Arlie R. Mansberger

Prospective comparison of technetium-99m-sestamibi/iodine-123 radionuclide scan versus high-resolution ultrasonography for the preoperative localization of abnormal parathyroid glands in patients with previously unoperated primary hyperparathyroidism

Surgery for primary hyperparathyroidism is successful in 95% of patients, but ectopic glands and anatomic variations in location are causes of surgical failure. The radionuclide imaging agent, technetium (Tc)-99m-sestamibi, in conjunction with subtraction iodine-123 scanning, is a new method of preoperative localization of abnormal parathyroid glands. In a study approved by the Institutional Review Board, 22 patients with primary hyperparathyroidism underwent preoperative evaluation with high-resolution ultrasonography and Tc-99m-sestamibi/I-123 radionuclide scanning for attempted localization of abnormal parathyroid glands. Results of Tc-99m-sestamibi scanning and ultrasound were correlated with surgical and pathologic findings. Of 22 patients, 16 had a solitary parathyroid adenoma, 1 had a double adenoma, and 5 had diffuse parathyroid hyperplasia. The Tc-99m-sestamibi/I-123 radionuclide scan preoperatively identified a solitary adenoma in 14 of 16 patients (sensitivity: 88%). However, when the data were analyzed retrospectively along with surgical and pathologic findings, the Tc-99m-sestamibi scan correctly localized all parathyroid adenomas for a sensitivity of 100%. The one patient with a double adenoma had a localization image consistent with two enlarged glands. All patients with diffuse parathyroid hyperplasia had Tc-99m-sestamibi imaging consistent with diffuse hyperplasia, although delineation of individual enlarged glands was not possible. High-resolution ultrasound identified 11 of 16 parathyroid adenomas (sensitivity: 69%). The patient with a double adenoma had a negative ultrasound. Ultrasound was less accurate in five patients with diffuse hyperplasia: one scan was completely negative, two scans revealed only one enlarged gland, and two scans revealed two enlarged glands. The Tc-99m-sestamibi/I-123 subtraction radionuclide scan is more sensitive than high-resolution ultrasonography for the preoperative localization of abnormal parathyroid glands. Tc-99m-sestamibi/I-123 radionuclide scanning may be more useful than ultrasonography to the surgeon in the preoperative localization of abnormal parathyroid glands.

Preoperative imaging of abnormal parathyroid glands in patients with hyperparathyroid disease using combination Tc-99m-pertechnetate and Tc-99m-sestamibi radionuclide scans.

ObjectiveTo evaluate the efficacy of combined Tc-99m-pertechnetate and Tc-99m-sestamibi radonuclide scanning for imaging abnormal parathyroid glands in hyperparathyroid disease in a prospective study. Summary Background DataSummary Background Data methods to localize abnormal parathyroid glands lack accuracy for routine use. Tc-99m-sestamibi used in conjunction with iodine-123 has excellent potential for preoperative imaging in patients with hyperparathyroid disease. An alternative method for parathyroid imaging was studied using Tc-99m-pertechnetate and Tc-99m-sestamibi. MethodsThirty patients with hyperparathyroid disease had Tc-99m-pertechnetate and Tc-99m-sestamibi subtraction radionuclide scanning to visualize abnormal parathyroid glands before surgery. The patients had surgery and pathologic confirmation of all parathyroid glands. ResultsResults 23 patients with primary hyperparathyroidism, 12 of 13 solitary adenomas were visualized. Six of nine patients with diffuse hyperplasia had bilateral uptake consistent with diffuse hyperplasia. Three of nine patients had negative scans. One patient previously operated on for diffuse hyperplasia had only one gland scanned. Seven patients with renal failure-associated hyperparathyroid disease were scanned: five had bilateral uptake of Tc-99m-sestamibi consistent with hyperplasia, and two who had been previously operated on had localization of remaining abnormal parathyroid glands. ConclusionConclusion-99m-pertechnetate combined with Tc-99m-sestamibi subtraction radionuclide scanning is less cumbersome to implement than iodine-123 combined with Tc-99m-sestamibi scanning. It has a high sensitivity for imaging solitary parathyroid adenomas or persistent solitary hyperplastic glands. However it does not have the resolution necessary to delineate all parathyroid glands in diffuse hyperplasia.

Total IgE in plasma is elevated after traumatic injury and is associated with sepsis syndrome.

Gamma E immunoglobulin (IgE) is associated with allergic reactions, but has not been described as being activated after trauma or sepsis. Total plasma IgE concentrations were determined in 32 patients with major traumatic injury, 29 patients undergoing elective abdominal operations, and 30 healthy volunteers. Mean total IgE concentrations were 271.7 ng/mL, 52.3 ng/mL, and 41.3 ng/mL, respectively (p less than 0.01 for each comparison with the trauma group). Total IgE concentrations in trauma patients at the time of admission were not significantly different from elective surgical controls, and tended to increase during the intensive care unit stay. In the trauma group, total IgE concentration was significantly greater in the 18 patients that developed sepsis syndrome compared with those that did not (p = 0.034). These data suggest that allergic mechanisms may be involved in the physiologic response to major traumatic injury and sepsis syndrome, or that other cells known to be involved in the immune responses to trauma and sepsis (macrophages, platelets, and B lymphocytes) may become activated by IgE-dependent mechanisms.

Clinical response to cold insoluble globulin replacement in a patient with sepsis and thermal injury

Cold insoluble globulin (fibronectin, alpha 2-surface binding glycoprotein) is a naturally occurring substance necessary for optimal stimulation of the reticuloendothelial system. While this globulin depends on macrophages as the effector cells for its opsonic function, as is true of both antibody and complement, it is neither part of nor dependent on these systems for its opsonic activity. A relatively simple bioassay developed at the Medical College of Georgia substantiated that cold insoluble globulin is severely depleted in sepsis. Cryoprecipitate, properly processed and stored, is an exogenous source of cold insoluble globulin. Infused into septic patients 10 units thawed at 2 degrees C and reconstituted to 250 ml with saline solution can temporarily restore cold insoluble globulin levels and enhance activity of the reticuloendothelial system. Proper current use dictates measurement of cold insoluble globulin levels in the infusate as well as levels in the patient and the clinical response to infusion. Our bioassay and a septic patients response to infusion of cold insoluble globulin are reported herein.

Deer stands: a significant cause of injury and mortality.

Deer hunting is a popular recreational activity in the United States. Although the risks associated with firearms are well known, the hazards related to deer stands are not widely appreciated. From September 1982 through December 1989, there were 19 patients admitted to the Medical College of Georgia Hospital and Clinics for injuries sustained from falls related to deer stands. One death occurred, and six of the 18 survivors remain paralyzed. Data from 18 of these patients showed that 83% of these falls (15/18) were associated with hunter-constructed stands. Structural failure accounted for 39% (7/18) of the accidents; other causes included carelessness, falling asleep, and medical events. Four of the 19 patients (21%) had elevated blood alcohol levels on admission. Fracture of the spine and long bones accounted for the majority of the injuries, and seven of the 18 survivors (39%) were hospitalized for more than 4 weeks. Eight of the survivors (44%) remain permanently disabled. Deer-stand-related falls may result in significant long-term disability, expensive and lengthy hospitalization, and even death. A preventive approach to these injuries is paramount, and published guidelines for safety while hunting from deer stands should be followed.

Percutaneous peritoneal lavage in blunt trauma patients: a safe and accurate diagnostic method.

We reviewed the records of 395 patients seen from January 1983 through May 1988, who after sustaining blunt thoracoabdominal trauma had diagnostic peritoneal lavage (DPL) performed percutaneously by the Seldinger wire technique of Lazarus and Nelson. The test was considered grossly positive if 10 cc of blood were aspirated from the catheter immediately after its insertion into the peritoneal cavity. Microscopic criteria for positivity included more than 100,000 RBC or 500 WBC/cc of lavage return, elevated amylase or bilirubin, or the presence of vegetable fibers or bacteria. Seventy-two (18%) of the patients were true positives and 315 (80%) were true negatives. There were four false positives (1.3%) and one false negative (0.2%), giving the test a sensitivity of 99% and a specificity of 98%. Complications occurred in three patients, for a rate of 0.8%, and included catheter insertion into a large ovarian dermoid cyst, needle perforation of the ileum, and needle perforation of the sigmoid colon. This technique of DPL can consistently be performed much more rapidly than the open method. Therefore we conclude that percutaneous DPL is as accurate as, as safe as, and quicker than open DPL for determining intra-abdominal injury in blunt trauma patients.

Highly selective vagotomy with dilatation or duodenoplasty: a surgical alternative for obstructing duodenal ulcer

Highly selective vagotomy (HSV) is an accepted choice for the treatment of uncomplicated duodenal ulcer. Its use in patients with gastric outlet obstruction, however, remains quite controversial. Since 1980, 69 patients have undergone HSV at the Medical College of Georgia Hospitals. Of these, 20 (29%) underwent either dilatation (14) or duodenoplasty (6) for accompanying outlet obstruction. The obstruction was graded as severe in 17 (85%) and moderate in three (15%). Follow-up evaluation has included Visick grading and endoscopy. There have been two deaths (38 and 54 months following surgery). Both patients were Visick I. Of the 18 patients available for review to date, 12 (67%) are Visick I and four (22%) are Visick II. There have been two failures (11%), discovered only by endoscopic follow-up in asymptomatic patients. No patients have required reoperation. HSV with dilatation or duodenoplasty is a reasonable surgical alternative for the treatment of obstructing duodenal ulcer disease.

Increased peritoneal fluid lactic acid values and progressive bowel strangulation in dogs

In the present study, we determined values for peritoneal fluid and blood ammonia, amylase, and lactic acid content in 11 dogs after experimental bowel strangulation. In the nine survivors of this group, we demonstrated a near linear increase in peritoneal fluid lactic acid over a 24-hour period, during which the plasma lactic acid remained relatively constant. A significant increase in peritoneal fluid ammonia was also demonstrated, but this did not occur until more than 16 hours after strangulation. In a second group of two dogs in which simple obstruction was produced, no significant increase in peritoneal fluid lactic acid or ammonia occurred. We did not find significant changes in peritoneal fluid amylase in this study. These data suggest that the determination of peritoneal fluid lactic acid content, especially when compared with concomitant plasma lactic acid, may be useful in the accurate preoperative diagnosis of bowel strangulation.

The influence of fibronectin administration on the incidence of sepsis and septic mortality in severely injured patients

Eighty-five trauma patients between the ages of 18 and 55, with American College of Surgeons (ACOS) trauma scores greater than or equal to 7 were entered into a double-blind, randomized, placebo-controlled study to assess the efficacy of prophylactic fibronectin (Fn) administration on clinical course, sepsis development, and septic mortality. Patients were randomized on admission to receive purified human virus-inactivated Fn or placebo control (human serum albumin, HSA). Fn or HSA was administered on a daily basis if and when the patient was Fn deficient (less than 75% normal). When a Fn deficiency was not evident, the patient received saline. Seventy one patients developed Fn deficiencies during their initial clinical course: 36 received Fn, 35 received HSA. Fourteen patients did not develop a Fn deficiency after trauma and thus received only saline. Analysis of admission data demonstrated no significant differences between the three groups with respect to extent of injury (injury severity score, ACOS trauma score) or physiologic assessments of organ function (serum creatinine, bilirubin, lactic acid). On day 1 after trauma, Fn levels were shown to correlate with other plasma proteins and cellular components (range of r values, 0.24 to 0.75; all p less than 0.05), but not with organ function parameters. Eighteen of 85 patients became septic as judged by clinical criteria. Ten of these patients had received Fn (10 of 36), five had received HSA (5 of 35), and three had received only saline (3 of 14) before the development of sepsis (differences not significant). When septic, nine of 17 patients developed Fn deficiencies. Six patients received Fn while septic, three received albumin, and eight received saline. Seven patients died: 5 of 6 Fn patients, 1 saline, and 1 HSA recipient. Our data suggest that exogenous Fn repletion in states of deficiency does not alter clinical course, the development of sepsis, or septic mortality.

Immunoglobulin E and eosinophil counts are increased after sepsis in trauma patients

OBJECTIVES To determine the time course of plasma immunoglobulin E (IgE) concentration increases after traumatic injury, if increased IgE concentrations were related to clinical events or complications, and if increased peripheral eosinophil counts could be related to trauma, sepsis, or organ-specific complications. DESIGN Data relating to severity of injury, clinical complications, plasma concentrations of IgE, and peripheral eosinophil counts were prospectively collected. SETTING Trauma service, tertiary-care medical center. PATIENTS One hundred adult trauma patients admitted to the intensive care unit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma IgE concentrations increased in most patients. However, the greatest increases were observed in patients with sepsis (p = .03), renal dysfunction (p = .04), or pneumonia (p = .02). IgE increases were not related to severity or mechanism of injury, allergy history, or age. The day of highest observed IgE concentration was related to the day of onset of sepsis (p = .012, r = .39), and occurred a mean of 3.8 days after sepsis. Most patients had increased peripheral eosinophil counts and eosinophil percentages of white blood cells during their intensive care unit stays. Eosinophil counts were greater in patients with sepsis (p < .0001), severe sepsis (p < .0001), or pneumonia (p < .002). CONCLUSIONS Increased IgE concentrations and eosinophil counts were found after sepsis and do not appear to be related to the initial injury. Since IgE and eosinophil production are enhanced by interleukin-4 and interleukin-5, respectively, these findings suggest that T-helper lymphocyte type 2 cytokines are activated in response to sepsis after traumatic injury.