[Large goiter--diagnosis and treatment]

BACKGROUND

The prevalence of large goiter is low in Norway compared with that for areas of iodine deficiency. Benign multinodular goiter is the most common cause. The most important differential diagnoses are cancer and autoimmune thyroid disease. Most multinodular goiters grow slowly and even large ones usually cause little discomfort.

MATERIAL AND METHODS

We present an overview of the most common causes, diagnostic procedures, complications and treatment of large goiters based on our own experience and selected literature.

RESULTS AND INTERPRETATION

The work-up aims at finding the cause and complications of goiter; i.e. hyperthyreosis, compression or cosmetic complaints. If cancer is considered, fine needle aspiration cytology, preferably ultrasound-guided, is the most important diagnostic tool. Imaging techniques do not differentiate precisely between benign and malignant lesions, but ultrasound is useful in guiding cytological sampling. Treatment of patients with multinodular goiter complications is influenced by general health, surgical risk and patient preferences. It is not necessary to treat all patients. The main treatments are thyroidectomy, partial resection and single or repeated radioiodine therapy. Pre-treatment with recombinant human thyroid stimulating hormone may increase the effect of radioiodine treatment and thereby expand the indication for non-surgical treatment.

Ropivacaine versus bupivacaine 0.125% with fentanyl 1 microg/ml for epidural labour analgesia: is daily practice more important than pharmaceutical choice?

Ropivacaine might be superior to bupivcaine for epidural labour analgesia because it appears to induce less lower extremity motor blockade. The clinical relevance of this difference is not yet clear.

METHODS

In a double-blind randomised trial bupivacaine and ropivacaine each at 0.125% with 1 microg/ml fentanyl were compared for epidural labour analgesia. This study was performed in two university hospitals.

RESULTS

Sixty-three nulliparous women with singleton pregnancies at term were included. There were no differences between bupivacaine and ropivacaine as far as motor blockade, analgesic outcome, mode of delivery and neonatal outcome are concerned. However, the clinical management of epidural analgesia differed significantly between the two institutions involved. Parturients of one institution had their epidural catheter placed earlier, needed less top-up medication, and had more successful mobilisations, when compared to the other institution.

CONCLUSIONS

Institutional clinical practice can be significantly different. Pharmacological differences between bupivacaine and ropivacaine at 0.125% with 1 microg/ml fentanyl seem to be less important than differences between institutions in terms of clinical practice.

mRNA expression of components of the IGF system and of GH and insulin receptors in ovaries of broiler breeder hens fed ad libitum or restricted from 4 to 16 weeks of age

An evaluation of the insulin-like growth factors (IGF) system in the ovaries of heavy breeder hens during the growing phase was performed to measure the effect of feed restriction. The transcripts of IGF-I, IGF-II, IGF receptor (IGF-R), two IGF binding proteins (IGFBP-2 and IGFBP-5), GH receptor (GH-R) and insulin receptor (I-R) were measured by RT-PCR at 4, 8, 12 and 16 weeks of age in the ovaries of ad libitum fed and feed restricted hens. The transcripts of all genes screened were detected in all feed regime groups and at all ages sampled. However, no significant overall effects of feed restriction on these transcripts were found despite the marked difference in body growth (200% at 16 weeks of age). Similarly there were no significant age effects except for the expression of GH-R-that showed a decrease after 8 weeks of age (P<0.01). Although feed restriction seems to have a relatively limited effect on the expression of these components of the ovarian IGF system in juveniles, a more detailed determination is necessary to determine possible changes nearer to sexual maturity (16 weeks of age onwards). It is concluded that components of the IGF system, GH or insulin may not be involved in the mechanisms that, through restricted feeding, alter ovarian development and function during growth to enable better reproductive performance during lay.

High frequency stimulation of the basal ganglia for the treatment of movement disorders: current status and clinical results

High frequency stimulation of the basal ganglia has gained much interest during the last years. Based on the reevaluation of the results of functional neurosurgery for movement disorders from Leksell's group, pallidotomy as lesional procedure was the first functional operation that underwent a renaissance for the treatment of movement disorders. The work by Benabid and Siegfried who carried out thalamic high frequency stimulation to suppress tremor, the knowledge about deep brain stimulation (DBS) for the treatment of chronic pain as well as better understanding in basal ganglia physiology and the development of reliable stimulation hardware led to an increasing number of centers worldwide who currently apply high frequency DBS for different movement disorders. In the present review the current status of DBS for movement disorders is presented and the results with high frequency stimulation targeted at different brain areas are summarized.

Separation and identification of enzymatic sucrose hydrolysis products by high-performance anion-exchange chromatography with pulsed amperometric detection

An accurate carbohydrate analysis method, namely high-performance anion-exchange chromatography with pulsed amperometric detection was successfully applied to the study of sucrose hydrolysis under enzymatic (baker's yeast invertase) conditions. The hydrolysis was monitored by determining sucrose degradation and the corresponding formation of D-glucose, D-fructose and five intermediate fructans using a CarboPac PA-100 (Dionex) analytical anion-exchange column. Highly reproducible results were obtained. The unknown fructans were collected from a semi-preparative CarboPac PA-100 (Dionex) column, neutralized and then desalted on a column containing mixed bed resin AG 501-X8 (D) before identification of the chemical structure. This procedure permitted us to obtain about 20 microg of pure product which is not enough for NMR analysis. Detailed GC-MS analytical data of the methylated compounds indicated that these oligosaccharides were beta-D-Fru-(2 --> 1)-beta-D-Fru-(2 --> 1)-alpha-D-glucopyranoside (1-kestose), beta-D-Fru-(2 --> 6)-alpha-D-glucopyranoside (6-beta fructofuranosylglucose), beta-D-Fru-(2 --> 1)-beta-D-fructofuranoside (inulobiose), beta-D-Fru-(2 --> 6)-beta-D-Fru-(2 --> 1)-alpha-D-glucopyranoside (6-kestose) and beta-D-Fru-(2 --> 6)-alpha-D-Glc-(1 --> 2)-beta-D-fructofuranoside (neokestose) coeluating with a disaccharide.

Deep brain stimulation for the treatment of Parkinson's disease: subthalamic nucleus versus globus pallidus internus

OBJECTIVES

Deep brain stimulation of the basal ganglia has become a promising treatment option for patients with Parkinson's disease who have side effects from drugs. Which is the best target-globus pallidus internus (GPi) or subthalamic nucleus (STN)-is still a matter of discussion. The aim of this prospective study is to compare the long term effects of GPi and STN stimulation in patients with severe Parkinson's disease.

PATIENTS AND METHODS

Bilateral deep brain stimulators were implanted in the GPi in six patients and in the STN in 12 patients with severe Parkinson's disease. Presurgery and 3, 6, and 12 months postsurgery patients were scored according to the CAPIT protocol.

RESULTS

Stimulation of the STN increased best Schwab and England scale score significantly from 62 before surgery to 81 at 12 months after surgery; GPi stimulation did not have an effect on the Schwab and England scale. Stimulation of the GPi reduced dyskinesias directly whereas STN stimulation seemed to reduce dyskinesias by a reduction of medication. Whereas STN stimulation increased the unified Parkinson's disease rating scale (UPDRS) motor score, GPi stimulation did not have a significant effect. Fluctuations were reduced only by STN stimulation and STN stimulation suppressed tremor very effectively.

CONCLUSION

Stimulation of the GPi reduces medication side effects, which leads to a better drug tolerance. There was no direct improvement of bradykinesia or tremor by GPi stimulation. Stimulation of the STN ameliorated all parkinsonian symptoms. Daily drug intake was reduced by STN stimulation. The STN is the target of choice for treating patients with severe Parkinson's disease who have side effects from drugs.

Decreasing children's risk taking on the playground

Playground mishaps are some of the most common sources of injury and are the leading killer of children. The present study used a multiple baseline design across three classrooms (N = 379 children). With minimal teaching and rewards, children decreased and maintained decreased risky playground behaviors on slides. Floor effects on climbers prevented the demonstration of similar effects. The decreases seen in risky slide behavior are discussed within the context of preventive safety training for playground injuries.

Application of high performance anion exchange chromatography to study invertase-catalysed hydrolysis of sucrose and formation of intermediate fructan products

Baker's yeast invertase was found to catalyse transfructosylation reactions in aqueous and anhydrous organic media with sucrose as a substrate, leading to the formation of five intermediate fructans in addition to the release of D-glucose (D-Glc)and D-fructose (D-Fru). All the reaction products were separated and quantitatively estimated using high performance anion exchange-pulsed amperometric detection equipment. The unknown products were subsequently identified by linkage analysis as beta-D-Fru-(2 --> 1)-beta-D-Fru-(2 --> 1)- alpha-D-glucopyranoside (1-kestose), beta-D-Fru- (2 --> 6)-alpha-D-glucopyranoside (6-beta-fructofuranosylglucose), beta-D-Fru-(2 -->1) -beta-D-fructofuranoside (inulobiose), beta-D-Fru-(2 --> 6)-beta-D-Fru-(2 --> 1)-alpha-D-glucopyranoside (6-kestose) and beta-D-Fru-(2 --> 6)-alpha-D-Glc-(1 --> 2)-beta-D-fructofuranoside (neokestose); and this last was eluted together with a disaccharide. The time-course of sucrose hydrolysis via fructan production in 2 ml of a 50 mM sodium acetate buffer (pH 4.5) containing 0.2 M sucrose and 25 U of invertase was different from that in 2 ml of anhydrous toluene with 1.46 M sucrose and 1,000 U of invertase as a suspended powder. Under the latter experimental conditions, invertase was found to exhibit cyclic behaviour, where sucrose was degraded and subsequently synthesised. This observation has not yet been reported, as far as we know.

[Contrast enhanced MR angiography in the preoperative evaluation of living kidney donors]

PURPOSE

To compare Gadolinium-enhanced MR angiography with conventional DSA in the preoperative evaluation of living kidney donors.

MATERIAL AND METHODS

27 potential living kidney donors were examined with contrast-enhanced MR angiography after conventional angiography. The MR angiograms were evaluated for the number of renal arteries, the presence of early arterial branching and vascular pathologies by two independent readers. The results were compared with those of selective conventional angiography and intraoperative findings.

RESULTS

Conventional angiography detected 14 accessory renal arteries. Reader A detected 13 of 14 accessory arteries with no false positive result (sensitivity 93%, specificity 100%). Reader B detected 11 of 14 accessory vessels with one false positive finding (sensitivity 79%, specificity 98%). Early arterial branching was detected by both readers in 9 of 12 vessels with no false positive result (sensitivity 75%, specificity 100%). None of the patients had additional vascular pathology.

DISCUSSION

Gadolinium-enhanced MR angiography is a non-invasive alternative to conventional angiography in the preoperative evaluation of living kidney donors. In order to achieve high accuracy in detecting accessory renal arteries and early arterial branching extensive experience with the method and the specific preoperative needs is required. Selective conventional angiography is still superior in detecting very small accessory vessels and early arterial branching.

Functional bovine immunoglobulins in Boophilus microplus hemolymph

The aim of the present work was to quantify the passage of bovine immunoglobulins into the hemolymph of the tick Boophilus microplus during the feeding process and to determine their antibody activity. The knowledge is of paramount importance when vector control or blocking of disease transmission is attempted by vaccination of cattle. Approximately 2% of bovine immunoglobulin present in the serum as determined by competitive ELISA was demonstrated in hemolymph of B. microplus and antibody activity against an antigen of B. microplus in the hemolymph of ticks fed on bovine immunized with the antigen purified from tick eggs was detected by Western blot assay. The antibody reactivity detected against the B. microplus antigen showed that functional antibodies are present in the hemolymph of fully engorged ticks for at least 48 h after completing the parasitic life cycle.

Echocardiographic diagnosis of effusive-constrictive pericarditis due to staphylococcal pericarditis after cardiac surgery

Two weeks after coronary artery bypass surgery, a 43-year-old man was readmitted with fever, pneumonia, left pleural effusion, and pericarditis. Echocardiography showed a localized posterior pericardial effusion, pericardial thickening, and bulging of the ventricular septum toward the left ventricle. Right-sided catheterization indicated pericardial constriction. Effusive-constrictive pericarditis was confirmed at surgery. Cardiac imaging played an important role in diagnosis of this unusual complication of cardiac surgery.

Localization of antibody in the central nervous system of a patient with paraneoplastic encephalomyeloneuritis

We report a patient with severe paraneoplastic encephalomyeloneuritis, occult small-cell carcinoma of the lung, and high titers of circulating antineuronal antibody who died shortly after developing limbic encephalitis. The antibody was of IgG class and reacted specifically with nuclei and cytoplasm of all neurons in the pattern typical for encephalomyelitis and subacute sensory neuropathy associated with small-cell carcinoma (type II, anti-Hu). At autopsy, perivascular inflammatory infiltrates were prominent. All samples of serum, CSF, and postmortem peritoneal and pleural fluid contained high titers of antibody. Direct immunofluorescence of frozen tissue revealed IgG bound to most remaining neurons in multiple brain regions in a pattern similar to indirect immunofluorescence of normal brain tissue. IgG was also bound to tumor. Attempts to elute antibody from tissue decreased background staining but did not remove neuronal immunofluorescence. These results indicate that antibody can access and bind specifically to neuronal antigens in the brain during the course of paraneoplastic disease.

Self-induced hematuria

Two patients, an adult and a child, are reported who presented with factitious hematuria secondary to self-induced finger sticks with contamination of unwitnessed urine samples. Feigned illness of this kind may be more common than generally appreciated.

[Reaction of stress parameters during electrostimulation analgesia and neuroleptanalgesia (author's transl)]

Surgical interventions produce a stress response in patients. Electrostimulation analgesia (ESA) has been described as a method yielding excellent results in poor-risk patients. The present study was undertaken to investigate the stress response of ESA compared with neuroleptanalgesia (NLA). 30 female patients (16 with ESA, 14 with NLA) ranging from 34 to 55 years without endocrine, hepatic, renal or cardiovascular disease who were undergoing vaginal hysterectomy, were subjected to the study. The concentrations of cortisol, cholesterol and glucose in the plasma, the mean arterial blood pressure, the heart rate and the tension-time-index were measured before and during anesthesia as well as during and after surgery. In patients receiving ESA the stress reaction seems to be more pronounced, judged by the higher level of plasma cortisol. The decrease of cholesterol as well as the increase of plasma glucose, mean arterial pressure, heart rate and tension-time-index supported this interpretation. During anaesthesia but before starting the operation the changes in the parameters showed that ESA induces a higher stress reaction than NLA.