Background
We sought to evaluate the relationship between the preoperative core‐laboratory parathyroid hormone (CL‐PTH) level and the baseline intraoperative PTH (IOPTH) level and assess the impact ...of any differences on clinical decision making in consecutive surgical patients with primary hyperparathyroidism undergoing parathyroidectomy.
Methods
The CL‐PTH and baseline IOPTH levels were compared. The influence of relying on either the CL‐PTH or baseline PTH levels for intraoperative decision making was determined.
Results
Data were available for 316 patients. Baseline IOPTH measurements were usually higher than the CL‐PTH (247 patients; 78.2%) measurements, with a mean difference of 68.2 pg/mL (P < .001). Using the CL‐PTH as a surrogate for the baseline parathyroid hormone (PTH) would have prolonged the operation in 23 patients (7.3%).
Conclusion
Baseline point‐of‐care IOPTH levels were higher than the preoperative CL‐PTH levels in >75% of patients undergoing parathyroidectomy. Using the CL‐PTH in lieu of an IOPTH baseline value would prolong the operation in some patients.
Background
Patients who require surgery for renal hyperparathyroidism represent a special population that is at high risk for postoperative complications. To optimize their treatment, we developed a ...multidisciplinary approach to the perioperative management of these patients undergoing parathyroidectomy.
Methods
The Augusta University endocrine surgery parathyroid database was interrogated to identify dialysis‐dependent patients undergoing parathyroidectomy from 2005 to 2015. Numerous clinical parameters were quantified. Patients were stratified into protocol patients and nonprotocol patients.
Results
A total of 42 patients undergoing renal parathyroidectomy who met the inclusion criteria were identified. Serious adverse events were nearly twice as common in the patients not treated on protocol. The length of stay was nearly 2 days shorter in the protocol group. Lowest calcium level and ionized calcium was higher in the protocol cohort despite a lower postoperative parathyroid hormone. The protocol group had fewer laboratory draws.
Conclusion
Implementation of a multidisciplinary renal hyperparathyroidism protocol has resulted in improved perioperative outcomes.
Purpose
While increased suicidal tendencies among cancer patients have been well documented, this study aims to examine suicide rates and factors associated with suicide specifically in patients with ...colorectal cancer (CRC).
Methods
Patients diagnosed with CRC between the years of 1988–2010 were selected from the Surveillance, Epidemiology, and End Result (SEER) database. Comparisons with the general population were done using the National Center for Disease Control registry.
Results
One thousand three hundred eighty-one suicides among 884,529 patients were identified, with a standardized mortality ratio (SMR) of 1.53 (95% CI, 1.13–1.33) compared to the general population. No statistically significant difference in suicide rate was found with respect to age, marital status, socio-economic status, surgical intervention, histologic subtype, or stage at diagnosis. Within the CRC population, Whites were significantly more likely to commit suicide than non-Whites (OR, 2.28; 95% CI, 1.89–2.75;
P
< 0.001), and males were significantly more likely than females (OR, 5.635; 95% CI, 4.85–6.54;
P
< 0.001). Most suicides occurred in patients with distal lesions in the sigmoid/rectosigmoid junction (
P
< 0.001). SMRs for CRC patients were 4.24 for females (95% CI, 3.69–4.86), 1.35 for males (95% CI, 1.28–1.43), 0.38 for African-Americans (95% CI, 0.28–0.52), 1.77 for Whites (95% CI, 1.68–1.87), and 0.90 for other races (95% CI, 0.72–1.12).
Conclusion
Identification of risk factors associated with suicide among patients with CRC is an important step in developing screening strategies and management of psychosocial stressors. These results could be helpful in formulating a comprehensive suicide risk scoring system for screening all cancer patients.
Objective
Recent advances in preoperative imaging techniques and intraoperative parathyroid hormone (ioPTH) assays have made single‐gland, minimally invasive parathyroidectomy (MIP) the preferred ...treatment option for most patients with primary hyperparathyroidism (pHPT). Despite this evolution, a recommendation for bilateral neck exploration (BNE) with four‐gland dissection in all patients has recently been advocated by a parathyroid surgical group. The current study compares the long‐term outcomes of MIP with those of conventional BNE with four‐gland dissection in patients with pHPT.
Methods
In order to objectively assess a recommendation in the literature that universal BNE with four‐gland dissection is advisable, all patients undergoing an initial MIP with ioPTH assessment for pHPT in a tertiary endocrine practice during a 10‐year period were reviewed. The cure rates from this procedure were compared with published results of conventional BNE with four‐gland dissection.
Results
Of the 561 patients undergoing parathyroidectomy during the study period, 337 had initial surgery for pHPT; 282 of these patients met inclusion criteria and 212 had sufficient follow‐up data available. A single adenoma was identified in 87.3% of cases. Preoperative imaging studies were co‐localizing in 148 (69.8%), and 127 (85.8%) of these patients with co‐localizing imaging required only single‐gland surgery. Imaging studies did not co‐localize in 49 patients, yet 32 (65.3%) of these patients were still cured with unilateral surgery. The cure rate for patients undergoing MIP was 98.6%, with a long‐term recurrence rate of <2%.
Conclusion
When coupled with the ioPTH assay, patients with at least one preoperative localizing study can undergo MIP and anticipate a cure rate of 99%, which is as good as or better than the published rates for conventional BNE with four‐gland dissection. With unilateral surgery, the risks of permanent hypoparathyroidism and airway obstruction from bilateral vocal fold paralysis are completely eliminated. Therefore, despite recommendations to the contrary, most patients with pHPT should not have a planned four‐gland exploration.
Level of Evidence
III or IV
Specifically, the signaling pathways involve a protein called mTOR, which stands for "molecular target of rapamycin." mTOR is a protein kinase involved in protein and lipid synthesis, cytoskeletal ...development, energy generation, cellular metabolism, and survival.3 TSC1 and TSC2 normally exert inhibitory effects on mTOR, thus keeping cell growth regulated and in check. ...cellular growth and synthetic processes are less inhibited and potentially unbridled, thus increasing risk of tumorigenesis.
Chronic pain frequently is associated with autosomal dominant polycystic kidney disease and is a significant cause of morbidity. The classic approach to treat pain in patients with this disease ...starts with nonpharmacologic therapy and progresses to high-dose opioid therapy and more invasive procedures, including surgery. We present the case of a 43-year-old white woman presenting in our clinic with poorly controlled chronic left flank and epigastric pain secondary to autosomal dominant polycystic kidney disease despite high-dose opioids and multiple cyst decompression procedures. After temporarily successful management with celiac plexus neurolysis and intercostal nerve radiofrequency ablations for years, the next more permanent step was dorsal column neurostimulation, affording excellent analgesia with significantly improved quality of life to this day.
Heat flow (Q) determined from bottom-hole temperatures measured in oil and gas wells in Alberta show a large scatter with values ranging from 40 to 90 mW m−2. Only two precise measurements of heat ...flow were previously reported in Alberta, and were made more than half a century ago. These were made in wells located near Edmonton, Alberta, and penetrated the upper kilometre of clastic sedimentary rocks yielding heat flows values of 61 and 67 mW m−2 (Garland & Lennox). Here, we report a new precise heat flow determination from a 2363-m deep well drilled into basement granite rocks just west of Fort McMurray, Alberta (the Hunt Well). Temperature logs acquired in 2010-2011 show a significant increase in the thermal gradient in the granite due to palaeoclimatic effects. In the case of the Hunt Well, heat flow at depths >2200 m is beyond the influence of the glacial-interglacial surface temperatures. Thermal conductivity and temperature measurements in the Hunt Well have shown that the heat flow below 2.2 km is 51 mW m−2 (±3 mW m−2), thermal conductivity measured by the divided bar method under bottom of the well in situ like condition is 2.5 W m−1 K−1, and 2.7 W m−1 K−1 in ambient conditions), and the geothermal gradient was measured as 20.4 mK m−1. The palaeoclimatic effect causes an underestimate of heat flow derived from measurements collected at depths shallower than 2200 m, meaning other heat flow estimates calculated from basin measurements have likely been underestimated. Heat production (A) was calculated from spectral gamma recorded in the Hunt Well granites to a depth of 1880 m and give an average A of 3.4 and 2.9 μW m−3 for the whole depth range of granites down to 2263 m, based on both gamma and spectral logs. This high A explains the relatively high heat flow measured within the Precambrian basement intersected by the Hunt Well; the Taltson Magmatic Zone. Heat flow and related heat generation from the Hunt Well fits the heat flow-heat generation relationship determined for other provinces of the Canadian Shield. However, this relationship could not be established for Q estimates from industrial temperatures data for the study area that includes the Taltson Magmatic Zone and neighbouring Buffalo High and Buffalo Utikuma domains to the west. It appears that the spatial wavelength of heat generation change is much smaller than that of heat flow. Thermal modelling of heat flow and heat generation data from the Hunt Well, using mantle heat flow contributions of 15 ± 5 mW m−2 results in lithosphere-asthenosphere boundary depth estimates of near 200 km. This mantle heat flow value is consistent with the range for the stable continental areas, 15 (±3) mW m−2.
Procedures and outcomes for pediatric esophageal foreign body removal were analyzed. Traditional methods of battery removal were compared with a magnetic tip orogastric tube (MtOGT). A single ...institution retrospective review from 1997 to 2014 of pediatric patients with esophageal foreign bodies was performed. Balloon extraction with fluoroscopy (performed in 173 patients with 91% success), flexible endoscopy (92% success in 102 patients), and rigid esophagoscopy (95% in 38 patients) had excellent success rates. A MtOGT had 100 per cent success in six disc battery patients, when other methods were more likely to fail, and was the fastest. Power analysis suggested 20 patients in the MtOGT group would be needed for significant savings in procedural time. Thirty-two per cent of all foreign bodies and 95 per cent of batteries had complications (P = 0.002) because of the foreign body. Overall, 1.2 per cent had severe complications, whereas 10 per cent of batteries had severe complications (P = 0.04). Each technique if applied appropriately can be a reasonable option for esophageal foreign body removal. Magnetic tip orogastric tubes used to extract ferromagnetic objects like disc batteries had the shortest procedure time and highest success rate although it was not statistically significant. Disc batteries require emergent removal and have a significant complication rate.
The lack of evidence in the published literature for the efficacy of perioperative radiation therapy and systemic chemotherapy; however, has prompted the search for other modalities to supplement ...surgical resection to improve local tumor control. Tumor types in the selected cases included adenocarcinoma (7), sarcoma (2), squamous cell carcinoma (1), carcinoid tumor (1), ovarian cancer (1), colon cancer (1), malignant triton tumor (1), and aggressive giant cell tumor (1).
Thoracic trauma (TT) has the second highest mortality rate in the geriatric population. These injuries cause significant morbidity in elderly patients. Little has been done to describe the ...demographics and mortality of specific injuries in these patients. ICD-9 codes corresponding with thoracic trauma for patients aged >80 years were extracted from the Nationwide Inpatient Sample database from 2000 to 2010. Characteristics including gender, race, Charlson Comorbidity Index (CCI), length of stay (LOS), and in-hospital mortality (IHM) were analyzed. For females and males, mean CCI was 4.84 and 4.93, respectively (P < 0.0001), and IHM was 5.49 and 2.44 per cent, respectively (P < 0.0001). For white and non-white patients, mean CCI was 4.88 and 4.84, respectively (P < 0.05), and IHM was 3.5 and 3.19 per cent, respectively. This difference was not statistically significant (P = 0.149). Logistic regression revealed correlation coefficient between CCI and mortality was 0.314 (P < 0.0001). Fitting a regression of CCI on LOS adjusting for gender and race, the adjusted effect was 0.146 (P < 0.0001). LOS was significantly less for patients surviving hospitalization. Males had higher CCI and mortality than females. Although whites had a higher CCI than non-whites, there was no difference in IHM between these two groups.
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