Asymptomatic hyperparathyroidism--need for multicentre studies

Long-term follow-up is initially considered appropriate for the majority of patients with primary hyperparathyroidism (PHPT) having small increases in calcium levels (< 2.8 mmol/l) and lacking the 'classical' symptoms of PHPT. The supportive reasoning is that many such patients never progress to more severe biochemical or clinical disease. There are, however, arguments in favour of early surgical treatment of such patients but adequately powered studies have not been carried out in this subgroup of patients to asses the impact of PHPT on their quality of life, cardiovascular risk and bone density. Progressive loss in bone mineral density and an increased risk of bone fracture become increasingly significant in an ageing population. Left ventricular hypertrophy, an increased risk of arrhythmia and/or myocardial infarction in addition to changes in atherogenic lipid profile and impaired glucose tolerance may translate into an increased risk of premature death in this group of patients. Changes in the quality of life identified using standardized questionnaires are sometimes recognized by patients only in retrospect (i.e. after resolution of symptoms following successful parathyroidectomy). In addition, many series fail to assess and record accurately such symptoms. Multicentre cohort studies of patients with asymptomatic PHPT randomized to immediate or delayed surgical treatment could address some of the debated issues highlighted in this review. Until such studies are set up, most surgeons would consider that parathyroid surgery should represent the first choice of treatment for all patients, but many physicians would favour a long-term follow-up. Nevertheless, the threshold for referral for surgical treatment has been lowered since the introduction of scan-directed minimally invasive parathyroidectomy, which enables the experienced parathyroid surgeon to successfully treat patients with PHPT with a minimum of complications as a day-case operation. In the context of improved surgical treatment, we need more data on the benefits or otherwise in so-called asymptomatic patients with a thorough assessment of their bone quality, cardiovascular risk and quality of life.     

Validity of the multidimensional fatigue symptom inventory-short form in an African-American community-based sample

Objectives. This study examined the psychometric properties of the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF) in a community-based sample of African-Americans.

Design. A sample of 340 African-Americans (116 men, 224 women) ranging in age from 18–81 years were recruited from the community (e.g., churches, health fairs, and beauty salons). Participants completed a brief demographic survey, the MFSI-SF and the Positive and Negative Affect Schedule.

Results. The structural validity of the MFSI-SF for a community-based sample of African-Americans was not supported. The five dimensions of fatigue (General, Emotional, Physical, Mental, Vigor) found for Whites in prior research were not found for African-Americans in this study. Instead, fatigue, while multidimensional for African-Americans, was best represented by a unique four-four profile in which general and emotional fatigue are collapsed into a single dimension and physical fatigue, mental fatigue, and vigor are relatively distinct. Hence, in the absence of modifications, the MFSI-SF cannot be considered to be structurally invariant across ethnic groups. A modified four-factor version of the MFSI-SF exhibited excellent internal consistency reliability and evidence supports its convergent validity. Using the modified four-factor version, gender, and age were not meaningfully associated with MFSI-SF scores.

Conclusion. Future research should further examine whether modifications to the MFSI-SF would, as the findings suggest, improve its validity as a measure of multidimensional fatigue in African-Americans.     

The evolution of a purpose designed hybrid trauma operating room from the trauma service perspective: The RAPTOR (resuscitation with angiography percutaneous treatments and operative resuscitations)

Traumatic injury is the leading cause of potentially preventable lost years of life in the Western world and exsanguination is the most potentially preventable cause of post-traumatic death. With mature trauma systems and experienced trauma centres, extra-abdominal sites, such as the pelvis, constitute the most frequent anatomic site of exsanguination. Haemorrhage control for such bleeding often requires surgical adjuncts most notably interventional radiology (IR). With the usual paradigm of surgery conducted within an operating room and IR procedures within distant angiography suites, responsible clinicians are faced with making difficult decisions regarding where to transport the most physiologically unstable patients for haemorrhage control. If such a critical patient is transported to the wrong suite, they may die unnecessarily despite having potentially salvageable injuries. Thus, it seems only logical that the resuscitative operating room of the future would have IR capabilities making it the obvious geographic destination for critically unstable patients, especially those who are exsanguinating.     

Cervical surgery and preterm birth

Treatment of cervical intraepithelial neoplasia (CIN) greatly reduces the risk of cervical cancer. Treatment involves ablation or excision of the transformation zone of the cervix, most commonly using an electrosurgical excision technique known as LLETZ. However, the peak incidence of CIN occurs in young women, so if excision of a portion of the cervix has an adverse effect on pregnancy outcome, this might have a significant impact. This review discusses the methodology and findings of the published literature on the association between cervical treatment and preterm birth, and the clinical implications of these findings.     

Regulation of actin dynamics by protein kinase R control of gelsolin enforces basal innate immune defense

Primary resistance to pathogens is reliant on both basal and inducible immune defenses. To date, research has focused upon inducible innate immune responses. In contrast to resistance via cytokine induction, basal defense mechanisms are less evident. Here we showed that the antiviral protein kinase R (PKR) inhibited the key actin-modifying protein gelsolin to regulate actin dynamics and control cytoskeletal cellular functions under homeostatic conditions. Through this mechanism, PKR controlled fundamental innate immune, actin-dependent processes that included membrane ruffling and particle engulfment. Accordingly, PKR counteracted viral entry into the cell. These findings identify a layer of host resistance, showing that the regulation of actin-modifying proteins during the innate immune response bolsters first-line defense against intracellular pathogens and has a sustained effect on virus production. Moreover, these data provide proof of principle for a concept in which the cell cytoskeleton could be targeted to elicit broad antiviral protection.     

Organ Transplantation and the Uniform Anatomical Gift Act: A Fifty‐Year Perspective

Fifty years ago this summer, the Uniform Anatomical Gift Act was adopted by the National Conference of Commissioners on Uniform State Laws and approved by the American Bar Association. The UAGA has provided a sound and stable legal platform on which to base an effective nationwide organ donation system. The cardinal principles of altruism, autonomy, and public trust are still important. At a time when confidence and trust in our government and many private institutions has declined, maintaining trust and confidence in our health care system and its commitment to “first, do no harm” has never been more important. Any policies that override these core ethical principles could cause irreparable damage to the public's faith in our transplant system. While progress has been made to increase organ registration and the number of organs transplanted, much more must be done to realize the potential of life‐saving therapy without jeopardizing ethical principles.     

Audit of short term outcomes of surgical and medical second trimester termination of pregnancy

Background  

As comparisons of modern medical and surgical second trimester termination of pregnancy (TOP) are limited, and the optimum method of termination is still debated, an audit of second trimester TOP was undertaken, with the objective of comparing the outcomes of modern medical and surgical methods.     

Parathyroidectomy is safe and improves symptoms in elderly patients with primary hyperparathyroidism (PHPT)

Objective Parathyroidectomy for primary hyperparathyroidism (PHPT) is curative in over 95% of cases. Although PHPT affects up to 2% of the elderly population, whose life expectancy may be a decade or more, such patients may be denied surgery because of perceived risk. This study investigates the outcomes of surgery for PHPT in the elderly. Design and patients Consecutive patients with PHPT treated at a tertiary referral centre over 5 years. Measurements A prospective database recorded clinical, biochemical and pathological information. Pasieka’s parathyroid symptom scores were obtained pre‐operatively and post‐operatively, from a recent subgroup of 70 consecutive patients. Deaths during follow‐up were identified using the NHS Strategic Tracing Service. Statistical analysis was performed with spss v12.0. Results Between November 2002 and October 2007, 224 patients (17–89 years) underwent surgery for PHPT. In the subgroup comprising patients aged >75 years there was a significantly greater proportion of women (47/56 vs. 52/81, P < 0·05). Pre‐operative indices of these patients were similar to younger patients, as were proportions undergoing minimally invasive parathyroidectomy (n = 134) or bilateral neck exploration (n = 90). Patients >75 years had a longer hospital stay (1·6 vs. 0·8 days, P = 0·003). Pasieka’s symptom scores improved significantly at 3–6 months postoperatively in all age groups. During a minimum median follow‐up of 22 months, there were seven patients with persistent/recurrent disease. Median 2‐year survival of those aged 60–74 and those over 75 ranged from 85–90%. Conclusion Parathyroidectomy is safe in the elderly and is associated with a significant improvement in symptoms. As survival after operation is similar to younger patients, surgery should be considered in all elderly patients with PHPT.