Georgios Kyriakos

Accuracy of ultrasound elastography in the diagnosis of thyroid cancer in a low-risk population.

OBJECTIVE Stiffness has been associated to malignancy in prostate and breast, as well as thyroid. Ultrasound elastography objectively measures tissue elasticity, and previous studies have described it as a high sensitivity and specificity technique for the detection of malignant thyroid nodules in high-risk populations. The aim was to assess the accuracy of elastography in a population with low risk of malignancy. DESIGN AND PATIENTS 128 consecutive patients with nodular goiter were recruited. Elastography and ultrasound-guided fine-needle aspiration were performed. When malignancy was suspected by citology, surgery was recommended. Thyroid nodules were classified by elastography according the criteria described by Ueno, and an alternative classification. Sensitivity, specificity, predictive values, and odds ratio were calculated. RESULTS Most patients were female, aged 56.1 year, with single nodule (52.0%) or multinodular goiter (45.6%), and a few thyroiditis (2.4%). The majority of nodules were mostly elastic. Fine-needle aspiration found 86% of benign nodules, 9.3% of indeterminate, and 4.7% possibly malignant. After surgery, 3 malignant nodules were confirmed, all of them being papillary carcinomas. All the malignant nodules were mostly elastic, as well as 75% of indeterminate nodules. Low values of sensitivity and specificity were found for elastic nodules being benign and hard nodules malignant. CONCLUSION In a low-risk population for thyroid cancer, elastography lacks accuracy for the diagnosis of malignant nodules.

CHRONIC ENTERITIS IN PATIENTS UNDERGOING PELVIC RADIOTHERAPY: PREVALENCE, RISK FACTORS AND ASSOCIATED COMPLICATIONS.

INTRODUCTION the radiation of tumours located in pelvic organs can cause mucositis in the bowel. The aim of this study was to determine the prevalence, risk factors, and complications of chronic radiation enteritis in patients who had received pelvic radiotherapy. PATIENTS AND METHODS cross-sectional study recruiting 150 patients that had been treated with radiation therapy during the year 2008 because of a prostate, cervical, endometrial or rectal cancer. The patients were asked about symptoms related to enteritis, and about changes in body weight and in dietary patterns. Sex, age, treatment modalities, acute enteritis, and type of cancer were considered possible risk factors, and were analysed with univariate and multivariate methods. RESULTS the study included 100 patients, 84% males, median age 72.3 years. Chronic radiation enteritis was found in 20% of the patients, most of them grade 1 (45%). Furthermore, 10% had lost ≥ 5 kg of weight, 3% had been hospitalized due to diarrhoea or bowel obstruction, and 11% had changed their diet, mainly by removing vegetables, legumes and pastry. Male gender, age, previous acute radiation enteritis, and chemotherapy were associated with chronic enteritis, but only chemotherapy remained independently related to bowel toxicity after multivariate analysis (OR = 3.59 [95% CI 1.20-10.73]). CONCLUSION chronic enteritis is common among patients treated with pelvic radiotherapy, especially if chemotherapy is associated. The complication rate is low, but a significant number of patients change their usual diet in order to prevent symptoms.

Estudio comparativo de la aplicación de la calibración FRIDEX y de la guía NOGG en el manejo de la osteoporosis en la práctica clínica habitual

OBJECTIVE The recent FRIDEX calibration proposed cost-effectiveness thresholds for the Spanish population. The aim of our study is to evaluate the impact of its application in routine clinical practice and to compare its thresholds with those of the National Osteoporosis Guideline Group (NOGG). MATERIAL AND METHODS Cross-sectional study in women referred to a bone densitometry unit who were not receiving antiresorptive therapy. The absolute risk of major fracture or hip fracture was calculated with the Spanish and British formulas of the FRAX® tool using the intervention thresholds of the FRIDEX calibration and the NOGG guideline, respectively. RESULTS The study included 607 women with a median age of 59.4 (IQR=14) years. Treatment was initiated in 31.4% after bone mineral densitometry. With the application of the FRIDEX calibration, bone mineral density testing would have been indicated in 35.4% of the sample and treatment in 26.7%, reducing costs by 18.8% over a 5-year period. The NOGG guideline would have recommended testing in 32% and treatment in 21.3% of the participants, resulting in a reduction in costs of 35% over 5years, when compared with the standard approach. Agreement between the FRIDEX calibration and the NOGG guideline, as defined by Cohens kappa coefficient, was low in terms of both diagnostic (0.16 [95%CI, 0.09-0.24]) and therapeutic indications (0.39 [95%CI, 0.31-0.47]). CONCLUSIONS The application of the FRIDEX calibration and the NOGG guideline improves efficiency in the management of osteoporosis, although the level of agreement between the two is low.

Impact of the NOGG and NOF Guidelines on the Indication of Bone Mineral Density in Routine Clinical Practice.

The universal screening for osteoporosis by bone mineral density (BMD) is not feasible because of its unfavorable cost-benefit due to its low sensitivity. The aim of the present study was to estimate the population and economic impact of the diagnostic criteria of the National Osteoporosis Guideline Group (NOGG) and the National Osteoporosis Foundation (NOF) and assess the appropriateness of the BMD tests performed in routine clinical practice. A cross-sectional study was conducted in individuals referred for BMD testing who were not receiving antiresorptive therapy. The absolute risk of major and hip fracture was calculated using the British formula of the Fracture Risk Assessment Tool. NOGG and NOF guidelines diagnostic thresholds interventions were used. A total of 640 individuals were included, of which 95% were women, with a median age of 59.4 years (interquartile range = 14). When applying the NOGG criteria, BMD testing was recommended in 32.3% of the individuals, whereas this percentage increased to 75.6% with the NOF guidelines (p < 0.05). Regarding the appropriateness of the BMD tests performed, 31.9% were deemed appropriate according to both the NOGG and NOF guidelines, whereas 23.9% were considered inappropriate. In conclusion, the application of the NOGG and NOF guidelines led to a decrease in BMD indications, reducing costs and improving efficiency in the diagnostic management of osteoporosis, although variability exists between the guidelines.

Prolonged fasting with fluid therapy is related to poorer outcomes in medical patients.

BACKGROUND AND OBJECTIVE An inadequate fluid therapy can worsen the outcomes of surgical patients, but there are no data in medical patients. The aim of this study was to determine the adequacy of fluid therapy in hospitalised patients of medical wards, and its influence on outcomes. METHODS Cross-sectional study including nil-per-os patients admitted in medical wards of the Complejo Asistencial Universitario de León. The administered fluid therapy was compared with the standardised requirements. Nutritional status was evaluated with Subjective Global Assessment. Fasting was considered inappropriate if it lasted > 7 days in well-nourished, and >5 days in malnourished patients if nutritional support had not been provided. RESULTS Fluid therapy lasted 4 (IQR = 2) days, and fasting was inadequately maintained in 27% of patients. Fluid requirements were correctly fulfilled, but patients received an excess of sodium (+58.4%) and chloride (+62.2%), and potassium administration was insufficient (-35.1%). Glucose supply was 68.8 (29.2) g/d, and 99% received < 130 g/d. Patients with an inadequate duration of fasting had a longer hospital stay after adjusting for sex, age, nutritional status, infused volume, electrolytes, glucose and diseases. Only malnutrition predicted mortality during hospitalisation (OR 10.5; 95%CI 1.3 to 83.2), when multivariate analysis was performed. CONCLUSIONS Fasting medical patients receive an inadequate supply of glucose and electrolytes. Prolonged fluid therapy and malnutrition may worsen the outcomes of these patients, independently of other conditions like age or diseases.

Is vitamin D deficiency being considered in the differential diagnosis of osteoporosis in routine practice

Vitamin D is essential for promoting calcium absorption in the intestine, maintaining serum calcium and phosphate concentrations, and allowing proper bone mineralization. Insufficient serum 25 hydroxyvitamin D3 (25OHD) concentrations lead to increased PTH secretion, which in turn accelerates bone resorption, especially of the cortical bone. Severe vitamin D deficiency occurs when serum 25OHD drops below 10 ng/ml, which may lead to rickets in children and osteomalacia in adults. In addition, osteomalacia during its mild and early clinical course can be misdiagnosed as osteopenia and osteoporosis. The objective of this study was to evaluate the request of biochemical determination of 25OHD concentration in routine practice during the differential diagnosis and workup of individuals with osteoporosis. A cross-sectional study was performed with a sample of individuals referred from different care settings (primary care and different specialists) with suspicion of osteoporosis for conducting an axial dual-energy X-ray absorptiometry (DXA) bone mineral density (BMD) test at the densitometric unit of the University Hospital of León in Spain. Individuals between 40 and 90 years of age who had received no previous treatment with antiresorptive medications were included. Blood tests were reviewed to assess whether the attending physician requested the determination of vitamin D concentrations, and if so, its value was collected. The following ranges were used to classify the status of vitamin D in: vitamin D deficiency if 25OHD was <20 ng/ml; vitamin D insufficiency if 25OHD was between 20 and 30 ng/ml; and vitamin D sufficiency if 25OHD was >30 ng/ml. A total of 640 individuals were recruited, 95% of whom were females, with a median age of 59.4 [interquartile range (IQR): 14] years. The concentrations of serum 25OHD were requested in 206 individuals (32.2%). The median concentration of 25OHD was 24.5 ng/ml (IQR: 14), with 68% of the individuals presenting a vitamin D status of insufficiency/deficiency. Serum 25OHD concentrations positively correlated with any of the BMD measurements both in the lumbar spine and the femoral neck [Pearson correlation coefficients (95% confidence interval): 0.32 (0.09--0.51) and 0.29 (0.07--0.46), respectively, p < 0.05]. Despite the important role of vitamin D in the diagnosis and therapeutic approach of osteoporosis, the assessment of its concentrations was requested by clinicians only in 32.2% of the study subjects. This may have important implications in the differential diagnosis of secondary causes of osteoporosis like osteomalacia. The recent guidance from the National Osteoporosis Society recommends determining concentrations of serum 25OHD in patients with bone diseases, prior to specific treatment where correcting vitamin D deficiency is appropriate, and in patients with bone diseases that may be improved with vitamin D treatment, like osteoporosis and osteomalacia. In patients with very low concentrations of vitamin D (and especially if PTH is high), the need for treatment of osteoporosis should be reassessed after correction of the vitamin D concentration. In these patients with severe vitamin D deficiency, a marked increase can be seen in BMD after treatment with calcium and vitamin D, making the treatment for low BMD unnecessary. Osteomalacia may occur with low BMD, and histological studies suggest that it is present in up to 40% of patients with hip fractures. Although definitive diagnosis is made by bone biopsy, it should be suspected in individuals with low vitamin D, hypophosphatemia, elevated alkaline phosphatase, and calcium in the lower limit of normality. If osteomalacia is misdiagnosed as osteoporosis and is treated with bisphosphonates, bone demineralization and risk of osteonecrosis of the jaw may increase. In addition, it has been suggested that middle-aged patients with inexplicable low BMD should be treated with high doses of vitamin D and calcium in order to rule out a possible mild or recent onset osteomalacia, and thereafter repeat the BMD test. Also, the prevalence of vitamin D deficiency in the study individuals was high. This is consistent with previous studies that have shown that even in countries with many hours of sunshine, the prevalence of vitamin D deficiency is elevated. Moreover, the state of vitamin D plays an important role in the success rate

OP047 FLUID THERAPY DURATION AND NUTRITIONAL STATUS INFLUENCE OUTCOME IN MEDICAL HOSPITALIZED PATIENTS

Rationale: Fluid and sodium overload has been related to poorer outcomes in surgical patients. The aim of the study was to determine the adequacy of fluid therapy in hospitalized patients of medical wards, and its influence on outcomes. Methods: Cross-sectional study including nil-per-os patients admitted in medical wards from September 2011 to February 2012. We compared the administered fluid therapy with standardized requirements: water 35ml/kg; K: 1mmol/kg, Na/Cl: 2mmol/kg; glucose >130 g/d. Nutritional status was evaluated with SGA. Fasting was considered inappropriate if lasted >7 days in wellnourished and >5 days in malnourished, and nutritional support had not been provided. Multivariate analysis was performed with linear/logistic regression. Results: A sample of 100 patients was included, 51% male, 76.6 (13.3) yr. Fluid therapy lasted 4 (IQR = 2) days, and fasting was inadequately maintained in 27% of patients. Fluid requirements were correctly fulfilled: they needed 2299.6 (355.4) ml and received 2295.7 (683.4) ml. Data about electrolytes are summarized in the table. Glucose supply was 68.8 (29.2) g/d, and 99% received <130 g/d. Patients with inadequate duration of fasting had a longer hospital stay [22.0 (IQR = 13.0) vs 13.0 (IQR = 11.0) days, p = 0.001], after adjusting for sex, age, nutritional status, infused volume, electrolytes, glucose and diseases. After adjusting for these factors, only malnutrition predicted mortality during hospitalization (OR 10.5; CI95% 1.3 to 83.2).