Indocyanine Green Fluorescence Angiography Can Guide Intraoperative Localization During Parathyroid Surgery

BACKGROUND AND AIMS

Intraoperative localization of pathologic parathyroid glands is of major importance for the hyperparathyroidism treatment. Based on the small size and the anatomic variability, the localization can be very challenging. The current practice is to compare preoperative ultrasonography with Technetium-99m sestamibi scintigraphy (MIBI) and plan the resection accordingly. In this study, we implemented indocyanine green angiography for the intraoperative localization of parathyroid glands.

MATERIALS AND METHODS

This is a retrospective analysis of 37 patients with primary, secondary, or tertiary hyperparathyroidism who were operated using indocyanine green angiography for the intraoperative localization of pathological parathyroid glands. An indocyanine green solution of 2.5 mg was were intravenously administered for parathyroid gland visualization. Different fluorescence scores were correlated with changes in postoperative parathyroid hormone levels.

RESULTS

Patients were divided into two groups depending on the presence of uniglandular or multiglandular disease. Sixty-four lesions were resected, and the final histopathologic analysis confirmed the parathyroid origin in 62 of them (96.8%). None of the patients with uniglandular disease developed postoperative hypoparathyroidism, whereas three patients in the multiglandular group developed temporary hypoparathyroidism symptoms. Indocyanine green imaging had higher sensitivity for the intraoperative detection of parathyroid glands compared with ultrasonography and MIBI (p < 0.001).

CONCLUSION

Indocyanine green angiography indicated high sensitivity for the intraoperative identification of pathologic parathyroid glands leading to a resection rate of 95.16%. The modality was useful, especially in cases of revisional surgery or ectopic parathyroid glands. Randomized trials have already proven the value of indocyanine green imaging in predicting postoperative hypocalcemia. Our results support the regular use of this method during parathyroid surgery.

Setting standards--antibiotic policies

It is important to choose appropriate topics for audit in order to produce satisfactory results and maintain interest and enthusiasm. A trail of incomplete audit cycles is unhelpful and demoralizing. The audit should be carefully designed and a vital stage is choosing appropriate standards upon which to measure current performance. An agreed policy provides a practical standard against which to audit the use of antibiotics.

Differential effects of the enantiomers R(-) and S(+) oxaprotiline on major endogenous depression, the sleep EEG and neuroendocrine secretion: studies on depressed patients and normal controls

The effects of the optically active enantiomers of oxaprotiline (OXP), R(-) OXP and S(+) OXP, on depressive symptomatology and the sleep EEG were investigated in two separate exploratory studies. In addition, the neuroendocrine profile of both compounds was characterized in normal controls. In the patients treated with a daily oral dose of 150 mg S(+) OXP we found a Hamilton depression score that decreased from 29.1 +/- 1.8 (SEM) on day 0 to 14.7 +/- 3.2 on day 28 (P < 0.01). Six patients were judged to be full responders (HAMD score 0-7 points), three were improved (HAMD score 8-15) and four were nonresponders (HAMD score > 16). The therapeutic effect achieved with 150 mg R(-) OXP daily was less pronounced: the HAMD score decreased from 27.8 +/- 2.5 on day 0 to 19.4 +/- 3.2 on day 28 (P < 0.05). There were two full responders, one improved patient and seven nonresponders. The sleep EEG scoring revealed a marked suppression of REM sleep among patients treated with S(+) OXP but not with R(-) OXP. In the normal controls, a single oral dose of 75 mg S(+) OXP prompted an increase in the secretion of cortisol and growth hormone, whereas 75 mg R(-) OXP did not. Neither enantiomer influenced the secretion of testosterone or prolactin.

Extrapyramidal symptoms and their relationship to clinical efficacy under perphenazine treatment. A controlled prospective handwriting-test study in 22 acutely ill schizophrenic patients

In order to verify the hypothesis of a strict relationship between clinical improvement and extrapyramidal side-effects, especially micrographia, twenty-two acutely ill schizophrenics were treated with perphenazine in a controlled prospective 28-day trial. During the study period, psychopathometric data, prolactin plasma levels, and handwriting samples were collected. According to the remission criteria fixed before the study began (both BPRS less than or equal to 25 and GAS greater than or equal to 80 points), 45.5% (10/22) of the total patient sample were classified as treatment responders. Handwriting tests were quantified in 21 patients. "Positive" handwriting results, i.e., a reduction of at least 13% in the overall area of 50% or more of the handwriting samples collected during the trial, were demonstrable in three of nine responders (33%) and nine of twelve nonresponders (75%). These results show that there is no positive correlation between clinical response and reduction in handwriting area. Consequently, the handwriting test is unable to predict clinical response. It is only one of a number of parameters with which to monitor the neurological side-effects of neuroleptic treatment. Outcome parameters show that psychopathological remission can be achieved with low neuroleptic dosages and few or virtually no extrapyramidal side-effects.

Cryptosporidiosis in Great Yarmouth--the investigation of an outbreak

A community outbreak of 36 cases of Cryptosporidium infection which occurred during Spring 1986 in Great Yarmouth and Waveney is described. A period prevalence study suggested that there was a more widespread outbreak of diarrhoeal illness in the locality although only 3/68 stool samples obtained at a median time interval of 38 days from the onset of symptoms contained Cryptosporidium oocysts. The distribution of cases of cryptosporidiosis in time and place suggested person to person spread rather than a common vehicle. A retrospective matched case-control study provided no evidence of water borne spread.

Effects of fluoxetine upon pharmacoendocrine and sleep-EEG parameters in normal controls

A single dose of 80 mg fluoxetine induced a slight increase in cortisol secretion when compared to placebo in an acute endocrine challenge test including assessment of prolactin, growth hormone, luteinizing hormone, follicle stimulating hormone, testosterone. This pretreatment with 80 mg fluoxetine did not change the ACTH release after blockade of the feed-back regulation of peripheral corticosteroids on ACTH secretion by metyrapone. Sleep-EEG revealed reduction of rapid-eye-movement sleep. Nocturnal penile tumescence activity was unaltered.

Mood elevating effect of fluoxetine in a diagnostically homogeneous inpatient population with major depressive disorder

According to severity of depressive symptomatology 14 inpatients with major depressive disorder (RDC) were assigned to 2 groups of 7 patients each with 6 of them receiving fluoxetine 60-80 mg/day and 1 receiving placebo in each group in a double-blind manner. After the treatment period of 35 days clinical improvement as assessed by standardized rating scales was more pronounced in the moderately depressed patients. There were no substantial side-effects in the 2 groups. These findings corroborate previous results from outpatient studies in more heterogeneous patient samples demonstrating safety and antidepressive efficacy of fluoxetine.

Results of an open clinical trial of brofaromine (CGP 11 305 A), a competitive, selective, and short-acting inhibitor of MAO-A in major endogenous depression

In an open clinical trial the authors treated 18 hospitalized patients suffering from endogenous depression with brofaromine (CGP 11305A), a competitive, selective, and short-acting inhibitor of type A monoamine oxidase (MAO). Four patients were defined as good responders, as they had a final HAMD score of between 0 and 7 points. Four patients were judged as improved, with final HAMD scores of between 8 and 15 points, while the remaining eight patients failed to respond (final HAMD score greater than or equal to 16 points). The major observations were a beneficial influence on drive in most patients, while paranoid symptoms worsened markedly, rendering the substance contraindicated in psychotic depression. Brofaromine appears to be safe and well tolerated and largely free of side effects. As objectified by the tyramine pressor test, dietary restrictions during brofaromine treatment require less stringency than is the case with conventional MAO inhibitors. The specificity of brofaromine to inhibit deamination is limited to MAO-A, since no reduction in platelet MAO activity was measurable. Sleep EEG recordings in a subset of patients reveals that the amount of rapid eye movement (REM) sleep is significantly reduced during brofaromine treatment.

Blunted aldosterone and ACTH release after human CRH administration in depressed patients

The authors measured pituitary adrenocortical responses to human corticotropin-releasing hormone (CRH) in 10 patients with a major depressive episode and 10 matched control subjects. Depressed patients had a significantly lower aldosterone and ACTH release, but cortisol and corticosterone responses were not different between groups.

Human corticotropin-releasing hormone in depression--correlation with thyrotropin secretion following thyrotropin-releasing hormone

Twenty-two subjects (11 patients with major endogenous depression and 11 controls) received an intravenous test dose of 100 micrograms human corticotropin-releasing hormone (h-CRH). Corticotropin (ACTH), but not cortisol, responses were blunted in depressives. Basal cortisol secretion was higher in depressives than in controls and was negatively correlated to the corticotropin response following h-CRH. This finding indicates the integrity of the glucocorticoid-dependent negative feedback regulation in depression and supports the view that hypercortisolism in depression is primarily due to a suprapituitary disturbance. Comparison of ACTH responses after h-CRH with thyrotropin (TSH) output following thyrotropin-releasing hormone (TRH) revealed a positive correlation (r = 0.65, p less than 0.001). The concordance between ACTH and TSH responses after specific challenges suggests that regulation of both systems is at least in part under a common control.

Multisteroid analysis after DST in depressed patients--a controlled study

111 consecutively admitted in-patients with a depressive syndrome received a dexamethasone suppression test (DST) after all known factors which might confound the test results had been carefully excluded. Plasma concentrations of cortisol, corticosterone and dexamethasone were compared with several diagnostic evaluations (RDC, DSM-III, ICD-9) in a controlled study. The positive predictive value of nonsuppressed corticosteroid levels was only moderate for each diagnostic category. Diagnostic specificities were 84.6% for major depression, endogenous subtype (RDC), 71.2% for melancholia (DSM-III) and 86.8% for endogenous depression (IDC-9) when using a post-DST cortisol value above 50 ng/ml (5 micrograms/dl) as the referent value to define DST nonsuppression. Combined determination of cortisol and corticosterone as an index of dexamethasone-induced suppression raised the sensitivity rate considerably at the cost of the predictive value for major diagnostic categories. Dexamethasone plasma levels were reciprocally correlated with cortisol levels and neglect of samples with low plasma dexamethasone contents improved the diagnostic performance for endogenous depression according to RDC and ICD-9, but not for DSM-III melancholia. Although it would be speculative to suppose that the observed low dexamethasone levels are involved in DST nonsuppression, the present findings emphasize that multisteroid analysis which includes dexamethasone is important in future studies designed to explore the clinical utility of the DST.

The plasma dexamethasone variable in depression: test-retest studies and early biophase kinetics

A dexamethasone suppression test (DST) was performed in 45 patients during depressive illness and after recovery. Thirty-one samples from patients in whom plasma cortisol was resistant to the suppressive action of dexamethasone contained significantly lower mean (+/- SD) concentrations of the test drug (0.63 +/- 0.39 ng/ml vs 1.10 +/- 0.53 ng/ml) during illness than after recovery and normalization of the DST. In a control group of 14 patients who exhibited adequate DST suppression during the depressive state and after recovery, the dexamethasone concentrations were unchanged (1.54 +/- 0.91 ng/ml vs. 1.30 +/- 0.92 ng/ml). To investigate further the influence of bioavailability or pharmacokinetics of the test drug on DST results, we conducted a catheter study during sleep in 11 endogenously depressed patients who received an oral 1.5 mg dose of dexamethasone at 11 p.m. The half-life of dexamethasone was markedly lower in five DST nonsuppressors (t1/2 = 160 +/- 33 minutes) than in six DST suppressors (t1/2 = 422 +/- 172 minutes). These preliminary results indicate that metabolism of dexamethasone should be controlled in studies evaluating the clinical utility of the DST.

Cortisol and corticosterone response after syn-corticotropin in relationship to dexamethasone suppressibility of cortisol

The current study was designed to investigate whether glucocorticoid output after syn-ACTH stimulation is different in depression associated with dexamethasone suppression test (DST) nonsuppression from the euthymic state and DST suppression. We gave 28 depressives a DST and an adrenocortical challenge with synthetic ACTH. Fourteen patients were nonsuppressors on the DST. After successful drug treatment, the subjects were reinvestigated by both tests; all DSTs revealed plasma cortisol concentrations below the criterion value of 50 ng/ml. Cortisol and corticosterone responses after syn-ACTH tended to be higher during depression. After clinical remission, higher cortisol and corticosterone responses occurred in those patients who were DST nonsuppressors during depression. This finding suggests that patients who suffer from a depression which is linked to an abnormal pituitary--adrenocortical regulation develop an enhanced sensitivity of the adrenal cortex to ACTH.

[Dimensions of the Hamilton Depression Scale. Factor analysis studies]

The results of factor analysis of HAMD are not unitary. Studying the stability in course and the independence of selection criteria for the population we rated two groups (n = 107, n = 98) of inpatients with HAMD; these groups differ in nosological selection criteria. We furthermore rated one group at different timepoints (before treatment and 3 weeks after). The one-factor-solution is the only stable one and the only one which is independent from selection criteria. In all groups the one-factor-solutions show a high similarity with other published solutions of the German version of HAMD. But there is no way to extract a general factor. Thus the ability of HAMD in judging the severity of depression is doubtful. Ways are discussed to circumvent this problem.

ACTH, cortisol, and corticosterone output after ovine corticotropin-releasing factor challenge during depression and after recovery

Synthetic ovine corticotropin releasing factor (o-CRF) was administered as an intravenous bolus (100 micrograms) to eight patients suffering from a major depressive disorder, endogenous subtype. All patients showed inadequately suppressed cortisol levels after 1 mg dexamethasone. After clinical remission and normalized dexamethasone responses, these patients were reinvestigated with o-CRF stimulation. The mean adrenocorticotropic hormone (ACTH) release from the pituitary corticotroph cells was indiscriminate at both test sessions. Cortisol and corticosterone output after o-CRF tended to be higher during depression than after recovery. The o-CRF-induced increments observed with corticosterone were more marked in comparison with cortisol. Within the limitations of the current protocol, our preliminary data lend support to the view that an increased pituitary ACTH reserve or adrenocortical steroid reserve is not likely to be responsible for the defective pituitary-adrenal regulation in some dexamethasone-resistant depressives.

Weekly monitoring of dexamethasone suppression response in depression: its relationship to change of body weight and psychopathology

Weekly dexamethasone suppression tests (DST) were performed in 19 hospitalized patients with major depressive disorder, endogenous subtype, and who had an abnormal DST at admission. Depression scores (Hamilton Rating Scale) and weight changes were collected by investigators who were blind to the test results. Major findings were: (1) the DST gradually normalized 3-4 weeks prior to full resolution of clinical symptomatology; (2) weight loss was an important patient variable which may have contributed to false positive DST results; however, the positive correlation between changes in DST results and changes in depression scores in all our patients with or without weight loss suggests that psychopathological factors other than weight change participate in the development of dexamethasone resistance in depression; (3) the low dose (1 mg) version of the test requires careful control of minor medical disturbances, which can make the test result ambiguous. The data suggest that after resolution of some methodological issues the DST may serve as a valuable laboratory test to monitor clinical progress during drug treatment.

Carriage of intestinal protozoal cysts in homosexuals

A total of 83 male homosexuals were studied to ascertain the carriage of intestinal protozoal cysts. The homosexual group had a significantly (p less than 0.0005) higher prevalence than a control group. One or more types of protozoa were found in 33 homosexuals. The carriage of intestinal protozoal cysts was associated with particular sexual practices and promiscuity, but not with symptomatic bowel disorders. The possible implications of the carriage of these cysts are discussed.

Mean 14.00-17.00 h plasma cortisol concentration and its relationship to the 1 mg-dexamethasone suppression response in depressives and controls

Three-hour cortisol-profiles and cortisol responses to a 1 mg dose of dexamethasone were recorded in 31 depressed patients and nine controls. The data indicate that the likelihood of detecting non-suppressible cortisol concentrations after dexamethasone is significantly increased in depressed patients with a hypersecretion of cortisol. However, a considerable subsample of normosecretors shows abnormal DST results. Conversely, hypersecretion is often associated with dexamethasone suppression. In this study a 1 mg-DST did not reflect the adrenocortical activity with ultimate accuracy. Therefore any attempts which correlate psychopathological or biological data with pituitary-adrenal activity and use a DST-result as measure are criticizable . Data derived from volunteers illustrate that medical factors such as weight-loss, steroid-containing contraceptives and sleep deprivation can make a pituitary-adrenal activity test ambiguous.

Plasma dexamethasone concentrations and differential suppression response of cortisol and corticosterone in depressives and controls

After a dexamethasone suppression test (DST), cortisol, corticosterone, and the test substance were determined by a direct radioimmunoassay in 42 samples obtained from 22 depressed patients and 8 controls. The DST results of both glucocorticoids agreed in most of the tests. In all seven cases with elevated but not definitely abnormal post-DST (1600 hr) cortisol levels (transitional range 30-50 ng/ml) the concurrent determination of corticosterone indicated that this corticosteroid may serve as a potent additional discriminator. Dexamethasone plasma concentrations at 1600 hr after a 1-mg test dose of dexamethasone at 2300 hr were significantly (p less than 0.01) lower in cortisol and corticosterone nonsuppressors than in suppressors. Since these data were obtained 17 hr after ingestion of dexamethasone (half-life 3.5-5 hr) any conclusions about an inverse correlation between dexamethasone and corticosteroid plasma concentrations would be speculative. However, the dexamethasone pharmacokinetics might be an important variable and may contribute to some of the recent uncertainty about the DST.

Cortisol, 11-deoxycortisol, and ACTH concentrations after dexamethasone in depressed patients and healthy volunteers

The 1 mg dexamethasone suppression test was used to assess pituitary-adrenal activity in 23 depressed patients and 8 healthy volunteers. At 1600h, after administration of the test dose of dexamethasone at 2300h, levels of cortisol, 11-deoxycortisol, and corticotropin were determined following a chromatographic extraction step applying highly specific radioimmunoassay techniques. Cortisol nonsuppressors had significantly increased adrenocorticotropic hormone (ACTH) values and cortisol/11-deoxycortisol ratios. The cortisol/11-deoxycortisol ratio was regarded as a measure of biologically active ACTH. The present results, which indicate a concordance of corticotropin and corticosteroid response, suggest that the parent abnormality of dexamethasone-resistant cortisol concentrations is elevation of biologically active corticotropin.

ACTH and multisteroid responses to corticotropin-releasing factor in depressive illness: relationship to multisteroid responses after ACTH stimulation and dexamethasone suppression

One hundred micrograms of ovine-corticotropin releasing factor (o-CRF) was administered intravenously to eight unmedicated patients with severe endogenous depression. Responses of immunoreactive (ir)-ACTH and the adrenal glucocorticosteroids corticosterone (B), 11-deoxycortisol (S), cortisol (F) and cortisone (E) were measured and compared with those following synthetic corticotropin stimulation and dexamethasone suppression. A comparative evaluation of the three pituitary--adrenal function tests suggests that hypersecretion of ir-ACTH and adrenal corticosteroids (B, S, F, and E) in depression reflects a central dysfunction rather than an altered responsiveness of the pituitary or adrenal glands. The data illustrate that the o-CRF paradigm is a valuable instrument to further support the hypothesis that a limbic--hypothalamic overdrive is the basic mechanism underlying exaggerated adrenocortical output in the endogenous subgroup of depressed patients.

Aetiology and management of non-specific vaginitis

In a study of 100 women with non-specific vaginitis, characterised by a vaginal discharge which was malodorous and pruritic in most cases and caused dyspareunia and dysuria in some, Gardnerella vaginalis was isolated in 46% of patients. When present, G vaginalis was significantly associated with Mycoplasma hominis and Bacteroides species. Isolation of G vaginalis was unrelated to the presenting symptoms. Treatment with povidone-iodine pessaries for two weeks produced no pronounced benefit, either clinically or microbiologically, compared with a placebo. Nevertheless, 68% of all patients followed reported improvement four weeks after the start of treatment. The findings suggest that G vaginalis is one cause of non-specific vaginitis, which is more likely to be seen in women using oral contraceptives and is usually cured spontaneously.

Rectal gonorrhoea in male homosexuals. Presentation and therapy

In a review of rectal gonorrhoea 73 episodes were studied in 65 homosexual men. The presenting signs and symptoms were carefully noted. Treatment with a single injection of spectinomycin hydrochloride 2 g resulted in a cure rate of 94.5%. The relatively high treatment failure rate associated with rectal gonorrhoea may possibly be due to microbial mechanisms.

Intraoperative autotransfusion for elective aortic surgery

Intraoperative autotransfusion using the Bentley ATS 100 was used in 23 patients requiring Dacron replacement of their abdominal aorta. An average 2000 ml of blood was reinfused and a total heparinization dose was given. The mean haemoglobin fell 2.8 g/dl and on average 2 pints of banked blood were given in the postoperative period. Coagulation studies performed before and after surgery showed minimal alteration. We feel that further evaluation of this system is essential so that an alternative is established for when banked blood is not available. The system is particularly useful at the present time for such emergencies as a leaking abdominal aortic aneurysm and severe trauma to the liver.