CT of a Parathyroid Lipoadenoma

A 54-year-old woman with primary hyperparathyroidism underwent parathyroid exploration following negative ultrasonography, CT and 99Tc-201T1 scintigraphy. A 2 × 1.5 × 1-cm large mass dorsal to the midportion of the left thyroid lobe was extirpated and a hyperfunctional lipoadenoma containing 70% or more of fatty tissue was verified microscopically. Retrospective evaluation of CT revealed a well demarcated lipomatous mass with a homogeneous density similar to that of subcutaneous fat corresponding to the surgical finding.

Prediction models of silage fermentation products on crop composition under strict anaerobic conditions: a meta-analysis

A meta-analysis was conducted to establish linkages between crop and fermentation variables. Data from well-controlled mini silage studies were used in which no additives had been used and no ingress of air had occurred. The silage set consisted of data on crop chemical composition and epiphytic lactic acid bacteria count, and fermentation products (organic acids, alcohols, and ammonia-N) from 118 silages made from 30 grass, 7 legume, 15 grass and legume mixtures, and 66 whole-crop maize samples. The prediction models for fermentation products on crop variables were obtained by stepwise multiple regression analysis. Perennial forage and maize silages were analyzed separately. The best models were obtained for acetic acid in perennial forage silages, with a coefficient of determination of 0.63, and for lactic acid and ethanol in whole-crop maize silages, with coefficients of determination of 0.84 and 0.61, respectively. Fermentation products of perennial forage and maize silages were best related to dry matter and crude protein contents, respectively. Overall, the prediction equations were weak.

Using a novel macro in vitro technique to estimate differences in absorption rates of volatile fatty acids in the rumen

A novel macro in vitro system was used to test the theory that rumen proportions of acetate, propionate and butyrate are not representative of their respective net production rates. Whole rumen content (10-16 kg) from two cows was mixed with a bicarbonate buffer and incubated separately in two 40-l in vitro vessels for 3 h. A total of six experimental periods were used. In this study, a total of six cows were used and fed 1/8 of the daily ration by hand every 3 h. To obtain differences in rumen volatile fatty acids (VFA) composition, 1 l of acetate (416 mm), propionate (108 mm), butyrate (79 mm), lactic acid (300 mm) or nothing was infused during 24 h into the rumen before collection of representative samples of rumen contents. Infusions of acids were then continued during the in vitro incubations in exact proportion to the digesta removed from the rumen. In Periods 1 and 2, the cows were alternatively infused with acetate or nothing. In Periods 3 and 4, the infusions consisted of propionate or butyrate and in Periods 5 and 6 of lactate or nothing. Nine liquid samples were obtained between 3 and 180 min after the start of incubation and analysed for concentrations of VFA. Changes in proportions of individual VFA were estimated by linear regression. No differences in VFA proportions were observed in the absence of infusion (p> 0.5) over time, but when individual VFA were infused, their respective proportions increased. This was interpreted as the result of a decreased in vitro fermentation rate of digesta substrates compared with that in the rumen. Lactate infusion increased butyrate proportion in vitro. It is concluded that this study could not provide any evidence that ruminal VFA proportions are unrepresentative of the proportions of net production.

Sources of Variation in Rates of in Vitro Ruminal Protein Degradation

Rates and extents of ruminal protein degradation for casein, solvent soybean meal (SSBM), expeller soybean meal (ESBM), and alfalfa hay were estimated from net appearance of NH3 and total amino acids in in vitro media containing 1 mM hydrazine and 30 mg/L of chloramphenicol. Protein was added at 0.13 mg of N/mL of medium, and incubations were conducted for 4 to 6 h, usually with hourly sampling. Inocula were obtained from ruminally cannulated donor cows fed diets of grass silage or alfalfa and corn silages plus concentrates. Preincubation or dialysis of inocula was used to suppress background NH3 and total amino acids; however, preincubation yielded more rapid degradation rates for casein and SSBM and was used in subsequent incubations. Preincubation with added vitamins, VFA, hemin, or N did not alter protein degradation. Protein degradation rates estimated for SSBM, ESBM, and alfalfa were not different when computed from total N release or N release in NH3 plus total amino acids, regardless of whether amino acids were quantified using ninhydrin colorimetry or o-phthalaldehyde fluorescence. Accounting for the release of peptide-N also did not affect estimated degradation. However, casein degradation rates were more rapid when using total N release or accounting for peptide-N, indicating significant accumulation of small peptides during its breakdown. Rates also were more rapid with inocula from lactating cows versus nonlactating cows with lower feed intake. Protein degradation rates were different due to time after feeding: casein rate was more rapid, but SSBM and ESBM rates were slower with inocula obtained after feeding. Several characteristics of ruminal inoculum that influenced breakdown of the rapidly degraded protein casein did not appear to have direct effects on degradation of protein in soybean meal.

CT of a parathyroid lipoadenoma. Case report

A 54-year-old woman with primary hyperparathyroidism underwent parathyroid exploration following negative ultrasonography, CT and 99Tc-201Tl scintigraphy. A 2 x 1.5 x 1-cm large mass dorsal to the midportion of the left thyroid lobe was extirpated and a hyperfunctional lipoadenoma containing 70% or more of fatty tissue was verified microscopically. Retrospective evaluation of CT revealed a well demarcated lipomatous mass with a homogeneous density similar to that of subcutaneous fat corresponding to the surgical finding.

Fibrin adhesive in radical mastectomy

OBJECTIVE

To find out if fibrin adhesive glue applied locally would reduce the incidence of seroma after modified radical mastectomy for breast cancer.

DESIGN

Prospective randomised study.

SETTING

City hospital, Sweden.

SUBJECTS

68 women undergoing modified radical mastectomy with axillary clearance for breast cancer.

MAIN OUTCOME MEASURES

Amount of postoperative drainage, number of seromas aspirated volumes; length of hospital stay, influence of surgeon operating.

RESULTS

Seromas developed in a total of 40/68 patients (59%), 23/36 in the fibrin adhesive group (64%) and 17/32 in the control group (53%); p = 0.5 (95% confidence interval of the difference--0.13 to 0.34). There were no significant differences in the volume of aspirations or in hospital stay. The skill of the surgeon influenced the incidence of seromas, but the differences were not significant (p = 0.5).

CONCLUSION

Local application of a fibrin adhesive glue has no effect on the incidence of seroma formation after modified radical mastectomy.

Set-point for parathyroid hormone release increases with postmaturational aging in the rat

The plasma concentration of immunoreactive PTH (iPTH) increases with postmaturational aging in both humans and animals. In the present study we determined the basal, maximally stimulated, and maximally suppressed levels of iPTH and the concentration of whole blood ionized calcium sufficient to produce half-maximal suppression of the plasma concentration of iPTH (set-point for PTH release) in male Fischer 344 rats aged 3, 6, 12, 18, 24, and 28 months. Basal iPTH increased 2.3-fold from 3 to 28 months of age, whereas basal blood ionized calcium remained unchanged. The set-point for PTH release increased steadily and significantly (P < 0.001) from 1.19 +/- 0.09 mM at 3 months to 1.37 +/- 0.13 mM at 24 months and then declined slightly to 1.32 +/- 0.11 mM at 28 months of age. Basal iPTH correlated significantly with set-point. Neither maximally stimulated nor maximally suppressed iPTH levels showed any significant change with advancing age. These results suggest that the age-related increase in basal plasma iPTH in the rat may be in part a consequence of an increase in the set-point for PTH release.

Primary hyperparathyroidism in younger and older patients: symptoms and outcome of surgery

Two-hundred and fifty patients undergoing initial exploration for primary hyperparathyroidism were analyzed for differences in clinical presentation, biochemical status, pathology, and outcome of surgery. In patients less than 60 years of age (younger patients, n = 119) the most common preoperative symptoms and signs were fatigue (40.3%), bone pain (33.6%), renal stones (31.0%), hypertension (27.7%), and psychiatric illness (27.7%). In patients greater than or equal to 60 years of age (older patients, n = 131) the most frequent symptoms and signs were hypertension (46.6%), fatigue (35.1%), bone pain (30.5%), muscle weakness (28.2%), and joint pain (22.9%). Renal stones were 2.6 times more common (p less than 0.001, chi 2) in younger patients and hypertension 1.7 times more common (p less than 0.05, chi 2) in older patients. There was no significant difference in the preoperative and postoperative laboratory values typically associated with primary hyperparathyroidism. Double adenomas were more common in older (9.2%) than in younger patients (2.5%, p less than 0.05, chi 2). Surgical cure was obtained in 98.8% of patients, and after parathyroidectomy 83% of the younger and 82% of the older patients experienced substantial relief of pre-operative symptoms. Specific questioning revealed most patients to be symptomatic and older patients appear to receive the same clinical and metabolic benefits from parathyroidectomy as younger patients.

Unilateral neck exploration for primary hyperparathyroidism: analysis of a controversy using a mathematical model

Most endocrine surgeons explore both sides of the neck and identify all parathyroid glands when operating on patients with primary hyperparathyroidism. Others, however, advocate the unilateral approach, i.e., if an adenoma and a normal gland are identified, the contralateral side is not explored. We analyzed the strategy of the unilateral approach using a mathematical model to determine the variables that influence the probability of missing a tumor on the unexplored side of the neck. Assuming the frequency of single adenoma is 80%, hyperplasia 14%, double adenomas 4%, triple adenomas 1%, and carcinoma 1%, and the probability of missing a tumor on the explored side is 5%, we found that: 1. Only 41% of the patients treated by the unilateral approach undergo unilateral exploration. This is increased to 62% when a localization study with a sensitivity of 80% is used pre-operatively. 2. The probability of missing a tumor on the unexplored side of the neck parallels the prevalence of multiple adenomas. Half of the patients with triple adenomas and two-thirds of the patients with double adenomas will have a missed tumor when treated by the unilateral approach. 3. Patients who undergo unilateral exploration have an additional 7% to 8% probability of missing a tumor that would have been found if bilateral exploration is performed. This risk is lowered to 2% by a pre-operative localization study that is 80% sensitive. 4. A prospective study will require 684 patients, randomized to the unilateral or bilateral approach, to have an 80% statistical power (alpha = 0.05, beta = 0.20) of detecting a difference between a 5% and a 10% risk of missing a tumor.

Current trends in the surgical treatment of solitary parathyroid adenoma. A questionnaire study from 53 surgical departments in 14 countries

Current trends in the surgical treatment of primary hyperparathyroidism due to solitary parathyroid adenoma were evaluated in a questionnaire study. Response was obtained from 53 departments highly active in endocrine surgery in 14 countries (response rate 95%). Intraoperative histologic examination is widely (70%) regarded as necessary, but utilized more in North America and Scandinavia (87%) than elsewhere (45%). Intraoperative fat staining is used in one-third of the departments. Excisional biopsy including one whole gland is preferred by 32% to multiple incisional biopsies. Gross inspection of three normal parathyroid glands without histologic identification is favoured in 21% of the departments, while 31% prefer bilateral exploration and incisional biopsy. When an adenoma is found on the first side to be explored, 17% advocate bilateral exploration with incisional biopsy of all three normal glands, whereas unilateral exploration with excisional or incisional biopsy of the ipsilateral normal gland is preferred by a similar percentage.

Adrenocortical carcinoma. A retrospective study of a rare tumor with a poor prognosis

A retrospective study was performed on 54 patients diagnosed as having adrenocortical carcinoma during 1974-1983. The initial symptoms were often diffuse: abdominal pain, weight loss, or fever, and more than 60% of the patients showed no evidence of overproduction of hormone. The median tumor diameter was 13 cm and almost half of the tumors had metastasized at diagnosis. A radical tumor resection could be performed in less than 50% of the patients, and at histopathological re-examination some tumors were not conclusively verified as malignant. Capsular invasion, nuclear pleomorphism and mitoses were found more commonly in patients who succumbed to the disease. Seven of 29 patients treated with chemotherapy showed an objective response and two of them are still alive and free of disease. The overall 5-year-survival rate was 19%, compared with 45% for patients with radically resected tumors. Patients with no biochemical signs of overproduction of adrenocortical hormone appeared to have a better prognosis than those with hormone excess. Together with increased use of ultrasound and computed tomography, a urinary steroid profile might hopefully contribute to earlier discovery of these often clinically silent tumors. However, it remains to be determined whether these diagnostic improvements, together with more aggressive surgery and adrenolytic chemotherapy, can improve the poor prognosis.

Preoperative localization in unilateral parathyroid surgery. A cost-benefit study on ultrasound, computed tomography and scintigraphy

In 50 patients with primary hyperparathyroidism, investigation before initial neck exploration included ultrasonography, computed tomography and 99technetium-201thallium subtraction scintigraphy. The sensitivity for correct preoperative localization was 50%, 54% and 56%, respectively. There was marked inter-observer variation in assessment of ultrasonography and computed tomography, while scintigrams were evaluated by only one person. The scintigraphic sensitivity increased with size of the glands. In cases where correct preoperative localization permitted unilateral parathyroidectomy, the time for surgery and anesthesia was significantly reduced. A cost-benefit analysis, however, revealed that the financial saving from this time reduction was outweighed by the cost of the localization procedures. The authors conclude that investigations for definition of enlarged parathyroid glands are not indicated prior to unilateral parathyroidectomy.

Protein C deficiency and splanchnic venous thrombosis. Case report

A patient with splanchnic venous thrombosis due to heterozygous deficiency of protein C is reported. A review of the literature revealed that out of nine previously reported patients an isolated protein C deficiency was present in only one. Anticoagulant regimen carries a risk of hypercoagulability and certain precautions with such regimens are therefore necessary when treating patients in this condition.

Impact of long-term relative bowel rest on conditions for colonic surgery

Collagen content, bursting wall tension, and suture-holding capacity in the proximal and distal colon of the rat were studied after long-term treatment with a low-residue or a standard laboratory chow diet. Collagen content decreased uniformly in both the proximal and distal colon of the low-residue diet group. In addition, the bursting wall tension of the nonoperated proximal colon was reduced, whereas the breaking strength of a newly constructed anastomosis at three different colonic sites was unaffected.

Influence of long-term relative bowel rest on the healing of a left colon anastomosis

The influence of long-term relative bowel rest, using a low residue diet, on healing of a left colon anastomosis was experimentally studied. Retarded and diminished gain of postoperative anastomotic collagen and strength was found. The healing of the anastomosis was uncomplicated, however, and it is concluded that anastomotic integrity after surgery in this condition is safe.

Influence of proximal colostomy on the healing of a left colon anastomosis: an experimental study in the rat

The healing of an experimental left colon anastomosis protected by a proximal diverting colostomy was studied in the rat. Collagen synthesis in the anastomotic area was measured by incorporation of [3H]proline. With a defunctioning proximal colostomy, the synthesis and accumulation of collagen in the anastomosis was diminished, and the anastomotic strength development delayed and reduced. The development of anastomotic strength seems to proceed according to the level of strain from intraluminal bulk. As the healing of the anastomosis protected by a diverting colostomy was uncomplicated, these findings should not contra-indicate the use of diverting colostomy.

Healing of a left colon anastomosis after early colostomy closure. An experimental study in the rat

The healing of a standardized left colon anastomosis after early (7 days) closure of a concomitant proximal diverting colostomy was studied experimentally. Early closure of the diverting colostomy could be conducted safely by an intraperitoneal technique and the healing of the primary anastomosis was uncomplicated. Colostomy closure in the proliferative phase of wound healing resulted in development of anastomotic strength similar to colonic healing without faecal diversion. The anastomotic strength had doubled after three weeks. As compared to colostomy closure in the remodelling phase of anastomotic healing development of anastomotic strength was more rapid and without serious local complications.

Left colon anastomotic healing following colostomy closure. An experimental study on rats

The impact of colostomy closure on the healing of a left colonic anastomosis performed 4 weeks earlier was studied in rats. Colostomy closure could be safely accomplished but in 3 of 25 rats was followed by faecal obstruction due to narrowing of the primary left colonic anastomosis. After colostomy closure the gain in anastomotic strength was slow and did not exceed the outset value until after 3 weeks. After colostomy closure, accumulation of collagen in the anastomotic region increased earlier than anastomotic strength, indicating delay in collagen maturation.

Parathyroid lipoadenoma: a rare cause of primary hyperparathyroidism. Case report

Three patients with lipoadenoma of the parathyroid gland are reported. This rare tumour was encountered at surgical exploration for primary hyperparathyroidism in two patients and as an incidental finding at autopsy in the third patient. In the 2 operated patients the lipoadenoma was the cause of primary hyperparathyroidism and they were both cured by extirpation of the tumour. In the autopsy case there was no evidence of excessive parathyroid hormonal activity. The dominating stromal component of all three cases was abundant adult adipose tissue interspersed with epithelial trabeculae of mainly chief cells.

Rumen and total diet digestibilities in lactating cows fed diets containing full-fat rapeseed

Effects of full-fat crushed rapeseed (0, 1, or 2 kg/d) on rumen and total digestion, rumen biohydrogenation, and rumen microbial protein synthesis were studied in lactating cows. Rumen digestibilities (%) of DM, NDF, and cellulose were 52.1, 46.1, and 51.8, respectively, for control. Rapeseed decreased rumen and total DM digestibilities and proportion of DM digested in the rumen. Rumen digestibility of cellulose was decreased by rapeseed, but this was apparently compensated by hindgut fermentation. Dry matter, NDF, and hemicellulose digestibilities were compensated at 1 kg but not at 2 kg/d. Biohydrogenation of 18:1 fatty acids increased with increasing dietary fat, whereas that of 18:2 and 18:3 was 85% on all diets. Fatty acid digestibility was not different among diets. Microbial nitrogen in the duodenum increased from 142 g/d for control to 191 g/d for 1 and 2 kg/d. Efficiency of microbial protein synthesis (grams of microbial nitrogen per kilogram organic matter apparently digested in the rumen) was 17.3, 24.8, and 26.6 for 0, 1, and 2 kg/d. Slow release of fat from crushed rapeseed minimized negative effects on rumen metabolism; 1 to 2 kg/d of full-fat crushed rapeseed may be fed to lactating cows without detrimental metabolic effects.

Influence of selective mesenteric arteriography on the outcome of emergency surgery for massive, lower gastrointestinal hemorrhage. A 15-year experience

From 1970 to 1984, 64 patients with massive hemorrhage of lower gastrointestinal origin were treated at the intensive care unit, Surgical Department, Malmö General Hospital. The records of these patients have been studied retrospectively. Emergency exploration for hemostasis was performed on 31 patients, while in 33 patients hemorrhage stopped with conservative therapy. Acute selective mesenteric arteriography revealed the bleeding site in 16 of 28 patients (57 percent). The commonest bleeding sources detected by selective mesenteric arteriography were diverticular disease and angiodysplastic lesions of the colon. Fourteen patients with positive arteriography finding were operated on as emergencies, resulting in two postoperative deaths. Ten patients were operated on as emergencies without preoperative arteriography. Despite intraoperative efforts, no bleeding source was found in three of those patients. In the remaining seven patients, the diagnoses were similar to the 14 patients with positive arteriography. Five of 10 patients in this group died postoperatively. Emergency laparotomy eventually was necessary in seven of 12 patients with negative arteriography. This group had a variety of diagnoses and no postoperative mortality. Positive preoperative mesenteric arteriography findings allowed the surgeon to perform a limited resection of the bleeding bowel segment with a reduced postoperative mortality.

Investigations of the in situ bag technique and a comparison of the fermentation in heifers, sheep, ponies and rabbits

Fiber fermentation using the in situ bag technique was studied in a hay-fed cow. Entry of fine particles into bags of varying pore size, the effect of sample size, rumen contractions, bag porosity and rumen contraction (bags suspended in vitro or in situ) and obstruction of liquid flow through the bag cloth were investigated (Exp. 1). In Exp. 2 fiber degradation in vitro and in situ with 5- and 37-micron pore size bags was measured utilizing six fistulated heifers (four large: 610 kg and two small: 243 kg), two sheep and two goats (30 kg), three ponies (130 kg) and four rabbits (3.2 kg). Degradation rate (k) and indigestible fiber (B) were determined after curve fitting. Lag of fermentation was also calculated. Results of Exp. 1 showed that plant fiber containing approximately 50% lignin and 2.9% N entered even 20-micron pores, that rumen contractions increased fiber disappearance and that obstructing liquid exchange limited fermentation. Results of Exp. 2 showed lower fiber residues for 37-micron than for 5-micron pore size bags and that in situ method, time and species were highly significant (P less than .0001). All model factors differed significantly among species (P less than .05), but not among the three methods. Lag approached significance for methods (P = .07), but not for species. In situ measurements (37-micron) resulted in the following values for k (h-1), B (%) and lag (h): large heifers .040, 39 and -1; small heifers .025, 39 and 0; sheep-goats .051, 42 and 2; ponies .030, 59 and -5 and rabbits .107, 85 and 3.

A clinical evaluation of postoperative peritoneal lavage in the treatment of perforated appendicitis

In a comparative investigation, 369 patients operated upon for perforated appendicitis were studied retrospectively. During the period 1973-1979 181 patients with perforated appendicitis, treated at Sundsvall Hospital, were all given postoperative peritoneal lavage, whereas 188 patients with the same diagnosis treated at Skövde Hospital received no such treatment. Appendicectomy was performed in all patients and all were given systemic antibiotic therapy. Complications recorded were postoperative deaths, intra-abdominal abscesses, wound infections, postoperative ileus and lavage catheter complications. Postoperative peritoneal lavage did not diminish the frequency of these postoperative complications.

The measurement of liquid and solid digesta retention in ruminants, equines and rabbits given timothy (Phleum pratense) hay

1. Digesta passage and retention were measured in heifers, sheep, goats, equines and rabbits of varying body-weights when given timothy (Phleum pratense) hay. 2. Two passage markers were compared, cobalt (III) ethylene diamine tetraacetate (CoEDTA) and chromiummordanted timothy fibre for liquid and solid phase respectively. Both markers were injected into the rumen of the ruminants and into the caecum of the equines and rabbits. 3. In ruminants, two different sets of rate constants (k1 and k2) were derived from a two-pool model for marker passage, using a graphical approach and a computer-based non-linear least-squares curve-fitting technique. 4. Retention times, due to unidirectional flow through the gastrointestinal tract (transit time) and due to pool effects (mean retention time, MRT), were calculated. 5. Curve fitting was only successful for the excretion of liquids in ruminants. The two-pool model was not applicable to the passage of solids. 6. Apparent retention of liquid was always shorter than for solids in all species, except in rabbits. However, absorption of CoEDTA was too large in the rabbits to determine liquid retention accurately. Times for first appearance of the two markers were similar within animal groups. 7. MRT values were lowest in the rabbit, intermediate in equines and high in the ruminants. The MRT values (h) of solids and liquids respectively were: large heifers 65, 18; small heifers 48, 20; goats 41, 28; sheep 57, 26; equines 23, 18; rabbits 5.3, not determined. 8. Liquid retention seemed to decrease somewhat with increasing body-weight in the ruminants. Solids retention decreased with decreasing body-weight in the ruminants, but sheep had longer retention times than goats of similar size. Equines exhibited large individual variation in retention of the liquid or solid markers, seemingly unrelated to size. No effect of size was seen in the retention of solids in the rabbits.

Comparative digestion of timothy (Phleum pratense) fibre by ruminants, equines and rabbits

1. The abilities of cattle, sheep, goats, equines and rabbits to digest mature timothy (Phleum pratense) hay were compared. Apparent digestibilities were partitioned into true digestibility, metabolic faecal output (MFO) and fibre digestibility. The aid of the study was to determine the relative effects of fermentation site (among groups) and of body-weight (within groups) on the efficiency of digestion. 2. The ruminants were superior to equines, which were in turn superior to rabbits, in digesting fibre-components of the hay. A large individual variation in digestibility was noted only for the equines. Increasing body-weight was associated with higher digestibility in ruminants, but no such trends were seen in the non-ruminants. 3. The MFO expressed as a proportion of dry matter intake gave similar values for all groups (0.085-0.118). As a proportion of available microbial substrate originating from the feed, the values were found to be 0.167 for the ruminant, 0.425 for the equines and 2.13 for the rabbits. The value for the rabbits shows that their lower tract microflora must obtain energy from non-fibre components of the feed. No appreciable digestion of the generated microbes by the host was suggested by the values obtained for the equines.