Hyperthyroidism

Hyperthyroidism is a clinical situation where there is excess thyroid hormones in the circulation due to increased synthesis of hormone from a hyperactive thyroid gland. Common causes are Graves' disease, toxic multinodular goitre and toxic solitary nodule. Excess thyroid hormones in the circulation are also found in thyroiditis (hormone leakage) and excess exogenous thyroxine intake. Thyrotoxicosis is the term applied when there is excess thyroid hormone in the circulation due to any cause. Thyrotoxicosis can be easily diagnosed by high serum level of thyroxine (T4) and triiodothyronine (T3) and low serum level of thyroid stimulating hormone (TSH). Hyperthyroidism is confirmed by high isotope (I 131 or Tc99) uptake by the thyroid gland, while in thyroiditis it will be low. Treatment of hyperthyroidism depends on the underlying cause. Antithyroid drugs, 1131 therapy and surgery are the options of treatment of hyperthyroidism. Surgery is the preferred treatment for toxic adenoma and toxic multinodular goitre, while 1131 therapy may be suitable in some cases. Antithyroid drugs and 1131 therapy are mostly preferred for Graves' disease. Beta-adrenergic blockers are used for symptomatic relief in most patients of thyrotoxicosis due to any cause. Other rare causes of hyperthyroidism like, amiodarone induced thyrotoxicosis, choriocarcinoma, thyrotropin secreting pituitary tumour are difficult to diagnose as well as to treat.     

Evolution of insulin resistance in coronary artery disease patients on four different pharmacological therapies

The objective of the study was to examine the evolution of insulin sensitivity in a group of patients with stable coronary artery disease receiving one of four different pharmacological therapies. Insulin sensitivity was evaluated using an insulin suppression test in 40 newly diagnosed patients with coronary artery disease and no previous history of metabolic disorders, who were not taking any medication which might affect insulin sensitivity. The insulin suppression test consisted of a constant infusion of glucose, insulin and somatostatin for 150 min; insulin resistance was estimated by determining the steady-state plasma glucose concentrations during the last 60 minutes of the test. The insulin sensitivity index was calculated by the formula: insulin sensitivity index = (glucose infusion rate/steady state plasma glucose concentrations) × 10³. A second insulin suppression test was performed after 6 months'' therapy with either isosorbide mononitrate, atenolol, diltiazem or captopril in 30 of the 40 patients.
  There were no differences between any of the groups before therapy was initiated. After 6 months, patients treated with captopril and, to a lesser extent, those treated with diltiazem showed statistically significantly decreased steady state plasma glucose concentrations and increased insulin sensitivity index compared to basal values. No statistically significant differences were found in the other two groups. We conclude that captopril and, to a lesser extent, diltiazem improve insulin sensitivity in patients with stable coronary artery disease.


     

Infective thyroiditis in northern Nigeria: a fifteen-year study

Infective (suppurative) thyroiditis is almost non-existent in the developed world and even in the developing world, it still remains a rare disease entity. Seventeen patients with this disease were seen in 15 years in Zaria, Northern Nigeria. Fourteen of these patients had multinodular goitre, one patient had an adenoma and 2 never had a pre-existing neck swelling. Two patients with multinodular goitres had associated papillary and follicular carcinoma respectively. Pus was not obtained for culture from 3 patients. The pus in 5 (29%) of 17 patients grew staphylococcus aureus. 2 patients grew salmonella typhi and E. coli respectively and 2 patients grew Group A beta-haemolytic streptococcus from the pus. In three patients the diagnosis of thyroid abscess was an incidental finding by the pathologist, in patients with tender goitre clinically suspected to have had recent haemorrhages. Indolent thyroid abscesses from which gram negative organisms are isolated may be a pointer to an associated underlying malignancy.     

Evolution of an inguinal hernia surgery practice

BACKGROUND—Inguinal hernia surgery has undergone numerous advances in the last few years. This study analysed the changes in the practice of one surgeon in a district general hospital over a seven year interval. The effect of changing from Bassini to Lichtenstein repair in 1994 was evaluated.
METHODS—The study involved two parts: first a search of a computerised database of inguinal hernia procedures, and second, postal audits of men who had an inguinal hernia repair in 1993 and 1994 with outpatient follow up for those with a possible recurrence.
RESULTS—A total of 1037 hernias were repaired over the seven years. There was an increase in the proportion of day cases from 18% to 70% and the number of operations performed under local anaesthetic rose from 1% to 45%. The postal audits had response rates of 79% (1993) and 66% (1994). Some 5/98 (5%) recurrent hernias were identified from the 1993 (Bassini) patients compared with 1/67 (1.5%) from the 1994 (Lichtenstein) cohort.
CONCLUSION—Lichtenstein hernia repair can be performed safely as a day case using local anaesthetic in the majority of patients and appears to have a lower recurrence rate than Bassini repair.


     

甲状腺功能亢进症合并甲状腺癌的临床分析

目的 了解甲状腺功能亢进症（甲亢）合并甲状腺癌的状况。方法 对本院１９８３年１月～１９９８年６月,接受手术方法治疗的３９４例甲亢和经手术病理诊断的２４５例甲状腺一并进行回顾性分析。结果 共发现甲亢合并甲状腺癌１２例,占甲亢的３．０％（１２／３９４）,占甲状腺癌的４．９％（１２／２４５）,Ｇｒａｖｅｓ病合并甲状腺癌６例,毒性结节必 腺肿合并甲状腺癌６例。１２例患者中,甲状腺呈弥漫性肿大３例甲,弥漫性     

Delivery of surgical care in a district general hospital without high dependency unit facilities

BACKGROUND—Many hospitals lack the facilities for high dependency care, and patients requiring this level of care are nursed on the surgical ward. The aim of this study was to assess the extent of this problem in a district general hospital, looking at the impact of providing high dependency unit (HDU) care at ward level.
METHODS—A 28 bed surgical ward was studied for 39 consecutive days. Patients were assessed as being either appropriately placed (routine) or inappropriately placed (HDU). Nursing interventions and observations over each 24 hour period were recorded for the most dependent patient in each group.
RESULTS—Data were collected for a total of 1092 bed days. Median bed occupancy was 22 patients/day (78%). Inappropriately placed HDU patients accounted for 55 bed days (5%, mean 1.4 patients/day). These patients required more nursing intervention than routine patients.
HDU patients received more observations during a 24 hour period than routine patients (mean 11.3 and 4.2 respectively, p<0.005). The number of observations recorded for a routine patient in a 24 hour period fell when a HDU patient was nursed concurrently on the ward (mean 5.1/24 hours, falling to 3.8 /24 hours in the presence of an HDU patient, p<0.02 ).
CONCLUSIONS—HDU patients require more intensive nursing care than routine surgical patients, and the nursing of HDU patients on the ward adversely affects the quantity of care available for less dependent patients. High dependency care should therefore be provided in dedicated units.
HDU is an essential facility for all surgical patients, including those who require intensive nursing, and the routine surgical patient whose nursing is compromised by the failure to provide comprehensive postoperative care.


     

Transient hyperthyroidism after surgery for secondary hyperparathyroidism: a common problem

Background

Postoperative hyperthyroidism occurs in approximately one third of patients following parathyroidectomy due to primary hyperparathyroidism (PHP), but has only rarely been described in secondary hyperparathyroidism (SHP). The frequency, course, and laboratory markers of postoperative hyperthyroidism in SHP remain unknown. Our purpose was to evaluate the frequency and the clinical course of postoperative hypcrthyroidism following surgery of SHP and to determine the diagnostic value of thyroglobulin in this setting.

Material and Methods

A total of 40 patients undergoing parathyroidectomy because of SHP were included in this study. Thyroid stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fl4), and thyroglobulin (Tg) were determined one day before and on day 1, 3, 5, 10, and 40 after surgery. At each of these visits patients were clinically evaluated for signs or symptoms of hyperthyroidism.

Results

Biochemical evidence of hyperthyroidism was evident in 77% of patients postoperatively despite of preoperatively normal serum levels. TSH dropped from 1.18 ± 0.06mU/L to 0.15 ± 0.07mU/L (p = 0.0015). Free triiodothyronine (fT3) and fT4 levels increased from 2.86 ± 0.02ng/L and 10.32 ± 0.13ng/L, respectively, to their maximum of 4.83 ± 0.17ng/L and 19.35 ± 0.58ng/L, respectively. Thyroglobulin levels rose from 3.8 ± 0.8ng/mL to 111.8 ± 45.3ng/mL (p < 0.001). At day 40 all thyroid related laboratory values were within normal range. Correlation analysis of postoperative values revealed significant correlations for lowest TSH (r = -0.32; p = 0.038), and highest fT3 (r = 0.55; p < 0.001) and fT4 levels (r = 0.67; p < 0.001) with Tg.

Conclusion

Transient hyperthyroidism is frequent after parathyroidectomy for SHP with Tg being a suitable marker. Awareness of this self-limiting disorder is important to avoid inappropriate and potentially harmful treatment.     

Out-of-hours work in cardiothoracic surgery: implications of the New Deal and Calman for training

With the introduction of the New Deal and the Calman Report, the duration of higher specialist training will be halved. We have examined the effect of reduced on-call rotas on exposure to relatively uncommon out-of-hours emergencies in cardiothoracic surgery. Operations for post-infarction ventricular septal defect, aortic dissection or transection, oesophageal perforation and pulmonary embolus performed out-of-hours between 1990 and 1995 were identified from hospital records. Over 6 years, the period of higher specialist training in cardiothoracic surgery, a trainee would see seven aortic emergencies on a 1:2 rota, four on a 1:4 rota and two on a 1:6 rota. These figures provide a powerful argument in support of the English Clause which allows trainees to be available for 83 hours a week, equivalent to a 1:4 rota, rather than 56 hours a week, equivalent to a 1:6 rota under the New Deal. This may need supplementation by a mechanism whereby trainees are `on call for training''.


     

Quadruple therapy for symptomatic spontaneous duodenal ulcer disease

AIM—To investigate Helicobacter pylori eradication in duodenal ulcer patients with a new regimen, lansoprazole 30 mg daily for one or four weeks plus twice daily tetracycline 500 mg, clarithromycin 250 mg, and metronidazole 400 mg.
BACKGROUND—Spontaneous duodenal ulcer is regularly associated with H pylori, and permanent cure follows eradication of this bacterium. Numerous treatments have been proposed and none is ideal, possibly because of primary or acquired antibiotic resistance. Quadruple regimens with proton pump inhibitor therapy and three antibiotics offer promise as the most effective therapy.
METHODS—From November 1995 all patients with spontaneous duodenal ulcer were offered quadruple therapy. A month after completion a carbon 14 urea breath test (UBT) was performed. Sensitivity of H pylori to the antibiotics used was tested in 1992-3, 1996, and 1999.
RESULTS—A total of 331 patients were treated; 313 attended for a UBT, of which 299 were negative (95.5%). Of those patients who had an endoscopy with positive urease test immediately before treatment, 95/101 (94.0%) on lansoprazole for one week and 116/121 (95.8%) on lansoprazole for four weeks had a negative UBT. H pylori antibiotic sensitivity did not change.
CONCLUSION—This regimen produced some of the best results yet seen and may be generally recommended as first line therapy.


     

Trends in the smoking habits of young adults with diabetes

OBJECTIVES—To examine changes in the prevalence of smoking in young adult diabetic patients between 1990 and 1999.
SETTING—Walton Diabetes Centre, University Hospital Aintree, Liverpool, UK.
DESIGN—Direct questioning as well as the urinary cotinine:creatinine ratio were used to assess the smoking habits of 99 young type 1 diabetic patients in 1991 (mean age 21.5 years, duration of diabetes 7.3 years), and in 112 similar patients in 1999 (mean age 23.4 years, duration of diabetes 9.6 years).
RESULTS—The admitted smoking rate was 31/99 (31%) in 1990 compared with 31/112 (28%) in 1999 (not significant). However, in 1990 there were an additional 17 "covert" smokers (patients who denied smoking, but had an unequivocally raised urinary cotinine:creatinine ratio), but only three in 1999 (p<0.05). This gave a corrected validated smoking rate of 48/99 (48%) in 1990 and 34/112 (30%) in 1999, representing a significant fall (p<0.02).
CONCLUSION—Smoking rates in young type 1 diabetic patients appear to have fallen during the last decade, and reporting of smoking behaviour is now more honest.


     

Outcome of oesophagogastric carcinoma in young patients

The survival of young patients (⩽ 50 years of age) with carcinoma of the oesophagus or stomach has been reported to be poorer than that of their older counterparts. The aim of the current study was to review the outcome of such young patients with oesophagogastric cancer and to compare the outcome in patients with carcinoma of the oesophagus/cardia with patients with carcinoma of the more distal stomach. The study population was 50 patients. Tumour location was oesophagus/cardia (n=33) and gastric body/antrum (n=17). The most common presenting symptoms were weight loss (66%), epigastric pain (54%), dysphagia (50%), and heartburn (40%). Seventeen patients had experienced foregut symptoms for a period of ⩾6 months. These patients were more likely to have symptoms of gastro-oesophageal reflux disease and to have received acid suppression therapy than patients with shorter symptom durations. Only 20 patients underwent a potentially curative resection, while 10 underwent open and close laparotomy. The overall median survival was 7 months and the 5-year survival was 8%. Multivariate analysis revealed that surgical resection and UICC stage were the only factors that significantly influenced survival. There was no difference in the survival of patients with proximally situated tumours compared to those with distally located tumours. Wide variations in clinical practice were seen between different surgeons. Consequently, a multidisciplinary team designed to manage all patients with oesophagogastric cancer according to nationally agreed protocols has been established in our hospital. Earlier diagnosis of these tumours is to be encouraged, even if this necessitates the more liberal use of endoscopy in the evaluation of young patients with persistent foregut symptoms.


     

Drug related medical emergencies in the elderly: role of adverse drug reactions and non-compliance

BACKGROUND—Adverse drug reactions and non-compliance are important causes of admissions in the elderly to medical clinics. The contribution of adverse drug reactions and non-compliance to admission by the medical emergency department was analysed.
METHODS—A total of 578 consecutive elderly patients admitted to the medical emergency department were interviewed to determine the percentage of admissions due to adverse drug reactions or non-compliance with medication regimens, their causes, consequences, and predictors.
RESULTS—Eighty three (14.4%) of the 578 admissions were drug related: 39 (6.7%) caused by adverse drug reactions and 44 (7.6%) caused by non-compliance with medication. One hundred ninety two (33.2%) patients had a history of non-compliance. Factors associated with an increased risk of admission because of an adverse drug reaction were patients with diabetes or neoplasms, and patients using numerous different medications. Factors associated with a higher risk of hospitalisation because of non-compliance were poor recall of the medication regimen, seeing numerous physicians, female sex, polypharmacy, drug costs, and switching over to non-conventional forms of treatment.
CONCLUSION—Many elderly admissions are drug related, with non-compliance accounting for a substantial fraction of these. Elderly people at high risk of suffering a drug related medical emergency are identified and suitable interventions may be planned by the healthcare policymakers to target them.


     

The diagnosis of thyrotoxicosis

Thyrotoxicosis is a clinical syndrome due to excessive amounts of thyroid hormone in the circulation and tissues. Graves'' disease, goitre and exophthalmos, is the commonest variety, but in some parts of the world thyrotoxicosis supervenes on the background of a long standing nodular goitre. Other varieties such as ectopic TSH syndromes are very rare.     

Delays by patients in seeking treatment for acute chest pain: implications for achieving earlier thrombolysis

A study was set up to identify why patients delay seeking medical assistance after myocardial infarction. The study was performed in 100 consecutive patients with suspected acute myocardial infarction admitted to either the University Hospital of Wales, Cardiff, UK, or the Royal Jubilee Hospital, Victoria, British Columbia, Canada (50 patients from each centre). The main outcome measure was the delay from the onset of symptoms to admission to hospital. The mean total delay before admission was 385 minutes (SEM 45). The mean delay incurred by the patient in seeking assistance was 172 minutes (SEM 27), representing 45% of the total. Delay was longer in patients with crescendo angina and shorter in those later confirmed to have myocardial infarction. Patients with prior ischaemic heart disease (74% of patients) presented later than those with no such history. No other demographic or clinical factors predicted early or late presentation.
Delays in seeking medical assistance after the onset of severe chest pain contribute significantly to total delays in patients'' hospital admission and thrombolysis. The unexpected observation that patients with known ischaemic heart disease delay longer before seeking help in spite of their frequent contact with doctors, suggests that opportunities for educating patients are being wasted. Major efforts are needed to understand and modify behaviour of patients with chest pain to further reduce delays in treatment.


     

Prognostic value of stress echocardiography in women with high (> or = 80%) probability of coronary artery disease

OBJECTIVE—To assess the prognostic significance of stress echocardiography in women with a high probability of coronary artery disease (CAD).
SETTING—Secondary and tertiary cardiology unit at a university teaching hospital.
PARTICIPANTS—A total of 135 women (mean (SD) age 63 (9) years) with pre-test probability of CAD ⩾80% were selected from a database of patients investigated by treadmill or dobutamine stress echocardiography between 1995 and 1998.
MAIN OUTCOME MEASURES—Patients were followed up for occurrence of subsequent cardiac events (cardiac death, myocardial infarction, admission with unstable angina, and revascularisation) using a structured telephone interview and case note review.
RESULTS—Each patient had between two and seven (mean 3.5) CAD risk factors and pre-test probability of CAD ⩾80%. Ninety three patients (68.9%) had negative stress echocardiography. Mean (SD) follow up was 20.1 (8.5) months. There were six events in the positive stress echocardiography group (two cardiac deaths, one unstable angina, three revascularisations), and one event in the negative stress echocardiography group. Cox regression analysis showed positive stress echocardiography (p=0.02) and age (p=0.03) to be the only univariate predictors and positive stress echocardiography to be the only independent predictor of future cardiac events (relative risk 8.9, confidence interval 1.0 to 76.5, p=0.04). Cumulative event free survival to 38 months was 98% in the negative stress echocardiography and 50.7% in the positive stress echocardiography groups.
CONCLUSION—In women with high pre-test likelihood of CAD: (1) negative stress echocardiography identifies a subgroup with low risk of cardiac events who do not require further invasive investigation and (2) positive stress echocardiography identifies a subgroup with increased risk of subsequent cardiac events.


     

Efficacy and safety of intravenous amiodarone in recent-onset atrial fibrillation: experience in patients admitted to a general internal medicine department

We examined the efficacy and safety of intravenous amiodarone in 20 unselected patients with recent-onset atrial fibrillation who were admitted to a general internal medicine department during a 6-month period. The treatment protocol included a loading dose of 1200 mg intravenous amiodarone in 24 hours, after which amiodarone treatment was continued orally. Eleven of the 20 patients (55%) converted to sinus rhythm within 48 hours of intravenous amiodarone treatment and were discharged in sinus rhythm, while 9/20 (45%) patients failed to convert during hospitalisation. Six patients (30%) failed to convert to sinus rhythm even after one further month of oral treatment. There was one death and a high frequency (25%) of thrombophlebitis during hospitalisation. The in-hospital non-convertors had a significantly lower ejection fraction and initial low ventricular response rate than the convertors. In conclusion, the acute conversion rate by intravenous amiodarone was at best modest. It is suggested that intravenous amiodarone is probably more effective in patients with rapid recent-onset atrial fibrillation and good left ventricular function.


     

Evaluation of renal function in elderly heart failure patients on ACE inhibitors

A total of 187 heart failure patients aged 65-92 years, with pretreatment serum creatinine levels below 200 µmol/l, were monitored for more than 12 months on angiotensin-converting enzyme (ACE) inhibitor therapy. Optimal ACE inhibitor dosage was found in 27% of patients, while a significant deterioration in renal function, characterised by >20% increase in serum creatinine to >200 µmol/l, occurred in 25 patients. This was most closely attributable to ACE inhibitor treatment per se (implying co-existence of bilateral renal artery stenosis) in only four cases, including one in whom renal deterioration was reproducible on inadvertent rechallenge. In the other 21, renal deterioration was attributable to diuretic-related blood volume depletion (two cases), nonsteroidal anti-inflammatory drugs (two cases), obstructive uropathy (two cases), preterminal renal shutdown (two cases), and the interaction between diuretic and ACE inhibitor dosage (including long-acting vs short-acting drugs) (13 cases). This study could serve as the basis for future comparisons of ACE-inhibitor-related renal deterioration when the entry requirement is optimal ACE inhibitor dosage.


     

Permanent pacemaker insertion in a district general hospital: indications, patient characteristics, and complications

This report reviews the experience of permanent pacemaker insertion in a district general hospital (catchment population of 350 000) and makes a comparison with the national database and other hospitals in the UK.
METHODS—The records of all patients receiving a permanent pacemaker in the inclusive period January 1996 to December 1998 were reviewed. Data collected included number of patients paced each year, age, sex, indications, and complications.
RESULTS—In the three years reviewed 200 patients received new permanent pacemakers, a rate of 190 per million population per year, which is similar to the national implantation rate of permanent pacemakers but lower than that of most European countries (see discussion). The majority of patients paced were elderly (75% were above the age of 70 years).
Atrioventricular block (including complete heart block, 45%, and Mobitz type 2 block, 12.5%) was the commonest indication for permanent pacemaker insertion, followed by sick sinus syndrome (25%) and these findings are comparable to those reported previously. However, carotid sinus syndrome was responsible for 16% of the patients paced and this was higher than that reported in the national database (6.5%). Only 1% of the pacemaker modes used was inappropriate and the complication rate was low at 3%.
CONCLUSIONS—This report confirms that permanent pacemaker insertion can be effectively and safely provided locally for the increasingly ageing population. The implantation rate both locally and nationally is still much lower than that of some countries in Europe.


     

Clinicopathological correlation of serum TSH in patients with thyroid nodule

Thyroid nodules and goitre are common. Carcinoma occurs in 5% of thyroid nodules. Early detection and treatment is beneficial to prolonged survival. Higher thyroid stimulating hormone (TSH) level in patient with thyroid nodule is associated with greater risk of differentiated thyroid carcinoma. To assess relationship of TSH with thyroid carcinoma in nodular goitre and usefulness of this marker in predicting likelihood of thyroid malignancy, a study was undertaken among patients with nodular goitre enrolled prospectively during the period 2007 to 2009. Clinically thyroid nodules, confirmed by high resolution USG underwent serum TSH estimation and FNAC of the the nodules. Finally outcome of histopathological examination of resected thyroid specimen were analysed. Overall 33 patients with thyroid nodules were included in this study. Fifteen patients belonged to age group of 31 to 40 years, 13 belonged to 21 to 30 years; 29 were women, 4 were men. Majority of nodules were in right lobe and firm or hard. Fifteen nodules were > 4cm in size. FNAC showed colloid goitre in 24 patients, 7 patients had papillary carcinoma, 2 patients had follicular nodule. Final histopathological report showed 9 papillary carcinoma, 1 medullary carcinoma, 1 follicular carcinoma, 2 follicular adenoma and rest being colloid goitre. Mean TSH value for colloid goitre was 1.8987 mlU/l, for papillary carcinoma it was 2.2400 mlU/l, for follicular carcinoma it was 2.8900 mlU/l, for medullat carcinoma it was 0.8500 mlU/l and for follicular adenoma it was 4.4200 mlU/l. In differentiated thyroid carcinoma TSH value is raised more than in colloid goitre (p = 0.687). Incidence of malignancy in nodular goitre was 30% (11 carcinoma out of 33) in this study. Incidence of malignancy in nodular goitre is rising. Firm to hard nodules, male sex, 3-4 cm sized nodules are mainly susceptible. There is an obvious trend towards cancer risk with higher TSH value. TSH may, therefore, be used as a supportive screening test to predict malignancy in patients with thyroid nodule.