Edwin L. Kaplan

Resurgence of acute rheumatic fever in the intermountain area of the United States.

We describe an outbreak of acute rheumatic fever that occurred in the intermountain area centered in Salt Lake City, Utah. Seventy-four children meeting the modified Jones criteria for the diagnosis of acute rheumatic fever were evaluated by the staff at Primary Childrens Medical Center, Salt Lake City, from January 1985 through June 1986. This represents an eightfold increase over the average annual incidence at this hospital during the past decade. Carditis, a dominant feature of the outbreak, was confirmed by auscultation in 53 of the patients (72 percent). An additional 14 patients were found to have mitral regurgitation by Doppler ultrasound examination, raising the total incidence of carditis to 91 percent. The children were predominantly from white (96 percent) middle-class families with above-average incomes and with ready access to medical care. There was no apparent increase in the incidence of streptococcal disease or other explanation for the marked increase in acute rheumatic fever. However, mucoid M type 18 and M type 3 group A streptococcal strains were isolated from several siblings of the patients and from schoolchildren (chosen at random) in the area. We conclude that acute rheumatic fever remains an important health problem in the United States.

Primary hyperparathyroidism in the 1990s. Choice of surgical procedures for this disease.

Many advances have occurred in recent years in the diagnosis, localization, and treatment of primary hyperparathyroidism. Several different operative choices for primary hyperparathyroidism also have been proposed--a unilateral approach versus the standard bilateral parathyroid exploration. The unilateral approach is based on the concept that if an enlarged parathyroid gland and a normal gland are found on the first side of the neck that is explored, then this is an adenoma and the second side should not be explored. Only if both glands on the initial side are recognized to be abnormal is the second side explored. The theoretical advantages of this unilateral approach are a decrease in operative morbidity rates--hypoparathyroidism and nerve injuries--and a decrease in operative time. Furthermore, proponents argue that if persistent hyperparathyroidism occurs, the second side can be easily explored because it was previously untouched. In the hands of several expert parathyroid surgeons, excellent results have been achieved. However, the unilateral approach has a number of disadvantages. It places considerable pressure on the surgeon and pathologist, for they have only one parathyroid gland other than the large one to examine. There is a significant potential risk of missing double adenomas or asymmetric hyperplasia because the second, ipsilateral parathyroid gland may appear normal or near normal in these conditions. This could lead to an increased incidence of persistent or recurrent hyperparathyroidism. Furthermore, a significant reduction of operative time may be questioned, especially when the time for performing special fat stains, which often are performed with unilateral explorations, is added. Finally, even if the intent is to perform a unilateral exploration, a bilateral exploration will be necessary about half of the time. The authors strongly recommend a bilateral parathyroid exploration for all patients undergoing an initial parathyroid operation. In cases of adenoma, bilateral visualization of normal parathyroid glands and careful biopsy of only one of them will minimize hypoparathyroidism. This operative approach will lead to better results, especially for the less experienced parathyroid surgeon.

The role of phosphate in the secretion of parathyroid hormone in man

In man, oral administration of 1 g of phosphorus resulted in a 60-125% increase in serum immunoassayable parathyroid hormone (PTH) concentration. Peak PTH levels were attained in 1 hr, and PTH returned to base line levels in 2 hr. This increase in PTH appeared to be initiated by a very small decrease of total and ionized calcium and was abolished by a calcium infusion. There was no correlation between serum phosphorus and PTH. The experiments show that oral phosphorus administration initiates a calcium-mediated control system for PTH secretion and that this system operates very sensitively in man.

Continuing Occurrence of Thyroid Carcinoma after Irradiation to the Neck in Infancy and Childhood

Abstract To determine wether the occurrence of x-ray-induced thyroid carcinoma has not declined, we examined 100 patients with a history of irradiation to the neck area. Irradiation had been given to tonsils (42 per cent), adenoids (10 per cent), tonsils and adenoids (7 per cent) and thymus (30 per cent), for acne (7 per cent), and for various other reasons (7 per cent). Operation was recommended to 18 of 26 patients with palpable abnormalities and 15 were operated upon; we found seven carcinomas, and eight benign lesions. Five of six carcinomas had invasive characteristics, with or without metastases, five of seven were multifocal, and six of seven had a follicular component. Of seven patients irradiated to both tonsils and adenoids and thus receiving higher radiation exposure, two had carcinoma, suggesting a dose relation. The overall 7 per cent prevalence of carcinoma in unselected patients with a history of irradiation to the neck area is higher than expected and implies a continuing important public-...

Relations of Calcitonin and Gastrin in the Zollinger-Ellison Syndrome and Medullary Carcinoma of the Thyroid

Abstract Fasting plasma immunoreactive human calcitonin and fasting serum immunoreactive human gastrin were measured by specific radioimmunoassays in 16 healthy persons, eight patients with the Zollinger-Ellison syndrome who had no clinical thyroid disease, and seven patients with medullary carcinoma of the thyroid. All patients with the Zollinger-Ellison syndrome had high serum immunoreactive gastrin (p < 0.01), and all with thyroid carcinoma had high plasma immunoreactive calcitonin (p < 0.025). Mean plasma immunoreactive calcitonin was increased significantly in patients with the Zollinger-Ellison syndrome (p<0.005). Mean serum immunoreactive gastrin was decreased significantly in the patients with carcinoma(p < 0.01). One patient with the Zollinger-Ellison syndrome and high plasma immunoreactive calcitonin had no post-mortem histologic evidence of medullary carcinoma of the thyroid. These observations suggest a possible interhormonal relation between calcitonin and gastrin in man, calcitonin inhibitin...

Intravenous Ferric Saccharate as an Iron Supplement in Dialysis Patients

In the present prospective study we examined the long-term effect of intravenous supplementation with ferric saccharate (IV Fe) in the treatment of the anemia of chronic dialysis patients. All patients, 64 on chronic hemodialysis (HD) and 9 on chronic ambulatory peritoneal dialysis (CAPD), were treated intravenously with this preparation in a dose of 100 mg elemental iron twice monthly. There were five groups. Group 1: 41 HD patients who were receiving erythropoietin (EPO) for at least 6 months prior to the addition of IV Fe. In this group, when IV Fe was given over 6 months, the hematocrit (Hct) increased from a mean of 28.7 to 33.7%. Over the next 6 months, the EPO dose was gradually reduced by a mean of 61.1%, but the mean Hct remained unchanged. Group 2: 11 HD patients who started IV EPO simultaneously with the IV Fe. In this group, over 6 months, the mean Hct increased from 28.1 to 34.1. Over the next 6 months, the EPO dose was gradually reduced by 75.7%, but the mean Hct remained unchanged. Group 3: 12 HD patients who received IV Fe alone for 12 months. The mean Hct increased from 30.5 to 37.9%. Group 4: 4 CAPD patients who had been receiving subcutaneous EPO for at least 6 months prior to IV Fe therapy. Over the subsequent 6 months of IV Fe, the mean Hct increased from 28.4 to 33.3%. Group 5: 5 CAPD patients not on EPO who received IV Fe for 6 months. The mean Hct increased from 27.7 to 35.6%. No adverse effects were seen in any patients throughout the study. In conclusion, adequate Fe supplementation may allow the target Hct of about 33% to be reached without, or with only very low doses of EPO. IV Fe as ferric saccharate is a new and safe form of parenteral iron therapy of the anemia of chronic dialysis patients.

The Clinical and Economic Burden of a Sustained Increase in Thyroid Cancer Incidence

Background: Thyroid cancer incidence is increasing worldwide at an alarming rate, yet little is known of the impact this increase will have on society. We sought to determine the clinical and economic burden of a sustained increase in thyroid cancer incidence in the United States and to understand how these burdens correlate with the National Cancer Institutes (NCI) prioritization of thyroid cancer research funding. Methods: We used the NCIs SEER 13 database (1992–2009) and Joinpoint regression software to identify the current clinical burden of thyroid cancer and to project future incidence through 2019. We combined Medicare reimbursement rates with American Thyroid Association guidelines, and our clinical practice to create an economic model of thyroid cancer. We obtained research-funding data from the NCIs Office of Budget and Finance. Results; By 2019, papillary thyroid cancer will double in incidence and become the third most common cancer in women of all ages at a cost of

Pheochromocytoma in Pregnancy. A Case Series and Review

18 to

Is preoperative iodine 123 meta-iodobenzylguanidine scintigraphy routinely necessary before initial adrenalectomy for pheochromocytoma? ☆

21 billion dollars in the United States. Despite these substantial clinical and economic burdens, thyroid cancer research remains significantly underfunded by comparison, and in 2009 received only

Follicular thyroid cancer incidence patterns in the United States, 1980-2009.

14.7 million (ranked 30th) from the NCI. Conclusion: The impact of thyroid cancer on society has been significantly underappreciated, as is evidenced by its low priority in national research funding levels. Impact: Increased awareness in the medical community and the general public of the societal burden of thyroid cancer, and substantial increases in research on thyroid cancer etiology, prevention, and treatment are needed to offset these growing concerns. Cancer Epidemiol Biomarkers Prev; 22(7); 1252–9. ©2013 AACR.