Successful Treatment of Differentiated Thyroid Carcinoma with Transaxillary Robotic Surgery and Radioiodine: The First European Experience.

OBJECTIVES: Transaxillary robotic thyroidectomy surgery (TARS) has been reported to be a safe approach in patients with differentiated thyroid carcinoma, and oncological responses are promising. STUDY DESIGN: This study aimed to evaluate the oncological outcomes of TARS followed by radioiodine (RAI) therapy in patients with differentiated thyroid carcinoma. Between 2011 and 2016, patients treated for differentiated thyroid carcinoma by TARS in a single institution, followed by RAI, were retrospectively included. The oncological response was performed according to the 2015 American Thyroid Association (ATA) guidelines 6-12 months later and at the last available visit. RESULTS: A total of 42 patients (30 females) were included, with a median tumor size of 20 mm (12 cases of N1a and 5 cases of N1b on initial pathology report). According to ATA classification of recurrence risk after surgery, 17 and 25 patients were classified as low and intermediate risk, respectively. After RAI, all patients had a normal posttherapeutic whole body scan (except 1 patient, who had pathological lymph node uptake), but no unusual uptake was seen. At the 6- to 12-month evaluation (n = 37), 24 patients had excellent response, 8 had indeterminate response, and 5 had incomplete response (2 biological and 3 structural); no distant metastasis was found. At the last evaluation (median follow-up 15.9 months), 35 patients had no evidence of disease and 1 patient had a structural incomplete response. In total, a second open surgery was necessary for 3 patients to treat persistent lymph nodes (all intermediate risk). CONCLUSION: In this study, TARS followed by RAI therapy seems to be curative, even for patients with lymph node metastases, after good preoperative staging. More studies are required to confirm the findings.

Additional diagnostic value of hybrid SPECT-CT systems imaging in patients with differentiated thyroid cancer.

AIM: : Nuclear medicine has entered a new era of multimodality imaging. Single-photon emission computed tomography/computed tomography (SPECT/CT) hybrid cameras are relatively new diagnostic tools that have been widely adopted and are present in most nuclear medicine units. SPECT/CT instruments allow functional and morphologic images to be acquired as superimposed (fusion images) in a single session. METHODS: The integration of CT enables better characterization of functional abnormalities identified on planar and SPECT scintigraphy by offering structural information. It thus highly improves accuracy compared with conventional scintigraphy. RESULTS AND CONCLUSIONS: The combination of functional information and anatomic localization has the potential to influence medical practice with newer imaging algorithms. This review presents the current evidence and potential indications of SPECT/CT imaging in the initial staging, treatment, and follow-up of patients with differentiated thyroid cancer.

Association between elevated blood glucose and outcome in acute heart failure: results from an international observational cohort.

OBJECTIVE: The aim of this analysis was to assess the association between elevated blood glucose level and mortality in acute heart failure (AHF). BACKGROUND: Elevated blood glucose has been reported to be prognostically meaningful in patients with cardiac diagnoses, such as coronary artery disease. The short-term prognostic impact of hyperglycemia in AHF is unknown, however. METHODS: In a multinational cohort of AHF, we examined the ability of blood glucose concentrations at presentation to predict all-cause mortality by 30 days. Fully adjusted models for prognosis included a previous diagnosis of diabetes mellitus as a covariate. RESULTS: A total of 6,212 subjects with AHF (mean age, 72 years; 52.5% male) were studied; the median blood glucose concentration on arrival at the hospital was 7.5 mmol/l (135 mg/dl), and 41% had a previous diagnosis of diabetes mellitus (DM). After 30 days, 618 patients (10%) had died. Compared with survivors, decedents had significantly higher median blood glucose concentrations (8.9 mmol/l vs. 7.4 mmol/l; p < 0.0001). In the fully adjusted model, an elevated blood glucose level was an independent predictor of 30-day mortality in AHF (odds ratio: 2.19; 95% confidence interval: 1.69 to 2.83; p < 0.001). The risk associated with an elevated blood glucose level appeared consistent across all subgroups of patients, including patients with preserved (hazard ratio: 5.41; 95% confidence interval: 2.44 to 12.0; p < 0.0001) and impaired systolic function (hazard ratio: 2.37; 95% confidence interval: 1.57 to 3.59; p < 0.0001). Furthermore, in reclassification analyses, elevated blood glucose added significant prognostic information to clinical parameters alone (4.4% net reclassification improvement; p = 0.01). CONCLUSIONS: Among patients with AHF, blood glucose concentrations at presentation are powerfully prognostic for 30-day mortality, independent of a diagnosis of diabetes mellitus or other clinical variables. Because blood glucose is easily modifiable, it may represent a valid target for therapeutic intervention.

Acute heart failure in patients with diabetes mellitus: clinical characteristics and predictors of in-hospital mortality.

OBJECTIVE/METHODS: ALARM-HF was an in-hospital observational survey that included 4953 patients admitted for acute heart failure (AHF) in six European countries, Mexico and Australia. This article is a secondary analysis of the survey which evaluates differences in clinical phenotype, treatment regimens and in-hospital outcomes in AHF patients with diabetes mellitus (DM) compared to non-diabetics. The data were collected retrospectively by the investigators, and the diagnosis of AHF (reported at discharge) was based on the definition and classification of ESC guidelines, while the diagnosis of DM was based on medical record (past medical and medication history). RESULTS: This sub-analysis demonstrates substantial differences regarding both baseline features and in-hospital outcome among diabetic and non-diabetic AHF patients. Diabetic patients (n=2229, 45%) presented more frequently with acute pulmonary edema (p<0.001) than non-diabetics, had more often acute coronary syndrome (p<0.001) as precipitating factors of AHF, and multiple comorbidities such as renal dysfunction (p<0.001), arterial hypertension (p<0.001), anemia (p<0.001) and peripheral vascular disease (p<0.001). All-cause in-hospital mortality of diabetics was higher compared to non-diabetics (11.7% vs 9.8%, p=0.01). The multivariate analysis revealed that older age (p=0.032), systolic blood pressure <100mm Hg (p<0.001), acute coronary syndrome and non compliance as precipitating factors (p=0.05 and p=0.005, respectively), history of arterial hypertension (p=0.022), LVEF<50% (p<0.001), serum creatinine >1.5mg/dl (p=0.029), absence of life saving therapies such as ACE inhibitors/ARBs (p<0.001) and beta-blockers (p=0.014) at admission, as well as absence of interventional treatment by PCI (p<0.001), were independently associated with adverse in-hospital outcome. CONCLUSION: Diabetics with AHF have higher in-hospital mortality than non-diabetics despite their intensive treatment regimens (regarding care for HF and ACS), possibly due to underlying ischemic heart disease and the presence of multiple comorbidities.

Role of prophylactic thyroidectomy in RET 790 familial medullary thyroid carcinoma.

BACKGROUND: We describe a family harboring RET 790 mutation and review the role of prophylactic thyroidectomy for medullary thyroid carcinoma. METHODS: We evaluated in detail both clinical and biological follow-up and reviewed literature reports. RESULTS: Among 86 family members, 15 of 22 members screened harbored the 790 mutation. Abnormal calcitonin levels were found in 8/15. Total thyroidectomy with lymph node dissection cured the 5 operated patients (range, 45-76 years). Tumor staging was pT1N0M0. Among 10 carriers who did not undergo surgery, 3 patients had abnormal calcitonin levels. For the others, calcitonin levels remained <30 pg/mL. Two asymptomatic carriers were older than 70 years. Four subjects were lost to follow-up. CONCLUSIONS: In RET codon 790 mutations families, a case-by-case decision instead of systematic prophylactic thyroidectomy should be discussed. Difficulties of follow-up should be taken into account and represent the main challenge.

Evaluation of retinal function and flicker light-induced retinal vascular response in normotensive patients with diabetes without retinopathy.

PURPOSE: To correlate retinal function with vascular response to flicker light in normotensive patients with diabetes without diabetic retinopathy (DR). METHODS: Twenty-eight normotensive patients with diabetes (11 with type 1, 17 with type 2) without DR and 28 sex- and age-matched healthy control subjects underwent color vision and contrast sensitivity testing, pattern, full-field, and multifocal electroretinography, and evaluation of the vascular response to flicker light with the dynamic vessel analyzer. RESULTS: In the patients with diabetes, electroretinogram (ERG) pattern responses, b-wave in the scotopic bright flash ERG, a-wave and b-wave in the photopic single-flash ERG, and oscillatory potential responses were significantly impaired compared with those in control subjects. Vascular response to flicker light was also impaired in patients with diabetes compared with controls. In the whole population, correlations were found between flicker light-induced arterial retinal vasodilation and the amplitude and implicit time of the N95 wave of pattern ERG (r = -0.27, P = 0.047 and r = -0.35, P = 0.008, respectively), the b-wave implicit time of rod ERG (r = -0.36; P = 0.01) and the oscillatory potentials (r = 0.4; P = 0.003), suggesting that impairment of the vascular response to flicker light may reflect inner retinal neural impairment. However, no correlation between these factors was found when only patients with diabetes were considered. CONCLUSIONS: In patients with diabetes, neural and neurovascular dysfunctions both precede the onset of clinically detectable DR. To which extent these abnormalities are related to each other remains to be determined. (ClinicalTrials.gov number, NCT00839150.)

Pathophysiology of insulin resistance in small for gestational age subjects: a role for adipose tissue?

Over the last 15 years a number of long-term health risks associated with reduced fetal growth have been identified, including cardiovascular diseases, hypertension, dyslipidemia, or type 2 diabetes. A common feature of these conditions is insulin resistance, which is thought to play a pathogenic role. However, despite abundant data in the literature, it is still difficult to trace the pathway by which fetal events, environmental or not, may lead to the increased morbidity later in life. To explain this association, several hypotheses have been proposed pointing to the role of either a detrimental fetal environment or a genetic susceptibility or an interaction between the two and of the particular dynamic changes in adiposity that occur during catch-up growth. The relative impact of early postnatal events in relation to fetal growth has to be considered for designing health policy strategies for early interventions aimed at decreasing the diseases risk throughout life.

[Biological procedures, civil and military health facilities, and recommendations of good practice and hospital reform: the example of diabetes management]. / Actes de biologie, établissements de santé civils et militaires, recommandations de bonnes pratiques et réformes hospitalières: exemple de la prise en charge du diabète.

In the context of implementing hospital reforms, the objective of this work was to compare practice in relation to evidence-based guidelines and recommendations for good practice in diabetes screening and management. Laboratory test consumption was determined for patients hospitalized for diabetes in 2005 in three public hospitals (one civilian, two military) taking care of diabetic patients and performing related biological tests. For the 395 admissions in these three hospitals during 2005 [Diagnosis-related group (DRG) 10M02V "Diabetes, age 36 to 69 years without co-morbidity"], the average length of stay and the number of biological acts ["B"] performed were lower than those given by the French national health cost study scale and by the Montpellier University Hospital database. In terms of qualitative coherence between the guidelines for treatment and the recommendations, the total number of biological acts ["B"] is higher than if one were to strictly apply the good practice suggested by the French Health Authority. These three hospitals have and apply different guidelines for practice in the area of diabetes management. The implementation of reforms such as DRG-based payment scales may be an additional leverage to ensure that the recommendations of best practices are effective. Improved methods and tools for data collection and monitoring are essential, especially for estimating revenue and expenditure.

Consequences of being born small for gestational age on body composition: an 8-year follow-up study.

CONTEXT: Increased fat mass has been reported in children and adults born small for gestational age (SGA). However, the progression of anthropometric parameters have been poorly documented in SGA adults. OBJECTIVE: We hypothesized that SGA individuals would remain susceptible to gain more fat when adults beyond the period of postnatal catch-up growth. STUDY POPULATION AND DESIGN: From a community-based cohort, 389 subjects born full-term SGA (body weight < 10th percentile) were compared with 462 subjects born appropriate for gestational age (25th < body weight < 75th percentile). Anthropometric parameters were measured at 22 and 30 yr as well as body composition (by multifrequency bioelectrical impedancometry and skinfold thickness) at 30 yr. RESULTS: Both groups gained weight, body mass index (BMI), and waist circumference. Progression of BMI was significantly greater in SGA (1.8 +/- 2.6 vs. 1.4 +/- 2.6 kg/m(2); P = 0.03). At 30 yr, the proportion of obese individuals was significantly increased in SGA (12.1 vs. 6.5%; P = 0.02), and percent body fat was significantly higher (23.5 +/- 8.7 vs. 21.9 +/- 8.0%; P = 0.01), the observation of which was confirmed by skinfold measures. Similarly, waist circumference gain was significantly greater in SGA (6.4 +/- 7.6 vs. 5.5 +/- 7.9, P = 0.04 when adjusted for gender and age). CONCLUSION: Over 8-yr follow-up, adults born SGA gained more BMI than appropriate for gestational age, resulting in greater fat mass with more abdominal fat. These data suggest that the consequences of fetal growth restriction on body composition are evolving beyond the period of early postnatal catch-up.

A possible hypophosphatemia-induced, life-threatening encephalopathy in diabetic ketoacidosis: a case report.

Hypophosphatemia, a common metabolic disorder, is usually silent and diagnosed by blood tests. However, misdiagnosis may result in delayed phosphate repletion, responsible for significant morbidity and potential mortality. We report an exceptional case of hypophosphatemia-related, life-threatening encephalopathy. A 49-year-old type-1 diabetic woman was admitted to our intensive care unit with coma and severe ketoacidosis. Initial neurologic impairment worsened despite improvement in acid-base disturbances and glucose levels. The electroencephalogram showed bilateral spikes with a background theta wave rhythm. Profound hypophosphatemia <0.20 mmol/L (<0.6 mg/dL) was diagnosed. No other cause of encephalopathy was found. Prompt phosphate repletion resulted in progressive and complete recovery. This observation allowed us to study the relations between the coma depth, the electroencephalographic findings, and the serum phosphate concentrations. Our data strongly suggest that phosphate depletion-induced encephalopathy probably originates from direct impairment of cerebral electrophysiological activity rather than from cardiac flow alteration.

[Drug treatment in type 2 diabetes (part 2)]. / Traitement médicamenteux du diabète de type 2 (deuxième partie).

Insulin secretagogues and insulin sensitizers can be combined with one another as well as with other treatments (described below). Alpha-glucosidase inhibitors delay intestinal absorption of carbohydrates and reduce postprandial glycemia. Orlistat and sibutramine improve insulin sensitivity by helping patients lose weight. Orlistat inhibits hydrolysis of dietary triglycerides. Sibutramine, a noradrenaline and serotonin reuptake inhibitor, reinforces feelings of satiety and increases energy expenditure. After approximately 10 years, insulin therapy is usually required together with oral antidiabetic agents (except glitazones) or alone if HbA(1c) (glycosylated hemoglobin) is>6.5%. New guidelines for management of type 2 diabetes were published in 2006.

[Drug treatment of type 2 diabetes]. / Traitement médicamenteux du diabète de type 2 (première partie).

Drug treatment of 2 diabetes is intended to normalize glycosylated hemoglobin levels (HbA(1c)<6.5%) and thereby prevent the development of micro- and macrovascular complications. Oral antidiabetic agents target the metabolic abnormalities that cause diabetes. The two principal families of oral antidiabetic agents - insulin sensitizers and insulin secretagogues - can be taken together. Thiazolidinediones or glitazones (insulin sensitizers) improve peripheral tissue sensitivity to insulin. Metformin (an insulin sensitizer) reduces hepatic glucose production. Sulfonylureas and meglitinides (insulin secretagogues) stimulate insulin secretion and can cause hypoglycemia. GLP-1 (Glucagon-Like Peptide-1) analogs and DPP-IV (dipeptidyl-peptidase-IV) inhibitors are new drug classes currently under development.

Endocrine consequences of premature pubarche in post-pubertal Caucasian girls.

BACKGROUND: It has been postulated that intrauterine undernutrition may predispose to serious endocrine consequences, including precocious pubarche (PP), functional ovarian hyperandrogenism and insulin resistance syndrome. OBJECTIVE: The aim of this study was to determine whether a history of PP was associated with the development of hyperandrogenism and/or metabolic consequences and to evaluate the effect of birth weight on this association. PATIENTS: The study population comprised 27 Caucasian girls with a history of PP and 25 healthy girls of similar age (17.4 +/- 1.3 vs. 17.7 +/- 0.9 years). RESULTS: Gynecological age, irregular menses and oral contraceptive use were similar in the two groups. PP girls showed an increased Ferriman-Gallway Score [median (range) 8 (4-17) vs. 6 (2-10), P = 0.02] and tended to have more previous history of acne. No statistical differences were found between the groups for mean testosterone (1.7 +/- 0.7 vs. 1.4 +/- 0.7 nmol/l, P = 0.49) and dehydroepiandrosterone sulphate concentrations (7.2 +/- 3.7 vs. 5.8 +/- 2.0 micromol/l, P = 0.15), but mean Delta4-androstenedione concentrations (7.3 +/- 2.4 vs. 4.9 +/- 2.1 nmol/l, P = 0.007) and free androgen index (8.5 +/- 9.7 vs. 3.6 +/- 3.9 IU, P = 0.003) were significantly increased in the PP group. All girls showed normal glucose tolerance with an oral glucose tolerance test. Derived insulin resistance parameters were not statistically different between the two groups and fasting lipids were comparable in both groups. There was no significant effect of birth weight on androgen levels in the PP girls. Moreover, none of the PP girls demonstrated the above-described association. CONCLUSIONS: Precocious pubarche could be the first sign of future functional ovarian hyperandrogenism but a link between this condition and intrauterine undernutrition or insulin resistance could not be demonstrated in this study.