Analysis of the Increase in Bone Mineral Density After Surgical Treatment of Primary Hyperparathyroidism.

AIM: To analyze the effect of the surgery in bone mineral density (BMD) and to study the value of preoperative clinical and analytical factors as predictors of bone increase. MATERIAL AND METHODS: Prospective observational study. Postmenopausal women who were operated for primary hyperparathyroidism were included. A bone densitometry of the lumbar spine and femoral neck and analytical determinations (parathyroid hormone [PTH], alkaline phosphatase, albumin, phosphate, creatinine, 25-hydroxy-vitamin D3, creatinine clearance, and calciuria) were performed previous to the intervention and after 12 months from surgery. RESULTS: Two hundred and twenty-eight patients were operated on for primary hyperparathyroidism were considered for study, 108 postmenopausal women entered in the final analysis. The mean age was 63 ± 7 yr. After the intervention, a significant increase in BMD was observed in the two locations analyzed, although this increase was significant greater at the level of the lumbar spine. In the lumbar spine, 68 patients (63%) recorded a significant postoperative increase in bone density. Median postoperative BMD was 0.860 g/cm2 (interquartile range: 0.93). The observed average percentage of density increase was 6.63 ± 17.9. In femoral neck, 61 patients (56.6%) registered a significant increase in bone density. Median postoperative BMD value was 0.741 g/cm2 (interquartile range: 0.76). The average percentage of density increase was 3.19 ± 17.9. In the lumbar spine, patients with osteoporosis before surgery increased postoperative BMD more frequently than those with osteopenia or normal density. Patients who increased BMD preoperatively presented lower bone density levels both in the lumbar spine (median: 0.775, interquartile range: 0.882) and in the hip (median: 0.655, interquartile range: 0.562) than patients in whom it was not observed postoperative increase. PTH preoperative serum was lower among patients who increased bone density in the femur (median: 141 pg/ml, interquartile range: 291) than among those who did not (median: 152 pg/ml, interquartile range: 342) (p = 0.01). In the multivariate analysis, the increase in BMD in the lumbar spine was related to preoperative BMD (odds ratio [OR] 0.084, 95% confidence interval [CI]: 0.007-0.961); in femoral neck it was related to preoperative BMD (OR 0.001; 95% CI: 0.0-0.028) and to the preoperative PTH serum concentration (OR 0.99; 95% CI: 0.98-0.99). CONCLUSIONS: After surgery, a significant increase in BMD was observed in the lumbar spine and femoral neck. In the multivariate analysis, preoperative bone density was the factor that showed the highest predictive value of the increase in BMD after surgery.

Hematoma espontáneo del músculo recto anterior del abdomen / Spontaneous haematoma of the anterior rectus abdominis muscle

INTRODUCCIÓN: El hematoma espontáneo del músculo recto del abdomen es una causa infrecuente de dolor abdominal que sucede con mayor frecuencia en pacientes anticoagulados. El objetivo de nuestro trabajo fue analizar la forma de presentación, el diagnóstico y los resultados del tratamiento en este grupo de pacientes. MÉTODOS: Análisis retrospectivo con una base de datos prospectiva de todos los casos de hematoma espontáneo del músculo recto del abdomen tratados en nuestro centro entre marzo de 2003 y diciembre de 2014. RESULTADOS: Se incluyó a 34 pacientes (25 mujeres) con una edad media de 80 años. En todos los casos el hematoma fue unilateral e infraumbilical. Veintiocho pacientes recibían tratamiento anticoagulante como parte de su tratamiento habitual (26 de ellos acenocumarol y 2 pacientes heparinas de bajo peso molecular a dosis terapéuticas). Seis pacientes recibían heparina de bajo peso molecular a dosis profilácticas. El diagnóstico se realizó mediante ecografía en 7 pacientes, tomografía axial computarizada con contraste intravenoso en fase arterial (angio-TC) en 27 y, con ambos métodos, en 6. El tratamiento consistió en la suspensión de la anticoagulación, corrección de la hemostasia y reposición hemática. En 10 pacientes se evidenció hemorragia activa en angio-TC y en 8 se realizó embolización selectiva. La evolución fue favorable en 32 pacientes. Dos pacientes fueron intervenidos debido a hemorragia grave persistente y fallecieron. CONCLUSIONES: El hematoma espontáneo del músculo recto del abdomen es más frecuente en mujeres de edad avanzada y en tratamiento con anticoagulantes orales. La mayoría evolucionan favorablemente con tratamiento no operatorio. La angio-TC es útil para indicar la embolización arterial selectiva en caso de hemorragia activa

INTRODUCTION: Spontaneous haematoma of the rectus abdominis muscle is an uncommon cause of abdominal pain. It occurs mostly in anticoagulated patients. The objective of this paper is to analyse the onset, diagnosis and treatment in patients under anticoagulant therapy. METHODS: A retrospective analysis of a prospectively maintained database of all patients with a diagnosis of spontaneous hematoma of the abdominal rectus muscle between March 2003 and December 2014. RESULTS: The study included 34 patients, of whom 28 were women, with an average age of 80 years old. All the patients showed a unilateral infraumbilical haematoma. Twenty- 8 patients had received long-term anticoagulant treatment (26 with acenocumarol and 2 low molecular weight heparin); and 6 patients were under anticoagulant prophylaxis with low molecular weight heparin. The diagnosis was performed with ultrasound in 7 cases, computed tomography angiography in 27 patients, and with both methods in 6 cases. The treatment consisted of stopping the anticoagulant drug, correcting haemostasis parameters and blood transfusion when required. Ten patients displayed active bleeding in the computed tomography angiography, and 8 underwent selective arterial embolization. The evolution was successful in 34 patients, however, 2 patients required surgery and, finally, died due to persistent haemorrhage. CONCLUSION: Spontaneous haematoma of the rectus abdominis muscle is more frequent in elderly women under oral anticoagulant treatment. Non-operative treatment is successful in most cases. Computed tomography angiography is useful to determine which patients could benefit from selective arterial embolization

Spontaneous haematoma of the anterior rectus abdominis muscle. / Hematoma espontáneo del músculo recto anterior del abdomen.

INTRODUCTION: Spontaneous haematoma of the rectus abdominis muscle is an uncommon cause of abdominal pain. It occurs mostly in anticoagulated patients. The objective of this paper is to analyse the onset, diagnosis and treatment in patients under anticoagulant therapy. METHODS: A retrospective analysis of a prospectively maintained database of all patients with a diagnosis of spontaneous hematoma of the abdominal rectus muscle between March 2003 and December 2014. RESULTS: The study included 34 patients, of whom 28 were women, with an average age of 80 years old. All the patients showed a unilateral infraumbilical haematoma. Twenty- 8 patients had received long-term anticoagulant treatment (26 with acenocumarol and 2 low molecular weight heparin); and 6 patients were under anticoagulant prophylaxis with low molecular weight heparin. The diagnosis was performed with ultrasound in 7 cases, computed tomography angiography in 27 patients, and with both methods in 6 cases. The treatment consisted of stopping the anticoagulant drug, correcting haemostasis parameters and blood transfusion when required. Ten patients displayed active bleeding in the computed tomography angiography, and 8 underwent selective arterial embolization. The evolution was successful in 34 patients, however, 2 patients required surgery and, finally, died due to persistent haemorrhage. CONCLUSION: Spontaneous haematoma of the rectus abdominis muscle is more frequent in elderly women under oral anticoagulant treatment. Non-operative treatment is successful in most cases. Computed tomography angiography is useful to determine which patients could benefit from selective arterial embolization.

[Serum PTH levels as a predictive factor of hypocalcaemia after total thyroidectomy]. / Determinación de paratirina en suero como factor predictivo de hipocalcemia tras tiroidectomía total.

INTRODUCTION: Postoperative parathyroid hormone (PTH) levels as a predictor of hypocalcaemia in patients subjected to total thyroidectomy is analyzed. MATERIAL AND METHOD: Prospective study involving 67 patients who underwent total thyroidectomy due to a benign disease. Serum PTH and ionised calcium were measured 20 h after surgery. Sensitivity, specificity and predictive values of PTH and ionised calcium levels were calculated to predict clinical and analytical hypocalcaemia. RESULTS: A total of 42 (62.7%) patients developed hypocalcaemia (ionised calcium<0.95 mmol/l), but only 20 (29.9%) presented with symptoms. PTH concentration the day after surgery was significantly lower in the group that developed symptomatic hypocalcaemia (5.57+/-6.4 pg/ml) than in the asymptomatic (21.5+/-15.3 pg/ml) or normocalcaemic (26.8+/-24.9 pg/ml) groups (p=0.001). Taking the value of 13 pg/ml as a cut-off point of PTH levels, sensitivity, specificity, positive predictive value and negative predictive value were 54%, 72%, 76% and 48%, respectively. On the other hand, sensitivity for predicting symptomatic hypocalcaemia was 95% and specificity was 76%. The test showed a high incidence of false positives (11/30, 36%). Negative predictive value was 97% and positive predictive value was 65%. In multivariate analysis, PTH and ionised calcium were the only perioperative factors that showed an independent predictive value as risk indicators of symptomatic hypocalcaemia. CONCLUSIONS: Normal PTH levels 20 h after surgery practically rule out the subsequent appearance of hypocalcaemia symptoms. On the other hand, low PTH levels are not necessarily associated to symptomatic hypocalcaemia due to the high number of false positives.

Determinación de paratirina en suero como factor predictivo de hipocalcemia tras tiroidectomía total / Serum PTH levels as a predictive factor of hypocalcaemia after total thyroidectomy

Introducción: se analiza el valor de la determinación postoperatoria de paratirina como indicador de riesgo de hipocalcemia tras tiroidectomía total. Material y método: estudio prospectivo de 67 pacientes sometidos a tiroidectomía total por enfermedad benigna. Se determinó la concentración de paratirina y calcio iónico a las 20h de postoperatorio. Se calculó la sensibilidad, la especificidad y los valores predictivos positivo (VPP) y negativo (VPN) de las concentraciones de paratirina y calcio iónico para predecir la aparición de hipocalcemia sintomática o no. Resultados: presentaron hipocalcemia (Ca iónico<0,95 mmol/l) 42 pacientes (62,7%) pacientes, pero únicamente 20 (29,9%) mostraron síntomas. La concentración de paratirina a las 20h de la intervención fue inferior en el grupo con hipocalcemia sintomática (5,57±6,4pg/ml) que en el grupo de hipocalcemia sin síntomas (21,5±15,3pg/ml) y que entre los pacientes normocalcémicos (26,8±24,9pg/ml) (p=0,001). Con un punto de corte para la paratirina en 13pg/ml, la sensibilidad, la especificidad, el VPP y el VPN de paratirina para predecir la aparición de hipocalcemia analítica fueron del 54, el 72, el 76 y el 48%, respectivamente. Por otro lado, la sensibilidad para predecir hipocalcemia sintomática fue del 95% y la especificidad, el 76%. El test presentó alta incidencia de falsos positivos (11/30) (36%). El VPN fue del 97% y el VPP, el 65%. Paratirina y calcio iónico en el análisis multivariable fueron los únicos factores con valor predictivo como indicadores de riesgo de hipocalcemia sintomática. Conclusiones: una concentración normal de paratirina a las 20h de la intervención prácticamente descarta la aparición posterior de síntomas de hipocalcemia. Por contra, cifras de paratirina bajas no se acompañan necesariamente de síntomas debido al elevado número de falsos positivos (AU)

Introduction: Postoperative parathyroid hormone (PTH) levels as a predictor of hypocalcaemia in patients subjected to total thyroidectomy is analyzed. Matherial and method: Prospective study involving 67 patients who underwent total thyroidectomy due to a benign disease. Serum PTH and ionised calcium were measured 20h after surgery. Sensitivity, specificity and predictive values of PTH and ionised calcium levels were calculated to predict clinical and analytical hypocalcaemia. Results: A total of 42 (62.7%) patients developed hypocalcaemia (ionized calcium<0.95mmol/l), but only 20 (29.9%) presented with symptoms. PTH concentration the day after surgery was significantly lower in the group that developed symptomatic hypocalcaemia (5.57±6.4pg/ml) than in the asymptomatic (21.5±15.3pg/ml) or normocalcaemic (26.8±24.9pg/ml) groups (p=0.001). Taking the value of 13pg/ml as a cut-off point of PTH levels, sensitivity, specificity, positive predictive value and negative predictive value were 54%, 72%, 76% and 48%, respectively. On the other hand, sensitivity for predicting symptomatic hypocalcaemia was 95% and specificity was 76%. The test showed a high incidence of false positives (11/30, 36%). Negative predictive value was 97% and positive predictive value was 65%. In multivariate analysis, PTH and ionised calcium were the only perioperative factors that showed an independent predictive value as risk indicators of symptomatic hypocalcaemia. Conclusions: Normal PTH levels 20h after surgery practically rule out the subsequent appearance of hypocalcaemia symptoms. On the other hand, low PTH levels are not necessarily associated to symptomatic hypocalcaemia due to the high number of false positives (AU)

FcRgamma chain does not replace CD3zeta chain in CD3zeta-deficient T lymphocytes of patients with gastric adenocarcinoma.

Defective CD3zeta chain expression has been reported in T lymphocytes of patients with inflammatory diseases, such as systemic lupus erythematosus or osteoarthritis, and with cancer. In lupus, the absent CD3zeta chain is replaced by the FcRgamma chain, rendering the T cells hyper responsive. However, there are no data on T lymphocytes from patients with cancer. In this study, the presence of the FcRgamma chain and its associated kinase, Syk, was analysed in patients with gastric adenocarcinoma and healthy subjects. Western blot and immunoprecipitation experiments were carried out with total cell or lipid raft extracts from fresh peripheral blood mononuclear cells or T lymphocytes, and Herpesvirus saimiri-derived T-cell lines (of blood or tissue origin). Our results revealed that the absent CD3zeta chain in cancer T lymphocytes was not replaced by FcRgamma either in fresh T cells or T-cell lines, in contrast to lupus T cells. This altered expression of signalling molecules in T lymphocytes of cancer patients, would explain their low proliferative capacity. Our T-cell lines represent tools to unveil the signalling abnormalities of cancer T lymphocytes.

Defective CD3zeta chain expression in Herpesvirus saimiri (HVS)-derived T-cell lines in gastric adenocarcinoma.

Low expression of the CD3zeta chain has been reported in patients with cancer and it has been suggested that tumor-derived factors are involved in its downregulation. The expression of CD3zeta chain was measured in T-cell lines from patients with gastric adenocarcinoma and healthy volunteers and grown in vitro for several months and, hence, in the absence of any tumor-derived factors. T-cell lines of mucosal origin were obtained by Herpesvirus saimiri transformation from gastric cancer patients. The expression of CD3zeta and CD3epsilon was measured by flow cytometry and Western-blot analysis. Calcium mobilization and apoptosis rate were also measured. The levels of CD3zeta, but not CD3epsilon, chain on the cell surface were significantly reduced in T-cell lines derived from patients with gastric cancer when cultured in the absence of IL-2. Western-blot analysis of total cell extracts or lipid raft fractions confirmed this finding. Calcium mobilization, a measure of signal transduction, was reduced in T cell lines from patients with gastric cancer. We conclude that T cells from patients with cancer express lower levels of CD3zeta. This downregulation is not caused by a direct effect of tumor-derived factors but, rather, it appears to be inherent to the patient cells. The low CD3zeta expression would render T lymphocytes unable to control the growth of tumor cells.

Torsión completa del epiplón mayor como causa de abdomen agudo. Contribución de la TC en el diagnóstico preoperatorio / Complete torsion of the greater omentum as a cause of acute abdomen. Contribution of computerized axial tomography to preoperative diagnosis

Se presenta el caso clínico de un varón joven intervenido por un cuadro de abdomen agudo secundario a la torsión completa del epiplón mayor, diagnosticado correctamente de manera preoperatoria mediante la realización de una tomografía axial computarizada. Se discuten los hallazgos clinicorradiológicos típicos, así como el tratamiento óptimo, haciendo una revisión de la bibliografía existente. (AU)