous cell carcinoma. He received image-guided intensity-modulated radiation therapy, with concurrent weekly carboplatin (area under curve 2 mg/mL per minute) and paclitaxel (50 mg/m² of body surface area). One week after treatment initiation (16.2 Gy thus far), he developed cough on swallowing. A TEF was detected on image-guided radiation therapy using cone-beam computed tomography during the treatment course, for which a tracheal stent was inserted. After discussing the risks and morbidity of continuing treatment, he resumed chemoradiotherapy with an additional radiation dose of 45 Gy in 25 fractions. Three months after completion of chemoradiotherapy, he developed an esophageal stricture that required esophageal stenting and dilatation. The patient remains cancer-free at two year on follow-up. Complete response of esophageal cancer was evident on post-treatment endoscopy and computed tomography imaging, with successful closure of TEF.

CONCLUSION

This case highlights that successful curative treatment for esophageal cancer complicated by a TEF is possible using novel chemotherapeutic regimens and modern radiation technologies.

Hippocampal Neurogenesis Requires Cell-Autonomous Thyroid Hormone Signaling

Adult hippocampal neurogenesis is strongly dependent on thyroid hormone (TH). Whether TH signaling regulates this process in a cell-autonomous or non-autonomous manner remains unknown. To answer this question, we used global and conditional knockouts of the TH transporter monocarboxylate transporter 8 (MCT8), having first used FACS and immunohistochemistry to demonstrate that MCT8 is the only TH transporter expressed on neuroblasts and adult slice cultures to confirm a necessary role for MCT8 in neurogenesis. Both mice with a global deletion or an adult neural stem cell-specific deletion of MCT8 showed decreased expression of the cell-cycle inhibitor P27KIP1, reduced differentiation of neuroblasts, and impaired generation of new granule cell neurons, with global knockout mice also showing enhanced neuroblast proliferation. Together, our results reveal a cell-autonomous role for TH signaling in adult hippocampal neurogenesis alongside non-cell-autonomous effects on cell proliferation earlier in the lineage.

Complex surgery and perioperative systemic therapy for genitourinary cancer of the retroperitoneum

Objective

The purpose of the present guideline is to recommend surgical or systemic treatment for metastatic testicular cancer; T3b or T4, or node-positive, and metastatic renal cell cancer (rcc); and T3, T4, or node-positive upper tract urothelial (utuc) cancer.

Methods

Draft recommendations were formulated based on evidence obtained through a systematic review of randomized controlled trials, comparative retrospective studies, and guideline endorsement. The draft recommendations underwent an internal review by clinical and methodology experts, and an external review by clinical practitioners.

Results

The primary literature search yielded eight guidelines, five systematic reviews, and twenty-seven primary studies that met the eligibility criteria.

Conclusions

Cytoreductive nephrectomy should no longer be considered the standard of care in patients with T3b or T4, or node-positive, and metastatic rcc. Eligible patients should be treated with systemic therapy and have their primary tumour removed only after review at a multidisciplinary case conference (mcc). Adjuvant sunitinib after surgery is not recommended. Patients with venous tumour thrombus should be considered for surgical intervention. Patients with T3, T4, or node-positive utuc should have their tumour removed without delay. Decisions concerning lymph node dissection should be done at a mcc and be based on stage, expertise, and imaging. Adjuvant systemic treatment is recommended for resected high-risk utuc. Patients with metastasis-positive testicular cancer with residual tumour after systemic treatment should be treated at specialized centres. For all complex retroperitoneal surgeries, the evidence shows that higher-volume centres are associated with lower rates of procedure-related mortality, and patients should be referred to higher-volume centres for surgical resection.

Urinary bisphenol A and thyroid function by BMI in the Korean National Environmental Health Survey (KoNEHS) 2012-2014

Bisphenol A (BPA) is one of the largest amounts of chemicals in daily life and source of polycarbonate plastics, epoxy resins, medical equipment, plastic consumer products. Recent studies reported that the effects of BPA on human health in the thyroid hormone. Therefore, this study aimed to indicate the association between urinary BPA concentration and thyroid function in total triiodothyronine (T3), thyroxine (T4), thyroidal stimulating hormone (TSH) and stratified the population by body mass index (BMI). This study was performed on 6478 adults aged 19 years and older based on the Second Korean National Environmental Health Survey (KoNEHS, 2012-2014). We measured BPA in urine and total T3, T4 and TSH in serum from the 2nd KoNEHS study. The multiple regression analysis was performed to assess the association of urinary BPA concentrations with thyroid hormone after BMI stratification. Urinary BPA associated with thyroid hormone. Especially, BPA is related to T3 (-0.627) in all group, and T4 (-0.060, -0.098) in all group and the group of BMI 25.0kg/m2 or more negatively. When stratified by BPA, T3 and T4 were significantly decreased with the high BPA exposure compared with the low BPA exposure for BMI more than 25.0kg/m2 (adjusted β = -3.402, 95% CI: 4.942, -1.862, adjusted β = -0.209, 95% CI: 0.328, -0.090). However, no obvious associations were found between BPA concentration and TSH. The results of urinary BPA decrease with T3 and T4 levels increase in the higher BMI group is a new finding which does not exist in recent studies of Korea.

Analysis of fistula formation of T4 esophageal cancer patients treated by chemoradiotherapy

BACKGROUND AND AIM

Fistula is one of the known complications of T4 esophageal cancer (T4-EC). The standard treatment for T4-EC is chemoradiotherapy, but detailed data about fistula resulting from chemoradiotherapy in this condition are limited. In particular, radiographic findings of T4-EC with fistula have not been reported. This study assessed the risk factors of fistula based on clinical information on patients with chemoradiotherapy for T4-EC.

METHODS

We retrospectively reviewed the clinical data of 59 T4-EC patients who had squamous cell carcinoma without any fistula before receiving definitive or palliative chemoradiotherapy.

RESULTS

A fistula was observed in 18 patients (31%) throughout their clinical course. The overall survival in the fistula group was significantly shorter than that in the non-fistula group (259 vs. 346 days; p = 0.0341). The axial tumor size on computed tomography (CT) was confirmed as an independent risk factor for esophageal fistula in multivariate analysis of stepwise methods [OR 1.226; 95% CI 1.109-1.411; p < 0.0001]. Twelve out of 14 patients with an axial tumor size of 50 mm or greater had developed a fistula.

CONCLUSIONS

A large tumor size on the axial plane on CT is a risk factor for fistula formation.

T4 + T3 combination therapy: any progress?

Guidelines on T4 + T3 combination therapy were published in 2012. This review investigates whether the issue is better understood 7 years later. Dissatisfaction with the outcome of T4 monotherapy remains high. Persistent symptoms consist mostly of fatigue, weight gain, problems with memory and thinking and mood disturbances. T4 monotherapy is associated with low serum T3 levels, which often require TSH-suppressive doses of L-T4 for normalization. Peripheral tissue thyroid function tests during T4 treatment indicate mild hyperthyroidism at TSH < 0.03 mU/L and mild hypothyroidism at TSH 0.3-5.0 mU/L; tissues are closest to euthyroidism at TSH 0.03-0.3 mU/L. This is explained by the finding that whereas T4 is usually ubiquinated and targeted for proteasomal degradation, hypothalamic T4 is rather stable and less sensitive to ubiquination. A normal serum TSH consequently does not necessarily indicate a euthyroid state. Persistent symptoms in L-T4 treated patients despite a normal serum TSH remain incompletely understood. One hypothesis is that a SNP (Thr92Ala) in DIO2 (required for local production of T3 out of T4) interferes with its kinetics and/or action, resulting in a local hypothyroid state in the brain. Effective treatment of persistent symptoms has not yet realized. One may try T4 + T3 combination treatment in selected patients as an experimental n = 1 study. The 2012 ETA guidelines are still valid for this purpose. More well-designed randomized clinical trials in selected patients are key in order to make progress. In the meantime the whole issue has become rather complicated by commercial and political overtones, as evident from skyrocketing prices of T3 tablets, aggressive pressure groups and motions in the House of Lords.

A critical evaluation of thyroid hormone measurements in OECD test guideline studies: Is there any added value?

Recently several OECD test guidelines were updated to include thyroid hormone measurements for assessing endocrine disruptor potency, which led to an imperative need to align interpretation of these results by the different stakeholders. We therefore evaluated 124 repro screening studies, which showed in 38% of the studies a statistical significant finding for T4 in at least one treatment group, probably due to disturbances of normal homeostasis causing high variation. Consequently, for a thorough evaluation it is extremely important to take the historical control range into account. In conclusion, the current testing approach is not providing specific information needed to assess endocrine disruption, as too often a statistical significant finding is noted and as down-stream adverse effects are not evaluated. Therefore, major modifications are urgently needed. Instead of extending the in vivo experiments, it should be investigated if in vitro assessments will provide more relevant information on human endocrine disruptor potential.

A Protocol for Extraction of Infective Viromes Suitable for Metagenomics Sequencing from Low Volume Fecal Samples

The human gut microbiome (GM) plays an important role in human health and diseases. However, while substantial progress has been made in understanding the role of bacterial inhabitants of the gut, much less is known regarding the viral component of the GM. Bacteriophages (phages) are viruses attacking specific host bacteria and likely play important roles in shaping the GM. Although metagenomic approaches have led to the discoveries of many new viruses, they remain largely uncultured as their hosts have not been identified, which hampers our understanding of their biological roles. Existing protocols for isolation of viromes generally require relatively high input volumes and are generally more focused on extracting nucleic acids of good quality and purity for down-stream analysis, and less on purifying viruses with infective capacity. In this study, we report the development of an efficient protocol requiring low sample input yielding purified viromes containing phages that are still infective, which also are of sufficient purity for genome sequencing. We validated the method through spiking known phages followed by plaque assays, qPCR, and metagenomic sequencing. The protocol should facilitate the process of culturing novel viruses from the gut as well as large scale studies on gut viromes.

More on Asperger's Career: A Reply to Czech

Czech's claims that my paper abounds with mistranslations, misrepresentations, and factual errors are refuted point-by-point, as is his declaration that the paper contains no relevant or new evidence. Asperger's statements that Franz Hamburger saved him from the Gestapo are reaffirmed and supported with a personal communication from Asperger's daughter, Dr. Maria Asperger Felder. Czech's criticism of anonymous peer reviewers and his call for retraction of my paper are, at best, unconstructive. In light of the current resurgence of authoritarian governments that promote xenophobic and racist ideology in the United States, Europe, and elsewhere, it is essential that details about the Nazi euthanasia program continue to be recalled and deliberated, as they are in this exchange. I stand by my paper.

Practical considerations for developmental thyroid toxicity assessments: What's working, what's not, and how can we do better?

Thyroid hormones (THs; T3 and T4) play a role in development of cardiovascular, reproductive, immune and nervous systems. Thus, interpretation of TH changes from rodent studies (during pregnancy, in fetuses, neonates, and adults) is critical in hazard characterization and risk assessment. A roundtable session at the 2017 Society of Toxicology (SOT) meeting brought together academic, industry and government scientists to share knowledge and different perspectives on technical and data interpretation issues. Data from a limited group of laboratories were compiled for technical discussions on TH measurements, including good practices for reliable serum TH data. Inter-laboratory historical control data, derived from immunoassays or mass spectrometry methods, revealed: 1) assay sensitivities vary within and across methodologies; 2) TH variability is similar across animal ages; 3) laboratories generally achieve sufficiently sensitive TH quantitation levels, although issues remain for lower levels of serum TH and TSH in fetuses and postnatal day 4 pups; thus, assay sensitivity is critical at these life stages. Best practices require detailed validation of rat serum TH measurements across ages to establish assay sensitivity and precision, and identify potential matrix effects. Finally, issues related to data interpretation for biological understanding and risk assessment were discussed, but their resolution remains elusive.

Morphological and physiological assessments reveal that freshwater turtle (Mauremys leprosa) can flourish under extremely degraded-polluted conditions

Freshwater turtles are long-lived sedentary organisms used as biological sentinels to assess anthropogenic perturbations in freshwater-ecosystems; notably because pollutants tend to accumulate in their tissues. Pollution has detrimental effects in sea turtles, but studies in freshwater turtles have provided contrasted results: several species have been impacted by habitat perturbation and pollution while others not. It is important to explore this issue since freshwater turtles are threatened worldwide. We compared two populations of the stripe necked terrapin (Mauremys leprosa) in a relatively pristine area (piedmont of the Atlas mountain) versus an extremely degraded-polluted area (sewers of a large city) in Morocco. All morphological and physiological proxies showed that turtles were able to cope remarkably well with highly degraded-polluted habitat. Population density, body size, and body condition were higher in the sewers, likely due to permanent water and food availability associated with human wastes. Stress markers (e.g. glucocorticoids) provided complex results likely reflecting the capacity of turtles to respond to various stressors. Reproductive parameters (testosterone level, indices of vitellogenesis) were lower in the relatively pristine area. The deceptive overall image provided by these analyses may hide the disastrous human impact on rivers. Indeed, Mauremys leprosa is the only aquatic vertebrate able to survive in the sewers, and thus, might nonetheless be a pertinent indicator of water quality, providing that the complexity of eco-physiological responses is considered.

Non-complicit: Revisiting Hans Asperger's Career in Nazi-era Vienna

Recent allegations that pediatrician Hans Asperger legitimized Nazi policies, including forced sterilization and child euthanasia, are refuted with newly translated and chronologically-ordered information that takes into account Hitler's deceptive 'halt' to the T4 euthanasia program in 1941. It is highly unlikely that Asperger was aware of the T4 program when he referred Herta Schreiber to Am Spiegelgrund or when he mentioned that institution 4 months later on the medical chart of another (unrelated) girl, Elisabeth Schreiber. Asperger campaigned vigorously from 1938 to 1943 to have his specialization, Curative Education, take priority in the diagnosis and treatment of disabled children over other fields that promoted Nazi racial hygiene policies. He neither disparaged his patients nor was he sexist. By 1938, he had identified the essentials of Asperger syndrome and described an unnamed boy whom he later profiled (as Ernst K.) in 1944. Rather than doing 'thin' research, Asperger made discoveries that were prescient, and some of his activities conformed to definitions of "individual resistance."

Treatment and clinical outcome of clinical T4 esophageal cancer: A systematic review

BACKGROUND

Survival of patients with cT4 esophageal cancer is dismal. Although the optimal treatment strategy remains to be established, two treatment options are available for cT4 esophageal cancers: definitive chemoradiation (dCRT) and induction treatment followed by conversion surgery (CS). However, little is known concerning the differences in clinical outcome between patients with T4 esophageal tumors treated with dCRT and those eventually treated with CS.

METHODS

A systematic search of the scientific literature on PubMed/MEDLINE was carried out using the keywords "T4 esophageal cancer," "invading (involving) adjacent organ," "definitive chemoradiation," "induction therapy," "salvage surgery," and "conversion surgery," obtaining 28 reports published up to July 2018.

RESULTS/CONCLUSION

We found that CS was superior to dCRT with respect to local disease control and short-term survival; however, CS was associated with relatively higher perioperative mortality and morbidity. Alternatively, although dCRT might often cause fistula formation, a clinical complete response to dCRT is likely to lead to a better prognosis. Recent advances in chemotherapeutic agents have led to triple induction chemotherapy, with docetaxel, cisplatin, and 5-fluorouracil (DCF), which has shown promise as an initial induction treatment for cT4 esophageal cancer. Indeed, this regimen could control both local and systemic disease, which enables curative resection without preoperative CRT. Moreover, some appropriate changes in perioperative management and intensive systemic chemotherapy might enhance patient outcome. Randomized controlled trials with a large sample size are needed to establish the standard treatment for cT4 esophageal cancer.

Assessment of the Adequacy of Thyroid Hormone Replacement Therapy in Hypothyroidism

Background: Recent studies identify a significant number of treated hypothyroid patients who express dissatisfaction with their therapy. At present there are sufficient measures of thyroid function to enable the clinician to establish a diagnosis of thyroid disease with a high degree of sensitivity and specificity. The purpose of this study was to quantitate the use of a new and novel assessment of clinically relevant hypothyroid symptoms in the management of patients with thyroid disease and to identify a tool that could help clinicians to assess adequacy of LT₄ treatment. Methodology: Unselected outpatients of the Thyroid Clinic of the North Shore University Hospital at Manhasset completed a questionnaire asking them to rate their physical symptoms related to thyroid disease as part of their standard care. This questionnaire consisted of 10 signs and symptoms. The questionnaire was collected from 198 control subjects, 241 subjects with primary hypothyroidism (under treatment), 113 euthyroid subjects (benign nodular thyroid disease), 73 previously hyperthyroid subjects (previously treated), and 27 subjects with thyroid cancer. A repeat questionnaire was obtained from 48 subjects with primary hypothyroidism (20%), 19 euthyroid subjects (17%), and 17 subjects previously hyperthyroid (23%). Data Analysis: The mean score for the sum of the signs and symptoms in the primary hypothyroid group with no medication change was 9.62 ± 1.29 for the initial questionnaire, and 10.04 ± 1.32 for the follow up questionnaire (not significant). For the primary hypothyroid patients requiring a medication change, at the time of the initial questionnaire the mean serum TSH was 12.86 ± 2.75 mcU/ml. Concurrently with the normalization of TSH, a statistically significant improvement in the sum of signs and symptoms mean score for this group was noted (16.32 ± 1.93 initial vs. 10.32 ± 1.46 after treatment to normalize TSH). Conclusion: The proposed newly devised hypothyroid scale correctly identified subjects with TSH elevation and clinical/subclinical hypothyroidism based on their clinical signs and symptoms. In this particular subset of patients, the hypothyroid symptom scale showed a statistically significant improvement in the sum of the signs and symptoms with the normalization of the subjects' thyroid function.

Multivisceral Resection for Locally Advanced Gastric and Gastroesophageal Junction Cancers-11-Year Experience at a High-Volume North American Center

INTRODUCTION

The oncologic benefit of multivisceral en bloc resections for T4 gastroesophageal tumors has been questioned, given the increased morbidity associated. We thus sought to investigate the surgical and oncologic outcomes of curative-intent en bloc multivisceral resections for T4 gastroesophageal carcinomas.

METHODS

Between 2005 and 2016, 35 of the 525 patients who had gastric or EGJ carcinomas underwent curative-intent multivisceral resections for direct invasion or adhesion to adjacent organs.

RESULTS

Postoperative complications occurred in 16(46%), 10 of which were Clavien-Dindo ≥ 3 (29%). Ninety-day mortality was 3%. The R0 resection rate was 94% (33). Direct organ invasion (pT4b) was confirmed on pathological analysis in 14 (40%) and did not affect survival. The majority (28, 80%) had lymph node involvement with a high nodal disease burden and was associated with decreased survival. Overall 5-year survival rate was 34%, and the vast majority of recurrences were distant/peritoneal (81%). On multivariate analysis, positive lymph nodes (H.R. 21.2; 95%CI 2.34-192) and R1 resection (H.R. 5.6; 95%CI 1.02-30.9) were predictors of survival.

CONCLUSION

Multivisceral resections for T4 gastric and GEJ adenocarcinomas, in combination with effective systemic therapy, result in prolonged long-term survival with acceptable morbidity. Complete resection to negative margins should remain a mainstay of curative-intent treatment in carefully selected patients.