Neuroendocrine tumors presenting with thyroid gland metastasis: a case series

<p>Abstract</p> <p>Introduction</p> <p>Autopsy series have shown that metastasis to the thyroid gland has occurred in up to 24% of patients who have died of cancer. Neuroendocrine tumors may metastasize to thyroid gland.</p> <p>Case presentations</p> <p>Case 1 was a 17-year-old Turkish woman who was referred from our Endocrinology Department for a thyroidectomy for treatment of neuroendocrine tumor metastasis. She was treated with a bilateral total thyroidectomy. Histopathological examination results were consistent with a neuroendocrine tumor; neoplastic cells showed strong immunoreactivity to chromogranin A and synaptophysin, but the immunohistochemical profile was inconsistent with medullary thyroid carcinoma in that the tumor was negative for calcitonin, carcinoembryonic antigen, and thyroid transcription factor-1.</p> <p>Case 2 was a 54-year-old Turkish woman who presented with a 3-cm nodule on her right thyroid lobe. She had undergone surgery for a right lung mass four years previously. After a right pneumonectomy, thymectomy and lymph node dissection, a typical carcinoid tumor was diagnosed. Under ultrasonographic guidance, fine needle aspiration biopsy of her right thyroid pole nodule was performed and the biopsy was compatible with a neuroendocrine tumor metastasis. She was treated with a bilateral total thyroidectomy. Histopathological examination indicated three nodular lesions, 5 cm and 0.4 cm in diameter in her right lobe and 0.1 cm in diameter in her left lobe. The tumors were consistent with a neuroendocrine phenotype, showing strong immunoreactivity to chromogranin A and synaptophysin.</p> <p>Conclusion</p> <p>Thyroid nodules detected during follow-up of neuroendocrine tumor patients should be thoroughly investigated. A fine needle aspiration biopsy of the thyroid confirms the diagnosis in most cases and leads to appropriate management of those patients and may prevent unnecessary treatment approaches.</p

Effect of sample type, centrifugation and storage conditions on vitamin D concentration

Introduction: Studies about vitamin D [25(OH)D] stability in plasma are limited and preanalytical variables such as tube type may affect results. We aimed to evaluate effect of storage conditions, sample type and some preanalytical variables on vitamin D concentration. Materials and methods: Blood samples from 15 healthy subjects were centrifuged at different temperatures and stored under different conditions. Serum and plasma 25(OH)D difference, effect of centrifugation temperature and common storage conditions were investigated. Results: There was no difference between serum and plasma vitamin D concentration. Centrifugation temperature had no impact on vitamin D concentration. 25(OH)D is stable under common storage conditions: 4 hours at room temperature, 24 hours at 2-8 °C, 7 days at -20 °C, 3 months at -80 °C. Conclusion: Vitamin D does not require any special storage conditions and refrigeration. Both serum and plasma can be used for measurement

The Relationship Between Procalcitonin Level and Short Term Mortality in Emergency Department

Aim: Procalcitonin (PCT) is a biomarker for infection, which has grown in popularity in recent years. In our study, we investigated whether there was a relationship between procalcitonin levels and seven-day mortality in all patients whose procalcitonin levels were measured in the emergency department (ED). Material and Methods: In this single-center, cross-sectional, analytic, retrospective study, the patients whose PCT levels were measured in Dokuz Eylül University Hospital adult emergency department between 01.01.2016 and 31.03.2016 were included. PCT level and other parameters were evaluated in the survived and non- survived groups, Results: We analyzed 499 patients whose PCT levels were measured. The median age was 74 (IQR: 63-82) years, and 54% were male. Of the 499 patients, 6 (1.2%) had a low procalcitonin level (median 0.03: IQR 0.02-0.04), 407 (81.6%) had an intermediate procalcitonin level (median 0.26; IQR 0.16-0.54) and 86 (17.2%) had a high procalcitonin level (median 5.54; IQR 3.20- 15.31). When the PCT level-high group was compared with the other groups; systolic blood pressure (SBP), diastolic blood pressure (DBP), platelet count, pCO2 were lower and pulse rate, WBC, lactate, base excess values were higher. It was found that 249 (49.9%) of the patients were discharged from the ED, 112 (22.4%) were hospitalized, 66 (13.2%) were hospitalized in the intensive care unit, and 72 (14.4%) died. The PCT level was higher in the non-survivor group than in the survivor group (0.29 ngr/mL vs 1.07 ngr/mL, p<0.001). Univariate analysis showed that the non- survivor group had higher age, pulse, respiratory rate, procalcitonin levels, lactate and base deficiency levels, and lower SBP, DBP, oxygen saturations, and pH. The AUC for PCT was 0.722 (CI% 0.660- 0.784) in the ROC curve In the multivariate logistic regression analysis, age, SBP, oxygen saturation, and lactate were independent risk factors for mortality in ED. Conclusion: High PCT levels are associated with increased mortality in patients admitted to the ED. Patients with high- PCT levels showed higher mortality and were hospitalized in the intensive care unit. Advanced age, low systolic blood pressure, low oxygen saturation and high lactate levels are independent risk factors for mortality in ED admissions

RET/PTC oncogene expression in papillary thyroid carcinoma and its correlation with clinicopathologic findings

Papillary thyroid carcinomas (PTCs) are the most frequent type of malignant thyroid tumors. Somatic rearrangements of the ret protooncogene are frequent genetic events in PTCs. Studies that are designed to determine the correlation between ret/PTC expression and biological characteristics, pathologic features, clinical behavior of PTC gave different results. We investigated the expression of ret/PTC oncogene product by immunohistochemistry to determine the relationship of ret/PTC expression with initial histopathologic findings, clinical markers, and prognosis in 44 papillary thyroid cancer patients. A monoclonal antibody was used. Patients between years 1995 and 2003 with a mean follow-up of 59 +/- 25 months (range 24-120) were evaluated retrospectively. Study group consisted of 38 women and 6 men, with a mean age of 44.6 +/- 11.2 years. Positive immunostaining was recorded if more than 5% of the tumor cells had intracytoplasmic staining. Adjacent nontumoral thyroid tissue was used as control. Seventeen (39%) of 44 patients showed intracytoplasmic staining specific for ret/PTC. Lymph node metastasis, capsule invasion, vascular invasion, soft tissue invasion, and multicentricity rates at initial examination were not significantly different between ret/PTC positive and negative patients. Turner size, follow-up period, age, and gender were not significantly different between ret/PTC positive and negative patients, either. These findings suggest that ret/PTC expression has no prognostic value in papillary thyroid cancer

Papillary Thyroid Carcinoma Patients Assessed to Be at Low or Intermediary Risk After Primary Treatment Are at Greater Risk of Long Term Recurrence If They Are Thyroglobulin Antibody Positive Or Do Not Have Distinctly Low Thyroglobulin at Initial Assessment

Background: In papillary thyroid carcinoma (PTC), recurrences during long-term follow-up (R-LTFU) occur even in those who appear to have an excellent prognosis after initial thyroid surgery and usually, radioactive iodine (i.e., "primary treatment"). Initial studies that predict R-LTFU are not well defined. Values for serum thyroglobulin (Tg) measurements when serum thyrotropin (TSH) is >30 mu U/mL, as a result of either recombinant TSH or L-thyroxine withdrawal, referred to here as stimulated Tg (STg), have been previously evaluated. The aim of the current study was to determine the parameters associated with R-LTFU in patients with PTC categorized as having low-risk disease 9 to 12 months after their primary treatment

Severe allergic reaction to human insulin in the patient with diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is an acute and major life-threatening complication of diabetes mellitus. Fluid resuscitation, insulin therapy, and electrolyte replacement are essential for DKA treatment. Rarely, life threatening allergic reactions might develop in a patient treated with insulin. If anaphylaxis develops after insulin, the DKA treatment options are restricted. A limited number of case reports have been reported in patients with severe anaphylactic reactions to human insulin who were then treated with synthetic insulin analogues. We present a case of a 45-year-old male patient with allergic reactions to human insulin. The patient was successfully treated with insulin aspart and hemodialysis. Keywords: Diabetic ketoacidosis, Regular insulin, Allergic reaction, Emergency treatment, Insulin aspar

Retrospective evaluation of patients with elevated digoxin levels at an emergency department

Objectives: We investigated the demographic characteristics, clinical and laboratory findings, treatment strategies and clinical outcomes of patients presenting at emergency department (ED) with digoxin levels at or above 1.2 ng/ml. Materials and methods: The demographic and clinical characteristics of patients with serum digoxin levels at or above 1.2 ng/ml admitted to an ED between January 2010 and July 2011 were investigated in this cross-sectional descriptive study. Patients with ECG and clinical findings consistent with digoxin toxicity and no additional explanation of their symptoms were evaluated for digoxin toxicity. Results: In this study 137 patients were included, and 68.6% of patients were women with mean age 76.1 ± 12.2. There was no significant difference between gender and digoxin intoxication. The mean age of intoxicated group was significantly higher than the non-intoxicated group (P = 0.03). The most common comorbidities were congestive heart failure (n = 91) and atrial fibrillation (n = 74). The most common symptoms were nausea, vomiting and abdominal pain. The levels of hospitalization and mortality in this group were significantly higher. Conclusion: Digoxin intoxication must be suspected in patients present in the ED, particularly those with complaints that include nausea and vomiting, as well as new ECG changes; serum digoxin levels must be determined. Keywords: Digoxin, Digoxin level, Intoxication, Emergency departmen

A New Model in Reducing Emergency Department Crowding: The Electronic Blockage System

SUMMARY: Objectives: Emergency department (ED) crowding is a growing problem across the world. Hospitals need to identify the situation using emergency department crowding scoring systems and to produce appropriate solutions. Methods: A new program (Electronic Blockage System, EBS) was written supplementary to the Hospital Information System. It was planned that the number of empty beds in the hospital should primarily be used for patients awaiting admission to a hospital bed at the ED. In the presence of patients awaiting admission at the ED, non-urgent admissions to other departments were blocked. ED overcrowded was measured in the period before initiation of EBS, the early post-EBS period and the late post-EBS period, of one-week's duration each, using NEDOCS scoring. Results: NEDOCS values were significantly lower in the early post-EBS period compared to the other periods (p≤0.0001). Although outpatient numbers applying to the ED and existing patient numbers at time of measurement remained unchanged in all three periods, the number of patients awaiting admission in the early post-EBS period was significantly lower than in the pre-EBS and late post-EBS periods (p=0.0001, p=0.001). Conclusions: EBS is a form of triage system aimed at preventing crowding and ensuring the priority admission of emergency patients over that of polyclinic patients. In hospitals with an insufficient number of total beds it can be used to reduce ED crowding and accelerate admissions to hospital from the ED. ÖZET: Amaç: Acil servis kalabalığı tüm dünyada giderek yaygınlaşan bir sorundur. Hastanelerin acil servis kalabalık ölçütlerini kullanarak durum tespiti yapması ve uygun çözüm önerileri üretmeleri gereklidir. Gereç ve Yöntem: Çalışmamızda Hastane Bilgi Yönetim Sistemine ek bir program (Elektronik Blokaj Sistemi, EBS) yazıldı. Buna göre hastanede bulunan boş yatakların öncelikli olarak acil serviste yatış bekleyen hastalar için kullanılması planlandı. Acil serviste yatış bekleyen hasta varken, ilgili servislere yapılacak acil olmayan poliklinik yatışları bloke edildi. EBS başlamadan önceki dönem, EBS sonrası erken dönem ve EBS sonrası geç dönemde birer hafta boyunca NEDOCS skorlaması ile acil servis kalabalıklığı ölçüldü. Bulgular: Elektronik blokaj sistemi sonrası erken dönemde diğer dönemlere göre NEDOCS değeri anlamlı olarak daha düşük bulundu (p≤0.0001). Her üç dönemde de acil servise başvuran günlük hasta sayısı ve ölçüm anında mevcut olan hasta sayısı değişmediği halde, acil servis içinde yatış bekleyen hasta sayısı EBS sonrası erken dönemde, EBS öncesi ve EBS sonrası geç döneme göre anlamlı olarak daha azdı (p=0.0001, p=0.001). Sonuç: Elektronik blokaj sistemi, acil hastaların poliklinik hastalarına göre öncelikli olarak hastaneye yatışını sağlayan, kalabalığı önlemeye yönelik bir çeşit yatış triajı sistemidir. Hastanedeki toplam yatak sayısının yeterli olmadığı hastanelerde, acil servis kalabalığını azaltmak için acil servisten hastaneye olan yatışları hızlandırmak amacıyla kullanılabilir. Key words: Emergency department, National Emergency Department Overcrowding Study, NEDOCS, overcrowding, Anahtar sözcükler: Acil servis, National Emergency Department Overcrowding Study, NEDOCS, kalabalı

Blunt Trauma Patient with Esophageal Perforation

Traumatic perforation of the esophagus due to blunt trauma is a rare thoracic emergency. The most common causes of esophageal perforation are iatrogenic, and the upper cervical esophageal region is the most often injured. Diagnosis is frequently determined late, and mortality is therefore high. This case report presents a young woman who was admitted to the emergency department (ED) with esophageal perforation after having fallen from a high elevation. Esophageal perforation was diagnosed via thoracoabdominal tomography with ingestion of oral contrast. The present report discusses alternative techniques for diagnosing esophageal perforation in a multitrauma patient. [West J Emerg Med. 2014;15(6):-0

Blunt Trauma Patient with Esophageal Perforation

Traumatic perforation of the esophagus due to blunt trauma is a rare thoracic emergency. The most common causes of esophageal perforation are iatrogenic, and the upper cervical esophageal region is the most often injured. Diagnosis is frequently determined late, and mortality is therefore high. This case report presents a young woman who was admitted to the emergency department (ED) with esophageal perforation after having fallen from a high elevation. Esophageal perforation was diagnosed via thoracoabdominal tomography with ingestion of oral contrast. The present report discusses alternative techniques for diagnosing esophageal perforation in a multitrauma patient. [West J Emerg Med. 2014;15(6):-0