Parathyroid imaging: Its current status and future role

The management of autonomous (primary or tertiary) hyperparathyroidism is controversial for two important reasons: (1) Diagnosis of primary or tertiary hyperparathyroidism (as distinct from reactive or secondary hyperparathyroidism) has been revolutionized in the past 20 years as a result of routine inclusion of serum calcium concentration assays in serum multiautomated analysis, now obtained routinely for both hospitalized as well as ambulatory patients. The prevalence of primary hyperparathyroidism in the general population has appeared to rise as a consequence of this assay and the enhanced detection of this disease. This situation has confused the management of hyperparathyroidism since most patients now present with asymptomatic disease, and the need for surgical treatment is controversial in asymptomatic individuals. (2) Primary hyperparathyroidism usually is caused by hypersecretion of parathyroid hormone by an autonomously functioning parathyroid adenoma. In a small percentage of cases, multigland hyperplasia is present. In experienced hands, surgical removal of an adenoma within the thyroid bed cures the hyperparathyroidism 90% to 95% of the time, without performance of a preoperative procedure to localize the adenoma. Approximately 10% of parathyroid tissue is ectopic in location, however. Furthermore, approximately two thirds of "missed" adenomas are within the thyroid bed. Reexploration in the event of a failed operation therefore is not an uncommon occurrence. Parathyroid localization procedures clearly are indicated in patients with primary hyperparathyroidism who have evidence of persistent disease after a failed attempt at surgical cure. In patients first presenting with primary hyperparathyroidism, the need for a localization procedure is less clear, since surgery appears to be successful much of the time without it. Regardless of the nature of the above controversies, surgery for autonomous hyperparathyroidism continues, and localization procedures become more popular. Preoperative localization procedures such as angiography and venography with venous sampling for parathormone are cumbersome and invasive. Noninvasive tests to localize the parathyroid glands have emerged in the past 10 years, including dual tracer radionuclide scintigraphy with 201-thallous chloride and 99m-technetium pertechnetate, high-resolution computer tomography, and fine parts ultrasonography. Dual tracer scintigraphy with thallium and technetium is reported to have a localization sensitivity of 70%-90%. False-negative studies occur primarily in patients with small adenomatous or hyperplastic glands.(ABSTRACT TRUNCATED AT 400 WORDS)     

The direct approach

In the following excerpt from Dealing Direct: A Strategy for Business-Provider Partnerships, published in February by American Hospital Publishing, authors Gee and Fine discuss the right and wrong reasons for considering one of health care's most talked about new relationships.     

New techniques and instruments for lens implantation

Although most of the new techniques and new instrumentation for intraocular lens implantation are related to foldable intraocular lenses or sutured posterior chamber lenses, there are some intriguing new concepts in intraocular lens techniques unrelated to these two areas.     

Recombinant human growth hormone in infants and young children with chronic renal insufficiency

Children with chronic renal insufficiency (CRI) secondary to congenital structural abnormalities frequently have significant growth retardation by 2 years of age. In a multicenter placebo-controlled study of the use of recombinant human growth hormone (rhGH), 30 of 125 (24%) participants were<2.5 years of age at enrollment. Since the treatment arms of the study were balanced for age at randomization, data for these patients were examined for efficacy and safety. During the first 2 years of the study, approximately two-thirds of the patients (n=19) received rhGH 0.05 mg/kg per day subcutaneously and one-third (n=11) received placebo injections. At entry into the study, the mean (± SD) calculated creatinine clearance was 29.2±14.3 (range 12.0–63.7) ml/min per 1.73 m² in the rhGH-treated group and 23.3±15.1 (range 8.0–59.4) ml/min per 1.73 m² in the placebo-treated group. The 1st year growth rate was 14.1±2.6 cm/year for the rhGH-treated group and 9.3±1.5 cm/year in the placebo-treated group (P<0.00005). During the 2nd year of the study, the growth rate was 8.6±1.2 cm/year in the rhGH-treated group compared with 6.9±1.0 in the placebo groupP=0.025). The height standard deviation score was +2.0±0.7 for the rhGH-treated group compared with –0.2±1.1 in the placebo-treated group (P<0.00005) during the 2 years of the study. Minor adverse events occurred with similar frequency in both groups. These data suggest that rhGH is efficacious and safe in children with CRI under age 2.5 years. rhGH therapy may correct significant loss of growth at this age when used in conjunction with optimal medical management.