Long-Term Surveillance of Treated Hyperparathyroidism for Multiple Endocrine Neoplasia Type 1: Recurrence or Hypoparathyroidism?

Background

Primary hyperparathyroidism (HPT) in multiple endocrine neoplasia type 1 (MEN1) is surgically treated with either a subtotal parathyroidectomy removing 3 or 3,5 glands (SPX), less than 3 glands (LSPX), or a total parathyroidectomy with autotransplantation (TPX). Previous studies with shorter follow-up have shown that LSPX and SPX are associated with recurrent HPT, and TPX with hypocalcemia and substitution therapy. We examined the situation after long-term follow-up (median 20,6 years).

Methods

Sixty-nine patients with MEN1 HPT underwent 110 operations, the first operation being 31 LSPX, 30 SPX, and 8 TPX. Thirty patients underwent reoperative surgery in median 120 months later, as completion to TPX (n = 12), completion of LSPX to SPX (n = 9), extirpation of single glands (n = 3) still resulting in LSPX, and resection of forearm grafts (n = 3). Nine patients underwent a second, and 2 a third reoperation. In 24 patients genetic testing confirmed MEN1, and in the remaining heredity and phenotype led to the diagnosis.

Results

TPX had higher risk for hypoparathyroidism necessitating substitution therapy, at latest follow-up 50 %, compared to SPX (16 % after 3–6 months; none at latest follow-up). Recurrent HPT was common after LSPX, leading to 24 reoperations in 17 patients. No need for substitution therapy after SPX indicated forthcoming recurrent disease. Not having hypocalcemia in the postoperative period and less radical surgery than TPX were significantly associated to risk for recurrence. Further, mutation in exon 3 in the MEN1 gene may eventually be linked to risk of recurrence.

Conclusion

LSPX is highly associated with recurrence and TPX with continuous hypoparathyroidism, also after long-term follow-up. SPX should be the chosen method in the majority of patients with MEN1 HPT.

     

Does Resident Involvement Impact Post-Operative Complications Following Primary Total Knee Arthroplasty? An Analysis of 24,529 Cases

Little is known about the impact of resident involvement on complication rates following total knee arthroplasty (TKA). The goal of our study was to determine the impact of resident involvement on complications following primary TKA. Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2005–2012) we identified 24,529 patients who underwent primary TKA. Of these, 5960 (24.3%) had a resident involved in a primary TKA. Using a multivariate logistic regression which incorporated propensity score adjustment, no differences were seen in morbidity and mortality following those cases with resident involvement (OR: 1.15, P = 0.129). In the first large scale, comprehensive analysis of resident impact on short-term morbidity and mortality, no increase in complications was observed with resident involvement in primary TKA.     

Post-operative delay in return of function following guided growth tension plating and use of corrective physical therapy

Purpose

Guided growth has long been used to treat growth deformities, but the Eight-Plate^® system has recently become more widely used by pediatric orthopaedists. Because the current literature lacks evaluation of functional status in the immediate post-operative period, we investigated functional status following use of the Eight-Plate^® system.

Methods

We evaluated post-operative delay in return of function following treatment with the Eight-Plate^® system at two weeks after surgery. Fifty-one consecutive patients with a growth deformity were treated with the Eight-Plate^® system. Patients were comprised of 32 male and 19 female patients with an average age of 11 years (range 2–17.9 years).

Results

Among study participants, 19 patients (37.3 %) had post-operative delay of function. The rate of delayed function for patients 10 years of age or younger and 11 years of age or older was respectively 11.8 and 50 % (P = 0.002). Six of the 19 patients were treated with four or more plates, of which five patients (83.3 %) developed delayed return of function. The rate of delayed function in patients with at least one femoral plate compared to no femoral plate was respectively 45 and 9.1 % (P = 0.006). Bilateral operations were associated with a 66.7 % rate of delayed function compared to 25 % with unilateral operations (P = 0.004). When patients with delay of function were treated with physical therapy, 12 of 13 patients (92.3 %) had complete resolution of their symptoms.

Conclusion

Statistical significance demonstrated that patients at the greatest risk were 11 years of age or older, with four or more plates, with femoral plates, or with bilateral operations. Patients with delayed function were readily corrected by physical therapy.     

Evaluation of dyskerin expression and the Cajal body protein WRAP53β as potential prognostic markers for patients with primary vaginal carcinoma

Primary vaginal cancer (PVC) is a rare gynaecological malignancy, which, at present, lacks appropriate biomarkers for prognosis. The proteins dyskerin and WD repeat containing antisense to TP53 (WRAP53β), both of which exert their functions in the telomerase holoenzyme complex, have been shown to be upregulated in different cancer types. These proteins have also been proposed as prognostic markers in some types of cancer. The aim of the present study was to examine the expression patterns of dyskerin and WRAP53β in patients with PVC. Moreover, as part of a search for effective biomarkers to evaluate prognosis in PVC, the expression of these two proteins and their potential association with clinical variables and survival were also evaluated. The expression of dyskerin and WRAP53β was assessed in PVC tumour samples from 68 patients using immunohistochemistry. The majority of tumour samples showed low and moderate expression levels of dyskerin. Upregulation of dyskerin in tumour samples was significantly associated with a shorter survival time and a poorer cancer-specific survival rate. WRAP53β was also expressed in most of the cells but was not significantly associated with clinical variables or survival. This study demonstrates that upregulation of dyskerin is significantly associated with poor prognosis. Thus, dyskerin may serve as a promising prognostic marker and a potential putative therapeutic target in PVC.     

Accessory spleens--diagnostic and therapeutic problem of the laparoscopic splenectomy in idiopathic thrombocytopenic purpura patients

The preoperative detection of accessory spleens (AS) is essential in ITP patients. The aim of this study was to evaluate the reasons of failure and long-term results of laparoscopic splenectomy (LS) in patients with idiopathic thrombocytopenic purpura (ITP). Thirty-four ITP patients (27 females and 7 males) underwent LS between June 1998 and January 2001. Computed Tomography (CT) and sonography (US) were performed preoperatively to evaluate the size of the spleen and to detect the presence of possible accessory spleens which were found in two cases. AS were seen during laparoscopy in three cases. During follow-up (median time = 23 months), in three patients a low platelet count was seen after 5 months, 1.5 and 1.8 years pop. In all these cases scintigraphy was performed, which revealed in one case the residual accessory spleen. In the two other patients, inspite of thrombocytopenia no residual spleens were found. The authors conclude that laparoscopic splenectomy is a safe and effective procedure in patients with ITP. The problem of accessory spleens can be managed by careful videoscopic examination of the abdominal cavity during splenectomy. The use of the preoperative imaging techniques for detection of accessory spleens is limited by the insufficient sensitivity of the examination.