Risk Assessment for Severe Postoperative Hypocalcaemia after Neck Exploration for Primary Hyperparathyroidism

Background and Aims:

A further development of the risk profile for severe postoperative hypocalcaemia after surgery for primary hyperparathyroidism (pHPT) was made with the aim of expanding the group of patients who can be discharged safely after 23 hours.

Methods:

Prospective study with 156 consecutive pHPT patients (158 operations) during 2001 and 2002. Risk factors for postoperative severe hypocalcaemia (ionised calcium <1 mmol/L), were (1) preoperative concentration of parathyroid hormone (PTH) > 35 pmol/L (five times the upper reference value, reference range 1.1 to 6.9), (2) history of previous neck surgery, (3) biopsy/excision of > 2 parathyroid glands or (4) concomitant thyroid surgery.

Results:

The risk factors showed a sensitivity of 100 % (9/9). In 110 of the operations (70%) no risk factors were identified. Postoperative calcium levels were significantly lower after 48 operations with risk factor(s) identified, as compared to the group without risk factors (p < 0.01). Seven of 17 patients (41%) with PTH > 35 pmol/L developed severe postoperative hypocalcaemia. Two of 31 patients (6%) with PTH < 35 pmol/L in the presence of other risk factor(s) developed severe postoperative hypocalcaemia.

Conclusion:

Patients with no risk factor can safely been discharged from hospital on the first postoperative day. Patients with preoperative concentration of PTH > 35 pmol/L (five times the upper reference value) should stay in hospital until nadir level of calcium is reached. Patients with concentration of parathyroid hormone less than 35 pmol/L in the presence of other risk factor(s) may have an early discharge from hospital (second postoperative day) combined with outpatient measurements of calcium levels.

Immunohistochemical staining for thyroid peroxidase (TPO) of needle core biopsies in the diagnosis of scintigraphically cold thyroid nodules

BACKGROUND

Cold thyroid nodules are common, in particular in iodine-deficient areas, but only a minority of them are malignant requiring surgery. Thyroid peroxidase (TPO) immunostaining of fine-needle aspiration cytology (FNAC) material has proven helpful in diagnosing cells from malignant lesions, but the procedure has its limitations in a routine setting.

PURPOSE

To improve diagnosis and reduce surgery rate, the FNAC procedure was replaced by needle core biopsy (NCB), which was routinely stained for TPO by the monoclonal antibody mAb 47.

MATERIALS AND METHODS

During a 5-year period 427 consecutive patients with a cold thyroid nodule were evaluated by ultrasound-guided NCB, which had been routinely stained for TPO in an automated immunostainer. Sensitivity and specificity and predictive values of the TPO immunostaining were estimated, based on the final diagnosis obtained from surgical resection.

RESULTS

The majority of nodules with benign NCB diagnosis were not surgically removed, and thus a subgroup of 140 operated nodules formed the basis for the calculations. Sensitivity and specificity for benign and malignant lesions were 100% if the oxyphilic variant of adenomas and minimally invasive follicular carcinomas were excluded. By inclusion of these, the values fell to 89% and 97%, respectively. The predictive value of a positive test was 96% and the predictive value of a negative test was 97%.

CONCLUSION

TPO immunostaining was found to be a valuable adjunct to morphology in the diagnosis of cold thyroid nodules of the nonoxyphilic type.

Incidence and prevention of deep venous thrombosis occurring late after general surgery: randomised controlled study of prolonged thromboprophylaxis

OBJECTIVE

To study the incidence of late deep venous thrombosis (DVT), and to evaluate a regimen of prolonged thromboprophylaxis after general surgery.

DESIGN

Randomised, controlled, open trial, with blinded evaluation.

SETTING

University hospital, Denmark.

SUBJECTS

176 consecutive patients undergoing major elective abdominal or non-cardiac thoracic operations, of whom 118 were eligible for evaluation.

INTERVENTIONS

Thromboprophylaxis with a low-molecular-weight heparin, tinzaparin, given for four weeks (n = 58), compared with one week (control group, n = 60).

MAIN OUTCOME MEASURES

Presence of DVT established by bilateral venography four weeks after the operation.

RESULTS

The incidence of late DVT in the control group was 6/60 (10%, 95% confidence interval (CI) 4% to 21%). In the prophylaxis group it was 3/58 (5.2%, 95% CI 1% to 14%) (p = 0.49).

CONCLUSION

Prolonged thromboprophylaxis had no significant effect on the incidence of DVT occurring late after general surgery.

Colour Doppler flow imaging ultrasonography versus venography as screening method for asymptomatic postoperative deep venous thrombosis

OBJECTIVE

To evaluate colour Doppler flow imaging ultrasonography (CDFI), compared with venography, as a screening method for postoperative deep venous thrombosis (DVT) in a clinical trial on thromboprophylaxis.

METHODS

Patients undergoing major abdominal or thoracic surgery were prospectively screened for DVT by CDFI. Patients were examined preoperatively, and on post-operative days 1, 3, 7, 14, 21, and 28. When the CDFI was positive venography was performed. Bilateral venography was performed on day 28 in all patients. The study group comprised 82 patients who underwent CDFI and venography on the same day: four because of suspected DVT (positive CDFI), and 78 on day 28 according to protocol.

RESULTS

DVT was detected by venography in seven patients, in three of whom CDFI was positive. CDFI was falsely positive in one case. There were two popliteal and five calf DVTs, of which CDFI detected one and two, respectively. The sensitivity of CDFI was 43%, the specificity 99%. The PVpos for CDFI was 75%, and the PVneg 96%.

CONCLUSION

Due to low sensitivity, CDFI cannot stand alone as a screening method for asymptomatic postoperative DVT.

Once- versus twice-daily amikacin regimen: efficacy and safety in systemic gram-negative infections. Scandinavian Amikacin Once Daily Study Group

Three hundred and sixteen patients with serious infections verified or suspected to be of Gram-negative aetiology were treated in an open, randomized, comparative multicentre study with amikacin 15 mg/kg/day given either as a single dose or in two divided doses at 12 h intervals. Two hundred patients were evaluated for efficacy and all 316 for safety. The efficacy of both dosage regimens was very good with a satisfactory clinical response in 90% of the patients. There were no significant differences between the two regimens regarding efficacy and safety. This was also confirmed in an analysis according to the principle of 'intention-to-treat' including all randomized patients. In 218 patients additional therapy, most commonly with piperacillin or ampicillin, was considered necessary. The mean peak serum concentration of amikacin was 40.9 mg/L in the once-daily group, which is 10 x MIC for most Gram-negative bacteria, compared to 24.4 mg/L in the twice-daily group, which is 6 x MIC. Mean trough serum concentrations after 24 h were 1.8 mg/L in the once-daily group and 3.1 mg/L after 12 h in the twice-daily group. These serum concentrations were often close to or just below the MICs of the isolated pathogens. Drug related adverse reactions were seen in 40 (13%) of the patients. Among the adverse reactions with possible or probable relation to amikacin were 20 nephrotoxic events, nine in the once-daily group and 11 in the twice-daily group. A multivariate analysis of selective causative factors and nephrotoxic events gave a low correlation for once- vs twice-daily amikacin therapy. Five ototoxic events were observed, three in the once-daily group and two in the twice-daily group. One patient in the once-daily group experienced nausea in connection with amikacin infusions.

Is there a need for long-term thromboprophylaxis following general surgery?

Thromboprophylaxis to surgical patients is generally accepted, and used in the perioperative period by many surgeons as effective means of reducing postoperative thromboembolic complications. Often the prophylaxis is stopped at the time of mobilization or discharge of the patient, although late thromboembolic complications after cessation of the postoperative prophylaxis are known to occur up to 7 weeks after surgery. By scrutinizing thromboprophylactic studies performed in general surgery during the last 20 years, we found the incidence of late thromboembolic complications reported to be about 1% when clinical diagnostics was applied. In studies where the patients were screened for late thromboembolic complications using paraclinical diagnostic methods the incidence is 10 times higher. The clinical relevance of these late postoperative thromboembolic complications is still uncertain, as is the value of long-term prophylaxis.

Efficacy and safety of amikacin in systemic infections when given as a single daily dose or in two divided doses. Scandinavian Amikacin Once Daily Study Group

Two hundred and twenty patients with serious infections verified or suspected to be of Gram-negative aetiology were treated in an open randomized comparative multicentre trial with amikacin 15 mg/kg/day given either as a single dose or in two divided doses at 12-h intervals. Amikacin was administered as a short-term iv infusion. When additional therapy was considered necessary piperacillin or ampicillin was recommended. The trial continues and an interim report on data from the 12 participating Scandinavian hospitals is presented. One hundred and forty-four patients have been evaluated for efficacy and 213 patients for safety. There were no significant differences between the two dosage regimens regarding efficacy and safety. A satisfactory clinical response was recorded in 129 (90%) of the evaluable patients. One serious adverse reaction was seen in a patient in the once-daily group. This was ototoxicity which was superimposed on a long standing hearing defect possibly caused by previous streptomycin therapy.

Disseminated peritoneal leiomyomatosis with malignant change, in a male

Disseminated peritoneal leiomyomatosis (DPL) is a rare disorder, characterized by the occurrence of multiple leiomyomas scattered throughout the peritoneal cavity. Until this report DPL had been observed only in women and there is only one previous case with malignant change. A case of DPL in a male, complicated by sarcomatous transformation is reported. DPL has a definite malignant potential; patients with the disease should be followed closely for signs of progression.

Detection of antibodies to human immunodeficiency virus (HIV) in eluates from whole blood impregnated filter paper discs

A method for elution of HIV antibodies from whole blood or serum impregnated filter paper discs was developed. The results from testing of 73 eluates in an enzyme linked immunosorbent assay and the immunoblotting test agreed with the results obtained by ordinary serum testing. Significant loss of antibody activity was not observed, neither in the eluates after storage for 1 mth at -20 degrees C nor in the filter paper discs after storage for 3 mths at +4 degrees C. This technique may be useful in facilitating sample collection and transportation, particularly in remote areas of the world.