Background:Fine-needle aspiration cytology remains a valuable screening tool for preoperative management of thyroid nodules. However, the rates of false-negative and false-positive diagnosis remain a challenge for pathologists.Objectives:To assess the value of thyroid fine-needle aspiration as a screening tool and its accuracy of diagnoses relative to final histological diagnoses.Patients and Methods:A chart review was conducted of all adult patients who underwent fine-needle aspiration of thyroid nodule(s) and were subjected to thyroid surgery at King Abdulaziz Medical City, Jeddah, Saudi Arabia, between January 2007 and June 2014. The fine-needle aspiration results were correlated with final histopathology results.Results:Of the 408 aspirates from 373 patients, the Bethesda System for Reporting Thyroid Cytology (BSRTC) diagnostic categories were as follows: nondiagnostic in 26 aspirates (6.4%); benign in 128 (31.4%); atypia/follicular lesion of undetermined significance in 52 (12.7%); follicular neoplasm/suspicion for a follicular neoplasm in 83 (20.3%); suspicious for malignancy in 23 (5.6%) and malignant in 96 (23.5%). The comparative histopathological diagnoses were benign in 192 (47.1%) and malignant in 216 (52.9%) aspirates. The calculated risk of malignancy in the fine-needle aspiration categories was 34.6% in diagnostic category (DC) I, 15.6% in DC II, 50% in DC III, 52% in DC IV, 95.7% in DC V and 100% in DC VI. The sensitivity of fine-needle aspiration with BSRTC was 88.9%, specificity was 75.6%, positive predictive value was 79.7%, negative predictive value was 84.4% and accuracy was 81.5%.Conclusion:The results of this retrospective study demonstrated higher risks of malignancy in DC I, DC II, DC III and DC IV than that of the original BSRTC definition, along with a higher specificity and positive predictive value for cancer diagnosis, and a lower sensitivity and negative predictive value.

BackgroundInternational guidelines for the treatment of patients with pulmonary arterial hypertension (PAH) recommend the use of risk stratification to optimise therapy to achieve and maintain a low-risk profile. However, recommended methods require hospital-based investigations. We sought to develop a method for daily, remote risk evaluation.MethodsConsecutive patients (n=5820) with pulmonary hypertension (PH) were identified from the ASPIRE registry and stepwise Cox regression applied to identify parameters associated with survival. A physiological risk score was applied to all patients and survival assessed by the Kaplan-Meier method. Physical activity was measured in patients with PAH implanted with insertable cardiac monitors (ICM, n=80) to provide a remote measure of exercise capacity. In patients with PAH and implanted pulmonary artery pressure (PAP) monitor and ICM (n=28) we undertook a time-stratified bidirectional case–crossover study to determine the physiology of therapeutic escalation (TE) and clinical worsening and a remote physiological risk score applied to the data.ResultsAge, male sex, PH aetiology, WHO functional class (FC), incremental shuttle walk-distance (ISWD), heart rate reserve (HRR) and total pulmonary resistance (TPR) as independent predictors of survival. Mortality increased with each decile of baseline physiological risk (p<0.001). In patients with PAH, thresholds of physiological risk were used to classify patients into low-, intermediate-low-, intermediate-high-, and high-risk groups for one-year mortality, which were well matched to COMPERA-2.0 score-stratified groups (Cohen’s weighted Kappa 0.61). ICM-measured physical activity decreased with indicators of increased clinical risk (WHO-FC, NT-proBNP, ISWD, COMPERA-2.0, p<0.0001). Following TE, remote monitored mean PAP and TPR were reduced, and cardiac output (CO) and physical activity increased at days seven, four, 22 and 42 respectively (p<0.05). Clinical worsening events (CWE) were preceded by an increased remote monitored mean PAP and TPR and reduced CO and physical activity (p<0.05). Change in remote physiological risk score identifiable six days after TE and twelve days prior to a CWE (p<0.05).ConclusionRemote risk evaluation may facilitate personalised medicine and proactive management. The physiological risk score accurately stratifies patients with PH and may be applied to remote monitoring data for early evaluation of clinical efficacy and detection of clinical worsening.

Background: In patients with pulmonary arterial hypertension (PAH) risk stratification is used to aid clinical decision making and guide treatment categorising patients as low (<5%), intermediate (5-10%), or high mortality risk (>10%) at 1 year based on hospital investigations. Risk stratification based on remote parameters may facilitate early evaluation of clinical efficacy following treatment change or indicate clinical stability/deterioration, thereby permitting early intervention. Methods: Patients with PH were identified from the ASPIRE (6/YH/0352) database 2/2001-6/2019. Random allocation was used to form a derivation (n=3832). Univariate Cox Regression and stepwise forward multivariate analysis were undertaken in the derivation cohort to identify parameters that may be remote monitored that were associated with mortality. Mortality weighted z-scores of age, incremental shuttle walk test (ISWT), heart rate (HR) and total pulmonary resistance (TPR) were summed to give an individual remote risk score value. LOESS regression was used to determine 1 year risk thresholds applied to a PAH validation cohort (n=590). Results: Multivariate analysis of the derivation cohort demonstrated that ISWT, HR and TPR had statistically significant relationships to mortality. Survival analysis showed increased mortality with each decile of baseline risk score with the 10 th decile at increased risk of mortality compared the 1 st decile (OR 5.5, 95%CI 4.3-7.0, each decile p<0.01, Figure). In patients with PAH, LOESS derived thresholds identified patients at low, intermediate and high risk with 1 year mortalities of 4.6, 9.8 and 15.1% respectively (low-int OR 1.9, low-high OR 2.7,p<0.01,Figure). Conclusion: A score of remote monitored parameters, when applied at diagnosis, accurately categorised patients as low, intermediate, or high risk. This system may be applied to remote monitored physiological data to provide real time risk stratification.

Background Hospital-based assessment of haemodynamics, exercise capacity and right heart function/strain are used for risk-stratification to aid clinical decision making and guide treatment in patients with pulmonary arterial hypertension. Advances in haemodynamic and cardiac monitoring now provide the capacity to remotely measure physiological parameters that relate to mortality from a patient’s home. We sought to examine remote monitored physiology in the time preceding and following increase in standard of care therapy and clinical worsening events in patients with pulmonary arterial hypertension. Methods Between January 2020 and October 2021 22 patients with WHO functional class III PAH and a hospitalisation in the preceding year were implanted with a pulmonary artery pressure monitor (CardioMEMS, Abbott) and an insertable cardiac monitor (LinQ, Medtronic) (FITPH 19/YH/0354). Remote data and clinical events were reviewed in a multidisciplinary team identifying 18 increases in therapy and 13 worsening events. For each parameter baseline was set at the 30-days preceding the event and daily data analysed as change from baseline. Statistical significance was determined using Wilcoxon matched pairs and One-way ANOVA with Dunnett’s correction as appropriate. Results Following clinically indicated increase in therapy improvements in field walk test, WHO functional class and NT-proBNP were observed (p<0.05) with mean time to follow up of 5.1 months. Remote monitored mean pulmonary artery pressure and total pulmonary resistance were reduced and cardiac output and physical activity increased compared to baseline at day 7, 4, 22 and 42 respectively (p<0.05). Clinical worsening events led to deterioration in field walk test, WHO functional class and NT-proBNP (p<0.05). Remote monitored mean pulmonary artery pressure and total pulmonary resistance were increased and cardiac output and physical activity reduced 10 days prior to a clinical worsening event (p<0.05). Conclusion Remote haemodynamic and cardiac monitoring may provide a means for early, remote evaluation of clinical efficacy and early identification of clinical worsening in patients with pulmonary arterial hypertension.