Imaging thyroid disease: updates, imaging approach, and management pearls.

There are many disorders that can occur in the thyroid gland, ranging from benign to malignant entities. This article focuses on 5 common problems of the thyroid that require special consideration with regard to optimizing imaging strategies in a multidisciplinary and collaborative platform. These problems are the incidental thyroid nodule, preoperative evaluation of goiter, hyperthyroidism, invasive thyroid cancer, and recurrent thyroid cancer. For each problem essential facts, interesting updates, imaging approach, and management pearls are reviewed.

Informatics in radiology: evaluation of an e-learning platform for teaching medical students competency in ordering radiologic examinations.

A preliminary audit of orders for computed tomography was performed to evaluate the typical performance of interns ordering radiologic examinations. According to the audit, the interns showed only minimal improvement after 8 months of work experience. The online radiology ordering module (ROM) program included baseline assessment of student performance (part I), online learning with the ROM (part II), and follow-up assessment of performance with simulated ordering with the ROM (part III). A curriculum blueprint determined the content of the ROM program, with an emphasis on practical issues, including provision of logistic information, clinical details, and safety-related information. Appropriate standards were developed by a committee of experts, and detailed scoring systems were devised for assessment. The ROM program was successful in addressing practical issues in a simulated setting. In the part I assessment, the mean score for noting contraindications for contrast media was 24%; this score increased to 59% in the part III assessment (P = .004). Similarly, notification of methicillin-resistant Staphylococcus aureus status and pregnancy status and provision of referring physician contact information improved significantly. The quality of the clinical notes was stable, with good initial scores. Part III testing showed overall improvement, with the mean score increasing from 61% to 76% (P < .0001). In general, medical students lack the core knowledge that is needed for good-quality ordering of radiology services, and the experience typically afforded to interns does not address this lack of knowledge. The ROM program was a successful intervention that resulted in statistically significant improvements in the quality of radiologic examination orders, particularly with regard to logistic and radiation safety issues.

Retrospective comparison of the original and revised McDonald criteria in a general neurology practice in Ireland.

BACKGROUND: The McDonald criteria were introduced in 2001 as guidelines to facilitate early and accurate diagnosis of multiple sclerosis (MS). They were revised in 2005. Although validated in a number of research-focused clinical centres, their adequacy and utility in the general neurology setting is less certain. OBJECTIVE: In this study, we assessed new diagnoses of MS in our practice for compliance with both the original and the revised criteria. METHODS: We retrospectively identified new diagnoses of MS from 2001. Clinical notes and imaging were evaluated for compliance with McDonald criteria. RESULTS: Sixty-two patients were included: 53 with ;practice-definite' and nine with ;practice-possible' diagnoses of MS. At the time of diagnosis, 47% of the ;practice-definite' group fulfilled the 2001 criteria and 49% the revised criteria. Among patients not satisfying the criteria at time of diagnosis, 21% went on to fulfil the McDonald criteria over the 23-month follow-up. CONCLUSIONS: There is a considerable gap between the clinical diagnosis of MS in a general neurology setting and compliance with the McDonald criteria. Failure to perform follow-up MRI on patients with clinically isolated syndromes is a sizeable factor in this diagnostic-gap and needs to be improved. In this setting, practical differences between the original and revised criteria appear to be small.

Diagnosis of equine infectious anaemia during the 2006 outbreak in Ireland.

In 2006 there was an outbreak of equine infectious anaemia (EIA) in Ireland. This paper describes the use of the diagnosis of clinical and subclinical cases of the disease. In acute cases the ELISAs and the immunoblot were more sensitive than the AGID. In one mare, fluctuating antibody levels were observed in all the serological assays before it seroconverted by AGID. Viral RNA and DNA were detected by RT-PCR and PCR in all the tissues from the infected animals examined postmortem. The PCR detected viral DNA in plasma regardless of the stage of the disease. In contrast, the RT-PCR detected RNA in only 52 per cent of the seropositive animals tested and appeared to be most sensitive for the detection of virus early in infection. Both PCR and RT-PCR demonstrated potential to detect acutely infected horses earlier than some of the official tests. The serological data suggest that the usual incubation/seroconversion period for this strain of the virus was approximately 37 days but may be more than 60 days in a few cases.

Evaluation of silicon and polymer substrates for fabrication of integrated microfluidic microsystems for DNA extraction and amplification.

This paper is presenting two different alternatives for the DNA extraction and amplification that will be carried out by two competitive research projects developing bioanalytical microsystems with microfluidics. The first project will develop the microfluidics part on polymer material and the other one on silicon. The polymer approach is currently under development based on a modular microfluidic architecture aimed to simplify the process of designing and building such a microsystem device. A silicon alternative is about to start and is expected to decrease packaging costs of the microsystem allowing future manufacturability of the device.

Clinical and economic impact of newer versus older antipsychotic medications in a community mental health center.

This pilot study was conducted to compare both the clinical effectiveness and the treatment costs of newer (atypical) antipsychotic medications (clozapine and risperidone) with those of older (classic) neuroleptic medications (chlorpromazine and haloperidol) for psychosis in a community mental health care setting. The study used a retrospective, uncontrolled, open, nonrandomized, within-subjects design and relied on medical records as a data source for 37 clients. All clients received older antipsychotics for at least 1 year, newer antipsychotics for a transition period of 3 months, and the newer agents for at least an additional year. The newer antipsychotic medications were more effective and less costly (total cost of care, $3000 less per client per year [1997 dollars]) than the older medications. Effect-size estimates for the measured variables provide a guide for future research into the cost-effectiveness of these newer medications within the community mental health care setting. These findings can provide policy makers with guidance on treating people with major mental disorders in the most effective and efficient manner. Because of limited budgets, community mental health centers making the investment in newer, more expensive medications to improve client outcomes have to maintain the same or lower total cost of care. Results of the current study suggest that short-term investment in the newer medications by community mental health centers offers superior clinical effectiveness and lower long-term overall cost of care.

PCR amplification of a polymorphic minisatellite VNTR locus in whiting (Merlangius merlangus L.).

An approach has been developed for the screening of allelic variation of minisatellite DNA loci that substantially reduces the time and hazards involved. Primers were designed for a minisatellite region isolated from a gadoid fish species (Merlangius merlangus L.), enabling amplification by polymerase chain reaction, so that differences in the number of minisatellite repeat units (allelic variability) were detectable by ethidium bromide fluorescence (over UV light) following separation by agarose gel electrophoresis. This amplifiable minisatellite variable number tandem repeat region, the first non-primate marker of its kind can be used successfully with DNA extracted by a rapid Chelex protocol. From a sample of 97 individuals, 24 alleles were resolved (750-2200 kb) and heterozygosity was estimated at 0.94.

Impaired glucose tolerance after endurance exercise is associated with reduced insulin secretion rather than altered insulin sensitivity.

Paired frequently sampled intravenous glucose tolerance tests (FSIGT) were performed on five highly trained athletes within 2 hours of completing a 6-day ultramarathon run (E) and after 2 weeks of complete rest (R). Severe exercise increased free fatty acid (FFA) levels (E 1.2 +/- 0.16 v 0.42 +/- 0.07 mmol/L, P < .01) and norepinephrine levels (E 573 +/- 141 v 224 +/- 33 pg/mL, P < .01), with only moderate reductions in glucose tolerance (glucose disappearance [Kg] E 1.06 +/- 0.2 v R 1.7 +/- 0.3 min-1 x 10(2), P < .05). The minimal model analysis of FSIGT data using the method of Bergman et al (Endocr Rev 6:45-86, 1985) showed a reduced second-phase insulin secretion ([phi 2] E 5.2 +/- 1.3 v 13 +/- 2.2 microU/mL.min-2 per mg/dL, P < .05) and glucose disposition index ([SI x phi 2] E 33.8 +/- 10 v 73.9 +/- 11 mg-1.dL.min-3 x 10(4), P < .02). Insulin sensitivity (SI) and glucose-mediated glucose disposal (SG) were unchanged (SI E 6.9 +/- 1.0 v 6.0 +/- 0.6 min-1 per microU/mL x 10(4); SG E 1.8 +/- 0.6 v 1.4 +/- 0.3 min-1 x 10(2)). Reduced glucose tolerance after prolonged extreme physical exercise was accompanied by reduced phi 2 and not by alterations of SI or SG, despite the marked increase of FFA levels. Elevated norepinephrine levels, reflecting activation of the sympathetic noradrenergic system, was also associated with the reduction in Kg. The reduction in phi 2 would promote mobilization of FFA, the predominant metabolic substrate in these endurance events.

A simple method for quantitation of insulin sensitivity and insulin release from an intravenous glucose tolerance test.

Both insulin secretion and insulin sensitivity are important in the development of diabetes but current methods used for their measurements are complex and cannot be used for epidemiological surveys. This study describes a simplified approach for the estimation of first phase insulin release and insulin sensitivity from a standard 40-min intravenous glucose tolerance test (IVGTT), and compares these parameter estimations with the sophisticated minimal model analysis of a frequently sampled 3-h IVGTT and the euglycaemic clamp technique. For the simplified IVGTT, first phase insulin release was measured as the insulin area above basal post glucose load unit-1 incremental change (i.e. peak rise) in plasma glucose over 0-10 min, and insulin sensitivity as a rate of glucose disappearance (Kg) unit-1 insulin increase above basal from 0-40 min post-glucose load in 18 subjects who were studied twice, either basally or in a perturbed pathophysiological state (i.e. pre- and post-ultramarathon race, n = 5; pre- and post-20 h pulsatile hyperinsulinaemia, n = 8; pre- and post-thyrotoxic state, n = 5). A further 12 subjects were compared by IVGTT, and glucose clamp. In addition, seven dogs were studied three times by IVGTT during normal saline infusion and after short-term (1/2 hour) or long-term (72 hour) adrenaline infusions. First phase insulin release and insulin sensitivity estimated from the simplified IVGTT as calculated by the two methods correlated closely (rs = 0.89 and rs = 0.87, respectively), although less precisely in markedly insulin-resistant subjects and the slopes and y intercepts of the linear regression lines were similar in the basal and perturbed states.(ABSTRACT TRUNCATED AT 250 WORDS)

Salivary oestriol and progesterone concentrations in women during late pregnancy, parturition and the puerperium.

Oestriol and progesterone concentrations were measured by specific radioimmunoassays in the saliva of six women on a daily basis during the last month of pregnancy, at frequent intervals during labour and daily during the puerperium. Salivary steroid concentrations are thought to reflect the circulating concentrations of the free hormone, and hence may be more biologically relevant than the total plasma concentration, or the urinary excretion of a metabolite. There was no sign of a fall in salivary oestriol or progesterone concentrations before the onset of labour. During the first and second stages, the concentrations fluctuated widely, perhaps due to alterations in uterine blood flow. After delivery of the placenta, hormone concentrations declined abruptly. Oestriol reached undetectable levels of less than 0.1 nmol/l within a day, whereas progesterone concentrations declined somewhat more slowly, approaching follicular-phase values after 2-3 days. This slower decline in the concentration of progesterone may be due to a leaching-out of the hormone from body fat stores. The absence of any prepartum progesterone withdrawal presumably explains the characteristic postpartum delay in the onset of lactogenesis.

Cholecystectomy and a simple technique of operative cholangiography.

A simple, easily reproducible technique of operative cholangiography is described. The technique has three advantages: (a) there is no need to divide or ligate the cystic duct; (b) it demonstrates the cystic duct anatomy clearly and is particularly useful in demonstrating stones in that duct thus eliminating the hazard of the retained stone in the cystic duct stump; (c) it is possible to eliminate the problem of false positives due to air bubbles. A consecutive series of 442 cholecystectomy patients is reviewed. The overall operative mortality was 1.6 per cent; no death could be attributed to operative cholangiography. Thirty-five of 324 patients (10.8 per cent) with gallstones and no history of jaundice were shown to have unexpected abnormalities in the common bile duct.