Abnormal Parathyroid Research Articles

Pseudohypoparathyroidism presenting in children at a tertiary hospital in Johannesburg, South Africa

Pseudohypoparathyroidism (PHP) represents a group of disorders due to end organ resistance to the actions of parathyroid hormone (PTH) and abnormalities in the PTH signalling pathway. PHP is charac...

Primary Hyperparathyroidism: To Evaluate Benefit of Ultrasound and Tc99m-SESTAMIBI Scan in Localizing Abnormal Parathyroid Gland Before Surgery, in a Secondary Care Hospital.

IntroductionPrimary hyperparathyroidism is a common endocrine condition requiring parathyroidectomy for curative management. Localization of parathyroid gland by ultrasound and Tc99m-SESTAMIBI is important to opt for less invasive and comparatively lower complication risk surgery minimal invasive parathyroidectomy (MIP) instead of four-gland exploration surgery.AimTo evaluate ultrasound and Tc99m-SESTAMIBI in localization of abnormal parathyroid gland before surgery.Method and materialsAll patients of primary hyperparathyroidism (PHPT) that presented to a secondary care hospital (endocrinology department) from 2015-2019 were recruited retrospectively from electronic fusion system of hospital. Results of ultrasound parathyroid and Tc99m-SESTAMIBI done for localization of abnormal parathyroid gland were analyzed.ResultsTotal PHPT patients recruited were 59, mean age 64.2 years, male 11 (18.64%) and female 48 (81.3%). Ultrasound parathyroid was done in 44 patients, Tc 99m-SESTAMIBI was done in 31, both tests were done in 31 patients. Combined concordant adenoma in both tests was seen in 11 (35%) cases which can opt for minimal invasive parathyroidectomy (MIP) with confidence whereas 65% of cases would require either four-gland exploration or further testing like single-photon emission computed tomography-computed tomography (SPECT-CT) or intraoperative parathyroid hormone measurement to opt for MIP.ConclusionCombined ultrasound parathyroid and Tc 99m-SESTAMIBI scan was useful in localization of parathyroid adenoma in 11 (35%) patients that can opt for MIP which is a lower complication risk surgery whereas 20 (65%) patients would need further investigation with SPECT-CT or intraoperative parathyroid hormone measurement or four-gland exploration surgery.RecommendationThird modality of investigation such as SPECT-CT or intraoperative parathyroid hormone measurement needs evaluation so that more patients can benefit from MIP instead of four-gland exploration surgery.

The diagnostic value of dual-phase SPECT/CT scintigraphy based on transport kinetics of 99mTc-sestamibi confirmed with histopathological findings in patients with secondary hyperparathyroidism - practical consideration.

Dual phase 99mTc-sestamibi SPECT/CT preoperative parathyroid scintigraphy (PPS) is seldom discussed in terms of the transport kinetics of the tracer. To assess the relationship between the characteristic type of tracer transport in particular PPS and histopathological findings in patients with secondary hyperparathyroidism (sHPT). The study comprised 27 patients (13 females and 14 males) with sHPT. Based on tracer accumulation in early phase (EP) and delayed phase (DP), the following types of accumulation for PPS(+) lesions were identified: EP(-)/ DP(+) (type I), EP(+)/DP(+) (type II), EP(+)/DP(-) (type III). EP(-)/DP(-) (type IV) lesions constituted PPS(-) group invisible in SPECT/CT. Overall, 69 lesions 59 PPS(+) and 10 PPS(-) were evaluated histopathologically. Among SPECT/CT PPS(+), types I, II and III occurred in 9 (15%), 49 (83%), and 1 (2%) lesions, respectively. The frequency of histopathological diagnosis of normal and abnormal (APG - adenoma or hyperplasia) parathyroid gland, as well as non-parathyroid (thyroid, lymph nodes, or fat) lesions differed significantly between type I, II, and III lesions (p = 0.036). APG histopathological diagnosis was significantly more frequent in lesions with type II uptake than in lesions with type I uptake (76% vs. 33%, p = 0.0197). Type II lesions had significantly higher odds for histopathological diagnosis of APG or NPG than type IV, PPS(-) lesions [odds ratio = 13.1 (95% CI: 2.75 to 63.27)]. For SHP patients evaluated with SPECT/CT PPS accumulation type I is a weak premise for surgeon to find parathyroid pathology. Only persistent 99mTc-sestamibi accumulation in both phases - equivocal with accumulation type II - effectively differentiates parathyroid and non-parathyroid lesions as well as indicates with high probability the presence of adenoma or hyperplasia. Type III consistent with washout pattern is rare in sHPT.

The effects of radioiodine therapy on parathyroid function among patients with papillary thyroid cancer: a retrospective cohort study.

To explore the effects of initial radioiodine therapy on parathyroid function among postoperative papillary thyroid cancer (PTC) patients. Postoperative PTC patients who were admitted in our department from April 2018 to April 2019 were recruited. Patients were divided into two groups: Group A, who underwent surgery and initial radioiodine therapy in our hospital, and Group B, who did not receive radioiodine therapy after surgery. The levels of serum calcium, magnesium, phosphorus, parathyroid hormone (PTH), and 25 hydroxyvitamin D3 were collected. Data were analyzed by SPSS 25.0. A total of 252 patients were included. Between the two groups, no significant difference of PTH in 6th, 9th, and 12th month was found during postoperative follow-up (p = 0.493, p = 0.202, p = 0.814). No significant difference of PTH was found after stratifying Group A according to 131I dosage (p = 0.751 for 6th month after operation, p = 0.130 for 9th month after operation, p = 0.683 for 12th month after operation), interval time between surgery and radioiodine therapy (p = 0.522 for 3rd day after 131I therapy, p = 0.184 for 9th month after operation, p = 0.311 for 12th month after operation), and ratio of parathyroid autotransplantation (p = 0.545 for 3rd day after 131I therapy, p = 0.485 for 6th month after operation, p = 0.201 for 9th month after operation, p = 0.146 for 12th month after operation). Initial radioiodine therapy following PTC surgery had no significant adverse effect on parathyroid function in the short term. However, physicians should inform patients of possible risks of abnormal parathyroid function prior to RAI therapy, and parathyroid function was periodically reviewed after RAI therapy.

Gonioprobe, an Innovative Gamma-probe to Guide Parathyroid Radioguided Surgery: First Clinical Experiences with Navigator and Lock-ontarget Functions.

Radioguided surgery represents a validated technique for the detection and the excision of abnormal parathyroid glands responsible for primary hyperparathyroidism (PHPT). To date little attention has been paid as to how the characteristics of gamma-probes can influence surgical procedure and time, thus having an impact on postoperative morbidity, hospitalization and costs. We designed a new prototype of gamma-probe, the Gonioprobe, and tested its clinical utility in the operating room. Gonioprobe, thanks to its 5 scintillating independent crystals, performs the dual function of Navigator and Lock-on-target. These characteristics allow the immediate guidance of the surgeon's hand towards the source with very high precision, and with a much higher spatial resolution than commercial probes. Gonioprobe was used during intervention to detect abnormal parathyroid tissue, and to ensure no radioactivity in surgery bed after adenoma removal. We tested our gamma-probe on parathyroid adenomas particularly difficult to identify at a visual inspection due to anatomy modifications from previous neck surgery and/or characterized by uncommon localization. Moreover, parathyroid adenomas were hardly removable due to the proximity to the esophagus, neck vessels and/or recurrent laryngeal nerve (RLN). An intraoperative nerve monitoring system was used to protect the recurrent laryngeal nerve from injuries. Parathyroid hormone (PTH) assay and frozen biopsy confirmed the successful excision of the adenomas. The intraoperative use of the innovative Gonioprobe along with the nerve monitoring system allowed an accurate and safe removal of parathyroid adenomas and offered a significant advantage by reducing surgical time and postoperative complications, as well as hospitalization and costs.

Selective parathyroid venous sampling in reoperative parathyroid surgery: A key localization tool when noninvasive tests are unrevealing

BackgroundPreoperative localization studies are essential for parathyroid re-exploration. When noninvasive studies do not regionalize the abnormal parathyroid gland, selective parathyroid venous sampling may be employed. We studied the utility of parathyroid venous sampling in reoperative parathyroid surgery and the factors that may affect parathyroid venous sampling results. MethodsPatients with hyperparathyroidism and previous cervical surgery undergoing evaluation for reoperative parathyroidectomy over a 20-year period were identified. Patients with indeterminate or negative noninvasive studies underwent parathyroid venous sampling. Parathyroid hormone values were mapped with a ≥2-fold increase above peripheral signifying positive parathyroid venous sampling. These results were correlated with reoperative findings. ResultsParathyroid venous sampling was positive in 113 of 140 (81%). Re-exploration occurred in 75 (66%). Parathyroid venous sampling correctly detected the region of abnormal glands in 58 (77%). With 1 gradient, 1 abnormal gland was found in 81%. With multiple gradients, 1 abnormal gland was found in 78%, most often at the site with the largest gradient. Eighty percent of patients who underwent reoperative parathyroidectomy were biochemically cured. ConclusionParathyroid venous sampling can guide parathyroid re-exploration when noninvasive localizing studies are indeterminate. Expectation of 1 versus multiple remaining glands was key in interpreting the results.

Race and Gender Disparities in Access to Parathyroidectomy: A Need to Change Processes for Diagnosis and Referral to Surgeons.

Hyperparathyroidism substantially impairs quality of life, and effective treatment depends on timely referral to surgeons. We hypothesized that there would be race and gender disparities in the time from initial diagnosis of hyperparathyroidism to treatment with parathyroidectomy. We reviewed administrative data on 2289 patients with hypercalcemia (calcium > 10.5mg/dL) and abnormal parathyroid hormone levels who were seen at a tertiary referral center from 2011 to 2016. We used two-phase parametric hazard modeling to identify predictors of time from index abnormal calcium until parathyroidectomy. The median age of our cohort was 63years, and 1685 (74%) were women. Of the total patients, 1301 (57%) were Caucasian, and 946 (41%) were African-American. Only 490 (21%) patients underwent parathyroidectomy. Among patients undergoing surgery, time from index high calcium to surgical treatment was longest for African-American men, who waited a median of 13.6months (interquartile range IQR 2-28), compared with 2.9months (IQR 1-8) for Caucasian males (p < 0.05). African-American women waited a median of 6.7months (IQR 2-16) versus 3.5months (IQR 2-14) for Caucasian women (p < 0.05). At 1year after the index abnormal calcium, only 6% of black men underwent surgery compared with 20% of white males (p < 0.05). Similarly, 13% of black women underwent surgery versus 20% of white women (p < 0.05). These differences remained significant after adjusting for age, calcium levels, insurance, and comorbidities. African-Americans face substantial delays in access to parathyroidectomy after diagnosis with hyperparathyroidism that could impair quality of life and increase health care costs. We must improve systems of diagnosis and referral to ensure timely treatment of hyperparathyroidism.

The use of computed tomography as a first-line imaging modality in patients with primary hyperparathyroidism.

The success of minimally invasive parathyroidectomy (MIP) relies on accurate localization of the abnormal parathyroid glands. Concordant findings on ultrasound (US) and 99mTc-scintigraphy (sestamibi) are currently considered the 'gold standard'. Computed tomography (CT) has also recently been used in preoperative planning. We sought to assess the accuracy of CT for localization of abnormal parathyroid glands in such patients. An audit of 75 patients with primary hyperparathyroidism (PHPT) who underwent neck US and CT between 2017 and 2019 at our center as their first-line imaging. All 75 patients underwent US and CT and 54 (72.0%) also had sestamibi. CT alone identified a potential target in all patients, of which the location was correct in 63 (84.0%). The overall combined sensitivity of US and CT was 88% (95% CI 78-94) and was higher than the combined sensitivity of US and sestamibi (65% [95% CI 53-76]; p < 0.001). Twenty-one patients (28.0%) had an ectopic gland, and the sensitivity of US and CT was 86% (95% CI 64-96) versus US and sestamibi (57% [95% CI 34-77]; p = 0.016). For adenomas < 1.0g (n = 36; 48%), the accuracy of CT was 81% (95% CI 64-91) compared with 62% (95% CI 44-77) for US and sestamibi (p = 0.04). The correct preoperative diagnosis of multiglandular disease (n = 9; 12%) seemed to be the most difficult, with similar accuracy for US and sestamibi (40% [95% CI 14-73]) and US and CT (50% [95% CI 20-80]) (p > 0.99). The combination of US and CT was able to correctly identify the location of the abnormal parathyroid in 88% of patients and, in comparison with US and sestamibi, had better diagnostic accuracy, especially for smaller and ectopic adenomas. This finding suggests that US and CT could be considered as a first-line imaging modality in patients with PHPT considered for MIP.

SAT-398 The Use of Imaging in Primary Hyperparathyroidism

Primary hyperparathyroidism is characterized by excessive dysregulated production of parathyroid hormone (PTH) by 1 or more abnormal parathyroid glands. Preoperative localization is important for surgical planning in primary hyperparathyroidism. Previously, it had been published that ultrasound (sensitivity of 76.1%, positive predictive value of 93.2%) and nuclear scintigraphy (Sestamibi-SPECT) (sensitivity of 78.9%, and a positive predictive value of 90.7%) are first line imaging modalities1. Currently, the imaging modality of choice varies according to region and institutional protocol. The aim of this study was to evaluate the imaging modality that is associated with an improved remission rate based on concordance with operative findings. A secondary aim was to determine the effect of additive imaging on remission rates. This was an IRB-approved retrospective review of 2657 patients with primary hyperparathyroidism undergoing surgery at a tertiary referral center from 2004–2017. Analyses were performed with SAS software using a 95% confidence interval (p<0.05) for statistical significance. After excluding re-operative and familial cases, 2079 patients met study criteria. There were 422 (20.3%) male and 1657 (79.7%) female patients with a mean age of 66 (+12.2) years, of which 1723 (82.9%) of patients were white and 294 (14.1%) patients were black. Ultrasound (US) was performed in 1891 (91.9%), sestamibi with SPECT (sestamibi/SPECT) in 1945 (93.6%), and CT in 98 (4.7%) patients. Of these, 1721 (82.8%) had combined US and sestamibi/SPECT. US was surgeon-performed in 94.2% of cases and 89.9% of the patients underwent a four gland exploration. Overall, US concordance was 52.4%, sestamibi/SPECT was 45.5%, and CT was 45.9%.US and sestamibi/SPECT both had an improved remission rate if concordant with operative findings, while CT had no effect (US p=0.04; sestamibi/SPECT p=0.01; CT p=0.50). The overall remission rate was 94% (CI=0.93–0.95), however, increasing the number of imaging modalities performed did not increase the remission rate (p=0.76) or concordance with operative findings (p=0.05). Despite having low concordance rates, US and sestamibi/SPECT that agreed with operative findings were associated with higher remission rates. Therefore, when imaging is to be used for localization, our data support the use of US and sestamibi/SPECT as the initial imaging modalities of choice for preoperative localization. 1Kuzminski SJ, Sosa JA, Hoang JK. Update in Parathyroid Imaging. Magn Reson Imaging Clin N Am. 2018;26(1): 151–166.

SAT-361 Familial Hypocalciuric Hypercalcemia Type 3: AP2S1 Mutation

Background: Familial hypocalciuric hypercalcemia (FHH) type 3 can appear similar to primary hyperparathyroidism and make the diagnosis of etiology of hypercalcemia challenging.Clinical Case: A 45-year-old man with hypertension and glaucoma was evaluated in clinic for hypercalcemia. His calcium was 12.3 mg/dL (8.4–10.2), PTH 41.9 pg/mL (15–65), Vitamin D 14.8 ng/mL (6.6–49) and phosphorus 1.7 mg/dL (2.7–4.5). He denied history of thiazide diuretic use, fragility fracture, nephrolithiasis and family history of calcium disorders. Further workup revealed normal kidney function, undetectable PTH related peptide and dual-energy x-ray absorptiometry (DEXA) scan with a T-score of -3.3 at spine L1-L4, -2.7 at femoral neck and -2.1 at distal one-third forearm. A 24-hour urine collection revealed a urinary calcium of 42.4 mg/24-hour (100–300) and calcium: creatinine clearance ratio of 0.003. Diagnosis of primary hyperparathyroidism was made despite low urinary calcium as this was thought to be due to vitamin D deficiency. Sestamibi scintigraphy and four-dimensional computed tomography did not localize a parathyroid adenoma, however, the patient was sent to surgery for four gland parathyroid exploration for primary hyperparathyroidism in setting of high calcium and young age with evidence of end-organ failure of osteoporosis. During surgery, three large abnormal parathyroid glands were identified and one normal parathyroid gland. Patient had a three-gland parathyroidectomy with intraoperative drop in PTH by 26.5%. Pathology returned as benign parathyroid tissues. After surgery, patient had persistently elevated calcium level of 12.6 mg/dL and an inappropriately non-suppressed PTH. He was then started on bisphosphonate and cinacalcet for osteoporosis and hypercalcemia, respectively and sent for genetic testing of FHH. His CASR gene was negative but his AP2S1 gene was positive which confirmed the diagnosis of FHH type 3. His calcium responded well to cinacalcet and repeat DEXA scan showed stability of bone mineral density in spine and hip after two years of treatment with bisphosphonate therapy.Conclusion: Familial hypocalciuric hypercalcemia type 3 is caused by an inactivating mutation in the AP2S1 gene. This gene encodes the adaptor-related protein complex 2, sigma 1 subunit which is located downstream from calcium-sensing receptor. This genetic mutation can appear similar to primary hyperparathyroidism in that it produces high levels of calcium and PTH and low phosphorus. Hypercalcemia, however, persists despite removal of parathyroid gland. This genetic mutation can be treated with cinacalcet in patients with high levels of calcium (>1 upper limit of normal) or symptoms of hypercalcemia.

SUN-137 Clonal Status of Multigland Disease Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common endocrine disorder that arises due to single or multiple parathyroid gland disease (MGD). The molecular mechanism(s) of parathyroid neoplasia are incompletely understood and both monoclonal (mono-X) and polyclonal (poly-X) parathyroid tumors have been described using methylation-sensitive PCR of X-linked Human Androgen Receptor (HUMARA) alleles. Our previous investigations of parathyroid tumor clonal status has shown that poly-X tumors are common and are associated with MGD in patients with non-familial PHPT (Shi et al. 2014 & 2018). This work examined the clonal status of the dominant gland and the clonal relationship of multiple tumors from the same patient has not been examined. The goal of the current study was to determine the clonal relationship of parathyroid tumors from PHPT patients with MGD. Banked parathyroid tissues from twenty-nine PHPT patients with MGD were examined in this study. Clonal status (mono-X vs poly-X) of multiple abnormal parathyroid glands from each patient was determined using a modification of the HUMARA assay used in our prior work. Briefly, methylation-sensitive PCR of HUMARA alleles was performed followed by fragment analysis using Capillary-Electrophoresis performed. Raw fragment sizing data analyzed using Peak Scanner software. Classification of samples as either mon-X or poly-X was made as described in (Shattuck et al.) Of 29 PHPT patients with MGD, 13 (45%) had pure mono-X, 5 (17%) had pure poly-X, and 11 (38%) had a mixture of mono-X and poly-X tumors. Five of 29 patients had three or more abnormal glands evaluated: 3 had mixture of poly-X and mono-X, 2 had pure mono-X tumors, and none were pure polyclonal-X. Eighteen (62%) out of 29 patients had paired upper or lower double adenomas. Of these, 9 (50%) were pure mono-X, 4 were pure poly-X, and 5 were mixed mono-X/poly-X. In 2 patients with multiple mono-X tumors, allele distribution was not the same in different abnormal glands. Our previous work has demonstrated that among patients with non-familial PHPT, poly-X parathyroid tumors are common and are associated with MGD. Our new data extend these findings to show that the clonal relationship between multiple parathyroid tumors from the same patient is complex and may reflect the emergence of single or multiple tumors from a background of parathyroid hyperplasia, or other mechanism(s). Future studies to explore the mechanisms behind these apparent clonal relationships are warranted and ongoing. Reference: (1) Shi et al., PNAS 2014, 201319742. (2) Shi et al., Surgery 2018, 9-14. (3) Shattuck. N Engl J Med 2005, 2406-12.

Imaging methods of the parathyroid glands in primary hyperparathyroidism. Literature review

Primary hyperparathyroidism (PHPT) is a common endocrine disease that occurs with multiple profiles in which no classical manifestation. Diagnosis revolves around routine measurement of serum calcium and parathyroid hormone more than in half cases. The understanding of clinical presentation, epidemiology and management tactics of patients with hyperparathyroidism has significantly changed by virtue of the use of biochemical calcium screening.&#x0D; The successful diagnosis and treatment are possible with the cooperation of a multidisciplinary team of endocrinologist, endocrine surgeon, radiologist, nuclear medicine physician and pathomorphologist.&#x0D; The only radical method of treatment is the surgical removal of abnormal parathyroid glands. In this regard, there is necessary to improve the parathyroid glands imaging algorithms.&#x0D; Early treatment of hyperparathyroidism allows to avoid severe damage to the bones, kidneys, heart, other organs, improving the quality of life and reducing the incidence of disability.&#x0D; For a systematic literature review, more than 100 articles published from 2000 to the present time were used, on following resources: PubMed, Embase, SciSearch, Scopus, Cochrane Databases, Research Gate, Google Scholar. Including recommendations from the American Association of Endocrinologists and Endocrine Surgeons (AACE/AAES), European Society of Nuclear Medicine (EANM), European Society ofEndocrinologists (ESE), Russian Association of Endocrinologists (RAE) and several other organizations.&#x0D; The main goal of this review is to summarize and present relevant information and a new look on preoperative imaging techniques, methods of intraoperative navigation, surgery, control quality of treatment in patients with primary hyperparathyroidism.

Preventing Blind Thyroid Lobectomy in Patients with Intrathyroidal Hyperfunctioning Parathyroid Glands with Radioguided Enucleation

Aim: Hyperfunctioning intrathyroidal parathyroid glands are rare and often result in thyroid lobectomy. This study examines the utility of radioguided surgery to guide enucleation of intrathyroidal parathyroids. Methods: Between December 2002 and March 2018, 2291 patients underwent parathyroidectomy by one surgeon for primary hyperparathyroidism. A total of 74 (3%) patients had an ectopic intrathyroidal parathyroid gland and underwent radioguided. Results: All of intrathyroidal parathyroid glands were localized with the gamma probe. In vivo radionuclide counts were above 120% of the background in all but three patients. All intrathyroidal parathyroids were enucleated with the guidance of the gamma probe. Conclusion: Radioguided surgery is useful for intraoperative identification of hyperfunctioning, intrathyroidal parathyroid glands. This technique allows for enucleation of the abnormal parathyroid gland, avoiding thyroid lobectomy and preserving healthy thyroid parenchyma.

Peripheral Vascular Calcification in Patients on Regular Hemodialysis in relation to Parathyroid Hormone Abnormalities

Background: Peripheral vascular calcification (PVC) commonly develop in patients on hemodialysis (HD) and associated with increase risk of morbidity and mortality. Aim of study: To study risk factors of developing peripheral vascular calcification in patients on hemodialysis especially in relation to parathyroid hormone abnormalities. Patients and Methods: Cross sectional (observational) study on 54 patients on regular hemodialysis and divided into 2 groups according to abdominal X-Ray. Results: 54 patient: 32 female, 22 male; mean age = 51.59 +/- 17.61, mean duration of HD = 44.83 +/- 38. 4 months Peripheral vascular calcification by lateral lumbar X-Ray is 12 patients i.e 22.22% We studied effects of many risk factors and appeared significant effects of age, duration of HD and use of calcium containing oral phosphate binders. Also there is some effects of increased serum calcium and phosphate, hypertension and DM but statistically not significant. PTH abnormalities also affect on PVC especially in low level of PTH (a dynamic bone disease) but statistically not significant. In this study, no apparent effect of inflammation on calcification. Conclusion: Peripheral vascular calcification, commonly present in patients on hemodialysis and associated with increase risk of morbidity and mortality, with many risk factors causing increase peripheral vascular calcification which can be prevented and treated

Surgical implications of recent modalities for parathyroid imaging.

Clinical or subclinical primary hyperparathyroidism (PHPT) is one of the most common endocrine disorders in the world. Parathyroidectomy is the treatment of choice in symptomatic patients, stabilizing the progression of complications caused by the destruction activity of parathyroid hormone (PTH). Parathyroid surgical techniques have evolved over the years from bilateral neck exploration, to minimally invasive single parathyroid gland exploration, to minimally invasive video-assisted parathyroidectomy. Localization of the abnormal parathyroid gland before surgery is crucial for the operation to be effective. Increased incidences of reoperations of the parathyroid glands and the rapid development of minimally invasive methods led to the development of new localization techniques. The noninvasive studies include ultrasound (US), computed tomography (CT), magnetic resonance (MR) and 99mTc-methoxyisobutylisonitrile (MIBI) scintigraphy combined with single-photon emission CT (SPECT/CT). Among the latest technologies, the four-dimensional (4D)-CT scan, positron emission tomography (PET)/CT and PET/MR are very promising, and are going to have surgical implications in the future.

Clinical Characteristics and Prevention Strategies of Falls in Hospitalized Patients with Chronic Kidney Disease

Objectives: To analyze the clinical features of falls in hospitalized patients with chronic kidney disease (CKD), and to provide basis for preventing the occurrence of falls in hospitalized patients with CKD. Method: A retrospective study was conducted to analyze the 27 adverse events of falls in hospitalized patients from the department of nephrology in Peking University Shenzhen Hospital during May 2009 and May 2019. Results: Among the 27 patients with falls, people over 65 years old accounted for 55.56%; 74.07% of the patients had caregivers; the peak period of falls was from June to August, accounting for 40.74%, mainly occurring from 7:00 to 8:00, 12:00 to 13:30 and 19:00 to 21:00; the locations of falls were mostly near the bed and in the bathroom, accounting for 33.33% and 22.22%, respectively; suffering from anemia, hypoproteinemia, abnormal serum potassium, calcium-phosphorus metabolism disorders accompanied by abnormal parathyroid hormone and hypertension accounted for 88.89%, 85.19%, 29.63%, 96.30% and 81.48% respectively. The inpatients on dialysis therapy accounted for 66.67%. Conclusion: The occurrence of falls in hospitalized patients with CKD was not only related to age, caregivers, time, months, locations or other conventional factors, but also the complications and dialysis therapies. To effectively reduce the occurrence of falls, it’s necessary to enhance the sense of safety and responsibility of caregivers. Besides, nurses should strengthen the inspection of wards for inpatients engaging in some intensive activities, and nurses should also pay more attention to the inpatients with anemia, hypoproteinemia, calcium-phosphorus metabolism disorders and those on dialysis therapies.

Stepwise Approach for Parathyroid Localisation in Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a relatively common condition in surgical practice. Availability of localisation studies has shifted the treatment from bilateral neck exploration to selective parathyroidectomy. Several imaging modalities, each with varying sensitivities, are available to detect abnormal parathyroid glands. Ultrasound is almost universally accepted as the first line radiological investigation however its sensitivity is particularly heterogeneous and operator-dependent. We studied 250 consecutive patients with PHPT who underwent parathyroidectomy in our hospital over a period of 33months. Pre-operative neck ultrasound, 99mTc-sestamibi and single-photon emission computed tomography (SPECT CT) were performed in 249, 237 and 198 patients respectively. Unilateral and bilateral neck exploration was performed in 190 and 60 patients, respectively. Sensitivity, positive predictive value (PPV) and accuracy were calculated comparing the results with surgical and pathology findings. Mean pre and postoperative PTH and adjusted calcium were, 11 ± 10.6pmol/L, 1.9 ± 3.6, 2.81 ± 0.2 and 2.45 ± 0.2mmol/L. There were 71 (29.95%) discordant results between US, compared to sestamibi and SPECT CT. An average of 1.9 parathyroid glands were removed with a mean weight of 0.92g. Overall success rate based on postoperative PTH levels was 94.8%. Overall sensitivity, PPV and accuracy for US were 80.80%, 92.35%, and 75.73% respectively; for sestamibi were 71.82%, 94.61%, 69.00% and for SPECT CT were; 70.21%, 97.78%, 69.11% respectively. Ultrasound performed by an experienced specialist sonographer is highly sensitive in localising abnormal parathyroid glands. It can be used as a main and sole investigation in the majority of patients. Sestamibi, SPECT CT and other investigations should be performed in a step-wise manner and reserved for patients with negative US, failed primary procedure and recurrences.

Receiver Operating Characteristic Analysis of Intraoperative Parathyroid Hormone Monitoring to Determine Optimum Sensitivity and Specificity: Analysis of 896 Cases

Objective: While intraoperative parathyroid hormone (IOPTH) monitoring with a ≥50% drop commonly guides the extent of exploration for primary hyperparathyroidism (pHPT), receiver operating characteristic (ROC) analysis has not been performed to determine whether other criteria yield better sensitivity and specificity. The aim of this study was to identify the optimum percent change of IOPTH following removal of the abnormal parathyroid pathology, in order to predict biochemical cure. Secondary aims were to identify patient subgroups with increased area under the ROC curve (AUC) and the need for moderated criteria. Methods: A retrospective review was performed on patients undergoing primary parathyroid surgery for sporadic pHPT between 1999 and 2010 at a tertiary center for endocrine surgery. Eight hundred and ninety-six patients with primary hyperparathyroidism were included. Multigland disease (MGD) was defined as the intraoperative detection of more than 1 enlarged hypercellular gland or persistent disease after single gland excision. ROC analysis was used to determine the value with the best performance at predicting MGD, following bilateral exploration. Results: MGD was diagnosed in 174 patients (19.4%). ROC analysis demonstrated an AUC of 0.69. An IOPTH drop of 72% was the point of optimal discrimination with a sensitivity of 55% and specificity of 76% for predicting MGD. Subgroup analysis by preoperative calcium, preoperative PTH, localization studies, or pre- and post-excision IOPTH, did not identify any factors associated with an improved AUC. Conclusion: To our knowledge, this is the first study to use ROC analysis in a large patient cohort. An IOPTH drop of 72% was found to have optimal discriminating ability. We failed to identify a subset of patients for whom there was substantial improvement in the AUC, sensitivity, or specificity. Abbreviations: AUC = area under the ROC curve; BE = bilateral neck exploration; FE = focal parathyroid exploration; IOPTH = intraoperative parathyroid hormone; MGD = multigland disease; MIBI = Tc99m-sestamibi I-123 subtraction single-photon emission computed tomography/computed tomography; pHPT = primary hyperparathyroidism; ROC = receiver operating characteristic; SGD = single gland disease; US = surgeon-performed neck ultrasound.

Persistent/Recurrent Primary Hyperparathyroidism: Does the Number of Abnormal Glands Play a Role?

BackgroundPersistent/recurrent hyperparathyroidism occurs in 2%-5% of patients with sporadic primary hyperparathyroidism (PHPT). In this study, the incidence and time to recurrence in patients with single-gland disease (SGD), double adenomas (DAs), or four-gland hyperplasia (FGH) at initial parathyroidectomy were compared. MethodsThis retrospective review included adult patients with sporadic PHPT who underwent initial parathyroidectomy with intraoperative parathyroid hormone monitoring (IOPTH) from 1/2000 to 12/2016 with ≥6 mo follow-up. An abnormal parathyroid was defined by a gland weight of ≥50 mg. A concurrent serum calcium >10.2 mg/dL and parathyroid hormone >40 pg/mL was defined as persistent PHPT if present <6 mo and recurrent PHPT if present ≥6 mo postoperatively after initial normocalcemia. ResultsOf 1486 patients, 1203 (81%) had SGD, 159 (11%) DA, and 124 (8%) FGH. Among the 3 groups, there was no difference in the percent decrease from the baseline or time of excision to final postexcision IOPTH levels between groups (79% versus 80% versus 80%, respectively; P = 0.954) or in the proportion of patients with a final IOPTH ≥40 (22% versus 18% versus 14%; P = 0.059). Overall, 22 (1.5%) had persistent PHPT and 26 (1.7%) had recurrent PHPT. Persistent PHPT was more frequent with DAs (6; 3.8%) than other groups (SGD: 16, 1.3%; FGH: 0; P = 0.02). At median follow-up of 33 mo (IQR, 18-60), there was no difference in recurrence rate (1.6% versus 2.5% versus 2.4%; P = 0.57) or median time (mo) to recurrence (SGD: 59 [IQR, 21-86], DAs: 36 [IQR, 29-58], FGH: 23 [IQR, 17-40]; P = 0.46). ConclusionsRecurrent PHPT occurred in 1.7% of patients who underwent curative initial parathyroidectomy, with no difference in incidence or time to recurrence between groups based on the number of glands removed. Patients with DA more commonly had persistent PHPT, raising the possibility of unrecognized FGH.

Discordant findings on preoperative imaging for primary hyperparathyroidism and thyroid disease: Choosing the path to follow

BackgroundPreoperative localization of abnormal parathyroid glands in primary hyperparathyroidism is often obtained by sestamibi, and ultrasonography. We aimed to identify which modality is most accurate when laterality of abnormal glands on preoperative imaging is discordant. MethodsA single institution retrospective review identified 112 consecutive patients with primary hyperparathyroidism who underwent successful parathyroidectomy and sestamibi with pertechnetate. ResultsSestamibi with pertechnetate had a sensitivity of 72% and positive predictive value of 90%; ultrasonography had sensitivity of 50% and positive predictive value 80%. Patients with thyroiditis had lesser sensitivity and positive predictive value on sestamibi with pertechnetate (53% and 77%, respectively), in contrast to ultrasonography (54%, 88%, respectively). The sensitivity and positive predictive value of sestamibi with pertechnetate and ultrasonography did not differ in patients with thyroid nodules. Seventeen patients (15%) had discordant laterality on preoperative imaging. In discordant cases, sestamibi with pertechnetate was correct in 53% overall but in only 17% of those with thyroiditis (P = .01), whereas ultrasonography was correct in 26% overall but in 50% of those with thyroiditis (P = .01). ConclusionThyroiditis decreased the sensitivity and positive predictive value of sestamibi with pertechnetate in primary hyperparathyroidism. In patients with discordant laterality on preoperative imaging, sestamibi with pertechnetate is the more accurate choice to guide operative planning, although ultrasonography may be a better guide in those with thyroiditis.