Accuracy of single versus combined use of ultrasonography or computed tomography in the localization of parathyroid adenoma.

OBJECTIVE: To assess the accuracy of a single versus combined use of ultrasound (US), or computed tomography (CT) in the localization of diseased parathyroid glands. METHODS: Forty-one patients with hyper-parathyroidism treated surgically between January 2000 to December 2005 at Jordan University Hospital, Amman, Jordan were included in this study. Preoperative ultrasonographic and CT findings were reviewed and compared to the intraoperative and pathologic diagnosis of diseased parathyroid glands. RESULTS: The mean age of patients was 46 years (range 16-70; 15 males and 26 females). Parathyroid adenoma was confirmed in 33 patients and hyperplasia of the parathyroid glands in 8 patients. Preoperative evaluation was carried out in 32 patients (CT scan), and in 23 patients (US). In 18 cases, the diagnosis of parathyroid disease was based on CT findings alone and in 9 patients the diagnosis was based on single US findings. Combined CT and US evaluation was carried out in 14 cases and accurate localization was reached in 12 cases yielding 86% sensitivity and 100% positive predictive value. The independent use of these techniques alone resulted in low (39%) sensitivity for US and high (78%) sensitivity values for the CT. CONCLUSION: Neck CT scan evaluation has almost an equivalent sensitivity to combined CT and neck US in the preoperative localization of diseased parathyroid glands, however the combined use of these techniques provides the best diagnostic accuracy.

Predictors of morbidity and mortality in the surgical management of hydatid cyst of the liver.

BACKGROUND/AIMS: Surgery for hydatid cyst of the liver is widely practiced worldwide; this type of management is still associated with high mortality and morbidity. The aim of this study is to find out possible predictors for this high mortality and morbidity. MATERIALS AND METHODS: The medical records of 169 patients who underwent surgery for hydatid cyst of the liver were retrospectively reviewed. The mortality and the morbidity rates were assessed as well as the following eight potential predictors of mortality and morbidity: age of the patients, size of the cyst, number of cysts, other organs involved by the disease, the presence of preoperative complications, the type of surgery performed (radical or conservative), whether the disease was new or recurrent, and when surgery was performed in the first period (1973-1986) or in the second period (1987-1999). Cross-tabulation and logistic regression between mortality and morbidity (dependent variable) and the above-mentioned eight potential predictors (independent variables) were carried out. RESULTS: Of the 169 patients, 112 were female subjects and 57 male subjects, the age range was from 5 to 85 years (mean=39.2 years), the mortality rate was 6.5% (n=11), and the overall morbidity rate was 53.8% (n=91), while specific complications of liver hydatid cyst surgery were seen in 32% (n=54). Patients of age >40 years, with a cyst diameter of >10 cm, who presented with pre-operative complications, who had conservative surgery, and who had surgery before 1987 were having a significantly higher mortality and morbidity rate. CONCLUSION: Age, size of the cyst, the presence of pre-operative complications particularly cyst-biliary communication, and type of surgical procedure performed (conservative or radical) represent as significant predictors of mortality and morbidity of surgery for liver hydatid cyst.

The spectrum of bone disease in Jordanian hemodialysis patients.

OBJECTIVE: To evaluate the spectrum of mineral abnormalities and bone disease (BD) in hemodialysis patients at Jordan University Hospital (JUH), Amman, Jordan. METHODS: A cross-sectional study was conducted among 63 patients (38 males and 25 females), mean age 44.19 years (range 17-76 years), with chronic kidney disease (CKD) on regular hemodialysis at JUH between November 2004 and April 2005. All patients have undergone complete blood count, chemistry profile, alkaline phosphatase, serum albumin, intact parathyroid hormone (iPTH) and plain x-rays. RESULTS: Bone disorders were identified in 45 patients on x-rays (70%). Osteopenia was found in 43 patients (68.3%), subperiosteal resorption in 24 patients (38.3%) and metastatic calcification in 22 patients (35%). Hypocalcemia was found in 28.6% and hypercalcemia in 7.9%. All patients were taking calcium carbonate, and 55.5% of patients were on vitamin D supplements. The calcium levels in 63.5% and the phosphorus levels in 50.8% of patients were within the recommended guidelines of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI). Serum i-PTH level was above 300 pg/ml high turnover bone disease in 24.6% of patients, 21.3% had iPTH of 150-300 pg/ml target, and 44.3% had i-PTH levels below 100 pg/mL suggesting a dynamic bone disease. Patients with severe bone disease had a statistically significant higher iPTH levels (p<0.005). CONCLUSION: Bone disease and mineral abnormalities are common in hemodialysis patients at JUH. Earlier detection of bone disease and better overall management strategy may reduce the frequency and severity of bone disease in CKD patients in Jordan.

New trends in the clinicopathological features of differentiated thyroid cancer in Central Jordan.

OBJECTIVE: To investigate the current trends in presentation and distribution of differentiated thyroid cancer (DTC) at the largest referral hospital for endocrine cancers in Central Jordan. METHODS: We analyzed the clinical features, management and outcome of 110 patients diagnosed with thyroid carcinoma at Jordan University Hospital, Amman, between 1996 and 2001. RESULTS: Papillary carcinoma was diagnosed in 87 patients (80%), follicular carcinoma in 3 patients (2.7%), Hurthle cell carcinoma in 8 patients (7.3%), medullary carcinoma in 5 (4.5%), and anaplastic carcinoma in 4 patients (3.6%), metastatic cancer in 2 patients and lymphoma in one patient. Time course analysis showed an increasing trend in surgery for thyroid cancer from 28 cases in 1986-1991 to 48 in 1996-2001. As time advanced, the incidence of locally invasive disease and lymph node involvement markedly increased over the last 5 years of the study (from 28-62%). All patients with follicular carcinoma were diagnosed in the period 1986-1994. After thyroidectomy and a follow up period of 2-15 years, 10 patients died of their disease, 4 of these died within one year from anaplastic thyroid carcinoma. CONCLUSION: The dramatic decline in the incidence of follicular thyroid carcinoma combined with the increase in the advanced forms of thyroid cancer in Central Jordan may suggest a possible environmental factor in thyroid carcinogenesis in this region. We suggest a larger scale studies and steps to investigate the etiologic factors for thyroid carcinogenesis in Central Jordan.

Gallbladder carcinoma in Jordan.

BACKGROUND/AIMS: Despite advances in diagnostic and therapeutic modalities, the prognosis of gallbladder carcinoma is still poor. The purpose of this study is to look for peculiarities of primary gallbladder carcinoma in Jordan regarding its incidence, clinical and pathological aspects. METHODOLOGY: A retrospective study over a period of 19 years comprising 66 patients was reviewed; only patients treated primarily in our hospital were included. There were 40 females and 26 males (ratio of 3:2). RESULTS: The main presenting symptom was abdominal pain in 54 patients (82%); correct preoperative diagnosis was made in only 20% of cases. Cholecystectomy alone was the most commonly performed operation (32 cases), cholecystectomy in combination with biliary bypass and/or hepatic resection (16 cases), biopsy of the gallbladder was performed in 12 cases and bypass with T-tube drainage in 6 cases. Postoperative morbidity and mortality were encountered in 48% and 18% respectively. CONCLUSIONS: The incidence and clinicopathological aspects of gallbladder cancer in Jordan seem to resemble that in the west, albeit with a lower age incidence. Diagnosis remains difficult and the outcome is still poor in the majority of cases.

Clinical spectrum of primary hyperparathyroidism.

OBJECTIVE: Primary hyperparathyroidism (1HPT) is now being diagnosed with increasing frequency. Simultaneously there has been an apparent change in the presentation of the disease and indications for surgery. The aim of this study was to examine the clinical presentation, indications for surgery, and outcomes of neck explorations for primary hyperparathyroidism. METHODS: This study was carried out over a 12 year period, January 1990 to April 2002 at Jordan University Hospital, Amman, Jordan. Information on the indications, procedure performed, pathology and complications of all neck explorations for 1HPT was obtained from a retrospective thyroid/parathyroid surgical database. A minimum of 12 months follow-up was required in order to determine outcome of surgery. RESULTS: Out of 40 patients diagnosed with primary hyperparathyroidism at Jordan University Hospital, Amman, over 12 years, 14 patients (35%) diagnosed 4 years after the onset of their disease. Severe bone disease was the main indication for surgery in 28 patients; 5 patients with fractured bones, 2 patients with bone cysts, 3 patients with brown tumors and severe osteoporosis and backache in 22 patients; renal calculi in 10 patients; muscle ache and weakness in 14 patients; acute pancreatitis in one patient and asymptomatic HPT following biochemical screening in one patient. Two patients continued to have persistent hypercalcemia after the first operation; one of them has been cured by reoperation for an ectopic parathyroid in the anterior mediastinum resulting in an overall cure rate of 97.5%. CONCLUSION: This study showed that severe bone disease with fractures, bone cysts and brown tumors are still the most common presentation of primary hyperparathyroidism in Jordan; this is most likely due to delay in diagnosis and initiation of treatment. It is important to screen for hyperparathyroidism in high risk patients and to refer these patients to specialized centers for proper management.