Background Rate of cesarean section (CS), including elective CS has globally increased. Studies have found that term elective CS before 39 weeks of gestation is associated with increased risk of adverse respiratory outcomes. Objective To determine the rate of elective CS and examine the association between timing of elective term CS and adverse neonatal outcomes in a large population of Lebanese women. Methods A Multi-Center Study was conducted using data from the National Collaborative Perinatal Neonatal Network database. Simple and multivariable logistic regression models were used to examine the association between timing of term elective CS and adverse neonatal outcomes. Some of the neonatal adverse outcomes we examined included respiratory distress syndrome, admission to the NICU, and a composite of respiratory outcomes. Results A total of 28,997 low risk mothers who delivered through primary and repeat elective CS were included in the study. Uncomplicated elective planned term CS constituted 25% of all CS deliveries in Lebanon. Primary and repeat CS at 37 weeks of gestation increased the odds of most of the studied adverse neonatal outcomes. There were few associations between CS and adverse neonatal outcomes at 38 weeks of gestation. Conclusions Term primary and repeat cesarean delivery prior to 39 weeks of gestation is associated with respiratory and other adverse neonatal outcomes. Delaying birth 1–2 weeks till 39 weeks of gestation can prevent 64–77% of adverse respiratory outcomes.
Intro: Insular thyroid cancer is a rare and complex form of thyroid cancer, often referred to as poorly differentiated carcinoma. The exact incidence of insular thyroid cancers is difficult to assess due to controversial classification of this thyroid cancer over the years. It is termed poorly differentiated as it falls between the well-differentiated and undifferentiated carcinomas both morphologically and biologically[1]. Case: A 41 year old Hispanic female, with a history of prolactinoma and hyperparathyroidism, presented to the hospital with 10 days of progressive lower extremity weakness and paresthesias from T4 downwards, inability to bear weight, and no bowel movement for 12 days. MRI revealed a large thoracic soft tissue mass (7x4x4cm) centered in the posterior and medial aspect of the chest wall at T4-T5 with involvement of the spinal cord and vertebral bodies. She was also found to have a right sided thyroid mass (4.5x5x4 cm) with tracheal deviation- HerThyoid function test, were normal Intact PTH was 261, Thyroglobulin over 300, and Thyroid Antibodies were negative. Patient underwent T3-T6 laminectomy, T2-T7 fusion, and T4-T5 tumor resection, which was subtotal due to vascularity. Second procedure included a right thoracotomy, chest wall resection of ribs 4 and 5 with full resection of paraspinal mass, total thyroidectomy, parathyroidectomy with central cervical lymphadenectomy. Pathology results of paraspinal mass showed insular thyroid carcinoma. Post operatively, the patient reported improvement of sensation and strength in lower extremities. Genetic testing for MEN syndrome was negative. Discussion: Insular thyroid carcinoma, also referred to as poorly differentiated carcinoma is a rare form of thyroid cancer. Insular carcinoma was characterized by to include the following complex histologic features, “formation of solid clusters (insulae) of tumor cells containing a variable number of small follicles; variable but consistently present mitotic activity, capsular and blood vessel invasion; and frequent necrotic foci, sometimes leading to formation of peritheliomatous patterns”[1]. The cells originate from follicular epithelium and possess the potential to concentrate radioiodine[2]. Unlike anaplastic carcinoma of the thyroid, p53 and p21 staining was negative in insular carcinomas[3]. Thyroglobulin staining is generally positive[4]. Distant metastasis occurs in about 31% of patients with insular thyroid carcinoma[5]. In cases of distant metastasis, treatment with thyroidectomy and radioiodine therapy were shown to independently improve survival[5]. The Constellation of Insular thyroid cancer, hyperparathyroidism and Prolactinoma, has not been reported before. References: [1]. Am J Surg Pathol. 1984;8:655- [2] J of Nuc Med 32(7), 1358 [3] Ann of Surg vol. 231,3 (2000): 329 [4] JCEM 99. 1167–9. 10.1210/jc.2014 [5] Cancer. 2012 Jul;118(13) 3260
Cushing's disease is caused by an excess of cortisol. In a cushingoid state, excess cortisol leads to a cytoplasmic accumulation of cytokeratin filaments. This accumulation of cytokeratin filaments and hyalinization characterizes a Crooke cell tumor which is an interesting variant of corticotroph adenoma (1) This transformation is known as Crooke’s cell transformation. Crooke’s cell tumors are very rare (largest case series of 36) reported by George et al. (2), aggressive, and prone to recurrence after resection which makes identification and distinction from adenomas important for treatment and patient management. A 42-year-old Caucasian male, with a PMH of obesity, HTN, DM2, and refractory hypokalemia presented to the hospital, with symptoms of headache, eye pressure, bilateral pedal edema, and weight gain x 4 weeks. admitted for evaluation with suspicion for Cushing's syndrome. The patient appeared cushingoid with positive parinaud sign (limited upward eye deviation) suggestive of a pituitary mass. CT head revealed a 1.2cm right pituitary macroadenoma with remodeling of sella turcica. Random cortisol 39.6 and ACTH 140. Dexamethasone suppression testing, low and high dose, failed to suppress cortisol production which suggested hypercortisolism from an ectopic source. Inferior petrosal sinus sampling confirmed pituitary Cushing's with lateralization to the right pituitary, as the source of hypercortisolemia. The patient underwent endoscopic endonasal transsphenoidal (EET) resection of pituitary macroadenoma, Postoperatively cortisol levels initially decreased, plateaued and then began rising again with suspicion for a residual tumor in the sella. The patient underwent repeat EET mass resection. Cortisol levels dropped and reached a nadir of 3.0 with ACTH 13 upon discharge. Pathology results revealed Crooke cell adenoma. Discussion : Crooke’s cell tumors are a rare variant of pituitary adenoma and are important to distinguish from other types of adenomas due to their unique cellular behavior. There isn’t a good explanation as to why these tumors cause hyalinization and despite this hyalinization and microfilament deposition, which would be expected to suppress functionality, result in increased production of ACTH. There have been cases reported multiple recurrences in patients requiring repeat surgical removal. Prompt and complete resection may limit the risk for recurrence, and the increase in morbidity and mortality that are inherent to tumor regrowth and continued invasive resection. Additionally, nonsuppressable serum cotrisol with high dexamethasone dose in the presence of pituitary tumor , should raise possibility of Crook cell tumor in addition to paraneoplastic syndromes . conclusion: this case highlights the importance of suspecting Crooke’s tumor in patients with evidence of pituitary adenoma and Cushing’s syndrome.
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