Patient outcomes following thyroid surgery for thyrotoxicosis.

OBJECTIVE: Total thyroidectomy can be used as a definitive treatment modality for thyrotoxicosis. This study assessed the outcomes of patients treated with surgery at a single secondary care site. METHOD: A retrospective cohort study was conducted analysing consecutive patients who underwent thyroid surgery for thyrotoxicosis between 24 November 2000 and 26 April 2019 (n = 595). RESULTS: Total thyroidectomy was performed in 95.4 per cent of patients. Two-thirds of patients had Graves' disease histology. Of patients, 22.8 per cent became transiently hypothyroid whilst on levothyroxine (thyroid hormone replacement therapy). Transient and persistent hypocalcaemia was present in 23.3 per cent and 2.8 per cent of patients respectively. Recurrent laryngeal nerve palsy was transient and persistent in 3.6 per cent and 0.3 per cent respectively. Of patients, 2.5 per cent developed post-operative haematomas that required surgical evacuation in the operating theatre. CONCLUSION: The overall complication rate for thyroid surgery is higher in thyrotoxic than in euthyroid patients. Compared to other treatment modalities, total thyroidectomy appears to be the most effective, definitive means of managing Graves' disease.

Pre-operative prediction of cholesteatomas from radiology: retrospective cohort study of 106 cases.

OBJECTIVE: Pre-operative imaging is often used to predict the extent of a cholesteatoma and anatomical variation to plan for surgery. This study aimed to measure the predictive accuracy of computed tomography findings. METHODS: A retrospective cohort study was conducted of all patients in a district general hospital undergoing mastoid surgery within a consecutive 12-month period, in whom computed tomography had been performed prior to operative intervention. The study measured the key findings of pre-operative computed tomography imaging and compared them to the intra-operative findings. RESULTS: A total of 106 patients were included. The sensitivity and specificity for predicting cholesteatoma were 79 per cent and 81 per cent respectively. The positive predictive value was 90 per cent and the negative predictive value was 65 per cent. In predicting complications of cholesteatomas, the sensitivity was 70 per cent, whereas the specificity was 91 per cent. The positive predictive value was 88 per cent and the negative predictive value was 76 per cent. CONCLUSION: Pre-operative computed tomography conducted prior to mastoid surgery has high positive predictive values for both predicting cholesteatomas and complications (90 per cent and 88 per cent respectively).

Reprinted article "Neovascularisation is the principal cause of varicose vein recurrence: results of a randomised trial of stripping the long saphenous vein".

OBJECTIVES: To determine whether routine stripping of the long saphenous vein reduces recurrence after varicose vein surgery. DESIGN: Randomised controlled trial. All operations done by a consultant vascular surgeon. Two year follow-up. MATERIALS AND METHODS: One hundred patients with primary long saphenous varicose veins (133 legs) were randomised. Two year follow-up in 81 patients (113 legs) with questionnaire, clinical examination and Duplex scanning. RESULTS: Some 89% remained satisfied with the results of their surgery, though 35% had recurrent veins on clinical examination. Recurrence was reduced from 43 to 25% in patients who had their long saphenous vein stripped (p = 0.04, χ(2)). Neovascularisation (serpentine tributaries arising from the ligated saphenofemoral junction) was detected in 52% of limbs and was the commonest cause of recurrence. Most tributaries were less than 3 mm in diameter and only caused recurrence if the long saphenous vein or a major thigh vein was intact. Twelve patients had tributaries greater than 3 mm diameter and all had recurrent varicose veins. CONCLUSIONS: Recurrence is common after varicose vein surgery and in this study was caused principally by neovascularisation at the ligated saphenofemoral junction. Clinical recurrence is reduced by routine stripping of the long saphenous vein.

Aspergillus terreus accessory conidia are unique in surface architecture, cell wall composition and germination kinetics.

Infection with Aspergillus terreus is more likely to result in invasive, disseminated disease when compared to other Aspergillus species; importantly this species appears to be less susceptible to the antifungal drug amphotericin B. Unique to this species is the ability to produce specialized structures denoted as accessory conidia (AC) directly on hyphae both in vitro and in vivo. With the hypothesis that production of AC by A. terreus may enhance virulence of this organism, we analyzed the phenotype, structure and metabolic potential of these conidia. Comparison of A. terreus phialidic conidia (conidia that arise from conidiophores, PC) and AC architecture by electron microscopy revealed distinct morphological differences between the two conidial forms; AC have a smoother, thicker outer cell surface with no apparent pigment-like layer. Further, AC germinated rapidly, had enhanced adherence to microspheres, and were metabolically more active compared to PC. Additionally, AC contained less cell membrane ergosterol, which correlated with decreased susceptibility to AMB as determined using a flow cytometry based analysis. Furthermore, AC exhibited surface patches of beta1-3 glucan, suggestive of attachment scarring. Collectively, the findings of this study suggest a possible role for AC in A. terreus pathogenesis.

Using sonography to screen women with mammographically dense breasts.

OBJECTIVE: Mammographically dense breast tissue has been reported both as a cause of false-negative findings on mammography and as an indicator of increased breast cancer risk. We conducted this study to evaluate the role of breast sonography as a second-line screening test in women with mammographically dense breast tissue. MATERIALS AND METHODS: Between January 2000 and January 2002, 1517 asymptomatic women with dense breasts and normal mammography and physical examination findings underwent physician-performed breast sonography as an adjunct screening test. Within the study group, 318 women had a first-degree family history or personal history of breast cancer. The high-risk subgroup comprised these women. The detection rate of breast cancer in this subgroup was compared with the detection rate in the remaining study population with baseline risk. RESULTS: Of 1517 women examined, seven breast cancers were diagnosed (cancer-detection rate, 0.46%). Four carcinomas were detected in high-risk women and three in women with baseline risk. The cancer-detection rate in the subgroup of high-risk women was 1.3%, significantly higher (p < 0.04) than the cancer-detection rate of 0.25% in the baseline risk subgroup. All cancers were T1 (range, 4-12 mm; mean, 9.6 mm). Sentinel lymph nodes were negative for cancer in six of seven carcinomas. CONCLUSION: Screening breast sonography in the population of women with dense breast tissue is useful in detecting small breast cancers that are not detected on mammography or clinical breast examination. The use of sonography as an adjunct to screening mammography in women with increased risk of breast cancer and dense breasts may be especially beneficial.

Neovascularisation is the principal cause of varicose vein recurrence: results of a randomised trial of stripping the long saphenous vein.

OBJECTIVES: To determine whether routine stripping of the long saphenous vein reduces recurrence after varicose vein surgery. DESIGN: Randomised controlled trial. All operations done by a consultant vascular surgeon. Two year follow-up. MATERIALS AND METHODS: One hundred patients with primary long saphenous varicose veins (133 legs) were randomised. Two year follow-up in 81 patients (113 legs) with questionnaire, clinical examination and Duplex scanning. RESULTS: Some 89% remained satisfied with the results of their surgery, though 35% had recurrent veins on clinical examination. Recurrence was reduced from 43 to 25% in patients who had their long saphenous vein stripped (p = 0.04, chi 2). Neovascularisation (serpentine tributaries arising from the ligated saphenofemoral junction) was detected in 52% of limbs and was the commonest cause of recurrence. Most tributaries were less than 3 mm in diameter and only caused recurrence if the long saphenous vein or a major thigh vein was intact. Twelve patients had tributaries greater than 3 mm diameter and all had recurrent varicose veins. CONCLUSIONS: Recurrence is common after varicose vein surgery and in this study was caused principally by neovascularisation at the ligated saphenofemoral junction. Clinical recurrence is reduced by routine stripping of the long saphenous vein.

Recovery of respiratory ciliary function after depression by inhalation anaesthetic agents: an in vitro study using nasal turbinate explants.

We have developed a human tissue preparation suitable for measurement of cilia beat frequency derived from nasal turbinates. Cilia beat frequency of turbinate explants from 11 patients did not change significantly over a 10-day observation period while maintained in an incubator, with mean cilia beat frequency of 13.1 (SEM 0.3) Hz to 14.4 (0.2) Hz (ANOVA for repeated measures, P = 0.168). We have used this preparation to investigate recovery of ciliary function after depression by inhalation anaesthetic agents. Eight or nine turbinate explants were exposed to three times the minimum alveolar concentration (MAC) of halothane, enflurane or isoflurane for a period of 1 h and thereafter to a period of air washout. After exposure to the inhalation agent there was a significant reduction in cilia beat frequency with all three agents: halothane 14.3 (0.4) Hz to 9.5 (0.3) Hz; enflurane 13.7 (0.6) Hz to 10.5 (0.5) Hz;isoflurane 15.9 (0.6) Hz to 10.6 (0.3) Hz. Cilia beat frequency returned to values after air washout that were not significantly different from baseline after 90 min of washout of halothane and 60 min of washout of enflurane and isoflurane (repeated measures ANOVA, unpaired t test; P = 0.01 at 60 min and P = 0.31 at 90 min washout for halothane; P = 0.83 at 60 min washout for enflurane; P = 0.26 at 60 min washout for isoflurane).

Effects of morphine on human nasal cilia beat frequency in vitro.

Using human nasal cytological brushings, we have investigated the effects of morphine on ciliary function by measurement of cilia beat frequency in vitro, and we have also determined opioid receptor binding in these specimens. We obtained ciliated samples from seven volunteers, and measured cilia beat frequency using the transmitted light technique during exposure to morphine 10 mumol litre-1 for 4 h. Mean cilia beat frequency of the samples exposed to morphine was 11.1 (95% confidence interval 10.9-11.5) Hz and that of the controls 11.3 (11.1-11.7) Hz. There was no significant effect of morphine on human cilia beat frequency in vitro (MANOVA for repeated measures and nested, F = 0.61, P = 0.66). In a separate study, we obtained nasal brushings from 20 patients and measured the binding of the opioid antagonist tritiated diprenorphine ([3H]DPN). Mean disintegrations per minute (dpm) for total and non-specific binding were 9036 (8105-9967) dpm and 9130 (8054-10206) dpm, respectively. These values did not differ significantly (paired t test, t = 0.22, P = 0.83). We conclude that morphine had no effect on cilia beat frequency in vitro and we were unable to demonstrate any significant numbers of opioid receptors on nasal ciliated epithelium.

A perfusion system for in vitro measurement of human cilia beat frequency.

We have designed and built a perfusion system and perfusion chamber to allow investigation of the effects of anaesthetic agents on human cilia in vitro. Using this system, samples of human respiratory cilia can be maintained in a stable and controlled environment for several hours. We measured cilia beat frequency of nasal respiratory epithelium from 10 healthy volunteers; cilia beat frequency was constant over a 4-h period, and measurements were found to be in good agreement with previously published work [1]. In a separate study we investigated the effect of a sleep dose of propofol on cilia beat frequency in samples from six patients undergoing minor surgery; samples were obtained before and immediately after induction of anaesthesia with propofol 2-3 mg kg-1. There was no statistically significant difference in cilia beat frequency between data obtained before and after induction with propofol.

Effects of 3 MAC of halothane, enflurane and isoflurane on cilia beat frequency of human nasal epithelium in vitro.

We have measured the effects of three times the minimum alveolar concentration (MAC) of halothane, enflurane and isoflurane on cilia beat frequency of human nasal epithelial brushings from 18 healthy adult patients. Using the transmitted light technique and paired perfusion chambers, the cilia were exposed to 2.25% halothane, 5% enflurane or 3.6% isoflurane in air, or air alone, in a controlled and blinded manner. Over a 4-h observation period, cilia beat frequency of the samples exposed to inhalation anaesthetic agents demonstrated a significant reduction in frequency compared with controls exposed to air alone. Mean cilia beat frequency for the samples exposed to halothane was 9.3 (SEM 1.3) compared with its controls of 11.4 (1.0); for the samples exposed to enflurane, 10.9 (1.3) compared with its controls of 11.6 (1.2); and for the samples exposed to isoflurane, 10.8 (1.1) compared with its controls of 11.6 (1.2). There was a statistically significant difference between the samples exposed to all three volatile agents and their associated controls (halothane, P = 0.01; enflurane, P = 0.03; isoflurane, P = 0.01; nested repeated measures analysis of variance utilizing polynomial contrasts).

Engineering as a clinical tool for geriatric rehabilitation.

Of all age-groups, the over-60 group has the highest percentage of people with permanent, incurable, progressive handicaps. Clinical research during the past 14 years at the National Institute for Rehabilitation Engineering has shown that many elderly persons with permanent vision, hearing, speech, and mobility handicaps can be helped to be happier and more independent through a multidisciplinary team approach. The team should be led by physicians specializing in geriatric medicine and should include medical specialists, industrial engineers, efficiency and mobility experts, and task-performance trainers.

La organización de los servicios de estadística vital y sanitaria en el Gobierno Federal de los Estados Unidos

También publicado en la OSP.Publicación No. 217,Septiembre,1945