Definition of an 18-mer Synthetic Peptide Derived from the GB virus C E1 Protein as a New HIV-1 Entry Inhibitor.

BACKGROUND: A slower progression of AIDS and increased survival in GBV-C positive individuals, compared with GBV-C negative individuals has been demonstrated; while the loss of GBV-C viremia was closely associated with a rise in mortality and increased progression of AIDS. Following on from the previous reported studies that support the thesis that GBV-C E2 interferes with HIV-1 entry, in this work we try to determine the role of the GBV-C E1 protein in HIV-1 inhibition. METHODS: The present work involves the construction of several overlapping peptide libraries scanning the GBV-C E1 protein and the evaluation of their anti-HIV activity. RESULTS: Specifically, an 18-mer synthetic peptide from the GBV-C E1 protein, E1(139-156), showed similar antiviral activity against HIVs from viruses from clades A, B, C, D and AE. Competitive ELISA using specific gp41-targeting mAbs, fluorescence resonance energy transfer as well as haemolysis assays demonstrated that this E1 peptide sequence interacts with the highly conserved N-terminal region of the HIV-1 gp41 (the fusion peptide) which is essential for viral entry. CONCLUSIONS: We have defined a novel peptide lead compound and described the inhibitory role of a highly conserved fragment of the E1 protein. GENERAL SIGNIFICANCE: The results together allow us to consider the non-pathogenic E1 GBV-C protein as an attractive source of peptides for the development of novel anti-HIV therapies.

Detection of Broadly Neutralizing Activity within the First Months of HIV-1 Infection.

UNLABELLED: A fraction of HIV-1 patients are able to generate broadly neutralizing antibodies (bNAbs) after 2 to 4 years of infection. In rare occasions such antibodies are observed close to the first year of HIV-1 infection but never within the first 6 months. In this study, we analyzed the neutralization breadth of sera from 157 antiretroviral-naive individuals who were infected for less than 1 year. A range of neutralizing activities was observed with a previously described panel of six recombinant viruses from five different subtypes (M. Medina-Ramirez et al., J Virol 85:5804-5813, 2011, http://dx.doi.org/10.1128/JVI.02482-10). Some sera were broadly reactive, predominantly targeting envelope epitopes within the V2 glycan-dependent region. The neutralization breadth was positively associated with time postinfection (P = 0.0001), but contrary to what has been reported for chronic infections, no association with the viral load was observed. Notably, five individuals within the first 6 months of infection (two as early as 77 and 96 days postinfection) showed substantial cross-neutralization. This was confirmed with an extended panel of 20 Env pseudoviruses from four different subtypes (two in tier 3, 14 in tier 2, and four in tier 1). Sera from these individuals were capable of neutralizing viruses from four different subtypes with a geometric mean 50% infective dose (ID50) between 100 and 800. These results indicate that induction of cross-neutralizing responses, albeit rare, is achievable even within 6 months of HIV-1 infection. These observations encourage the search for immunogens able to elicit this kind of response in preventive HIV-1 vaccine approaches. IMPORTANCE: There are very few individuals able to mount broadly neutralizing activity (bNA) close to the first year postinfection. It is not known how early in the infection cross-neutralizing responses can be induced. In the present study, we show that bNAbs, despite being rare, can be induced much earlier than previously thought. The identification of HIV-1-infected patients with these activities within the first months of infection and characterization of these responses will help in defining new immunogen designs and neutralization targets for vaccine-mediated induction of bNAbs.

Broadly cross-neutralizing antibodies in HIV-1 patients with undetectable viremia.

Several recent studies have identified HIV-infected patients able to produce a broad neutralizing response, and the detailed analyses of their sera have provided valuable information to improve future vaccine design. All these studies have excluded patients on antiretroviral treatment and with undetectable viral loads, who have an improved B cell profile compared to untreated patients. To better understand the induction of neutralizing antibodies in patients on antiretroviral treatment with undetectable viremia, we have screened 508 serum samples from 364 patients (173 treated and 191 untreated) for a broadly neutralizing antibody (bNAb) response using a new strategy based on the use of recombinant viruses. Sera able to neutralize a minipanel of 6 recombinant viruses, including envelopes from 5 different subtypes, were found in both groups. After IgG purification, we were able to confirm the presence of IgG-associated broadly neutralizing activity in 3.7% (7 of 191) of untreated patients with detectable viremia and 1.7% (3 of 174) of aviremic patients receiving antiretroviral treatment. We thus confirm the possibility of induction of a broad IgG-associated neutralizing response in patients on antiretroviral treatment, despite having undetectable viremia. This observation is in stark contrast to the data obtained from long-term nonprogressors, whose little neutralizing activity has been attributed to the low levels of viral replication.

Impact of locally advanced or metastatic prostate cancer on the quality of life. / Impacto del cáncer de próstata localmente avanzado/metastásico en la calidad de vida.

OBJECTIVE: The aim of this study was to assess the health-related quality of life of patients with prostate cancer in advanced phases to obtain additional information on the patients' health. The growing interest in understanding the patient's perspective and the scarcity of prospective studies of this population motivated this research study. MATERIAL AND METHODS: We present an observational study performed on 131 urology consultations, with a sample of 601 patients with locally advanced or metastatic prostate cancer, assessed during 2 visits: baseline and at 12 months. We collected demographic, clinical, quality-of-life (PROSQoLI and EuroQoL-5D-5L questionnaires) and anxiety/depression (HADS questionnaire) endpoints. RESULTS: The mean age (SD) was 73.8 (8.2) years, and 87.2% of the participants were retired or pensioners. Some 58.7% of the patients presented locally advanced prostate cancer. Urinary symptoms were the most common, decreasing significantly after one year (P<.05). Urinary problems and fatigue were the most affected measures, and pain/discomfort was the dimension present in most patients (65.3%). According to the linear regression model, asthenia and pain were 2 of the factors most closely related to a poorer quality of life. The presence of anxiety/depression was low. Finally, the health condition as assessed by the clinician was more positive than when assessed by the patients. CONCLUSIONS: This study broadens the scarce information on the quality of life of the population with advanced prostate cancer, information of use for the clinical management of these patients.

Confronting and eradicating an epidemic of bacteraemia.

Obtaining vascular access by catheterisation is a good option, especially in patients with vascular system fragility. In the authors' department, there was an increase in Gram Negative Bacillus (GNB) infection in patients with long term catheters (LTC). An objective was set to design an action plan and a new working methodology in order to eradicate the infection and the cause. Three periods were established in the prospective follow-up of LTC patients: the pre-epidemic period (01/94 to 03/99), with a bacteraemia every 144 days per patient, the epidemic period (04/99 to 12/00) with a bacteraemia every ten days per patient, and the post-epidemic period (01/01 to 04/02). A multidisciplinary working group was established, which produced action plans for nursing and technical staff. The working methodology of the service was studied and analysed by means of a review. The deionised water cultures at the entrance to the haemodialysis ward were negative. The dialysis and connector cultures were positive for GNB, confirming that they were of the same genetic origin. An evaluation of the periods was carried out, studying the working methodology, to which no changes were made between the pre-epidemic and epidemic period. In the post-epidemic period, a number of changes were made to the care dynamic, with no other bacteraemia arising to date. Adapting and improving protocols is a good indicator of quality. The role of nursing staff is vital in prevention of GNB.

Random important alterations in HIV-1 viral quasispecies after antiviral treatment.

The evolution of HIV-1 viral populations was studied in a set of MT-2-co-cultured viruses isolated from five patients at the beginning of treatment with zidovudine and after 11-36 months of drug therapy. We first characterized the HIV-1 pol gene to detect the zidovudine-resistance mutations at codons 215 and 219. To analyse the effect that the selective pressure of zidovudine on pol exerted on other genomic regions, we also studied the env gene. The env gene sequence of virus isolated from one individual was unchanged, whereas three other sample pairs had minor alterations in env. In one individual, we detected a significant change in the env gene sequence, and so performed a clonal analysis on viruses isolated before and after treatment. In this individual, the zidovudine-resistant variant that became predominant in the resistant virus population was an undetected minority variant of the viral population before treatment was initiated. These results indicate that the evolution of quasispecies produced by selective pressure on the pol gene from zidovudine treatment could select, in a random process, important changes in other genomic regions; in particular, we describe alterations in the env gene.

Virus population dynamics, fitness variations and the control of viral disease: an update.

Viral quasispecies dynamics and variations of viral fitness are reviewed in connection with viral disease control. Emphasis is put on resistance of human immunodeficiency virus and some human DNA viruses to antiviral inhibitors. Future trends in multiple target antiviral therapy and new approaches based on virus entry into error catastrophe (extinction mutagenesis) are discussed.

Estimation of the prevalence of diabetes mellitus diagnosed, and incidence of type 1 (insulin-dependent) diabetes mellitus in the Avila Health Care region of Spain.

We studied the prevalence of diabetes mellitus diagnosed in the Avila Health Care region, Spain, based on the prescribed daily dosage (PDD) of insulin (corrected in function of insulin loss (PDDc)) and sulphonureas, from a sample representative of prescribing physicians (A, n = 48) and pharmacies (B, n = 25) in our region. The amounts of the PDDcs of insulin sold during 1989 per 1000 inhabitants/day were 6.06 and 6.20, respectively for the two samples (A and B). The figures for PDDs of sulphonurea/1000 inhabitants/day were 16.25 and 19.16, respectively. We determined the proportion that diabetic patients on diet alone represented in relation to non-insulin treated diabetic patients who visited the only specialized clinic for diabetic patients in our province in 1989. These patients accounted for 40.83% of non-insulin treated diabetic patients. The patients being treated with biguanides or with a combination of anti-diabetic drugs accounted for less than 1% of those treated in the specialized clinic. Taking this into account, the prevalence of diabetes mellitus in Avila was 3.35% (C.I. 95%: 3.10-3.59), according to the sample A and 3.85% (C.I. 95%: 3.50-4.31) according to the sample B. In addition, we studied the hospital admission records during three consecutive years in order to find out the incidence of type 1 insulin-dependent diabetes mellitus (IDDM) below 15 years of age in the Avila Health Care region of Spain. All prescribing physicians that did not work in the Hospital (197 in the rural area and 18 in the urban area) were used as the secondary source for validation of case ascertainment.(ABSTRACT TRUNCATED AT 250 WORDS)

Behaviour modification in obese subjects with type 2 diabetes mellitus.

We have followed prospectively, 46 obese, type 2 diabetic patients for a 55-week period, in order to evaluate the efficiency of an educational programme based on behaviour modification to enhance weight loss and changes of other cardiovascular risk factors. No patient received pharmacological treatment during the study. At the end of the follow-up the patients obtained an average weight loss of 9.250 kg (range: 0.500-17.500 kg); the BMI was reduced from 34.2 +/- 0.8 kg/m2 to 30.6 +/- 1.1 kg/m2 (P less than 0.01); fasting serum glucose descended from 7.9 +/- 0.4 to 6.1 +/- 0.5 mM (P less than 0.05); SBP (systolic blood pressure) decreased from 145.7 +/- 3 to 126.4 +/- 5.1 mmHg (P less than 0.01); DBP (diastolic blood pressure) decreased from 83.5 +/- 2.5 to 65 +/- 2.6 mmHg (P less than 0.01); triglyceride levels were lowered from 164.5 +/- 12 to 109.7 +/- 10 mg/dl (P less than 0.01); HDL-cholesterol levels increased from 1.27 +/- 0.05 to 1.53 +/- 0.12 mM (P less than 0.01). Serum glucose 2 h after a 75 g glucose oral load decreased from 14.9 +/- 0.6 to 12.7 +/- 0.9 mM (P less than 0.05) on week 35 of follow-up. Twelve patients no longer presented a diabetic curve (8 normal oral glucose tolerance test (OGTT) curves, and 4 impaired glucose tolerance (IGT) curves). No significant changes in the parameters studied were obtained in the group of patients on conventional treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Nursing protocol for manipulation of haemodialysis catheters.

This study looked at the incidence of infection complications, in relation to central vein catheterisation as a provisional HD access, by means of the establishment of a nursing protocol for the handling of these catheters. Central vein catheterisation is a classical technique in Nephrology.

[An outbreak of gram-negative bacteremia (GNB), especially enterobacter cloacae, in patients with long-term tunnelled haemodialysis catheters]. / Brote epidémico de bacteriemias por bacilos gram-negativos (BGN), especialmente enterobacter cloacae, en una unidad de hemodiálisis, en pacientes portadores de catéteres permanentes tunelizados.

Vascular access through a venous catheter for haemodialysis is associated with increased risk of thrombosis, central venous stenosis, short access survival and inadequate dialysis. The most important catheter-related complications, which determine method survival, are infection and dysfunction. In particular, infectious episodes are in some studies the leading cause for untimely catheter removal and for catheter-related morbidity but also for morbidity in dialysis patients. Double-lumen central venous catheters used for haemodialysis, are common causes of septicaemia. Most cases are caused by staphylococci. Episodes of gram-negative bacteriemia have been traced to bacterial contamination of water and/or dialysate, errors in dialyzer reprocessing, and improper setup procedures. In this paper, we describe and outbreak of gram-negative bacteremia, firstly E. cloacae, in an outpatients haemodialysis unit, in the patients with long-term tunnelled haemodialysis catheters. We describe the epidemic investigation that we achieved to identify the source of contaminating bacteria and the route by which bacteria gained access to the bloodstream. We prove the contamination by gram-negative bacterium of the water-distribution lines and haemodialysis machines. Moreover, E. cloacae strains isolated from the lines and machines are genotypically identical to the isolated from the patients. Also, we prove that the hands of health care personnel are unintentional carriers. The outbreak was finished when decontamination of dialysis machines was enhanced and dialyzer-priming fluid was modified.

[Patients with end-stage chronic renal insufficiency on programmed withdrawal from dialysis]. / Pacientes con insuficiencia renal crónica terminal retirados de diálisis bajo protocolización.

UNLABELLED: The voluntary discontinuation of dialysis by patients is a common mode of death in dialysis programmes. Unfortunately the Spanish experience has not been related in the nephrological literature. Initiation of, and withdrawal from, dialysis pose ethical questions for medicine in the 21st century. The dialysis population is aging and they have multiple medical problems. The choice may be between prolongation of quantity or quality of life. We evaluated a protocol for initiation of dialysis in patients with end stage renal failure and their subsequent withdrawal. We determined the factors predicting withdrawal of dialysis and revised the protocol to take account of these. We carried out an opinion poll of doctors and nurses about the effectiveness of the protocol. We studied prospectively the reasons for death of patients in the last seven years. RESULTS: Thirty patients were withdrawn from dialysis out of 116 who died during treatment by hemodialysis or continuous ambulatory peritoneal dialysis (CAPD) in the last seven years. Vascular nephropathy is the principal disease predicting withdrawal from dialysis; the main precipitating cause is mental incapacity. The availability of a protocol for withdrawal of dialysis is well received by doctors and nurses and it engenders moral and legal calm when facing difficult decisions. Twenty-six per cent of deaths on regular dialysis are the result of withdrawal of treatment.

[Programs of diabetological education: a basic tool in the treatment of diabetes mellitus]. / Programas de educación diabetológica: arma fundamental para el tratamiento de la diabetes mellitus.

To assess whether the programs of diabetologic education (PDE) are effective to improve metabolic control in diabetes mellitus, depending on their inclusion in an overall therapeutic program and on the setting where they are imparted (hospital versus primary care center, PCC), we evaluated the changes in the HbA1 values in 230 insulin-treated diabetic patients, after receiving a PDE in a PCC (group A; n = 88) or as hospital inpatients (group B; n = 72) or outpatients (group C; n = 50). The remaining 20 patients (group D) received the same PDE, but their treatment did not depend on our Unit. The initial mean HbA1 levels were significantly reduced 3, 6 and 9 months after the PDE in group A patients (10.6% vs 9.6%, p less than 0.05; vs 9.4%, p less than 0.02; vs 9.1%, p less than 0.01), in group B patients (10.0% vs 9.5%, p less than 0.05; vs 9.1%, p less than 0.05; vs 9.0%, p less than 0.05) and group C patients (10.1% vs 9.5%, p less than 0.05; vs 9.1%, p less than 0.02; vs 8.9, p less than 0.01); however, they did not significantly change in group D patients (10.3% vs 10.7%, vs 10.3%, and vs 10.0%). Mean HbA1 in months 3, 6 and 9 were not different between groups A, B and C, but they were lower (p less than 0.05) than in group D. Our results confirm that PDE and treatment are effective to improve metabolic control in diabetic patients, whereas diabetological education alone is not useful. The place where PDE is given is not determinant for its effectiveness.

Impacto del cáncer de próstata localmente avanzado/metastásico en la calidad de vida / Impact of locally advanced or metastatic prostate cancer on the quality of life

Objetivo: El objetivo de este estudio fue evaluar la calidad de vida relacionada con la salud en pacientes con cáncer de próstata en fases avanzadas para obtener información adicional sobre la salud de los pacientes. El creciente interés por conocer la perspectiva del paciente y la escasez de estudios prospectivos en esta población motivaron esta investigación. Material y métodos: Se presenta un estudio observacional realizado en 131 consultas de urología, con una muestra de 601 pacientes con cáncer de próstata localmente avanzado o metastásico, evaluados en 2 visitas: basal y a los 12 meses. Se recogieron variables sociodemográficas, clínicas, de calidad de vida (cuestionarios PROSQoLI y EuroQoL-5D-5L) y ansiedad/depresión (cuestionario HADS). Resultados: La edad media (DE) era de 73,8 (8,2) años y el 87,2% eran jubilados o pensionistas. El 58,7% de los pacientes presentaba cáncer de próstata localmente avanzado. La sintomatología urinaria fue la más frecuente, disminuyendo significativamente al cabo de un año (p < 0,05). Los problemas urinarios y el cansancio fueron las dimensiones más afectadas y el dolor/malestar la dimensión presente en más pacientes (65,3%). Según el modelo de regresión lineal, la astenia y el dolor fueron 2 de los factores más relacionados con una peor calidad de vida. La presencia de ansiedad/depresión fue baja. Finalmente, el estado de salud valorado por el clínico fue más positivo que el valorado por los pacientes. Conclusiones: Este estudio amplía la escasa información existente sobre la calidad de vida de la población con cáncer de próstata avanzado, información de utilidad en el manejo clínico de los pacientes

Objective: The aim of this study was to assess the health-related quality of life of patients with prostate cancer in advanced phases to obtain additional information on the patients’ health. The growing interest in understanding the patient's perspective and the scarcity of prospective studies of this population motivated this research study. Material and methods: We present an observational study performed on 131 urology consultations, with a sample of 601 patients with locally advanced or metastatic prostate cancer, assessed during 2 visits: baseline and at 12 months. We collected demographic, clinical, quality-of-life (PROSQoLI and EuroQoL-5D-5L questionnaires) and anxiety/depression (HADS questionnaire) endpoints. Results: The mean age (SD) was 73.8 (8.2) years, and 87.2% of the participants were retired or pensioners. Some 58.7% of the patients presented locally advanced prostate cancer. Urinary symptoms were the most common, decreasing significantly after one year (P< .05). Urinary problems and fatigue were the most affected measures, and pain/discomfort was the dimension present in most patients (65.3%). According to the linear regression model, asthenia and pain were 2 of the factors most closely related to a poorer quality of life. The presence of anxiety/depression was low. Finally, the health condition as assessed by the clinician was more positive than when assessed by the patients. Conclusions: This study broadens the scarce information on the quality of life of the population with advanced prostate cancer, information of use for the clinical management of these patients

Unusual distribution of mutations associated with serial bottleneck passages of human immunodeficiency virus type 1.

Repeated bottleneck passages result in fitness losses of RNA viruses. In the case of human immunodeficiency virus type 1 (HIV-1), decreases in fitness after a limited number of plaque-to-plaque transfers in MT-4 cells were very drastic. Here we report an analysis of entire genomic nucleotide sequences of four HIV-1 clones derived from the same HIV-1 isolate and their low-fitness progeny following 7 to 15 plaque-to-plaque passages. Clones accumulated 4 to 28 mutations per genome, with dominance of A --> G and G --> A transitions (57% of all mutations) and 49% nonsynonymous replacements. One clone-but not three sibling clones-showed an overabundance of G --> A transitions, evidencing the highly stochastic nature of some types of mutational bias. The distribution of mutations along the genome was very unusual in that mutation frequencies in gag were threefold higher than in env. Particularly striking was the complete absence of replacements in the V3 loop of gp120, confirmed with partial nucleotide sequences of additional HIV-1 clones subjected to repeated bottleneck passages. The analyses revealed several amino acid replacements that have not been previously recorded among natural HIV-1 isolates and illustrate how evolution of an RNA virus genome, with regard to constant and variable regions, can be profoundly modified by alterations in population dynamics.

Drastic fitness loss in human immunodeficiency virus type 1 upon serial bottleneck events.

Muller's ratchet predicts fitness losses in small populations of asexual organisms because of the irreversible accumulation of deleterious mutations and genetic drift. This effect should be enhanced if population bottlenecks intervene and fixation of mutations is not compensated by recombination. To study whether Muller's ratchet could operate in a retrovirus, 10 biological clones were derived from a human immunodeficiency virus type 1 (HIV-1) field isolate by MT-4 plaque assay. Each clone was subjected to 15 plaque-to-plaque passages. Surprisingly, genetic deterioration of viral clones was very drastic, and only 4 of the 10 initial clones were able to produce viable progeny after the serial plaque transfers. Two of the initial clones stopped forming plaques at passage 7, two others stopped at passage 13, and only four of the remaining six clones yielded infectious virus. Of these four, three displayed important fitness losses. Thus, despite virions carrying two copies of genomic RNA and the system displaying frequent recombination, HIV-1 manifested a drastic fitness loss as a result of an accentuation of Muller's ratchet effect.

Effect of the infusion of p-Glu-His-Ala-OH, analog of the anorexigenic peptide, on the insulin response induced by intravenous glucose. Preliminary results with obese subjects.

The effect of the intravenous infusion of peptide p-Glu-His-Ala-OH, analog of the postulated anorexigenic peptide, on the insulinaemic response to an intravenous bolus of 20 g glucose was studied in 6 obese patients (body mass index 43.12 +/- 5.77 kg/m2). The infusion of the peptide reduced the insulinaemic response (p < 0.05) without modifying either the C-peptide or the glucose response. This decreased insulinaemic response is associated with a greater hepatic extraction of insulin (86.45 +/- 1.1% vs 82.1 +/- 1.2%; p 0.05), determined in terms of the molar ratio of the C-peptide to insulin) but not with a smaller pancreatic secretion (determined as C-peptide levels). Our results confirm that the infusion of the peptide increases the hepatic insulin extraction without its effect being mediated by any intestinal factor. Its therapeutic application remains to be determined.

Programme of education for obese patients. Preliminary results after one year.

We have evaluated the effects of a Programme of education for Obese Patients with a duration of 12 hours on weight loss and the modification of other indices for cardiovascular risk in 88 obese patients, during the first year of therapy. The BMI dropped from 33.1 +/- 0.2 Kg/m2 to 31.7 +/- 0.7 (p less than 0.01) and 30.9 +/- 0.7) (p less than 0.01) at 5 and 10 weeks respectively, stabilizing subsequently at 35 and at 55 weeks. This was accompanied by a decrease of the triglycerides levels (141 +/- 9 vs 111 +/- 6 mg/dl; p less than 0.01) and of the total cholesterol/HDL-cholesterol ratio (4.7 +/- 0.3 vs 4.2 +/- 0.12; p less than 0.05), as well as of the values for systolic blood pressure (143 +/- 3 vs 121 +/- 3 mm Hg; p less than 0.05) and diastolic blood pressure 81 +/- 2 vs 64 +/- 1 mm Hg; p less than 0.01) at the end of the study. In terms of OGTT, initially 23 patients were classified as diabetic (BMI 32 +/- 0.9 Kg/m2), 25 presented intolerance to carbohydrates (BMI 34.1 +/- 1.6 Kg/m2) and 40 were normal (BMI 33.2 +/- 1.2 Kg/m2). The weight loss in the first 5 weeks was less in patients with diabetes then in those with carbohydrate intolerance and in the normal patients (2.2 vs 3.7 vs 5.9 Kg; p less than 0.01). From the 10th week on no differences were recorded.(ABSTRACT TRUNCATED AT 250 WORDS)

Association of a thyrotropin-secreting pituitary adenoma and a thyroid follicular carcinoma.

The different factors involved as etiological agents in thyroid cancer have in common long term thyroid follicle stimulation. On this base, a patient with a TSH-producing pituitary adenoma could be at high risk for developing thyroid cancer. A patient consulting for a single thyroid nodule was studied in our unit. He was diagnosed as having a TSH-producing pituitary adenoma and the Thyroid nodule was shown to be a follicular carcinoma following removed. We speculate that elevated TSH levels could have contributed to neoplastic transformation of the thyroid in this patient.