Negative imaging studies for primary hyperparathyroidism are unavoidable: correlation of sestamibi and high-resolution ultrasound scanning with histological analysis in 150 patients.

BACKGROUND: Preoperative localization studies with Tc99m-sestamibi have become an integral step in the preoperative assessment of patients with primary hyperparathyroidism (PHPT). This enables scan-directed minimally invasive parathyroidectomy (MIP) to be the preferred treatment for PHPT in many units. This study aimed to identify factors that lead to negative imaging studies in patients with PHPT. METHODS: Over a 3-year period consecutive unselected patients with PHPT underwent Tc99m-sestamibi scanning and high-resolution ultrasound (US) scanning by the same radiologist. When localization studies were concordant, patients underwent MIP. Those patients with negative imaging studies underwent bilateral neck exploration. Histology slides were independently reviewed and the proportion of chief cells and oxyphil cells within each adenoma was estimated. RESULTS: One hundred and fifty-eight patients underwent localization studies (38 men and 120 women, aged 61.8 +/- 15.2 years). Sestamibi scans were negative in 52 (32%) and positive in 106 (68%) patients. There was a higher incidence of hyperplasia in the group of patients with negative sestamibi scans (4 out of 52 vs. 4 out of 103, P < 0.05, chi2 test). In patients with negative sestamibi scans the majority of adenomas were formed predominantly from chief cells (26 out of 36) while the majority of patients with adenomas composed predominantly of oxyphil cells had positive scans (21 out of 23) (P < 0.05, chi2 test). The weight of parathyroid adenomas was higher when sestamibi scans were positive (median: 1,180 vs. 517 mg, P < 0.05, Student's t-test). CONCLUSION: Successful preoperative localization of parathyroid adenomas using Tc99m-sestamibi scanning is influenced by the cytological predominance of individual tumors. Negative scans might therefore be unavoidable in a subgroup of patients

HIV associated cytomegalovirus colitis as a mimic of inflammatory bowel disease.

Cytomegalovirus (CMV) colitis may cause symptoms and signs identical to those of idiopathic inflammatory bowel disease. Although difficult to diagnose with certainty, the histological finding of cytomegalovirus inclusions in tissue from a case of suspected inflammatory bowel disease is strongly suggestive. CMV colitis is an entity almost entirely confined to cases of severe immunosuppression. The case of a 79 year old widower who was admitted to hospital with symptoms suggestive of inflammatory bowel disease is presented. Despite medical treatment his condition worsened and he developed toxic dilatation of the colon requiring colectomy. Histological examination showed a mild superficial pancolitis, with focal severe inflammation, deep fissuring ulceration, and pseudopolyposis. Abundant CMV inclusions were seen in cells associated with the ulcerating inflammatory tissue. A diagnosis of indeterminate colitis with CMV was made. The patient's condition worsened after surgery and he died a few days later despite intensive treatment, including antiviral chemotherapy directed against CMV. After death HIV serology was found to be positive. Regardless of the age and perceived lifestyle of the patient, a diagnosis of CMV colitis in someone not known to be immunosuppressed raises the possibility of HIV infection

The Shame of Not Belonging: Navigating Failure in the Colonial Petition, South Africa 1910–1961

This essay examines letters of petition sent by failed white settlers in South Africa to the British Governor General. These letters comprise a particular discursive genre that combine aspects of both private and public. The key to their success was controlled emotion: petitioners had to present their distress in such a way as to excite the exercise of compassion. Allowing subversive or stray emotions to enter a letter was bound to undermine a petitioner’s appeal. Reading this epistolary corpus critically allows us to understand the discursive strategies by which colonials claimed a sentimental attachment to Britain, the empire and, indeed, the Governor General himself

A randomized controlled trial of gabapentin for chronic low back pain with and without a radiating component

Gabapentin is prescribed for analgesia in chronic low back pain, yet there are no controlled trials supporting this practice. This randomized, two-arm, 12-week, parallel group study compared gabapentin (forced titration up to 3600 mg daily) to inert placebo. The primary efficacy measure was change in pain intensity from baseline to the last week on treatment measured by the Descriptor Differential Scale; the secondary outcome was disability (Oswestry Disability Index). The intention-to-treat analysis comprised 108 randomized chronic back pain patients (daily pain for ≥ 6 months) whose pain did (43%) or did not radiate into the lower extremity. Random effects regression models which did not impute missing scores were used to analyze outcome data. Pain intensity decreased significantly over time (p < .0001) with subjects on gabapentin or placebo reporting reductions of about 30% from baseline, but did not differ significantly between groups (p = .423). The same results pertained for disability scores. In responder analyses of those who completed 12 weeks (N=72), the proportion reporting at least 30% or 50% reduction in pain intensity, or at least “Minimal Improvement” on the Physician Clinical Global Impression of Change did not differ significantly between groups. There were no significant differences in analgesia between participants with radiating (n = 46) and non-radiating (n = 62) pain either within or between treatment arms. There was no significant correlation between gabapentin plasma concentration and pain intensity. Gabapentin appears to be ineffective for analgesia in chronic low back pain with or without a radiating component