Parathyroid cysts: a case report and review of the literature.

OBJECTIVES/HYPOTHESIS: Parathyroid cysts are rare clinical entities. They frequently present as a clinical diagnostic problem. They may mimic solitary thyroid nodules. The purpose of the study was to review the literature and present a case of a 22-year-old euthyroid woman presenting with recurrent swelling in the neck. Her complaints included choking and dysphagia. Fine-needle aspiration of the mass revealed clear, watery fluid with an extremely high level of calcium and c-terminal midmolecule parathyroid hormone assay in excess of 8000 pg/mL. Treatment consisted of neck exploration and removal of a 6 x 5-cm cystic encapsulated mass. Pathological diagnosis revealed a benign parathyroid cyst. The role of needle aspiration in diagnosing thyroid masses and the importance of parathyroid hormone assay in diagnosing parathyroid cyst are emphasized.

The role of "one-shot" intravenous pyelogram in evaluation of penetrating abdominal trauma.

The role of limited "one-shot" intravenous pyelogram (IVP) in patients sustaining proximity penetrating trauma is not well defined, although formal IVP remains the "gold standard" for evaluating possible urological injuries. This retrospective review evaluates the efficacy and usefulness of limited one-shot IVP in penetrating abdominal trauma patients who are suspected of having urological injuries. The charts of 40 patients with penetrating abdominal trauma who had one-shot IVP performed in the emergency room at presentation were reviewed. Of the total, 36 patients had gunshot wounds and only 4 patients had stab wounds. Mean Penetrating Abdominal Trauma Index was 15.7, with 47.5 per cent of patients in shock. Only 2 out of 10 urological injuries were detected by one-shot IVP. The positive predictive value of limited one-shot IVP was only 20 per cent, with sensitivity 25 per cent and specificity 76.2 per cent. The results of the one-shot IVP did not influence the decisions for laparotomy in any of the 35 (87.5%) patients who underwent exploratory laparotomy. In the two patients with positive one-shot IVPs who had urological injuries, the decision to operate was again determined by the presence of other associated intra-abdominal injuries. Eighty per cent of patients with normal one-shot IVP findings had renal injuries not detected by one-shot IVP, and 20 per cent of patients with abnormal IVP findings had no intraoperative evidence of renal injury. The presence of gross hematuria appeared to correlate with the presence of significant urological injuries. We therefore conclude that limited one-shot IVP is of no significant value in assessing penetrating abdominal trauma patients who subsequently undergo exploratory laparotomy for other associated intra-abdominal injuries, and indeed, the delay imposed, before definitive operative intervention in potentially unstable patients, is unjustified.

Reduction of left ventricular spontaneous echo contrast in cardiomyopathy by acute inotropic intervention or aggressive therapy.

The purpose of this study was to determine whether improvement of left ventricular (LV) systolic function could reduce the severity or eliminate LV spontaneous echo contrast found with transthoracic echocardiography in a group of patients with advanced cardiomyopathy. A successful reduction of this by hemodynamic means might indicate an additional beneficial method of helping prevent thromboembolism in advanced cardiomyopathy. Six patients with advanced cardiomyopathy and demonstrating spontaneous echo contrast on transthoracic echocardiography were treated with acute inotropic drug infusions or aggressive medical therapy to improve LV systolic function to determine whether reduction in spontaneous contrast could be achieved by such means. A spontaneous echo contrast scoring system was devised: 0 to 4, indicating absent to severe. Six observers, unacquainted with the study plan, were blinded as to the source of the 12 pre- and post-therapy two-dimensional echocardiograms obtained and re-recorded in a random sequence, and were asked to grade the degree of spontaneous echo contrast. In all six patients, LV spontaneous echo contrast was reduced by improvement in LV systolic function (average score lowered from 2.94 to 1.25, p < 0.005). Among patients with cardiomyopathy at high risk for LV thromboembolism, as indicated by the presence of LV spontaneous echo contrast, improvement in LV systolic function may serve as an adjunct to anticoagulation or, in some cases, as a substitute when the latter is contraindicated in the prevention of thromboembolism. The results obtained suggest merit in prospective, long-term studies of a larger group of such patients.

Treatment of hyperesthetic neuropathic pain in diabetics. Decompression of the tarsal tunnel.

OBJECTIVE: The authors evaluated the causal relationship between entrapment of the posterior tibial nerve and neuropathic pain and describe the results of nerve decompression in a selected group of patients with intractable pain. SUMMARY BACKGROUND DATA: Painful metabolic neuropathy has, until recently, been thought to be an irreversible and essentially untreatable complication of diabetes. Recent studies have shown that metabolic deterioration is only one component of the disease process. METHODS: A group of patients with intractable painful neuropathy and a positive percussion sign underwent posterior tibial nerve decompression. RESULTS: Nerve decompression relieved the pain in the majority of treated patients. Return of other sensory function also was noted. CONCLUSIONS: Painful diabetic neuropathy of the lower extremities is potentially reversible. It appears to be caused partially by nerve entrapment and can be reversed by decompression.

Effect of metatarsal head resection for diabetic foot ulcers on the dynamic plantar pressure distribution.

Diabetic neuropathic ulcers are thought to arise from repetitive injury during normal walking in areas of high plantar pressures. It has been suggested that metatarsal head (MTH) resection alleviates elevated pressures at the site of the ulcer and, thus, expedites healing and prevents recurrence. We investigated the effect of MTH resection on plantar pressure distribution and ulcer healing. Sixteen diabetic patients with neuropathic plantar ulcers present for a mean of 36 +/- 28 weeks undergoing MTH resection were studied. Plantar pressure distribution was measured preoperatively and postoperatively using the EMED-SF pressure sensor platform (Novel, Munich, Germany). The data showed that 68.8% of the patients had mean peak plantar pressures (MPPs) elevated (greater than 500 kilopascal (kPA)) at sites of plantar ulceration. The MPPs following MTH resection were significantly reduced irrespective of the site (p = 0.002). There was maximal MPP reduction following the resection of the 1st MTH (70%) and a lower reduction with 2nd-3rd MTH (39.9%) and 4th-5th MTH (45.8%) resections. We found no significant transfer of pressure to adjacent metatarsal heads following resection of the 1st MTH (p = 0.87), 2nd-3rd MTH (p = 0.11), and 4th-5th MTH (p = 0.75). All patients achieved complete ulcer healing within 8 +/- 2 weeks after surgery. We concluded that reduction of plantar pressure is crucial for plantar ulcer healing, and we have demonstrated definitively that MTH resection leads to reduced peak plantar pressure, thus, expediting ulcer healing.

Detection of epidermal growth factor receptor mRNA in tissue sections from biopsy specimens using in situ polymerase chain reaction.

Human epidermal growth factor (EGF) receptor mRNA was detected in cryopreserved tissue sections adherent to whole glass slides using in situ reverse transcriptase polymerase chain reaction. EGF receptor cDNA was synthesized in situ by reverse transcription using an EGF receptor-specific oligonucleotide primer. In situ polymerase chain reaction amplification in the presence of digoxigenin-11-dUTP and subsequent binding with an antidigoxigenin antibody conjugated to alkaline phosphatase allowed direct visualization. Because DNase, RNase, or proteinase K are not required, tissue integrity is maintained. EGF receptor mRNA is expressed in the basal layer of normal human skin epithelium and is significantly overexpressed in squamous cell tumor specimens, which is consistent with conventional analysis of EGF receptor expression. The assay is semiquantitative, quicker, more sensitive, and void of the nonspecific binding associated with in situ hybridization. In situ reverse transcriptase polymerase chain reaction using whole glass slides is ideally suited for detecting moderate to infrequently expressed transcripts in biopsy specimens.