Vandetanib Tumor Shrinkage in Metastatic Medullary Thyroid Cancer Allowing Surgical Resection of the Primary Site: A Case Report.

Vandetanib has been shown to improve progression-free survival in adults with advanced medullary thyroid cancer. This article describes a pediatric patient with metastatic medullary thyroid cancer secondary to sporadic multiple endocrine neoplasia 2B, treated with vandetanib. At presentation, he had an inoperable primary tumor, with carotid encasement, and pulmonary metastases. Vandetanib induced a significant response: calcitonin and carcinoembryonic antigen levels both fell considerably, primary tumor maximal diameter decreased by 68%, and pulmonary metastases became no longer detectable. This allowed surgical resection of the primary tumor. The patient remains well after over 6 years of vandetanib therapy, with no treatment toxicity.

Use of Vandetanib in Metastatic Medullary Carcinoma of Thyroid in a Pediatric Patient With Multiple Endocrine Neoplasia 2B.

We describe a child with advanced, metastatic, inoperable medullary carcinoma of thyroid associated with multiple endocrine neoplasia 2B and rearranged during transfection mutation with a positive response to vandetanib treatment. He responded well with a fall in calcitonin levels and a reduction in size of the thyroid malignancy, lymph nodes, and pulmonary metastases. He has been on vandetanib for 4 years with good clinical and biochemical response. Vandetanib has a role in the treatment of patients including children with inoperable locally advanced and metastatic medullary carcinoma of thyroid. More information is needed on its use in children and long-term outcome.

Does timing of tocilizumab administration affect mortality in COVID-19? A Scottish multicentre retrospective cohort study.

BACKGROUND: The optimal timing of tocilizumab treatment during the disease course of COVID-19 has yet to be adequately defined in the context of randomised controlled trials and the effect of tocilizumab on real-world populations remains unclear. We examined the effect of different timing of tocilizumab, on mortality, in a cohort of adults with COVID-19. METHODS: All adults (≥18 years old) with confirmed COVID-19 admitted to four hospitals in the West of Scotland between 8 January 2021 and 31 March 2021 and who received tocilizumab were included in a retrospective observational cohort study. Patients were assigned to either an early (day of admission or first day after admission) or late (days 2-7 of admission) cohort based on tocilizumab initiation. The primary outcome was 90-day all-cause mortality in early versus late cohorts. Secondary outcomes were 28 and 180-day all-cause mortality. RESULTS: 203 patients were included in the analysis (138 in the early cohort, 65 in the late cohort). Mortality in 90 days in the early cohort was 22% (n=30) compared with 45% (n=29) in the late cohort (p<0.001). The adjusted mortality was significantly higher in the late cohort compared with the early cohort (adjusted OR: 3.33; 95% CI: 1.29 to 8.54; p=0.012). The secondary outcomes demonstrated the same effect with higher rates of death in 28 days (late cohort adjusted OR: 3.28; 95% CI: 1.23 to 8.75; p=0.018) and 180 days (late cohort adjusted OR: 3.70; 95% CI: 1.45 to 9.45; p=0.006). The effect was seen whether the outcome was adjusted or unadjusted. CONCLUSION: Early administration of tocilizumab within the first 2 days of hospitalisation was associated with a significant survival benefit compared with late exposure. Late administration was associated with particularly high mortality. The observed association may be a result of residual confounders and further research is needed.

Women's experiences of information, education and support when undergoing pelvic radiotherapy for gynaecological cancer: An exploratory qualitative study.

INTRODUCTION: As cancer survival rates increase, so does the importance of preventing and alleviating the late effects of radiotherapy. The effect of long-term problems on patients' physical, social and psychological well-being must be addressed along with the importance of developing an understanding of the late effects of treatment to find ways of maximising the quality of life of cancer survivors. The aim of this service evaluation was to establish what support, information and education on post treatment changes women who have undergone pelvic radiotherapy for gynaecological cancer were provided with, and whether it met their needs. METHODS: An interpretative phenomenological analysis was undertaken to explore the support, information and education on post treatment changes women who have undergone pelvic radiotherapy for gynaecological cancer are currently provided with and whether or not it meets their needs. Semi-structured interviews were conducted to gain insight into the experiences of participants. Researcher reflexivity was considered and ethics permissions granted. RESULTS: This paper reports the themes from analysis; communication and information provision, abandonment, service provision, and sexual health and intimacy. All patients experienced feelings of abandonment at the completion of treatment and those experiencing ongoing side effects needing greater support, particularly to manage side effects affecting the bowel and bladder. CONCLUSION: This study fills a gap in existing knowledge and identifies that patients with a gynaecological cancer require greater communication and support. The introduction of a therapeutic radiographer led late effects clinic and sexual care after radiotherapy clinic could provide the support and information that patients need to cope with the long-term side effects experienced due to pelvic radiotherapy. IMPLICATIONS FOR PRACTICE: This service evaluation highlights the importance of including patient perspectives when designing and developing services.

Evaluation of medication changes following severe COVID-19 infection: a multicentre evaluation.

BACKGROUND: Critically ill patients often experience several transitions of care following critical illness. Research has explored the challenges which patients have with medication management across these transitions. It is unclear whether patients admitted to critical care due to COVID-19 will have similar challenges. The aim of this study was to explore medication management in critical care survivors following severe COVID-19. METHODS: Between 3 and 7 months post hospital discharge, patients who had been admitted to critical care due to severe COVID-19 were invited to an established recovery service. During the clinic consultation a medication review was performed by a pharmacist. This included medicines reconciliation, assessing the appropriateness of each of the prescribed medications and identification of medication changes. We also assessed changes to pain management in the discharge period. RESULTS: In total, 78 patients had a full medication review available. Over 70% of patients were taking an increased dose of medicine or a new medicine at clinic. There was a significant overall increase in new medication during the clinic consultation, across different British National Formulary classifications (OR: 1.73 (95% CI: 1.28 to 2.34), p<0.001). Compared with pre critical care admission, there was a significant increase in the number of patients taking regular analgesia following severe COVID-19 infection (23 (29.5%) vs 39 (50%), p<0.001). CONCLUSION: Following severe COVID-19, patients may require new or increasing doses of medicines. Ongoing review of these patients is crucial to ensure optimal outcomes.

Standardising reporting of cervical lymphadenopathy in paediatric neck ultrasound: a pilot study using an evidence-based reporting protocol.

OBJECTIVES: Cervical lymphadenopathy is common in children and can arise from a wide range of aetiologies. Ultrasound can be a useful imaging tool for initial investigation but is known to be operator dependent. We aimed to compare the content of ultrasound reporting in this clinical scenario before and after the introduction of an evidence-based reporting protocol. METHODS: We performed a prospective 8-month pilot study assessing the content of ultrasound reports generated from scans to investigate suspected cervical lymphadenopathy in children referred to our tertiary referral otolaryngology service. We found wide variation in report content and inconsistent reporting of certain radiological features. In response to this we performed a literature search to identify key, clinically relevant ultrasonographic features for cervical lymphadenopathy and then in consultation with our radiology colleagues, devised a protocol to facilitate the reporting of these key features. Content of reports was then prospectively re-audited over a further 8-month period. RESULTS: 23 reports were assessed before and 26 after introduction of the reporting protocol. Fisher's exact test was used to analyse the data. We found a statistically significant (p < 0.05) improvement in the frequency of reporting of various key features such as nodal distribution, shape, echogenicity, calcification, necrosis and vascular pattern. CONCLUSIONS: The introduction of a standardised protocol has helped to streamline the reporting of ultrasounds to investigate cervical lymphadenopathy within our department. In the absence of any national guidelines on the reporting of paediatric neck ultrasound in this scenario, we propose that our protocol could be used by other departments to improve standardisation and as a teaching aid.

Extracranial meningioma presenting as a neck mass in a patient with underlying ankylosing spondylitis.

Extracranial meningiomas are rare. They account for only 2% of meningiomas compared to the much more common intracranial site. We describe a rare case of extracranial meningioma presenting as a neck lump in a patient with preexisting neck disease due to ankylosing spondylitis. Extracranial meningioma should be considered in the differential diagnosis of atypical neck lumps. Investigations including magnetic resonance imaging and histopathology are discussed, as well as the results of a literature review on extracranial meningiomas.