No abstract

More than two thirds of seriously ill patients prefer CPR for cardiac arrest and 80% had stable preferences over 2 months. Factors associated with preference change suggest that depression may lead patients to refuse life-sustaining care. Providers should evaluate mood state when eliciting patients' preferences for life-sustaining treatments.

Laparoscopic management of insulinomas is feasible and safe. Laparoscopic intraoperative ultrasonography is a promising adjunct to the procedure, even after accurate preoperative localization.

Over a 14-year period 34 patients were referred for surgical treatment of insulinoma. The diagnosis was confirmed by demonstrating hypoglycaemia with inappropriate hyperinsulinaemia during prolonged fasting. Selective visceral angiography localized 30 solitary benign insulinomas and two carcinomas. In two patients with islet cell hyperplasia, angiography demonstrated a single lesion only. Ultrasonography had a sensitivity of 15 per cent and computed tomography a sensitivity of 24 per cent in the localization of tumours. All patients but one were treated by operation. Eighteen tumours were enucleated and 13 (including both patients with islet cell hyperplasia) were treated by distal pancreatectomy. Two patients underwent negative primary exploration; both had single adenomas removed at re-exploration. There were no operative deaths but nine patients (predominantly those undergoing pancreatic resection) had complications. Thirty-one patients were symptom-free following operation at a mean follow-up of 16 months.

To evaluate the efficacy of subtotal parathyroidectomy (STP) in the treatment of primary hyperparathyroidism due to multiple gland disease, 12 patients with multiple endocrine neoplasia (MEN) type I syndrome were reviewed out of 132 patients undergoing parathyroidectomy. Each patient had yearly follow-up examinations and calcium determinations for a minimum of four years except for one patient who died one year after S.T.P. Permanent hypoparathyroidism occurred in three patients. Two patients remained persistently hypercalcemic, and two patients developed recurrent hypercalcemia. One patient required oral administration of calcium and vitamin D for ten years following STP before recurrent hypercalcemia developed. Another patient was normocalcemic for three years before recurrent hypercalcemia was noted. Only five of these 12 patients remain normocalcemic without need of calcium and vitamin D therapy. In patients with MEN type I, the long-term results of STP are less than satisfactory. Not only is it difficult to gauge how viable parathyroid tissue must be left to prevent both permanent hypoparathyroidism and persistent hyperparathyroidism but there is also a long-term risk of recurrence.