Recent advances in the arena of theranostics have necessitated a re-examining of previously established fields. The existing paradigm of therapeutic thyroid-stimulating hormone receptor (TSHR) ...targeting in the post-surgical management of differentiated thyroid cancer using levothyroxine and recombinant human thyroid-stimulating hormone (TSH) is well understood. However, in an era of personalized medicine, and with an increasing awareness of the risk profile of longstanding pharmacological hyperthyroidism, it is imperative clinicians understand the molecular basis and magnitude of benefit for individual patients. Furthermore, TSHR has been recently re-conceived as a selective target for residual metastatic thyroid cancer, with pilot data demonstrating effective targeting of nanoparticles to thyroid cancers using this receptor as a target. This review examines the evidence for TSHR signaling as an oncogenic pathway and assesses the evidence for ongoing TSHR expression in thyroid cancer metastases. Priorities for further research are highlighted.
Purpose
Prehospital guidelines stratify and manage patients with Glasgow Coma Scale (GCS) less than nine and any sign of head injury as affected by severe traumatic brain injury (STBI). We ...hypothesized that this group of patients is so inhomogeneous that uniform treatment guidelines cannot be advocated.
Methods
Patients (2005–2012) with prehospital GCS below nine and abbreviated injury scale head and neck above two were identified from trauma registry. Patients with acute lethal injuries, isolated neck injuries, extubated within 24 h or transferred interhospitally were excluded. Patients were dichotomized based on the worst prehospital GCS (recorded before sedatives) into two groups: GCS 3–5 and GCS 6–8. These were statistically compared using univariate analysis.
Results
The GCS 3–5 group (99 patients) when compared with the GCS 6–8 group (49 patients) had shorter prehospital times (63 vs. 79 min;
p
< 0.05), more frequent episodes of both hypoxia (30.3% vs. 7.7%;
p
< 0.05) and hypotension (26.7% vs. 6.4%;
p
< 0.05), more often required craniectomy (15.1% vs. 4.0%;
p
= 0.05) and higher mortality (33.3% vs. 2%;
p
< 0.05). In the GCS 3–5 group, prehospital endotracheal intubation was attempted more often (57.5% vs. 28.6%,
p
< 0.05) and was more often successful (39.3% vs. 10.2%;
p
= 0.05). Length of stay in ICU did not differ.
Conclusions
STBI patients are fundamentally different based on whether their initial GCS falls into 3–5 or 6–8 category. Recommendations from trials investigating trauma patients with GCS less than nine as one group should be translated with caution to clinical practice.
The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were ...identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.
In 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of ...conservative treatment, timing of surgery and indications for laparoscopy.
In absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay.NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution, surgery is recommended.Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not decrease recurrence rates or recurrences needing surgery.Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin decrease incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.
The role of invasive intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (STBI) remain unclear. Perfusion computed tomography (CTP) provides crucial information ...about the cerebral perfusion status in these patients. We hypothesised that CTP abnormalities would be associated with the severity of intracranial hypertension (ICH). To investigate this hypothesis, twenty-eight patients with STBI and ICP monitors were investigated with CTP within 48 h from admission. Treating teams were blind to these results. Patients were divided into five groups based on increasing intervention required to control ICH and were compared. Group I required no intervention above routine sedation, group II required a single first tier intervention, group III required multiple different first-tier interventions, group IV required second-tier medical therapy and group V required second-tier surgical therapy. Analysis of the results showed demographics and injury severity did not differ among groups. In group I no patients showed CTP abnormality, while patients in all other groups had abnormal CTP (p = 0.003). Severe ischaemia observed on CTP was associated with increasing intervention for ICH. This study, although limited by small sample size, suggests that CTP abnormalities are associated with the need to intervene for ICH. Larger scale assessment of our results is warranted to potentially avoid unnecessary invasive procedures in head injury patients.
Abstract
Background
Recent trauma guidelines recommend non-operative management for grade III splenic injury without contrast extravasation on computed tomography. Nevertheless, such recommendations ...rely on low-quality evidence, and practice variation characterizes clinical management for this type of injury. We aimed to identify the role of eleven selected clinical factors influencing the management of grade III splenic injury without contrast extravasation by expert consensus and a modified Delphi approach.
Methods
A questionnaire was developed with the endorsement of the World Society of Emergency Surgery (WSES). This was delivered and answered live by acute care surgeons attending the 6
th
WSES congress in Nijmegen in 2019. A dedicated mobile phone application was utilized to collect the answers. All answers were evaluated for areas of discrepancy with an 80% threshold for consensus between respondents.
Results
Three factors generated discrepancy in opinion for managing this pattern of injury: the patients’ injury severity, the presence of a bleeding diathesis, and an associated intra-abdominal injury. Agreement was obtained for the other eight factors.
Conclusion
Researchers should focus their efforts on the identified area of discrepancy. Clinicians should use additional care in the presence of the three factors for which discordant opinions were found.
Abstract Background The role of brain CT perfusion (CTP) imaging in severe traumatic brain injury (STBI) is unclear. We hypothesised that in STBI early CTP may provide additional information beyond ...the non contrast CT (NCCT). Methods Subset analysis of an ongoing prospective observational study on trauma patients with STBI who did not require craniectomy and deteriorated or failed to improve neurologically during the first 48 h from trauma. Subsequently to follow-up NCCT, a CTP was obtained. Additional findings were defined as an area of altered perfusion on CTP larger than the abnormal area detected by the simultaneous NCCT. Patients who had additional finding (A-CTP) were compared with patients who did not have additional findings (NA-CTP). Results Study population was 30 patients male: 90%, mean age: 38.6 (SD 16.9), blunt trauma: 100%; prehospital intubation: 6 (20%); lowest GCS before intubation: 5.1 (SD 2.0); mean ISS: 30.5 (SD 8.3); mean head and neck AIS: 4.4 (SD 0.8). Days in ICU: 10.2 (SD 6.3). Intracranial pressure (ICP) monitored in 12 (40%). Mean highest ICP in mmHg: 30.1 (SD14.1). There were five (17%) deaths. Findings of NCCT: primarily diffuse axonal injury (DAI) pattern in seven (23%), primarily haematoma in ten (33%), and primarily intracerebral contusion in nine (30%). CTP was performed 24.9 (SD 13) hours from trauma. There were 18 (60%) patients in the A-CTP group and 12 (40.0%) in NA-CTP. The A-CTP group was older (41.7 (SD16.9) vs 27.7 (SD 12.8): P < 0.02) and showed on admission NCCT presence of cerebral contusion and absence of DAI. The degree of hypoperfusion was found to be severe enough to be in the ischaemic range in eight patients (27%). CTP altered clinical management in three patients (10%), who were diagnosed with massive and unsurvivable strokes despite minimal changes on NCCT. Conclusion When compared to NCCT, CTP provided additional diagnostic information in 60% of patients with STBI. CTP altered clinical management in 10% of patients.
Permanent hypoparathyroidism, a feared thyroidectomy complication, leads to significant patient morbidity, medical treatment, and monitoring. This study explores whether preoperative high-dose ...vitamin D loading decreases the incidence of permanent hypoparathyroidism. In a subgroup analysis, the study examines the predictive utility of day 1 parathyroid hormone (PTH) in permanent hypoparathyroidism. Patients (
= 150) were previously recruited in the VItamin D In Thyroidectomy (VIDIT) trial, a multicentre, randomised, double blind, placebo-controlled trial evaluating the role of 300,000 IU cholecalciferol administered orally a week before total thyroidectomy. Patients were contacted postoperatively beyond six months through a telephonic questionnaire. The primary outcome was permanent hypoparathyroidism, strictly defined as the need for activated vitamin D six months postoperatively. Out of 150 patients, 130 (86.7%) were contactable. Permanent hypoparathyroidism occurred in 11/130 (8.5%) patients, with a lower incidence of 5.3% (3/57) in the cholecalciferol group compared to 11% (8/73) in the placebo group; however, this was non-significant (
= 0.34). In a subgroup analysis, no relationship between day 1 PTH level and the incidence of permanent hypoparathyroidism was found (
≥ 0.99). There was a lower rate of permanent hypoparathyroidism in the cholecalciferol group, which was not significant. The predictive utility of day 1 postoperative PTH levels may be limited to transient hypoparathyroidism.
Nerves and neurotrophic growth factors are emerging promoters of cancer growth. The precursor for Nerve Growth Factor (proNGF) is overexpressed in thyroid cancer, but its potential role as a clinical ...biomarker has not been reported. Here we have examined the value of proNGF as a serum and biopsy-rinse biomarker for thyroid cancer diagnosis.
Patients presenting for thyroid surgery or biopsy were enrolled in separate cohorts examining serum (n = 204, including 46 cases of thyroid cancer) and biopsy-rinse specimens (n = 188, including 26 cases of thyroid cancer). ProNGF levels in clinical samples were analysed by ELISA. Univariate and multivariate statistical analyses were used to compare proNGF levels with malignancy status and clinicopathological parameters.
ProNGF was not detected in the majority of serum samples (176/204, 86%) and the detection of proNGF was not associated with thyroid cancer diagnosis. In the few cases where proNGF was detected in the serum, thyroidectomy did not affect proNGF concentration, demonstrating that the thyroid was not the source of serum proNGF. Intriguingly, an association between hyperthyroidism and serum proNGF was observed (OR 3.3, 95% CI 1.6-8.7 p = 0.02). In biopsy-rinse, proNGF was detected in 73/188 (39%) cases, with no association between proNGF and thyroid cancer. However, a significant positive association between follicular lesions and biopsy-rinse proNGF was found (OR 3.3, 95% CI 1.2-8.7, p = 0.02).
ProNGF levels in serum and biopsy-rinse are not increased in thyroid cancer and therefore proNGF is not a clinical biomarker for this condition.
PDF
