Contemporary Management of Thyroid Nodules.

Thyroid nodules are common in the general population, with higher prevalence in women and with advancing age. Approximately 5% of thyroid nodules are malignant; the majority of this subset represents papillary thyroid cancer. Ultrasonography is the standard technique to assess the underlying thyroid parenchyma, characterize the features of thyroid nodules, and evaluate for abnormal cervical lymphadenopathy. Various risk stratification systems exist to categorize the risk of malignancy based on the ultrasound appearance of a thyroid nodule. Nodules are selected for fine-needle aspiration biopsy on the basis of ultrasound features, size, and high-risk clinical history. Cytology results are classified by the Bethesda system into six categories ranging from benign to malignant. When cytology is indeterminate, molecular testing can further risk-stratify patients for observation or surgery. Surveillance is indicated for nodules with benign cytology, indeterminate cytology with reassuring molecular testing, or non-biopsied nodules without a benign sonographic appearance.

Macrocalcifications Do Not Alter Malignancy Risk Within the American Thyroid Association Sonographic Pattern System When Present in Non-High Suspicion Thyroid Nodules.

Background: The American Thyroid Association Sonographic Pattern System (ATASPS) depicts five levels of suspicion for malignancy based on the sonographic appearance of a thyroid nodule. However, 3-37% of nodules are non-classifiable when the combination of grayscale findings is not depicted by the ATASPS. The only calcifications included in the ATASPS are in solid hypoechoic high suspicion (HS) nodules and include both microcalcifications and peripheral interrupted calcifications with soft tissue extrusion. Non-hypoechoic nodules with these and other calcification patterns, which we defined as non-high suspicion calcifications (NHSC), are not classifiable by ATASPS. We assessed the effect of assigning an ATASPS risk level to nodules with NHSC based on analysis of their other grayscale features. Methods: A retrospective review of 728 consecutively biopsied nodules was performed. Nodules were classified by ATASPS as HS, intermediate suspicion (IS), low suspicion (LS), or very low suspicion (VLS); other nodules with patterns not described by ATASPS were non-classifiable (NC). If NC was due to NHSC, the nodule was assigned an ATASPS by analysis of grayscale features alone. Cytology and pathology results were correlated with assigned ATASPS level. Results: A NC pattern was observed in 144 of the 728 nodules (20%). Of these, 101/144 (70%) had NHSC and the assigned ATASPS was IS (n = 18), LS (n = 62) and VLS (n = 21). The distribution of cytology diagnoses within this group was similar to classifiable nodules (IS p = 0.13, LS p = 0.55, VLS p = 0.44). The majority of NHSC (n = 92, 91%) were macrocalcifications (large central or linear dystrophic calcifications); however, 9 LS pattern nodules had punctate echogenic foci, possibly representing microcalcifcations, with an estimated cancer prevalence of 19% (vs. 10% for total LS group, p = 0.24). The remaining NC nodules (43/144, 30%) included solid nodules with heterogeneous echogenicity (n = 30) or presence of a complete circumferential rim calcification, limiting further sonographic assessment (n = 13). Malignancy was identified in 11 out of 43 (26%) of these [9/30 (30%) heterogeneous solid and 2/13 (15%) with complete rim calcifications]. Conclusions: Macrocalcifications accounted for the majority of NHSC and these did not alter the expected ATASPS malignancy risk based on grayscale features.

Hyperthyroidism and Pregnancy.

Clinical hyperthyroidism affects 0.1% to 0.4% of pregnancies. Gestational thyrotoxicosis is due to homology of the structure of TSH and HCG, which weakly stimulates the TSH receptor. Graves' disease (GD) most commonly causes clinically significant hyperthyroidism. Given concerns for teratogenicity from antithyroid drugs, these may be discontinued in low-risk GD patients. High-risk patients are treated with propylthiouracil in the first trimester then may transition to methimazole. Surgery is reserved for special circumstances; radioactive iodine is contraindicated. In late pregnancy, GD may remit; postpartum relapse is common. Measurement of serum thyrotropin receptor antibodies identifies pregnancies at-risk for fetal and neonatal hyperthyroidism.

Clinical review: Thyroid cancer mimics on surveillance neck sonography.

Sonography of the neck is a critical tool in monitoring patients after near-total thyroidectomy for differentiated thyroid cancer. Sonography has proven to be among the most sensitive imaging techniques for the detection of recurrent or residual cancer in the thyroidectomy bed and metastatic cervical lymph nodes. It is important for the sonologist to be familiar with normal postsurgical findings and other disease processes that may imitate malignant lesions. We describe the typical sonographic appearance of benign lesions that can resemble recurrent thyroid cancer.

Parent-of-origin effects on glucose homeostasis in polycystic ovary syndrome.

CONTEXT: Polycystic ovary syndrome (PCOS) is a highly heritable complex trait. Parents of affected women have reproductive and metabolic phenotypes. OBJECTIVE: We tested the hypothesis that there are parental effects on the heritability of fasting dysglycemia in women with PCOS. DESIGN AND SETTING: This was a cross-sectional study at an academic medical center. PARTICIPANTS: PARTICIPANTS included 367 women with PCOS and their parents (1101 total subjects). MAIN OUTCOME MEASURES: We compared maternal and paternal contributions to heritability of fasting dysglycemia and to transmission of the PCOS susceptibility allele of D19S884 within the fibrillin-3 gene (D19S884-A8) on fasting dysglycemia. RESULTS: Fathers had higher fasting glucose levels, prevalence of fasting dysglycemia and proinsulin to insulin molar ratios (P < .0001), a marker of defective insulin processing, compared with mothers. Heritability of fasting dysglycemia was significant in PCOS families (h(2) = 37%, SE = 10%, P = .001). Maternal heritability (h(2) = 51%, SE = 15%, P = .0009) was higher than paternal heritability (h(2) = 23 %, SE = 23%, P = .186) of fasting dysglycemia after adjustment for age and body mass index. Within dysglycemic probands, there was increased maternal compared with paternal transmission of D19S884-A8 (maternal 84% vs paternal 45%, χ(2) = 6.51, P = .011). CONCLUSIONS: There was a sex difference in the parental metabolic phenotype with fathers having an increased risk of fasting dysglycemia and evidence for pancreatic ß-cell dysfunction compared with mothers. However, only maternal heritability had significant effects on the prevalence of fasting dysglycemia in women with PCOS. Furthermore, there were maternal parent-of-origin effects on transmission of D19S884-A8 probands with fasting dysglycemia. These findings suggest that maternal factors, genetic and perhaps epigenetic, contribute to the metabolic phenotype in affected women.

Effects of occlusion on the skin of atopic dermatitis patients.

BACKGROUND: Atopic dermatitis (AD) may be exacerbated by occlusion from items such as occlusive gloves or textiles, especially if the occlusion is removed suddenly, creating a steep humidity gradient. Most previous studies of occlusion have focused on normal skin. Occlusion has been shown to be beneficial in psoriatic skin, but many atopic patients complain of increased inflammation after occlusion. OBJECTIVE: To evaluate the response of noninflamed AD skin to occlusion. METHODS: Six patients with AD were patch-tested with occlusive polyethylene wrap and sodium lauryl sulfate (SLS) in standard Finn Chambers taped to noninflamed skin of the back. Cytokine and chemokine messenger ribonucleic acid (mRNA) for interleukin-8 (IL-8), interleukin-1 alpha (IL-1α), and interleukin-1 receptor antagonist (IL-1RA), as well as the 18S rRNA housekeeping gene, was obtained via tape-stripping the skin and measured using quantitative real-time polymerase chain reaction. We also measured transepidermal water loss after removal of occlusion. RESULTS: Polyethylene occlusion alone with abrupt removal induced IL-8 and IL-1α levels similar to or exceeding that of SLS. IL-1RA was up-regulated by SLS and occlusion, with SLS showing a stronger response. CONCLUSION: Removal of occlusion with polyethylene film up-regulates the inflammatory cytokines IL-8, IL-1α, and IL-1RA in patients with AD. This may explain the worsening of AD with the use of occlusive gloves, athletic equipment, and fabrics.

Outcomes of extremely low birth weight (<1 kg) and extremely low gestational age (<28 weeks) infants with bronchopulmonary dysplasia: effects of practice changes in 2000 to 2003.

OBJECTIVE: The goal was to evaluate whether changes in neonatal intensive care have improved outcomes for children with bronchopulmonary dysplasia (oxygen dependence at corrected age of 36 weeks). METHODS: We compared outcomes of extremely low birth weight (<1 kg) and extremely low gestational age (<28 weeks) infants with bronchopulmonary dysplasia between 2 periods (period I, 1996-1999: extremely low birth weight, n = 122; extremely low gestational age, n = 118; period II, 2000-2003: extremely low birth weight, n = 109; extremely low gestational age, n = 107). RESULTS: For both groups, significant practice changes between period I and period II included increased prenatal and decreased postnatal steroid therapy and increased surfactant therapy, indomethacin therapy, and patent ductus arteriosus ligation. Significant morbidity changes included decreased rates of severe cranial ultrasound abnormalities and increased rates of ventilator dependence. Rates of bronchopulmonary dysplasia did not change (52% vs 53%). Follow-up evaluation revealed significantly lower rates of neurosensory abnormalities during period II (extremely low birth weight: 29% vs 16%; extremely low gestational age: 31% vs 16%). There were no changes in rates of Mental Developmental Index scores of <70 (extremely low birth weight: 42% vs 42%; extremely low gestational age: 37% vs 45%) or overall developmental impairment (extremely low birth weight: 51% vs 49%; extremely low gestational age: 50% vs 51%). For the extremely low gestational age group, predictors of neurosensory abnormalities were severe cranial ultrasound abnormality and postnatal steroid therapy. Predictors of overall impairment included severe cranial ultrasound abnormalities, ventilator dependence, postnatal steroid therapy, and patent ductus arteriosus ligation. For the extremely low birth weight group, the only predictor of neurosensory abnormalities was severe cranial ultrasound abnormality. Predictors of overall impairment included multiple birth, ventilator dependence, and severe cranial ultrasound abnormalities. CONCLUSIONS: Neurosensory outcomes of infants with bronchopulmonary dysplasia improved during 2000 to 2003 but overall neurodevelopmental outcomes did not change.