Primary Hyperparathyroidism: To Evaluate Benefit of Ultrasound and Tc99m-SESTAMIBI Scan in Localizing Abnormal Parathyroid Gland Before Surgery, in a Secondary Care Hospital

Introduction

Primary hyperparathyroidism is a common endocrine condition requiring parathyroidectomy for curative management. Localization of parathyroid gland by ultrasound and Tc99m-SESTAMIBI is important to opt for less invasive and comparatively lower complication risk surgery minimal invasive parathyroidectomy (MIP) instead of four-gland exploration surgery.

Aim

To evaluate ultrasound and Tc99m-SESTAMIBI in localization of abnormal parathyroid gland before surgery.

Method and materials

All patients of primary hyperparathyroidism (PHPT) that presented to a secondary care hospital (endocrinology department) from 2015-2019 were recruited retrospectively from electronic fusion system of hospital. Results of ultrasound parathyroid and Tc99m-SESTAMIBI done for localization of abnormal parathyroid gland were analyzed.

Results

Total PHPT patients recruited were 59, mean age 64.2 years, male 11 (18.64%) and female 48 (81.3%). Ultrasound parathyroid was done in 44 patients, Tc 99m-SESTAMIBI was done in 31, both tests were done in 31 patients. Combined concordant adenoma in both tests was seen in 11 (35%) cases which can opt for minimal invasive parathyroidectomy (MIP) with confidence whereas 65% of cases would require either four-gland exploration or further testing like single-photon emission computed tomography-computed tomography (SPECT-CT) or intraoperative parathyroid hormone measurement to opt for MIP.

Conclusion

Combined ultrasound parathyroid and Tc 99m-SESTAMIBI scan was useful in localization of parathyroid adenoma in 11 (35%) patients that can opt for MIP which is a lower complication risk surgery whereas 20 (65%) patients would need further investigation with SPECT-CT or intraoperative parathyroid hormone measurement or four-gland exploration surgery.

Recommendation

Third modality of investigation such as SPECT-CT or intraoperative parathyroid hormone measurement needs evaluation so that more patients can benefit from MIP instead of four-gland exploration surgery.

Differential effects of experimental hyperthyroidism on declined immunity of broiler chicken

Thyroid hormones (THs) are involved in the development of lymphoid organs and regulation of immune function in birds. However, their role as an immune-modulator in the hyperthyroid state is still debatable. To explore the interrelationship of thyroxine (T₄ ) and the immune system, chicks were divided into three groups. Group I was comprised of control birds, who received the basal diet while group II and III were given diets supplemented with 5 μg and 10 μg thyroxine/kg feed, respectively, from 15 to 28 days of age. Cell-mediated immune response was evaluated through in vitro abdominal macrophage phagocytosis assay, macrophage nitric oxide (NO) production, heterophil-to-lymphocyte (H:L) ratio and delayed-type hypersensitivity response against phytohemagglutinin (PHA). Humoural immune response was assessed through serum IgG and IgM antibody production against sheep red blood cells (SRBCs) and antibody production against infectious bronchitis virus (IBV). Sampling was carried out at 7, 14 and 21 days of treatment. Results have shown higher levels (p < .001) of circulating T₄ in both treatment groups compared to the control group. There was a lower (p < .05) macrophage engulfment percentage, an increase in H:L ratio (p < .001) in treated birds, while their NO production remained higher (p < .05) in thyroxine supplemented groups after bacterial lipopolysaccharide stimulation. The humoural immune response revealed a significant decline (p < .001) in IgG, IgM antibody production against SRBCs but IBV circulating antibodies increased with age. In conclusion, hyperthyroidism has a strong co-relation with decreased immune performance of birds.

Effects of dietary chromium supplementation on muscle and bone mineral interaction in broiler chicken

The study was conducted to ascertain the effects of dietary chromium chloride (CrCl₃·6H₂O) supplementation on mineral interaction in blood serum, leg muscles and bones of broilers at 35^th day of age. For this purpose, ninety male broiler chicks were divided into three groups. One served as control (group I) while, the other two groups were supplemented with CrCl₃ (group II-12.5mg/Kg feed; group III-25mg/Kg feed) from 12 to 28days of age. In serum, Cr concentration remained non-significant however, Zn, and K concentrations decreased (P<0.05) with both levels of Cr-supplementation. Furthermore, in muscles Cr, Cu, Ca and Na levels remained non-significant but concentrations of Zn and K decreased (P<0.05) with feed Cr enrichment. Chromium had a substantial effect on femur and fibula Zn retention with 25mg/Kg feed supplementation while, Cr deposition decreased (P<0.05) in fibula. Femur Ca (P<0.002), Na (P<0.001) and K (P<0.05) retention was inversely proportional to both Cr concentrations in feed. In tibia, Cu and Na concentration decreased (P<0.002) with high dietary Cr supplementation. Fibular Ca and Na concentrations remained significantly (P<0.001) lower in Cr supplemented groups. Bone robusticity index was non-significant but ash to weight ratio of femur, tibia and fibula decreased (P<0.05) in group III. Chromium supplementation has a major effect on serum or muscle Zn and K deposition while bone mineral interaction shows a major thrust on Zn, Ca and Na levels.

Antinuclear antibodies: when to test and how to interpret findings

Order ANA assays only when clinical features suggest a connective tissue disorder. Let ANA immunofluorescent patterns direct additional testing decisions.

Vitamin B12 deficiency causing night sweats

Vitamin B12 deficiency is common. It is known to cause a wide spectrum of neurological syndromes, including autonomic dysfunction. Three cases are discussed here in which drenching night sweats were thought to be caused by vitamin B12 deficiency. All three responded dramatically to vitamin B12 therapy.

Evidence of lifestyle modification in the management of hypercholesterolemia

BACKGROUND

Coronary heart disease (CHD) is the leading cause of morbidity and mortality worldwide. The growth of ageing populations in developing countries with progressively urbanized lifestyles are major contributors. The key risk factors for CHD such as hypercholesterolemia, diabetes mellitus, and obesity are likely to increase in the future. These risk factors are modifiable through lifestyle.

OBJECTIVES

To review current literature on the potential benefit of cholesterol lowering in CHD risk reduction with a particular focus on the evidence of non-pharmacological/lifestyle management of hypercholesterolemia.

METHODS

Medline/PubMed systematic search was conducted using a two-tier approach limited to all recent English language papers. Primary search was conducted using key words and phrases and all abstracts were subsequently screened and relevant papers were selected. The next tier of searching was conducted by (1) reviewing the citation lists of the selected papers and (2) by using PubMed weblink for related papers. Over 3600 reports were reviewed.

RESULTS

Target cholesterol levels set out in various guidelines could be achieved by lifestyle changes, including diet, weight reduction, and increased physical activity with the goal of reducing total cholesterol to <200 mg/dL and LDL-C<100 mg/dL. Various dietary constituents such as green tea, plant sterols, soy protein have important influences on total cholesterol. Medical intervention should be reserved for those patients who have not reached this goal after 3 months of non-pharmacological approach.

CONCLUSION

CHD remains as a leading cause of death worldwide and hypercholesterolemia is an important cause of CHD. Non-pharmacological methods provide initial as well as long-term measures to address this issue.

The work-up for mixed hyperlipidemia: a case study

This case demonstrates that a history, physical exam, and laboratory studies are all needed to determine if the disorder is primary, secondary, or both.

Systematic review on evidence of the effectiveness of cholesterol-lowering drugs

INTRODUCTION

Coronary heart disease (CHD) is the leading cause of mortality worldwide. With increasingly urbanized lifestyles in developing countries and the aging populations, the major risk factors for CHD such as obesity, diabetes mellitus, and hypercholesterolemia are likely to increase in the future. In the current report, we reviewed the evidence on the effect of cholesterol lowering using pharmacological agents.

METHODS

A PubMed/Medline systematic search was performed over the past 12 years (1998-2009 inclusive) and relevant papers written in the English language were selected. We used key phrases including, "risk factors for hypercholesterolemia," "management of hypercholesterolemia," "guidelines for management of hypercholesterolemia," and "pharmacological management of hypercholesterolemia."

RESULTS

There were a total of over 3500 reports. We selected key publications on the effect of cholesterol lowering using different pharmacological agents.

CONCLUSION

Several options exist with regards to pharmacological management of hypercholesterolemia. There is a substantial body of evidence to support the effect of a population shift towards a favorable risk profile, which has huge potential in reducing the burden of CHD globally.

Condom use among high-risk heterosexual women with concurrent sexual partnerships, Houston, Texas, USA

Concurrent sexual partnerships allow for enhanced transmission of sexually transmitted infections (STIs). Condom use dynamics in this context may be an important factor for transmission of HIV. We conducted a cross-sectional study to describe the frequency of concurrency among high-risk heterosexual women in Houston, Texas and determine the factors associated with condom use. A total of 553 participants were recruited using respondent-driven sampling and completed an anonymous questionnaire; 256 (49%) were identified as having a concurrent partnership. The prevalence of condom use at last sexual encounter was 26%. Women were significantly more likely to use condoms if their sexual encounter was with a casual partner and if alcohol and/or drugs were not used. The high prevalence of concurrent partnerships suggests the presence of a dense sexual network which may enable the rapid spread of STIs and HIV. The risk of transmission may be additionally increased due to the low prevalence of condom use.

Neuroendocrinology of menopause

It was once thought that menopause is the result of exhaustion of ovarian follicles. However, it is now known that complex interplay of neurohormonal and ovarian signals heralds the onset of menopause and hypothalamus plays an important role. Increasing dysfunction of these neurohormonal and ovarian factors with aging ultimately leads to reproductive senescence. Early in the menopause transition, the initial event is a decline in circulating inhibin-B levels in the early follicular phase. In the late perimenopause, levels of estradiol (E2) and inhibin-A also fall, inhibin-B levels remain low and follicle stimulating hormone (FSH) is markedly elevated. Serum androgen levels appear to fall with age rather than having any clear-cut relationship to the menopausal transition or menopause.

Neuroendocrinology of female aging

BACKGROUND

Because the average human life span has increased, a greater part of more women's lives will be lived in a hypoestrogenic state.

OBJECTIVE

This article provides an overview of our current knowledge of the neuroendocrine processes in the aging female brain.

METHODS

Using the search terms cardiovascular disease, cognition, dementia, depression, estrogens, female aging, gonadotropins, immune function, mood, neuroendocrinology, neurotransmitters, osteoporosis, and ovarian steroids, a review of English-language literature on the MEDLINE database was conducted from 1970 through June 2004.

RESULTS

It is thought that the temporal patterns of neural signals are altered during middle age, leading to cessation of reproductive cycles, and that the complex interplay of ovarian and hypothalamic/pituitary pacemakers becomes increasingly dysfunctional with aging, ultimately resulting in menopause. Estrogen deficiency is associated with low mood, whereas estrogen therapy tends to be linked with improvements in measures of well-being and a decline in depression scores. It is likely that these effects of estrogens are mediated through changes in the metabolism of serotonin and nor epinephrine. Evidence exists to support the role of estrogens in specific effects on cognitive functioning in women, enhancing aspects of verbal memory, abstract reasoning, and information processing. Significant gender dimorphism is evident in both humoral and cell-mediated immune responses. The effects of estrogens on the cardiovascular system are complex; recent evidence suggests a negative role for oral estrogen in primary and secondary prevention of cardiovascular events. Additionally, estrogens increase the risk of stroke, and estrogen deficiency influences the pathogenesis of osteoporosis in both men and women.

CONCLUSIONS

Changes in the neuroendocrine system due to the loss of ovarian function at menopause have an important biological role in the control of reproductive and nonreproductive functions, and regulate mood, memory, cognition, behavior, immune function, the locomotor system, and cardiovascular functions. More detailed insights are needed into the complex mechanisms of neuroendocrine alterations with aging.

Cryoglobulinaemia

Cryoglobulins are proteins, usually immunoglobulins that precipitate at temperatures less than 37 degrees C and redissolve on rewarming. Cryoglobulinaemias are classified according to the type of immunoglobulins and are associated with a number of disorders including plasma cell dyscrasias, lymphoproliferative disorders, autoimmune diseases and hepatitis C. The exact pathogenesis of the condition is not known. The clinical manifestations are varied and are due to ischaemia of tissues caused by the occlusion of vessel lumen. This review discusses the clinical manifestations, the current hypotheses of pathogenesis, the role of hepatitis C and finally the possibilities of treatment of the disease.

Role of CRH in the pathogenesis of dementia of Alzheimer's type and other dementias

This review focuses on the role of corticotrophin-releasing hormone (CRH) in the pathogenesis of Alzheimer's disease (AD) and briefly discusses its role in other dementias, including Parkinson's disease (PD), progressive supranuclear palsy (PSP) and Huntington's disease (HD). During aging the hypothalamic-pituitary-adrenal (HPA) axis changes, which has repercussions on hormonal levels in the brain. The significance of these changes has been examined by many researchers, but the relationship between CRH and other neurotransmitters needs to be further explored.

Frontalis muscle flap advancement for jaw-winking ptosis

PURPOSE

To describe the technique and results of frontalis muscle flap advancement for correction of ptosis associated with jaw-winking.

METHODS

Four cases of unilateral jaw-winking ptosis were corrected with frontalis muscle flap advancement after excision of levator muscle on the affected side.

RESULTS

Three of the 4 patients achieved good results with the correction within 1 mm of the opposite eyelid. The residual asymmetry on downgaze after follow-up of 4 to 18 months ranged from 1 to 5 mm. The main complication was mild forehead hypoesthesia in 2 patients, which resolved over a period of 1 month.

CONCLUSIONS

Frontalis muscle flap advancement is an effective procedure when performed unilaterally for jaw-winking ptosis. It is simple, safe, and involves a single surgical field. Eyelid lag on downgaze improves considerably over time, and the remaining asymmetry between the two eyelids is cosmetically acceptable to most patients.

Babinski sign

Despite all of the medical advances, Babinski sign has proved reliable in precise localization of central nervous system dysfunction. It is well accepted that Babinski sign is indicative of dysfunction of fibers within the pyramidal tract. Joseph François Félix Babinski first described the clinical significance of the reflex in 1896. He showed that the extensor plantar response was indicative of pyramidal dysfunction and that it was absent in hysteria. He also illustrated that it was present in infancy and transiently appeared in epilepsy and strychnine poisoning. Babinski also pointed to the existence of "formes frustes" of his reflex and recognized its occasional absence in patients with other clinical signs of pyramidal lesions. The sign emerges when the dysfunction of the pyramidal tract involves the fibers that project on motoneurons of foot muscles and is mediated by extensor hallucis longus. Babinski sign may not be present acutely after transverse lesions of the spinal cord or acute brain lesions because of temporary inexcitability of spinal motoneurons.

Multifocal osteonecrosis -- a case report

The pathogenesis of idiopathic multifocal osteonecrosis is poorly understood. It is difficult to diagnose with conventional radiography or computed tomography and poses a great management challenge. A case of idiopathic multifocal osteonecrosis is presented in a young boy illustrating the difficulties in the management of such patients.

Neuroendocrinology of ageing

Many common problems encountered in the ageing patient can be related to neuroendocrine phenomena. These include Alzheimer's disease, dementia and cognitive dysfunction, depression, Parkinson's disease, hyponatraemia and the postmenopausal increase in both vascular risk and osteoporosis. This review concentrates on the hypothalamic neuroendocrine system, including the dopaminergic, noradrenergic, serotoninergic, cholinergic and neurohypophyseal systems and the roles of the anterior pituitary and monoamine oxidases, luteinizing hormone-releasing hormone, corticotrophin-releasing factor, the pro-opiomelanocortin-derived and opioid peptides, peptides involved in growth hormone and thyrotropin regulation, and amino acid transmitters.

Progressive supranuclear palsy

Progressive supranuclear palsy (PSP) or Steele-Richardson-Olszewski syndrome is a neurodegenerative disease of middle and late age. It is under-diagnosed not only by general physicians but also by neurologists. The cause of PSP is not known. Exposure to toxins and viruses has been proposed in the aetiology of PSP without any concrete evidence. The features of PSP resemble those of Parkinson's disease and the two diseases are often confused. Corticobasal degeneration and multisystem atrophy are other differential diagnoses. Despite certain common features with Parkinson's disease, corticobasal degeneration, and mutisystem atrophy, there are important differences that help to differentiate it from these disorders.