Detectability and surgical outcomes in parathyroid surgery – a single-centre experience

The incidence of primary hyperparathyroidismand referrals for the removal of parathyroid adenomas are increasing. Factors that improve the detectability, and ultimately the surgical outcome, are the focus of this retrospective study. We included 117 patients who had parathyroid operations with intraoperative monitoring of parathyroid hormone (PTH). Sestamibi, ultrasound and, in selected cases, fusion with computed tomograms (CT), were done to locate the lesion preoperatively. Concentrations of calcium and PTH before and after operation, specimen weight, and preoperative vitamin D concentrations, were assessed. The sensitivity of sestamibi and ultrasound for the preoperative location of adenomas was 92% and 80%, respectively. Sestamibi located them more accurately in patients with low preoperative concentrations of vitamin D (p = 0.037) and with heavier adenomas (p < 0.001). We found no significant association between the preoperative concentrations of PTH and detectability on preoperative scans (p = 0.058). Postoperative follow up showed that 97% of the 117 patients were biochemically cured. Accurate location helps to lower morbidity as it facilitates a targeted approach. Further studies are needed to explore the role of vitamin D in the location of parathyroid adenomas before parathyroidectomy.     

Michelangelo’s Sistine Chapel Frescoes: communications about the brain

ABSTRACT

In a 1990 JAMA cover story Frank Meshberger reported that Michelangelo’s central composition on the Sistine Chapel ceiling (1508–1512), The Creation of Adam, portrays God in the form of a brain. The present report suggests that Michelangelo’s images on the chapel ceiling depicting Creation describe the course of vertebrate brain development. Further, on the front wall of the Sistine Chapel, within the work titled The Last Judgment (1525–1541), the central ellipse, where Jesus is making judgments about good and evil, represents a mid-coronal cross-section of a human brain, implying that the brain is man’s instrument for making decisions.     

Paracetamol versus paracetamol-codeine in the treatment of post-operative dental pain: a randomized,double-blind,prospective trial

BACKGROUND: Codeine is frequently added to paracetamol to treat post-operative dento-alveolar pain; studies have shown effectiveness in relief of post-operative pain at high doses but at the expense of central nervous and gastrointestinal side effects. There has been no trial to compare the efficacy and safety of paracetamol 1000 mg with paracetamol 1000 mg combined with codeine 30 mg. METHOD: A randomized, single centre, double-blind prospective parallel group trial was performed to compare paracetamol 1000 mg with paracetamol 1000 mg with codeine 30 mg for the relief of pain following surgical removal of impacted third molars, and analysed on an intention-to-treat (ITT) basis. Eighty-two patients were assigned randomly to receive either drug for a maximum of three doses. Patients recorded their pain intensity one hour after surgery and hourly thereafter for 12 hours. RESULTS: The average increase in pain intensity over 12 hours was significantly less in patients receiving paracetamol plus codeine than in those receiving paracetamol alone (p=0.03) -1.81 cm/h compared with 0.45 cm/h - a difference of 1.13 cm/h (95 per cent CI: 0.18 to 2.08). Of the patients who received the paracetamol codeine combination, 62 per cent used escape medication compared with 75 per cent of those on paracetamol alone (p=0.20). There was no significant difference between the two groups in the proportion of patients experiencing adverse events (p=0.5). CONCLUSION: A combination of 1000 mg paracetamol and 30 mg codeine was significantly more effective in controlling pain for 12 hours following third molar removal, with no significant difference of side effects during the 12 hour period studied.     

SARS-CoV-2 Vaccine Responses in Individuals with Antibody Deficiency: Findings from the COV-AD Study

Background

Vaccination prevents severe morbidity and mortality from COVID-19 in the general population. The immunogenicity and efficacy of SARS-CoV-2 vaccines in patients with antibody deficiency is poorly understood.

Objectives

COVID-19 in patients with antibody deficiency (COV-AD) is a multi-site UK study that aims to determine the immune response to SARS-CoV-2 infection and vaccination in patients with primary or secondary antibody deficiency, a population that suffers from severe and recurrent infection and does not respond well to vaccination.

Methods

Individuals on immunoglobulin replacement therapy or with an IgG less than 4 g/L receiving antibiotic prophylaxis were recruited from April 2021. Serological and cellular responses were determined using ELISA, live-virus neutralisation and interferon gamma release assays. SARS-CoV-2 infection and clearance were determined by PCR from serial nasopharyngeal swabs.

Results

A total of 5.6% (n?=?320) of the cohort reported prior SARS-CoV-2 infection, but only 0.3% remained PCR positive on study entry. Seropositivity, following two doses of SARS-CoV-2 vaccination, was 54.8% (n?=?168) compared with 100% of healthy controls (n?=?205). The magnitude of the antibody response and its neutralising capacity were both significantly reduced compared to controls. Participants vaccinated with the Pfizer/BioNTech vaccine were more likely to be seropositive (65.7% vs. 48.0%, p?=?0.03) and have higher antibody levels compared with the AstraZeneca vaccine (IgGAM ratio 3.73 vs. 2.39, p?=?0.0003). T cell responses post vaccination was demonstrable in 46.2% of participants and were associated with better antibody responses but there was no difference between the two vaccines. Eleven vaccine-breakthrough infections have occurred to date, 10 of them in recipients of the AstraZeneca vaccine.

Conclusion

SARS-CoV-2 vaccines demonstrate reduced immunogenicity in patients with antibody deficiency with evidence of vaccine breakthrough infection.

     

Prediction and prevention of relapse of acute lymphoblastic leukaemia after bone marrow transplantation

Results of bone marrow transplantation (BMT) in 63 adults and children with ALL transplanted in the 5-year period 1979-83 were analysed. Twenty-one patients (33%) relapsed, 25% of the group died in relapse and 19% died from complications of BMT. The actuarial disease-free survival at 6 years was 38%. Relapse after BMT could be predicted by standard prognostic diagnostic features such as age, sex, cell type and presenting blast cell count. Patients transplanted in first remission selected for their poor prognosis had a lower relapse risk than a similar group of poor prognosis patients transplanted in second or subsequent remission (P less than 0.05). Relapse following second and subsequent remission BMT was predicted by a score based on standard prognostic features or by the pace of the disease: patients with an interval of less than 2 years between diagnosis and first relapse having a 15% actuarial disease-free survival, compared with 81% for patients with an interval greater than 2 years (P less than 0.001). These results emphasize that ALL is a heterogeneous disease and establishes the importance of determining relapse risk when selecting BMT and other treatment schedules for ALL patients.     

Seminal papers in orthopaedic oncology

The management of a patient with a tumour of the musculoskeletal system has progressed over recent decades. The development of evidence based medicine is a key factor in driving such change. Although now predominantly treated within specialist centres, all orthopaedic surgeons require an understanding of such malignancies and the management options available to the patients affected. We review the literature in three main areas; soft-tissue sarcoma (STS), primary malignant bone tumours and skeletal metastases. We take a critical look at the papers which have helped shape modern practice, and offer discussion into their relevance. We have given a historical perspective to demonstrate key themes in tumour surgery, and given examples of on-going research to provide an understanding of current developments.     

Environmental determinants of the distribution of Phlebotomus orientalis in Sudan.

Despite its importance as a vector of visceral leishmaniasis in Sudan, the ecology of Phlebotomus orientalis is still poorly understood. The results of a ground-based survey and a geographical-information-system (GIS) study, carried out to investigate the environmental determinants of the distribution of P. orientalis in the wooded areas of the central savannah belt of Sudan, are described here. The survey, carried out in April-June 1996, consisted of a collection of sandflies over two consecutive nights at each of 44 study sites, using three CDC, miniature, light traps at each site. During the survey, the ecology of each site was described. Phlebotomus orientalis was caught at 17 of the sites. Environmental data on the collection sites (rainfall, minimum and maximum temperatures, soil class, vegetation and land-surface-temperature indices) were extracted from a range of sources of digital data collected by satellites in the National Ocean and Atmospheric Administration's series. These data were then analysed, to ascertain which variables were significantly associated with sites positive for P. orientalis. In line with the results of previous studies, P. orientalis was found to have a significant association with the presence of the tree species Acacia seyal and Balanites aegyptiaca and with the black cotton (vertisolic) soils of eastern Sudan. The positive sites were found to have significantly higher annual mean maximum and minimum daily temperatures than the negative sites and the annual mean maximum normalized-difference vegetation index (NDVI) value was also found to be significantly higher in these sites than in sites where no P. orientalis were found.