Mediastinal parathyroid adenoma: diagnostic and management challenges.

Primary hyperparathyroidism due to ectopic parathyroid adenomas can pose diagnostic and management challenges, especially when imaging studies have localised the lesions to different sites. We report a case of symptomatic hypercalcaemia due to a mediastinal parathyroid adenoma. Ultrasonography identified a nodule posterior to the right thyroid gland. However, computed tomography and technetium-99m sestamibi scintigraphy revealed an ectopic parathyroid adenoma located in the anterior mediastinum. The adenoma was successfully removed through a median sternotomy. However, postoperatively, the patient developed prolonged symptomatic hypocalcaemia, possibly due to suppression of the normal parathyroid gland function, although the presence of concomitant hungry bone syndrome was possible. The histopathology of the mediastinal mass was consistent with a parathyroid adenoma.

Intestinal helminthiasis in relation to height and weight of early primary school children in northeastern peninsular Malaysia.

Stool examination, height and weight measurements were undertaken on 249 early primary school children at two schools in North-eastern Peninsular Malaysia. Helminth infected children were treated and follow-up anthropometric measurements and stool examination undertaken on all (n = 100) children at one of the schools 16 months later; to observe the relationship between acquisition of infection and growth. Baseline Ascaris prevalence rates at the two schools were 16.0% (23/144) and 47.6% (50/105) respectively whilst Trichuris rates were 33.3% (48/144) and 52.4% (55/105). Hookworm infection was uncommon. There was no difference in weight or height for age between infected and uninfected children at any time. Acquisition of worm infection over the initial 16 month follow-up period was not associated with significant decreases in growth rates. However the small subsets of children with heavy Ascaris infection were consistently lighter and shorter at all evaluation times. They also gained significantly less weight and tended to have reduced linear growth rates between measurements. Further interventional studies are required to determine if this association is one of cause and effect or largely incidental.

Effect of intestinal helminthiasis on school attendance by early primary schoolchildren.

Stool examination of 249 early primary schoolchildren at 2 schools in north-eastern peninsular Malaysia revealed that 73 were infected with Ascaris lumbricoides, 103 with Trichuris trichiura, and 18 with hookworms. Infected children were treated with a single dose of 400 mg of albendazole. The school attendance records during a 60 d period before treatment and 2 consecutive 60 d periods after treatment were examined. The absenteeism rate did not improve more among infected children after treatment than it did among the uninfected control children. The correlation between worm intensity and the number of lost school-days was poor. There was no evidence that intestinal helminthiasis caused school absenteeism among this group of children.

Effect of intestinal helminthiasis on intestinal permeability of early primary schoolchildren.

Intestinal permeability of 246 early primary schoolchildren at 2 schools (106 of whom were infected with intestinal helminths) was assessed by using the lactulose/mannitol differential absorption test. The ratio of the urinary recoveries of lactulose and mannitol was determined after oral administration of a standard solution of the 2 sugars. Assessment of intestinal permeability was repeated on 100 infected children after treatment and on a cohort of 68 uninfected children. Infected and uninfected groups were compared with respect to baseline lactulose/mannitol ratio (L/M1) and change in lactulose/mannitol ratio between assessments (delta L/M). The correlations between baseline intensity of infection and L/M1, and between fall in intensity and delta L/M, were evaluated. Based on a crude index of socioeconomic status, each child was assigned to one of 3 socioeconomic groups; all but 3 children belonged to either groups 2 or 3. Trichuris trichiura and Ascaris lumbricoides were the 2 predominant infections; the hookworm infection rate was relatively low. The results suggested that helminthiasis exerted only a marginal effect on intestinal permeability, the impact of which in children from lower socioeconomic backgrounds was negligible in comparison with the cumulative effects of other factors.

Prevalance of obesity and overweight in northeastern peninsular Malaysia and their relationship with cardiovascular risk factors.

Height and body weight were measured in 2,284 subjects over 20 years old. The subjects were chosen by cluster sampling in 9 districts of Kelantan. Blood was drawn after an overnight fast for measurement of cholesterol (chol), triglyceride (TG), VLDL and HDL-Chol. Oral glucose tolerance test was performed with 75 g glucose. The overall prevalence of overweight [BMI (kg/m2) > or = 25-< or = 30] and obesity (BMI > 30) was 21.3% and 4.5% respectively. The overweight and obese were significantly younger than the lean subjects. The prevalence of hypercholesterolemia (chol > 5.2 mmol/l) in lean, overweight and obese subjects was 65.3%, 70.2% and 74.7%, respectively. Impaired glucose tolerance was found in 16.6% of the lean, 21.6% of the overweight and 32.0% of the obese subjects. Diabetes mellitus was found in 7.9% of the lean, 10.5% of the overweight and 6.7 of the obese subjects. 10.1% of lean, 13.2% of overweight and 23.3% of obese individuals were hypertensive. In conclusion, the high prevalence of overweight and obesity in Malaysia was associated with adverse lipid and glucose metabolism as well as poor blood pressure control.

Screening proteinuria and hematuria in Malaysian children.

Screening for proteinuria and hematuria is important in the prevention of chronic renal disease. In Malaysia to date no such attempt has been made to establish the prevalence of proteinuria and hematuria. A total of 45,149 primary school children from three districts in Kelantan were screened for proteinuria and hematuria. They were 23,289 boys and 21,860 girls. The prevalence of abnormal urinary sediments after third screening was 0.17% ie 0.07% were in boys and 0.10% were in girls. The commonest abnormality was proteinuria (0.12%), followed by hematuria (0.03%) and combination of proteinuria and hematuria (0.02%). Hematuria was more commonly seen in girls compared to boys while proteinuria was seen in almost equal proportion in boys and girls. Despite screening large number of children the prevalence of asymptomatic proteinuria and hematuria was far lower than in an earlier reported study. Furthermore the majority had mild abnormalities.

Carcinoma of thyroid--clinical presentation and outcome.

The clinical, biochemical and pathological features of 31 patients with thyroid carcinoma managed at Hospital Universiti Sains Málaysia, Kubang Kerian from 1985 to 1989 were analyzed. There were 25 females and 6 males. The types of carcinoma were: papillary-17 cases; follicular-10 cases; medullary-2 cases and anaplastic-2 cases. For papillary carcinoma the mean age of the patients was 52.9 years. For follicular carcinoma the mean age was 48.3 years, for medullary carcinoma, 48.5 years and for anaplastic, 74.5 years. All patients had pre-existing goitre except for 2 and most presented with advanced disease. The mean duration of symptoms for papillary carcinoma was 3.7 years, follicular carcinoma 1.6 years, medullary carcinoma 13.5 years and anaplastic carcinoma 6 months. 12 patients presented with goitre of increasing size; 9 had compression symptoms; 4 presented with cervical lymph node enlargement and 6 presented with bony pains of whom 2 had paraplegia. None of the patients were ever thyrotoxic or hypothyroid. Treatment in general was unsatisfactory because of patients' non-acceptance of surgery and/or radioactive iodine.

Diabetes mellitus in peninsular Malaysia: ethnic differences in prevalence and complications.

Estimated prevalence of diabetes mellitus in Malaysia was about 2%. Diabetes was most common in Indians especially males and least common in Chinese. There was a slight male preponderance seen in Malays and Indians. Positive family history was obtained in 14% of cases most commonly in Malays, almost 1/3 of whom had more than one family member with diabetes. Familial association was uncommon in Chinese. Over 50% of patients were overweight. Obesity was noted in nearly 70% of female Malays and Indians while the majority of Chinese were not overweight. More than 80% of patients were non insulin requiring. Youth onset diabetes was considered rare; those 10 years and below were estimated to be only 0.4% and below 20 years of age between 2%-4% of the diabetic population. Females were twice as common than males in this type of diabetes and familial association was greater. Malnutrition-related diabetes and pancreatic calcification were not well-documented but youth-onset non insulin requiring diabetics with mild symptoms but strong family history of diabetes were observed. More than half of hospital-based patients had evidence of complications, mainly amongst Malays and Indians. Hypertension was the most frequent associated disease followed by foot ulcers and ischaemic heart disease. Hypertension usually associated with chronic renal failure was most common amongst Malays while gangrenic ulcers and heart diseases were seen mainly in Indians. The major causes of death were chronic renal failure, myocardial infarction, ketoacidosis, stroke and septicaemia related to gangrene.(ABSTRACT TRUNCATED AT 250 WORDS)

Decrease of antibodies to insulin, proinsulin and contaminating hormones after changing treatment from conventional beef to purified pork insulin.

The sera of 30 patients who had been treated with conventional beef insulin were tested for binding of insulin and other pancreatic hormones. All showed antibody binding of insulin, 29 binding of proinsulin, 29 binding of pancreatic polypeptide, two binding of glucagon but none of the sera bound vasoactive intestinal peptide or somatostatin. After changing therapy to highly purified pork insulin the binding capacity of sera for insulin and the other hormones was monitored for up to 35 months and a steady fall was found in nearly all cases. In eight of the patients conventional beef insulin treatment was resumed: in one month binding of insulin and of the other hormones increased back to the initial levels. In eighteen subjects who had only received highly purified pork insulin low levels of insulin binding were found with no binding of proinsulin or other hormones. The amounts of proinsulin and contaminating hormones in highly purified pork insulin are so low that they are not immunogenic; conventional beef insulin not only contains immunogenic amounts of proinsulin and the contaminating hormones pancreatic polypeptide and glucagon but also is more immunogenic than purified pork insulin.

Insulin deficient diabetes. Contrasts with other endocrine deficiencies.

Comparisons are made between the incidence, prognosis and treatment of juvenile-onset diabetes and other endocrinopathies in the young. 548 patients with insulin deficient diabetes diagnosed before 20 years of age have been reviewed. Excess mortality, especially at 35--40 years of age was found. Profiles of blood glucose and serum insulin have been studied and compared to those of normal subjects. The variation of insulin absorption and effect of insulin antibodies on the free insulin levels achieved after exogenous insulin injections have been demonstrated. The common occurrence of nocturnal subclinical hypoglycaemia following intermediate or long-acting insulin was often found to be the cause of poor diabetic control. Five out of 33 patients with 'difficult' diabetes had an unexplained resistance to high levels of free-insulin. The value of self-monitoring and HbAl measurements in the improvement of diabetic control and possibly life expectation is reviewed. The incidence of thyroid disease was found to be increased in 1779 insulin deficient diabetics of all ages and persistence of islet-cell antibodies suggests that the diabetes may be due to autoimmunity in some of these patients.

Insulin binding capacity in patients changed from conventional to highly purified insulins. An indicator of likely response.

Highly purified insulins offer the possibility of reducing insulin antibody levels and insulin requirement. Those likely to respond cannot be predicted on clinical grounds and a simple laboratory test is recommended for this purpose. This is based on insulin binding capacity (IBC) of plasma and has been used to follow a group of 47 patients over six months. 47 patients previously treated with British soluble and isophane insulins were changed to highly purified Leo Neutral and Leo Retard. 36 showed a reduction of insulin requirement and two groups could be identified. An IBC of greater than 40 muU/ml was associated in 94% with a reduction of insulin dose; if the IBC was less the response was unpredictable. The initial IBC was related to the initial insulin requirement and to the eventual percentage reduction. Serial measurements in patients with high initial IBC showed a steady fall. Measurement of the IBC is a simple investigation; if the level is greater than 40 muU/ml changing to a highly purified insulin is likely to be associated with reduction of insulin requirement.

Effect of insulin antibodies on free and total plasma-insulin.

Insulin administration often causes the development of insulin antibodies. Plasma insulin-binding capacity was assessed and free and total plasma insulin were measured in 96 insulin-dependent diabetic patients. Patients with the highest insulin binding capacity not only had the highest total insulin but also had the lowest free insulin. It is concluded that bound insulin is not unavailable to cells, that sufficient dissociation can occur for this insulin source to make a sizeable contribution to insulin delivery to the cell receptors, and that this can happen at a very low free insulin concentration.

Improvements in skin reactions to insulin, produced by a highly purified preparation.

A group of 14 patients with skin reactions to insulin have been treated with highly purified insulin over a period of 5--14 months while continuing to inject into the abnormal areas. Fat atrophy improved in all cases, coincident with a reduction in insulin requirement and insulin binding capacity. The response of patients with fat hypertrophy was less predictable, but there was an improvement in 3 out of 6 cases. Measurements of insulin binding capacity of the plasma suggested that fat atrophy and hypertrophy are immunologically distinct and some explanations for this are discussed. It is concluded that highly purified insulin benefits some patients with skin reactions to insulin.