Use of the parathyroid hormone assay at H6 post thyroidectomy: an early predictor of hypocalcemia

PURPOSE

Hypocalcemia linked to a diminished circulating intact parathormone (iPTH) is the most common complication after total thyroidectomy. The objective of this study was to evaluate iPTH as a predictor of post-thyroidectomy hypocalcemia.

METHODS

Hundred-and-eight patients who underwent total thyroidectomy were included. Blood samples (iPTH, calcium and albumin) were performed at different times: preoperatively (H₀), after removal of the gland (H_drop), 6 h (H₆) and one day (D₁) after the surgery. Hypocalcemia was defined by total calcium corrected by serum albumin ≤ 2.10 mmol/l. The area under the ROC curve (AUC) was used to determine the best cut-off value and predictability of iPTH for hypocalcemia in terms of absolute value (ng/L), decrease in the slope (ng/L) and decline (%) between two times.

RESULTS

The study included 101 patients. Among them, 39 had hypocalcemia (38.6%). At H₆, an iPTH absolute value less than 14.35 ng/L (Se = 0.706; Sp = 0.917) and a decline from the preoperative time of more than 59.5% (Se = 0.850; Sp = 0.820) were predictive of hypocalcemia. Other absolute values, decrease in the sloop and decline between preoperative and postoperative values were less relevant.

CONCLUSION

The iPTH 6 h after total thyroidectomy is predictive of hypocalcemia. It might be used to identify patients not at risk of hypocalcemia and earlier discharge could be considered.

Evaluation of the performance of ultrasonography and 99mTc-sestamibi scintigraphy for primary hyperparathyroidism surgery

INTRODUCTION

Minimally invasive surgery has become the standard surgical attitude in primary hyperparathyroidism. It requires precise preoperative lesion localization. The aim of the present study was to evaluate the performance of ultrasonography and 99mTc-sestamibi scintigraphy in minimally invasive surgery for primary hyperparathyroidism.

MATERIALS AND METHODS

A retrospective study included all patients managed surgically for primary hyperparathyroidism between January 2008 and November 2017 in the University Hospital of Brest (France). Two hundred and seventy-three patients underwent ultrasonography and 99mTc-sestamibi scintigraphy. Results determined intrinsic (sensitivity and specificity) and extrinsic (positive and negative predictive values) performance on per-patient and per-gland analysis. Demographic, preoperative, interventional and cure data were compared according to ultrasonography and scintigraphy results, distinguishing 3 patient groups: concordant n=156, discordant n=99, negative n=18.

RESULTS

On per-gland analysis, sensitivity was 70% for ultrasound, 74% for 99mTc-sestamibi scintigraphy and 81% for associated ultrasound-scintigraphy; positive predictive values were 89%, 91% and 96%, respectively. Gland volume and concomitant thyroid pathology rates differed significantly (both p=0.003) between the 3 imaging results groups.

CONCLUSION

The performance of associated ultrasound-99mTc-sestamibi-scintigraphy provided a positive predictive value of 96%. Combining the two techniques reduced surgical morbidity.

Outpatient hemithyroidectomy

Outpatient surgery consists of performing an elective surgical procedure in the context of a day-only admission. This type of management is the result of sociological changes and allows a reduction of the cost. Hemithyroidectomy is a well-defined surgical procedure with known complications. The authors assessed the feasibility, patient satisfaction and cost of outpatient hemithyroidectomy.

MATERIAL AND METHODS

One hundred and forty-six hemithyroidectomies were performed between August 2011 and September 2012. Inclusion criteria for outpatient surgery were surgical, anaesthetic and patient-dependent. Exclusion criteria were related to the bleeding risk, socio-economic conditions and the patient's understanding of the procedure. Preoperative information and the modalities of anaesthesia, surgery, postoperative surveillance and follow-up were standardized. Patient satisfaction was evaluated by questionnaire and cost was evaluated on the basis of medical information department data.

RESULTS

Forty patients were eligible and 34 patients agreed to outpatient surgery (M/F sex ratio: 1/4; mean age: 46 ± 6.3 years), but only 32 operations were performed on an outpatient basis. Two conversions to conventional hospitalisation were required, one because of preoperative initiation of platelet anti-aggregants and the other because of nausea. One patient remained in hospital on the day after the operation because of severe asthenia and nausea.

CONCLUSION

Patients were satisfied with this type of management and 100% of them reported that they would repeat the experience. The economy for our establishment was €711 per patient. This procedure improves patient comfort without increasing the risks and allows a reduction of management costs.

[Adult localized congenital cholesteatoma]

PURPOSE OF THE STUDY

Congenital cholesteatoma is a well-described anatomical and clinical entity. Adult forms are rare. We describe a posterosuperior encapsulated cholesteatoma and compare this case to other infantile and adult forms described in the literature.

MATERIAL AND METHODS

A 25-year-old patient with no medical history consulted for left conductive hearing loss. A flat tympanogram was obtained. The temporal bone computed tomographic scan showed a soft tissue density lesion of the middle ear and anterior stapes erosion. A congenital cholesteatoma was discovered during surgical exploration. The lesion was removed and the ossicular chain was reconstructed with a Shea piston.

RESULTS

The patient showed approximately 20dB conductive hearing improvement.

DISCUSSION

Existence of congenital cholesteatoma is well established. Adult forms are exceptional and often diffuse. A localized, encapsulated form is described in this article. The specificity remains unknown. It is uncertain whether the adult and infantile forms have the same origin. A multifactorial or metaplastic mechanism could explain adult congenital cholesteatoma.

CONCLUSION

Pathogenic hypothesis for adult forms of congenital cholesteatoma are different from infantile forms.

[Post-traumatic orbital emphysema: a case report]

Orbital emphysema is often associated with orbital fracture or communication with paranasal sinuses. It is usually moderate but could be the cause of optic neuropathy or central retinal artery occlusion. We report a case of massive orbital emphysema with ocular hypertony and prethrombosis of the central retinal artery. Emergency surgical decompression performed by an ophthalmologist and an otorhinolaryngologist provided complete and prompt relief. The authors emphasize the importance of preventing nose blowing after orbital trauma or surgery.

[Capillary hemangioma of the ethmoid sinus. Case report and review of the literature]

We report the rare observation of a 38-year-old man diagnosed with capillary hemangioma exclusively involving the ethmoid sinus. Complete resection was obtained via ethmoid endoscopy combined with an intracranial approach. Capillary hemangioma is a rare and benign vascular tumor in adults primarily developing in the skin and subcutaneous tissues of the head and neck, and/or within oral and nasal cavities. No hemangioma exclusively involving the ethmoid sinus has been previously reported. Complete resection is the treatment of choice, providing a favorable prognosis with low risk of recurrence.

Adénome parathyroïdien : stratégie chirurgicale

OBJECTIVES

The purpose of this study is to reach a better understanding in the handling of parathyroid adenomas, and to emphasize the importance of pre-operatory explorations in order to establish the best surgical approach and its cost.

MATERIAL AND METHODS

We are using a retrospective study of 51 patients that underwent surgery in our department between the years 1997 and 2002, for the treatment of primary hyperparathyroidism. Every patient received to a pre-operatory exploration in order to localize the parathyroid tumors, including cervical echography in 51 of the cases, and a sestamibi scintigraphy in 49 of the cases. Two surgical procedures were performed: unilateral approach, and bi-lateral approach.

RESULTS

The implementation of a systematic pre-surgical checkup allowed for unilateral surgery in 76% of the patients (39 out of 51), from which 31% (12 out of 39) under local anesthesia.

CONCLUSIONS

The accuracy of the pre-operatory explorations in order to localize the parathyroidian tumors in regard to HPTP, allows for precise surgery via unilateral approach under local anesthesia. The benefits are significant with shorter procedure time, shorter patient hospitalization, and lower risks for complications. The pre-operatory explorations also decrease the total cost of the procedure and are a critical tool for the surgeon.

The stripping technique: in vitro absorption and penetration of five UV filters on excised fresh human skin

This article gives the results of a study whose aim was to compare the compartmental distribution and absorption of 5 UV filters, in vitro, by fresh human skin, after exposure times of 30 min and 16 h. These UV filters from BASF (octyl methoxycinnamate, benzophenone 4, benzophenone 3, octyl triazone and octocrylene) were incorporated separately in a simple oil-in-water emulsion. The composition of the emulsions was designed in order to obtain a sun protection factor of 5. Therefore the UV filters were introduced into the emulsions at different concentrations. We show that the affinity for each skin level [stratum corneum (SC), viable epidermis, dermis and receptor fluid] is different according to the test substance used. Some substances accumulated in the SC, whereas others passed through the skin very quickly and were quantified in the receptor fluid. The stripping technique allowed us to see that more than 94% of the chemical compound in the SC was in the first eight tapes. The problem of individual values below the limit of detection was raised, a correlation between the two exposure times was found (y = 1.702x - 0.105; R = 0.94) and a classification of products according to their affinity for the SC was determined.

Modulated release of triterpenic compounds from a O/W/O multiple emulsion formulated with dimethicones: infrared spectrophotometric and differential calorimetric approaches

From the use of silicones within O/W/O multiple emulsions, we can expect, two principal advantages: (1) the silicones with the lowest molecular weight decrease the oily touch; (2) due to the large range of viscosity, this excipient should influence the skin distribution of actives after topical application. The purpose of our work is to highlight these advantages. Multiple emulsions were formulated with several dimethicones and with drug model. Firstly, the effects of different dimethicones incorporated within multiple emulsions were studied, through in vitro penetration results. Secondly, we investigated the residual film on the skin by Differential Scanning Calorimetry (DSC) and by Fourier Transform Infrared (FTIR) to determine its structure. Correlations were established between the silicone structure and the distribution of drugs in different skin levels or between the silicone structure and the percutaneous penetration. The incorporation of silicones within O/W/O multiple emulsions seems to be an efficient means of modulating the penetration and the distribution of drugs in the skin.

Quantitative HPLC analysis of sunscreens and caffeine during in vitro percutaneous penetration studies

This report describes rapid analytical HPLC for the quantification of five UV filters (octyl methoxycinnamate, benzophenone-3, benzophenone-4, octyl triazone and octocrylene) and of caffeine in various skin layers (stratum corneum, dermis, epidermis and receptor fluid) and in cosmetic preparations. The predominant purpose of the study was to establish standard operating procedures for rapid analysis of the compounds in various skin samples. Particular attention was paid to the preparation of biological samples whose natural constitution could interfere with the quantitative analysis. Our methods used the isocratic chromatographic mode in an RP-HPLC with UV detection and did not involve centrifugation or evaporation. Our results were validated in terms of specificity, linearity, precision, accuracy and limits of detection and quantification. The first results, obtained after in vitro experiments, are presented in this report.

[Accidental intracerebral penetration of a nasal hemostatic probe]

We report a case of inadvertent intracerebral introduction of a haemostatic device (Brighton tube) inserted into a nasal cavity for control of epistaxis in a patient with major craniofacial trauma. This complication remained unrecognized in the unconscious patient until the subsequent CT-scan control. In unconscious patients with a major facial trauma, intranasal haemostatic probes should be inserted under direct visual control by a ENT specialist and their position checked by digital palpation of the inflated cuffs behind the soft palate.

[Fistula of the 4th endobranchial pouch: a case report]

Fourth branchial arch fistula are rare. Their diagnosis is difficult and anknow. It is confirmed by fistulography and endoscopy. It's an surgical treatment.

[Fluctuant perception hearing loss after hepatitis B vaccine]

A 42 year old physician doctor presented with temporary tinnitus after a first dose of a hepatitis B vaccination (Engerix B*). One month after, a fluctuant sensori-neural hearing loss with tinnitus appeared few hours after a second dose of hepatitis B vaccination (Engerix B*). The auditory thresholds varied from 45 dBHL and 0 dBHL for low frequencies below 1.5 kHz. The fluctuant hearing loss and tinnitus disappeared after a 6 month course.

[Prospective study of thromboses of the subclavian vein after setting implantable venous access systems in cervico-facial cancerology]

Seventy-eight consecutive patients treated by chemotherapy for ENT cancers and having a subclavian catheter for venous access were studied prospectively to assess the prevalence of venous thrombosis. Thrombosis of the subclavian vein was demonstrated clinically in 4 patients and by ultrasonography in 7 patients. The prevalence of thrombosis was 14.1%. No clinical or biological predisposition factor could be identified. Subclavian thrombosis mostly occurred during the second month after implantation (91% of cases). Ultrasonography seems the most useful non-invasive technique for the diagnosis of subclavian thrombosis.