Thyroid incidentalomas on 18FDG-PET/CT: a metabolico-pathological correlation.

BACKGROUND: Thyroid incidentaloma is defined as an unsuspected thyroid lesion found on imaging study or while performing a surgery non-related to the thyroid gland. Most recent scientific literature tends to demonstrate a detection rate of 0.1-4.3% for incidental findings of thyroid focal uptake identified by 18F-fluorodeoxyglugose Positron Emission Tomography with computed tomography (18FDG-PET/CT) initially prescribed for nonthyroid disease. From 10.3 to 80.0% of patients who underwent further evaluation are diagnosed with malignant lesions. Our first objective is to determine the risk of malignancy confined in thyroid incidentalomas(IT) detected on 18FDG-PET/CT in patients treated in a tertiary care center (Centre Hospitalier Universitaire de Sherbrooke). Second, we want to identify a cut-off value for SUVmax in order to distinguish benign from malignant IT. Third, we look for predictive criterion that can be outlined to help in their management. METHODS: We retrospectively reviewed 40 914 charts of patients who had a 18FDG-PET/CT done in a tertiary center from 2004 to 2014. For each patient where a thyroid incidentaloma has been identified, Maximum Standardized Uptake Value (SUVmax), ultrasound report, cytology and histopathological results as well as oncologic outcomes were compiled and analyzed. RESULTS: In this study, the incidence for thyroid incidentaloma detected with 18FDG-PET/CT is 0.74%. The rate of malignancy present in IT is 8.2% based on histopathological results. Of the patients who underwent surgery, thyroid malignancy was identified in 54.3% of them. Cytoponction showed a strong correlation with final histopathological results (p = 0.009). CONCLUSION: Thyroid incidentalomas detected with 18FDG-PET/CT are relatively infrequent, but the potential risk of malignancy remains elevated. Fine needle aspiration biopsy is the investigation of choice to rule out a malignant incidentaloma when there is no other element in the clinical portrait to preclude such additional work up.

Impact of in-barn manure separation on biological air quality in an experimental setup identical to that in swine buildings.

In-barn manure separation systems are becoming popular due to various environmental pressures on the swine industry. According to the literature, separation of feces and urine directly underneath the slats should have a positive impact on barn air quality. Removal and rapid separation of the two phases (solid/liquid) would reduce the dust and bioaerosol emissions, which would significantly improve the air quality in pig-housing facilities. From an occupational health and safety perspective, the maximum endotoxin and total bacteria concentrations to ensure workers' safety should not exceed 450 endotoxin units per cubic meter of air (EU m(-3)) and 10(4) colony-forming units per cubic meter of air (CFU m(-3)), respectively. In the current study, the effect on air quality of six in-barn manure handling systems was measured. A flat scraper system and four separation systems installed under the slats (a conveyor belt system, a conveyor net system, and a V-shaped scraper operated at two operation frequencies) were evaluated and compared to a conventional pull-plug system (control). The experiment took place in twelve independent and identical rooms housing four grower-finisher pigs each, and air samples were collected and analyzed for total dust, endotoxins, bacteria, and mold counts. The results obtained from this experimental setup show that the separation of feces and urine under the slats would concentrate at least 80% of the phosphorus in the solid phase. The total bacteria and endotoxin concentrations are lower than those found in commercial hog barns but remain higher than the recommended levels. Only the total dust concentrations are approximately 10% of their regulated value. This separation has no impact on dust and bioaerosol concentrations compared to the control.

A double-blind, crossover study of controlled-release metoclopramide and placebo for the chronic nausea and dyspepsia of advanced cancer.

To compare a novel controlled-release formulation of metoclopramide with placebo in patients with cancer-associated dyspepsia syndrome, 26 adult patients with a >/=1 month history of cancer-associated dyspepsia syndrome were randomized to receive either controlled-release metoclopramide 40 mg every 12 hours or matching placebo for a period of 4 days. On day 5, patients crossed over to the alternate treatment for a further period of 4 days. Dose adjustments and rescue antiemetics were permitted during both phases. Nausea, anorexia, bloating, vomiting/retching, and drowsiness were assessed on a 100-mm VAS scale in a daily diary. On the last day of treatment of each phase, nausea was significantly lower in the controlled-release metoclopramide group compared to placebo (17 +/- 12 mm versus 12 +/- 10 mm). Nausea scores tended to increase across days during the placebo phase and to decrease during the controlled-release metoclopramide phase. There was a trend for improvement in the intensity of all symptoms on controlled-release metoclopramide with the exception of appetite, but this trend only reached statistical significance for nausea. The frequency and severity of elicited adverse events did not differ significantly between treatments, although drowsiness, dizziness, and poor sleep were somewhat higher in the placebo group. In no case was it necessary to discontinue controlled-release metoclopramide because of toxicity. These results indicate that controlled-release metoclopramide reduces gastrointestinal symptoms in this population of advanced cancer patients.

Twice-daily versus once-daily morphine sulphate controlled-release suppositories for the treatment of cancer pain. A randomized controlled trial.

We evaluated the safety and efficacy of controlled-release morphine sulphate suppositories administered 12-hourly and once daily in patients with chronic cancer in a randomized double-blind crossover trial. Pain was assessed using a 100-mm VAS pain scale and a five-point ordinal pain scale. The VAS pain intensity score was 17.5+/-17.2 after suppositories every 12 h, versus 16.2+/-13.4 after suppositories every 24 h (difference not significant). The difference between the mean VAS pain scores with 12-hourly and once-daily dosing was 1.3 mm (not significant). The mean ordinal pain scores were 1.0+/-0.7 versus 1.0+/-0.6 for 12-hourly and once-a-day dosing, respectively (not significant). A retrospective power analysis indicated that a difference of 5.9 mm was detectable, even with only 6 patients. Adverse events noted were constipation, nausea, anorexia, and dry mouth. The use of once-a-day controlled-release morphine suppository is a more convenient and equally effective alternative to twice a day dosing.

Randomized, double-blind, cross-over trial comparing safety and efficacy of oral controlled-release oxycodone with controlled-release morphine in patients with cancer pain.

PURPOSE: Use of oxycodone for chronic cancer pain has been hampered by its short elimination half-life. This study was designed to compare the efficacy and safety of controlled-release formulations of oxycodone and morphine for cancer pain. PATIENTS AND METHODS: Thirty-two adult patients with cancer pain and a > or = 3-day history of stable analgesia with oral opioids provided written informed consent and were randomized to controlled-release oxycodone or controlled-release morphine for 7 days. To blind the study using available tablet strengths, the dose ratio of oxycodone to morphine was set at 1:1.5. On day 8, patients were crossed over to the alternate drug for 7 days. Pain intensity was assessed using a visual analog scale (VAS 0 to 100 mm) and a categorical scale (CAT 0 to 4). Side effects were assessed using a checklist (four-point categorical severity) and a nondirected questionnaire. Patients and investigators made blinded global ratings of efficacy and treatment preference. RESULTS: Twenty-three patients completed the study (10 men, 13 women). The VAS and CAT scores were (mean+/-SD) 23+/-21 and 1.2+/-0.8 on controlled-release oxycodone, and 24+/-20 (P=.43) and 1.3+/-0.7 (P=.36) on controlled-release morphine. No period or carryover effect was detected. There were no significant differences in adverse effects (P=.40) or ratings of efficacy and preference. The median oxycodone/morphine dose ratio was 1.5 and the maximum was 2.3. CONCLUSION: Controlled-release oxycodone is as safe and effective as controlled-release morphine in the treatment of cancer pain.

Effectiveness of megestrol acetate in patients with advanced cancer: a randomized, double-blind, crossover study.

PURPOSE: To evaluate the effect of megestrol acetate at a lower dose than previously investigated on the symptoms of cachexia in patients with advanced cancer. METHODS: A total of 84 patients with advanced, solid tumours not responsive to hormone therapy were enrolled in this double-blind, crossover study. During phase 1, patients were randomly assigned to receive megestrol acetate (160 mg 3 times daily) for 10 days or placebo. During phase 2, after a 2-day washout period, patients received the alternate treatment for 10 days. Patients underwent daily assessments of activity, nausea, appetite and well-being by means of a visual analogue scale (VAS). In addition, nutritional status (weight, tricep skinfold measure, arm muscle circumference), energy intake, fatigue (Piper Fatigue Scale) and quality of life (Functional Living Index-Cancer [FLIC]) were assessed. RESULTS: Among the 53 evaluable patients megestrol acetate resulted in a significant improvement in appetite (p = 0.005), activity (p = 0.007) and well-being (p = 0.03). There was no significant change in the intensity of nausea, nutritional parameters, energy intake or FLIC scores. There was a significant improvement in 2 of the 3 factors measured by the Piper Fatigue Scale and in the overall fatigue score. Upon completion of the study, while still blind to the treatment condition, 30 patients indicated that they felt better overall after megestrol, 15 said they felt better after placebo, and 10 indicated no preference (p = 0.001). CONCLUSION: Treatment with megestrol acetate results in rapid and significant improvement of symptoms in terminally ill patients at lower doses than previously reported. The effects are not secondary to nutritional changes. The FLIC quality-of-life questionnaire was unable to detect these changes.

Equianalgesic dose/ratio between methadone and other opioid agonists in cancer pain: comparison of two clinical experiences.

BACKGROUND: Oral methadone is considered to be a valid opioid analgesic alternative to morphine and hydromorphone in treating cancer pain. However, the use of methadone could be complicated by the limited knowledge of the equianalgesic dose/ratio with the other analgesic opioids when switching in tolerant patients. PATIENTS AND METHODS: In two Palliative Care Units, data collected regarding 88 advanced cancer patients with pain switched from different opioids to oral methadone were reviewed and compared with the aim of determining the equianalgesic dose ratio in relation to the dose of opioid previously administered. RESULTS: The results of this retrospective study suggest that: (1) methadone is much more potent than previously described in literature, (2) the dose ratio between hydromorphone and methadone is higher than as suggested by equianalgesic tables, and (3) the ratio correlates with total opioid dose administered before switching. CONCLUSIONS: The fact that methadone ratio is different according to the opioid dose used previously should be taken into careful consideration by the clinician in order to avoid severe toxicity or death during switchover. Prospective studies should be carried out in order to better define our findings.

Euthanasia and physician-assisted suicide: a comparative survey of physicians, terminally ill cancer patients, and the general population.

PURPOSE AND METHODS: There is an ongoing debate about the legalization of euthanasia. The attitudes and beliefs of the general public and physicians appear to differ; the views of patients have not been adequately explored. During 1995, we conducted a simultaneous survey in the province of Alberta, Canada, of a random sample of 1,240 individuals from the general population, 179 physicians, and 62 consecutive patients with terminal cancer. The same instrument was administered to the public and physicians through telephone interview, and to patients in a face-to-face interview. Statements related to the legalization of euthanasia and physician-assisted suicide were scored using 1-to-7 Likert agreement scales. RESULTS: A slight majority of members of the public and terminally ill patients (50% to 60%) agreed with the legalization of euthanasia and assisted suicide, while most physicians (60% to 80%) opposed it. In multivariate analysis, independent associations with support of active end of life measures included the following: group surveyed, strength of religious beliefs, religion (highest support by individuals with no religion), education (lower education associated with higher support), and the perception of burden on families, and physical and emotional suffering by cancer patients. CONCLUSION: In all groups, a marked polarization of attitudes was observed, with most individuals either strongly agreeing or strongly disagreeing with the statements in the survey. Although a slight majority of the public supported euthanasia, one third opposed it. Most physicians opposed these interventions and appeared not to be willing to perform these procedures if legalized. Our findings suggest that legalization at this time could be highly divisive and controversial from a societal perspective.

Opioid rotation in patients with cancer pain. A retrospective comparison of dose ratios between methadone, hydromorphone, and morphine.

BACKGROUND: When a change of opioid is considered, equianalgesic dose tables are used. These tables generally propose a dose ratio of 5:1 between morphine and hydromorphone. In the case of a change from subcutaneous hydromorphone to methadone, dose ratios ranging from 1:6 to 1:10 are proposed. The purpose of this study was to review the analgesic dose ratios for methadone compared with hydromorphone. METHODS: In a retrospective study, 48 cases of medication changes from morphine to hydromorphone, and 65 changes between hydromorphone and methadone were identified. the reason for the change, the analgesic dose, and pain intensity were obtained. RESULTS: The dose ratios between morphine and hydromorphone and vice versa were found to be 5.33 and 0.28, respectively (similar to expected results). However, the hydromorphone/methadone ratio was found to be 1.14:1 (5 to 10 times higher than expected). Although the dose ratios of hydromorphone/morphine and vice versa did not change according to a previous opioid dose, the hydromorphone/methadone ratio correlated with total opioid dose (correlation coefficient = 0.41 P < 0.001) and was 1.6 (range, 0.3-14.4) in patients receiving more than 330 mg of hydromorphone per day prior to the change, versus 0.95 (range, 0.2-12.3) in patients receiving ae330 mg of hydromorphone per day (P = 0.023). CONCLUSIONS: These results suggest that only partial tolerance develops between methadone and hydromorphone. Methadone is much more potent than previously described and any change should start at a lower equivalent dose.

Volume of hydration in terminal cancer patients.

In this retrospective study we reviewed the volume and modality of hydration of consecutive series of terminal cancer patients in two different settings. In a palliative care unit 203/290 admitted patients received subcutaneous hydration for 12 +/- 8 days at a daily volume of 1015 +/- 135 ml/day. At the cancer center, 30 consecutive similar patients received intravenous hydration for 11.5 +/- 5 days (P > 0.2) but at a daily volume of 2080 +/- 720 ml/day (P < 0.001). None of the palliative care unit patients required discontinuation of hydration because of complications. Hypodermoclysis was administered mainly as a continuous infusion, an overnight infusion, or in one to three 1-h boluses in 62 (31%), 98 (48%) and 43 (21%) patients, respectively. Our findings suggest that, in some settings, patients may be receiving excessive volumes of hydration by less comfortable routes such as the intravenous route. Increased education and research in this area are badly needed.

Capsules and suppositories of methadone for patients on high-dose opioids for cancer pain: clinical and economic considerations.

The dose ratio, analgesic efficacy, toxicity and cost of methadone for cancer pain were evaluated in a retrospective review of 50 consecutive patients treated on a Palliative Care Unit. Patients were switched from hydromorphone 267.7 +/- 178.8 mg sc per day to custom-made capsules (24) or suppositories (26) of methadone for reasons of uncontrolled pain (24), toxicity (8), both (15) or other (2). The change in opioid occurred over 2.5 +/- 3.6 days, with another 4.4 +/- 3.7 days required to reach stable methadone dose. The ratio of stable methadone dose to final hydromorphone dose was 1.07 +/- 0.9 (oral) and 1.88 +/- 1.27 (rectal) (p = 0.01). Visual analogue scores for pain intensity (0-100 mm) declined from 50.8 +/- 22 to 40 +/- 20 (p = 0.01). The most frequent toxicities were constipation (46), sedation (42) and nausea (18). Six patients developed respiratory depression. Total cost of treatment was Canadian $116.77 +/- 157.17 for methadone capsules and Canadian $105.34 +/- 146.35 for methadone suppositories, vs Canadian $3450.51 +/- 5098.58 (p = 0.0001) for hydromorphone parenteral solution and Canadian $1801.21 +/- 2661.52 (p = 0.0001) for hydromorphone powder. It is concluded that methadone is an effective and inexpensive alternative in patients receiving high-dose opioids for cancer pain, at dose ratios much lower than recommended in the literature. The incidence of serious toxicities suggests that methadone should only be initiated in an adequately monitored setting by pain management experts.

Decreased opioid doses used on a palliative care unit.

We have previously published data on our use of opioids in the last week of life. A change in our pattern of opioid use, i.e. switching opioids more frequently and using high-dose methadone suppositories, appears to have resulted in a decrease in the number of patients requiring high-dose opioids. A retrospective chart review of 100 consecutive patients treated on our palliative care unit during 1992 was completed and compared to the original data from 1990. Results confirmed a decrease in the range of opioids used, as well as a statistically significant decrease in the daily opioid dose in the last week of life. We believe that this difference is most likely due to the use of methadone in patients showing either a poor response to other opioids or a rapid development to tolerance, as well as switching opioids more frequently to take advantage of incomplete cross-tolerance.

Effects of a modified dance-based exercise on cardiorespiratory fitness, psychological state and health status of persons with rheumatoid arthritis.

Cardiorespiratory function and exercise tolerance appear very limited in persons with rheumatoid arthritis (RA). Many studies have demonstrated that aerobic exercise training is beneficial to prevent physical deconditioning without inducing adverse effects on an individual's joints and general health. The present study was conducted to demonstrate that a dance-based exercise program is a safe and efficient activity to improve physical fitness and psychological state in persons with RA. A group of 19 persons (mean age, 49.3 +/- 13 yr) participated in a 12-wk exercise program (twice weekly), whereas 10 persons (mean age, 49.4 +/- 12 yr) served as controls. Health status, use of medication, joint pain and swelling, physical fitness, activity of daily living and psychological state were assessed at baseline, after the 12-wk training program and 6 mo after the end of the program. Exercise training induced a mean improvement of 13% in aerobic power, with the highest values reaching 40%. No significant changes were observed in joint status, even though the count of painful joints tended to decrease in the exercise group. Positive changes in depression, anxiety, fatigue and tension were observed after the 12-wk exercise program. These findings provide some evidences in favor of aerobic exercise in individuals with RA. Furthermore, it is of primary interest to note that a weight-bearing activity with limited ground impacts do not provoke short-term adverse effects on joint status. Further studies, however, are required to determine the long-term effect of weight-bearing exercise on the health status of individuals with RA.

Ectopic thyroid tissue--a review of the literature.

With only two cases in 20 years in their service and considering the low incidence of ectopic thyroid gland, the authors present a review of the literature with emphasis on clinical and pathological description and modern medical or surgical management of this entity known as ectopic thyroid gland.