Objective-To evaluate the prognostic factors in uncomplicated venous leg ulcer healing.Design-Randomised parallel group controlled trial with subjects stratified by initial ulcer diameter and four months' maximum duration offollow up.Setting
A case is described of a successful radioguided forearm graft parathyroidectomy. This is the first report of both pre-operative diagnostic and successful intra-operative localisation during a single procedure, of autologous transplanted parathyroid tissue.
Excision of ectopic parathyroid adenomas located within the mediastinum has traditionally relied on open techniques such as full median sternotomy, manubrial split or thoracotomy.1,2 Thoracoscopy is a well-established thoracic surgical technique used to biopsy pleural or pulmonary lesions, drain pleural effusions, and to perform pleurodesis for recurrent pneumothorax and effusions. 3 The application of thoracoscopy to the excision of mediastinal ectopic parathyroid adenomas represents a novel treatment with the potential for greatly reduced complication rates and length of stay compared to conventional open thoracic surgery, 4 and represents a technique that has not yet been reported in British medical literature. Case 1A 70-year-old man with a history of hypertension, repair of a ruptured abdominal aortic aneurysm and transient ischaemic attacks, was referred by his GP for renal investigation because of a raised creatinine of 255 mmol/l. Blood tests revealed corrected calcium of 2.97 mmol/l (range, 2.15-2.6) and parathyroid hormone (PTH) level of 25.8 pmol/l (range, 0.5-4.4). Glomerular filtration rate (GFR) was estimated at 22 ml/min. An ultrasound showed no renal tract abnormality. Tertiary hyperparathyroidism was suspected. A technetium-labelled sestamibi scan was reported as showing no increased uptake in the neck or upper mediastinum. The patient's calcium had risen to 2.99 with a PTH of 45.6, and he was symptomatic with profound lethargy, bone and abdominal pains. He had required two pamidronate infusions, with only minimal improvement. A neck exploration was performed despite the negative sestamibi: this revealed three normal glands, which were left in situ.A computerised tomography (CT) scan subsequently revealed a 1.5-cm enhancing mass adjacent to the
ance of immunological tolerance to these natural compounds.' Under conditions of autoimmunity, such as experimentally induced immune mediated demyelination of the peripheral nerves, injections of pure gangliosides do not result in the induction of antibodies to gangliosides and do not worsen the course of the disease.7 A neurological syndrome induced in rabbits by injecting gangliosides derived from brain reported by Nagai et at could not be reproduced and could be explained as resulting from contamination of the ganglioside preparation by myelin proteins. Antibodies reactive with gangliosides recognise the carbohydrate portion of the molecule. These carbohydrate epitopes are not uniquely expressed on gangliosides but are also present on glycoproteins and bacterial cell walls.9 Controlled studies in humans have proved that the prolonged administration of Gmi in healthy individuals as well as in patients with neurological diseases does not modify the pattern of antibody crossreactivity to glycoconjugates.'°I n conclusion, all available data are consistent with the lack of immunogenicity of brain-derived gangliosides if purity is guaranteed. Thus, their use for therapeutic purpose should not be restricted by the present immunological knowledge.
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