Total thyroidectomy for differentiated thyroid cancer: primary compared with completion thyroidectomy.

OBJECTIVE: To analyse morbidity after completion total thyroidectomy compared with primary total thyroidectomy in a specialist thyroid surgery centre. DESIGN: Retrospective study. SETTING: Tertiary referral hospital, India. PATIENTS: Medical records of 143 patients who had total thyroidectomy between January 1990 and December 1999. 95 had primary thyroidectomies and 48 were completion thyroidectomies. MAIN OUTCOME MEASURES: Complication rate in both groups. RESULTS: The groups were comparable in respect of clinicopathological variables. Residual tumour was found in 19/48 (40%). After completion thyroidectomy, transient hypoparathyroidism and transient recurrent laryngeal nerve palsy were recorded in 8/48 (17%) and 2/48 (4%), respectively. No permanent hypoparathyroidism or permanent recurrent laryngeal nerve palsy was recorded in the completion thyroidectomy group. CONCLUSIONS: Completion thyroidectomy can be done with acceptable morbidity in a specialist thyroid surgery centre. Fear of increased morbidity after the procedure should not deter surgeon from doing this operation or referring the patients to a specialist centre.     

True epiphrenic diverticulum of esophagus secondary to tubercular adenitis.

Ephiphrenic esophageal diverticulum is rare and usually is a pulsion-type pseudodiverticulum that occurs in association with motility disorders of the esophagus. We report a 35-year-old man with tubercular lymphadenitis causing true traction type of epiphrenic diverticulum. Esophageal diverticulectomy and esophagomyotomy was done; he is doing well on antitubercular drugs.     

Effects of prednisolone treatment on cytokine expression in patients with leprosy type 1 reactions

Leprosy type 1 reactions (T1R) are due to increased cell-mediated immunity and result in localized tissue damage. The anti-inflammatory drug prednisolone is used for treatment, but there is little good in vivo data on the molecular actions of prednisolone. We investigated the effect of prednisolone treatment on tumor necrosis factor alpha (TNF-alpha), interleukin-1beta (IL-1beta), IL-10, and transforming growth factor beta1 (TGF-beta1) mRNA and protein expression in blood and skin biopsies from 30 patients with T1R in India. After 1 month of prednisolone treatment the sizes of the skin granulomas were reduced, as were the grades of cells positive for TNF-alpha and IL-10 in skin lesions. Increased production of TGF-beta1 was seen in skin lesions after 6 months of prednisolone treatment. Expression of mRNA for TNF-alpha, IL-1beta, and TGF-beta1 was reduced, whereas no change in IL-10 mRNA expression was detected during treatment. The circulating cytokine profiles were similar in patients with and without T1R, and prednisolone treatment had no detectable effects on cytokine expression in the blood. The data emphasize the compartmentalization of pathology in T1R and the importance of the immune response in the skin. Clinical improvement and cytokine expression were compared. Surprisingly, patients with improved skin and nerve function and patients with nonimproved skin and nerve function had similar cytokine profiles, suggesting that clinical improvement is not directly mediated by the cytokines studied here. This in vivo well-controlled study of the immunosuppressive effects of prednisolone showed that the drug does not switch off cytokine responses effectively.     

Non-fermenters in human infections

One thousand and one hundred thirty non-fermenting gram negative bacteria were isolated from various samples. Of these, Pseudomonas aeruginosa was the commonest isolate (72.83%) followed by Acinetobacter anitratus (8.4%), Alcaligenes faecalis (7.6%), Acinetobacter lwoffi (4.4%), Pseudomonas flourescens (2.4%), Schwanella putrefaciens (1.6%), Stenotrophomonas maltophilia (1.6%), Pseudomonas putida (0.4%), Bravundimonas vesicularis (0.4%) and Flavobacterium meningosepticum (0.4%). Antibiotic sensitivity pattern showed multiple drug resistance pattern with majority of the isolates being resistance to two or more drugs.     

Potential tolerance against bromobenzene-induced acute hepatotoxicity due to prior subchronic exposure

Groups of adult male Sprague-Dawley rats were treated i.p. with 0, 0.3 and 0.5 mmole bromobenzene (BB)/kg per day in corn oil, 5 days a week for 4 weeks. Thereafter, one half of each of these groups was treated i. p. with a single acute toxic dose of 2.5 mmole BB/kg. Urines were then collected for 24 h and the animals were then sacrificed. The hepatotoxicity induced by an acute dose of BB was significantly reduced due to prior subchronic exposure to BB at 0.5 mmol/kg, but not so at 0.3 mmol/kg. These data indicate a potential tolerance against acute hepatotoxicity of BB due to prior subchronic exposure. A significant increase in the urinary excretion of thioethers or mercapturic acids of BB combined with a significant increase in the urinary level ofp-bromocatechol due to prior subchronic treatment with 0.5 mmol BB/kg relative to those due to acute treatment alone was observed. Thus enhanced bromobenzene metabolism could partly explain such potential tolerance against its acute hepatotoxicity. Such protection may also be related to certain cellular events which might occur subsequent to metabolic activation of BB.     

Endocrine effects of dehydroepiandrosterone and its fluorinated analog,fluasterone, in rats

Cancer chemoprevention is the use of pharmacologic agents to inhibit the development of cancer. The adrenal steroid dehydroepiandrosterone (DHEA) has demonstrated chemopreventive efficacy in animal models of tumorigenesis. However, due to DHEA's undesirable hormonal actions, the fluorinated analog fluasterone (fl‐DHEA), which also has chemopreventive characteristics, was synthesized as a potential alternate agent. It is not known whether fl‐DHEA has hormonal actions. The endocrinologic effects of DHEA and fl‐DHEA in adult male and female Fischer 344 rats were examined following 28 days of daily oral treatment. Initial doses tested were 30 and 300 mg/kg/day for each drug (n=12/sex/group), which are equivalent to 104 and 1,042 µmoles/kg/day DHEA, and 103 and 1,034 µmoles/kg/day fl‐DHEA. However, due to weight loss at the high dose, doses were lowered to 150 mg/kg/day for each drug (521 and 517 µmoles/kg/day DHEA and fl‐DHEA, respectively). Administration of DHEA resulted in dose‐dependent increases in plasma DHEA and DHEA‐S 1 h after dosing in week 4. DHEA produced an estrogenic effect in female rats expressed as decreased plasma FSH and LH, inhibition of ovulation, prolonged estrus, and increased uterine estrogen receptors. DHEA also increased plasma levels of androstenedione in males and females. Administration of fl‐DHEA increased the estrus cycle length due to a prolonged diestrus II phase and decreased the weights of the uterus, prostate, seminal vesicles, and testes. In addition, fl‐DHEA decreased plasma FSH, LH, and tissue estradiol, and increased plasma dihydrotestosterone levels in both sexes. These results indicate that fl‐DHEA is hormonally active and additional studies are warranted to further describe its endocrinologic effects. Drug Dev. Res. 58:169–178, 2003. © 2003 Wiley‐Liss, Inc.     

病人付费增加了中国医疗体制面临的挑战

编辑：你好。刘涛的述评（见本刊2006，4期，200页）在病人零付费问题上没有充分考虑医疗保健的政策选择问题。中国先前的情况表明，如需自己支付医药费，病人会减少看病次数，随之导致人民生活质量更差，现在的证据证实了这一点。在中国，老年人40％不看病和75％不住院的原因是由于医疗费用（病人付费）。另外，有人指出病人付费导致医疗不公平现象更加严重。进一步危害包括拖延老年病人病情造成人为的花费，以及延误治疗以增加长期的治疗费用。     

Use of Ilizarov Device to Gain Early Range of Motion in the Treatment of Pediatric Talus Body Fractures: A Series of Four Cases and Literature Review

BackgroundTalus fractures are rare in children but can lead to severe outcomes if untreated. The Ilizarov external fixator has been used in the treatment of a variety of lower extremity pathologies. The purpose of this study was to investigate the clinical outcomes of talus body fractures treated with the Ilizarov external fixator.Case PresentationFour male pediatric patients (age range, 5–11 years) with talus body fractures who were treated by open reduction and internal fixation combined with Ilizarov external fixator between November 2015 and April 2016 were reviewed. Mean follow‐up period was 4 years (range, 4–5). Clinical outcome was evaluated using the clinical rating scale of the American Orthopaedic Foot and Ankle Society (AOFAS). All four patients achieved good to excellent results at the last follow‐up. None of the patients developed avascular necrosis. One patient developed automatic fusion of tibiotalar joint.ConclusionUse of the Ilizarov external fixator to gain early range of motion is a valuable option for treatment of talus body fractures in children.     

Fetal cardiac rhabdomyoma with maternal tuberous sclerosis complicating pregnancy

INTRODUCTION: Tuberous sclerosis is an autosomal dominant disorder of hamartoma formation that can manifest as cardiac or central nervous system lesions and adversely affect maternal and fetal outcome. CASE REPORT: We report a case of maternal tuberous sclerosis with fetal cardiac rhabdomyoma detected in utero at 26 weeks gestation. CONCLUSION: To conclude, a pregnancy complicated by maternal or fetal tuberous sclerosis deserves careful vigilance and the fetus should undergo prenatal fetal Doppler echocardiography and if possible an MRI, so that parents can be counseled regarding its future prognostic implications.