Absence of abdominal pain in older persons with endoscopic ulcers: a prospective study.

OBJECTIVE: In a retrospective study we reported absence of abdominal pain in 35% of elderly patients with peptic ulcer disease. We now report a prospective study on this question. METHODS: Patients undergoing upper GI endoscopy were systematically questioned before endoscopy. A reproducible method for identifying the location of symptoms was used. Among patients referred for upper endoscopy, there was no selection of patients for study purposes as all had strong indications, such as pain, dyspepsia, GI bleeding, weight loss, or anemia. Patients were divided into two groups according to age: A younger group consisting of patients <50 yr (mean, 33.6 yr) and an older group >60 yr (mean, 70.9 yr). RESULTS: A total of 277 patients were included in the study. There was no significant difference in reported use of medications, alcohol, or cigarette use between the groups. Of the 106 patients with peptic ulcer, 15 (14.2%) had not experienced pain. Abdominal pain was absent in 5 (6.9%) of the younger patients and 10 (29.4%) of the older patients. The difference was significant using the chi2 method (p = 0.004). A trend toward an even higher proportion of pain-free peptic ulcer disease was noted in the elderly female group (37.5%), but it did not reach statistical significance. CONCLUSIONS: Absence of abdominal pain is confirmed in approximately 30% of elderly patients with peptic ulcer disease.

99m-Technetium sestamibi localized solitary parathyroid adenoma as an indication for limited unilateral surgical exploration.

BACKGROUND: Because of its successful localization of solitary adenomas, 99m-Technetium sestamibi (MIBI) may challenge the standard operation for primary hyperparathyroidism. METHODS: Thirty-five consecutive patients underwent preoperative MIBI localization to optimize a surgical approach. Single-site localization in 21 patients directed a limited unilateral neck exploration (UNE) with adenomectomy and ipsilateral gland biopsy. Fourteen patients who did not localize underwent bilateral neck exploration (BNE). Conversion to a bilateral operation was required in 1 UNE patient because no adenoma was found on that side. RESULTS: There were no significant differences in preoperative and postoperative serological markers between the two groups. However, the total operative time for UNE (49 +/- 21 minutes) was significantly less than for BNE (103 +/- 45 minutes; P <0.001). CONCLUSIONS: Preoperative MIBI scan-directed limited unilateral neck operation may be used reliably for primary hyperparathyroidism due to a single adenoma, and thereby reduce operative time, extent of surgical dissection, and risk.

Cost utility of routine imaging with Tc-99m-sestamibi in primary hyperparathyroidism before initial surgery.

Tc-99m-sestamibi has been shown to localize parathyroid adenomas effectively, but controversy continues as to the use of this scan before initial surgery for primary hyperparathyroidism. We analyzed the cost utility of obtaining this study before initial surgery for primary hyperparathyroidism. Twenty-two consecutive patients with primary hyperparathyroidism underwent dual-phase Tc-99m-sestamibi scan before initial bilateral neck exploration. Surgical findings were correlated with the results of sestamibi scan. There were 15 women and 7 men, with a mean age of 50.5 years (range, 22-76). Preoperative mean total calcium was 11.74 mg/dL (range, 10-15), ionized calcium was 6.19 mg/dL (range, 5.2-7.7), and intact parathyroid hormone was 153.5 pg/mL (range, 83.1-551). Postoperative mean ionized calcium was 4.56 mg/dL (range, 4.1-5.57). Twenty sestamibi scans had a positive localization, and 2 scans had no localization. At surgery, 18 solitary adenomas, 3 diffuse hyperplasias, and 1 patient with four normal parathyroid glands were found. Sixteen sestamibi scans were true positive (solitary adenoma), 4 scans were false positive (2 diffuse hyperplasia, 1 wrong side, and 1 lymph node), 1 negative scan was true negative (diffuse hyperplasia), and 1 negative scan was false negative (adenoma). One patient (four normal glands) at the second operation had a supernumerary fifth gland adenoma excised from the mediastinum. Preoperative Tc-99m-sestamibi scan did not offer any advantage when a complete bilateral neck exploration is performed. Sixteen of (84%) adenomas were correctly localized, but 18 of 19 adenomas were in the neck and were easily found. The 1 ectopic adenoma was not found by scanning or with initial surgery. The 4 of 22 (18%) false-positive localizations and the 2 of 22 (9%) negative scans contributed nothing to the surgery. Of the 22 localizing sestamibi scans, surgery was not altered to affect the outcome. At a cost of $550 per sestamibi scan and with the error inherent in the scan, it is not cost effective to obtain Tc-99m-sestamibi scan before initial surgery for primary hyperparathyroidism.

Opportunistic lung infection with Corynebacterium pseudodiphtheriticum after lung and heart transplantation.

Corynebacterium pseudodiphtheriticum is usually regarded as a harmless commensal of the skin and mucous membranes. We describe two cases of bronchiolitis and bronchitis after lung and heart transplantation, respectively, in which this organism was strongly implicated as the pathogen.

In vivo uptake of technetium-99M-sestamibi by parathyroid glands in comparison to surrounding tissues of the neck.

Technetium-99M-sestamibi (Tc-99M-sestamibi) has recently been proven to be a sensitive and specific agent for imaging of parathyroid disease; however, the selective nature of its uptake by different tissues has not been investigated. Fifteen consecutive patients undergoing neck exploration for hyperparathyroidism were given 3 to 15 mCi of Tc-99M-sestamibi at various times before surgery, and at the time of exploration, samples of parathyroid tissue, blood, fat, muscle, and thyroid were taken from the neck. All samples were carefully weighed and counts of radioactivity were measured. Activity was normalized to counts per gram of tissue and counts of radioactivity were compared using a multiple range analysis of variance test. Mean counts per gram (+/- SE) in abnormal parathyroid tissue (adenomas and hyperplastic glands; 1.1 x 10(6) +/- 2.7 x 10(6)) were significantly higher than in any of the other tissues measured (P < 0.05): thyroid, 7.0 x 10(4) +/- 1.6 x 10(4); muscle, 8.9 x 10(4) +/- 2.1 x 10(4); fat, 2.1 x 10(4) +/- 4.2 x 10(3); and blood, 9.8 x 10(3) +/- 2.3 x 10(3). Mean ratios of counts (+/- SE) of abnormal parathyroid tissue to other tissues were found to be as follows: thyroid, 35.3 +/- 12.6; muscle, 17.4 +/- 6.2; fat, 80.7 +/- 20.0; and blood, 161.0 +/- 31.6. From these data, Tc-99M-sestamibi clearly exhibits significantly higher uptake in abnormal parathyroid tissue relative to other tissues measured in the neck. This increased uptake in parathyroid gland tissue accounts for the utility of Tc-99M-sestamibi in localization studies for hyperparathyroidism. Quantification of in vivo uptake of Tc-99M-sestamibi may help refine techniques for improved localization of hyperfunctional parathyroid glands.

Breath test diagnosis of Helicobacter pylori in peptic ulcer disease: a noninvasive primary care option.

BACKGROUND: Helicobacter pylori is implicated as the causative agent for most duodenal and gastric ulcers. Invasive (endoscopy and biopsy) and noninvasive (serology, breath test) methods are currently available for definitive diagnosis of infectious peptic ulcer disease. METHODS: Twenty-six patients with chronic gastritis symptoms underwent upper endoscopy, biopsy, rapid urease test, and [14C]urea breath test for the detection of H pylori. RESULTS: Twenty of 26 patients (77 percent) had biopsy-proved H pylori infection. All 20 (100 percent) with definite H pylori proved by invasive diagnosis had strongly positive results on urea breath test. Six patients with absence of H pylori on biopsy had negative urea breath test results. The urea breath test displayed 100 percent sensitivity, specificity, and predictive value compared with endoscopy and biopsy. CONCLUSIONS: [14C]Urea breath testing is comparable to endoscopy and biopsy in the diagnosis of H pylori infection and could become useful in primary care settings for noninvasive evaluation of peptic ulcer disease.

Analysis of savings in operative time for primary hyperparathyroidism using localization with technetium 99m sestamibi scan.

BACKGROUND: The cost effectiveness of preoperative localization in cases of primary hyperpara-thyroidism has not been established. We analyzed the potential savings in operative time after localization with technetium 99m (99mTc) sestamibi scan. METHODS: Thirty-three patients had localization of a solitary adenoma with 99mTc-sestamibi. Measurement was made of the time required for adenomectomy, unilateral neck exploration (UNE), unilateral neck exploration and confirmation of one contralateral parathyroid gland (UNEC), or bilateral neck exploration (BNE). RESULTS: The total operative time in minutes was 76.4 +/- 18.8 for adenomectomy; 87.5 +/- 20.4 for UNE; 105.6 +/- 25.0 for UNEC; and 117.9 +/- 26.7 for BNE. The time difference was significant between adenomectomy versus UNE, UNEC, and BNE. There were also significant time differences between UNE versus UNEC and BNE. CONCLUSIONS: The preoperative localization of a solitary parathyroid adenoma may optimize operative time with UNE, saving approximately 30 minutes.

Ga-67 used to localize the tumor bed for radiation therapy after lumpectomy.

The authors present a new method to locate the tumor bed after lumpectomy. The method relies on accumulation of Ga-67 at the surgical site. This technique was useful in identifying the tumor bed in six candidates for breast conserving surgery and radiation therapy. This method may be applicable in other soft tissue malignancies that require postoperative radiation.

The subxiphoid laparoscopic approach for resection of mediastinal parathyroid adenoma after successful localization with TC-99m-sestamibi radionuclide scan.

Primary hyperparathyroidism is caused by an ectopically located parathyroid adenoma in a small percentage of cases. Parathyroid adenomas located within the retrosternal area of the anterior mediastinum account for a large proportion of failed initial cervical explorations. Current surgical approach to these lesions is via median sternotomy, with the discomfort, hospitalization, and morbidity associated with a major thoracic operation. We report a new technique for the resection of these ectopic parathyroid adenomas after successful radiologic localization: a minimally invasive subxiphoid laparoscopic approach. The procedure was performed in a symptomatic patient with documented primary hyperparathyroidism who had failed three previous neck operations. The ectopic parathyroid adenoma was successfully resected endoscopically, with resolution of the hypercalcemia. The patient was discharged on the third postoperative day, avoiding completely the morbidity of a median sternotomy.

Characterization of the neoplastic potential of solitary solid thyroid lesions with Tc-99m-pertechnetate and Tc-99m-sestamibi scanning.

BACKGROUND: Radionuclide scans that use Tc-99m-pertechnetate or I-123 currently lack the specificity to assess the malignant potential of solitary solid lesions of the thyroid gland. Tc-99m-sestamibi scanning was used to determine the neoplastic potential of thyroid lesions. METHODS: Patients with lesions of the thyroid underwent Tc-99m-sestamibi imaging to assess the neoplastic potential of their thyroid lesions, identified as solitary and cold by radionuclide imaging with Tc-99m-pertechnetate. Tc-99m-sestamibi uptake was correlated with fine-needle aspiration cytology or surgical pathology. RESULTS: Twenty-seven patients were evaluated using Tc-99m-pertechnetate and Tc-99m-sestamibi scans: 14 had right thyroid lesions, and 13 had left thyroid lesions. Of 27 patients, 10 had a positive Tc-99m-sestamibi scan: one Hürthle cell adenoma, one papillary carcinoma, six follicular adenomas, and two nodular goiters. Of 27 patients, 17 had a negative Tc-99m-sestamibi scan: one follicular carcinoma, one papillary carcinoma, two follicular adenomas, one Hürthle cell adenoma, one metastatic adenocarcinoma, one medullary carcinoma, four nodular goiters, and six colloid nodules. Positive Tc-99m-sestamibi scan identified neoplasms with a sensitivity of 53%, a specificity of 83%, and a positive predictive value of 80%. CONCLUSIONS: Tc-99m-sestamibi scanning lacks sufficient sensitivity for diagnosis of solitary thyroid nodules. Future work may define a role for its use in recurrent or metastatic thyroid neoplasms.

Technetium Tc 99m sestamibi scan for localizing abnormal parathyroid glands after previous neck operations: preliminary experience in reoperative cases.

We used technetium Tc 99m sestamibi for successful preoperative localization of abnormal parathyroid glands in nine patients with hyperparathyroidism and a history of neck surgery. The intraoperative and pathological findings were correlated with the preoperative technetium-sestamibi scan results. These nine patients had had 13 previous neck operations, two for thyroid disease, and 11 for hyperparathyroidism. In the two operated on for thyroid disease, the 99mTc-sestamibi scan localized a parathyroid adenoma. In one patient, the three remaining hyperplastic parathyroid glands were localized using 99mTc-sestamibi scan. The other six patients had 10 operations for hyperparathyroidism; the 99mTc-sestamibi scan localized the remaining parathyroid glands causing hypercalcemia. In this preliminary experience, the 99mTc-sestamibi scan localized all the abnormal parathyroid glands causing hyperparathyroidism in patients who had previously had neck surgery.

Nonadenomatous thymic unencapsulated parathyroid tissue as a cause of persistent primary hyperparathyroidism.

Primary hyperparathyroidism may be caused by ectopic intrathymic parathyroid adenomas or hyperplastic parathyroid glands. The association of the ectopic inferior parathyroid glands and the thymus is due to their common embryologic origin from the third pharyngeal pouch. We report a case of primary hyperparathyroidism due to an unusual pathologic parathyroid gland formation: nonadenomatous thymic unencapsulated parathyroid tissue. Two unsuccessful neck exploration revealed only two normal parathyroid glands within the cervical area. Radiologic imaging studies failed to localize an ectopic parathyroid adenoma. Mediastinal exploration and thymectomy showed one small focus of unencapsulated hypercellular parathyroid tissue expanding peripherally along the septa of thymic adipose tissue. The hyperparathyroidism resolved with the surgical procedure.

Preoperative imaging of abnormal parathyroid glands in patients with hyperparathyroid disease using combination Tc-99m-pertechnetate and Tc-99m-sestamibi radionuclide scans.

OBJECTIVE: To evaluate the efficacy of combined Tc-99m-pertechnetate and Tc-99m-sestamibi radionuclide scanning for imaging abnormal parathyroid glands in hyperparathyroid disease in a prospective study. SUMMARY BACKGROUND DATA: Established methods to localize abnormal parathyroid glands lack accuracy for routine use. Tc-99m-sestamibi used in conjunction with iodine-123 has excellent potential for preoperative imaging in patients with hyperparathyroid disease. An alternative method for parathyroid imaging was studied using Tc-99m-pertechnetate and Tc-99m-sestamibi. METHODS: Thirty patients with hyperparathyroid disease had Tc-99m-pertechnetate and Tc-99m-sestamibi subtraction radionuclide scanning to visualize abnormal parathyroid glands before surgery. The patients had surgery and pathologic confirmation of all parathyroid glands. RESULTS: In 23 patients with primary hyperparathyroidism, 12 of 13 solitary adenomas were visualized. Six of nine patients with diffuse hyperplasia had bilateral uptake consistent with diffuse hyperplasia. Three of nine patients had negative scans. One patient previously operated on for diffuse hyperplasia had only one gland scanned. Seven patients with renal failure-associated hyperparathyroid disease were scanned: five had bilateral uptake of Tc-99m-sestamibi consistent with hyperplasia, and two who had been previously operated on had localization of remaining abnormal parathyroid glands. CONCLUSIONS: Tc-99m-pertechnetate combined with Tc-99m-sestamibi subtraction radionuclide scanning is less cumbersome to implement than iodine-123 combined with Tc-99m-sestamibi scanning. It has a high sensitivity for imaging solitary parathyroid adenomas or persistent solitary hyperplastic glands. However it does not have the resolution necessary to delineate all parathyroid glands in diffuse hyperplasia.

Use of technetium Tc 99m sestamibi and iodine 123 radionuclide scan for preoperative localization of abnormal parathyroid glands in primary hyperparathyroidism.

The imaging methods currently used to localize the parathyroid gland in patients with hyperparathyroidism have been criticized as unreliable and even misleading. We evaluated a new imaging technique that uses technetium Tc 99m sestamibi and iodine 123. We studied 21 patients having a diagnosis of primary hyperparathyroidism and no previous parathyroid surgery. Scintigraphy to localize the abnormal parathyroid was done before operation. A solitary adenoma was localized in 14 patients. Six patients had images consistent with diffuse hyperplasia, and one patient had a dual adenoma. The surgical and histologic findings confirmed the preoperative data. The sensitivity of this method is 87.5%, the specificity is 100%, and the predictive value is 100%. This new method of preoperative localization of abnormal parathyroid glands is useful in patients having initial neck exploration for primary hyperparathyroidism.

Impact of technetium-99m-sestamibi localization on operative time and success of operations for primary hyperparathyroidism.

Intraoperative identification of abnormal parathyroid glands during initial neck exploration for primary hyperparathyroidism is challenging and may require extensive dissection of the neck and mediastinum. We, therefore, evaluated the impact of preoperative localization with Technetium-99m-sestamibi (Tc-99m-sestamibi) and Iodine-123 radionuclide subtraction imaging on operative time and success of initial operation for primary hyperparathyroidism. From January 1989 to September 1992, 42 patients underwent neck exploration for primary hyperparathyroidism; 21 patients underwent neck exploration without preoperative radionuclide scanning, and 21 patients were operated upon following radionuclide Tc-99m-sestamibi localization. In the control group, pathologic exam revealed 15 patients had solitary adenomas, and six patients had diffuse hyperplasia. In the Tc-99m-sestamibi group, 16 patients had solitary adenomas, four had diffuse hyperplasia, and one had multiple adenomas. Analysis of patient demographic data revealed no differences between the control group and the Tc-99m-sestamibi group in mean age (56 vs 59 years), mean intact PTH levels (249 vs 234 pg/mL), mean total calcium (11.3 vs 12.0 mg/dL), and mean ionized calcium (6.19 vs 6.28 mg/dL). Comparison of operative data revealed no differences between groups in the mean number of parathyroid glands identified and biopsied per patient (3.1 vs 3.3), the mean largest diameter of the resected adenomas (19.6 vs 20.0 mm), and the number of patients requiring thymectomy, thyroid resection, retroesophageal exploration, mediastinal exploration, or carotid sheath exploration. The operative success rate was 90 per cent for the control group versus 100 per cent for the Tc-99m-sestamibi group.(ABSTRACT TRUNCATED AT 250 WORDS)

Parathyroid scintigraphy with iodine-123 and 99mTc-sestamibi: imaging findings.

Subtraction scintigraphy with 99mTc-pertechnetate and 201Tl-chloride is widely used for localizing the parathyroid gland, but the sensitivity of this method averages only 55%. The sensitivity of scintigraphy is improved by using a combination of 99mTc-sestamibi and iodine-123. Parathyroid adenomas can also be localized with 99mTc-sestamibi alone by subtracting early images from late sequential images. The fast washout of 99mTc-sestamibi from the thyroid gland allows visualization of the parathyroid gland. The purpose of this essay is to illustrate the findings of abnormalities of the parathyroid glands when using a combination of 99mTc-sestamibi and iodine-123.