Fwd: Thyroid Cancer/Whistling in the Dark some new info on Thyroid problems recently discussed.

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Begin forwarded message:From: NEJM Resident E-Bulletin <resebulletin@...>Date: May 2, 2012 5:24:41 PM CDTlowerbp2@...Subject: Thyroid Cancer/Whistling in the DarkReply-resebulletin@... NEJM Resident E-Bulletin To ensure that you always receive the NEJM Resident E-Bulletin, add the e-mail address resebulletin@... to your address book. Having trouble reading this e-mail? Please view it in your web browser. ADVERTISEMENT Clarence Grim, MD | My NEJM | Subscribe | Search Forward | Sign up | e-Bulletin Archive TEACHING TOPICS from the New England Journal of Medicine Teaching Topics | May 3, 2012 Thyroid Cancer: What were the primary results of this study, which compared different doses of postoperative radioactive iodine in patients with low-risk thyroid cancer? Whistling in the Dark: How does one make the diagnosis of tracheomalacia? NEJM 200th Anniversary Documentary Getting Better, a 45-minute documentary video, explores three remarkable stories of medical progress that have taken place during the long history of NEJM. It is the story of research, clinical practice, and patient care, and of how health care has continued to get better over the past 200 years. View the film in its entirety, or in segments, now on the 200th anniversary website. Teaching Topic Thyroid Cancer Original Article Strategies of Radioiodine Ablation in Patients with Low-Risk Thyroid Cancer M. Schlumberger and Others In patients with low-risk thyroid cancer, it is unclear whether the administration of radioiodine provides any benefit after a complete surgical resection, and radioiodine is not recommended in patients with disease that is categorized as consisting of a tumor less than 1 cm in diameter and clinical stage N0. Therefore, radioiodine should be used with great care in order to minimize harm and administer the minimal amount of radioactivity. Clinical Pearls Why is radioiodine administered to patients with thyroid cancer after total thyroidectomy?Radioiodine (131I) is administered to patients with thyroid cancer after total thyroidectomy for three reasons: first, to eradicate normal-thyroid remnants (ablation) to obtain an undetectable serum thyroglobulin level; second, to irradiate any neoplastic focus to decrease the risk of recurrence; and third, to perform a 131I total-body scan to detect persistent carcinoma. Successful ablation is defined by the combination of undetectable serum thyroglobulin levels after thyrotropin stimulation and normal results on neck ultrasonography 6 to 12 months after 131I administration. What are the two methods used for thyrotropin stimulation prior to the administration of radioactive iodine for ablation?The two methods used for thyrotropin stimulation are the use of recombinant human thyrotropin and thyroid hormone withdrawal. Each is administered after surgery and before radioiodine administration. The method used is a matter of debate. The use of recombinant human thyrotropin maintains quality of life, is cost-effective, and reduces the radiation dose delivered to the body as compared with the amount delivered with thyroid-hormone withdrawal. Recombinant human thyrotropin and thyroid-hormone withdrawal provide similar ablation rates when a radiation activity of 3.7 GBq is administered. Furthermore, whether the 3.7-GBq dose is necessary has been questioned. Morning Report Questions Q. What were the primary results of this study, which compared different doses of postoperative radioactive iodine in patients with low-risk thyroid cancer? A. The primary outcome of this study was thyroid ablation. Ablation was assessed at a mean (±SD) of 8±2 months after radioiodine administration with the use of neck ultrasonography and determination of the level of recombinant human thyrotropin-stimulated serum thyroglobulin or a diagnostic 131I total-body scan in patients with detectable antithyroglobulin antibody. For the 684 patients who could be evaluated in this study, a follow-up study was performed between 6 and 10 months (average, 8.3±1.6 months) after 131I administration, and no significant difference was found between the 1.1-GBq group and the 3.7-GBq group. Q. What were the findings in this study with respect to use of thyroid hormone withdrawal versus recombinant human thyrotropin prior to radioactive iodine? A. The proportion of patients with symptoms of hypothyroidism was significantly higher in the groups undergoing thyroid-hormone withdrawal than in the groups receiving recombinant human thyrotropin. Thyroid-hormone withdrawal was associated with deterioration of the quality of life, as compared with recombinant human thyrotropin. Radioiodine may induce lacrimal and salivary-gland disturbances, depending on the amount of radioactivity administered. The incidence of salivary problems did not differ significantly between groups, but lacrimal dysfunction (runny eyes) was more frequent among patients undergoing thyroid-hormone withdrawal along with low (19%) or with a high (25%) 131I activity than among patients receiving recombinant human thyrotropin (10%). Teaching Topic Whistling in the Dark Clinical Problem-Solving Whistling in the Dark D.A. and Others It is important to consider a broad differential diagnosis for wheezing, especially when findings are atypical for asthma or when symptoms fail to subside as expected in response to conventional therapy. This case highlights the importance of measuring lung function both when attempting to confirm (or rule out) a diagnosis of asthma if it is suspected and when adjusting medications in patients with established asthma. Clinical Pearls What is the differential diagnosis of a patient who presents with a cough and wheezing?Recurrent episodes of shortness of breath, cough, and wheezing suggest a diagnosis of asthma. Nocturnal worsening of symptoms is consistent with this diagnosis. Atypical features, opening the possibility of alternative diagnoses, would be a late age at onset and the absence of identifiable triggers for the symptoms. Other potential causes include recurrent respiratory tract infections, gastroesophageal reflux with microaspiration of gastric contents, and congestive heart failure, including that resulting from valvular heart disease or diastolic dysfunction, which may cause “cardiac asthma.” How does aspirin-associated respiratory disease present?Aspirin-exacerbated respiratory disease often presents in adulthood with a characteristic sequence of recurrent sinusitis, followed by the development of asthma and then the recognition of exacerbations of asthma precipitated by ingestion of aspirin or any other cyclooxygenase-1 inhibitor. Morning Report Questions Q. How does one make the diagnosis of tracheomalacia? A. The diagnosis of tracheomalacia may be made with the use of fiberoptic bronchoscopy, but the speed of image collection on modern multidetector CT equipment makes chest CT a useful alternative means of diagnosis. Images should be obtained during inspiration and expiration and then compared. For images collected during expiration, the goal is to maximize the abnormal movement of the posterior tracheal wall (or any other malacic portion of the wall). The best time to obtain the image is near but not at the end of exhalation, when the pleural pressure is still positive. Precise criteria for radiographic diagnosis of tracheomalacia have not yet been defined, but many radiologists use a luminal narrowing of 50% on exhalation as a benchmark. Q. What is the most common cause of tracheomalacia? A. In adults, the most common cause of tracheomalacia is prolonged mechanical ventilation; high pressures in the endotracheal tube cuff may cause localized ischemic injury to the tracheal wall (the cartilage and the membranous sheath). Other causes of segmental tracheomalacia include prolonged external pressure on the tracheal wall, such as may be caused by a large substernal goiter or a congenital vascular sling (e.g., a right-sided aortic arch with an aberrant subclavian artery). More diffuse tracheomalacia is encountered in patients with the rare conditions of tracheobronchomegaly (Mounier–Kuhn syndrome) and relapsing polychondritis. Archive of Teaching Topics » quote of the week “A 2-year follow-up of patients in the PARTNER trial supports TAVR as an alternative to surgery in high-risk patients. The two treatments were similar with respect to mortality, reduction in symptoms, and improved valve hemodynamics, but paravalvular regurgitation was more frequent after TAVR and was associated with increased late mortality.” S.K. Kodali and Others, Original Article, “Two-Year Outcomes after Transcatheter or Surgical Aortic-Valve Replacement” IMAGE CHALLENGE What is the diagnosis? 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