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Prevalence and predictor for malignancy of contralateral thyroid nodules in patients with unilateral PTMC: a systematic review and meta-analysis
Authors: Weidi Wanghttps://orcid.org/0000-0003-3617-577X1, Lingjun Kong2, Hongkun Guo3, and Xiangjin Chen2
1 Department of Emergency, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| 2 Department of Thyroid and Breast, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| 3 Department of Emergency, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
Correspondence should be addressed to X Chen: rjbhcxj@sina.com
© The authors 2021
The presence of clinically negative nodules on the contralateral lobe is common in patients with unilateral papillary thyroid microcarcinoma (PTMC). The appropriate operational strategies of contralateral thyroid nodules remain controversial. In this study, we analyzed clinical features that could be predictors for malignancy of contralateral thyroid nodules coexisting with diagnosed unilateral PTMC.
The literatures published from January 2000 to December 2019 were searched in PubMed, Cochrane Library, Embase, Web of Science, CNKI, and Wan Fang database. Odds ratio (OR) with 95% CI was used to describe categorical variables. Heterogeneity among studies was examined by the Q test and I2 test; potential publication bias was detected by Harbord test and 'trim and fill' method.
In this meta-analysis, 2541 studies were searched and 8 studies were finally included. The results showed that the rate of carcinoma in contralateral nodules was 23% (OR = 0.23, 95% CI = 0.18–0.29). The pooled data indicated that contralateral malignancy was not associated with age, gender, primary lesion size, ipsilateral central lymph node metastasis and multifocality of contralateral lesion. The following variables have correlations with an increased risk of contralateral malignancy: multifocality of primary carcinomas (OR = 3.93, 95% CI = 2.70–5.73, P < 0.0001), capsular invasion (OR = 1.61, 95% CI = 1.10–2.36, P = 0.01), and Hashimoto's thyroiditis (OR = 1.57, 95% CI = 1.13–2.20, P = 0.008).
Based on our meta-analysis, the rate at which contralateral malignancies are preoperatively misdiagnosed as benign is 23%. The risk factors for contralateral malignancy in unilateral PTMC patients with contralateral clinical negative nodules include multifocality of primary carcinomas, capsular invasion, and Hashimoto's thyroiditis.
Keywords: unilateral PTMC; risk factors; contralateral thyroid nodules; meta-analysis
Papillary thyroid carcinoma (PTC) is the most common pathological subtype of thyroid carcinoma (TC). In recent years, the incidence of PTC is gradually increasing worldwide (1, 2). The increase in incidence is explained by the improvement of examination techniques, which have promoted the detection of unilateral papillary thyroid microcarcinoma (PTMC) (3).
PTMC has been regarded as indolent. It is controversial whether all patients with PTMC confined to the unilateral lobe determined by fine-needle aspiration (FNA) or clinical negative nodules in the contralateral lobe should undergo a total thyroidectomy (TT). Thyroid lobectomy alone may be sufficient for PTMC, which is considered as low-risk and unifocal tumor (4). A study evaluating the long-term effect of lobectomy showed that lobectomy (with isthmectomy) is effective for most patients with unilateral multifocal PTC (5). Moreover, the risk of injury to the contralateral parathyroid gland and recurrent laryngeal nerve during TT is also increased. Besides, patients undergoing TT need lifelong thyroid hormone replacement, which requires more compliance.
So far, only a few studies have analyzed the risk factors for malignancy of contralateral nodules in unilateral PTMC patients, and the incidence of carcinoma in contralateral nodules obtained from each study is inconsistent (7.7%~43.3%) (6, 7, 8, 9, 10, 11, 12, 13). In addition, relevant studies have not found consistent risk factors. We aimed to identify specific types of unilateral PTMC patients, whose contralateral nodules present a high risk of carcinoma. According to our data, the risk factors for contralateral malignancy in unilateral PTMC patients with contralateral clinical negative nodules include multifocality of primary carcinomas, capsular invasion, and Hashimoto's thyroiditis.
This systematic review was conducted following the criteria of the Preferred Reporting Items for Systematic Review and Meta-Analyzes (PRISMA) (14). (Supplementary Table 1, see section on supplementary materials given at the end of this article). The protocol for this systematic review was registered on PROSPERO (http://www.crd.york.ac.uk/prospero/) under No. CRD42021232568.
Characteristics of the included studies.
Study (author, year)
Median age (range)
No. of carcinoma/no. of case(%)
Surgical time span
Bom Seok Koo 2010 (6) Retrospective Korea 48
(26–84) 18/74 (24.3%) TT 2005–2009 8
Connor Matt 2011 (7) Retrospective USA 43
(13–64) 1/13 (7.7%) TT 1998–2008 8
Li Wei Meng 2012 (8) Retrospective China 48
(19–80) 53/253 (20.9%) TT/NTT 2007–2011 8
Ming Yang 2013 (9) Retrospective China 56
(42–64) 19/90 (21.1%) TT/NTT 2009–2012 7
Sung Yong Choi 2013 (10) Retrospective Korea 51
(26–76) 16/106 (15.1%) TT 2005–2009 8
Han Feng Wan 2014 (11) Retrospective China 40.5
Young Chan Lee 2015 (12) Retrospective Korea 53
(–) 51/241 (21.2%) TT 2007–2013 9
Zeng Gui Wu 2016 (13) Retrospective China 48
(–) 100/347 (28.9%) TT/NTT 2011–2015 9
NTT, nearly total thyroidectomy; TT, total thyroidectomy.
We accessed PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), and Wan Fang database to search for potential studies from January 2000 to December 2019. The following keywords ((PTMC OR PTC OR microcarcinoma) AND (thyroid nodules) AND (risk or predictive or factor) AND (bilateral or contralateral or unilateral)) were used. No language restriction was applied. To expand our search, references of the retrieved articles were also screened to identify additional studies.
Two reviewers independently read the titles and abstracts of all articles to search for relevant studies. We included studies fulfilling all the following criteria: (i) prospective or retrospective original studies; (ii) all of the patients were diagnosed unilateral PTMC preoperatively by US or FNA; (iii) all of the patients underwent TT or nearly total thyroidectomy; (iv) none of the patients had clinical evidence of contralateral thyroid carcinoma preoperatively (If any suspicious ultrasound images exist, FNA was performed); (v) sufficient data provided concerning the feature of patients.
Studies were excluded if (i) they were case reports, reviews, conference abstracts, and posters; (ii) patients with other pathologic types of thyroid carcinoma or preoperatively bilateral thyroid cancer; (iii) patients who had undergone head and neck irradiation or oncological surgery radiotherapy; (iv) patients with a family history of thyroid cancer.
We define contralateral carcinoma as a nodule in the contralateral lobe that was diagnosed as benign by ultrasound (US) or FNA preoperatively, but the nodule was diagnosed as malignant by postoperative pathological examination.
Two reviewers independently selected studies for inclusion and exclusion. Discrepancies in the selection were resolved by consensus. The following variables were recorded: first author, journal and year of publication, countries of study, number of carcinomas, number of cases, the features of patients (age, sex, size of primary lesion, ipsilateral central lymph node metastasis, multifocality of primary lesion, multifocality of contralateral lesion, capsular invasion, and Hashimoto's thyroiditis). If necessary, the corresponding authors of the studies were contacted to obtain additional information.
Two independent evaluators used the Newcastle–Ottawa quality assessment scale (NOS) (15). The content of the evaluation includes the following four aspects: quality of selection, comparability, exposure, and outcome of study participants. The total score of NOS (maximum 9 points) is obtained according to the specific requirements of each item above. Studies with a total score > 7 were considered as high quality. We assessed the overall certainty of the evidence for each outcome using the Grading Recommendations Assessment, Development and Evaluation (GRADE) approach (16). Disagreements for GRADE assessments were resolved by discussion. We used the Guideline Development Tool (https://www.gradepro.org) to formulate the summary of findings table.
We utilized Review Manager (Revman) for statistical analysis. Heterogeneity was quantified using the Cochran Q test and I2 statistics. A fixed-effects model or random-effects model was used to calculate the pooled odds ratio (OR) with its 95% CI. A P value of less than 0.05 was considered as statistically significant in the present meta-analysis. I2 > 50% was regarded to indicate significant heterogeneity, where random-effects model would be used. Otherwise, fixed-effects model would be applied. Sensitivity analysis for each study, especially the study with low-quality control, large weight and results that greatly differ from other works. These studies were excluded to recalculate the number of combined effects, which were compared with the previous meta-analysis. We selected a conservative conclusion if the sensitivity analysis is inconsistent with the original results. For publication bias evaluation, we utilized Harbord test (17). Although planned, we did not construct funnel plots to assess for publication bias as these are inaccurate when less than ten trials are included in the analysis. If the Harbord test showed a P value < 0.05, we assumed publication bias was present. The Duval & Tweedie non-parametric 'trim and fill' method was used to adjust for it (18).
The comprehensive computer study search revealed 2541 potentially relevant studies. According to the above criteria, a total of 8 studies and 1221 patients were included in this meta-analysis. The main characteristics of the included studies are summarized in Table 1. A flow chart of the selection process is presented in Fig. 1.
Flowchart of the study selection.
Citation: Endocrine Connections 10, 6; 10.1530/EC-21-0164
The included studies were statistically heterogeneous (I2 = 84.6%) for the prevalence of carcinoma, which ranged from 7.7% to 43.3%. A random-effects model shows the pooled prevalence of carcinoma in contralateral nodules in the eight included studies was 23% (95% CI = 0.17–0.29) (Fig. 2).
Forest plots of the pooled prevalence of carcinoma in contralateral nodules.
Meta-analysis indicated that contralateral malignancy was not associated with age, sex, primary lesion size, ipsilateral central lymph node metastasis, and multifocality of the contralateral lesion. Forest plots are shown in Fig. 3 (see Supplementary Figs 1, 2, 3, 4, 5 for more details). A summary of the meta-analytic statistics is presented in Table 2.
Forest plot for the meta-analysis of studies reporting on the association with the risk of contralateral carcinoma of (A) age, (B) sex, (C) size of primary lesion, (D) ipsilateral central lymph node metastasis, (E) multifocality of contralateral lesion.
Summary of data synthesis.
OR (95% CI)
Pub bias
Q test
I 2 (%)
Harbord test
Age 1.16 (0.82–1.64) 0.40 0.46 0 0.154
Sex 0.84 (0.56–1.26) 0.40 0.63 0 0.516
Size of primary lesion 1.18 (0.67–2.09) 0.57 0.04 59 0.541
Ipsilateral central lymph node metastasis 1.16 (0.83–1.62) 0.37 0.58 0 0.490
HT 1.57 (1.13–2.20) 0.008 0.24 28 0.333
Multifocality of primary lesion 3.93 (2.70–5.73) <0.00001 0.87 0 0.025
Multifocality of contralateral lesion 1.32 (0.56–3.10) 0.52 0.04 68 0.220
Capsular invasion 1.61 (1.10–2.36) 0.01 0.38 2 0.115
This article includes four studies on Hashimoto's thyroiditis (HT) (8, 9, 12, 13). The heterogeneity test showed no significant heterogeneity among these studies (P = 0.24, I2 = 28%). The results indicated that HT was associated with a high rate of malignancy in contralateral nodules (OR = 1.57, 95% CI = 1.13–2.20, P = 0.008) (Fig. 4). The same results were obtained after sensitivity analysis. Publication bias was evaluated by Harbord test, which revealed that the impact of publication bias was minimal on the meta-analysis study.
Forest plots of the association between HT and contralateral carcinoma.
Multifocality of primary lesion
Four studies were included in the analysis of multifocality of primary lesion (6, 8, 9, 13). We found a positive correlation between multifocality of primary lesion and contralateral malignancy (OR = 3.93, 95% CI = 2.70–5.73, P < 0.0001) (Fig. 5). The same results were obtained after sensitivity analysis.
Forest plots of the association between multifocality of primary lesion and contralateral carcinoma.
Capsular invasion
Four studies relating to capsular invasion were included (6, 8, 9, 13). A fixed-effects model was applied due to insignificant heterogeneity (P = 0.38, I2 = 2%). It is shown that patients with capsular invasion exhibited a 1.61-fold risk of contralateral malignancy (OR = 1.61, 95% CI = 1.10–2.36, P = 0.01) compared with the patients without capsular invasion (Fig. 6). The same results were obtained after sensitivity analysis.
Forest plots of the association between capsular invasion and contralateral carcinoma.
Sensitivity analyses
Sensitivity analysis was performed by excluding one study at a time, where no significant influence on the stability of the results was identified.
The size of primary lesion was not associated with contralateral carcinoma (OR = 1.18, 95% CI = 0.67–2.09, P = 0.57). Following the leave-one-out method (sensitivity analysis), the results were statistically significant only when Meng (2012) is excluded (OR = 1.71, 95% CI = 1.15–2.56, P = 0.008) (Supplementary Fig. 6), but the results were reversed compared with the results before sensitivity analysis. Due to the low stability of the results, a conservative conclusion was taken and the correlation was not considered. In addition, the study of Meng (2012) (8) was considered as one of the sources of heterogeneity.
Publication bias and safety
Evaluation of publication bias by the Harbord test is shown in Table 2. The Harbord test result for multifocality of primary lesion suggests that the presence of publication biasmay distort the meta-analysis. The Duval & Tweedie non-parametric 'trim and fill' method was employed and generally resulted in similar conclusions of the unadjusted random-effect model of 3.93 (95% CI = 2.70–5.73); we calculated a summary adjusted OR of 3.75 (95% CI = 2.64–5.32). Publication bias was not evident from the Harbord test for any other clinical feature. The GRADE approach was adopted to evaluate the overall certainty of evidence and 'Summary of findings' tables were presented (Table 3).
GRADE summary of findings.
No of participants (studies), follow up
Certainty of the evidence (GRADE)
Relative effect* (95% CI)
Anticipated absolute effects
Risk with benign nodule
Risk difference contralateral cancer
Age 764 (4 observational studies) ⨁⨁◯◯
Low OR 1.16 (0.82–1.64) 228 per 1000 27 more per 1000 (33 fewer to 98 more)
Sex 967 (6 observational studies) ⨁⨁◯◯
Low OR 0.84 (0.56–1.26) 262 per 1000 32 fewer per 1000 (96 fewer to 47 more)
Size of primary lesion 601 (5 observational studies) ⨁⨁◯◯
Low OR 1.18 (0.67–2.09) 195 per 1000 27 more per 1000 (55 fewer to 141 more)
CLNM 890 (4 observational studies) ⨁⨁◯◯
HT 931 (4 observational studies) ⨁⨁◯◯
Low OR 1.57 (1.13–2.20) 220 per 1000 87 more per 1000 (22 more to 163 more)
Multifocality of primary lesion 764 (4 observational studies) ⨁◯◯◯
Very lowa OR 3.93 (2.70–5.73) 189 per 1000 289 more per 1000 (197 more to 383 more)
Multifocality of contralateral lesion 690 (3 observational studies) ⨁◯◯◯
Very lowb,c OR 1.32 (0.56–3.10) 204 per 1000 49 more per 1000 (79 fewer to 239 more)
Capsular invasion 764 (4 observational studies) ⨁⨁◯◯
*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI); aThe Harbord test result for multifocality of primary lesion suggests that the presence of publication bias may distort the meta-analysis; bHigh I2 (68%) and non-overlapping CI suggest that important inconsistency which lowers our certainty in effect; cWide CIs do not exclude important benefit or harm which lowers our certainty in effect.
GRADE Working Group grades of evidence – High certainty: we are very confident that the true effect lies close to that of the estimate of the effect; Moderate certainty: we are moderately confident in the effect estimate, the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different; Low certainty: our confidence in the effect estimate is limited, the true effect may be substantially different from the estimate of the effect; Very low certainty: we have very little confidence in the effect estimate, the true effect is likely to be substantially different from the estimate of effect.
Debate extent of surgery for PTMC
For unilateral PTMC patients with thyroid nodules in the contralateral lobe that was preoperatively diagnosed as benign, the appropriate operational strategy of thyroid nodules remains controversial. When a unilateral PTMC coexists with contralateral nodules diagnosed by US as benign, most clinicians tend to perform a TT for worrying the risk of recurrence in remnant thyroid tissue.
However, the recent consensus statements from the Japan Association of Endocrine Surgery show that no evidence exists that patients with benign nodules should be excluded for active surveillance of PTMC (19).
Furthermore, for low-risk PTMC, the few recurrences that develop during long-term follow-up are readily detected and appropriately treated with no impact on survival (20). Given that PTMC typically exhibits low malignancy, good prognosis (3), it is widely recognized that 'delayed treatment' does not affect the prognosis of patients with low-risk PTMC.
A large number of studies have investigated the clinical features as potential predictors for malignancy of contralateral thyroid nodules coexisting with proven unilateral PTMC; however, the outcomes of these studies are discrepant. Here, we conducted a meta-analysis of eight retrospective studies that evaluated the possible correlation between carcinoma in contralateral nodules and related clinical-pathological features of PTMC patients.
Age is closely related to the prognosis of PTMC. The cut-off point of age in the studies included was 45 years old. However, a multicenter retrospective study found that by increasing the cut-off point of age to 55 years old, about 17% of the patients have a lower pathological stage compared to the 45 years old patients. However, there was no significant difference in the overall survival rate in this group of patients (21). The American Joint Committee on Cancer (AJCC) 8th edition for TC adjusted the age cut-off point from 45 to 55 years. This adjustment avoided overtreatment of low-risk patients. Meanwhile, Jeon et at. reported that age over 50 is closely related to PTMC progression (22). Kwong et al. reported that the prevalence of thyroid nodules increases with age but the risk of malignancy is reduced (23).
At present, there is no conclusion on the correlation between age and contralateral carcinoma. Our meta-analysis found that age is not a risk factor for malignancy in the contralateral nodules.
TC has a high incidence in women. Several studies have suggested that this phenomenon is related to the overexpression of estrogen receptors in TC since ER-α promotes the growth and progress of PTC (24). Male gender was identified as a risk factor for malignancy of indeterminate thyroid nodules (25).
On one hand, this work showed that there was no correlation between sex and contralateral carcinoma. Small number of included samples may cause the result. On the other hand, a recent meta-analysis shows that the male gender is associated with a high risk of recurrence in PTC patients (26). Further genomic and large-scale population epidemiological studies are required to understand the mechanism underlying the sex differences.
In this study, multifocality is defined as multiple primary foci that exist only in unilateral glands and are not related to contralateral nodules.
This meta-analysis shows consistent results as demonstrated by several previous studies that the multifocality of the primary tumor is an important risk factor for contralateral cancer, regardless of whether there are contralateral nodules (27, 28). Recently, some studies have reported that the multifocal PTCs are multiple synchronous primary tumors arising from independent clones (29, 30). Shattuck et al. analyzed the pattern of X chromosome inactivation in 17 cases of highly differentiated multifocal PTC and suggested that PTC may have an independent genetic origin (31). Therefore, most guidelines recommend total/subtotal thyroidectomy for PTMC, with multifocal primary tumors, regardless of stage.
It is worth noting that multifocality indicated by preoperative ultrasound could not be used as a prediction for malignancy, a final surgical strategy should be based on pathological results such as frozen section. This suggests that preoperative ultrasound is insufficient to evaluate the foci (12). A TT is required to reduce recurrence when the frozen section results show that the primary tumor is multifocal PTMC.
Size of primary lesion
Tumor size is an important factor affecting the prognosis of TC. The heterogeneity among the included studies is significant and the results are unstable. Unfortunately, the correlation between the size of primary lesions and contralateral carcinoma cannot be determined. Feng et al. demonstrated that tumor > 1 cm was an independent predictor of contralateral carcinoma (32). In contrast, Park et al. suggested that the size of the primary tumor could not be a predictor for contralateral carcinoma (33). Meanwhile, in a study that followed 992 patients with benign thyroid nodules for 5 years, Durant et al. reported an increase in diameter for at least 2 mm in 15.4% of the nodules (34). However, the significance of this growth pattern is unclear, as changes in the size of nodules are not an effective predictor of malignancy (35).
Although tumor size is an important factor affecting the prognosis of PTMC, we could not draw definitive conclusions regarding the possible association between the size of primary lesions and the existence of contralateral carcinoma.
Multifocality of contralateral lesion
So et al. reported that the presence of contralateral nodules is a predictor of carcinoma on the contralateral lobe of unilateral PTMC (36). Lee et al. showed that the contralateral multiple non-suspicious nodules were more likely to coexist with carcinoma (37). This phenomenon may be related to intrathyroidal metastasis of tumors, which has been confirmed by a number of studies (38, 39). Frate et al. pointed out that for the general population, the probability of thyroid cancer in nodules is not related to the number of nodules (40).
Given that low certainty of the evidence and low stability of the results included in our meta-analysis, it is not clear whether the multifocality of contralateral nodules is correlated with contralateral carcinoma. Lin et al. reported that 49.3% of patients with thyroid cancer smaller than 1 cm could not be accurately diagnosed by preoperative FNA (41). Furthermore, other studies have pointed out that ultrasound, FNA and ultrasound combined with FNA all have high sensitivity and accuracy in the diagnosis of the thyroid nodule in the >1 cm group, without significant differences (42). We speculate that these results may arise from the fact that the background of multiple nodules makes it more difficult to determine nodules, which leads to misdiagnosis of contralateral nodules before operation.
Ipsilateral central lymph node metastasis
Cervical lymph node metastasis (CLNM) is the most common form of PTC metastasis. It occurs in the early stage of the disease, especially in the ipsilateral cervical lymph node (43). Previous study has shown that central lymph node metastasis is a predictor for malignancy of contralateral thyroid nodules, which can be evaluated by preoperative ultrasound examination and intraoperative frozen biopsy (44). The results of this work show that ipsilateral central lymph node metastasis is not correlated with contralateral carcinoma.
In order to reduce the risk of local recurrence, Asian national guidelines recommend prophylactic central lymph node dissection if allowed. By contrast, routine lymph node dissection is less performed in PTMC patients with clinically negative central lymph nodes (cN0) and more postoperative I131 treatment is selected in Europe and the United States (4, 45). Different treatment strategies lead to a higher detection rate of ipsilateral CLNM in Asian studies, and the resulting selection bias may be one of the reasons for significant heterogeneity.
Hashimoto's thyroiditis is a common autoimmune disease of the thyroid. This meta-analysis suggests that PTMC patients with HT exhibited a 1.56-fold higher risk of contralateral malignancy, suggesting that HT was a risk factor for cancer in contralateral nodules. The relationship between TC and HT has evoked broad interest in the field.
On one hand, Liu et al. conducted a population-based study of HT. The study showed that HT was strongly correlated with PTMC, and HT was an important risk factor for PTMC in young people aged between 18 and 30 years (46). A meta-analysis involving 64,628 patients showed that HT was associated with a high risk of PTC (47). It suggested that excessive lymphocyte infiltration could release higher levels of inflammatory factors, such as interferon-γ, tumor necrosis factor-α, etc. which may lead to an increased risk of cancer (48).
On the other hand, PTC with HT is characterized by smaller tumor size, less capsule infiltration, less lymph node metastasis and better prognosis, which may represent weaker invasiveness and the regulation of autoimmune response (49). However, there are also studies suggesting that HT is not an independent risk factor of contralateral cancer (50).
In view of the correlation between HT and PTMC, when frozen section results show the coexistence of PTMC and HT, TT should be adopted to avoid misdiagnosis of contralateral malignant nodules.
When the primary tumor is growing close to the thyroid capsule, it is very likely to invade capsule tissue. Once the capsule invasion occurs, it may further lead to an extra-glandular invasion, including recurrent laryngeal nerve, esophagus, trachea and other organs. TT is recommended for patients with extra-glandular invasion (4).
Thyroid capsule in front of the trachea is discontinuous, and the possible existence of adipose tissue and skeletal muscle tissue in the thyroid tissue itself may lead to clinical pathologists' misjudgment of minimal extraglandular invasion of PTMC. Moreover, some studies have shown that there was no significant difference in the prognosis between patients with minor extraglandular invasion and patients without capsule invasion (51, 52).Therefore, we chose capsule invasion as a potential predictor for contralateral cancer rather than extraglandular invasion or micro-extraglandular invasion.
Previous studies have suggested that contralateral nodule with carcinoma is not associated with capsule invasion (53). However, our results showing that patients with capsular invasion exhibited a 1.61-fold increased risk of contralateral malignancy. Given that the thyroid capsule is rich in lymphatic vessels, capsule invasion may lead to an increase in the risk of metastasis. Although most guidelines do not specify the scope of resection of PTMC with capsule invasion, total / subtotal thyroidectomy should be performed actively considering the high possibility of extraglandular invasion.
This meta-analysis has several limitations. First, in order to execute the inclusion criteria in strict rotation, the sample size of this meta-analysis was relatively small. Secondly, several detailed information of the tumor was not recorded, such as the location of the primary tumor in the glandular lobe, the size and location of the contralateral nodule. The loss of information may lead to inevitable biases. Thirdly, most of the patients from the included studies were Asian. Given the differences between Asian and Western populations with regard to culture, genetic background, lifestyle, so that the conclusions of our study may be applicable for Asian populations only, more studies from other regions or countries should be included to support the results. Fourthly, the judgment of contralateral nodules is based on preoperative FNA and ultrasound, even if the same standards are followed, errors may be caused by different operators and pathological interpretations.
In conclusion, for unilateral PTMC patients, the rate at which contralateral carcinomas are preoperatively misdiagnosed as benign is 23%. The risk factors for contralateral malignancy in unilateral PTMC patients with contralateral clinical negative nodules include multifocality of primary carcinomas, capsular invasion, and HT. When frozen section examination reveals the above risk factors, TT/subtotal TT should be performed to avoid misdiagnosis as much as possible. For patients without high-risk factors, more conservative treatment can be tried, which can reduce the complications of operation and improve the compliance of patients.
This is linked to the online version of the paper at https://doi.org/10.1530/EC-21-0164.
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this study.
This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
The paper is exempted from ethical committee approval since this is a systematic review and meta–analysis.
Author contribution statement
X J C, W D W and L J K conceived and designed the experiments. W D W and L J K performed the experiments and contributed analysis tools. W D W, L J K and H K G analyzed the data. W D W wrote the paper.
Wei-Kun Huang, the English language editor, was responsible for correcting language and grammar issues.
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Supplemental Table 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyzes.
Supplemental Figure 1. Forest plots of the association between age and contralateral carcinoma.
Supplemental Figure 2. Forest plots of the association between sex and contralateral carcinoma.
Supplemental Figure 3. Forest plots of the association between size of primary lesion and contralateral carcinoma.
Supplemental Figure 4. Forest plots of the association between CLNM and contralateral carcinoma.
Supplemental Figure 5. Forest plots of the association between multifocality of contralateral lesion and contralateral carcinoma.
Supplemental Figure 6. Forest plot of the association between size of primary lesion and contralateral carcinoma (Excluding Meng 2012).
https://ec.bioscientifica.com/view/journals/ec/10/6/EC-21-0164.xml
unilateral PTMC; risk factors; contralateral thyroid nodules; meta-analysis
Article by Weidi Wang
Article by Lingjun Kong
Article by Hongkun Guo
Article by Xiangjin Chen


text:
Inês Pires (por vezes, erradamente, chamada Inês Pires Esteves) (Borba, Matriz) foi amante do Mestre da Ordem de Avis e futuro Rei D. João I de Portugal.

Filiação
Era irmã de Gil Peres e filha do casal Pedro Esteves e Maria Anes Maceiro, neta paterna de Estêvão Peres e de sua mulher Leonor Anes e neta materna de João Anes Maceiro e de sua mulher Constança Garcia.

Pedro Esteves ou Pero Esteves, conhecido pela alcunha "o Barbadão", erroneamente confundido com Mendo da Guarda, que era um sapateiro Judeu de Castela. Seja como for, a sua origem ainda é um tema bastante discutido pelos especialistas da época. Diante de tudo o que foi dito, é importante mencionar que nem sequer o seu nome consta dos documentos seus contemporâneos sendo que o primeiro a mencioná-la é Fernão Lopes que escreve por volta de 1420.

Descendência
Teve três filhos naturais de D. João I:
 Afonso I (10 de agosto de 1377 – 15 de dezembro de 1461), primeiro duque de Bragança
 Branca (1378 - 1379)
 Beatriz (ca. 1382 – 25 de outubro de 1439), casada com Thomas FitzAlan, 12.º Conde de Arundel

Naturais de Borba (Portugal)
Pessoas da história de Portugal
Mulheres de Portugal medieval

redpajama_set_name: RedPajamaWikipedia


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text:
(512) 957-1900 info@soberingcenter.org
1213 Sabine Street, Austin, Texas 78701
Why We Need It
ATOD Results
by Rhonda Patrick | Dec 12, 2017 | News
Contact: City of Austin Communication and Public Information Office, 512-974-2220
Sobering Center names founding Executive Director
Rhonda G. Patrick will serve as the founding Executive Director of the new Austin-Travis County Sobering Center, a facility created to address public safety issues related to public intoxication more effectively than a jail cell.
The Sobering Center, a joint project between the City of Austin and Travis County, will provide an alternative for individuals who are either in the custody of law enforcement for the offense of public intoxication, or in the care of Austin Travis County Emergency Medical Services for extreme alcohol or drug consumption. Transporting individuals to the Sobering Center takes much less time than arresting a person. It is anticipated that because of this, the number of bookings for public intoxication will drop.
The new Executive Director will be responsible for launching the Center, hiring staff, overseeing building renovations, improving public health and safety and relieving some of the financial burdens on the criminal justice and emergency medical systems.
Rhonda G. Patrick brings a wealth of experience to the position and will be responsible for opening the facility and future operations. She has a Master's degree in Social Work and Public Administration from University of Houston and was most recently the Chief Executive Officer of the Behavioral Health Alliance of Texas, for which she secured and managed $2.5m in state and federal addiction and maternal health grants.
Ms. Patrick has been in the addictions and mental health recovery field for nearly 20 years. She has been a professional social worker, entrepreneur, and social service innovator for most of her professional life. She is a Licensed Clinical Social Worker and accomplished executive. Ms. Patrick has worked in many distinct positions in the treatment industry and has gained firsthand experience in all of the different facets of how to effectively help others recover from addiction. Before coming to the Austin Travis County Sobriety Center, she served at some of the most well respected and trusted treatment centers in the world. She is often called on by others in the field as an expert on mental health, addiction and recovery, and stands on the front lines welcoming people into recovery programs.
Ms. Patrick said: "I would like to thank the Board of Directors for entrusting me with the honor to serve our city and county towards ensuring what is one of its most important missions, the safety and well-being of our citizens and visitors. I am looking forward to continuing our work with the business and community leadership, area social service providers, and our public officials as we integrate the Sobering Center into the existing continuum of care."
She added: "We want the Sobering Center to provide a safe environment for publicly intoxicated individuals to sober up and, when appropriate, initiate recovery. We are aiming to enhance public health and public safety by providing an alternative to the emergency room and jail."
The Center is due to open next summer at 1213 Sabine Street, on the site of the former Travis County Medical Examiner's facility, which is being renovated.
A non-profit local governmental corporation was formed to oversee the Center by Travis County and the City of Austin in 2016 after a collaborative stakeholder process. Judge Nancy Hohengarten serves as Board Chair and board members include Mayor Pro Tem Kathie Tovo and Commissioner Margaret Gómez.
Margaret Gómez, Travis County Commissioner Precinct 4, said: "The Sobering Center is an opportunity for those who have made serious mistakes regarding alcohol and drugs to begin the process to correct their mistakes and find the treatment they need. I congratulate Rhonda Patrick and look forward to working with her during her tenure."
Sarah Eckhardt, Travis County Judge, said: "Congratulations are in order to Rhonda Patrick as she takes on the role of Executive Director of the Sobriety Center. With her experience and talent, Rhonda and the Sobriety Center will provide Travis County residents with a public health alternative to the criminal justice process."
For more information go to soberingcenter.org
Board Meeting January 8, 2020
Board Meeting December 11, 2019
Board Meeting November 13, 2019
One Year Anniversary Celebration and Fundraiser
Board Meeting October 9, 2019
Ways To Donate Click Below
1213 Sabine Street
info@soberingcenter.org
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Wow, I feel so awed by these lines, these lines questions the validity of our perceptions/views/ beliefs/thoughts about this world… brilliance is one word which sums it! do pay attention to each word ( can be interpreted in multiple ways, this is my interpretation).
are all of these just my dreams?
are they mere illusions that my thoughts make me beleive of this world?
are all these petty illusions?
don't all these thing have a deeper meaning/significance?
are all of you merely a mirage?
are these just a result of my erroneous view?
isn't this world a lie too?
are all these forms (appearances) mere lies?
there, what we perceive as characters (qualities of a person), aren't these too lies?
am I just a dream?
[Subramanya Bharathi] Love thine enemy!
You have done justice to the immortal lyrics, as Chayaji Shinde did in the film.
I've been searching this translation for 5-6 years, thanks a lot mate. When you get some time, read this facebook note, http://www.facebook.com/notes/arun-rajagopal/subramanya-bharathi-on-metaphysics-epistemology-and-quantum-reality/402081669824387 . Thanks again mate.
Hi Arun, I liked the way you relate the verses to physics. Very glad that my translations were of use.
Thanks Ganesh, was exploring your blog, really fantastic blog you have .
Excellent translation.. great work my friend!!
Thanks for taking the time to do this wonderful translation. WIth Raja Sir's music,this song give me peace It is a grand feeling just to listen to this song and then with meaning, I am in awe of MahaKavi Bharathi. I am glad that his thoughts are alive among this generation.
When you find time, please continue doing such wonderful work .
I echo your views. Bharathiyaar's verses with the music and rendition makes this song a true gem.
A few corrections in the text.
1. gnAlam =ஞாலம். It means earth, world, universe, magic, and also the great.
It is not to be construed as knowledge which is ஞானம்.
4. In #6 "nAnumOr kanavO…." is repeated. Instead in Bharathi's version it is "VeeNpaDu poyyilE niththam vidhi thoDarnthiDumO…" The song in the video does not have this.
There are a couple of more stanzas in Bharatiyar's original composition. I am unable to find those lyrics through Google search. That almost completely negates the philosophical view of the stanzas stated above. If anyone can post those lyrics that would be great.
Either the movie makers deliberately changes the song or Bharathiyar had two alternate endings. I am not sure which is the case.
While the original song's philosophy is trancendental here is is completely existentialist.
Thanks Rajaram for your effort, its intriguing as you point out. Wonder what went through Mahakavi's mind when he penned this.
He is good one. Can able to feel his thoughts from his great poems. Great man with potential laugage. We are so lucky to live in this tamil society. Thanks to Tamil rasigan.
Thanks, I will be waiting for the translation from lyrical delights. Let me know once it is done. I also need the translator's name, in case if i need to share it.
Here it is! Hope you like it!
I am not a tamilian to share the pride of this immortal song. I feel my throught choked and tears run because of an emotion which I could not explain.
What a spiritual awakening bharathi had.. bless to have him in our life.


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Q: Adding a Hebrew Autocorrect entry using VBA in Excel I can add an English Autocorrect entry using VBA in Excel
Application.AutoCorrect.AddReplacement What:="helo", Replacement:="hello"

However if the replacement word is Hebrew then it doesn't work (nothing is added)
aHebrewWord = Range("C1").Value
Application.AutoCorrect.AddReplacement What:="helo", Replacement:=aHebrewWord

I know that VBA does work with Hebrew, even though you can't actually see Hebrew in VBA (source declaring a unicode string in vba in excel) - for instance the following function works fine:
function getReverse(aHebrewWord)
  getReverse=StrReverse(aHebrewWord)
end function

How can I add a Hebrew Autocorrect entry using VBA?

A: There shouldn't be anything preventing VBA from using one string instead of another; your code should work.
The problem, if it exists, might be with the way you're obtaining aHebrewWord.

A: The VBA editor expects VBA files to be encoded in Windows-1252, which is a 8-bit codepage and does not support hebrew.
You can either build your string as a concatenation of wide character code :
'this replace 'hello' to 'שלום'
Application.AutoCorrect.AddReplacement What:="hello", Replacement:=ChrW(&H05E9) & ChrW(&H05DC) & ChrW(&H05D5) & ChrW(&H05DD)

Or you can convert a Windows-1252 string which is a binary equivalent of the unicode string:
Application.AutoCorrect.AddReplacement What:="hello", Replacement:=StrConv("éÜÕÝ", vbFromUnicode)

Use notepad to convert the string: copy-paste the unicode string, save the file as unicode (not utf-8) and open it as ASCII (which is in fact Windows-1252),then copy-paste it into the VBA editor without the first two characters (ÿþ), which is the BOM marker.

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text:
Odd Christian Gøthe (30 December 1919 – 23 September 2002) was a Norwegian civil servant and politician for the Labour Party.

He was a cand.oecon. by education, and was head of economics in the Norwegian Confederation of Trade Unions from 1947 to 1952. He served as state secretary in the Ministry of Finance from 1952 to 1955, in the cabinet Torp, and in the Ministry of Industry from 1955 to 1958 in the third cabinet Gerhardsen. After this, he worked as deputy under-secretary of state in the Ministry of Industry from 1958 to 1975. From 1975 to 1986 he served as state negotiator. He published a number of books.

References

1919 births
2002 deaths
Norwegian economists
Norwegian trade unionists
Norwegian state secretaries
Labour Party (Norway) politicians


Try our APPLE PIE Bourbon Cream!
Classic Apple Pie à la mode infused with fiery bourbon with a hint of cinnamon for a taste of your last bite of grandma's apple pie.
Fiery bourbon combined with the cool, silky smoothness of fresh dairy cream, available sweetened with real honey or real maple syrup.
Whether you're looking for a smooth cocktail to savor while sitting by the fire, or a round of fiery shots to get the party started, we've got you covered. Straight up, mixed in or blended, Woody's is all in.
With balance in mind, Woody's blends spicy bourbon with the cool, silky smoothness of real American Cream. Our flavors include Original, Maple, Honey, and Apple Pie bourbon Cream.
I recently had your bourbon creams while I was visiting family in Albuquerque, NM. I normally am not a bourbon drinker, but I LOVED it!
Really has a smooth, rich flavor. Nice on ice but, I love it in my coffee and hot cocoa!
THIS IS THE BEST THING I'VE EVER TASTED IN MY SHORT LIFE HERE ON EARTH! Somebody gave it to me…I'm on the hunt to buy more!!


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HomeGeneration & StorageGannawarra and Wemen solar farms now operating
Gannawarra and Wemen solar farms now operating
Managing director of WIRSOL Mark Hogan
Gannawarra Solar Farm is now operating at full capacity having successfully passed all commissioning tests approved by the Australian Energy Market Operator (AEMO).
In addition to the 60MW Gannawarra Solar Farm in north-west Victoria, Wemen Solar Farm is now connected and generating power. With 110MW capacity, the two solar farms are contributing 170MW of renewable generation to the national grid.
WIRSOL Energy, the Australian arm of the WIRCON Group developed both farms, with Wemen Solar Farm being the company's largest solar project to date.
RCR Tomlinson, the EPC Contractor responsible for constructing Wemen Solar Farm, achieved the first-generation milestone on schedule and will continue commissioning with the goal of achieving completion by year-end.
At 110MW DC, Wemen Solar Farm has approximately 319,000 modules installed across an area of close to 700 acres.
Related article:Energy generation begins at Victoria's largest solar plant
The two projects combined will provide enough energy to power the equivalent of approximately 52,100 Victorian households with sustainable electricity, whilst preventing the emission of approximately 390,000 tonnes of CO2 per year.
The Victorian Government consciously committed to re-establishing the state as a front-runner in renewable energy, with targets of 25 per cent by 2020, 40 per cent by 2025 and 50 per cent by 2030 if re-elected.
Furthermore, Gannawarra Solar Farm's retrofitted 25MW/50MWh Tesla powerpack battery, Gannawarra Energy Storage System (GESS), has reached its own project milestone, completing the construction phase ahead of schedule.
Related article:Solar and battery tech deal signed with developer
GESS's owners, WIRSOL and Edify Energy, have overcome regulatory and technical challenges to become the first battery storage system that has been retrofitted to an existing solar farm. The facility holds great significance and further demonstrates the great opportunity for integrating large-scale battery storage with solar projects.
Managing director of WIRSOL Mark Hogan says, "The overall project and how it has evolved is unique to the industry which in turn sets a benchmark for future projects, which enables the ability to optimise the delivery of energy at peak times supporting demand throughout the daily cycle.
"This also underwrites our own personal mission of deploying greater than one gigawatt of solar energy by the year ending 2020 in Australia.
"Maintaining the deployment of solar, coupled with storage where appropriate, is a cornerstone in attaining sustainable and affordable clean energy, which is evidently now within reach on a global scale, specifically within Australia."
Gannawarra Solar Farm
Wemen Solar Farm
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Q: signal Segmentation fault after specific url access In my PHP program when I access specific URL (POST some data) the request has been aborted and this logs appear in Apache error.log:
WARNING: HOME is not set, using root: /
[Thu Sep 13 22:49:47 2012] [notice] child pid 32111 exit signal Segmentation fault (11)

What's the problem?

A: This is a software problem (could be one of many, but almost certainly a programming error).
In order to figure it out you would need to run your web server inside of a debugger to locate the point in the code where the segfault is happening -- if your "server experience is weak" there is a very good chance that this sort of debugging will be out of your depth, and you should refer the problem to the person who wrote the code that is trying to handle this POST request.

A: HOME is not set means that the user under which the web server is running does not have a home directory defined (or maybe it doesn't exist).
If your code is the same on both local machine and the server, try comparing the data you POST. Check if:

*

*there is anything unusual in the data you sent

*there is a problem when you POST the same data


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Q: How to call power bi api using power bi desktop to access access content from Power BI service Do you know how to call power bi api using Power BI Desktop to access access content from Power BI Service. I want to get number of workspaces and number of Reports, dataset Last Refresh time.

A: here is option on home ribbon, you can access all your datasets on Power Bi Service within Power Bi Desktop from here
screenshot
hope this will help (i noticed your question is 11 months old and may be you already have find the answer)

A: The easy way is to use the Power BI REST API Connector from Github (link). Then you can connect to the service directly from PBI Desktop.
The hard way is to register an app into AAD and then use the credentials to connect to the API, as described in this video


oftwominds-Charles Hugh Smith: How Bad Can Things Get?
How bad can things get? Nobody knows, but it makes sense to look ahead and plan a response to all 10 problems heading our way rather than bask in the false confidence that 9 will magically vanish before we have to deal with them.
How Bad Can Things Get? Nobody knows the answer, so we have to consider our responses to a spectrum of possibilities. President Calvin Coolidge famously remarked, "If you see ten troubles coming down the road, you can be sure that nine will run into the ditch before they reach you." While there is certainly much wisdom in this reassurance, that still leaves us the task of preparing for the one that doesn't run harmlessly into the ditch.
There are all sorts of martial processes for assessing which troubles are the most dangerous and hence the ones that we should prioritize as high-risk: threat matrix, etc. Then there are assessment-response-feedback schemes such as the OODA loop developed by USAF Colonel John Boyd: "observe, orient, decide, and act."
These conceptual frameworks have value, of course, but they remain abstract until some extremely unwelcome events don't run into the ditch: a negative health diagnosis, loss of a job, and so on. Once the problem is real, our instinct is denial, seeing only what we want to see to avoid the trauma that results from responding to the problem.
Thus people with throat cancer will wait until they can no longer swallow before admitting to themselves that denial will cost them their life.
In less-than life-threatening circumstances, we are prone to all-or-nothing thinking, and we lose sight of the spectrum of threat and response.
One of the most under-appreciated psychiatrists of the 29th century, Karen Horney, wrote extensively about all-or-nothing thinking as an emotional trap, and I think we can discern a bit of this in conventional prepper advice, which is often geared to the expectation of complete social breakdown and open warfare in the streets.
While this is certainly one possible outcome, it is by no means the only one or even the most likely, at least in food/energy-rich North America. In focusing on the currently remote outcome, we lose sight of all the less drastic but more likely possibilities, chief of which is a reduction in our real income (purchasing power).
On the other side of the all-or-nothing coin, the typical American household has made no preparation for anything but the state-debt-feudal Status Quo: they have essentially no food, cash or energy in reserve, leaving the household extremely vulnerable to the slightest disruptions in income, energy and food delivery.
How bad can things get? I confess to following Andy Grove's dictum that "only the paranoid survive." Clearly, a healthy appreciation for risk and the benefits of advance planning should obstacles arise offers selective advantages.
Even if 9 of 10 problems run into the ditch, it pays to look ahead and think about what responses are likely to be the lowest cost and most successful should any of the 10 reach us.
Once again this is easy when in the abstract, but less easy in real life. One potentially straightforward tool to aid our planning and response is a three-three matrix.
One set of three is the classic Plan A, Plan B and Plan C, with Plan A being the easiest, cheapest response to low-level disruption, either in our household or the wider economy or both. Plan B is a more comprehensive set of responses to serious disruptions and Plan C is the "Katie bar the door" set of responses to severe disruptions.
How bad can things get? Nobody knows, but it makes sense to look ahead and plan a response to all 10 problems heading our way rather than bask in the false confidence that 9 will magically vanish before we have to deal with them, and the one that reaches us will require no forethought or planning.
There is a time-decay feature in all this; cancer that is detected and accepted very early has a very high cure rate, and putting aside small amounts of money monthly builds a useful nestegg of capital with little sacrifice in the present. As the Chinese saying has it, "When you're thirsty, it's too late to dig a well."
What is the most likely disruption? I would guess involuntary poverty, i.e. a reduction in purchasing power coupled with increasing costs for essentials.
Voluntary poverty is a strategy for hardening the household while options are still plentiful: drastically reducing expenses so the household can get by quite nicely on half the current income, sacrificing discretionary spending to accumulate cash capital to invest in small enterprises the household owns and controls, and reducing earnings voluntarily to avoid confiscatory tax rates.
This can be called resilience or wealth-building. Both terms apply, as wealth is more than cash in the bank: it is social capital, skills, income sources we control and a desire for active independence over passive dependence.
Thank you, Warren C. ($10/month), for your outrageously generous subscription to this site-- I am greatly honored by your support and readership.


When purchasing goods cost can be a big factor, but the value of savings dwindles when you are paying for a service. When you honor a loved one and gather to grieve for them, you only get one chance to have it done right. You want to be taken care of by a staff that gives you their full attention and works with you. The facilities should be clean and be able to accommodate relatives and friends for a small or large service. If you are comparing funeral homes, we encourage you to look beyond costs, look at the value of the services provided.
What should you consider when comparing funeral homes?
Accessibility: Is it easy to find the building? Plentiful parking space? Is there a ramp or easy access for elderly or disabled visitors?
Cleanliness: What is the condition of the building, furnishing, and other equipment? Are the restrooms and chapel clean?
Functionality: Is this just a funeral home or are they affiliated with a cemetery or crematory as well? Is there a chapel you may use for a funeral or memorial service? Is there a reception area available for after a service?
Comfort: Does the building feel spacious and homey, or cramped? If you have your service here, is there enough seating for family and friends who may be attending?
Hospitality: When arriving, are you greeted and helped in a timely manner? Offered snacks and beverages if you need to wait for the right staff member to be available?
Attentiveness: Do you feel like you have the funeral director's full attention? Are you being listened to? Are your questions being answered in in full detail?
Accommodating: Is the staff able to help arrange for an officiant, clergy, or musician? Does the staff sound like they will help you add meaningful touches to a service such as arranging a dove release, put together a memorial video, or find centerpieces for a reception?
Availability: How quickly did you get a call back from or were connected with an Advanced Planning Specialist or Funeral Director? Did the staff member you were working with offer a cell phone number or email so you could directly contact them?
Funeral Directors: Is the person you are working with a licensed funeral director? Do they also have a cremation License? If they do, there is a far greater chance that the director you work with will be looking after your loved one through all steps of care and service.
Advanced Planning Specialists: If the funeral home also has a cemetery, these team members normally have a real estate license.
Notary: Is there a staff member able to notarize documents?
Other: In cases where a funeral home offers assistance with arranging a reception, are staff members food handler's cards current?
Selection: Does their selection of goods reflect what you are looking for? If not, will the staff help you find what you are looking for elsewhere or with a new vendor?
Accommodating: Does the staff oppose or support your choice of purchasing goods elsewhere and bringing them in? Common items families ask to bring in include urns, keepsake jewelry, and register books.
Religious and Cultural Accommodations: Does the funeral director understand your religious or cultural needs? If you or others need to wash, dress, or perform other final rites in a private setting, is there a room or area available? Are incense allowed for use within the chapel?
At Mountain View Funeral Home and Cemetery, we encourages families to learn about our services, facility, cemetery, crematory, and staff. We also encourage families to compare us to other funeral homes by ask questions and getting a tour of the facility and grounds. We value the trust families have given us since 1951 and we will continue to provide the utmost care and respect towards valley families.


text:
← Klaus Kinski Only The Cool poster and some photos
More Klaus Kinski photos →
Klaus Kinski needs to work on his interview technique
Posted on May 15, 2011 by tinynoggin
Circus of Fear aka Circus of Terror; Das Rätsel des silbernen Dreieck; Psycho-Circus (Dir John Llewellyn Moxey, 1966)
Basic plot: A security guard is killed during an armed robbery on Tower Bridge. The robbers get away with the money leaving no traces behind them. Inspector Elliott is getting nowhere fast with his investigation to find both the robbers and the money, until he discovers some of the money has been banked by Barberini, the owner of a visiting circus. At the circus Elliott uncovers blackmail, murder and concealed identities, but will he track down the robbers and the money?
Cast: Manfred Hart – Klaus Kinski; Gregor – Christopher Lee; Elliott – Leo Genn; Barberini – Anthony Newlands; Carl – Heinz Drache; Eddie – Eddi Arent; Gina – Margaret Lee; Natasha – Suzy Kendall; Sir John – Cecil Parker; Mason – Victor Maddern; Mario – Maurice Kaufmann; Manley – Lawrence James; Jackson – Tom Bowman; Mr Big – Skip Martin; Red – Nosher Powell
Filming locations: Winkfield, Berkshire; Bray Studios, near Windsor, Berkshire; Tower Bridge, Tower Hill and Tower Bridge Road, London
Release date: 29 April 1966 West Germany; May 1967 USA; November 1967 UK
Availability: Circus of Fear is available in various issues – the copy I have (Cinema Club), and which is reviewed here, runs at just 82 minutes and has no extras. There is another version, undoubtedly better, available from Blue Underground which runs at 90 minutes and has a director's commentary and trailers. I'll update the review when I have the Blue Underground version…
Circus of Fear is a great little film packed with mystery. It opens with Klaus, which is always a bonus. The location is the Thame s River, near Tower Bridge. Manfred (KK) is a shady character, skulking around and watching a man through a window at 6:50am. We later discover he is a criminal with "plenty of form here and on the continent; smuggling mainly with a touch of violence thrown in."
Manfred is working with a gang of robbers who are planning to hold up a security van, which is helpfully being driven by one of their men, Mason. The plan works like clockwork with each gang member assigned duties to be carried out according to their precise timings. That is, until Mason shoots his fellow security guard who was about to attack one of the gang members…
But the money has quickly been zipped down a wire from the bridge to a boat below and the gang have all descended to the boat in the same way, so other than the inju red security guard there is no evidence left behind to identify the perpetrators. And the only witness to the crime unfortunately dies when Inspector Elliott arrives on the scene, leaving him with no leads whatsoever.
Elsewhere, the gang carry out a post mortem of the crime and Mason is in trouble. Jackson, who appears to have line management responsibilities for the gang, calls the mysterious boss and informs him of Mason's misdemeanour. Whilst this takes place it should be noted that Manfred is lurking in the background listening in. This is a major theme of the film – people surreptitiously watching and listening, in fact there are so many of them watching in the shadows that I'm surprised they don't bump into each other! – along with the other theme which is identities or rather uncertainty regarding identity.
Mason is told that the boss wants him to go to The Old Farm in Englemere – he needs to hire a car and get rid of it before he arrives – with some of the takings from the robbery. But who is the boss? Jackson says that no one knows this and it is better that way – a big question here, how is it possible that no one knows who the boss is? At least one person must know otherwise how did the gang get together and plan the job in the first place?
Anyway, Mason is told that if he manages to fulfil this task they will get him out of the country. With Manfred discovered lurking in the background, Jackson tells him that they should meet in a week's time to arrange to get the money out of the country. Manfred's main concern is when he is going to get his share of the loot – but he won't be getting that until he has finished the job, which means waiting for a week.
Whilst Mason heads off to Englemere, the Inspector gets his first tip off about a vehicle which may have been involved in the robbery. The vehicle is traced and chased up the motorway by the police and eventually crashes into the woods and explodes. Jackson is dead and one of the gang informs the Inspector that Mason was behind the shooting and he has left with the bulk of the money.
Meantime Mason is approaching The Old Farm, as instructed he disposes of the car and goes on foot to the farm with £250,000 in a suitcase. The Old Farm is dark inside and there are no lights. By torchlight Mason makes out the outlines of some sinister masks and suddenly a wild cat in a cage roars. Naturally Mason realises that something is amiss and tries to flee but a knife in the back puts paid to that. There is a silver triangle on the handle of the knife. A hand reaches out and takes the case – we don't see the murderer; we don't know if it's the mysterious boss or if it is someone else; we don't yet know the relevance of the silver triangle.
This is what I love about Circus of Fear, that there is so much that we do not know, that there are so many red herrings, and that the camera restricts our knowledge by keeping characters in the off-screen space at key moments. As a viewer we're in a position where we know more than the Inspector, and we're privy to certain scenes that some of the characters in the film are unaware of and yet there is still so much that we do not know; it's very difficult to work out what all the characters are up to and what their motivations are.
We're introduced to a great number of characters who, for a variety of reasons, can be treated with suspicion:
The mystery man – the beautiful Gina (Margaret Lee) is having an affair with an unidentified character. The mystery man strokes her legs, helps her to fasten her leotard, lights her cigarette and not once does he speak or show his face. A great way to restrict our knowledge! He has a mirrored cabinet on the wall and this is full of knives with the silver triangle symbol on them. One of them is missing… he's undoubtedly the murderer and the man who took the money, but who is he? All we know about this mystery man is that he is incredibly hairy on his arms and his back and he wears a white vest in bed!
The Great Gregor – Gregor wears a mask much like the one worn by The Elephant Man, apparently due to a terrible accident which resulted in severe facial injuries. But has anyone actually seen his face without the mask? He works as a lion tamer and he has a suitcase of money hidden underneath the lion's cage, which he keeps dipping into from time to time. The rest of the circus people suspect him when the lion is let loose on Gina, could it be that Gregor is the mystery man who took the case of money? He's quite hairy as well, he could easily be the mystery man, but is he really guilty of murder? Or is this just a red herring? And if so, what is it that Gregor is really hiding?
Mario – Gina's fiancé, he seems to have a bit of a temper on him as he manhandles Gina when she tells him that it is none of his business where she has been when she's been off with her hairy fancy man. And Mario fights with Carl when he thinks he is flirting with Gina. Mario is a knife thrower but he is not Gina's mystery man and he asks the same question as the viewer – "Who is it? Who is it?!!" But Mario wants to know this for very different reasons to the viewer
Gina – the lovely knife thrower's assistant is said to be a tad unfaithful to her fiancé, let's say, and she is currently having an affair with the mystery man. She accidentally discovers his knives in the cabinet on the wall and notices that there is one knife missing. Her suspicions are aroused later when a knife with a silver triangle is discovered to have been a murder weapon. She starts to believe that someone is trying to kill her when a lion is let loose on her, she is about to speak to the Inspector about her suspicions when she is found dead with a knife in the back – another knife with a silver triangle on it…
Mr Big – O! The irony! This well-spoken little fellow appears to be both a blackmailer and a voyeur, but then watching in the shadows gives him the information he needs to be able to continue with his extortion and threatening behaviour… Whilst he may not be the mystery man with the suitcase, he seems to know quite a lot. Will he get his comeuppance?
Barberini – the owner of the circus, he banks some money that is traced back as being part of the Tower Bridge robbery, is he the mystery man with the suitcase?
Manfred – our old friend Manfred arrives at the circus, announces that he is looking for work and lurks in the shadows but we know he's not the mystery man with the suitcase because he is frantically looking for the suitcase himself
Carl – the ringmaster at the circus, Carl seems to be a bit too nosey and always checking up on the other circus folk; he seems to be most interested in Gregor and is always prying about the accident and whether or not anyone has ever seen his face without the mask. What information is Carl looking for? Mr Big is suspicious of Carl and his motives for joining the circus. Carl flirts with Gina, but could he really be Gina's mystery lover and the murderer?
Eddie – he's totally annoying with his constant attempts to get the attention of Barberini and to get his useless act incorporated into the show. He certainly doesn't look like Gina's type either, so there's no reason to believe he is the murderer. Or is there…?
Natasha – Gregor's niece, whilst not a suspect she does appear to be keeping some kind of secret. With Gregor under suspicion, does she know the identity of the murderer? If not, why does Gregor disapprove of her having visitors and talking to the nosey Carl? Is her father really in South Africa?
The Great Danilla – a famous knife thrower who died ten years ago, we're told that he had a son but he kept him out of the circus as he wanted him to be a gentleman. But what is the relevance of this story? And who is the Great Danilla's son? Could he be the murderer?
All these mysteries are solved one by one in this great little film which really keeps you guessing, until Inspector Elliott finds the murderer and the man behind the Tower Bridge robbery. Klaus is amazing; Margaret Lee is gorgeous; the cinematography is interesting with some lovely, quirky images throughout; Leo Genn provides a bit of gentle, wry humour in his role as the Inspector, especially during his scenes with Sir John. I'd definitely recommend this film.
Kinski's acting methods: Just got to say, Klaus looks superb in this film. As ever he has his hands in his pockets throughout:
But he also appears to be smoking for Germany and even speaks lines of dialogue with a cigarette dangling from his mouth:
Klaus also manages to get in the odd "staring through a window" shot as well:
My favourite part of the film is the sequence where Klaus arrives at the circus and says he is looking for work. Mr Big is practising with a whip and we're alerted to Manfred's presence when we see a foot stepping on the end of the whip.
He definitely needs to brush up on his interview technique:
Mr Big: What do you want?
Manfred: Work
Carl: What's your name?
Manfred: That's my business
Carl: I see. Have you ever worked in the circus before?
Manfred: Maybe
Carl: You'd better tell the truth. Why have you come here?
Manfred: I've just told you. All I want is work
Barberini: We don't want any help
Manfred: I don't want hard work
Barberini: If there is any work, I will let you know. Where are you living?
Manfred: I'll be around
Eddie: Okay, let's have your name and address
Manfred: Forget it, I will be back
Somehow, I don't think Manfred would have got a job offer after that interview!
Another great moment is Manfred's death – as he is stabbed in the chest, he falls over and as he does so he grabs one of the huge circus character heads and lands in the hay with the head next to him:
Other information about the film: I haven't managed to track down any horror stories about Klaus misbehaving on this film, but given that he worked regularly with Christopher Lee and Heinz Drache and did more than 10 films with both Margaret Lee and Eddi Arent, I'm sure they would have been used to his behaviour anyway!
This film seems to be available in as many issues as it has alternative titles – the issue I have is an edited version and as I said before a full length version is available through Blue Underground. But I'm not sure if that is the same version as a video I have read about which has extra footage and an introduction by John Carradine. I'll find out when I get my hands on it.
Also, I understand from IMDB that the film was released in b+w in West Germany upon its original release and was not made available in its colour version in Germany until 2006. Apparently the reason for this is because Rialto, the German production company, wanted to promote a different film (Der Bucklige von Soho) as the first Edgar Wallace film in colour.
This entry was posted in Film Review and tagged Anthony Newlands, Christopher Lee, Circus of Fear, Das Rätsel des silbernen Dreieck, Eddi Arent, Heinz Drache, John Llewellyn Moxey, Klaus Kinski, Leo Genn, Margaret Lee, Maurice Kaufmann, Skip Martin, Suzy Kendall, Victor Maddern. Bookmark the permalink.