A 20-Year Study on 190 Patients With Primary Hyperparathyroidism in a Developing Country: Turkey Experience

The aim of this study was to present our 20-year experience regarding primary hyperparathyroidism (PHPT). PHPT patients who underwent parathyroidectomy in our clinic were reviewed retrospectively. There were 190 PHPT patients, of whom 137 were asymptomatic (72%). The mean serum calcium at the time of diagnosis was 11.9 ± 2.2 mg/dL. The mean parathyroid hormone (PTH) level was 467 ± 78 pg/mL. Ultrasonography (USG) identified all abnormal glands accurately (82.6%) and Technetium-99m sestamibi scintigraphy (MIBI) was used in 89.4% of the patients and magnetic resonance imaging (MRI) in 61%. The common use of USG and MIBI detected 92% of the lesions. Bilateral neck exploration (BNE) was performed in 12.2% of the patients and focused unilateral neck exploration (FUNE) in the remaining 87.8%. Surgical intervention was unsuccessful in 1 patient (0.5%). The conversion ratio from FUNE to BNE was 5.2%. The mean operation time and mean hospital stay decreased significantly in patients with FUNE. Pathologic examination revealed single adenoma in 93% of the patients. New imaging techniques result in the conversion of surgical treatments of PHPT. FUNE in parathyroidectomy performed by an experienced surgeon may provide successful treatment rates.Key words: Primary hyperparathyroidism, Focused surgical neck exploration, Developing countryPrimary hyperparathyroidism (PHPT) is defined as hypercalcemia with an excessive, uncontrolled parathyroid hormone (PTH) secretion by 1 or more parathyroid glands in the absence of secondary or tertiary factors. In some cases, normocalcemia can be present with osteopenia and vitamin-D deficiency, and normal PTH can occur with high markers of bone formation and bone resorption. The prevalence varies between 1 or 2 people out of 1000 in the USA and the incidence varies between 27 and 30 people out of 100,000 per year, according to the population and research methods.^1–3The first parathyroidectomy was performed in 1924 by Mandl with the exploration of 4 parathyroid glands and excision of an enlarged single parathyroid adenoma.⁴ This operation was followed by the discovery of parathormone and the development of many measurement methods of PTH.⁵ In the last 30 years, the wide use of the multichannel autoanalyzer; use of USG, MIBI, computed tomography (CT), and MRI for the diagnosis of PHPT; and new surgical methods and techniques for the surgical treatment of PHPT have resulted in easier diagnosis of the disease, correct localization of pathologic lesions, and different surgical approaches.^1,5–17The aim of this study was to present our 20-year-experience with 190 patients diagnosed with PHPT, their clinical features, diagnostic methods, surgical treatment and pathology, and review of the literature.     

Melatonin inhibits oxidative stress and apoptosis in fetal brains of hyperhomocysteinemic rat dams

Moderate hyperhomocysteinemia is a risk factor for neurodegenerative diseases and complications during pregnancy. Increased homocysteine levels during pregnancy may elevate developmental risk on fetal brain structure and function. However, little is known about the mechanism of action of homocysteine on the degeneration of the fetal brain. Hence in this study, we examined the effects of maternal hyperhomocysteinemia on oxidative stress and apoptosis in brain tissues and investigated whether administration of melatonin to the mother would prevent homocysteine-induced oxidative cerebral damage in pups. Hyperhomocysteinemia was induced in female rats by administration of methionine at a dose of 1 g/kg body weight dissolved in drinking water during pregnancy. Some animals received methionine plus 10 mg/kg/day melatonin subcutaneously throughout pregnancy. After delivery, the level of lipid peroxidation (malondialdehyde + 4-hydroxyalkenals) was determined in different subfractions of pup brains. Furthermore, DNA fragmentation, levels of Bcl-2 protein and p53 mRNA expression were determined to evaluate apoptosis. Significant elevation was found in the levels of lipid peroxidation in subcellular fractions of the brain of pups of hyperhomocysteinemic dams. Increased DNA fragmentation and p53 mRNA expression was observed in the brain of pups of homocysteine-treated rats, while a significant reduction was seen in the levels of anti-apoptotic Bcl-2 levels. Melatonin administration prevented markers of oxidative stress and biochemical signs of apoptosis. In conclusion, therapeutic administration of melatonin protects against the induction of oxidative stress and neural tissue injury and might prevent congenital malformations of fetal brain caused by maternal hyperhomocysteinemia.     

Transcortical-transventricular approach in colloid cysts of the third ventricle: surgical experience with 26 cases

Colloid cysts of the third ventricle account for 0.5–2% of all intracranial tumors. The treatment of these benign tumors remains controversial, and the best surgical option has not yet been determined. Between 1995 and 2002, 27 patients with colloid cysts of the third ventricle presented at our clinic. Twenty-six underwent transcortical-transventricular approaches. One refused surgical treatment. There was no surgical mortality. The main morbidity was epileptic seizures in two patients. Overall outcome was good in all patients. The mean follow-up period was 3.4 years. There were no tumor recurrences. The transcortical-transventricular approach can be used safely to excise third ventricle colloid cysts with low risk of mortality and morbidity.     

Pre-emptive effect of epidural sufentanil in abdominal hysterectomy

Background. Experimental studies suggest pre-emptive administrationof analgesics is effective but clinical evidence is less convincing. Methods. Forty-one patients undergoing abdominal hysterectomywere allocated randomly in a double-blind fashion to receivesufentanil 50 µg via a lumbar epidural catheter beforeor at the end of surgery. Results. Sufentanil consumption from a patient-controlled epiduralanalgesia (PCEA) system and numerical pain scores at rest andduring movement over the initial 72 h were similar in thetwo groups. When the study period was divided into five timeintervals, sufentanil consumption in the pre-emptive group wassignificantly less than in the control group between 8 and 16 hafter surgery (P=0.04). Furthermore, the number of failed bolusattempts from the PCEA device was significantly lower and patientsatisfaction was significantly better in the pre-emptive groupduring the 72 h of PCEA treatment (P<0.05). In addition,the median decrease in ACTH and cortisol on the first postoperativemorning relative to baseline values was greater in the pre-emptivegroup than in the control group (P<0.05). In subjects whohad a Pfannenstiel incision, touch and pain sensitivity in thewound area were less in the pre-emptive group over the first4 postoperative days (P<0.05). Conclusions. We conclude that pre-emptive analgesia with epiduralsufentanil was associated with a short-term sufentanil-sparingeffect, and could have reduced stress hormone responses andwound sensitization after abdominal hysterectomy. Br J Anaesth 2002; 88: 803–8     

Effects of maternal hyperhomocysteinemia induced by methionine intake on oxidative stress and apoptosis in pup rat brain

Maternal hyperhomocysteinemia is associated with a number of complications such as preeclampsia syndrome, thromboembolic events, repeated miscarriages, abruptio placentae, in utero fetal death, intrauterine fetal growth restriction and fetal neural tube defects. However, little is known about the mechanism of homocysteine on the degeneration of fetal brain. Thus, our study is aimed to investigate the effects of maternal hyperhomocysteinemia on oxidative stress and apoptosis in pup brain. Hyperhomocysteinemia was induced in female rats by way of administrating methionine dissolved in water at a dose of 1 g/kg body weight throughout the pregnancy. After delivery, level of lipid peroxidation (LPO; as malondialdehyde + 4-hydroxyalkenals) was determined in various fractions of pub brains. Furthermore, DNA fragmentation, levels of Bcl-2 protein and p53 mRNA expression were determined to evaluate apoptosis. Significant elevation was found in the levels of LPO in subcellular fractions of pup brains delivered from hyperhomocysteinemic mothers. DNA fragmentation, a hallmark of apoptosis was observed in the brain of pups of homocysteine group while significant reduction was seen in the levels of anti-apoptotic Bcl-2 levels. In addition, maternal hyperhomocysteinemia increased cerebral p53 mRNA expression above the control value. As a conclusion, we demonstrate and suggest that the pups of hyperhomocysteinemic mothers have an increased oxidative stress in brain tissues. The increased oxidative stress appears to cause apoptosis and cell death. These results may be significant to understand chronic pathology of the complications of hyperhomocysteinemia and congenital malformations of fetuses.     

Correlation of injury severity and tissue Evans blue content, lipid peroxidation and clinical evaluation in acute spinal cord injury in rats

OBJECTIVE: To demonstrate the changes in microvascular permeability occurring in association with graded acute spinal cord injury and to determine whether tissue Evans blue content is a useful indicator of the severity of spinal cord injury. The study also aimed to test the ability of the Evans blue method to demonstrate secondary injury after spinal cord contusion. METHODS: In step one of the study, spinal cord lipid peroxidation levels and spinal cord Evans blue content were evaluated at 2 h post-injury in five groups of rats: a control group, a laminectomy-only group and three trauma groups (10, 50, and 100 gcm). In step two, these rats were used for Evans blue assessment following clinical examination at 24 h post-injury. RESULTS: The laminectomy-only group showed no difference from the control group with regard to spinal cord lipid peroxidation levels, tissue Evans blue content, and clinical findings. Increase in spinal cord tissue Evans blue content and lipid peroxidation was correlated with increasing intensity of trauma. There was a negative correlation between trauma intensity and clinical findings, and there was an increase in spinal cord tissue Evans blue content at 24 h compared with that at 2 h. CONCLUSIONS: Determination of spinal cord tissue Evans blue content is a reliable, rapid, simple and inexpensive method that can be used in experimental spinal cord injury to assess the severity of injury and to evaluate neuroprotection studies. The present study is the first to show that the Evans blue technique is a useful method to demonstrate secondary injury of spinal cord tissue and vasculature.     

Maternal treatment with propofol attenuates lipid peroxidation after transient intrauterine ischemia in the neonatal rat brain

The purpose of this study was to investigate whether propofol has a neuroprotective effect on the fetal brain after intrauterine ischemia-reperfusion (I/R) injury in the rat fetus. Fetal brain ischemia was induced by clamping the utero-ovarian artery bilaterally for 30 min and reperfusion was achieved by removing the clamps for 2 h. A 40-mg/kg single dose of propofol was administered intraperitoneally 15 min before I/R injury. Lipid peroxidation in the brain tissue was determined as the concentration of thiobarbituric acid reactive substances (TBARS) for each fetal rat. Results showed that lipid peroxidation byproducts increased after I/R injury. Maternal treatment with propofol reduced TBARS compared to the I/R group. Propofol has been shown to have neuroprotective effects in intrauterine I/R-induced fetal brain damage in rats.     

Effects of the Celecoxib on the Acute Necrotizing Pancreatitis in Rats

The investigation of the effects of the celecoxib as a cylooxygenase-2 (COX-2) inhibitor on the course of the acute necrotising pancreatitis (ANP) in rats. ANP was induced in 72 rats by standardized intraductal glycodeoxycholic acid infusion and intravenous cerulein infusion. The rats were divided into four groups (six rats in each group): Sham + saline, sham + celecoxib, ANP + saline, ANP + celecoxib. Six hours later after the ANP induction, celecoxib (10 mg/kg) or saline was given i.p. In the 12th hour, routine cardiorespiratuar, renal parameters were monitored to assess the organ function. The serum amylase, alanine amino transferase (ALT), interleukin 6 (IL-6), lactate dehydrogenase (LDH) in bronchoalveolar lavage (BAL) fluid, the serum concentration of the urea, the tissue activity of myeloperoxidase (MPO) and malondialdehyde (MDA) in pancreas and lungs were measured. The pancreas histology was examined. In the second part of the study, 48 rats were studied in four groups similar to the first part. Survival of all the rats after the induction of ANP was observed for 24 h. The induction of the pancreatitis increased the mortality from 0/12, in the sham groups to 4/12 (30%) in the acute pancreatitis with saline group, 5/12 (42%) in the acute pancreatitis with celecoxib group respectively, heart rate, the serum activities of amylase, ALT, the tissue activities of MPO, MDA in the pancreas and lung, and LDH in BAL fluid, the serum concentration of the urea and IL-6, the degree of the pancreatic damage and decreased the blood pressure, the urine production, pO₂ and the serum concentration of calcium. The use of celecoxib did not alter these changes except the serum IL-6 concentration, urine production and MPO, MDA activities in the tissue of the lungs and pancreas. Serum urea concentration and pancreatic damage in ANP + celecoxib group were insignificantly lesser than ANP + saline group. Whereas treatment with celecoxib improves lung and renal functions, the degree of pancreatic damage partially and the serum IL-6 level completely, it does not improve the cardiovascular and liver functions, the mortality rate and the calcium level. Celecoxib may be useful for the support of some organ functions during ANP in rats.     

Results of transvenous lead extraction of coronary sinus leads in patients with cardiac resynchronization therapy

Background The need for transvenous lead extraction procedures of coronary sinus （CS） leads is increasing due to rising numbers of implanted cardiac resynchronization therapy devices during the past decade. Methods From January 2009 to June 2013, 27 CS leads were scheduled for extraction in 27 patients （mean age （63.1±14.6） years）. Indications for lead extraction were infection in 13 and lead dysfunction in 14 cases. Isolated extraction of CS leads was performed in eight, extraction of multiple leads in 19 cases. Among leads with an implant time of 〉12 months （n=19） mean implant duration （MID） was （46.4±15.2） （12-76） months. Groups were formed depending on infectious or non-infectious indications （INF vs. Non-INF）, and the use or non-use of extraction tools （ET1 vs. ET0）. Results Among patients with an implant duration of 〉12 months, complete procedural success was 94.7% and clinical success 100%. Operative mortality was zero. In the INF versus NON-INF groups complete procedural success （100% vs. 91.7%, P=0.43）, mean number of required extraction tools （0.7 （0-2） vs. 0.9 （0-3）, P=0.65） and MID （49.1±15.0 vs. 44.7±15.8, P=0.83） did not differ significantly. Comparing the groups ET1 and ET0 showed no significant differences in complications （n=l vs. n=l, P=-0.81） and MID （47.0±17.5 vs. 45.5±12.6, P=0.71）. Conclusions In specialized centers transvenous lead extraction of coronary sinus leads with a mean implant duration of almost four years can be performed safely and effectively. Neither non-infectious indications nor the use of extraction tools negatively affected the outcome of the procedure.