An audit of management of differentiated thyroid cancer in specialist and non-specialist clinic settings

OBJECTIVE

Thyroid cancer is the most common endocrine malignancy but is none the less rare. Some aspects of its management remain controversial. Previous audits of patient management in the United Kingdom have revealed deficiencies, especially in communication between specialists. We have audited patient management in a large university-associated teaching hospital, assessing points of good practice identified from published guidelines and reviews, and have compared findings in groups of patients managed jointly by specialists with an interest in thyroid cancer (including surgeon, endocrinologist and oncologist) with a group managed by other clinicians outside that setting.

DESIGN AND PATIENTS

Retrospective case-note review of 205 patients with differentiated (papillary or follicular) cancer including group A (n = 134; managed in a specialist multi-disciplinary clinic setting) and group B (n = 71; managed in other clinic settings). Points of good practice investigated were adequacy of surgery, surgical complications, prescription and adequacy of T4 treatment, adequacy of monitoring by measurement of serum thyroglobulin and action taken and appropriate administration of ablative radioiodine.

RESULTS

Deficiencies in management of the cohort as a whole were identified, including inadequate surgery and inadequate TSH suppression in approximately one-fifth of the cases. Monitoring with thyroglobulin measurements and action when serum thyroglobulin was high were also inadequate in some cases and ablative radioiodine was not given, despite being indicated in 11.7% of the cohort. Inadequate surgery and failure to administer radioiodine were less common in those managed in a specialist clinic setting than in those managed in other clinic settings.

CONCLUSIONS

The findings highlight the need for locally agreed protocols in managing relatively rare endocrine disorders such as thyroid cancer and argue in favour of centralization of expertise and patient management in multi-disciplinary specialist clinic settings.

Human retinal S-antigen: T cell epitope mapping in posterior uveitis patients

Uveitis, an intraocular inflammatory disease which affects the uveal tract and the retina of the eye in humans, is one of the major causes of visual impairment. Posterior uveitis is often associated with inflammation of the retina and vitreous. Unfortunately, etiological diagnosis of the disease is not possible in the majority of patients. It is generally felt that an autoimmune mechanism may be involved in so-called idiopathic cases. The role of retinal S-antigen, its 20 linear peptides spanning the entire sequence, and 2 additional peptides, known to be uveitopathogenic in experimental animals, was studied in 26 patients with uveitis. Lymphocyte proliferative response was tested in vitro to identify the epitopes of S-antigen involved and to establish their role in the pathogenesis of uveitis. Of 26 uveitis patients tested, 11 showed a significant T cell proliferative response in vitro to at least 1 antigen used. None among the controls showed any response to the peptides or native S-antigen used in this study. We have found that uveitis patients respond most frequently to peptide 4 (61--80), peptide 5 (81--100), peptide 8 (141--160), peptide 9 (161--180), peptide 12 (221--240), and peptide 13 (241--260) of the human S-antigen. These results further confirm that autoimmunity to retinal S-antigen may play a role in the etiopathogenesis of a subset of patients with idiopathic uveitis.

Pericardial effusion as a cause of morbidity in patients on maintenance hemodialysis: is it preventable?

OBJECTIVE

Cardiovascular diseases are the cause for 45% mortality and 20% morbidity in hemodialysis (HD) patients. Pericardial effusion (PE) accounts for 03-04% of all deaths in HD patients as a result of tamponade, arrhythmias or heart failure. This study aims to find out the prevailance and precipitating factors for PE in hemodialysis patients.

PATIENTS AND METHODS

Fifty-five patients were identified for echo-cardiographic assessment on the basis of signs and symptoms suggestive of PE i.e., hypotension during dialysis, dyspnea, globular heart in chest x-ray, raised JVP, soft heart sounds and low voltage ECG. A matched controlled group of 55 patients for age, sex, dialysis schedule, cause of ESRD and dialysis bath, was also studied echocardiographically.

RESULTS

Pericardial Effusion was detected in 12 patients (10.9%), 10 (83.3%) were on 2/week and only two on 3/week dialysis. Of these 75% were non-compliant in fluid intake and 58.3% were irregular in treatment. The morbidity of PE in study group (18.2%) is significantly higher as compared to controls (3.6%) (P = < 0.05). No correlation was found between development of PE and high iPTH and low albumin levels. Ten patients with mild PE responded to vigorous dialysis. Two patients developed cardiac tamponade needing pericardiocentesis.

CONCLUSION

We have identified 2/week dialysis (inadequate dialysis dose), acetate bath and fluid and dialysis non-compliance as factors contributing to development of PE in HD patients.

Retinopathy of prematurity: mutations in the Norrie disease gene and the risk of progression to advanced stages

BACKGROUND

Retinopathy of prematurity (ROP) is a retinal vascular disease that occurs in infants with short gestational age and low birth weight and may lead to retinal detachment and blindness. Missense mutations in the Norrie disease (ND) gene have been associated with the risk of progression to advanced stages in cases of ROP from the US and also in clinically similar ND and familial exudative vitreoretinopathy.

METHODS

We have screened two ND gene mutations, namely A105T and Val60Glu, by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and allele-specific PCR methods, respectively, in 210 Kuwaiti premature newborns to replicate these findings in a different ethnic group.

RESULTS

In the Kuwaiti premature newborn cohort, 115 of 210 babies had no eye problems and served as controls, while 95 were cases of ROP. In 71 of 95 ROP cases, the disease regressed spontaneously on or before stage 3, while in 24 of 95 ROP cases the disease progressed to advanced stages 4 and 5. In case of missense mutation (A105T), the AA genotype was detected in 96% of controls compared with 87% of ROP cases (NS); similarly no significant difference was found between spontaneously regressed ROP cases and those who progressed to advanced stages. For the Val60Glu mutation, no significant association was detected between the genotype and progression of ROP to advanced stages.

CONCLUSIONS

Unlike data from the US, our findings from a Kuwaiti cohort of ROP cases and controls suggest a lack of association between the two ND gene mutations (A105T and Val60Glu) and ROP and the risk of progression of the disease to advanced stages.

Pre-operative serum vascular endothelial growth factor can select patients for adjuvant treatment after curative resection in colorectal cancer

We aim to determine the clinical usefulness of pre-operative serum vascular endothelial growth factor (VEGF) as a predictor of outcome in patients undergoing curative resection for colorectal cancer. Serum VEGF was assayed by quantitative ELISA in 81 patients prior to curative resection for node-negative (n = 53) and node-positive (n = 28) disease. Median follow-up for patients without cancer death was 27 months (range 21-37). Pre-operative serum VEGF was significantly higher in patients who went on to develop metastases than those who did not (median, 713 pg ml-1 vs. 314 pg ml-1, P < 0.0001). Using multivariate Cox regression analysis, pre-operative serum VEGF was the most important prognostic factor independent of nodal status and adjuvant chemotherapy, and was superior to nodal status in predicting outcome (P < 0.00001). At 575 pg ml-1, pre-operative serum VEGF was 64% sensitive and 89% specific in predicting the development of metastases in curative resections, with a positive predictive value of 73% and a negative predictive value of 85%. Pre-operative serum VEGF is a powerful predictor of outcome following curative surgery for colorectal cancer. These data support the measurement of pre-operative serum VEGF as a method for selecting patients who require adjuvant therapy.

Parental age in Indian patients with sporadic hereditary retinoblastoma

There is a consistent correlation between sporadic hereditary retinoblastoma and parental age. It has been proven beyond doubt that the birth rank is correlated with parental age. In the present study, a test for the effect of birth rank was performed in order to assess the risk of developing retinoblastoma with increased parental age. The study of the effect of birth rank showed a significant association between sporadic retinoblastoma (bilateral and unilateral) and late para, indicating that fresh germline mutations must have taken place in some of the sporadic cases. An investigation of the effect of birth rank on familial cases, obtained from published papers and our own series, showed that familial retinoblastoma is significantly associated with early para, suggesting early parental age. Further analysis of the mean paternal and maternal ages of sporadic cases (bilateral and unilateral) showed that the mean paternal age of sporadic bilateral (sporadic hereditary) cases was higher than that of sporadic unilateral cases (p<0.05). No such correlation was seen with mean maternal age. Thus, the present study shows that a high paternal age may be associated with sporadic bilateral (sporadic hereditary) retinoblastoma.

Immobilization of hormones for drug targeting

Biological active compounds such as insulin, heparin, progesterone and labeled-LH were entrapped in glutaraldehyde cross-linked bovine serum albumin (BSA) and human serum albumin (HAS) microspheres. Studies were carried out for their binding capacity and biodegradability using new proteolytic enzymes. Effects of proteolytic enzymes such as trypsin, chymotrypsin, papain and pronase-E on microspheres were studied in order to understand the biodegradability of the cross-linked proteins. It has been observed that labeled-LG was entrapped 60% in BSA and HAS microspheres. Labelled-LH-BSA, Labelled-LH-HAS and insulin microspheres were injected into mice and rabbits. It was observed that these cross-linked microspheres were biodegradable and the process appeared to be slow one, useful for sustained release of hormones. It was also observed that these albumin microspheres exhibit fluorescence at 495 nm.

Cutting edge: CD1d deficiency impairs murine host defense against the spirochete, Borrelia burgdorferi

CD1 molecules can present microbial lipid Ag to T cells, suggesting that they participate in host defense against pathogens. In this study, we examined the role of CD1d in resistance to infection with the Lyme disease spirochete, Borrelia burgdorferi (Bb), an organism with proinflammatory lipid Ag. Bb infection of CD1d-deficient (CD1d(-/-)) mouse strains normally resistant to this pathogen resulted in arthritis. Pathology correlated with an increased prevalence of spirochete DNA in tissues and enhanced production of Bb-specific IgG, including IgG to Ag rapidly down-modulated on spirochetes in vivo. CD1d(-/-) mice exhibited high-titer Bb-specific IgG2a, an isotype commonly induced in disease-susceptible mice but not in the disease-resistant control mice in this study. These results show that CD1d deficiency impairs host resistance to a spirochete pathogen, and are the first example of a mutation that imparts Bb-resistant mice with the Ab and disease profile of a susceptible mouse strain.

Advances in enzymatic transformation of penicillins to 6-aminopenicillanic acid (6-APA)

This article elaborates on the important recent developments in the enzymatic transformation of penicillins to 6-aminopenicillanic acid (6-APA), which is the basic raw material for the industrial production of semisynthetic penicillins such as amoxycillin and ampicillin. Particular emphasis is placed on the improvements in purification, stability, and immobilization of the enzymes, (i.e. penicillin acylases) used for these transformations.

Incidence, clinical spectrum, and outcome of intrauterine infections in neonates

A prospective study was undertaken on the incidence of intrauterine infections by screening 1302 cord blood samples for total IgM by radial immunodiffusion. Specific IgM against cytomegalovirus (CMV), rubella and Toxoplasma were estimated in cord blood samples found to contain total IgM > 20 mg/dl. All these neonates were examined at birth and at discharge. Cord blood samples with total IgM > 20 mg/dl were further screened for specific IgM against rubella, CMV and Toxoplasma. Neonates found to have positive specific IgM were followed-up for hearing, opthalmological and developmental assessment. Raised cord blood (IgM > 20 mg/dl) was found in 270/1302 (20.6 per cent). Mean birth weight was comparable in babies with raised (> 20 mg/dl) or low (< 20 mg/dl) cord blood total IgM. Incidence of prematurity and low birth weight were not statistically different in babies with raised cord blood IgM when compared to those with low cord blood IgM levels. Similarly, incidence of intrauterine growth retardation (IUGR) idiopathic was similar in two groups. Specific IgM for rubella was found to be positive in eight (0.6 per cent). Of these, three had symptomatic rubella infection. Two mothers of these symptomatic babies had exanthematous viral illness during first trimester. Specific IgM for CMV was found to be positive in 23 (1.8 per cent) while two infants had symptomatic CMV disease. None of the babies was found to have specific IgM against Toxoplasma. One baby with symptomatic CMV disease and one with rubella died. Another baby with symptomatic CMV disease developed neonatal hepatitis which improved on follow-up but the infant went on to develop sensorineural deafness. All other asymptomatic babies with specific IgM positive against rubella and CMV were found to have normal vision, hearing and development on follow-up.

Laparoscopic ultrasound for the detection of hepatic metastases during laparoscopic colorectal cancer surgery

PURPOSE

The search for liver metastases before surgery forms an accepted part of colorectal cancer surgical practice. Intraoperative ultrasound and manual palpation of liver together form the criterion standard as far as screening for metastases is concerned. However, extracorporeal imaging, such as ultrasound and magnetic resonance imaging, are also widely used. The purpose of this study was to demonstrate the efficacy of laparoscopic ultrasound scan in detection of liver metastases during laparoscopic colorectal cancer surgery by comparison with conventional imaging modalities.

METHODS

A prospective, controlled study was undertaken. A total of 76 consecutive patients undergoing laparoscopic colorectal resections for malignancy were recruited. Patients underwent preoperative liver ultrasound scan and intraoperative blinded laparoscopic ultrasound scan examination performed by a single surgeon. Contrast-enhanced magnetic resonance imaging was performed within 30 days of surgery.

RESULTS

Conventional ultrasound scan was negative in all cases. Metastases were identified during simple laparoscopic inspection of the liver in one case. Two cases shown by laparoscopic ultrasound scan to have definite metastases were confirmed by magnetic resonance imaging. In seven further instances laparoscopic ultrasound scan identified suspicious liver masses. In three cases these were confirmed to be metastases at magnetic resonance imaging; one was confirmed as a cyst, and the remaining three suspicious lesions were confirmed at serial magnetic resonance imaging scans to be benign and of no significance.

CONCLUSION

Laparoscopic ultrasound scan with a flexible-tipped probe permits satisfactory hepatic examination. It is superior to conventional ultrasound scan and seems to be as effective as magnetic resonance imaging, although the latter modality is still required to delineate identified lesions.

Missense mutations in norrie disease gene are not associated with advanced stages of retinopathy of prematurity in Kuwaiti arabs

Retinopathy of prematurity (ROP) is a disease characterized by retinal neovascularization, possibly leading to retinal detachment and finally blindness. In a proportion of ROP cases, the disease progresses to advanced stages despite rigorous intervention. Missense mutations of the Norrie disease (ND) gene have been associated with progression of the disease in ROP cases from the USA. We have investigated the presence of ND gene mutations in 102 premature newborns of Kuwaiti Arab origin to replicate this finding in a different population/racial group. 56 (55%) of these newborns had normal eyes and served as controls. In 35 (34%) cases, the ROP regressed spontaneously during stage 1-3. In 11 (11%) cases, ROP progressed to advanced stages. A PCR-RFLP method was used to detect the mutations in exon 3 of the ND gene and confirmed the DNA sequence by direct sequencing of the PCR product. The [R121W] mutation of the ND gene was not detected in the premature newborns screened from our Kuwaiti population/group. For the second mutation [L108P], a genotype (PP) was present in 98% of the premature newborns screened and only in 1 of 56 normal infants was the (LL) genotype detected. Our population is genetically homogenous in that genotype (PP) was detected at codon 108 in almost all controls and ROP cases. We did not find an association between the presence or absence of missense mutations of the ND gene and the risk of severe ROP.

Immobilization of cholesterol oxidase on Formvar using organic solvents

The present study describes a new immobilization support for the preparation of enzyme membrane in the presence of organic solvents. The support was composed of Formvar solubilization in organic solvents with enzyme. More than 90% of the enzyme was immobilized on the membrane. The membrane was prepared by mixing 4% Formvar in organic solvents and 1% cholesterol oxidase was immobilized by entrapment technique. Practically no leaching of the entrapped enzyme was observed. The resultant immobilized enzyme membrane was stored at 4 degrees C for 10 days without losing its activity. The pH and temperature stabilities were greater than those of the native enzyme. The immobilized enzyme membrane has a long life due to its hydrophobic nature, as compared with other membranes.

Periurethral Goretex sling in lower urinary reconstruction

Urethral incontinence in patients with neuropathic bladders remains a management problem not only to urologists but also to the primary carers of these patients. It impairs quality of life and encourages social withdrawal, but also leads to perineal soreness and inflammation. A number of surgical techniques have been described to increase bladder outlet resistance in order to render patients with neuropathic bladders perineally dry. We report our experience in achieving dryness with a periurethral Goretex sling in 17 patients.

Effect of buffalo follicular fluid treatment on follicle population and ovulation rate in guinea pigs

A number of workers have studied the effect of follicular fluid (FF) on the secretion of follicular stimulating hormone (FSH) but little is known about its potential as a regulator of ovarian activity, including ovulation rate. This paper describes the effect of charcoal treated-buffalo follicular fluid (buFF) treatment on follicular growth and ovulation rate in guinea pigs. Eighteen guinea pigs in three groups of 6 each were given 0.2 ml buFF at 12 hr interval for 3 days at different stages of estrous cycle viz., early-luteal, mid-luteal or follicular phase. One control group received equal volume of saline. Estrus was monitored every morning and evening by inspection of the opening of vaginal membrane and its cytology. All animals were sacrificed at 24 hr after the onset of estrus. Both the ovaries were dissected out, weighed and number of ovulation points recorded. One ovary from each animal was processed for histological examination to determine the population of healthy and atretic follicles. In early-luteal and follicular phase-treated animals the onset of estrus was delayed (P < 0.01) and ovulation rate was not affected. However, estrus occurred at normal when the treatment was initiated at midluteal stage and 50% animals failed to ovulate in this group. The total follicle population at metestrus increased significantly in all treated animals because of increase in number of follicles of size class II (400 to < 600 microns diam.). Atresia was also declined due to treatment. These results demonstrated that the buFF contained some inhibitory substances that delayed the onset of estrus in guinea pigs.

Diagnostic intraocular fine-needle aspiration biopsy--An experience in three cases of retinoblastoma

Ophthalmoscopically guided intraocular fine-needle aspiration biopsy (FNAB) under general anesthesia was performed in three suspected cases of retinoblastoma (Rb). The first case presented with uveitis and the second with unusual radiological features. The third case had classical clinical features of bilateral Rb but the parents refused enucleation. After a cytologic diagnosis of retinoblastoma, two cases were subjected to enucleation and a histologic confirmation was obtained. The present article discusses the technique of guided intraocular FNAB and its limitations as well as utility in the preoperative diagnosis of retinoblastoma (Rb). The authors are of the opinion that FNAB should be considered a viable diagnostic option in selected cases of leucocoria when conventional investigative modalities prove inconclusive or for tissue diagnosis when a patient of suspected Rb refuses enucleation.

Gender, clinical findings, and serum thyrotropin measurements in the prediction of thyroid neoplasia in 1005 patients presenting with thyroid enlargement and investigated by fine-needle aspiration cytology

One thousand five euthyroid patients (870 females and 135 males, mean age 47 years), who presented with thyroid enlargement were evaluated by fine-needle aspiration cytology (FNAC) of the thyroid as the first-line investigation. The final cytological or histological diagnosis was determined after surgery (n = 312) or clinical follow-up for a minimum period of 2 years (range 2-14 years, mean 6.7 years). Goiter type was assessed clinically and was classified as diffuse in 147, multinodular in 247, or solitary nodule in 611. The overall sensitivity and specificity of the procedure in the detection of thyroid neoplasia was 88% and 89%, respectively. Males who presented with thyroid enlargement had significantly higher rates of malignancy (p = 0.007) and neoplasia (benign + malignant) (p = 0.002) than females, as did subjects with solitary nodule compared with diffuse or multinodular goiters (malignancy p = 0.001, neoplasia p < 0.001). Subjects with normal thyrotropin (TSH) (>0.4 mU/L) at presentation had a nonsignificantly increased risk of thyroid neoplasia (p = 0.07) and malignancy, in contrast to those with low TSH (<0.4 mU/L). We confirmed FNAC of the thyroid to be an accurate test in the detection of thyroid neoplasia. Gender and goiter type at presentation both contribute significantly to the prediction of the diagnosis of thyroid neoplasia.

Gene expression in the brain across the hibernation cycle

The purpose of this study was to characterize changes in gene expression in the brain of a seasonal hibernator, the golden-mantled ground squirrel, Spermophilus lateralis, during the hibernation season. Very little information is available on molecular changes that correlate with hibernation state, and what has been done focused mainly on seasonal changes in peripheral tissues. We produced over 4000 reverse transcription-PCR products from euthermic and hibernating brain and compared them using differential display. Twenty-nine of the most promising were examined by Northern analysis. Although some small differences were observed across hibernation states, none of the 29 had significant changes. However, a more direct approach, investigating expression of putative hibernation-responsive genes by Northern analysis, revealed an increase in expression of transcription factors c-fos, junB, and c-Jun, but not junD, commencing during late torpor and peaking during the arousal phase of individual hibernation bouts. In contrast, prostaglandin D2 synthase declined during late torpor and arousal but returned to a high level on return to euthermia. Other genes that have putative roles in mammalian sleep or specific brain functions, including somatostatin, enkephalin, growth-associated protein 43, glutamate acid decarboxylases 65/67, histidine decarboxylase, and a sleep-related transcript SD464 did not change significantly during individual hibernation bouts. We also observed no decline in total RNA or total mRNA during torpor; such a decline had been previously hypothesized. Therefore, it appears that the dramatic changes in body temperature and other physiological variables that accompany hibernation involve only modest reprogramming of gene expression or steady-state mRNA levels.

Usefulness of percutaneous transhepatic biliary drainage in patients with surgical jaundice--a prospective randomised study

BACKGROUND

Patients with obstructive jaundice undergoing surgical procedures have a significant risk of morbidity and mortality. The role of preoperative percutaneous transhepatic biliary drainage (PTBD) was evaluated in a randomized trial.

METHODS

A total of 40 patients were assigned to either preoperative PTBD (n = 20), or surgery alone (n = 20). PTBD was performed under ultrasound guidance. There were no major complications related to the procedure.

RESULTS

Ultrasound guided drainage was a successful and safe method of preoperative biliary decompression. There was a marked relief from pruritus and significant reduction of hyperbilirubinaemia from a mean of 386.48 mumol/L to 116.10 mumol/L (p < 0.001). Mean duration of drainage was 42.5 days. Postoperative complications occurred in five patients in PTBD group (25%) compared to 11 patients (55%) in the control group. One death (5%) occurred in PTBD group compared to four deaths (20%) in the control group (significant at 5% level with probability 0.2).

CONCLUSIONS

Ultrasound guided drainage is a useful preoperative supportive measure in preparing deeply jaundiced patients for surgery and permits hepatic function to return to a near normal state preoperatively. The improved results in our study were due to longer duration of drainage.