Making Choices: A Multi-institutional, Longitudinal Cohort Study Assessing Changes in Treatment Outcome Valuation for Low-Risk Thyroid Cancer.

OBJECTIVE: To evaluate the relative importance of treatment outcomes to patients with low-risk thyroid cancer (TC). SUMMARY BACKGROUND DATA: Overuse of total thyroidectomy (TT) for low-risk TC is common. Emotions from a cancer diagnosis may lead patients to choose TT resulting in outcomes that do not align with their preferences. METHODS: Adults with clinically low-risk TC enrolled in a prospective, multi-institutional, longitudinal cohort study from 11/2019-6/2021. Participants rated treatment outcomes at the time of their surgical decision and again 9 months later by allocating 100 points amongst 10 outcomes. T-tests and Hotelling's T 2 statistic compared outcome valuation within and between subjects based on chosen extent of surgery (TT vs. lobectomy). RESULTS: Of 177 eligible patients, 125 participated (70.6% response) and 114 completed the 9-month follow-up (91.2% retention). At the time of the treatment decision, patients choosing TT valued the risk of recurrence more than those choosing lobectomy and the need to take thyroid hormone less ( P <0.05). At repeat valuation, all patients assigned fewer points to cancer being removed and the impact of treatment on their voice, and more points to energy levels ( P <0.05). The importance of the risk of recurrence increased for those who chose lobectomy and decreased for those choosing TT ( P <0.05). CONCLUSION: The relative importance of treatment outcomes changes for patients with low-risk TC once the outcome has been experienced to favor quality of life over emotion-related outcomes. Surgeons can use this information to discuss the potential for asthenia or changes in energy levels associated with total thyroidectomy.

Imaging Concordance With Vein Sampling for Primary Aldosteronism: A Cohort Study and Literature Review.

INTRODUCTION: Adrenal venous sampling (AVS) is used to distinguish unilateral from bilateral aldosterone hypersecretion as a cause of primary aldosteronism (PA). Unilateral disease is treated with adrenalectomy and bilateral hypersecretion managed medically. METHODS: We performed a single institution retrospective cohort study of adult patients undergoing adrenalectomy for PA from July 2013 to June 2022. Concordance of imaging findings with AVS was evaluated. Statistical analysis was performed with Mann-Whitney U and chi-squared Fisher's exact. Literature review performed via triple method search strategy. RESULTS: Twenty-one patients underwent AVS and adrenalectomy for PA. Two patients did not have imaging findings and 19 were localized with an adenoma. For patients with image localization, AVS was concordant in nine, discordant in four, and nondiagnostic in six. For patients with discordant findings, age range was 35.8 to 72.4 y compared with concordant patient age range of 49.8 to 71.7 y. Overall discordance between imaging results and AVS was 40%. The aldosterone level was associated with concordance with a median of 52 ng/dL compared with 26 ng/dL if discordant (P = 0.002). There was a significant reduction in antihypertensive medications for the entire cohort from a median of three medications (interquartile range 2-4) to 1 medication (interquartile range 1-2), P < 0.001. CONCLUSIONS: In this cohort, 40% of patients with selective AVS had discordant imaging and AVS results. Aldosterone level was associated with concordance. Hypertension was significantly improved with a median decrease of two antihypertensives. Our results support performance of AVS on all candidates for adrenalectomy for PA.

Excellent Response to Therapy Occurs for Most Patients With Thyroid Cancer Treated With Lobectomy.

INTRODUCTION: American Thyroid Association (ATA) Guidelines for Management of Thyroid Nodules and Thyroid Cancer indicate that thyroid lobectomy (TL) or total thyroidectomy (TT) are appropriate surgery for low- and intermediate-risk well-differentiated thyroid carcinoma. We sought to determine outcomes of TL or TT by ATA response to therapy (RTT) classification. METHODS: This is a single-institution retrospective cohort study of adults with unilateral suspicious or malignant thyroid nodules under 4 cm from January 2016 through December 2021. Our primary outcome was ATA RTT. RESULTS: During the study period, 118 met inclusion criteria: 37 (31%) underwent TL and 81 (69%) TT. Of the TL patients, 7 (19%) underwent completion thyroidectomy. Response to therapy (RTT) was similar with TT versus TL: excellent response 56 (69%) versus 30 (81%), indeterminate response 20 (25%) versus 5 (14%), and biochemically incomplete response 5 (6%) versus 2 (5%), P = 0.20. There were no differences between the groups for age, sex, race or ethnicity, tumor size, histologic type, or complications. Thyroidectomy (TT) was associated with multiple nodules 47% versus 22% for TL (P = 0.009), bilateral nodules 43% versus 16% (P = 0.004), central neck lymph nodes removed median 3 (interquartile range [IQR] 1-8) versus 0 (IQR 0-2) P < 0.001, lymph node metastases median 0 (IQR 0-1) versus 0 (0-0) P = 0.02. Median follow-up was 32.5 mo (IQR 17-56 mo) and was similar between the groups. CONCLUSIONS: Patients with TL for well-differentiated thyroid carcinoma without high-risk features have an RTT similar to patients undergoing TT. In this cohort, 81% of patients treated with TL have not required additional intervention.

How to teach ERAS protocols: surgical residents' perspectives and perioperative practices for breast surgery patients.

Purpose: Breast enhanced recovery after surgery (ERAS) protocols emphasize multimodal analgesia to expedite home recovery, but variable implementation remains. This study examines how residents learn and use ERAS protocols, how they conceptualize pain management, and what influences breast surgery patients' same-day discharges. Methods: Interviews were conducted with surgical residents following their breast surgery rotation using an interview guide adapted from existing pain management literature. Interviews were transcribed, de-identified, and independently inductively coded by two researchers. A codebook was developed and refined using the constant comparative method. Codes were grouped into categories and explored for thematic analysis. Results: Twelve interviews were completed with plastic and general surgery residents. Ultimately, 365 primary codes were organized into 26 parent codes, with a Cohen's kappa of 0.93. A total of six themes were identified. Three themes described how participants learn through a mixture of templated care, formal education, and informal experiential learning. Two themes delineated how residents would teach breast surgery ERAS: by emphasizing buy-in and connecting the impetus behind ERAS with daily workflow implementation. One theme illustrated how a patient-centered culture impacts postoperative management and same-day discharges. Conclusions: Residents describe learning breast surgery ERAS and postoperative pain management by imitating their seniors, observing patient encounters, completing templated orders, and translating concepts from other ERAS services more so than from formal lectures. When implementing breast ERAS protocols, it is important to consider how informal learning and local culture influence pain management and discharge practices. Ultimately, residents believe in ERAS and often request further educational tools to better connect the daily how-to of breast ERAS pathways with the why behind the enhanced recovery principles.

Factors Associated With Persistent Post-transplant Hyperparathyroidism After Index Renal Transplantation.

INTRODUCTION: Secondary hyperparathyroidism (SHP) is common in end-stage renal disease and may progress to persistent post-transplant hyperparathyroidism (PTHP) following renal transplantation (RT). We sought to describe the frequency and determine factors associated with the incidence of PTHP for patients undergoing RT at a single institution that restricts RT for patients with uncontrolled SHP with a parathyroid hormone (PTH) of >800pg/mL at time of initial transplant evaluation. METHODS: We conducted a single-institution retrospective study of adults undergoing index RT from 2012 to 2020 who had a calcium and PTH level within 12 mo prior to RT and at least 6 mo following RT. PTHP was defined as calcium of >10 mg/dL with an elevated PTH > 88pg/mL at six or more months following RT. Univariate analysis and multivariable logistic regression were performed for factors associated with developing PTHP. RESULTS: We identified 1110 patients with RT, 65 were excluded for prior RT, 549 did not have a pre-RT and post-RT calcium, and PTH laboratories for inclusion, yielding 496 for analysis. Following RT, 39 patients (7.9%) developed PTHP, compared to those who did not develop PTHP; these patients had significantly higher pre-RT PTH, pre-RT calcium, and frequency of calcimimetic therapy. In multivariable logistic regression factors significantly associated with PTHP were pre-RT calcium of more than 10 mg/dL with an odds ratio (OR) of 3.57 (95% confidence interval [CI] 1.52-8.39, P = 0.003) and pre-RT calcimimetic therapy with an OR 1.30 (95% CI 1.06-2.85, P = 0.041). Compared with patients who had a pre-RT PTH of less than 200 pg/mL, a PTH of 200-399 pg/mL increased risk of PTHP with an OR of 4.52 (95% CI 1.95-21.5, P = 0.048) and a PTH of > 400 pg/mL increased risk of PTHP with an OR of 7.17 (95% CI 1.47-34.9, P = 0.015). In this cohort, 11 patients (28.2%) with PTHP underwent parathyroidectomy (PTx) at a mean of 1.4 y post-RT (standard deviation 0.87). CONCLUSIONS: For patients required to have a PTH < 800pg/mL for initial transplant candidacy, the subsequent incidence of PTHP is relatively low at 7.9%. Risk factors for PTHP include higher pre-RT calcium and PTH levels and pre-RT calcimimetic therapy. PTx remains underused in the treatment of PTHP. Further study is warranted to determine the optimal PTH cutoff for transplant candidacy and recommendation for PTx in patients requiring calcimimetic therapy for SHP.

Cross-Suturing is Effective for Teaching Suturing Skills: A Randomized, Controlled Trial.

INTRODUCTION: Basic suturing is a skill expected from graduating medical students. A proposed concept to increase suturing competency is to integrate art by mixing cross-stitching with suturing. We hypothesize that students trained with "cross-suturing" would improve suturing performance. METHODS: We performed a randomized controlled trial of preclinical medical students using an art-based cross-stitching method intervention compared with conventional suturing. Both groups were provided with an introductory suturing video. Assessment of simple interrupted suturing were conducted preintervention and postintervention, and at 2-wk follow-up with a video review by blinded expert raters using the American College of Surgeons basic suturing and knot tying performance rating tool. Students completed a self-assessment of proficiency, confidence, and anxiety. Statistical analysis was performed using unpaired t-tests. RESULTS: A total of 16 preclinical medical students participated. Self-assessment and objective suturing performance were comparable in the preintervention measurements. The intervention group showed significant improvement compared to the control group with median (interquartile range) self-assessment scores 9 (8.5-9) compared with 6.5 (6-7.5) (P < 0.01) and objective performance scores of 25.25 (22.75-27) compared with 16.5 (14.5-18.5) (P < 0.01). The intervention group showed retained skills at the 2-wk follow up with no differences in self-assessment or objective suturing scores immediately postintervention compared with two-wk follow-up with self-assessment scores of 9 (8.5-9) versus 9 (8-9) at 2 wk (P = 0.16) and objective performance score of 25.25 (22.75-27) versus 24.75 (23.5-26.5) at 2 wk (P = 0.29). CONCLUSIONS: The cross-suturing intervention improved suturing skills in this cohort. This low-cost approach to medical student surgical education should be explored on a larger scale.

Parathyroid Carcinoma: A National Cancer Database Analysis.

INTRODUCTION: Parathyroid carcinoma is a rare diagnosis. The association of clinical and pathologic factors as well as treatment on overall survival (OS) is not well established. METHODS: A retrospective review of patients with parathyroid carcinoma was performed using the National Cancer Database for patients diagnosed from 2004 through 2017. Clinical and demographic variables were assessed. A Cox proportional hazards model was used to assess for factors associated with survival. OS rates were determined for 5 and 10 y. RESULTS: Data for 1057 patients were analyzed. The mean age at diagnosis was 57.5 y (standard deviation [SD] 14.0), and 542 (51.3%) were male. The median tumor size was 2.7 cm (interquartile range 2.0-3.7 cm). For the extent of surgery, 38 (3.6%) had no surgery, 568 (53.7%) had incomplete resection, 359 (34.0%) had complete resection, 58 (5.5%) had radical resection, and 34 (3.2%) did not have specified and were not used in the Cox proportional hazard regression model. For the cohort, 488 (46.2%) had lymph nodes resected with a mean of 5.5 (SD 6.6) removed. Of these, 32 (8.3%) had nodal metastases with one to six positive nodes. For adjuvant therapy, 159 (15.0%) had external beam radiation with a mean dose of 5463 cGy (SD 1464). Overall, 214 patients died (21.55%), and the estimated 5- and 10-y OS were 82.9% and 57.0%, respectively. In a Cox proportional hazard regression model, age at diagnosis as a continuous variable with hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.01-1.06, P = 0.003, and extent of surgery as a categorical variable with no surgery as the referent group: incomplete surgery HR 0.05, 95% CI 0.01-0.19, P < 0.001; complete surgery HR 0.04, 95% CI 0.01-0.19, P < 0.001; radical surgery HR 0.10, 95% CI 0.02-0.45, P < 0.001; and tumor size as a continuous variable was not associated with OS with an HR of 1.00, 95% CI 0.99-1.00, P = 0.738. CONCLUSIONS: Patient age and extent of surgery are modestly associated with survival for parathyroid carcinoma but not patient sex, nodal metastases, or adjuvant therapy in this cohort.

Recurrent Cushing Syndrome From Metastatic Adrenocortical Carcinoma With Fumarate Hydratase Allelic Variant.

Background: Adrenal Cushing syndrome (CS) is usually benign in etiology; however, although rarely, it can be due to adrenocortical carcinoma (ACC); in which case, diagnosis and management are quite complicated. Case Report: A 34-year-old woman presented with worsening confusion, weight gain, new-onset diabetes, and hypertension. Her history was significant for a 7.4-cm left adrenal mass and CS, which were treated with left adrenalectomy 2 years ago. She received hydrocortisone replacement therapy after the surgery, which was discontinued on admission when evaluation showed hypokalemia, hypercortisolemia, and undetectable adrenocorticotropic hormone. Subsequent testing included 1-mg and 8-mg dexamethasone suppression tests, which did not suppress cortisol; late-night salivary cortisol measurement, which yielded a very high salivary cortisol level; and 24-hour urinary cortisol measurement. The level of 11-deoxycortisol was elevated. A computed tomography scan revealed multiple hepatic lesions, which were fluorodeoxyglucose avid, and a biopsy confirmed metastatic ACC. She received treatment with mitotane, metyrapone (later changed to mifepristone), doxorubicin, cisplatin, and etoposide. Over 8 weeks, mitotane levels became therapeutic at 20 mcg/mL, the hepatic masses decreased in size, and she transitioned to adrenal insufficiency and improved glycemic control. Next-generation sequencing of liver biopsy and germline testing revealed a frameshift loss-of-function allelic variant in the FH gene that encodes the protein fumarate hydratase. Discussion: We report a case of recurrent CS due to metastatic ACC in a patient with a previously resected adrenal adenoma and FH allelic variant. Conclusion: Metastatic ACC presenting with severe CS presents a diagnostic and management challenge where combination therapy guided by a multidisciplinary team is essential. FH allelic variant may contribute to ACC progression.

The impact of patient age on practice patterns and outcomes for primary hyperparathyroidism.

BACKGROUND: Management of asymptomatic primary hyperparathyroidism (PHPT) in older patients (age >50) is controversial. The 4th International Workshop on the Management of Asymptomatic PHPT recommends surveillance for older patients who lack objective signs of disease, whereas The American Association of Endocrine Surgeons (AAES) guidelines recommend consideration of parathyroidectomy for patients of any age with subjective constitutional, neuropsychiatric, or cognitive symptoms. Therefore, the primary objective of this study was to evaluate the association between patient age and both practice patterns and outcomes in the management of patients with sporadic PHPT. METHODS: The Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) database was queried for all adults (age ≥18) who underwent an index parathyroidectomy for sporadic primary hyperparathyroidism between 2014 and 2020. Associations between patient age (≤50 years vs. >50 years) and both practice patterns and outcomes were evaluated separately using adjusted multivariable logistic and multinomial regression models. RESULTS: Of 9,938 patients who underwent parathyroidectomy, 8,080 (81.3%) were >50 years old and 1,858 (18.7%) were ≤50. Of this cohort, 17% of older patients and 26% of younger patients presented with only subjective symptoms. Compared to younger patients, older patients were more likely to have an objective indication for parathyroidectomy (aOR = 1.8, 95%CI: 1.6-2.0, p < 0.001). They were also more likely to undergo ≥2 imaging studies pre-operatively (aOR = 1.2, 95%CI: 1.1-1.3, p = 0.003), to undergo bilateral neck exploration (aOR = 1.4, 95%CI: 1.3-1.6, p < 0.001), and to have multi-gland disease (aOR = 1.6, 95%CI: 1.4-1.8, p < 0.001). There was no difference between age groups and parathyroidectomy-related complications including hypocalcemia, vocal cord dysfunction, hematoma requiring evacuation, or reintubation, however, older patients were less likely to have any peri-operative morbidity (aOR = 0.7, 95%CI: 0.6-0.9, p = 0.011). CONCLUSIONS: Older patients were more likely to meet objective criteria prior to undergoing parathyroidectomy by CESQIP participating high-volume endocrine surgeons, however they were less likely to have peri-operative complications compared to younger patients. Given the growing evidence demonstrating improvement of both objective and subjective symptoms after parathyroidectomy for PHPT, additional studies are still needed to fully understand the benefit of surgical referral in older adults for less objective indications.

Management of Incidentalomas.

Incidental findings are common in the evaluation of surgical patients. Understanding the appropriate assessment and management of these frequent occurrences is important for the provision of comprehensive quality care. This review details the epidemiology, considerations, and recommendations for management of common incidental manifestations in surgical patients, including Meckel diverticulum, adrenal incidentaloma, thyroid nodule, solitary pulmonary nodule, small bowel intussusception, gallstones, and incidental appendectomy.

Comparison of Afirma GEC and GSC to Nodules Without Molecular Testing in Cytologically Indeterminate Thyroid Nodules.

BACKGROUND: Analysis of cytologically indeterminate thyroid nodules with Afirma Gene Expression Classifier (GEC) and Genomic Sequencing Classifier (GSC) can reduce surgical rate and increase malignancy rate of surgically resected indeterminate nodules. METHODS: Retrospective cohort analysis of all adults with cytologically indeterminate thyroid nodules from January 2013 through December 2019. We compared surgical and malignancy rates of those without molecular testing to those with GEC or GSC, analyzed test performance between GEC and GSC, and identified variables associated with molecular testing. RESULTS: 468 indeterminate thyroid nodules were included. No molecular testing was performed in 273, 71 had GEC, and 124 had GSC testing. Surgical rate was 68% in the group without molecular testing, 59% in GEC, and 40% in GSC. Malignancy rate was 20% with no molecular testing, 22% in GEC, and 39% in GSC (P = 0.022). GEC benign call rate (BCR) was 46%; sensitivity, 100%; specificity, 61%; and positive predictive value (PPV), 28%. GSC BCR was 60%; sensitivity, 94%; specificity, 76%; and PPV, 41%. Those with no molecular testing had larger nodule size, preoperative growth of nodules, and constrictive symptoms and those who underwent surgery in the no molecular testing group had higher body mass index, constrictive symptoms, higher Thyroid Imaging Reporting and Data System and Bethesda classifications. Type of provider was also associated with the decision to undergo surgery. CONCLUSION: Implementation of GEC showed no effect on surgical or malignancy rate, but GSC resulted in significantly lower surgical and higher malignancy rates. This study provides insight into the factors that affect the real-world use of these molecular markers preoperatively in indeterminate thyroid nodules.

Patient Reported Outcome Measures of Health-Related Quality of Life and Asthenia after Thyroidectomy.

BACKGROUND: After thyroidectomy some patients experience a chronic fatigue syndrome called asthenia. The purpose of this study was to determine the post-operative health related quality of life (HRQOL) and risk of asthenia in patients undergoing thyroidectomy. METHODS: A single institution prospective observational cohort study of adults undergoing thyroidectomy from September 2016 to July 2019 with four HRQOL surveys: preoperative baseline, 2 wk-, 6 mo- and 12 mo-postoperatively. Patients were surveyed using the Short Form 36 version 2 and Brief Fatigue Inventory. Asthenia was defined as Brief Fatigue Inventory > 60 at 12 mo. HRQOL was compared between patients undergoing thyroid lobectomy (TL) or total thyroidectomy (TT) with benign (-B) or malignant (-Ca) final pathology. RESULTS: A total of 182 patients were included: 67 (37%) with TL-B, 32 (17%) with TL-Ca, 40 (22%) with TT-B, and 43 (24%) with TT-Ca. The incidence of asthenia was 42% for TT and 4% for TL. In the TL-B group, 2 patients (3%) developed asthenia, compared with 2 patients (6.25%) in the TL-Ca group, 14 patients (35%) in the TT-B group, and 21 (48.8%) in the TT-Ca group (P = 0.0001). The odds ratio of asthenia for TT compared to TL was 10.4 (95% CI 3.86-28.16) and for patients with malignancy compared to benign disease was 2.05 (95% CI 1.17-3.61). CONCLUSIONS: Patients undergoing TT have a higher risk of developing asthenia than those undergoing TL, particularly if the final pathology shows malignancy.

Contemporary Evaluation and Management of Parathyroid Carcinoma.

Parathyroid carcinoma is a rare malignancy, representing 0.005% of all cancers and 0.5%-1% of all parathyroid disorders. Parathyroid carcinoma occurs equally in males and females, as opposed to primary hyperparathyroidism, which has a female predominance. Patients with parathyroid carcinoma present with symptoms of hypercalcemia, similar to those with benign primary hyperparathyroidism. Parathyroid carcinoma should be suspected when calcium or parathyroid hormone levels are high. Because of the difficulty of discerning parathyroid carcinoma from adenoma preoperatively, the diagnosis of carcinoma is often made only after parathyroidectomy. The goals of surgery are resection with negative margins because surgery represents the only opportunity for cure. Adjuvant therapy with chemotherapy or external beam radiation has not been proven to affect disease-free or overall survival for these patients. Recurrence is common, with reoperation recommended for resectable recurrent disease. Palliation with calcimimetic pharmacotherapy can aid with management of symptomatic hypercalcemia in recurrent or persistent disease after parathyroidectomy. Ultimately, patients succumb to sequelae of hypercalcemia rather than tumor burden.

Postoperative thyroid hormone supplementation rates following thyroid lobectomy.

BACKGROUND: Thyroid lobectomy is performed for symptomatic benign nodules, indeterminate nodules, or low-risk well differentiated thyroid cancer. We aimed to determine factors associated with thyroid stimulating hormone over goal (TH) following lobectomy. METHODS: We performed a retrospective single-institution cohort study of patients undergoing thyroid lobectomy from January 2016 to December 2017. TH was defined as need for thyroid hormone in accordance with guidelines. Univariate and multivariate logistic regression analysis was performed. RESULTS: One hundred patients were included and 47% developed. TH: 73% of those with cancer, 38% with benign pathology (p = 0.002). Patients with TH were more likely to have thyroiditis 26% versus 3.8% (p = 0.002); higher preoperative TSH: mean 1.88mIU/L (SD 1.17) versus 1.16mIU/L (SD 0.77) (p = 0.0002), and smaller remnant thyroid lobe adjusted for body surface area 2.99ml/m2 versus 3.72ml/m2 (p = 0.003). CONCLUSIONS: After thyroid lobectomy, TH is associated with preoperative TSH level, thyroiditis, remnant thyroid volume, and malignancy. The majority of patients with final pathology of carcinoma will require thyroid hormone supplementation to achieve TSH goal.

Accuracy of 4-Dimensional Computed Tomography for Localization in Primary Hyperparathyroidism.

BACKGROUND: The etiology of primary hyperparathyroidism (PHP) is single-gland adenoma in most patients. Imaging localization of single-gland disease allows for a focused operation. We sought to determine the accuracy of imaging for localizing a solitary parathyroid adenoma. METHODS: A single-institution retrospective review was performed of adult patients with PHP undergoing parathyroidectomy from January 2017 through December 2018. Surgeon-performed ultrasound (US), four-dimensional computed tomography (4DCT), and sestamibi were assessed for localization of a parathyroid adenoma yielding a single-gland parathyroidectomy. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for each imaging modality. RESULTS: One hundred fifty-four patients underwent parathyroidectomy for PHP during the study period, with 100 patients meeting inclusion criteria with a mean age of 61.1 (SD 10) y and 80% women. Mean calcium was 11.1 mg/dL (SD 0.7) and mean PTH was 116 pg/mL (SD 66). All 100 patients had surgeon-performed US with 17 localized, 51 patients had 4DCT with 41 (80%) localized, and 69 patients had sestamibi with 53 (77%) localized. Eighty-two patients underwent successful unilateral parathyroidectomy, 18 required bilateral neck exploration. US was the most specific imaging modality at 94%. Accuracy of imaging localization was 32% for US, 70% for sestamibi, and 86% for 4DCT. CONCLUSIONS: Surgeon-performed US is a highly specific imaging modality for preoperative localization of solitary parathyroid adenoma in patients with PHP. 4DCT is the most accurate imaging localization study and should be considered for patients with a nonlocalized US.

Evaluation for Primary Hyperparathyroidism in Patients Who Present With Nephrolithiasis.

BACKGROUND: The incidence of primary hyperparathyroidism (PHP) is likely underestimated. Nephrolithiasis may indicate PHP with indication for parathyroidectomy. We sought to determine the proportion of patients with an index diagnosis of nephrolithiasis that have serum calcium levels measured, parathyroid hormone (PTH) levels measured if hypercalcemic, and time to referral for definitive management if PHP is diagnosed. METHODS: A single-institution retrospective review was performed of adult patients presenting with nephrolithiasis between July 1, 2016 and December 31, 2018. Exclusion criteria included currently admitted patients, prior nephrolithiasis, congenital or acquired urinary tract anomalies, and patients on calciuretics. Records were assessed for serum calcium and PTH measurement, as well as referrals. Univariate statistical analysis was performed. RESULTS: Of 1782 patients with nephrolithiasis screened, 968 met inclusion criteria. Patients were 49.8% female, 88.9% white. Mean age was 53 y. Within this cohort, 620 (64.0%) patients had a calcium measured, with a mean elapsed time from presentation of 27 d (interquartile range [IQR] 0-8). Twelve patients (1.58%) with calcium measured were hypercalcemic and eight (66.7%) had PTH measured with a mean elapsed time from presentation of 183 d (IQR 72-310), all had elevated or non-suppressed PTH. Five (62.5%) were referred to surgeons with mean elapsed referral time of 270 d (IQR 95-492). CONCLUSIONS: Many with index nephrolithiasis are not assessed for hypercalcemia or hyperparathyroidism. Patients with serum calcium and PTH values indicating PHP diagnosis may have significant delay to parathyroidectomy. Targeted interventions with electronic health record alerts or automated reflex testing may improve care in this domain.

Hemithyroidectomy for Thyroid Cancer: A Review.

Thyroid cancer incidence is on the rise; however, fortunately, the death rate is stable. Most persons with well-differentiated thyroid cancer have a low risk of recurrence at the time of diagnosis and can expect a normal life expectancy. Over the last two decades, guidelines have recommended less aggressive therapy for low-risk cancer and a more personalized approach to treatment of thyroid cancer overall. The American Thyroid Association (ATA) and National Comprehensive Cancer Network (NCCN) thyroid cancer guidelines recommend hemithyroidectomy as an acceptable surgical treatment option for low-risk thyroid cancer. Given this change in treatment paradigms, an increasing number of people are undergoing hemithyroidectomy rather than total or near-total thyroidectomy as their primary surgical treatment of thyroid cancer. The postoperative follow-up of hemithyroidectomy patients differs from those who have undergone total or near-total thyroidectomy, and the long-term monitoring with imaging and biomarkers can also be different. This article reviews indications for hemithyroidectomy, as well as postoperative considerations and management recommendations for those who have undergone hemithyroidectomy.

THERAPEUTIC PLASMA EXCHANGE AS A BRIDGE TO TOTAL THYROIDECTOMY IN PATIENTS WITH SEVERE THYROTOXICOSIS.

OBJECTIVE: Graves disease is the most common cause of thyrotoxicosis. Medical management is the first-line treatment but may be contraindicated or ineffective. In patients with severe, refractory thyrotoxicosis therapeutic plasma exchange (TPE) may be indicated as a bridge to thyroidectomy. METHODS: We present 3 cases of thyrotoxicosis refractory to medical management that were successfully treated with TPE and subsequent total thyroidectomy, and provide an analysis of the response to therapy via a change in free thyroxine (fT4) levels throughout their treatment course. RESULTS: The average change in fT4 per liter of fluid exchanged was 0.37 ng/dL (SD = 0.08) and the average percentage change of fT4 after each treatment was 20.7% (SD = 8.28). The mean decrease in fT4 after 4 TPE treatments was 57.4%. All patients successfully underwent total thyroidectomy without complication and were discharged from the hospital. CONCLUSION: TPE should be considered for thyrotoxic patients with severe hyperthyroidism or thyroid storm refractory to medical management or contraindications to antithyroid drugs who need a bridge to total thyroidectomy. In these cases, TPE was a safe and effective treatment that enabled definitive management with thyroidectomy and may be considered in other patients with severe refractory hyperthyroidism or thyrotoxicosis.

Racial Disparities of Adrenalectomy.

PURPOSE: Racial disparities of surgical outcomes have been demonstrated for a variety of operations. We sought to determine whether minority status is associated with disparate care for adrenalectomy. METHODS: This study is a retrospective database review of the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) from January 1, 2014 through April 30, 2018. Primary outcome was complication rate. Secondary outcomes were length of stay and surgeon experience. Minority status was defined as Black or Hispanic and outcomes were compared with White patients. RESULTS: For the study period, 1141 patients who underwent adrenalectomies were included, of whom 69.9% were White and 22.6% minority. The minority patients were significantly younger with higher rates of diabetes mellitus. Minority patients had higher rates of complication and longer length of stay. Minority patients were more likely to have an adrenalectomy by a low-volume surgeon. In multivariate logistic regression, minority status remained associated with complication rate. CONCLUSIONS: Minority patients undergoing adrenalectomy have higher rates of complication and longer lengths of stay when controlling for common comorbidities. Minority patients have decreased access to high-volume surgeons.

Cardiovascular Outcomes of Thyroidectomy or Radioactive Iodine Ablation for Graves' Disease.

BACKGROUND: Treatment options for Graves' disease (GD) include medical management with antithyroid medications, radioactive iodine (RAI) ablation, or total thyroidectomy (TT). Definitive treatment with RAI ablation may be associated with worse cardiovascular morbidity and mortality than TT. We sought to determine the rate of cardiovascular morbidity before and after definitive treatment for GD. METHODS: This study is a retrospective single-institution study of sequential adult patients with GD from 2012 to 2018 treated with RAI ablation or TT. Patients with prior thyroid surgery or RAI ablation with subsequent thyroidectomy were excluded. Demographic and clinical variables were collected from diagnosis of GD to last follow-up. Data analysis was performed with descriptive statistics, univariate analysis with Fisher's exact test for categorical variables and the Mann-Whitney U test for continuous variables. RESULTS: One-hundred and eighty-four patients underwent definitive treatment for GD during the study period, of which 164 met inclusion criteria. One hundred and ten patients (67%) in the study group had TT and 54 (33%) had RAI ablation with a mean dose of 18.4 mCi (standard deviation 6.1). There were no differences in clinical or demographic factors in patients undergoing RAI ablation versus TT for definitive treatment including age, sex, thyroid-stimulating hormone level, free thyroxine level, or thyroid-stimulating immunoglobulin level at time of diagnosis, nor was there any difference in pretreatment cardiovascular comorbidity. Patients with TT had higher rates of resolution of arrhythmia after treatment than those undergoing RAI ablation, P = 0.02. There were no differences in treatment-related complications between the groups. CONCLUSIONS: For patients undergoing definitive treatment for GD, TT is associated with improved rate of resolution of cardiac arrhythmia compared with RAI ablation.