IgG4-positive Hashimoto thyroiditis and its association with IgG4-related sclerosing disease.

A woman in her 50s was referred with suspected thyroid malignancy and underwent total thyroidectomy. Immunohistochemical analysis revealed IgG4-positive Hashimoto's thyroiditis. IgG4-related thyroid disease is poorly understood, and thought to encompass various entities including IgG4-positive Hashimoto's thyroiditis, Fibrosing Variant of Hashimoto's thyroiditis, Reidel's thyroiditis and Graves' disease with elevated IgG4 levels. Furthermore, it may be associated with a systemic fibrosing condition called 'IgG4-related sclerosing disease'. The clinical significance of IgG4-positive thyroid disease, however, remains unclear.

Elsberg syndrome following acute immunosuppressive treatment for multiple sclerosis relapse.

First described more than 80 years ago, Elsberg Syndrome (ES) continues to be an under-recognized cause of cauda equina syndrome (CES). ES is an infectious disorder that presents with lower thoracic and/or lumbosacral myelitis in conjunction with CES, and most often occurs in the setting of herpes simplex virus 2 (HSV-2) reactivation (Savoldi et al., 2017; Eberhardt et al., 2004; Whalen et al., 2019). Comorbid neurologic diseases like multiple sclerosis (MS) can become a detrimental confounding factor leading to delayed diagnosis and management of ES due to pre-existing diagnostic bias. We present a case of relapsing-remitting MS (RRMS) complicated by ES, likely due to reactivation of a latent HSV infection following high immunosuppression for presumed refractory MS relapses.

Multiple concurrent atypical parathyroid adenomas: a rare occurrence.

We present a case of an 80-year-old patient with three concurrent multiple atypical parathyroid adenomas. The patient was managed with bilateral parathyroid exploration and concurrent parathyroidectomy. Postoperative recovery was uneventful. Atypical parathyroid adenomas are a rare entity that are clinically difficult to distinguish from parathyroid carcinoma. Histological characteristics are similar however atypical adenomas lack complete capsular or vascular invasion and cannot be considered malignant. All reported cases of atypical parathyroid adenoma are solitary lesions. We present the first case of multiple concurrent atypical parathyroid adenomas.

A systematic review of the incidence of thyroid carcinoma in patients undergoing thyroidectomy for thyrotoxicosis.

INTRODUCTION: Hyperthyroidism (HT) has been associated with no insignificant rates of thyroid malignancy. There are no current specific guidelines that suggest routine preoperative imaging for thyroid nodules in patients with Grave's disease. We therefore performed a systematic review assessing rates of thyroid malignancy in patients undergoing surgery for different causes of HT: Grave's disease (GD), toxic adenoma (TA) and toxic multinodular goitre (TMNG). METHODS: Major databases (MEDLINE, PubMed and the Cochrane library) were searched to identify eligible studies. RESULTS: After searching and appraising, 33 papers were found to be eligible for analysis. The mean overall rate of malignancy was 8.5% (range 0.8%-32.4%). The mean rates based on histological subtype were as follows: papillary thyroid cancer (PTC), 3.1% (range 0%-13.2%); micropapillary carcinoma (mPTC), 5.1% (range 0%-16.9%); and follicular thyroid cancer (FTC), 0.8% (range 0%-4.4%). In those patients who had preoperative imaging, mean malignancy rates were higher in patients with pre-identified nodules (19.8%) compared to those without any nodules (8.7%). Mean rates were lower in patients with GD/diffuse goitre (5.9%) compared to patients with TA (6.5%) and TMNG (12%). CONCLUSION: Hyperthyroidism is associated with notable rates of thyroid cancer, although the mechanisms for this are not clear. The presence of nodules increases this risk. This review raises the question for considering preoperative assessment of nodules in all patients undergoing surgery for HT, in order to correctly assess and evaluate any patients with suspected concurrent thyroid malignancy, before proceeding with surgery.

A UK reported case of Graves' disease with thyroid hemiagenesis.

We present a rare case of a 31-year-old patient with Graves' disease with agenesis of the left thyroid lobe. The patient was managed with a right hemithyroidectomy and isthmusectomy as definitively treatment of Graves' disease. The patient had an uneventful postoperative outcome and the histology was benign and consistent with Graves' disease. This is a rare case in the literature of Graves' disease with unilateral thyroid agenesis, and to our knowledge is the first reported case from the UK.

Silent cerebral infarct definitions and full-scale IQ loss in children with sickle cell anemia.

OBJECTIVE: To evaluate whether application of the adult definition of silent cerebral infarct (SCI) (T2-weighted hyperintensity ≥5 mm with corresponding T1-weighted hypointensity on MRI) is associated with full-scale IQ (FSIQ) loss in children with sickle cell anemia (SCA), and if so, whether this loss is greater than that of the reference pediatric definition of SCI (T2-weighted hyperintensity ≥3 mm in children on MRI; change in FSIQ -5.2 points; p = 0.017; 95% confidence interval [CI] -9.48 to -0.93). METHODS: Among children with SCA screened for SCI in the Silent Cerebral Infarct Transfusion trial, ages 5-14 years, a total of 150 participants (107 with SCIs and 43 without SCIs) were administered the Wechsler Abbreviated Scale of Intelligence. A multivariable linear regression was used to model FSIQ in this population, with varying definitions of SCI independently substituted for the SCI covariate. RESULTS: The adult definition of SCI applied to 27% of the pediatric participants with SCIs and was not associated with a statistically significant change in FSIQ (unstandardized coefficient -3.9 points; p = 0.114; 95% CI -8.75 to 0.95), with predicted mean FSIQ of 92.1 and 96.0, respectively, for those with and without the adult definition of SCI. CONCLUSIONS: The adult definition of SCI may be too restrictive and was not associated with significant FSIQ decline in children with SCA. Based on these findings, we find no utility in applying the adult definition of SCI to children with SCA and recommend maintaining the current pediatric definition of SCI in this population.

Small cell lung cancer presenting as unilateral rhinorrhoea.

The metastatic spread of infraclavicular malignancies to the nasal cavity is rare. We describe the case of a 58-year-old man who presented with a 4-month history of right-sided rhinorrhoea, maxillary hypoesthesia, hyposmia and hypogeusia. Clinical examination revealed an irregular mass within the right nasal cavity. Immunohistochemical analyses of biopsies were consistent with small cell carcinoma of indeterminate origin. A positron emission tomography scan demonstrated extensive mediastinal lymphadenopathy with collapse-consolidation of the right lung's middle lobe and no other sites of metastasis. Following discussion at the lung multidisciplinary team meeting, a diagnosis of metastatic small cell lung cancer (SCLC) was made; the patient was staged with N3, M1b disease and palliative chemo-radiotherapy was started. To the best of our knowledge, this report represents the first documented case of a solitary nasal cavity metastasis arising from a SCLC.

Improving the ward-based care of patients post-thyroidectomy.

Nursing staff play a crucial role in managing surgical patients in the postoperative period. However, with an increasing risk of subspecialty wards facing closure as a result of financial pressures within the NHS, the knowledge base and expertise of ward-based nursing staff of surgical subspecialties is becoming increasingly limited. Using patients undergoing thyroidectomy as an example, a quality improvement multidisciplinary audit is presented, which shows how simple targeted interventions through a multidisciplinary approach can help maintain high standards of patient care in a secondary care setting.

Higher Prevalence of Human Papillomavirus-Related Cervical Precancerous Abnormalities in HIV-Infected Compared to HIV-Uninfected Women.

INTRODUCTION: Persistent high risk human papillomavirus (hrHPV) has been associated with cervical abnormalities and cancer. There are few studies comparing HIV-infected with uninfected African American women from the Southern U.S. We evaluated medical records of a women's cohort in an urban clinic in Tennessee to assess the prevalence of hrHPV and cytology correlates, as well as HPV vaccination rates. METHODS: We reviewed medical records of 50 HIV infected and 304 HIV uninfected women, including Pap smears and hrHPV. RESULTS: HIV-infected women were older than HIV-uninfected women (p<0.0001) and were more likely to have hrHPV (p=<0.0001) and LGSIL/HGSIL (p=0.006). Within the HIV uninfected group, Hispanic women were younger than non-Hispanic African American women (p=0.04) and non-Hispanic white women (p=0.0002). Non-Hispanic African-American women were younger (p=0.004) than non-Hispanic white women. Both HIV-uninfected and HIV-infected women had an 11-fold and 5-fold odds, respectively, of having precancerous lesions when harboring hrHPV, compared to hrHPV-uninfected women. Of the 125 HIV-uninfected women, only 17% had received at least one dose of the HPV vaccine. None of the 21 vaccine recipients had evidence of SILs compared to 9% of vaccine non-recipients (p=0.35, Fisher's exact test). CONCLUSION: HIV-infected women remained at significantly higher risk for developing cervical precancerous lesions when exposed to hrHPV than their uninfected counterparts. Hispanic women were least likely to have been vaccinated. Missed HPV vaccination trended towards being associated with a higher odds of precancerous lesions. Routine HPV vaccination should be reinforced for adolescents and young women using public hospital facilities of all races and ethnic backgrounds.

Endoscopic management of antrochoanal polyps: a single UK centre's experience.

Antrochoanal polyps (ACPs) are benign lesions that originate from the mucosa of the maxillary sinus, and extend into the nasal cavity to reach the choana and nasopharynx. The treatment of ACPs is surgical, with a number of different surgical techniques having been described. We describe the first case series of ACPs from the UK and the endoscopic surgical technique that we have employed. A retrospective case note review of patients with ACPs managed under the care of the senior author was conducted. Demographic and clinical data for all patients were reviewed. The main outcome parameter measured was any sign of recurrence. A total of 29 consecutive patients were included for analysis from a 5-year study period, with 19 males and 10 females, and a mean age of 37.4 ± 13.6 years. Four patients within our group were referred to us with recurrent ACPs for revision surgery. All patients underwent surgery via the same endoscopic technique. The mean follow-up period was 14.7 ± 16.9 months, with an average follow-up of 22.5 months for the four revision cases. There were no recurrences in any of our patients. We describe the first reported series of endoscopic sinus surgery for antrochoanal polyps in the UK, and the largest worldwide series described for endoscopic management of ACPs in adults. We have had no recurrent cases, with a mean follow-up period of 14.7 months.

Z-plasty of the alar subunit to correct nasal vestibular stenosis.

Nasal vestibular stenosis can result in a challenging cosmetic deformity, for which a variety of techniques have been described, including scar excision and replacement with local flaps, composite or cartilage grafts, with or without stents. We describe the Z-plasty technique to widen the alar base and assess patient satisfaction from the surgery. A retrospective review of patients who underwent Z-plasty to the alar subunit for nasal vestibular stenosis over a 4-year period was conducted. Demographic data and patient satisfaction were evaluated using pre- and postoperative visual analog scores and Rhinoplasty Outcome Evaluation questionnaires. Eight patients underwent the procedure, and all confirmed significant improvement in their esthetic outcome. We describe our Z-plasty technique to the alar base and review patient satisfaction.

A multidisciplinary audit of head and neck referrals: considerations for patients' timelines and outcomes.

The Rapid Diagnostic Clinic (RDC) was introduced to comply with NICE recommendations for improving head and neck cancer services (National Institute of Clinical Excellence 2004 Improving outcomes in head and neck cancer: the manual. NICE, London). It provides multi-modality specialist assessment for new referrals, with on-site sonography and cytology. We have critically appraised the efficacy of our RDC, with respect to its impact on patients' timelines and outcomes. A retrospective audit of new referrals to the head and neck clinic during a 6-month period was conducted (pre-RDC period); areas in delay in patients reaching a definitive outcome were identified. Following implementation of the RDC, a second cycle, prospective audit was performed and its impact on timelines for patients' journey and outcomes determined. One hundred and ninety-seven patients were seen during the pre-RDC period. The average time from referral to being seen was 11 days for 2-week wait (2WW) referrals and 34 days for other sources. During the RDC period, 299 patients were seen in total. The average waiting time was reduced to 9 days for 2WW referrals and 23 days for other referrals. During the RDC period, over one-third of patients utilised the provision of ultrasound ± FNAC, and consequently, the majority reached a definitive outcome (discharged or scheduled for surgery) following their first consultation. This was a significant improvement compared to the pre-RDC period, where the main outcome was referral for an investigation, with consequently longer waiting time for surgery. We report the first study to consider the effect of a 'one-stop' clinic on patients' journey timelines and outcomes. Our study has shown that the RDC provides an efficient and effective system, which facilitates the patients' pathway to a definitive management plan.

Branchiootic syndrome--a clinical case report and review of the literature.

Branchiootoic syndrome is part of the spectrum of brachiootorenal disorders. Brachiootorenal disorder is a rare autosomal dominant condition, characterized by malformations of the outer, middle, and inner ear, which are associated with branchial and renal anomalies. We describe a case of bilateral branchiootoic syndrome and discuss the anatomy of second branchial cleft fistulae and the surgical management of this uncommon condition. We report the case of a 6-year-old girl referred to our department with bilateral intermittently discharging neck swellings. Clinical examination revealed bilateral branchial fistulae and preauricular sinuses, on a background of a positive family history of branchial fistulae. A magnetic resonance imaging scan confirmed the diagnosis of bilateral second branchial cleft fistulae. In view of her symptoms, she underwent bilateral branchial fistula excision and tonsillectomy with an uneventful postoperative recovery.