Lipoadenoma of the parathyroid gland.

An unusual parathyroid adenoma containing abundant adipose tissue is described in four patients. In one patient, hyperparathyroidism was documented; in another, studies were incomplete but the adenoma was probably functioning. Prior reports of similar lesions have been called "parathyroid hamartoma or parathyroid adenoma with myxoid stroma," and some of these also have been shown to be functional. They may create diagnostic difficulties because of the presence of adipose tissue, a feature associated with normal parathyroid glands.

Asymptomatic primary hyperparathyroidism. 10-year prospective study.

Because factual basic knowledge is lacking regarding the natural history of primary hyperparathyroidism, it has been impossible to make a reasonable prognostication of the risks inherent to judicious observation as a justifiable alternative to neck exploration in patients with mild asymptomatic and uncomplicated hyperparathyroidism. Therefore, in January 1968 a prospective study was initiated at the Mayo Clinic in an effort to provide more information regarding the natural history of this disease. The cumulative 10-year findings of this study are presented. On the basis of the findings, it was not possible to define criteria that will predict which patients with primary asymptomatic hyperparathyroidism will ultimately require surgery.

Primary hyperparathyroidism associated with hypernephroma: a diagnostic challenge.

During the past 16 years, in which 1,600 patients were surgically treated for primary hyperparathyroidism, 10 of these patients also were operated on for hypernephroma; in another patient a hypernephroma was detected 7 2/3 years after treatment for hyperparathyroidism. Four additional patients have elevated serum calcium and immunoreactive parathyroid hormone values after nephrectomy for hypernephroma, and a provisional diagnosis of primary hyperparathyroidism has been made in these patients. Thus, the occurrence in the same patient of two disorders that may have similar biochemical abnormalities produced by similar pathophysiologic mechanisms provides a unique diagnostic challenge to the physician. The correct diagnosis of these occasionally associated disorders is facilitated by a high degree of alertness and the performance of adequate renal radiographic procedures. These should include excretory urography in patients with persistent hypercalcemia unless the procedure is contraindicated.

Primary hyperparathyroidism with multiple parathyroid gland enlargement: review of 53 cases.

Of 53 patients who had hyperparathyroidism assocated with multiple parathyroid gland enlargement, 39 (74%) had primary hyperparathyroidism without clinical or laboratory evidence of associated endocrine gland dysfunction, 2 had documented familial primary hyperparathyroidism, and 12 had hyperparathyroidism as part of the multiple endocrine neoplasia syndrome. When last studied, 31 of the 39 patients with nonfamilial hyperparathyroidism had normal serum calcium levels, 3 had permanent hypoparathyroidism, 2 had recurrent hyperparathyroidism, and 3 were lost to follow-up. The two patients with familial hyperparathyroidism were treated by removal only of enlarged parathyroid glands, and in each, hyperparathyroidism recurred. Five patients with multiple endocrine neoplasia, type 1, were treated by removal only of enlarged parathyroid glands, and hyperparathyroidism recurred in four. Four patients with multiple endocrine neoplasia, type 1, were treated by removal of three or more parathyroid glands, and there were no instances of recurrent hyperparathyroidism. In one patient, permanent hypoparathyroidism developed. Three patients with multiple endocrine neoplasia syndrome, type 2, had total parathyroidectomies as a part of thyroidectomy for medullary thyroid carcinoma. In each patient, permanent hypoparathyroidism developed. When primary hyperparathyroidism occurs in the absence of a definite history of polyendocrine or familial disease, only the glands that are definitely enlarged should be removed, and normal-appearing glands should be tagged rather than risk the possibility of permanent hypoparathyroidism that may attend routine subtotal parathyroid gland excision.

Results of subtotal parathyroidectomy for primary chief cell hyperplasia.

Analysis of the long-term results of subtotal parathyroidectomy in patients with primary chief cell hyperplasia provides evidence that refutes the recent assertion that such treatment is often ineffective. With the use of rigid criteria, 55 patients with unequivocal chief cell hyperplasia were culled from 1,576 patients who had been operated on for primary hyperparathyroidism at the Mayo Clinic between July, 1959, and July, 1976. Follow-up information, including serum levels of calcium, was obtained for all patients up to at least July, 1977. Follow-up for surviving patients ranged from 1 year to 17 years (average, 3.9 years). Seven patients (13%) were not cured by subtotal parathyroidectomy and were left with persistent hyperparathyroidism after operation, presumably because a supernumerary gland was overlooked. However, not a single patient experienced recurrent hyperparathyroidism during the 213 patient-years of follow-up. In only three patients (5%) did permanent hypoparathyroidism develop following operation. These results reaffirm the efficacy of subtotal parathyroidectomy for primary chief cell hyperplasia and call into serious question the recent advocacy of total parathyroidectomy and autotransplantation of parathyroid tissue in these cases.

Hyperparathyroidism due to single gland enlargement: prospective postoperative study.

Subtotal parathyroidectomy in all patients with primary hyperparathyroidism has been proposed by several authors. Their data suggest that hyperparathyroidism may recur in up to 30% of patients treated by a conservative operation. This recurrence is attributed to chief-cell hyperplasia as the pathology in one third to one half of all patients. A conservative operation was performed on 198 hyperparathyroid patients with a single enlarged parathyroid gland between 1968 and 1970. Mild elevation of the serum calcium level was noted in two patients three months after operation. Normal serum calcium values were noted each time they were measured in the remaining patients. The present study does not support subtotal parathyroidectomy in all patients with hyperparathyroidism.

Success rate of cervical exploration for hyperparathyroidism.

In a three-year experience with 361 patients who underwent exploratory surgery for hyperparathyroidism, the success rate for primary cervical operations was 95% and that for secondary operations (cervical and mediastinal) was 62%; for all operations, it was 94%. The three most important factors in determining successful cervical exploration of the parathyroid glands are correct preoperative diagnosis, meticulous surgical technique, and accurate determination of abnormal locations of pathologic conditions. Ancillary studies or techniques for preoperative localization of parathyroid tissue were utilized in only a few patients who had unusually complicated problems. The results of this study suggest that, because of cost, time involvement, and potential risk, selective venous sampling with radioimmunoassay of parathyroid hormone or arteriography or both should be reserved for complicated problems and for patients being considered for a second or third exploratory operation.

Acute nonfatal erysipelas in sows in a commercial farrow-to-finish operation.

Acute nonfatal erysipelas was diagnosed in 4 sows in a 1,000-sow commercial farrow-to-finish operation in Indiana. Sows were pyrexic, lethargic, lame, and had multiple, 1.3- to 7.6-cm, erythematous rhomboid skin lesions. Outbreak was attributed to failure to properly vaccinate pigs. Further morbidity and mortality were prevented by treatment of clinically affected sows and all pigs in close proximity with procaine penicillin G daily for 3 consecutive days and vaccination of all pigs with questionable vaccination status, using bacterin of killed Erysipelothrix rhusiopathiae. Periodic review of herd management protocols is important to ensure that recommended vaccination schedules are being followed and animals are receiving quality vaccinations. Human error can contribute to many production problems and should be included on the differential diagnoses list.

Pediatric emergency review: a "hands-on" approach.

A "hands-on" approach to pediatric emergency review was developed to improve retention of psychomotor skills and instill critical thinking for pediatric nurses in anticipation of pediatric emergency situations.

The social consequences of accidental injury.

A case history is presented showing how traditional beliefs affect the understanding of accidental injury. The impact of such an event on the life of a particular village is also described, and certain implications for medical workers are noted.