Göran Wallin

Anaplastic thyroid carcinoma: three protocols combining doxorubicin, hyperfractionated radiotherapy and surgery

Patients with anaplastic thyroid carcinoma can rarely be cured, but every effort should be made to prevent death due to suffocation. Between 1984 and 1999, 55 consecutive patients with anaplastic thyroid carcinoma were prospectively treated according to a combined regimen consisting of hyperfractionated radiotherapy, doxorubicin, and when feasible surgery. Radiotherapy was carried out for 5 days a week. The daily fraction until 1988 was 1.0 Gy × 2 (A) and 1989–92 1.3 Gy × 2 (B) . Thereafter 1.6 Gy × 2 (C) was administered. Radiotherapy was administered to a total target dose of 46 Gy; of which 30 Gy was administered preoperatively in the first two protocols (A and B), while the whole dose was given preoperatively in the third protocol (C). The therapy was otherwise identical. Twenty mg doxorubicin was administered intravenously weekly. Surgery was possible in 40 patients. No patient failed to complete the protocol due to toxicity. In only 13 cases (24%) was death attributed to local failure. Five patients (9%) ‘had a survival’ exceeding 2 years. No signs of local recurrence were seen in 33 patients (60%); 5 out of 16 patients in Protocol A, 11 out of 17 patients in Protocol B, 17 out of 22 patients in Protocol C (P=0.017). In the 40 patients undergoing additional surgery, no signs of local recurrence were seen in 5 out of 9 patients, 11 out of 14 patients and 17 out of 17 patients, respectively (P=0.005).

Anaplastic carcinoma of the thyroid gland: Treatment and outcome over 13 years at one institution

Anaplastic thyroid carcinoma (ATC) is a highly aggressive malignancy of the thyroid gland. Patients at our institution are treated with external radiotherapy up to 46 Gray (Gy) and low‐dose doxorubicin prior to surgery. We retrospectively evaluated the outcome of ATC patients over a 13‐year period.

Preinjury β-blockade is protective in isolated severe traumatic brain injury

BACKGROUND The purpose of this study was to investigate the effect of preinjury &bgr;-blockade in patients experiencing isolated severe traumatic brain injury (TBI). We hypothesized that &bgr;-blockade before TBI is associated with improved survival. METHODS The trauma registry of an urban academic trauma center was queried to identify patients with an isolated severe TBI between January 2007 and December 2011. Isolated severe TBI was defined as an intracranial injury with an Abbreviated Injury Scale (AIS) score of 3 or greater excluding all extracranial injuries AIS score of 3 or greater. Patient demographics, clinical characteristics on admission, injury profile, Injury Severity Score (ISS), AIS score, in-hospital morbidity, and &bgr;-blocker exposure were abstracted for analysis. The primary outcome evaluated was in-hospital mortality stratified by preinjury &bgr;-blockade exposure. RESULTS Overall, a total of 662 patients met the study criteria. Of these, 25% (n = 159) were exposed to &bgr;-blockade before their traumatic insult. When comparing the demographics and injury characteristics between the groups, the sole difference was age, with the &bgr;-blocked group being older (69 [12] years vs. 63 [13] years, p < 0.001). &bgr;-blocked patients had a higher rate of infectious complications (30% vs. 19%, p = 0.04), with no difference in cardiac or pulmonary complications between the cohorts. Patients exposed to &bgr;-blockade versus no &bgr;-blockade experienced 13% and 22% mortality, respectively (p = 0.01). Stepwise logistic regression predicted the absence of &bgr;-blockade exposure as a risk factor for mortality (odds ratio, 2.7; 95% confidence interval, 1.5–4.8; p = 0.002). After adjustment for significant differences between the groups, patients not exposed to &bgr;-blockade experienced twofold increased risk of mortality (adjusted odds ratio, 2.2; 95% confidence interval, 1.3–3.7; p = 0.004). CONCLUSION Preinjury &bgr;-blockade improves survival following isolated severe TBI. The role of prophylactic &bgr;-blockade and the timing of initiation of such therapy after TBI warrant further investigations. LEVEL OF EVIDENCE Therapeutic study, level III; prognostic study, level II.

The prevalence of lithium-associated hyperparathyroidism in a large Swedish population attending psychiatric outpatient units

Objective This retrospective study determined the prevalence of lithium-associated hyperparathyroidism (LHPT) in 2 geographically defined, equivalent populations in Sweden, with no other selection bias. Methods The medical journals of all patients receiving lithium treatment were examined specifically regarding their biochemistry: calcium, parathyroid hormone (PTH), creatinine, and vitamin D. The condition LHPT was defined biochemically. All patient data were noted, and the prevalence of the condition could thereby be calculated. Results A total of 423 patients were included (251 women and 172 men; 3:2), treated over a mean of 13.5 years (range, 1–46 years), aged 19 to 92. 77 patients (18%) were identified with LHTP whose median serum calcium was 2.55 mmol/L and PTH was 99 ng/L. A further 21% showed tendencies toward hypercalcemia. Forty-three percent had vitamin D insufficiency. Five patients (approximately 1%) had undergone parathyroidectomy. Conclusion The prevalence of LHPT is high and often goes undetected. Vitamin D insufficiency is common as is polypharmacy. Surgery, for unclear reasons, has not been performed extensively, possibly because of limited knowledge of the underlying pathophysiology or surgery’s significance. We present standard recommendations on patient management and suggest continual, specific follow-up including the monitoring of calcium, PTH, and vitamin D at least annually. Surgery should be considered with intention to improve psychiatric well-being and provide multiorgan protection.

Reply to comments From Dr Lozano, et al - Concerning the prevalence of lithium-associated hyperparathyroidism

Reply to comments From Dr Lozano, et al - Concerning the prevalence of lithium-associated hyperparathyroidism