Referrals for Elevated Thyroid Stimulating Hormone to Pediatric Endocrinologists

Abstract Objective We aimed to determine the reproducibility of TSH testing in pediatric patients referred to pediatric endocrinologists and to identify the threshold TSH levels that would predict the presence of antithyroid autoantibodies and inform decisions by pediatric endocrinologists to initiate or continue treatment with levothyroxine. Study Design We analyzed a retrospective case series of 325 children aged 1 to 18 years referred for hypothyroidism to the endocrinology clinic at a tertiary care children’s hospital. The receiver operating characteristic area under curve (AUC) determined the ability of the initial TSH level to predict pediatric endocrinologists’ treatment decisions, presence of thyroid autoantibodies, and reproducibility of elevated TSH on repeat testing. Results Of 325 patients, 191 were treated. The treated patients were more likely to have had a higher referral TSH, positive autoantibodies, and abnormal thyroid gland examination findings. An initial TSH of 5 had a specificity of only 14% for a repeat TSH of ≥5. An initial TSH level of 11 had a specificity of 90% for a repeat TSH of ≥11, with sensitivity of 90%. TSH was a relatively poor predictor (AUC, 0.711) of the presence of autoantibodies with optimal classification at TSH >8.8 mIU/L. It was better (AUC, 0.878) at predicting whether endocrinologists started or continued treatment with levothyroxine, with optimal classification at 8.2 mIU/L. TSH levels combined with antibody status and thyroid examination findings had the best ability to predict treatment (AUC, 0.930). Conclusions TSH levels slightly above the reference range should not prompt referral to pediatric endocrinologists unless another basis for clinical concern is present.

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Peripartum hysterectomy: a five year review at a tertiary care centre

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20173490 ◽

2017 ◽

Vol 6 (8) ◽

pp. 3590

Author(s):

Deepak A. V. ◽

K. J. Jacob ◽

Sumi P. Maria

Keyword(s):

Tertiary Care ◽

Case Series ◽

Case Fatality ◽

Tertiary Care Centre ◽

Retrospective Case ◽

College Hospital ◽

Peripartum Hysterectomy ◽

Medical College ◽

Obstetric Haemorrhage ◽

Suboptimal Care

Background: Peripartum hysterectomy is a life-saving procedure resorted to when conservative measures fail to control obstetric haemorrhage. Several predisposing factors, suboptimal care and lack of infrastructure may lead to this emergency procedure. We wanted to find out factors associated with peripartum hysterectomy and the adverse maternal outcomes at our centre.Methods: A retrospective case series analysis of 40 cases of peripartum hysterectomy performed over a period of 5 years from January 2010 to December 2014 at Government Medical College Hospital, Thrissur, Kerala was done.Results: The incidence of peripartum hysterectomy was 0.29%. The most common indication for peripartum hysterectomy was hysterectomy was uterine atony (50%). Thirty-five women (88%) were between 20 and 35 years. Most of the subjects were unbooked. There were two maternal deaths (case fatality rate of 5%) following peripartum hysterectomy during this period. All the subjects required blood transfusion.Conclusions: Prompt performance hysterectomy before the patient’s clinical condition deteriorates is the key to success. The incidence of adherent placenta is increasing, so every effort should be taken to reduce the caesarean section rates globally.

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The Medially-Invasive Cholesteatoma: An Aggressive Subtype of a Common Pathology

Annals of Otology Rhinology & Laryngology ◽

10.1177/0003489420937731 ◽

2020 ◽

Vol 130 (1) ◽

pp. 38-46

Author(s):

Geoffrey Casazza ◽

Matthew L. Carlson ◽

Clough Shelton ◽

Richard K. Gurgel

Keyword(s):

Skull Base ◽

Tertiary Care ◽

Case Series ◽

Hearing Preservation ◽

Csf Leak ◽

Petrous Apex ◽

Otic Capsule ◽

Retrospective Case ◽

Presenting Symptoms ◽

Subtotal Petrosectomy

Objective: Describe the outcomes of treatment for patients with cholesteatomas that are medially invasive to the otic capsule, petrous apex, and/or skull base. Study Design: Retrospective case series Setting: Two tertiary care academic centers. Patients: Patients surgically managed for medially-invasive cholesteatoma at two tertiary care institutions from 2001 to 2017. Interventions: Surgical management of medially-invasive cholesteatomas. Main Outcome Measures: The presenting symptoms, imaging, pre- and post-operative clinical course, and complications were reviewed. Results: Seven patients were identified. All patients had pre-operative radiographic evidence of invasive cholesteatoma with erosion into the otic capsule beyond just a lateral semicircular canal fistula. Five patients had a complex otologic history with multiple surgeries for recurrent cholesteatoma including three with prior canal wall down mastoidectomy surgeries. Average age at the time of surgery was 41.3 years (range 20-83). Two patients underwent a hearing preservation approach to the skull base while all others underwent a surgical approach based on the extent of the lesion. Facial nerve function was maintained at the pre-operative level in all but one patient. No patient developed cholesteatoma recurrence. Conclusions: The medially-invasive cholesteatoma demonstrates an aggressive, endophytic growth pattern, invading into the otic capsule or through the perilabyrinthine air cells to the petrous apex. Surgical resection remains the best treatment option for medially-invasive cholesteatoma. When CSF leak is a concern, a subtotal petrosectomy with closure of the ear is often necessary.

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Tracheo-bronchial foreign bodies: our experience at a tertiary care hospital

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20161848 ◽

2016 ◽

Author(s):

Shashidhar S. Suligavi ◽

Mallikarjun N. Patil ◽

S. S. Doddamani ◽

Chandrashekarayya S. Hiremath ◽

Afshan Fathima

Keyword(s):

Foreign Body ◽

Early Diagnosis ◽

Foreign Bodies ◽

Tertiary Care ◽

Case Series ◽

Team Work ◽

Care Hospital ◽

Retrospective Case ◽

Presenting Symptoms ◽

Case Series Study

Background:Tracheo- bronchial foreign bodies have always posed a challenge to the ENT surgeon as they present with varied symptomatology ranging from a simple cough and fever to more grave respiratory distress. It requires a strong suspicion, early diagnosis and timely intervention to reduce the overall morbidity and mortality .This study was undertaken to highlight our experiences in handling cases of tracheo- bronchial foreign bodies (FB) at our setup.Methods:It is a retrospective case series study conducted in S. Nijalingappa Medical College between January 2011 and January 2015. Results:Most commonly affected were children between 1year to 3years of age. Chronic cough and wheeze were the commonest presenting symptoms. Vegetative foreign body was found to be the commonest variety of foreign body. The mortality rate in our study was 4.7% (n=3).Conclusions:A good clinical acumen, team work, early diagnosis and timely intervention are all needed to reduce the overall mortality and morbidity associated with tracheo- bronchial foreign bodies.

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Transcanal Endoscopic Antrostomy Hole : Its Utility in Restoring Ventilation Pathway to Epitympanum and Mastoid Antrum During Tympanoplasty

Bangladesh Journal of Endosurgery ◽

10.3329/bje.v2i1.19588 ◽

2014 ◽

Vol 2 (1) ◽

pp. 9-14

Author(s):

Sheikh Shawkat Kamal

Keyword(s):

Middle Ear ◽

Tertiary Care ◽

Case Series ◽

Care Hospital ◽

Retrospective Case ◽

Middle Ear Mucosa ◽

Case Series Study ◽

Temporal Bones ◽

Mastoid Antrum

Aim: To evaluate the role of newly created transcanal endoscopic antrostomy hole as a passage in restoring the aeration of epitympanum and mastoid antrum.Materials & Methods: Study design: Retrospective case series study. Study duration: From January 2013 to January 2014. Study place: Private tertiary care hospital. Patients: 27 ears of 23 adult patients (age ranging from 15years to 54years) underwent transcanal endoscopic tympanoplasty for their chronic middle ear diseases in presence of inflamed middle ear mucosa along with radiological shadows of stagnant fluid in their epitympanum and mastoid antrum. Structured three months follow-up was ensured in every case. Intervention: A hole was created at a selected site of posterior meatal wall purely through transcanal endoscopic approach that established direct communication between mastoid antrum and external auditory canal. Thereafter this newly created passage was used for three purposes- assessment of the condition of mastoid antrum, performing the water test for checking epitympanic patency and in few cases placement of temporary tube for postoperative ventilation and drainage of middle ear. Main out come measures: The feasibility, performance and management of transcanal endoscopic antrostomy hole as passage for reestablishing the aeration of epitympanum and mastoid antrum.Results: The chosen site for antrostomy hole was found effective and safe in providing convenient entrance into the mastoid antrum in every case in this study with out facing technical complexity and failure. Postoperative healing of skin over antrostomy hole was found complete in all ears without any inward growth of skin in to mastoid antrum. Available post operative CT scan imaging of temporal bones showed improved aeration in their epitympanum and mastoid antrum.Conclusions: The role of transcanal antrostomy hole has been proved worthy in restoring ventilation pathway to epitympanum and mastoid antrum during tympanoplasty. This antrostomy hole has the potentiality to be considered in future for placement of long term mastoid ventilation tube in order to treat persistent atelectatic middle ear.

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Relationship between Drug-Induced Sleep Endoscopy Findings, Tonsil Size, and Polysomnographic Outcomes of Adenotonsillectomy in Children

Otolaryngology ◽

10.1177/0194599819860777 ◽

2019 ◽

Vol 161 (3) ◽

pp. 507-513 ◽

Cited By ~ 6

Author(s):

Derek J. Lam ◽

Natalie A. Krane ◽

Ron B. Mitchell

Keyword(s):

Rating Scale ◽

Tertiary Care ◽

Case Series ◽

Apnea Hypopnea Index ◽

Strongly Correlated ◽

Sleep Endoscopy ◽

Retrospective Case ◽

Drug Induced ◽

Failure Assessment ◽

The Relationship

Objective (1) Determine the correlation of awake tonsil scores and preadenotonsillectomy (pre-AT) sleep endoscopy findings. (2) Assess the relationship between polysomnographic AT outcomes with awake tonsil scores and sleep endoscopy ratings of tonsil and adenoid obstruction. Study Design Retrospective case series with chart review. Setting Tertiary care children’s hospital. Subjects and Methods Children aged 1 to 18 years who underwent sleep endoscopy and AT from January 1, 2013, to August 30, 2016, were included. Pre-AT sleep endoscopy findings were scored with the Sleep Endoscopy Rating Scale. Awake tonsil scores and sleep endoscopy ratings were compared with Spearman correlation. Associations between changes in pre- and post-AT polysomnography parameters and (1) awake tonsil scoring and (2) sleep endoscopy scoring were assessed with 1-way analysis of variance and linear regression. Results Participants included 36 children (mean ± SD age, 6.8 ± 4.3 years; 68% male, 44% obese). Awake tonsil scores and sleep endoscopy ratings were strongly correlated ( R = 0.58, P = .003). Awake tonsil scores were not associated with changes in any polysomnography parameters after AT (all P > .05), while sleep endoscopy ratings of adenotonsillar obstruction were significantly associated (all P < .05, R2 = 0.16-0.35). Patients with minimal adenotonsillar obstruction during sleep endoscopy had less improvement than those with partial or complete obstruction (mean obstructive apnea-hypopnea index change: −8.2 ± 11.5 vs −15.9 ± 14.3, and −46.8 ± 31.3, respectively; P < .001). Conclusions In children at risk for AT failure, assessment of dynamic collapse with sleep endoscopy may better predict the outcome of AT than awake tonsil size assessment, thus helping to inform surgical expectations.

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Over-under cartilage tympanoplasty: technique, results and a call for improved reporting

The Journal of Laryngology & Otology ◽

10.1017/s0022215120001978 ◽

2020 ◽

Vol 134 (10) ◽

pp. 875-881

Author(s):

I D Erbele ◽

M R Fink ◽

G Mankekar ◽

L S Son ◽

R Mehta ◽

...

Keyword(s):

Tertiary Care ◽

Case Series ◽

Senior Author ◽

Retrospective Case ◽

Closure Rate ◽

Hearing Results ◽

Middle Ear Cholesteatoma ◽

Cartilage Tympanoplasty ◽

The Mean ◽

Clinically Significant

AbstractObjectiveThis study aimed to describe the microscopic over-under cartilage tympanoplasty technique, provide hearing results and detail clinically significant complications.MethodThis was a retrospective case series chart review study of over-under cartilage tympanoplasty procedures performed by the senior author between January 2015 and January 2019 at three tertiary care centres. Cases were excluded for previous or intra-operative cholesteatoma, if a mastoidectomy was performed during the procedure or if ossiculoplasty was performed. Hearing results and complications were obtained.ResultsSixty-eight tympanoplasty procedures met the inclusion criteria. The median age was 13 years (range, 3–71 years). The mean improvement in pure tone average was 6 dB (95 per cent confidence interval 4–9 dB; p < 0.0001). The overall perforation closure rate was 97 per cent (n = 66). Revision surgery was recommended for a total of 6 cases (9 per cent) including 2 post-operative perforations, 1 case of middle-ear cholesteatoma and 3 cases of external auditory canal scarring.ConclusionOver-under cartilage tympanoplasty is effective at improving clinically meaningful hearing with a low rate of post-operative complications.

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Laser Therapy for Refractory Myringitis in Children

Otolaryngology ◽

10.1067/mhn.2002.127628 ◽

2002 ◽

Vol 127 (3) ◽

pp. 163-168 ◽

Cited By ~ 9

Author(s):

Frank P. Fechner ◽

Michael J. Cunningham ◽

Roland D. Eavey

Keyword(s):

Laser Treatment ◽

Tertiary Care ◽

Case Series ◽

Laser Technique ◽

Retrospective Case ◽

Tympanic Membrane Perforations ◽

Specialty Hospital ◽

Associated Symptoms ◽

Initial Results

OBJECTIVE: We present the application and initial results of a CO2 laser technique for the treatment of medically refractory chronic granular myringitis (CGM). STUDY DESIGN AND SETTING: Retrospective case series of 15 treated ears in 13 consecutive patients between the ages of 6 and 14 years (median age, 9.0 years) cared for in a tertiary care specialty hospital. RESULTS: Eleven of 15 treated ears had total resolution of CGM and associated symptoms; median follow-up time was 10 months. Three ears were improved, and 1 ear remained unchanged. Three of 5 preoperative tympanic membrane perforations healed after laser treatment; 1 patient developed a postoperative, dry perforation. Hearing was not impaired in any patient tested. CONCLUSION: Preliminary results suggest that CGM, when refractory to medical treatment, can often be treated effectively by a single laser treatment.

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Screening of IRF6 Variants in Patients Subjected to Genetic Association Studies for Nonsyndromic Cleft Lip/Palate

The Cleft Palate-Craniofacial Journal ◽

10.1177/1055665620980238 ◽

2020 ◽

pp. 105566562098023

Author(s):

José A. Velázquez-Aragón ◽

Ariadna González-del Angel ◽

Miguel A. Alcántara-Ortigoza ◽

Miriam E. Reyna-Fabián ◽

Bernardette Estandia-Ortega

Keyword(s):

Association Study ◽

Cleft Lip ◽

Diagnostic Yield ◽

Association Studies ◽

Tertiary Care ◽

Case Series ◽

Case Control ◽

Retrospective Case ◽

Cleft Lip Palate ◽

Control Association

Objective: To screen for interferon regulatory factor 6 (IRF6) pathogenic variants in patients clinically diagnosed with nonsyndromic cleft lip palate (NSCL/P) and establish the proportion of misdiagnosed Van der Woude syndrome (VWS) cases, which could have biased previous NSCL/P case–control association studies. Design: Retrospective case series. Setting: Tertiary care children’s hospital. Participants: One hundred seventy-two unrelated Mexican patients with NSCL/P, 128 of whom had previously been included in a NSCL/P case–control association study. Main Outcomes Measurements: Sanger sequencing of the 9 IRF6 exons were performed, all variants respect with sequence reference were reported and classified for their pathogenic significance according to the American College of Medical Genetics and Genomics guidelines. Results: Seven percent of cases were familial. No pathogenic variant was identified in IRF6. We identified 12 previously reported benign variants; their frequencies did not significantly differ from those reported for individuals of Mexican ancestry. Three of them were uncommon intronic variants not reported in ClinVar. The rs2235371 and rs2235375 variants, which were previously analyzed in a NSCL/P case–control association study (containing 132 patients, 128 of whom were analyzed herein) did not show discordant association results comparing to the 370 controls from the previous study. Conclusions: The misdiagnosis of IRF6-related VWS as NSCL/P appears to be infrequent in our sample, suggesting that mutational screening of IRF6 would have a low diagnostic yield in patients with NSCL/P. The absence of IRF6 pathogenic alleles could be related to the application of an exhaustive clinical evaluation that discarded the syndromic forms and/or the low proportion of familial cases included.

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Management and Outcomes of Interstitial Ectopic Pregnancies at a Tertiary Care Centre: a Retrospective Case Series

Journal of Obstetrics and Gynaecology Canada ◽

10.1016/j.jogc.2018.03.109 ◽

2018 ◽

Vol 40 (6) ◽

pp. 852

Author(s):

Angel Shan ◽

Mary Ellen Conway ◽

Lindsay Machan ◽

Laura Cormack ◽

Nadia Branco ◽

...

Keyword(s):

Tertiary Care ◽

Case Series ◽

Care Centre ◽

Tertiary Care Centre ◽

Retrospective Case ◽

Retrospective Case Series ◽

Ectopic Pregnancies

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Laryngeal Web in the Pediatric Population: Evaluation and Management

Otolaryngology ◽

10.1177/0194599819893985 ◽

2019 ◽

Vol 162 (2) ◽

pp. 234-240 ◽

Cited By ~ 1

Author(s):

Claire M. Lawlor ◽

Natasha D. Dombrowski ◽

Roger C. Nuss ◽

Reza Rahbar ◽

Sukgi S. Choi

Keyword(s):

Pediatric Population ◽

Care Center ◽

Tertiary Care ◽

Case Series ◽

22Q11.2 Deletion Syndrome ◽

Deletion Syndrome ◽

Retrospective Case ◽

Presenting Symptoms ◽

Subglottic Extension ◽

Type 3

Objective To discuss the presentation, evaluation, and management of pediatric laryngeal web. Study Design Retrospective case series. Setting Single tertiary care center. Subjects All patients with laryngeal web at Boston Children’s Hospital in the past 22 years. Methods No exclusion criteria. Charts mined for age at presentation, presenting symptoms, degree/location of web, associated syndromes, number/type of surgical procedures, and postoperative outcomes. Results Thirty-seven patients were included (13 male, 24 female). Average age at diagnosis was 3.7 years (0-19.5 years). Mean follow-up was 4.4 years (range, 0-16.4 years). There were 26 congenital webs (70.2%) and 11 acquired webs (29.8%). Presenting symptoms were vocal (29 patients, 78.4%) and respiratory (22 patients, 60%). Underlying syndromes or synchronous airway lesions included the following: premature (n = 5), congenital heart disease (n = 18), subglottic stenosis (n = 5), 22q11.2 deletion syndrome (n = 10), and recurrent respiratory papillomatosis (n = 4). There were 20 type 1 webs, 6 type 2 webs, 8 type 3 webs, and 3 type 4 webs; 10 had subglottic extension of the laryngeal web. Twelve patients were managed conservatively with observation. Eighty-four interventions were performed: 18 open and 66 endoscopic (sharp division, 32; dilation, 33; mitomycin C, 14; laser, 5; keel, 6; triamcinolone injection, 8; stent, 15; removal of granulation tissue, 5). Tracheotomy was required in 11 patients, and 5 patients were decannulated. Voice improved in 12 patients, with respiratory symptoms in 12 patients. Web recurred in 17 patients. One patient died due to airway complications. Conclusions Pediatric laryngeal web is an uncommon but challenging lesion. Patients need to be evaluated for comorbid syndromes and synchronous airway lesions. Management includes open and endoscopic procedures. Procedures should be tailored to the child’s presentation.

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