Deescalating Follow-up after Hemithyroidectomy for Patients with Low-risk Papillary Thyroid Microcarcinoma

Importance: Structural recurrent disease (RD) after surgical treatment of papillary thyroid microcarcinoma (mPTC) is rare. We hypothesized that the RD rate after hemithyroidectomy in low-risk patients with mPTC is low.Objective: To assess the occurrence of RD in Dutch patients with mPTC who received surgical treatment according to the Dutch guidelines.Design, Setting, and Participants: This nationwide retrospective cohort study included all patients who had undergone surgery with a diagnosis of cN0/cNx mPTC in the Netherlands between January 2000 and December 2020 were identified from the Netherlands Cancer Registry database. Patients with preoperative lymph node metastases were excluded. Two groups were defined: group 1 (incidental), mPTC in pathology report after thyroid surgery for another indication; and group 2 (nonincidental), patients with a preoperative highly suspect thyroid nodule (Bethesda 5) or proven mPTC (Bethesda 6). Dutch guidelines state that a hemithyroidectomy is sufficient in patients with unifocal, intrathyroidal mPTC. Main Outcomes and Measures: The occurrence of RD in patients with low-risk mPTC after hemithyroidectomy.Results: In total, 1636 patients with mPTC were included. Patients had a median (IQR) follow-up time of 71 (32-118) months. Median (IQR) age at time of diagnosis was 51 (41-61) years and 1292 (79.0%) were women. Overall, RD after initial treatment was seen in 25 patients (1.5%). The median (IQR) time to RD was 8.2 (3.6-16.5) months and 22 of the 25 (88%) patients developed RD within 2 years. Recurrent disease was not significantly different between both groups (group 1, n = 15 [1.3%]; group 2, n = 10 [2.1%]; difference, 0.8%; 95% CI, -0.5% to 2.5%). Of the 484 patients with nonincidental mPTC (group 2), 246 (50.8%) patients were treated with a hemithyroidectomy and follow-up in accordance with Dutch guidelines. Lymph node metastases were found in 1 of 246 (0.4%) patients after hemithyreoidectomy, and new mPTC in the contralateral thyroid was detected in 3 of 246 (1.2%) patients. Median (IQR) follow-up of this patient group was 37 (18-71) months. The 10-year probability of RD was 1.3% for patients without vascular invasion and 24.4% for patients with vascular invasion. Conclusions and Relevance: This nationwide cohort study found that overall, RD after hemithyroidectomy for patients with low-risk mPTC was rare (&lt;2%). Based on these results, it seems reasonable to deescalate follow-up of patients with low-risk mPTC without vascular invasion after hemithyroidectomy. From a health care perspective, deescalation of follow-up may contribute to increased sustainability and accessibility to health care, both large challenges for the future..</p

Regional Collaboration and Trends in Clinical Management of Thyroid Cancer

Objective: This study examines the trends in the management of thyroid cancer and clinical outcomes in the Southwestern region of The Netherlands from 2010 to 2021, where a regional collaborative network has been implemented in January 2016. Study Design: Retrospective cohort study. Setting: This study encompasses all patients diagnosed with thyroid cancer of any subtype between January 2010 and June 2021 in 10 collaborating hospitals in the Southwestern region of The Netherlands. Methods: The primary outcome of this study was the occurrence of postoperative complications. Secondary outcomes were trends in surgical management, centralization, and waiting times of patients with thyroid cancer. Results: This study included 1186 patients with thyroid cancer. Median follow-up was 58 [interquartile range: 24-95] months. Surgery was performed in 1027 (86.6%) patients. No differences in postoperative complications, such as long-term hypoparathyroidism, permanent recurrent nerve paresis, or reoperation due to bleeding were seen over time. The percentage of patients with low-risk papillary thyroid carcinoma referred to the academic hospital decreased from 85% (n = 120/142) in 2010 to 2013 to 70% (n = 120/171) in 2014 to 2017 and 62% (n = 100/162) in 2018 to 2021 (P &lt;.01). The percentage of patients undergoing a hemithyroidectomy alone was 9% (n = 28/323) in 2010 to 2013 and increased to 20% (n = 63/317; P &lt;.01) in 2018 to 2021. Conclusion: The establishment of a regional oncological network coincided with a de-escalation of thyroid cancer treatment and centralization of complex patients and interventions. However, no differences in postoperative complications over time were observed. Determining the impact of regional oncological networks on quality of care is challenging in the absence of uniform quality indicators.</p

European experience with the Afirma Gene Expression Classifier for indeterminate thyroid nodules:A clinical utility study in the Netherlands

Background: The Gene Expression Classifier (GEC) and Genomic Sequencing Classifier (GSC) were developed to improve risk stratification of indeterminate nodules. Our aim was to assess the clinical utility in a European population with restrictive diagnostic workup. Methods: Clinical utility of the GEC was assessed in a prospective multicenter cohort of 68 indeterminate nodules. Diagnostic surgical rates for Bethesda III and IV nodules were compared to a historical cohort of 171 indeterminate nodules. Samples were post hoc tested with the GSC. Results: The GEC classified 26% as benign. Surgical rates between the prospective and historical cohort did not differ (72.1% vs. 76.6%). The GSC classified 59% as benign, but misclassified six malignant lesions as benign. Conclusion: Implementation of GEC in management of indeterminate nodules in a European country with restrictive diagnostic workup is currently not supported, especially in oncocytic nodules. Prospective studies with the GSC in European countries are needed to determine the clinical utility.</p

A symptom-based algorithm for calcium management after thyroid surgery: a prospective multicenter study

Objective: Evidence-based treatment guidelines for the management of postthyroidectomy hypocalcemia are absent. The aim of this study was to evaluate a newly developed symptom-based treatment algorithm including a protocolized attempt to phase out supplementation. Methods: In a prospective multicenter study, patients were treated according to the new algorithm and compared to a historical cohort of patients treated with a biochemically based approach. The primary outcome was the proportion of patients receiving calcium and/or alfacalcidol supplementation. Secondary outcomes were calcium-related complications and predictors for supplementation. Results: One hundred thirty-four patients were included prospectively, and compared to 392 historical patients. The new algorithm significantly reduced the proportion of patients treated with calcium and/or alfacalcidol during the first postoperative year (odds ratio (OR): 0.36 (95% CI: 0.23–0.54), P < 0.001), and persistently at 12 months follow-up (OR: 0.51 (95% CI: 0.28–0.90), P < 0.05). No severe calcium-related complications occurred, even though calcium-related visits to the emergency department and readmissions increased (OR: 11.5 (95% CI: 4.51–29.3), P <0.001) and (OR: 3.46 (95% CI: 1.58–7.57), P < 0.05), respectively. The proportional change in pre- to post operative parathyroid hormone (PTH) was an independent predictor for supplementation (OR: 1.04 (95% CI: 1.02–1.07), P < 0.05). Conclusions: Symptom-based management of postthyroidectomy hypocalcemia and a protocolized attempt to phase out supplementation safely reduce d the proportion of patients receiving supplementation, although the number of calcium-related hospital visits increased. For the future, we envision a more individualized treatment approach for patients at risk for delayed symptomatic hypocalcemia, including the proportional change in pre- to post- operative PTH

rs2735383, located at a microRNA binding site in the 3 ' UTR of NBS1, is not associated with breast cancer risk

NBS1, also known as NBN, plays an important role in maintaining genomic stability. Interestingly, rs2735383 G > C, located in a microRNA binding site in the 3'-untranslated region (UTR) of NBS1, was shown to be associated with increased susceptibility to lung and colorectal cancer. However, the relation between rs2735383 and susceptibility to breast cancer is not yet clear. Therefore, we genotyped rs2735383 in 1,170 familial non-BRCA1/2 breast cancer cases and 1,077 controls using PCR-based restriction fragment length polymorphism (RFLP-PCR) analysis, but found no association between rs2735383CC and breast cancer risk (OR = 1.214, 95% CI = 0.936-1.574, P = 0.144). Because we could not exclude a small effect size due to a limited sample size, we further analyzed imputed rs2735383 genotypes (r(2) > 0.999) of 47,640 breast cancer cases and 46,656 controls from the Breast Cancer Association Consortium (BCAC). However, rs2735383CC was not associated with overall breast cancer risk in European (OR = 1.014, 95% CI = 0.969-1.060, P = 0.556) nor in Asian women (OR = 0.998, 95% CI = 0.905-1.100, P = 0.961). Subgroup analyses by age, age at menarche, age at menopause, menopausal status, number of pregnancies, breast feeding, family history and receptor status also did not reveal a significant association. This study therefore does not support the involvement of the genotype at NBS1 rs2735383 in breast cancer susceptibility.Peer reviewe

Fizioterapijski proces nakon ugradnje TEP-a koljena

Koljeni zglob najveći je zglob u ljudskom tijelu, pokretač je tijela, podupire težinu cijelog tijela, ali pogodan je i ozljedama. Totalna endoproteza koljena postupak je koji se izvodi kod pacijenata sa uznapredovalim stadijem osteoartritisa i reumatoidnog artritisa. Artroplastika je kirurški zahvat kojim ugrađujemo umjetni zglob umjesto bolesnog. Endoproteze dijelimo na totalne, parcijalne i revizijske. Glavni razlozi za ugradnju proteze su bol, smanjena pokretljivost, nestabilnost i oticanje zgloba. Fizioterapijski proces kojeg provodi fizioterapeut sastoji se od fizioterapijske procjene, fizioterapijske intervencije i evaluacije. Fizioterapijska procjena provodi se po SOAP modelu. Najprije je potrebno napraviti procjenu, a tek onda krećemo sa intervencijom i izradom plana terapije. U objektivnoj procjeni provodimo palpaciju, opservaciju te razna mjerenja poput cirkularnosti, longitudinalnosti, manualnog mišićnog testa, opsega pokreta te specifične testove. Plan određujemo na temelju izvršene procjene i definiraju se kratkoročni i dugoročni ciljevi koji moraju biti realni. Kada smo napravili procjenu izrađujemo plan tako da odaberemo postupke koji će najbrže dovesti do željenog rezultata. U fizioterapijsku intervenciju kod neoperativnog liječenja ubrajamo edukaciju pacijenta, vježbe jačanja te vježbe snage za donje ekstremitete. Po završetku operacije odmah zapoćinjemo sa rehabilitacijom kako bi se pacijent što prije vratio normalnom načinu života i aktivnostima svakodnevnog života. Fizioterapijska intervencija kod operativnog liječenja sastoji se od mobilizacije patele, pasivnih vježbi za donje ekstremitete, aktivno potpomognutih vježbi te krioterapije i elektroterapije. Važno je naučiti pacijenta vježbe koje će samostalno izvoditi kod kuće nakon završetka terapija, te ga educirati o pravilnom korištenju pomagala. Unutar intervencije koristimo mnoge tretmane koji poboljšavaju i vraćaju izgubljene funkcije nakon ugradnje TEP-a. Cilj ovog rada je prikazati anatomiju koljena, vrste endoproteza, simptome i probleme koji se javljaju u koljenu te fizioterapijski proces odnosno procjenu i intervenciju nakon totalne endoproteze koljen

Izazovi za demokraciju - analiza neuspjeha demokracije u Egiptu

Nedavni događaji u arapskom svijetu ponovno su stavili Bliski istok u fokus globalne politike, a kao dio tih događaja uključen je i Egipat, zemlja koja je imala ključnu ulogu u oblikovanju suvremene islamističke politike, a samim time i budućnost regije ovisi o daljnjim postupcima te zemlje. Demokratski procesi u Egiptu suočavaju se s nizom izazova koji su doveli do neuspjeha u uspostavi stabilnih demokratskih institucija. Unatoč težnji prema demokraciji, politički, socijalni i kulturni faktori iznjedrili su složenu dinamiku koja je ograničila napredak prema održivoj demokraciji. Ovaj rad se upravo bavi problemom demokratskih procesa u Egiptu te koji su izazovi za demokraciju na temelju analize događaja u Egiptu

Fizioterapijski proces nakon ugradnje TEP-a koljena

Koljeni zglob najveći je zglob u ljudskom tijelu, pokretač je tijela, podupire težinu cijelog tijela, ali pogodan je i ozljedama. Totalna endoproteza koljena postupak je koji se izvodi kod pacijenata sa uznapredovalim stadijem osteoartritisa i reumatoidnog artritisa. Artroplastika je kirurški zahvat kojim ugrađujemo umjetni zglob umjesto bolesnog. Endoproteze dijelimo na totalne, parcijalne i revizijske. Glavni razlozi za ugradnju proteze su bol, smanjena pokretljivost, nestabilnost i oticanje zgloba. Fizioterapijski proces kojeg provodi fizioterapeut sastoji se od fizioterapijske procjene, fizioterapijske intervencije i evaluacije. Fizioterapijska procjena provodi se po SOAP modelu. Najprije je potrebno napraviti procjenu, a tek onda krećemo sa intervencijom i izradom plana terapije. U objektivnoj procjeni provodimo palpaciju, opservaciju te razna mjerenja poput cirkularnosti, longitudinalnosti, manualnog mišićnog testa, opsega pokreta te specifične testove. Plan određujemo na temelju izvršene procjene i definiraju se kratkoročni i dugoročni ciljevi koji moraju biti realni. Kada smo napravili procjenu izrađujemo plan tako da odaberemo postupke koji će najbrže dovesti do željenog rezultata. U fizioterapijsku intervenciju kod neoperativnog liječenja ubrajamo edukaciju pacijenta, vježbe jačanja te vježbe snage za donje ekstremitete. Po završetku operacije odmah zapoćinjemo sa rehabilitacijom kako bi se pacijent što prije vratio normalnom načinu života i aktivnostima svakodnevnog života. Fizioterapijska intervencija kod operativnog liječenja sastoji se od mobilizacije patele, pasivnih vježbi za donje ekstremitete, aktivno potpomognutih vježbi te krioterapije i elektroterapije. Važno je naučiti pacijenta vježbe koje će samostalno izvoditi kod kuće nakon završetka terapija, te ga educirati o pravilnom korištenju pomagala. Unutar intervencije koristimo mnoge tretmane koji poboljšavaju i vraćaju izgubljene funkcije nakon ugradnje TEP-a. Cilj ovog rada je prikazati anatomiju koljena, vrste endoproteza, simptome i probleme koji se javljaju u koljenu te fizioterapijski proces odnosno procjenu i intervenciju nakon totalne endoproteze koljen

Heart Rate Monitoring System Based on Pulse Oximeter

U ovom završnom radu razvijen je sustav za praćenje srčanog ritma načelom pulsne oksimetrije. Opisane su komponente elektroničkog sustava koji omogućuje praćenje srčanog ritma te programska potpora koja omogućuje rad tih komponenti. Za mjerenje srčanog ritma koristi se modul s integriranim senzorom za pulsnu oksimetriju i srčani ritam MAX30100. Radi se o optičkom senzoru koji očitavanja dobiva emitiranjem dviju valnih duljina svjetlosti iz LED dioda. Ugradbeni računalni sustav temelji se na STM32F0Discovery razvojnom sustavu s mikrokontrolerom niske potrošnje STM32F051R8T6. Korisničko sučelje koje omogućuje prikaz mjerenog rezultata izvedeno je putem Android aplikacije na pametnom telefonu, a s ugradbenim sustavom povezuje se putem Bluetooth modula HC 05.In this thesis a system for heart rate monitoring based on pulse oximetry was developed. The components of electronic system that enable heart rate monitoring were described, along with the accompanying software that controls the electronic circuitry. For heart rate monitoring the module with an integrated pulse oximetry and heart rate monitoring sensor MAX30100 was used. This is an optical sensor that provides measurement based on two wavelengths emitted by two LED diodes. The embedded system was build around STM32F0Discovery development kit, based on a low power microcontroller STM32F051R8T6. The user interface enables display of the measurement results through the Android application on a smart phone, which is connected wirelessly with the embedded system through the Bluetooth HC-05 module