Calcitriol supplementation before parathyroidectomy and calcium level after surgery in parathyroid adenoma patients: a randomized controlled trial

BACKGROUND

Hypocalcemia is the most common complication after parathyroidectomy, contributing to extended hospital stays and higher hospitalization costs. The present study aimed to evaluate whether preoperative Calcitriol could help reduce hypocalcemia rates.

METHOD

In this randomized controlled trial, we included 80 patients with primary hyperparathyroidism candidates for parathyroidectomy. The intervention group received Calcitriol 0.25 µg/day 1 week before parathyroidectomy. Baseline laboratory data, parathyroid hormone level (before, during, after 5, and 10 min of operation), calcium level (6, 24, and 48 h after operation), and clinical signs and symptoms were recorded.

RESULTS

Of the 80 participants, 40 (mean age: 53.36 ± 12.97) were randomized to the intervention, and 40 (mean age: 52.84 ± 12.32) to the control group. There were no statistically significant differences in age, tumor size, gender, baseline laboratory data, intra-operative PTH, and calcium level 6 and 24 h after the operation. We observed a significantly higher calcium level in the intervention group 48 h post-operation (8.57 ± 0.30 vs. 8.33 ± 0.38). Also, days of hospital stay and symptomatic hypocalcemia rate were significantly lower in the intervention group.

CONCLUSION

In patients with primary hyperparathyroidism, preoperative Calcitriol may be of value in preventing post-parathyroidectomy hypocalcemia and subsequent complications.

A183 VARIATION IN HEALTH SERVICES UTILIZATION AND RISK OF SURGERY ACROSS CHILDREN WITH INFLAMMATORY BOWEL DISEASE: A MULTIPROVINCE COHORT STUDY

Background

Marked variation in access to care and health services utilization is a marker of variation in quality of care. With the rising incidence of pediatric inflammatory bowel disease (IBD), we must understand variation in access to and outcomes of care to improve quality.

Purpose

Describe variation in care for pediatric IBD treated in 4 Canadian provinces.

Method

Incident cases of IBD diagnosed in children <16y were identified from health administrative data in Alberta (AB), Manitoba, Nova Scotia, and Ontario (ON) using validated algorithms. Children were assigned to one of 8 centres of care using a hierarchical assessment of health services use within 6 months of diagnosis. Children treated by adult gastroenterologists or community-based pediatric gastroenterologists were excluded due to small sample size. Outcomes included IBD-related hospitalizations, emergency department (ED) visits (AB/ON only), and IBD-related abdominal surgery. Hospitalizations and ED visits were counted cumulatively from 6-60 months after diagnosis. The risk of first surgery was defined during the same 6-60 month period. Mixed-effects meta-analysis was used to pool results across centres. Heterogeneity among centres was quantified using I² (variation in pooled event rates between centres) and τ (standard deviation of the true event rates). R² quantified the residual heterogeneity in outcomes not attributable to among-province variation.

Result(s)

We identified 3777 incident cases of pediatric IBD, 2936 (78%) of which were treated at 8 pediatric centres. The number of hospitalizations was 0.67 (95% CI 0.56-0.79) per person with high between-centre heterogeneity (I² 84%, τ 0.1556). Provincial differences accounted for 93% of heterogeneity across centres (residual heterogeneity: I² 29%, τ 0.0412). Hospitalizations were less frequent in AB than other provinces (0.43 vs. 0.72-0.78). Children averaged 1.94 IBD-related ED visits, with significant heterogeneity (I² 99%, τ 1.33) with 99.7% of heterogeneity attributable to among-province differences (residual heterogeneity: I² 32%; τ 0.074). Mean ED visits were 1.1 visits in ON (I² 39%) and 3.7 in AB (I² 0%). Intestinal resection was required by 12% (95% CI 0.08-0.15) of Crohn’s patients with high among-centre heterogeneity (I² 81%, τ 0.042), and low (19%) heterogeneity due to provincial differences (residual heterogeneity: I² 76%; τ 0.039). Colectomy was required by 12% (95% CI 10-14) of children with ulcerative colitis (UC) with no between-centre heterogeneity (I² 0%, τ 0).

Conclusion(s)

There is a high degree of between-province (but not between-centre, within province) variability in health services utilization among children with IBD. There was significant between-centre variability in surgery rates for Crohn’s, but not colectomy for UC. Differences in patient characteristics or provincial health systems may be more important predictors of variation in care. Surgery for Crohn’s disease may be a target for inter-centre quality improvement efforts.

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Disclosure of Interest

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Autotransplantation of parathyroid tissue into subcutaneous subclavicular area following total parathyroidectomy in secondary hyperparathyroidism

BACKGROUND

Total parathyroidectomy with autotransplantation is still an excellent treatment option for secondary hyperparathyroidism. Intramuscular or subcutaneous parathyroid autotransplantation has been previously reported; however, there have been no studies to date regarding the implantation of the parathyroid tissue in the subclavian area of the neck.

METHODS

This was a prospective cross-sectional study between 2018 and 2019. Patients who underwent total parathyroidectomy with autotransplantation of parathyroid tissue into subcutaneous subclavicular area due to secondary hyperparathyroidism were included. The patients' demographic information, including age and gender, was gathered, and the length of the dialysis period was asked from the patients. To evaluate the outcome of the study, parathyroid hormone (PTH) was measured and recorded before and after the operation. SPSS software, version 26, was used for data analysis.

RESULTS

Forty-two patients with a mean age of 41.05 ± 9.41 years were included. The mean length of the dialysis period was 8.07 ± 2.68 years. The mean primary PTH was 1770.61 ± 482.97 pg/ml (range: 656-2500 <). After 6 weeks of operation, 19 patients (45.2%) had functional autotransplanted tissue, and the median PTH was 28 pg/ml (IQR: 33.55, range: 0.1-221.8). However, the results showed that after 10 weeks, the patients with functional tissue were increased to 22 (52.4%), and the median PTH was 35 pg/ml (IQR: 48, range: 5.0-602.9). The functionality of autotransplanted tissue in the 6th and 10th weeks after surgery had no significant association with age, gender, and length of the dialysis period (p value > 0.05).

CONCLUSION

Subcutaneous implantation is recommended in the treatment of secondary hyperparathyroidism based on its high success rate and ease of use, suitable vascularization, easy accessibility to the surgery location in case of the need for autographtectomy.

Chronic non-healing ulcers as presenting sign of acquired immunodeficiency syndrome

Atypical forms of herpes simplex virus (HSV) infections, which indicate severe impairment of cellular immunity can be challenging to diagnose. In this paper, we report the case of an atypical HSV infection presenting as chronic nonhealing wounds, which are the first sign of HIV, in a 50-year-old female patient. The lesions had emerged as two large, chronic, and painful ulcerations on the left buttock and labia major 8 months prior. The skin biopsy revealed multinucleated keratinocytes with ground glass nuclei and intranuclear Cowdry type A viral inclusions. A serologic test for HIV-1 was positive. Her CD4⁺ T-cell count was 42/mm³. Clinicians should be familiar with the dermatologic manifestations of HIV, as they are occasionally key to correctly suspecting an underlying HIV infection, allowing for early diagnosis and treatment.

A comparative immunohistochemical study of epidermal and dermal/perifollicular Langerhans cell concentration in discoid lupus erythematosus and lichen planopilaris: a cross-sectional study

BACKGROUND

There are times when differentiation between discoid lupus erythematosus (DLE) and lichen planopilaris (LPP) becomes quite challenging clinicopathologically.

OBJECTIVES

The aim of this study was to evaluate and compare the concentration, distribution pattern and role of Langerhans cells (LCs), identified by CD1a staining in DLE and LPP.

METHODS

Twenty-five specimens of skin biopsies from patients diagnosed with LPP and DLE were included. Immunohistochemistry (IHC) staining was performed against CD1a antigen to assess and compare the concentration and distribution pattern of LCs.

RESULTS

Compared with LPP, the mean number of epidermal CD1a⁺ cells per three high power fields was significantly lower in DLE ( p = 0.003). On the other hand, DLE cases had a significantly higher mean number of dermal/perifollicular CD1a⁺ cells in three high power fields than LPP cases ( p = 0.01).

LIMITATIONS

A small sample size and limited IHC markers.

CONCLUSIONS

There are differences in the density and distribution pattern of LCs in LPP and DLE in the epidermis and perifollicular regions. Our findings of a statistically significant decrease in LC concentration in the epidermis of DLE cases and also in the perifollicular region of LPP may serve as helpful clues in further characterization of these entities, especially in equivocal cases. However, more extensive studies are required to better understand the underlying immunopathogenesis of these diseases in providing further clues to a specific diagnosis.

Randomized clinical trial of subcutaneous versus interfascial bupivacaine for pain control after midline laparotomy

Background

Although patient-controlled analgesia for pain management after abdominal surgery is common, efforts to find alternative effective methods to control postoperative pain are continuing. The aim of this study was to compare postoperative pain levels following intermittent regional administration of bupivacaine via a catheter placed in the rectus sheath or subcutaneously at abdominal surgery through midline incisions.

Methods

Consecutive patients undergoing elective midline laparotomy were assigned randomly to a group with two catheters placed over the fascia (suprafascial group) before surgical wound closure or to a group with catheters placed between the two sheaths of each rectus muscle (interfascial group). Pain levels were determined every 12 h, both at rest and with movement, by means of a standard visual analogue scale (VAS) for 72 h after surgery. The amounts of administered opioid were recorded.

Results

Sixty patients were enrolled in the study (30 patients in each group). The median VAS score 36 h after surgery, both at rest and with movement, was significantly lower in the interfascial group than in the suprafascial group (P &lt; 0·050). Repeated-measures ANOVA also showed a significant difference in the postoperative VAS scores (P &lt; 0·007). The amount of self-administered morphine was significantly lower in the interfascial group, overall (P = 0·001) as well as on postoperative day 1 (P = 0·001) and day 2 (P = 0·016). Bowel sounds returned more quickly in the interfascial group (P = 0·040).

Conclusion

Locoregional catheter administration of bupivacaine following midline laparotomy is more effective when the catheter is placed in the rectus sheath compared with suprafascial delivery. Registration number: IRCT138810142982N1 (http://www.irct.ir).

Hair regrowth with topical triiodothyronine ointment in patients with alopecia areata: a double-blind, randomized pilot clinical trial of efficacy

BACKGROUND

Thyroid hormone receptors are expressed in hair follicles and it is known that thyroid hormones can have a positive effect on hair growth, i.e. process which is disrupted in alopecia areata.

OBJECTIVES

The aim of this study was to determine the efficacy of topical triiodothyronine in patients with patchy alopecia areata.

METHODS

Ten patients with patchy alopecia areata were treated with triiodothyronine and placebo applied twice daily to either of two bilaterally symmetrical patches for 12 weeks. The two sides were randomly assigned following simple randomization procedure to one of the two treatment groups. The patients and the investigator were blinded to the content of the tubes. Hair regrowth was evaluated every 4 weeks. Blood samples for measurements of complete blood count along with thyroid function (T3, T4 and TSH) and liver function tests were taken at the baseline and at the end of study.

RESULTS

After 12 weeks of treatment, there was no statistically significant difference between the outcome in terms of reduction of the patch size and hair regrowth. No adverse effects were noted.

CONCLUSION

Triiodothyronine in the studied dosage and formulation was safe but not more effective than placebo. However, newer thyroid hormone analogues might be more effective and evaluating their effects probably warrants further consideration.

A Case with a Fistula Draining into the Stomach due to Retained Surgical Gauze

Retained surgical gauze is occasionally observed in general practice. Herein, we report a case with surgical gauze retained for over 13 years that created a fistula which drained pus into the stomach.

Accuracy of serum pepsinogens I and II, gastrin-17 and anti-helicobacter pylori antibodies in histological diagnoses of atrophic gastritis

AIM

Atrophic gastritis is defined as a chronic inflammatory process in gastric mucosa leading to loss of glandular cells. It is considered a precancerous condition, thus its early diagnosis is of importance. Although histo-pathologic studies remain as the gold standard of diagnosis, non-invasive methods suitable for screening purposes are being developed. This includes measurement of serum gastric profile.

METHODS

Two hundred and fifty 250 patients who were planned to undergo upper gastrointestinal endoscopy were randomly selected to be included in this study. Serum levels of pepsinogen I and II, gastrin-17 and anti-Helicobacter pylori (Hp) antibody were measured and the results were compared with that of histopathologic assessment of biopsy specimens obtained during endoscopy.

RESULTS

IgG anti-Hp, PGII and PGI/PGII ratio showed correlation with age. PGI/PGII ratio showed best sensitivity (96.1%) and negative predictive value (97.7%). PGI has the highest specificity (94.6%), and PGII also had a high negative predictive value (90.7%). IgG anti-Hp showed poor sensitivity and specificity (58.8% and 26.5%, respectively).

CONCLUSIONS

Pepsinogen I/II ratio appears to be the most suitable single measurement for screening purposes in atrophic gastritis.

Prognostic factors in survival of colorectal cancer patients after surgery

OBJECTIVE

To determine the factors affecting survival, following resection of large bowel for colorectal carcinoma.

METHOD

From the cancer database of a single referral institution, a total of 1090 patients who had undergone colorectal resection between 1999 and 2002 were identified. Cases with recurrent colorectal cancer or previous history of neoadjuvant chemotherapy were excluded. Survival curves were plotted using the Kaplan-Meier method. Univariate analysis of factors thought to influence survival was then made using Logrank test. Criteria studied consisted of age, sex, TNM stage, T-status, nodal status, distant metastasis, histological grade, lymphatic and vascular invasion, tumour location, preoperative carcinoembryonic antigen (CEA) level and liver function tests. Multivariate analysis was conducted using Cox regression analysis.

RESULTS

The mean survival time for all patients was 42.8 (SEM = 2.8) months. The overall 1-, 3- and 5-year survival rates were 72%, 54% and 47%, respectively. In univariate analysis, patients' age (P < 0.0001), TNM stage (P < 0.0001), T-status (P = 0.015), nodal status (P = 0.016), distant metastasis (P < 0.0001), grade (P = 0.005), lymphatic and vascular invasion (P < 0.0001) and presurgery CEA level > 5 ng/ml (P = 0.021) were found to be predictors that could affect survival. In Cox regression analysis, age (P < 0.0001), TNM stage (P = 0.001) and grade (P = 0.008) were determined as independent prognostic factors of survival.

CONCLUSION

Age, TNM stage, T-status, nodal status, distant metastasis, grade, lymphatic and vascular invasion and presurgery CEA level can predict the postsurgical survival rate in patients with colorectal cancer.