Hyperthyroidism in pregnancy

Hyperthyroidism is second to diabetes mellitus as the most common endocrinopathy in pregnancy. Inappropriate secretion of hCG is the most common cause of hyperthyroidism in the first part of gestation. In addition to hydatidiform mole and hyperemesis gravidarum, nonpathologic-conditions including multiple gestation, mild nausea and vomiting, and even normal pregnancies may present with transient undetectable or suppressed serum TSH values. The syndrome of transient hyperthyroidism of hyperemesis gravidarum is defined as severe nausea and vomiting, dehydration, ketonuria, and weight loss of more than 5% by 6 to 9 weeks of pregnancy. Thyroid tests are in the hyperthyroid range, and the abnormalities are related to the severity of symptoms. Tests normalize with resolution of the vomiting, and ATD therapy is not indicated. The natural history of Graves' disease in pregnancy is characterized by aggravation in the first trimester, amelioration in the second half, and recurrence in the year following delivery. ATD treatment is the therapy of choice in pregnancy. Either PTU or MMI may be used; the goal is to keep the FT4I in the upper limits of normal with the minimum dose of ATD. In approximately 30% of patients, ATDs may be discontinued in the last few weeks of gestation. Maternal, fetal, and neonatal complications are frequent when hyperthyroidism is not under control. Postpartum hyperthyroidism may be caused by an episode of silent thyroiditis or Graves' disease.     

Obsessive-compulsive disorder in elderly patients

Obsessive-compulsive disorder (OCD) is a common illness which starts in young adulthood and persists into late life. OCD is associated with dysregulation of the serotonin system and may also be related to the dysregulation of dopamine. When OCD starts in an elderly patient, either an organic or a neurological diagnosis should be considered. Clomipramine and serotonin reuptake inhibitors are the mainstay of treatment for OCD. Choice of a particular agent should be based on the patient's previous response and the adverse effect profile of the drug. Pharmacokinetics should also be a consideration due to age-related changes in hepatic and renal function leading to increased plasma concentrations as well as prolonged elimination half-lives of these agents. Behavioural therapy, in addition to pharmacological management, is essential to treat compulsions and to improve response.     

Hospital-acquired infection in elderly patients

Increasing numbers of elderly people are being treated in hospitals and are at particular risk of acquiring infections. The incidence, risk factors and types of hospital-acquired infection (HAI) in the elderly are reviewed. Special reference is made to urinary tract infections, respiratory tract infections, gastrointestinal infections including Clostridium difficile, bacteraemia, skin and soft tissue infections and infections with antibiotic-resistant organisms.     

Heart failure in elderly patients

The incidence and prevalence of congestive heart failure increase exponentially with advancing age. Congestive heart failure in the elderly is characterized by a multifactorial etiology, a high proportion of accompanying degenerative changes of the cardiovascular system and age-specific problems regarding diagnosis and treatment. The treatment strategy is the same as in younger patients, but the higher incidence of adverse effects and complications demands special awareness. The majority of decompensations leading to hospitalization are precipitated by insufficient compliance in life style change and drug intake.     

Hyperthyroidism in a renal transplant recipient

We report a case of toxic multinodular goiter with severe symptomatic hyperthyroidism in a female diagnosed 5 months after successful renal transplantation. To our knowledge, this is the first well-documented case of hyperthyroidism in a renal transplant recipient that responded well to methimazole. Special attention should be made to the use of methimazole and the possible interaction with immunosuppressive drugs.     

Surgery in elderly patients with otosclerosis

Hearing results and complications of surgery were studied in 42 patients with otosclerosis (46 ears operated on) who were over the age of 60 years at the time of stapedectomy. The mean follow-up period was 8 years. The results were compared with those obtained in 275 patients (330 ears operated on) younger than 60 years of age undergoing stapes surgery during the same time period. Large fenestra stapedectomy with fascia seal to the oval window was used in all cases. Hearing results as judged by postoperative air-bone gaps were as good in the older age group as in the younger patients. In contrast to some earlier reports, complications of surgery such as postoperative sensorineural hearing loss occurred not more frequently among elderly patients than in younger patients. It is concluded that stapes surgery should be offered to elderly patients with the same indications as in younger patients with otosclerosis.     

Pancreatic cancer resection in elderly patients

The paper deals with the data on treatment of 63 patients with serous borderline tumors of the ovary (SBTO). Mean age was 40.2 years. The study included 30 patients (47.6%) with stage IA tumor, 15 (23.8%)--IB, 4 (6.3%)--II and 14 (22.2%)--stage III. Relapse frequency was 14.3%, irrespective of stage and method of therapy. Surgery was given to 18 patients (28.6%), combined therapy--by 45 (71.4%). Recurrent tumor was recorded after surgery in 2 (3.2%) and in 7 (14.8%) after combined therapy. Generally, surgery is the main treatment received by patients with SBTO. Adjuvant chemotherapy was not followed by decrease in relapse rates.     

Systemic diseases in elderly dental patients

There has been increasing interest in gender disparities in clinical decisionmaking. Few studies have examined this issue in nationally representative samples or focussed on primary care. In addition, few of the studies have examined the role of physician gender. The 1987 National Medical Expenditure Survey was used to examine the relationship between physician gender and screening deficiency in women for three gender-sensitive tests (breast examinations, Papanicolaou tests, and mammograms) and one gender-neutral test (blood pressure checks). Women reporting a female physician as their usual provider compared with those reporting a male physician were less likely to be deficient for Papanicolaou tests and mammograms. There was a smaller, but nonsignificant similar trend for breast examinations. No gender bias was evident for blood pressure checks. These results persisted after multivariate adjustment for patient age, race, education, income, insurance status, subjective health status, other health behaviors, and attitude toward health care and health insurance. The results confirm the existence of physician gender bias in clinical decision making and represent one area for quality improvement.     

Lung cancer surgery in elderly patients

Immuno-electron microscopic methods revealed that the protective antigen (PAg) of Leptospira interrogans serovar lai exists on the outer envelope sheathing the leptospiral cell body. PAg lost its protective activity after treatment by hydrolysis with 2 M formic acid at 100 C for 2 hr, or oxidation with periodate at 4 C for 40 hr. The antigenic oligosaccharide fraction was further purified from the hydrolyzed PAg by immunoaffinity column coupled with protective monoclonal antibody, LW2, and by gel filtration of HPLC. The antigenic oligosaccharide fraction contained two unknown sugars and 4-O-methylmannose (molar ratio 3:5:1). These findings suggested that these sugars are components of an antigenic determinant contributing to the protective immunity against serovar lai infection.     

Radiotherapy for elderly patients

Fifty-seven revision total hip arthroplasties in fifty-six patients were performed with a Harris-Galante porous-coated acetabular component by one surgeon, and the patients were followed prospectively for a mean of seven years (range, five to twelve years). A trochanteric osteotomy was performed in forty hips, and a posterior approach with an extended anterior capsulectomy was used in the other seventeen. The acetabular defect was classified as segmental in seven hips, cavitary in twenty-three, and combined in twenty-one; six hips had no notable defect. A bulk allograft was used in eleven hips, and morseled cancellous-bone allograft or autogenous graft was used in thirty-four hips; twelve hips did not have bone-grafting. Both the femoral and the acetabular component were revised in forty-five hips, and only the acetabular component was revised in twelve. Thirty-nine hips (68 per cent) had a good or excellent clinical result according to the Harris hip score. The acetabular component was well fixed in the fourteen hips that had a fair result and the four hips that had a poor result. The acetabular component was considered to have migrated if there was a change in the angle of the cup of 5 degrees or more or a change in the horizontal or vertical position of the cup of more than three millimeters. Despite varying degrees of bone loss, no acetabular component had radiographic evidence of loosening at the latest follow-up examination. No component was revised and no revisions were scheduled. One hip was debrided for a late metastatic infection, but the component was well fixed and was not revised. There were no complications related to the use of screws for fixation. These mid-term results confirm the early success of acetabular revisions performed with fixation of a titanium fiber-metal-coated hemispherical component with multiple screws and no cement.     

Hyperthyroidism in the cat: ten cases

The effects of Ni2+ on contractility, NADH-fluorescence, O2-consumption and total coronary resistance (TCR) of isolated perfused rat heart were studied in the presence of glucose or pyruvate and at different perfusate calcium concentations (Cap2+). Ni2+ 1 mM, abolished contractility, reduced O2-consumption, increased TCR and caused biphasic NADH-fluorescenceresponse, i.e., an initial reduction followed by NADH oxidation, regardless of the substrate present. Three-fold elevation of Cap2+, from 1.3 to 3.9 mM restored contractility and O2-consumption while enhancing the increase of TCR. NADH-oxidation was antagonized by excess Cap2+ in the presence of glucose only. Inhibition of cardiac contractility in response to increasing concentrations of N2+ (10(-7)--10(-3) M), in the presence of 1.3 mM Cap2+, proved to be dose-dependent, whereas the amplitude of TCR elevation reached its maximum already at Ni2+ concentration of 10(-6) M. The present results emphasize the biomedical significance of this trace metal.