Surgical strategy for primary hyperparathyreoidism with thyroid hemiagenesis

Background

Thyroid hemiagenesis is a rare congenital anomaly, and still more rarely associated with primary hyperparathyroidism (pHPT). Due to the embryologic pathways of the thyroid and parathyroid glands, it remains unclear whether or not thyroid hemiagenesis may be linked to ipsilateral parathyroid agenesis, and consequently, surgical strategy for thyroid hemiagenesis associated pHPT (THAP) does not only depend on preoperative localization but also on the thyroid anomaly.

Methods

Including the present case report, a total of nine cases with THAP retrieved from the literature were reviewed. Seven of nine cases had thyroid hemiagenesis on the left side, three out of nine showed a parathyroid adenoma on the contralateral side to the thyroid hemiagenesis.

Conclusions

Based on these cases, it can be concluded that the embryologic pathways of the thyroid and parathyroid glands are different, and in cases of THAP, parathyroid exploration should follow standard recommendations for pHPT surgery.     

Ketoconazole-induced hepatitis. Case report

Since Oct. 1981 a new systemic antifungal drug Ketoconazole is available in the Federal Republic of Germany that has proven effective even in severe cases with fungal infections. This case-study will call attention on a rare but important side effect, namely Ketoconazole induced hepatitis. As an acute icteric viral hepatitis, type Non-A-Non-B-hepatitis possibly misdiagnosed only a carefully compiled history of the recent intake of drugs points at the real cause of hepatitis. In our case-report we observed a considerable increase in serum enzymes, especially GOT, GPT and GLDH after a drug-challenge with two tablets. We recommend so-called liver functions tests 2 to 3 weeks after beginning of therapy and further-on in monthly intervals. Histologically at that time toxic hydropic changes of the liver cells and a mesenchymal reaction with portal and intralobular mainly eosinophilic infiltration could be established. The serum enzymes came to normal only after 12 weeks.     

Glucose utilization and glycogen turnover are accelerated in hypertrophied rat hearts during severe low-flow ischemia

We undertook this study to determine if the metabolism of exogenous glucose and glycogen in hypertrophied hearts differed from that in normal hearts during severe ischemia. Thus, rates of glycolysis (3H2O production) and oxidation (14CO2 production) from exogenous glucose and glycogen were measured in isolated working control (n = 13) and hypertrophied (n = 12) hearts from sham-operated and aortic-banded rats during 40 min of severe low-flow ischemia. Hearts, in which glycogen was prelabelled with [5-3H]- or [14C]-glucose, were paced and perfused with Krebs-Henseleit solution containing 1.2 mM palmitate, 5.5 mM [5-3H]- or [14C]-glucose (different from the isotope used to label glycogen), 0.5 mM lactate and 100 microU/ml insulin during ischemia. Rates of glycolysis from exogenous glucose (3301 +/- 122 v 2467 +/- 167 nmol/min/g dry wt, mean +/- S.E.M., P < 0.05) and glucose from glycogen (808 +/- 27 v 725 +/- 21 nmol/min/g dry wt, P < 0.05) were accelerated in hypertrophied hearts compared to control hearts. However, rates of oxidation of exogenous glucose and glucose from glycogen were not significantly different between the two groups. As observed in normoxic non-ischemic hearts, glucose from glycogen was preferentially oxidized compared to exogenous glucose. Additionally, rates of glycogen synthesis (167 +/- 7 v 140 +/- 9 nmol/min/g dry wt, P < 0.05) were increased in hypertrophied hearts compared to control hearts during severe low-flow ischemia indicating that glycogen turnover (i.e. simultaneous synthesis and degradation) was accelerated in the hypertrophied heart. Thus, we demonstrate that glucose utilization and glycogen turnover are accelerated in the hypertrophied heart during severe low-flow ischemia as compared to the normal heart.     

Clinical comparison of extracorporeal piezoelectric lithotripsy (EPL) and intracorporeal electrohydraulic lithotripsy (EHL) in difficult bile duct stones

Today, nearly 90% of common bile duct stones are extracted endoscopically. Problems are encountered if there are large stones or a duct stenosis. Extracorporeal piezoelectric lithotripsy (EPL) as well as intracorporeal electrohydraulic lithotripsy (EHL) serve as an alternative to surgical intervention for those few patients in whom endoscopic measures have failed. A total of 35 patients with common bile duct stones in whom conventional endoscopic treatment had failed were selected on the condition that stone visualization through ultrasound was possible and that the papilla was within easy reach of the endoscope. Patients fulfilling the inclusion criteria were randomly treated either by EPL or EHL. The average age of our patients was 73 years. The main reasons for failure of conventional endoscopy were due to the large size of the stones (13 patients), impacted stones (16), or the presence of a biliary stricture (6). In the EPL group, visualization of the stones by ultrasound and ensuing treatment were possible in 16 of 18 patients (89%); stones could be fragmented in 15 patients. In 13 patients, the biliary tree could then be completely freed of calculi; the success rate was 72% for all the patients (13 of 18). On average, the patients had 2.3 treatments on the lithotripter, and 3870 shock waves were applied per treatment. In the EHL group stones were successfully fragmented in 13 of 17 patients (76.5%). The average number of treatments was 1.4. Comparing both therapies, there was no difference in stone-free rates. In both groups, additional endoscopic interventions were necessary to clear the bile duct. The mean number of lithotripsy sessions was less in the EHL group (1.4 vs 2.3). There were no major differences in average hospital stay, 30-day mortality was zero in both groups. Combined treatment including EPL, EHL, and intracorporeal laser lithotripsy was finally successful in 32 patients (91.5%). It is concluded that EHL might be the method of choice for smaller, single stones in the more proximal parts of the common bile duct. In these cases, complete duct clearance in one lithotripsy session can be achieved. Multiple and large stones are probably best accessible to EPL. With a combination of the methods described, the bile duct can be cleared of concrements in almost every instance. As a result, surgery for choledocholithiasis has become the absolute exception.This work was presented in part at the 1993 Annual Meeting of the american Gastroenterological Association in Boston and published in abstract form (Gastroenterology 104:A347, 1993).     

A pragmatist approach to the hope discourse in health care research

Hope is a central concept in nursing and other fields of health care. However, there is no consensus about the concept of hope. We argue that seeking consensus is futile given the multifaceted and multidimensional nature of the concept, but instead we encourage in‐depth studies of the assumptions behind talk about hope in specific contexts. Our approach to the ‘science of hope’ is inspired by philosophical pragmatism. We argue that hope is a concept that opens different rooms for action in different contexts and that accordingly, all hope interventions are contextually sensitive. Careful attention to how the relative positions and power of nurses and patients influence what can be inferred from their different ways of talking about hope may make hopeful conversations more meaningful in health care relationships.