Follow-up of Benign Thyroid Nodules-Can We Do Less?

OBJECTIVE: To determine the incidence of malignancy, follow-up ultrasound (US), and repeat fine needle aspiration (FNA) in thyroid nodules that have been previously biopsied as benign. METHODS: This is a retrospective, descriptive study of benign thyroid nodules evaluated by US between 2010-2011. We determined the frequency of follow-up ultrasounds and FNAs, mean years of follow-up, interval between follow-up US, change in nodule size, reasons for repeat FNA (rFNA), frequency of thyroidectomy, and thyroid malignancy during 5 years of follow-up. RESULTS: A total of 733 benign thyroid nodules were reviewed in 615 patients. Mean years of US follow-up was 3.47 ± 1.65 years; 275 (37.5%) had no follow-up US; 109 (14.9%) had 1 follow-up US; 93 (12.7%) had 2 follow-up US; and 256 (34.9%) had 3 or more follow-up US. Assessment of thyroid nodule size showed that 215 (28.8%) nodules decreased in size, 145 (19.4%) increased in size by less than 50%, and 91 (12.1%) increased in size by more than 50%. Of the 733 nodules, 17 nodules (2.3%) underwent thyroidectomy for which the pathology result of 9 (1.2%) showed malignancy, and 65 (8.9%) thyroid nodules underwent rFNA. When applying the 2015 recommendations for repeat FNA, 35% were done unnecessarily. CONCLUSION: In our sample of initially benign thyroid nodules, only 9 patients (1.2%) had pathology-proven malignancy after a mean follow-up of 3.5 years. Over 30% of patients had more than 3 rUSs. Decreased interval and frequency of rUS should be considered in future guidelines for thyroid management.

Retrospective Application of the 2015 American Thyroid Association Guidelines for Ultrasound Classification, Biopsy Indications, and Follow-up Imaging of Thyroid Nodules: Can Improved Reporting Decrease Testing?

INTRODUCTION: Thyroid ultrasound has been widely used to determine which nodules need further investigation. The goal of this study is to determine if using an ultrasonographic features checklist based on 2015 American Thyroid Association (ATA) guidelines can improve reporting and decrease unnecessary further testing. METHODS: In this retrospective study, ultrasonographic images of all nodules biopsied at our institution in 2014 and 2015 were reviewed by radiologists blinded to fine needle aspiration (FNA) biopsy result using a checklist. The checklist was prepared based on 2015 ATA guidelines. The ultrasonographic characteristics of thyroid nodules were compared with the result of biopsy to determine positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity for predicting malignancy. Radiologists also made an overall recommendation on need for FNA. RESULTS: A total of 425 thyroid nodule ultrasound scans were reviewed by radiologists. Biopsy results of 31 nodules were malignant and 394 were non-malignant. Malignant nodules showed higher frequency of solid composition, hypoechoechogenicity, and cervical lymph node involvement compared to benign nodules. Solid nodule composition had the highest PPV (13%) and NPV (94.7%). Extra-thyroid extension had the highest specificity (90.1%). Lesion vascularity had the highest sensitivity (83.8%), followed by hypoechogenicity (65.6%). Overall, the checklist had a positive predictive value of 9%, negative predictive value of 97.5%, sensitivity of 96.8%, and specificity of 11.14%. Radiologists determined that 10% of the nodules were very low-risk and did not require FNA. CONCLUSION: Using a checklist based on 2015 ATA guideline thyroid nodule ultrasonographic features is a sensitive tool with high NPV to predict benign thyroid nodule, thereby preventing unnecessary FNAs.

Characteristic Findings of Primary Sclerosing Cholangitis on Endoscopic Retrograde Cholangiography: Which is the Most Common Finding?

BACKGROUND: Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease and one of the most common indications for liver transplantation in adults. There are conflicting data regarding characteristic findings of PSC disease on endoscopic retrograde cholangiography (ERCP). We undertook this study to clarify whether there is a specific pattern of involvement of the biliary tract in patients with PSC and to evaluate features of PSC disease on ERCP in order to be able to manage this disease better. METHODS: This retrospective study included 45 patients admitted to Taleghani Hospital in 2004-2010 and diagnosed to have PSC on the basis of typical cholangiographic findings in combination with clinical and laboratory data. Patients suspected to have secondary sclerosing cholangitis were excluded. Demographic and clinical data were recorded, along with cholangiographic findings and the frequency of large duct and small duct PSC. RESULTS: Forty-five patients of mean age 34.8 (range 15-66) years were included. Twenty-nine patients (64.4%) had inflammatory bowel disease, and the frequency of large duct PSC and small duct PSC was 93.4% and 6.6%, respectively. The intrahepatic ducts alone were involved in 11 (24.4%) patients and the extrahepatic ducts were involved in 14 (31.1%), with 17 (37.7%) patients having both intrahepatic and extrahepatic PSC. Three (6.6%) patients did not have bile duct involvement on ERCP, and their disease was diagnosed by liver biopsy as small duct PSC. The most common type of cholangiographic feature of intrahepatic duct involvement was type 2, found in 15 (33.3%) patients, with type 3 being the most common type of extrahepatic duct involvement and detected in 16 (35.5%) patients. CONCLUSION: Our study demonstrates that the most common PSC finding on ERCP is involvement of both the extrahepatic and intrahepatic bile ducts, with small duct PSC being less common than large duct PSC.

Reviewing the effectiveness of pre-pregnancy counseling protocol on pregnancy and labor indices.

BACKGROUND: Pre-pregnancy care is considered as the services assessing and reducing the pregnancy risks through providing medical care and mental support. Therefore, a pre-pregnancy counseling protocol was prepared based on a series of guidelines. This study aimed to determine the effect of the protocol on pregnancy and labor indices. METHODS: This was a four-phase field study conducted in four randomly selected urban and rural health centers in Shahreza. In the first phase, the information including pregnancy and labor indices was extracted. The participants were all the women who had a delivery in the year before the study (census). In the second and third phases (3 and 6 months after implementing the protocol in the case centers), the process of implementing the protocol was assessed. In the fourth phase (a year later), pregnancy and labor indices were determined in case and control centers (on all the women who had labor in the year before) again and the results were compared in case and control groups as well as before and after implementing the protocol. Data was collected by reviewing documentations and using data collection forms. It was then analyzed by descriptive and analytical statistics using SPSS13. RESULTS: The obtained results indicated the positive effects of pre-pregnancy cares on cesarean indices, percentage of underlying diseases, pregnancy over the age of 35, and pregnancy intervals of less than 3 years. In addition, the protocol had been implemented correctly in 8.2% of the cases in the second phase, and in 30.2% of the cases in the third phase. CONCLUSIONS: The positive effects of pre-pregnancy cares on some of the indices raised the necessity of seriously considering and integrating this program in the routine women's health care programs. Considering that less than one-third of the staff members of the case centers had completely conducted the pre-pregnancy cares, monitoring the staff's performance is essential for improving the effectiveness of the care.

Predictive Value of Absent Septal q Wave in Patients with Significant Stenosis of Proximal Left Anterior Descending Coronary Artery.

AIMS: There is conflicting data about the predictive value of absent septal q wave in patients with significant stenosis of proximal Left Anterior Descending coronary artery. To clarify the exact role of this simple electrocardiographic sign we conducted this prospective descriptive study. METHODS: Patients who were referred for coronary angiography in Milad Hospital between December 2008 and September 2009 were chosen randomly. Standard ECG was performed and reviewed for presence or absence of septal q wave, and then the coronary angiography was done and reported by another cardiologist. RESULTS: Of 148 patients with absent septal q wave in ECG, 85 patients (57%) had significant stenosis of proximal LAD in coronary angiography. Statistical analysis showed that significant stenosis of proximal LAD could be predicted by absence of septal q wave in ECG with sensitivity of 59% and specificity of 47%. However, Kappa statistic (Kappa = 0.36) showed low agreement between them. CONCLUSION: Absence of normal septal q wave in ECG could be a low value predictor of coronary artery disease mainly significant proximal LAD stenosis.