Dr. Pradeep Jacob

Background: The association between primary hyperparathyroidism (PHPT) and acute pancreatitis (AP) is well known. However, the causal association is disputed.

Aims: The present cohort study of PHPT patients was done: (1) to assess the prevalence of AP and (2) to assess the effect of successful parathyroidectomy in preventing further recurrence.

Materials and Methods: Case records of patients admitted with AP during the study period were reviewed. Diagnosis of PHPT among this group was based on serum level of corrected calcium and parathyroid hormone. Review of records of patients who were successfully operated for PHPT was done. Records of patients treated with confirmed diagnosis of AP during the study period were reviewed. Variables used for analysis were serum levels of calcium (adjusted to serum albumin), phosphate, intact parathyroid hormone, 25-OH-Vitamin D, alkaline phosphatase, and estimated glomerular filtration rate (eGFR). For continuous/numerical variables with two groups, Mann–Whitney U-test was applied. Multivariate regression analysis was done if the univariate analysis showed significance (P < 0.05).

Results: There were 13 (7.5%) patients with confirmed diagnosis of AP and serum calcium level significantly elevated in this group. There was a linear association of serum calcium with AP. Successful parathyroidectomy prevented further episodes in 11 (84.6%) of patients. There was 2% prevalence of PHPT among 558 patients with AP.

Conclusions: Hypercalcemia in PHPT patients was significantly associated with AP and early parathyroidectomy prevented further recurrence.

Introductíon:
Goiter is a very common problem dealt with by surgeons. Surgical treatment of thyroid requires removal of a part (hemi) or whole of the gland (total thyroidectomy). The external branch of the superior laryngeal nerve (EBSLN) is an important but less researched structure to be preserved during surgery. Various studies have described the incidence of different types of EBSLN, but have not described regarding the relationship between the change in volume of the gland to the nerve

Materials and Methods:
A prospective analysis of 100 patients who underwent total thyroidectomy in our department was done. All patients underwent preoperative ultrasonography and the volume of the gland was calculated. Intraoperatively, the EBSLN was identified and preserved prior to ligating the superior thyroid vessels. The nerve was classified as per the Cernea classification. The gland was divided into high and low volume, taking 20 ml as the cutoff. The incidence of Type 2 nerve in a low-volume gland was compared with that of a high-volume gland.

Results:
In 100 patients (200 nerves), 191 nerves were identified. The nerve was type 1 in 56/200 (28%), Type 2a in 116/200 (58%), and Type 2b in 19/200 (9%) patients. In large-volume glands, Type 2 nerve was more common (87%).

Conclusion:
Dissection of thyroid gland requires expertise to preserve the EBSLN. Large volume glands pose a more difficult challenge, as the gland is more closer to the nerve.

INTRODUCTION:
Renal dysfunction associated with primary hyperparathyroidism was studied mostly in patients with mildly asymptomatic or asymptomatic parathyroid disorders. Clinical and biochemical profile of asymptomatic and symptomatic disease vary grossly. The present study analyzed renal function in patients with primary hyperparathyroidism and the relation with clinical features, biochemical features and sonologic changes of kidneys in a cohort of primary symptomatic hyperparathyroidism.

STUDY DESIGN:
Cross-sectional study was done in a cohort of surgically proven patients of primary symptomatic hyperparathyroidism. Urinary tract was evaluated with high definition Ultrasonography and renal function was estimated using Modification of Diet in Renal disease (MDRD) Study equation before and after parathyroidectomy.

RESULT:
Case records 145 patients were studied and there were 44 patients (30.4%) with estimated Glomerular Filtration Rate (eGFR) less than 60&nbsp;mL/min/1.73&nbsp;m2. Associated renal complications, coincident hypertension and high serum level of calcium were strongly associated with renal dysfunction. Renal dysfunction marginally improved after 1 year following surgical cure of hyperparathyroidism in 25% of patients with renal dysfunction. There was no detectable change in renal function during the follow up period.

CONCLUSION:
There was high prevalence of renal dysfunction among symptomatic hyperparathyroidism. Patients with primary hyperparathyroidism should undergo complete sonological assessment of kidneys which may include presence of nephrocalcinosis and cortical echogenicity. Successful parathyroidectomy prevented deterioration of renal function in most of patients and a significant subset with renal dysfunction showed improvement of functional status.

Chronic inflammatory diseases of the non-lactating breasts cause considerable difficulty in diagnosis and treatment. There is a spectrum of aetiological factors ranging from infection to autoimmune disorders. The disease causes considerable morbidity and psychological distress in relatively young females. The study aimed to analyse the spectrum of chronic disease and to formulate a treatment protocol.

Method: Female patients with histological confirmation of inflammatory disease of the breast in the non-lactational phase were included in the study. The patients were categorized based on histological findings supplemented with immunohistochemical staining with CD3 and CD20 antibodies.

Result: Out of 50 patients included in the study, 38 patients (76%) were diagnosed as idiopathic granulomatous mastitis (IGM) and 12 (24%) patients as periductal mastitis (PD). The possible aetiology of IGM was localized autoimmunity as evidenced by the infiltration of CD3 positive T lymphocyte. Systemic prednisolone was given for 6 months and 95.6% patients were disease-free after 24months. Out of 15 patients who did not receive prednisolone, only 2 patients were disease-free after 24 months (p&nbsp;=&nbsp;.003).

Conclusion: Idiopathic granulomatous mastitis is an uncommon inflammatory disease of the non-lactating breast. The combination of limited surgical treatment and systemic prednisolone given for 6 months effectively controls the disease as well as prevents recurrence.

Lithium salts are widely used in psychiatric practice and are known to induce thyroid dysfunction. Lithium-induced parathyroid dysfunction is rare. We are reporting a case of hyperparathyroidism in a 28-year-old female patient who was on lithium carbonate for 2 years, when she developed osteopenia and girdle girdle-type muscle weakness. Biochemical parameters showed hyperparathyroidism with shift of calcium creatinine clearance ratio to 0.013, indicating an error in threshold of calcium sensing receptor. The patient eventually required parathyroidectomy and the histology of the gland showed atypical features.

Sir,
Differentiated thyroid cancer may coexist with hyperthyroidism. Cancer cell mass is less functional and appears as cold nodule in thyroid scintigraphy. Cancer cell mass rarely becomes site of excess hormone production. When thyroid cancer cell mass occupies a scintigraphically hot, functionally autonomous thyroid nodule and if thyrotoxicosis is attributable exclusively to this nodule, as shown by clinical and histologic correlation, a toxic thyroid carcinoma is diagnosed.[1] We are reporting case feature which coincides well with the above mentioned diagnosis.

Role of total thyroidectomy in treatment of patients with benign diseases of thyroid gland remains controversial. The hypothesis behind the study is that total thyroidectomy can be performed in all benign thyroid diseases with equal rate of immediate and late complications compared with those of subtotal thyroidectomy. The retrospective case control study was done by reviewing the case records of patients with benign thyroid diseases involving both lobes operated during May, 2002 to September, 2004. The minimum follow-up period was 3 years. Of the 189 patients included in the study 94 underwent total thyroidectomy and 95 patients underwent subtotal thyroidectomy. There was no incidence of permanent recurrent laryngeal nerve paralysis in both groups. Temporary unilateral recurrent laryngeal nerve paralysis occurred in 3 patients (3.2%) in total thyroidectomy group and 1 (1.1%) patient in subtotal thyroidectomy group, which was not statistically significant (p=0.307). Temporary hypocalcaemia was noted in 10 patients of total thyroidectomy group (10.6 %) and 3 patients of subtotal thyroidectomy group (3.2%). Permanent hypocalcaemia was noted in 2 patients each in total thyroidectomy group and subtotal thyroidectomy group (p=0.991). Total thyroidectomy is an acceptable alternative to subtotal thyroidectomy in benign diseases, considering the higher rate of postoperative morbidity in recurrent goitres.