Difficulties in the management of a parathyroid carcinoma - case-report

The case of a parathyroid carcinoma in a 61-year-old woman is described. The patient was referred to our hospital, with the diagnosis of medullary thyroid carcinoma, after a prior thyroidectomy performed at another hospital. On admission, serum calcium was 3.92 mmol/l (n.r. 2.2-2.5), PTH level was 320 ng/l (n.r. 10-65), urinary cAMP was 508.9 mmol/mmol creatinine (n.r. 330- 630) and serum calcitonin was 2.1 ng/l (n.r.<10). The patient was then submitted to a complete neck exploration and multiple nodules were removed. Histopathological diagnosis of parathyroid carcinoma was made by local recurrence and retrospectively upon closer examination of the original specimen. After surgery, normocalcemia was achieved and maintained for about four months. Serum PTH decreased to 28.8 ng/l after surgery but increased quickly to 75.6 ng/l ten days later. Three months later, there was both biochemical and clinical evidence of disease. In the following eight months, calcium levels ranged from 2.99 mmol/l to 4-24 mmol/l and PTH from 135 ng/l to 1431 ng/l. However no distant metastases were found. To Control hypercalcemia, the patient was treated with bisphosphonates but normocalcemia was never achieved. A slight and transient reduction in serum calcium as response to an acute administration of octreotide, made us not to consider this eventual modality of therapy. Sonographically guided percutaneous injection of ethanol was performed but the treatment was not found to be effective. Finally, the use of chemotherapy with 5-fluorouracil, cyclophosphamide and dacarbazine was also unsuccessful. The patient died two years after the initial diagnosis.

Differences in nigral neuron number and sensitivity to 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine in C57/bl and CD-1 mice

The present study demonstrates that the neurotoxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) causes significantly greater reductions in striatal dopamine levels in C57/bl mice than in CD-1 mice, thus confirming a greater sensitivity of the C57/bl mice to MPTP. To determine the possible reasons for this difference in MPTP sensitivity between these two mouse strains, we have compared both the organization and the number of substantia nigra (SN) neurons, the primary target of MPTP, in C57/bl and in CD-1 mice using immunostaining for tyrosine hydroxylase (TH) and calbindin-D28k (calbindin). In saline-injected animals, there is a significantly lower number of SN TH-positive and calbindin-positive neurons in C57/bl than CD-1 mice; no significant differences in the numbers of these neurons are found in the ventral tegmental area between the two strains. In MPTP-injected animals, the reductions in SN TH-positive neurons are significantly greater in C57/bl than in CD-1 mice. In contrast, MPTP does not cause any significant changes in the numbers of SN calbindin-positive neurons in either strain. The present study shows that C57/bl mice which have fewer SN TH-positive neurons are more sensitive to MPTP-induced toxicity than CD-1 mice. This observation suggests a possible inverse relationship between SN TH-positive neuron number and MPTP sensitivity. If correct, this hypothesis may be of major importance for Parkinson's disease since it is suggested that individuals at risk of developing this neurodegenerative disorder may have lower numbers of SN TH-positive neurons to start with. The present study also shows that SN calbindin-positive neurons are spared following MPTP administration. However, the observed difference in SN calbindin-positive neuron numbers does not account for the differential sensitivity to MPTP between these two mouse strains.

Determinants of urinary thioethers, D-glucaric acid and mutagenicity after exposure to polycyclic aromatic hydrocarbons assessed by air monitoring and measurement of 1-hydroxypyrene in urine: a cross-sectional study in workers of coke and graphite-electrode-producing plants

A cross-sectional epidemiological study was performed on 286 workers from two coke oven and one graphite electrode plants. The aim was to evaluate the usefulness of monitoring 1-hydroxypyrene (1-HOP) in urine for assessing exposure to polycyclic aromatic hydrocarbons (PAHs), and that of the urinary excretion of thioethers and D-glucaric acid, and the mutagenic activity of urine as indicators or biological effects of PAHs. The results confirm that 1-HOP determination in urine probably reflects exposure to PAHs by all routes and is not significantly influenced by the smoking habit. In comparison with the total PAHs in the air and 1-hydroxypyrene in urine, taken as reference exposure parameters, the results indicate that urinary D-glucaric acid excretion is not positively influenced by PAHs exposure; thioethers determination in urine is of poor value, since the smoking habit is a strong confounding factor. The determination of urinary mutagenicity might contribute to the detection of groups of workers exposed to potentially genotoxic PAHs.

Bioavailability of residues of diazepam and its metabolites

The present study was performed to determine the metabolic fate of the residues of diazepam and its metabolites in an in vivo model and using two different animal species, guinea pigs and rats, successively. Guinea pigs were orally dosed with diazepam at 100 mg/kg bw and 10 mg/kg bw. After 2 h the animals were sacrificed and their livers were removed. Rats were fed these livers and sacrificed 8 h later after having ingested the portion given. Blood, kidney, and liver of rats were collected to quantify drug residues. Oxazepam and demethyldiazepam were identified by HPLC-UV in liver and kidney rat extracts and also in some blood samples. Temazepam was only found in liver from rats that had eaten guinea pig liver dosed at the highest level. The identity of demethyldiazepam was confirmed in rat liver extracts by GC-MS. This study demonstrates the bioavailability of diazepam metabolites in a second animal (rat simulating a consumer) following a diazepam administration to a first animal (guinea pigs simulating a target animal). Residue concentrations were reduced from 9.7 and 243 micrograms in consumed guinea pig liver to 3.75 and 455 ng/g in rat liver for parent drug and oxazepam, the lowest and highest residues found, respectively.

Immediate pars plana vitrectomy in the management of inadvertent intracameral injection of gentamicin. A rabbit experimental model

PURPOSE

Acute retinal toxicity secondary to inadvertent intracameral injection of massive doses of gentamicin is a devastating complication of cataract surgery, for which no treatment, to date, either surgical or medical, has been shown to be effective. A rabbit experimental model was used to examine the effect of immediate pars plana vitrectomy in the management of inadvertent intracameral injection of gentamicin.

METHODS

Twenty-seven rabbit eyes were subjected to lensectomy with or without preservation of the lens capsule. Aphakic rabbit eyes and rabbit eyes with an intact lens capsule were then subjected to injections of massive doses (4 mg and 20 mg) of gentamicin into the anterior chamber. Experimental eyes underwent an immediate pars plana vitrectomy and posterior segment lavage. The rabbits were killed after 7 days. Light microscopic examination was then performed to ascertain the degree of retinal damage caused by the injection.

RESULTS

Rabbit eyes receiving immediate pars plana vitrectomy exhibited far less structural damage to the retina, as seen by light microscopy, than did corresponding control eyes. Furthermore, there appeared to be a protective effect of an intact lens capsule with regard to retinal damage.

CONCLUSIONS

Immediate pars plana vitrectomy and posterior segment lavage may alleviate the effects of intracameral injection of gentamicin. This preliminary study demonstrates the need to perform further studies with a vascularized primate retina to evaluate immediate pars plana vitrectomy in the management of inadvertent intracameral injection of gentamicin.

[Fetal cardiology. Bases for the prenatal diagnosis of congenital cardiopathies]

The bases for prenatal diagnosis of congenital heart disease are presented, in the line of a comprehensive program undertaken by paediatric cardiology and obstetrics. This program is designed to improve the screening of fetal heart diseases by obstetric echographists, particularly those working at peripheral high risk clinics. It includes the visit of paediatric cardiologists to district hospitals for joint meetings with local physicians, going over theoretical aspects, case presentation and four chamber view with outflow tract demonstrations using local ultrasound equipment. Referring protocols, handouts and support media exchange are contemplated. Support texts on the program divulged, on etiology of congenital heart disease, on abnormal fetal echocardiography and on fetal dysrhythmias are presented here in. The need for an organized national effort to increase the prenatal diagnosis of congenital heart disease is emphasized as well as the need to centralize some aspects related to diagnosis and treatment in order to improve the care of newborns with congenital heart disease.

Chronic levodopa administration alters cerebral mitochondrial respiratory chain activity

Parkinson's disease (PD) is characterized mainly by a loss of nigrostriatal dopamine neurons. Thus far, the actual physiopathology of PD remains uncertain, although recent studies have found decreased activity of complex I, one of the enzymatic units of the mitochondrial respiratory chain, in various tissues of PD patients. Because most, if not all, of PD patients are treated chronically with levodopa, the precursor of dopamine, and because we have shown previously that catecholamines may alter mitochondrial respiration, we assessed the effects of chronic administration of levodopa on complex I activity in rat brain. We found that chronic administration of levodopa, at a dose used in PD patients, caused a significant reduction in complex I activity while it did not affect the activities of complex II, complex IV, and citrate synthase. Reduction in complex I activity correlated well with catecholamine innervation as the reduction was observed mainly in the striatum and substantia nigra and to a lesser extent in the frontal cortex but not in the cerebellum. Moreover, the levodopa-induced decrease of complex I activity was reversible since activities at 1, 3, and 7 days after the last injection showed a progressive return to control values. Incubation of whole brain mitochondria in vitro showed that both levodopa and dopamine inhibit complex I activity in a dose- and time-dependent manner. In contrast, other compounds such as homovanillic acid, 3,4-dihydroxyphenylacetic acid, and 3-O-methyl-dopa were minimally effective. Reduced glutathione, ascorbate, superoxide dismutase, and catalase prevented the effect of levodopa and dopamine on complex I. Various inhibitors of monoamine oxidase also prevented the effect of dopamine.(ABSTRACT TRUNCATED AT 250 WORDS)

[Fetal echocardiography. The results of a 3-year study]

During the last three years (July 89 to July 92), 875 fetal echocardiographic studies were performed, at a mean gestational age of 26 +/- 6.5 weeks (12 to 40 weeks), with the following main referral indications: family history of congenital heart disease 23%; advanced maternal age 13%; fetal arrhythmia 10%; amniotic fluid abnormalities 8%; fetal malformations 7%; diabetes 6%; four chamber view changes 4%. There were 15 twin pregnancies, two of them thoracopagus. The referral patterns with higher percentage of cardiac pathology were: abnormal four chamber view 56%; fetal chromosomal anomalies 50%; omphalocele 33%; twin pregnancy 33%; IUGR 29%; arrhythmias 20%. The referral patterns with lower percentage of cardiac pathology were: congenital heart disease in the family 0.2%; maternal risk 2%; amniotic fluid volume alterations 2%. The diagnosis of congenital heart disease was made in 37 fetus (4.2%), with the following most frequent: 9 cases with the atrioventricular septal defect, 5 cases with ventricular septal defect, 5 cases with hypoplastic left heart syndrome and 5 cases with tricuspid valve abnormalities. From a total of 78 referred fetal arrhythmias, 25 were confirmed, 20 being ectopic beats without structural heart disease, 3 with tachycardia, and 2 with bradycardia. One newborn with tachycardia and Ebstein's disease died, and the fetus with AV block and left atrial isomerism died in utero. The treatment and follow up of the remaining cases with heart disease are described. The whole mortality in the cases with heart pathology was 65%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clear cell hepatocellular carcinoma]

A case of a 62 year old white patient with mild dyspeptic symptoms and nodular hepatomegaly is presented. The histologic examination of a liver biopsy revealed a hepatocellular carcinoma clear cell variant. There were no signs of chronic hepatic failure. The disease showed an indolent clinical behaviour, thus the beginning of chemotherapy was delayed until clinical deterioration was obvious. Clinical improvement was obtained with adriamycin. A review of the literature on this rare histologic variant of hepatocellular carcinoma is made.

Adenosine receptor antagonists potentiate dopamine receptor agonist-induced rotational behavior in 6-hydroxydopamine-lesioned rats

Adenosine receptor antagonists, DMPX, PACPX and theophylline, produce contralateral rotations in unilateral 6-hydroxydopamine-lesioned rats. DMPX and theophylline markedly increase rotations produced by bromocriptine (a dopamine D2 receptor agonist) and/or SKF38393A (a dopamine D1 receptor agonist). All of these effects are inhibited by CGS21680C (an adenosine A2 receptor agonist). These findings suggest synergistic interactions among D1, D2 and A2 receptors that may be relevant to the treatment of Parkinson's disease.

[Functional assessment of the autonomic nervous system in rheumatoid arthritis]

Sympathetic and parasympathetic nervous system evaluation was performed in 21 patients with rheumatoid arthritis. Every patient had autonomic nervous system (ANS) dysfunction, the parasympathetic involvement being the most frequent. ANS dysfunction may explain some manifestations and may well be the expression of a larger neuropathic involvement with pathogenic implications.

Endomysial antibody: is it the best screening test for coeliac disease?

The sensitivities and specificities of the IgA and IgG antigliadin antibody and the IgA antireticulin antibody have been compared with the recently described endomysial antibody directed against the basement membrane of smooth muscle in monkey oesophagus. One hundred and seventeen patients with adult coeliac disease (21 untreated), 84 patients with inflammatory bowel disease, systemic lupus erythematosus and rheumatoid arthritis (comprising the disease control group), 47 normal controls and a miscellaneous group of 29 patients, who were selected because of a positive reticulin staining pattern, were investigated. These results were correlated with the degree of abnormality of the intestinal mucosa in patients with adult coeliac disease. Endomysial antibodies were found in all patients with untreated coeliac disease and subtotal villous atrophy and in 47% of patients on a non-strict gluten free diet. One patient on a strict gluten free diet was positive and had partial villous atrophy while all patients in disease control groups were negative. Results were variable with the antireticulin and antigliadin antibodies. Sensitivity and correlation with subtotal villous atrophy in the untreated patients was 100%. It is concluded that the endomysial antibody is superior to other current antibody tests and should be used in preference for the diagnosis of coeliac disease.

Functional significance of premature ventricular complex morphology evaluated during treadmill exercise stress test in patients with coronary artery disease

OBJECTIVES

To evaluate the relation between premature ventricular complexes morphology and left ventricular myocardial systolic function in patients with proved coronary artery disease.

SETTING

Department of Cardiology at General Hospital.

METHODS

From 112 patients (pts) with proved coronary artery disease, thirty-three pts with premature ventricular complexes (PVC) detected during treadmill exercise stress test were selected. Two groups of pts were considered: group I-20 pts with regular contour or with a narrow notching (< 40 ms; type I PVC) and group II-13 patients with wide notching (> 40 ms; type II PVC). In each group the following parameters were studied: ejection fraction, QRS duration, duration of exercise, number of metabolic units and the prevalence of ventricular aneurysm and mitral regurgitation.

RESULTS

Statistical significant differences were found between group I and II concerning the mean ejection fraction (59.2% vs 48.6%; p < 0.05). The prevalence of ventricular aneurysm and mitral regurgitation was higher in patients with type II ventricular premature complexes (10% vs 30%).

CONCLUSION

Particular characteristics of premature ventricular complexes detected during treadmill exercise stress test, in patients with proved coronary artery disease, suggest the presence of left ventricular myocardial systolic dysfunction.

[Enalapril and myocardial protection from stress by cold]

PURPOSE

To evaluate the myocardial protective effect of enalaprilat in rats submitted to stress by cold.

METHODS

Fifteen adults, male rats were studied. They were allocated into four groups: group A received unrestricted diet + intraperitoneal (IP) diluent; group B: unrestricted diet + IP enalaprilat 1.0 mg/kg; group C: high salt diet (HD) for seven days + IP indomethacin 1.0 mg/kg and group D received high salt diet for seven days + IP indomethacin 1.0 mg/kg + IP enalaprilat 1.0 mg/kg. Three animals were the control group. The animals of the groups A, B, C and D were then submitted to stress by cold. Fragments of the left ventricle were obtained for electron microscopy and the occurrence of mitochondrial lysis or preservation of the mitochondrial ultrastructure were considered as parameter for myocardial protective effect evaluation.

RESULTS

Crystolysis (partial or total) was observed in 16.2% group A; 19.5% of group C; 3.2% of group B and in 8.8% of group D.

CONCLUSION

Enalaprilat protects the cardiomyocyte from the stress by cold.

Composite tumor of the main bile duct producing several regulatory peptides

Herein we describe what is, to our knowledge, the first reported case of a composite tumor of the main bile duct with epiploon metastases. Glucagon, pancreatic polypeptide, and somatostatin-immunoreactive cells were demonstrated in these metastases, but not serotonin, gastrin, or insulin-immunoreactive cells. The clinical significance of the neuroendocrine cells in the present case is discussed.

[Heart surgery without previous heart catheterization, in pediatric cardiology]

STUDY OBJECTIVE

To determine the influence of echocardiography in the preoperative diagnosis of heart diseases in children.

DESIGN

Retrospective study.

SETTING

Hospitalized children admitted in Departments of Pediatric Cardiology and Cardiothoracic Surgery.

PATIENTS

Children of both sexes, aged from neonate to 14 years old, with heart disease who underwent cardiac surgery.

MATERIAL AND METHODS

From January 1989 to July 1990, 220 consecutive cardiac surgeries were performed in children with heart disease. The initial diagnosis was based on data from clinical examination, electrocardiogram, thorax X-Ray and echocardiogram (M-mode, 2D, conventional and colour Doppler). Patients were separated in three groups according to their ages: newborn infants less than 28 days old; infants less than 12 months old; children more than 1 year old and less than 14 years old. Patients were separated according to the investigations used further for preoperative diagnosis: whether they had or not cardiac catheterization performed prior to surgery.

RESULTS

From 220 surgical interventions performed, 124 were "open heart" surgeries (9 neonates, 28 infants and 87 children) and the remaining had "closed heart" operations (14 neonates, 37 infants and 45 children). Preoperative diagnosis was mainly dependent on echocardiography, dispensing catheterization in 90 cardiac interventions. The diagnosis was confirmed at surgery or at autopsy. There were 9 deaths, 3 of which occurred in patients not submitted to cardiac catheterization.

CONCLUSIONS

Echocardiography is a reliable method for investigation and establishment of the preoperative diagnosis of heart diseases in children. Its use may further reduce the need for diagnostic catheterization in children, particularly in risk groups.

Changes in sex ratio during attempts to establish a laboratory colony of Lutzomyia longipalpis (Diptera: Psychodidae)

After the discovery of "one spot" and "two spot" male Lutzomyia longipalpis in the same dog's kennel, attempts were made to establish laboratory colonies of the two forms. Pure lines of the two forms were not obtained and various "intermediate" males were recorded. Interbreeding between the two populations probably occurs in nature but appears precarious. In one colonization attempt a change in sex ratio was noted from the 7th generation onwards and only females emerged in the 11th generation.

Mating behaviour between different lines of Lutzomyia longipalpis (Diptera: Psychodidae)

Homologous and heterologous crosses were made between laboratory-reared Lutzomyia longipalpis. One line of insects originated from Para State and the other from Minas Gerais. Homologous matings showed that the two lines behaved differently before and during coition and that a mixture of the two behaviour patterns occurred in heterologous crossings.

Plasma catecholamines and postural hypotension in familial amyloidotic polyneuropathy of the Portuguese type

Plasma adrenaline and noradrenaline levels were measured while supine and following head-up tilt to 45 degrees, in both normal controls and in patients with familial amyloidotic polyneuropathy of the Portuguese type. In nine patients systolic blood pressure fell by less than 15 mmHg, while in seven patients it fell by more than 15 mmHg. Plasma noradrenaline rose during tilt in the majority of patients, as in the controls. There was no correlation between levels of catecholamines and fall in blood pressure on head-up tilt. The data excludes widespread sympatho-neural failure as a cause for postural hypotension in familial amyloidotic polyneuropathy of the Portuguese type. The results are compatible with either segmental/patchy sympathetic denervation or dysfunction of the receptor/effector mechanisms in target organs such as the heart and blood vessels.

An alternative methodological approach for studies in family planning

"An alternative to the methodological approach traditionally used in studies on family-planning practices was developed and applied in a retrospective investigation of the decision making of a sample of women [in South Africa] regarding their adoption of contraceptive sterilization. The approach is based on the premise of an interparadigmatic overlap and makes provision for integrating analytical levels and employing a combination of quantitative and qualitative research methods in a research design.... The results of the investigation showed the respondents' perceptions of the most important reasons for their decision to be sterilized. The findings provided insight into the interdependence of the sample's fertility behaviour and societal modernism within the particular institutional and socio-cultural setting." The data are from a survey carried out in the Cape Peninsula. (SUMMARY IN AFR)

Anatomy of the buccal fat pad and its clinical significance

Interest in the anatomy of the buccal fat pad was aroused by two clinical cases where the fat pad was involved by pathology. In one, there was an extensive lipoma of the buccal fat pad which had been unsuccessfully operated on on two previous occasions. The reason for the lack of success was incomplete removal of the fat pad. In the second case, there was an arteriovenous malformation involving the fat pad which necessitated complete removal. Fresh cadaver dissections were carried out to accurately determine the anatomy. Particular attention was paid to the temporal extension, since this area is frequently disregarded.