The incidence of hyperthyroidism in Austria from 1987 to 1995 before and after an increase in salt iodization in 1990.

Between 1963 and 1990, Austria had iodized salt prophylaxis of endemic goitre with 10 mg KI (7.5 mg I) per kg. This was obviously insufficient, as urinary iodine excretion ranged from 42 to 78 microg I per g of creatinine and goitre in adults remained in the endemic range of 15%-30%. Therefore salt iodization was doubled in 1990. The aim of this study was to assess the annual incidence of different types of hyperthyroidism (HT) before and after this increase in salt iodization. The incidence of HT was recorded in 14 nuclear medicine centres from 1987 to 1995. In five additional centres data were available from 1992 onwards. Data prior to 1992 were documented retrospectively, while those after 1992 were recorded prospectively. The 14 centres drew patients from an area with a population of approximately 4.23 million while all 19 institutes were estimated to cover an area with a population of 5.4 million (the total population of Austria is 7.86 million). A total of 414232 persons were examined for the first time in the participating centres. HT and the type of HT were defined by clinical examination, serum TSH, thyroid hormone levels in blood, ultrasonography, scintigraphy and serum autoantibody titres. HT was classified into immunogenic HT (Graves' or Basedow's disease, GD) and HT with intrinsic thyroid autonomy (uni-, multinodular or disseminated Plummers' disease, PD). HT was also divided into overt (o) or subclinical (sc) disease. The following data were calculated: annual incidence per 100000 and the relative risk (RR) for HT with 95% confidence intervals (CI). In addition, linear trends were calculated for each type of HT by means of logistic regressions. In the 19 centres a total of 47834 patients with HT were registered from 1987 to 1995. PD accounted for 75% of all cases of HT and GD for 19%, while other types of HT were present in 6%. From 1987 to 1989 (time period T0), the annual incidence of oPD was 30.5 (95% CI 29.6-31.5) per 100000. The RR compared to the baseline period T0 was highest in 1992 (1.37; 1.3-1.45) and decreased to 1.17 (1.1-1.24) in 1995. The annual incidence of scPD in T0 was 27.4 (26.5-28.3) per 100000. The RR was highest in 1991 (1.64; 1.56-1.73) and was 1.60 (1. 51-1.69) in 1995. In oPD and scPD a higher RR was observed in persons older than 50 years of age, particularly in men. The incidence of oGD in T0 was 10.4 (9.8-10.9) per 100000; the maximum RR increased to 2.19 (2.01-2.38) in 1993 and decreased to 1.95 (1.78-2.13) in 1995. The incidence of scGD was 1.9 (1.6-2.1) in T0. The maximum RR was observed in 1994 (2.47; 2.04-3.0) and it was still 2.26 (1.85-2.77) in 1995. The increased incidence of oGD and scGD was evenly distributed in all ages and both sexes. The time course of different types of HT following the increase in salt iodization could be divided into two phases: an increase in the incidences of HT with peaks after 1-4 years and a subsequent decrease, the only exception being scGD. The effect was more pronounced in GD than in PD. PD showed an age and gender dependency over time, while GD did not.

Fine needle aspiration cytodiagnosis of subacute (de Quervain's) thyroiditis in an endemic goitre area.

Between 1977 and 1989 252 fine needle aspirates (FNAs) of the thyroid from patients with a clinical suspicion of subacute granulomatous (de Quervain's) thyroiditis were examined in the Department of Pathology of the University of Innsbruck, Austria. In the same period 31 cases with preoperative FNA were diagnosed histologically as subacute thyroiditis. Only in three of these cases were the cytological features of de Quervain's thyroiditis found in the preoperative FNA. However, in 13 of these 31 cases a cytological suspicion of malignancy was obtained. Subsequent histological examination revealed an acute phase inflammation of de Quervain's thyroiditis in most of these cases. We conclude that an accurate FNA diagnosis of de Quervain's thyroiditis, particularly in the acute stage, may cause difficulties due to a lack of typical features and the appearance of atypical thyroid follicular cells. For the cytopathologist, accurate clinical information relating to the possibility of de Quervain's thyroiditis is essential if unnecessary surgery is to be avoided.

Usefulness of physiologic dual-chamber pacing in drug-resistant idiopathic dilated cardiomyopathy.

The beneficial effects of physiologic dual-chamber (DDD) pacing in the treatment of end-stage idiopathic dilated cardiomyopathy were evaluated in 16 patients in whom conventional drug therapy had failed. Candidates for cardiac transplantation as well as patients not accepted for transplantation participated. During DDD pacing at an atrioventricular delay of 100 ms, left ventricular ejection fraction increased from 16.0 +/- 8.4 to 25.6 +/- 8.6% (p less than 0.001) accompanied by a striking improvement in clinical symptoms, such as severe dyspnea at rest and pulmonary edema. The New York Heart Association class decreased from 3.6 +/- 0.4 to 2.1 +/- 0.5 (p less than 0.001). The decrease in cardiothoracic ratio from 0.60 +/- 0.06 to 0.56 +/- 0.05 (p less than 0.001) coincided with a decrease in left atrial and right ventricular echocardiographic dimensions, indicating a decrease in preload. Systolic blood pressure increased from 108 +/- 29 to 126 +/- 21 mm Hg (p less than 0.01) and diastolic blood pressure from 67 +/- 15 to 80 +/- 11 mm Hg (p less than 0.01). Normalization of heart rate was achieved. No major complications developed as a consequence of DDD pacing. All patients could be discharged from the hospital within 3 weeks after pacemaker implantation and return to a relatively normal life. Within 1 year after onset of DDD pacing only 4 of the patients died (from either sudden death or stroke). DDD pacing could represent an alternative approach to the management of chronic heart failure due to dilated cardiomyopathy, especially for heart transplant candidates and patients who are not accepted for cardiac transplantation, but no longer respond to drug therapy.

Clinicopathologic management of tumors of the thyroid gland in an endemic goiter area. Combined use of preoperative fine needle aspiration biopsy and intraoperative frozen section.

In total, 15,325 fine needle aspiration (FNA) biopsies of the thyroid were examined in the Department of Pathology of the University of Innsbruck, Austria, between 1976 and 1985, with the cytologic results histologically verified in 3,112 cases. Since (1) it is frequently impossible to distinguish benign from malignant encapsulated follicular thyroid tumors by cytologic criteria and (2) there is a high level of follicular thyroid carcinoma in our endemic goiter area, we have adopted a diagnostic strategy that accepts a high percentage of false-positive cytologic results in order not to miss highly differentiated follicular carcinoma. To avoid unnecessarily extensive surgical treatment, 1,079 intraoperative frozen section examinations of the thyroid were performed in the same time period in (1) patients with preoperative suspicious or positive FNA cytologic findings, (2) cases with suspicious clinical and anamnestic data and (3) tumors with a suspicious macroscopic appearance without preoperative FNA or with negative or unsatisfactory cytologic findings. In 48 cases (4.5%), the frozen section diagnosis had to be revised after examination of paraffin-embedded tissue. An intraoperative false-positive diagnosis was obtained in 3 cases (0.3%) while a false-negative diagnosis was made in 45 cases (4.2%). The main effort in examining frozen sections should be concentrated on avoiding false-positive errors, which can lead to unnecessary thyroidectomies.

An experimental approach to explain some misinterpretations of diuresis renography.

Since its introduction in 1978, gamma camera diuresis renography has proved a useful technique in the differential diagnosis of the dilated renal pelvis. Comparative analyses with perfusion pressure flow studies have revealed discrepancies in a number of cases. These may have been caused in part by incorrect interpretation of the renograms. A renal pelvis model has been developed that permits renograms to be obtained for different renal pelvis volumes, different flow rates and different degrees of obstruction. The results show that a curve approaching an exponential function after increased flow rules out an obstruction. A slight flattening of the curve, however, is indicative of obstruction. Failure to take note of these finer distinctions can lead to misinterpretations.

[On the problem of the cardiotoxicity of epirubicin-cisplatin]. / Zur Frage der Kardiotoxizität von Epirubicin--Cisplatin.

Cardiotoxicity is supposed to be the most important limiting factor in chemotherapy with anthracycline derivatives. The left ventricular ejection fraction was measured several times by means of radionuclid - scintigraphy in 24 patients treated with epirubicin - cisplatinum. Pathologic values have been found only in 3 patients, but no correlation with age, cumulative dose or dose/m2 of body surface could be demonstrated.

Papillary carcinoma of the thyroid gland. Analysis of 94 cases with preoperative fine needle aspiration cytologic examination.

From 1979 to 1983, 94 papillary carcinomas of the thyroid gland were examined histologically in our institute after a preoperative cytologic examination. Material for cytologic examination was obtained using fine needle aspiration (FNA) biopsy. Eighty-five (90.4%) of the 94 examined cytologic smears were representative. Among these 85 cases suspicion for malignancy or malignancy itself was found in 64 cases (75.3%). The remaining 21 smears, classified as cytologically not as suspect for malignancy, were reclassified and the previous diagnosis had to be revised in one case. In the other 20 cases no clue for malignancy could be demonstrated even after reexamination. In the 85 cases with representative cytologic findings, tumor size was determined on surgical material, in order to establish how many carcinomas with a diameter less than 3 cm could not be reached by FNA biopsy. Except for one case, all carcinomas with negative preoperative cytologic findings had a diameter less than or equal to 3 cm. The question arising is the possibility of improving the accuracy of FNA biopsy in tumor detection within cold nodules of the thyroid by combined use of scintigraphy and ultrasound-guided FNA biopsy.

[Improvement in the informativeness of diuretic kidney function scintigraphy by calculation of a washout index]. / Verbesserung der Aussagekraft der Diuresenierenfunktionsszintigraphie durch Berechnung eines Auswaschindexes.

Diuresis renography after administration of 123I-(131I-)Hippuran of 248 patients (492 kidneys) were compared retrospectively with clinical findings, history, i.v. urography, and ultrasound examinations. A new wash-out-index was calculated. In cases with obstructive dilatation of the collecting system this index was smaller than 0.9. If it was 0.9 to 1.2 additional diagnostic procedures seem necessary. An index more then 1.4 excludes obstruction. The shape of the renogram curve after furosemide is important for the diagnosis too. A concave shape was found in non-obstructive dilatation, a convex shape in obstructive dilatation of the renal pelvis. The wash-out-index is a reliable parameter if cases with reflux, lower ureteral obstruction and shrunken kidneys are excluded.

A fourteen year practice with the fine needle aspiration biopsy of the thyroid in an endemic area.

In our institute from 1970 to 1983 12,829 fine needle aspiration biopsies (FNB) of the thyroid were cytologically examined. Cytologically unsatisfactory specimens were found in 17.7%. 2,709 patients with representative cytological findings were operated and histological examinations were performed. The cytological and histological findings were correlated. There was a false-negative rate of 2.0% and a false-positive rate of 18.4%. Furthermore we divided the results into two time periods (1970-1977 and 1978-1983) because of a change in the indication for surgery in the last years. Although the indication has changed, cytological findings of both time periods investigated were almost similar.

[Prevention and therapy of accidental radionuclide uptake]. / Prävention und Therapie akzidenteller Inkorporation.

After accidental incorporation of radionuclides in the organism uptake in the whole-body and in critical organs can be either reduced or blocked (prevention) by appropriate medication and behaviour. Effective half-lives after incorporation in critical organs can be shortened (therapy). For different fallout-radionuclides a variety of preparations exists for such purposes. For large-scale prevention only iodine administration seems appropriate to block the uptake of the generally occurring 131-I in the thyroid. Such an iodine prophylaxis, however, seems only necessary when drinking water concentrations exceed 5000 nCi/l. Excessive amounts of iodine can influence thyroid function significantly.

[Differentiated thyroid carcinoma in an endemic area. Clinical aspects, prognosis, therapeutic considerations]. / Das differenzierte Schilddrüsenkarzinom im Endemiegebiet. Klinik, Prognose, therapeutische Uberlegungen.

A retrospective analysis was undertaken of 179 cases of differentiated thyroid carcinoma (89 follicular and 90 papillary; first operations 1952-1977). At the time of the diagnosis there was no significant difference between the two types of malignancy as to age, sex, stage of tumour and degree of local radical operation. Nor was there any difference as to clinical course, but for papillary carcinoma the recurrence rate was higher and the survival time significantly shorter. Simple histological classification as to type did not help in prognosis. Compared with published reports, the unfavourable course of papillary carcinoma can be explained by the high proportion of haematogenous metastasizing tumours and the great prognostic significance of distant metastases, especially with papillary carcinoma. The differences in prognosis of other clinical examinations is ascribed to the broad spectrum of tumour-biological aggressivity which hides under the expression "differentiated carcinoma". Our results underline the need to take into account different clinical and histopathological influences which differ for each tumour type.

Early surgery in the management of pediatric blunt renal trauma.

Of 40 children with major blunt renal injuries managed surgically 30 (75 per cent) could be followed up to 13 years postoperatively (mean 4.5 years). Measurements of renal size on sequential excretory urograms demonstrated normal growth of the traumatized kidney in all but 1 child. No hypertrophy of the contralateral kidney was noted in any child. Kidney length correlated with renal plasma flow calculated by sequential scintiscans (r equals 0.77). Hypertension was noted in 3 patients. Split renal vein renin studies and angiography showed that hypertension was caused by renal artery stenosis in 1 patient. Although we cannot draw any firm conclusions with regard to the optimal management of major blunt renal injuries, we present precise data that are valuable in comparison to other series of patients managed conservatively or surgically.

[Value and indication for isotope reflux cystography in children]. / Aussagekraft und Indikation der Isotopen-Refluxcystographie im Kindesalter.

65 children with recurrent urinary infections were investigated by a reflux-cystography method, using 99mTc labelled millimicrospheres. Our results show that this method allows a clinically sufficient diagnosis of reflux. The radiation exposure of the patient is 50-200 times less than the established reference method (X-ray refluxcystography). However, the amount of reflux, i.e. the stage of disease can only be determined by the radiologic method. On the basis of our results it is therefore recommended to use the radionuclide reflux-cystography method as basic investigation and for follow-up. If the basic investigation shows a reflux classification of the reflux has to be evaluated by X-ray reflux-cystography.

[Early diagnosis of thyroid cancer in endemic goitre area reflections and management based on the epidemiological situation in Tyrol (author's transl)]. / Die Früherfassung des Schilddrüsenkarzinoms im Strumaendemiegebeit. Uberlegungen und Vorgehen auf der Basis der epidemiologischen Verhältnisse in Tirol.

Until recently the prognosis of thyroid cancer has been poor in this endemic goitre area due to the predominance of aggressive tumour types and belated diagnosis of the carcinoma. Iodine prophylaxis has changed this epidemiological profile: the mortality of goitre has generally decreased and there has been a relative increase in differentiated carcinomas. Preoperative diagnosis and operability have been favourably influenced by this new situation. Thus, whereas from 1960 to 1967 radical operation was impossible in 78.6% of thyroid cancers, between 1978 and 1981 only 12.4% of all cases had invasive tumours of distant metastases at the time of operation and 79.3% of all patients were staged as To-2N0Mo. An improvement in survival rate can be expected with early diagnosis of thyroid cancer. Nevertheless, individual prognostic statements can be made only after evaluation of these findings according to "prognostic systems", for in thyroid cancer--as in no other kind of carcinoma--prognosis is determined by a combination of the patient's age and sex, cell type and histological tumour pattern and TNM status.

[Stepwise combination of skeletal scintigram and x-rays in the improvement and rationalisation of skeletal metastases detection (author's transl)]. / Schrittweise Kombination von Skelettszintigramm und Röntgen zur Verbesserung und Rationalisierung des Metastasennachweises im Skelettsystem.

Skeletal scintigraphy with 99mTc phosphate complexes allows the early detection of sites of pathological activity in bones. High sensitivity of this procedure (93%) contrasts with low specificity (59%). Scintigraphically-located sites are uncharacteristic and can imply various diagnoses and require radiodiagnostic investigation. The stepwise application of both methods is recommended, according to tumour type and clinical picture in order to avoid unnecessary and costly duplication of investigation procedures. Thus, the combination of the high specificity of skeletal radiology and the high sensitivity of scintigraphy aids the early detection of skeletal metastases, whereby whole-body skeletal scintigraphy forms the basis for such investigations.

[Adrenal scintigraphy-value and indications in adrenal disease]. / Nebenniererindenszintigraphie-Stellenwert und Indikation bei Erkrankungen der Nebenniere.

Adrenal scintillation scanning is a very useful method in the diagnosis of steroid producing diseases of the adrenal glands. The diagnosis of bilateral hyperplasia and primary adenoma of the adrenal cortex in Cushing's syndrome and Conn's syndrome is possible by this non-invasive procedure. Morphological questions (e.g. the localization of a phaeochromocytoma) cannot be answered. It is not a screening examination.

[Lymphocytic infiltrations in normal and pathological thyroid glands (so-called focal lymphocytic thyroiditis) (author's transl)]. / Lymphozytenherde in normalen und pathologisch veränderten Schilddrüsen (sogenannte fokale lymphozytäre Thyreoiditis).

A series of 1004 goitres removed surgically before (1959) and after (1970, 1975) the introduction of the iodine prophylaxis reveals an impressive increase in lymphocytic infiltration of the thyroid gland parenchyma. So-called focal lymphocytic thyroiditis is closely associated with the functional state of the organ. Furthermore, there is an increase in focal thyroiditis, especially in younger persons, after the introduction of iodine prophylaxis. Autoantibodies or clinical signs of inflammation were not found in these cases. Focal lymphocytic thyroiditis is seen as the expression of a regulatory function of the immunological system over the thyroid gland.

[Functional examination findings after parietal pleurectomy in patients with recurrent of spontaneous pneumothorax (author's transl)]. / Ergebnisse funktioneller Untersuchungen nach parietaler Pleurektomie bei Patienten mit rezidivierendem Spontanpneumothorax.

Eight patients with recurrent of spontaneous pneumothorax were re-examined sixteen months or more after a total parietal pleurectomy had been carried out. This re-examination included: 1. Detailed case history with emphasis on physical performance; 2. clinical findings; 3. Thorax x-ray at two planes; 4. Lungscintigraphy; 5. Spirometry. Following parietal pleurectomy, none of the patients exhibited any functional disturbance worthy of mention. This operative technique, perhaps modified as a partial parietal pleurectomy, can be recommended at this time as the method of choice for treating recurrent spontaneous pneumothorax.