Use of 1,25(OH)2-vitamin D3 in prevention of renal osteodystrophy: preliminary observations

Hypercalcaemia regularly occurs when "prophylactic" 1,25-dihydroxyvitamin D3 (1,25[OH)2D3) in a dose of 1.0 microgram daily is given to haemodialysis patients without clinical biochemical or radiological evidence of osteodystophy. This dose is too large for such patients. Hypercalcaemia may persist for several weeks after withdrawal of 1,25(OH)2D3, particularly when previous attempts at control by dosage reduction have failed. Hypercalcaemia is better managed by stopping 1,25(OH)2D3, albeit temporarily, than by reducing the dose.

Ceiling-mounted radiographic equipment for trauma management in the emergency room

Use of ceiling-mounted radiographic equipment in an emergency room for management of the multiply injured patient is described. The protocol of the Advanced Trauma and Life Support manual is followed and three plain radiographs (lateral cervical spine, anteroposterior views of the chest and pelvis) are obtained by the radiographers, who are members of the trauma team. Abnormalities were diagnosed on 7 per cent of the cervical radiographs, 31 per cent of the chest and 28 per cent of the pelvis in 108 patients during the first year of use. With full integration of the radiographers into the trauma team these three initial films are obtained within 10 min. Subsequent films can be taken of skeletal injuries found clinically or incidentally on the first three plain radiographs. It is recommended that all emergency rooms should have a ceiling-mounted radiographic unit with an automatic daylight processor to provide the best service for patients with major trauma.

Preliminary experience with the Berger neurobiopsy device for ultrasound guided aspiration and biopsy of intracranial lesions

Our preliminary experience is presented in the use of the Berger neurobiopsy device for ultrasound localization and biopsy of intracranial lesions through a burr hole. The apparatus and technique are described, along with the results of its use in the first 49 patients. In these patients 43 tumours were biopsied, all except one successfully. Three abscesses were aspirated, two intraventricular shunt catheters were sited and in one patient the diagnosis of postradiation gliosis was confirmed and tumour excluded. The advantages and limitations of the technique are discussed. It is advocated as a simple and time-saving alternative to CT stereotactic biopsy in many cases.

Controlled trial of calcitriol in hemodialysis patients

We report on a 5-year, prospective, double-blind trial of 1,25 dihydroxycholecalciferol (calcitriol) versus placebo in 76 hemodialysis patients without biochemical or radiological evidence of bone disease. Calcitriol, 1 microgram daily, regularly induced hypercalcemia. Doses of 0.25 microgram daily or less proved satisfactory in most patients. During calcitriol treatment, plasma calcium concentration was significantly higher and serum parathyroid hormone concentration significantly lower than on placebo. There was no difference in the rates of development or of progression of vascular calcification in the two groups. Significantly more patients on placebo (17 vs. 6, p less than 0.05) developed a sustained elevation of plasma alkaline phosphatase concentration. Calcitriol appeared to protect against the development of histological evidence of osteitis fibrosa but not of osteomalacia, but accumulation of aluminum in bone occurred during the study. We conclude that calcitriol delays and may prevent the development of osteitis fibrosa in patients receiving regular hemodialysis and may reasonably be prescribed routinely in hemodialysis patients without biochemical or radiological abnormality, unless there is a substantial prospect of early renal transplantation.

Percutaneous aspiration of renal cortical abscess

Two patients with renal cortical abscesses were treated successfully by an intensive antibiotic regimen together with percutaneous aspiration, rather than by the conventional treatment of open drainage, which often is followed by secondary nephrectomy. This adaptation of percutaneous aspiration to the management of renal carbuncle coincides with a change in the causative microorganism which today is often a gram-negative coliform rather than a hematogenously borne staphylococcus, which usually complicates some pre-existing abnormality in the urinary tract.

The diagnosis of testicular swellings using water-path ultrasound

Water-path ultrasound was used to investigate 29 patients with swellings of the testicle. When the swelling contained fluid, such as a hydrocele or a cyst of the epididymis, it was accurately depicted in the ultrasound scan. Seminomas appeared as anechoic areas which could not be distinguished from granulomatous orchitis, but were clearly different from the homogeneous echo pattern of the normal testis. The depiction of the epididymis was less clear. Water-path ultrasonography is a promising addition to our diagnostic armamentarium.

Hyperparathyroidism in chronic renal failure

The high circulating concentrations of immunoassayable parathyroid hormone observed in chronic renal failure are due to a number of factors. These include altered metabolism of the hormone and also end-organ unresponsiveness which may, indirectly, cause increased secretion of parathyroid hormone. The response of the overactive parathyroid glands to changes in plasma calcium and magnesium is variable and caution is needed in evaluating the suppressibility of parathyroid hormone secretion in acute studies. 1alpha-Hydroxylated derivatives of vitamin D can effectively suppress parathyroid gland overactivity. This effect may not necessarily be medicated through hypercalcaemia and vitamin D metabolites may act directly on the parathyroid glands.

1-alpha-hydroxycholecalciferol for renal osteodystrophy

Fourteen patients with renal osteodystrophy were treated for at least one year with 1-alpha-hydroxycholecalciferol (1-alpha-OHD3) in a dose varying from 1 microgram/week to 3 microgram/day. Plasma calcium and inorganic phosphorus concentrations increased significantly. The plasma alkaline phosphatase concentration fell in 11 of the 12 patients in whom it was initially raised and returned to normal in seven. Serum parathyroid hormone concentrations were initially raised in all patients, but they decreased significantly with treatment and became normal in eight patients within one year. The 10 patients with radiological abnormalities showed some improvement. Hypercalcaemia occurred in 11 patients, and necessitated a reduction in the dose of 1-alpha-OHD3 in some. 1-alpha-OHD3 was effective in reducing the biochemical and radiological abnormalities of renal osteodystrophy, but it should be used wtih care, and plasma calcium concentrations should be monitored.

Hypertension and renal artery stenosis with aneurysm formation in a solitary kidney in a patient with neurofibromatosis

A case of hypertension in a patient with neurofibromatosis and renal artery stenosis with aneurysm formation in a solitary kidney is described. Studies of plasma renin activity and body sodium content are presented and have been related to findings in patients and experimental animals with renovascular hypertension. A reconstructive operative procedure is described in which the kidney is perfused in situ.

Gastropericardial fistula--a complication of hiatus hernia

A case is reported of a pneumopericardium in a 69-year-old woman caused by the rupture into the pericardium of a gastric ulcer situated in a hiatus hernia. Gastrografin studies were used to confirm the diagnosis and her initial conservative management was successful. However, she died at the operation to close her fistula, probably largely as a result of multiple unsuspected pulmonary emboli compounding her acid pericarditis.

Bronchoscopy and the chest x-ray

Fifty-seven cases of primary bronchogenic carcinoma with X-ray changes, but with negative bronchoscopies, have been reviewed to illustrate the limitations of this method of examination. The reasons for these limitations are discussed.