Rates of malignancy in incidentally discovered thyroid nodules evaluated with sonography and fine-needle aspiration

OBJECTIVE

The purpose of this study was to compare the rate of malignancy in thyroid nodules discovered incidentally on magnetic resonance imaging, computed tomography, and sonography with the rate of malignancy in nonincidentally discovered nodules.

METHODS

All thyroid sonographic and fine-needle aspiration (FNA) procedures performed during a 6-month period were retrospectively reviewed. Study indications were categorized as incidental (thyroid nodules found on magnetic resonance imaging, computed tomography, or sonography performed for nonthyroid indications) or nonincidental (studies prompted by abnormal physical examination findings or laboratory values or signs or symptoms suggestive of thyroid disease). Rates of malignancy in patients with incidentally discovered nodules were compared with rates in patients with nonincidental thyroid abnormalities by the Fisher exact test.

RESULTS

Of 225 thyroid sonographic studies, 35 (16%) were performed for incidentally discovered thyroid nodules, and 190 (84%) were performed for evaluation of nonincidental thyroid abnormalities. A total of 21 patients (60%) in the incidental group and 90 patients (47%) in the nonincidental group underwent FNA. The rate of malignancy in nodules examined by biopsy in the incidental group was 17% compared with 3% in the nonincidental group (P = .020). Patient sex, multiplicity of nodules, nodule size, echo texture, and presence of calcifications did not differ significantly between the groups. The mean age of patients in the incidental group was significantly higher (61 versus 51 years; P = .007); however, advanced age was not associated with a greater rate of malignancy.

CONCLUSIONS

This study identified an unexpectedly high rate of malignancy in incidentally discovered thyroid nodules, suggesting that incidentally discovered thyroid nodules should be evaluated with follow-up thyroid sonography and FNA.

A placebo-controlled, double-blind study of the efficacy and safety of aripiprazole in patients with acute bipolar mania

OBJECTIVE

The authors compared the efficacy and safety of aripiprazole, a novel antipsychotic, to placebo for treatment of patients in an acute manic or mixed episode of bipolar disorder.

METHOD

This 3-week, multicenter, double-blind study randomly assigned 262 bipolar disorder patients in an acute manic or mixed episode to aripiprazole, 30 mg/day (reduced to 15 mg/day if needed for tolerability), or placebo. Patients remained hospitalized for at least 2 of the weeks. The primary efficacy measure was mean change from baseline in total score on the Young Mania Rating Scale; response was defined as a decrease in score of > or =50%.

RESULTS

Aripiprazole produced statistically significant mean improvements in total score on the Young Mania Rating Scale compared with placebo (-8.2 versus -3.4, respectively) and produced a significantly higher response rate (40% versus 19%). For key efficacy variables (response per Young Mania Rating Scale; Clinical Global Impression-Bipolar Version scores for severity of illness [mania] and change from preceding phase [mania]), aripiprazole separated from placebo by day 4. The completion rate was significantly higher with aripiprazole than with placebo (42% versus 21%). Discontinuations due to adverse events did not differ significantly between the aripiprazole and placebo groups. There were no significant changes in body weight versus placebo, and aripiprazole was not associated with elevated serum prolactin or QTc prolongation.

CONCLUSIONS

Aripiprazole had significantly greater efficacy than placebo for the treatment of bipolar disorder patients in acute manic or mixed episodes and was safe and well tolerated in this randomized controlled trial.

Switching patients to aripiprazole from other antipsychotic agents: a multicenter randomized study

RATIONALE

Switching patients from one antipsychotic to another can lead to tolerability problems or transient symptom exacerbations. It is important to compare switching strategies to determine which methods produce the best possible patient outcomes.

OBJECTIVE

To investigate the efficacy, safety and tolerability of three dosing strategies for switching chronic, stable patients with schizophrenia from current oral antipsychotic monotherapy to once-daily oral aripiprazole monotherapy.

METHOD

Patients in this 8-week, open-label, outpatient study were randomized to: 1). immediate initiation of 30 mg/day aripiprazole with simultaneous immediate discontinuation of current antipsychotic; 2). immediate initiation of 30 mg/day aripiprazole while tapering off current antipsychotic over 2 weeks; or 3). up-titrating aripiprazole to 30 mg/day over 2 weeks, while simultaneously tapering off current antipsychotic. Efficacy assessments included PANSS, CGI-S, and CGI-I scores. Safety assessments included: adverse events (AEs) recording, evaluation of extrapyramidal symptoms (EPS), vital signs, ECG, and clinical laboratory tests.

RESULTS

Efficacy with aripiprazole was maintained during the study with numerical improvements compared with baseline in all three groups. The overall incidence of AEs was broadly comparable across all groups, and AEs were generally mild to moderate in severity and time-limited. Discontinuations due to AEs were comparable across the groups. No deterioration in EPS occurred in any group. The reduction in body weight and plasma prolactin levels following switch to aripiprazole were comparable across the three groups.

CONCLUSION

Any of the three strategies evaluated can be used safely for switching patients to aripiprazole from antipsychotic monotherapy. Furthermore, patients' symptoms may continue to improve after switching to aripiprazole.

Using sonography to examine adult patients at an academic medical center: have usage patterns changed with the expansion of managed care?

OBJECTIVE

This study was designed to determine whether significant changes have occurred in the utilization of sonography relative to more expensive cross-sectional imaging techniques in adult patients during a time of increasing reliance on managed care.

MATERIALS AND METHODS

Use of sonography was compared with use of CT and MR imaging of the abdomen, pelvis, and retroperitoneum in adult patients in 1993 and 1998 at an academic medical center. Clinicians who requested the greatest number of examinations in both years were surveyed to assess their perception of changes in their practice patterns during the interim.

RESULTS

Between 1993 and 1998, the use of sonography relative to the other cross-sectional imaging modalities decreased from 56% to 43% (p < or = 0.001). During the same time, CT use increased from 30% to 41% (p < or = 0.001), and MR imaging use increased from 14% to 16% (p < or = 0.001). Survey responses indicated that potential cost saving was not a major factor in physicians' decisions to use sonography rather than other cross-sectional imaging modalities.

CONCLUSION

Sonographic utilization decreased during a 5-year period in which managed care provided an increasingly large proportion of overall reimbursement. Cost did not appear to be a major factor in selection of diagnostic tests. Differences over time in refering clinicians' perception of the relative usefulness of sonography, CT, and MR imaging may have contributed to the change in usage patterns.

Retinoic acid stimulates immature lung fibroblast growth via a PDGF-mediated autocrine mechanism

All trans-retinoic acid (RA) enhances alveolarization in neonates and reinitiates alveolarization in emphysematous adult rat lungs, suggesting that RA may stimulate cell proliferation by upregulating growth factor ligand and/or receptor expression either indirectly or directly by acting on RA-responsive genes encoding growth factors. We report that RA and 1,25-dihydroxyvitamin D(3) (Vit D), alone and in combination, significantly increase [(3)H]thymidine incorporation in cultured fetal and postnatal rat lung fibroblasts (P < 0.05). The greatest increase (11-fold) was seen in 4-day cells treated with the two agents in combination (P < 0.0001). [(3)H]thymidine incorporation was age dependent. The greatest response to RA occurred in 4-day fibroblasts (P < 0.01), whereas the response to Vit D was greatest in embryonic day 20 fibroblasts (P < 0.001). Neutralizing antibody to platelet-derived growth factor (PDGF)-AB decreased [(3)H]thymidine incorporation in response to RA alone or in combination with Vit D, indicating a role for PDGF. Expression of mRNAs for PDGF-A and PDGF receptor (PDGFR)-alpha and -beta was upregulated at the transcriptional level in an age- and treatment-dependent manner. Thus exogenous RA may influence alveolarization by stimulating fibroblast proliferation through a PDGF-mediated autocrine mechanism, which is enhanced when RA and Vit D are administered in combination.

Dacryocystography: the technique and its role in the practice of ophthalmology

Modern lacrimal tract imaging has most recently been enhanced by computerized digital subtraction techniques. Current standard dacryocystography technique includes the injection of a water-soluble agent and the use of topical anesthesia. In this article the dacryocystogram of the normal lacrimal system and those with various types of obstruction are presented.

Growing intracranial aneurysms

Cerebral angiography is the best means by which an intracranial aneurysm can be demonstrated and studied in vivo. In 16 cases clinical deterioration paralleled a variable degree of enlargement of the aneurysms. In all patients the aneurysms were irregular and/or bior multilocular. Possible factors causing aneurysmal enlargement are discussed.

Cerebral angiographic changes associated with tuberous sclerosis

Two patients with tuberous sclerosis were examined angiographically. In one, direct left carotid angiography showed a contralateral shift of the anterior cerebral artery and lateral displacement of the middle cerebral artery. On the lateral series, increase in the sweep of the anterior cerebral artery as well as stretching of the opercular branches of the middle cerebral artery were noted in the early arterial phase. In the later arterial phase, there was marked hypervascularity, with the contrast substance temporarily pooling in small, rounded collections. In the mid-arterial phase of the second case, pooling of the the contrast medium within the tumor and many small, berry-like outpunchings were noted. There was no evidence of early venous drainage in either case.

The moving embolus seed during serial cerebral angiography

Movement of an occlusive process in an angiographical study is diagnostic of embolization.

Two cases are reported in which the demonstration of a moving embolism on serial angiography is shown.