Virtual neck exploration: a new method for localizing abnormal parathyroid glands.

BACKGROUND DATA: Computed tomography (CT) together with 99mTc-sestamibi single photon emission computed tomography (MIBI-SPECT) image fusion (CT-MIBI-SPECT image fusion) allows virtual exploration of the neck. The aim of this study was to evaluate whether CT-MIBI-SPECT image fusion is superior to MIBI-SPECT and CT in detecting abnormal parathyroid glands in patients with primary hyperparathyroidism. METHODS: CT-MIBI-SPECT image fusion for preoperative localization was performed in 116 patients with primary hyperparathyroidism (pHPT). Both investigations were performed with reproducible fixation of the patient on a vacuum mattress. At a special work station the neck was virtually explored by viewing the CT images in all 3 dimensions. The MIBI-SPECT images were superimposed on underlying CT images. Only patients with single-gland disease were evaluated (pHPT: 112, persistent pHPT: 1, recurrent pHPT: 1, persistent secondary hyperparathyroidism: 1, tertiary HPT after kidney transplantation: 1). CT-MIBI-SPECT image fusion results were compared with those obtained with CT alone and MIBI-SPECT alone. The predicted positions were correlated with the intraoperative findings. RESULTS: CT-MIBI-SPECT image fusion was able to predict the exact position of the abnormal gland in 102 (88%) of the 116 patients, whereas CT alone showed in 75 (65%) patients and MIBI-SPECT alone in 64 (55%) patients the exact position of the abnormal gland. Sixty-two patients underwent minimally invasive surgery, namely in 21 patients with a unilaterally focused approach and in 33 patients with a bilateral approach (27 of these underwent simultaneous thyroid resection). Sensitivity for CT-MIBI-SPECT image fusion was 88%, for CT alone 70%, and for MIBI-SPECT alone 59%. Specificity for CT-MIBI-SPECT image fusion was 99%, for MIBI-SPECT alone 95%, for CT alone 94%. Overall accuracy for CT-MIBI-SPECT image fusion was 97%, for CT alone 89%, for MIBI-SPECT 87%. CONCLUSIONS: This study provides evidence that CT-MIBI-SPECT image fusion is superior to CT or MIBI-SPECT alone for preoperative localization of enlarged parathyroid glands in patients with single-gland primary hyperparathyroidism.

Virtual neck exploration in patients with hyperparathyroidism and former cervical operations.

BACKGROUND: In surgery for primary hyperparathyroidism, preoperative localization together with intraoperative parathyroid hormone assay is important when minimal invasive operations of the parathyroid glands are intended. In cases of reoperation, correct localization of the abnormal parathyroid glands is extremely instrumental. Computed tomography (CT)-(99m)Tc-sestamibi (MIBI)-single photon emission computed tomography (SPECT) image fusion allows for a virtual exploration of the neck by showing the suspected gland three-dimensionally with all the anatomic landmarks in correct position. The aim of this study was to evaluate whether CT-MIBI-SPECT image fusion is superior to MIBI-SPECT alone in detecting abnormal parathyroid glands in patients with previous neck surgery. PATIENTS AND METHODS: In a prospective study, CT-MIBI-SPECT image fusion for preoperative localization was performed in 28 patients with hyperparathyroidism and previous neck surgery. Twenty-one patients had thyroidectomy and seven patients had surgery for hyperparathyroidism. The results of MIBI-SPECT alone and CT-MIBI-SPECT image fusion were compared in these patients. The outcome and the exact predicted position, not just the predicted side, were correlated with intraoperative findings. RESULTS: CT-MIBI-SPECT image fusion was able to predict the exact position of the abnormal gland in 24 of 28 patients (86%), whereas MIBI-SPECT alone was successful in 12 of 28 cases (43%, p < 0.004) only. CT-MIBI-SPECT image fusion detected all three pathologic glands in their ectopic position. With MIBI-SPECT alone, just one ectopic pathologic gland was found. CONCLUSION: This study provides evidence that CT-MIBI-SPECT image fusion is superior to MIBI-SPECT alone in preoperative localization of enlarged parathyroid glands in patients with hyperparathyroidism and previous neck surgery. This should be kept in mind if the results are compared to earlier studies concerning CT-MIBI-SPECT image fusion.

Impaired anal sphincter function in professional cyclists.

BACKGROUND: The purpose of our study was to assess anal function in professional mountain bikers, as an increasing number of cycling enthusiasts report functional and morphological problems in the anal region. We tried to find out if constant saddle vibration suffered by professional cyclists could lead to defecation disorders. METHODS: 19 professional male mountain bikers took part in this study. The findings were compared with those of a control group (CG) of healthy volunteers who rode bikes less frequently. Both groups underwent rectal examination and anorectal manometry. Rectal sensation, rectal compliance and the anorectal inhibitory reflex were also assessed. Information on anal pain, blood on the toilet tissue, history of hemorrhoids, anal fissure, abscess formation and problems with defecation was collected by questionnaire and local examination was carried out. RESULTS: Sphincter resting pressures (89 +/- 27 mmHg vs CG: 69 +/- 16 mmHg), squeeze pressures (137 +/- 36 mmHg vs CG: 96 +/- 19 mmHg) and sphincter volumes (resting vector volume: 513 +/- 277 cc vs CG 273 +/- 170 cc, squeeze vector volume: 1389 +/- 867 cc vs CG: 490 +/- 219 cc) were significantly higher in the professional mountain bikers. Values reflecting rectal sensation (sensory threshold: 51 +/- 32 ml vs CG: 46 +/- 12 ml) were not significantly different between the groups. CONCLUSION: Proctological problems are very common in professional mountain bikers. Permanent microtrauma through constant saddle vibration may lead to chronic inflammation and anal fissure resulting in anal pain and therefore high sphincter pressure. Muscle hypertrophy as a consequence may lead to defecation disorders.

Another 'soberade' on the market: does Outox keep its promise?

OBJECTIVE: Several products are being widely promoted for reduction of the concentration of alcohol in the human body. One of these preparations, the fructose soft drink Outox, claims to noticeably increase the alcohol elimination rate (beta 60). Theories to explain this 'fructose effect' are based on the assumption that NAD+, the coenzyme for alcohol dehydrogenase, is regenerated faster in the presence of fructose. METHOD: A randomized double-blind, placebo-controlled cross-over study was performed with 30 volunteers in two drinking sessions each. Under strictly identical conditions, the same amount of alcohol was consumed, followed by the consumption of either 250 ml Outox or 250 ml placebo. Periodical measurements of blood (BAC), breath (BrAC) and urine alcohol concentration (UAC) were performed. RESULTS: Analyses revealed a significant difference (P<0.0001) between the mean alcohol levels of the Outox and the placebo drinking sessions. The overall mean BAC difference was 0.077 g/l (BAC 0.748 g/l without vs 0.671 g/l with Outox), equivalent to 10.3%. The mean BrAC difference was 0.045 mg/l (BrAC 0.314 mg/l without vs 0.269 mg/l with Outox), equivalent to 14.3%. Differences were lower for women than for men. A significant difference between the alcohol elimination rates (beta 60) was not found. CONCLUSIONS: The results show that the soft drink Outox may decrease the alcohol concentration by about 10%. However, BAC and BrAC differences are rather a consequence of slower gastric absorption of alcohol, because Outox does not increase the alcohol elimination rate. Our study demonstrates that the claim of Outox or other fructose drinks to work as a 'soberade' cannot be proven from a scientific point of view. It should be the task of physicians to warn potential consumers, especially in connection with drinking and driving.

Insular-type component follicular thyroid carcinoma in a 10-year-old girl--case report.

Insular-type carcinoma of the thyroid is a rare form of undifferentiated thyroid cancer. The manifestation of disease occurs mainly in adults and is extremely rare in children. Prognosis of this type of thyroid carcinoma is unfavorable in childhood. Because of its rarity, it is not yet clear whether these tumors carry the same risk of progression. Therapy of choice is total thyroidectomy combined with a cervical lymph node dissection. In children, surgery is associated with a higher risk of recurrent nerve palsy and loss of parathyroid glands than in adults. Therefore, identification and protection of the recurrent laryngeal nerve using electrical neuromonitoring as well as exact preparation of parathyroid glands may reduce these risks. The history of a 10-year-old girl with insular-type thyroid carcinoma is presented. Surgical considerations such as total thyroidectomy vs less-than-total thyroidectomy with unilateral or bilateral cervical lymph node dissection are presented. Prognosis concerning morbidity, pointing out the aspect of electrical neuromonitoring and precaution of parathyroid glands, and survival rate of this extremely rare entity are discussed.

Neuroendocrine tumors and second primary malignancy--a relationship with clinical impact?

BACKGROUND: Neuroendocrine tumors (NET) are frequently associated with synchronous or metachronous secondary primary malignancies (SPM). The aim of this study was to report on 14 patients with NET and SPM from a series of 96 patients with NET. PATIENTS AND METHODS: Fourteen patients with NET and synchronous or metachronous SPM were reviewed for primary site and characteristics of NET and associated SPMs as well as the outcome of these combined malignancies. RESULTS: From 1987 to 2002, 14 (14.6%) out of 96 patients with NET were identified with SPM. The median age of the patients at diagnosis of NET was 69 years (range: 56-86 yrs). There were nine female and five male patients. The localization of NET was: four in appendix, three ileum, two duodenum, one stomach, one jejunum, one pancreatic tail, one rectum and one lung. Five patients had synchronous SPM (two colon cancers with one double colon cancer, one gastric cancer, one bladder cancer, one ovarian cancer) and nine metachronous SPM (two basal cell carcinomas, one colon cancer, two breast cancer, one gastric MALT-lymphoma, one ductal pancreatic adenocarcinoma, one bladder cancer, one hepatocellular carcinoma), three months to five years after diagnosis of NET. Five patients died of metastatic tumor (three SPM: 1, 7, 10 yrs; two NET: 1, 9 yrs), two patients died of other causes (1, 7 yrs), three patients are alive with metastatic tumor (two NET: 5, 6 yrs; one SPM: 10 yrs) while four patients are tumor-free (6 ms, 2, 9, 10 yrs). CONCLUSION: NET is associated to a high degree with gastrointestinal and genitourinary SPM. In 5/14 (36%) patients SPM was diagnosed synchronously, while in 8/14 (57%) patients SPM was diagnosed metachronously. In 8/14 patients (57%) primary symptoms were caused by SPM. As a consequence, every NET should be regarded as an index tumor and risk-adapted follow-up with thorough investigation, mainly of the GI and genitourinary tracts, is to be recommended.

CT-MIBI image fusion: a new preoperative localization technique for primary, recurrent, and persistent hyperparathyroidism.

BACKGROUND: Successful minimally invasive or imaging-guided operations in patients with primary, recurrent, and persistent hyperparathyroidism are based on the reliability of preoperative parathyroid localization studies. The CT-MIBI image fusion promises a higher diagnostic accuracy than current imaging procedures. The aim of our study was to assess its reliability in correctly detecting enlarged parathyroid glands. METHODS: In a prospective study 24 consecutive patients underwent CT-MIBI image fusion as preoperative parathyroid localization procedure. The results of technetium 99m sestamibi single photon emission computed tomography (MIBI-SPECT) alone, today the standard method in parathyroid imaging, and CT-MIBI image fusion were analyzed by a blinded reviewer, and the imaging results were compared with the intraoperative findings. RESULTS: For CT-MIBI image fusion a sensitivity of 93% and a specificity of 100% in correctly detecting the position of enlarged parathyroid glands was calculated and compared with a sensitivity of MIBI-SPECT of 31% and a specificity of 87% (P<.001). This new imaging technique enabled us to successfully treat 22 of our patients (92%) with imaging-guided surgery. Twenty (83%) underwent unilateral or minimally invasive operations. CONCLUSIONS: CT-MIBI image fusion appears to be superior to MIBI-SPECT in preoperative parathyroid imaging. CT-MIBI image fusion can be performed on existing CT- and MIBI-SPECT units. We recommend this method for preoperative localization in patients with primary, recurrent and persistent hyperparathyroidism.