Performance of chloride/phosphate test in patients with primary hyperparathyroidism. Is it related to calcium level?

To examine the sensitivity of the chloride/phosphate [Cl/PO[4]] ratio with a cut-off point of >33 as a diagnostic test for primary hyperparathyroidism [pHPT] in surgically proven patients, and its performance at different calcium levels. This is a retrospective medical records based study. Data of 120 patients diagnosed with pHPT, already operated in the Department of Surgery, Cisanello Hospital, Pisa, Italy between March 2010 and June 2011 were reviewed. They were divided into 4 subgroups according to their calcium levels. The Cl/PO[4] ratio was measured for each patient, with a cut-off point of 33, sensitivity of Cl/PO[4] test was measured. Test sensitivity was calculated for each subgroup, and a correlation with the parathyroid hormone [PTH] level was investigated. Performance of the equation was tested for the normocalcemic patients with a suitable control group. The sensitivity of Cl/PO[4] ratio for the whole group was 0.883 [0.809-0.932]. The sensitivity was 0.9340 [0.857-0.973] for patients with serum calcium above normal levels. A similar result of 0.933 [0.830-0.978] was demonstrated for the subgroup with hypercalcemia <1 [mg/dL] above normal level. Normocalcemic patients constituted 24%; for this subgroup, the sensitivity test was 0.724 [0.562-0.887], specificity was 0.763 [0.628-0.898], positive predictive value was 0.700 [0.536-0.864], and negative predictive value was 0.784 [0.651-0.916]. No correlation was identified between the performance of formula and serum PTH level. The Cl/PO[4] test seems to be a good tool to anticipate pHPT and showed a fair performance in normocalcemic patients

Prevalence of diabetic foot ulcer and its associated risk factors among diabetic patients in Jordan

The objectives of this study were to assess the prevalence of diabetic foot ulcers and their risk factors among patients attending the National Center for Diabetes, Endocrinology, and Genetics [Amman, Jordan]. A systematic random sample of 1,000 diabetic patients was selected from patients attending the diabetes clinic at the National Center for Diabetes, Endocrinology, and Genetics [Amman, Jordan]. Vascular, neurological, musculoskeletal, and ulcer risk categories were all assessed. There were 49% males in the sample. The mean age of the sample was 52 years, and the mean duration of diabetes was 9.7 years. Diabetic foot ulcer prevalence was 4.6%, sensory neuropathy 14.9%, lower limb ischemia 7.5%, and amputation 1.7%. Ulceration was associated mainly with the male gender, neuropathy, and increased duration of diabetes. Future efforts should be directed toward educating both healthcare professionals and patients about proper foot care. Community based studies are also necessary to determine the actual prevalence of diabetic foot complications

Unusual association between adrenal leiomyoma and autoimmune disease

Adrenal leiomyoma is a rare solid tumor of unknown etiology. Here, we present a case of a 38-year-old woman, a known case of Hashimoto's thyroiditis, presented with right adrenal mass incidentally discovered by computed tomography imaging. The mass was non-functioning according to laboratory results, but because the mass increased in size in a follow up visit, she underwent right adrenalectomy. The histological findings confirmed the diagnosis of adrenal leiomyoma, which was supported by a panel of immunohistochemical stains. Surprisingly, there was a dense lymphocytic infiltrate in the background of the tumor, forming germinal centers. Although most of the reported adrenal leiomyoma cases are associated with immune deficiency, none of the previous cases was associated with an autoimmune disease. We report a case of an unusual adrenal leiomyoma with a dense lymphocytic infiltrate

Hurthle cell carcinoma: expanded view

The definition, rarity, and natural history of Hurthel Cell Cancer [HCC] is not well understood, which makes the diagnosis and management of this cancer a controversial issue. The objective of this study is to report a series of patients with HCC and to discuss the clinical behavior along with the prognostic indicators of this disease in an attempt to make more accurate suggestions for treatment. We conducted a retrospective study reporting on all patients with HCC observed at Jordan University Hospital [JUH] and King Abdullah University Hospital [KAUH], during the period from January 2001 to December 2008. Data were collected, analyzed and compared with different results published in the literature. There were 56 Patients with Hurthle Cell Tumor [HCT], diagnosed on fine needle aspiration, of those; 16 were diagnosed as hurthle cell carcinoma by histopathology. All patients with HCC were treated by total thyroidectomy. Postoperatively, all patients with HCC ware treated with radioactive idodine except for 3 patients. Follow-up period for all patients with HCC ranged from 6 to 84 months. No recurrence or distant metastasis were documented during the study period. We could not find higher incidence of local recurrence, distant metastatis or mortality rates compared to literature. HCC seems to have favorable outcome in our part of the world when treated with total thyroidectomy

Rupture of spleen post colonoscopy

We review an interesting case of elective colonoscopy for rectal bleeding in a 68-year-old woman complicated by splenic rupture. She was managed by aggressive fluid and blood resuscitation followed by splenectomy. She had a smooth recovery and was discharged home 4 days after admission. The extreme rarity and interesting clinical course of the patient are discussed

Islet transplantation: the quest for an ideal source

The progress of islet transplantation as a new therapy for patients with diabetes mellitus depends directly upon the development of efficient and practical immunoisolation methods for the supply of sufficient quantities of islet cells. Without these methods, large scale clinical application of this therapy would be impossible. Two eras of advances can be identified in the development of islet transplantation. The first was an era of experimental animal and human research that centered on islet isolation procedures and transplantation in different species as evidence that transplanted islets have the capability to reverse diabetes. The second was the era of the Edmonton protocol, when the focus became the standardization of isolation procedures and introduction of new immunosuppressive drugs to maintain human allograft transplantation. The quest for an alternative source for islets [xenographs, stem cells and cell cultures] to overcome the shortage of human islets was an important issue during these eras. This paper reviews the history of islet transplantation and the current procedures in human allotransplantation, as well as different types of immunoisolation methods. It explores novel approaches to enhancing transplantation site vascularity and islet cell function, whereby future immunoisolation technology could offer additional therapeutic advantages to human islet allotransplantation

New trends in the clinicopathological features of differentiated thyroid cancer in Central Jordan

To investigate the current trends in presentation and distribution of differentiated thyroid cancer [DTC] at the largest referral hospital for endocrine cancers in Central Jordan. We analyzed the clinical features, management and outcome of 110 patients diagnosed with thyroid carcinoma at Jordan University Hospital, Amman, between 1996 and 2001. Papillary carcinoma was diagnosed in 87 patients [80%], follicular carcinoma in 3 patients [2.7%], Hurthle cell carcinoma in 8 patients [7.3%], medullary carcinoma in 5 [4.5%], and anaplastic carcinoma in 4 patients [3.6%], metastatic cancer in 2 patients and lymphoma in one patient. Time course analysis showed an increasing trend in surgery for thyroid cancer from 28 cases in 1986-1991 to 48 in 1996-2001. As time advanced, the incidence of locally invasive disease and lymph node involvement markedly increased over the last 5 years of the study [from 28-62%]. All patients with follicular carcinoma were diagnosed in the period 1986-1994. After thyroidectomy and a follow up period of 2-15 years, 10 patients died of their disease, 4 of these died within one year from anaplastic thyroid carcinoma. The dramatic decline in the incidence of follicular thyroid carcinoma combined with the increase in the advanced forms of thyroid cancer in Central Jordan may suggest a possible environmental factor in thyroid carcinogenesis in this region. We suggest a larger scale studies and steps to investigate the etiologic factors for thyroid carcinogenesis in Central Jordan

Topical phenytoin ointment increases autograft acceptance in rats

To examine the effectiveness of topical phenytoin in preserving the skin viability and increasing acceptance rate of autograft. We conducted this study in the Central Laboratory Animal House of Jordan University of Science and Technology, Irbid, Jordan during the period from September 2004 to June 2005. Forty-two rats were divided into 2 equal groups; full thickness dorsal skin wound [4 cm2] was created in the rats. Twenty-one rats were treated with phenytoin [10% w/w ointment], the other 21 [control] were treated with standard dressing and Vaseline. An autograft was performed one week after treatment. Rats were examined for the presence of healthy granulation tissue, reduction in wound surface dimensions, and time for complete graft attachment. Phenytoin ointment had significantly increased wound bed viability and the rate of graft acceptance [p-value <0.0001]. Twenty rats had successful grafting [10% phenytoin]; while only 3 rats out of the 21 control had successful grafts. The mean time to complete graft attachment and hair growth in the grafted skin was 6.6 +/- 0.5 days. The mean wound contraction measurements [taken just before grafting] were as follow: control group 59.2 +/- 11.6%, and phenytoin group 55.7 +/- 9.2, difference in skin contractility was not statistically significant. Skin viability was evident by increased vascularity and granular tissue formation at the edges of the wound. Phenytoin appears to be an effective method for enhancing the take of the full-thickness skin graft. Further clinical use and evaluation of topical phenytoin ointment in skin grafting are merited

Brown tumor of the femur associated with double parathyroid adenomas

Severe parathyroid bone disease is a rare clinical presentation of primary hyperparathyroidism. Double parathyroid adenomas are even more rare cause of primary hyperparathyroidism. The authors present a case of double parathyroid adenomas in a 48-year-old man, who presented with painful left lower limb swelling, which was slowly growing in size in the last 20 years. Magnetic resonance imaging revealed a cystic bony lesion and coincidentally, a urinary bladder calculus. Biopsy of the mass revealed giant cell lesion. Laboratory investigations showed hypercalcemia and hypophosphatemia with elevated parathyroid hormone level. A computerized tomography scan of the neck delineated an adenoma of the left superior parathyroid gland, which was surgically removed. The left inferior parathyroid was also enlarged and was removed. Histological diagnosis confirmed double parathyroid adenomas. The rarity and the interesting clinical presentation of such association are discussed

Clinical spectrum of primary hyperparathyroidism

Primary hyperparathyroidism [1HPT] is now being diagnosed with increasing frequency. Simultaneously there has been an apparent change in the presentation of the disease and indications for surgery. The aim of this study was to examine the clinical presentation, indications for surgery, and outcomes of neck explorations for primary hyperparathyroidism. This study was carried out over a 12 year period, January 1990 to April 2002 at Jordan University Hospital, Amman, Jordan. Information on the indications, procedure performed, pathology and complications of all neck explorations for 1HPT was obtained from a retrospective thyroid/parathyroid surgical database. A minimum of 12 months follow-up was required in order to determine outcome of surgery. Out of 40 patients diagnosed with primary hyperparathyroidism at Jordan University Hospital, Amman, over 12 years, 14 patients [35%] diagnosed 4 years after the onset of their disease. Severe bone disease was the main indication for surgery in 28 patients; 5 patients with fractured bones, 2 patients with bone cysts, 3 patients with brown tumors and severe osteoporosis and backache in 22 patients; renal calculi in 10 patients; muscle ache and weakness in 14 patients; acute pancreatitis in one patient and asymptomatic HPT following biochemical screening in one patient. Two patients continued to have persistent hypercalcemia after the first operation; one of them has been cured by reoperation for an ectopic parathyroid in the anterior mediastinum resulting in an overall cure rate of 97.5%. This study showed that severe bone disease with fractures, bone cysts and brown tumors are still the most common presentation of primary hyperparathyroidism in Jordan; this is most likely due to delay in diagnosis and initiation of treatment. It is important to screen for hyperparathyroidism in high risk patients and to refer these patients to specialized centers for proper management

Surgery versus pharmacotherapy of benign thyroid diseases

Surgical management of benign thyroid diseases [BTDs] has been a topic of interest and confusion for many years. Almost 80% of thyroidectomies at an average endocrine surgical unit are carried out for BTDs. Resistance to surgical intervention in BTDs has been based on the belief that increased complication rate is inherent in its use, this is despite the potential advantages in terms of confirming the benign nature of the lesion, controlling the disease, and relieving local symptoms of large neck mass. Benign thyroid diseases are more likely to occur in middle-aged women living in iodine deficient areas, or have a family history of goiter, or in patients taking iodine-containing drugs, like amoidarone, or in patients with previous history of x-ray exposure. However, the physician must be careful in making the diagnosis of BTDs in patients at the extremes of age or in the presence of positive history of radiation, or in patients with family history of thyroid or colon cancer. In this article we will review the etiology, epidemiology, diagnostic methodologies and the recent trends in the surgical and medical management of BTDs