Emergency thyroidectomy in a patient with severe upper airway obstruction caused by goiter: case for regional anesthesia

A case of severe airway obstruction caused by a giant malignant goiter is presented. The patient had emergency thyroidectomy under regional anesthesia (bilateral superficial cervical plexus block). The procedure was well tolerated and the intraoperative course was uneventful. The anesthetic challenges are discussed and a case is made for regional anesthesia as a safe and reliable anesthetic option for thyroidectomy in this situation.     

Low cost continuous femoral nerve block for relief of acute severe cancer related pain due to pathological fracture femur

Pathological fractures in cancer patient cause severe pain that is difficult to control pharmacologically. Even with good pain relief at rest, breakthrough and incident pain can be unmanageable. Continuous regional nerve blocks have a definite role in controlling such intractable pain. We describe two such cases where severe pain was adequately relieved in the acute phase. Continuous femoral nerve block was used as an efficient, cheap and safe method of pain relief for two of our patients with pathological fracture femur. This method was proved to be quite efficient in decreasing the fracture-related pain and improving the level of well being.     

Mechanisms of airway obstruction in the asthmatic patient: from past to present.

Allergen-induced increase in airway responsiveness to histamine or methacholine provides a useful model for investigation of prophylactic or "antiinflammatory" asthma treatments. This can be inhibited by corticosteroids or by sodium cromoglycate but not by beta agonists or by theophylline. A single-blind, crossover, random-order trial was conducted to compare ketotifen, clemastine, and placebo in six atopic subjects undergoing allergen inhalation tests. Ketotifen, 2 mg; clemastine, 1 mg; and placebo one tablet were administered twice daily for four days (eight doses) up to and including one hour before allergen inhalation. None of the three produced a significant reduction in the allergen-induced early or late asthmatic responses, or in the allergen-induced fall in methacholine PC20. There was a subtle nonsignificant suggestion of a reduction in the early portion of the early asthmatic response induced by both ketotifen and clemastine. Both ketotifen and clemastine produced a similar 8-fold inhibition of histamine skin test endpoint indicating equal systemic H1 blocking effect at the time of allergen inhalation. Sodium cromoglycate, 10 mg, single dose, by metered dose inhaler ten minutes before allergen challenge, added as an unblinded "positive control", inhibitory effects on the allergen-induced late and presumed inflammatory sequelae. It is possible that longer treatment periods (several weeks or months) might prove effective.     

含小剂量吗啡的局麻复合液颈丛阻滞麻醉用于甲状腺手术的观察

目的探讨甲状腺手术舒适有效的麻醉方式。方法选择48例甲状腺手术病人,随机分为含小剂量吗啡的局麻复合液的试验组(A组)和不含吗啡的局麻复合液的对照组(B组)进行颈丛阻滞麻醉,分别观察作用起效、显效、维持时间和循环变化情况及术中病人反应、术后刀口疼痛情况。结果两组病人在麻醉效力作用时间方面无显著性差异;在循环系统变化上试验组比对照组明显更加稳定;术中病人对不适刺激的反应试验组比对照组明显少;试验组病人可以维持术后刀口无痛时间达12~23h以上。结论含小剂量吗啡的局麻复合液颈丛阻滞麻醉用于甲状腺手术是一种优良、可靠且具有良好术后镇痛作用的麻醉方法。     

Gas-exchange impairment: its correlation to lung mechanics in acute airway obstruction (studies on a rabbit asthma model)

A rabbit model was developed for the studies of ventilation/perfusion relationships (VA/Q) and thorax mechanics during bronchial provocation tests. Baseline data from 14 anaesthetized rabbits show a VA/Q distribution that is broader (less efficient VA/Q match) than that of lung-healthy humans, dogs and horses. Airway provocation was created by inhalation of ammonia, prostaglandin (PGE1) and methacholine bromide. Methacholine bromide was the only substance that triggered measurable VA/Q changes. Measurements 5 min after methacholine provocation showed markedly increased thorax resistance, widened VA/Q distribution and in some rabbits an increased shunt. Fifteen minutes after provocation that was still a broad VA/Q distribution and in several rabbits a further increase of shunt. Both thorax resistance and perfusion of regions with low VA/Q were reduced. Our results suggest a correlation between thorax resistance and perfusion of regions with low VA/Q. However, the slower normalization in VA/Q disturbance and the remaining or increased shunt suggests that factors other than airway resistance contribute to the gas-exchange impairment. These factors might be alveolar oedema, or mucus and oedema in the smallest airways.     

Detection of autoantibodies to survivin in cervical mucus from patients with human papillomavirus-associated cervical cancer and precursor lesions

OBJECTIVES: To investigate the prevalence of mucosal autoantibodies to survivin in patients with human papillomavirus (HPV)-associated cervical cancer and precursor lesions. METHODS: Cervical mucus from 117 HPV-associated cervical cancer, 102 high-grade squamous intraepithelial lesion (HSIL), 107 low-grade SIL (LSIL), and 80 normal controls were tested by ELISA using either full length recombinant survivin or survivin-derived peptides. Survivin expression in cervical tissue biopsies was studied by Western Blotting. RESULTS: Cervical mucus from 33 cervical cancer (28.2%), 17 HSIL (16.6%), and 8 LSIL (7.4%) patients reacted with recombinant survivin. The IgA-class antibody response was significantly higher than that observed in the normal controls. The level of mucosal anti-survivin response was associated to the level and intensity of survivin expression in the different lesions. Finally, reactivity against a survivin Nt-derived peptide was found more frequently than reactivity against a Ct-derived peptide. CONCLUSIONS: IgA-class autoantibodies against survivin are present in a substantial proportion of cervical mucus from patients with HPV-associated cervical cancer, and precursor lesions. Mucosal anti-survivin response is positively associated with the level of survivin expression and the grade of cervical lesion.     

Vibrational spectroscopy for cervical cancer pathology, from biochemical analysis to diagnostic tool

Cervical cancer is the second most common cancer in women worldwide with 80% of cases arising in the developing world. The mortality associated with cervical cancer can be reduced if this disease is detected at the early stages of development or at the pre-malignant state (cervical intraepithelial neoplasia, CIN). The aim of this study was to investigate the potential of Raman spectroscopy as a diagnostic tool to detect biochemical changes accompanying cervical cancer progression. Raman spectra were acquired from proteins, nucleic acids, lipids and carbohydrates in order to gain an insight into the biochemical composition of cells and tissues. Spectra were also obtained from histological samples of normal, CIN and invasive carcinoma tissue from 40 patients. Multivariate analysis of the spectra was carried out to develop a classification model to discriminate normal from abnormal tissue. The results show that Raman spectroscopy displays a high sensitivity to biochemical changes in tissue during disease progression resulting in an exceptional prediction accuracy when discriminating between normal cervical tissue, invasive carcinoma and cervical intraepithelial neoplasia (CIN). Raman spectroscopy shows enormous clinical potential as a rapid non-invasive diagnostic tool for cervical and other cancers.     

Dependence of lipid peroxidation changes and antioxidant activity in myocardium under acute and chronic stress from organism thyroid status

In experiments on 122 unbreed white male rats with body weight 250-300 g investigated influence of thyroid status on evoked by chronic stress (CS--immobilization on 3 h during 5 days) and acute stress (AS--once immobilization during 3 h) changes of lipid peroxidation (LP) intensivity and antioxidant activity (AOA) in myocardium. It was shown that chronic stress, which decreases triiodothyronine and thyroxine levels in blood, leads to more market LP activation and lowering of superoxiddismutase activity in myocardium than acute stress, which reducts only T3 concentration. Close correlation between T3 and T4 concentration in blood and LP speed, level of its products, general AOA in myocardium was founded in both stresses. Hypothyrosis (1.2 mg/kg body weight during 14 days intragastrally) leads to more market accumulation of initial lipid peroxidation products and general AOA depression in myocardium under acute and, especially, chronic stress. Like to physiological doses of thyroxine (from 5.0 to 8.0 mkg/kg body weight during 28 days same way) prevent LP activation and limit AOA decreasing in myocardium under both stresses.     

Local production of IgG to pneumococcal C-polysaccharide in upper airway secretions from children with recurrent acute otitis media

Antibodies against C-polysaccharide (C-Ps), a common cell wall component of all pneumococci, may be of importance for the elimination of decaying pneumococci. By means of ELISA with phenylated C-Ps, anti-C-Ps IgG was measured in samples of plasma and upper airway secretions from otitis-prone children (OP), children with fewer episodes of recurrent acute otitis media (rAOM), and children with no previous history of AOM, but suffering from secretory otitis media (SOM). All children were free from acute illness at the time of sampling. No statistically significant differences of anti-C-Ps IgG in plasma or in nasopharyngeal secretions (NPS) were found between any of the groups. Based on calculations of the correlation between levels of anti-C-Ps IgG in plasma and NPS, and of the transudation ratios of anti-C-Ps IgG, total IgG, and albumin from plasma to NPS, we suggest that a significant amount of the anti-C-Ps IgG in NPS must be locally produced. The additional finding that OP children had significantly higher levels of anti-C-Ps IgG in their middle ear effusions (MEE) than SOM children points in the same direction. Anti-C-Ps IgA and IgM were detected in very low concentrations in plasma and secretion samples.     

Which patients benefit from adding theophylline to beta 2-agonist treatment in severe acute asthma?

The aim of this investigation was to study whether certain patients benefit from adding theophylline to the beta 2-agonist treatment of acute asthma. The study group comprised 101 patients who were taking oral theophylline. The patients received inhaled salbutamol (albuterol) (0.15 mg/kg x 2) (n = 53) or IV salbutamol (5 micrograms/kg) (n = 48). Aminophylline (3 mg/kg) was infused intravenously 60 minutes after the start of the salbutamol treatment. The mean increase in peak flow (PEF) after the aminophylline infusion was 22 +/- 33 L/min or 4% +/- 6% of the predicted value (mean +/- SD). A change in PEF correlated negatively to plasma theophylline before treatment (P less than .01) and positively to a change in plasma-theophylline after treatment (P less than .05). All patients with an increase in PEF of more than 10% of the predicted value (n = 14) after the theophylline infusion had plasma-theophylline levels before treatment of below 7.5 mg/L (41 mumol/L). No significant difference in the change in PEF after the theophylline infusion was found between patients who had received inhaled or intravenous salbutamol. This investigation could indicate that IV theophylline as an additive to beta 2-agonist treatment should be reserved for patients who are either not taking theophylline or who have only taken a low dose before arriving for the emergency treatment of acute asthma.     

Dendritic cells from aged subjects contribute to chronic airway inflammation by activating bronchial epithelial cells under steady state

The mechanisms underlying the increased susceptibility of the elderly to respiratory infections are not well understood. The crosstalk between the dendritic cells (DCs) and epithelial cells is essential in maintaining tolerance as well as in generating immunity in the respiratory mucosa. DCs from aged subjects display an enhanced basal level of activation, which can affect the function of epithelial cells. Our results suggest that this is indeed the scenario as exposure of primary bronchial epithelial cells (PBECs) to supernatants from unstimulated DCs of aged subjects resulted in activation of PBECs. The expression of CCL20, CCL26, CXCL10, mucin, and CD54 was significantly increased in the PBECs exposed to aged DC supernatants, but not to young DC supernatants. Furthermore, aged DC supernatants also enhanced the permeability of the PBEC barrier. We also found that DCs from aged subjects spontaneously secreted increased levels of pro-inflammatory mediators, interleukin-6, tumor necrosis factor (TNF)-α, and metalloproteinase A disintegrin family of metalloproteinase 10, which can affect the functions of PBECs. Finally, we demonstrated that TNF-α, present in the supernatant of DCs from aged subjects, was the primary pro-inflammatory mediator that affected PBEC functions. Thus, age-associated alterations in DC–epithelial interactions contribute to chronic airway inflammation in the elderly, increasing their susceptibility to respiratory diseases.     

Metastases to the ovary arising from endometrial,cervical and fallopian tube cancer: recent advances

The introduction of genomic studies has enabled assessment of the clonality of synchronous tumours involving the ovary and other sites in the female genital tract in a definitive way. This has led to the abandonment of conventional approaches to primary site assignment, and the recognition that most such synchronous neoplasms are clonally related single tumours with metastatic spread, rather than independent primary tumours. These discoveries have implications for diagnostic practice, analogous to the gradual change over the last few decades in our approach to mucinous neoplasms of the ovary metastatic from the gastrointestinal tract. In this review, we first examine the routes of metastasis to the ovary, and then discuss the diagnostic and clinical implications of concurrent ovarian carcinomas arising in combination with endometrial, endocervical and tubal carcinomas. It is proposed that cases of primary low-grade endometrioid endometrial carcinoma with a secondary unilateral ovarian tumour, both with indolent characteristics, may be classified as ‘FIGO stage IIIA-simulating independent primary tumours’, with a comment that conservative management would be appropriate. It should be recognised that human papillomavirus-associated endocervical adenocarcinomas may result in synchronous or metachronous ovarian metastases that appear to be unrelated to the primary tumour, and that these may be managed conservatively in the absence of other sites of disease. In cases of tubo-ovarian high-grade serous carcinoma, tubal intraepithelial or contralateral adnexal involvement should count as a pelvic disease site for staging purposes.     

Risk of thyroid cancer after exposure to fertility drugs: results from a large Danish cohort study

BACKGROUND: Findings from the few epidemiological studies that have investigated thyroid cancer risk after fertility drugs have been inconclusive. Using data from the largest cohort of infertile women to date, we examined the effects of fertility drugs on thyroid cancer risk. METHODS: A cohort of 54 362 women with infertility problems referred to Danish fertility clinics in the period 1963-1998 was established. A detailed data collection including information about type and amount of treatment was conducted. Using case-cohort techniques, we calculated rate ratios (RRs) of thyroid cancer associated with different fertility drugs after adjustment for age at first live birth. RESULTS: A total of 29 thyroid cancers were identified during follow-up through 2000. Use of clomiphene [RR = 2.28; 95% confidence interval (CI): 1.08-4.82] or progesterone (RR = 10.14; 95% CI: 1.93-53.33) was associated with an increased thyroid cancer risk, although the latter estimate was based on few cases. When stratifying for parity status, the risk was primarily associated with clomiphene (RR = 3.09; 95% CI: 1.21-7.88) in parous women. No significantly increased risk was found after use of gonadotrophins, hCG or GnRH. We observed no association with number of cycles of use or years since first use (latency). CONCLUSIONS: Clomiphene and possibly progesterone may increase thyroid cancer risk, particularly among parous women. Longer follow-up is needed to confirm our findings.     

No evidence of increased chromosomal aberrations and micronuclei in lymphocytes from nonfamilial thyroid cancer patients prior to radiotherapy

The relationship between the presence of high frequencies of chromosomal aberrations in peripheral lymphocytes and predisposition to cancer has been suggested for some cancer diseases. In nonfamilial thyroid cancer, the few reports available are equivocal. The aim of this study was to assess the possible chromosomal instability in peripheral blood lymphocytes from 22 patients suffering from nonfamilial thyroid cancer. For this purpose, 2 classic cytogenetic assays, the chromosomal aberrations assay and cytokinesis-blocked micronucleus assay, were chosen. The frequency of chromosomal aberrations excluding gaps (%) was 1.68 +/- 1.39 (mean value +/- SD) for the patients group versus 2.20 +/- 1.87 for the control group. The frequency of binucleated lymphocytes with micronuclei ( per thousand) was 5.41 +/- 3.51 (mean value +/- SD) for the patients group versus 5.37 +/- 3.21 for the control group. The results obtained revealed no significant differences between both groups. The present study reinforces the idea that constitutional chromosomal instability in peripheral blood lymphocytes is not visible in nonfamilial thyroid carcinomas.     

Preoperative serum thyroglobulin as a useful predictive marker to differentiate follicular thyroid cancer from benign nodules in indeterminate nodules

Indeterminate cytology results increase the number of repetitive procedure and unnecessary surgery. This study was designed to find useful and simple predictive tools to differentiate malignant thyroid nodules from indeterminate nodules. We retrospectively enrolled 164 patients who had undergone thyroid surgery as a result of indeterminate cytology in the National Cancer Center. We reviewed patients' age at diagnosis, sex, preoperative biochemical markers such as thyroglobulin (Tg), anti-Tg antibody, free T4 and TSH level, and sonographical and pathological findings, which were subjected to statistical analysis. We found several clinical and sonographical predictive factors that showed significant differences. Young age, male, preoperative high Tg level, and hypoechoic nodule on sonography all increased cancer probability significantly in multivariate analysis. With a cut-off value of 187.5 ng/mL Tg, sensitivity and specificity were 54.8% and 90.1%, respectively (AUC 0.748, P < 0.001). In the case of nodule size > 1.7 cm, elevated serum Tg predicts the risk of malignancy; especially Tg > 70 ng/mL (odds ratio 3.245, 95% confidence interval 1.115-9.450, P = 0.038). Preoperative Tg levels had very high specificity in predicting thyroid cancer in case of suspicious follicular neoplasm. Therefore, Tg levels may be a useful marker for differentiating thyroid cancer from benign thyroid nodules in the cytological diagnosis of indeterminate nodules.