Use of the parathyroid hormone assay at H6 post thyroidectomy: an early predictor of hypocalcemia.

PURPOSE: Hypocalcemia linked to a diminished circulating intact parathormone (iPTH) is the most common complication after total thyroidectomy. The objective of this study was to evaluate iPTH as a predictor of post-thyroidectomy hypocalcemia. METHODS: Hundred-and-eight patients who underwent total thyroidectomy were included. Blood samples (iPTH, calcium and albumin) were performed at different times: preoperatively (H0), after removal of the gland (Hdrop), 6 h (H6) and one day (D1) after the surgery. Hypocalcemia was defined by total calcium corrected by serum albumin ≤ 2.10 mmol/l. The area under the ROC curve (AUC) was used to determine the best cut-off value and predictability of iPTH for hypocalcemia in terms of absolute value (ng/L), decrease in the slope (ng/L) and decline (%) between two times. RESULTS: The study included 101 patients. Among them, 39 had hypocalcemia (38.6%). At H6, an iPTH absolute value less than 14.35 ng/L (Se = 0.706; Sp = 0.917) and a decline from the preoperative time of more than 59.5% (Se = 0.850; Sp = 0.820) were predictive of hypocalcemia. Other absolute values, decrease in the sloop and decline between preoperative and postoperative values were less relevant. CONCLUSION: The iPTH 6 h after total thyroidectomy is predictive of hypocalcemia. It might be used to identify patients not at risk of hypocalcemia and earlier discharge could be considered.

Germline mutations in the thyrotropin receptor gene cause non-autoimmune autosomal dominant hyperthyroidism.

The thyrotropin receptor (TSHR), a member of the large family of G protein-coupled receptors, controls both the function and growth of thyroid cells via stimulation of adenylyl cyclase. We report two different mutations in the TSHR gene of affected members of two large pedigrees with non-autoimmune autosomal dominant hyperthyroidism (toxic thyroid hyperplasia), that involve residues in the third (Val509Ala) and seventh (Cys672Tyr) transmembrane segments. When expressed by transfection in COS-7 cells, the mutated receptors display a higher constitutive activation of adenylyl cyclase than wild type. This new disease entity is the germline counterpart of hyperfunctioning thyroid adenomas, in which different somatic mutations with similar functional characteristics have been demonstrated.

Limited contribution of indocyanine green (ICG) angiography for the detection of parathyroid glands and their vascularization during total thyroidectomy: A STROBE observational study.

INTRODUCTION: In total thyroidectomy, indocyanine green (ICG) angiography has mainly been evaluated at end of procedure to predict postoperative hypoparathyroidism. By using it during surgery, we sought to determine whether it could also be an aid to the surgeon. OBJECTIVE: To determine whether ICG used intraoperatively in total thyroidectomy modified the surgical procedure. MATERIAL AND METHOD: Thirty-two patients who underwent ICG angiography during total thyroidectomy were included in our single-center retrospective study. The number of parathyroid (PT) glands visualized in white light and on ICG angiography was collected, as well as PT vitality of at end of surgery according to these two modalities. Vitality scores were 0 (no vascularity), 1 (moderately vascularized) or 2 (well vascularized). Postoperative calcemia at D1, D2 and D7 was analyzed. RESULTS: In the 32 operations, the surgical procedure was modified in 10 cases (31%). The average number of PTs detected was 2.4 (77 PT) on ICG angiography and 2 (65 PT) in white light. Eleven patients (37.5%) had postoperative hypocalcemia. Cumulative vitality scores at end of procedure were 3.75/8 and 3.37/8 in white light and on ICG angiography respectively (P=0.648). The use of the device did not predict the occurrence of postoperative hypocalcemia. CONCLUSION: Indocyanine green angiography used in thyroid surgery could assist the surgeon in the identification of PT glands, sparing them in one third of cases.

Haemangioma of the temporal bone.

INTRODUCTION: Haemangiomas of the temporal bone are rare tumours and haemangiomas involving the middle ear are even rarer. The exceptional nature of these lesions makes their management particularly complicated. CASE REPORT: The authors report the case of a 16-year-old girl, who presented with an osteolytic lesion of the left petrous temporal bone that proved to be a haemangioma with extension to the middle ear, causing conductive hearing loss. DISCUSSION: Surgical biopsy is essential to establish the diagnosis of haemangioma because imaging alone only rarely provides a definitive diagnosis. Surgery is the reference treatment to prevent recurrence. Arteriography is an essential part of the preoperative assessment in order to limit the risk of bleeding.

Evaluation of the performance of ultrasonography and 99mTc-sestamibi scintigraphy for primary hyperparathyroidism surgery.

INTRODUCTION: Minimally invasive surgery has become the standard surgical attitude in primary hyperparathyroidism. It requires precise preoperative lesion localization. The aim of the present study was to evaluate the performance of ultrasonography and 99mTc-sestamibi scintigraphy in minimally invasive surgery for primary hyperparathyroidism. MATERIALS AND METHODS: A retrospective study included all patients managed surgically for primary hyperparathyroidism between January 2008 and November 2017 in the University Hospital of Brest (France). Two hundred and seventy-three patients underwent ultrasonography and 99mTc-sestamibi scintigraphy. Results determined intrinsic (sensitivity and specificity) and extrinsic (positive and negative predictive values) performance on per-patient and per-gland analysis. Demographic, preoperative, interventional and cure data were compared according to ultrasonography and scintigraphy results, distinguishing 3 patient groups: concordant n=156, discordant n=99, negative n=18. RESULTS: On per-gland analysis, sensitivity was 70% for ultrasound, 74% for 99mTc-sestamibi scintigraphy and 81% for associated ultrasound-scintigraphy; positive predictive values were 89%, 91% and 96%, respectively. Gland volume and concomitant thyroid pathology rates differed significantly (both p=0.003) between the 3 imaging results groups. CONCLUSION: The performance of associated ultrasound-99mTc-sestamibi-scintigraphy provided a positive predictive value of 96%. Combining the two techniques reduced surgical morbidity.

Correlation between fluorodeoxyglucose hotspots on preradiotherapy PET/CT and areas of cancer local relapse: Systematic review of literature.

The aim of the present paper is to systematically review all available literature on preradiotherapy high uptake areas (hotspots) as a potential target for dose escalation in different tumour sites, and to understand the potential role and limitations of fluorodeoxyglucose (FDG)-positron-emission tomography (PET)/computed tomography (CT) in this context. An electronic database (Medline) search was conducted to identify articles reporting on a correlation between high tracer uptake on pretreatment PET and preferential sites of local recurrence after radiotherapy. Search was limited to English language. No date range limitation was applied. Among 45 studies initially identified, nine series matching with inclusion criteria have finally been retained from the literature after reviewing (5 retrospective and 4 prospective). Primary tumour locations were head-neck (n=2), lung (n=4), oesophageal (n=2) and rectal (n=1) areas. Overlaps between FDG hotspot on preradiotherapy PET/CT and site of local recurrence on post-treatment scan showed good to excellent agreement. Only studies on head-neck cancer reported moderate agreement probably explained by the lack of reproducibility of the patients positioning between pre- and post-treatment FDG-PET/CT; and by the rigid registration process of images limited by post-therapeutic changes that highly affect anatomical landmarks. FDG hotspot-guided radiotherapy may allow dose escalation in respecting a robust methodology (treatment position, co-registration method, four-dimensional PET).

Guidelines of the French Society of Otorhinolaryngology. Role of the ENT specialist in the diagnosis of childhood obstructive sleep apnea-hypopnea syndrome (OSAHS). Part 1: Interview and physical examination.

OBJECTIVES: To present the 2017 Clinical Practice Guidelines of the French Society of Otorhinolaryngology concerning the role of the ENT specialist in the diagnosis of pediatric obstructive sleep apnea-hypopnea syndrome. This article focuses specifically on medical history and physical examination. METHODS: A multidisciplinary work-group drew up a first version of the guidelines, graded according to level of evidence following the GRADE grading system. The final version was obtained by including the suggestions and comments from the editorial group. RESULTS: At the end of the process, guidelines were established and graded regarding the following points: interview and analysis of the various interview scores recommended in the literature; clinical examination with awake upper-airway endoscopy; and indications for referral to non-ENT specialists.

Guidelines of the French Society of Otorhinolaryngology. Role of the ENT specialist in the diagnosis of obstructive sleep apnea-hypopnea syndrome (OSAHS) in children. Part 2: Diagnostic investigations apart from sleep studies.

OBJECTIVES: To present the 2017 Clinical Practice Guidelines of the French Society of Otorhinolaryngology concerning the role of the ENT specialist in the diagnosis of pediatric obstructive sleep apnea-hypopnea syndrome. This manuscript specifically focuses on diagnostic investigations apart from sleep studies. METHODS: A multidisciplinary work-group drew up a first version of the guidelines, graded according to level of evidence following the GRADE grading system. The final version was obtained by including the suggestions and comments from the editorial group. RESULTS: At the end of the process, guidelines were established and graded regarding diagnostic investigations apart from sleep studies, in particular respiratory functional tests, biological markers, and morphologic assessment under induced sleep (drug-induced sleep endoscopy (DISE) and cine-MRI).

Bone metastases from differentiated thyroid carcinoma.

The presence of distant metastases from differentiated thyroid carcinoma decreases the 10-year survival of patients by 50%. Bone metastases represent a frequent complication especially of follicular thyroid cancer and severely reduce the quality of life causing pain, fractures, and spinal cord compression. Diagnosis is established by correlating clinical suspicion with imaging. Imaging is essential to detect, localize, and assess the extension of the lesions and should be used in conjunction with clinical evidence. Bone metastases are typically associated with elevated markers of bone turnover, but these markers have not been evaluated in differentiated thyroid cancer. Skeletal and whole-body magnetic resonance imaging and fusion 2-deoxy-2-[18F]fluoro-D-glucose whole-body positron emission tomography/computed tomography (PET/CT) are the best anatomic and functional imaging techniques available in specialized centers. For well-differentiated lesions, iodine-PET scan combined (124)I-PET/CT is the newest imaging development and (131)I is the first line of treatment. Bisphosphonates reduce the complications rate and pain, alone or in combination with radioiodine, radionuclides, or external beam radiotherapy and should be employed. Surgery and novel minimally invasive consolidation techniques demand an appropriate patient selection for best results on a multimodal approach. Basic research on interactions between tumor cells and bone microenvironment are identifying potential novel targets for future more effective therapeutic interventions for less differentiated tumors.

Intralabyrinthine sporadic endolymphatic sac tumour.

INTRODUCTION: Endolymphatic sac tumours are benign, slowly growing tumours that invade the temporal bone, and present clinically in the form of unilateral hearing loss. They can be sporadic or occur in the context of Von Hippel-Lindau disease (VHL). CASE SUMMARY: The authors report a case of endolymphatic sac tumour arising in the utricle presenting histological and immunohistochemical features corresponding to endolymphatic sac tumour in a patient without VHL. DISCUSSION: Endolymphatic sac tumours invade the posterior part of the petrous temporal bone. According to two studies concerning patients with Von Hippel-Lindau disease, endolymphatic sac tumours arise from the endolymphatic duct. This case of intralabyrinthine sporadic endolymphatic sac tumour supports this hypothesis for sporadic forms, indicating the need for labyrinthectomy associated with tumour resection to avoid recurrence.

Reduced intensity allogeneic umbilical cord blood transplantation in children and adolescent recipients with malignant and non-malignant diseases.

There is a significant amount of morbidity and mortality following myeloablative umbilical cord blood transplantation (UCBT). Reduced intensity (RI) conditioning offers an alternative to myeloablative conditioning before UCBT. We investigated RI-UCBT in 21 children and adolescents with malignant (n=14), and non-malignant diseases (n=7). RI conditioning consisted of fludarabine (150-180 mg/m2) with either busulfan (< or = 8 mg/kg)+rabbit antithymocyte globulin (R-ATG; n=16) or cyclophosphamide+R-ATG+/-etoposide (n=5). Human leukocyte antigen match: 4/6 (n=13), 5/6 (n=5) and 6/6 (n=3). The median total nucleated cell and CD34+ cell dose per kilogram were 3.58 x 10(7) and 2.54 x 10(5), respectively. The median time for neutrophil and platelet engraftment was 17.5 and 52 days, respectively. There were six primary graft failures (chronic myelogenous leukemia (CML), beta-thalassemia, hemophagocytic lymphohistiocytosis (HLH) and myelodysplastic syndrome (MDS)). The probability of developing grade II to grade IV acute graft-versus-host disease (GVHD) and chronic GVHD was 28.6 and 16.7%, respectively. Incidence of transplant-related mortality (TRM) was 14%. The 5 years overall survival (OS) in all patients was 59.8%. The 5 years OS for patients with average versus poor-risk malignancy was 77.8 versus 22.2% (P=0.03). RI-UCBT may result in graft failure in specific high-risk chemo-naïve patients (CML, beta-thalassemia, HLH and MDS), but in more heavily pretreated pediatric and adolescent recipients results in rapid engraftment and may be associated with decreased severe GVHD and TRM.

[The radiological report: shaping it up]. / Le compte-rendu radiologique: à fond la forme.

The studies found in the literature investigated the structure of the radiological report, its standardization, communication with the general physician, regulations, and the medicolegal importance of the report. What to include in terms of content was most often considered: identification, clinical context and questions asked, technique and technical limitations, ordered results, relevant negative elements, a conclusion including a response to the question, diagnostic orientation, and suggestions for other examinations if necessary. In terms of the report's form, computerized reports have advanced the debate, opposing free composition and the structured report. No recommendations on the style were found in the recent studies, even though the problem is not a new one. In 1904, Hickey introduced the term "interpretation." In 1922, he observed that the style of reports was always individualistic and often eccentric. He suggested standardizing the reports to "avoid verbosity and encourage concision and clarity." After revising the information that should be included in a report, we wish to emphasize the form and style of the writing. This is not a scientific work, but rather we wish to express our opinion through a critical analysis based on examples taken from patient files. Many reports contain needlessly repeated words and language tics that harm the credibility of the analysis. The main qualities of the radiological report that are useful for the clinician are clarity, concision, and results correlated with the clinical situation.

[Cannabis and crossed allergy with food]. / Cannabis et allergie croisée alimentaire.

Cannabis use has increased over the last decade. At the same time, we see cannabis allergies appearing, ranging from simple rhinoconjunctivitis to anaphylactic-type reactions, some of which are severe since fatal cases have been described, but we also see allergic-induced food allergies cross-linked in the family of lipid transfer proteins (LTP). Indeed, cannabis contains an LTP called Can s 3. The LT are very widespread in the vegetable kingdom and are present in many vegetables and fruits. LTPs have a similar chemical structure and therefore cross-allergy is common. Thus, by becoming aware of the LTP of cannabis, it is possible to become allergic by a mechanism of cross-allergy to the other LTPs present in fruits and vegetables. This syndrome is referred to as cannabis-fruit-vegetable syndrome.

[Communication between radiologist and cancer patients]. / Dialogue entre le radiologue et le patient atteint d'un cancer.

Along with advances in medicine and social evolution, we are seeing an increase in the number of patients afflicted with cancer, and a change in the doctor-patient relationship. Patients' rights are now registered in the Hospitalised Patient's Charter, the Huriet Act and the Act of March 4, 2002. The evolution in cancer diseases is monitored by a range of imaging examinations, putting the radiologist in the front line. Lesions are typically first detected by the radiologist. This task is complicated by the fact that radiologists usually have no formal training with regards to the disclosure of cancer diagnoses to patients. There is a great risk of inappropriate responses which can have a profoundly damaging effect on the patient's state of mind. Even if we have the best of ideals and intentions, there is a great need for us to examine and improve our modes of interaction, in dealing with the patient's need for information. The radiologist possesses technical know-how, but technique alone is not enough - the right amount of information, based on clinical competence, is required; but so is empathy towards the patient, and respect for his or her wishes and rights.

[Improving overall patient care during imaging studies: the radiologist's CREDO and PERLES]. / Améliorer la prise en charge des malades en imagerie médicale: le CREDO et les PERLES du radiologue.

The protocols specifying the basic rules of the doctor-patient relationship that have been proposed in the literature are primarily intended for referring physicians, in particular oncologists. With regard to the improving radiologists' communication skills, a simple tool, RADPED, was developed to help residents in pediatric radiology to memorize the main points of the patient-radiologist interaction. We suggest a protocol, CREDO, more precisely appropriated to the everyday practice of medical imaging, in particular in oncology. This protocol relates not only to the radiologist-patient relationship, but also to the rules common to the department's entire team. The aims are to establish a partnership with the patient (for this purpose, we suggest using the PERLES model: partnership, excuses (apology), respect, legitimization, empathy, support), carrying out the examination under optimal conditions, listening to what the patient has to say, giving information and, above all, organizing the imaging department around the patient.

Serum parathormone profile during surgical treatment of hyperfunctioning parathyroid adenoma: a multicompartmental model.

Patterns of intact parathyroid hormone (iPTH) elimination and subsequent recovery of parathyroid function were studied in seven patients undergoing surgical removal of solitary hyperfunctioning parathyroid adenoma. Using a sensitive two-site immunoradiometric assay, iPTH levels were measured pre, peri-, and postoperatively. Blood samples were taken at very early and at late stages, including 3, 6, 9, and 15 minutes and 48, 72, and 96 h after adenomectomy. A biexponential formula was calculated to fit the decreasing values of iPTH in all patients. The PTH half-life in the early phase was 1.4 +/- 1.1 minutes (95% confidence limits). The PTH half-life in the second phase was 64.45 +/- 32.19 minutes (95% confidence limits). A third phase is represented by a slow, linear increase in plasma iPTH values as a result of the recovery of healthy suppressed parathyroid glands. The extrapolation to baseline of the later phase shows that the recovery of normal parathyroid function begins as soon as 240 minutes after adenomectomy and is independent of the decrease in PTH of adenomatous origin. All individual results were consistent with this model. Five patients had iPTH values below 5 pg/ml, one had 15 pg/ml, and the last had 27 pg/ml 5 h after parathyroid adenomectomy. The recovery of the hormonal activity of the remaining glands occurred rapidly. By the postoperative hour 24 the mean serum iPTH concentration was 12.28 +/- 8.07 pg/ml. The intraoperative serum iPTH concentration offers a model to assess both recovery of hormonal secretion from functionally suppressed parathyroid glands and disappearance of parathyroid hormone.