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Αλέξανδρος Γ. Σφακιανάκης

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Tuesday, November 8, 2022

Nódulos tiroideos: síntomas, causas y tratamiento

alexandrossfakianakis shared this article with you from Inoreader

Conoce todo sobre los nódulos tiroideos como síntomas, causas, diagnóstico y tratamiento, entre otra información de interés.

¿Qué son los nódulos tiroideos?

Los nódulos tiroideos se forman por un crecimiento anormal de células de la glándula tiroidea que dan lugar a bultos.

Los nódulos tiroideos son muy frecuentes. Se calcula que si se realizaran ecografías de forma masiva a toda la población, se detectarían nódulos en el 60%- 68% de las personas, según diversos estudios. Es habitual que se descubran en una revisión médica normal o bien de forma casual al llevar a cabo pruebas médicas por algún motivo diferente en la zona de la tiroides.

Son más comunes en mujeres que en hombres, y la probabilidad de que aparezcan se incrementa con la edad.

Hay muy pocos nódulos tiroideos de tipo canceroso, pero algunos factores de riesgo hacen que sea recomendable realizar una vigilancia más estrecha, tales como:

 

Síntomas del nódulo tiroideo

Es muy habitual que los nódulos tiroideos no causen síntomas.

Si un nódulo alcanza un tamaño grande, puede ejercer presión sobre alguna parte del cuello. Entonces puede provocar:

  • Dolor
  • Dificultad al tragar o respirar
  • Ronquera
  • Otros cambios en la voz
  • Bocio (aumento del tamaño de la tiroides)

Los nódulos tiroideos, cuyas células producen hormonas tiroideas pueden provocar síntomas de hipertiroidismo (elevación de las hormonas tiroideas en sangre):

  • Nerviosismo
  • Debilidad muscular
  • Cambios súbitos del estado de ánimo
  • Alteraciones del sueño
  • Alteraciones del ritmo del corazón

Si el paciente tiene hipotiroidismo, los nódulos tiroideos pueden dar lugar a síntomas como:

  • Fatiga
  • Intolerancia al frío
  • Fatiga
  • Sequedad de la piel
  • Pérdida del cabello
  • Inflamación del rostro
  • Aumento injustificado de peso

 

¿Cuáles son las causas de los nódulos tiroideos?

Las causas de los nódulos tiroideos muchas veces se desconocen. Las condiciones que con mayor frecuencia se observan en pacientes con nódulos son:

  • Falta de yodo
  • Enfermedad de Hashimoto
  • Adenoma tiroideo (benigno)
  • Quiste tiroideo
  • Cáncer de tiroides (poco frecuente)

 

Diagnóstico de los nódulos tiroideos

En los nódulos tiroideos, el diagnóstico suele realizarse tras una detección casual. El médico inicia pruebas para descubrir cuál es la alteración que da lugar al nódulo o nódulos.

Las pruebas de diagnóstico pueden incluir:

  • Reconocimiento físico
  • Pruebas de función tiroidea
  • Ecografía
  • Biopsia por aspiración con aguja fina
  • Escáner

 

Tratamiento de los nódulos tiroideos

Ante los nódulos tiroideos, el tratamiento se diseña en función de cuál sea su causa y los síntomas que provoquen.

En ocasiones se considera suficiente realizar revisiones periódicas para controlar su evolución. Es una estrategia avalada por muchos estudios científicos pero que se va implantando poco a poco. Cuando se ha descartado que sea un tumor canceroso y no provoca molestias, se establecen una serie de consultas periódicas para observar su evolución, con la realización de nuevas biopsias o ecografías. Esta estrategia se conoce como "watchful waiting".

Tratamiento de los nódulos tiroideos benignos

En ocasiones los nódulos tiroideos benignos requieren tratamiento quirúrgico si:

  • Son de gran tamaño
  • Producen síntomas y signos compresivos (dificultad para tragar o para respirar o compresión vascular)
  • Ocasionan molestias en el cuello

Cuando se trata de un nódulo quístico, la punción del mismo puede ser diagnóstica y terapéutica, ya que se puede extraer gran parte o todo el contenido líquido del quiste y de paso, analizarlo. Si los quistes vuelven a acumular líquido en su interior se puede intentar, después de vaciarlos, un tratamiento inyectando sustancias esclerosantes.

Tratamiento de los nódulos tiroideos que provocan hipertiroidismo

Si los nódulos tiroideos son causa de hipertiroidismo se pueden tratar con:

  • Yodo radiactivo, que muy frecuentemente restaura la función tiroidea normal y permite en unos meses notar la reducción de tamaño de los nódulos.
  • Medicamentos antitiroideos
  • Cirugía

Si los nódulos tiroideos están asociados a tiroiditis subaguda, pueden desaparecer espontáneamente al resolverse la enfermedad.

Tratamiento de los nódulos cancerosos

En los nódulos tiroideos cancerosos el tratamiento viene determinado por el tipo de cáncer que sea la causa y de la fase en la cual se encuentra. La terapia puede incluir:

  • Cirugía (tiroidectomía total o parcial), es una terapia que se considera necesaria prácticamente en todos los casos.
  • Ablación
  • Radioterapia
  • Quimioterapia

En la actualidad se está analizando la eficacia y seguridad de nuevos medicamentos denominados "terapias dirigidas" y de inmunoterapias que ayudan al propio sistema inmunológico a combatir el cáncer, con datos cada vez más prometedores para una población creciente de pacientes.

 

FUENTES

  • Kant R, et al. Thyroid Nodules: Advances in Evaluation and Management. Am Fam Physician. 2020 Sep 1;102(5):298-304.
  • Singh Ospina N, et al. Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment. BMJ 2020;368:l6670 http://dx.doi.org/10.1136/bmj.l6670
  • Popoveniuc G y Jonklaas J. Thyroid Nodules. Med Clin North Am. Author manuscript; available in PMC 2013 Feb 19. American Thyroid Association. Thyroid Nodules.
  • Mayo Clinic. Patient Care & Health Information. Diseases & Conditions. Thyroid nodules.
  • American Cancer Society. Tratamiento del cáncer de tiroides en función del tipo y la etapa.

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La entrada Nódulos tiroideos: síntomas, causas y tratamiento se publicó primero en Cuida tu tiroides.
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Incidence, Clinical Characteristics, and Impact of Absent Echocardiographic Signs in Patients with Infective Endocarditis after Transcatheter Aortic Valve Implantation

alexandrossfakianakis shared this article with you from Inoreader
Abstract
Background
Echocardiography is the primary imaging modality for diagnosis of infective endocarditis (IE) in prosthetic valve endocarditis (PVE) including IE after transcatheter aortic valve implantation (TAVI). This study aimed to evaluate the characteristics and clinical outcomes of patients with absent compared with evident echocardiographic signs of TAVI-IE.
Methods
Patients with definite TAVI-IE derived from the Infectious Endocarditis after TAVI International Registry were investigated comparing those with absent and evident echocardiographic signs of IE defined as vegetation, abscess, pseudoaneurysm, intracardiac fistula or valvular perforation or aneurysm.
Results
Among 578 patients, 87 (15.1%) and 491 (84.9%) had absent (IE-neg) and evident (IE-pos) echocardiographic signs of IE, respectively. IE-neg were more often treated via a transfemoral access with a self-expanding device, and had higher rates for peri-interventional complications (e.g. stroke, major vascular complications) during the TAVI procedure (p < 0.05 for all). IE-neg had higher rates of IE caused by staphylococcus aureus (33.7% vs. 23.2%, p = 0.038) and enterococci (37.2% vs. 23.8%, p = 0.009), but lower rates of coagulase-negative staphylococci (4.7% vs. 20.0%, p = 0.001).IE-neg was associated with the same dismal prognosis for in-hospital mortality in a multivariate binary regression analysis (OR 1.51, 95%-CI 0.55-4.12) as well as a for 1-year mortality in a Cox regression analysis (HR 1.10, 95%-CI 0.67-1.80).
Conclusions
Even with negative echocardiographic imaging, patients who have undergone TAVI and presenting with positive blood cultures and symptoms of infection are a high-risk patient group having a reasonable suspicion of IE and the need for an early treatment initiation.
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Efficacy and tolerability of concomitant use of bedaquiline and delamanid for multidrug- and extensively drug-resistant tuberculosis: a systematic review and meta-analysis

alexandrossfakianakis shared this article with you from Inoreader
Abstract
The introduction of two novel drugs, bedaquiline and delamanid, has given hope for better and shorter treatments of drug-resistant tuberculosis. A systematic review was conducted to evaluate the efficacy and safety of concomitant bedaquiline and delamanid administration. Pooled estimates of WHO-defined favorable treatment outcome and significant QTc-interval prolongation (QTc ≥500 ms or ≥60 ms increase from baseline) were calculated using a random effects model. Thirteen studies including a total of 1031 individuals with multidrug-resistant/rifampicin-resistant tuberculosis who received bedaquiline and delamanid were included. The pooled estimate of favorable treatment outcome was 73.1% (95%CI: 64.3-81.8). Sputum culture conversion at six months ranged from 61-95%. Overall, the pooled proportion of QTc-prolongation was 7.8% (95%CI: 4.1-11.6) and few cardiac events were reported (0.8%, n = 6/798). Rates of sputum culture conversion and favorable treatment outcome were high in patients treated concomitantly with bedaquiline and delamanid, and the treatment seemed tolerable with low rates of clinically significant cardiac toxicity.
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Characterization of Viruses in Phase III and Phase IIIb Trials (The Ring Study and DREAM) of the Dapivirine Vaginal Ring for HIV-1 Infection Risk Reduction

alexandrossfakianakis shared this article with you from Inoreader
Abstract
Background
The Ring Study, a 2:1 randomized, double-blind, placebo-controlled Phase III trial, demonstrated 35.1% HIV-1 infection risk reduction among participants using the Dapivirine Vaginal Ring-004 (DVR). An open-label extension trial, DREAM, approximated a 62% risk reduction. The analysis of NNRTI resistance-associated mutations (RAMs) and effects on viral susceptibility observed in these trials are described.
Methods
Population-based genotyping was performed on plasma samples collected longitudinally, and Next Generation Sequencing (NGS) and phenotypic susceptibility testing was done on plasma collected at seroconversion. Retrospective HIV-1 RNA testing was used to establish more accurately the time of infection.
Results
In The Ring Study, NNRTI RAMs were not observed in most viruses at seroconversion (population-based genotyping: DVR: 71/84, 84.5%; placebo: 50/58, 86.2%). However, more E138A was found in the DVR group (E138A: DVR: 9/84, 10.7%; placebo: 2/58, 3.4%, P = 0.2, Fisher's exact test). NGS detected one additional mutation in each group (DVR: G190A; placebo: G190A and G190E). Marginal dapivirine susceptibility reduction was found with NNRTI RAMs at seroconversion (geometric mean fold-change [FC], range: DVR: 3.1, 1.3–5.1; placebo: 5.8, 0.9–120). NNRTI RAMs were not emergent between first detectable HIV-1 RNA and seroconversion when these visits differed (paired samples, mean ring use: DVR: n = 52, 35 days; placebo: n = 26, 31 days). After stopping DVR, 2/63 viruses had emergent G190G/A or K103K/N with V106V/M at final study visit. Resistance profiles from DREAM were consistent with The Ring Study.
Conclusion
DVR used for HIV-1 prevention showed little potential for selection of NNRTI resistant variants.
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Impact of AJCC 8 pT staging in cutaneous head and neck squamous cell carcinoma in a nonselected real‐world patient sample

alexandrossfakianakis shared this article with you from Inoreader

Abstract

Objective

Our aim was to evaluate characteristics associated with worse survival and the effectiveness of AJCC 8 in a real-world cohort of HNCSCC from South Brazil.

Methods

A 10-year retrospective cohort study (2011–2020) at a tertiary care center comprising 647 HNCSCC excised from 435 patients.

Results

At multivariable analysis, ear/nose/zygomatic or periorbital site, compromised or exiguous margins, and advanced pT stage were independent factors associated to DFS, while age, pN, and loco-regional recurrence were independent factors associated to DSS. Cox-regression multivariable models showed that the pT stage was statistically significant for the DFS, but not DSS. A significant distinction was only observed between T1 and T2.

Conclusion

It was only in the lower categories of AJCC 8 (T1 and T2) that we were able to demonstrate the ability to stratify tumors with a significant risk of poor disease-related outcomes.
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A novel stapler‐assisted technique for closure of persistent tracheoesophageal puncture fistula

alexandrossfakianakis shared this article with you from Inoreader

Abstract

Tracheoesophageal puncture (TEP) is a reliable method to restore voice and is an important part of voice rehabilitation following laryngectomy. However, complications following this procedure, including peri-prosthetic leakage and resulting aspiration pneumonia, may necessitate surgical closure. In this study, we present an effective and reliable method for TEP closure using a stapler-assisted technique. Case series study for patients who underwent stapler-assisted TEP closure reviewed from 2017 to 2021. All five patients had successful closure of their TEP tract without further leakage. No postoperative bleeding, wound infection, or esophageal stenosis occurred. One patient had postoperative stomal stenosis. The stapler-assisted technique for TEP closure is easy, quick, and effective. The reliability and quick return to oral intake post-operatively make it a preferable option over previous techniques.
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Dosage optimization of voriconazole in children with haematological malignancies based on population pharmacokinetics

alexandrossfakianakis shared this article with you from Inoreader
Dosage optimization of voriconazole in children with haematological malignancies based on population pharmacokinetics

This is a population pharmacokinetic study of voriconazole in Chinese children with haematological malignancies. A population pharmacokinetic model was developed and evaluated. Based on the final model, appropriate administration regimens were recommended, which could enhance the rational use of voriconazole in children with haematological malignancies.


Abstract

What is Known and Objectives

Voriconazole has a complex pharmacokinetic profile and exhibits different pharmacokinetic characteristics in adults and children. Nevertheless, few studies have been conducted on the population pharmacokinetics (PPK) of voriconazole in children with haematological malignancies. This study aims to build a PPK model and propose a suitable voriconazole treatment scheme for children with haematological malignancies.

Methods

We retrospectively collected 146 samples from 67 children aged from 1.08 to 17.92 years. The PPK model was established using nonlinear mixed effects modelling (NONMEM). Dosage simulations were conducted on the basis of the final model's covariates.

Results and Discussion

Data were fully characterized by a one-compartment model with first-order absorption and elimination. The weight (WT), CYP2C19 phenotype, and Albumin (ALB) were notable covariates for clearance (CL). The typical values of CL, the volume of distribution (V), and oral bioavailability (F) were 2.29 L/h, 76 L, and 0.902, respectively. The proposed doses for different CYP2C19 genotypes were presented in this ranking: EM (extensive metabolizer) > IM (intermediate metabolizer) > PM (poor metabolizer). Furthermore, higher dosages for light WT patients were recommended while lower ALB levels required lower doses. The probability of achieving the target (PTA) for the recommended doses ranged from 72.2% to 99%.

What is New and Conclusion

We successfully built a voriconazole PPK model for children with hematologic malignancies. Dosing regimens were developed for different patients based on the final model, which could enhance the rational use of voriconazole in children with haematological malignancies.
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Efficacy and safety of rituximab biosimilars or reference product as first‐line treatment in patients with low‐tumour‐burden follicular lymphoma: A systematic review and meta‐analysis

alexandrossfakianakis shared this article with you from Inoreader
Efficacy and safety of rituximab biosimilars or reference product as first-line treatment in patients with low-tumour-burden follicular lymphoma: A systematic review and meta-analysis

Follicular lymphoma is a subtype of B-cell Non-Hodgkin lymphoma and is the second most common lymphoma diagnosed in the United States and Western Europe. The role of rituximab in the first-line treatment of low-tumour-burden follicular lymphoma has been supported by a large number of data. However, whether rituximab biosimilars have the same efficacy and safety as the reference drug (MabThera) is still controversial. Electronic databases and the ClinicalTrail.gov website were extensively searched using relevant search criteria. Studies were screened according to inclusion and exclusion criteria. Then the risk of bias of the included studies was assessed using the RoB 2 assessment scale, and the RevMan 5.4 statistical software was used for meta-analysis. Finally, four clinical randomized controlled trials involving 1223 patients were included. There were no statistically significant differences in efficacy and safety between biosimilars and MabThera groups. Our study concluded that the efficacy and safety of rituximab biosimilars in the treatment of low-tumour-burden follicular lymphoma are highly similar to those of the original drug.


Abstract

What is Known and Objective

The role of rituximab in the first-line treatment of low-tumour-burden follicular lymphoma (LTB-FL) has been supported by a large number of data. However, whether rituximab biosimilars have the same efficacy and safety as the reference drug (MabThera) is still controversial.

Methods

Electronic databases and the ClinicalTrail.gov website were extensively searched using relevant search criteria. The risk of bias of the included studies was assessed using the RoB 2 assessment scale, and the RevMan 5.4 statistical software was used for meta-analysis.

Results and Discussion

A total of 1223 patients were included in four clinical randomized controlled trials. There was no statistical difference in efficacy between biosimilars and MabThera groups (the objective response rate: RR = 1.00, 95% CI: 0.93–1.08, p = 0.92; the progression-free survival: RR = 1.04, 95% CI: 0.96–1.12, p = 0.30; the overall survival: RR = 1.00, 95% CI: 0.98–1.03, p = 0.76; the serious adverse events: RR = 1.15, 95% CI: 0.69–1.89, p = 0.59; the infusion-related reaction: RR = 0.91, 95% CI: 0.77–1.09, p = 0.32). In terms of safety, there was also no significant difference between two groups.

What is New and Conclusion

Our study concluded that the efficacy and safety of rituximab biosimilars in the treatment of LTB-FL are highly similar to those of the original drug.
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A Breakthrough Improvement Collaborative Significantly Reduces Hospital Stay After Elective Colectomy for Cancer Across a Healthcare System

alexandrossfakianakis shared this article with you from Inoreader
imageObjective: This multicenter study aimed to assess (1) the effect of an improvement collaborative on enhanced recovery after surgery (ERAS) protocol adherence after elective colectomy and (2) the association between adherence and patient outcomes. Background: ERAS pathways provide a framework to standardize care processes and improve postoperative outcomes in patients after colon surgery. Despite growing evidence of its effectiveness, adherence to these guidelines remains a challenge. Methods: This prospective, multicenter collaborative was initiated throughout 11 hospitals in Flanders, Belgium. A structured audit tool was used to study patient outcomes and adherence to 12 ERAS components, defined by the collaborative. Three retrospective audits (based on patient record analysis) were conducted in 2017, 2019, and 2021, respectively. Results: Overall, 740 patients were included (45.4% female; mean±SD age, 71±12 years). The overall adherence increased from 42.8% in 2017 to 58.4% in 2019 and 69.2% in 2021. Compared with low adherence, length of stay was increasingly reduced by 1.3 days for medium [95% confidence interval (95% CI): −2.5; 0.0], 3.6 days for high (95% CI: −4.9; −2.2), and up to 4.4 days for very high adherence (95% CI: −6.1; −2.7). Corresponding odds ratios for postoperative complications were 0.62 (95% CI: 0.33; 1.17), 0.19 (95% CI: 0.09; 0.43), and 0.14 (95% CI: 0.05; 0.39), respectively. No increase in 30-day readmissions was observed. Conclusions: A peer-constructed improvement collaborative effectively increases adherence to an ERAS protocol in individual hospitals. Across time, length of stay and postoperative complications decreased significantly, and a dose-response relationship was observed.
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