Prospective Validation of Two 4D-CT-Based Scoring Systems for Prediction of Multigland Disease in Primary Hyperparathyroidism.

BACKGROUND AND PURPOSE: Patients with multigland primary hyperparathyroidism are at higher risk for missed lesions on imaging and failed parathyroidectomy. The purpose of this study was to prospectively validate the ability of previously derived predictive score systems, the composite multigland disease score, and the multiphase multidetector contrast-enhanced CT (4D-CT) composite multigland disease score, to identify patients with a high likelihood of multigland disease. MATERIALS AND METHODS: This was a prospective study of 71 patients with primary hyperparathyroidism who underwent 4D-CT and successful parathyroidectomy. The size and number of lesions identified on 4D-CT, serum calcium levels, and parathyroid hormone levels were collected. A composite multigland disease score was calculated from 4D-CT imaging findings and the Wisconsin Index (the product of the serum calcium and parathyroid hormone levels). A 4D-CT multigland disease score was obtained by using the CT data alone. RESULTS: Twenty-eight patients with multigland disease were compared with 43 patients with single-gland disease. Patients with multigland disease had a significantly smaller lesion size (P < .01) and a higher likelihood of having either ≥2 or 0 lesions identified on 4D-CT (P < .01). Composite multigland disease scores of ≥4, ≥5, and 6 had specificities of 72%, 86%, and 100% for multigland disease, respectively. 4D-CT multigland disease scores of ≥3 and 4 had specificities of 74% and 88%. CONCLUSIONS: Predictive scoring systems based on 4D-CT data, with or without laboratory data, were able to identify a subgroup of patients with a high likelihood of multigland disease in a prospectively accrued population of patients with primary hyperparathyroidism. These scoring systems can aid in surgical planning.

Predictors of Multigland Disease in Primary Hyperparathyroidism: A Scoring System with 4D-CT Imaging and Biochemical Markers.

BACKGROUND AND PURPOSE: Multigland disease represents a challenging group of patients with primary hyperparathyroidism. Additional lesions may be missed on imaging because they are not considered or are too small to be seen. The aim of this is study was to identify 4D-CT imaging and biochemical predictors of multigland disease. MATERIALS AND METHODS: This was a retrospective study of 155 patients who underwent 4D-CT and successful surgery with a biochemical cure that compared patients with multigland and single-gland disease. Variables studied included the size of the largest lesion on 4D-CT, the number of lesions prospectively identified on 4D-CT, serum calcium levels, serum parathyroid hormone levels, and the Wisconsin Index (the product of serum calcium and parathyroid hormone levels). Imaging findings and the Wisconsin Index were used to calculate a composite multigland disease scoring system. We evaluated the predictive value of individual variables and the scoring system for multigland disease. RESULTS: Thirty-six patients with multigland disease were compared with 119 patients with single-gland disease. Patients with multigland disease had significantly lower Wisconsin Index scores, smaller lesion size, and a higher likelihood of having either multiple or zero lesions identified on 4D-CT (P ≤ .01). Size cutoff of <7 mm had 85% specificity for multigland disease, but including other variables in the composite multigland disease score improved the specificity. Scores of ≥4, ≥5, and 6 had specificities of 81%, 93%, and 98%, respectively. CONCLUSIONS: The composite multigland disease scoring system based on 4D-CT imaging findings and biochemical data can identify patients with a high likelihood of multigland disease. Communicating the suspicion for multigland disease in the radiology report could influence surgical decision-making, particularly when considering re-exploration in a previously operated neck or initial limited neck exploration.

Laparoscopic surgery is safe for large adrenal lesions.

INTRODUCTION: Laparoscopic adrenalectomy has surpassed open adrenalectomy as the gold standard for excision of benign adrenal lesions. The size threshold for offering laparoscopic adrenalectomy is controversial as the prevalence of adrenocortical carcinoma increases with increasing tumour size. The aim of this paper was to assess the safety of laparoscopic adrenalectomy for large adrenal tumours (tumours > or = 60 mm). METHODS: A retrospective cohort study of patients who underwent adrenalectomy in a single unit during the period 1995-2005 was undertaken. RESULTS: One hundred and seventy patients with 173 tumours were included in this study. Of these, 29 were > or = 60 mm in size, and 16 of these patients underwent laparoscopic adrenalectomy. There were 8 adrenocortical carcinomas in the group with tumours > or = 60 mm in size. Five of these patients underwent an open adrenalectomy, while 2 and 1 patients had laparoscopic and laparoscopic converted to open adrenalectomy respectively. Four of the patients undergoing open adrenalectomy died of their disease while 1 is alive with recurrence 3 years later. The 3 patients who underwent either laparoscopic or laparoscopic converted to open adrenalectomy are alive without evidence of disease after 18 months follow up. CONCLUSION: Our data show that patients with tumours > or = 60 mm with no preoperative or intraoperative evidence of malignancy can undergo laparoscopic adrenalectomy without evidence of recurrence on short term follow up. These findings are concordant with the growing body of literature supporting laparoscopic adrenalectomy for potentially malignant tumours > or = 60 mm in size without preoperative or intraoperative features of malignancy.

Cytokine-stimulated, but not HIV-infected, human monocyte-derived macrophages produce neurotoxic levels of l -cysteine.

Approximately one-quarter of individuals with AIDS develop neuropathological symptoms that are attributable to infection of the brain with HIV. The cognitive manifestations have been termed HIV-associated dementia. The mechanisms underlying HIV-associated neuronal injury are incompletely understood, but various studies have confirmed the release of neurotoxins by macrophages/microglia infected with HIV-1 or stimulated by viral proteins, including the envelope glycoprotein gp120. In the present study, we investigated the possibility that l -cysteine, a neurotoxin acting at the N-methyl-d -aspartate subtype of glutamate receptor, could contribute to HIV-associated neuronal injury. Picomolar concentrations of gp120 were found to stimulate cysteine release from human monocyte-derived macrophages (hMDM) in amounts sufficient to injure cultured rat cerebrocortical neurons. TNF-alpha and IL-1beta, known to be increased in HIV-encephalitic brains, as well as a cellular product of cytokine stimulation, ceramide, were also shown to induce release of cysteine from hMDM in a dose-dependent manner. A TNF-alpha-neutralizing Ab and an IL-1betaR antagonist partially blocked gp120-induced cysteine release, suggesting that these cytokines may mediate the actions of gp120. Interestingly, hMDM infected with HIV-1 produced significantly less cysteine than uninfected cells following stimulation with TNF-alpha. Our findings imply that cysteine may play a role in the pathogenesis of neuronal injury in HIV-associated dementia due to its release from immune-activated macrophages but not virus-infected macrophages. Such uninfected cells comprise the vast majority of mononuclear phagocytes (macrophages and microglia) found in HIV-encephalitic brains.

A cane reduces loss of balance in patients with peripheral neuropathy: results from a challenging unipedal balance test.

OBJECTIVE: To test the hypothesis that use of a cane in the nondominant hand during challenging balance tasks would significantly decrease loss of balance in patients with peripheral neuropathy while transferring from bipedal to unipedal stance on an unsteady surface. DESIGN: Nonrandomized control study. SETTING: Tertiary-care institution. PARTICIPANTS: Eight consecutive patients with peripheral neuropathy (PN) and eight age- and gender-matched controls (C) with a mean (SD) age of 65 (8.2) years. METHODS: Subjects were asked to transfer their weight onto their right foot, despite a rapid +/- 2 degrees or +/- 4 degrees frontal plane tilt of the support surface at 70% of weight transfer, and balance unipedally for at least 3 seconds. The efficacy of their weight transfer was evaluated over 112 consecutive randomized and blocked trials by calculating loss of balance as failure rates (%FR) with and without visual feedback, and with and without use of a cane in the nondominant (left) hand. Results were analyzed using a 2 x 2 x 2 x 2 x 2 repeated-measures analysis of variance (rm-ANOVA) and post hoc t tests. RESULTS: The rm-ANOVA showed that the FR of the PN subjects (47.6% [18.1%]) was significantly higher than C (29.2% [15.2%], p = .036). Removing visual feedback, simulating the dark of night, increased the FR fourfold (p = .000). Use of a cane in the contralateral nondominant hand significantly reduced the FR (p = .000), particularly in the PN group (cane x disease interaction: p = .055). Post hoc t tests showed that with or without visual feedback, the cane reduced the FR of the PN group fourfold and enabled them to perform more reliably than matched controls not using a cane (p = .011). An inversion perturbation resulted in a higher FR than an eversion perturbation (p = .007). The PN group employed larger mean peak cane forces (21.9% BW) than C (13.6% BW) in restoring their balance (p = .000). CONCLUSION: Use of a cane by PN patients significantly reduced their risk of losing balance on unstable surfaces, especially under low-light conditions.