Nutrient adequacy and nutrient sources of adults among ninety-two First Nations communities across Canada

OBJECTIVES

To identify food sources of nutrients in First Nations adults in Canada and to establish whether these populations are meeting their nutrient requirements and whether traditional foods (TF) contribute to better nutrient intake.

METHODS

The First Nations Food, Nutrition and Environment Study is a cross-Canada participatory study of First Nations adults living south of the 60th parallel. Twenty-four-hour recalls were conducted in 92 First Nations communities from 2008 to 2016. Repeat recalls were attempted with 20% of participants to adjust for within-person variation and estimate the proportion of individuals below recommendations according to Institute of Medicine guidelines. Nutrients from days with and without TF were compared. The main food sources of select nutrients were identified, including TF.

RESULTS

Mean energy intakes among women and men ranged from 1664 to 1864 and from 1761 to 2298 kcal/day respectively. Most macronutrients were within the acceptable macronutrient diet range except for fat in most age groups and carbohydrates in men 71 years of age and older. Saturated fat was above recommendations for all ages. Only niacin was identified as above recommendations in all age and sex categories. Days where TF were eaten showed greater intakes of key nutrients.

CONCLUSION

It is imperative that we find culturally appropriate ways to improve the quality and nutritional value of First Nations Peoples food intake by improving TF access and use on the one hand and conversely providing better quality store-bought foods. For success in this, we must empower First Nations communities and health practitioners to collaboratively overcome these challenges.

Associations of health status and diabetes among First Nations Peoples living on-reserve in Canada

OBJECTIVE

Our objective is to describe self-reported health status, prevalence of diabetes and obesity and their associations in participants from the First Nations Food, Nutrition and Environment Study (FNFNES) in order to identify possible correlates of health in First Nations adults.

METHODS

FNFNES is a participatory study with First Nations Peoples living on reserve lands south of the 60th parallel. Health and diabetes were self-reported, and prevalence of obesity was evaluated. Socio-demographic and lifestyle factors and traditional food (TF) activities were investigated for associations with health parameters.

RESULTS

High prevalence rates of overweight/obesity (78-91%) and diabetes (19% age-standardized prevalence) were found. Smoking rates were high and physical activity was low. In multivariable analyses, obesity was associated with region, income source, age, gender, smoking and self-reported health; diabetes and lesser self-reported health were associated with obesity and lower education. Diabetes was strongly associated with lesser self-reported health and weakly associated with being a smoker.

CONCLUSION

We have identified possible correlates of health in this population that can help to better understand the underlying concerns and identify solutions for First Nations and their partners. We urge governments and First Nations to address the systemic problems identified with a holistic ecosystem approach that takes into consideration the financial and physical access to food, particularly TF, and the facilitation of improved health behaviour. New mechanisms co-developed with First Nations leadership should focus on supporting sustainable, culturally safe and healthy lifestyles and closing the gaps in nutrition and food insecurity.

Comparison of measures of diet quality using 24-hour recall data of First Nations adults living on reserves in Canada

OBJECTIVE

Assess the diet quality of First Nations adults in Canada using percentage energy from traditional foods (TF) and ultra-processed products (UPP), food portions from the 2007 Eating Well with Canada's Food Guide - First Nations, Inuit and Métis (EWCFG-FNIM) and a Healthy Eating Index (HEI).

METHODS

Data collection for this participatory research occurred in 92 First Nations reserves across Canada from 2008 to 2016. Percent daily energy intakes were estimated from 24-hour recalls for TF and NOVA food categories. Portions of food groups from the 2007 EWCFG-FNIM were compared to recommendations. A Canadian-adapted HEI was calculated for each participant.

RESULTS

The percent energy from TF was 3% for all participants and 18% for consumers. Meat and alternatives were above the EWCFG-FNIM recommendations and all other food groups were below these. HEI was "low" with only older individuals attaining "average" scores. HEI was above "average" in 4 regions. UPP represented 55% of energy, the largest proportion from a NOVA category.

CONCLUSION

The diet quality of First Nations adults in Canada is nutritionally poor. The nutrition, food security and health of First Nations would be improved by better access to TF and healthy store-bought food. However, poor diet is only one aspect of the difficulties facing First Nations in Canada. Researchers and policy makers must strive to better understand the multiple challenges facing First Nations Peoples in order to foster empowerment and self-determination to develop First Nations living conditions and lifestyles that are more culturally sound and more conducive to health.

Importance of the traditional food systems for First Nations adults living on reserves in Canada

OBJECTIVE

To describe the traditional food (TF) systems of First Nations in Canada, including intake, barriers and promoters.

METHODS

The First Nations Food, Nutrition and Environment Study is a cross-Canada participatory study of First Nations adults below the 60th parallel that obtained data for communities excluded from other national studies. A food frequency questionnaire was used to establish frequency of TF intake (number of days in a year) to allow comparisons across ecozones/regions in Canada. Grams of TF intake were also calculated using frequency multiplied by average portions from 24-h recalls. Closed- and open-ended questions attempted to identify some of the key barriers and concerns regarding TF access and use. Multivariable analyses were run to determine what factors are associated with increased TF consumption.

RESULTS

Across communities, there is a strong preference by adults to have TF in the diet more often. Consumption of land animals was most frequently reported in most ecozones except for the Pacific Maritime and Mixedwood Plains, where fish and plants, respectively, were more frequently consumed. First Nations identified structural and environmental challenges such as development, government regulations and climate change, along with household barriers such as insufficient capital for equipment and transportation, lack of time and absence of a hunter in the household. Multivariable analyses revealed that the highest intake of TF occurred in the Taiga Plains ecozone, and for older individuals and men.

CONCLUSION

Identifying solutions that empower First Nations at all levels is required to overcome the multiple challenges to the inclusion of TF in the diet.

Prevalence of Iron Deficiency and Iron Deficiency Anemia in the Northern and Southern Provinces of Rwanda

Background

Anemia remains a public health problem in Rwanda, affecting 38% of young children and 17% of reproductive-aged women (Demographic and Health Survey [DHS] 2010). The importance of iron deficiency (ID) as a cause of anemia in Rwanda is not known.

Objective

We aimed to estimate the prevalence of ID and iron deficiency anemia (IDA) among young children and women in 2 provinces of Rwanda.

Methods

We conducted a cluster randomized survey, selecting 408 rural households each in the Northern and Southern Provinces of Rwanda in 2010. Anemia was defined as hemoglobin <110 g/L in children and <120 g/L in nonpregnant women after correction for altitude. We defined ID as (1) serum transferrin receptor (TfR) >8.3 mg/L or (2) serum ferritin (SF) <12 µg/L in children and <15 µg/L in nonpregnant women after correction for inflammation.

Results

The prevalence of anemia was 30.9% (95% confidence interval [CI], 26.4-35.8) in children (n = 577) and 11.2% (95% CI, 8.4-14.7) in women (n = 595). The prevalence of ID in children was 3.1% (95% CI, 1.8-5.1) as defined by high TfR and 5.9% (95% CI, 4.0-8.4) as defined by low SF. Similarly, 3.0% (95% CI, 1.8-4.8) of women had high TfR and 4.8% (95% CI, 3.2-7.2) had low SF. The prevalence of IDA (low SF with concurrent anemia) ranged from 1.4% (95% CI, 0.5-3.6) among women in the North to 5.6% (95% CI, 3.1-10.0) among children in the South.

Conclusions

ID is likely not an important contributor to anemia in the Northern and Southern Provinces of Rwanda. This finding warrants further investigation into other causes of anemia.

Cardiovascular changes in patients with primary aldosteronism after surgical or medical treatment

BACKGROUND

Data on the cardiovascular middle-term follow-up of patients with primary aldosteronism (PA) are scanty.

AIM

To detect the cardiovascular effects of surgery in patients with aldosterone (ALD)-producing adenoma (APA) and of pharmacotherapy in those with bilateral adrenal hyperplasia (BAH), a prospective study involving 60 consecutive patients with PA was performed. MATERIAL/ METHODS: Clinical, biochemical, and cardiovascular assessment was obtained before and after (31.5±4.4 months) surgery or proper medical treatment (32.1±5.0 months) in 19 and 41 patients, respectively.

RESULTS

As expected, plasma ALD normalized in all operated patients, while in the other group it did not change. Systolic and diastolic blood pressure decreased (p<0.001) after both treatments. However, absolute and percentage reduction was significantly more pronounced (p<0.01) in operated than in non-operated patients. Left ventricular (LV) mass showed significant reduction after surgery (LV mass g/m(2), p<0.0007; LV mass g/m(2.7), p<0.01), but no change after medical treatment, so that the differences between absolute and percentage values at follow- up were statistically significant (p<0.01) between groups. Basal LV mass/m(2.7) was positively associated with age (p<0.009), body mass index (p<0.0008), drug number (p<0.03), and ALD/plasma renin activity ratio (p<0.01). Allocating the patients according to plasma ALD and cardiac parameters, patients who presented ALD reduction during the study also had a decrement in cardiac mass (p<0.04).

CONCLUSIONS

Our data indicate that in patients with PA the removal of ALD excess by surgery in APA is effective in reducing blood pressure and in improving cardiac parameters, while anti-hypertensive therapy in BAH shows less positive impact on cardiovascular system.

Stem cells: their role in breast cancer development and resistance to treatment

About 20% of the total cells from primary breast tumors could generate palpable tumors in non-obese diabetic severe combined immunodeficient (NOD/SCID) immunocompromised mice. All the tumorigenic cells originate from a normal mammary stem cell. Human mammary stem cells are sensitive to oncogenic mutations and in mouse models they share similarities with breast cancer stem cells (BrCSCs). Tumorigenicity, invasion, progression and metastasization are further BrCSCs properties likely depending on their CD44+/CD24- phenotype. Local invasion and tumor metastasization seem to be facilitated by the epithelial to mesenchymal transition (EMT) program. This program may be reactivated from stable genetic alterations or through exposure of cancer cells to factors present in the surrounding micro-environment, or by an up-regulation of EMT-inducing transcription factors. One main explanation for resistance to treatment by cancer cells is that a rare subpopulation of cells in residual tumors with tumorigenic potential is intrinsically resistant to therapy. Consistent with this hypothesis, in human breast tumors, the subpopulation of tumor-initiating cancer cells with CD44(high)/CD24(low) cell surface-marker profile was found more resistant to cancer therapies (chemo, hormone and radiotherapy) than is the major population of more differentiated breast cancer cells. The reasons for CSC resistance to chemotherapy, hormone therapy and radiotherapy also have been examined and they opened new scenarios for cancer therapy.

Real-time elastosonography: useful tool for refining the presurgical diagnosis in thyroid nodules with indeterminate or nondiagnostic cytology

BACKGROUND

Indeterminate and nondiagnostic patterns represent the main limitation of fine-needle aspiration (FNA) cytology of thyroid nodules, clinical and echographic features being poorly predictive of malignancy. The newly developed real-time ultrasound elastography (USE) has been previously applied to differentiate malignant from benign lesions. The aim of this study was to get further insights into the role of USE in the presurgical diagnosis of nodules with indeterminate or nondiagnostic cytology.

PATIENTS

The study included 176 patients who had one (n=138) or multiple (n=38) nodules with indeterminate or nondiagnostic cytology on FNA, for whom histology was available after thyroidectomy. A total of 195 nodules (142 indeterminate, 53 nondiagnostic) were submitted to USE, and elasticity was scored as 1 (high), 2 (intermediate), or 3 (low).

RESULTS

In indeterminate lesions, the score 1, describing high elasticity, was strongly predictive of benignity, being found in 102 of 111 benign nodules and in only one of 31 carcinomas (P<0.0001). By combining the scores 2 and 3, USE had a sensitivity of 96.8% and a specificity of 91.8%. In nodules with nondiagnostic cytology, score 1 was found in 39 of 45 benign nodules and in only one of eight carcinomas (P<0.0001). By combining the scores 2 and 3, USE had a sensitivity of 87.5% and a specificity of 86.7%.

CONCLUSIONS

USE may represent an important tool for the diagnosis of thyroid cancer in nodules with indeterminate or nondiagnostic cytology and may prove useful in selecting patients who are candidates for surgery.

Contribution of integrated campaign distribution of long-lasting insecticidal nets to coverage of target groups and total populations in malaria-endemic areas in Madagascar

In October 2007, Madagascar conducted a nationwide integrated campaign to deliver measles vaccination, mebendazole, and vitamin A to children six months to five years of age. In 59 of the 111 districts, long-lasting insecticidal nets (LLINs) were delivered to children less than five years of age in combination with the other interventions. A community-based, cross-sectional survey assessed LLIN ownership and use six months post-campaign during the rainy season. LLIN ownership was analyzed by wealth quintile to assess equity. In the 59 districts, 76.8% of households possessed at least one LLIN from any source and 56.4% of households possessed a campaign net. Equity of campaign net ownership was evident. Post-campaign, the LLIN use target of > or = 80% by children less than five years of age and a high level of LLIN use (69%) by pregnant women were attained. Targeted LLIN distribution further contributed to total population coverage (60%) through use of campaign nets by all age groups.

Beta-catenin activation is not involved in sporadic parathyroid carcinomas and adenomas

Aberrant accumulation of beta-catenin has been found in various types of human tumors. The aim of this study was to evaluate whether Wnt/beta-catenin signaling is activated in parathyroid carcinomas and adenomas. We studied 154 parathyroid tumors (18 carcinomas (13 with distant metastases), six atypical adenomas, and 130 adenomas). Three normal parathyroid tissues were used as control. Direct sequencing of exon 3 of the CTNNB1 gene showed absence of stabilizing mutations in all the tumors. Immunostaining of beta-catenin was performed in all carcinomas and in 66 adenomas (including three atypical). Normal parathyroid showed a homogeneous distinct outer cell membrane staining in the majority of cells and no nuclear staining. A weak cytoplasmic staining was observed in one case. All tumors showed negative nuclear staining. With the exception of one carcinoma, which had a negative membrane staining, all other samples showed a membrane staining which was similar to that of the normal parathyroid. beta-Catenin expression was heterogeneous with a range of positive cells between 5 and 80%, independently of tumor type. Our results suggest that the Wnt/beta-catenin signaling pathway is not involved in the development of parathyroid carcinomas and adenomas.

Lower levels of TSH are associated with a lower risk of papillary thyroid cancer in patients with thyroid nodular disease: thyroid autonomy may play a protective role

Higher TSH values, even within normal ranges, have been associated with a greater risk of thyroid malignancy. The relationship between TSH and papillary thyroid cancer (PTC) has been analyzed in 10 178 patients submitted to fine needle aspiration of thyroid nodules with a cytology of PTC (n=497) or benign thyroid nodular disease (BTND, n=9681). In 942 patients, submitted to surgery (521 from BTND and 421 from PTC), the histological diagnosis confirmed an elevated specificity (99.6%) and sensitivity (98.1%) of cytology. TSH levels were significantly higher in PTC than in BTND both in the cytological and histological series and also in patients with a clinical diagnosis of multinodular goiter (MNG) and single/isolate nodule (S/I). A significant age-dependent development of thyroid autonomy (TSH <0.4 microU/ml) was observed in patients with benign thyroid disease, but not in those with PTC, diagnosed both on cytology and histology. In patients with MNG, the frequency of thyroid autonomy was higher and the risk of PTC was lower compared to those with S/I. In all patients, the presence of thyroid auto-antibodies (TAb) was associated with a significant increase of TSH. However, both in TAb positive and TAb negative patients TSH levels were significantly higher in PTC than in BTND. Our data confirm a direct relationship between TSH levels and risk of PTC in patients with nodular thyroid diseases. Thyroid autonomy conceivably protects against the risk of PTC, while thyroid autoimmunity does not play a significant role.

Update on the diagnosis and treatment of differentiated thyroid cancer

During the 1990s, with the general tendency to develop minimally invasive operations, an endoscopic approach has been applied to neck surgery for both parathyroidectomy and thyroidectomy. The most widely spread minimally invasive technique for thyroidectomy is minimally invasive video assisted thyroidectomy (MIVAT), described and developed for the first time at our institution in 1998. Ideal candidates for MIVAT are patients with a thyroid volume lower than 25ml with nodules smaller than 35 mm. Consequently, MIVAT will present restricted indications, being suitable only for the treatment of about 10-15% of the whole standard surgical case load. Thus, together with small follicular lesions, "low risk" papillary carcinoma will result the main indication for MIVAT, being this small cancer usually harboured in normal glands of young females. On the other hand, in case of locally invasive carcinomas and/or lymph node metastasis the procedure must be immediately converted to the conventional technique. MIVAT also is not indicated for the treatment of medullary and anaplastic carcinomas. Recent prospective randomized studies clearly demonstrate that MIVAT allows achieving same clearance at the thyroid bed level and same outcome as conventional technique, when dealing with "low risk" papillary carcinoma. At the same time, patients can benefit from the main advantages of this minimally invasive technique: lower postoperative pain, faster postoperative recovery and excellent cosmetic outcome.

Papillary thyroid cancer, although strongly associated with lymphocytic infiltration on histology, is only weakly predicted by serum thyroid auto-antibodies in patients with nodular thyroid diseases

OBJECTIVE

We evaluated the association between thyroid autoimmunity and thyroid cancer in a retrospective series of unselected thyroid nodules submitted to fine-needle aspiration (FNA) cytology.

DESIGN

Anti-thyroid antibodies (TAb) were measured in patients with multinodular goiter (MNG) and single/isolated thyroid nodule (S/I) submitted to FNA. Thyroid lymphocytic infiltration (LI) on histology was studied in a subgroup of patients submitted to thyroidectomy; 13,021 patients were included: on cytology 622 had papillary thyroid cancer (c- PTC) and 12,399 benign thyroid nodular diseases (c-BTN). LI was evaluated in histological samples of 688 patients: 304 with PTC (h-PTC) and 384 with BTN (h-BTN).

RESULTS

TAb prevalence was not different in c-BTN and c-PTC (38.7% vs 35.6%). TAb were more frequent in c-BTN than c-PTC in females with MNG (40.1% vs 32.5%, p=0.02), and in c-PTC than in c-BTN in males with S/I (31.2% vs 20.4%, p=0.02) and, although not significantly, in females younger than 30 yr (35.1% vs 30.7%). The frequency and severity of LI was significantly higher in h-PTC than h-BTN, both in MNG (82.5% vs 45.0%, p<0.001) and S/I (85.6% vs 71.0%, p<0.001), but a higher number of patients with h-PTC had negative circulating TAb, despite the presence of moderate/severe LI.

CONCLUSIONS

TAb are weakly associated to PTC in males and young females, while they are more frequent in older females with BTN. The frequency and severity of LI is significantly higher in PTC than in BTN, but in cancer patients TAb are frequently negative, despite the evidence of histological thyroiditis. These data suggest that different kinds of immune response may be involved in PTC and BTN.

Video-assisted surgery: what is its role in the treatment of thyroid carcinoma?

Thyroid carcinoma can be divided in two main groups, differentiated, with a good prognosis and an average 10 years survival ranging from 70% to 95%, and undifferentiated which is lethal in few months. Differentiated thyroid carcinoma can be distinguished in those variants coming from follicular cells (papillary and follicular) and those from C cell (medullary carcinoma). Surgical approach represents the first step in the treatment of thyroid carcinoma. Minimally-invasive endoscopic technique can be applied only to a minority of case, the so called ''low risk'' carcinoma according to AGES and AMES criteria. During the last ten years many different endoscopic approaches have been proposed for the treatment of thyroid carcinoma and the minimally invasive videoassisted (MIVAT) by Prof Miccoli is undoubtly the one which resulted to be the most successful and spread all over the world. Through a 1.5 cm central skin incision 2 cm above the sternal notch MIVAT allows to perform a total thyroidectomy for low risk papillary carcinoma with a completeness similar to that of conventional thyroidectomy. Using the same central access it is also possible to perfom a prophylactic central neck dissection for RET gene positive carriers. A lateral neck minimally invasive videoassisted lymphadenectomy is under development for those patients with low risk papillary carcinoma and isolated lateral lymph node metastasis.

Perspectives and lessons learned after a decade of minimally invasive video-assisted thyroidectomy

Minimally invasive video-assisted thyroidectomy (MIVAT) was introduced in our department in 1998. The procedure is based on a unique incision in the central neck, 2 cm above the sternal notch, using small conventional retractors and 2-mm reusable instruments. Hemostasis is achieved by using a Harmonic scalpel. 1,320 (1,136 female and 184 male, ratio 4:1) patients have undergone MIVAT since June 1998. Lobectomy was carried out in 421 patients, while 899 patients underwent total thyroidectomy. In 21 cases (RET oncogene mutation carriers), MIVAT was associated with central compartment lymph node clearance. Mean operative time of lobectomy was 32.3 min (range 20-120 min); for total thyroidectomy it was 44.1 min (range 30-130). Mean time for video-assisted central compartment lymphadenectomy was 57 min. Conversion to standard cervicotomy was required in 30 cases (2.2%); operative complications included transient unilateral recurrent nerve palsy in 35 cases (2.65%) and definitive unilateral recurrent nerve palsy in 15 cases (1.13%). Thirty-eight patients exhibited hypoparathyroidism, which corresponds to 4.2% of total thyroidectomies performed, but only 2 showed permanent hypoparathyroidism. MIVAT can be considered a safe operation offering significant cosmetic advantages and has possible new promising indications such as prophylactic thyroidectomy in RET gene mutation carriers.

Analysis of leucocyte populations with the Coulter S-Plus STKR as a screening tool for haematological abnormalities

In two institutions at Rome and Florence we evaluated the clinical sensitivity of two Coulter STKR systems using the NCCLS standard H20-T for leucocyte differential count in a patient population with high prevalence of haematologic abnormalities. Reference ranges of normal leucocytes were obtained on 278 adult subjects. On a population of 455 patient specimens, 200 specimens (44%) were flagged by the STKR because of a distributional abnormality, and 122 (27%) because of a morphological abnormality. Percentage of subtotal agreements between the STKR and the reference manual differential count was 85.4%, with 67.5% full and 20.9% partial agreements. Eight specimens that showed a morphological abnormality with the reference manual differential count were classified as normal by the STKR, with a false normal rate of 6.6%. Analysis of the STKR performance for morphological abnormalities showed acceptable sensitivity (82.0%) and rather low specificity (71.5%), low predictive value of positive results (51.3), high predictive value of negative results (91.5%) and efficiency of 74.3%. The main problems of the STKR differential count were a high rate of false monocyte count, and the misidentification of eosinophilias and low-concentration abnormal cells.

[Surgical timing in bleeding liver adenoma: case report]

The diagnosis of liver adenoma, which etiopathogenesis most often involves a prolonged assumption of estrogen (90% of adenomas occurs in women after more than 5 years of estrogen therapy), always imposes a surgical resection. The reason depend from neoplasia characteristics like the malignant evolution (4%) and the high risk of abdominal/intratumoral bleeding (30-50%), that increases during pregnancy and postpartum period. Regression of lesion after discontinuation of hormone therapy is rare and does not remove the degeneration and/or haemorrhagic risk. Liver resection should be performed with appropriate selective endovascular embolization, considering that an inept emergency surgery may impose a greater risk ot the liver, exposing the patient to major risk of morbidity and mortality. The correct timing from embolization to elective surgery is not yet standardized in the literature. The surgeon's personal experience and mainly a careful patient follow-up suggest the timing of surgery after embolization. The authors relate their own experience about the therapeutic strategy and surgical timing in a case of bleeding liver adenoma.

[New technologies in thyroid surgery. Endoscopic thyroid surgery]

The onset of cervicoscopy dates back to the first endoscopic parathyroidectomy in 1996. This operation, along with its several variants, has become a valid option widespread in many important centres. Later on, endoscopic or video assisted thyroidectomy was introduced in spite of the limits imposed by the mass of the gland to remove. It is indicated for a minority of patients for this reason but both parathyroidectomy and thyroidectomy showed some important advantages with respect to conventional surgery, advantages demonstrated also in prospective studies. They are mainly represented by a better cosmetic outcome and a less distressful postoperative course. These approaches proved to be safe and feasible in any surgical background: their complication rate is the same as traditional open surgery in the neck. Very promising seems to be the videoscopic access to neck lymph nodes (central and lateral compartments) whereas other fields of application such as carotid artery surgery and spine surgery still remain object of experimental studies. As far as the lateral neck dissection is concerned the technique is going to be standardized in our centre as a variant of the well known video assisted approach adding a 5 mm trocar placed in the supraclavicular space. By consequence, cervicoscopy has to be considered an important surgical tool which can be further improved but which also has an excellent potentiality.

The impact of thyroidectomy on parathyroid glands: a biochemical and clinical profile

INTRODUCTION

An evaluation of PTH levels during thyroid surgery may reflect the functional status of the parathyroids and be useful in identifying patients at risk for hypocalcemia. This study aims to monitor the parathyroid function during total thyroidectomy through intra-operative serial samples for calcium and PTH.

MATERIALS AND METHODS

Forty-seven patients undergoing total thyroidectomy for different diseases were selected for the study. Patients underwent serum PTH and calcium sampling at the induction of anesthesia (T0) and after the first (T1) and the second (T2) lobectomy. Serum calcium was also drafted 24 h after the operation.

RESULTS

Mean PTH at T0, T1, and T2 was, respectively: 32.1 pg/ml, 19.6 pg/ml, and 11.5 pg/ml. PTH was significantly higher at T0 when compared to T1 (p<0.0001). It was also significantly higher at T1 than at T2 (p<0.0001). At T1 PTH levels were below the normal range in 20/47 cases (42.5%) and at T2 in 31/47 cases (66%). Twenty-four h after surgery, 8 patients (17%) demonstrated a biochemical hypocalcemia. A PTH value at T0 in the upper (>70 pg/ml) or in the lower (<20 pg/ml) limits of the normal range was statistically related to post-operative hypocalcemia (p=0.017).

DISCUSSION

The study seems to confirm that serum PTH during thyroidectomy does not represent a sensitive tool in precociously identifying hypocalcemic patients. Nevertheless, before surgery, a PTH concentration at the higher or lower normal limit may help to identify patients "at risk" of developing hypocalcemia.

Clinical features of thyroid autoimmunity are associated with thyroiditis on histology and are not predictive of malignancy in 570 patients with indeterminate nodules on cytology who had a thyroidectomy

BACKGROUND

The relationship between thyroid autoimmunity and cancer is still uncertain.

PATIENTS

We approached this issue in 570 consecutive patients submitted to thyroidectomy for an indeterminate nodule on cytology. Thyroid autoimmunity was defined as positivity of circulating thyroid autoantibodies (TAb), autoimmune hypo- or hyperthyroidism, thyroid hypoechogenicity on ultrasound, and lymphocytic infiltration on histology.

RESULTS

TAb were found in 122/570 (21.4%), hypoechogenicity in 115/570 (20.1%), and lymphocytic infiltration in 117/570 (20.5%) of patients. The three features of thyroid autoimmunity were highly concordant: hypoechogenicity was observed in 71/448 (15.8%) patients with negative TAb and in 44/122 (36%) with positive TAb (P < 0.0001); lymphocytic infiltration was found in 53/448 (11.8%) patients with negative TAb and in 64/122 (52.4%) with positive TAb (P < 0.0001); hypoechogenicity on ultrasound was observed in 73/453 (16.1%) patients without, and in 42/117 (35.9%) with lymphocytic infiltration (P < 0.0001). None of these parameters was associated with malignancy. TAb were found in 32/135 (23.7%) patients with carcinoma and in 90/435 (20.6%) with a benign lesion (P = NS); hypoechogenicity was observed in 26/135 (19.2%) patients with carcinoma and in 89/435 (20.4%) patients with benign lesions (P = NS); lymphocytic infiltration was present in 28/135 (20.7%) patients with carcinoma and in 89/435 (20.4%) with benign lesions (P = NS). The frequency of cancer in 11 patients with clinically overt thyroid autoimmune disease did not differ from that observed in the whole study group.

CONCLUSION

In this group of patients with indeterminate thyroid nodules at cytology, clinical and pathological criteria of thyroid autoimmunity were strongly concordant and not associated with malignancy.

Endoscopic bilateral neck exploration versus quick intraoperative parathormone assay (qPTHa) during endoscopic parathyroidectomy: A prospective randomized trial

BACKGROUND

Quick intraoperative parathormone assay (qPTHa) during paratyroidectomy has become a standard procedure for patients with primary hyperparathyroidism (PHPT). This paper aims to compare endoscopic bilateral neck exploration (BE) versus focused parathyroidectomy plus qPTHa during minimally invasive video-assisted parathyroidectomy (QM). The endpoints of the study are the mean operative time and outcome of the surgical procedure (PTH and calcemia normalization at one and six months postoperatively).

METHODS

Forty patients with PHPT, positive to preoperative localization studies (ultrasonography evaluation and (99)Tc-MIBI scan) for a single parathyroid adenoma, were randomly allotted into two groups. In the first group (QM), 20 patients (17 women, three men, mean age 57.6 years) underwent focused endoscopic parathyroidectomy (MIVAP tecnicque) plus qPTHa . In the second group (BE) 20 patients (17 women, three men, mean age 59.6 years) underwent endoscopic parathyroidectomy plus bilateral exploration in order to check the integrity of the remaining glands.

RESULTS

There were no significant differences between groups at baseline. No conversion to cervicotomy was required. No postoperative complications were reported. The mean operative time was 32.0 vs 33.1 min [BE and QM group respectively, p = not significant (ns)]. A second macroscopically enlarged gland was removed in four patients in the BE group. Only one out of four glands was reported to be hyperplastic in the final histology. All patients were discharged on the first postoperative day. Calcemia levels were normalized in all patient of both groups, despite persistently high level of serum PTH in one patient in the QM group.

CONCLUSIONS

BE can be performed endoscopically, avoiding both the time necessary for qPTHa and its cost, with the same effectiveness, but might in few cases lead to the unjustified removal of parathyroid glands slightly enlarged but not necessarily pathologic.

One-day thyroid surgery: retrospective analysis of safety and patient satisfaction on a consecutive series of 1,571 cases over a three-year period

Short-stay thyroid surgery (<24 h hospital stay) is becoming increasingly popular but some potentially lethal complications are considered strong arguments against shortening hospitalization after thyroidectomy. The authors reviewed the data of 1,571 patients undergoing one-day thyroid surgery over a 3-year period to determine safety and patient satisfaction. There were 1,244 females and 327 males. Mean age was 43 years. Patient satisfaction was evaluated by a questionnaire given on discharge, while post-discharge surgical recovery was analyzed by the PSR scale. Total thyroidectomy was performed in 1,119 patients (71%), hemithyroidectomy in 450 (29%), isthmusectomy in 2. Morbidity occurred in 152 patients (9.6%). Surgical complications were transient hypocalcemia in 112 cases and permanent hypoparathyroidism in 3; monolateral transient nerve palsy occurred in 10 cases, bilateral in 3; definitive monolateral recurrent palsy in 4 cases. Bleeding requiring re-intervention occurred in 10 cases, wound complications in 5 cases, and intraoperative tracheal lesion in 1 patient. Among complicated patients, 129 (84.8%) were treated after discharge as outpatients. Conversion to inpatient treatment occurred in 28 patients (1.7%) (25 for surgical reasons). Four patients (0.2%) required hospital readmission. Patients were very satisfied in 84.2%, satisfied in 9.5%, poorly satisfied in 4.3%, completely unsatisfied in 2%. Postoperative recovery mean score by PSR scale resulted in 85.14% (0-100%). Our results confirm that the one-day surgery model is safe, effective, and highly agreeable in patients undergoing surgery for thyroid disease.

Role of frozen section associated with intraoperative cytology in comparison to FNA and FS alone in the management of thyroid nodules

AIMS

The utilization of fine needle aspiration (FNA) biopsy is an accurate and cost-effective method in the diagnosis of thyroid diseases. However, the non-diagnostic cases and cases of suspicious carcinoma remain a dilemma, and in these cases thyroidectomy is usually recommended, even if only 15-20% of these patients really need a thyroidectomy. To avoid unnecessary surgical treatment, frozen section (FS) is usually performed. This method is well recognized, but is not useful for the diagnosis of follicular lesions. Therefore, many authors have tried to increase the specificity and sensibility of intraoperative examination, supporting it with an intraoperative cytological technique (IC). To clarify the role of intraoperative exam (FS and IC), also comparing to FNA, we have reviewed our own experiences.

METHODS

In a period covering 6 years (2000-2005), FS was performed in 1,472 cases out of 11,420 total thyroidectomy operations. FS diagnosis and definitive diagnosis, were reviewed and confirmed, moreover, FNA diagnosis and definitive diagnosis were also considered and all intraoperatory cytological slides were reviewed. Diagnostic accuracy was assessed for FNA and FS with or without intraoperative cytology. We compared 1,472 FS diagnoses with their definitive histological diagnosis; 728 FNA out of 1,472 patients with definitive histological diagnosis, and 564 FS associated with IC out of 1,472 patients with definitive diagnosis.

RESULTS

The diagnostic accuracy of these three methods were, respectively, 88.8%, 88.8% and 95.7%.

CONCLUSION

We can assert that FS associated with IC remains the most accurate technique in the surgical management of thyroid nodules.

Combined clinical, thyroid ultrasound and cytological features help to predict thyroid malignancy in follicular and Hupsilonrthle cell thyroid lesions: results from a series of 505 consecutive patients

OBJECTIVE

The cytological patterns of follicular and Hupsilonrthle cell nodules are included among the indeterminate results of fine-needle aspiration cytology, because distinction between benign and malignant lesion can only be made on histological criteria. The diagnostic value of atypia at cytology, clinical parameters and echographic patterns were examined to establish the risk of malignancy in 505 patients with follicular and Hupsilonrthle cell thyroid nodules at cytology.

DESIGN AND PATIENTS

The study included 505 consecutive patients who had undergone thyroidectomy from the period 2002-2005.

RESULTS

Histological diagnosis of malignancy was carried out in 125 of 505 (25%) patients, the follicular variant of papillary carcinoma being the most frequent histotype. Only atypia at cytology (P < 0.0001) and spot microcalcifications at ultrasound (P = 0.009) were predictive of malignancy. Male gender, normal thyroid volume, single nodularity, nodule hypoechogenicity, size and blurred margins were associated with malignancy, although not significantly. An arbitrary clinical score allowed the identification of patients with high (41%, 110 patients) and low (16%, 242 patients) risk of malignancy. Combining the clinical score with the presence of atypia at cytology we could identify 30 patients (6%) in whom the risk of malignancy was as high as 63%.

CONCLUSIONS

Twenty-five per cent of patients with a cytological result of follicular and Hupsilonrthle cell thyroid lesion had a final diagnosis of malignancy. Only atypia at cytology and spot microcalcifications at thyroid ultrasound were significantly associated with malignancy. Other clinical parameters and thyroid ultrasound patterns can be used to set up a clinical score useful for predicting the individual risk of malignancy before surgery.

Overall prognosis in younger patients with colorectal carcinoma

AIM

Prognosis of colorectal cancer in younger patients is a controversial issue. While survival after curative resection seems not worse than in older patients, few data are available about the overall survival of younger patient with colorectal cancer irrespective of receiving a curative treatment or not. In this study we have reviewed our experience with patients under 45 years of age affected by colorectal cancer.

METHODS

A total of 358 patients with colorectal cancer were operated on between 2001 and 2005. Nineteen patients were younger than 45. Schedules were reviewed as to palliative vs curative resection, Duke's classification, tumor grading, and compared with data from patients older than 45.

RESULTS

Though no significant difference in survival can be detected after curative resection, fewer patients less than 45 years are eligible to be treated curatively. Significantly worse tumor grading and rates of curative resection make for a poorer prognosis in younger patients when compared with older ones.

CONCLUSIONS

Prognosis for colorectal cancer in the overall group of patients less than 45 years is worse than in older patients. Younger patients more frequently present with distant metastases or peritoneal carcinosis which preclude the possibility of a curative treatment.

Video-assisted central compartment lymphadenectomy in a patient with a positive RET oncogene: initial experience

BACKGROUND

Prophylactic surgery for patients carrying a positive RET proto-oncogene proved to be highly effective in curing those likely to experience the development of a medullary carcinoma. Video-assisted procedures have been proved feasible for central compartment dissection.

METHODS

A total of 15 patients (7 men and 8 women) with a positive RET proto-oncogene underwent total thyroidectomy and central compartment lymphadenectomy via a video-assisted approach. The mean age of the patients was 32.5 years. The echographically estimated mean volume was 10.3 ml, and the mean diameter of the main nodule was 8.8 mm. Preoperative ultrasound showed an absence of lateral neck lymph node involvement in all cases. No drain was used. Direct laryngoscopy was performed in all cases 1 month after surgery.

RESULTS

The mean operative time was 67.3 min. A transient hypoparathyroidism occurred in one patient, and a permanent hypoparathyroidism occurred in another patient. No laryngeal nerve palsy was present. All the patients were discharged on postoperative day 1. Histology showed a medullary carcinoma in 10 patients and diffuse C-cell hyperplasia in 5 patients. The mean number of lymph nodes removed was 5.1. None of these nodes proved to be metastatic. Calcitonin levels were undetectable in all six patients who had a follow-up period longer than 1 year.

CONCLUSION

Video-assisted central compartment lymphadenectomy was proved to be effective and safe. The procedure demonstrated a complication rate comparable with that for the conventional procedure, a better cosmetic outcome, and less postoperative pain. Although the video-assisted access proved to be a valid option for the treatment of patients carrying a positive RET proto-oncogene, a greater number of cases with a longer follow-up period is necessary to estimate the impact of the video-assisted approach on central neck lymphadenectomy.

Unusual association of adrenal pheochromocytoma and para-aortic neurofibroma in pregnancy

The association of pheochromocytoma (PHEO) and pregnancy is uncommon and life threatening for both the fetus and the mother. Early diagnosis and treatment is essential to decrease maternal and fetal mortality and to differentiate the disease from the more common pre-eclampsia. While medical treatment should be started immediately after diagnosis, the timing of surgical treatment is still debated. We describe the case of a 27-yr-old woman in the 18th week of pregnancy who showed a biochemical pattern typical of PHEO and, by imaging studies, 2 tumors with the same characteristics: the first localized on the right adrenal gland, the second at the right renal hilum. The patient underwent surgery because of suspicion of malignant PHEO with local metastasis, while histology revealed a rare association of a solitary PHEO and para-aortic neurofibroma, both tumors embryologically deriving from a common cell precursor.

Metastatic breast cancer: an updating

This article reports on recent advances on metastatic breast cancer. Detection, prognostic factors, predictors of response to therapy and therapy, with particular regard to targeted therapies, were examined.

DETECTION

Unlike current guidelines that yet do not routinely recommend intensive clinical-instrumental post-operative follow-up of breast cancer patients, relatively large data collected in the last decades have shown that an intensive post-operative follow-up with 'dynamic evaluation' of a suitable tumour marker panel precedes a few months as average the clinical and/or instrumental sign of a pending relapse in most relapsed patients and largely limits the use of the common instrumental examinations.

PROGNOSIS AND THERAPY PREDICTORS

Disease-free interval (DFI)<or=24 months, adjuvant chemotherapy, liver and distant soft tissue involvement or DFI>24 months and disease confined to bony skeleton are prognostic factors more often correlated with relatively poor or prolonged survival, respectively. Estrogen receptor (ER) expression in primary tumour and at the relapse correlates strongly with response to salvage hormone therapy and data from large trials showed that 38-59% of ER and/or PR+ post-menopausal patients had clinical benefit from first line tamoxifen or aromatase inhibitors. An inverse correlation of ER with epidermal growth factor receptor (EGFR) has been found. The co-expression of HER-2/neu and/or elevated serum HER-2/neu protein level were associated with a low rate and shorter duration of response of ER+ patients to first line hormone therapy. Accordingly, ER-EGFR- compared with ER-EGFR+ tumours are usually more responsive to endocrine therapy. High class III beta-tubulin expression or fall in insulin-like growth factor binding protein-3 (IGFBP-3) from baseline levels have been found to significantly predict resistance to chemotherapeutic agents.

THERAPY

Liposomes as carrier of doxorubicin (Caelix, Evacet, Myocet) is one approach to decrease the anthracycline-related cardiac toxicity. Weekly paclitaxel or docetaxel and oral formulation of vinorelbine and 5-fluorouracil (5-FU) (capecitabine) provide new effective and well tolerated options that reach greater dose intensity and cumulative dose than with the conventional schedules. As to the so called 'tailored' or targeted therapies, the more potent and highly selective third generation of aromatase inhibitors (letrozole, anastrozole, exemestane) targeting ER+ tumours by estrogen deprivation, challenge tamoxifen as current standard first line therapy in postmenopausals. One pilot study showed that stimulation of cellular immunity by the addition of beta-interferon-interleukin-2 sequence in patients on clinical benefit on first line tamoxifen significantly prolonged median overall survival (OS) and duration of response compared to that observed in similar patients only treated with tamoxifen. Trastuzumab, a humanised monoclonal antibody to extracellular domain of HER-2, plus conventional chemotherapy has become a standard of care for women with overexpressing HER-2 tumours. Bevacizumab is a recombinant humanised monoclonal antibody to vascular endothelial growth factor (VEGF) that in refractory metastatic breast cancer doubled the response rate of capecitabine although it did not affect survival. Finally, the so called 'oligometastatic' and a few stage IV diseases are conditions amenable to be rendered with no evidence of disease (NED) after local surgery and/or radiation. In both, as well as in complete responders to chemotherapy, minimal residual disease (m.r.d.) likely continues to be present. Recent data suggest that 'biological' therapy (immunomodulators and/or retinoids with or without hormone therapy), might be suitable to be successfully tested in these patients as maintenance treatment given soon after local intervention or chemotherapy.

The newly developed three-dimensional (3D) and two-dimensional (2D) thyroid ultrasound are strongly correlated, but 2D overestimates thyroid volume in the presence of nodules

The newly developed three-dimensional (3D) and two-dimensional (2D) thyroid ultrasound (US) were compared in assessing thyroid volume (TV) in 104 patients: 53 had an isolated thyroid nodule, 32 toxic diffuse goiter, 17 non-toxic multinodular goiter, 1 toxic multinodular goiter and 1 a toxic adenoma. A real-time Technos apparatus (Esaote SpA, Italy) with a 7,5 MHz linear transducer was used. The volume of thyroid lobes by 2D was calculated according to the ellipsoid formula. In the same session, TV by 3D US was calculated using a probe tracking system (in vivo ScanNT Esaote 3.4 MedCom. Darmasdt) and software to reconstruct 3D images, directly giving the lobe volume. There was a very good agreement between 2D and 3D, but in 94/208 lobes with nodular lesions 2D showed a 10% systematic overestimation compared to 3D, the percentage error being higher in lobes with lower volumes. A possible explanation for this result is the inadequacy of the ellipsoid formula in forecasting the correct lobe profile in the presence of nodules. This intrinsic defect of 2D US should be taken into account when evaluating TV in patients with nodular goiter.

Familial parathyroid hyperplasia: is there a place for minimally invasive surgery? Description of the first treated case

While the majority of patients affected with sporadic primary hyperparathyroidism (sPHPT) can be selected for minimal access surgery, patients affected with 4-gland hyperplasia still do not represent an indication for it. Minimally invasive video-assisted parathyroidectomy (MIVAP) was introduced in 1996; this technique relies on a single central incision and external retraction and therefore allows a bilateral neck exploration. This was the case of a 27-yr-old female with familial primary hyperparathyroidism (FPHPT). Three enlarged glands were immediately identified in orthotopic positions and the fourth was intrathyroideal. A subtotal parathyroidectomy was then performed, leaving a small fragment of the inferior right gland and completed with the cervical thymectomy by inverting the positions of the camera and the retractor assistants with regard to the positions originally described. Quick intraoperative PTH assay (QPTH) confirmed the surgical cure of the disease.

Role of cyclooxygenases 1 and 2 in the modulation of neuromuscular functions in the distal colon of humans and mice

BACKGROUND

Cyclooxygenase isoforms (COX-1, COX-2) may exert differential regulatory actions on enteric motor functions under normal or pathological conditions.

AIMS

To examine the occurrence and functions of COX-1 and COX-2 in the neuromuscular compartment of normal distal colon using human and murine tissue.

METHODS

Gene expression (human, mouse), protein expression (human), gene deletion (mouse), and the effects of dual and isoform specific COX inhibitors on in vitro motility (human, mouse) were investigated.

RESULTS

Reverse transcription-polymerase chain reaction (RT-PCR) showed mRNA expression of COX-1 and COX-2 in human and wild-type mouse colonic muscle whereas only COX-2 or COX-1 was detected in COX-1 or COX-2 knockout animals. Immunohistochemistry localised both isoforms in neurones of myenteric ganglia, COX-1 in circular layer myocytes, and COX-2 in longitudinal muscle. Indomethacin (COX-1/COX-2 inhibitor), SC-560 (COX-1 inhibitor), or DFU (COX-2 inhibitor) enhanced atropine sensitive electrically induced contractions of human longitudinal muscle. The most prominent actions were recorded with indomethacin or SC-560 plus DFU. These results were confirmed under pharmacological blockade of non-cholinergic nerves. Atropine sensitive contractions evoked by carbachol in the presence of tetrodotoxin were enhanced by indomethacin or DFU but not by SC-560. In wild-type mice, contractile responses to electrical stimulation were enhanced by indomethacin, SC-560, or DFU. SC-560 potentiated electrically induced contractions in COX-2, but not COX-1, knockout mice. In contrast, DFU enhanced the contractions elicited by electrical stimuli in COX-1, but not in COX-2, knockout mice.

CONCLUSIONS

These results indicate that COX-1 and COX-2 are expressed in the neuromuscular compartment of normal human colon where they modulate cholinergic excitatory control of colonic motility at prejunctional and postjunctional sites, respectively.

Type I interferons modulate the expression of thyroid peroxidase, sodium/iodide symporter, and thyroglobulin genes in primary human thyrocyte cultures

We evaluated in primary human thyrocyte cultures the effect of interferon (IFN)-alpha and -beta on the expression of thyroid peroxidase (TPO), sodium/iodide symporter (NIS), and thyroglobulin (Tg) as well as T(4) release. Human thyrocyte cultures were carried out with fresh normal thyroid tissue. Gene and protein expression of Tg, TPO, and NIS were assessed by RT-PCR and Western blot analysis after 24, 48, and 72 h of treatment with TSH alone (10 mIU/ml) and in combination with IFN alpha or -beta (10(4) U/ml). IFN inhibited the TSH-stimulated gene expression of Tg, TPO, and NIS in a time-dependent manner without significant differences between IFN alpha and -beta. Moreover, the addition of both type I IFNs clearly reduced the TSH-stimulated protein expression of Tg, TPO, and NIS after 72 h of exposure. Finally, this down-regulation was associated with a reduction of T(4) release by almost 50%. In conclusion, our study shows that both IFN alpha and -beta down-regulate the TSH-stimulated expression of Tg, TPO, and NIS as well as T(4) release. Indeed, the development of hypothyroidism during type I IFN therapy may be related, at least in part, to an abnormal expression and function of key proteins involved in iodine uptake and organification.

Age differences in vitamin A intake among Canadian Inuit

BACKGROUND

Inuit traditional food provides ample amounts of preformed vitamin A. However, the dietary transition away from traditional food raises concerns regarding dietary adequacy. Vitamin A is an essential nutrient with inadequate and excessive exposures having adverse effects.

OBJECTIVE

To evaluate total dietary vitamin A intake for Canadian Inuit from market food and traditional food sources and to evaluate retinol concentrations in liver and blubber.

METHODS

Dietary surveys were conducted in 18 communities representing 5 Inuit regions, and traditional food items were evaluated for nutrient content.

RESULTS

Among those 15-40 years of age, 68% of men and 60% of women had a dietary vitamin A intake below the estimated average requirement (EAR) for retinol activity equivalents (RAE)/day. Among those over 40 years of age, only 11 % of men and 15% of women had a dietary vitamin A intake below the EAR. Young Inuit men had a relative risk of 6.2 (95% CI= 4.5-8.4), and young Inuit women had a relative risk of 4.0 (95% CI= 3.1-5.0) for dietary inadequacy compared to the older Inuit men and women, respectively. The median retinol content of liver of ringed seal, caribou, and fish were comparable to levels observed in market food liver. Liver was less frequently consumed by those 15-40 years of age than among older Inuit.

DISCUSSION

Sub-optimal vitamin A intake is the predominant nutritional concern rather than excessive exposures. Public health education campaigns are needed to improve vitamin A intake among the younger generations of Inuit men and women.

Plasma and tissue chromogranin in patients with adrenocortical adenomas

Adrenal adenomas frequently arise from cortical islets in the medulla, and these islets seem to present a greater risk for pathological growth than cortical cells within the adrenal cortex. Chromogranin A (CgA), a glycoprotein co-stored in secreting granules and co-released with resident hormones of chromaffin cells, behaves as a prohormone, generating several biologically active peptides capable of influencing growth, morphogenesis and progression of endocrine tumors. The aim of our study was to investigate whether chromaffin cells may be involved in the development and growth of adrenocortical adenomas. We enrolled 19 patients (12 females and 7 males, mean+/-SD age 54.9+/-11.2 yr, age range 34-75 yr) with incidental, non-functioning, benign adrenocortical adenomas, and measured circulating levels of CgA, catecholamines and creatinine before and 2 months after surgery. Plasma CgA was evaluated by immunoradiometric assay. Testing for CgA immunoreactivity in the removed tissues was performed by immunohistochemical analysis. Mean plasma CgA did not significantly change following surgery (before 73.7+/-15.2 ng/ml; after 68.9+/-14.8 ng/ml). Individual CgA values indicated that 4 patients had plasma CgA levels above our cut-off of normality. After mass removal, CgA further increased in 2 cases, decreased in 1 and normalized in 1. No variation in CgA levels was found in the other patients. No correlation was observed between CgA and the variables measured, except between CgA and plasma creatinine (r=0.472, p<0.05). Histopathological evaluation revealed adrenocortical adenomas in all cases and immunohistochemical analysis detected no CgA immunoreactivity in any specimen. Our results show that in human adrenocortical adenomas CgA is not expressed and that removal of the mass does not modify plasma CgA levels. For these reasons the endocrine involvement of local CgA in adrenocortical tumorigenesis is unlikely.

Spontaneous short-term remission of primary hyperparathyroidism from infarction of a parathyroid adenoma

We report a 39-yr-old woman with spontaneous short-term remission of primary hyperparathyroidism (PHPT). She was referred to our Department for PHPT with bilateral kidney stones diagnosed elsewhere; at the time of our observation she had developed anterior neck pain associated with swelling and tenderness. Biochemical data (serum ionized calcium and PTH) suggested a remission of the PHPT. The local symptoms gradually improved and disappeared over the next several days without therapy. Serum ionized calcium and PTH levels remained normal for up to 11 months. Subsequently, the patient had a recurrence of PHPT with mild hypercalcemia and elevated PTH levels. The patient underwent surgery and pathological examination revealing a 1.0 x 1.2 cm parathyroid adenoma with areas of necrosis with hemosiderinladen macrophages. In conclusion, we describe a case of spontaneous short-term remission of PHPT due to infarction of parathyroid adenoma.

Video-assisted thyroidectomy for Graves' disease: report of a preliminary experience

BACKGROUND

Ever since the introduction of video-assisted thyroidectomy (VAT), Graves' disease has represented a contraindication. This study aimed to demonstrate that VAT can be proposed also for Graves' disease.

METHODS

From January 2002 to March 2003, 21 patients (20 women and 1 man) with Graves' disease underwent VAT. One patient showed positive test results for gene RET. The mean age of the patients was 36.4 years.

RESULTS

No conversions of procedure were necessary. The mean operative time was 56.9 min. The RET-positive patient underwent total thyroidectomy and central compartment lymphadenectomy. Postoperative bleeding occurred in the patient with the largest gland. Histology showed goiter in 18 cases, medullary carcinoma in 1 case, and papillary carcinoma in 2 cases. No cases of vocal cord palsy but three cases of transient hypocalcemia were registered.

CONCLUSIONS

Graves' disease can be treated safely using VAT only if selection criteria are carefully respected. The young age of the patients with this disease encourages us to propose VAT for its good cosmetic and postoperative outcome.

Serum haptoglobin: a novel marker of adiposity in humans

Haptoglobin (Hp) is a glycoprotein involved in the acute phase response to inflammation. Our previous findings indicate that Hp mRNA and protein are present in the adipose tissue of rodents and that Hp gene expression is up-regulated in obese models. The aim of the present study was to establish whether Hp could be considered a marker of obesity in humans. In 312 subjects, serum Hp was correlated directly with body mass index (BMI), leptin, C-reactive protein (CRP), and age. In a multivariate stepwise regression analysis, BMI and CRP were independent determinants of serum Hp in females, with BMI having the strongest effect. CRP and age were independent determinants of serum Hp in males, although explaining only a modest percentage of the total variability. Serum Hp was positively associated with body fat, as assessed by dual-energy x-ray absorptiometry, both in female and in male groups. The level of significance improved when serum Hp was analyzed against fat mass adjusted for lean mass. Finally, Northern and Western blot analyses performed in biopsies of sc abdominal fat from 20 obese individuals showed the presence of Hp mRNA and protein in the human adipose tissue. In conclusion, serum Hp constitutes a novel marker of adiposity in humans, and the adipose tissue likely contributes to determine its levels.

Video assisted prophylactic thyroidectomy and central compartment nodes clearance in two RET gene mutation adult carriers

Activating point mutations of RET gene have been demonstrated to be causative of the familial form of medullary thyroid cancer (MTC), both isolated (FMTC) and associated to other endocrine neoplasia [multiple endocrine neoplasia (MEN) 2A and 2B]. In RET gene mutation carriers, who are prone to developing MTC, prophylactic thyroidectomy is recommended to obtain their definitive cure. The simultaneous excision of the central node compartment is mandatory when the stimulation pentagastrin test for serum calcitonin is positive. Although the minimally invasive video assisted thyroidectomy (MIVAT) is nowadays currently adopted in many centers, it has never been employed for the prophylactic thyroidectomy of RET gene mutation carriers. The fear of obtaining an incomplete lymphadenectomy of the central compartment was the main reason for this reluctance. Since RET gene mutation carriers have often normal thyroid volume and, if involved, small lymph nodes, they indeed represent the best candidates to this approach especially when considering that they are usually young and concerned about the cosmetic results and the period of hospitalization. The excellent results obtained by MIVAT in the last few years induced us to propose this procedure together with a central compartment lymphadenectomy to 2 RET gene mutation carriers recently found by genetic screening. As assessed by a negative pentagastrin stimulation test performed after 6 months from the MIVAT, they were definitively cured without any surgical complication with the exception of a transient hypoparathyroidism. They showed a great satisfaction for both the cosmetic results and the very short period of hospitalization, thus supporting the idea that MIVAT can be used in association with the central node dissection for the prophylactic treatment of RET mutation gene carriers whose thyroid volume is still normal.

[Minimally invasive video-assisted thyroidectomy--techniques and results over 4 years of experience (1999-2002)]

INTRODUCTION

This study reviews four years of Minimally Invasive Video Assisted Thyroidectomy (MIVAT) technique and compares the results to those of traditional thyroid surgery.

MATERIALS AND METHODS

Between 1999 and 2002, a series of 427 patients were submitted to MIVAT at our Department. Selection criteria were: thyroid nodule maximum diameter of 3.5 cm, total thyroid volume under 25 cc, no signs associated thyroiditis, diagnosis of benign thyroid disease or "low risk" thyroid tumor, no evidence of nodal disease of the neck.

RESULTS

We operated on 362 females and 65 males and the mean age of the population was 39.6 years (range 10-77). A total thyroidectomy was performed in 208 cases, and 219 patients underwent a single-side procedure. Mean operative time was 30.4 minutes for lobectomy (range 20-140 minutes) and 50.2 for total thyroidectomy (range 35-140). Complications were represented by definitive recurrent nerve palsy in 3 patients (0.7%) and one case of definitive hypoparathyroidism (0.4%). A wound infection is reported in 3 cases and we had no major bleeding that required surgical revision. A conversion to open procedure was performed in 5 cases (1.2%); mean hospitalisation was 1.28 days (range: 1-4).

CONCLUSIONS

This series demonstrates that MIVAT is not different to conventional open surgery in terms of complications, radicality of the procedure and operative time. Moreover, even if not statistically proved, MIVAT appears to offer some advantages in terms of cosmetic results and postoperative pain. In conclusion, we believe that MIVAT is a perfectly reproducible and safe technique for both benign and low-risk malignant thyroid disease, when correct indications are strictly followed.

[Video-assisted minimally invasive parathyroidectomy with median access. Technical changes: case load 1999-2002]

INTRODUCTION

In 1997 a Minimally Invasive Video Assisted Technique for Parathyroidectomy (MIVAP) was developed in the University of Pisa. In this review we examine the last three years of MIVAP (240 cases) in order to identify the advantages and the limits of the procedure after the first-period development of the technique.

RESULTS

In our experience, 65% of patients affected by primary hyperparathyroidism (PHPT) turned out to be eligible for MIVAP. During the first years several selection criteria were strictly followed; more recently, some initially absolute contraindications to the operation have been interpreted more flexibly. Mean operative time is 35 minutes. 18 conversions (7.5%) to traditional open cervicotomy were needed and in 4 cases (1.6%) no affected parathyroid tissue was removed.

CONCLUSIONS

At present, we consider absolutely necessary for MIVAP: preoperative localization of an adenoma with at least one imaging study (US or MIBI scintiscan) and the availability of QPTH intraoperative assay. No absolute contraindications other than the size of the lesions and the suspect of parthyroid carcinoma are identified for patients with PHPT. Moreover, MIVAP has proved to have further advantages when compared to other mini invasive procedures such as the demonstrated possibility to perform a traditional bilateral exploration, when indicated. Nevertheless, a great degree of experience is requested for this procedure. In conclusion, MIVAP permits to significantly reduce postoperative pain, size of the incision, days of hospitalisation and, finally, the cost of the entire procedure without affecting in any way the success rate of the traditional operation and without an increase of the complications.