Thyroid surgery in untreated severe hyperthyroidism: perioperative kinetics of free thyroid hormones in the glandular venous effluent and peripheral blood

BACKGROUND AND METHODS

It is generally believed that thyroid surgery in Graves' disease requires a euthyroid state to avoid thyrotoxic reactions. We carried out a prospective study on 23 patients who had severe hyperthyroidism with free thyroid hormone concentrations (fT3 or fT4) exceeding the upper normal boundary by 300% or more and who were not pretreated with thyrostatic agents. We determined hormone levels during operation in the thyroid venous effluent before and after surgical trauma and monitored their postoperative elimination kinetics.

RESULTS

The concentration of fT3 and fT4 in the venous effluent of the hyperactive gland did not exceed the peripheral levels. Surgery did not induce any intraoperative or postoperative increase in fT4 or fT3, whereas thyroglobulin concentrations rose sharply. Both fT4 and fT3 followed biphasic elimination kinetics, and a significant decline of circulating free hormone concentrations was measurable within the first postoperative hour.

CONCLUSIONS

Contrary to widely held assumptions, the surgical trauma does not stimulate the release of thyroid hormones. Hence this mechanism cannot account for the postoperative development of thyroid storm. Our observations imply that immediate operation should generally be considered for the emergency treatment of an imminent thyroid storm.

Clinical pharmacology of human insulin

Nowadays, human insulin is used daily by millions of diabetic patients. The biological effect of human insulin is comparable to that of porcine insulin. However, after subcutaneous injection, pharmacological and clinical studies showed pharmacokinetic and pharmacodynamic differences between human and animal insulins. Human insulin tends to have faster absorption and shorter duration of action compared with animal insulin. These differences are more pronounced and can be of clinical relevance with intermediate- and long-acting insulin preparations. Optimal metabolic control can be achieved with either human or highly purified animal insulin preparations, provided appropriate insulin replacement strategies are used.

Cost-effectiveness of a structured treatment and teaching programme on asthma

The purpose of this study was to perform a cost-effectiveness analysis of the structured treatment and teaching programme for patients with asthma (ATTP) at Düsseldorf University. We investigated whether the monetary benefits outweighed the costs of the intervention. Adult patients with moderate to severe asthma participated in a 5 day in-patient programme. Follow-up was 3 yrs. The incremental costs and benefits of the intervention, compared with standard treatment, were calculated. Costs were incurred by the hospitalization and by lost productivity. Compared to the year before the programme, (average reduction) days spent in hospital (5.2 days per patient per year), days of absence from work (18.4 days per patient per year), acute severe asthma attacks (3.8 attacks per patient per year), and physician consultations (2.3 visits per patient per month), decreased in the 3 yrs after the intervention. The programme produced net benefits of DM 12,850 (in 1991 German marks) per patient within 3 yrs. Within the health care sector, the net benefits were DM 5,900. Within 3 yrs, the paying bodies saved DM 2.70, and society as a whole saved DM 5 on each DM spent for the programme. We conclude that the intervention produced net monetary benefits. This result was stable over a wide range of variation of the outcome measures. Therefore, programme deserves implementation, not only for its demonstrated medical benefits but also for its economic savings.

Cost-effectiveness of a structured treatment and teaching programme on asthma

The purpose of this study was to perform a cost-effectiveness analysis of the structured treatment and teaching programme for patients with asthma (ATTP) at Dusseldorf University. We investigated whether the monetary benefits outweighed the costs of the intervention. Adult patients with moderate to severe asthma participated in a 5 day in-patient programme. Follow-up was 3 yrs. The incremental costs and benefits of the intervention, compared with standard treatment, were calculated. Costs were incurred by the hospitalization and by lost productivity. Compared to the year before the programme, (average reduction) days spent in hospital (5.2 days per patient per year), days of absence from work (18.4 days per patient per year), acute severe asthma attacks (3.8 attacks per patient per year), and physician consultations (2.3 visits per patient per month), decreased in the 3 yrs after the intervention. The programme produced net benefits of DM 12,850 (in 1991 German marks) per patient within 3 yrs. Within the health care sector, the net benefits were DM 5,900. Within 3 yrs, the paying bodies saved DM 2.70, and society as a whole saved DM 5 on each DM spent for the programme. We conclude that the intervention produced net monetary benefits. This result was stable over a wide range of variation of the outcome measures. Therefore, programme deserves implementation, not only for its demonstrated medical benefits but also for its economic savings.

[Cortisone level and emotional support by key figures in patients with bronchial asthma]

In a subgroup of patients with bronchial asthma, irrational fears of cortisone medication can be observed beyond justified worries about side-effects. A cortisone image which involves overemphasizing the threatening aspects of cortisone, often underlies noncompliant illness behaviour. In the present study, cortisone image and subjectively experienced emotional support by a key figure was investigated in 62 patients, all of whom had participated in the Düsseldorf Asthma treatment and teaching programme (ATTP). The data show that patients having a supportive relationship with their key figures are less likely to experience threatening aspects of cortisone. The findings are discussed in light of psychoanalytic object relations theory.

[Plasma- and tissue concentrations following intramuscular administration of etofenamat. Pharmacokinetics of etofenamat and flufenamic acid in plasma, synovium, and tissues of patients with chronic polyarthritis after administration of an oily solution of etofenamat]

Studies on Plasma and Tissue Concentrations of Etofenamate following Intramuscular Application/Pharmacokinetics of etofenamate and flutenamic acid in plasma, synovia and tissues of patients with chronic polyarthritis after application of oily etofenamat solution Pharmacokinetics of etofenamate (ETO, CAS 30544-47-9; Rheumon i.m.) and flufenamic acid (FLU, CAS 530-78-9) were investigated in plasma, synovial fluid, and tissues after single intramuscular application of etofenamate to patients with rheumatoid arthritis. 62 patients with indicated operative procedure in the knee-joint received a single dose of etofenamate dissolved in oil before operation. At definite times between 1.5 and 48 h post injectionem samples from 6 patients of each time group were collected. Samples of plasma, synovial fluid, synovial membrane, muscle, bone, hyaline cartilage, and fat tissue and in some cases meniscus cartilage were taken. Concentrations of ETO and its active metabolite, FLU, were determined by HPTLC. In all tissues investigated, concentration/time courses of ETO and FLU were observed. ETO and FLU were measured first in all matrices 1.5 h at the latest 3 h post injectionem. Pharmacokinetics in tissues follows that in plasma. Rate-limiting step is the liberation of drug from the oil depot. For a long period pharmacokinetics of ETO and FLU is mainly determined by the constant liberation from the oil depot (zero order kinetics of liberation). Zero order kinetics is deduced from the linear ascent of the cumulated AUC (in percent) vs. time plot. It is directly related to the liberation of drug from the galenical formulation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Negative cortisone attitude in patients with bronchial asthma]

Patients with bronchial asthma often exhibit irrational fears of cortisone medication beyond justified worries about side-effects. A negative cortisone image, which means overemphasizing the damaging and threatening aspects of cortisone, often underlies non-compliant illness behaviour. In the present study, cortisone image was investigated in 54 patients with bronchial asthma before and after participation in the Düsseldorf Asthma treatment and teaching programme (ATTP) and one year later. By participating in ATTP, a significant reduction of the negative cortisone image and thus a more realistic view of cortisone could be achieved in most patients. This effect was also evident at the follow-up examination one year later. On the other hand, persistence of a negative cortisone image in a subgroup of patients turned out to be a potent predictor of later non-compliant illness behaviour. Psychological implications of a persistent negative cortisone image are discussed.

[Affective-cognitive coping with attacks and illness behavior in patients with bronchial asthma]

The purpose of this study was to investigate attack-related cognitive coping styles in 80 patients with bronchial asthma and to relate them to outcome parameters of illness behaviour. All patients had participated in a 5-day-lasting asthma treatment and teaching programme (ATTP). Outcome variables to be predicted were: The number of days in hospital due to asthma during the year following the training programme and the patients' adherence to the recommendations of the programme one year later. Independent predictor variables were: pre-training attack frequency, hospitalization due to asthma, medication intensity, pulmonary function, asthma symptom anxiety, trait anxiety and attack-related cognitive coping styles. Multiple regression analyses show the importance of a "minimizing/self-confident" coping style in predicting days in hospital, while a "diverting" style predicts best a poor management of attacks in patients on oral steroids.

Evaluation of a structured treatment and teaching programme on asthma

The objective of this study was to evaluate a structured treatment and teaching programme for adult patients with moderate to severe asthma. The design consisted of a prospective, before-after trial: the same consecutive patients were studied before and after intervention with observation periods 1 year before and 1 year after intervention. The investigation took place within a tertiary care centre (university hospital). A total of 142 consecutive patients were referred for in-patient treatment of their asthma, of whom 132 (93%) patients participated in the follow-up examination. The intervention consisted of a structured 5-d in-patient treatment and teaching programme presented by a specialized nurse educator. The aim of the programme was for the patient to assume greater responsibility for disease management, including self-monitoring of peak expiratory flow and qualified self-adaptation of drug therapy. The main outcome measures were the frequency of severe asthma attacks, hospitalization, and absenteeism from work (data provided by health insurance companies), patients' compliance and management skills. During the year before and the year after the intervention 71% and 36%, respectively of patients had one or more severe asthma attacks (mean difference 35%, 95% CI: 25-45%, P less than 0.0001). The percentage of patients who were hospitalized because of asthma decreased from 39% to 22% (mean difference 17%, 95% CI: 7-27%, P less than 0.002). The percentage of employed patients (n = 67) who were absent from work because of asthma decreased from 60% to 43% (mean difference 17%, 95% CI: 4-30%, P less than 0.04). The patients' adherence to maintenance drug therapy and their management skills improved significantly. It was concluded that the participation of patients with moderate to severe asthma in a structured treatment and teaching programme resulted in a substantial reduction in asthma morbidity in the year following the intervention.

Children's compliance to dialysis

Relationships among physiologic measures of compliance to dialysis therapy and selected parent and child variables were investigated. Child's age and length of time receiving dialysis related significantly to compliance.

[Detection of IgG antibodies against rubella virus using the "Rubella-IgG-EIA SSW" test kit]

A new commercial ELISA test kit "Rubella-IgG-EIA SSW" is described for the determination of IgG antibodies to rubella virus. A panel of 99 sera was tested by "Rubella-IgG-EIA SSW" and by hemagglutination-inhibition (HI test). The results of enzyme-immunoassay (EIA) and of HI test correlate well; the coefficient of correlation is 0.95, the specificity is 90.9% and the sensitivity is 100%. A coefficient of correlation was found out of 0.92 between EIA and HI test in the evaluation of the quantitative procedure. The test kit can be used for determination of immune status to rubella virus and for quantitative detection of rubella-IgG antibodies.

[Comparison between oral nutrition and enteral nutrition using a percutaneous endoscopically guided gastrostomy (PEG) in patients undergoing radiotherapy for head and neck tumors]

The nutritional state of 99 patients with tumors in the head and neck area was determined prior to, during and after radiotherapy by anthropometric, laboratory-chemical and immunological parameters. In 73 orally nourished patients, the nutritional parameters deteriorated very quickly during radiotherapy and recovered slowly and incompletely after radiotherapy. In 26 patients treated prospectively by percutaneous endoscopically guided gastrostomy (PEG), however, an improved nutritional state was achieved already during the irradiation in spite of a less favorable starting point. The subjective feeling of patients was questioned by means of the "quality of life" index according to Padilla et al. (1983). The preliminary results show an identical deterioration of the subjective feeling in both groups, but - as opposed to the other patients - force and working capacity did not decrease during radiotherapy in the enterally nourished patients. This corresponds to the objective nutritional parameters. However, an improvement of the subjective feeling after the end of radiotherapy was observed only in the orally nourished patients. Possible reasons are discussed. We have the opinion that an early and constant enteral nutrition by PEG can stabilize the nutritional state of patients with tumors in the head and neck area. Therefore we recommend to establish a prophylactic, pretherapeutic PEG if an aggressive multimodal therapy is planned, especially in case of apparent primary malnutrition.

[The content of lysosomal enzymes in the synovial membrane affected by a rheumatoid process and in the normal orthological one]

The activity of lysosomal hydrolases in biopsy samples of the synovial membrane taken from patients with rheumatoid arthritis gives an idea about the local activity of the process. This agrees with the histological picture of the synovial membrane. It has been established that the enzymatic activity depends on the site of the puncture for taking biopsy material.

[Complications of temporary transvenous endocardial pacemaker therapy]

The prospective analysis of the results of the temporary transvenous-endocardial pacemaker therapy in 591 cases of treatment resulted in a total rate of complications of 37.1%. Hereby the main part of complications were disturbances of the function of electrodes (28.3%). The greatest numbers of complications showed infiltrable electrode catheters which were applied at bedside with a dislocation rate of 17.2% and a rate of not achieved stable stimulation positions of 13.7%. The smallest numbers of complications were to be observed in semiflexible stimulation catheters, which were positioned under X-ray control (dislocations in 4.1%, no achievement of a stable stimulation position in 3.3%). For the practice of the temporary pacemaker therapy from this analysis result particularly consequences in the choice of a suitable stimulation catheter and the methodical approach in positioning of this catheter.

Low total protein S antigen but high protein S activity due to decreased C4b-binding protein in neonates

Protein S, a vitamin K-dependent cofactor for activated protein C, exists in normal adult plasma in a free anticoagulantly active form and in an inactive form complexed to C4b-binding protein. Immunologic and functional levels of protein S and C4b-binding protein in plasma were determined for 20 newborn infants and compared with adult normal pooled plasma. Total protein S antigen levels averaged 23%, similar to other vitamin K-dependent plasma proteins. However, the protein S anticoagulant activity was 74% of that of adult normal plasma. This apparent discrepancy of activity to antigen was shown to be due to low or undetectable levels of C4b-binding protein, which results in the presence of most if not all of protein S in its free and active form. The relatively high level of anticoagulantly active protein S in infants may enhance the potential of the protein C pathway, thereby minimizing risks of venous thrombosis in this group.