A cross-specialty survey to assess the application of risk stratified surgery for differentiated thyroid cancer in the UK

Introduction

This study describes variability of treatment for differentiated thyroid cancer among thyroid surgeons, in the context of changing patterns of thyroid surgery in the UK.

Methods

Hospital Episodes Statistics on thyroid operations between 1997 and 2012 were obtained for England. A survey comprising six scenarios of varying ‘risk’ was developed. Patient/tumour information was provided, with five risk stratified or non-risk stratified treatment options. The survey was distributed to UK surgical associations. Respondent demographics were categorised and responses analysed by assigned risk stratified preference.

Results

From 1997 to 2012, the Hospital Episode Statistics data indicated there was a 55% increase in the annual number of thyroidectomies with a fivefold increase in otolaryngology procedures and a tripling of cancer operations. Of the surgical association members surveyed, 264 respondents reported a thyroid surgery practice. Management varied across and within the six scenarios, and was not related consistently to the level of risk. Associations were demonstrated between overall risk stratified preference and higher volume practice (>25 thyroidectomies per year) (p=0.011), fewer years of consultant practice (p=0.017) and multidisciplinary team participation (p=0.037). Logistic regression revealed fewer years of consultant practice (odds ratio [OR]: 0.96/year in practice, 95% confidence interval [CI]: 0.922–0.997, p=0.036) and caseload of >25/year (OR 1.92, 95% CI: 1.044–3.522, p=0.036) as independent predictors of risk stratified preference.

Conclusions

There is a substantial contribution to thyroid surgery in the UK by otolaryngology surgeons. Adjusting management according to established case-based risk stratification is not widely applied. Higher caseload was associated with a preference for management tailored to individual risk.     

Enumeration of lactotropes and somatotropes among male and female pituitary cells in culture: evidence in favor of a mammosomatotrope subpopulation in the rat

The hemolytic plaque assay technique can be used to detect specific hormone release from single pituitary cells. Using antisera raised against murine GH or rat PRL, we have enumerated the active lactotropes and somatotropes from male and female rat pituitary glands. These studies reveal sex-related differences in the number of cells exporting GH and PRL among anterior pituitary cells in culture. In the presence of human GH-releasing factor (hGRF), the mean percentage of GH cells was 53% in males and 30% in females (P less than 0.005). The mean percentage of PRL cells was 15% in males and 39% in females (P less than 0.008). These values were not significantly altered when hGRF was omitted. The sum of GH and PRL cells identified in separate plaque assays significantly exceeds the number obtained when GH and PRL cells were determined concurrently with a simultaneous plaque assay for both hormones. This difference is dependent on the presence of hGRF, since there was no difference when hGRF was omitted. These data identify the mammosomatotrope in numbers lower than previous reports. By this approach, the mammosomatotrope subpopulation numbers about 5% of all cells in culture. In summary, we demonstrate a sex-related difference in the number of cells exporting GH or PRL among pituitary cells in culture. This difference corresponds with and may underly sex-related differences in the responsiveness of GH and PRL secretion from the pituitary gland. Furthermore, a minor subpopulation of normal pituitary cells appears capable of simultaneous secretion of both GH and PRL.     

Near infrared spectroscopy for monitoring flap viability following breast reconstruction

Free flap monitoring is essential to the early detection of compromise thereby increasing the chance of successful salvage surgery. Many alternatives to classical clinical monitoring have been proposed. This study seeks to investigate a relatively new monitoring technology: near infrared spectroscopy (NIRS). Patients were recruited prospectively to the study from a single center. During the research period, 10 patients underwent reconstruction with a free deep inferior epigastric perforator flap (DIEP). Measurements of flap perfusion were taken using NIRS in the preoperative and intraoperative phases and postoperatively for 72 hours. NIRS showed characteristic changes in all cases which returned to theater for pedicle compromise. In these cases, NIRS identified pedicle compromise prior to clinical identification. There were no false-positives. NIRS accurately identified all compromised flaps in our study. In most cases, there was an evidence of changes in oxygen saturation on NIRS prior to clinical observation. Further research, ideally double blind randomized control trials with large sample groups would be required to definitively establish NIRS as an ideal flap monitoring modality.     

Terazosin therapy for chronic prostatitis/chronic pelvic pain syndrome: a randomized,placebo controlled trial

PURPOSE: We evaluate terazosin therapy for chronic prostatitis/chronic pelvic pain syndrome. MATERIALS AND METHODS: The study included 100, 20 to-50-year-old subjects who met the consensus criteria for chronic prostatitis/chronic pelvic pain syndrome and had not received previous alpha-blockers. Subjects were randomized to receive terazosin with dose escalation from 1 to 5 mg. daily or placebo for 14 weeks. The primary criterion for response was scoring 2 or less ("delighted-to-mostly satisfied") on the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) quality of life item. The secondary criterion for response was greater than 50% reduction in NIH-CPSI pain score at 14 weeks. Other outcomes included total and NIH-CPSI domain scores, International Prostate Symptom Score, peak urinary flow rate, post-void residual urine and adverse effects. RESULTS: Using the primary criterion 24 of 43 evaluable subjects (56%) responded in the terazosin group compared to 14 of 43 (36%) in the placebo group (p = 0.03). Using the secondary criterion 26 of 43 subjects (60%) responded in the terazosin group compared to 16 of 43 (37%) in the placebo group (p = 0.03). The terazosin group had greater reductions (p <0.05) in NIH-CPSI total score, individual domain scores and International Prostate Symptom Score than the placebo group. There was no difference in peak urinary flow rate or post-void residual. In the terazosin group 18 patients (42%) had side effects compared to 9 (21%) in the placebo group (p = 0.04). CONCLUSIONS: Terazosin proved superior to placebo for patients with chronic prostatitis/chronic pelvic pain syndrome who had not received alpha-blockers previously.     

外科手术中产生的烟气:仅仅是大量的热空气吗?

外科医生和手术室人员经常接触手术设备产生的烟气,病人也会暴露于烟气中,特别是腹腔镜手术中产生的烟气滞留于腹腔内这一密闭空间并被吸收.这些烟气是一种与香烟烟气相似的毒性物质,然而对这种毒性物质的影响还未引起足够重视.应该采取必要措施尽可能减少手术中烟气的不良影响.     

Learning resources and activities: students' feedback from two Malaysian medical schools

In a survey of clinical students in two Malaysian medical schools, it was found that students used a wide variety of learning resources, but textbooks were still the primary source of their information. Students had positive views about clinical teaching and lectures but somewhat lower opinions on problem-based learning. They generally did not perceive lecturers as facilitators, role models and counselors. In spite of the stated curricular goals of promoting self-directed learning via problem-based learning, students in these medical schools were driven by the nature of examinations and focused mainly on clinical contents rather than the process of learning.     

Discordancy between clinical predictions vs lymphoscintigraphic and intraoperative mapping of sentinel lymph node drainage of primary melanoma

OBJECTIVE: To evaluate discordancy between clinical predictions and lymphatic drainage patterns of primary cutaneous melanoma as determined by preoperative lymphoscintigraphy and intraoperative lymphatic mapping of sentinel lymph nodes (SLNs). DESIGN: Before selective SLN dissection, 226 consecutive patients with melanoma underwent preoperative lymphoscintigraphy. SETTING: Teaching hospital tertiary care center. MAIN OUTCOME MEASURE: Correlation of lymphatic drainage patterns from the following 3 data sources: clinical predictions preoperatively based on anatomical location of primary melanoma, lymphatic drainage patterns as determined by preoperative lymphoscintigraphy, and identification of SLNs during surgery. RESULTS: Preoperative lymphoscintigraphy was successful in identifying at least 1 SLN in all 226 patients. In head and neck melanomas, at least 1 SLN was identified in an area outside what would have been clinically predicted in 11 (36.7%) of 30 cases. Discordancy for trunk melanomas was seen in 24 (25.3%) of 95 cases. Extremity melanomas showed drainage to unexpected SLNs in 6 (13.6%) of 44 and 3 (5.3%) of 57 patients for the upper and lower extremities, respectively. The overall rate of discordancy was 44 (19.5%) of 226. The SLNs were identified in surgery in all but 4 cases. CONCLUSIONS: Discordancy is most frequent in melanomas of the head and neck region, followed by that of the trunk. Preoperative lymphoscintigraphy identifies the occasional cases in the upper and lower extremities where drainage occurs to a basin that is not clinically predictable. Preoperative lymphoscintigraphy is a prerequisite for characterizing the lymphatic drainage pattern in patients with primary melanoma, especially for sites such as head and neck as well as trunk, before selective SLN dissection.     

Neutrophil activation and production of reactive oxygen species in pre-eclampsia

OBJECTIVE: To investigate neutrophil NADPH oxidase activation and subsequent production of reactive oxygen species (ROS) in pre-eclampsia. DESIGN: Baseline values and the activated response of neutrophils upon stimulation of the NADPH oxidase with the agonists was measured. Neutrophils from 17 third-trimester pre-eclamptic and 17 age- and gestation-matched normal pregnant women were examined. METHODS: Neutrophil ROS production was measured by both lucigenin- and luminol-derived chemiluminescence. The abundance of the various phox proteins was examined using Western blotting techniques. Lucigenin-derived ROS generation was significantly increased in neutrophils isolated from women with pre-eclampsia compared with normotensive controls in the case of both agonists [n-formyl-met-leu-phe (fMLP): pre-eclamptic 2.071 +/- 0.336 relative light units seconds (RLU.s) and normotensive 1.141 +/- 0.249 RLU.s, P = 0.035; phorbol-12-myristate-13-acetate (PMA): pre-eclamptic 34.954 +/- 2.634 RLU.s and normotensive 17.208 +/- 3.325 RLU.s, P = 0.0001]. Luminol-derived ROS generation was also significantly increased in the neutrophils isolated from the women with pre-eclampsia compared with the normotensive controls in the case of both agonists (fMLP: pre-eclamptic 1.955 +/- 0.316 RLU.s and normotensive 1.058 +/- 0.191 RLU.s, P = 0.023; PMA: pre-eclamptic 4.108 +/- 0.351 RLU.s and normotensive 3.073 +/- 0.332 RLU.s, P = 0.042). There were no differences between the relative abundance of the phox proteins in the two groups. CONCLUSIONS: Neutrophils isolated from women with pre-eclampsia during the third trimester showed increased sensitivity to agonist stimulation and produced significantly more ROS than age-matched normotensive controls. This was not due to an increased abundance of any of the phox proteins. Increased ROS production in pre-eclampsia may highlight a role for neutrophils in the oxidative stress and associated endothelial dysfunction that are characteristic of the condition.