Primary tumour size is a prognostic parameter in patients suffering from differentiated thyroid carcinoma with extrathyroidal growth: results of the MSDS trial.

OBJECTIVE: The Multicentre Study Differentiated Thyroid Cancer (MSDS) collective represents a well-defined group of patients with thyroid carcinomas with extrathyroidal extension. The aim of the present study was to evaluate the relationship of the primary tumour size with clinicopathological features as well as the outcome of patients with minimum and extensive extrathyroidal growth (pT3b- and pT4a-tumours; UICC 2002/2003, 6th ed). METHODS: The tumour diameter was available in 324 out of 351 MSDS patients (244 females, 80 males). Mean age of patients was 47.7±12.0 years (range, 20.1-69.8 years), and the median follow-up was 6.2 years. The relationship between primary tumour size and the following clinicopathological data was investigated: age, gender, histological tumour type (papillary thyroid carcinomas (PTC) versus follicular thyroid carcinomas (FTC)) and UICC/AJCC TNM classification. In addition, the correlation between primary tumour size and event-free and overall survival was assessed. RESULTS: The FTC of our series were significantly larger than PTC (3.46 vs 1.84 cm; P<0.001). Patients suffering from pT3b-tumours presented with significantly smaller tumour size than those with extensive extrathyroidal growth (pT4a-tumours) (1.9 vs 3.0 cm; P<0.01). All patients with distant metastases suffered from tumours >2 cm. Furthermore, event-free and overall survival were significantly correlated with increasing tumour size (P<0.05). Using multivariate analysis, a pT4a-category and a tumour diameter >2 cm remained independent predictors of survival. CONCLUSIONS: In patients suffering from differentiated thyroid carcinoma with extrathyroidal growth (pT3b and pT4a), the tumour size is an independent predictor of event-free and overall survival.

Insulin leakage value in relation to pen needle length and administered dose after subcutaneous injection.

OBJECTIVE: During a subcutaneous injection with commonly used pen needles, the safety of drug administration plays an essential role. Today short needles with a length of 5.0 mm are increasingly being used. However, so far it is unresolved whether short needles of <5.0 mm affect the safety of insulin injections because of an increased backflow to the skin surface. We examined the influence of needle length and administered insulin dosage on the insulin backflow and the distribution of human insulin in the tissue by a quantitative determination of the amount of backflow of insulin to the skin surface. For the first time a new 4.5-mm pen needle was examined for its administration safety. RESEARCH DESIGN: Human insulin was radioactively marked. By means of an insulin pen different insulin dosages with pen needles of different lengths into fresh pork rind (ex vivo model) were administered. The amount of the marked insulin leaking from the tissues at the injection site was covered and absorbed immediately into a cotton swab. The amount of leakage was calculated by means of the radioactivity taken up by the swab. RESULTS: The amount of leakage for each measurement was less than 1% of the total dosage administered. The amount of leakage increased with increased dosage administered in absolute terms, but expressed as a percentage of the increased dosage administered the leakage decreased. CONCLUSION: The needle length (between 12 mm and 4.5 mm) did not have a meaningful influence on the amount of leakage; however, significant differences with different needle lengths could be observed.

Comparison of 4 different types of surgical gloves used for preventing blood contact.

BACKGROUND: Needlestick injuries are always associated with a risk of infection, because these types of punctures may expose healthcare workers to a patient's blood and/or body fluids. OBJECTIVE: To compare the efficacy of 4 different types of surgical gloves for preventing exposure to blood as a result of needlestick injury. METHODS: For simulation of needlestick injury, a circular sample of pork skin was tightened onto a bracket, and a single finger from a medical glove was stretched over the sample. First, a powder-free surgical glove with a gel coating was used to test blood contact. Second, a glove with a patented puncture indication system was used to test blood contact with a double-gloved hand. Third, 2 powder-free latex medical gloves of the same size and hand were combined for double gloving, again to test blood contact. Finally, we tested a glove with an integrated disinfectant on the inside. The punctures were carried out using diverse sharp surgical devices that were contaminated with (99)Tc-marked blood. The amount of blood contact was determined from the transmitted radioactivity. RESULTS: For the powder-free surgical glove with a gel coating, a mean volume of 0.048 microL of blood (standard error of the mean [SEM], 0.077 microL) was transferred in punctures with an automated lancet at a depth of 2.4 mm through 1 layer of latex. For the glove with an integrated disinfectant on the inside, the mean volume of blood transferred was 0.030 microL (SEM, 0.0056 microL) with a single glove and was 0.024 microL (SEM, 0.003 microL) with 2 gloves. For the glove with the patented puncture indication system, a mean volume of 0.024 microL (SEM, 0.003 microL) of blood was transferred. CONCLUSIONS: Double gloving or the use of a glove with disinfectant can result in a decrease in the volume of blood transferred. Therefore, the use of either of these gloving systems could help to minimize the risk of bloodborne infections for medical staff.

Cardiac neurotransmission imaging with 123I-meta-iodobenzylguanidine in postural tachycardia syndrome.

BACKGROUND: Postural orthostatic tachycardia syndrome (POTS) is a disorder of orthostatic intolerance characterised by excessive tachycardia of unknown aetiology. Whether this condition involves abnormal cardiac sympathetic innervation or function remains elusive. Meta-iodobenzylguanidine (MIBG) resembles guanethidine and is a pharmacologically inactive analogue of norepinephrine, which is similarly metabolised in noradrenergic neurons. MIBG myocardial scintigraphy is used clinically to estimate local myocardial sympathetic nerve damage in some forms of heart disease and autonomic neuropathy. The objective of this study was to evaluate cardiac sympathetic innervation in patients with POTS. METHODS: 20 patients with POTS were studied using (123)I-MIBG-single photon emission computed tomography, standardised autonomic testing, assessment of catecholamine plasma levels and sympathetic skin response. RESULTS: In four POTS patients (20.0%), myocardial MIBG uptake was markedly decreased. The mean heart to mediastinum ratio was reduced to 1.22+/-0.08 compared with the normal range of >1.7. No correlation was found between myocardial MIBG uptake and degree of postural tachycardia, baroreflex sensitivity, catecholamine plasma levels or other autonomic parameters. Sympathetic skin responses were normal in all patients. CONCLUSIONS: These findings suggest that POTS may be, in part, a manifestation of autonomic cardiac neuropathy. MIBG myocardial scintigraphy may be helpful to distinguish patients with neuropathic POTS from patients with orthostatic intolerance of other origin.

Cardiac denervation in postural tachycardia syndrome.

Myocardial 123I-Meta-iodobenzylguanidine uptake was markedly reduced in a patient with postural tachycardia syndrome (POTS). This finding suggests that loss of sympathetic autonomic neurons in the heart may play a role in the etiology of POTS.

Evaluation of renovascular hypertension: comparison of functional MRI and contrast-enhanced MRA with a routinely performed renal scintigraphy and DSA.

OBJECTIVE: The main objective of this study was to evaluate a clinically suspected renovascular hypertension (RVH) by means of MRI. It was to find out if functional MRI (fMRI) is able to provide adequate results with regard to MAG3 captopril scintigraphy and if contrast-enhanced MR angiography (MRA) is able to provide adequate results in the stenosis grading compared with the nonselective digital subtraction angiography (DSA). METHODS: This open, monocentric, prospective, phase 3 study included patients with a clinically suspected RVH. For fMRI a dynamic TurboFLASH sequence and for MRA a single-shot breath-hold flash 3D sequence was performed. Gadodiamide was injected as contrast medium. RESULTS: Sixty patients were included in the study. The correlation between fMRI and scintigraphy had an accuracy, a sensitivity, and a specificity of 69%, 5%, and 92%, respectively, and correlations between MRA and DSA of 95%, 92%, and 96%. CONCLUSION: The noninvasive MRA can replace DSA in the diagnosis of renal artery stenosis. However, fMRI can not replace renal scintigraphy.

Three-dimensional localization of sentinel lymph nodes using combined emission and transmission SPECT data.

PURPOSE: With conventional planar imaging, preoperative anatomic localization of a sentinel lymph node is possible in only two dimensions. To improve spatial localization of sentinel lymph nodes, a dual-head camera equipped with a transmission source was used to create combined transmission-emission SPECT images in a patient with a malignant melanoma of the left forearm. METHODS: Lymph node scintigraphy was performed after injection of Tc-99m-labeled nanocolloid around the tumor site 1 day before operation. SPECT was performed using a gamma camera equipped with a transmission collimator system originally designed to correct attenuation. Transmission and emission images were created simultaneously, matched, and displayed in three dimensions. RESULTS: In the combined emission-transmission images, the sentinel lymph node was clearly located in the left axilla. The lymph nodes could be identified during operation at the same location as that detected by SPECT. Based on preoperative information, the sentinel lymph node was identified rapidly and the extent and duration of the operation were minimized. CONCLUSIONS: This method provides better anatomic information, especially in deep structures such as the axilla or pelvis. With accurate three-dimensional preoperative information, intraoperative access is quicker and less invasive for the patient.