Nodules — a type of abnormality detected by ultrasound — are extremely common in the thyroid gland. Up to two-thirds of adults have nodules in this gland, and most are benign or only cause a slow-growing cancer that is no threat to life.
A minority are aggressive cancer that requires treatment, leaving physicians and patients with a problem — which nodules need to be biopsied for malignancy tests, which nodules show a small risk and merit observation without a biopsy, and which need no follow-up at all?
“If you have a cancer that is not going to harm you, and you are not aware of it, is it useful to do a fine-needle aspiration?” said Franklin Tessler, M.D., C.M, a professor in the University of Alabama at Birmingham Department of Radiology. “People are asking, what are we doing? Are we using scarce resources wisely?”
Thyroid cancers are greatly over-diagnosed in the United States. About three-quarters of thyroid cancers in women and nearly one-half in men would not — if the nodules had been left alone and not biopsied with a needle — resulted in symptoms or death.
Tessler and a national committee of experts have now published American College of Radiology guidelines for an ultrasoundbased risk stratification system to identify nodules that warrant biopsy or sonographic follow-up. The guidelines, they write, are “designed to identify most clinically significant malignancies while reducing the number of biopsies performed on benign nodules.”
“This potentially will have a big public health effect,” said Tessler, who is also the Radiology executive vice chair and medical director, vice chair for Radiology Informatics, and division director of Diagnostic Radiology.
Their Thyroid Imaging, Reporting and Data System, or TI-RADS, is modelled after the American College of Radiology’s BI-RADS, a widely accepted risk stratification system for breast lesions.
The experts sought guidelines that are 1) founded on ultrasound features defined in their previously published lexicon; 2) easy to apply across a wide gamut of ultrasound practices; 3) able to classify all thyroid nodules; and 4) evidence-based, to the greatest extent possible, with the aid of underlying data on 3,800 nodules and more than 100,000 cancers.
Their new guidelines follow many attempts over the past 15 years to create guidelines for whether to do a fine-needle aspiration biopsy. Most are based on details of the appearance and size of nodules that are visualized with high-resolution ultrasound. But “the plethora, complexity and lack of congruence of these systems has limited their adoption by the ultrasound community and inspired our effort to publish a classification system under the auspices of the American College of Radiology,” Tessler and colleagues write.
The American College of Radiology TIRADS has five different categories for nodule appearance — composition, echogenicity, shape, margin and echogenic foci. The shape category has two choices — widerthan- tall vs. taller-than-wide. The other four categories have four choices each, such as “hypoechoic” under the category echogenicity or “lobulated or irregular” under margin. Each choice as a point value, ranging from 0 to 3 points.
“Wider-thantall,” for example, is 0 points, and “tallerthan- wide” is 3 points. As the authors explain, “Points are given for all the ultrasound features in a nodule, with more suspicious features being awarded additional points. … When assessing a nodule, the reader selects one feature from each of the first four categories and all the features that apply from the final category and sums the points. The point total determines the nodule’s ACR TI-RADS level, which ranges from TR1, benign, to TR5, high suspicion of malignancy.”
If the sum is 0 points, the nodule is TR1 and the guidelines recommend no fineneedle aspiration or follow-up. If the sum is 2 points, the nodule is TR2, or “not suspicious,” and the guidelines recommend no fine-needle aspiration or follow-up.
A sum of 3 points is TR3, or “mildly suspicious.” For these nodules, the guidelines recommend fine-needle aspiration if the nodule is 2.5 centimeters or greater, or about 1 inch or more, and they recommend follow-ups with subsequent ultrasounds if it is 1.5 centimeters or greater.
TR4 nodules, or “moderately suspicious,” are 4 to 6 points, and TR5 nodules, or “highly suspicious,” are 7 points or more. For TR4 nodules, the guidelines recommend fine-needle aspiration if the nodule is 1.5 centimeters or greater and followups if it is 1 centimeter or greater. For TR5 nodules, the guidelines recommend fine-needle aspiration if the nodule is 1 centimeter or greater and follow-ups if it is 0.5 centimeters or greater.
The guidelines recommend limiting fineneedle aspiration to two nodules per patient because biopsy of three or more nodules is poorly tolerated by patients, and the third biopsy increases cost with little added benefit and some additional risk. The guidelines also suggest appropriate timing for follow-up sonograms.

University of Alabama http://tinyurl.com/y7q9gbse

In the largest, most rigorous study of its kind, acupuncture was found to significantly reduce the debilitating joint pain experienced by tens of thousands of women each year while being treated for early stage breast cancer, according to SWOG research results.
Investigators from SWOG, the global cancer clinical trials network funded by the National Cancer Institute (NCI), conducted a randomized, blinded, multicentre trial, known as S1200, to test whether acupuncture is effective in alleviating pain caused by aromatase inhibitors, a common treatment for hormone sensitive breast cancers.
Treating this pain effectively, without the use of opioids or other drugs, is a top cancer research priority. Tens of thousands of women each year are treated with aromatase inhibitors (AIs), pills that stop the production of estrogen and essentially starve hormone receptor-positive breast cancer cells. Some women are advised to take these pills daily for up to 10 years. But as a side effect of this therapy, many women – as many as 50 percent – experience joint pain and stiffness. This affects knees, hips, hands, and wrists, and makes it difficult for women to walk, sit, climb stairs, and perform simple tasks like typing or driving.
“Some of my patients have difficulty getting out of a chair,” said Dr. Dawn Hershman, the lead researcher of the study and a SWOG vice chair. “As a result, with no good treatment options for their pain and stiffness, many women stop their cancer treatment. This is probably the most commonly cited reason breast cancer patients stop taking AI medication. So we need a solution – one that doesn’t include opioids or drugs that can be addictive or have serious side effects. We want women to continue their cancer treatment and have a good quality of life.”
SWOG researchers for years have chased a way to relieve AI pain – known as AI-Associated Musculoskeletal Syndrome (AIMSS). Many women don’t want to take pills to relieve symptoms caused by other pills, according to Hershman, leader of the Breast Cancer Program at the Herbert Irving Comprehensive Cancer Centre at NewYork-Presbyterian/Columbia University Irving Medical Centre and professor of medicine and epidemiology at Columbia. In a single-centre study at Columbia, acupuncture showed promise. Hershman wanted to put it to the test in a larger, more rigorous study. Hershman and her team enrolled a total of 226 patients from 11 cancer centres nationwide and randomly assigned them to one of three arms. One group received true acupuncture. Another received sham acupuncture, a method of superficially inserting needles in different, non-therapeutic locations on the body. Finally, another group received no treatment at all.
Patients got twice-weekly treatments for six weeks, then a weekly maintenance treatment for another six weeks. Patients reported on their pain before, during, and after treatment using a variety of methods. The primary endpoint – or key indicator for the trial – was the patient’s level of worst pain using the Brief Pain Inventory (BPI-WP), a patient-reported measure, at the end of the first six weeks of treatment.
Results showed that, on average, patients experienced less pain on the acupuncture arm compared with the sham and treatment-free arms. Patients experienced relief for 24 weeks.
“This work strongly shows that true acupuncture results in better outcomes for women,” said Dr. Katherine Crew, a SWOG executive officer, director of the Clinical Breast Cancer Prevention Program at NewYork-Presbyterian/Columbia University Irving Medical Center and an associate professor of medicine and epidemiology at Columbia and a co-investigator on the study team. “I expect this work to influence medical practice, as well as insurers’ willingness to reimburse for acupuncture during AI treatment.”
SWOGhttps://tinyurl.com/ya58napm

Microfluidic platforms have revolutionized medical diagnostics in recent years. Instead of sending blood or urine samples off to a laboratory for analysis, doctors can test a single drop of a patient’s blood or urine for various diseases at point-of-care without the need for expensive instruments. Before the sample can be tested however, doctors need to insert specific disease-detecting biomolecules into the microfluidic platform. While doing so, it has to be ensured that these biomolecules are well-bound to the inside of the device to protect them from being flushed out by the incoming sample. As this preparatory step can be time-consuming, it would be advantageous if microfluidic platforms could come pre-prepared with specific biomolecules sealed inside. However, this sealing process requires exposure of the device components to high energy or ‘ionized’ gas and whether biomolecules can survive this harsh process is unknown.
To answer this question, researchers at the Okinawa Institute of Science and Technology Graduate University (OIST) have created a novel sensor that detects biomolecules more accurately than ever before. This sensor was used to demonstrate that biomolecules can be successfully sealed within microfluidic devices. The results have profound implications for healthcare diagnostics and open up opportunities for producing pre-packaged microfluidic platform blood or urine testing devices.
The microfluidic platform device, in which disease-detecting biomolecules can be bound for ready-to-use test kits, is not much bigger than a thumbtack.
Traditionally, metal oxide semiconductor (MOS) sensors are used to detect the binding of biomolecules to a surface by measuring changes in charge. Comprised of a silicon semiconductor layer, a glass insulator layer and a gold metal layer, these sensors are incorporated in an electric circuit with the biomolecule sitting in an electrolyte-filled plastic well on top of the sensor. If you then apply a voltage and measure current, you can work out the charge from the capacitance reading given off. Biomolecules with different charges will give you different capacitance readings, enabling you to quantify the presence of biomolecules.
The novel sensor created by researchers in OIST’s Micro/Bio/Nanofluidics Unit, measures charge using the same technique as conventional sensors but has the additional function of measuring mass. Instead of having a solid gold metal layer, the so-called nano-metal-insulator semiconductor (nMIS) sensor has a layer of tiny gold metal islands. If you shine light on these nanostructures, the surface electrons start oscillating at a specific frequency. When biomolecules are added to these nanoislands, the frequency of these oscillations change proportional to the mass of the biomolecule. Based on this change, you can use this technique to measure the mass of the biomolecule, and confirm whether it survives exposure to ionized gas during encapsulation within the microfluidic platform.   
 “We made a simple sensor that can answer very complex surface chemistry questions,” says Dr. Nikhil Bhalla who worked on the creation of the nMIS sensor.
Measuring two fundamental properties of surface chemical reactions on the same device means that researchers can be far more confident that biomolecules have been successfully encapsulated within the microfluidic platform. A measurement of charge or mass alone could be misleading, making it look like biomolecules have bound to a surface when in fact they have not. Having more than one technique in the same device means that you can switch from one mode to the other to see if you have the same result.
“Scientists have to validate one reaction with multiple techniques to confirm that an observation is authentic. If you’ve got a sensor that enables the detection of two parameters on a single platform, then it is really beneficial for the sensing community,” says Dr. Bhalla.
“By combining these two simple measurement techniques into one compact platform, it opens doors to create portable and reliable sensing technologies in the future”, adds PhD student Shivani Sathish.

Okinawa Institute of Science and Technology Graduate Universityhttp://tinyurl.com/ycy35a79

Despite evidence showing that the routine use of sonography in hospital emergency departments can safely improve care for adults when evaluating for possible abdominal trauma injuries, researchers at UC Davis Medical Center could not identify any significant improvements in care for pediatric trauma patients. The findings, which resulted from a randomized clinical study involving 925 children with blunt torso trauma who were evaluated in the emergency department at the medical centre, showed no difference in important clinical outcomes. The outcomes assessed were developed for the study mainly based on previous research in injured adults.
The UC Davis team investigated the Focused Assessment with Sonography for Trauma (FAST) to determine whether the use of the FAST examination could safely lead to a decrease in the use of computed tomography (CT) scans for children, and other outcomes. FAST is a bedside ultrasound examination using a portable ultrasound machine. It has not been routinely used in the initial emergency department evaluations of injured children. CT scans represent the “gold standard” in diagnostic imaging for clinicians, including the identification of intra-abdominal injuries, but they also pose a greater radiation risk for children than they do for adults.
“A lot of our work has looked at the appropriate use of CT scans in injured patients,” said James Holmes, professor of emergency medicine and the study’s lead author. “At least in the adult trauma population, there’s evidence that you can use ultrasound to safely decrease CT use. One of the big questions has been whether that holds true for children, too.”
Holmes and his colleagues identified a study cohort of hemodynamically-stable children who presented in the emergency department at UC Davis Medical Center with blunt torso injuries resulting from mechanisms such as motor vehicle collisions and falls greater than 20 feet (6m). Four hundred and sixty patients were randomized to the FAST group and 465 to the no-FAST group, who received the same standard trauma evaluations but without ultrasound.
As in previous studies, the researchers wanted to determine whether the FAST protocol could significantly decrease the length-of-stay for patients in the emergency department, reduce hospital billing charges and still identify injuries when compared to patients who did not receive a FAST examination.
“We were surprised that the routine use of FAST did not show any significant differences,” said Nathan Kuppermann, professor and chair of emergency medicine at UC Davis and the study’s senior author and co-principal investigator. “The use of FAST compared with our standard trauma care did not decrease CT scan use, improve resource use, emergency department length-of-stay, safety or hospital charges.”

UC Davis Health http://tinyurl.com/yceftcp4

Postmenopausal hormone therapy is not associated with increased risk of stroke, provided that it is started early, according to a report from Karolinska Institutet.
Roughly three in ten women in the menopause transition are afflicted by symptoms that seriously affect their wellbeing, such as hot flushes, dry mucosa and insomnia. However, although the symptoms can be treated effectively with female sex hormones, prescriptions have been low over the past 15 years as researchers have demonstrated a link between such therapy and an increased risk of certain diseases, including stroke.
There is still, however, a need for more research on the issue, as the risk can be influenced by the time of the treatment and other factors, reasons Karin Leander, researcher at Karolinska Institutet’s Institute of Environmental Medicine.
“New research shows us that hormone therapy actually has a positive effect on blood vessels if initiated early on in the menopause, but not if initiated late,” says Dr Leander. “So there was reason to re-examine whether hormone therapy is linked to the risk of stroke, taking, of course, the time of administering into consideration.”
Dr Leander and her colleagues have now analysed data on postmenopausal hormone therapy from five Swedish cohort studies covering a total of 88,914 women, combined with data from national registries on diagnoses and causes of death during a follow-up period.
Hormone therapy was not linked to increased risk of stroke (ischemic and hemorrhagic stroke combined) if the therapy was initiated within five years of menopausal onset, regardless of means of administration (oral, via the skin or vaginal), type of therapy (combination or estrogen only), active substance and treatment duration.
In sub-analyses, however, there was an observable increase in risk for hemorrhagic stroke (the less common form) if the therapy contained the active substance conjugated equine estrogens. Drugs containing estradiol, on the other hand, were not associated with a higher risk. A higher risk was also seen for both ischemic and hemorrhagic stroke if the treatment was initiated later than five years after the onset of menopause and contained conjugated equine estrogens.
“The risk of stroke seems virtually eradicable if treatment commences early, but it’s naturally important to take account of the increase in risk that exists under certain circumstances,” says Dr Leander. “These results provide doctors with a better scientific base on which to take decisions on treatment for menopausal symptoms.”
Karolinska Institutehttps://tinyurl.com/ycqy6tdg