The relation of serum calcium and immunoparathormone levels to parathyroid size and weight in primary hyperparathyroidism.

This study was designed to determine whether the serum calcium or immunoparathormone (iPTH) level would be of value in predicting the size or weight of the parathyroid gland in patients with single-gland enlargement caused by primary hyperparathyroidism. Ninety-two patients who underwent parathyroidectomy with removal of a single enlarged gland at the North Carolina Memorial Hospital (1974 to 1984) were reviewed. The preoperative calcium and immunoparathormone levels were correlated to the weight and calculated volume of the removed gland. The calcium level was found to be significantly associated with parathyroid gland weight and volume (p less than 0.001), as determined by linear regression analysis. Despite the statistical association, the correlation coefficient (calculated with the Pearson correlation matrix) was low, 0.16 for the relation of calcium to gland weight and 0.25 for the relation of calcium to calculated gland volume. The calculated coefficients of correlation of iPTH (three different assays) to gland weight and volume were similarly low. These findings demonstrate a variable relationship between the preoperative serum calcium level or the iPTH level to the weight or volume of the enlarged hyperfunctioning parathyroid gland. Identification of the pathologic parathyroid gland(s) in primary hyperparathyroidism cannot be based on a perceived relation of preoperative calcium or iPTH levels to the size of the enlarged glands.

The use of barium enema in the evaluation of patients with possible appendicitis.

Patients with right lower quadrant pain and possible appendicitis may present a difficult diagnostic dilemma to the surgeon. Barium enema has been used as an adjunctive test in the evaluation of patients with right lower quadrant pain in whom the diagnosis is unclear. The authors retrospectively reviewed their experience with 33 patients to determine the value of barium enema. The average age was 32 years (range, 2-89 years). Twenty-five patients had nonfilling of the appendix; nine of these patients had a mass effect on the cecum. Three patients had partial filling of the appendix and five patients had a normally filled appendix. Of the 16 patients who had nonfilling of the appendix without a filling defect of the cecum, 14 patients underwent operation. Eleven patients had appendicitis and three patients had a normal appendix. Two patients with nonfilling did not undergo operation and did well. All patients with a filling defect of the cecum on barium enema had appendicitis. All patients with partial filling of the appendix had appendicitis. Of five patients with normal appendices on barium enema, one patient had a diverticular abscess and underwent operation, and another patient had Meckel's diverticulitis which was excised. Barium enema can provide information to aid in the management of patients in whom the diagnosis of appendicitis is not clear. It can prevent unnecessary operation in some, and assist in earlier operation in others.

Candida species. Insignificant contaminant or pathogenic species.

The pathogenicity of Candida species cultured from peritoneal fluid or from an intra-abdominal abscess is unknown. A review of cultures at NCMH from 1978 to 1983 showed that Candida species were cultured from the peritoneal fluid of 39 patients and from intra-abdominal abscesses in 24 patients. The average age was 49 (range 6 months to 102 years); there were 38 men and 25 women. None of the 39 patients with Candida species grown from the peritoneal fluid was treated with Amphotericin B and only 1 (2.6%) subsequently developed an abscess. This patient was treated by surgical drainage without Amphotericin B and recovered. Twenty-four patients had Candida cultured from an intra-abdominal abscess. Of these, 21 (87.5%) also grew other bacterial organisms. Twenty of these 24 patients were treated with surgical drainage and antibacterial antibiotics without Amphotericin B. Six (30%) died, but only one death was felt to be directly related to the Candida infection. The remaining four were treated with surgical drainage, appropriate antibacterial antibiotics, and Amphotericin B. Two of these four (50%) died; one of the two deaths was related to Candida infection. Candida species grown from the peritoneum were not related to later Candida infection. Treatment of patients with contamination of the peritoneum by Candida with Amphotericin B appears unnecessary and because of Amphotericin renal toxicity, may be potentially harmful. Patients with polymicrobial intra-abdominal abscesses that contain Candida species should be treated with surgical drainage and appropriate antibacterial antibiotics. The value of adding Amphotericin B therapy in patients with polymicrobial abscess containing Candida was not demonstrated in this study, and its role is unclear.