Presentazione a cura della Dottoressa Rosella Pasqualoni e del dottor Gregorio Reda - "TIROIDE 2018 Nuovi approcci diagnostici e terapeutici" - Roma 24/11/2018
06 acute coronary syndromes is there a place for a real pre hospital treatmen...NPSAIC
1) The management of acute coronary syndrome (ACS) patients requires close collaboration between emergency physicians and cardiologists according to simplified protocols.
2) Key challenges for pre-hospital ACS management include precise knowledge of new drugs, developing regional hospital cooperation, organizing the healthcare network, and regularly analyzing practices.
3) The emergency physician must adapt strategies to international guidelines and the patient's needs, routing high-risk patients directly to catheterization facilities within recommended time limits.
This systematic review and meta-analysis compares appendectomy (ST) to antibiotic therapy (AT) for uncomplicated acute appendicitis (AA) in adults. Five randomized controlled trials with 1,351 patients were included. The analysis found higher treatment efficacy based on 1-year follow-up for ST (98.3%) compared to AT (75.9%). AT was associated with higher rates of complicated appendicitis with peritonitis identified at surgery (19.9% for AT vs 8.5% for ST). No significant differences were found for post-intervention complications, length of hospital stay, or period of sick leave. The review concludes that while AT may be considered for select patients, appende
This document summarizes a study examining biases that could affect the diagnostic accuracy of CT scans and MRI for detecting appendicitis in pediatric patients. It notes several potential biases including: selection bias from only enrolling patients over 12 years old; information bias from differences in protocols for oral contrast and radiologist experience levels; and confounding biases from longer interpretation times for MRI and differences in experience between abdominal and pediatric radiologists. The study included 48 patients ages 12-20 years old who received CT scans and MRI reads by both abdominal and pediatric radiologists to evaluate differences in diagnostic performance between imaging modalities and reader specialties.
This survey aimed to assess clinicians' use of stereotactic radiotherapy and targeted therapies for metastatic renal cell carcinoma and determine support for future clinical trials. The primary objective was to evaluate the proportion of clinicians using radiotherapy for metastatic renal cell carcinoma. Secondary objectives included evaluating the proportion using targeted therapies and radiotherapy simultaneously, stopping targeted therapies for radiotherapy, and supporting further research. The online survey was distributed to members of urology and oncology groups in Australia and New Zealand to collect data on current practices. Results and conclusions will be presented at an upcoming conference.
This study evaluated the diagnostic accuracy of CT scans for detecting injuries in 100 patients with blunt abdominal trauma. CT scans had high sensitivity for liver (100%) and spleen (86.6%) injuries. Specificity was highest for retroperitoneal hematoma (100%) and kidney injuries (93.5%). The accuracy of CT scans for detecting injuries to spleen, liver, kidney, and retroperitoneal hematoma ranged from 91.6% to 96.1%. The study concluded that CT scans are a good tool for evaluating blunt abdominal trauma in teaching hospitals.
18 stent for life initiative placed at the forefront in egypt 2011NPSAIC
1. The Stent for Life registry in Egypt aimed to assess the current situation for patients presenting with STEMI and identify barriers to appropriate care.
2. The registry involved 1,324 consecutive STEMI patients treated at 14 centers across Egypt between January and November 2011. Risk factors were common, with most patients experiencing smoking, dyslipidemia, diabetes or hypertension.
3. Bare metal stents were used more often than drug-eluting stents. In-hospital mortality was low at 2.9%. The registry identified opportunities to improve emergency response times and increase primary PCI rates in Egypt.
Missed Diagnoses association in Rear end collisions Nelson Hendler
There are a number of overlooked diagnoses which occur after a rear-end accident. This paper shows an attorney how to convert a misdiagnosed 'soft tissue injury case" into damaged cervical disc,TMJ, thoracic outlet syndrome,and post concussion syndrome using a diagnostic paradigm to get diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This improves patient care and increases recovery.
40%-80% of auto accident claimants have overlooked diagnoses. The most commonly overlooked are thoracic outlet syndrome, cervical disc damage mistakenly called sprain or whiplash, post-concussion syndrome, slipping rib syndrome, Tietze syndrome and Tempro-mandibular joint syndrome. This article tells readers the clinical sign and symptoms of each and the correct medical tests to use, which are employed by doctors at Johns Hopkins Hospital. It also described an on-line questionnaire at www.DiagnoseThePains.com which gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors.
06 acute coronary syndromes is there a place for a real pre hospital treatmen...NPSAIC
1) The management of acute coronary syndrome (ACS) patients requires close collaboration between emergency physicians and cardiologists according to simplified protocols.
2) Key challenges for pre-hospital ACS management include precise knowledge of new drugs, developing regional hospital cooperation, organizing the healthcare network, and regularly analyzing practices.
3) The emergency physician must adapt strategies to international guidelines and the patient's needs, routing high-risk patients directly to catheterization facilities within recommended time limits.
This systematic review and meta-analysis compares appendectomy (ST) to antibiotic therapy (AT) for uncomplicated acute appendicitis (AA) in adults. Five randomized controlled trials with 1,351 patients were included. The analysis found higher treatment efficacy based on 1-year follow-up for ST (98.3%) compared to AT (75.9%). AT was associated with higher rates of complicated appendicitis with peritonitis identified at surgery (19.9% for AT vs 8.5% for ST). No significant differences were found for post-intervention complications, length of hospital stay, or period of sick leave. The review concludes that while AT may be considered for select patients, appende
This document summarizes a study examining biases that could affect the diagnostic accuracy of CT scans and MRI for detecting appendicitis in pediatric patients. It notes several potential biases including: selection bias from only enrolling patients over 12 years old; information bias from differences in protocols for oral contrast and radiologist experience levels; and confounding biases from longer interpretation times for MRI and differences in experience between abdominal and pediatric radiologists. The study included 48 patients ages 12-20 years old who received CT scans and MRI reads by both abdominal and pediatric radiologists to evaluate differences in diagnostic performance between imaging modalities and reader specialties.
This survey aimed to assess clinicians' use of stereotactic radiotherapy and targeted therapies for metastatic renal cell carcinoma and determine support for future clinical trials. The primary objective was to evaluate the proportion of clinicians using radiotherapy for metastatic renal cell carcinoma. Secondary objectives included evaluating the proportion using targeted therapies and radiotherapy simultaneously, stopping targeted therapies for radiotherapy, and supporting further research. The online survey was distributed to members of urology and oncology groups in Australia and New Zealand to collect data on current practices. Results and conclusions will be presented at an upcoming conference.
This study evaluated the diagnostic accuracy of CT scans for detecting injuries in 100 patients with blunt abdominal trauma. CT scans had high sensitivity for liver (100%) and spleen (86.6%) injuries. Specificity was highest for retroperitoneal hematoma (100%) and kidney injuries (93.5%). The accuracy of CT scans for detecting injuries to spleen, liver, kidney, and retroperitoneal hematoma ranged from 91.6% to 96.1%. The study concluded that CT scans are a good tool for evaluating blunt abdominal trauma in teaching hospitals.
18 stent for life initiative placed at the forefront in egypt 2011NPSAIC
1. The Stent for Life registry in Egypt aimed to assess the current situation for patients presenting with STEMI and identify barriers to appropriate care.
2. The registry involved 1,324 consecutive STEMI patients treated at 14 centers across Egypt between January and November 2011. Risk factors were common, with most patients experiencing smoking, dyslipidemia, diabetes or hypertension.
3. Bare metal stents were used more often than drug-eluting stents. In-hospital mortality was low at 2.9%. The registry identified opportunities to improve emergency response times and increase primary PCI rates in Egypt.
Missed Diagnoses association in Rear end collisions Nelson Hendler
There are a number of overlooked diagnoses which occur after a rear-end accident. This paper shows an attorney how to convert a misdiagnosed 'soft tissue injury case" into damaged cervical disc,TMJ, thoracic outlet syndrome,and post concussion syndrome using a diagnostic paradigm to get diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This improves patient care and increases recovery.
40%-80% of auto accident claimants have overlooked diagnoses. The most commonly overlooked are thoracic outlet syndrome, cervical disc damage mistakenly called sprain or whiplash, post-concussion syndrome, slipping rib syndrome, Tietze syndrome and Tempro-mandibular joint syndrome. This article tells readers the clinical sign and symptoms of each and the correct medical tests to use, which are employed by doctors at Johns Hopkins Hospital. It also described an on-line questionnaire at www.DiagnoseThePains.com which gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors.
Fifteen Years Experience of Managing Penetrating Extra-Peritoneal Rectal Inju...Crimsonpublisherssmoaj
This document summarizes a study examining 15 years of experience managing penetrating extra-peritoneal rectal injuries at Aga Khan University Hospital in Karachi, Pakistan. The study reviewed 15 patients who sustained such injuries. All patients underwent fecal diversion via colostomy. Overall post-operative morbidity was 40%, including two patients who developed necrotizing faciitis and one with an intra-abdominal abscess. The study concludes that drainage with fecal diversion is the most common management for extra-peritoneal rectal injuries, and delayed or inadequate drainage can lead to serious complications.
This study evaluated the management of pulmonary nodules between 8-20mm by 18 community pulmonology practices across the US. The researchers reviewed records of 377 patients and found:
1) The prevalence of lung cancer was 25% (n=94). Nearly half of patients (46%) underwent surveillance alone while 33% had a biopsy and 20% had surgery.
2) Predicted probability of malignancy models had good accuracy but invasive procedures were still common in low risk nodules and surgery was performed in 35% of benign nodules.
3) Adherence to guidelines for pulmonary nodule management may be lacking, as invasive sampling and surgery of low risk nodules remained common despite available
This document summarizes a clinical trial that compared two adjuvant chemotherapy regimens for node-positive breast cancer patients: 1) six cycles of fluorouracil, epirubicin, and cyclophosphamide (FEC) or 2) three cycles of FEC followed by three cycles of docetaxel (FEC-D). The trial found that the sequential FEC-D regimen significantly improved disease-free survival and overall survival compared to FEC alone, with a favorable safety profile. The FEC-D regimen was associated with more febrile neutropenia, stomatitis, edema and nail disorders but fewer cardiac events due to the lower cumulative anthracycline dose.
This study evaluated outcomes of 28 patients with intracranial meningiomas treated with hypofractionated radiosurgery. Most tumors were treated with 22.5-30 Gy delivered in 5 fractions. With a mean follow up of 32.6 months, the local tumor control rate was 100% with only one instance of marginal progression. Symptoms improved or resolved in over 66% of patients who originally presented with symptoms. Side effects occurred in 4 patients but the permanent morbidity rate was low at 3.5%. Hypofractionated radiosurgery provided high tumor control with a low risk of side effects, even for large tumors greater than 9 cm3.
According to the American Cancer Society, up to 10% of people with malignant mesothelioma live at least 5 years after diagnosis, though survival rates have been improving with advances in treatment. Recent innovations like the drug pemetrexed disodium have begun to show benefits to survival statistics but their full impact has yet to appear. Individual cases demonstrate that some patients experience long-term survival or remission due to factors like their tumor characteristics or treatment received. While statistics reflect past group outcomes, they do not determine an individual patient's future.
Mesothelioma is a form of cancer caused by exposure to asbestos.To get more information about mesothelioma symptoms, diagnosis, treatment options, mesothelioma news and resources for dealing with the cancer mesothelioma or call us at 1.866.855.1229 .
Development of the A-DIVA Scale (Medicine) (1) - KopieLisette Puijn
This study developed and validated the A-DIVA scale, a predictive scale to identify adult patients at high risk of difficult intravenous access based on 5 clinical factors. Researchers prospectively observed 1063 adult patients undergoing a procedure requiring IV access. They found that 17% had failed first attempt cannulation. Through logistic regression, they identified 5 independent predictors of difficult access - poor vein palpability/visibility, history of difficult access, unplanned surgery, and small vein size. These factors were used to create the additive A-DIVA scale, which classified patients into low, medium, and high risk groups with failure rates of 5%, 37%, and 93% respectively. The A-DIVA scale provides a reliable method to prospectively
1. The document discusses a study comparing surgical treatment versus conservative treatment for patients with spontaneous intracerebral hemorrhage who are positive for the "spot sign" on imaging.
2. The study found that while mortality at 90 days was significantly lower in patients who received surgery, there was no significant difference in clinical outcomes like the Glasgow Outcome Scale between the surgical and conservative treatment groups.
3. Therefore, the study concludes that while surgery may reduce mortality risk, it does not clearly provide a clinical outcome benefit over conservative treatment for spot sign positive intracerebral hemorrhage patients.
Preoperative leukocytosis as predictor of intraabdominal injury in penetratin...Juan de Dios Díaz Rosales
This document summarizes a study on using preoperative leukocytosis as a predictor of intraabdominal injury in patients with penetrating abdominal trauma. The study included 231 patients who underwent exploratory laparotomy for abdominal trauma. Patients were divided into two groups: those with therapeutic laparotomy who had intraabdominal injuries (Group I), and those with non-therapeutic laparotomy who did not have intraabdominal injuries (Group II). The study found that 74.2% of patients in Group I had leukocytosis levels over 12,500/mm3, compared to only 27.7% of patients in Group II, indicating leukocytosis over 12,500/mm3 may help predict which patients have intra
Managing central venous access devices in cancer patients a practice guidelin...Clinica de imagenes
This document provides a summary of a practice guideline for managing central venous access devices (CVADs) in cancer patients. The guideline was developed by reviewing existing literature and clinical practice guidelines to make recommendations on: whether CVADs should be locked with heparin or saline, the volume and strength of locking solution, locking frequency, and type of catheter. The review found limited evidence to directly answer these questions for cancer patients. As such, the guideline aims to standardize CVAD management protocols across cancer care settings based on the best available evidence and expert consensus, in order to improve patient care and outcomes.
The study evaluated practices around informed consent for surgery at a hospital in Pakistan. It found that consent was often taken by nurses for elective surgeries and residents for emergencies, rather than surgeons. Patients were usually not well informed about risks and complications. While most patients were told the type of anesthesia, very few were told about anesthesia risks. Consent was often signed by family rather than patients. Overall, current practices did not adequately inform patients or respect patient autonomy, indicating a need for improved informed consent procedures.
This document summarizes an article about volunteer surgeons providing care to wounded soldiers in Iraq and Afghanistan. It discusses the senior visiting surgeon program established by the American College of Surgeons that allows surgeons to volunteer their time. The volunteer rotation described involved caring for patients at Landstuhl Regional Medical Center in Germany as part of the complex medical evacuation process bringing wounded soldiers from war zones to the United States for further treatment and recovery.
This study reviewed 232 patients with low-grade (Spetzler-Martin Grade I-II) brain arteriovenous malformations (AVMs) who underwent surgical resection. The key findings were:
1) AVM resection was successful in all patients and confirmed angiographically in 94% with no residual AVMs found.
2) Overall good functional outcomes (mRS 0-1) were found in 78% at last follow-up, with 97% improved or unchanged from their preoperative status.
3) Patients with unruptured AVMs had better functional outcomes (91% good) than those with ruptured AVMs (65% good), but equivalent relative outcomes (96-98% improved
TAVI is now an accepted treatment option for low-risk patients with aortic stenosis based on evidence from the NOTION trial. Risk calculators can help evaluate surgical and interventional risk for individual patients. Younger patient age, valve durability, and risk of permanent pacemaker are factors to consider when choosing between TAVI and surgical replacement. The choice between TAVI and surgery should involve shared decision making between doctors and informed patients, considering individual preferences and long-term management. TAVI is now a competitive strategy even in low-risk patients when treatment is customized to each patient.
Therapeutic options for young females with rheumatic mitral valve disease include mitral valve surgery with frequent valve replacement due to disease pathology. For young patients, the prosthetic valve choice is currently restricted to mechanical valves requiring accurate anticoagulation. Pregnancy poses challenges due to the need to stop or adjust warfarin dosing during different trimesters. Studies show better fetal outcomes with warfarin doses of 5mg or less. Surgery combining mitral valve repair/replacement and the Maze procedure reduces atrial fibrillation and improves survival rates without increasing operative risk compared to mitral surgery alone.
Ultra sonographic Evaluation and Management of the First Trimester Bleedingiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
75.8% of the 62 patients studied were male with an average age of 33. In most cases (67%), injuries were from road accidents. The majority (58 patients) had injuries classified between grades I-III. 18 patients underwent surgical treatment while 44 were managed non-operatively. No patients who received non-operative management died. The study confirms the good results seen in international literature for non-operative and damage control surgical approaches in hemodynamically stable patients. While mortality is lower with non-operative management, morbidity is higher, showing a need to further assess the role of interventional procedures in treating complications.
HRV in trauma patients during prehospital transportRachel Russo, MD
1) The study found that prehospital heart rate variability (HRV), specifically standard deviation of normal-to-normal R-R intervals (SDNN), predicted patients with a base excess ≤-6, those requiring life-saving procedures, and those classified as seriously injured better than routine trauma criteria or vital signs.
2) When used alone as a triage tool, SDNN had a sensitivity of 80%, specificity of 75%, and accuracy of 76% for predicting life-saving interventions, outperforming other prehospital measures.
3) Incorporating SDNN into trauma triage criteria models improved prediction of outcomes compared to models without SDNN, better discriminating patients who were seriously or minimally injured
The COFIDIS study aims to prove the superiority of the radial approach compared to the femoral approach for coronary interventions in patients with fistulas for dialysis in terms of vascular and bleeding complications. The study is a prospective, multicenter, randomized trial that will enroll 784 patients undergoing planned coronary interventions who will be randomized 1:1 to either radial or femoral access. The primary endpoint is the total in-hospital vascular and bleeding complications. Secondary endpoints include major and minor bleeding, vascular complications, radial occlusion rates, and outcomes at 6 months. The results of this study could demonstrate that the radial approach reduces complications in dialysis patients undergoing coronary procedures.
The document discusses parotid gland disorders that necessitated parotidectomy. It summarizes that:
- The majority (90.47%) of cases involved benign pathology, most commonly pleomorphic adenoma. Superficial parotidectomy was the most common surgery.
- Post-operative complications occurred in about 30% of cases, most frequently greater auricular nerve paresis (15%) or facial nerve transient paresis (8%).
- Fine needle aspiration cytology (FNAC) was found to be a useful diagnostic tool for parotid gland tumors, with 98.24% specificity and 83.33% sensitivity for detecting malignancy.
There are many guidelines and recommendations suggesting ablation/therapy in Differentiated Thyroid Carcinoma. This presentation will be focused on the details of these recommendations and guidelines.
Furthermore, it will be discussed the use of recombinant human thyrotropin (rhTSH) prior to radioactive iodine remnant ablation for patients with differentiated thyroid cancer.
Fifteen Years Experience of Managing Penetrating Extra-Peritoneal Rectal Inju...Crimsonpublisherssmoaj
This document summarizes a study examining 15 years of experience managing penetrating extra-peritoneal rectal injuries at Aga Khan University Hospital in Karachi, Pakistan. The study reviewed 15 patients who sustained such injuries. All patients underwent fecal diversion via colostomy. Overall post-operative morbidity was 40%, including two patients who developed necrotizing faciitis and one with an intra-abdominal abscess. The study concludes that drainage with fecal diversion is the most common management for extra-peritoneal rectal injuries, and delayed or inadequate drainage can lead to serious complications.
This study evaluated the management of pulmonary nodules between 8-20mm by 18 community pulmonology practices across the US. The researchers reviewed records of 377 patients and found:
1) The prevalence of lung cancer was 25% (n=94). Nearly half of patients (46%) underwent surveillance alone while 33% had a biopsy and 20% had surgery.
2) Predicted probability of malignancy models had good accuracy but invasive procedures were still common in low risk nodules and surgery was performed in 35% of benign nodules.
3) Adherence to guidelines for pulmonary nodule management may be lacking, as invasive sampling and surgery of low risk nodules remained common despite available
This document summarizes a clinical trial that compared two adjuvant chemotherapy regimens for node-positive breast cancer patients: 1) six cycles of fluorouracil, epirubicin, and cyclophosphamide (FEC) or 2) three cycles of FEC followed by three cycles of docetaxel (FEC-D). The trial found that the sequential FEC-D regimen significantly improved disease-free survival and overall survival compared to FEC alone, with a favorable safety profile. The FEC-D regimen was associated with more febrile neutropenia, stomatitis, edema and nail disorders but fewer cardiac events due to the lower cumulative anthracycline dose.
This study evaluated outcomes of 28 patients with intracranial meningiomas treated with hypofractionated radiosurgery. Most tumors were treated with 22.5-30 Gy delivered in 5 fractions. With a mean follow up of 32.6 months, the local tumor control rate was 100% with only one instance of marginal progression. Symptoms improved or resolved in over 66% of patients who originally presented with symptoms. Side effects occurred in 4 patients but the permanent morbidity rate was low at 3.5%. Hypofractionated radiosurgery provided high tumor control with a low risk of side effects, even for large tumors greater than 9 cm3.
According to the American Cancer Society, up to 10% of people with malignant mesothelioma live at least 5 years after diagnosis, though survival rates have been improving with advances in treatment. Recent innovations like the drug pemetrexed disodium have begun to show benefits to survival statistics but their full impact has yet to appear. Individual cases demonstrate that some patients experience long-term survival or remission due to factors like their tumor characteristics or treatment received. While statistics reflect past group outcomes, they do not determine an individual patient's future.
Mesothelioma is a form of cancer caused by exposure to asbestos.To get more information about mesothelioma symptoms, diagnosis, treatment options, mesothelioma news and resources for dealing with the cancer mesothelioma or call us at 1.866.855.1229 .
Development of the A-DIVA Scale (Medicine) (1) - KopieLisette Puijn
This study developed and validated the A-DIVA scale, a predictive scale to identify adult patients at high risk of difficult intravenous access based on 5 clinical factors. Researchers prospectively observed 1063 adult patients undergoing a procedure requiring IV access. They found that 17% had failed first attempt cannulation. Through logistic regression, they identified 5 independent predictors of difficult access - poor vein palpability/visibility, history of difficult access, unplanned surgery, and small vein size. These factors were used to create the additive A-DIVA scale, which classified patients into low, medium, and high risk groups with failure rates of 5%, 37%, and 93% respectively. The A-DIVA scale provides a reliable method to prospectively
1. The document discusses a study comparing surgical treatment versus conservative treatment for patients with spontaneous intracerebral hemorrhage who are positive for the "spot sign" on imaging.
2. The study found that while mortality at 90 days was significantly lower in patients who received surgery, there was no significant difference in clinical outcomes like the Glasgow Outcome Scale between the surgical and conservative treatment groups.
3. Therefore, the study concludes that while surgery may reduce mortality risk, it does not clearly provide a clinical outcome benefit over conservative treatment for spot sign positive intracerebral hemorrhage patients.
Preoperative leukocytosis as predictor of intraabdominal injury in penetratin...Juan de Dios Díaz Rosales
This document summarizes a study on using preoperative leukocytosis as a predictor of intraabdominal injury in patients with penetrating abdominal trauma. The study included 231 patients who underwent exploratory laparotomy for abdominal trauma. Patients were divided into two groups: those with therapeutic laparotomy who had intraabdominal injuries (Group I), and those with non-therapeutic laparotomy who did not have intraabdominal injuries (Group II). The study found that 74.2% of patients in Group I had leukocytosis levels over 12,500/mm3, compared to only 27.7% of patients in Group II, indicating leukocytosis over 12,500/mm3 may help predict which patients have intra
Managing central venous access devices in cancer patients a practice guidelin...Clinica de imagenes
This document provides a summary of a practice guideline for managing central venous access devices (CVADs) in cancer patients. The guideline was developed by reviewing existing literature and clinical practice guidelines to make recommendations on: whether CVADs should be locked with heparin or saline, the volume and strength of locking solution, locking frequency, and type of catheter. The review found limited evidence to directly answer these questions for cancer patients. As such, the guideline aims to standardize CVAD management protocols across cancer care settings based on the best available evidence and expert consensus, in order to improve patient care and outcomes.
The study evaluated practices around informed consent for surgery at a hospital in Pakistan. It found that consent was often taken by nurses for elective surgeries and residents for emergencies, rather than surgeons. Patients were usually not well informed about risks and complications. While most patients were told the type of anesthesia, very few were told about anesthesia risks. Consent was often signed by family rather than patients. Overall, current practices did not adequately inform patients or respect patient autonomy, indicating a need for improved informed consent procedures.
This document summarizes an article about volunteer surgeons providing care to wounded soldiers in Iraq and Afghanistan. It discusses the senior visiting surgeon program established by the American College of Surgeons that allows surgeons to volunteer their time. The volunteer rotation described involved caring for patients at Landstuhl Regional Medical Center in Germany as part of the complex medical evacuation process bringing wounded soldiers from war zones to the United States for further treatment and recovery.
This study reviewed 232 patients with low-grade (Spetzler-Martin Grade I-II) brain arteriovenous malformations (AVMs) who underwent surgical resection. The key findings were:
1) AVM resection was successful in all patients and confirmed angiographically in 94% with no residual AVMs found.
2) Overall good functional outcomes (mRS 0-1) were found in 78% at last follow-up, with 97% improved or unchanged from their preoperative status.
3) Patients with unruptured AVMs had better functional outcomes (91% good) than those with ruptured AVMs (65% good), but equivalent relative outcomes (96-98% improved
TAVI is now an accepted treatment option for low-risk patients with aortic stenosis based on evidence from the NOTION trial. Risk calculators can help evaluate surgical and interventional risk for individual patients. Younger patient age, valve durability, and risk of permanent pacemaker are factors to consider when choosing between TAVI and surgical replacement. The choice between TAVI and surgery should involve shared decision making between doctors and informed patients, considering individual preferences and long-term management. TAVI is now a competitive strategy even in low-risk patients when treatment is customized to each patient.
Therapeutic options for young females with rheumatic mitral valve disease include mitral valve surgery with frequent valve replacement due to disease pathology. For young patients, the prosthetic valve choice is currently restricted to mechanical valves requiring accurate anticoagulation. Pregnancy poses challenges due to the need to stop or adjust warfarin dosing during different trimesters. Studies show better fetal outcomes with warfarin doses of 5mg or less. Surgery combining mitral valve repair/replacement and the Maze procedure reduces atrial fibrillation and improves survival rates without increasing operative risk compared to mitral surgery alone.
Ultra sonographic Evaluation and Management of the First Trimester Bleedingiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
75.8% of the 62 patients studied were male with an average age of 33. In most cases (67%), injuries were from road accidents. The majority (58 patients) had injuries classified between grades I-III. 18 patients underwent surgical treatment while 44 were managed non-operatively. No patients who received non-operative management died. The study confirms the good results seen in international literature for non-operative and damage control surgical approaches in hemodynamically stable patients. While mortality is lower with non-operative management, morbidity is higher, showing a need to further assess the role of interventional procedures in treating complications.
HRV in trauma patients during prehospital transportRachel Russo, MD
1) The study found that prehospital heart rate variability (HRV), specifically standard deviation of normal-to-normal R-R intervals (SDNN), predicted patients with a base excess ≤-6, those requiring life-saving procedures, and those classified as seriously injured better than routine trauma criteria or vital signs.
2) When used alone as a triage tool, SDNN had a sensitivity of 80%, specificity of 75%, and accuracy of 76% for predicting life-saving interventions, outperforming other prehospital measures.
3) Incorporating SDNN into trauma triage criteria models improved prediction of outcomes compared to models without SDNN, better discriminating patients who were seriously or minimally injured
The COFIDIS study aims to prove the superiority of the radial approach compared to the femoral approach for coronary interventions in patients with fistulas for dialysis in terms of vascular and bleeding complications. The study is a prospective, multicenter, randomized trial that will enroll 784 patients undergoing planned coronary interventions who will be randomized 1:1 to either radial or femoral access. The primary endpoint is the total in-hospital vascular and bleeding complications. Secondary endpoints include major and minor bleeding, vascular complications, radial occlusion rates, and outcomes at 6 months. The results of this study could demonstrate that the radial approach reduces complications in dialysis patients undergoing coronary procedures.
The document discusses parotid gland disorders that necessitated parotidectomy. It summarizes that:
- The majority (90.47%) of cases involved benign pathology, most commonly pleomorphic adenoma. Superficial parotidectomy was the most common surgery.
- Post-operative complications occurred in about 30% of cases, most frequently greater auricular nerve paresis (15%) or facial nerve transient paresis (8%).
- Fine needle aspiration cytology (FNAC) was found to be a useful diagnostic tool for parotid gland tumors, with 98.24% specificity and 83.33% sensitivity for detecting malignancy.
There are many guidelines and recommendations suggesting ablation/therapy in Differentiated Thyroid Carcinoma. This presentation will be focused on the details of these recommendations and guidelines.
Furthermore, it will be discussed the use of recombinant human thyrotropin (rhTSH) prior to radioactive iodine remnant ablation for patients with differentiated thyroid cancer.
This document provides an introduction to thyroid cancer and radioiodine refractory disease. It discusses the epidemiology of thyroid cancer, noting it is the most common endocrine tumor. Histological classification of thyroid cancer according to the WHO 2017 guidelines is presented. Management concepts are reviewed including staging, surgery, radioiodine therapy, and systemic treatment. Refractory disease is defined as disease that continues to progress despite radioactive iodine treatment. Prognostic factors and outcomes for patients with radioiodine refractory disease are discussed.
This study retrospectively analyzed 69 patients who underwent total thyroidectomy with lymph node dissection for papillary thyroid cancer with clinical nodal metastases. The rate of locoregional recurrence with positive cervical lymph nodes after an average 8-year follow-up was 34.7%, which was higher than the 4.2% recurrence rate reported in patients without nodal metastases. Nodal metastases were found to be a predictor of local recurrence. Male gender and age under 50 were associated with higher risk of nodal recurrence. The study concludes that nodal metastases increase the likelihood of local recurrence after surgery for papillary thyroid cancer.
This document discusses a case of a 64-year-old man presenting with right flank pain and a history of smoking who is found to have clear-cell renal cell carcinoma (RCC). He undergoes a right radical nephrectomy and pathology confirms grade 3 clear-cell RCC without margins or lymph node involvement. Small lung nodules are detected 18 months later and biopsy confirms metastatic clear cell RCC. Systemic therapy options for the metastatic disease are discussed, including tyrosine kinase inhibitors, immunotherapy, and their combinations. Ongoing trials of immunotherapy in the adjuvant and metastatic settings are also summarized. Risk stratification models and their impact on treatment selection are reviewed.
Targovax has two immuno-oncology programs - ONCOS, an oncolytic virus, and TG, a RAS neoantigen vaccine. TG has shown promising results in pancreatic cancer trials, with 20% 10-year survival in previous trials. An ongoing phase I/II trial is validating these results with adjuvant chemotherapy. ONCOS has demonstrated the ability to increase tumor-infiltrating T-cells in early trials. Targovax has a broad clinical program with several upcoming data readouts in 2017-2018 from trials in melanoma, mesothelioma, ovarian/colorectal, prostate, and pancreatic/colorectal cancers.
Oncoanaesthesia involves the anesthetic management of patients undergoing cancer-related procedures. It is a vital part of cancer care as 80% of cancer patients require anesthesia. Anesthesiologists play key roles in preoperative optimization, intraoperative management considering implications of cancer and its treatments, and postoperative care including management of complications like pain, DVT and PONV. Special considerations include impacts of cancer type and stage, prior treatments, and multidisciplinary teamwork to improve outcomes.
Co-Chairs and Presenter Jessica Donington, MD, Jonathan D. Spicer, MD, PhD, FRCSC, and Patrick M. Forde, MD, prepared useful Practice Aids pertaining to NSCLC for this CME/MOC/CC/AAPA activity titled “A Practical Guide for Making Multidisciplinary Decisions About Neoadjuvant and/or Adjuvant Immunotherapy in Resectable NSCLC.” For the full presentation, downloadable Practice Aids, and complete CME/MOC/CC/AAPA information, and to apply for credit, please visit us at https://bit.ly/3MQVu5l. CME/MOC/CC/AAPA credit will be available until February 27, 2025.
Avoidng disruption of timely surgical management of genitourinary cancers ...Valentina Corona
This article describes the experience of a large cancer center in Southern Italy in continuing timely surgical treatment of genitourinary cancers during the early phase of the COVID-19 pandemic. The center established a multidisciplinary team to prioritize urgent cancer cases and implemented screening, safety protocols, and transfer agreements to identify and manage any COVID-19 positive patients while maintaining surgical volume. Through regional healthcare reorganization designating the center as "COVID-free" and other measures, the hospital was able to safely perform a similar number and mix of cancer surgeries compared to the previous year without major disruption of care.
Targovax presentation december 2017 carnegietargovax2017
Targovax provided an overview of its clinical programs for its two immuno-oncology platforms: ONCOS oncolytic virus and TG mutRAS neoantigen vaccine. For ONCOS, interim data from ongoing phase I/II trials in several solid tumors was highlighted. For TG, encouraging survival data from a phase I/II trial in resected pancreatic cancer was summarized. Upcoming clinical readouts and trial initiations in 2017-2018 were outlined for both platforms.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...daranisaha
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...JohnJulie1
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...eshaasini
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...NainaAnon
Upper rectal cancer management is controversial. The present series reports the outcomes of treatment comparing neoadjuvant chemoradiation (NCRT) versus upfront surgery.
Clinics of Oncology | Oncology Journals | Open Access JournalEditorSara
Clinics of OncologyTM (ISSN 2640-1037) - Impact Factor 1.920* is a medical specialty that focuses on the use of operative techniques to investigate and resolve certain medical conditions caused by disease or traumatic injury.
Upper Rectal Cancer: Benefit After Preoperative Chemoradiation Versus Upfront...semualkaira
In this retrospective study we enrolled patients with upper rectal or sigmoid junction locally advanced tumors (stages II-III). At the first Institution patients received NCRT followed by surgery (study group); at the second Institution patients were referred to upfront surgery (control group). Overall survival was the main endpoint of the analysis. Local relapse and other clinical variables were also analyzed.
Similar to Follow up della neoplasia tiroidea operata (17)
Presa in carico del paziente con LMC e gestione della terapia a medio e lungo...ASMaD
This document discusses cardiovascular risk management from the perspective of a vascular surgeon. It summarizes the author's experience treating patients with chronic myeloid leukemia who developed vascular complications. The main points are:
1) Patients with chronic myeloid leukemia often have multi-level vascular disease involving the carotid, renal, mesenteric, and lower extremity arteries.
2) Endovascular interventions had high restenosis and failure rates, while open surgeries resulted in better mid-term patency but higher amputation rates.
3) An aggressive surgical approach along with intensive medical management and follow-up is needed for these high-risk patients due to their underlying disease and risk factors. A multidisciplinary team approach
I meccanismi del danno gastrico e la patologia H. Pylori correlataASMaD
Presentazione a cura del Dottor Vincenzo De Francesco - "Malattia da reflussogastroesofageo e infezione da Helicobacter Pylori: old topics?" - Roma 11/05/2019
Ph impedenziometria nella MRGE: quando, come e perchèASMaD
Presentazione a cura della Dottoressa Francesca Galeazzi - "Malattia da reflussogastroesofageo e infezione da Helicobacter Pylori: old topics?" - Roma 11/05/2019
This document discusses the classification of gastroesophageal reflux disease (GERD) and challenges in classifying patients. It notes that while some patients with typical GERD symptoms respond to treatment, they remain unclassified and may not actually have GERD. A single classification system based on symptoms and endoscopy does not capture all clinical conditions related to GERD. Patients who do not respond to PPIs should be referred to a gastroenterologist. Some GERD patients have significant esophageal motility issues. Those who do not respond to PPIs may require an esophageal biopsy. Some PPI responders actually have eosinophilic esophagitis. Some GERD patients have multiple gastrointestinal comor
Cambiamenti di popolazione e flussi migratori: cambiano anche le malattie met...ASMaD
Presentazione a cura della Dottoressa Migneco Maria Giuseppina - "Incontri endocrinologici AME LAzio - L'endocrinologia nel SSN: prospettive e nuove problematiche" - Roma 17/12/2018
Tiroide: chi decide quale intervento e per chi?ASMaD
Presentazione a cura del Dottor Bellotti Carlo - "Incontri endocrinologici AME LAzio - L'endocrinologia nel SSN: prospettive e nuove problematiche" - Roma 17/12/2018
Tiroide: Integrazione tra elementi nutriacetici e farmacologia: utile o inutile?ASMaD
Presentazione a cura del Dottor Roberto Cesareo - "Incontri endocrinologici AME LAzio - L'endocrinologia nel SSN: prospettive e nuove problematiche" - Roma 17/12/2018
L'ecografia tiroidea: strumento cruciale nella gestione clinica?ASMaD
Presentazione a cura del Dottor Guglielmi Rinaldo - "Incontri endocrinologici AME LAzio - L'endocrinologia nel SSN: prospettive e nuove problematiche" - Roma 17/12/2018
Il chirurgo e la tiroide oggi un rapporto in crisi?ASMaD
Presentazione a cura del Dottor Luca Piantoni e del Dottor Francesco Pedicini - "TIROIDE 2018 Nuovi approcci diagnostici e terapeutici" - Roma 24/11/2018
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
2. Il punto di vista del Medico Nucleare
Follow up della neoplasia tiroidea operata
La terapia radiometabolica
3. APPROCCI PERSONALIZZATI
uno spettro di possibilità
dalla … sorveglianza attiva
alla TT + RT
“ ONE-SIZE-FITS-ALL”
TT + RT + OT
Evoluzione del paradigma di trattamento del
carcinoma della tiroide
Una grande confusione
!!!
the role of post-operative 131 I
has been reviewed and the
number of patients in whom
treatment was recommended
has been progressively
decreasing over the last
decade.
4. VISION
Precision
Medicine
Nuovo paradigma di cura
the right treatment
for the right patient,
at the right time,
with the right dose
fornendo una terapia più mirata ed efficiente
Selezionare la terapia più appropriata in base a caratteristiche paziente specifiche
VISION
6. ATA 2015 & BTA 2014 EANM & Italian Consensus
Punti di accordo: la terapia con radiodio
1. is not routinely recommended for ATA [very ] low-risk DTC patients
(as identified as very low risk according to the European Consensus Report)
2. There is an “indication for” in high-risk DTC patients.
Recommendation 51 of ATA:
indicazioni per l’uso del radioiodio dopo la TT in pazienti con ca tiroide differenziato - DTC
Punti di disaccordo: la terapia con radiodio nelle categorie intermedie
should be “considered” in “low- to intermediate-risk”
only in the presence of other adverse features
non ci sono indicazioni chiare riguardo l’uso del radioiodio dopo la TT nei
pazienti classificati low - to - intermediate risk
vs.
7. EANM and the EANM Thyroid Committee (2016)
The reasons for declining to endorse these guidelines fall into two categories.
1. In most cases our objections are based on differences in the interpretation of the available
evidence, especially where the role of nuclear medicine is concerned. In spite of solid
evidence on the clinical efficacy of nuclear medicine in both the diagnostic work-up of
nodular thyroid disease and the care of DTC, the 2015 ATA guidelines appear to marginalise
the role of nuclear medicine in the care of DTC.
2. Some of our objections also concern the wording of some parts of the text which differ
from our current viewpoint and are mostly based on a cautious, legally motivated choice
of words.
Pur riconoscendo lo sforzo e il carattere
innovativo delle ATA
tentativo di stratificare il rischio come
un continuum
distinzione del RAI come ablazione
adiuvante e terapia
NE NEGANO FORMALMENTE il
recepimento
8. “…For the entire population of patients with DTC exceeding 1 cm in diameter, there is some evidence of
the usefulness of postoperative 131I ablation. However, we do agree that not all patients who are treated
with 131I will in fact benefit from it, even though we cannot yet reliably identify these patients.
We therefore take this opportunity to warn our colleagues that the currently proposed strategy may not
yet be based on solid evidence. It is not long since esteemed colleagues Mazzaferri and Jhiang showed in
landmark studies that the introduction of postoperative 131I treatment leads to a dramatic decline in both
recurrence and DTC-specific mortality rates.
There are currently no prospective, controlled studies available that precisely indicate which patients
with low-risk DTC may or may not benefit from postoperative 131I therapy.
To that end, two well-regarded trials in the UK and France (IoN and ESTIMABL2) comparing 131I ablation
and no ablation in patients with lower risk DTC are currently recruiting. A long follow-up of at least
10 years will be needed before these studies are able to provide strong, reliable prospective data on
patient outcome...”
Therefore we would advise caution in altering long-established and
successful practice until sufficient evidence is available indicating that
it is safe to omit postoperative 131I treatment – “ablation” or
“adjuvant” – in patients with non-microcarcinoma….”
EANM and the EANM Thyroid Committee (2016)
Motivazioni specifiche
9. Italian consensus on diagnosis and treatment of differentiated thyroid
cancer: joint statements of six Italian societies.
Six scientific Italian societies entitled to cure thyroid cancer patients
felt the need to develop a consensus report based on significant scientific advances
occurred in the field.
(the Italian Thyroid Association, the Medical Endocrinology Association, the Italian
Society of Endocrinology, the Italian Association of Nuclear Medicine and Molecular
Imaging, the Italian Society of Unified Endocrine Surgery and the Italian Society of
Anatomic Pathology and Diagnostic Cytology)
10. Italian consensus on diagnosis and treatment of differentiated thyroid
cancer: joint statements of six Italian societies.
The indication to post-surgical thyroid ablation with radioiodine should be
established both on the basis of :
the AJCC/UICC staging (VIII ed.) useful to predict the risk of mortality
the Initial Risk Stratification System (ATA) useful to predict the risk of
disease recurrence/ persistence
The indication should be based on post-operative disease status evaluation with
stimulated Tg (hypotiroidism or rhTSH) + [ whole body scan]
11. Italian consensus on diagnosis and treatment of differentiated thyroid
cancer: joint statements of six Italian societies.
In patients with ATA low-risk (T1a-b, N0-X, M0-X), RAI remnant ablation is
not generally recommended.
However, consideration of specific features could lead to consider RAI
remnant ablation in individual patients.
In patients with intermediate or low-to-intermediate risk (T1-2, N1a–N1b,
M0-X), RAI remnant ablation should be considered, particularly in patients
with adverse features such as advanced age, larger tumors, macroscopic
or clinically evident lymph nodes or the presence of extranodal extension,
or aggressive histology or vascular invasion.
In patients with high risk or intermediate to high risk (T3-4, any N, any M),
RAI ablation is routinely recommended.
12. The risk of structural disease recurrence associated with selected clinico-pathological
features are shown as a continuum of risk with percentages (ranges, approximate
values) presented to reflect our best estimates based on the published literature.
Intermed
LOW
< 5%
> 20%
5- 20%
RAI agree
13. Ma … Quale è il RISCHIO ACCETTABILE
Per il
paziente
ATTENZIONE
Le stime del rischio ATA sono basate su popolazioni che sono state
trattate con radioiodio
Per il
medico
Per la
società
14. RISCHIO DINAMICO
Il rischio iniziale deve essere completato e aggiornato incorporando la risposta al trattamento
Italian consensus on
diagnosis and treatment
of DTC
ERGO … la vera stratificazione del rischio si ha solo dopo aver valutato la
risposta alla terapia
15. Proposed terminology to classify response to therapy
and clinical implications
RECOMMENDATION 49
ATA 2015
Excellent response:
no clinical, biochemical, or structural
evidence of disease
How should initial risk estimates be modified over time?
Negative imaging and either
Suppressed Tg <0.2 ng/mLbor
TSH-stimulated Tg <1 ng/mLb
1% –4 % recurrencec
<1% disease specific
death
Negative imaging and
Suppressed Tg ≥1 ng/mL or
Stimulated Tg ≥10 ng/mL or
Rising anti-Tg antibody levels
At least 30% spontaneously
evolve to NED;
20% achieve NED after
additional therapy;
20% develop structural disease
<1% disease specific death
Structural or functional
evidence of disease
with any Tg level
with or without anti-Tg
antibodies
50%–85% persistent disease
despite additional therapy.
Disease specific death rates as
high as 11% with loco-regional
metastases and 50% with
structural distant metastases
Nonspecific findings on
imaging and/or basal
thyroglobulin ≥0.2 to <1 ng/ml
or stimulated thyroglobulin ≥1
to <10 ng/ml or stable or
declining thyroglobulin
antibodies over time
15%–20%
will have structural disease
identified during follow-up
Biochemical incomplete response:
abnormal Tg or rising anti-Tg antibody levels
in the absence of localizable disease.
Structural incomplete response: persistent
or newly identified loco-regional or distant
metastases
Indeterminate response: nonspecific
biochemical or structural findings that cannot be
confidently classified as either benign or
malignant. This includes patients with stable or
declining anti-Tg antibody levels without
definitive structural evidence of disease.
La prognosi cambia
significativamente
sulla base della
negatività
dell’imaging post-
terapia
16. This figure describes the follow-up protocol for patients with papillary thyroid cancer who are at a low risk of
recurrence (part a), a low or intermediate risk of recurrence (part b) or a high risk of recurrence (part c). 18F-FDG–PET,
18F-fluorodeoxyglucose–PET; RRA, radioactive iodine remnant ablation.
Follow-up protocols for patients with papillary thyroid cancer Lamartina. Nature Reviews Endocrinology Volume: 14 Issue
9 (2018)
17. ESPERIENZA IFO
• maggiore casistica mondiale
omogenea per trattamento
• migliore sopravvivenza
• minore morbilità
a proposito di
evidenze ….
Misure di outcome
overall survival (morti specifiche)
progression free disease
disease free survival
morbidità (recidive + malattia persistente)
19. il fattore predittivo più significativo di aumentato rischio di mortalità per tumore è la
mancata risposta al trattamento con 131I (hazard ratio = 211 , p < 0,0001)
altre variabili indipendenti predittive di rischio di sono l’età, il sesso e l’istologia follicolare.
Structural incomplete
response: persistent or
newly identified loco-
regional or distant
metastases
50%–85% persistent disease
despite additional therapy.
Disease specific death rates as
high as 11% with loco-regional
metastases and 50% with
structural distant metastases
RISPOSTA alla TERAPIA : valore prognostico
21. Casi clinici
Donna 70 anni; TT 17/09/2015
E.I ca papillare variante follicolare del lobo dx della tiroide di 0,8 cm;
non invasione vascolare. pT1a
VERY LOW RISK
Tg in OT > 70 ng/ml. 10/2015 TB 131I riscontro di metastasi omero dx trattata con osteosintesi
preventiva con chiodo endomidollare pre terapia 131I
Novembre 2015 TRM 131-I (150 mCi) con TSH = 32 uUI/ml, Tg > 4000 ng/ml, Ab anti Tg neg
Scintigrafia di controllo terapia : M1 su omero dx + residuo
M1 - HIGH RISK
22. Casi clinici
CDT 06/2016
Previa ristadiazione con TB131I in ipotiroidismo viene sottoposta ad ulteriori due cicli di
TRM 131I (06/2016 e 06/2017) con pressochè assenza di significativa iperfissazione a
livello omerale dx all’ultimo CDT con valori rispettivamente di TSH = 128 uUI/ml e 194
uUI/ml, Tg = 12,2 e 1,0 ng/ml
CDT
06/2017
23. Casi clinici
06/2018 TB 131I con rh-TSH negativo con valore max di TSH = 367 uUI/ml, Tg < 0,1 ng/ml, AbTg
<10 UI/ml
Risposta eccellente
LOW RISK
24. Casi clinici
Donna 49 anni; TT 03/11/2016 con E.I. ca papillifero variante follicolare dell’istmo di 8.5 mm
che giunge a meno di 1 mm dal margine di resezione; a carico del lobo sinistro nodulo di 1.5
cm sede di ca papillare var follicolare; margini indenni – pT1bm.
TB/SPET gen 2018
01/2017 TB 131I iperfissazione focale regione anteriore del collo + ulteriore focalità regione
latero-cervicale dx di verosimile pertinenza linfonodale confermata alla SPET/TC
TSH = 41 uUI/ml; Tg = 1,7 ng/ml; Ab anti Tg < 10 IU/ml N1 LOW RISK
LOW RISK
25. Casi clinici
In data 16/01/2017 TRM 131-I
TSH = 41 uUI/ml; Tg = 1,7 ng/ml; AbTg < 10 IU/ml
Sorveglianza attiva
O
Terapia ?
Ecografia ogni 6 mesi
Tg dopo stimolo ? N.S.
26. Casi clinici
In data 19/01/2018 TB 131-I con rh-TSH risultato negativo
TSH max = 205 uUI/ml; Tg = < 0,1 ng/ml; AbTg < 10 IU/ml
Risposta eccellente
LOW RISK
27. Casi clinici
TB/CDT gen 2017
Donna, 67 anni; TT 07/06/2010 E.I. Ca papillifero variante follicolare del lobo sx di 1,6 cm.
Capsula tiroidea esente. Non figure di invasione linfovascolare e perineurale. pT1b
01/17 TB con 131I : intensa iperfissazione regione anteriore del collo; TSH = 67,3 uUI/ml, Tg
1023; Ab anti Tg < 15 IU/ml. Segue TRM 131I con comparsa di iperfissazione emitorace sx
(alla SPET/TC lesione IX arco costale sx). TSH = 72,8 uUI/ml; Tg 1161 ng/ml
28. Casi clinici
TB/CDT dic 2017
12/17 TB con 131I: iperfissazione regione anteriore del collo + emitorace sx TSH = 72.8
uUI/ml, Tg 1165; Ab anti Tg < 11 IU/ml. Segue II ciclo di TRM 131I (200 mCi) che ha
evidenziato PD di malattia per comparsa di più lesioni scheletriche di tipo litico alla SPET/TC
TSH =83 uUI/ml; Tg 1428 ng/ml
29. Casi clinici
SPET/CDT dic 2017
01/17 TB con 131I: iperfissazione regione anteriore del collo + emitorace sx TSH = 83 uUI/ml,
Tg 1165; Ab anti Tg < 11 IU/ml. Segue II ciclo di TRM 131I (200 mCi) che ha evidenziato PD di
malattia per comparsa di più lesioni scheletriche di tipo litico alla SPET/TC TSH = 72,8
uUI/ml; Tg 1428 ng/ml
30. Casi clinici
CDT 09/2018
Segue III di TRM 131I (200 mCi) con sostanziale SD di malattia al CDT e Tg 1426 ng/ml
CDT 12/2017
Risposta strutturale incompleta
31. Casi clinici
CDT 10/2018
Uomo, 54 anni; TT con E.I multipli focolai di ca papillifero var follicolare (max lobo dx 1cm e
paraistmo 1.1 cm); focale infiltrazione del tessuto muscolare striato peritiroideo pT3b(m)
UICC 2017
TB 10/2018
10/2018 TB 131I : “alcune immagini di intensa iperfissazione regione ant collo” TSH = 87
uUI/ml, Tg 96.4 ng/ml , Ab anti Tg < 10 UI/ml. Segue TRM 131I (150 mCi)
32. ATA RECOMMENDATION 62 and 63
rhTSH (Thyrogen) in the follow-up of DTC
During initial follow-up, serum Tg on thyroxine therapy should be measured every 6–12
months. More frequent Tg measurements may be appropriate for ATA high-risk patients.
1. In ATA low- and intermediate-risk patients that achieve an excellent response to
therapy, the utility of subsequent Tg testing is not established. The time interval
between serum Tg measurements can be lengthened to at least 12–24 months.
2. In ATA high-risk patients (regardless of response to therapy) and all patients with
biochemical incomplete, structural incomplete, or indeterminate response should
continue to have Tg measured at least every 6–12 months for several years.
3. In ATA low-risk and intermediate-risk patients who have had remnant ablation or
adjuvant therapy and negative cervical US, serum Tg should be measured at 6–18
months on thyroxine therapy with a sensitive Tg assay (<0.2 ng/mL) or after TSH
stimulation to verify absence of disease (excellent response).
Repeat TSH-stimulated Tg testing is not recommended for low- and intermediate-risk
patients with an excellent response to therapy.
Subsequent TSH-stimulated Tg testing may be considered in patients with an indeterminate,
biochemical incomplete, or structural incomplete response following either additional
therapies or a spontaneous decline in Tg values on thyroid hormone therapy over time in
order to reassess response to therapy.
Subsequent stimulated testing is rarely needed for those with NED, because there are rarely
benefits seen in this patient population from repeated TSH-stimulated Tg testing. The use of
sensitive methods for serum Tg may obviate the need for rhTSH stimulation in low-risk
patients with a Tg on LT4 treatment below 0.1–0.2 ng/mL
33. CONCLUSIONI
la “gestione strategica” del DTC sta evolvendo da una responsabili-
tà individuale a una responsabilità collegiale - DMT con expertise
specifica … ma le “responsabilità” restano individuali !
Le linee- guida presentano aspetti controversi
bias di interpretazione e … contraddizioni
in particolare la “responsabilità clinica” della terapia (indicazioni,
modalità e FUP è del Medico-Nucleare (D.Lgs. 187/00, art. 5, comma 2)
Con l’idea di evitare terapie potenzialmente inutili si corre il rischio di
“non verificare “ lo stato effettivo della malattia e peggiorare la
prognosi a lungo termine attualmente eccellente
34. CONCLUSIONI
Nell’attesa che le società scientifiche italiane varino le Linee-Guida
ufficiali
usare il buon senso
utilizzare tutti gli strumenti per una stadiazione corretta (ATA,
TNM, Tg, 131 I whole body
basarsi sulla propria esperienza ma ..
documentare le scelte
informare il paziente
tenere conto delle sue preferenze