Endocrine incidentalomas.

OBJECTIVES: Endocrine incidentalomas are very common in the practice of every physician, mostly primary care and family physicians. Incidentalomas are discovered in the thyroid, pituitary and adrenal glands during imaging studies performed for non-endocrine reasons. The aim of this review article is to familiarise health professionals with all three endocrine incidentalomas, and give some guidance on how to initiate the right endocrine workup. METHODS: We reviewed the most pertinent literature published on this topic through PubMed and Medline. We also discussed our own approach to incidentalomas in the endocrine clinic at Thomas Jefferson Hospital in Philadelphia. RESULTS/CONCLUSIONS: Thyroid incidentalomas are very common, with a prevalence close to 50% on imaging studies. Thyroid-stimulating hormone (TSH) is the first test to obtain; if not suppressed, next step is fine-needle aspiration biopsy of any nodule above 1 cm and/or with suspicious ultrasound characteristics. Adrenal incidentalomas have a prevalence of almost 5%. All adrenal nodules above 4 cm should be resected. Regardless of the size, a workup for pheochromocytoma should always be done. Only hypertensive patients should be screened for primary hyperaldosteronism. Pituitary incidentalomas are also common, with a prevalence of 10-20%. All patients with pituitary masses should have a workup for hormonal hypersecretion. Only patients with macroadenomas will have additional screening for hypopituitarism and visual field defects. All hyperfunctioning adenomas are resected except prolactinomas which are treated medically. Similarly, if a macroadenoma is causing hypopituitarism or visual deficit, surgery should also be considered.

Endoscopic feeding tube placement in patients with cancer: a prospective clinical audit of 2055 procedures in 1866 patients.

BACKGROUND: Feeding tube placement in patients with aero-digestive cancer is challenging because of the distortion and/or obstruction of the upper digestive passage. As a result, many patients may receive intravenous fluids and parenteral nutrition instead of enteral feeds. AIM: To audit all the endoscopic feeding tube placements in large sample of patients to determine difficulties, success, reasons for failures and procedure-related complications. METHODS: Audit of all consecutive feeding tube placements from January 1996 to December 2003 was conducted. Tubes were placed depending on the site of cancer and anticipated duration of feeding: naso-gastric tubes, naso-enteral tubes and percutaneous endoscopic gastrostomy. Nutrition support team evaluated these patients. Technical modifications, difficulties, success and complications encountered during the procedure were recorded. RESULTS: Two thousand and fifty-five attempts were made for feeding tube placements (naso-gastric tube - 1637, naso-enteral tube - 177 and percutaneous endoscopic gastrostomy - 241) in 1866 patients. Technical success was achieved in 1969 (96%, 95% CI: 95-97%). Immediate complications occurred in 62 (3%, 95% CI: 2-4%), seven needed hospitalization and one patient died of tumour perforation caused by naso-gastric tube placement. The technical success and complications rates of the procedures performed by fellows in training were comparable to those performed by attending consultants. CONCLUSIONS: Enteral feeding tubes can be placed in almost all patients with cancer using endoscopic techniques. Adequate training of the endoscopy fellows and sufficient care by nutrition support team help achieve high success with few complications.

Subjective global assessment: a simple and reliable screening tool for malnutrition among Indians.

BACKGROUND AND AIMS: Subjective global assessment (SGA) is a simple and reliable malnutrition-screening tool. The SGA has not been evaluated in India or in populations where chronic energy deficiency (CED) is rampant. We evaluated the value of preoperative nutrition, determined using the SGA, in predicting postoperative adverse outcomes in cancer patients. METHODS: Two hundred and ninety-four cancer patients undergoing elective surgery were screened for malnutrition using a modified version of the SGA, and 266 patients (aged 14-73 years [median 50]; 165 male) were eligible. All patients were followed up till discharge, and number of days on antibiotics, length of postoperative stay, occurrence of major adverse events, and death within 30 days were recorded. The association of preoperative SGA scores (A, B, or C) and BMI groups (< 18.5, 18.5-20 or> 20 Kg/m2) and four outcome variables were tested for statistical significance. RESULTS: The cancer sites included head and neck region in 112, gastrointestinal tract in 53, thoracic organs in 28, and other sites in 73 patients. The SGA scores were A in 152, B in 98, and C in 16 patients. The BMI was < 18.5 in 110 (41.8%) patients. The length of postoperative stay and the number of antibiotic days revealed a significant trend from SGA-A to SGA-C (p=0.000). Pre-defined adverse events occurred in 7.9%, 17.3% and 25% of SGA groups A, B, and C, respectively (p=0.025). The risk for adverse events was significantly higher in SGA-C group (OR 5.27, 95% CI 1.35-20.51, p< 0.016) compared to SGA-A group. Three patients in SGA-B group and one in SGA-C group died within 30 days (p=0.04). No significant association was detected between the three BMI groups and duration of antibiotic use, length of postoperative stay, adverse events or mortality. CONCLUSION: SGA is a simple and inexpensive way to identify clinically relevant malnutrition in Indian patients undergoing cancer surgery. Low BMI was not associated with postoperative adverse outcomes, and its use for nutritional screening is likely to overestimate severe malnutrition in Indian patients.

Etanercept therapy in patients with autoimmunity and hepatitis C.

Accumulated data suggest that etanercept may be a therapeutic option in patients with hepatitis C and coexisting autoimmune disorders such as rheumatoid arthritis, psoriasis, psoriatic arthritis and ankylosing spondylitis. Additionally, etanercept may actually be of benefit, when used in combination with standard treatments, for hepatitis C.

Total parenteral nutrition.

Parenteral nutrition is a form of therapy in which elemental nutrients (sugars, lipids, amino acids, vitamins and minerals) are given as an intravenous infusion. It is complementary and not competitive to enteral nutrition. While a vast majority of patients can be managed by enteral nutrition, a few patients need parenteral nutrition for survival. Very few patients may need both enteral and parenteral nutrition for short periods. The indications, delivery methods and formulations of parenteral nutrition have been refined in the past 30 years. It is now possible to give parenteral nutrition for prolonged periods at home. Three-in-one parenteral nutrition mixture bags are presently available in India. This article discusses the practical aspects of using parenteral nutrition in everyday practice.

Enteral nutrition by tube feeding in adults.

Patients who cannot eat enough require alternatives to oral feeding. Tube feeding is one such method for patients with a functioning gut. The techniques for the placement of feeding tubes and diets for tube feeding have improved during the past 20 years. Comfortable thin-bore polyurethane tubes are replacing the thicker vinyl tubes. Long term access routes such as gastrostomy and jejunostomy are being done by endoscopic or radiological techniques. Pre-defined formula feeds have reduced the effort and labour involved in the preparation, storage and administration of blenderized tube feeds. However, the use of soft feeding tubes and commercial formulae will increase the cost of nutrition therapy in India. The ultimate cost-effectiveness of tube feeding will depend on whether it is used appropriately during an illness with adequate delivery of feeds, and whether attention is given to small details by a dedicated nutritional support team. A strong commitment to the scientific use of nutritional support is necessary for getting the best results from tube feeding in everyday practice.

Singular anti-RNA virus-directed proteins.

AIMS: To additionally purify and characterise the anti-RNA virus-directed protein termed p14. MATERIALS AND METHODS: Antiviral assays of p14 against RNA and DNA viruses were carried out and its antigenic similarities with chicken interferon (CIFN) were studied. HPLC-Reverse Phase of p14 was performed to further purify p14. RESULTS: p14 showed antiviral activity against RNA viruses only and not against DNA viruses. It was antigenically distinct from CIFN. Purification of p14 yielded three proteins with antiviral activity, which had different physico-chemical properties than those described for interferons. CONCLUSIONS: The data presented on the antiviral, immunological and physico-chemical properties, establish the unique nature of p14 vis-á-vis those of interferons.

A rapid method for the evaluation of new antituberculous agents.

Fifty-one new synthetic compounds belonging to four different series, namely (1a) substituted aryl-4-(substituted phenyl) succinimide; (1b) N-(substituted methyl)-4-(heterocyclic) succinimide; (2) heterocyclic 4-(5'-nitro-2-furyl) thiazoles; (3) substituted aryl-4-(3', 4'-dihydroxy phenyl) thiazoles, and (4) phenyl-N,N-1,2,3-bis-methoxy carbonyl guanidines were screened for antituberculous activity using a conventional broth dilution test (BDT) and a liquid scintillation radiometric method (LSRM). Eight compounds showed in vitro activity. LSRM showed 100% agreement with BDT. LSRM is completed within 60 h, while BDT requires 8-9 days. Unlike BDT, LSRM allowed one to measure the graded changes in the metabolism and the growth rate of Mycobacterium tuberculosis in response to various concentrations of the drug. It permits the measurement of the relative prolongation of the replication time by the drug or the test compound. With LSRM it was possible to detect the phase of growth during which the test compound shows or begins its antituberculous activity. It improves our understanding of the antituberculous activity of the test compound and hence is more advantageous. It is rapid, reliable, quantitative and more sensitive than BDT. LSRM is thus suitable for the evaluation of new drugs.