Technetium-99m methoxy isobutyl isonitrile (MIBI) imaging of the parathyroid glands in patients with renal failure.

BACKGROUND: Technetium-99m methoxy isobutyl isonitrile (Tc-99m MIBI) scintigraphy has been reported to be at least as reliable as thallium-technetium subtraction imaging in the preoperative localization of hyperplastic parathyroid glands in patients with renal failure. Reports have suggested that 50% of glands can be identified correctly by this method. The aim of this study was to improve on previous results and demonstrate that Tc-99m MIBI imaging has an important place in the preoperative work-up of these patients. METHODS: Eighteen patients on renal replacement therapy were studied. All had tertiary hyperparathyroidism and had Tc-99m MIBI imaging prior to parathyroidectomy. A refined reporting method was employed. The imaging results were compared to the subsequent surgical and histological findings. RESULTS: In the 12 patients in whom serum parathyroid hormone levels fell postoperatively to within or below the normal range, 38 of 46 glands (82.6%) were correctly identified and located in the correct quadrant of the thyroid gland. There were two false positive results where the imaging predicted glands not subsequently found by the surgeon. In the patients who had post-operative hyperparathyroidism, repeat Tc-99m MIBI imaging was able to locate accurately the site of the residual parathyroid tissue. CONCLUSIONS: Tc-99m MIBI imaging is able to identify more than 80% of hyperplastic parathyroid glands in renal failure patients if this reporting process is used, and locate them in the correct quadrant of the thyroid gland. Tc-99m MIBI imaging is of particular value when re-exploration of the neck is required for post-parathyroidectomy hyperparathyroidism. These results represent a significant improvement on the sensitivity of this imaging technique when compared to previous published data.

Hyponatraemia and dehydration in severe malaria.

The prevalence and likely cause of hyponatraemia in severe childhood malaria were investigated. One hundred and thirty two children, 47 of whom had cerebral malaria, were prospectively recruited and serial simple indices of fluid and electrolyte balance and renal function monitored during admission. In 55%, hyponatraemia (sodium < 135 mmol/l) was present on admission. Hyponatraemia was pronounced (sodium < or = 130 mmol/l) in 21%, and these children gained less weight during admission (mean weight gain 2.4% v 4.3%) than children with a normal sodium (135-145 mmol/l). Overall, 31% of survivors were at least moderately dehydrated on admission (5% weight gain by discharge). These children had higher plasma urea concentrations on admission (6.1 v 4.5 mmol/l) and were more acidotic (mean base excess -12.1 v -8.0) than children who were not dehydrated. There were changes in simple indices of renal function between admission and discharge in children who survived (creatinine 65.7 v 37.9 mumol/l and urea 5.5 v 1.9 mmol/l). The results suggest that dehydration is common in severe childhood malaria, that it may contribute to mild impairment in renal function, and that hyponatraemic children are less water depleted, showing appropriate rather than inappropriate secretion of antidiuretic hormone.

Antineutrophil cytoplasmic antibody-positive crescentic glomerulonephritis associated with anti-thyroid drug treatment.

Two cases of antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis following treatment with propylthiouracil and carbimazole are described. Both patients had crescentic glomerulonephritis proven by renal biopsy and responded to immunosuppressive therapy and withdrawal of the anti-thyroid drugs. Though systemic vasculitis associated with propylthiouracil is reported, this is the first report to our knowledge of renal biopsy-proven vasculitis associated with either of these drugs.

Identification of auto-transplanted parathyroid tissue by Tc-99m methoxy isobutyl isonitrile scintigraphy.

Parathyroid tissue is sometimes auto-transplanted into the forearm after 'total' parathyroidectomy in patients with renal failure. Recurrent hyperparathyroidism demands identification of the source of PTH secretion which cannot be assumed to be the forearm. To this end, Tc-99m methoxy isobutyl isonitrile (MIBI) scintigraphy was used to identify functioning auto-transplanted parathyroid tissue in seven patients undergoing renal replacement therapy (five with functioning renal transplants and two on haemodialysis). Serum PTH was estimated in venous blood taken proximal and distal to the forearm graft and from the contralateral arm, and subsequent Tc-99m MIBI scanning was carried out without knowledge of the PTH results. Five patients had a significant gradient in PTH levels between sites proximal and distal to the graft, and between the proximal site and the contralateral arm, suggesting functioning parathyroid tissue in the graft. Subsequent Tc-99m MIBI scintigraphy confirmed the activity of the auto-transplanted parathyroid tissue in these five patients. In the remaining two patients without a significant PTH gradient between the sampling sites, Tc-99m MIBI scintigraphy did not identify any functioning forearm parathyroid tissue. The scan results therefore correlated well with the gradients in PTH levels, suggesting that MIBI scintigraphy can be used to identify functioning auto-transplanted parathyroid tissue. The results also indicate that any patient who has undergone auto-transplantation of parathyroid tissue must have blood samples taken from veins proximal to the graft and either distal to it, or from the contralateral arm when parathyroid status is re-assessed, particularly when surgery is being considered for recurrent hyperparathyroidism.

Lacrimomimetic effect of topical cyclosporine a in canine keratoconjunctivitis

Realizou descriçäo dos resultados obtidos com o uso tópico da Ciclosporina A em casos clínicos de ceratoconjuntivite seca em cäes. Observam que em todos os casos tratados houve o aumento dos valores da prova de Schirmer, melhora marcada do estado clínico dos olhos e depositado sobre a córnea

Isolated tibial fractures in children.

In a review of 65 tibial fractures in children of which 25 were isolated and not associated with a fracture of the fibula, we found that isolated tibial fractures were not uncommon, and accounted for one-third of all tibial fractures in children under 11 years of age. They occur after two types of force, the most common being indirect violence involving a torsional injury. Isolated fractures unite easily without delayed union. Isolated transverse fractures never displace, and consequently do not require further radiographs following the initial check radiograph after the application of the plaster cast. In seven of the 25, the fracture was spiral or oblique and displacement into varus occurred for up to 2 weeks after the initial injury. These need careful follow-up, with weekly radiographs for the first 2 weeks. If the varus displacement is greater than 5 degrees we recommend manipulation in that period. After this time the fracture site is sticky, and manipulation will fail. Non-operative treatment is recommended for this fracture.

Total hip replacement in inflammatory hip disease using the Charnley prosthesis.

The Charnley low-friction arthroplasty was performed on 73 hips in 55 patients with inflammatory joint disease, usually for intolerable pain. Sixty-five of these operations were reviewed at a special clinic or by postal questionnaire; 57 hips were painfree or gave rise to only occasional discomfort, in 58 there was an increased range of movement, and in 46 of the 59 hips assessed clinically, the results were excellent or good. The most serious complication was deep infection, which occurred in 7 operations.

Total hip replacement in osteoarthrosis using the Charnley prosthesis.

Charnley low-friction arthroplasty was performed on 352 osteoarthritic hips, usually because of severe pain. Three hundred and twenty hips were reviewed at a special follow-up clinic or by postal questionnaire. After operation 89% of hips were pain-free or caused only occasional discomfort, and in 76% there was an increased range of movement. Of those patients actually seen for review 79% were judged to have a good or excellent result. The most frequent single complication was deep infection, which occurred in 5.3% of hips.