Background:The role of routine intra-operative parathyroid hormone monitoring for sporadic primary hyperparathyroidism is contentious. Satisfactory results can be achieved in high-volume centres. The results of low-volume hospitals are rarely studied.Methods:A retrospective, non-comparative study was conducted. From November 2002 to October 2012, 105 patients with clinically sporadic primary hyperparathyroidism underwent focused parathyroidectomy without intra-operative parathyroid hormone monitoring. Single adenoma was localised on pre-operative ultrasonography or sestamibi scan. The cure rate, surgical complication rate and pathology findings were evaluated.Results:Most of the operations (63.8 per cent) were performed under local anaesthesia. All but two patients (98.1 per cent) were cured after surgery. There was only one case of double adenomas. No recurrent hyperparathyroidism was observed after a mean follow up of 56.9 months. Surgical complications comprised two cases (1.9 per cent) of transient vocal fold palsy and one case (1.0 per cent) of permanent vocal fold palsy. Seven patients (6.7 per cent) suffered temporary hypocalcaemia.Conclusion:Satisfactory results of focused parathyroidectomy without routine intra-operative parathyroid hormone monitoring for appropriately selected primary hyperparathyroidism cases can be attained in a low-volume hospital.

Three patients in two families presented with many years' history of fragile skin, blisters, erosions and scars affecting almost exclusively the shin areas, accompanied by a variable degree of itching. Two of the patients also had toenail dystrophy. Skin biopsy revealed dermal-epidermal blister formation and milia but no immunohistochemical evidence of immunoglobulin or complement deposition. Electron microscopic study of the lesional and perilesional skin showed very sparse or absent anchoring fibrils. Immunolabelling for type VII collagen using LH 7.2 monoclonal antibody revealed a bright, linear staining pattern at the dermal-epidermal junction. The clinicopathological features were thus compatible with pretibial epidermolysis bullosa, a subtype of dystrophic epidermolysis bullosa. Of note, the inflammatory nature of the skin lesions, and their resemblance to nodular prurigo and hypertrophic lichen planus, had caused diagnostic difficulties in all cases in the past. A high degree of awareness of this rare subtype of epidermolysis bullosa is important to establish the correct diagnosis, to allow for genetic counselling and to plan clinical management.

A B S T R A C TGoitres usually enlarge and descend caudad into the substernal space and are not palpable. We report on a patient whose goitre spread downward but anterior to the sternum. The thyroid mass was subsequently removed and was proven to be a papillary thyroid carcinoma. The mechanism by which a presternal goitre develops is probably due to invasion and erosion of the strap muscles and the cervical linea alba. The clinical implication of this presentation is complete extirpation of the presternal goitre with a cuff of the strap muscles.

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