Papillary thyroid carcinoma: the impact of histologic vascular invasion

BACKGROUND

The American Thyroid Association (ATA) recurrence risk prediction system considers vascular invasion (VI) as a relative indicator for adjuvant radioactive iodine (RAI) treatment, nevertheless VI final role in PTC management is yet to be defined. This study aims to assess the impact of histologic VI in papillary thyroid carcinoma (PTC).

METHODS

A retrospective study with PTC patients admitted in our Thyroid Cancer Unit, between January 1960 and December 2016 was performed. We reviewed 905 patient records with 275 having full information about VI on their pathological reports. Demographic and clinical variables were obtained, and univariate/multivariate analysis was performed in order to obtain potential predictive prognostic factors.

RESULTS

Fifty-one out 275 patients presented VI (18.5%; 95% CI 14.4-23.6%), these individuals had larger tumors (median 19 mm vs. 12 mm, P<0.001) with more frequent extraglandular invasion (54.0% vs. 17.1%, P<0.001), regional lymph nodes involvement (29.8% vs. 12.6%, P=0.003)and distant metastasis (10.9% vs. 1.9%, P=0.003) at diagnosis. VI was an independent predictor for regional lymph node and/or distant metastasis at diagnosis (OR 2.93 [IC 95% 1.16-7.41, P=0.008]). After a median follow-up time was 68.5 months patients with VI presented higher rates of local recurrence and lymph node metastasis recurrence.

CONCLUSIONS

In this study, the presence of VI in PTC is associated to higher rate of lymph node and distant metastasis at diagnosis. Its presence should be probably considered an adverse prognostic factor in PTC, perhaps justifying more aggressive therapeutic and follow-up approaches in such cases.

Serum TSH as a predictor of malignancy in indeterminate thyroid nodules

INTRODUCTION

Thyroid nodules are lesions that are radiologically distinct from the thyroid parenchyma. Cervical ultrasound diagnoses 19-67% of nodules and is crucial in identifying those that lack cytological characterisation. Approximately 25% of biopsies reveal an indeterminate cytological result (Bethesda III), in which the risk of malignancy is variable (5-15%). The clinical importance of the diagnostic strategy used for thyroid nodules results from the need to exclude malignancy. The aim of this study was to evaluate the usefulness of serum thyroid-stimulating hormone (TSH) levels as a predictor of malignancy in cytologically indeterminate thyroid nodules.

METHODS

Our retrospective study included 40 patients with cytologically indeterminate thyroid nodules seen in our hospital between January 2013 and December 2017. Clinical parameters were reviewed, including age, gender, serum TSH levels, family history of thyroid carcinoma, radiation exposure and some sonographic features of the nodules. Statistical analysis was performed using SPSS. Statistical significance was defined as p<0.05.

RESULTS

Female gender was predominant (85%) and the mean (SD) age was 53.3 (15) years. Thyroid carcinoma was confirmed in 28% of patients. Median TSH levels were higher in patients with malignant (2.73µIU/ml) compared with benign (1.56µIU/ml) nodules (p<0.05). We demonstrated an increased risk of malignancy in patients with TSH levels of 2.68µIU/ml or above (p<0.05).

CONCLUSION

Higher serum TSH levels are associated with an increased risk of thyroid carcinoma in cytologically indeterminate nodules. TSH can become a fundamental diagnostic tool in stratifying the risk of malignancy and assist in diagnostic and therapeutic approaches to these nodules.

Third trimester HbA1c and the association with large-for-gestational-age neonates in women with gestational diabetes

Objective

To evaluate the association between HbA1c levels measured in the third trimester and the risk for large for gestational age (LGA) in neonates of mothers affected by gestational diabetes mellitus (GDM). Secondarily, we aimed to identify an ideal cut-off for increased risk of LGA amongst pregnant women with GDM.

Methods

Observational retrospective review of singleton pregnant women with GDM evaluated in a diabetes and pregnancy clinic of a tertiary and academic hospital. From January/2011 to December/2017, 1,085 pregnant women underwent evaluation due to GDM, of which 665 had an HbA1c test in the third trimester. A logistic regression model was performed to evaluate predictors of LGA. A receiver-operating-characteristic (ROC) curve was used to evaluate the predictive ability of third trimester HbA1c for LGA identification.

Results

A total of 1,085 singleton pregnant women were evaluated during the study period, with a mean age of 32.9 ± 5.3 years. In the multivariate analysis, OGTT at 0 minutes (OR: 1.040; CI 95% 1.006-1.076, p = 0.022) and third trimester HbA1c (OR: 4.680; CI 95% 1.210-18.107, p = 0.025) were associated with LGA newborns. Using a ROC curve to evaluate the predictive ability of third trimester HbA1c for LGA identification, the optimal HbA1c cut-off point was 5.4% where the sensitivity was 77.4% and the specificity was 71.7% (AUC 0.782; p < 0.001).

Conclusion

Few studies in the Mediterranean population have evaluated the role of HbA1c in predicting neonatal complications in women with GDM. A third trimester HbA1c > 5.4% was found to have good sensitivity and specificity for identifying the risk of LGA.

Prevalence of Nutritional Risk at Admission in Internal Medicine Wards in Portugal: The Multicentre Cross-Sectional ANUMEDI Study

INTRODUCTION

Disease-related undernutrition is highly prevalent and requires timely intervention. However, identifying undernutrition often relies on physician judgment. As Internal Medicine wards are the backbone of the hospital setting, insight into the prevalence of nutritional risk in this population is essential. We aimed to determine the prevalence of nutritional risk in Internal Medicine wards, to identify its correlates, and to assess the agreement between the physicians' impression of nutritional risk and evaluation by Nutritional Risk Screening 2002.

MATERIAL AND METHODS

A cross-sectional multicentre study was performed in Internal Medicine wards of 24 Portuguese hospitals during 2017. Data on demographics, previous hospital admissions, primary diagnosis, and Charlson comorbidity index score were collected. Nutritional risk at admission was assessed using Nutritional Risk Screening 2002. Agreement between physicians' impression of nutritional risk and Nutritional Risk Screening 2002 was tested by Cohen's kappa.

RESULTS

The study included 729 participants (mean age 74 ± 14.6 years, 51% male). The main reason for admission was respiratory disease. Mean Charlson comorbidity index score was 5.8 ± 2.8. Prevalence of nutritional risk was 51%. Nutritional risk was associated with admission during the previous year (odds ratio = 1.65, 95% confidence interval: 1.22 - 2.24), solid tumour with metastasis (odds ratio = 4.73, 95% confidence interval: 2.06 - 10.87), any tumour without metastasis (odds ratio = 2.04, 95% confidence interval:1.24 - 3.34), kidney disease (odds ratio = 1.83, 95% confidence interval: 1.21 - 2.75), peptic ulcer (odds ratio = 2.17, 95% confidence interval: 1.10 - 4.25), heart failure (odds ratio = 1.51, 95% confidence interval: 1.11 - 2.04), dementia (odds ratio = 3.02, 95% confidence interval: 1.96 - 4.64), and cerebrovascular disease (odds ratio = 1.62, 95% confidence interval: 1.12 - 2.35). Agreement between physicians' evaluation of nutritional status and Nutritional Risk Screening 2002 was weak (Cohen's kappa = 0.415, p < 0.001).

DISCUSSION

Prevalence of nutritional risk in the Internal Medicine population is very high. Admission during the previous year and multiple comorbidities increase the odds of being at-risk. Subjective physician evaluation is not appropriate for nutritional screening.

CONCLUSION

The high prevalence of at-risk patients and poor subjective physician evaluation suggest the need to implement mandatory nutritional screening.

High prevalence of malnutrition in Internal Medicine wards - a multicentre ANUMEDI study

BACKGROUND

Disease-related malnutrition is a significant problem in hospitalized patients, with high prevalence rates depending on the studied population. Internal Medicine wards are the backbone of the hospital setting. However, prevalence and determinants of malnutrition in these patients remain unclear. We aimed to determine the prevalence of malnutrition in Internal Medicine wards and to identify and characterize malnourished patients.

METHODS

A cross-sectional observational multicentre study was performed in Internal Medicine wards of 24 Portuguese hospitals during 2017. Demographics, hospital admissions during the previous year, type of admission, primary diagnosis, Charlson comorbidity index, and education level were registered. Malnutrition at admission was assessed using Patient-Generated Subjective Global Assessment (PG-SGA). Demographic characteristics were compared between well-nourished and malnourished patients. Logistic regression analysis was used to identify determinants of malnutrition.

RESULTS

729 participants were included (mean age 74 years, 51% male). Main reason for admission was respiratory disease (32%). Mean Charlson comorbidity index was 5.8 ± 2.8. Prevalence of malnutrition was 73% (56% moderate/suspected malnutrition and 17% severe malnutrition), and 54% had a critical need for multidisciplinary intervention (PG-SGA score ≥9). No education (odds ratio [OR] 1.88, 95% confidence interval [CI]: 1.16-3.04), hospital admissions during previous year (OR 1.53, 95%CI: 1.05-2.26), and multiple comorbidities (OR 1.22, 95%CI: 1.14-1.32) significantly increased the odds of being malnourished.

CONCLUSIONS

Prevalence of malnutrition in the Internal Medicine population is very high, with the majority of patients having critical need for multidisciplinary intervention. Low education level, admissions during previous year, and multiple comorbidities increase the odds of being malnourished.

Cardiovascular Risk Factors in Acromegaly: What's the Impact of Disease Control?

Objective Cardiovascular disease is one of the most important causes of death in acromegalic patients. The aim of this study is to compare the prevalence of cardiovascular risk factors among acromegalic patients and to evaluate the impact of disease control on these factors.

Material and Methods 11 acromegalic patients with active disease and 12 controlled patients were evaluated for blood pressure, body mass index, glucose, coagulation status, and lipid profile. A group of 11 patients with non-functioning pituitary adenomas was used as control population.

Results Significant differences were found in lipid profile, glucose and coagulation status in both active and controlled patients. Higher levels of fasting glucose (151.2±102.5 mg/dL, p=0.05 and 108.3±23.4 mg/dL, p=0.02 for active and controlled patients respectively) and fibrinogen (427.1±61.9 mg/dL, p=0.02 and 437.3±106.6 mg/dL, p=0.04 for active and controlled patients respectively) were present in both acromegalic groups. Active patients had higher levels of antithrombin III (1.1±0.1 U/mL, p=0.005) and the controlled ones had higher levels of high density lipoprotein cholesterol (56.1±12.5 mg/dL, p=0.05), compared with the non-functioning group. The differences between active and controlled acromegalic patients are that the latter have reduced total cholesterol (170.4±31.7 vs 201.7±34.6 mg/dL, p=0.02), lower density lipoprotein cholesterol (96,8±25,2 vs 130.8±31.5 mg/dL, p=0.01) and antithrombin III (1.0±0.2 vs 1.1±0.1 U/mL, p=0.05).

Conclusion There is some reduction in cardiovascular risk factors with control of the disease, but possibly without the return to basal levels.

Do community pharmacists actively engage elderly patients in the dialogue? Results from pharmaceutical care consultations

BACKGROUND

Little is known about community pharmacist-patient interaction within a consultation room, particularly in terms of patient activation and engagement.

OBJECTIVE

To explore pharmacists' communication and attitudes while providing advanced medication-related services.

METHODS

A cross-sectional descriptive study, using the Roter Interaction Analysis System (RIAS) framework, to analyse a sample of audio-recorded pharmaceutical care consultations with elderly patients.

RESULTS

Around 15.0 per cent of pharmacists' utterances and 3.6 per cent of patients' were related to engagement with the latter during the exchange. To improve health outcomes, such as adherence to a therapeutic regime, pharmacists should augment patients' participation in the dialogue, facilitating concerns and disclosure of doubts, thus improving correct medication use behaviour.

Stevens Johnson Syndrome in a patient undergoing gynaecological brachytherapy: An association or an incident?

BACKGROUND

Stevens Johnson Syndrome and Erythema Multiforme are hypersensitivity skin reactions generally arising in the context of multiple causes. Radiation therapy is considered to be one of these causes, although most reports are hindered by concomitant medications.

AIM

The aim of this paper was to present a case of Stevens Johnson Syndrome arising in a patient undergoing gynaecological brachytherapy with an unusual presentation.

CASE

We describe a case of a 56-year-old woman with endometrial cancer undergoing adjuvant gynaecological radiotherapy. While undergoing a gynaecological brachytherapy boost, she developed bilateral conjunctivitis that progressed to oral mucositis and pruritic erythema with sloughing of the skin on her arms and legs but not the torso or irradiated fields (namely the vaginal mucosa).

CONCLUSION

This case illustrates the association of RT/SJS; however, it also raises the question of patients undergoing RT being more susceptible to SJS as opposed to a direct cause of the disease.

Comparison of three DNA extraction methods for Mycobacterium bovis, Mycobacterium tuberculosis and Mycobacterium avium subsp. avium

AIMS

To compare three methods for DNA extraction from Mycobacterium bovis, Mycobacterium tuberculosis and Mycobacterium avium subsp. avium.

METHODS AND RESULTS

The DNA was extracted from mycobacterial cultures using enzymatic extraction, combined bead beating and enzymatic extraction and cetyltrimethylammonium bromide (CTAB) extraction. The yield and quality of DNA were compared by spectrophotometry, agarose gel electrophoresis, restriction endonuclease analysis and PCR. The combined bead beating and enzymatic extraction method yielded more DNA. However, that method produced some sheared DNA, visible either by agarose gel electrophoresis or by restriction endonuclease analysis. All methods were appropriate for PCR amplification of a 123 bp fragment of IS6110 in M. bovis and M. tuberculosis, and of a 1700 bp fragment of FR300 region in M. avium avium.

CONCLUSIONS

Combined bead beating and enzymatic extraction method was the most efficient and easy method for extracting DNA from bacteria of the M. tuberculosis complex.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results reveal important differences among the DNA extraction methods for mycobacteria, which are relevant for the success of further downstream molecular analysis.

Spoligotype diversity of Mycobacterium bovis and Mycobacterium caprae animal isolates

The genetic diversity of 283 Mycobacterium bovis (M. bovis) and 10 Mycobacterium caprae (M. caprae) strains, isolated between 2002 and 2007 from cattle, goat, red deer and wild boar from six different geographical regions of Portugal was investigated by spoligotyping. The technique showed a good discriminatory power (Hunter-Gaston Index, h=0.9) for the strains, revealing 29 different patterns. One pattern (SB0121) was clearly predominant, accounting for 26.3% of the isolates; ten patterns, representing 20.7% of the isolates, had never been reported previously. Multiple spoligotypes were detected in thirteen cattle and one goat herd, most of which were found in beef cattle and extensive management regions, suggesting different infection sources. With the exception of two spoligotypes, those in wildlife species were also found in domestic species.

[Contact dermatitis caused by foods]

Cutaneous adverse reactions to foods and food additives are a growing public health problem which can occur both in the avocational and occupational settings. This article reviews different reaction patterns which can occur upon contact with foods and discusses some clinically important food-associated metal and fragrance allergens responsible for these adverse effects. As ultimately, education and guidance can minimize the morbidity of food allergy and enhance the quality of life of the affected individual; this article highlights this growing problem.

Gastrointestinal complications in renal transplant recipients: MITOS study

INTRODUCTION AND METHODS

An epidemiologic multicenter study was performed to evaluate the prevalence and management of gastrointestinal (GI) complications in solid organ transplant patients. A total of 1788 recipients were included, 1132 of which corresponded to renal transplanted patients.

RESULTS

The mean age for the renal transplanted patients was 52 +/- 13.2 years. The mean time from the transplantation was 5.4 +/- 5.4 years. 17.7% showed some pretransplant GI disease, while 53% presented this type of complication in the posttransplant period. Diarrhea was the most prevalent GI complication (51.5%) and digestive perforation was the GI disorder that affected the patients daily living the most. From the patients with GI complications, 71% received pharmacological treatment, using gastric protectors in 91.3% of the cases. Regarding immunosuppressive drugs, in 30.9% of the cases the dose of the drug was reduced, in 9.3% discontinued temporarily and in 7.5% discontinued permanently. These changes mainly affected the MMF (89%, 83% and 74% for dose change, temporary and permanent discontinuation, respectively).

CONCLUSIONS

The prevalence of GI complications in renal transplant exceeded 50%, and affected patients' daily living. The management of these complications was based on treatment with gastric protectors, dose reduction and/or partial or definitive MMF discontinuation.

Primary lung liposarcoma

Liposarcoma of the lung is extremely rare with only 11 cases previously reported. A case of a locally advanced pulmonary pleomorphic liposarcoma in a 49-year-old male is presented. Surgery was performed but radical resection was not possible. Post-operative radiotherapy (40 Gy) was given concurrently with cisplatin (12.5 mg daily for 10 days). A partial response of short duration was obtained. The patient died 8 months following surgery with disseminated disease. Based on reports in the literature, liposarcoma of the lung must be classified as an aggressive highly metastatic disease responding poorly to both chemotherapy and radiotherapy.