"Body packers" in Israel: a case series.

BACKGROUND: "Body packers" swallow multiple packets filled with illicit drugs, mainly cocaine, in order to smuggle them across international borders. In recent years, an increasing number of body packers have been hospitalized after their detention by the police upon arrival in Israel. OBJECTIVES: To characterize the clinical features and outcomes of body packers hospitalized at the Sheba Medical Center. METHODS: We conducted a retrospective case series of body packers hospitalized between January 2010 and October 2012 in our medical center. Electronic medical records and imaging files were reviewed to extract clinical, laboratory and radiological data as well as details on medical treatments. RESULTS: We identified 23 body packers (mean age 38 +/- 10 years), 20 of whom smuggled cocaine from South America. The number of packets transported ranged from 1 to 242 (median 42) and duration of hospitalization from 1 to 14 days (median 2). Two subjects required surgical intervention. All others were treated conservatively by polyethylene glycol-electrolyte lavage solution, laxatives, or watchful waiting. Ten patients underwent a urinary screen for illicit drugs, 7 of whom tested positive for cocaine and 2 for cannabinoids. Abdominal X-rays were performed in all patients at admission, and 14 had follow-up imaging, including abdominal CT scans without contrast media in 8. CONCLUSIONS: The main treatment goals for body packers are the rapid excretion of drug packets and early detection of complications, i.e., drug intoxication and bowel obstruction. We suggest the use of a structured treatment approach for the in-hospital management of body packers.

Missense mutation in the MEN1 gene discovered through whole exome sequencing co-segregates with familial hyperparathyroidism.

Familial isolated hyperparathyroidism (FIHP) can be encountered in the context of multiple endocrine neoplasia type 1 (MEN1), hyperparathyroidism and jaw tumour syndrome (HPT-JT) and in familial hypocalciuric hypercalcaemia (FHH). In these syndromes, germline mutations in the relevant genes (MEN1, HPRT2 and CaSR, respectively) are detected. In some FIHP cases, the causative gene is still elusive. The objective of this study is to define the genetic basis of FIHP in a Georgian Jewish family with FIHP using whole exome capture and sequencing. DNA extracted from two sibs and one offspring from a single family all affected with multiglandular hyperparathyroidism was subjected to whole exome capturing and sequencing using the Roche NimbleGen V2 chip and the Illumina HiSeq2000 sequencing platform. Genetic variants were detected and annotated using a combination of the Genome Analysis Tool Kit and in-house scripts. Subsequent confirmation of the mutations and co-segregation analyses were carried out by Sanger sequencing in additional affected and unaffected family members. Whole exome capture and sequencing revealed the collection of variations common to the three-sequenced patients, including a very rare previously described missense mutation (c.T1021C: p.W341R) in the MEN1 gene. The p.W341R mutation in the MEN1 gene showed complete co-segregation in the family. Whole exome capture and sequencing led to the discovery of a missense mutation in the MEN1 gene and ruling out of the additional candidates in a single experiment. The limited expressivity of this mutation may imply a specific genotype-phenotype correlation for this mutation.

Differences in heart rate profile during exercise among subjects with subclinical thyroid disease.

BACKGROUND: Clinical thyroid disease is associated with changes in the cardiovascular system, including changes in heart rate during exercise. However, data on the relation between subclinical thyroid disease (SCTD) and heart rate during exercise are limited. METHODS: We investigated 3799 apparently healthy subjects who were evaluated in the Institute for Preventive Medicine at the Sheba Medical Center. All subjects answered standard health questionnaires; were examined by a physician; completed routine blood tests including thyrotropin, free triiodothyronine, and free thyroxine levels; and underwent a treadmill exercise according to the Bruce protocol. Subjects with known thyroid disease or those who were taking thyroid-related drugs were excluded from the analysis. Heart rate profile was compared between patients with subclinical hypothyroidism (SCHypoT), patients with normal thyroid function, and patients with subclinical hyperthyroidism (SCHyperT) using propensity score matching. RESULTS: Seventy patients had SCHyperT and 273 had SCHypoT. Compared with age- and sex-matched normal subjects, SCHyperT subjects had a higher resting heart rate (83±17 vs. 76±12 beats per minute [bpm], p=0.006), a significantly higher recovery heart rate (94±12 vs. 90±12 bpm, p=0.045), and a significantly lower heart rate reserve (80±20 vs. 87±18 bpm, p=0.006). Subjects with SCHypoT showed a trend toward a lower resting heart rate (75±13 vs. 77±15 bpm, p=0.09) and had a significantly lower recovery heart rate (88±12 vs. 90±13 bpm, p=0.035). There was no significant difference in exercise duration or blood pressure between subjects with SCTD and their matched normal controls. CONCLUSIONS: Subjects with SCTD have a significantly different heart rate profile during rest, exercise, and recovery.

The association between serum uric acid and diabetes mellitus is stronger in women.

OBJECTIVE: Previous studies have demonstrated an association between increased serum uric acid (SUA) levels and incident diabetes. Most clinical and epidemiological investigations, however, focused solely on male populations or did not analyze men and women separately. We assessed the association between SUA levels and diabetes incidence in a large cohort of apparently healthy men and women. METHODS: Data were retrospectively gathered from 9140 adults who participated in annual medical screening visits during 2000-2009. Mean follow-up time was 4.8 years, and the median age was 50 years. Laboratory test results, data from physical examinations, medical history, and lifestyle information were extracted. The main outcome measure was incident diabetes, defined as two consecutive fasting glucose tests higher than 125 mg/dL. Cox proportional-hazards multivariate models were applied for measuring hazard ratios (HRs) for diabetes according to continuous and categorical levels of uric acid. RESULTS: We identified 499 new cases of diabetes (total, 5.5%: men, 6.2%; women, 3.6%) during the follow-up period. The gender-specific HRs for diabetes, adjusted for age and a set of prespecified multiple risk and protective factors, were 1.57 for each 1 mg/dL increase in SUA (95% confidence interval [CI], 1.32-1.86) in women and 1.08 (95% CI, 0.99-1.17) in men; p for interaction of SUA by gender <0.001. CONCLUSION: SUA is independently associated with diabetes outcome, considerably more in women than in men.

Association of serum uric acid and cardiovascular disease in healthy adults.

Studies in different populations with high risk for cardiovascular disease (CVD) have shown an association between serum uric acid (SUA) and CVD. However, only a few studies have demonstrated such an association in healthy populations. The aim of this study was to investigate the association between SUA and CVD in a cohort of men and women without diabetes or CVD. A retrospective study was conducted, with a mean 4.8-year follow-up. The outcome was the occurrence of a cardiovascular event, defined as the diagnosis of ischemic heart disease, acute coronary syndrome, acute myocardial infarction, or ischemic stroke. Mean SUA levels were 6.2 ± 1.1 mg/dl for men (n = 6,580) and 4.4 ± 1.1 mg/dl for women (n = 2,559). For women, the rate of CVD occurrence was 11.6% for the highest quartile of SUA level, compared with 5.0% to 6.5% for the lower 3 quartiles. For men, the rate of CVD occurrence was 14.0% for the highest quartile of SUA level, compared with 10.8% for the lowest quartile. The hazard ratio for CVD, adjusted for age, serum creatinine level, body mass index, systolic blood pressure, low-density lipoprotein cholesterol level, triglyceride level, plasma fasting glucose, physical activity, cardiovascular family history, use of diuretics, and current smoking, was 1.24 (95% confidence interval 1.08 to 1.41) for women and 1.06 (95% confidence interval 1.00 to 1.13) for men (p for interaction = 0.04). In conclusion, the strong association of SUA levels with CVD in women, compared with the much lesser degree in men, highlights the necessity of stratifying by gender in investigations of cardiovascular risk factors and supports exploration of SUA as a marker of CVD risk in healthy populations.

Kikuchi-Fujimoto disease.

BACKGROUND: Kikuchi-Fujimoto disease is a benign and self-limited disease, first reported in Japan in 1972. The characteristic features of this disorder include lymphadenopathy and fever. OBJECTIVES: To summarize our experience with Kikuchi disease with regard to clinical manifestations and outcome. METHODS: The patients included in the study were those diagnosed with Kikuchi disease during the years 2005-2008 in two departments of internal medicine at Sheba Medical Center. RESULTS: We identified five patients with Kikuchi disease; four were women and the mean age was 22.6 years. All the patients had cervical lymphadenopathy; three had other sites of lymphadenopathy. Four of the patients had fever higher than 39 degrees C. Two of them had splenomegaly and three reported weight loss. Three of the five patients experienced a relapse of the disease and were treated with steroids or non-steroidal anti-inflammatory agents. The diagnosis was confirmed in all the patients by an excisional biopsy of lymph node. CONCLUSIONS: Kikuchi disease must be considered in every young patient with fever and lymphadenopathy. The disease usually has a benign course.

Efficacy of long-term lanreotide treatment in patients with acromegaly.

We investigated the effectiveness of lanreotide for the treatment of active acromegaly in a retrospectively multicenter case series including 53 patients (24 male, 29 female; mean age at diagnosis, 49.5 +/- 13.9 years) with acromegaly treated with lanreotide in nine different centers. Mean tumor diameter was 20 +/- 13 mm; mean basal levels of growth hormone (GH) and insulin-like growth factor I (IGF-I) were 21.3 +/- 26.3 and 579 +/- 177 mug/l, respectively. The primary mode of treatment was surgery in 70% of patients. Twenty-nine patients received only lanreotide (Prolonged Release, Autogel), whereas 24 subjects were also treated with octreotide at another treatment stage. Primary therapy with lanreotide was administered in five patients. Maximal monthly dose of lanreotide Autogel (n = 44) was 60 mg in 45%, 90 mg in 26%, 120 mg in 21% and 180 mg in 8%. During 36 months of lanreotide treatment, mean IGF-I levels decreased from 443 +/- 238 to 276 +/- 147 mug/l (P < 0.001), and mean GH levels, from 5.2 +/- 6.4 to 3.2 +/- 3.0 mug/l (P < 0.001). IGF-I levels normalized in 51% of patients and decreased by >50% towards normal in 32%; the normalization rate was higher in women (65%) than men (33%, P = 0.04). Safe random GH levels (

Hepatitis C, B, and human immunodeficiency virus infections in illicit drug users in Israel: prevalence and risk factors.

BACKGROUND: Infections with blood-borne viruses are a major health problem among illicit drug users. There is little information about infection rates and risk factors for hepatitis virus B, C or the human immunodeficiency virus in drug users in Israel. OBJECTIVES: To determine the prevalence of HCV, HBV and HIV infections in a large cohort of drug users in Israel; to compare rates of HCV, HBV and HIV between injecting versus non-injecting drug users and between different countries of origin; and to identify risk factors for HCV among illicit drug users. METHODS: We conducted a cross-sectional study using an interviewer-administered questionnaire and serological screening for HCV, HBV and HIV in 1443 consecutive drug users diagnosed at the Israeli National Center for Diagnosis of Drug Addicts between January 2003 and December 2005. RESULTS: Fourteen (0.9%), 51 (3.5%) and 515 (35.7%) subjects tested positive for HIV, HBV and HCV, respectively. All three infections (HIV, HBV and HCV) were significantly more common among injecting drug users and immigrants from the former Soviet Union and other East European countries compared to native Israelis. Multivariate analysis showed that HCV infection was associated with age (> 40 years) (OR=2.06, 95% CI 1.40-3.03), immigration from East European countries and the former Soviet Union (OR=4.54, 95% CI 3.28-6.28), and injecting drug use (OR=16.44, 95% CI 10.79-25.05). CONCLUSIONS: HIV, HBV and HCV prevalence among drug users in Israel is significantly lower than in North America and West Europe. Risk factors for HCV infection in this population include injecting drug use, older age, and immigration from the former Soviet Union.

Cytomegalovirus-associated colitis causing diarrhea in an immunocompetent patient.

Cytomegalovirus (CMV) colitis rarely occurs in immunocompetent patients. We report a case of disabling and life threatening diarrhea in an immunocompetent elderly woman due to CMV colitis. The diagnosis of CMV was based on histological examination of tissues biopsied at colonoscopy, positive CMV antigen and high CMV-IgM titer in peripheral blood samples and a good response to systemic gancyclovir treatment. We conclude that CMV should be considered in the differential diagnosis of colitis in elderly immunocompetent patients.

Low-dose recombinant human thyrotropin-aided radioiodine treatment of large, multinodular goiters in elderly patients.

OBJECTIVE: We aimed to assess low-dose recombinant human thyroid-stimulating hormone (rhTSH)-aided, fixed-activity radioiodine therapy of large, multinodular goiters (MNGs) in elderly patients with comorbidities. DESIGN: This was a short-term, observational study. METHODS: We measured 24-h thyroid radioiodine uptake (RAIU) of 2 microCi 131-iodine at baseline and 24 h after intramuscular injection of 0.03 mg rhTSH in 17 patients (aged 60-86 years, 12 women), who subsequently received 30 mCi 131-iodine 24 h after an identical rhTSH injection. TSH and free thyroxine (FT4) were measured at baseline and days 10, 30 and 90 after therapy. Thyroid volume was assessed by computed tomography at baseline and day 180. RESULTS: rhTSH, 0.03 mg, significantly increased mean 24-h thyroid RAIU from 25.8% +/- 10.3% to 43.3% +/- 8.4% (68% relative increase; t(16) = -8.43, P < 0.001). The proportion of patients overtly or subclinically hyperthyroid (TSH < 0.5 mU/l) decreased from 71% (12/17) at baseline to 19% (3/16) at 3 months. Mean serum FT4 peaked at slightly above normal range, 25.9 +/- 7.7 pmol/l (46% over baseline) and was 21% under baseline levels at 3 months. Mean estimated thyroid volume fell 34% from baseline to 6 months (170.0 +/- 112.8 to 113.1 +/- 97.5 ml; P < 0.01). Symptomatic relief, improved well-being, and/or reduction or elimination of antihyperthyroid medication were seen in 76% of patients. Three (18%) patients had transient neck pain or tenderness, or palpitations; one had transient asymptomatic thyroid enlargement; and three (18%) became hypothyroid by 3 months. CONCLUSIONS: Intramuscular rhTSH, 0.03 mg, followed 24 h later by 30 mCi 131-iodine, is a safe, effective and convenient treatment for MNG in elderly patients with comorbidities.

Simultaneous deep vein thrombosis and transverse myelitis with negative serology as a first sign of antiphospholipid syndrome: a case report and review of the literature.

Transverse myelitis is a rare manifestation of antiphospholipid syndrome, usually secondary to systemic lupus erythematosus (Rheum Dis Clin North Am 20:129-158, 1994). Only about 110 reports of this complication have been reported (Lupus 10:851-856, 2001). A connection has been demonstrated between positive serology for antiphospholipid and transverse myelitis (Lupus 8:109-115, 1999). Herein, we report of a young patient admitted with deep vein thrombosis and neurological manifestations of transverse myelitis with negative serology for systemic lupus erythematosus and antiphospholipid, who developed positive anticardiolipin antibody during pulse therapy with cyclophosphamide and methylprednisolone.

Osteoporosis health-related behavior among healthy peri-menopausal and post-menopausal Israeli Jewish and Arab women.

BACKGROUND AND AIMS: Health practices such as calcium-rich diet and exercise, are associated with the prevention of osteoporosis. Since studies showed that ethnic minorities are less involved in preventive practices, the aim of this study was to examine patterns and correlates of osteoporosis health-related behavior in Israeli-Jewish and Arab women. METHODS: Interviews were conducted with 261 women aged 45 and older (70% Jewish). Health behavior included: physical activity, smoking, alcohol consumption, use of hormone replacement therapy, screening behavior, calcium intake, pharmacological prevention, and help-seeking patterns. Correlates included demographic variables, health characteristics (menopausal status, family history of osteoporosis), knowledge about osteoporosis, and beliefs (susceptibility and worries about developing osteoporosis). RESULTS: Compared with Jewish participants, a lower percentage of Arab women engaged in physical activity, were on HRT, and had had bone density examinations. Their overall calcium intake was significantly lower as well. Levels of knowledge were moderate to low for the whole group, but more so among Arab women. Engaging in physical activities was associated with being menopausal and with having more knowledge among Jewish women, and with having more knowledge and lower rates of concern among Arab women. CONCLUSIONS: Expanding knowledge about osteoporosis may prove beneficial for increasing participation in preventive behavior in both groups. Special attention should be paid to different levels of education and to differences in subjects' needs and accessibility to sources of information.

Complex drug-drug-disease interactions between amiodarone, warfarin, and the thyroid gland.

Many patients with cardiac arrhythmias require concomitant therapy with warfarin and amiodarone. Beyond the predictable pharmacokinetic drug-drug interaction requiring a significant warfarin dose reduction, the iodine-rich amiodarone affects the thyroid gland, causing overt hypothyroidism or thyrotoxicosis in 14%-18% of cases. In turn, thyroid disorders may affect warfarin sensitivity, with hypothyroidism and thyrotoxicosis resulting in increased or decreased warfarin requirements, respectively. We describe 3 patients on concomitant amiodarone and warfarin who developed amiodarone-induced thyrotoxicosis heralded by a significant decrease in warfarin requirements. We review the literature on the mechanisms of the complex drug-drug and drug-disease interactions within the thyroid gland, warfarin, and amiodarone triad. Given that significant thyroid disorders may be only mildly symptomatic and thus may escape clinical detection, we suggest that thyroid function should be tested in any patient with otherwise unexplained changes in warfarin dose requirements, particularly if concomitantly treated with amiodarone.

Osteoporosis health-related behaviors in secular and orthodox Israeli Jewish women.

OBJECTIVE: To compare patterns of osteoporosis health-related behaviors in peri and postmenopausal ultra-orthodox and secular Jewish women. METHODS: Interviews were conducted with 277 Israeli-Jewish women aged 45+. Health behaviors examined included: physical activity, smoking behavior, alcohol consumption, hormone replacement usage, screening behavior, calcium intake, pharmacological prevention, and help-seeking patterns. Correlates included demographic variables, health characteristics, knowledge, susceptibility beliefs, and familiarity with the disease. RESULTS: Low proportions of women in both groups participated in physical activities, but differed in type. Calcium intake was deficient in both groups. Education was the only correlate of calcium intake among secular women, and previous experience with the disease was the main determinant among orthodox women. Compared with the secular group, a considerably lower proportion of orthodox women reported using HRT or having performed a bone density examination. Orthodox participants' level of knowledge about osteoporosis was significantly lower as well. Education was an important correlate of knowledge in both groups, as was having performed a bone density examination. Higher age and being menopausal were important correlates of knowledge only for secular women. Having a family member suffering from the disease was associated with higher levels of knowledge among orthodox women. Marked differences were found in the participants' sources of information across groups. CONCLUSIONS: Findings emphasize the need to expand education in all areas of osteoporosis health-related behaviors among ultra-orthodox women, and in calcium intake and exercise for secular women as well. The transmission of the information should be adapted to the practices of each group.

Comparison of oral vs intravenous phytonadione (vitamin K1) in patients with excessive anticoagulation: a prospective randomized controlled study.

BACKGROUND: Treatment of patients with excessive anticoagulation is routinely done by intravenous phytonadione (vitamin K1). Oral administration of phytonadione has been shown to be an effective alternative to the intravenous route, but these methods have never been compared directly. Our objective was to compare efficacy and safety of intravenous vs oral phytonadione treatment in patients with excessive anticoagulation without bleeding. METHODS: The study was a prospective randomized controlled trial of consecutive patients presenting with excessive anticoagulation without major bleeding. Patients with a baseline international normalized ratio (INR) of 6 to 10 (n = 44, 47 episodes) received either intravenous or oral phytonadione (0.5 mg or 2.5 mg, respectively), and patients with an INR greater than 10 (n = 17, 19 episodes) received 1 mg or 5 mg, respectively. Efficacy and safety end points were sequential INR changes and the proportion of patients achieving therapeutic range (INR, 2-4), overcorrection (INR<2.0), or undercorrection (INR>4.0) INR values. RESULTS: Sixty-six episodes of excessive anticoagulation were studied. In patients with baseline INR 6-10 the response to intravenous phytonadione was more rapid than in the oral group, and the proportion of patients reaching therapeutic range INR at 6 hours (11/24 vs 0/23) and at 12 hours (16/24 vs 8/23) was significantly higher. However, mean +/- SD INR values were similar for both groups at 24 hours (2.9 +/- 0.8 vs 2.6 +/- 0.8). Patients in the intravenous group tended to be more often (7/24 vs 2/23) overcorrected (INR<2). In patients with baseline INR values greater than 10 efficacy and safety were comparable for both routes of administration. CONCLUSION: Oral administration of phytonadione had similar efficacy and safety as intravenously administered phytonadione and may be suitable for treatment of patients with excessive anticoagulation.

Impact of pre-treatment INR level on the effect of intravenous low dose vitamin K in patients with excessive anticoagulation.

Administration of vitamin K is the common mode of treatment in excessively anticoagulated patients. However, patient's response to vitamin K varies, depending on the vitamin K dose and the route of administration. Another potential source of variation is the pre-treatment INR which has not been accounted for in most previous studies. In the present study the effect of baseline INR on the response to a single dose of intravenous vitamin K (0.5 mg) was studied in 95 episodes of excessively anticoagulated patients (n = 76). In 67 episodes of moderately excessive baseline INR (6-10) mean INR declined from 8.0 +/- 1.2 to 2.6 +/- 0.9 at 24 hours, 59/67 (88%) responding within the first 12 hours and not requiring a second dose. In contrast, in 28 episodes with highly excessive baseline INR (> 10) response was slower; mean INR declining from 13.6 +/- 2.7 to 4.0 +/- 2.1 at 24 hours. In 14/28 of these episodes, patients failed to respond to vitamin K in the first 12 hours and required a second vitamin K dose. We conclude that INR at presentation affects the response to vitamin K and that this INR value should be considered in determining appropriate vitamin K doses.

Focused, minimally invasive radio-guided parathyroidectomy: a feasible and safe option for elderly patients with primary hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism in elderly patients is usually associated with additional co-morbidity that increases operative risk, and thus many geriatric patients are denied the benefit of surgery for a single parathyroid adenoma. OBJECTIVES: To evaluate the safety and efficacy of accurate single photon emission computed tomography sestamibi scintigraphy, enabling precise localization of a single adenoma, in the geriatric population. METHODS: Twenty-two patients aged 70 years and over with biochemically proven PHPT and with a single parathyroid adenoma identified by localization studies (sestamibi SPECT scan and ultrasonography) underwent 23 operations over 29 months (out of a total of 140 patients operated upon during the same period). Immediate preoperative sestamibi scintigraphy and marking of focal adenoma uptake followed by intraoperative hand-held gamma probe were used for the removal of the parathyroid adenoma by unilateral minimal access surgery. Associated major co-morbid conditions and pre- and postoperative calcium, phosphorus and parathormone levels were recorded. Indications for surgery were listed and operative and postoperative complications were noted. The patients were followed for a mean period of 17.7 months using the same parameters. RESULTS: The 22 patients with PHPT had a mean age of 76.3 +/- 5.9 years (range 70-88 years) and a female to male ratio of 13:9. Associated co-morbidity included ischemic heart disease (n = 15), hypertension (n = 22), non-insulin-dependent diabetes mellitus (n = 9), chronic obstructive pulmonary disease (n = 3), and previous neck surgery (n = 3). Mean preoperative serum calcium, phosphorous and PTH were 11.7 +/- 1.3 mg/dl, 2.5 +/- 0.5 mg/dl and 160.9 +/- 75.4 pg/ml respectively. In 20 of the 22 patients, surgery was successful in curing PHPT (91%). One patient had persistent hypercalcemia due to a missed adenoma, and repeat operation (by focused minimal accesss surgery) was successfully performed 2 weeks later. There were no complications and no morbidity postoperatively. Mean postoperative serum calcium, phosphorous and PTH were 9.6 +/- 1.2 mg/dl, 3.0 +/- 0.5 mg/dl and 35.2 +/- 24 pg/ml respectively. In all patients, serum calcium levels remained normal (9.7 +/- 1.3 mg/ml) after long-term follow-up (mean 17.7 +/- 9.6 months). CONCLUSIONS: Minimally invasive, radio-guided focused parathyroidectomy for a single adenoma is a safe and effective method to cure hyperparathyroidism in the elderly. Success of surgery is directly related to the surgeon's experience and to the precise localization marking provided by sestamibi scintigraphic SPECT localization and concurrent sonographic findings.

[Novel approach to parathyroid adenoma: minimally invasive, focused, scan guided parathyroidectomy--experience from the first 100 cases].

BACKGROUND: Traditionally, the surgical approach to parathyroid adenoma included formal bilateral neck exploration, inspection and evaluation of all four glands. Recently, following progress in the precision of pre-operative localization by sonography and scintigraphy and the availability of a real time PTH assay, focused, minimally invasive approaches to the removal of a single adenoma were proposed. We review our experience in the first 100 cases. METHOD: After localization of the suspected adenoma by TC-99m-MIBI scintigraphy and neck sonography, a second scan was performed just before surgery and the presumed site was marked on the patients skin. Under general anesthesia, via a limited incision, the suspected adenoma was excised and examined by a frozen section. RESULTS: Between July 1999 and August 2001, 97 patients (64 females and 33 males, mean age; 56 +/- 14, range 19-88) underwent 100 focused, minimally invasive, MIBI guided parathyroidectomies (3 patients were operated on twice due to a residual second adenoma). Pre-operative blood levels of calcium and PTH were 11.5 +/- 0.8 mg/dl and 140 +/- 90 pg/ml, respectively. In 93 cases, an adenoma was identified and excised (mean weight, 600 mg, range, 100-4900). Mean operative time, including frozen section was 66 +/- 39 minutes. The patients were discharged on the same day or on POD 1 (mean calcium level 9 +/- 0.9 mg/dl) and had normal calcium levels at the follow-up tests. In 2 cases, the scan was falsely negative for adenoma (positive for other thyroid pathology), but the adenoma was successfully excised according to the sonographic localization (overall success rate in the primary procedure, 95%). In 3 cases, pathologically proven enlarged parathyroid was excised, as localized by the scan, but hypercalcemia relapsed. The patients were re-operated in a focused fashion and a residual second adenoma was found (N = 2), or underwent formal exploration for hyperplasia of the remaining 3 glands (N = 1). In 2 more cases, no parathyroid tissue was found in the specimen. However, consequently, calcium levels normalized after surgery (N = 1) and a successful focused re-operation was performed after relocalization (N = 1). There were no significant post-operative complications. CONCLUSIONS: Focused MIBI guided parathyroidectomy is safe and efficient in most patients. Failures, which may be the results of erroneous diagnosis (hyperplasia vs. adenoma, 1%), residual additional adenoma (2%) or a false positive scan due to pathology in the thyroid gland (2%), can be treated safely and effectively in a second focused procedure.

First-degree relatives of persons suffering from osteoporosis: beliefs, knowledge, and health-related behavior.

OBJECTIVE: The aim of the present study was to compare the beliefs, knowledge, and health-related behaviors of first-degree relatives (FDRs) of osteoporotic women with a comparison group of women not having a FDR with osteoporosis. RESEARCH DESIGN: Telephone interviews. PARTICIPANTS: Participants were 172 women (48 FDRs and 124 comparisons), recruited by a systematic sampling from the list of all women aged 40+ attending an outpatient screening program at a large tertiary medical center in Israel. METHODS: Information was collected regarding participants' perceived susceptibility to develop osteoporosis, perceived concerns, and perceived prevention optimism. Additionally, information was collected regarding knowledge about osteoporosis, and participation in screening and preventive behavior. RESULTS: Participants in the FDR group reported higher perceived susceptibility and higher concerns about developing the disease than participants in the comparison group. A higher proportion of FDRs reported engaging in screening behavior, but no differences were found in preventive behaviors. Screening behavior was associated with perceived concerns and age for members of the comparison group, and with age for FDRs. CONCLUSIONS: FDRs are characterized by greater perceived vulnerability and concerns. However, they are no more likely to engage in preventive behaviors or have more knowledge about the disease. These findings stress the importance of expanding efforts to increase the knowledge and awareness of at-risk persons.