SEVERE REFRACTORY HYPOTHYROIDISM IN A 48-YEAR-OLD FEMALE: ROLE OF LOW-DOSE THYROXINE ABSORPTION TEST IN ESTABLISHING DIAGNOSIS OF NONCOMPLIANCE

A 48-year-old female presented with severe chronic hypothyroidism despite progressively increasing doses of levothyroxine. Poor adherence was suspected based on previous laboratory investigations. A low dose thyroxine absorption test using 400 µg of levothyroxine taken orally was performed. FT4 increased by 4.7 pmol/L at 3 hours and 6.6 pmol/L at 5 hours, following ingestion, effectively ruling out malabsorption. Her cardiac hemodynamic profile, measured noninvasively, also improved following levothyroxine intake, further supporting our diagnosis. Poor adherence was successfully managed by implementing twice weekly visits by a registered nurse and an improvement in both thyroid function tests and cardiac parameters was seen at the one-month follow-up visit. We suggest using a lower dose thyroxine absorption test, owing to its efficacy in establishing diagnosis and a safer alternative compared to higher doses in particular in high-risk cardiac patients.

[Suicide prevention: How to act?]

Although being complex, suicide is a phenomenon considered as preventable, and its prevention has been made as a public health priority. Some interventions to prevent suicide have been evaluated, such as the education of the healthcare workers, especially in the suicidal assessment (suicidal risk and suicidal emergency/dangerousness), the diagnosis and management of common mental disorders, the care provided after a suicide attempt, the restriction access to common means of suicide, the use of websites to educate the public, or the appropriate reports of suicide in media. Other interventions, even not rigorously evaluated, are implemented in France as in many parts of the world. It is the case of interventions among identified high-risk groups. To be efficient, prevention programs should simultaneously include different strategies targeting several known risk factors for suicide. Clinicians play a crucial role in the suicide prevention strategies.

Identifying Spatial Variation Along the HIV Care Continuum: The Role of Distance to Care on Retention and Viral Suppression

Distance to HIV care may be associated with retention in care (RIC) and viral suppression (VS). RIC (≥ 2 HIV visits or labs ≥ 90 days apart in 12 months), prescribed antiretroviral therapy (ART), VS (< 200 copies/mL at last visit) and distance to care were estimated among 3623 DC Cohort participants receiving HIV care in 13 outpatient clinics in Washington, DC in 2015. Logistic regression models and geospatial statistics were computed. RIC was 73%; 97% were on ART, among whom 77% had VS. ZIP code-level clusters of low RIC and high VS were found in Northwest DC, and low VS in Southeast DC. Those traveling ≥ 5 miles had 30% lower RIC (adjusted odds ratio (aOR) 0.71, 95% CI 0.58, 0.86) and lower VS (OR 0.70, 95% CI 0.52, 0.94). Geospatial clustering of RIC and VS was observed, and distance may be a barrier to optimal HIV care outcomes.

[Is the orientation of patients suffering from depressive disorder to the psychiatric emergencies by a general practitioner associated with the decision to hospitalize?]

INTRODUCTION

Depressive disorders affect nearly 350 million people worldwide and are the world's leading cause of incapacity. Patients who are depressed preferentially approach their general practitioner (GP), who is their first point of contact, in 50-60% of cases. The aim of our study is to assess whether the orientation of patients suffering from anxiety-depressive disorder towards a GP in a general emergency is a factor associated with hospitalization when compared to patients who present themselves spontaneously for the same disorders. Our secondary objective was to identify the different profiles of patients who were hospitalized for these disorders as an emergency.

MATERIALS AND METHODS

We conducted a cross-sectional study for the year 2015, targeting patients who presented as general emergencies at the centre hospitalier de Troyes and who had received a psychiatric diagnosis in the context of an anxiety or depressive disorder.

RESULTS

Five hundred and twenty four patients were included. A univariate analysis showed that referral by the attending physician was associated with hospitalization in 57.9% vs. 42.1% cases (P=0.007), at an odds ratio at 1.98 [1.22-3.21] by multivariate analysis. Analysis by ascending hierarchical classification made it possible to identify 3 profiles for hospitalized patients: 1) patients with a known psychiatric history, a history of past or current follow-ups directed by a psychiatrist, with at least one psychotropic treatment, the presence of psychotic symptoms and a low suicidal risk compared to the rest of the study population; 2) patients without a psychiatric history, or a history of past or ongoing psychiatric follow-up and the absence of ongoing psychotropic treatment. These patients were referred by a GP (67% vs 23%, P<0.001) and their suicidal risk was higher (59% vs 26%, P<0.001); 3) patients about whom the psychiatrist had little information at the time of the emergency consultation.

CONCLUSIONS

The relevance of GPs in orientation towards emergencies pleads in favor of a partnership and an early exchange between treating physicians and the psychiatrists.

Attempted and completed suicide in primary care: not what we expected?

BACKGROUND

General Practitioners (GPs) play a central role in suicide prevention. This study aims to compare the characteristics of individuals who attempt suicide to those who complete suicide in a same primary care setting.

METHODS

We compared the characteristics and GP's management of all patients with attempted (N=498, SA) or completed suicide (N=141, SC) reported to the GPs'French Sentinelles surveillance system (2009-2013).

RESULTS

Compared to patients who attempted suicide, those who completed suicide were more likely to be male, older and to have used a more lethal method; for men they were less likely to have a history of previous suicide attempt and prior contacts with their GP. In terms of GPs' management, we found no differences between the SA and SC groups in the identification of psychological difficulties and in the care, but GPs were more likely to provide psychological support to the SA group. During the last consultation, the SC group expressed suicidal ideas more frequently than the SA group (26.7% vs. 14.8%, p<0.01), only for women.

LIMITATIONS

The network may have missed cases and selected more serious SA.

CONCLUSIONS

Individuals who commit suicide differ from those who attempt suicide in terms of demographic characteristics and by sex, of history of suicide attempt, previous contact and expressed suicidal ideas. We show that GPs do not act more intensively with patients who will commit suicide, as if they do not foresee them. Current prevention programs particularly in primary care should be tailored.

Epidemiology of Genito-Urinary Tumors in Qatar (From a paper read in the 2nd Congress of Qatar Cancer Society

A retrospective review of genito-urinary tumors examined histopathologically in Qatar during the period 1998-2004 showed bladder cancer to be the most common followed by prostate, renal, testicularrenal pelvis and urethral tumours in order of decreasing prevalence. The apparent increasing annual prevalence of some tumors is discussed and the findings are compared with those reported from neighbouring countries and in literature from the West.

Longitudinal growth of hospitalized very low birth weight infants

BACKGROUND

The interpretation of growth rates for very low birth weight infants is obscured by limited data, recent changes in perinatal care, and the uncertain effects of multiple therapies.

OBJECTIVES

To develop contemporary postnatal growth curves for very low birth weight preterm infants and to relate growth velocity to birth weight, nutritional practices, fetal growth status (small- or appropriate-for-gestational-age), and major neonatal morbidities (chronic lung disease, nosocomial infection or late-onset infection, severe intraventricular hemorrhage, and necrotizing enterocolitis).

DESIGN

Large, multicenter, prospective cohort study.

METHODS

Growth was prospectively assessed for 1660 infants with birth weights between 501 to 1500 g admitted by 24 hours of age to 1 of the 12 National Institute of Child Health and Human Development Neonatal Research Network centers between August 31, 1994 and August 9, 1995. Infants were included if they survived >7 days (168 hours) and were free of major congenital anomalies. Anthropometric measures (body weight, length, head circumference, and midarm circumference) were performed from birth until discharge, transfer, death, age 120 days, or a body weight of 2000 g. To obtain representative data, nutritional practices were not altered by the study protocol.

RESULTS

Postnatal growth curves suitable for clinical and research use were constructed for body weight, length, head circumference, and midarm circumference. Once birth weight was regained, weight gain (14.4-16.1 g/kg/d) approximated intrauterine rates. However, at hospital discharge, most infants born between 24 and 29 weeks of gestation had not achieved the median birth weight of the reference fetus at the same postmenstrual age. Gestational age, race, and gender had no effect on growth within 100-g birth weight strata. Appropriate-for-gestational age infants who survived to hospital discharge without developing chronic lung disease, severe intraventricular hemorrhage, necrotizing enterocolitis, or late onset-sepsis gained weight faster than comparable infants with those morbidities. More rapid weight gain was also associated with a shorter duration of parenteral nutrition providing at least 75% of the total daily fluid volume, an earlier age at the initiation of enteral feedings, and an earlier age at achievement of full enteral feedings.

CONCLUSIONS

These growth curves may be used to better understand postnatal growth, to help identify infants developing illnesses affecting growth, and to aid in the design of future research. They should not be taken as optimal. Randomized clinical trials should be performed to evaluate whether different nutritional management practices will permit birth weight to be regained earlier and result in more rapid growth, more appropriate body composition, and improved short- and long-term outcomes.

Outcomes of very low birth weight twins cared for in the National Institute of Child Health and Human Development Neonatal Research Network's intensive care units

OBJECTIVE

The study's aim was to compare outcomes of very low birth weight twins with those of matched singletons.

STUDY DESIGN

With data from the Neonatal Research Network registry (May 1991 to December 1994), univariable and multivariable comparisons of very low birth weight twin pairs and singletons were performed in 2 subgroups: (1) all paired twins and singletons with birth weights between 401 and 1500 g and (2) all paired twins and singletons born at <28 weeks' gestation.

RESULTS

Twins constituted 19% of infants admitted with very low birth weight. Mothers of twins were more likely to receive prenatal care, have labor, have cesarean delivery, and receive antenatal glucocorticoids. Twins were more likely to have respiratory disease and to receive surfactant. Second-born twins had more early respiratory disease but similar longer-term outcomes. The risks of death, chronic lung disease, and grade III or IV intracranial hemorrhage were similar in twins and singletons.

CONCLUSIONS

Although very low birth weight twins compose a sizable proportion of admissions, in National Institute of Child Health and Human Development Neonatal Research Network intensive care units, twins and singletons have similar outcomes.

The presence of K-12 ras mutations in duodenal adenocarcinomas and the absence of ras mutations in other small bowel adenocarcinomas and carcinoid tumors

BACKGROUND

Adenocarcinomas and carcinoid tumors are the most common malignant tumors of the small intestine. K-ras oncogene mutations at codon 12 are common in gastric, pancreatic, and colon carcinomas, with an incidence of 35-88%. K-ras mutations have not been extensively studied in either adenocarcinomas or carcinoid tumors of the small bowel. The purpose of this study was to determine whether ras mutations play an important role in the formation of these tumors.

METHODS

Archival tissues from 28 adenocarcinomas and 22 carcinoid tumors of the small bowel were studied, along with archival tissues from 32 adenocarcinomas of the large bowel, which were used as controls. DNA from the small intestine tumors was analyzed for K-ras, H-ras, and N-ras oncogene mutations at codons 12, 13, and 61, using polymerase chain reaction and sequence specific oligonucleotide hybridization techniques. Large bowel adenocarcinomas were analyzed for K-ras mutations at codons 12 and 13.

RESULTS

A point mutation of K-ras at codon 12 was detected in 4 of 28 (14.3%) of the small bowel adenocarcinomas, in 12 of 32 (37.5%) of the large bowel adenocarcinomas, and in 0 of 22 small intestine carcinoid tumors. No other K-ras, H-ras, or N-ras mutations were detected in any of the small bowel tumors. Each small intestine K-ras mutation was found in a duodenal adenocarcinoma (4 of 12 cases, 33%), whereas none occurred in 16 other jejunal or ileal adenocarcinomas.

CONCLUSIONS

K-ras mutations appear to play a significant role in the pathogenesis of duodenal adenocarcinomas, but they do not appear to be important in the development of jejunal or ileal adenocarcinomas or of carcinoid tumors of the small intestine.

Viability, morbidity, and resource use among newborns of 501- to 800-g birth weight. National Institute of Child Health and Human Development Neonatal Research Network

OBJECTIVES

To assess risk factors affecting viability and analyze the effects of mechanical ventilation (MV) on neonatal outcome and resource use among extremely premature infants.

DESIGN

Inception cohort study.

SETTING

Neonatal intensive care units of the 12-center National Institute of Child Health and Human Development Neonatal Research Network.

PARTICIPANTS

A total of 1126 infants with a birth weight of 501 to 800 g born in network centers between January 1, 1994, and December 31, 1995.

MAIN OUTCOME MEASURES

Observed survival; maximum estimated survival (assuming the same survival among infants who died without MV as among infants in the same risk category who received MV); observed and maximum estimated survival without severe brain injury (either interventricular echodensity with ventricular dilation or parenchymal echodensity); hospital stay; resource investment.

RESULTS

Overall mortality was 43%; mortality in infants without MV was 93%. A total of 15% of all the infants died without MV. Females, small-for-gestational-age infants, and infants whose mothers received antenatal steroids had an advantage in survival with MV equivalent to an increase in birth weight of 90 g, 57 g, and 67 g, respectively. The corresponding advantage of these infants in survival without severe brain injury was 107 g, 97 g, and 64 g, respectively. Females in the lowest birth-weight group were more likely to die without MV than were larger males with a similar estimated likelihood of survival with MV. Mean hospital stay was 115 days for the survivors, values much greater than the 17.9-day standard for 501- to 800-g survivors under the diagnosis related group system. Resource investment was considerable (127 hospital days per survivor and 148 days per survivor without severe brain injury), but, like outcome, varied markedly between risk categories. Had MV been used for all infants who died, we estimate a substantial increase in resource use and a maximum of 8 additional survivors (no more than 6 without severe brain injury per 100 infants with a birth weight of 501 to 800 g.

CONCLUSIONS

Although recommendations to initiate or forgo MV for extremely premature infants have often focused on 1 factor (birth weight or gestational age), multiple factors should be considered. Other factors being equal, our analyses support use of MV for females at a minimum birth weight approximately 100 g lower than that for males. The current diagnosis related group reimbursement system can be expected to compromise resources for 501- to 800-g infants who would benefit from MV. Such care entails considerable resource use, although the cost per life-year gained is likely to be considerably less than that for many adults given intensive care. Our findings can be used to facilitate more appropriate treatment decisions, determine adequate resources, and better inform the debate about the benefits and burdens of intensive care for extremely premature newborns.

The aetiology, investigation and management of surgical disorders of the thyroid gland

There have been many recent advances in our understanding of thyroid disease, including thyroid physiology, the molecular biology of thyroid neoplasms, guidelines for the management of surgical thyroid disease and the operative approach to thyroidectomy. The control of thyroid growth and function is better understood now that the thyroid stimulating hormone (TSH) receptor has been characterized as a G-protein coupled transmembrane receptor. The peripheral action of thyroid hormones is also better understood in terms of their interaction with nuclear thyroid hormone receptors. An adenoma-carcinoma sequence for the development of thyroid neoplasms has been proposed based on the characterization of a number of proto-oncogenes and tumour suppressor genes, and different pathways for the development of papillary and follicular thyroid carcinoma have been demonstrated. Fine needle biopsy has become, over the past few years, the principal diagnostic technique for evaluation of thyroid nodules, and has resulted in a significant reduction in the need for surgery for benign thyroid nodules. The approach to the management of thyroid carcinoma can now be based on comprehensive scoring systems for assigning patients to a particular risk group, the most recent of which is the MACIS system based on distant metastases (M), age (A), completeness of resection (C), invasion (I) and size (S). The capsular technique of thyroidectomy as described has now been shown to be the best method to preserve parathyroid blood supply, protect the recurrent laryngeal nerve and minimize the complications of thyroid surgery.

Very-low-birth-weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, May 1991 through December 1992

OBJECTIVES

Our goals were to determine the mortality risk for infants weighing 501 to 1500 gm according to gestational age, birth weight, and gender and to document birth weight-related changes in mortality and morbidity over a 5-year time period.

STUDY DESIGN

In this observational study perinatal data were prospectively collected by the 12 participating centers of the National Institute of Child Health and Human Development Neonatal Research Network from May 1991 through December 1992 and compared with the corresponding data from 1987 through 1990. Standard definitions were used to record sociodemographic factors, perinatal events, and the neonatal course to 120 days of life, discharge, or death.

RESULTS

The 1991 and 1992 cohort included 4279 in-born infants. Among their mothers 10% were < 18 years old; 55% were black, 31% were white, and 11% were Hispanic; 14% had received no prenatal care; and 20% had received antenatal corticosteroids. Multiple gestations accounted for 20% of the births. Fifty percent of the infants were delivered by cesarean section. During 1991 and 1992 the overall survival for infants weighing 501 to 1500 gm at birth was 81%, compared with 74% in 1987 and 1988. Survival at birth weight 501 to 750 gm was 44%; it was 81% at 751 to 1000 gm, 92% at 1001 to 1250 gm, and 95% between 1251 and 1500 gm. Female infants had a significantly greater chance of surviving than male infants at similar birth weights and gestational ages. At any given gestational age, smaller infants were less likely to survive. Survival in all birth weight categories increased between 1987 and 1992, without accompanying increases in medical morbidity. Major morbidity increased with decreasing birth weight and included late-onset septicemia 22%, chronic lung disease (oxygen dependence at 36 weeks' corrected age) 18%, severe intraventricular hemorrhage (grades III and IV) 11%, and necrotizing enterocolitis 5%. Twelve percent of all infants were treated with corticosteroids for chronic lung disease, including 36% of infants who were oxygen dependent at age 28 days. The mean length of hospital stay was 69 days for survivors and 18 days for infants who died.

CONCLUSIONS

Mortality for infants between 501 and 1500 gm at birth has declined over the past 5 years. There are interactions between birth weight, gestational age, gender, and survival rate. This increase in survival was not accompanied by an increase in medical morbidity.

Rapid identification of Mycobacterium xenopi from bacterial colonies or "Bactec" culture by the polymerase chain reaction and a luminescent sandwich hybridization assay

Oligonucleotide primers were used in the polymerase chain reaction (PCR) to amplify a specific 584-bp DNA fragment, located in the 16S RNA gene of Mycobacterium xenopi. This set of primers, X222 and X224, was able to discriminate between the pathogen and other mycobacterial species as well as non-mycobacterial strains; it detected down to 3 fg of M. xenopi DNA, i.e. about one genome equivalent. These oligonucleotide primers proved suitable for the routine identification of M. xenopi cultures, starting from one single colony on solid medium or from a liquid culture in Middelbrook 12B "Bactec" medium. In addition, a luminescent hybridization assay was designed for use on PCR-amplified DNA. This system, which, for capture, relied on a matrix-bound oligonucleotide (M30) specific for the genus Mycobacterium and, for detection, on a biotinylated xenopi-specific X221 probe, proved fully specific, highly sensitive and rapid for the evaluation of M. xenopi Bactec cultures at low growth index.

Very-low-birth-weight outcomes of the National Institute of Child Health and Human Development Neonatal Network, November 1989 to October 1990

OBJECTIVE

Our purpose was to describe the neonatal outcomes of 1804 very-low-birth-weight (< or = 1500 gm) infants delivered between November 1989 and October 1990 in the participating centers of the National Institute of Child Health and Human Development Neonatal Research Network.

STUDY DESIGN

In an observational study sociodemographic, pregnancy, and delivery data were collected soon after birth, and neonatal and outcome data at discharge, at 120 days, or at death.

RESULTS

Maternal and birth weight characteristics included 64% black, 29% white; 71% single mothers; 18% no prenatal care; 17% antenatal steroids; and 12% multiple gestations. Birth weight distributions included 18% weighing 501 to 750 gm, 23% 751 to 1000 gm, 28% 1001 to 1250 gm, and 31% 1251 to 1500 gm. Survival was 39% at < 751 gm birth weight, 77% at 751 to 1000 gm, 90% at 1001 to 1250 gm, and 93% at 1251 to 1500 gm. Survival was 15% to 18% at < or = 23 weeks' gestation, 54% at 24 weeks, 59% at 25 weeks, and 71% at 26 weeks. Surfactant was administered to 45% of the 56% of infants with respiratory distress syndrome. Morbidity, including intraventricular hemorrhage (40%), septicemia (24%), symptomatic patent ductus arteriosus (22%), and necrotizing entercolitis (8%), increased with decreasing birth weight. Oxygen was administered for > or = 28 days to 82% of < 751 gm infants, 49% of 751 to 1000 gm infants, and 10% of > 1001 gm infants. Steroids were administered to 28% of infants who required oxygen for > or = 28 days. Mean hospital stay was 62 days for survivors and 18 days for infants who died. There were large intercenter variations in mortality and morbidity.

CONCLUSION

Mortality and morbidity in very-low-birth-weight infants improved in 1989 to 1990 without an increase in morbidity or length of hospital stay. The threshold of the improved survival was > or = 24 weeks and 601 to 700 gm. Although such data are reassuring, the rate of major morbidity in < 1001 gm birth weight infants continues to be high.