Search

Laryngopharyngeal reflux (LPR) has been suggested as a possible cause of post-thyroidectomy syndrome. However, the pathophysiology and relationship between thyroidectomy and LPR have not been well investigated. We aimed to evaluate the correlation between thyroidectomy and LPR by assessing changes in LPR-related symptoms and laryngoscopic findings before and after thyroidectomy. Ninety-five patients who underwent thyroidectomy with or without central neck dissection were included. The reflux finding score (RFS) and reflux symptom index (RSI) were investigated one day before surgery and two, four, six, and twelve months after surgery. The RFS scores increased significantly after thyroidectomy and decreased to the preoperative level 12 months after surgery. The RSI scores increased after surgery and decreased gradually by 12 months postoperatively, although it was not statistically significant. The RSI and RFS scores improved with the administration of proton pump inhibitors. In conclusion, LPR-related laryngoscopic findings were exacerbated after uncomplicated thyroidectomy. Further studies using pH-monitoring and esophageal manometry are required to investigate the possible deterioration of LPR itself and the UES pressure after thyroidectomy.

Background The study aimed to evaluate the sensory changes on the chin and neck in transoral thyroidectomy. Methods We prospectively assessed the cutaneous sensation of 10 zones of the chin, face, and neck in 43 patients who underwent transoral robotic or endoscopic thyroidectomy using the Semmes-Weinstein monofilaments test, preoperatively and postoperatively at 1 week, 1 month, and 3 months. Results The sensation of the chin and lower lip did not differ before and after surgery. However, the pressure threshold of the submental and level VI area increased significantly after surgery, and returned to the preoperative level 1 month and 3 months postoperatively, respectively. Conclusion In terms of mental nerve injury, transoral thyroidectomy is safe when performed successfully. However, proper placement of oral vestibular incisions and minimal dissection of the chin is essential to avoid mental nerve injury.

Effective treatment of diabetic neuropathy (DN) remains unsolved. We serendipitously observed dramatic relief of pain in several patients with painful DN receiving granulocyte-colony stimulating factor (G-CSF). The aim of this study was to determine if G-CSF could treat DN in an animal model and to ascertain its mechanism of action. In a rodent model of DN, G-CSF dramatically recovered nerve function, retarded histological nerve changes and increased the expression of neurotrophic factors within nerve. A sex-mismatched bone marrow transplantation (BMT) study revealed that G-CSF treatment increased the abundance of bone marrow (BM)-derived cells in nerves damaged by DN. However, we did not observe evidence of transdifferentiation or cell fusion of BM-derived cells. The beneficial effects of G-CSF were dependent on the integrity of BM. In conclusion, G-CSF produced a therapeutic effect in a rodent model of DN, which was attributed, at least in part, to the actions of BM-derived cells.

Background This study aimed to identify the gender-specific characteristics of the surrogate measures of insulin resistance and to establish valid cut-off values for metabolic abnormalities in a representative sample in Korea. Methods Data were collected from the datasets of the Korean National Health and Nutrition Examination Survey between 2007 and 2010. The total number of eligible participants was 10,997. We used three measures of insulin resistance: the homeostasis model assessment-insulin resistance (HOMA-IR), McAuley index, and triglyceride and glucose (TyG) index. The estimated cut-off values were determined using the highest score of the Youden index. Results The area under the curve (AUC) of the HOMA-IR, McAuley index, and TyG index were 0.737 (95% confidence interval [CI], 0.725-0.750), 0.861 (95% CI, 0.853-0.870), and 0.877 (95% CI, 0.868-0.885), respectively. The cut-off values of the HOMA-IR were 2.20 in men, 2.55 in premenopausal women, and 2.03 in postmenopausal women, and those of the McAuley index were 6.4 in men and 6.6 in premenopausal and postmenopausal women. For the TyG index, the cut-off values were 4.76 in men and 4.71 in premenopausal and postmenopausal women. Conclusion In conclusion, the present study provides the valid cut-off values of the indirect surrogate measures of insulin sensitivity. These values may be used as reference for insulin sensitivity in a clinical setting and may provide a simple and supplementary method for identifying populations at risk of insulin resistance.

Background Robotic thyroidectomy and conventional endoscopic thyroidectomy have not been thoroughly compared. In this study, we compared the potential advantages of robotic versus endoscopic thyroidectomy. Methods We analyzed 218 consecutive patients who underwent endoscopic (105 cases) or robotic (113 cases) thyroidectomy using a gasless unilateral axillo-breast or gasless unilateral axillary approach. Results Because of the dexterity of robotic instruments and the improved surgical view, it was subjectively easier and took less time to perform a complete total thyroidectomy and central compartment neck dissection in robotic thyroidectomy. In the case of unilateral lobectomy, endoscopic and robotic thyroidectomy had quite similar surgical outcomes. Cosmetic satisfaction was excellent in both groups. Conclusion In this series by a single surgeon, robotic thyroidectomy was superior to endoscopic thyroidectomy for performing total thyroidectomy and bilateral central compartment neck dissection. However, in terms of cost-effectiveness, endoscopic thyroidectomy was comparable to robotic thyroidectomy in patients who undergo unilateral lobectomy. © 2012 Wiley Periodicals, Inc. Head Neck, 2013

Peripheral neuropathy is somewhat common in hypothyroidism. But, demyelinating peripheral neuropathy in Hashimoto’s thyroiditis is extremely rare. The pathophysiology of demyelinating peripheral neuropathy associated with Hashimoto’s thyroiditis is unclear and complex and various mechanisms including the cell mediated and antibody mediated responses may be operative. We report a 68-year-old woman who presented with paresthesia and gait disturbance. She was diagnosed with hypothyroidism 7 years prior and has been on thyroid hormone. Serum antithyroglobulin antibody was significantly elevated. Nerve conduction studies revealed sensory-motor demyelinating polyneuropathy with prolonged distal latencies and reduced conduction velocities. She was under the suspicion of the lymphoma of thyroid. Surgery was performed which turned up to be Hashimoto’s thyroiditis. With the impression of rare demyelinating peripheral neuropathy associated with Hashimoto’s thyroiditis after other causes were excluded, she was treated with steroid which ameliorated rapidly her neurological symptoms.

Background and Aims: There were no objective data presented about the association between erosive esophagitis and abdominal fat. We conducted this study to examine the association of abdominal fat and gastroesophageal reflux disease-related erosive esophagitis. Methods: Between May 2004 and October 2005, a total of 100 erosive esophagitis patients diagnosed by upper endoscopy were evaluated in a prospective manner. All study patients and controls underwent abdominal computed tomography (CT) scan. Body fat distribution was assessed by CT with a 10-mm-thick slice at the level of the fourth lumbar vertebra. Results: Erosive esophagitis patients presented with a significantly higher mean visceral fat (VF) area (104.68 ± 39.47 vs. 75.90 ± 49.10 cm 2 , P = 0.014) than the control group. However, there was no association between erosive esophagitis and subcutaneous fat area (109.72 ± 49.09 vs. 98.66 ± 52.43 cm 2 , P - 0.379) or total fat area (214.41 ± 78.78 vs. 172.59 ± 90.49cm2, P = 0.054). Multi-variate logistic regression analysis demonstrated that high VF areas (P = 0.0035), VF/subcutaneous fat area (P = 0.005), hiatal hernia (P = 0.001), high body mass index (P = 0.047), high waist-to-hip ratio (P = 0.042), and smoking (P = 0.005) are independent risk factors of erosive esophagitis. Conclusions: These results suggest a role for visceral obesity, quantified by CT, as a risk factor for erosive esophagitis.

Background The relationship between the number of parathyroid glands preserved and hypoparathyroidism is not well understood. We sought to determine the number of parathyroid glands that need to be preserved to prevent hypoparathyroidism. Methods We analyzed 454 patients who underwent total thyroidectomy for papillary thyroid carcinoma. We analyzed the frequency of hypoparathyroidism according to the number of parathyroid glands preserved. Results Incidental parathyroidectomy occurred in 19.8% of the patients; one parathyroid gland in 17.6%, two in 1.5%, and three in 0.7%. Transient hypoparathyroidism was increased when incidental parathyroidectomy occurred (odds ratio 1.83, 95% confidence interval 1.04 to 3.23, P = 0.036) on multivariate regression analysis, but was not influenced by the actual number of parathyroid glands removed. There was no relationship between the number of parathyroid glands preserved and permanent hypoparathyroidism (P = 0.147). Conclusions Preservation of all parathyroid glands decreases transient hypoparathyroidism compared with when three or fewer glands are preserved, but does not affect permanent hypoparathyroidism. During total thyroidectomy, preserving at least one parathyroid gland with an intact blood supply appears to be sufficient to prevent permanent hypoparathyroidism when autotransplantation is not performed.

The effects of thyroid hormone on hepatic and gastric alcohol dehydrogenase (ADH) activities (nM of NADH/min/mg of cytosolic protein) have been investigated in male Sprague Dawley rats treated with thyroxine (1 mg/kg, po) for 14 days. Whereas hepatic ADH activity in thyroxine-treated rats decreased by 61.3% of control rats (26.4 vs 43.2, p

Objective: Robotic thyroidectomy and conventional endoscopic thyroidectomy have not been thoroughly compared. In this study, we compared the potential advantages of robotic versus endoscopic thyroidectomy.Method: We analyzed 218 consecutive patients who underwent endoscopic (105 cases) or robotic (113 cases) thyroidectomy using a gasless unilateral axillo-breast (GUAB) or axillary (GUA) approach.Results: Because of the dexterity of robotic instruments and the improved surgical view, it was subjectively easier and took less time to perform a complete total thyroidectomy and central compartment neck dissections (CCND) in robotic thyroidectomy. In the case of unilateral lobectomy, endoscopic and robotic thyroidectomy had quite similar surgical outcomes. Cosmetic satisfaction was excellent in both groups.Conclusion: Robotic thyroidectomy is superior to endoscopic thyroidectomy for performing total thyroidectomy and bilateral CCND. However, in terms of cost-effectiveness, endoscopic thyroidectomy is comparable...

Acute suppurative thyroiditis (AST) is a rare condition, as the thyroid gland is relatively resistant to infection. Thyroid function tests are usually normal in AST. A few cases of AST associated with thyrotoxicosis have been reported in adults. We report a case of AST that was associated with thyrotoxicosis in a 70-year-old woman. We diagnosed AST with thyroid ultrasonography and fine needle aspiration of pus. The patient improved after surgical intervention and had no anatomical abnormality. Fine needle aspiration is the best method for the difficult task of differentiating malignancy and subacute thyroiditis from AST with thyrotoxicosis. Earlier diagnosis and proper treatment for AST might improve the outcome.

This study was to examine the effects of adherence to a 6-month t'ai chi exercise program on glucose control, diabetic self-care activities, and quality of life among individuals with type 2 diabetes.The data from a quasi-experimental study at multisite health-promotion centers in Korea with pretest and 3- and 6-month post-test measures were used. Ninety-nine (99) adults diagnosed with type 2 diabetes and HbA1c 6.0 or higher were included in the analysis. The t'ai chi intervention consisted of 19 movements from Yang and Sun styles provided twice a week for 6 months. Sixty-two (62) subjects completed both pretest and post-test measures. To achieve the desired outcomes, subjects needed to complete 80% of the sessions of the t'ai chi program, and 31 subjects who met this criteria were compared to those who did not (n = 31). Outcome measures included glucose control (fasting blood sugar, HbA1c), diabetic self-care activities, and quality of life (36-Item Short Form Health Survey, version 2).Using repeated measure analysis of variance for baseline, 3 months, and 6 months, the adherent group had greater decline in fasting glucose (interaction effect F = 5.60, df = 2, p0.05) and HbA1c (interaction effect F = 4.15, df = 2, p0.05) than the nonadherers. The adherent group performed significantly more diabetic self-care activities (interaction effect F = 5.13, df = 2, p0.05), and had better quality of life in mental component summary, social functioning, mental health, and vitality as compared to the nonadherent group. The significant differences in quality of life remained after adjusting for self-care activities except for mental health, which was no longer significant.For those with type 2 diabetes, t'ai chi could be an alternative exercise intervention to increase glucose control, diabetic self-care activities, and quality of life. Whether t'ai chi can reduce or prevent diabetic complications requires further study.

Diabetes is one of the risk factors of gallstone diseases. Many studies found a positive association between insulin and gallstones in individuals with diabetes. However, this association is unclear in non-diabetes. So we conducted a case-control study for the evaluation of the association between gallstone diseases and fasting serum insulin level, insulin resistance in non-diabetic Korean general population.This study was a prospective case-control study on 118 Korean subjects which included clinical examination, abdominal ultrasound, and blood chemistries. Serum fasting insulin level were determined by radioimmunoassay and concentrations of cholesterol, glucose, and triglycerides by standard enzymatic colorimetric methods. Insulin resistance was determined by the homeostasis model assessment (HOMA-IR). Body mass index (BMI), percentage of body fat, and waist hip ratio were also measured.We studied 118 subjects with no clinical evidence of diabetes mellitus and serum glucose126 mg/dL. Compared with controls (n=89), cases (n=29) had higher levels of serum insulin, glucose, triglyceride levels, and BMI. In t-test and chi-square test for variables, the association between gallstone disease and serum insulin, HOMA-IR index, and BMI were statistically significant (p0.05). In multiple logistic regression analysis, gallstone disease risk increased with the level of serum insulin (p=0.024, odds ratio=1.376) and HOMA-IR index (p=0.013, odds ratio=2.006).We suggest that hyperinsulinemia and insulin resistance could be associated with gallstone formation in individuals without clinical diagnosis of diabetes mellitus and with normal serum glucose level.

Low-dose aspirin therapy is widely used to prevent cardiovascular thrombotic events. However, the safety of low-dose aspirin therapy in the gastrointestinal tract is uncertain. Our aim was to evaluate endoscopic findings in patients taking low-dose aspirin.Sixty-two patients who received 100 mg enteric coated aspirin daily more than 30 days were included in this study. Patients' medical records and endoscopic data were reviewed retrospectively. As controls, 70 of age- and gender-matched patients who received an endoscopy without gastrointestinal symptoms were employed.The overall prevalence of gastroduodenal mucosal injury was higher in the aspirin group than in the control group. Erosive gastritis was noted more frequently in the aspirin group than in the control group. However, the prevalence of ulcer was not different between the aspirin group and the control group.Patients treated with low-dose aspirin therapy are more likely to have endoscopic evidence of mucosal damage. Our study suggests that even a low-dose aspirin therapy can induce a gastroduodenal mucosal injury. In the future, a prospective randomized control study is needed.

Gynecomastia is a benign enlargement of the male breast caused by the proliferation of glandular breast tissue. Determining the various causes of gynecomastia such as physiological causes, drugs, systemic diseases, and endocrine disorders is important. Androgen insensitivity syndrome (AIS) is a rare endocrine disorder presenting with gynecomastia and is a disorder of male sexual differentiation caused by mutations within the androgen receptor gene. All individuals with AIS have the 46 XY karyotype, although AIS phenotypes can be classified as mild, partial or complete and can differ among both males and females including ambiguous genitalia or infertility in males. We experienced a case of partial AIS presenting with gynecomastia and identified the androgen receptor gene mutation.

Polymorphisms of DNA repair genes, X-ray repair cross-complementing group 1 (XRCC1) might contribute to individual susceptibility to different types of cancers. We analyzed the relationship between XRCC1 polymorphisms and the risk of papillary thyroid carcinoma in a Korean sample. A hospital-based case-control study was performed in 111 papillary thyroid carcinoma patients and 100 normal control subjects. XRCC1 Arg194Trp and Arg399Gln single nucleotide polymorphisms (SNPs) were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The XRCC1 Arg194Trp Arg/Trp genotype was significantly associated with a decreased risk of papillary thyroid carcinoma compared to that of Arg/Arg genotype (odds ratio [95% confidence intervals]; 0.550 [0.308-0.983]). There was no significant association between XRCC1 Arg399Gln genotypes and risk of papillary thyroid carcinoma. Based on these results, the XRCC1 Arg194Trp Arg/Trp genotype could be used as a useful molecular biomarker to predict genetic susceptibility for papillary thyroid carcinoma in Koreans.

Received August 16, 2011 Revised September 30, 2011 Accepted October 4, 2011 Address for correspondence Kyung Tae, MD Department of OtolaryngologyHead and Neck Surgery, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul 133-791, Korea Tel +82-2-2293-8585 Fax +82-2-2293-3335 E-mail kytae@hanyang.ac.kr Background and ObjectivesZZThyroidectomy for Graves’ disease is a rapid, safe, highly successful treatment modality. Also thyroidectomy allows pathological examination for diagnosis of suspected cancer. However, the extent of thyroidectomy in Graves’ disease is still controversial. The aim of this study is to evaluate the appropriate surgical extent by comparing the postoperative outcomes of two groups of patients with Graves’ disease who underwent total or less than total thyroidectomy. Subjects and MethodZZWe carried out a retrospective review of 33 patients who underwent thyroidectomy for Graves’ disease from January 2001 to December 2010. We investigated the postoperative thyroid hormone function and complication rate according to the extent of thyroidectomy. ResultsZZAmong the 33 patients with Graves’ disease, 19 patients underwent total thyroidectomy, six patients bilateral subtotal thyroidectomy (BST) and eight patients lobectomy and contralateral subtotal lobectomy (LCSL). Postoperative hypothyroidism, euthyroidism, and hyperthyroidism occurred in 27 (81.7%), 2 (6.1%) and 4 (12.2%) patients, respectively. Postoperative recurrent hyperthyroidism was observed in 2 (33.3%) patients of BST and in 2 (25.0%) of LCSL. One patient was found with permanent hypoparathyroidism, and two with transient vocal cord paralysis. According to histopathologic report, nine patients were accompanied with thyroid cancer. ConclusionZZThyroidectomy for Graves’ disease has high success rate, low recurrence rate and low complication rate. In terms of surgical extent, total thyroidectomy is a more appropriate procedure because of its low recurrence of hyperthyroidism. Korean J Otorhinolaryngol-Head Neck Surg 2011;54:771-7

Pseudohypoparathyroidism is a rare disease that is characterized by target cell resistance to the effects of parathyroid hormone and this disease is classified into various types depending on the phenotypic and biochemical findings. The patients with pseudohypo parathyroidism present with the clinical and biochemical features of hypoparathyroidism, but they have an increased serum level of parathyroid hormone. We experienced a case of pseudohypoparathyroidism in a 24 years old woman who had Graves’ disease at that time. She had hypocalcemia, hyperphosphatemia, an elevated serum parathyroid hormone level and a normal urinary basal cyclic AMP(adenosine monophosphate) level. She also had a normal phenotypic appearance. Therefore, she was classified as suf fering with pseudohypoparathyroidism type II. The clinical and laboratory abnormalities were improved by calcium supplementa tion in addition to vitamin D. To the best of our knowledge, this is the first case of pseudohypoparathyroidism combined with Graves’ disease in Korea. (Endocrinol Metab 25:221-225, 2010)

Gastroesophageal reflux disease (GERD) is caused by abnormal reflux of gastric contents into the esophagus. GERD can be divided into two groups, erosive esophagitis and non-erosive reflux disease (NERD). The aim of this study was to compare the clinical characteristics of patients with erosive esophagitis to those with NERD. All participating patients underwent an upper endoscopy during a voluntary health check-up. The NERD group consisted of 500 subjects with classic GERD symptoms in the absence of esophageal mucosal injury during upper endoscopy. The erosive esophagitis group consisted of 292 subjects with superficial esophageal erosions with or without typical symptoms of GERD. Among GERD patients, male gender, high body mass index, high obesity degree, high waist-to-hip ratio, high triglycerides, alcohol intake, smoking and the presence of a hiatal hernia were positively related to the development of erosive esophagitis compared to NERD. In multivariated analysis, male gender, waist-to-hip ratio and the presence of a hiatal hernia were the significant risk factors of erosive esophagitis. We suggest that erosive esophagitis was more closely related to abdominal obesity.

Background and ObjectivesZZThe effectiveness of suppressive therapy with Levothyroxine in benign thyroid nodule is controversial. The favorable response varies between 9-68%. The aim of this study was to evaluate the effect of Levothyroxine suppressive therapy on benign thyroid nodules in comparison with untreated patients.

Background: The purpose of this study was to assess the prevalence of thyroid nodules in healthy adults without a history of thyroid disease and the results of fine needle aspiration cytology (FNAC). Methods: We retrospectively studied 4,832 adults (2,427 women, 2,405 men) over the age of 20 who had visited our health care center from January, 2005, to March, 2008. Subjects with previous thyroid disease were excluded. All were screened by thyroid ultrasonography and FNAC was performed on large or potentially malignant nodules. Results: Thyroid nodules were present in 686 women (28.3%) and 396 men ( 16.5%), with a female predominance (odds ratio = 1.47, 95% CI = 1.35~1.60). The prevalence of a thyroid nodule was significantly correlated with age in both women and men (P < 0.001). Multinodularity also increased according to age in both groups. Ninety patients were tested with conventional FNAC and 195 underwent ultrasonography-guided FNAC. The rate of inadequate cytology by ultrasonographic guidance was lower than by freehand methods, and the total rate of malignant cytology per patient was 17.9%. Ultrasonographic characteristics that significantly correlated with histologically-confirmed papillary carcinoma included a solid component, hypoechogenecity, irregular margin, and the presence of microcalcification or macrocalcification. Conclusion: The prevalence of thyroid nodules detected by ultrasonography was 28.3% in healthy women and 16.5% in healthy men population. The prevalence and multinodularity was significantly correlated with age in both groups. It’s useful to examine thyroid by ultrasonography because of detecting more nodules, providing guidance of FNAC, achieving more adequate sampling and not missing small malignant nodules. (J Korean

There have been a few reports on rhabdomyolysis caused by thyroid storm, but no cases of thyrotoxicosis related rhabdomyolysis have been reported until now. Here, a rare case of rhabdomyolysis, accompanied by thyrotoxicosis, is reported. A 21-year-old man was admitted to our hospital with severe pain and weakness in both legs. The initial laboratory findings revealed a high muscle enzyme level and severe hypokalemia. In evaluation of the rhabdomyolysis, the thyroid function test was compatible with that of Graves' disease, with the rhabdomyolysis subsequently diagnosed, presenting as thyrotoxicosis. The possible mechanisms for this complaint were hypokalemia - induced muscle ischemia, a thyrotoxicosis - induced excessive hypermetabolic state and pressure - induced muscle ischemia. Therefore, the work up for the cause of rhabdomyolysis should include thyrotoxicosis. The management of rhabdomyolysis is hydration, prevention of acute renal failure, correction of aggravating factors and treatment of the underlying cause, for example, thyrotoxicosis (J Kor Soc Endocrinol 20:381～384, 2005).

Cystic fibrosis is a hereditary disease involving recessive transmission. The fundamental abnormality consists of the production of abnormal secretion from a variety of exocrine glands such as salivary and sweat glands and those of the pancreas, colon, and tracheobronchial trees. Cystic fibrosis is the most common lethal genetically transmitted disease among whites, but is uncommon in Asians, including Koreans. Although a case involving a Korean was reported in 1988, the focus was diagnosis rather than the radiological findings. In the case of cystic fibrosis we now describe, the focus is inverted: we enphasise the reported in 1988, focusing on radiologic findings

Purpose: After the RS (respiratory syncytial) virus, the influenza virus is the most common cause of childhood lower respiratory tract infection. We assessed the radiologic findings of childhood lower respiratory tract infection by the influenza virus. Materials and Methods: A total of 105 pediatric patients (76 males and 29 females; mean age, 2.4 years) with symptoms of respiratory tract infection were examined between March 1997 and April 2000. Nasopharyngeal aspirates were obtained and influenza virus infection was confirmed by direct or indirect immunofluorescent assays. Peribronchial infiltration, hyperinflation, atelectasis, pulmonary consolidation, and hilar lymphadenopathy were evaluated retrospectively at simple chest radiography. Results: Bilateral perihilar peribronchial infiltration was noted in 78.1% of patients (n=82), hyperinflation in 63.8% (n=67), atelectasis in 3.8% (n=4; segmental 50%, lobar 50%), and pulmonary consolidation in 16.2% [n=17; segmental 70.6% (n=12), lobar 29.4% (n=5)]. Hilar lymphadenopathy was noted in one patient in whom there was no pleural effusion, and subglottic airway narrowing in 12 of 14 in whom the croup symptom complex was present. Conclusion: The major radiologic findings of influenza virus infection were bilateral perihilar peribronchial infiltration and hyperinflation. In some patients, upper respiratory tract infection was combined with subgolttic airway narrowing. Atelectasis or pleural effusion was rare.

A 49-year-old man with liver cirrhosis and hypertension was found to have hyperkalemia out of a degree of renal insufficiency and metabolic acidosis with low to normal anion gap, aggravated by volume contraction with diarrhea and medications (captopril, spironolactone and atenolol) interfering with potassium homeostasis. Plasma renin activity and serum aldosterone levels of this patient on a regular diet after discontinuation of medications were very low compared to those of five other cirrhotic patients with normokalemia as controls. Also, the renin-aldosterone stimulation testing on this patient performed by sodium restricted diet and furosemide, upright position and by angiotensin converting enzyme inhibition (captopril, 50 mg) showed the blunted renin and aldosterone responses to each of these stimuli, almost no changes from baseline renin and aldosterone levels, it was concluded that the underlying defect responsible for hyperkalemia in this case was hyporeninemic hypoaldosteronism and this was aggravated by other factors or drugs affecting potassium homeostasis.

Chronic stable diabetic patients (n = 6) were compared with healthy control subjects (n = 5) after acute oral intake of 50 mEq of potassium chloride (KCl) to investigate for possible derangements of homeostatic responses for acute term (3 hrs) to acute potassium load. Plasma renin activity (PRA), plasma aldosterone (PA), and transtubular potassium concentration gradient (TTKG) known as a useful semiquantative index of distal nephron potassium secretion were measured. All the baseline parameters were comparable between diabetic and non-diabetic subjects except for significantly reduced creatinine clearance in diabetics (mean +/- SEM, 105 +/- 4 vs. 85 +/- 5 ml/min, p < 0.05). Following acute oral KCl load, the peak increases of serum potassium changes from basal levels were noted at 2 hours in both groups, but were higher in diabetic subjects (mean +/- SEM, 0.42 +/- 0.06 vs. 0.62 +/- 0.09 mEq/L). Also, 4 out of 6 diabetic subjects but none of the control subjects at 2 hours after oral KCl load became hyperkalemic ( > 5.0 mEq/L). PRA did not show any significant changes, whereas PA was increased simultaneously with increments in serum potassium in both groups, with blunted increases in the diabetics. However, TTKG was increased prominently in control subjects (8.18 from 4.98), but only slightly in diabetic subjects (4.55 from 4.18), with statistical difference between the two groups (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

• The association of diabetes mellitus with gastric bezoars is not well documented. Our endoscopic experience over a seven-year period (1979 to 1985) included 3247 esophagoduodenoscopies (EGDs). Bezoars were found in 14 patients (0.4%). The mean age of these 14 patients was 63 years (range, 27 to 84 years); there were eight men and six women. In 11 patients, there was a history and/or findings of peptic ulcer disease (PUD). Two patients had prior surgery (Billroth II in one and vagotomy in another). Seven patients had diabetes mellitus; five had diabetes for over five years, and three of these five had diabetes for over ten years. Diabetes was newly diagnosed in one patient. Except for the newly diagnosed patient, the other diabetic patients had evidence of autonomic neuropathy. Two other patients (not included with the diabetic patients) had hyperglycemia only during stress. The three patients with bezoars but without PUD all had diabetes for many years (9,17, and 19 years). In two control groups of 14 patients each who also underwent endoscopy, only one diabetic patient was discovered. We conclude that diabetes mellitus and associated gastropathy are major risk factors for bezoar formation, especially in the absence of PUD. ( Arch Intern Med 1987;147:527-528)

Excerpt To the editor: Recently, several studies have found a high incidence of adverse reactions to treatment with high-dose intravenous trimethoprim-sulfamethoxazole in patients with pneumocystis...

To the Editor.— It is generally agreed that individuals at high risk for developing osteoporosis should ingest adequate amounts of calcium and vitamin D. Maintenance doses of approximately 400 units of vitamin D 3 and 1 to 2 g of calcium are recommended in patients whose diet is inadequate in calcium. Unfortunately, it is not commonly realized that the physiological dose of vitamin D (approximately 400 units daily) is not generally available in the United States except in combination with other vitamins or with calcium. Therefore, if "vitamin D" is ordered, pharmacologic doses (25,000 to 50,000 units) may be dispensed, resulting in severe hypercalcemia. We have recently seen several cases of improper dosing with vitamin D. Report of Cases.— An 81-year-old normocalcemic woman was admitted for rehabilitation of a broken femur. Before admission she was taking a preparation containing 125 units of vitamin D and 500 mg of calcium carbonate

Background The indications and extent of cervical lymph node dissection in papillary thyroid carcinoma (PTC) are still being debated. The aim of this study was to analyze the patterns of cervical lymph node metastasis in the lateral and central compartment and related factors and suggest the optimal extent of lateral and central neck dissection for PTC patients with clinical lateral lymph node metastasis. Methods We retrospectively analyzed 72 patients with unilateral PTC who underwent therapeutic lateral neck dissections with concomitant total thyroidectomy and central neck dissection between January 2001 and December 2009. Results The 72 patients underwent 79 sides of therapeutic lateral neck dissection. The most frequent metastatic level in the ipsilateral lateral compartment was level IV (75.0%), followed by level III (69.4%), level II (56.9%) and level V (20.8%). Multiple level metastases were common (77.8%) and were correlated with tumor size (≥ 10 mm). The central compartment lymph node metastasis rate was 87.5%, including 26.4% of contralateral central compartment metastases. Conclusion In PTC patients with clinical lateral lymph node metastasis, the optimal extent of lateral and central neck dissection should include levels II, III, IV and V as well as the bilateral central compartment.