Barbara Lenfesty

Anatomical Heterogeneity of Parathyroid Glands in Posttransplant Hyperparathyroidism

Successful renal transplantation may be complicated by persistent hyperparathyroidism due to diffuse parathyroid hyperplasia remaining from a prolonged period of pretransplant chronic renal failure treatment. Posttransplant hyperparathyroidism is distinct from primary hyperparathyroidism, being characterized by multiple gland involvement and diffuse hyperplasia rather than a single adenoma. The gross pathologic anatomy of the parathyroid glands was assessed in 17 successful renal transplant recipients. Individual and total gland volumes were measured at the time of total parathyroidectomy and forearm reimplantation. Parathyroid hyperplasia was heterogenous in both location and gland size. Right-sided glands were enlarged more than left-sided ones. Subjects with primary tubulointerstitial disease exhibited greater hyperplasia than patients with glomerular disorders. Clinicians should be aware of the heterogeneity of the gland enlargement in patients with diffuse parathyroid hyperplasia, so that these patients are not misdiagnosed as suffering from adenomatous parathyroid disease.

Total parathyroidectomy for posttransplantation hyperparathyroidism

The acute and short-term clinical course of 19 subjects who underwent total parathyroidectomy and forearm implantation for persistent hyperparathyroidism following successful kidney transplantation (mean [±SD] time after transplant 43.7±29.5 months) is described. Their mean preoperative serum calcium level of 10.8±0.5 mg% decreased to a nadir of 7.9±0.9 mg%, 62.5±27.7 hr after the operation. The lowest serum ionized calcium (1.80±0.2 mEq/L) was recorded 57±49 hr postoperatively. After an average of five hospital days. the patients were discharged with a mean serum total calcium concentration of 8.3±1.0 mg%. Three months following the operation, the mean serum total calcium concentration was 9.5±0.6 mg%. With an average follow-up of 19 months (range 3–36 months) serum total calcium was 9.6±0.6 mg%, with only one subject requiring calcium supplementation. Total parathyroidectomy with forearm implantation was associated with normalization of serum-immunoreactive parathyroid hormone concentrations and maintenance of stable allograft function. Our experience suggest that this procedure is an effective modality with a predictable postoperative recovery of parathyroid function when used to treat persistent hyperparathyroidism in the long-term survivor of renal transplantation.

Derivation of a clinical decision rule to guide the interhospital transfer of patients with blunt traumatic brain injury

Objective: To derive a clinical decision rule for people with traumatic brain injury (TBI) that enables early identification of patients requiring specialised trauma care. Methods: We collected data from 1999 through 2003 on a retrospective cohort of consecutive people aged 18–65 years with a serious head injury (AIS ⩾3), transported directly from the scene of injury, and evaluated in the ED. Information on 22 demographical, physiological, radiographic, and lab variables was collected. Resource based “high therapeutic intensity” measures occurring within 72 hours of ED arrival (the outcome measure) were identified a priori and included: neurosurgical intervention, exploratory laparotomy, intensive care interventions, or death. We used classification and regression tree analysis to derive and cross validate the decision rule. Results: 504 consecutive trauma patients were identified as having a serious head injury: 246 (49%) required at least one of the HTI measures. Five ED variables (GCS, respiratory rate, age, temperature, and pulse rate) identified subjects requiring at least one of the HTI measures with 94% sensitivity (95% CI 91 to 97%) and 63% specificity (95% CI 57 to 69%) in the derivation sample, and 90% sensitivity and 55% specificity using cross validation. Conclusions: This decision rule identified among a cohort of head injured patients evaluated in the ED the majority of those who urgently required specialised trauma care. The rule will require prospective validation in injured people presenting to non-tertiary care hospitals before implementation can be recommended.

A retrospective case control study of recombinant factor VIIa in patients with intracranial haemorrhage caused by trauma

Rita Campanelli Letizia Lupo Gabriela Fois Gianluca Viarengo Vassili Jemos Vittorio Rosti Giovanni Barosi Biotechnology Laboratory, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, Unit of Clinical Epidemiology and Centre for the Study of Myelofibrosis, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, Immunohaematology and Transfusion Service, Apheresis and Cell Therapy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, and Unit of Haematopancreatic Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy. E-mail: m.massa@smatteo.pv.it

The use of recombinant factor VIIa in warfarin patients with traumatic brain injury: A retrospective case-control study

Patients on warfarin who have traumatic intracranial haemorrhage have a high mortality. The procoagulant recombinant factor VIIa (rFVIIa) is widely used off-label to treat intracranial haemorrhaging in patients taking warfarin to try to improve these adverse outcomes, but its effectiveness is unknown. In this study, medical records from 2002 to 2010 were reviewed for 27 warfarin patients who received rFVIIa for their traumatic intracranial haemorrhage and were compared with a matched control group of 27 warfarin patients who did not receive rFVIIa. The two groups were matched for sex, age and Injury Severity Score. The rFVIIa patients had 33.3% mortality compared with the 37% for the control patients, but this was not a statistically significant difference. There was also no significant difference in plasma unit use between the groups. However, the rFVIIa group had a significantly higher number of subdural haemorrhages, which carry a better prognosis. The initial international normalized ratios (INRs) of the rFVIIa patients were higher, and the decrease of INR was more pronounced than in the control patients. From the data, it appears that although the INRs of rFVIIa patients did improve compared with the control group, there was no reduction in plasma use or mortality.

REGIONAL DIFFERENCES IN OUTCOMES FOR HOSPITALIZED INJURED PATIENTS IN THE UNITED STATES

BACKGROUND Our goal was to use a hospital population-based data set that was a sample of all injured patients admitted to a hospital in the United States to develop universal measures of outcome and processes of care. METHODS Patients with a primary discharge diagnosis of injury (ICD-9 800 to 959) in the HCUP/Nationwide Inpatient Sample for the years 1995 to 2000 were used to estimate the annual number of hospitalized injured patients. Using census data, we calculated age- and sex- adjusted average annual incidence rates for four census regions in the United States: Northeast, Midwest, South and West. Outcomes measured were annual rates per million populations of hospitalization rate, death rate, and potentially ineffective care (PIC) rate defined as >28 days of hospitalization ending in death. Length of stay (LOS) was calculated as total number of days annually hospitalized for injury for census regions per million populations. RESULTS Incidence rates per million populations and 95% confidence intervals for rate of hospitalizations for injury were: Northeast, 5596 (5338-5853); Midwest, 5516 (5316-5716); South, 5639 (5410-5869); West, 5307 (5071-5543). Incidence rates per million populations and 95% confidence intervals for rate of in-hospital deaths were: Northeast, 129 (119-139); Midwest, 131 (122-139); South, 141 (129-152); West, 114 (106-123). Incidence rates per million populations and 95% confidence intervals for rate of PIC were: Northeast, 11 (10-13); Midwest, 5 (4-5); South, 6 (5-7); West, 4 (3-4). Incidence rates per million populations and 95% confidence intervals for hospital days were: Northeast, 34 (32-36); Midwest, 30 (28-31); South, 30 (29-32); West, 26 (24-27). CONCLUSION Regional differences in outcomes and processes of care for hospitalized injured patients exist and may be influenced by hospital characteristics and region of the country. Research to identify the factors that cause these hospital and regional variations is needed. These observations suggest that to develop a uniform standard for quality of care, it will be essential to have valid and robust hospital population-based measures.