Crohn's disease in the elderly

Primary Crohn's disease in the elderly is a not frequent pathology, which however have distinguished from the reheightening or relapse of an inflammatory illness risen up in juvenile age. The Authors compare the personal experience (6 cases on 120 patients operated for Crohn's disease) with the data of the literature. The more frequent localization stays the ileo-colic one, also if in the elderly present better impact the cases of Crohn's colitis (pancolitis or left colitis), with frequent and- perianal implications. The symptomatology is not pathognomonic and above all in the cases of colitis sets problems of differential diagnosis with other pathologies, among which the diverticular disease, that on the other hand, can also coexist with the inflammatory illness. A pharmacological treatment is desiderable, but frequently doesn't result effective. The surgical conservative therapy is not always possible and could be necessary resort to maiming interventions, like massive ileal resections or a total proctocolectomy. From the prognostic point of view, the course appears from the beginning or very favorable (with low index of relapse) or tumultuous (with acute manifestations, which require an emergency surgery, wighted by a more elevated rates of mortality and morbidity.     

Hodgkin''s disease in the thyroid gland

Gaining a sufficient exposure for aortic valve surgery after previous coronary artery bypass grafting (CABG) has been a problem due to the patent saphenous vein grafts. Although a patient had had CABG twice we performed aortic valve replacement (AVR) with almost the usual exposure. We attached the proximal anastomosis in a more distal position of the ascending aorta than usual, at the first CABG, as he was diagnosed to have mild aortic valve stenosis prior to surgery. We consider this method allows easier AVR after previous CABG when the patient is diagnosed with mild aortic valve stenosis before CABG.     

Low selenium status in the elderly influences thyroid hormones

The synthetic retinoid, N-(4-hydroxyphenyl)retinamide (4-HPR; Fenretinide), is a cancer chemopreventive and antiproliferative agent whose mechanism of action is unknown. 4-HPR alone is a poor inducer of differentiation of HL-60 cells compared to all-trans-retinoic acid (RA). Here, we found that combinations of 4-HPR and RA synergistically induced differentiation of HL-60 cells. In addition, 4-HPR increased the level of retinoylation, the covalent binding of RA to proteins. Retinoylation occurs in many eukaryotic cell lines and may be involved in RA-induced differentiation. These results suggest that 4-HPR may be a member of a class of retinoids that are active because they displace RA from extracellular and intracellular sites or because they inhibit RA catabolism. On the basis of these proposed mechanisms, retinoids that do not cause differentiation as sole agents may have utility in the clinic in combination with RA.     

A simple health control for the elderly. Screening for vitamin B12 deficiency and thyroid disease

Screening for vitamin B12 deficiency and thyroid disease is cheap and enables early diagnosis to be made and treatment to be started while it is still simple and can prevent the development of such serious conditions as dementia, depression, or irreversible tissue damage. In 1995-6, 83% (126/151) of all 75-year-olds in H?rryda, a district (population 28,500) to the east of Gothenburg, agreed to undergo a health control designed to detect hypo- or hyper-thyroidism or vitamin B12 deficiency among elderly residents without symptoms (or with atypical symptoms not easily recognised). Of the 126 participants, four (3%) had low plasma cobalamin (vitamin B12) levels (a figure similar to or lower than those reported by others), and were treated with vitamin B12 after further examination; eight (6%) had serum thyroid stimulating hormone (TSH) levels below the lower normal limit, though further examination showed all eight to be euthyroid; and two (1.6%) were diagnosed as being hypothyroid (a lower prevalence than figures reported elsewhere), and were treated with laevothyroxine. The findings suggest that such screening might be useful in primary care. However, the clinical diagnosis of vitamin B12 deficiency, and of hypo- or hyperthyroidism, is often difficult, especially in the elderly; and although a low serum TSH level is also considered to be a reliable marker of hyperthyroidism, like others this study showed that it may occur even in the absence of disease. Thus, serum TSH and plasma B12 levels are useful screening variables, but need to be complemented by other tests before diagnosis is set.     

Advances in the cutaneous manifestations of thyroid disease

OBJECTIVES: To use a serum and salt challenge in narrow-lumen carriers to evaluate a 10% ethylene oxide plus 90% hydrochlorofluorocarbon (EO-HCFC) sterilant mixture in a retrofitted 12/88 sterilizer as an alternative to the banned chlorofluorocarbon-ethylene oxide (EO) sterilant mixture. DESIGN: An EO-HCFC sterilizing gas mixture in a retrofitted 12/88 sterilizer was compared to 100% ethylene oxide (100% EO) sterilizing gas to determine its relative ability to kill seven different bacteria (Escherichia coli, Pseudomonas aeruginosa, Enterococcus faecalis, Bacillus subtilis spores, Bacillus stearothermophilus spores, Bacillus circulans spores, and Mycobacterium chelonei) in the presence or absence of a combined 10% serum and 0.65% salt challenge using both penicylinders (PC) and long narrow-lumen (LU) carriers. RESULTS: The EO-HCFC sterilant mixture (96% sterile carriers) was equivalent to the 100% EO sterilant (98% sterile carriers) for killing vegetative organisms, as well as spore suspensions, on the 27 PC and 27 LU carriers in the absence of serum and salt. In the presence of serum and salt, the EO-HCFC sterilant mixture was markedly better than the 100% EO sterilant at reducing the bacterial load on the 63 PC carriers (95% vs 62% sterile PC carriers, respectively), whereas both sterilizers were equivalent for the 63 LU carriers (49% vs 40% sterile LU carriers, respectively). Of the seven test organisms, E faecalis, B subtilis, B stearothermophilus, and B circulans were the most difficult to kill for both PC and LU carriers when serum and salt were present. CONCLUSIONS: The data presented in this report indicate that the EO-HCFC sterilant mixture is an effective alternative for gas sterilization. Indeed, the efficiency of bacterial killing for the EO-HCFC sterilant mixture was similar to that achieved by the 12/88 EO-CFC sterilant mixture.     

Treatment of thyroid disease in pregnancy

With appropriate therapy, complications related to thyroid disease in pregnancy can be minimized. Although the diagnosis of thyroid endocrinopathy may be difficult in pregnancy, few therapies are contra-indicated. Because medications may cross the placenta, however, clinicians need always to be mindful of potential fetal effects and should work to use the minimal dose necessary to achieve maternal euthyroidism. Thyroid function tests, in particular free T4 and TSH, remain good measures of thyroid function and therapy in pregnancy.     

Iodine induced thyroid disease

Although iodine prevents goiter, enlarged thyroid glands continue to be detected in subjects, especially children, in spite of adequate iodine ingestion. Iodine may cause goiter in susceptible individuals by inhibiting the organic binding of iodine as is seen in adult asthmatics, neonates born of iodine ingesting mothers and in subjects residing along the littoral of Japan. Myxedema, especially in treated Graves' disease and Hashimoto's disease, may also be precipitated by iodine. On the other hand, iodine given to euthyroid subjects in areas of endemic goiter and to subjects with nontoxic nodular goiter may induce thyrotoxicosis by disclosing diffuse autonomously functioning thyroid tissue. An indirect adverse effect of iodine upon the thyroid gland may be manifested by lymphocyte glandular infiltrates and chronic thyroiditis which were sparse or absent in thyroid glands removed from subjects living in iodine deficient areas before iodine prophylaxis and therapy. Not only has the incidence of thyroiditis increased, but the histologic and clinical distinctions between treated Graves' disease and chronic thyroiditis have become indistinct. Experimentally, chronic thyroiditis has been produced in animals following large doses of iodine. Accumulated evidence supports the concept that iodine contributes to the genesis of chronic thyroiditis.     

F-qi-FDG PET of the thyroid gland in Graves' disease

AIM: This study evaluates F-18-FDG PET of the thyroid in Graves' disease. METHODS: Thirty patients were investigated the day before radioiodine therapy, 15 patients 3-10 days after radioiodine therapy. Twenty patients with cancer of the head or neck and normal thyroid function served as controls. RESULTS: F-18-FDG uptake was higher in Graves' disease patients than in controls. Negative correlations of F-18-FDG uptake with half-life of radioiodine and absorbed radiation dose due to radioiodine therapy were found along with a positive correlation to autoantibody levels. CONCLUSION: Thus F-18-FDG PET is likely to give information on the biological activity of Graves' disease as well as on early radiation effects.     

The role of ultrasonography in thyroid disease

Ultrasound examination of the thyroid gland is widely used in the diagnosis of thyroid disease. This test is easy and rapid to perform, widely available and the results are readily interpreted. Using ultrasound the image of foci of disease within the gland are easily identified, especially using high frequency probes which enable solid nodules up to approx 3 mm to be revealed with 10 MHz probes. In non-nodular thyroid disease the ultrasonic structure guides the diagnosis (thyroiditis, Graves' disease). During the follow-up of thyroidectomised patients ultrasound can easily reveal postoperative anatomic variations and an early diagnosis can be obtained of any signs of local recurrence of the primary disease. Only hemiagenesia and hypoplasia can be accurately evaluated in congenital disease, whereas in the event of the persistence of the thyroglossal duct the latter can only be diagnosed if it presents a cystic evolution. Thyroid ectopia cannot be identified and must be studied using thyroscintigraphy, preferably performed using 131I as the isotope. The acquired pathology is classified into phlogistic processes, diffuse or nodular hyperplasia, benign and malignant neoplasia. This classification is widely accepted by virtually all authors. In thyroiditis, ultrasound may facilitate the diagnosis of De Quervain's non-suppurative sub-acute thyroiditis (TANS) and Hashimoto's chronic thyroiditis, although always in association with clinical and laboratory tests. The most frequent thyroid pathology is without doubt goitre. This disorder may occur in a non-nodular (widespread goitre with an endemic or sporadic pattern) or nodular form which may be single or multiple. The term goitre is used to indicate the increased volume of the thyroid gland independently of the causes which have provoked it. Common goitre is defined as being endemic when in some geographic area 10% of the general population or 20% of the school-aged population suffers from thyroid hyperplasia (areas of goitrogenic endemic disease). Graves' disease may be included in the group of thyroid hyperplasia diseases, although it is distinguished from the simple versions by the marked glandular hyperactivity which creates manifest hyperthyroidism. In this pathology ultrasonography must be supplemented by colour-Doppler wherever possible. Thyroid nodules are subdivided in terms of their echostructure into 5 types: liquid, mixed (prevalently solid or prevalently liquid), hyperechogenic solid, isoechogenic solid and hypoechogenic solid. The characteristics of benign nodules are: hypoechogenic structure, regular edges, complete and uniform hypoechogenic peripheral halo.(ABSTRACT TRUNCATED AT 400 WORDS)     

Stress testing for coronary artery disease in the elderly

The elderly constitute an increasing percentage of patients evaluated and treated for coronary artery disease. Clinical and noninvasive evaluation are important in both the diagnosis and prognosis of coronary disease in the elderly, and stress testing is an important part of that evaluation. For older individuals capable of vigorous treadmill or cycle exercise, the exercise electrocardiogram, either alone or combined with radionuclide or echocardiographic imaging, remains an excellent diagnostic and prognostic tool. For the large percentage of elderly patients unable to perform adequate exercise, pharmacologic stress testing with dipyridamole, adenosine, or dobutamine is a valuable alternative. The clinician's challenge is to choose the most appropriate cardiac stress test for his or her patient from among the many alternatives available. Future studies comparing the accuracy and cost-to-benefit ratio of various stress tests with regard to the elderly will help achieve this goal.     

A study of thyroid disease in family practice

Thyroid disease is relatively common in family practice, yet is often undiagnosed or poorly managed. This study examines several aspects of thyroid disease in a large, semirural family practice setting and exemplifies the type of practical clinical research that can be done in family medicine. An overall prevalence of approximately one percent was determined for thyroid disease in this practice. In a series of 85 patients, the ratio of hypothyroidism:hyperthyroidism:euthyroid goiter was 9:2:1 respectively. Initial signs and symptoms recorded for these patients conformed closely to the findings in other large series. Eighty percent of the patients with idiopathic hypothyroidism never had enlarged glands, whereas 100 percent of the patients with hypothyroidism associated with Hashimoto's thyroiditis had enlarged glands. Laboratory aids such as serum thyroid stimulating hormone (TSH), anti-thyroid antibodies, and radioactive iodine uptake (RAIU) and scans were inadequately utilized. Medical and/or surgical consultation was obtained in 17.5 percent of patients with hypothyroidism, 80 percent of patients with hyperthyroidism, and 63 percent of those with euthyroid goiter. Currently 95 percent of the hypothyroid patients and 100 percent of the hyperthyroid patients are euthyroid.     

Refined use of scintigraphy in the evaluation of nodular thyroid disease

BACKGROUND: Scintigraphy has been advocated in patients with a thyroid nodule when fine needle aspiration biopsy (FNAB) is not definitive. The purpose of this study was to determine the incidence of hyperfunctioning nodules in patients without a definitive FNAB, the correlation of serum thyrotropin (TSH) levels with the functional status of a nodule, and whether a sensitive TSH assay can be used in lieu of scintigraphy. METHODS: From 1990 to 1996, patients with a thyroid nodule were evaluated with FNAB and serum TSH measurement. Iodine-123 scintigraphy was reserved for patients without a definitive FNAB and was correlated with TSH levels. RESULTS: Of 356 patients with a thyroid nodule, 102 did not have a definitive FNAB. A hyperfunctioning nodule was diagnosed in 14 of the 102 patients. A low TSH level was detected in 12 (86%) of 14 patients with a hyperfunctioning nodule (mean = 0.04 +/- 0.38 microIU/mL) and only 20 (23%) of 88 patients with a hypofunctioning nodule (mean = 0.87 +/- 4.11 microIU/mL) (P < .05). Only 2 of 70 (2.8%) patients with a normal or increased TSH level had a hyperfunctioning nodule. CONCLUSIONS: A 14% incidence of hyperfunctioning nodules in patients without a definitive FNAB warrants the use of scintigraphy but only when serum TSH levels are low, thus avoiding unnecessary scans in 91% of patients with a thyroid nodule.