Giant recurrent intrathoracic goitre treated by clamshell thoracotomy and reverse sternotomy.

A 59-year-old man with a giant recurrent intrathoracic goitre was admitted for completion thyroidectomy for recurrent severe retrosternal pain. The patient had undergone a cervical thyroidectomy elsewhere 13 years earlier, during which only the cervical part of the goitre had been resected. Owing to the previous operation with an expected scar around the innominate vein, and the goitre's size and localisation obstructing the upper chest aperture, we chose an alternate access. Clamshell thoracotomy with reverse sternotomy allows central vascular control and excision of large goitres bypassing predictable problems at the cervicothoracic junction. Surgery was performed with minimal blood loss and with excellent functional outcome. The described access adds to the repertoire to deal with this unusual situation.

Georg Philip Nenter and medicine "by notes" in the 18th century.

Even though it is true that the medical historiography of the 18th century is lacking in great scientific personalities, it is equally true that the entire century is characterized by continuous efforts to encapsulate the medical area of knowledge, acquired until then, in precise and systematic outlines, to serve the academic teaching of the subject of medicine. Georg Philip Nenter, a pupil of Georg Ernst Stahl and a professor of medicine in the University of Strasburg, could not help being influenced by that atmosphere. He added though, in our opinion, a touch of remarkable modernity. In fact his volume Fundamenta medicinae teoretico-pratica (Venice, 1735) is a wonderful collection of the notes taken during his lectures. The description of various diseases - renal diseases in particular - maintains a very systematic development of the subject through various chapters (definition, clinical manifestations, differential diagnosis, prognosis, treatment and examples of specific prescriptions), as if students were being addressed.

Subcutaneous epoetin-alpha every one, two, and three weeks in renal anemia.

BACKGROUND: The same epoetin dose administered subcutaneously (SC) once weekly instead of thrice or twice weekly to patients with renal anemia is reported to be equally effective. The aim of this study was to verify whether a target hemoglobin (Hb) could be maintained with SC epoetin administered at longer intervals - every one, two or three weeks. METHODS: This was a single-center, retrospective cohort study on 67 consecutive outpatients (35 adult caucasian males) with anemia secondary to chronic renal insufficiency, all in follow-up for at least 12 months, who maintained the target Hb of 11 to 13 g/dL for six months with one SC injection of 10,000 U epoetin-alpha every five days (14,000 U/wk), or every one (Epo/1, 10,000 U/wk), two (Epo/2, 5,000 U/wk) or three weeks (Epo/3, 3,333 U/wk) according to their Hb concentrations after the induction phase. RESULTS: The target Hb > or = 11 g/dL was maintained over six months of treatment with SC epoetin > 10,000 U/week in 4 patients (6.0%, 95% CI 1.5-14.6) and with SC epoetin < or = 10,000 U/week in 63 patients (94.0%, 95% CI 85.4-98.4). Among the latter, 16 (25.4 %, 95% CI 15.3-37.9) maintained the target with Epo/1, 25 (39.7 %, 95% CI 27.6 to 52.8) with Epo/2, and 22 (34.9 %, 95% CI 23.3 to 48.0) with the Epo/3 regimen. On average, they received 5,688 U/week (86.2 U/kg/week) and the expected number of injections was 30 per year. CONCLUSIONS: Epoetin 10,000 U SC every two or three weeks maintained the target Hb concentration of 11-13 g/dL over a six month period in 75% of patients. Prospective, randomized and controlled trials are needed to establish the validity of this simplified regimen.