Thyroid-stimulating hormone (TSH)-secreting pituitary adenoma (TSHoma) is the rarest functioning pituitary adenoma.A retrospective analysis of eight patients of TSHomas to highlight the presentations, diagnostic challenges, and treatment outcomes.Median age at diagnosis was 42 years, median latency to diagnosis was 2.5 years, and thyrotoxic and compressive symptoms were the most common presenting symptoms. At presentation, three cases were plurihormonal, six cases were on medical treatment including thyroxine, and two cases were incidentally discovered. Imaging revealed macroadenoma in all cases. Seven cases underwent pituitary surgery, after which three achieved remission. Another case entered remission after adjunctive radiotherapy. Thyrotropin (TSH) immunostaining was demonstrated in six out of seven adenomas.TSHoma is a rare functioning pituitary tumor with both silent and symptomatic presentations. Diagnosis can be established with biochemical and imaging features, even without dynamic tests.
Aim To compare the clinical effectiveness, functional outcome and patient satisfaction following intra articular injection with Synvisc ¯ and Hyalgan ¯ in patients with osteoarthritis (OA) of the knee. Methods 348 consecutive patients were randomised into two groups to receive either Hylan G-F 20 -Synvisc (n= 181) or Sodium Hyaluronate -Hyalgan (n=167). All patients were prospectively reviewed by independent assessors blinded for the treatment. Knee pain on a VAS were recorded. The functional outcome was assessed using Tegner, UCLA, Oxford knee score and EuroQol-5D scores. VAS was used to quantify patient satisfaction. Mean follow-up was 12 months. Results Mean age 66.7 yrs. Patients predominantly had grade III OA. Knee pain improved from 6.7 to 3.2 by 6 weeks (p=0.02) and was sustained until 12 months (3.7, p=0.04) with Synvisc. In the Hyalgan group, pain improved from 6.6 to 5.7 at 6 weeks (p>0.05) and to 4.1 at 3 months (p=0.04) but was sustained only until 6 months (5.9, p>0.05). Similarly, the Tegner, UCLA and Oxford knee scores were significantly better in the Synvisc group at 6 weeks (p=0.02) and 6 months (p=0.03) and 12 months (p=0.04). EQ-5D description scores were higher in the Synvisc group at 6 months (p=0.03) and 1 year (p=0.04). There was local increase in knee pain in one patient (Synvisc), which settled by 4 weeks. Patient compliance was 99.2% in the Synvisc group as compared to 92.2% in the Hyalgan. Treatment cost was 23% more in the Hyalgan group. Conclusion Although both treatments offered significant pain reduction, it was earlier and sustained for a longer period in patients with Synvisc. Patients treated with Synvisc have demonstrated an early increase in activity levels. Local reaction of pseudo sepsis was observed with Synvisc in one patient. Total treatment cost, both for patient and hospital, is higher with Hyalgan.
Abstract A 32-year-old lady presented to us at 6 months of gestation with acute pancreatitis due to parathyroid hormone-dependent hypercalcemia and with insulin-dependent hypoglycemia, owing to parathyroid adenoma and possibly insulinoma, respectively. The parathyroid adenoma was localized on the magnetic resonance imaging of the neck; however, imaging for the insulinoma could not be done due to the gravid state. Due to the simultaneous occurrence of tumours in two endocrine glands, namely, parathyroid gland and pancreatic islet cells, a diagnosis of MEN-1 (multiple endocrine neoplasia) was considered, which is very rarely seen in pregnancy. Her hypercalcemia was effectively managed with cinacalcet and alcohol ablation of the parathyroid adenoma while her hypoglycemic episodes were managed with short and long-acting octreotide injections during the antenatal period. She had a full-term cesarean delivery, with no maternal or neonatal complications, except for transient neonatal hypoglycemia. The patient was followed up for 1 year after her delivery with no further episodes of hypercalcemia and hypoglycemia, on medical management. Tc99m sestamibi scan was done after delivery which confirmed the presence of a left inferior parathyroid adenoma. MEN-1 with pregnancy thus poses a diagnostic and therapeutic challenge and our case highlights the role of multimodal medical therapy for successful management.
ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Dayal D, Gupta A, Gupta S, Dutta A. Recombinant parathyroid hormone for hypoparathyroidism in children: a narrative review. Pediatric Endocrinology Diabetes and Metabolism. 2019;25(4):194-201. doi:10.5114/pedm.2019.89642. APA Dayal, D., Gupta, A., Gupta, S., & Dutta, A. (2019). Recombinant parathyroid hormone for hypoparathyroidism in children: a narrative review. Pediatric Endocrinology Diabetes and Metabolism, 25(4), 194-201. https://doi.org/10.5114/pedm.2019.89642 Chicago Dayal, Devi, Atul Gupta, Saniya Gupta, and Aditya Dutta. 2019. "Recombinant parathyroid hormone for hypoparathyroidism in children: a narrative review". Pediatric Endocrinology Diabetes and Metabolism 25 (4): 194-201. doi:10.5114/pedm.2019.89642. Harvard Dayal, D., Gupta, A., Gupta, S., and Dutta, A. (2019). Recombinant parathyroid hormone for hypoparathyroidism in children: a narrative review. Pediatric Endocrinology Diabetes and Metabolism, 25(4), pp.194-201. https://doi.org/10.5114/pedm.2019.89642 MLA Dayal, Devi et al. "Recombinant parathyroid hormone for hypoparathyroidism in children: a narrative review." Pediatric Endocrinology Diabetes and Metabolism, vol. 25, no. 4, 2019, pp. 194-201. doi:10.5114/pedm.2019.89642. Vancouver Dayal D, Gupta A, Gupta S, Dutta A. Recombinant parathyroid hormone for hypoparathyroidism in children: a narrative review. Pediatric Endocrinology Diabetes and Metabolism. 2019;25(4):194-201. doi:10.5114/pedm.2019.89642.
The use of topical 10% lidocaine spray on the vocal cords is common practice to anaesthetise the cords and supraglottic structures and blunt the intubation response. Complications with this method are rare [1]. We encountered an unusual and unforeseen complication while using a lidocaine spray in the airway. An 18-year-old, 156-cm, 52-kg, ASA-I female was admitted to hospital with an isolated crush injury to her right thumb sustained while travelling in a bus. She was scheduled for emergency thumb repair and K-wire fixation along with split skin grafting. Upper airway assessment revealed no abnormality and her past medical history was unremarkable. After application of monitoring (Spo2, NIBP, ECG) and gaining appropriate venous access, the patient was induced with sodium thiopental 300 mg, morphine 6 mg and midazolam 1 mg intravenously. Following succinylcholine 75 mg, direct laryngoscopy revealed a Cormack and Lehane [2] grade I view. The vocal cords were to be sprayed with 10% lidocaine prior to intubation. However, as we attempted topical anaesthesia of the vocal cords via the long spray delivery tube, the nozzle tip ( Fig. 5) was ejected into the larynx through the relaxed cords. Intubation was abandoned and the patient was maintained thereafter with gentle positive pressure ventilation via a face mask. Air entry was equal and chest wall movements were adequate and symmetrical. Glycopyrrolate 0.2 mg, hydrocortisone 100 mg and pancuronium 4 mg were given intravenously and the patient mask ventilated using 50% nitrous oxide in oxygen administered via a circle with carbon dioxide absorber. An otorhinolaryngologist was called on and the nozzle tip was extracted by rigid bronchoscopy from the right main bronchus. Thereafter, the airway was secured with a 7.0-mm I.D. polyvinyl chloride cuffed tracheal tube. The remaining intra-operative and postoperative periods were uneventful. Chest radiography was not performed as we focused our attention on extracting the unusual foreign body. The lidocaine 10% aerosol spray assembly showing detached nozzle tip of the spray delivery tube. This case reiterates the significance of ensuring strength/fixation of every joint and connection in all anaesthetic equipment, particularly airway equipment.
Purpose Primary hyperparathyroidism (PHPT) is characterized by increased bone remodeling and hypercalcemia. Parathyroidectomy (PTX), the current standard of care, is recommended in all symptomatic and some groups of asymptomatic patients. Anti-resorptive therapies (bisphosphonates and denosumab) have been used in patients where PTX is refused or contraindicated. In this meta-analysis, we investigated the effectiveness of anti-resorptives in preventing/treating PHPT-induced bone loss and mitigating hypercalcemia. Method PubMed, Scopus, and Cochrane Library databases were searched for articles with keywords containing PHPT, bisphosphonates, and denosumab in various combinations. We extracted and tabulated areal BMD (aBMD), serum mineral, and bone turnover parameters from the qualified studies and used comprehensive meta-analysis software for analysis. Results Of the 1,914 articles screened, 13 were eligible for meta-analysis. In the pooled analysis, 12 months of anti-resoptives (bisphosphonates and denosumab) therapy significantly increased aBMD at the lumbar spine (Standard difference in means (SDM)=0.447, 95% CI=0.230 to 0.664, p=0.0001), femoral neck (SDM=0.270, 95% CI=0.049 to 0.491, p=0.017) and increased serum PTH (SDM=0.489, 95% CI=0.139 to 0.839, p=0.006), and decreased serum calcium (SDM=-0.545, 95% CI=-0.937 to -0.154, p=0.006) compared with baseline. 12 months of bisphosphonate use significantly increased aBMD only at the lumbar spine (SDM=0.330, 95% CI=0.088 to 0.571, p=0.007) with a significant increased in serum PTH levels (SDM=0.546, 95% CI= 0.162 to 0.930, p=0.005), and a decreased in serum calcium (SDM=-0.608, 95% CI=-1.048 to -0.169, p=0.007) and bone-turnover markers (BTMs) compared with baseline. Denosumab use for 12 months significantly increased aBMD at both the lumbar spine (SDM=0.828, 95% CI=0.378 to 1.278, p=0.0001) and femur neck (SDM=0.575, 95% CI=0.135 to 1.015, p=0.010) compared with baseline. Mean lumbar spine aBMD (SDM=0.350, 95% CI=0.041 to 0.659, p=0.027) and serum PTH (SDM=0.602, 95% CI= 0.145 to 1.059, p=0.010) were significantly increased after 12 months of alendronate use compared with placebo. When compared with baseline, alendronate significantly decreased BTMs after 12 months and increased aBMD without altering the PTH and calcium levels after 24 months. Conclusion Anti-resorptives are effective in mitigating bone loss and hypercalcemia in PHPT while maintaining or increasing aBMD. PTX reversed all changes in PHPT and normalized PTH levels.
Aim: To compare the clinical effectiveness, functional outcome and patient satisfaction following intra articular injection with Hylan G-F-20 and Sodium Hyaluro-nate in patients with osteoarthritis (OA) of the knee. Methods: In this independent study, 382 consecutive patients with OA of the knee were prospectively randomized into two groups to receive Hylan G-F-20 -Syn-visc (n=196) or Sodium Hyaluronate -Hyalgan (n=186) and reviewed by blinded independent assessors at pre injection, 6 weeks, 3, 6, 12 months. Knee pain, patient satisfaction was measured on a VAS. Functional outcome was assessed using WOMAC, UCLA, Tegner, Oxford knee score and EuroQol- 5D scores. Mean follow up was 14 months. Results: Patients in both groups predominantly had grade III OA. Knee pain on VAS improved from 6.7 to 3.2 by 6 weeks (p=0.02) and was sustained until 12 months (3.7, p=0.04) with Synvisc. In the Hyal-gan group, pain improved from 6.6 to 5.7 at 6 weeks (p>0.05) and to 4.1 at 3 months (p=0.04) but was sustained only until 6 months (5.9, p>0.05). Improvements in the WOMAC pain and physical activity subscales were significantly superior in the Synvisc group at 3 months (p=0.02), 6 months (p=0.01) and 12 months (p=0.02). General patient satisfaction was better in the Synvisc group at all times although statistically significant at 3 months (p=0.01) and 6 months (p=0.02). There was local increase in knee pain in one patient who received Synvisc, which settled by 4 weeks. Total treatment cost was 23% more in the Hyalgan group due to the two additional visits. Conclusion: Although both treatments offered significant pain reduction, it was achieved earlier and sustained for a longer period in patients with Synvisc with early increase in activity levels. However, a local reaction of pseudo sepsis was observed with Synvisc in one patient. The total treatment cost, both for the patient and the hospital are higher with Hyalgan. From this study, it appears that the clinical effectiveness and general patient satisfaction are better amongst patients who received Synvisc.
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