A Multidisciplinary Head-to-Head Comparison of American College of Radiology Thyroid Imaging and Reporting Data System and American Thyroid Association Ultrasound Risk Stratification Systems.

BACKGROUND: Ultrasound plays a critical role in evaluating thyroid nodules. We compared the performance of the two most popular ultrasound malignancy risk stratification systems, the 2015 American Thyroid Association (ATA) guidelines and the American College of Radiology Thyroid Imaging and Reporting Data System (ACR TI-RADS). MATERIALS AND METHODS: We retrospectively identified 250 thyroid nodules that were surgically removed from 137 patients. Their ultrasound images were independently rated using both ATA and ACR TI-RADS by six raters with expertise in ultrasound interpretation. For each system, we generated a receiver operating characteristic curve and calculated the area under the curve (AUC). RESULTS: Sixty-five (26%) nodules were malignant. There was "fair agreement" among raters for both ATA and ACR TI-RADS. Our observed malignancy risks for ATA and ACR TI-RADS categories were similar to expected risk thresholds with a few notable exceptions including the intermediate ATA risk category and the three highest risk categories for ACR TI-RADS. Biopsy of 226 of the 250 nodules would be indicated by ATA guidelines based on nodule size and mean ATA rating. One hundred forty-six nodules would be biopsied based on ACR TI-RADS. The sensitivity, specificity, and negative and positive predictive values were 92%, 10%, 79%, and 27%, respectively, for ATA and 74%, 47%, 84%, and 33%, respectively, for ACR TI-RADS. The AUC for ATA was 0.734 and for ACR TI-RADS was 0.718. CONCLUSION: Although both systems demonstrated good diagnostic performance, ATA guidelines resulted in a greater number of thyroid biopsies and exhibited more consistent malignancy risk prediction for higher risk categories. IMPLICATIONS FOR PRACTICE: With the rising incidence of thyroid nodules, the need for accurate detection of malignancy is important to avoid the overtreatment of benign nodules. Ultrasonography is one of the key tools for the evaluation of thyroid nodules, although the use of many different ultrasound risk stratification systems is a hindrance to clinical collaboration in everyday practice and the comparison of data in research. The first step toward the development of a universal thyroid nodule ultrasound malignancy risk stratification system is to better understand the strengths and weaknesses of the current systems in use.

Gender-specific care of the patient with diabetes: review and recommendations.

BACKGROUND: Men and women differ in their experience of diabetes mellitus (DM). For optimal prevention and treatment of the disease, these differences must be acknowledged. Unfortunately, most studies of diabetes have focused almost exclusively on men. OBJECTIVE: The purpose of this review was to survey the literature about the sex-specific features of DM and to make recommendations for the gender-specific care of patients. METHODS: An initial literature search was performed with Google Scholar and MEDLINE (1995-2005) using the search terms sex/gender, women, diabetes mellitus, and coronary artery disease, and specific topic headings such as polycystic ovary syndrome. The bibliographies of articles were used extensively to augment the search, and more specific search terms were included. The strength of each recommendation was assessed. RESULTS: : Even when women were included in clinical trials, investigators typically made no attempt to assess the impact of sex differences on the reported results. Existing studies, however, reveal several differences between men and women with diabetes. The prevalence of DM is growing fastest for older minority women. Women with diabetes, regardless of menopausal status, have a 4- to 6-fold increase in the risk of developing coronary artery disease (CAD), whereas men with diabetes have a 2- to 3-fold increase in risk. Women with diabetes have a poorer prognosis after myocardial infarction and a higher risk of death overall from cardiovascular disease than do men with diabetes. Women with type 2 DM experience more symptoms of hyperglycemia than do their male counterparts. Obesity, an important contributor to type 2 DM, is more prevalent in women. Women with diabetes have an increased risk of hypertension compared with men with diabetes. Women have a more severe type of dyslipidemia than do men (low levels of high-density lipoprotein cholesterol, small particle size of low-density lipoprotein cholesterol, and high levels of triglycerides), and these risk factors for CAD have a stronger influence in women. Oxidative stress may confer a greater increase in the risk of CAD for women with diabetes than for men with diabetes. Many other sex differences in DM are due to women's reproductive physiology. Polycystic ovary syndrome is an important correlate of insulin resistance and the metabolic syndrome. Gestational diabetes mellitus (GDM) increases the risk of cardiovascular disease and type 2 DM. Women are less likely than men to receive aggressive treatment for CAD and to achieve treatment goals. Critical recommendations for women include exercise, testing for CAD, daily aspirin to counteract the prothrombotic state, depression screening, careful treatment to avoid weight gain, long-term follow-up of children of women with GDM, control of risk factors for CAD, and aggressive treatment with coronary angioplasty for CAD. Disease management programs for patients with diabetes have been shown to save money and improve outcomes, and should continue to incorporate information about sex-specific differences in DM as it becomes available. CONCLUSION: Gender-specific care of the patient with diabetes should be informed by evidence-based recommendations.

Langerhans Cell Histiocytosis: Diagnosis on Thyroid Aspirate and Review of the Literature.

Thyroid gland involvement by Langerhans cell histiocytosis is extremely rare. A 35-year-old woman with a history of a suprasellar mass previously diagnosed as a ganglioglioma and complicated by diabetes insipidus, hypogonadotropic hypogonadism, and central hypothyroidism presented with acute onset of neck enlargement. On ultrasound examination, almost the entire thyroid appeared replaced by abnormal lobulated hypoechoic tissue with increased vascularity. Fine needle aspiration (FNA) of the thyroid was performed and revealed singly scattered and loosely cohesive large cells with abundant cytoplasm, including some with irregular nuclear contours and nuclear grooves. No thyroid follicular cells were noted. Based on the cytomorphologic findings and ancillary studies (immunohistochemistry and flow cytometry analysis) a cytological diagnosis of "positive for neoplastic cells" with features suggestive of monocytic/histiocytic origin, possibly Langerhans cell histiocytosis (LCH) was rendered. Following FNA, the patient underwent an incisional thyroid biopsy that confirmed the cytological impression of LCH. In light of the new diagnosis of LCH, the prior suprasellar mass biopsy slides were re-reviewed and rare cells suspicious for LCH were observed. Appropriate treatment for systemic LCH was initiated successfully. This case demonstrates that the presence of enlarged and loosely cohesive cells, especially those with irregular nuclear contours, in thyroid FNA specimens should raise suspicion for LCH. The diagnosis of LCH in FNA specimens is challenging. Additional material should be allocated for ancillary studies to confirm the morphological impression. In our case, not only was the thyroid FNA crucial in diagnosing LCH, but instrumental in initiating a thorough diagnostic work-up for multisystem involvement and thus unmasking the true etiology of the patient's suprasellar mass and associated endocrinopathies.