Follicular nodules (Thy3) of the thyroid: is total thyroidectomy the best option?

BACKGROUND: Identification of the best management strategy for nodules with Thy3 cytology presents particular problems for clinicians. This study investigates the ability of clinical, cytological and sonographic data to predict malignancy in indeterminate nodules with the scope of determining the need for total thyroidectomy in these patients. METHODS: The study population consisted of 249 cases presenting indeterminate nodules (Thy3): 198 females (79.5%) and 51 males (20.5%) with a mean age of 52.43 ± 13.68 years. All patients underwent total thyroidectomy. RESULTS: Malignancy was diagnosed in 87/249 patients (34.9%); thyroiditis co-existed in 119/249 cases (47.79%) and was associated with cancer in 40 cases (40/87; 45.98%). Of the sonographic characteristics, only echogenicity and the presence of irregular margins were identified as being statistically significant predictors of malignancy. 52/162 benign lesions (32.1%) and 54/87 malignant were hypoechoic (62.07%); irregular margins were present in 13/162 benign lesions (8.02%), and in 60/87 malignant lesions (68.97%). None of the clinical or cytological features, on the other hand, including age, gender, nodule size, the presence of microcalcifications or type 3 vascularization, were significantly associated with malignancy. CONCLUSIONS: The rate of malignancy in cytologically indeterminate lesions was high in the present study sample compared to other reported rates, and in a significant number of cases Hashimoto’s thyroiditis was also detected. Thus, considering the fact that clinical and cytological features were found to be inaccurate predictors of malignancy, it is our opinion that surgery should always be recommended. Moreover, total thyroidectomy is advisable, being the most suitable procedure in cases of multiple lesions, hyperplastic nodular goiter, or thyroiditis; the high incidence of malignancy and the unreliability of intraoperative frozen section examination also support this preference for total over hemi-thyroidectomy

Effective Electromagnetic Lagrangian at Finite Temperature and Density in the Electroweak Model

Using the exact propagators in a constant magnetic field, the effective electromagnetic Lagrangian at finite temperature and density is calculated to all orders in the field strength B within the framework of the complete electroweak model, in the weak coupling limit. The partition function and free energy are obtained explicitly and the finite temperature effective coupling is derived in closed form. Some implications of this result, potentially interesting to astrophysics and cosmology, are discussed.Comment: 14 pages, Revtex

Gauge Independence of Limiting Cases of One-Loop Electron Dispersion Relation in High-Temperature QED

Assuming high temperature and taking subleading temperature dependence into account, gauge dependence of one-loop electron dispersion relation is investigated in massless QED at zero chemical potential. The analysis is carried out using a general linear covariant gauge. The equation governing the gauge dependence of the dispersion relation is obtained and used to prove that the dispersion relation is gauge independent in the limiting case of momenta much larger than $eT$. It is also shown that the effective mass is not influenced by the leading temperature dependence of the gauge dependent part of the effective self-energy. As a result the effective mass, which is of order $eT$, does not receive a correction of order $e^2T$ from one loop, independent of the gauge parameter.Comment: Revised and enlarged version, 14 pages, Revte

Neutrino Propagation in a Strongly Magnetized Medium

We derive general expressions at the one-loop level for the coefficients of the covariant structure of the neutrino self-energy in the presence of a constant magnetic field. The neutrino energy spectrum and index of refraction are obtained for neutral and charged media in the strong-field limit ($M_{W}\gg \sqrt{B}\gg m_{e},T,\mu ,| \mathbf{p}|$) using the lowest Landau level approximation. The results found within the lowest Landau level approximation are numerically validated, summing in all Landau levels, for strong $B\gg T^{2}$ and weakly-strong $B \gtrsim T^{2}$ fields. The neutrino energy in leading order of the Fermi coupling constant is expressed as the sum of three terms: a kinetic-energy term, a term of interaction between the magnetic field and an induced neutrino magnetic moment, and a rest-energy term. The leading radiative correction to the kinetic-energy term depends linearly on the magnetic field strength and is independent of the chemical potential. The other two terms are only present in a charged medium. For strong and weakly-strong fields, it is found that the field-dependent correction to the neutrino energy in a neutral medium is much larger than the thermal one. Possible applications to cosmology and astrophysics are considered.Comment: 23 pages, 4 figures. Corrected misprints in reference

Tillage erosion as an important driver of in‐field biomass patterns in an intensively used hummocky landscape

Tillage erosion causes substantial soil redistribution that can exceed water erosion especially in hummocky landscapes under highly mechanized large field agriculture. Consequently, truncated soil profiles can be found on hill shoulders and top slopes, whereas colluvial material is accumulated at footslopes, in depressions, and along downslope field borders. We tested the hypothesis that soil erosion substantially affects in-field patterns of the enhanced vegetation index (EVI) of different crop types on landscape scale. The interrelation between the EVI (RAPIDEYE satellite data; 5 m spatial resolution) as a proxy for crop biomass and modeled total soil erosion (tillage and water erosion modeled using SPEROS-C) was analyzed for the Quillow catchment (size: 196 km2) in Northeast Germany in a wet versus normal year for four crop types (winter wheat, maize, winter rapeseed, winter barley). Our findings clearly indicate that eroded areas had the lowest EVI values, while the highest EVI values were found in depositional areas. The differences in the EVI between erosional and depositional sites are more pronounced in the analyzed normal year. The net effect of total erosion on the EVI compared to areas without pronounced erosion or deposition ranged from −10.2% for maize in the normal year to +3.7% for winter barley in the wet year. Tillage erosion has been identified as an important driver of soil degradation affecting in-field crop biomass patterns in a hummocky ground moraine landscape. While soil erosion estimates are to be made, more attention should be given toward tillage erosion.ISSN:1085-3278ISSN:1099-145

Vascular endothelial growth factor in node-positive breast cancer patients treated with adjuvant tamoxifen

In 212 postmenopausal women with node-positive oestrogen receptor-positive (ER(LBA)) breast cancer subjected to radical surgery and adjuvant tamoxifen, the risk of 6-year relapse increased with increasing values of intratumoral vascular endothelial growth factor (VEGF) in patients whose tumours had a low/intermediate ER(LBA) content compared to patients with high-ER(LBA) tumours. These findings indicate that tumour progression, activated or sustained by high VEGF levels, may be counteracted in high-ER(LBA) cancers by tamoxifen, which in contrast fails to contrast the metastatic potential in low-ER(LBA) tumours

Laparoscopic right hemicolectomy: the SICE (Societ\ue0 Italiana di Chirurgia Endoscopica e Nuove Tecnologie) network prospective trial on 1225 cases comparing intra corporeal versus extra corporeal ileo-colic side-to-side anastomosis

Background: While laparoscopic approach for right hemicolectomy (LRH) is considered appropriate for the surgical treatment of both malignant and benign diseases of right colon, there is still debate about how to perform the ileo-colic anastomosis. The ColonDxItalianGroup (CoDIG) was designed as a cohort, observational, prospective, multi-center national study with the aims of evaluating the surgeons\u2019 attitude regarding the intracorporeal (ICA) or extra-corporeal (ECA) anastomotic technique and the related surgical outcomes. Methods: One hundred and twenty-five Surgical Units experienced in colorectal and advanced laparoscopic surgery were invited and 85 of them joined the study. Each center was asked not to change its surgical habits. Data about demographic characteristics, surgical technique and postoperative outcomes were collected through the official SICE website database. One thousand two hundred and twenty-five patients were enrolled between March 2018 and September 2018. Results: ICA was performed in 70.4% of cases, ECA in 29.6%. Isoperistaltic anastomosis was completed in 85.6%, stapled in 87.9%. Hand-sewn enterotomy closure was adopted in 86%. Postoperative complications were reported in 35.4% for ICA and 50.7% for ECA; no significant difference was found according to patients\u2019 characteristics and technologies used. Median hospital stay was significantly shorter for ICA (7.3 vs. 9 POD). Postoperative pain in patients not prescribed opioids was significantly lower in ICA group. Conclusions: In our survey, a side-to-side isoperistaltic stapled ICA with hand-sewn enterotomy closure is the most frequently adopted technique to perform ileo-colic anastomosis after any indications for elective LRH. According to literature, our study confirmed better short-term outcomes for ICA, with reduction of hospital stay and postoperative pain. Trial registration: Clinical trial (Identifier: NCT03934151)

Global overview of the management of acute cholecystitis during the COVID-19 pandemic (CHOLECOVID study)

Background: This study provides a global overview of the management of patients with acute cholecystitis during the initial phase of the COVID-19 pandemic. Methods: CHOLECOVID is an international, multicentre, observational comparative study of patients admitted to hospital with acute cholecystitis during the COVID-19 pandemic. Data on management were collected for a 2-month study interval coincident with the WHO declaration of the SARS-CoV-2 pandemic and compared with an equivalent pre-pandemic time interval. Mediation analysis examined the influence of SARS-COV-2 infection on 30-day mortality. Results: This study collected data on 9783 patients with acute cholecystitis admitted to 247 hospitals across the world. The pandemic was associated with reduced availability of surgical workforce and operating facilities globally, a significant shift to worse severity of disease, and increased use of conservative management. There was a reduction (both absolute and proportionate) in the number of patients undergoing cholecystectomy from 3095 patients (56.2 per cent) pre-pandemic to 1998 patients (46.2 per cent) during the pandemic but there was no difference in 30-day all-cause mortality after cholecystectomy comparing the pre-pandemic interval with the pandemic (13 patients (0.4 per cent) pre-pandemic to 13 patients (0.6 per cent) pandemic; P = 0.355). In mediation analysis, an admission with acute cholecystitis during the pandemic was associated with a non-significant increased risk of death (OR 1.29, 95 per cent c.i. 0.93 to 1.79, P = 0.121). Conclusion: CHOLECOVID provides a unique overview of the treatment of patients with cholecystitis across the globe during the first months of the SARS-CoV-2 pandemic. The study highlights the need for system resilience in retention of elective surgical activity. Cholecystectomy was associated with a low risk of mortality and deferral of treatment results in an increase in avoidable morbidity that represents the non-COVID cost of this pandemic

Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

Despite current guidelines, intraperitoneal drain placement after elective colorectal surgery remains widespread. Drains were not associated with earlier detection of intraperitoneal collections, but were associated with prolonged hospital stay and increased risk of surgical-site infections.Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien-Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk