Angelos Kyriacou

Benign thyroid disease in pregnancy: A state of the art review

Highlights • Overt hypothyroidism needs to be treated with levothyroxine.• Subclinical hypothyroidism treated with thyroxine has not been proven to improve maternal outcomes.• Overt hyperthyroidism usually needs to be treated with thioamides.• Subclinical hyperthyroidism does not require treatment.• Evidence linking TPO antibodies with miscarriages and preterm labour is unequivocal.

Proopiomelanocortin interference in the measurement of adrenocorticotrophic hormone: a United Kingdom National External Quality Assessment Service study.

It is recognized that measurement of ACTH‐precursor peptides including proopiomelanocortin (POMC) has clinical utility in identifying the aetiology of Cushings syndrome. Recent data have also demonstrated cross‐reactivity of POMC in ACTH immunoassays used in clinical laboratories. The aim of this study was to assess the cross‐reactivity of POMC in the main commercial immunoassays for ACTH and to survey the awareness of laboratory professionals to this potential interference.

Gastric bypass surgery in women with or without polycystic ovary syndrome: A comparative observational cohort analysis

Medicine. The definitive publisher-authenticated version Kyriacou A, Hunter AL, Tolofari S, Syed AA. Gastric bypass surgery in women with or without polycystic ovary syndrome—A comparative observational cohort analysis. Eur J Intern Med 2014;25(2):e23-e24 is available online at: http://dx.doi.org/10.1016/j.ejim.2013.09.012 Gastric bypass surgery in women with or without polycystic ovary syndrome – a comparative observational cohort analysis Angelos Kyriacou, Ann Louise Hunter, Sotonye Tolofari, Akheel A. Syed Department of Obesity Medicine and Endocrinology, Salford Royal NHS Foundation Trust and University Teaching Hospital, Salford M6 8HD. Faculty of Medical and Human Sciences, The University of Manchester, Manchester M13 9PL.

Recurrence of phaeochromocytoma in pregnancy in a patient with multiple endocrine neoplasia 2A: a case report and review of literature

Abstract Multiple endocrine neoplasia type 2A (MEN 2A) is an autosomal dominant inherited condition with a prevalence of one in 40 000 individuals. It causes the development of tumours in endocrine glands, such as medullary thyroid cancer, pheochromocytomas, as well as primary hyperparathyroidism. MEN 2A in pregnancy is very rare with only 29 cases reported in the literature. The presence of pheochromocytoma is a rare cause of hypertension during pregnancy with an incidence of 0.007% of all pregnancies. This has severe implications on both mother and the foetus. This case report describes a 22-year-old nulliparous Caucasian woman with known MEN2A syndrome, who underwent thyroidectomy for medullary thyroid carcinoma in childhood and excision of left sided pheochromocytoma at the age of 19. She was found to have a recurrence of pheochromocytoma in the right adrenal gland during pregnancy at 16 weeks of gestation and was oddly normotensive. Catecholamine effects were blocked with phenoxybenzamine and she delivered by an uneventful elective caesarean section at 36 weeks gestation. She underwent a laparoscopic right adrenalectomy six weeks postpartum, followed by lifelong corticosteroid replacement.

The value of second fine needle aspiration cytology tests when investigating benign thyroid nodules (Thy2/Thy2c)

Although the vast majority of thyroid nodules are benign, evaluation by ultrasound-guided fine needle aspiration (FNA) biopsy is usually necessary to exclude underlying malignancy. Partially in recognition of reported variability in FNA sensitivity and specificity, the 2007 British Thyroid Association (BTA) guidelines recommended two benign results 3?6 months apart to exclude neoplasia. The 2014 BTA guidance states that a second FNA is not required for nodules with benign Thy2 cytology and ultrasound characteristics unless there is strong clinical evidence to suggest malignancy. We report a retrospective analysis of patients from two large teaching hospitals who had repeat ultrasound-guided FNA biopsy between 2009 and 2014 following an initial report of Thy2/Thy2c. Radiology and cytology findings for first, second and any subsequent investigations were reviewed. Of the 162 patients with a first FNA of Thy2/2c, 25 repeat biopsies were non-diagnostic (Thy1/1c), and 130 patients again had benign Thy2/2c cytology, although 14 of these repeat biopsies were taken from the opposite side; one of these patients was later diagnosed with an incidental follicular variant of papillary thyroid cancer, another with Hurthle cell adenoma. Seven of the 162 patients with a first FNA of Thy2/2c were found to have Thy3 cytology or higher (3 Thy3a, 2 Thy3, 1 Thy4 and 1 Thy5) on repeat biopsy and progressed to thyroid surgery, where four were diagnosed with thyroid carcinoma. There was no strong clinical evidence to suggest malignancy in any of these patients, and initial ultrasound characteristics were also unremarkable. These results suggest that a second ultrasound-guided FNA biopsy may be necessary to avoid incorrect exclusion of neoplasia in patients initially found to have benign cytology, unless it is proven beyond doubt that by doing so we do not alter clinical outcomes in these generally indolent tumours.

Intractable hypoglycaemia in a patient with advanced carcinoid syndrome successfully treated with hepatic embolization.

A male patient presented at the age of 54 years with metastatic pancreatic neuroendocrine tumour (NET). He was managed with interferon and multiple courses of MIBG therapy which controlled his disease for about seven years. He then developed symptomatic hypoglycaemia which resolved with the introduction of somatostatin analogue treatment and further therapeutic MIBG. However, three years later he was admitted to hospital with severe and intractable hypoglycaemia, which persisted despite treatment with dietary manipulation, diazoxide, long-acting octreotide injections, intravenous infusion of dextrose and octreotide and everolimus. Bland hepatic embolization was attempted as a last resort and resulted in prompt and dramatic improvement of his condition with no hypoglycaemia for five months. We recommend that hepatic embolization should be considered in patients with advanced and metastatic NETs accompanied by refractory hypoglycaemia, with the aim of symptomatic relief and palliation, and possibly some survival benefit.

Time to end medical nihilism in non-surgical weight management

This review summarizes recent evidence related to the safety, efficacy, and metabolic outcomes of bariatric surgery to guide clinical decision making. Several short term randomized controlled trials have demonstrated the effectiveness of bariatric procedures for inducing weight loss and initial remission of type 2 diabetes. Observational studies have linked bariatric procedures with long term improvements in body weight, type 2 diabetes, survival, cardiovascular events, incident cancer, and quality of life. Perioperative mortality for the average patient is low but varies greatly across subgroups. The incidence of major complications after surgery also varies widely, and emerging data show that some procedures are associated with a greater risk of substance misuse disorders, suicide, and nutritional deficiencies. More research is needed to enable long term outcomes to be compared across various procedures and subpopulations, and to identify those most likely to benefit from surgical intervention. Given uncertainties about the balance between the risks and benefits of bariatric surgery in the long term, the decision to undergo surgery should be based on a high quality shared decision making process.