Thoracoscopic removal of mediastinal hyperfunctioning parathyroid glands: personal experience and review of the literature.

BACKGROUND: The presence of a mediastinal hyperfunctioning parathyroid gland is a rare condition that occurs in about 1% to 2% of cases. We present our experience with video-endoscopic parathyroidectomy and a review of the literature. METHODS: In seven patients (four male, three female; age 28-67 years) mediastinal hyperfunctioning parathyroid glands were removed by the thoracoscopic route (VATS). Six patients suffered from primary hyperpathyroidism and one woman from recurrent secondary hyperparathyroidism. Additionally, articles concerning endoscopic treatment of mediastinal parathyroid glands were collected from the medical databases. A total of 58 patients were found in the English and French literature. RESULTS: Neither intraoperative nor postoperative complications occurred in our patients. Operating time was 90 minutes (range 40-180 minutes). After a mean follow-up of 29+/-12 months (range 3-64), all patients are biochemically cured. The cases in the literature showed healing in 57 of 58 cases. Their mean operating time was 112 minutes (range 40-240 minutes). One perioperative death due to myocardial infarction and a major complications rate of 7% are described. CONCLUSION: The thoracoscopic approach to mediastinal parathyroidectomy is a safe, feasible technique with a low complication rate and good cosmetic outcome. It should become the standard surgical access for mediastinal hyperfunctioning parathyroid glands.

Triiodothyronine, thyroxine, and TSH response to dexamethasone in depressed patients and normal controls.

In view of recent investigations concerning alterations of thyroid function in depression, the pre- and postdexamethasone levels of T3, T4, and TSH of 14 patients during depression and after recovery were studied, in addition to those of 27 healthy controls. A reduction of T3 and TSH levels was shown to be dependent on the depressive state, with a tendency to lower T4 levels after recovery. Dexamethasone had a pronounced suppressive effect on TSH levels in healthy controls and in patients after recovery, but not during the depressive episode. These results point to an inadequate suppressibility of the hypothalamo-pituitary-thyroid (HPT) axis to dexamethasone during depression. There are close interrelations between the hypothalamo-pituitary-adrenal (HPA) and the HPT axes that are possibly affected during depressive illness.

[Reversible functional disorders of the intestinal tract caused by abdominal radiotherapy]. / Reversible Funktionsstörungen des Intestinaltraktes durch abdominelle Strahlentherapie.

In 20 patients with malignancies receiving abdominal radiotherapy, tests for disturbed intestinal functions were performed at the beginning and at the end of the therapy and after 6 to 12 month following radiation. Four noninvasive tests were performed: 75Se-homotaurocholate (75SeHCAT) test for estimation of bile acid malabsorption; Schillings test for quantification of vitamin B12 absorption; H2-breath analysis before and after a test meal containing lactose as a parameter of lactose malabsorption; and 51Cr-EDTA test for estimation of intestinal permeability. Both bile acid and vitamin B12 absorption decreased significantly towards the end of abdominal radiotherapy in more than 50% of patients. Only one patient developed lactose malabsorption. After 6 to 12 month, these abnormalities had completely disappeared. In contrast, small intestinal permeability did not increase during radiotherapy but was significantly elevated 6 to 12 month following treatment as the only indication of chronic injury of small intestinal mucosa. During radiotherapy, a significant correlation existed between the severity of diarrhea and the degree of bile acid malabsorption.

Can the outcome after trauma or sepsis be predicted from biochemical or hormonal parameters?

The severity of shock of 36 surgical ICU patients was classified using the Injury Severity Score (N = 20) and the Sepsis Score (N = 16). A great number of laboratory parameters were repeatedly determined on 5 days following the trauma or the onset of septic symptoms. Blood lactate, C-peptide, BUN, osmolality, and thyroid hormones were most closely related to the severity of the disease. This correlation was, however, less pronounced in the trauma than in the septic patients. Lactate and thyroid hormones showed a typical course in the non-survivors and may therefore be valuable as prognostic indices.

[Autologous replantation of spleen particles--an established procedure? An opinion]. / Die autologe Replantation von Milzpartikeln--ein etabliertes Verfahren? Eine Stellungnahme.

Autologous splenic replantation after splenectomy for trauma is generally recommended in order to prevent postsplenectomy sepsis. Several aspects, however, make this method uncertain: The extent of splenosis induced is not to be predicted. Even if the whole spleen is replanted, the resulting mass may not exceed splenosis, which sometimes develops spontaneously after sole splenectomy. But patients with extended splenic regenerates do not differ from those without any splenosis, considering various immunologic parameters. Postoperative complications after splenic replantation (abscess, intestinal occlusion) are possible, although they may be rare. Fatal cases of postsplenectomy sepsis despite massive splenosis are known. The most important reasons apparently are the altered vascularity and scarring in splenic regenerates. There is no specific test for immunological splenic function. Therefore there is no test to judge the success of replantation, too. Overall, the preservation of the spleen and the vaccination of splenectomized individuals are the most important surgical intentions.

The nonspecific clearance function of the reticuloendothelial system in patients with immune complex mediated diseases before and after therapeutic plasmapheresis.

The nonspecific clearance function of the reticuloendothelial system (RES) in six patients with immune complex mediated systemic vasculitis was determined by the evaluation of the disappearance rate of technetium 99m labelled microaggregated human serum albumin colloid (MHAC) injected IV before and after therapeutic plasma exchange. Three patients with systemic lupus erythematosus (SLE) and one patient with immune complex vasculitis (ICV) exhibited a significant clinical improvement after plasmapheresis which was paralleled by an accelerated MHAC elimination rate following plasma exchange therapy. One patient with ICV and unresponsive to plasma exchange showed delayed MHAC elimination. In one patient with myasthenia gravis (MG), the elimination rate was not altered by plasmapheresis. The data obtained indicate that nonspecific clearance of the RES may be one effect of plasma exchange therapy in patients with immune complex mediated diseases.

[Results of scintigraphic studies with 131I-meta-benzylguanidine in space-occupying lesions of neuroectodermal origin]. / Ergebnisse szintigraphischer Untersuchungen mit 131J-meta-Benzylguanidin (MIBG) bei Raumforderungen neuroektodermaler Herkunft.

Between 1982 and 1984, 48 studies with 131I-meta-benzylguanidine were carried out in Erlangen in patients with suspected pheochromocytoma or neuroblastoma. Scintigraphy with MIBG was found to be highly specific. False positive findings can be avoided if with weak uptakes an exact correlation with the results of morphological studies such as CT or sonography is sought and if follow-up observations ensure that they are not caused by activity residues in the biliary, intestinal or urinary pathways. False negative findings are made in 5-10% of the investigations in pheochromocytoma and in 41% of those in neuroblastoma patients. In pheochromocytoma the uptake rates are generally low (1-2%), whereas in neuroblastoma they may reach 10% and more.

[Combined bone marrow and skeletal scintigraphy in osseous and myelogenous diseases]. / Kombinierte Knochenmark- und Skelettszintigraphie bei ossären und myelogenen Erkrankungen.

In 87 patients with proved diagnosis and a normal or pathologic bone scan (BS) in addition a bone marrow scan (BMS) was performed using a 99mtechnetium-labelled microcolloid. The analysis of scintigraphic findings included those obtained by other investigations shows that in these selected patients a false normal or false positive interpretation would have been resulted in 18% performing the BS only. Both methods BS and BMS were capable of diagnosing the correct stage of disease in all patients. The results indicate an augmentation of diagnostic facilities by the BMS in diseases affecting bone or bone marrow.

[Interdisciplinary diagnosis of choledochus cysts]. / Interdisziplinäre Diagnostik von Choledochuszysten.

Cystic dilatations of the biliary tract are rare anomalies. In the individual case, diagnosis may pose great problems. The relevance of the various methods was assessed in eight patients investigated with different diagnostic methods. In all patients the predominant symptom was uncharacteristic upper abdominal complaints. Two patients showed intermittent jaundice. Among non-invasive methods sonography is preeminent and permits precise demonstration of intra- and extrahepatic biliary duct dilatations. It can be complemented by CAT-scanning. Whereas intravenous cholegraphy does not permit sufficient ascertainment of the diagnosis, ERCP and PTC allow precise demonstration of the anomaly. Functional hepatobiliary scanning is indicated where endoscopic methods are not available. Among the eight patients sonography was decisively relevant in five cases and ERCP in all cases. The remaining functional assessments furnished important additional informations.

Increased serum concentration of free L-triiodothyronine in patients treated with L-thyroxine.

This study demonstrates that in spite of measured normal concentrations of carrier proteins one cannot deduce in all cases a normal fT3 from a normal level of TT3 when l-thyroxine given for diagnostic or therapeutic purposes is present in excess. The displacement of l-triiodothyronine from its binding sites is shown in 35 patients with non-toxic goitre who received an oral dose of 200 micrograms l-thyroxine/die for two weeks. Apart from a significant increase of TT4 (from 7.85 to 14.21 micrograms/dl equal + 81%) and of fT4 (from 1.58 to 3.7 ng/dl equal + 134%) there is only a slight increase in TT3 from 148 to 158 ng/dl (equal + 10%) after 14 days of treatment. By contrast fT3 rises clearly from 4.97 to 8.07 pg/ml equal + 63% (normal range: 2.8-5.6 pg/ml). Compared with the increase of TT3 (+ 10%) the free T3 rises by a factor of 6.3 (63%/10%). On account of higher affinity of l-thyroxine to binding proteins the free T4 is influenced to a lesser degree. Compared with the increase of TT4 (+ 81%) free T4 rises by a factor of 1.6 (134%/81%). It is supposed that the serum concentration of free T3 can be increased despite a normal concentration of TT3 when l-thyroxine is present in excess. Therefore, for laboratory work fT3 should be assigned a higher validity than TT3 when patients are treated with comparatively high doses of l-thyroxine.

Intracystic radiotherapy (90Y) of craniopharyngiomas: CT-guided stereotaxic implantation of indwelling drainage system.

An indwelling drainage system for percutaneous drainage and radiotherapy of cystic craniopharyngiomas is described. The catheter is implanted into the cyst stereotaxically with a computed tomography-guided targeting device and connected to a Rickham reservoir. In addition to the repeated percutaneous evacuation of the cysts, this closed system enables intracavitary radiotherapy (yttrium-90) without the risk of leakage of the radioactive material into the cerebrospinal fluid spaces. The technique and relevant literature are discussed, and three typical cases are described.

Immunomodulating properties and tissue distribution of aromatic retinoids in the immunologically responsive albino rabbit eye.

The effects of retinoid Ro 10-9359 no normal albino rabbit eyes and antigen-induced intra-ocular inflammations were investigated. The distribution pattern of intravenously applied 3H--Ro 10-9359 correlated well with the sites of pharmacological action. Whereas immunologically naive rabbits showed a uveal uptake of 0.164 ng/g wet wt. tissue when 100 micrograms of Ro 10-9359 was administered intravenously, accumulation may amount up to 17.46 ng/g in secondary ocular immune responses. Ro 10-9359 accumulated markedly during secondary stimulation in the uvea, preauricular lymph nodes and the spleen. The chemotactic peptide NForm-Leu-Leu-Phe used to incite a hypopyon attracted Ro 10-9359 into the anterior chamber in vivo. This study indicates that the aromatic retinoid Ro 10-9359 is able to alter certain immune responses and may be involved in intercellular communication during secondary immune responses in the albino rabbit eye.

[Intrinsic value of a radioimmunologic TSH assay]. / Alleinige Aussagekraft der radioimmunologischen TSH-Bestimmung.

TSH-measurements in plasma as a single parameter for the evaluation of thyroid status need a highly sensitive radioimmunoassay, hitherto not available from commercial sources. The results, however, of such an assay allow to distinguish satisfactorily between suppressed, partially suppressed and normal regulation as well as overstimulation of the thyroid. For several indications, the TRH-test could be replaced by a basal TSH-value. Suppressed regulation without measurable TSH-levels is not to be identified automatically with clearcut hyperthyroidism because of several disturbing factors to be considered in clinical circumstances. Normally the positive TRH-test includes basal TSH-levels between 0.5 and 5 microunits/ml thereby excluding significant hormone excess as a possible cause of clinical signs of hyperthyroidism; however, some exceptions do exist (TSH-secreting pineal tumors; partial TSH-resistance of the hypophysis; crossreacting immunoglobulins after microbial vaccination) and should be considered in case of conflicting results. From a clinical point of view a highly sensitive TSH-RIA would be very interesting but would require the use of most recent technologies.

[Early recognition of potential hyperthyroidism in endemic goitre areas (author's transl)]. / Früherkennung potentieller Hyperthyreosen im Struma-Endemiegebiet.

Equal amounts of autonomous thyroid tissue were found with the same frequency before and after 40 years of age in eumetabolic patients in endemic goitre areas. A tentative diagnosis of thyroid autonomy can be made already in euthroid patients with an 80% accuracy by combined estimation of an equivalent of free thyroxine and iodine uptake. The equivalent is taken from determination of thyroid pertechnetate uptake by quantitative scan evaluation. Proof of autonomy is established by the suppression test which in a prolonged fractionated form also permits estimation of the amount of functioning autonomous tissue. There is a linear correlation of technetium thyroid uptake after suppression and the volume of autonomous thyroid tissue. As free thyroxine increases after iodine intake of sufficient amount and duration in proportion with the volume of autonomous tissue, prognosis appears possible: patients with autonomous thyroid tissue above a "critical" volume can be expected to develop hyperthyroidism in case of sufficient iodine uptake. Iodine salt prophylaxis however does not induce hyperthyroidism in patients below 50 years of age provided that the daily additional iodine intake does not exceed 100 micrograms.

[Early recognition of autonomous thyroid tissue by a combination of quantitative thyroid pertechnetate scintigraphy with the free T4 equivalent (author's transl)]. / Früherkennung der thyreoidalen Autonomie durch Kombination von quantitativer Szintigrammauswertung mit einem Aquivalent des freien T4.

Autonomously functioning thyroid tissue (AFTT) of the circumscribed as well as the disseminated form was found with equal frequency and extent in eumetabolic patients under and over 40 years of age who live in an endemic goitre area. In an area of iodine deficiency this is the most frequent precondition for hyperthyroidism induced by iodine administration. A suspicion of AFTT can be raised in 80% of still euthyroid patients by a combined evaluation of an equivalent to the free T4 (FTE) and an equivalent to the clearance using a quantitative evaluation of the thyroid technetium scan (TcTU). The suppression test not only confirms the autonomy in a qualitative manner but also provides an estimate of the volume of autonomous tissue because the TcTU after suppression strictly correlates linearly with the volume of the AFTT. Since after iodine administration FTE increases proportionally to the volume of AFTT, the procedure can be of some prognostic value: those with autonomous tissue in excess of a "critical" volume will almost certainly develop hyperthyroidism following a certain minimum rate of iodine administration. A prospective study of patients under age 50 whose thyroids contained various amounts of AFTT has shown that prophylactic dietary iodine supplementation will not cause hyperthyroidism to develop provided the additional iodine intake does not exceed 100 micrograms per day.