Selection of treatment in the management of thyrotoxicosis in childhood and adolescence.

The management of 105 patients between the ages of three and 18 years, 83 females and 22 males, with thyrotoxicosis was reviewed retrospectively (1952-1976) with the intent of identifying criteria that would help predict response to therapy with antithyroid drugs and thereby permit earlier selection of alternative treatment. All patients were initially treated with antithyroid drugs. Twenty-six per cent (27) achieved remission with thioamides, 68% (72) underwent subtotal thyroidectomy with three patients requiring subsequent therapy with radioiodine, 6% (6) received radioiodine with one patient subsequently requiring subtotal thyroidectomy. Failure of remission after thioamide therapy was related to drug toxicity, persistent disease, noncompliance and recurrence after an initial remission. During the last decade there was earlier selection of subtotal thyroidectomy based on prior experience. The most significant discriminants were sex, age, and regression of thyromegaly. Ninety-one per cent of the males, 89% of children over 11 years of age and all patients who had no regression of their thyromegaly after a sustained period of control of their thyrotoxicosis by thioamide therapy received subtotal thyroidectomy or radioiodine therapy for control of their thyrotoxicosis. Recognition of these factors at the time of diagnosis should permit earlier selection of the most suitable treatment and expedite patient care. Subtotal thyroidectomy has a low morbidity and is effective treatment for thyrotoxicosis in adolescence and childhood.

Aneurysms of the hepatic artery.

Aneurysms of the hepatic artery are rare and, when symptomatic, they may present a triad of upper abdominal pain, gastrointestinal bleeding, and obstructive jaundice. Asymptomatic and unsuspected aneurysms are demonstrated occasionally by abdominal arteriography or are encountered infrequently during abdominal operation for an unrelated disease. Hepatic artery aneurysms have great potential for rupture with bleeding into the peritioneal cavity, the common bile duct, or an adjacent hollow viscus. Morbidity and mortality with a ruptured aneurysm are high, and aggressive and imaginative operative therapy is required. Patients with an asymptomatic aneurysm should have operation to prevent subsequent rupture and hemorrhage.

Gastrocutaneous fistula following radiation therapy for seminoma of the testis.

A case presentation of a gastrocutaneous fistula following orthovoltage radiotherapy for prophylactic lymph node sterilization for seminoma of the testis is recorded. Many factors determine the response of an organ to radiation and with certain circumstances irreversible damage ensues. The pathologic effects of radiation on the stomach in the reported patient illustrates two stages of injury, acute and chronic. The insidious course of chronic injury eventually destroyed gastric and abdominal wall tissue to create a gastrocutaneous fistula 45 months after radiotherapy. Radiation therapy is a critical therapeutic modality in the treatment of neoplastic diseases and should be carefully administered with close followup of patients for acute and latent radiation effects.