Coexisting hyperparathyroidism with thyrotoxicosis

The coexistence of hyperparathyroidism complicating thyrotoxicosis is quite rare. We report the case of one patient who presented with thyrotoxicosis, (total thyroxine of 15.1 micrograms/dl (5-13), free thyroxine index of 18 (4-15) and triiodothyronine by RIA of 305 ng/dl (70-230) and asymptomatic hypercalcemia of 15 mg/dl (8.5-10.6), who was also initially noted to have an elevated (C-terminal) serum immunoreactive parathyroid hormone (iPTH) level of 8,800 pg/ml (50-340). With propylthiouracil and propranolol, however, this patient became normocalcemic with a decrease in iPTH values to 714 pg/ml. As the patient was tapered from medication, after being rendered euthyroid, a recurrence of hypercalcemia with rising iPTH levels occurred. PTH levels should be helpful in defining coexisting hyperparathyroidism in patients with thyrotoxicosis since in the latter iPTH is usually suppressed. Our findings support the recommendation that in patients suspected of having both hyperparathyroidism and hyperthyroidism, a diagnosis of the former can only be made with certainty after the patient has been rendered euthyroid with persistently elevated serum calcium and iPTH levels. While there are no clinical features which permit the easy identification of patients who present with dual lesions, the determination of iPTH values may be the most consistently helpful test initially, whereas other parameters such as vitamin D, serum phosphate are less reliable.     

Validity of self-report of recent opiate use in treatment setting

Self-report validity of recent drug use among heroin abusers depends on many factors including the population being studied and the setting in which the study is carried out. This study was conducted by the treating physicians to assess the self-report validity of recent heroin use by heroin dependent patients in the outdoor setting using 'thin layer chromatography' (TLC) and two highly sensitive methods of urinalysis viz. 'gas liquid chromatography' (GLC) and 'high performance liquid chromatography' (HPLC). Out of seventy-six heroin dependent patients who entered the study, 64 provided urine sample on the same day. Patients' self-report about recent opiate use was found to have a moderate agreement with urinalysis report. However, it is important to validate it with urinalysis during the treatment process because a substantial proportion of patients fails to report recent opiate use. It is recommended that all drug dependence treatment centres should be equipped with a sensitive urinalysis facility. Otherwise, the outcome of the treatment process should be considered with caution.     

Serum osteocalcin and total body calcium in normal pre- and postmenopausal women and postmenopausal osteoporotic patients

Serum osteocalcin was measured in 51 normal pre- and 114 postmenopausal women and in 41 postmenopausal osteoporotic patients. Total body calcium (TBCa) was determined in the same individuals by neutron activation analysis. Many of the perimenopausal nonosteoporotic women had increased serum osteocalcin values, but 15 yr or more after the menopause most of the women had serum osteocalcin levels in the normal range. Comparing normal women before and after menopause, the mean serum osteocalcin levels [7.8 +/- 4.7 (+/- SE) and 10.1 +/- 9.4 ng/mL] were not significantly different; however, the TBCa values (898 +/- 99 and 806 +/- 111 g) were significantly different (P less than 0.001). When the normal postmenopausal women were regrouped according to high vs. low osteocalcin values, TBCa and phosphorus content as well as forearm linear bone density were significantly lower in the high osteocalcin group, even though most of the other variables, including urinary hydroxyproline excretion, serum alkaline phosphatase, age, height, and weight, were not different. Osteoporotic women had a mean serum osteocalcin concentration of 17.4 +/- 8.6 ng/ml and a TBCa of 657 +/- 83 g, both significantly different from the respective values in normal and pre- and postmenopausal women (P less than 0.001 for both variables in comparison to each group). These data suggest that high serum osteocalcin levels, at least on a group basis, are an index of low skeletal mass.     

Safety and efficiency of interventional pulmonologists performing percutaneous tracheostomy

Background: The steady rise in the number of critically ill patients in the USA has led to an increase in the need for tracheostomies in patients requiring chronic ventilatory support. There is a matched need for experienced operators to safely and efficiently perform these procedures. Objectives: We evaluated the effects on procedural outcomes and efficiency of percutaneous dilatational tracheostomy (PDT) placement in the medical intensive care unit (MICU) by the surgical team (ST) or interventional pulmonologists (IP). The IP team joined the PDT team in September 2007 and became primarily responsible for all PDT in the MICU. Methods: A retrospective analysis of prospectively collected data of patients who received PDT in the MICU by ST and IP from September 2007 to August 2010 was made. Outcomes including safety, efficacy, and procedural efficiency were compared. Results: One hundred seven patients underwent bedside PDT in the MICU during this period. Forty-three procedures (40.2%) were performed by the ST and 64 procedures (59.8%) were performed by IP. There was no statistical difference between the incidence of airway injury and infection between the two procedural groups. There were no deaths related to the performance of PDT in our series. PDT was completed within 48 h of request in 100% of IP patients and 95% of ST patients (p = 0.08). Conclusions: There were no statistical differences in PDT between the ST and IP groups when comparing complications. There was a trend towards an increased efficiency in time to PDT after consultation within the IP PDT group. Trained IP can safely and effectively perform PDT.     

Recurrent gallstone ileus: a case report

Gallstone ileus is a rare complication of recurrent gallstone cholecystitis and usually occurs in elderly female patients. Recurrent gallstone ileus occurs in 5% of patients with a previous episode of gallstone ileus and is associated with a mortality of 20%. We present a 52-year-old female with recurrent gallstone ileus 1 year after her initial episode. Electronic Publication     

Moyamoya syndrome in a child with Down syndrome

Moyamoya syndrome has rarely been reported in association with Down syndrome. We report a case of an 11-year-old female child with Down syndrome who presented with hemiparesis and facial palsy. Imaging investigations (magnetic resonance angiography and digital subtraction angiography) revealed the classical Moyamoya pattern. Work-up for prothrombotic and autoimmune disorders was negative. The neurological deficits recovered well. The association of Moyamoya syndrome in patients with Down syndrome has been highlighted. The possible causes for the association and management have been reviewed briefly.     

Changes in body composition following therapy of osteoporosis with methandrostenolone

A two compartment, double-blind, randomized, parallel study was performed comparing methandrostenolone with placebo in the treatment of osteoporosis. The duration of the study was 24 mo. Dependent parameters included total body calcium (TBCa), measured by neutron activation analysis; bone mineral content of the radius (BMC), measured by photon absorptiometry; and total body potassium (TBK), measured by total body counting. A significant increase in TBK occurred in the treated group, primarily in the first 6 mo; thereafter the TBK remained fairly constant. No significant changes in bone mass occurred, except the 6 mo TBCa measurement increased by 11 grams for the methandrostenolone group and decreased by 6 grams for the placebo group (p = .05). Other evidence also suggests that anabolic steroids may not produce sustained uncoupling of bone formation and bone resorption in osteoporosis. If methandrostenolone is capable of producing an increment in bone mass in osteoporosis, it was not readily observable with the sensitivity of the techniques employed in this study.