Combined cervicosternotomy and cervicotomy for true retrosternal goiters: a surgical cohort study

Objective

Intrathoracic goiters are a heterogeneous group characterized by limited or extensive substernal extension. Whereas the former can be treated through cervicotomy, the latter sometimes requires a cervicosternotomy. Whether cervicosternotomy leads to more morbidity remains unclear.

This study aimed to compare intra- and postoperative morbidity in patients treated by cervicotomy or cervicosternotomy for intrathoracic goiters and standard thyroidectomy.

Methods

In a prospectively gathered cohort undergoing thyroid surgery (2010–2019) intra- and postoperative morbidity of cervicotomy (N = 80) and cervicosternotomy (N = 15) for intrathoracic goiters was compared to each other and to a ‘standard’ thyroidectomy (N = 1500).

Results

An intrathoracic extension prior to surgery was found in 95 (6%) of all thyroidectomies. Eighty patients (84%) were operated by cervicotomy and 15 (16%) by cervicosternotomy. The risk of temporary recurrent laryngeal nerve palsy was much higher in the cervicosternotomy group (21%) compared to cervicotomy (4%) and standard thyroidectomy (3%). The risk of temporary hypocalcemia after cervicotomy (28%) was comparable to a standard thyroidectomy (32%) but higher after cervicosternotomy (20%). No cases of permanent hypocalcemia or laryngeal nerve palsy were observed in both groups with substernal extension. The need for surgical reintervention was significantly higher in the cervicotomy group (6%) compared to cervicosternotomy (0%) and standard thyroidectomy (3%).

Conclusion

In patients undergoing thyroid surgery for an intrathoracic goiter, cervicosternotomy was associated with more temporary laryngeal nerve palsy, but none of the interventions resulted in higher risks of permanent nerve damage, permanent hypocalcemia, or reintervention for bleeding. Reintervention was even more common after cervicotomy compared to cervicosternotomy.

Level of evidence

IV

Supplementary Information

The online version contains supplementary material available at 10.1007/s13304-021-01027-1.

In antibody-positive first-degree relatives of patients with type 1 diabetes, HLA-A*24 and HLA-B*18, but not HLA-B*39, are predictors of impending diabetes with distinct HLA-DQ interactions

AIMS/HYPOTHESIS

Secondary type 1 diabetes prevention trials require selection of participants with impending diabetes. HLA-A and -B alleles have been reported to promote disease progression. We investigated whether typing for HLA-B*18 and -B*39 may complement screening for HLA-DQ8, -DQ2 and -A*24 and autoantibodies (Abs) against islet antigen-2 (IA-2) and zinc transporter 8 (ZnT8) for predicting rapid progression to hyperglycaemia.

METHODS

A registry-based group of 288 persistently autoantibody-positive (Ab(+)) offspring/siblings (aged 0-39 years) of known patients (Ab(+) against insulin, GAD, IA-2 and/or ZnT8) were typed for HLA-DQ, -A and -B and monitored from the first Ab(+) sample for development of diabetes within 5 years.

RESULTS

Unlike HLA-B*39, HLA-B*18 was associated with accelerated disease progression, but only in HLA-DQ2 carriers (p < 0.006). In contrast, HLA-A*24 promoted progression preferentially in the presence of HLA-DQ8 (p < 0.002). In HLA-DQ2- and/or HLA-DQ8-positive relatives (n = 246), HLA-B*18 predicted impending diabetes (p = 0.015) in addition to HLA-A*24, HLA-DQ2/DQ8 and positivity for IA-2A or ZnT8A (p ≤ 0.004). HLA-B*18 interacted significantly with HLA-DQ2/DQ8 and HLA-A*24 in the presence of IA-2 and/or ZnT8 autoantibodies (p ≤ 0.009). Additional testing for HLA-B*18 and -A*24 significantly improved screening sensitivity for rapid progressors, from 38% to 53%, among relatives at high Ab-inferred risk carrying at least one genetic risk factor. Screening for HLA-B*18 increased sensitivity for progressors, from 17% to 28%, among individuals carrying ≥ 3 risk markers conferring >85% 5 year risk.

CONCLUSIONS/INTERPRETATION

These results reinforce the importance of HLA class I alleles in disease progression and quantify their added value for preparing prevention trials.

Gestational diabetes: overview of the new consensus screening strategy and diagnostic criteria

Gestational diabetes (GDM) is a frequent medical condition during pregnancy. GDM is associated with an increased risk of complications for both the mother and the baby during pregnancy and birth. Women with GDM also have an increased risk of developing type 2 diabetes later in life. Two large randomised intervention trials demonstrated improvement in perinatal outcomes in the group that received treatment of mild glucose intolerance during pregnancy. However, there is lack of international uniformity in the approach to ascertainment and diagnosis of GDM. The HAPO trial studied for the first time on a very large scale the relationship between glucose tolerance of the mother and the risk for complications for both mother and child. The 'International Association of Diabetes and Pregnancy Study Groups (IADPSG)' subsequently published a new consensus for a screening strategy and diagnosis of GDM which has now been adopted by the American Diabetes Association (ADA). This remains controversial as the American College of Obstetricians and Gynecologists (ACOG) advices to continue with the two-step screening strategy, while other associations have not yet reached a consensus. The discussion now focuses on two issues: an improved detection of pregestational diabetes and an improved detection of GDM. The new screening strategy and the more stringent diagnostic criteria for GDM will probably lead to an important increase in the prevalence of GDM in Belgium and might lead to logistical problems to organise an universal screening with the 2-hour 75 g oral glucose tolerance test (OGTT). We performed an audit on the current two-step screening strategy for GDM in the university hospital Leuven. Diagnosis of GDM seems sub-optimal as only two thirds of abnormal glucose challenge tests were appropriately followed by an OGTT. When the new criteria for GDM are used, the prevalence for GDM increases significantly from 3.3% to 5.7%. We feel that more data are necessary on the cost-effectiveness of an universal screening strategy using an OGTT with more stringent diagnostic criteria for GDM, especially in a population with a low background prevalence of GDM.

Organization of a quality-assurance project in all Belgian multidisciplinary diabetes centres treating insulin-treated diabetes patients: 5 years' experience

AIMS

To describe the IQED, a quality-assurance system started in 2001 in Belgian hospital-based multidisciplinary diabetes centres, and its effects on the quality of care.

METHODS

The study was conducted through four data collections (in 2001, 2002, 2004 and 2006). Approximately 120 diabetes centres provided data on a systematic random sample of 10% of their adult diabetic patients on at least two daily insulin injections. Data on patient characteristics, glycaemic control, cardiovascular risk, diabetes complications, follow-up procedures and treatment were obtained. Local quality promotion was encouraged by returning comprehensive feedback (benchmarks) and during information meetings.

RESULTS

Nearly all diabetes centres (98-100%) participated. The pooled sample consisted of 9194 (32%) Type 1 and 19 828 (68%) Type 2 diabetes patients, with mean diabetes duration of 17 years and 14 years, prevalence of microvascular complications of 23% and 38% and prevalence of macrovascular complications of 9% and 26%, respectively. At the start, the quality of care was good in terms of risk-factor testing rates and moderate in terms of patients meeting goals for risk-factor management. At least 50% of the centres initiated quality-promoting initiatives. After 5 years, significant improvements were seen in risk-factor testing rates, apart from renal screening. Improvements in intermediate outcomes were less obvious, apart from an increase in patients reaching the targets for blood pressure and LDL cholesterol.

CONCLUSIONS

It is feasible to implement a continuous quality-improvement project on a nationwide scale, with improvements particularly in process indicators.

[Social aspects of diabetes mellitus]

A diabetic patient may suffer from social discriminations. We will briefly describe the problems related to licence driving, employment and insurances. Diabetic associations work to attenuate such discriminations and try to provide a practical help to diabetic patients confronted to such difficulties.

Feasibility of a quality assurance programme of bedside blood glucose testing in a hospital setting: 7 years' experience

AIMS

Description of the long-term use of a quality assurance (QA) programme for bedside capillary blood glucose (CBG) testing in a general hospital.

METHODS

The main points of the programme were selection of instrumentation using a standardized testing procedure, design and implementation of a quality control (QC) procedure, and training and motivation of nurses. The QC procedures consisted of a daily aqueous control and a weekly split-sample control (a measurement on a capillary blood sample using the glucose meter and on a simultaneously drawn venous sample with the laboratory analyser). When the result was out of range, a laboratory technician visited the ward to investigate the problem. All wards received a weekly report.

RESULTS

The programme was introduced in 1995 and followed up through 2002. The split-sample control was more efficient in detecting clinically relevant errors than the aqueous control. Most errors (91-97%) were operator-related rather than instrument-related. The compliance with the split-sample controls remained high, with 84-91% of weekly controls performed over 7 years. Respectively 91, 95 and 96% of the measurements remained within the range of +/- 20% of the laboratory value in the years 2000, 2001 and 2002.

CONCLUSION

A QA programme of bedside CBG testing can successfully be implemented. It is feasible to obtain a satisfying level of measurement accuracy and to maintain a high level of compliance with the programme over several years. Split-sample controls are an essential part of the control procedure.

Fractional flow reserve in patients with prior myocardial infarction

BACKGROUND

Fractional flow reserve (FFR), an index of coronary stenosis severity, can be calculated from the ratio of hyperemic distal to proximal coronary pressure. An FFR value of 0.75 can distinguish patients with normal and abnormal noninvasive stress testing in case of normal left ventricular function. The present study aimed at investigating the value of FFR in patients with a prior myocardial infarction. Methods and Results-- In 57 patients who had sustained a myocardial infarction >/=6 days earlier, myocardial perfusion single photon emission scintigraphy (SPECT) imaging and FFR were obtained before and after angioplasty. The sensitivity and specificity of the 0.75 value of FFR to detect flow maldistribution at SPECT imaging were 82% and 87%. The concordance between the FFR and SPECT imaging was 85% (P<0.001). When only truly positive and truly negative SPECT imaging were considered, the corresponding values were 87%, 100%, and 94% (P<0.001). Patients with positive SPECT imaging before angioplasty had a significantly lower FFR than patients with negative SPECT imaging (0.52+/-0.18 versus 0.67+/-0.16, P=0.0079) but a significantly higher left ventricular ejection fraction (63+/-10% versus 52+/-10%, P=0.0009) despite a similar degree of diameter stenosis (67+/-13% versus 68+/-16%, P=NS). A significant inverse correlation was found between LVEF and FFR (R=0.29, P=0.049).

CONCLUSIONS

The present data indicate (1) that the 0.75 cutoff value of FFR to distinguish patients with positive from patients with negative SPECT imaging is valid after a myocardial infarction and (2) that for a similar degree of stenosis, the value of FFR depends on the mass of viable myocardium.

Combined Conn's and Cushing's syndrome: an unusual presentation of adrenal adenoma

In most aldosterone-producing adenomas (APA) dedifferentiation occurs with formation of transitional cells, bearing characteristics of both glomerulosa and fasciculata cells. These cells are able to produce cortisol, and their aldosterone production follows the circadian rhythm of ACTH. Usually, no clinical signs of cortisol excess develop, since the cortisol production remains under ACTH feedback control. Only a few cases have been described with autonomous cortisol secretion, not suppressible by low dose dexamethasone. We present a patient with an APA, synthesizing enough cortisol to cause the typical clinical expression of Cushing's syndrome. Possible etiopathological mechanisms are discussed.

Influence of age on the associations among insulin autoantibodies, islet cell antibodies, and HLA DAQ1*0301-DQB1*0302 in siblings of patients with type 1 (insulin-dependent) diabetes mellitus. Belgian Diabetes Registry

In recent-onset type 1 (insulin-dependent) diabetes mellitus (IDDM), insulin autoantibodies (IAA) and islet cell antibodies (ICA) occur preferentially in young (< 10 yr) patients with the HLA DQA1*0301-DQB1*0302 risk haplotype. We investigated whether this association also exists in siblings of IDDM patients. In our group of 310 siblings, aged 0-39 yr, 6% were positive for IAA, 7% for ICA 12 Juvenile Diabetes Foundation units (JDFU) or more, 5% for ICA 20 JDFU or more, and 2% for high titer ICA (> or = 80 JDFU). The occurrence of IAA and ICA (> or = 20 JDFU) was significantly associated, with a preferential relationship to the HLA DQA1*0301-DQB1*0302 susceptibility haplotype. In the present group of siblings, IAA and DQA1*0301-DQB1*0302 were significantly associated under age 10 yr (26% positivity for IAA vs. 4% in relatives without this haplotype). In this age group, IAA were more prevalent than (high titer) ICA (6%) in the presence of the haplotype. The association between (high titer) ICA and DQA1*0301-DQB1*0302 was not restricted to subjects under age 10 yr. High titer ICA (n = 5) occurred exclusively in homozygotes for the latter haplotype and in carriers of the heterozygous DQA1*0301-DQB1*0302/DQA1*0501-DQB1*0201 high risk genotype, mostly under age 20 yr (four of five). The preferential occurrence of IAA in DQA1*0301-DQB1*0302-positive siblings under age 10 yr was caused by their high prevalence (47%) in subjects with the heterozygous high risk genotype in this age group. As in patients at onset, IAA and high titer ICA are preferentially associated with the DQA1*0301-DQB1*0302 haplotype in siblings of IDDM patients, but, unlike at onset, these associations are observed with specific genotypes only and are more pronounced in subjects under age 10 yr for IAA only. Longitudinal analysis in first degree relatives and other normal controls carrying the DQA1*0301-DQB1*0302 haplotype should assess the hypothesis that IAA qualify as earlier predictive markers for IDDM than high titer ICA.

Self blood glucose monitoring: evaluation of Haemo-Glukotest 20-800R, Visidex I and Reflolux

Trained staff-members evaluated the accuracy of Haemo-Glukotest 20-800R (= HG 20-800R), Visidex I and Reflolux in 135 blood glucose measurements. A glucose-oxidase method was used as reference method. Although the correlation between the 3 methods tested was excellent, more detailed analysis revealed for all methods a clear deviation from the real blood glucose, especially in the low blood glucose range. This might result in an inappropriate adaptation of the insulin dose, when the estimated blood glucose is used in connection with a classic algorithm. Apart from this limitation, Reflolux had the best accuracy, followed by HG 20-800R. If stored in a desiccated tube, the HG 20-800R strip can be reliably re-read (visually or with Reflolux) even after 7 days. Visidex I is unsuitable for storage and re-reading.

Thyroid carcinoma and eosinophilia

An elderly woman with a thyroid nodule slowly growing over ten years is described. During follow-up, this patient developed a rapidly expanding thyroid tumour, multiple lung nodules, hypercalcaemia and pronounced eosinophilia. A needle biopsy of the thyroid revealed a giant-cell carcinoma. This was later confirmed at autopsy. Tumour associated blood eosinophilia has rarely been described with thyroid carcinoma and is discussed here.