Skeletal remineralization after surgery for primary and secondary hyperparathyroidism.

Bone mineral was measured by photon absorptiometry before and after parathyroid surgery in patients with primary or secondary hyperparathyroidism (HPT). The mean bone mineral density of lumbar vertebrae was 0.82 +/- 0.04 (SEM) gm/cm2 in primary HPT (n = 7) and 0.86 +/- 0.05 gm/cm2 in secondary HPT (n = 11). These values are significantly lower than for age-matched normal subjects. After successful parathyroid surgery, the bone mass of the distal radius and lumbar vertebrae increased by approximately 10% within 3 months after operation and then remained stable during the first postoperative year. In conclusion, parathyroid surgery is followed by a significant increase of bone mass in primary and secondary HPT. The substantial increase in bone mass in parts of the skeleton consisting predominantly of trabecular bone, as well as in sites with predominantly cortical bone, indicates that remineralization after operation involves a generalized increase in bone mass.

Skin circulation in the nipple after reduction mammaplasty by upper and lower glandular resections.

Avascular necrosis of the nipple is a serious complication of reduction mammaplasty with nipple transposition. A study was undertaken to measure the skin circulation in the nipple before, during and after this operation. In 14 patients undergoing a reduction mammaplasty according to the method of Strömbeck, the skin circulation was measured in 25 breasts with laser doppler flowmetry (LDF) and fluorescein flowmetry (FF). LDF showed that the skin circulation increased after de-epithelialization to 204.4 +/- 31.0% of the preoperative value (100%) (mean +/- SEM, p less than 0.01). After the upper and lower glandular resection the circulation was reduced to 90.7 +/- 12.3% of the preoperative value. The division of the lateral pedicle did not affect the circulation. After the skin had been sutured, the circulation was 71.5 +/- 9.1% of the preoperative value (p less than 0.01). One to four days postoperatively the circulation was 100.3 +/- 13.2% of the preoperative value. At FF uniform fluorescence was observed in the nipple postoperatively in all patients but two, in whom avascular necrosis later developed. Our results thus show that the circulation in the nipple after reduction mammaplasty by the Strömbeck method is adequate and that it is safe to divide the lateral dermal pedicle.

The role of parathyroidectomy in the treatment of secondary hyperparathyroidism before and after renal transplantation.

In a series of 335 renal transplant recipients, 28 patients underwent parathyroidectomy due to secondary hyperparathyroidism. Twenty patients were operated on prior to renal transplantation, 8 subsequent to it. Solitary adenomas were found in 6 cases, diffuse hyperplasia in 22. Fifteen of the patients with diffuse hyperplasia underwent total parathyroidectomy with autotransplantation of parathyroid fragments into the sternocleidomastoid muscle, subtotal parathyroidectomy was performed in 7. Four hypercalcaemic patients underwent parathyroid surgery because of deteriorating transplant function but without improvement. Following parathyroidectomy, 21 patients became hypocalcaemic. 15 of these patients had undergone total parathyroidectomy and autotransplantation. Dihydrotachysterol substitution was accompanied by toxic symptoms in three patients on dialysis and by deteriorating renal function in two transplanted patients. Therefore, subtotal parathyroidectomy is recommended as the surgical procedure of choice in the treatment of secondary hyperparathyroidism before, as well as after renal transplantation.

Secondary hyperparathyroidism and its sequelae in renal transplant recipients. Long term findings in a series of conservatively managed patients.

The prevalence and duration of secondary hyperparathyroidism in 42 renal transplant recipients, and the sequelae of this condition, were studied. Immediately before transplantation, an elevated PTH-value was recorded in 76% of the patients, postoperatively there was a marked drop. Early after successful transplantation, 57% of the patients had hypercalcemia. At follow-up 3 years later, moderate hypercalcemia persisted in half of the patients but only 3 patients had significantly elevated PTH. The quality of renal graft function was not inferior in the hypercalcemic patients. Subperiosteal bone resorption and soft tissue calcifications were more common among the hypercalcemic patients. Our data suggest that secondary hyperparathyroidism can be managed conservatively in most renal transplant recipients. If progressive bone changes occur, surgical removal of parathyroid tissue should be considered.

Diurnal variations in the urinary excretion of calcium and phosphate in hyperparathyroidism.

The urinary excretion of calcium and phosphate during the day and night was studied in 20 patients with primary hyperparathyroidism and in the same number of controls with normal function of the parathyroids. A significant difference in TRP between day and night was found in the controls but not in the HPT group. In other respects there were no substantial differences between day and night. The higher excretion of calcium observed in the HPT group was largely attributable to the patients with remal calculi. The simplified sampling procedure when only night urine is analysed has no disadvantages-it is more likely to improve the diagnostic reliability as it reduces the influence of meals, for example.

Neutrophil leucocyte function in primary hyperparathyroidism.

Neutrophil leucocyte chemotaxis, phagocytosis and oxidative metabolism were measured in six patients with primary hyperparathyroidism (HPT) who underwent parathyroidectomy. The preoperative neutrophil chemotaxis value was 6.2 +/- 0.3 arb.U. and this decreased to 5.8 +/- 0.5 arb.U. (p less than 0.05) on the third postoperative day and to 5.4 +/- 0.3 arb.U. three weeks later. Serum calcium levels were 2.95 +/- 0.06 mmol/l preoperatively and decreased to 2.20 +/- 0.05 (p less than 0.05) and 2.34 +/- 0.05 mmol/l (p less than 0.05) on the third and 21st day after parathyroidectomy. Phagocytosis measured as the intracellular uptake of complement-opsonized yeast particles by neutrophils was not influenced by operation. In a control group, six patients undergoing hemithyroid ectomy due to microfollicular tumours were studied. In this group leucocyte chemotaxis, phagocytosis and serum calcium levels were not significantly different before and after surgery. Neutrophil oxidative metabolism, measured by the ability of the cells to reduce nitroblue tetrazolium (NBT), was similar in the HPT and control groups both before and after operation. The results indicate that HPT is associated with an abnormal leucocyte migration which is reversed after successful parathyroidectomy.

Jejunal diverticula causing massive haemorrhage.

Two elderly patients with massive bleeding from jejunal diverticulosis are reported. Scintigraphy revealed the bleeding source. Emergency resection of the involved portion of jejunum cured the patients. Few such cases have been published. Although very rare, one must always have in mind jejunal diverticula to be the source of gastrointestinal haemorrhage.

Physical interpretation of diaphanograms using the computer-controlled image scanner OSIRIS.

Experiments have shown that the light recorded in diaphanography covers approximately the wavelength region of 645 to 900 nm. No significant change in image quality was noted by changing the camera distance between 10 and 25 cm and the light source aperture between 5 and 30 mm. Experiments using polarising filters indicated that the breast is optically isotropic; therefore the results cannot be improved by using polarising filters. In a comparison of various films. Kodak Ektachrome Infrared Film gave the best results. No degradation or variation in image quality was observed when different batches were compared or when the exposed film was stored for 3 weeks before processing. The exposure level is a critical factor and a series of 3 images is needed for optimum evaluation of diaphanograms. The experiments indicate that diaphanography gives consistent results.

Breast carcinoma and benign breast lesions. Diaphanography and quantitative evaluation using the computer-controlled image scanner OSIRIS.

A total of 110 diaphanograms from women with breast carcinoma and 154 diaphanograms from women with benign breast disorders were quantitatively evaluated using the OSIRIS image scanner. Optical density values in the green and red spectral bands were recorded. The malignant and the benign groups, were statistically evaluated using linear discriminant analysis. Correct classification was obtained in 73.5 per cent of women with breast carcinoma and in 84.6 per cent of women with benign breast disorders. Visual interpretation of the findings alone classified 84.5 per cent of the malignant lesions correctly and 90.8 per cent of the benign lesions correctly. Quantitative evaluation combined with visual interpretation improved the accuracy of classification of breast carcinoma (91.8%), but not of benign breast disorders, which was about the same (83.8%).

Urinary phosphate excretion after total thyro-parathyroidectomy in thyroid carcinoma.

It is well established that deficiency of parathyroid hormone causes an increase of the tubular reabsorption of inorganic phosphate. Earlier evaluations, however, are based on animal experiments or in clinical studies where the degree of a postoperative hypoparathyroidism is not clearly defined. Eight patients with thyroid cancer have been operated on with a total thyroparathyroidectomy, biopsy of all identified parathyroids and autotransplantation of these glands. During a postoperative period of 3-5 days there is an arrest of the paraghyroid function before the glands have a new vascular supply. The levels in the serum and urine of calcium, phosphate, sodium, potassium, magnesium, chloride and creatinine were recorded. The excretion of phosphate diminished to unmeasurable values, indicating a complete tubular reabsorption of phosphate. After 5-6 days, when the autografted parathyroids began to function, phosphate reappeared in the urine together with a slow increase in S-Ca. No substitution with calcium or vitamin D was given in the postoperative period.

Dexon for sutures and ligatures.

Dexon has been used in 375 operations of various types on 360 patients. No wound infection was observed in the group of 'clean' cases. As Dexon is absorbed completely but relatively slowly and at an even rate, it can even be used in most instances instead of non-absorbable suture and ligature materials. When used for sutures and ligatures in operations of various types, Dexon costs about the same as catgut.

Neural crest tumour syndromes.

Cells eminating from the embryological neural crest can create different neoplasias, some of them endocrinological active and sometimes multiple (MEN or MEA). The relationship between these conditions and multiple neurofibromas is pointed out. Three cases of MEA which have been operated on at Huddinge Hospital are presented.

Transitory congenital hypothyroidism and maternal thyroiditis.

The case histories of two sisters with congenital hypothyroidism are described. Their mother had had high titers of circulating thyroid antibodies during each pregnancy. In the older sister, antibodies were detected at 4 weeks but not a 6 months of age. This girl showed a partial hypothyroidism, that required replacement therapy. However, in the younger sister, the hypothyroidism was reversible and replacement therapy was discontinued after 2 years.

The value of diaphanography as an adjunct to mammography in breast diagnostics.

Histologically classified carcinoma and benign breast disorder was present in 100 respectively 163 cases of symptomatic women. The results of diaphanography were correlated with those obtained by clinical examination, mammography and histology. A false negative diagnosis was made in 17 cases (15.5%) using diaphanography and in 13 cases (11.8%) using mammography. A false positive diagnosis was made in 15 cases (9.2%) with diaphanography and in 33 cases (20.2%) with mammography. The use of both mammography and diaphanography reduced the number of false negatives from 11.8 per cent to 5.5 per cent. In conclusion, diaphanography has been demonstrated to be a useful adjunct to mammography.

The ambulance helicopter is a prerequisite for centralised emergency care.

During the summer seasons of 1978-1983 (56 weeks), trial activity with a physician-manned ambulance helicopter was carried out in the County of Stockholm (population 1.5 million). The area includes an extensive archipelago. Within the region there are 11 large general hospitals, three of which are supplied with a helicopter pad. During the trial period 1 246 helicopter missions were undertaken, of which 943 resulted in emergency transportation of the patient (83% by helicopter, 17% by ambulance). The number of missions per day varied from 0-11, with a mean number of 3.2. The turn-out time from receipt of the call to arrival at the scene of the accident or illness was less than 30 minutes in 75% of the cases. Of the emergency calls, 57% involved cases of illness and 43% accidents. Therapeutic intervention by doctors at the scene was considered to have been of vital importance in 22% of the cases, desirable in 28% and unnecessary in 50%. This intervention was regarded as life-saving in 18 cases (2%). By special training of emergency call operators, the number of unnecessary helicopter missions could be minimised (9% of all missions). To continuing specialisation and centralisation of emergency care with extended catchment areas, demands an advanced transport system. This trial has shown that through the use of a physician-manned ambulance helicopter the emergency care within the region can be centralised with retention of adequate turn-out times.

Ophthalmopathy and hyperthyroidism. A comparison between patients receiving different antithyroid treatments.

The ocular manifestations in 125 thyrotoxic patients observed for 6-20 years are presented. The incidence and development of ophthalmopathy in three different treatment group medical- (eta = 72), radionuclear (eta = 36) and surgical (eta = 17) are showed. The degree of ophthalmopathy is similar in all groups, and no statistically significant difference is found in the development of ophthalmopathy.

Indications for surgery in the elderly patient with primary hyperparathyroidism.

The major symptoms presented by the elderly patient with primary hyperparathyroidism (HPT) were studied in 30 patients, all of whom were over 70 years of age (70-89). Neuromuscular symptoms, fatigue or mental symptoms were the main complaint in 14 patients. Nephrolithiasis, pancreatitis, skeletal changes or thyroid diseases were associated with HPT in 13 patients. Three patients were considered to be asymptomatic. Seven out of the eight patients with neuromuscular symptoms, and two of the three patients with extreme fatigue as the dominant symptom, improved postoperatively. This study indicates that for elderly patients with HPT especially when associated with neuromuscular symptoms or fatigue, surgical therapy is the treatment of choice.

Diaphanography in breast carcinoma. Correlation with clinical examination, mammography, cytology and histology.

Histologically classified carcinoma was present in 110 breasts of 108 symptomatic women. The results of diaphanography (DPG) were correlated with those obtained by clinical examination (CE), mammography (M) and cytology (C). A tumour was palpable in 87 cases (79.1%). A false negative diagnosis was made in 17 cases (15.5%) using DPG, in 13 cases (11.8%) using M and in 15 cases (13.6%) using C, but in 12 of the latter cases (10.9%) the specimen was not representative. The validity of the findings using DPG and M was also analysed. The calculations were based on the results obtained from the present investigation and from a study of diaphanography in 163 cases of benign breast disorders. For DPG the sensitivity was 85 per cent, the specificity 91 per cent, the positive predictive value 86 per cent and the negative predictive value 90 per cent. For M the sensitivity was 86 per cent, the specificity 80 per cent, the positive predictive value 75 per cent and the negative predictive value 91 per cent. The specificity for diaphanography was significantly different from mammography (p less than 0.05). The use of both M and DPG reduced the number of false negatives from 11.8 per cent to 5.5 per cent. In conclusion, DPG has been demonstrated to be a useful adjunct to CE and M.

The catecholamine concentration in central veins of hypertensive patients--an aid not without problems in locating phaeochromocytoma.

The concentrations of adrenaline, noradrenaline and cortisol in blood sampled at routine attempts at catheterization of the adrenal and renal veins, the inferior vena cava and the azygos and hepatic veins were measured in six patients with a phaeochromocytoma and six patients with hypertension due to other causes. In the non-tumour patients the adrenaline and noradrenaline concentrations, compared with normal values for peripheral venous blood, were abnormally high in five out of seven samples from the site of the left adrenal vein but in only one out of seven from the right side. In all the adrenal vein samples with an abnormally high catecholamine concentration the cortisol level was also elevated, and it was at least 100 per cent higher than in samples from the inferior vena cava. This suggests that a high catecholamine concentration linked with an elevated cortisol level is merely an indication of correct adrenal vein sampling and is not necessarily evidence of a tumour. In successful attempts of sampling adrenal venous blood (cortisol levels increased), concentrations of adrenaline and noradrenaline of up to 100 and 20 nmol/l, respectively, can be regarded as normal. From a retrospective analysis of catecholamine levels in the six tumour patients it is clear that owing to the variability of venous drainage from the right adrenal gland, the technique of adrenal venous blood sampling may be unreliable and even misleading in attempts to locate a phaeochromocytoma. This is also true in patients with generally elevated catecholamine levels.