Acromegalia y cáncer de tiroides

RESUMEN: Introducción La acromegalia se asocia con un mayor riesgo de morbilidad y mortalidad por cáncer. Sin embargo, los datos respecto de la incidencia de cáncer en acromegalia son controvertidos. Objetivos Describir las características clínicas, bioquímicas e imagenológicas de un grupo de pacientes acromegálicos con carcinoma diferenciado de tiroides (CDT). Analizar las características de riesgo de recurrencia (RR) y respuesta en el seguimiento (RtaSg) y comparar la evolución con la de pacientes con CDT no acromegálicos. Materiales y métodos Se realizó un análisis retrospectivo multicéntrico de pacientes con diagnóstico de acromegalia y CDT. Se realizó un análisis comparativo entre los pacientes de bajo RR inicial acromegálicos con una muestra aleatoria de pacientes no acromegálicos con CDT de bajo RR inicial (1:4). Resultados Se analizaron 16 pacientes con diagnóstico de CDT y acromegalia. En 93,8% se hizo el diagnóstico por ecografía, sólo el 50% tenían un nódulo tiroideo palpable. En el momento del diagnóstico del CDT, los valores de IGF-1 fueron 1,8 ± 1,3 LSN, con 62,5% con acromegalia activa. La histología fue papilar en todos los casos, el 56,3% variedad clásica y el resto papilar variedad folicular. El 75% de los pacientes presentó un Estadio I (12/16), sólo 3 pacientes Estadio II y 1 Estadio IVb. El RR inicial fue bajo en el 87,6% (14/16), intermedio en 1 paciente y alto en 1 paciente. Las respuestas al final del seguimiento fueron: 86,7% (13/15) sin evidencia de enfermedad, 1 paciente bioquímica incompleta y 1 estructural incompleta. La RtaSg no tuvo diferencias con los no acromegálicos. Conclusiones Los pacientes acromegálicos con CDT presentaron predominantemente un bajo RR inicial. Al realizar la comparación con el grupo control, se puede concluir que el CDT en pacientes acromegálicos no presentó una evolución más agresiva.

Impacto de las metástasis óseas en 47 pacientes con cáncer diferenciado de tiroides / Outcome of Bone Metastases in 47 Patients with Differentiated Thyroid Cancer

Las metástasis a distancia ocurren en el 10 % de los pacientes con carcinoma diferenciado de tiroides (CDT). Las metástasis óseas (MO) son las segundas en frecuencia, luego de las pulmonares. Son causa de morbilidad significativa y su manejo es complejo. Objetivo: Revisar la experiencia en el diagnóstico y tratamiento de pacientes con MO evaluados en 10 centros asistenciales. Material y métodos: Estudio retrospectivo multicéntrico. Criterio de inclusión: presencia de MO en pacientes con CDT, diagnosticada por a) biopsia de la lesión, b) lesión estructural ósea con captación de 131I asociada a Tiroglobulina (Tg) elevada o c) lesión estructural ósea captante de (fluor-deoxi-glucosa) 18FDG en (Tomografía por emisión de positrones) PET-TC y Tg elevada. Se evaluaron datos extraídos de la revisión de historias clínicas. Resultados: Se incluyeron 47 pacientes, 55 % mujeres; edad: mediana 55 años (rango 15-84). La histología fue carcinoma papilar en 55 %, folicular en 32 % y otros tipos en 13 %. El diagnóstico de las MO fue sincrónico en 47 % y metacrónico en 53 %, estas últimas detectadas en promedio a los 72 meses (7-240) luego del diagnóstico inicial. Las MO fueron sintomáticas en 64 %. El síntoma más frecuente fue el dolor (70 %). La localización más frecuente fue la vertebral (36 %), con compromiso de múltiples sitios en el 68% de los casos. Dieciséis pacientes (34 %) tuvieron además persistencia/recurrencia locorregional y 68 % metástasis en otras localizaciones, siendo la más frecuente la pulmonar (90 %). Los niveles de Tg estimulada se obtuvieron en 38 pacientes; fueron > 100 ng/ml en 87 % y <100 ng/ml en 13 %. La calcemia fue normal en todos los casos. Los marcadores de remodelado óseo estuvieron elevados en 9 de 31 pacientes (29 %). Los tratamientos efectuados fueron 131I (78 %), bifosfonatos (64 %), cirugía (53 %), radioterapia externa (55 %) y otras modalidades (23 %). La mediana de seguimiento fue de 24 meses (1-228). La sobrevida fue de 41 %. Un paciente fue considerado sin evidencia de enfermedad. Veintiocho pacientes (59 %) murieron con enfermedad. La causa de muerte se conoció en 27 casos, relacionándose con las MO en 8 casos (30 %). Conclusiones: Las MO se observaron predominantemente en pacientes >45 años, con una distribución similar por sexo. Fueron múltiples a predomino axial, ocasionando morbilidad en la mayoría de los pacientes. Los marcadores de remodelado óseo estuvieron elevados en un tercio de los casos evaluados. Ningún paciente presentó hipercalcemia. El tratamiento incluyó múltiples modalidades, lo que demuestra la importancia del enfoque multidisciplinario en estos pacientes. Aunque las MO se asociaron a enfermedad incurable, la mortalidad se relacionó principalmente con la diseminación en otras localizaciones del CDT. Rev Argent Endocrinol Metab 51:51-58, 2014 Los autores declaran no poseer conflicto de interés.

Distant metastasis is an infrequent event in patients with differentiated thyroid cancer (DTC) and it occurs approximately in 10 % of cases. Bone is the second metastatic site in patients with DTC. The aim of this multicenter retrospective study was to describe the diagnosis and treatment of bone metas­tases (BMs) in patients followed up in ten different hospitals from Argentina. Diagnosis of BMs was made when: a) BM was confirmed by biopsy, b) a structural bone lesion was found following 131I uptake associated with elevated levels of serum thyroglobulin (Tg) or c) a structural bone lesion was demonstrated by 18FDG uptake on PET/CT, also associated with high levels of serum Tg. Demographical, clinical, pathological and outcome data were obtained from hospital charts. We included 47 patients: 55 % were women, with a median age of 55 years old. Histology of DTC was as follows: 55 % had papillary thyroid cancer, 32 % had follicular thyroid cancer and 13 % had other variants. Diagnosis of BMs were synchronous in 47 % of patients (at the same time as DTC diagnosis) and metachro­nous in 53 %, occurring within a mean period of 72 months after initial diagnosis. In 64 % of patients, BMs were symptomatic: pain was referred in 70 % of these cases. In 68 % of cases, there were multiple sites of BMs, with the spine being the most frequent localization (36 %). In 68 % of patients, other distant metastases were observed, mainly in the lungs. Stimulated Tg levels were known in 38 patients at diagnosis: > 100 ng/ml in 87 % and <100ng/ml in 13 %. Serum calcium level was normal in all subjects in whom it was measured (n = 41). In 9 (29 %) of the 31 patients studied, serum bone turnover markers were elevated. At least one modality of treatment was prescribed in 96 % of patients with BMs. Radioiodine was indicated in 78 % of cases, bisphophonates were prescribed in 64 % of patients, while surgery was performed in 53 %. In 55 % of cases, external beam radiotherapy was also indicated and 23 % of individuals received other therapeutic approaches. Median follow-up was 24 months (range 1-228 months). The survival rate at the end of follow-up was 41 %. One patient (3 %) was considered to have no evidence of disease, 28 patients (59 %) died as a consequence of the DTC. The cause of death was known in 27 cases and it was related to BMs in only 8 patients (30 %). In conclusion, BMs were mainly observed in patients >45 years old, with similar gender distribution. BMs were multiple and had mainly an axial skeletal localization, causing high morbidity in most patients. Although bone turnover markers were elevated in one third of cases, no patient had hypercalcemia. Multiple modali­ties of treatment were used in the majority of cases, which indicates the importance of a multidisciplinary approach. Finally, although BMs were associated with incurable disease, mortality was mainly related to the spread of DTC to other sites, and not specifically to BM. Rev Argent Endocrinol Metab 51:51-58, 2014 No financial conflicts of interest exist.

Carcinoma medular de tiroides: estudio multicéntrico. Presentación y evolución en 219 pacientes / Medullary Thyroid Carcinoma: Clinical Presentation and Outcome in 219 Patients

Ante la baja frecuencia del carcinoma medular de tiroides (CMT), en el Departamento de Tiroides de SAEM nos propusimos realizar un estudio de cohorte, observacional, retrospectivo y multicéntrico. Se incluyeron 219 pacientes con diagnóstico histológico de CMT. El 65 % fueron mujeres, la edad promedio fue de 39 ± 20 años (1 a 84 años); 44-% de los casos fueron familiares. Las formas de presentación más frecuentes fueron nódulo tiroideo (58 %) y pesquisa genética por antecedente familiar (22 %). Si bien la citología tiroidea fue diagnóstica de CMT en el 39 % de los casos, fue determinante de indicación quirúrgica en el 79 %. En el 47 % de los pacientes el diagnóstico de CMT se obtuvo previamente al tratamiento quirúrgico inicial por punción aspiración con aguja fina (PAAF), estudio genético o nivel de calcitonina (CT)). El 65 % se presentó en estadios avanzados (TNM III y IV). El estudio del protoncogen RET se realizó en 162 pacientes (74 %). En el 49 % se observó mutación siendo la más frecuente (76 %) en el codón 634. La forma hereditaria más frecuentemente observada fue el síndrome de neoplasia endocrina múltiple (NEM) 2A (57 % de los casos familiares), seguida por carcinoma medular familiar (25 %) y NEM 2B (13 %). Los casos familiares tuvieron menor edad al diagnóstico y mayor frecuencia de diagnóstico prequirúrgico. Los casos índice tuvieron mayor edad al momento del diagnóstico, mayores niveles de antígeno carcinoembrionario (CEA) y CT prequirúrgicos, mayor proporción de estadios III y IV y mayor porcentaje de evidencia de enfermedad al momento de la última consulta que aquellos detectados por pesquisa. En 143 pacientes (65 %) se obtuvieron registros completos de seguimiento en los que se analizaron los factores relacionados con la evolución. La mediana de seguimiento fue de 44 meses: fallecieron 21 pacientes (14,6 %) y 122 (86 %) viven; 76 de estos (54 %) se encuentran libres de enfermedad. El grupo con evidencia de enfermedad se presentó en estadios más avanzados. Resultaron factores de mayor riesgo para evidencia de enfermedad: sexo masculino, CMT esporádico, niveles elevados de CT prequirúrgicos, estadio IV y presencia de metástasis. Los niveles de CT posquirúrgicos fueron menores en aquellos pacientes que en la evolución final no presentaron evidencia de enfermedad. El principal factor pronóstico de la evolución de los pacientes con CMT fue el estadio de presentación, determinando la importancia del diagnóstico precoz con el fin de poder implementar un tratamiento quirúrgico curativo en estadios menos avanzados.

Due to the low frequency of medullary thyroid cancer (MTC), an observational, cohort, retrospective multicenter study was conducted at the Thyroid Department of the Endocrine and Metabolism Argentine Society (SAEM). We included 219 patients with histologically proven MTC, with a mean age of 39 ± 20 yr (range 1-84 years). Sixty five percent were women and 44% were familial cases. The most common presentations were thyroid nodule (58 %) and genetic screening due to family history (22 %). In 39 % of patients, diagnosis of MTC was made by fine needle aspiration, but cytology led to surgery in 79 %. In 47 % of patients, MTC was diagnosed by cytology, calcitonin (CT) levels or genetic studies prior to initial surgery. Sixty five percent of patients had advanced stages of the disease (TNM III or IV) at diagnosis. Proto-oncogene RET was studied in 162 patients (74 %). In 49% a mutation was reported, most frequently in codon 634 (76 %). Regarding hereditary forms of MTC, MEN 2A was the most frequent (57%), followed by familial MTC in 25 % and MEN 2B in 13 % of cases. Familial cases were younger subjects and had more frequently a pre-surgery diagnosis. Index cases were older, with higher CEA and CT levels, presented in more advanced stages and had more frequently evidence of disease at final assessment than patients who were diagnosed by genetic screening. Follow-up records of 143 patients were analyzed (65%); median time was 44 months; 21 patients died (14.6 %) and 122 survived (86 %), 76 showed no evidence of disease (NED) (54 %). High risk factors for evidence of disease at the final evaluation were: male gender, sporadic MTC, higher CT pre-surgery levels, stage IV and metastasis. Post surgery CT levels were lower in patients with NED. Stage at initial diagnosis was the main prognostic factor in patients with MTC, determining the importance of early detection for performing curative surgery in less advanced stages.

Carcinoma medular de tiroides: estudio multicéntrico. Presentación y evolución en 219 pacientes / Medullary Thyroid Carcinoma: Clinical Presentation and Outcome in 219 Patients

Ante la baja frecuencia del carcinoma medular de tiroides (CMT), en el Departamento de Tiroides de SAEM nos propusimos realizar un estudio de cohorte, observacional, retrospectivo y multicéntrico. Se incluyeron 219 pacientes con diagnóstico histológico de CMT. El 65 % fueron mujeres, la edad promedio fue de 39 ± 20 años (1 a 84 años); 44-% de los casos fueron familiares. Las formas de presentación más frecuentes fueron nódulo tiroideo (58 %) y pesquisa genética por antecedente familiar (22 %). Si bien la citología tiroidea fue diagnóstica de CMT en el 39 % de los casos, fue determinante de indicación quirúrgica en el 79 %. En el 47 % de los pacientes el diagnóstico de CMT se obtuvo previamente al tratamiento quirúrgico inicial por punción aspiración con aguja fina (PAAF), estudio genético o nivel de calcitonina (CT)). El 65 % se presentó en estadios avanzados (TNM III y IV). El estudio del protoncogen RET se realizó en 162 pacientes (74 %). En el 49 % se observó mutación siendo la más frecuente (76 %) en el codón 634. La forma hereditaria más frecuentemente observada fue el síndrome de neoplasia endocrina múltiple (NEM) 2A (57 % de los casos familiares), seguida por carcinoma medular familiar (25 %) y NEM 2B (13 %). Los casos familiares tuvieron menor edad al diagnóstico y mayor frecuencia de diagnóstico prequirúrgico. Los casos índice tuvieron mayor edad al momento del diagnóstico, mayores niveles de antígeno carcinoembrionario (CEA) y CT prequirúrgicos, mayor proporción de estadios III y IV y mayor porcentaje de evidencia de enfermedad al momento de la última consulta que aquellos detectados por pesquisa. En 143 pacientes (65 %) se obtuvieron registros completos de seguimiento en los que se analizaron los factores relacionados con la evolución. La mediana de seguimiento fue de 44 meses: fallecieron 21 pacientes (14,6 %) y 122 (86 %) viven; 76 de estos (54 %) se encuentran libres de enfermedad. El grupo con evidencia de enfermedad se presentó en estadios más avanzados. Resultaron factores de mayor riesgo para evidencia de enfermedad: sexo masculino, CMT esporádico, niveles elevados de CT prequirúrgicos, estadio IV y presencia de metástasis. Los niveles de CT posquirúrgicos fueron menores en aquellos pacientes que en la evolución final no presentaron evidencia de enfermedad. El principal factor pronóstico de la evolución de los pacientes con CMT fue el estadio de presentación, determinando la importancia del diagnóstico precoz con el fin de poder implementar un tratamiento quirúrgico curativo en estadios menos avanzados.(AU)

Due to the low frequency of medullary thyroid cancer (MTC), an observational, cohort, retrospective multicenter study was conducted at the Thyroid Department of the Endocrine and Metabolism Argentine Society (SAEM). We included 219 patients with histologically proven MTC, with a mean age of 39 ± 20 yr (range 1-84 years). Sixty five percent were women and 44% were familial cases. The most common presentations were thyroid nodule (58 %) and genetic screening due to family history (22 %). In 39 % of patients, diagnosis of MTC was made by fine needle aspiration, but cytology led to surgery in 79 %. In 47 % of patients, MTC was diagnosed by cytology, calcitonin (CT) levels or genetic studies prior to initial surgery. Sixty five percent of patients had advanced stages of the disease (TNM III or IV) at diagnosis. Proto-oncogene RET was studied in 162 patients (74 %). In 49% a mutation was reported, most frequently in codon 634 (76 %). Regarding hereditary forms of MTC, MEN 2A was the most frequent (57%), followed by familial MTC in 25 % and MEN 2B in 13 % of cases. Familial cases were younger subjects and had more frequently a pre-surgery diagnosis. Index cases were older, with higher CEA and CT levels, presented in more advanced stages and had more frequently evidence of disease at final assessment than patients who were diagnosed by genetic screening. Follow-up records of 143 patients were analyzed (65%); median time was 44 months; 21 patients died (14.6 %) and 122 survived (86 %), 76 showed no evidence of disease (NED) (54 %). High risk factors for evidence of disease at the final evaluation were: male gender, sporadic MTC, higher CT pre-surgery levels, stage IV and metastasis. Post surgery CT levels were lower in patients with NED. Stage at initial diagnosis was the main prognostic factor in patients with MTC, determining the importance of early detection for performing curative surgery in less advanced stages.(AU)

Programa nacional de bocio nodular (PRONBONO): Estudio multicéntrico de bocio nodular único palpable / National Program for Nodular Goiter (PRONBONO): Multicenter study of single palpable thyroid nodules

Introducción: La presencia de nódulos tiroideos palpables en la población general, es uno de los signos clínicos tiroideos más frecuentes en la práctica diaria. Objetivos: 1) establecer la prevalencia de las distintas patologías en bocio nodular único palpable y analizar sus características y su relación con los resultados citológicos. 2) analizar la existencia de diferencias regionales en Argentina. Pacientes y Métodos: Estudio prospectivo de 739 pacientes con bocio nodular único palpable evaluados entre el 1/1/2000 y el 31/12/2001 en Centros de Buenos Aires, Bahía Blanca, Mendoza y La Pampa. Se recabaron datos de examen clínico, ecografía tiroidea, TSH, ATPO y citología por punción con aguja fina. (PAAF). Fue utilizado para el análisis estadístico Correlación de Pearson, X2 y Test de Fisher. Resultados: la edad (X ± DS) fue 46,3 ± 14 años, 93,1 % eran de sexo femenino. El 1,6 % tenía historia de radiación en cuello y el 29,9 % antecedentes familiares de patología tiroidea. Hallazgos clínicos: disfagia en el 7,9 %, disfonía 3,5 %, crecimiento nodular en los últimos 6 meses 19,2 %, consistencia dura el 24,7 %, fijeza a estructuras adyacentes 1,5 % y adenopatías en el 3 %. Hallazgos bioquímicos: TSH normal en el 81,2 % y ATPO positivos en el 30,3 % de los casos. Características Ecográficas: nódulos sólidos: 53,1 %, hipoecoicos: 63,8 %, microcalcificaciones 10,3 %, halo incompleto: 15 %, multinodular: 30,5 %, tiroides heterogénea: 60,2 % y adenopatías: 3,8 %. Hallazgos citológicos: En el 86,8 % de los casos fue necesario solo una punción para llegar al diagnóstico. Insatisfactorio (excluyendo quiste): 3,2 %: benignos: 77,3 %; sospechosos: 12,6 % y cáncer: 7 % (42 papilar, 2 medular y 3 sin especificar). Una correlación significativa (p<0,02) fue observada entre citología maligna y crecimiento rápido, dureza, fijeza a estructuras vecinas, nódulo sólido, halo incompleto y adenopatías aunque estos parámetros son más frecuentes en números absolutos en nódulos benignos. La mayoría de las cirugías fueron indicadas en base al hallazgo citológico. El diagnóstico histológico de los 96 pacientes que fueron operados mostró 51 carcinomas, de los cuales solo dos tenían citología benigna y 31 adenomas. Conclusión: Los nódulos palpables únicos fueron más frecuentes en mujeres eutiroideas en la edad media de la vida. Un tercio tenía historia familiar de patología tiroidea, similar al porcentaje hallado de ATPO positivos. Por ecografía los nódulos fueron predominantemente sólidos, hipoecoicos, únicos con resto de la glándula tiroides heterogénea. La PAAF fue predominantemente benigna. El crecimiento rápido, la dureza, la fijeza a estructuras adyacentes, el halo incompleto y la presencia de adenopatías fueron relacionados con malignidad, pero la benignidad fue más frecuente. En la mayoría de los pacientes la cirugía fue recomendada por los hallazgos citológicos. Nuestros resultados son similares a los reportados en otras áreas geográficas.

Introduction: the presence of palpable thyroid nodules in the general population is one of the most common clinical signs of thyroid disease in daily practice. Objectives: 1) To assess the prevalence of pathologies, clinical and cytological findings of single palpable thyroid nodules (SPTN) in Argentina. 2) Analyze the regional differences in Argentina. Methods: Prospective study of 739 patients with STPN were evaluated at centres in Buenos Aires, Bahía Blanca, Mendoza, and La Pampa between 1/1/00 and 12/31/01. Clinical examination, thyroid ultrasound scan (US), TSH, TPOAb and fine needle aspirations (FNA) were performed. Statistics: Pearson Correlation, X2 & Fisher Tests. Results: Age (X ± SD) 46 ± 14ys: 93.1 % were women. Previous history of neck radiation & familial thyroid disease were found in 1.6 and 29.9 % respectively. Clinical findings: dysphagia: 7.9 %; dysphonia: 3.5%; nodule growth: 19.2 %; hard consistence: 24.7 %; fixation to adjacent structure: 1.5 % and lymphadenopathies (ADP): 3 %. Biochemical findings: TSH was normal in 81.2 % & TPOAb+ in 30.3 %. US features: solid: 53.1 %; hypoechoic: 63.8 %; microcalcifications: 10.3 %; incomplete halo: 15 %; more than 1 nodule: 30.5 %; thyroid heterogeneity: 60.2 % and ADP: 3.8 %. Cytology: Only 1 FNA was needed in 86.8%. Unsatisfactory (excluding cysts): 3.2 %; benign: 77.2%; suspicious: 12.6 % and cancer: 7 % (42 papillary, 2 medullary and 3 non specified). A significant correlation (p<0.02) was established between malignant nodules and rapid growth, hard, fixed, solid nodule, incomplete halo and ADP, though these parameters were more frequent (in absolute number) in benign nodules. Surgery was mainly indicated based on FNA results. Histological diagnosis of 96 patients who underwent surgery showed 51 carcinomas, of which only 2 were cytologically benign and 31 adenomas. Conclusion: Palpable single nodules were more frequent in middle aged euthyroid women. One third had familial thyroid pathology, similar to the presence of TPOAb. On US, nodules were predominantly solid, hypoechoic, single with heterogeneous thyroid gland. FNA was predominantly benign. Rapid growth, hard, fixed, solid nodule, incomplete halo and ADP were associated with malignancy, but benignity was more common. In most of the patients surgery was recommended based on cytological findings. Our results are similar to those reported in other geographic areas.

Utilidad de la Tiroglobulina sérica preablación como predictor de evolución en los pacientes con carcinoma diferenciado de tiroides / Usefulness of preablation serum thyroglobulin as a predictor of the evolution of patients with differentiated thyroid carcinoma

El presente es un trabajo retrospectivo y multicéntrico para evaluar el valor de la Tiroglobulina (Tg) medida preablación como predictor de evolución en 274 pacientes con Carcinoma Diferenciado de Tiroides (CDT). Se incluyeron pacientes con anticuerpos a Tg (TgAb) negativos, tratados con tiroidectomía total, ablación del remanente, con una evolución mayor a 2 años y a los cuales se les midió la Tg bajo estímulo de TSH. Se correlacionó la Tg preablación con el primer control de Tg bajo estímulo de TSH, con el estadio de TNM y con el estado de la enfermedad a Tiempo Final (TF) de seguimiento. Según el TNM, 205 pacientes estuvieron en Estadio 1, 19 en 2, 34 en 3 y 16 en 4. A T F, 172 pacientes estuvieron Libres de Enfermedad (LE), 43 con Enfermedad Dudosa (ED) y 59 con Enfermedad Persistente/Recurrente (EP). Agrupamos la población en rangos de Tg de 0.5-2.0; 2.1-10.0; 10.1-40.0, 40.1-100 y > 100 ng/mL. No hubo asociación significativa entre la Tg preablación y el estadio del TNM en tanto que la correlación con la Tg estimulada se observó solo en los pacientes con Tg < 2.0 ng/mL ya que el 86.7 % se mantuvo en ese rango. El resto de los grupos mostró, en respuesta a la ablación, una disminución de la Tg en porcentajes variables mientras que otros la aumentaron. Relacionando la Tg preablación con el estado de enfermedad a TF observamos que los pacientes con valores =10 ng/mL llegaban en mayor proporción LE al T F. El estadio de TNM mostró correlación con el estado de enfermedad a TF estando LE los de menor riesgo. En pacientes con CDT, los niveles de Tg preablación menores a 10 ng/mL son un marcador de buen pronóstico. Consideramos que la Tg preablación es útil para inferir la probable evolución de los paciente y una herramienta auxiliar para cálculo de riesgo del paciente. Los autores declaran no tener conflictos de interés.

We present a retrospective and multicentric study to evaluate the measurement of preablation Thyroglobulin (Tg) as a predictor of the evolution of 274 patients with DTC. All the patients included in the study had negative TgAb, were treated with total thyroidectomy, ablation of the remnant tissue and an evolution period of more than 2 years. We measured preablation Tg under stimulation with endogenous TSH. We correlated the preablation Tg with that at the first control at LT4 withdrawal, with TNM stratification and the final statement of the disease at Final Time (FT). At the end of the evolution period, patients were classified as: free of disease (n=172), with doubtful disease (n=43) and with persistent disease (n=50). According to their Tg levels, patients were subdivided the following ranges of Tg: 0.5-2.0; 2.1-10.0; 10.1-40.0; 40.1-100 and >100 ng/mL. There was not significant correlation between preablation Tg and TNM stratification. We observed correlation between preablation Tg and the first stimulated Tg =2.0 ng/mL as 86.7 % of the patients persisted in this range while the rest of them either moved to a lower or a higher range in response to the ablation. Considering the relationship between preablation Tg and the state of disease at FT, we found out that most of the patients with preablation Tg <10.0 ng/mL were free of disease. TNM classification correlated with the final state of the disease, with low risk patients having a high probability of being free of disease. In patients with CDT, preablation Tg below =10.0 ng/mL could be a marker of good prognosis. We consider that preablation Tg can be a valuable tool to predict the evolution and risk of patients with CDT. No competing financial interests exist.

Psycho-social factors affecting elders' maltreatment in long-term care facilities.

AIM: To examine and analyse major variables affecting maltreatment of elderly nursing home residents. The study was based on two theoretical paradigms: the theoretical model for predicting causes of maltreatment of elderly residents developed by Pillemer, and the Theory of Reasoned Action developed by Ajzen & Fishbein. METHODS: The study employed a correlational quantitative method. The research population consisted of the staff of 22 nursing homes in Israel. Six hundred questionnaires were distributed in these facilities and 510 were completed and returned (85%). In addition, 24 questionnaires were distributed among directors of the facilities and 22 were returned (91.6%). FINDINGS: Slightly more than half of the staff sampled reported abuse of elderly residents over the past year, as manifested in one or more of types of maltreatment. The total number of various types of maltreatment reported was 513. About two-thirds of the cases were incidents of neglect. Seventy per cent of respondents reported that they had been present at incidents in which another staff member abused an elderly resident in one or more types of maltreatment, and in such situations mental abuse and mental neglect were the most prevalent forms of maltreatment. CONCLUSION AND RECOMMENDATIONS: This is the first study to examine elder maltreatment in the long-term care population of Israel. The research findings produce an expanded and improved research model investigating elder maltreatment in long-term nursing homes.

Decreased prevalence of asymptomatic choroidal metastasis in disseminated breast and lung cancer: argument against screening.

AIM: To determine the frequency of visually asymptomatic choroidal metastases in patients with disseminated breast and lung carcinomas in order to establish optimal patient management policies. METHODS: All patients with confirmed metastatic disease treated in our institution between January 2002 and December 2003 were invited to undergo a funduscopic examination and a B-scan ultrasound evaluation. RESULTS: Of the 169 study participants, 77 had breast cancer (64 with metastases in one organ and 13 with multiple-organ involvement) and 92 had lung cancer (85 with metastases in one organ and 7 with multiple-organ involvement). No patient with metastatic breast cancer and two patients with metastatic lung disease (each with multiple-organ involvement) were found to have choroidal metastases. The choroidal metastases were detected by both the funduscopic and ultrasound examinations. CONCLUSIONS: The 2.17% incidence of choroidal metastasis in disseminated lung cancer and the 0% incidence in disseminated breast cancer speaks against the practicality of screening for early detection of choroidal metastasis among these patients, even though it would lead to early implementation of appropriate, often vision saving, therapeutic management. Its low incidence probably testifies to progress achieved by enhanced systemic oncological treatment policies that have been introduced into routine patient management over the past few years.

A case management demonstration project for the frail elderly in Israel.

This article presents an evaluation of an innovative community-based case management demonstration project for the frail elderly in Israel. The evaluation study was part of a nine-countries European project within the framework of the 1999 International Year of the Older People. The Department for the Aged of the Israeli Ministry of Labor and Social Affairs and the author initiated the project. The basis for the project development is described, including institutional structure, workers' qualifications, technical resources, and clients assessment criteria. The findings showed increased quality of life for the elders and their caregivers, more coordination and cooperation between various social and health services, activation of a variety of services, and client satisfaction. Recommendations are made to continue and expand this type of project to a larger segment of the elderly population.

A legislative infrastructure that fosters case management. The Israeli Long-Term Care Insurance Law.

This article presents a legislative infrastructure that fosters the development of case management model and demonstration projects within the framework of the Israeli Long-Term Care Insurance Law of 1988. A brief demographic description of the aged population of Israel is presented along with an outline of the basic policy and service structures. The basic principles of the Long-Term Care Insurance law are presented, discussed and analyzed, outlining the pathways that the law guarantees that foster case management interventions and projects.

Intergenerational family relations and social support.

A parallel process to the aging of societies in the Western world occurs in changing family structures and network compositions. The shape of families is shifting from horizontal to vertical, where the size of generations is becoming smaller but the number of living generations is increasing. Recently there is an increased emphasis in the study of intergenerational relations on the interdependence of generations. The "aging of the aged", though, means the need for more care and support. It is well documented that there is continued high involvement of families in care giving. However, as the age structure of the society and the family change so does the availability and ability for care of its networks. The presentation will, thus, discuss and analyze the following three issues: First, a theoretical perspective on family intergenerational relationships will be presented, based on social exchange theory and the intergenerational solidarity model. Empirical findings will focus on grandparent-grandchild relations and on immigrant families, stressing the importance of ethnicity. Second, care giving and support to frail elderly family members, in different types of living arrangements, will be described and analyzed, as a major topic in research and policy. Third, the relations and impact of family solidarity, support and care on the quality of life of the older people will be discussed.

Caring for parents with Alzheimer's: comparing perceptions of physical and mental health in the Jewish and Arab sectors in Israel.

This study examines the effects of demographic, ethnic, personal and familial resources on well-being--perceptions of physical and mental health--of children caring for parents with Alzheimer's, comparing Jewish and Arab caregivers. Two groups of 64 Jewish and 50 Arab caregivers were selected from a cognitive diagnostic unit operating in a geriatric rehabilitative hospital in the north of Israel. The theoretical base was family systems and stress theories, using the ABCX model. The results show that ethnicity and parent-child relations were the strongest predictors of physical and especially mental health of these caregivers, followed by employment status of the caregivers and patient's functioning.

The consequences of a major bile duct injury during laparoscopic cholecystectomy.

Bile duct injury is perhaps the most feared complication of laparoscopic cholecystectomy. The focus of this study was on the immediate and short-term outcome of patients who have undergone repair of major bile duct injuries with respect to hospital stay, perioperative interventions, and reoperations. The records of patients who underwent surgery at three academic hospitals in Philadelphia (Hospital of the University of Pennsylvania, Thomas Jefferson University Hospital, and Graduate Hospital) from 1990 to 1995 for repair of a major biliary injury following laparoscopic cholecystectomy were reviewed. A major biliary injury was defined as any disruption (including ligation, avulsion, or resection) of the extrahepatic biliary system. Small biliary leaks not requiring surgery were excluded. Thirty-two patients sustained major bile duct injuries. The injury was recognized immediately in 10 patients. The remaining 22 patients had pain (59%), jaundice (50%), and/or fever (32%) as the symptom heralding the injury. Bismuth classification was as follows: 13% of patients were class I, 63% were class II, 7% were class III, 7% were class IV, and 10% were class V. Biliary reconstruction included a Roux-en-Y hepaticojejunostomy in 30 patients and two were primary repairs. There was one postoperative death from multiorgan system failure. The mean length of hospital stay after repair was 17 +/- 8 days. Over a mean follow-up period of 11.5 +/- 10.5 months, 11 patients (38%) required 19 emergency readmissions, most commonly for cholangitis. Five patients (17%) required postoperative balloon dilatation for biliary stricture. At follow-up 18 patients (62.0%) remain asymptomatic with normal liver function, eight (28%) are experiencing episodic cholangitis, and three (10%) are asymptomatic with persistently elevated liver function values. The consequences of a major biliary tract injury following laparoscopic cholecystectomy include a complex operative repair resulting in a lengthy postoperative stay with an increased risk of death, an excessive number of perioperative diagnostic and therapeutic studies, frequent readmissions (often as emergencies), and a lifelong risk of restricture. The "cost" to these patients remains enormous.

The meaning of grandparenthood: a critical review and research agenda.

Despite the importance of grandparenthood in the personal and family context, as well as its increasing economic, political and legal implications, research addressing its meaning and significance has been sparse and characterized by theoretical and methodological limitations. The main theoretical limitation is the lack of a clear definition at the conceptual level. Methodological limitations include not only the use of small and non-inclusive samples, most of which pertain to only one or two generations, but also the lack of a well-developed multidimensional measurement approach. The aim of the present paper is to describe the status of research on the meaning of grandparenthood, and discuss its conceptual and methodological developments, especially regarding measurement issues. An example of an ongoing research program is provided as a guideline for future research.

Resources, stigma, and patterns of disclosure in rural women with HIV infection.

A growing number of cases of HIV infection are being diagnosed in rural communities especially among women. Although HIV-specific education and care delivery programs have been focused on rural areas in recent years, limited data are available on the impact of such initiatives on the lives of women with HIV infection. The purpose of this study was to examine characteristics of women with HIV disease living in rural communities. The study used a cross-sectional sample of rural women in Georgia. Data analysis indicated that although a majority of the women reported adequate resources, there was a group of women for whom resources for basic needs were not always adequate. Additionally, women with HIV who had not progressed to AIDS had greater difficulty in obtaining a number of resources. Almost half of the women felt stigmatized due to having HIV. Yet, a high percentage of these women had disclosed their HIV status to health care workers, sexual partners, and family. Study results provide insight into the needs of HIV-infected rural women from their perspective. This information can be important to nurses working in public health and community settings as they face the challenge of developing effective health care services for this population.

Suicide among the elderly in Israel.

This comparative analysis examines the data on attempted and completed suicides among the aged population (65+) in Israel to assess what changes have occurred in recent years. The sources of the data used in this review were statistics reported by the Israeli Ministry of Health and the Israeli Central Bureau of Statistics for two decades, 1962-1971 and 1977-1986, with additional data provided for previous years. Analysis of these data shows a rise in both attempted and completed suicides among the elderly in Israel over the last decade. However, a comparison with selected European and Western countries reveals that these rates are still lower than those of other Western countries. These findings are discussed within the framework of family care, religious tradition, and social policy. In light of the fact that suicide rates are shown to rise with increasing age both in Israel and in other countries, the need to understand suicide among the elderly is becoming even more urgent and should generate more research.

Cultural diversity and conflict in the health care workplace.

Cultural diversity issues affect the health care workplace and nursing practice. The Lowenstein-Glanville conflict model can be used for assessing and intervening in racial and status conflict in hospital settings. Implications for nursing practice include recognizing that cultural diversity will continue to grow in the health care workplace. Nurses must increase sensitivity, become aware of cultural nuances and issues, and make cultural assessment a routine part of their assessment and planning, not only for patient care, but also with their co-workers and subordinates.