Does the intraoperative parathormone monitoring really affect surgical success in primary hyperparathyroidism?

BACKGROUND: Surgery is the only curative treatment option for primary hyperparathyroidism (PHPT). The intraoperative parathormone (IOPTH) monitoring is recommended to confirm that all pathological glands have been removed. This study aimed to evaluate the effect of IOPTH monitoring on the surgical success of parathyroidectomy performed for PHPT. METHODS: The demographic, biochemical, operative and pathological data of patients who underwent parathyroidectomy for PHPT in a single institute over a three-year period were retrospectively analyzed. RESULTS: The total number of patients included in the study was 182. The IOPTH monitoring had been performed in 92 patients (50.5%). The IOPTH monitoring had a clinical accuracy of 89.2%, sensitivity of 89.8%, and specificity of 75%. The rate of surgical success was 95.7% in the group with IOPTH monitoring and 91.1% in the group without this monitoring (p = .21). Of the 40 patients who underwent minimally invasive parathyroidectomy (MIP), 25 patients had IOPTH monitoring, and the surgery was successful for all these patients (100%). Surgical success was achieved in 14 (93.3%) patients who underwent MIP without IOPTH monitoring (p = .37). CONCLUSION: The IOPTH monitoring is a reliable test with high accuracy. The lack of IOPTH monitoring may result in lower than acceptable surgical success rates. Even though preoperative localization studies are compatible with surgical findings, the IOPTH monitoring should also be undertaken, especially in patients scheduled for MIP for PHPT.

Beta-Cell Golgi Stress Response to Lipotoxicity and Glucolipotoxicity: A Preliminary Study of a Potential Mechanism of Beta-Cell Failure in Posttransplant Diabetes and Intraportal Islet Transplant.

OBJECTIVES: Lipotoxicity and glucolipotoxicity are among the mostimportanttriggers of beta-cell failure in patients with type 2 and posttransplant diabetes. Because the Golgi apparatus is a vital organelle in secretory cells like beta cells, its behavior under stress conditions determines the cell's functional capacity. MATERIALS AND METHODS: To mimic lipotoxicity and glucolipotoxicity as metabolic stresses for beta-cell failure, rat insulinoma INS-1E cells were treated with palmitic acid, glucose, or both. Cells were cultured in the presence of 5.0, 16.7, or 33 mM glucose with or without 0.5 mM palmitic acid for 8, 16, 24, and 48 hours. Incubation in the presence of any of the 3 concentrations of glucose with 0.5 mM palmitic acid provided glucolipotoxicity. In addition to the endoplasmic reticulum stress marker (Hspa5), we evaluated changes in Golgi function under experimental metabolic stresses. In doing this, we measured expression levels of the genes coding Golgi structural proteins (Acbd3,Golga2, and Arf1), Golgi glycosylation enzymes sialyltransferaz10 and sialyltransferase 1 (St3gal1), and Golgi stress mediators (Creb3 and Arf4). RESULTS: Golgi responded to lipotoxicity and glucolipotoxicity by increasing the expression of St3gal1 (P = .05 in both conditions) and Creb3 (P = .022 and P = .01, respectively). The Arf4 gene transcript also increased in glucolipotoxic media (P = .03). Glucotoxicity alone did not induce a change in the transcript levels of Creb3 and Arf4. Lipotoxicity and glucolipotoxicity induced Creb3 and Arf4 expression, which are important Golgi stress response mediators leading to apoptosis. CONCLUSIONS: This preliminary study showed that the Golgi stress response is important in lipotoxic and glucolipotoxic conditions in terms of beta-cell failure. Solving the mystery of intracellular molecular mechanisms leading to beta-cell dysfunction is crucial to understanding the pathophysiology of posttransplant diabetes and most probably the failure of intraportal islet transplants in the long term.

A scoring system for preoperative assessment of resectability in periampullary neoplasms.

BACKGROUND: To identify the preoperative factors predicting resectability in periampullary neoplasms. METHODS: Twenty-three different parameters representing the clinical, laboratory and radiological data of 65 patients, who were operated for periampullary neoplasms, were analyzed to determine their value in assessing neoplasm resectability. Coefficients were calculated by Cox regression analysis for significant factors. A scoring system was designed for resectability. All patients were divided into 4 groups according to their scores. RESULTS: Twenty-six patients who had a resectable neoplasm underwent pancreatico-duodenectomy and surgical palliation was performed in the remaining 39 patients. After multivariate analysis, neoplasms larger than 4.5 cm, low leukocyte count (<9500/mm3), high bilirubin levels (>137.5 micromol/L) and tomographic findings indicating neoplasm invasion were found to be independent factors predicting resectability. The score range was between 0 and 12. Patients were grouped as Group-1 (total score 0-2), Group-2 (total score 3-5), Group-3 (total score 6-8), and Group-4 (total score 9 and higher). Resectability rates were 100% in Group 1 (n=13), 44% in Group-2 (n=23), 21% in Group-3 (n=14), and 0% in Group-4 (n=15), respectively. Mean score was 3.3 in patients with resectable lesions and 7.2 in patients with unresectable lesions (p<0.001). CONCLUSION: This simple scoring system can be a guide in the management plans of patients with periampullary neoplasms. By using this scoring system, patients with an unresectable neoplasm can be predicted and most unnecessary laparotomies can be avoided (Tab. 3, Fig. 2, Ref. 27). Full Text (Free, PDF) www.bmj.sk.

The significance of pulmonary nodule in breast cancer patients.

BACKGROUND: Pulmonary nodule in patients with breast cancer is a difficult problem and constitutes a therapeutic challenge. This study questioned the significance of solitary pulmonary nodule in breast cancer patients and compared the survival with patients who had normal thorax tomography. METHODS: There were 58 breast cancer patients included in the study. From these, 28 patients had normal preoperative tomography (group 1), and 30 patients had pulmonary nodule less than 1 cm on thorax tomography (group 2). Chi-square and Fisher tests were used for comparisons and Kaplan-Meier test for survival. RESULTS: Stage, tumour size, treatment, histology, lymph node involvement, adjuvant therapy, were similar in both groups. We did not find a significant difference in disease-free and overall survival rates, between two groups. CONCLUSIONS: For the nodules that show benign properties at tomography, there is no need to do further investigation and no need to change treatment plan in breast cancer patients (Tab. 2, Fig. 2, Ref. 12). Full Text (Free, PDF) www.bmj.sk.

Laparoscopic cholecystectomy under spinal anesthesia.

BACKGROUND: Advantages of laparoscopic cholecystectomy (LC) such as less pain and short hospital stay make it the treatment of choice for cholelithiasis. There are limited data about LC under spinal anesthesia. This study was designed to evaluate LC under spinal anesthesia. METHODS: Twenty-nine patients underwent surgery for LC under spinal anesthesia at the 4th Department of Surgery of the Ankara Numune Education and Research Hospital between April 2005 and January 2006. All patients were informed about spinal anesthesia in detail. The patients also were informed about the risk of conversion to general anesthesia, and all patients provided informed consent. The election criteria for spinal anesthesia were as follows: American Society of Anesthesiologists (ASA) risk group 1 or 2; risk score for conversion from LC to open cholecystectomy (RSCO) less than negative 3; and presence of gallstone disease. Standard laparoscopic technique was applied to all patients. Simple questionnaire forms were developed for both patients and surgeons to provide comments about the operation. RESULTS: The operation was completed laparoscopically on 26 patients, while 3 patients needed general anesthesia due to severe right shoulder pain. None of the patients had cardiopulmonary problems other than transient hypotension during surgery. Intravenous fentanyl (25 microg) was needed in 13 patients due to severe right shoulder pain. Five patients still had severe shoulder pain after fentanyl injection. Local washing of the right diaphragm with 2% lidocaine solution was successful in the remaining 5 patients in whom fentanyl injection failed to stop the pain. All of the patients' answers to the questions regarding the comfort of operation were "very well" at the 1-month postoperative evaluation. All surgeons stated that there was no difference from LC under general anesthesia. CONCLUSIONS: All of the patients and surgeons were satisfied with LC under spinal anesthesia. Therefore, LC under spinal anesthesia may be an appropriate treatment choice to increase the number of patients eligible for outpatient surgery.

Methimazole protects lungs during hepatic ischemia-reperfusion injury in rats: an effect not induced by hypothyroidism.

BACKGROUND: Hepatic ischemia-reperfusion injury may lead to remote organ failure with mortal respiratory dysfunction. The aim of the present study was to analyze the possible protective effects of methimazole on lungs after hepatic ischemia-reperfusion injury. METHODS: Forty male Wistar albino rats were randomized into five groups: a control group, in which bilateral pulmonary lobectomy was done; a hepatic ischemia-reperfusion group, in which bilateral pulmonary lobectomy was done after hepatic ischemia-reperfusion; a thyroidectomy-ischemia-reperfusion group (total thyroidectomy followed by, 7 days later, bilateral pulmonary lobectomy after hepatic ischemia-reperfusion); a methimazole-ischemia-reperfusion group (following methimazole administration for 7 days, bilateral pulmonary lobectomy was done after hepatic ischemia-reperfusion); and a methimazole +L-thyroxine-ischemia-reperfusion group (following methimazole and L-thyroxine administration for 7 days, bilateral pulmonary lobectomy was performed after hepatic ischemia-reperfusion). Pulmonary tissue specimens were evaluated histopathologically and for myeloperoxidase and malondialdehyde levels. RESULTS: All of the ischemia-reperfusion intervention groups had higher pulmonary injury scoring indices than the control group (P < 0.001). Pulmonary injury index of the ischemia-reperfusion group was higher than that of both the methimazole-supplemented hypothyroid and euthyroid groups (P = 0028; P = 0,038, respectively) and was similar to that of the thyroidectomized group. Pulmonary tissue myeloperoxidase and malondialdehyde levels in the ischemia-reperfusion group were similar with that in the thyroidectomized rats but were significantly higher than that in the control, and both the methimazole-supplemented hypothyroid and euthyroid groups. CONCLUSION: Methimazole exerts a protective role on lungs during hepatic ischemia-reperfusion injury, which can be attributed to its anti-inflammatory and anti-oxidant effects rather than hypothyroidism alone.

Long-term outcome of Graves' disease patients treated in a region with iodine deficiency: relapse rate increases in years with thionamides.

BACKGROUND: Graves' disease (GD) is an autoimmune disease affecting the thyroid gland and eyes and is treated with three therapeutic modalities. This prospective study was designed to find out the outcome of patients with GD treated with thionamides, radioactive iodine (RAI) or surgery in an iodine deficient region. MATERIALS AND METHODS: Fifty-six nonsmoking patients (mean age 38.9 +/- 13.7 years) with GD were enrolled and followed for a mean period of four years. They were analyzed with respect to their treatment options and their outcome. RESULTS: Remission rate by thionamides was 74.4% in the first year but decreased to 65.1% in the following four years (p=0.0001). Remission rate achieved in the second year did not predict long-term remission with thionamides. Long-term remission rates for RAI and surgery were 100% during about seven years of follow-up. These remission rates for RAI and surgery were reached in the first year and did not reveal a statistically significant change in the following years. Thyroidectomy, both subtotal and total, was carried out without any complication. Graves' ophthalmopathy emergence and progression were not found to be correlated with the preferred therapeutic modality of thyrotoxicosis. CONCLUSION: Long-term thionamide therapy offered a relatively low rate of long-term remission in a region with iodine deficiency. Two years of remission achieved by thionamides did not predict long-term remission in patients living in iodine-deficient areas. RAI and thyroidectomy in experienced hands proved to be better therapeutic alternatives that can be carried out safely.

A clinical forensic scientist in the burns unit: necessity or not? A prospective clinical study.

Child abuse by burning is a common means of assault that may be difficult to prove. Even though well trained in burns management physicians on the burn team may not be sufficiently qualified to clarify the medicolegal aspects of the incident. In Turkey, physicians have a responsibility to notify the law offices of injury to children caused by any non-accidental mechanism including neglect. The consequences of false positive and/or false negative reports to the legal offices may be damaging for the care-takers and/or the children. In our study, 239 consecutively hospitalized children with burns were studied prospectively. A clinical forensic scientist and a physician of the burns team interpreted incidents separately so that neither had an idea about the other's diagnoses until the end of the study. There were found to be some differences in the interpretation of the incidents by the clinical forensic scientist and the burns team physician. These differences were described as discordant diagnoses. The physician accepted 99 (41.4%) of the incidents as an accident while only 66 (27.6%) of the victims were labelled as accidents by the forensic scientist. A multivariate analysis identified low socioeconomic status, aged between 3 and 6 years, and a family size of more than six as independent variables significantly associated with discordant diagnoses (p = 0.0388, 0.0001, 0.0203, respectively). As a conclusion, we suggest that to minimize the likelihood of a legally inaccurate diagnosis, a clinical forensic scientist seems to be necessary in the emergency department.

Melatonin levels decrease in type 2 diabetic patients with cardiac autonomic neuropathy.

The present study has been designed to determine melatonin levels in type 2 diabetic patients and test the relationship between the autonomic nervous system and melatonin dynamics. Thirty-six type 2 diabetic patients and 13 age-matched healthy subjects were recruited for the study. Circadian rhythm of melatonin secretion was assessed by measuring serum melatonin concentrations between 02:00-04:00 and 16:00-18:00 hr. Melatonin dynamics were re-evaluated with respect to autonomic nervous system in diabetic patients with autonomic neuropathy who were diagnosed by the cardiovascular reflex tests, heart rate variability (HRV), and 24-hr blood pressure monitoring. Nocturnal melatonin levels and the nocturnal melatonin surge were low in the diabetic group (P = 0.027 and 0.008 respectively). Patients with autonomic neuropathy revealed decreased melatonin levels both at night and during day when compared with healthy controls (P < 0.001 and 0.004 respectively) while the melatonin dynamics were similar to controls in patients without autonomic neuropathy. Nocturnal melatonin level was positively correlated with nocturnal high and low frequency components of HRV (P = 0.005 and 0.011 respectively) and systolic and diastolic blood pressures at night (P = 0.002 and 0.004 respectively) in patients with autonomic neuropathy. We found a negative correlation between nocturnal melatonin levels and the degree of systolic blood pressure decrease at night (r = -0.478, P = 0.045). As a conclusion this study has shown that circadian rhythm of melatonin secretion is blunted in type 2 diabetic patients and there is a complex relationship between various components of autonomic nervous system and melatonin secretion at night. Among the patients with autonomic neuropathy those with more preserved HRV and the systolic nondippers (<10% reduction in blood pressure during the night relative to daytime values) have more pronounced melatonin surge at night.

Using a risk score for conversion from laparoscopic to open cholecystectomy in resident training.

BACKGROUND: We previously developed a risk score for conversion from laparoscopic to open cholecystectomy (RSCLO). The aim of this study is to validate this scoring system in a new patient population and test its use in case selection for resident training. METHODS: The data of 1,000 laparoscopic cholecystectomies (LC) that had been performed in our clinic between 1992 and 1999 were analyzed retrospectively, and RSCLO was developed. Scores take values between -20 and 41; values below -3 represent low risk, and values over -3 represent high risk. Analyses in this group of patients showed that at least 15 cases have to be performed for adequate LC training. The current study is a clinical prospective study based on data of the previous study and evaluates RSCLO in a new patient population of 400 LCs. All patients were scored preoperatively; surgeons who had performed 15 or fewer LCs previously operated only patients with a score below -3. Patients with high scores (>values of -3) were operated only by surgeons who had performed at least 16 LCs. Results of the first 1,000 cases and later 400 cases (new patient population of the current study) were compared in terms of conversion to open cholecystectomy, complications, and operation times. RESULTS: Both in the first 1,000 patients and later in 400 patients, increasing scores resulted with higher conversion rates and complication rates and longer operation times (P<.05). In the later 400 patients, conversion rate (4.8% vs 3.0%, P=.08), complication rate (5.5% vs 3.5%, P=.07), and mean operation time (56.8 min vs 52.5 min, P=.004) were decreased when compared with the first 1,000 patients. In resident training cases, conversion and complication rates decreased to 0%, and mean operation time was shortened by nearly 10 minutes. In high-score difficult cases, conversion and complication rates decreased, and mean operation time was shortened by nearly 20 minutes. CONCLUSIONS: This risk score can predict the difficulty of LC cases reliably. Scoring patients preoperatively can decrease the problems in training cases, and management of difficult cases may be left to experienced surgeons.