[Clinical study on the treatment of differentiated carcinoma of the thyroid gland]. / Studio clinico sul trattamento del carcinoma differenziato della tiroide.

A study on 88 patients operated for a differentiated thyroid carcinoma (63 papillary and 25 follicular cancer) is reported. In 66 cases a total thyroidectomy was performed (in 16 associated with an ipsilateral lymphadenectomy), in 11 a subtotal thyroidectomy and in 11 a lobar isthmectomy. In the follow-up there were 3 deaths and 4 recurrences. Notwithstanding the limited number of cases, the Authors registered a worse diagnosis for the follicular carcinomas (2 deaths and 2 recurrences on 25) compared to the papillary (1 death and 2 recurrences on 63).

[The surgical treatment of primary hyperparathyroidism: clinical experience]. / Il trattamento chirurgico dell'iperparatiroidismo primitivo: esperienza clinica.

The primitive hyperparathyroidism (PHPT) constitutes still cause of discussion both from the diagnostic point of view and from the therapeutic one although surgical successes are generally reported. Between the most important problems there is the increase of the HPT asymptomatic or oligosymptomatic patients with the decisional difficulties in the timing of the surgical treatment and the difficult framing of the HLP disease associated with MEA and the relating surgical failures. Besides some authors support an unilateral dissection of the neck in patients with adenoma diseases diagnosed before the intervention against the traditional address of a bilateral exploration. Our experience is based on 31 patients subjected to intervention of parathyroidectomy for primitive HPT: 26 carriers of adenomas, of which 1 double, and 5 of diffused hyperplasia. We have effected 25 simple parathyroidectomy for adenoma, 1 resection of three parathyroid glands for double adenoma, 2 subtotal parathyroidectomy (7/8) for diffused hyperplasia. 2 patients had new surgical treatment for persistent hypercalcemia, and they were respectively carriers: 1 of a second ectopic adenoma and 1 of asymmetrical hyperplasia; 2 patients finally, operated in other hospitals had a second exploration and they were affected from MLP. In 26 patients we had very good results, in 2 persistence of hypercalcemia (patients who had a second look) and 3 hypocalcemia.

[Clinical experience in Hurthle cell tumors]. / Studio clinico sui tumori a cellule di Hürthle.

In the period 1987-1997 6 patients with Hürthle cell carcinomas and 4 patients with Hürthle cell adenomas underwent primary surgical treatment (8.1% of all thyroid carcinomas). The diagnosis of Hürthle cell tumor was based on the presence of more then 75% Hürthle cells and the malignity on capsular or/and vascular invasion. All the patients with Hürthle cell cancer underwent total thyroidectomy, in three cases with Hürthle cell adenoma thyroid lobectomy was performed and in one case total thyroidectomy. Follow-up time ranged from 1 to 8 years after surgery (mean 4.5 years). There was no death and no recurrence. The Authors have studied the nuclear DNA content in Hürthle cell tumors: 3 adenomas were euploid and 1 was aneuploid, 4 carcinomas were aneuploid and 2 were euploid. The results in Authors' study of the DNA content and nuclear DNA ploidy are not uniformly consistent enough to allow a distinction between benign and malignant neoplasms and to evaluate the prognosis, but the number of patients and the follow up are still too limited.

[Medullary carcinoma of the thyroid]. / II carcinoma midollare della tiroide.

Medullary thyroid carcinoma represents 4-8% of thyroid malignancies; regional nodal involvement is commonly found, even at the time of first surgical approach. In these patients after surgical resection, other therapeutic choices are really limited. The Authors evaluated their experience in the period 1981-1994, concerning 14 patients, 9 females and 5 males, all affected with sporadic MTC. Diagnosis was preoperative in 10 patients and intraoperative in 4; as for the staging: in 8 patients the tumor resulted confined to the thyroid, while in the remaining 6 patients it was extra-thyroidal. In 5 patients a total thyroidectomy with regional lymphadenectomy was performed, with in 6 patients a total thyroidectomy with cervico-mediastinic total lymphadenectomy was achieved. Survival was evaluated with a short, follow-up (3 months) and calculated using the K-Mayer method. Average survival was: 5 years in patients undergoing only total thyroidectomy; 3 years and 1 month in patients undergoing total thyroidectomy and lymphadenectomy; 6 months in patients undergoing no treatment at all. Among the factors negatively affecting patients survival, the Authors pointed out: metastasis occurrence; incomplete resection and mediastinal metastasis. In conclusion surgical resection (total thyroidectomy) associated with radical lymphadenectomy resulted to be a good approach. However, prognostic factors require further investigation.

[Gynecomastia]. / Ginecomastia.

Gynaecomastia is a benign enlargement of the male breast commonly occurring in healthy adolescent boys and in adults (50 to 80 years old). It is a source of cosmetic and psychologic problems. The secondary forms usually require no therapy other than the removal of any identified inciting cause. Most of the idiopathic forms last only a few months and then gradually disappear. In secondary gynaecomastia and idiopathic forms present for more than 12 months a medical hormonal treatment often fails and the only therapy is surgery consisting in a subtotal subcutaneous mastectomy. In the last years the surgical treatment is often completed with suction lipectomy: this procedure reduces the surgical traumatism. The authors present their experience concerning 47 patients: 27 were surgical treated with subcutaneous subtotal mastectomy and 18 had an abjunctive liposuction treatment with good results.

[Surgical treatment of hyperthyroidism]. / Trattamento chirurgico dell'ipertiroidismo.

The most important problems of hyperthyroidism surgery are: the correct indication of operation, the choice of the best moment for operation and at last the extension of the resection. The authors experience include 365 patients with hyperthyroidism; 201 of them had monolateral autonomous nodules, 82 had diffuse multinodular goitre and 79 had Graves disease. In the first group of patients surgical treatment was total extracapsular isthmo-lobectomy, in the second group was performed subtotal thyroidectomy and in the third group was almost performed near-total thyroidectomy. Three relapses were found: two of that regarded patients with autonomous function nodule and one in patient with Graves disease. In 201 patients with toxic monolateral hyperfunction of the node, an extracapsular isthmo-lobectomy was performed. In the greater part of the 82 multinodular goiter cases a sub-total thyroidectomy was performed, as well as in 79 patients with Graves disease. Among the 3 recidive cases of hyperthyroidism (0.8%) one was recorded in a patient with Graves disease, (after subtotal thyroidectomy) and two in patients with hyperfunction of the node, (after isthmo-lobectomy). The authors justify the low incidence of recurrence by the choice of large extension of resection without a great number of complications.

Optimizing staff scheduling by Monte-Carlo simulation.

DOCS is a computer program which generates the staff schedule. An accounting framework is combined with an optimization technique that searches for a schedule in which all accounts are simultaneously in balance. The search is accomplished using a Monte-Carlo process which shuffles staff within the schedule. The shuffling is biased according to each staffer's account balance: the staffer who owes the most is most likely to be scheduled.

Angiotensin-producing serum enzyme II. Formation by inhibitor removal and proenzyme activation.

A highly active angiotensin-producing enzyme (enzyme II) was obtained from dog serum by acid treatment and fractionation to remove angiotensinase and converting enzyme, separate an inhibitor, and convert an inactive precursor (proenzyme II) to enzyme II. Proenzyme II was found to be converted to enzyme II by an endogenous activating enzyme identified as plasmin. Conversion was also caused by the interaction of bacterial streptokinase with human proactivator, by trypsin, and by an activator formed from liver tissue extract and dog serum. Neither plasma kallikrein nor the labile, human extrinsic tissue-type plasminogen activator induced activation. The inhibitor, which normally blocks the activation of proenzyme II, was unusually stable against high temperatures and extremes of pH, and it was not identical to any of the six known protease inhibitors of serum. Enzyme II was not identical to other angiotensin-producing enzymes such as enzyme I, renin, cathepsin D, pepsin, plasmin, tonin, or cathepsin G. Enzyme II reacted maximally at pH 4.7 and produced up to 2250 ng of angiotensin I/ml serum/hr from the substrate of dog serum (i.e., amounts 3200-fold higher than that produced by endogenous renin of normal dog serum). Since at pH 7.2, angiotensin I formation is still about 30 times higher than that of renin, enzyme II may be physiologically active under some conditions.

Angiotensin-producing enzyme I of serum: formation by immunization with renin.

Immunization with renin from the kidneys of hog, beef, dog, rabbit and man induced the formation of a highly active enzyme (enzyme I) in the serum of dogs, guinea pigs, rabbits and rats. Enzyme I produces angiotensin I maximally at pH 4.7, up to 2900 ng/ml serum/h, i.e. at a rate 2500 times higher than the endogenous renin of normal serum. At pH 7.2 the angiotensin I production by enzyme I is about 16 to 28 times higher than that of plasma renin. Enzyme I is produced by immunization with renin and not by other kidney proteins. Enzymatically-active renin is required and separate mechanisms are involved in the formation of enzyme I and antirenin. Enzyme I is not identical to renin, pepsin, cathepsin D, plasmin, tonin or cathepsin G and it is inhibited by pepstatin, but not by diisopropyl fluorophosphate.

Effects of angiotensin II on the cardiac responses to sympathetic nerve stimulation in dogs.

In anesthetized dogs with the left cardiac sympathetic nerves and both vagal nerves intact, angiotensin II (AII) induced a substantial, dose-dependent increase in arterial blood pressure and small increments in cardiac cycle length and ventricular contractile force. In dogs in which the cardiac sympathetic and vagal nerves had been interrupted, AII produced similar increases in blood pressure and larger increases in contractile force, but it decreased the cardiac cycle length. In both groups of dogs, AII augmented substantially the positive inotropic responses to sympathetic nerve stimulation, but it enhanced the positive chronotropic responses only slightly. However, AII did not appreciably prolong the cardiac responses to sympathetic nerve stimulation, nor did it alter significantly the cardiac responses to norepinephrine infusions. Hence, at the dosage levels used, AII probably did not inhibit the neuronal uptake of norepinephrine appreciably nor did it enhance the responsiveness of the cardiac effector sites to norepinephrine. Therefore, the potentiation of the cardiac responses to sympathetic nerve stimulation by AII in these experiments was probably achieved principally by facilitating norepinephrine release from the adrenergic nerve terminals in the heart.

Micromethod for the assay of renin of seven species.

Renin was extracted and purified from human, dog, hog, rat, beef, rabbit and sheep kidneys. The renin "concentration" of these preparations was determined and expressed in international (Goldblatt) units by measuring the pressor effect produced by intravascular injection into normal dogs of a permanent colony. The renin "activity" was determined by bioassay, in the rat, of the angiotensin produced by incubation in vitro with renin substrate prepared from the serum of nephrectomized dogs. The rate of angiotensin formation was proportional to the concentration of renin, independent of the substrate concentration, and rather similar for renin of all seven species (mean rate = 55 x 10(4) ng angiotensin/unit renin/16 hrs). Due to this uniformity, either of the two international reference preparations of renin (human or hog) from the World Health Organization can serve as an internal standard in the assay of reninof each of the seven species, to express their concentration in terms of the international unit. Renin substrate from hog plasma was suitable for the assay of human, dog and hog renin (mean rate = 55 x 10(4)). However, it reacted much more slowly with the renin of rat, beef, rabbit and sheep (mean rate = 9 x 10(4)) and was, therefore, less suitable for their assay.