Comparison of Cytological Adequacy between 23- and 25-Gauge in Ultrasound-Guided Fine-Needle Aspiration of Thyroid Nodules: A Single-Center Prospective Study

INTRODUCTION

Approximately 15% of fine-needle aspiration (FNA) of thyroid nodules are considered nondiagnostic. Several factors are potentially involved, including clinical and nodule features but also the gauge (G) of the needle used. However, few studies have compared the cytological adequacy obtained with different gauge needles and the data are controversial. We aimed to evaluate cytological adequacy results using 23- or 25-G needles.

METHODS

This study is an observational and prospective study of thyroid nodules submitted to ultrasound-guided FNA. The procedure was performed randomly using 23- or 25-G needles. The samples were reported by different cytopathologists who were blinded to the information of the gauge of the needle used. Statistical analysis was performed to compare cytological adequacy of FNA between the two groups.

RESULTS

A total of 177 thyroid nodules were included - 98 (55.4%) using 23-G and 79 (44.6%) using 25-G needles. The 23-G group presented a higher rate of cytological adequacy (69.4% [68/98] vs. 46.8% [37/79], p = 0.002). No differences were found between the two groups regarding patient or nodule characteristics. On logistic regression, 23-G needles correlated with better cytological adequacy (unadjusted OR 2.57 [95% CI: 1.39-4.77]), even after adjusting for nodule dimension, location, and type of cytology (slides +/- additional liquid-based cytology) (adjusted OR 2.44 [95% CI: 1.23-4.84]).

CONCLUSION

The gauge of the needle used was found to be an independent predictor of cytological adequacy, with 23-G needles providing more adequate samples. Further investigation is needed to confirm our results in order to stablish the optimal diagnosis technique.

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.

Leg dystrophic calcification as a consequence of chronic diabetic foot infection: a case report

Foot ulceration and infection is associated with a substantial increase in morbidity and mortality in patients with diabetes. We present a clinical case of recurrent diabetic foot infection with an atypical clinical evolution. A 58-year-old male patient with type 1 diabetes and a history of bilateral Charcot foot neuroarthropathy was followed at our Diabetic Foot Clinic for an unhealed plantar foot ulcer for >1.5 years with recurrent episodes of infection. He was admitted to hospital due to foot ulcer reinfection with sepsis and ipsilateral lower limb cellulitis. The foot infection was found to be associated with an underlying abscess in the anterior compartment of the leg, with a cutaneous fistulous course with extensive alterations of an inflammatory nature. Exudate from the lesion was drained and tissue biopsied, revealing Serratia marcescens and Klebsiella oxytoca with dystrophic calcification (DC). Surgical excision of dystrophic tissue with debridement of the fistulous tracts was performed. The excised material corroborated the presence of fibroadipose connective tissue with marked DC, as well as areas of mixed inflammation compatible with a chronic infectious aetiology. Targeted long-term antibiotic therapy was implemented, for a total of six weeks, with a favourable clinical evolution and complete closure of the lesion at the final follow-up. DC results from calcium deposition in degenerated tissues without evidence of systemic mineral imbalance and is a potential cause of non-healing ulcers. Few cases of DC have been reported in diabetic foot patients and its treatment remains challenging and controversial. A longer follow-up period is necessary to verify the effectiveness of our approach.

Distinct TNF-alpha and HLA polymorphisms associate with fibrotic and non-fibrotic subtypes of hypersensitivity pneumonitis

INTRODUCTION

Since Hypersensitivity Pneumonitis (HP) categorization in fibrotic and nonfibrotic/inflammatory types seems to be more consistent with the distinctive clinical course and outcomes, recent international guidelines recommended the use of this classification. Moreover, fibrotic subtype may share immunogenetic and pathophysiological mechanisms with other fibrotic lung diseases.

AIM

To investigate HLA -A, -B, -DRB1 and TNF-α -308 gene polymorphisms among fibrotic and nonfibrotic HP patients due to avian exposure, also in comparison with asymptomatic exposed controls.

METHODS

We prospectively enrolled 40 HP patients, classified as fibrotic or nonfibrotic/inflammatory, and 70 exposed controls. HLA and TNF-α polymorphisms were determined by polymerase chain reaction-sequence specific primer amplification.

RESULTS

While HLA alleles were not associated to HP susceptibility, fibrotic HP patients showed increased frequencies of HLA A*02 (46.7% vs 25.7%; OR=2.53, p = 0.02) and HLA DRB1*14 (10.0% vs 0.7%; OR=15.44, p=0.02) alleles when compared with exposed controls, although not statistically significant after correction for multiple comparisons. TNF-α G/G genotype (associated with low TNF-α production) frequencies were significantly increased among the non-fibrotic/inflammatory HP patients comparatively to fibrotic presentations (88% vs 60%; RR=0.44; p=0.04) and controls (88% vs 63%, OR 4.33, p=0.037). Also, these patients had a significantly increased frequency of the G allele (94.0% vs 73.3%, RR=0.44, p=0.01), while fibrotic HP patients predominantly presented the A allele (26.7% vs 6.0%, RR=2.28, p=0.01).

CONCLUSIONS

Our results support the hypothesis that fibrotic and non-fibrotic HP subtypes exhibit a distinct profile of TNF-α and HLA polymorphisms, which may be relevant to predict disease course and better define treatment strategies.

Decoupling of Temperature and Strain Effects on Optical Fiber-Based Measurements of Thermomechanical Loaded Printed Circuit Board Assemblies

This study investigated the use of distributed optical fiber sensing to measure temperature and strain during thermomechanical processes in printed circuit board (PCB) manufacturing. An optical fiber (OF) was bonded to a PCB for simultaneous measurement of temperature and strain. Optical frequency-domain reflectometry was used to interrogate the fiber optic sensor. As the optical fiber is sensitive to both temperature and strain, a demodulation technique is required to separate both effects. Several demodulation techniques were compared to find the best one, highlighting their main limitations. The importance of good estimations of the temperature sensitivity coefficient of the OF and the coefficient of thermal expansion of the PCB was highlighted for accurate results. Furthermore, the temperature sensitivity of the bonded OF should not be neglected for accurate estimations of strains. The two-sensor combination model provided the best results, with a 2.3% error of temperature values and expected strain values. Based on this decoupling model, a methodology for measuring strain and temperature variations in PCB thermomechanical processes using a single and simple OF was developed and tested, and then applied to a trial in an industrial environment using a dynamic oven with similar characteristics to those of a reflow oven. This approach allows the measurement of the temperature profile on the PCB during oven travel and its strain state (warpage).

Survey on selenium clinical supplementation in autoimmune thyroid disease

Objective

Previous trials show that selenium could be a very useful tool in the control and treatment of autoimmune thyroid diseases. In this cross-sectional study, through a survey, we aim to evaluate Portuguese endocrinologists' perception and pattern of prescription of selenium supplements in these diseases and verify its agreement with current guidelines.

Methods

The endocrinologists registered in the Portuguese Medical Association were sent an email with a web-based questionnaire, regarding their knowledge and use of selenium supplements in thyroid autoimmune pathology.

Results

A total of 105 physicians (33% of the total) submitted the survey. The selenium serum concentration in the general population was unknown to 80% of respondents. Over a third of respondents have never prescribed selenium for autoimmune thyroid disease. However, 89% are not afraid of recommending it, and 61% indicate Graves' orbitopathy as the pathology they would supplement. In Hashimoto's thyroiditis, 36% of respondents use selenium occasionally or frequently, and this percentage rises to 60% in Graves' disease.

Conclusions

Although recommendations only encompass mild Graves' orbitopathy, selenium is prescribed across the spectrum of autoimmune thyroid diseases, probably due to recent studies that consistently show improvement of biochemical hallmarks in these patients. Further investigation is required on the impact of selenium supplements on primarily clinical outcomes and to identify disorders and/or patients who will benefit the most. Also, there is still insufficient knowledge of this field in the medical community, and evidence-based practice should continue to be promoted by endocrinology societies.

The influence of simultaneous pancreas-kidney transplantation on the evolution of diabetic foot lesions and peripheral arterial disease

PURPOSE

Simultaneous pancreas-kidney transplantation (SPKT) remains the best treatment option in patients with type 1 diabetes and chronic kidney failure. There are only a few studies addressing the potential ischemic deterioration of peripheral arterial disease (PAD) due to blood diverting from the iliac artery to the kidney graft. We aimed to evaluate diabetic foot lesions and PAD evolution in SPKT recipients and investigate if they are more frequent in ipsilateral lower limb of kidney graft.

METHODS

We developed a retrospective cohort, including patients submitted to SPKT in our tertiary center, between 2000 and 2017. Diabetic foot lesions and PAD frequencies were compared in the period before and after transplantation.

RESULTS

Two hundred and eleven patients were included, 50.2% (n = 106) female, with a median age at transplantation of 35 years (IQR 9). After a median follow-up period of 10 years (IQR 7), patient, kidney, and pancreatic graft survival were 90.5% (n = 191), 83.4% (n = 176), and 74.9% (n = 158), respectively. Before transplant, 2.8% (n = 6) had PAD and 5.3% (n = 11) had history of foot lesions. In post-transplant period, 17.1% (n = 36) patients presented PAD and 25.6% (n = 54) developed diabetic foot ulcers, 47.6% (n = 35) of which in the ipsilateral and 53.3% (n = 40) in the contralateral lower limb of the kidney graft (p = 0.48). Nine patients (4.3%) underwent major lower limb amputation, 3 (30%) ipsilateral and 7 (70%) contralateral to the kidney graft (p = 0.29).

CONCLUSIONS

Diabetic foot lesions were not more frequent in the ipsilateral lower limb of the kidney graft, therefore downgrading the 'steal syndrome' role in these patients.

Levothyroxine malabsorption or pseudomalabsorption? A question in the management of refractory hypothyroidism

PURPOSE

The levothyroxine absorption test (LT4AT) is an important tool for distinguishing hypothyroidism due to malabsorption from 'pseudomalabsorption' conditions. Our aim was to review our institution's LT4AT results and assess its role in the management of patients with refractory hypothyroidism.

METHODS

We performed a retrospective study of all patients evaluated for refractory hypothyroidism who underwent LT4AT in our tertiary center between 2014 and 2020. Its results and the impact on thyroid function management during follow-up were assessed.

RESULTS

Ten female patients were included with a mean age of 40 years (min-max: 26-62). Mean weight was 72 kg (min-max: 43-88) and baseline LT4 dosage ranged from 2.5 to 5.3 µg/kg/day. The most common causes of hypothyroidism were postsurgical in 50% (n = 5) and autoimmune in 20% (n = 2). During LT4AT, normal LT4 absorption was found in all but one individual (mean FT4 increase of 231%, min-max: 85-668). The only patient with objective LT4 absorption impairment (maximal increase of 48% by hour 5) presented also Helicobacter pylori gastritis and prior history of 'intestinal surgery' during childhood. No adverse events were reported during any of the LT4ATs. During follow-up (median 11.5 months (IQR 23)), three patients obtained euthyroidism and six had improved their hypothyroidism state.

CONCLUSIONS

The LT4AT is an effective and safe way to assess refractory hypothyroidism and provides valuable information to distinguish LT4 malabsorption from 'pseudomalabsorption'. Our data suggest that most patients with suspicious LT4 malabsorption perform normally during LT4AT. This test provides relevant information for better management of patients with refractory hypothyroidism.

Geographic variation in heart failure with reduced ejection fraction: insights from the VICTORIA trial

Background

Geographic differences and background therapy have not been explored in the global VICTORIA trial, which enrolled high-risk patients with recent worsening heart failure with reduced ejection fraction (HFrEF).

Methods and results

Among 5050 patients enrolled in 5 pre-specified geographic regions, 34% were from Eastern Europe, 18% Western Europe, 23% Asia Pacific, 14% Latin and South America, and 11% North America (Table 1). Patients from Western Europe were older, had more atrial fibrillation, and lower glomerular filtration rates. Patients from Eastern Europe had more coronary artery disease and exhibited more advanced symptoms (∼50% New York Heart Association [NYHA] class III), whereas those from Latin and South America were less symptomatic (∼70% NYHA class II). North American patients had the largest body mass index as well as more diabetes and hypertension. Levels of NT-proBNP at randomization and MAGGIC risk scores were highest in Western European patients. Evidence-based triple medication therapy was used most frequently in Latin and South America and less frequently in North America; conversely, cardiac resynchronization therapy and implantable cardioverter defibrillators were most frequently used in North America and least frequently in Latin and South America. The overall primary composite event rate (cardiovascular death or HF hospitalization) in the placebo arm was 36.6/100 person-years over a median of 10.8 months and after adjusting for the MAGGIC score. When examined by region, these event rates were nominally highest in North America and lowest in Western Europe.

Conclusion

Substantial regional differences exist in characteristics and treatments among patients in this global trial of patients with HFrEF and a recent worsening event. These findings demonstrate the continuing unmet needs and opportunities for enhancing care in HFrEF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): VICTORIA was funded by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA and Bayer AG, Wuppertal, Germany.

Predictors of lung entrapment in malignant pleural effusion

INTRODUCTION

Malignant pleural effusion (MPE) is a common complication in advanced stages of malignancy and is associated with poor prognosis. Non-expandable lung (NEL) often occurs and its presence influences the MPE approach. Our main objective was to assess risk factors for malignant NEL.

METHODS

Patients diagnosed with pathologically confirmed MPE between January 2012 and December 2018 in our institution were retrospectively analyzed. Demographic and clinical data of patients were reviewed and compared according to the presence or absence of NEL. A univariate and multivariate binary logistic regression analysis were used to determine predictors of the development of NEL.

RESULTS

Of 365 patients included, 68 (18.6%) had NEL. After multivariate analysis, we found that loculated MPE (OR 8.63, 95%CI 4.30-17.33, p<0.001), complete hemithorax opacification (OR 2.81, 95%CI 1.17-6.76, p<0.021), lung cancer (OR 2.09, 95%CI 1.01-4.31, p=0.047) and higher effusion-serum LDH ratio (OR 1.09, 95%CI 1.00-1.17, p=0.039) were independent predictors of malignant NEL. There were no significant differences compared with expandable lung group regarding time from primary malignancy diagnosis to MPE diagnosis (3.0, IQR 0.0-75.8 vs 2.0, IQR 0.0-75.5 weeks, p=0.942) or MPE symptoms onset to MPE diagnosis (4.0, IQR 1.0-9.0 vs 3.0, IQR 1.0-9.0 weeks, p=0.497). Patients with NEL had a higher number of therapeutic pleural drainages (3.0, IQR 2.0-6.0 vs 2.0, IQR 1.0-3.0; p<0.001) and longer hospital stay (32.5, IQR 15.5-46.3 vs 21.0, IQR 11.0-36.0, p=0.007), measured in hospitalization days until the end of life, than patients with expandable lung. The rate of recurrence of pleural effusion was not significantly different between groups (p=0.291). Overall survival (OS) was 3.0 (95%CI, 2.3-3.7) months, regardless of lung expandability (p=0.923).

CONCLUSION

Loculated MPE, complete hemithorax opacification, lung cancer and a higher effusion-serum LDH ratio were found to be independent predictors for NEL. These patients underwent thoracocenteses more frequently and had longer hospitalization days, although without significant impact in the OS.

A Retrospective Cohort Study on Diabetic Foot Disease: Ascertainment of Ulcer Locations by Age Group

Background and aims

Diabetic foot ulcer location is a known independent predictor for cure with a better healing gradient proximal to distal. Although advanced age is one of the main factors associated with greater diabetic foot ulcer severity, there are no studies evaluating diabetic foot ulcer location specifically in the elderly population in an outpatient setting. This study evaluated diabetic foot ulcer location and age-group interactions in diabetic foot presentation.

Methods

A retrospective cohort study including adult patients with diabetic foot ulcers observed on their first visit to our center's Diabetic Foot Unit in 2018, divided into younger adults (YA) (18 to 64 years) and older adults (OA) (≥65 years).

Results

A total of 435 patients were included in the study with 159 (36.6%) in the YA, and 276 (63.4%) in the OA group.

Neuro-ischemic diabetic foot ulcers were more frequent in the OA group (71.4% vs 43.4%, p<0.001). The number of patients with a history of diabetic foot ulcers was lower in the OA group (18.1% vs 25.2%, p=0.03). A smaller proportion of forefoot diabetic foot ulcers (74.9% vs 86.2%, p=0.007) and plantar location diabetic foot ulcers (9.4% vs 24.5%, p<0.001) occurred in the OA group.

By univariate logistic regression analysis, we found two associations with older age: proximal (odds ratio (OR) 2.09 (1.23-3.53), p=0.006), and non-plantar (OR 3.13 (1.82-5.37), p<0.001) diabetic foot ulcer location. After adjusting for potential confounders in a multivariate analysis, older age lost the association to more proximal (OR 1.72 (0.94-3.15), p=0.081) and non-plantar (OR 1.78 (0.83-3.77), p=0.133) diabetic foot ulcer location.

Conclusions

There are essential age differences in diabetic foot ulcer presentation. The OA group more frequently presents neuro-ischemic diabetic foot ulcers with more proximal and non-plantar locations.

Non-thyroidal second primary malignancy in papillary thyroid cancer patients

INTRODUCTION

The occurrence of non-thyroidal second primary malignancy (NTSPM) in patients with papillary thyroid cancer (PTC) is well documented, but epidemiological data are conflicting.

OBJECTIVE

The aim of this study was to evaluate the incidence of NTSPM in a large series of patients with PTC and to assess its potential risk factors.

METHODS

Single-center cohort study with retrospective data collection conducted on consecutive PTC patients diagnosed from 1988 to 2018 with a minimum follow-up time of 2 years. NTSPM was defined as any primary malignancy with histological confirmation occurring in an anatomical site other than the thyroid. According to the timing of occurrence, NTSPM were subdivided into anachronous, synchronous or metachronous (diagnosed >6 months before, within 6 months and >6 months after PTC diagnosis, respectively).

RESULTS

We included 773 individuals (83.3% females), median age at PTC diagnosis was 47.0 (IQR: 37.0-58.0) years and median follow-up time was 9.9 (6.2-16.3) years. Incidence of NTSPM was 15.5% (n = 120) and its standard incidence ratio (SIR) was higher when compared to the general population (SIR: 2.70). Family history of malignancy and younger age at diagnosis were associated respectively with 206 and 4% increased risk of developing metachronous neoplasia (HR: 2.06 (95% CI: 1.10-3.86) and 1.04 (95% CI: 1.02-1.05), respectively).

CONCLUSION

In our series, the occurrence of NTSPM was not uncommon and its incidence was higher compared to the general population. First-degree family history of malignancy was a strong risk factor for multiple primary malignancies.

Rationality and suicide, cultural context and mental illness – tenuous limits: about a clinical case

Introduction

Suicide results from a complex interaction between biological, genetic, psychological, sociological, cultural and environmental factors. The frequency of suicide among psychiatric pathologies is quite variable, with depression accounting for 45% to 70% of suicides. The association of suicide with the existence of mental illness is not consensual, with reports of rational suicides in 2% to 9% of suicide cases. It is unquestionable that the awareness of the lived experience limits the person’s condition to what it is.

Objectives

To describe a clinical case on the subject and discuss the influence of cultural context in suicide.

Methods

The authors describe a case of a patient hospitalized in Psychiatry, after a suicide attempt and a consummated suicide by his wife.

Results

The patient and his wife lived their entire lives as hermits. Although no acute psychopathology was found in the patient to justify the act, such as psychotic or depressive symptoms, dysfunctional personality traits were found, which translated into an attitude of superiority, requirement of subservience, hostility when contradicted and breaches of basic rules.

Conclusions

Taking into account what has been described, the authors discuss the influence of personality on the patient’s life choices and on the decision that led to the suicide attempt, as well as the suicide of his wife. A reflection is made on whether suicide can be completely independent of mental illness or whether, even in cases where rationality seems to be the causal factor, personality dysfunctionality and a profound influence of the cultural context, are present or not.

Disclosure

No significant relationships.

Valproic acid-induced hyperammonemic encephalopathy: a clinical case

Introduction

Valproic acid is a psychotropic drug used for several years, due to its properties as a mood stabilizer, being considered as first-line treatment for bipolar disorder. In addition to its teratogenic potential, which prevents its recommendation for the treatment of bipolar disorder in women of childbearing age, valproic acid is associated with some side effects, such as gastrointestinal symptoms, alopecia, weight gain, tremor or hepatotoxicity. Hyperammonemia is a side effect that is little described, but relatively frequent, and may progress to variable encephalopathy.

Objectives

The authors describe a clinical case of a 48-year-old female patient, hospitalized due to a manic episode, who was prescribed valproic acid, in association with lorazepam and olanzapine.

Methods

After three days on a dose of 1000mg of valproic acid, the patient began an acute condition of confusion, psychomotor retardation, temporal-spatial disorientation and ataxia. Infection, electrolyte disturbance and acute cerebral event were excluded. Noteworthy only hyperammonemia. Valproic acid was withdrawn and replaced by lithium, with the patient recovering from the confusional state two days later.

Results

Hyperamonemic encephalopathy secondary to valproic acid was concluded. The mechanisms of valproic acid-linked hyperammonemia are not clear, although it appears to be independent of hepatotoxicity. The most studied hypotheses are related to glutamine reabsorption and serum levels carnitine in patients medicated with valproic acid.

Conclusions

It is essential that there is a high level of suspicion in clinicians for this secondary effect of valproic acid, in order to adequately treat the patient who presents with acute confusional conditions, not explained by other complications.

Disclosure

No significant relationships.

Predictors of immune-related adverse events and outcomes in patients with NSCLC treated with immune-checkpoint inhibitors

OBJECTIVE

To identify predictors of immune-related adverse events (IRAEs) in patients with non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICIs). Assess associations between outcomes and the development of IRAEs.

METHODS

Retrospective analysis of patients with NSCLC treated with ICIs between 2016 and 2020 in the Pulmonology Department of our hospital. Patients with and without IRAEs were compared. A logistic regression analysis was performed to determine predictors of IRAEs. Progression-free survival (PFS) and overall survival (OS) curves were calculated using the Kaplan-Meier method, and the long-rank test was used to assess survival differences between groups. Univariate and multivariate Cox proportional-hazards regression models were used to identify factors associated with PFS and OS. The value considered statistically significant was p≤0.05.

RESULTS

A total of 184 patients (77.7% men, mean age 66.9±9.5 years) treated with ICIs were analyzed. During follow-up, 49 (26.6%) patients developed IRAEs and 149 (81.0%) died. According to the multivariate logistic regression analysis, treatment with statins (OR:3.15; p = 0.007), previous systemic corticosteroid therapy (OR:3.99; p = 0.001), disease controlled as response to ICI (OR:5.93; p < 0.001) and higher hemoglobin values (OR:1.28; p = 0.040) were independent predictors for the development of IRAEs. Patients who developed IRAEs had significantly longer medians of PFS (41.0 vs 9.0 weeks, p < 0.001) and OS (89.0 vs 28.0 weeks; p < 0.001).

CONCLUSIONS

Patients treated with statins, pre-ICI systemic corticosteroids, higher baseline hemoglobin value and controlled disease as initial response to ICI had a higher risk of developing IRAEs. The development of IRAEs was associated with better outcomes.

Towards Machine Learning-Aided Lung Cancer Clinical Routines: Approaches and Open Challenges

Advancements in the development of computer-aided decision (CAD) systems for clinical routines provide unquestionable benefits in connecting human medical expertise with machine intelligence, to achieve better quality healthcare. Considering the large number of incidences and mortality numbers associated with lung cancer, there is a need for the most accurate clinical procedures; thus, the possibility of using artificial intelligence (AI) tools for decision support is becoming a closer reality. At any stage of the lung cancer clinical pathway, specific obstacles are identified and “motivate” the application of innovative AI solutions. This work provides a comprehensive review of the most recent research dedicated toward the development of CAD tools using computed tomography images for lung cancer-related tasks. We discuss the major challenges and provide critical perspectives on future directions. Although we focus on lung cancer in this review, we also provide a more clear definition of the path used to integrate AI in healthcare, emphasizing fundamental research points that are crucial for overcoming current barriers.

Thyroid-Stimulatory Antibody as a Predictive Factor for Graves’ Disease Relapse

Introduction: Thyroid-stimulatory antibody (TSAb) assays have been recently optimized, potentially allowing to determine thyrotropin receptor antibodies' (TRAbs) functionality in routine clinical practice. We aimed to determine TSAb's predictive role of relapse at antithyroid drug (ATD) withdrawal in Graves’ disease (GD).

Methods: Retrospective study of GD patients with stable normal thyroid function under low ATD doses that were proposed for withdrawal. Thyroid function tests and TRAb and TSAb levels were obtained at ATD suspension and every three to six months after that, for a minimum of 16 months. Clinical factors associated with GD relapse, such as age at diagnosis, sex, smoking status, thyroid volume, and presence of orbitopathy, were also evaluated.

Results: Thirty-five patients with GD were included for analysis, with a median follow-up period of 24 months, during which 14 patients (40%) relapsed. Relapse was more common in patients with positive TSAb than patients with negative TSAb at ATD withdrawal (79% vs. 33%, p=0.01). Relapse-free survival was shorter in TSAb-positive patients (p=0.01). There were no differences in relapse rates according to TRAb positivity at ATD withdrawal (42.9% vs. 36.4%, p=0.74). We also did not find any differences in relapse rate regarding age, sex, smoking status, thyroid volume, or presence of Graves’ orbitopathy. On multivariate analysis, only TSAb positivity at ATD withdrawal was independently associated with relapse (hazard ratio [HR] 6.63, 95% confidence interval [CI], 1.30-33.7, p=0.02).

Conclusion: At ATD withdrawal, TSAb-positive patients demonstrated a higher risk for GD relapse. Measuring TSAb before ATD suspension, instead of TRAbs, could become an important tool for the clinical management of these patients.

Predictors of survival and technical success of bronchoscopic interventions in malignant airway obstruction

Background

Malignant airway obstruction (MAO) leads to quality of life impairment and increased mortality. Interventional bronchoscopy allows airway patency restoring, leading to a better survival. We investigated predictors of survival and successful bronchoscopic intervention among MAO patients.

Methods

This observational prospective study enrolled 100 patients who were newly diagnosed with MAO. Survival was estimated with Kaplan-Meier method and curves compared by log-rank test. Multivariate analyses were performed using Cox proportional hazard models. Univariate and multivariate logistic regression were used for odds ratio calculation.

Results

A proportion of 73% of the patients were male with a median age was 62.5 years (range, 21–88 years). Lung cancer was the most common primary malignancy (74%). The majority had single (61%), endoluminal (62%) lesions and were classified as grade III in Myer Cotton scale (57%). The most used techniques comprised mechanical debulking (n=81) and laser therapy (n=68). Twenty-two airway stents were placed. While eleven patients were considered untreatable, technical success was achieved in 78%. Haemorrhage was the most common acute complication (16%). No deaths occurred as a result of the procedure. Median global survival was 8 months. Adjusting for age and Eastern Cooperative Oncology Group Performance Status (ECOG), extrinsic compression or mixed airway obstructions [hazard ratio (HR) =2.075; P=0.012], successful bronchoscopic intervention (HR =0.468; P=0.025) and initiation of cancer treatment (HR =0.373; P=0.006) were independent predictors of survival. The absence of distal airway patency on thoracic CT was independently associated with failure of the intervention [odds ratio (OR) =0.013; P<0.001].

Conclusions

Interventional bronchoscopy has proven to be an efficient and safe strategy to manage MAO patients. The patients who benefit the most in terms of survival are those with purely endoluminal lesions, in whom technical success was achieved and those whose cancer-specific treatment was initiated. Distal airway patency on thoracic CT predicts the technical success of bronchoscopic intervention.

Liquid biopsy: the value of different bodily fluids

Liquid biopsies have gained an increasing interest in the last years among medical and scientific communities. Indeed, the value of liquid effusions, while less invasive and more accurate techniques, has been markedly highlighted. Peripheral blood comprises the most often analyzed sample, but recent evidences have pointed out the huge importance of other bodily fluids, including pleural and peritoneal fluids, urine, saliva and cerebrospinal fluid in the detection and monitoring of different tumor types. In face to these advances, this review aims to provide an overview of the value of tumor-associated mutations, detectable in different effusions, and how they can be used in clinical practice, namely in prognosis assessment and early disease and minimal disease recurrence detection, and in predicting the treatment response or acquired-resistance development.

Enlightening clinical and therapeutic heterogeneity in thoracic actinomycosis: A review in bronchiectasis and non-bronchiectasis patients

Actinomycosis is a rare chronic infection triggered by species of Actinomyces. Although thoracic involvement represents about 15% of human actinomycosis, its true incidence may be underestimated, not only because of its challenging diagnosis, but also because it can be treated unintentionally with antibiotics for other diseases. In this sense, this work aims at providing an up-to-date literature review on thoracic actinomycoses, with particular emphasis on presentation, diagnostic and therapeutic approaches, also paving upcoming clinical interventions from findings obtained of a presentation of a case series. Data discussed here clearly denote the rarity, non-specificity and heterogeneity of clinical presentations of the disease, reinforcing the need for individualized therapeutic approaches.

Long-term home non-invasive ventilation in chronic hypercapnic chronic obstructive pulmonary disease patients: Real-world impact on lung function, acute exacerbations and survival

INTRODUCTION

Although long-term home non-invasive ventilation (H-NIV) has been used among chronic hypercapnic COPD patients, its clinical benefit is still on debate. We aim to assess the impact of H-NIV in chronic hypercapnic COPD patients.

METHODS

COPD patients who initiated H-NIV between January 2010 and December 2017 were included. Patients with concomitant respiratory disorders were excluded. Acute exacerbation (AE) before and 2 years after H-NIV initiation was assessed as main outcome. Secondary outcomes included lung function and gas exchange parameters. Survival since H-NIV initiation was determined, and factors related with survival were explored.

RESULTS

Seventy-two patients were enrolled. A decrease in partial pressure of carbon dioxide (PaCO₂ ) in arterial blood (p < 0.001) and an improvement of partial pressure of oxygen (PaO₂ ) (p < 0.001) were achieved using a high-intensity H-NIV. Regarding lung function, residual volume (RV) reduced (p = 0.010) and forced-expiratory volume in 1 s (FEV₁ ) improved (p = 0.043) after H-NIV initiation. No significant differences in 6-min walking test (6MWT) were found. Compared with the year before H-NIV initiation, the number of AE diminished in the first and in the second years of follow-up (p < 0.001). The median survival was 79.0 months (95% confidence interval [CI], 52.9-105.1), and the covered distance in 6MWT predicted survival (hazard ratio [HR] = 0.026, p = 0.003) in the multivariate analysis.

CONCLUSIONS

High-intensity H-NIV significantly improved FEV1 and hyperinflation, decreased frequency of AEs and led to a remarkable median survival, which was independently predicted by the walking distance in 6MWT.

Sharing Biomedical Data: Strengthening AI Development in Healthcare

Artificial intelligence (AI)-based solutions have revolutionized our world, using extensive datasets and computational resources to create automatic tools for complex tasks that, until now, have been performed by humans. Massive data is a fundamental aspect of the most powerful AI-based algorithms. However, for AI-based healthcare solutions, there are several socioeconomic, technical/infrastructural, and most importantly, legal restrictions, which limit the large collection and access of biomedical data, especially medical imaging. To overcome this important limitation, several alternative solutions have been suggested, including transfer learning approaches, generation of artificial data, adoption of blockchain technology, and creation of an infrastructure composed of anonymous and abstract data. However, none of these strategies is currently able to completely solve this challenge. The need to build large datasets that can be used to develop healthcare solutions deserves special attention from the scientific community, clinicians, all the healthcare players, engineers, ethicists, legislators, and society in general. This paper offers an overview of the data limitation in medical predictive models; its impact on the development of healthcare solutions; benefits and barriers of sharing data; and finally, suggests future directions to overcome data limitations in the medical field and enable AI to enhance healthcare. This perspective is dedicated to the technical requirements of the learning models, and it explains the limitation that comes from poor and small datasets in the medical domain and the technical options that try or can solve the problem related to the lack of massive healthcare data.

The Role of Liquid Biopsy in Early Diagnosis of Lung Cancer

Liquid biopsy is an emerging technology with a potential role in the screening and early detection of lung cancer. Several liquid biopsy-derived biomarkers have been identified and are currently under ongoing investigation. In this article, we review the available data on the use of circulating biomarkers for the early detection of lung cancer, focusing on the circulating tumor cells, circulating cell-free DNA, circulating micro-RNAs, tumor-derived exosomes, and tumor-educated platelets, providing an overview of future potential applicability in the clinical practice. While several biomarkers have shown exciting results, diagnostic performance and clinical applicability is still limited. The combination of different biomarkers, as well as their combination with other diagnostic tools show great promise, although further research is still required to define and validate the role of liquid biopsies in clinical practice.

Comprehensive Perspective for Lung Cancer Characterisation Based on AI Solutions Using CT Images

Lung cancer is still the leading cause of cancer death in the world. For this reason, novel approaches for early and more accurate diagnosis are needed. Computer-aided decision (CAD) can be an interesting option for a noninvasive tumour characterisation based on thoracic computed tomography (CT) image analysis. Until now, radiomics have been focused on tumour features analysis, and have not considered the information on other lung structures that can have relevant features for tumour genotype classification, especially for epidermal growth factor receptor (EGFR), which is the mutation with the most successful targeted therapies. With this perspective paper, we aim to explore a comprehensive analysis of the need to combine the information from tumours with other lung structures for the next generation of CADs, which could create a high impact on targeted therapies and personalised medicine. The forthcoming artificial intelligence (AI)-based approaches for lung cancer assessment should be able to make a holistic analysis, capturing information from pathological processes involved in cancer development. The powerful and interpretable AI models allow us to identify novel biomarkers of cancer development, contributing to new insights about the pathological processes, and making a more accurate diagnosis to help in the treatment plan selection.

Cytokine gene polymorphisms in Pigeon Breeder's Disease expression

BACKGROUND

Exaggerated immunological response to repeated inhalation of organic or chemical dusts may lead to Hypersensitivity Pneumonitis among sensitized individuals. Only a few exposed individuals became ill and disease expression pattern is highly variable which suggest that genetic factors may play a role.

AIM

To investigate interferon (IFN)-γ, tumour necrosis factor (TNF)-α, interleukin (IL)-6, transforming growth factor (TGF)-ß, and IL-10 gene polymorphisms in a cohort of pigeon breeder's disease (PBD) patients in comparison with exposed but healthy controls and the association with different patterns of disease.

METHODS

We evaluated 40 PBD patients and 70 exposed controls. IFN-γ, TNF-α, IL-6, TGF-ß, and IL-10 polymorphisms were determined by polymerase chain reaction-sequence specific primer amplification.

RESULTS

Polymorphism analysis of IFN-γ, TNF-α, IL-6, TGF-ß, and IL-10 genotypes and allele frequencies showed no differences between patients and controls. IFN-γ T/T genotype frequency was increased among patients with chronic presentation (RR=2.33, p=0.047) compared with those with acute/subacute presentation. Also, chronic presenting patients had an increased frequency of IFN-γ T allele (50% vs 22.5%, RR=1.76, p=0.011). No differences were found in TNF-α, IL-6, TGF-ß, and IL-10 genotypes neither allelic frequencies between both groups of patients. IL-6 C/C genotype was more frequent in patients who showed chronic evolution (RR=2.54, p=0.017), when comparing with patients with disease resolution.

CONCLUSION

IFN-γ T/T and the IL-6 C/C genotypes seem to play a role in HP expression due to avian exposure, as their frequencies are increased in chronic presentations or in those with chronic evolution one year after the initial diagnosis, respectively. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (3): e2020004).

Evolutionary trends in bacteria isolated from moderate and severe diabetic foot infections in a Portuguese tertiary center

INTRODUCTION

Diabetic Foot infections (DFI) are a major cause of hospitalization in patients with diabetes. The microbiological study of diabetic ulcers is essential to adequate antibiotic therapy and to minimize the selection of resistant microorganisms. The aim of this study was to characterize and to compare the evolution of isolated microorganisms between the biennium 2010-2011 and 2016-2017, in hospitalized patients with DFI.

MATERIAL AND METHODS

Retrospective evaluation of the clinical and analytical data of patients who were admitted due to DFI in 2010-2011 (group 2010/11) and 2016-2017 (group 2016/17). Only the first hospitalization for each patient was included. An adequate descriptive and comparative statistical analysis was performed.

RESULTS

There were 274 admissions due to DFI, 151 in 2010/11 and 123 in 2016/17. There was an increase in admissions due to neuroischemic DFI (51.0% in 2010/11 to 61.8% in 2016/17, p = 0.048). Staphylococcus aureus (SA) was the most common isolate in 2010/11 (26.7%). In 2016/17 most cultures were mixed polymicrobial and isolation of Enterobacteriaceae and Pseudomonas aeruginosa increased from 2010/11 to 2016/17 (15.9% to 30.6%, p = 0.001, and 9.1% to 13.7%, p = 0.048, respectively).

CONCLUSION

There was an increase in the prevalence of neuroischemic DFU. The Enterobacteriaceae family replaced SA as the most prevalent pathogen in DFI, with an increase in the isolation of gram-negative microorganisms and mixed polymicrobial cultures. Chronic neuroischemic infected ulcers usually present distinct bacterial isolates; knowledge about the most common agents is warranted in order to better select empiric antibiotic therapy.

Can mindfulness bring post-traumatic stress disorder patients to focus on the present?

Introduction

Over the last years, literature has dedicated increased interest to post-traumatic stress disorder (PTSD), a mental disorder that was initially included in Diagnostic and Statistical Manual of mental disorders in 1980. Trauma is any event that overwhelms the individual coping strategies. Patients with PTSD experience symptoms of hyper-vigilance, intrusive thoughts, flashbacks, re-experiencing the trauma event, avoidance of stimuli related with trauma or exaggerated startle response. Mindfulness is the process of being aware, paying attention in the present moment, in a non-judgmental way. Research has been showing that mindfulness has positive effects on mental health.

Objectives and aims

Assessment of eventual benefits of mindfulness in patients with PTSD.

Methods

Literature research.

Results

Many studies have reported on correlations between self-reported mindfulness and mental health. Literature suggests that mindfulness training can enhance life skills and its effectiveness is being studied in several mental disorders. Its positive effects on enhancing emotion regulation and decreasing anxiety, hyperarousal and depressive symptoms, led to investigation in the context of PTSD's treatment. Some studies show decreased perceived stress and post-traumatic avoidance symptoms and increased positive states of mind. Most studies reviewed were related with war veterans with PTSD and showed that mindfulness-based treatments could enhance their quality of life. Other results imply that mindful awareness alone may not be sufficient to help reduce symptoms.

Conclusions

Mindfulness based therapies could be useful on improving PTSD symptoms but, to assess its efficacy, further research is needed, in different samples of patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Identifying relationships between imaging phenotypes and lung cancer-related mutation status: EGFR and KRAS

EGFR and KRAS are the most frequently mutated genes in lung cancer, being active research topics in targeted therapy. The biopsy is the traditional method to genetically characterise a tumour. However, it is a risky procedure, painful for the patient, and, occasionally, the tumour might be inaccessible. This work aims to study and debate the nature of the relationships between imaging phenotypes and lung cancer-related mutation status. Until now, the literature has failed to point to new research directions, mainly consisting of results-oriented works in a field where there is still not enough available data to train clinically viable models. We intend to open a discussion about critical points and to present new possibilities for future radiogenomics studies. We conducted high-dimensional data visualisation and developed classifiers, which allowed us to analyse the results for EGFR and KRAS biological markers according to different combinations of input features. We show that EGFR mutation status might be correlated to CT scans imaging phenotypes; however, the same does not seem to hold for KRAS mutation status. Also, the experiments suggest that the best way to approach this problem is by combining nodule-related features with features from other lung structures.

The role of interventional bronchoscopy in the management of post-intubation tracheal stenosis: A 20-year experience

PURPOSE

Benign tracheal stenosis management is still controversial, and there is no international consensus on the best treatment option. Thus, we aimed to look into the history of PITS and the different strategies used in its treatment. The importance of bronchoscopic treatment was also defined, and its effectiveness and safety were assessed.

METHODS

Retrospective study of patients diagnosed with PITS, who were referred to the Bronchology Department between January 1996 and December 2016.

RESULTS

Of 115 patients enrolled (mean age 48.5±17.6 years, 53% males), 66.1% had complex stenosis. The most common causes of intubation were respiratory (29.9%), neurological (26.8%) and surgical (19.6%). Complex stenosis was caused by longer intubation, and was more frequent among previously tracheostomized patients. The most common location was the upper third of trachea (60.9%). Most cases were initially treated by interventional bronchoscopy, and although serial dilations were effective in some complex PITS, a higher proportion of simple stenosis was successfully managed with this treatment option. Long-term recurrence after serial dilation was observed in 25.0% of cases. Stent placement was required (19.1%) only for complex PITS. Stent-related complications were frequent (61.9%) and linked to the stenting time (p<0.001). Overall, there were no procedure-related complications. Surgical intervention was also performed (30.0%), always with complex PITS. Post-surgical recurrences were observed in 24.2% of cases.

CONCLUSIONS

Interventional bronchoscopy is an efficient and safe modality in PITS management. Further studies are needed for better classification and improved knowledge of PITS pathogenesis, and to achieve international consensus of definition to guide clinicians in their practice.

Maternal country of birth and in-hospital exclusive breastfeeding: results from a Portuguese study

Background

Breastfeeding provides benefits for children, mothers, society and the environment. The promotion of optimal breastfeeding, from an early stage in life is, therefore, a public health priority. Infant feeding can be influenced by maternal country of birth. However, studies carried out in European settings point to inconsistent findings. This study aims to compare first day in-hospital exclusive breastfeeding among migrant and native women in Portugal.

Methods

This study is based on a national project on perinatal health among migrants and natives in Portugal (baMBINO). Out of 39 public maternity units in mainland Portugal, 32 were enrolled. Women aged 18 years old or older with a live birth were recruited. The final sample included 5109 participants (2431 natives and 2678 migrants). Logistic regression was used to assess the association between maternal country of birth and in-hospital exclusive breastfeeding.

Results

Migrant participants included women from Portuguese-speaking African countries (PSAC) (49,7%), Brazil (18%), Eastern Europe (10.2%), other European countries (9.6%), Asia (5.5%) and other countries (7.0%). No differences were found between migrants and natives, with the exception of women from PSAC who were more likely to exclusively breastfeed during the first day of hospital stay (aOR 1.34 CI95% 1.05-1.72), irrespective of maternal age, education, parity, type of pregnancy, reproductive assistance, tobacco use, gestational age, newborn birth weight, mode of delivery and antenatal care.

Conclusions

In Portugal, women from PSAC are more likely to exclusively breastfeed their babies during the first day of hospital stay when compared to native women. Strategies to maintain healthy breastfeeding practices in this population are fundamental.

Key messages

Women from PSAC are more likely to breastfeed exclusively in the first day after delivery than Portuguese natives. They should be supported in the maintenance of optimal breastfeeding practices.

P3518Men with heart failure have higher readmission rates: a closer review of sex and gender based analyses

Background

There has been increased attention on reducing hospital readmission rates. However, little is known about any difference in readmission rates in heart failure by sex, although evidence exists demonstrating differences in the etiology of heart failure. As a result, strategies to optimize readmission reduction programs and care strategies for women and men remain unclear.

Purpose

(1) To identify studies examining readmission rates according to sex, and (2) to provide a qualitative overview of possible considerations for the impact of sex or gender.

Methods

A scoping protocol was developed using the Arksey and O'Malley framework and the Joanna Briggs Institute methodology. Our search strategy was reviewed according to the peer-review of electronic search strategy (PRESS) checklist. Full text articles published between 2002 and 2017 and drawn from multiple databases (i.e. MEDLINE, EMBASE), grey literature (i.e. National Technical Information, Duck Duck Go), and experts were consulted for additional articles. Screening criteria were established a priori. Once an acceptable inter-rater agreement was established at 80% by two independent reviewers, articles were screened for potential eligibility. A descriptive analytical method was employed to chart primary research articles. Articles were considered relevant if the cohort consisted of adult heart failure patients who were readmitted after an index hospitalization and a sex/gender-based analysis was performed.

Results

The literature search yielded 5887 articles, of which 746 underwent full text assessment for eligibility. Of 164 eligible articles, 34 studies addressed the primary outcome, 103 studies considered sex differences as a secondary outcome and 25 studies included disaggregated data for sex but no subsequent interaction was reported. Good inter-rater agreement was reached: 83% for title and abstract screening; 88% for full text review; kappa: 0.69 (95% CI: 0.526–0.851). Twelve of 34 studies included for the primary outcome reported higher readmission rates for men compared to five studies reporting higher readmission rates for women. However, there were differential readmission rates that were dependent on duration of follow-up. Women were more likely to experience higher readmission rates than men when time to event was less than one year. Readmission rates for men were higher when follow-up was longer than one year.

Conclusion

Sex differences in readmission rates were dependent on follow up time. Most studies used composite outcomes and had short times to event, which may mask underlying effects of sex on readmission.

Acknowledgement/Funding

Ontario SPOR Support Unit