Value of surveillance ultrasound following hemithyroidectomy.

BACKGROUND: There is limited evidence or agreement on the benefit, duration and frequency of post-operative surveillance neck ultrasound in patients with differentiated thyroid cancer treated with hemithyroidectomy alone. This study's primary aim was to assess the benefit of neck ultrasound in this situation, with a secondary aim to assess the detection of malignancy in the contralateral lobe in patients undergoing completion surgery. METHODS: A retrospective observational study was conducted involving patients who had differentiated thyroid cancer found at diagnostic hemithyroidectomy between 1 December 2013 and 31 December 2016. RESULTS: Of 105 patients, 74 underwent completion thyroidectomy. Thirty-five per cent of these patients had malignancy identified in the contralateral lobe, the majority were unsuspected sonographically. Of 31 hemithyroidectomy patients, 1 had a nodule classified as 'U3' (indeterminate) at the first ultrasound surveillance, ultimately identified as incidental papillary microcarcinomas on completion thyroidectomy. There was no other disease recurrence or malignancy at a median of 3.8 years' follow up. CONCLUSION: The findings indicate a limited role for ultrasound follow up of patients with differentiated thyroid cancer treated with hemithyroidectomy alone.

Can we better advise our patients with nodular thyroid disease?

BACKGROUND: The 2014 British Thyroid Association guidelines acknowledged the value of risk-stratifying thyroid nodules by utilising an ultrasound reporting system ('U' classification). This study assessed whether using pre-existing parameters in combination can better stratify patients' malignancy and completion thyroidectomy risks. METHOD: A multicentre, retrospective, observational review identified 936 NHS Greater Glasgow and Clyde patients from pathology records who underwent hemithyroidectomy between 1 January 2014 and 31 December 2019. RESULTS: A total of 308 patients had thyroid malignancy, 180 (58.4 per cent) progressed to completion thyroidectomy. A nodule classified as 'U3' (indeterminate) was associated with a 35.4 per cent chance of malignancy and a 21.6 per cent risk of requiring completion surgery. Amalgamation of 'U' score with Thy score enhanced risk prediction. The malignancy rate in U3, Thy-3f nodules was 38 per cent, and 21 per cent required completion surgery. The malignancy and completion thyroidectomy rates were comparatively lower for U3, Thy-3a nodules (22 per cent and 14.3 per cent, respectively). CONCLUSION: Combining ultrasound 'U' score and Thy score improves pre-operative thyroid nodule risk stratification, leading to better informed patients regarding the risks of malignancy and completion surgery. A move towards an integrated assessment approach should be considered.

Isolated vocal cord palsy secondary to a paraoesophageal hiatus hernia: a rare variant of Ortner's syndrome.

Dysphonia is a common presenting symptom to the outpatient ear, nose and throat team and the need to have a systematic approach to its investigation and management is imperative. Red flag features combined with clinical examination including flexible nasoendoscopy will help to identify laryngeal causes of dysphonia. Vocal cord palsy can have both laryngeal and extralaryngeal aetiologies including Ortner's syndrome. We present a case where a woman in her 70s was referred with persistent hoarseness, found to have an isolated vocal cord palsy with CT scan revealing a very large hiatus hernia producing mass effect at the aortopulmonary window with no other pathology identified. To our knowledge, this is the second case in the literature of a hiatus hernia causing a vocal cord palsy. This case underpins the need for prompt assessment by flexible laryngoscopy, and consideration of extralaryngeal causes of vocal cord palsy during a dysphonia assessment.

Comparison of British Thyroid Association, American College of Radiology TIRADS and Artificial Intelligence TIRADS with histological correlation: diagnostic performance for predicting thyroid malignancy and unnecessary fine needle aspiration rate.

OBJECTIVES: To compare diagnostic performance of British Thyroid Association (BTA), American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS) and Artificial Intelligence TIRADS (AI-TIRADS) for thyroid nodule malignancy. To determine comparative unnecessary fine needle aspiration (FNA) rates. METHODS: 218 thyroid nodules with definitive histology obtained during 2017 were included. Ultrasound images were reviewed retrospectively in consensus by two subspecialist radiologists, blinded to histopathology, and nodules assigned a BTA, ACR-TIRADS and AI-TIRADS grade. Nodule laterality and size were recorded to allow accurate histopathological correlation and determine which nodules met criteria for FNA. RESULTS: 77 (35.3%) nodules were malignant. Deeming ultrasound Grade 4-5 as test-positive and 1-2 as test-negative, sensitivity and specificity for BTA was 98.28 and 42.55%, for ACR-TIRADS: 95.24 and 40.57% and for AI-TIRADS: 93.44 and 45.71%. FNA was indicated in 101 (71.6%), 67 (47.5%) and 65 (46.1%) benign nodules utilising BTA, ACR-TIRADS and AI-TIRADS respectively. The unnecessary FNA rate was significantly higher with BTA (46.3%) compared to ACR-TIRADS (30.7%) and AI-TIRADS (29.8%) p < 0.001. CONCLUSION: BTA, ACR-TIRADS and AI-TIRADS had similar diagnostic performance for predicting thyroid nodule malignancy with sensitivity >93% for all systems when considering ultrasound Grade 4-5 as malignant and Grade 1-2 as benign. ACR-TIRADS and AI-TIRADS both had a significantly lower rate of recommended FNA in benign nodules compared to BTA. ADVANCES IN KNOWLEDGE: BTA, ACR-TIRADS and AI-TIRADS have comparable diagnostic performance with high sensitivity but relatively low specificity for predicting thyroid nodule malignancy in this cohort using histology as gold-standard. Using Grade 1-2 as benign and 4-5 as malignant there were more false negatives with TIRADS but this improved when taking other features into account while BTA had a significantly higher rate of unnecessary FNA.

Epiploic Appendagitis in a Femoral Hernia.

Both epiploic appendagitis and femoral herniae are rare diagnoses individually. No radiological cases of a patient having epiploic appendagitis within a femoral hernia have been documented in the literature. We present a case of a 65-year-old patient who underwent clinical work-up for a tender left groin lump. When undergoing a CT scan for investigating possible lymphadenopathy, she was found to have epiploic appendagitis contained within an incarcerated left sided femoral hernia. In this case report, we review the relevant anatomy, aetiology, patient demographics, as well as clinical and imaging findings and management.

Case 266: Pontine Tegmental Cap Dysplasia.

History A 1-year-old boy was referred for cochlear implant assessment after he received a diagnosis of bilateral profound sensorineural hearing loss at neonatal hearing screening shortly after birth. The child was born at term via uneventful delivery, and there was no history of familial hearing loss or maternal illness. Tympanic membranes were normal, and hearing loss was confirmed with auditory brainstem testing, which showed no response from either ear. Hearing aids were provided from 3 months of age, but no behavioral responses were noted when these were worn. He was also noted to have some mild developmental delay throughout his 1st year of life and was slow to crawl, roll over, and stand up. Physical examination showed no syndromic features or physical abnormalities. Ophthalmology confirmed normal vision and visual movements but bilateral anesthetic corneas. He had corneal abrasions due to minor repeated corneal trauma, and left-sided tarsorraphy was performed at 6 months. Facial nerve function, swallow, and voice quality were normal. To assess suitability for a cochlear implant, the patient underwent MRI of the temporal lobe and brain and thin-section CT of the temporal bones. The patient subsequently underwent left cochlear implantation.

Case 266.

History A 1-year-old boy was referred for cochlear implant assessment after he received a diagnosis of bilateral profound sensorineural hearing loss at neonatal hearing screening shortly after birth. The child was born at term via uneventful delivery, and there was no history of familial hearing loss or maternal illness. Tympanic membranes were normal, and hearing loss was confirmed with auditory brainstem testing, which showed no response from either ear. Hearing aids were provided from 3 months of age, but no behavioral responses were noted when these were worn. He was also noted to have some mild developmental delay throughout his 1st year of life and was slow to crawl, roll over, and stand up. Physical examination showed no syndromic features or physical abnormalities. Ophthalmology confirmed normal vision and visual movements but bilateral anesthetic corneas. He had corneal abrasions due to minor repeated corneal trauma, and left-sided tarsorraphy was performed at 6 months. Facial nerve function, swallow, and voice quality were normal. To assess suitability for a cochlear implant, the patient underwent MRI of the temporal lobe and brain ( Figs 1 - 4 ) and thin-section CT of the temporal bones ( Figs 5 , 6 ). The patient subsequently underwent left cochlear implantation. Figure 1: Sagittal midline T1-weighted 1.5-T MR image (repetition time msec/echo time msec, 541/15). Figure 2: Axial T2-weighted MR image (6703/116, 4-mm section thickness) at the level of the pontomesencephalic junction. Figure 3: Axial T2-weighted MR image one level inferior to that shown in Figure 2 . Figure 4a: (a) Axial 1.5-T single-slab three-dimensional (3D) turbo spin-echo MR image (1200/271) at the level of the right internal auditory canal. (b) Corresponding axial 1.5-T single-slab 3D turbo spin-echo MR image at the level of the left internal auditory canal. Figure 4b: (a) Axial 1.5-T single-slab three-dimensional (3D) turbo spin-echo MR image (1200/271) at the level of the right internal auditory canal. (b) Corresponding axial 1.5-T single-slab 3D turbo spin-echo MR image at the level of the left internal auditory canal. Figure 5: Unenhanced axial thin-section (0.7-mm section thickness) CT image of the temporal bone at the level of the internal auditory canals and middle cochlear turns. Figure 6: Unenhanced axial thin-section (0.7-mm section thickness) CT image of the temporal bone at a level slightly inferior to that shown in Figure 5 .

Development of the larval migration inhibition test for comparative analysis of ivermectin sensitivity in cyathostomin populations.

Cyathostomins are the most prevalent parasitic pathogens of equids worldwide. These nematodes have been controlled using broad-spectrum anthelmintics; however, cyathostomin resistance to each anthelmintic class has been reported and populations insensitive to more than one class are relatively commonplace. The faecal egg count reduction test (FECRT) is considered the most suitable method for screening anthelmintic sensitivity in horses, but is subject to variation and is relatively time-consuming to perform. Here, we describe a larval migration inhibition test (LMIT) to assess ivermectin (IVM) sensitivity in cyathostomin populations. This test measures the paralysing effect of IVM on the ability of third stage larvae (L3) to migrate through a pore mesh. When L3 from a single faecal sample were examined on multiple occasions, variation in migration was observed: this was associated with the length of time that the L3 had been stored before testing but the association was not significant. Half maximal effective concentration (EC50) values were then obtained for cyathostomin L3 from six populations of horses or donkeys that showed varying sensitivity to IVM in previous FECRTs. Larvae from populations indicated as IVM resistant by FECRT displayed significantly higher EC50 values in the LMIT than L3 from populations classified as IVM sensitive or L3 from populations that had not been previously exposed to IVM or had limited prior exposure. The analysis also showed that EC50 values obtained using L3 from animals in which IVM faecal egg count reduction (FECR) levels had been recorded as <95% were significantly higher than EC50 values obtained using L3 from animals for which FECR was measured as >95%. For one of the populations, time that had elapsed since IVM administration had an effect on the EC50 value obtained, with a longer time since treatment associated with lower EC50 values. These results indicate that the LMIT has value in discriminating IVM sensitivity amongst cyathostomin populations, but several factors were identified that need to be taken into account when executing the test and interpreting the derived data.

Posterior dislocation of long head of biceps tendon following traumatic anterior shoulder dislocation: imaging and intra-operative findings.

A case of posterior dislocation of the long head of biceps tendon, a rare occurrence following traumatic anterior glenohumeral dislocation, along with complete rotator cuff rupture and large haemarthrosis is presented with imaging and intra-operative findings. The interposed tendon prevented complete reduction. Appearances at MRI were diagnostic and directed the surgical approach.

The in vitro diagnosis of anthelmintic resistance in cyathostomins.

Cyathostomins are the primary parasitic pathogens of equids. For over 40 years, these nematodes have been controlled using broad spectrum anthelmintics. Three classes of anthelmintic are currently available for this use but, unfortunately, resistance to each of these has now been recorded in cyathostomin populations. As part of an optimal strategy to control cyathostomin infections in the field, it will be important to identify drug-resistant worms at as early a stage as possible. This objective needs to be supported by methodologies that will allow the accurate comparison of anthelmintic resistance in different nematode populations. At present, the faecal egg count reduction test is considered the most suitable method for initial screening for anthelmintic resistance in equine nematode populations. However, in its current state, this test lacks sensitivity. It is also costly and time-consuming to perform. Laboratory-based techniques, such as the egg hatch assay, larval development assay, larval migration inhibition assay and the larval feeding inhibition assay offer alternative options for assessing anthelmintic resistance in nematode populations. All of these tests have been investigated for their utility in measuring drug resistance in sheep nematode populations and some have proven useful. The egg hatch assay, larval development assay and larval migration inhibition assay have been investigated for use in measuring levels of drug resistance in equine nematode populations. However, at best, the results obtained thus far indicate that these tests require further refinement.

Early measurement of pulsatility and resistive indexes: correlation with long-term renal transplant function.

PURPOSE: To correlate pulsatility index (PI) and resistive index (RI) measured at early specific intervals after transplantation with 1-year estimated glomerular filtration rate (eGFR) and death-censored transplant survival to assess the long-term prognostic value of these Doppler indexes. MATERIALS AND METHODS: The local ethics committee was consulted, and no formal approval was required. This retrospective review included 178 consecutive patients (111 male, 67 female; mean age, 43.9 years ± 13.4 [standard deviation]; age range, 16-72 years) undergoing first deceased-donor renal transplantation between 1997 and 2000. All patients were identified from a prospectively maintained database. Spectral Doppler analysis was performed within 1 week after transplantation in all patients and between 1 week and 3 months after transplantation in 124 patients. Average PI and RI were determined from measurements obtained in the upper, lower, and interpolar regions. For statistical analysis, the χ(2) test, analysis of variance, the Student t test, Kaplan-Meier survival plots, and Cox proportional hazards models were used. RESULTS: Within 1 week after transplantation, there was a significant association between PI and 1-year eGFR when analyzed as tertiles (P = .02). Between 1 week and 3 months after transplantation, there was a significant relationship between 1-year eGFR and both PI and RI when comparing the lowest and highest tertiles (47.5 mL/min/1.73 m(2) for PI <1.26 vs 32.7 mL/min/1.73 m(2) for PI >1.49 [P = .01], 42.8 mL/min/1.73 m(2) for RI <0.69 vs 32.3 mL/min/1.73 m(2) for RI >0.74 [P = .03]). Both PI and RI were independent predictors of death-censored transplant survival (hazard ratio, 1.68 per unit [P < .001] and 260.4 per unit, respectively [P = .02]). CONCLUSION: PI and RI in the early posttransplantation period correlate with long-term transplant function and can potentially be used as prognostic markers to aid risk stratification for future transplant dysfunction.