Correlation of ACR TI-RADS and Patient Outcomes in a Real-World Cohort Presenting for Thyroid Ultrasonography.

Context: The American College of Radiology Thyroid Image Reporting and Data System (ACR TI-RADS) was developed to predict malignancy risk in thyroid nodules using ultrasound features. TI-RADS was derived from a database of patients already selected for fine-needle aspiration (FNA), raising uncertainty about applicability to unselected patients. Objective: We aimed to assess the effect of ACR TI-RADS reporting in unselected patients presenting for thyroid ultrasound in a real-world setting. Methods: Records for all patients presenting for thyroid ultrasonography in Canterbury, New Zealand, were reviewed across two 18-month periods, prior to and after implementation of TI-RADS reporting. Patient outcomes were compared between the 2 periods. Malignancy rates were calculated for nodules 10 mm or larger with a definitive FNA or histology result. Results: A total of 1210 nodules were identified in 582 patients prior to implementation of TI-RADS; 1253 nodules were identified in 625 patients after implementation of TI-RADS. TI-RADS category was associated with malignancy rate (0% in TR1 and TR2, 3% in TR3, 5% in TR4, 12% in TR5; P = .02); however, 63% of nodules were graded TR3 or TR4, for which malignancy rate did not meaningfully differ from baseline risk. After implementation of TI-RADS there was a small reduction in the proportion of patients proceeding to FNA (49% vs 60%; P < .01) or surgery (14% vs 18%; P < .05), with no difference in cancer diagnoses (3% vs 4%, not significant). Conclusion: TI-RADS category is associated with malignancy rate and may alter clinical decision-making in a minority of patients; however, it is nondiscriminatory in the majority of nodules. In this study of unselected patients, nodules classified as TR5 and thus considered "highly suspicious" for cancer had only a modest risk of malignancy.

Do medical interns publish findings of compulsory audit or research projects? Five-year experience from a single centre in New Zealand.

INTRODUCTION: There is a paucity of literature on research output of Australasian interns. We have previously shown great interest among interns rotating in our department to publish or present their findings from an audit or research project (ARP). The aim of this study was to examine the output of the intern ARP. METHODS: ARP titles over a five-year period were searched in academic databases. We compared the output rate from our institution to a rate estimated a priori from previously published literature. RESULTS: A total of 186 ARPs were conducted over the study period. Of these, only two were published (one original article and one letter) and one was presented at a national conference. The observed productivity rate was significantly lower than that of the estimated rate (χ2 = 4.49, p = 0.034). CONCLUSION: Despite potential limitations, our study remains the largest study to report on intern research productivity in Australasia. It provides evidence of the need for improvement in and encouragement of research conducted by junior doctors.

TIRADS Management Guidelines in the Investigation of Thyroid Nodules; Illustrating the Concerns, Costs, and Performance.

CONTEXT: Ultrasound (US) risk-stratification systems for investigation of thyroid nodules may not be as useful as anticipated. OBJECTIVE: We aimed to assess the performance and costs of the American College of Radiology Thyroid Image Reporting And Data System (ACR-TIRADS). DESIGN SETTINGS AND PARTICIPANTS: We examined the data set upon which ACR-TIRADS was developed, and applied TR1 or TR2 as a rule-out test, TR5 as a rule-in test, or applied ACR-TIRADS across all nodule categories. We assessed a hypothetical clinical comparator where 1 in 10 nodules are randomly selected for fine needle aspiration (FNA), assuming a pretest probability of clinically important thyroid cancer of 5%. RESULTS: The gender bias (92% female) and cancer prevalence (10%) of the data set suggests it may not accurately reflect the intended test population. Applying ACR-TIRADS across all nodule categories did not perform well, with sensitivity and specificity between 60% and 80% and overall accuracy worse than random selection (65% vs 85%). Test performance in the TR3 and TR4 categories had an accuracy of less than 60%. Using TR5 as a rule-in test was similar to random selection (specificity 89% vs 90%). Using TR1 and TR2 as a rule-out test had excellent sensitivity (97%), but for every additional person that ACR-TIRADS correctly reassures, this requires >100 ultrasound scans, resulting in 6 unnecessary operations and significant financial cost. CONCLUSIONS: Perhaps surprisingly, the performance ACR-TIRADS may often be no better than random selection. The management guidelines may be difficult to justify from a cost/benefit perspective. A prospective validation study that determines the true performance of TIRADS in the real-world is needed.

Three-year follow up of adrenal incidentalomas in a New Zealand centre.

BACKGROUND: The international guidelines for management of adrenal incidentalomas (AI) are becoming more conservative. These changes are based on the growing body of evidence suggesting that non-functioning adenomas have a low likelihood of becoming functional or malignant over time. AIMS: To follow up at least 100 patients for 3 years who were originally found to have benign adrenal adenomas which were non-functional or had subclinical Cushing syndrome (SCS). METHODS: This study prospectively evaluated consecutive patients aged 18 years or older with benign adrenal incidentalomas (AI), not treated with adrenalectomy, which were non-functioning or had SCS. The initial and follow-up evaluation, including clinical assessment, hormonal investigations and imaging were coordinated via a standardised nurse-led AI clinic. RESULTS: Of 233 patients referred to the AI clinic, 101 patients met the inclusion criteria and completed 3-year follow up. Most of those excluded were due to incomplete initial or follow-up evaluation or were not true AI. Most AI either remained stable or decreased in size on repeat imaging, while 5% of patients had AI enlargement of >5 mm diameter. No patient developed features suggesting adrenal carcinoma. Ninety-two patients had an initial diagnosis of non-functioning adenoma and nine patients had SCS. After 3 years (range 2.9-4.7 years), five of the nine patients with SCS showed normalisation of cortisol parameters (44%), and five of the 92 non-functional AI patients developed SCS (5%). CONCLUSION: After 3 years of follow up, approximately half of patients with SCS normalised, while 5% of patients with initially non-functioning adenomas developed biochemical evidence of SCS. This study found a low likelihood of progressive hormonal excess with no evidence of malignancy developing on follow-up evaluation, providing support for the shift towards the more conservative approach to management of AI recommended in recent guidelines.

Characteristics of adrenal incidentalomas in a New Zealand centre.

BACKGROUND: Management of adrenal incidentalomas (AI) is becoming more conservative, based on international data showing a low incidence of functional or malignant lesions. The clinical characteristics of AI in New Zealand are unknown. Therefore, whether the AI guidelines apply to the New Zealand population is also unknown. AIMS: To investigate the clinical characteristics of patients with AI presenting to a tertiary-care centre in New Zealand. METHOD: This study prospectively evaluated consecutive patients aged 18 or older with AI, 1 cm or larger, diagnosed in Canterbury, New Zealand. A standardised nurse-led dedicated AI clinic was used, including clinical assessment, hormonal evaluation and imaging. RESULTS: From January 2010 to April 2016, 306 patients were referred to the AI clinic, 228 met the inclusion criteria. Most of those excluded were not true AI, due to imaging performed for known or suspected non-adrenal malignancy. The most common reason for imaging was abdominal pain (46%). Most cases were benign (96.5%) and 88.6% of all cases were non-functional. Of the functioning tumours (26 patients), 18 had subclinical Cushing syndrome, four had late-onset congenital adrenal hyperplasia, two had phaeochromocytoma and one had primary hyperaldosteronism. Three patients had primary adrenal cancer, one of whom was secreting excess cortisol. One adrenal metastasis was diagnosed. CONCLUSION: This study found a similar prevalence of functional and malignant AI as international centres, although mild cortisol excess and primary aldosteronism may be under-represented. Therefore, the conservative approach to management of AI recommended in current guidelines is likely to be applicable to New Zealand population.

Impact of the Christchurch earthquakes on hospital staff.

INTRODUCTION: On September 4, 2010 a major earthquake caused widespread damage, but no loss of life, to Christchurch city and surrounding areas. There were numerous aftershocks, including on February 22, 2011 which, in contrast, caused substantial loss of life and major damage to the city. The research aim was to assess how these two earthquakes affected the staff in the General Medicine Department at Christchurch Hospital. Problem To date there have been no published data assessing the impact of this type of natural disaster on hospital staff in Australasia. METHODS: A questionnaire that examined seven domains (demographics, personal impact, psychological impact, emotional impact, impact on care for patients, work impact, and coping strategies) was handed out to General Medicine staff and students nine days after the September 2010 earthquake and 14 days after the February 2011 earthquake. RESULTS: Response rates were ≥ 99%. Sixty percent of responders were <30 years of age, and approximately 60% were female. Families of eight percent and 35% had to move to another place due to the September and February earthquakes, respectively. A fifth to a third of people had to find an alternative route of transport to get to work but only eight percent to 18% took time off work. Financial impact was more severe following the February earthquake, with 46% reporting damage of >NZ $1,000, compared with 15% following the September earthquake (P < .001). Significantly more people felt upset about the situation following the February earthquake than the September earthquake (42% vs 69%, P < .001). Almost a quarter thought that quality of patient care was affected in some way following the September earthquake but this rose to 53% after the February earthquake (12/53 vs 45/85, P < .001). Half believed that discharges were delayed following the September earthquake but this dropped significantly to 15% following the February earthquake (27/53 vs 13/62, P < .001). CONCLUSION: This survey provides a measure of the result of two major but contrasting Christchurch earthquakes upon General Medicine hospital staff. The effect was widespread with minor financial impact during the first but much more during the second earthquake. Moderate psychological impact was experienced in both earthquakes. This data may be useful to help prepare plans for future natural disasters. .

Coronary artery spasm due to thyrotoxicosis.

A 50-year-old lady presented with chest pain, tremor, weight loss and intermittent ST elevation in her ECG associated with elevated markers of myocardial injury. She was diagnosed with Graves' disease and coronary angiogram showed normal coronary arteries. It was felt coronary artery spasm secondary to thyrotoxicosis was the cause for her ECG changes and pain. She was successfully treated with diltiazem, metoprolol and carbimazole. This case highlights the importance of considering hyperthyroidism in the diagnosis of chest pain with normal coronary arteries.

The relationship of omental and subcutaneous adipocyte size to metabolic disease in severe obesity.

OBJECTIVE: Several studies have reported the existence of a subgroup of obese individuals with normal metabolic profiles. It remains unclear what factors are responsible for this phenomenon. We proposed that adipocyte size might be a key factor in the protection of metabolically healthy obese (MHO) individuals from the adverse effects of obesity. SUBJECTS: Thirty-five patients undergoing bariatric surgery were classified as MHO (n = 15) or metabolically unhealthy obese (MUO, n = 20) according to cut-off points adapted from the International Diabetes Federation definition of the metabolic syndrome. Median body mass index (BMI) was 48 (range 40-71). RESULTS: There was a moderate correlation between omental adipocyte size and subcutaneous adipocyte size (r = 0.59, p<0.05). The MHO group had significantly lower mean omental adipocyte size (80.9+/-10.9 microm) when compared with metabolically unhealthy patients (100.0+/-7.6 microm, p<0.0001). Mean subcutaneous adipocyte size was similar between the two groups (104.1+/-8.5 microm versus 107.9+/-7.1 microm). Omental, but not subcutaneous adipocyte size, correlated with the degree of insulin resistance as measured by HOMA-IR (r = 0.73, p<0.0005), as well as other metabolic parameters including triglyceride/HDL-cholesterol ratio and HbA1c. Twenty-eight patients consented to liver biopsy. Of these, 46% had steatohepatitis and fibrosis. Fifty percent (including all the MHO patients) had steatosis only. Both omental and subcutaneous adipocyte size were significantly associated with the degree of steatosis (r = 0.66, p<0.0001 and r = 0.63, p<0.005 respectively). However, only omental adipocyte size was an independent predictor of the presence or absence of fibrosis. CONCLUSION: Metabolically healthy individuals are a distinct subgroup of the severely obese. Both subcutaneous and omental adipocyte size correlated positively with the degree of fatty liver, but only omental adipocyte size was related to metabolic health, and possibly progression from hepatic steatosis to fibrosis.

Natural killer cells in obesity: impaired function and increased susceptibility to the effects of cigarette smoke.

BACKGROUND: Obese individuals who smoke have a 14 year reduction in life expectancy. Both obesity and smoking are independently associated with increased risk of malignancy. Natural killer cells (NK) are critical mediators of anti-tumour immunity and are compromised in obese patients and smokers. We examined whether NK cell function was differentially affected by cigarette smoke in obese and lean subjects. METHODOLOGY AND PRINCIPAL FINDINGS: Clinical data and blood were collected from 40 severely obese subjects (BMI>40 kg/m(2)) and 20 lean healthy subjects. NK cell levels and function were assessed using flow cytometry and cytotoxicity assays. The effect of cigarette smoke on NK cell ability to kill K562 tumour cells was assessed in the presence or absence of the adipokines leptin and adiponectin. NK cell levels were significantly decreased in obese subjects compared to lean controls (7.6 vs 16.6%, p = 0.0008). NK function was also significantly compromised in obese patients (30% +/- 13% vs 42% +/-12%, p = 0.04). Cigarette smoke inhibited NK cell ability to kill tumour cell lines (p<0.0001). NK cells from obese subjects were even more susceptible to the inhibitory effects of smoke compared to lean subjects (33% vs 28%, p = 0.01). Cigarette smoke prevented NK cell activation, as well as perforin and interferon-gamma secretion upon tumour challenge. Adiponectin but not leptin partially reversed the effects of smoke on NK cell function in both obese (p = 0.002) and lean controls (p = 0.01). CONCLUSIONS/SIGNIFICANCE: Obese subjects have impaired NK cell activity that is more susceptible to the detrimental effects of cigarette smoke compared to lean subjects. This may play a role in the increase of cancer and infection seen in this population. Adiponectin is capable of restoring NK cell activity and may have therapeutic potential for immunity in obese subjects and smokers.

BMI > or = 50 kg/m2 is associated with a younger age of onset of overweight and a high prevalence of adverse metabolic profiles.

OBJECTIVE: To study the demographic and clinical parameters of three different categories of obesity, with particular focus on a cohort of individuals with BMI > or = 50 kg/m2, the fastest growing category of obesity. DESIGN: Over 700 obese individuals were studied (186 with BMI = 30-39 kg/m2, 316 with BMI = 40-49 kg/m2 and 290 with BMI > or = 50 kg/m2). RESULTS: Median BMI was 51 kg/m2 for patients who reported onset of overweight before 15 years of age, 47 kg/m2 for patients who reported onset between 15 and 30 years, and 42 kg/m2 for patients who became overweight after 30 years of age. The BMI > or = 50 kg/m2 group was notably younger than the group with BMI = 30-39 kg/m2 (44 (SD 11) years v. 50 (SD 15) years; P < 0.0001). Eighteen per cent of obese patients studied were considered metabolically healthy according to standard cut-off points for blood pressure, fasting glucose and lipid profiles. However, the proportion of metabolically healthy individuals was significantly higher in the BMI = 30-39 kg/m2 group than in the BMI = 40-49 kg/m2 and BMI > or = 50 kg/m2 groups (31% v. 17% and 12% respectively; P < 0.05 and P < 0.005). When compared with people of similar age in the general population, individuals with BMI > or = 50 kg/m2 had lower rates of marriage (51% v. 72%) and a higher prevalence of unemployment (14% v. 5%). CONCLUSIONS: The current study suggests that the increasing prevalence of childhood obesity worldwide will lead to many more individuals achieving a higher BMI at a younger age. Furthermore, an earlier onset of overweight does not appear to prevent the adverse metabolic health outcomes associated with extreme obesity.

Bone mineral density in cystic fibrosis: benefit of exercise capacity.

The aim of this study was to evaluate the association between bone mineral density (BMD) and objective maximal exercise measurements in adults with cystic fibrosis (CF). Twenty-five CF patients (19 males, 6 females, mean age 25.5 yr, range: 17-52) underwent BMD assessment and maximal-cycle ergometer exercise testing. We examined the relationship between gas exchange (% peak-predicted O(2) uptake, CO(2) output, O(2) saturation), exercise performance (maximum power, exercise duration), and respiratory mechanics (tidal volume, rate) with lumbar spine and total proximal femur BMD. The strongest clinical correlate with BMD was forced expiratory volume at 1s (lumbar spine Z-score, r=0.36; total proximal femur Z-score, r=0.68, p<0.01). The strongest exercise correlate was % peak-predicted O(2) uptake (lumbar spine Z-score, r=0.44, p<0.01; total proximal femur Z-score, r=0.59, p<0.01). There was a closer association between exercise parameters and total proximal femur BMD (r=0.43-0.60) than with lumbar spine BMD (r=0.04-0.45). Multiple regression analysis revealed VO(2) to be the strongest independent predictor of BMD (R(2)=0.86, p<0.001) followed by petCO(2) and body mass index (R(2)=0.7 and 0.5, respectively, p<0.01). Exercise appears to influence total proximal femur BMD more than lumbar spine BMD in CF. Exercise rehabilitation programs focusing on peripheral strength training may benefit those CF patients with low total proximal femur BMD.