Thyroid nodule management: clinical, ultrasound and cytopathological parameters for predicting malignancy

Although fine-needle aspiration cytology is considered to be the reference method for evaluating thyroid nodules, the results are inaccurate in approximately 10-30% of cases. Several studies have attempted to predict the risk of malignancy in thyroid nodules based on age, nodularity, thyrotropin values, thyroid autoimmune disease, hot/cold nodule status, and ultrasound parameters. However, no consensus has been found, and none of these parameters has significantly affected patient management. The management of indeterminate thyroid nodules and re-biopsies of nodules with initially benign cytological results remain important and controversial topics of discussion. The Bethesda cytological system and several studies on the use of molecular markers to predict malignancy from cytological samples of thyroid nodules need further clarification. More in-depth discussions among and continuous education of the specialists involved in treating thyroid disease are necessary to improve the management of these patients. This review aims to examine the clinical, laboratory, ultrasound, and scintigraphic parameters that can be used for thyroid nodule management

Consecutive use of the 52 mg levonorgestrel-releasing intrauterine system: variations in bleeding patterns

Changes in bleeding patterns could influence the decisions of healthcare professionals to change the levonorgestrel-releasing intrauterine system (LNG-IUS) before 7 years of use, the recommended period of extended use. We evaluated changes in the bleeding patterns of users of the 52 mg LNG-IUS at the end of use of the first (IUS-1) and during the second device (IUS-2) use. We performed an audit of the medical records of all women who used two consecutive LNG-IUSs at the Family Planning clinic. We evaluated the sociodemographic/gynecological variables, the length of use, and the bleeding patterns reported in the reference periods of 90 days before removal of the IUS-1 and at the last return in use of IUS-2. We used the McNemar test to compare bleeding patterns. Statistical significance was established at p < 0.05. We evaluated 301 women aged (mean ± SD) 32 (±6.1) years, with lengths of use of 68.9 (±16.8) and 20.3 (±16.7) months for the IUS-1 and IUS-2, respectively. No pregnancies were reported. Bleeding patterns varied significantly among women who used the IUS-2 for ≥ 7 months to 6 years when compared the bleeding patterns reported in IUS-1 use. Eighty-nine out of 221 (40%) women maintained amenorrhea and infrequent bleeding; 66 (30%) evolved to bleeding patterns with light flow, and 66 (30%) maintained or evolved to heavy flow patterns (p = 0.012). No differences were observed among the 80 women with ≤ 6 months of use. Changes in bleeding patterns occur during the use of LNG-IUS and should not be decisive for the early replacement of the device424194199Variações no padrão de sangramento podem afetar a decisão de troca do sistema intrauterino de levonorgestrel (SIU-LNG) antes do período de uso estendido recomendado de 7 anos. Nós avaliamos mudanças no padrão de sangramento de usuárias ao final do uso do primeiro SIU-LNG 52 mg (SIU-1) e durante o uso do segundo dispositivo (SIU-2). Revisamos os prontuários de todas as mulheres que inseriram consecutivamente o SIU-LNG no ambulatório de Planejamento Familiar. Foram avaliadas as variáveis sociodemográficas/ginecológicas, o tempo de uso, e os padrões de sangramento relatados nos períodos de referência de 90 dias antes da remoção do SIU-1 e no último retorno em uso do SIU-2. Usamos o teste de McNemar para comparar os padrões de sangramento. A significância estatística foi estabelecida em p < 0,05. Analisamos os dados de 301 mulheres com idade (média ± desvio padrão [DP]) de 32 (±6,1) anos e tempo de uso de 68,9 (±16,8) e 20,3 (±16,7) meses para o SIU-1 e SIU-2, respectivamente. Nenhuma gravidez foi relatada. Os padrões de sangramento variaram significativamente durante o uso do SIU-2 (≥ 7 meses a 6 anos) em relação ao padrão relatado no SIU-1. Oitenta e nove das 221 (40%) mulheres mantiveram amenorreia e sangramento infrequente; 66 (30%) evoluíram para padrões de sangramento com fluxo leve e 66 (30%) mantiveram ou evoluíram para padrões de fluxo intenso (p = 0,012). Não foram observadas diferenças entre as 80 mulheres que utilizavam o SIU-2 há ≤ 6 meses. Mudanças nos padrões de sangramento ocorrem durante o uso do LNG-IUS e não devem ser decisivas para a troca precoce do dispositiv

High Prevalence of Infertility among Women with Graves’ Disease and Hashimoto’s Thyroiditis

Objectives. To evaluate the prevalence of infertility in women with Graves’ disease (GD) or Hashimoto’s thyroiditis (HT) and associated factors. Material and Methods. This cross-sectional study was conducted at the Endocrinology Clinic for Thyroid Autoimmune Diseases, with 193 women aged 18–50 years with GD and 66 women aged 18–60 years with HT. The women were interviewed to obtain data on their gynecological and obstetric history and family history of autoimmune diseases. Their medical records were reviewed to determine the characteristics of the disease and to confirm association with other autoimmune diseases. Infertility was defined as 12 months of unprotected sexual intercourse without conception. Results. The prevalence of infertility was 52.3% in GD and 47.0% in HT. Mean age at diagnosis was 36.5 years and 39.2 years, in GD and HT, respectively. The mean number of pregnancies was lower in women who were 35 years old or younger at diagnosis and was always lower following diagnosis of the disease, irrespective of age. The only variable associated with infertility was a shorter time of the disease in HT. Conclusions. The prevalence of infertility was high in women with GD and HT and affected the number of pregnancies in young women

Severe Rhabdomyolysis Due To Adipsic Hypernatremia After Craniopharyngioma Surgery.

The association of diabetes insipidus and adipsia after craniopharyngioma surgery has high morbidity. Hypernatremia can be caused by adipsia and be aggravated by diabetes insipidus. Rhabdomyolysis rarely occurs. This is the first report of a diabetic patient with craniopharyngioma who developed diabetes insipidus and adipsia after surgery, evolving with severe hypernatremia that caused considerable rhabdomyolysis. The importance of the evaluation of muscle integrity when under hypernatremic states is pointed out. Although adipsia may have a simple solution through volunteer water ingestion, serious consequences such as repeated severe hypernatremia episodes and intense rhabdomyolysis with high morbidity could occur, if adipsia is not diagnosed.511175-

Usefulness of pre-thyroidectomy neutrophil–lymphocyte, platelet–lymphocyte, and monocyte–lymphocyte ratios for discriminating lymph node and distant metastases in differentiated thyroid cancer

OBJECTIVE: This study aimed to analyze the relationship of neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and monocyte-lymphocyte ratio (MLR) with clinicopathological characteristics of patients with differentiated thyroid cancer (DTC). METHODS: This retrospective study included 390 patients with DTC who had complete blood cell counts available at the time of surgery. NLR, PLR, and MLR were calculated, and the risk of cancer-related death, structural recurrence, and response to therapy were assessed using the eighth edition of the tumor-node-metastasis classification, American Thyroid Association (ATA) Risk Stratification System, and ATA Response to Therapy Reclassification, respectively. RESULTS: PLR was higher in patients with distant metastasis than in those without (133.15±43.95&nbsp;versus&nbsp;119.24±45.69,&nbsp;p=0.0345) and lower in patients with disease-free status (117.72±44.70&nbsp;versus&nbsp;131.07±47.85,&nbsp;p=0.0089) than in those who experienced persistent disease or death. Patients aged ≥55 years had a higher MLR than those aged &lt;55 years (0.26±0.10&nbsp;versus&nbsp;0.24±0.12,&nbsp;p=0.0379). Higher MLR (odds ratio [OR]: 8.775, 95% confidence interval [CI]: 1.532-50.273,&nbsp;p=0.0147), intermediate ATA risk (OR: 4.892, 95% CI: 2.492-9.605,&nbsp;p≤0.0001), and high ATA risk (OR: 5.998, 95% CI: 3.126-11.505,&nbsp;p≤0.0001) were risk factors associated with active disease. NLR was not significantly different among the studied variables. Receiver operating characteristic curve cut-off values for NLR, PLR, and MLR were able to differentiate distant metastasis from lymph node metastasis (NLR&gt;1.93: 73.3% sensitivity and 58.7% specificity, PLR&gt;124.34: 86.7% sensitivity and 69.2% specificity, MLR&gt;0.21: 80% sensitivity and 45.2% specificity). CONCLUSION: Cut-off values of NLR, PLR, and MLR differentiated distant metastasis from lymph node metastasis with good sensitivity and accuracy. PLR was associated with disease-free status and it was higher in DTC patients with distant metastasis, persistent disease, and disease-related death. MLR was a risk factor for active disease

Insulin sensitivity is not decreased in adult patients with hypopituitarism without growth hormone replacement

Decreased insulin sensitivity in patients with hypopituitarism without GH replacement (pHP-WGHR) remains conflicting in literature. It is known that these patients present a decrease in free fat mass and an increase in fat mass. Typically, these kinds of alterations in body composition are associated with a decrease in insulin sensitivity; however, there is no consensus if this association is found in pHP-WGHR. Thus, we investigated pHP-WGHR regarding insulin sensitivity by euglycemic hyperinsulinemic clamp, the gold standard method, and body composition. In a cross-sectional study, we evaluated 15 pHP-WGHR followed up in a Service of Neuroendocrinology and 15 individuals with normal pituitary function as a control group with similar age, gender and body mass index. Insulin sensitivity was evaluated by euglycemic hyperinsulinemic clamp and homeostatic model assessment insulin resistance (HOMA-IR). Kappa coefficient evaluated the agreement between these two methods. Percentage of fat mass, percentage of free fat mass, fat mass weight and free fat mass weight were assessed by electrical bioimpedance. The pHP-WGHR presented similar insulin sensitivity to control group by euglycemic hyperinsulinemic clamp, both by the M-value, (p = 0.0913) and by the area under the glucose infusion rate curve, (p = 0.0628). These patients showed lower levels of fasting glycemia (p = 0.0128), insulin (p = 0.0007), HOMA-IR (p = 0.009). HOMA-IR shows poor concordance with euglycemic hyperinsulinemic clamp (Kappa = 0.16) in pHP-WGHR, while in the control group the agreement was good (Kappa = 0.53). The pHP-WGHR presented higher values of percentage of fat mass (p = 0.0381) and lower values of percentage of free fat mass (p = 0.0464) and free fat mass weight (0.0421) than the control group. This study demonstrated that the insulin sensitivity evaluated by euglycemic hyperinsulinemic clamp in pHP-WGHR was similar to individuals with normal pituitary function, despite the pHP-WGHR presenting higher fatmass percentage. HOMA-IR was not a good method for assessing insulin sensitivity in pHP-WGHR10CONSELHO NACIONAL DE DESENVOLVIMENTO CIENTÍFICO E TECNOLÓGICO - CNPQSem informaçã

A logística na cadeia de frio em Portugal: transporte de produtos perecíveis congelados

Trabalho Final de Mestrado para obtenção do grau de Mestre em Engenharia MecânicaEste trabalho é o resultado de uma dissertação de mestrado no âmbito do 2º ano de Mestrado em Energia, Refrigeração e Climatização do Instituto Superior de Engenharia de Lisboa, e vai desenvolver- se numa empresa que comercializa e distribui uma vasta gama de produtos originários do mar, com maior incidência no peixe congelado e marisco. No contexto atual da sociedade e face às exigências do mercado e dos Clientes, o transporte do produto congelado é um tema da atualidade e que reveste de importância crucial, uma vez que deve ser garantido que o produto perecível foi transportado dentro dos padrões legais de conservação e transporte e sem interrupção na cadeia logística. O principal objetivo do projeto foi identificar qual o método mais adequado de transporte rodoviário de produtos perecíveis congelados (peixe), e analisar a importância da minimização da variação da temperatura na gestão do transporte de produtos perecíveis (TPP), integrada na Supply Chain Management (SCM). Apurar quais as causas e as consequências das variações de temperatura e as medidas a implementar para minimizar o seu impacto, numa perspetiva logística. As medições das variações térmicas foram realizadas no interior da caixa isotérmica com o recurso a equipamentos de medição de temperatura, “Data Logger” e o “Termopar”, tendo sido coletados os dados que após análise foram produzidas as respetivas conclusões. De modo a avaliar esta temática foi elaborada uma revisão de literatura qualificada, base da em artigos científicos, livros da especialidade, teses e dissertações. O estudo foi realizado numa Empresa de dimensão média, localizada nos arredores de Lisboa, que realiza o transporte de peixe congelado e marisco. O referido estudo permitiu concluir que existem variações térmicas à medida que se aproxima do ponto de distribuição final e apresentadas soluções para a minimização deste problema.Abstract: This work aims is the resu lt of a master's thesis under the 2nd year of Master in Energy, Refrigeration and Air Conditioning of the Instituto Superior de Engenharia de Lisboa, and will develop a company that markets and distributes a wide range of products originating Sea, focusing on the frozen fish and seafood. In the current context of society and meet the demands of the market and customers, the transport of frozen product is a topical issue and of crucial importance, since it must be ensured that the perishable product has been transported within the legal conservation standards and transportation and rolling in the logistics chain. The main objective of the project was to identify the most appropriate method of road transport frozen perishable products (fish), and analyse the i mportance of minimizing the variation of temperature in the transport of perishables management (TPP), part of the Supply Chain Management (SCM). Which determine the causes and consequences of temperature changes and the measures to be implemented to minimize its impact on a logistics perspective. Measurements were made of the thermal variations within the isothermal box with the use of temperature measuring devices, " Data Logger" and "Thermocouple", the data having been collected which after analysis the respective conclusions were produced. In order to assess this issue was elaborated a qualified literature review based on scientific papers, specialty books, theses and dissertations. The study was performed in a medium- sized company located in the outskirt s of Lisbon, which transports frozen fish and seafood. The study concluded that there are temperature changes as it approaches the final distribution point and presented solutions to minimize this problem

Comparative analysis of diagnostic performance, feasibility and cost of different test-methods for thyroid nodules with indeterminate cytology

Since it is impossible to recognize malignancy at fine needle aspiration (FNA) cytology in indeterminate thyroid nodules, surgery is recommended for all of them. However, cancer rate at final histology is < 30%. Many different test-methods have been proposed to increase diagnostic accuracy in such lesions, including Galectin-3-ICC (GAL-3-ICC), BRAF mutation analysis (BRAF), Gene Expression Classifier (GEC) alone and GEC+BRAF, mutation/fusion (M/F) panel, alone, M/F panel+miRNA GEC, and M/F panel by next generation sequencing (NGS), FDG-PET/CT, MIBI-Scan and TSHR mRNA blood assay. We performed systematic reviews and meta-analyses to compare their features, feasibility, diagnostic performance and cost. GEC, GEC+BRAF, M/F panel+miRNA GEC and M/F panel by NGS were the best in ruling-out malignancy (sensitivity = 90%, 89%, 89% and 90% respectively). BRAF and M/F panel alone and by NGS were the best in ruling-in malignancy (specificity = 100%, 93% and 93%). The M/F by NGS showed the highest accuracy (92%) and BRAF the highest diagnostic odds ratio (DOR) (247). GAL-3-ICC performed well as rule-out (sensitivity = 83%) and rule-in test (specificity = 85%), with good accuracy (84%) and high DOR (27) and is one of the cheapest (113 USD) and easiest one to be performed in different clinical settings. In conclusion, the more accurate molecular-based test-methods are still expensive and restricted to few, highly specialized and centralized laboratories. GAL-3-ICC, although limited by some false negatives, represents the most suitable screening test-method to be applied on a large-scale basis in the diagnostic algorithm of indeterminate thyroid lesions

Role of ultrasound, clinical and scintigraphyc parameters to predict malignancy in thyroid nodule

Background: This study aimed to evaluate clinical, laboratory, ultrasound (US) and scintigraphyc parameters in thyroid nodule and to develop an auxiliary model for clinical application in the diagnosis of malignancy. Methods: We assessed 143 patients who were surgically treated at a single center, 65% (93) benign vs. 35% (50) malignant lesions at final histology (1998-2008). The clinical, laboratory, scintigraphyc and US features were compared and a prediction model was designed after the multivariate analysis. Results: There were no differences in gender, serum TSH and FT4 levels, thyroid auto-antibodies (TAb), thyroid dysfunction and scintigraphyc results (P = 0.33) between benign and malignant nodule groups. The sonographic study showed differences when the presence of suspected characteristics was found in the nodules of the malignant lesions group, such as: microcalcifications, central flow, border irregularity and hypoechogenicity. After the multivariate analysis the model obtained showed age (>39 years), border irregularity, microcalcifications and nodule size over 2 cm as predictive factors of malignancy, featuring 81.7% of accuracy. Conclusions: This study confirmed a significant increase of risk for malignancy in patients of over 39 years and with suspicious features at US