Role of preoperative ultrasonography in the management of thyroid nodules

Ultrasonography is the evidence-based diagnostic method for thyroid nodules. The account has to specify the technical used, and has to exactly describe the echogenicity of the thyroid, the feature of the nodules (number, size, echostructure, echogenicity, edges), and the presence or absence of lymph nodes. The malignancy criteria of thyroid nodules are: (1) hypoechoic solid nodule, (2) presence of internal microcalicifications, (3) ill-defined-irregular edges or absence or breaking of the peripheral halo. The nodes' criteria of malignancy are: (1) diameter of 1 cm or more, (2) clear hypoechoic pattern or non-homogeneous pattern, with alternating hypoechoic and hyperechoic areas, (3) cystic appearance (4) presence of internal calcifications (5) rounded shape with increased anteroposterior diameter, (6) long/short diameter ratio higher than 0.7, (7) absence of hilum. When these criteria are present, a histological diagnosis has to be performed. They could change the operative procedure in the patients.     

Management of adrenal incidentaloma combined with high blood pressure

Hypertension (HTA) is a very common disease but its origin is well known only in 1 to 5% of the cases. HTA is present in half of the patients who have an adrenal incidentaloma. Clinical data, hormonal sampling, computed tomography and adrenal scintigraphies are necessary to identify hyperfunctioning adrenal tumors. Adrenalectomy is indicated in case of potential malignant tumors and hyperfunctioning tumors. If HTA seems to be not in relation with the adrenal mass, it is recommended to recognize a congenital enzymatic block in order to ovoid an unnecessary adrenalectomy and to search for a preclinical Cushing's syndrome. The last one is associated with HTA in 91% of the cases, and with a morbid obesity, mellitus diabetes or dyslipidemia in 50% of the cases. The removal of the adrenal mass improves the HTA for half of the patients. If the adrenocortical tumor is nonfunctioning, patients have to be followed during a long time. HTA will be considered as "essential" after a new comprehensive analysis performed 3 years later.     

Predictive factors for successful sacral nerve stimulation in the treatment of faecal incontinence: results of trial stimulation in 200 patients

Aim Sacral nerve stimulation (SNS) has a place in the treatment algorithm for faecal incontinence (FI). However, after implantation, 15–30% of patients with FI fail to respond for unknown reasons. We investigated the effect of SNS on continence and quality of life (QOL) and tried to identify specific predictive factors of the success of permanent SNS in the treatment of FI. Method Two hundred consecutive patients (six men; median age = 60; range 16–81) underwent permanent implantation for FI. The severity of FI was evaluated by the Cleveland Clinic Score. Quality of life was evaluated by the French version of the American Society of Colon and Rectal Surgeons (ASCRS) quality of life questionnaire (FIQL). All patients underwent a preoperative evaluation. After permanent implantation, severity and QOL scores were reevaluated after six and 12 months and then once a year. Results The severity scores were significantly reduced during SNS (P = 0.001). QOL improved in all domains. At the 6‐month follow‐up, the clinical outcome of the permanent implant was not affected by age, gender, duration of symptoms, QOL, main causes of FI, anorectal manometry or endoanal ultrasound results. Only loose stool consistency (P = 0.01), persistent FI even though diarrhoea was controlled by medical treatment (P = 0.004), and low stimulation intensity (P = 0.02) were associated with improved short‐term outcomes. Multivariate analysis confirmed that loose stool consistency and low stimulation intensity were related to a favourable outcome. Conclusion Stool consistency and low stimulation intensity have been identified as predictive factors for the short‐term outcome of SNS.     

In vitro apoptotic induction of human glioblastoma cells by Fas ligand plus etoposide and in vivo antitumour activity of combined drugs in xenografted nude rats

Human glioblastomas that express Fas/CD95 receptor are highly resistant to conventional brain tumour therapies. The aim of this study is to evaluate anti-tumour properties of a combination of Fas ligand (FasL) plus etoposide with or without dexamethasone on intracerebral experimental glioblastomas. The human Fas-expressing glioblastoma cell line, U-87 MG, was firstly studied in vitro for apoptosis and proliferation assays in the presence of FasL and etoposide, separately or associated, in order to detect a supra-additive effect on FasL or etoposide-induced apoptosis. The tumourigenicity of the U-87 MG cell line and therapeutic effects of FasL-etoposide alone or combined with dexamethasone were next studied on U-87 MG cells xenografted to nude-rat brain and tumour size was hence examined by histological and immunohistochemical stainings. We demonstrated in vitro that the combination of both molecules strongly inhibited the proliferation rate and increased the sensitivity of glioblastoma cells to Fas or etoposide-mediated apoptosis. Moreover, analysis of rat brains was performed 30 days after xenograft of glioblastoma cells. These data show that the combination of FasL and etoposide could reduce significantly the tumour size and that the addition of dexamethasone enhanced the inhibiting effect of FasL and etoposide on tumour growth in vivo.     

Whole-genome array CGH identifies pathogenic copy number variations in fetuses with major malformations and a normal karyotype

Despite a wide range of clinical tools, the etiology of mental retardation and multiple congenital malformations remains unknown for many patients. Array-based comparative genomic hybridization (aCGH) has proven to be a valuable tool in these cases, as its pangenomic coverage allows the identification of chromosomal aberrations that are undetectable by other genetic methods targeting specific genomic regions. Therefore, aCGH is increasingly used in clinical genetics, both in the postnatal and the prenatal settings. While the diagnostic yield in the postnatal population has been established at 10-12%, studies investigating fetuses have reported variable results. We used whole-genome aCGH to investigate fetuses presenting at least one major malformation detected on ultrasound, but for whom standard genetic analyses (including karyotype) failed to provide a diagnosis. We identified a clinically significant chromosomal aberration in 8.2% of tested fetuses (4/49), and a result of unclear clinical significance in 12.2% of tested fetuses (6/49). Our results document the value of whole-genome aCGH as a prenatal diagnostic tool and highlight the interpretation difficulties associated with copy number variations of unclear significance.     

Host–pathogen interactions and prognosis of critically ill immunocompetent patients with pneumococcal pneumonia: the nationwide prospective observational STREPTOGENE study

Purpose

To assess the relative importance of host and bacterial factors associated with hospital mortality in patients admitted to the intensive care unit (ICU) for pneumococcal community-acquired pneumonia (PCAP).

Methods

Immunocompetent Caucasian ICU patients with PCAP documented by cultures and/or pneumococcal urinary antigen (UAg Sp) test were included in this multicenter prospective study between 2008 and 2012. All pneumococcal strains were serotyped. Logistic regression analyses were performed to identify risk factors for hospital mortality.

Results

Of the 614 patients, 278 (45%) had septic shock, 270 (44%) had bacteremia, 307 (50%) required mechanical ventilation at admission, and 161 (26%) had a diagnosis based only on the UAg Sp test. No strains were penicillin-resistant, but 23% had decreased susceptibility. Of the 36 serotypes identified, 7 accounted for 72% of the isolates, with different distributions according to age. Although antibiotics were consistently appropriate and were started within 6 h after admission in 454 (74%) patients, 116 (18.9%) patients died. Independent predictors of hospital mortality in the adjusted analysis were platelets?≤?100 × 10⁹/L (OR, 7.7; 95% CI, 2.8–21.1), McCabe score?≥?2 (4.58; 1.61–13), age?>?65 years (2.92; 1.49–5.74), lactates?>?4 mmol/L (2.41; 1.27–4.56), male gender and septic shock (2.23; 1.30–3.83 for each), invasive mechanical ventilation (1.78; 1–3.19), and bilateral pneumonia (1.59; 1.02–2.47). Women with platelets?≤?100 × 10⁹/L had the highest mortality risk (adjusted OR, 7.7; 2.8–21).

Conclusions

In critically ill patients with PCAP, age, gender, and organ failures at ICU admission were more strongly associated with hospital mortality than were comorbidities. Neither pneumococcal serotype nor antibiotic regimen was associated with hospital mortality.