Parathyroidectomy in the elderly: do the benefits outweigh the risks?

Although the incidence of hyperparathyroidism (HPT) in the elderly exceeds 1.5%, limited resources and co-morbidity inhibit referral for parathyroidectomy. To determine the risks and benefits of surgery, we examined the outcomes of elderly patients who underwent exploration for primary HPT. Data from 211 consecutive patients who underwent parathyroidectomy by one surgeon at the Johns Hopkins Hospital between August 1990 and May 1996 were recorded prospectively. Of these patients, 184 had primary HPT. Demographic and outcome data of elderly patients (> 70 years of age) (n = 36) were compared to those from younger patients (< 70 years of age) (n = 148). Preoperative symptoms of mental impairment, bone disease, and fatigue were more common in elderly patients (p < 0.05), and nephrolithiasis was more frequent in younger patients (p < 0.025). Elderly patients presented with more advanced disease, manifested by higher preoperative parathyroid hormone levels (301.9 +/- 63.3 vs. 169.2 +/- 14.3 pg/ml, p < 0.05). The cure rate (94.4%), morbidity (5.5%), and mortality (0%) in the elderly were indistinguishable from those of their younger cohorts (98%, 1.4%, and 0%, respectively). In conclusion, the more advanced disease seen in the elderly suggests that they are referred for surgery with a higher threshold than younger patients. Although several series of parathyroidectomy in elderly patients have reported high morbidity rates, significant mortality, and long length of stay (LOS), we found that parathyroidectomy in these patients can be performed with high cures, low morbidity, no mortality, short LOS, and high patient satisfaction. These data suggest that the benefits of surgery outweigh its risks and argue for a lower threshold for referral of elderly patients with primary HPT for surgical treatment.

Hürthle cell neoplasms of the thyroid: are there factors predictive of malignancy?

OBJECTIVE: To determine if any preoperative or intraoperative factors can reliably predict malignancy in patients with Hürthle cell neoplasms. SUMMARY BACKGROUND DATA: Most experienced surgeons recommend total thyroidectomy for Hürthle cell carcinomas and reserve thyroid lobectomy for Hürthle cell adenomas. However, delineation between Hürthle cell adenoma versus carcinoma often cannot reliably be made either before or during surgery. METHODS: Medical records from 57 consecutive patients who underwent thyroid resections for Hürthle cell neoplasms between October 1984 and April 1995 at The Johns Hopkins Hospital were analyzed to determine if any factors were predictive of malignancy. RESULTS: Of the 57 patients with Hürthle cell neoplasms, 37 had adenomas and 20 had carcinomas, resulting in a 35% prevalence of malignancy. Patients with adenomas did not differ from those with carcinoma with respect to age, sex, or history of head and neck irradiation. However, patients with Hürthle cell carcinomas had significantly larger tumors (4.0 +/- 0.4 cm vs. 2.4 +/- 0.2 cm, p < 0.005). Furthermore, although the incidence of malignancy was only 17% for tumors 1 cm or less and 23% for tumors 1 to 4 cm, tumors 4 cm or greater were malignant 65% of the time (p < 0.05). Both fine-needle aspiration and intraoperative frozen section analysis had low sensitivities in the detection of cancer (16% and 23%, respectively). With up to 9 years of follow-up, there has been no tumor-related mortality. CONCLUSIONS: These data demonstrate that the size of a Hürthle cell neoplasm is predictive of malignancy. Therefore, at the time of initial exploration for large Hürthle cell neoplasms (>4 cm), definitive resection involving both thyroid lobes should be considered because of the higher probability of malignancy.

Laminar air flow versus reverse isolation: nurses' assessments of moods, behaviors, and activity levels in patients receiving bone marrow transplants.

PURPOSE/OBJECTIVES: To compare nursing assessments of moods, behaviors, and activity levels of patients receiving bone marrow transplants (BMTs) according to type of isolation environment. DESIGN: Retrospective, descriptive. SETTING: University BMT unit. SAMPLE: Records of 22 patients receiving BMT treated over a two-year period-12 were treated in laminar air flow (LAF) rooms and 10 in reverse isolation. METHODS: Using a retrospective chart review, daily nursing assessments of patients' moods, behaviors, and activity levels were collected and compared based on type of isolation. MAIN RESEARCH VARIABLES: Type of isolation and patient's behavior, mood, and activity level. FINDINGS: Patients assigned to LAF had significantly higher anxiety levels at admission than those assigned to reverse isolation. CONCLUSIONS: Admission to LAF isolation appeared to be more anxiety-provoking than admission to reverse isolation; however, this finding needs to be replicated in a study with a prospective design using standardized psychosocial assessment. Findings are consistent with the evidence that patients view isolation as a temporary inconvenience rather than a major stressor. IMPLICATIONS FOR NURSING PRACTICE: Future research is needed. Preparing patients for isolation can include tours, educational materials, and explanations of procedures and events. Physical contact, even through gloves, can impart warmth and caring in the isolation environment.

Relationships between oral mucositis and treatment variables in bone marrow transplant patients.

The pattern of oral mucositis and related treatment variables was studied in 20 bone marrow transplant patients. Patients received either total body irradiation (TBI) or busulfan in combination with cyclophosphamide and etoposide as pretransplant conditioning. Daily oral assessment scores were analyzed. Mucosal changes began approximately 2 days before transplant and peaked approximately 8 days after transplant. There was a trend for patients receiving TBI to have slightly higher oral scores during the first week posttransplant than patients receiving busulfan. The TBI patients averaged almost twice the number of days of continuous intravenous morphine infusion for oral pain and 6 additional days of total parenteral nutrition when compared with patients receiving busulfan. Subjects who died during aplasia manifested mucositis that gradually worsened and did not return to baseline. Differences in oral status based on type of transplant, either autologous or allogeneic, were not shown in this study.