Preoperative work-up and results of parathyroidectomy plus auto-transplantation for the elderly with secondary hyperparathyroidism.

BACKGROUND: Total parathyroidectomy for secondary hyperparathyroidism has low morbidity and mortality rates and requires a special workup in the preoperative period. METHODS: Neck echography and technetium-99m-sestamibi scintigraphy were performed preoperatively. Cardiac echography, a thallium-201 myocardial perfusion scan, and cardiac catheterization were performed if necessary. During surgery, we removed all the parathyroid glands and the upper thymus and autotransplanted 100 mg of the smallest gland into the subcutaneous tissue of the forearm. RESULTS: The success rate in three months after total parathyroidectomy was 91.7% without mortality. In the elderly (age ≤65 years, n = 35), bone pain, skin itching, general weakness, and insomnia improved three months after surgery, and grip strength increased significantly. One year after parathyroidectomy, the serum levels of Ca, P, alkaline phosphatase, and intact parathyroid hormone were all within the normal ranges. Except for the bone mineral density (BMD) of the radial distal one-third, the BMD of the lumbar spine (L2 to L4), femoral neck, femoral global, and radial global increased significantly. Furthermore, the bone density T-scores of the lumbar spine (L2 to L4), femoral neck, femoral global, radial distal one-third, and radial global improved significantly. CONCLUSIONS: After a meticulous preoperative workup, parathyroidectomy plus autotransplantation can be performed safely for the treatment of symptomatic secondary hyperparathyroidism in the elderly to improve their quality of life and decrease their incidence of bone fractures.

Localization Strategy Prior to Radiofrequency Ablation for Primary and Secondary Hyperparathyroidism.

OBJECTIVE: Preoperative localization in patients with primary or secondary hyperparathyroidism before radiofrequency ablation (RFA) is crucial. There is currently a lack of consensus regarding imaging protocol. Evaluating the diagnostic performance of ultrasound, four-dimensional computed tomography (4D-CT), and technetium 99m-sestamibi single-photon-emission-computed tomography/computed tomography (SPECT/CT) is necessary for RFA of hyperparathyroidism. METHODS: This retrospective study recruited patients with primary or secondary hyperparathyroidism who underwent ultrasound, 4D-CT, and SPECT/CT before RFA at a single institution. The sensitivity, accuracy, and receiver operating characteristic curve analysis were used to evaluate the diagnostic performance of the imaging modalities. RESULTS: A total of 33 patients underwent RFA for hyperparathyroidism (8 patients with primary hyperparathyroidism, 25 patients with secondary hyperparathyroidism). Ultrasound had the highest sensitivity (0.953) and accuracy (0.943), while 4D-CT had higher sensitivity and accuracy than SPECT/CT (sensitivity/accuracy, 4D-CT vs. SPECT/CT: 0.929/0.920 vs. 0.741/0.716). Combined ultrasound with 4D-CT and the three combined modalities achieved equivalent, and the highest, diagnostic performance (sensitivity 1.000, accuracy 0.989). The lesion length and volume were important predictors of the diagnostic performance of 4D-CT and SPECT/CT (area under curve of length in 4D-CT/volume in 4D-CT/length in SPECT/volume in SPECT: 0.895/0.834/0.767/0.761). CONCLUSION: Combined ultrasound with 4D-CT provides optimal preoperative localization prior to RFA in patients with primary or secondary hyperparathyroidism. The length and volume of parathyroid lesions are determinative of the diagnostic performance of 4D-CT and SPECT/CT.

Combination of treatments with transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves' disease.

Although the success rates of non-surgical treatments for Graves' disease such as antithyroid medication and radioiodine ablation were good, there were still failure of treatments or intolerance for some patients. Traditional thyroid surgery could treat these patients but result in unaesthetic neck scars. Herein, we report the preliminary results of our combination of treatments with the transoral endoscopic thyroidectomy vestibular approach for Graves' disease. A retrospective review of patients who underwent the transoral endoscopic thyroidectomy vestibular approach for the treatment of different sizes of goiters between January 2019 and December 2020 was performed. The demographic and clinical data of patients were collected. All patients were followed up for > 12 months. Each patient's goiter size was determined using four grades-from 0 to 3. In total, 14 female patients receiving the combination treatment with > 1 year of follow-up and a median (range) age of 35 (20-48) years at surgery were included. There were two, three, four, and five patients with grade 0, 1, 2, and 3 goiters, respectively. The median (range) intraoperative blood loss was higher in grade 3 patients (100 [20-850] mL) than in grade 2 patients (20 [10-200] mL) and grade 1 and 0 patients (both < 10 mL) (p = 0.033). All patients had normal-looking necks with a euthyroid or hypothyroid status within 1 year. There were no complications, including re-operation for bleeding, hypoparathyroidism, vocal cord palsy, or infections. The designed combination treatment with the transoral endoscopic thyroidectomy vestibular approach for Graves' disease provides optimal cosmetic results with a high success rate.

Impact of Thyroid Incidentaloma on Liver Transplant: A Study of 1010 Recipients at a Single Center.

BACKGROUND Thyroid incidentalomas are typically nonpalpable thyroid nodules discovered during radiographic evaluation for a non-thyroid issue. Thyroid incidentalomas visualized by computed tomography (CT) and ¹8F-flurodeoxyglucose (FDG) positron emission tomography (PET) before living donor liver transplantation (LDLT) are rare. The aim of the study was to analyze the clinical impact of thyroid incidentalomas discovered prior to transplantation. MATERIAL AND METHODS This retrospective study recruited 1010 patients undergoing LDLT between 2010 and 2019. CT was performed on each patient, whereas PET was performed on randomized patients (n=498). RESULTS The prevalence and malignant risk of thyroid incidentaloma on CT was 2.3% (23/1010) and 13.0% (3/23), respectively. The prevalence of thyroid incidentaloma on PET was 3.0% (15/498). Approximately half of the FDG uptake on PET was diffuse uptake (n=7), whereas the other half was focal uptake (n=8). The malignant risk of PET incidentaloma with focal FDG uptake was 37.5% (3/8). Four asymptomatic thyroid cancers were identified incidentally. After total thyroidectomy followed by LDLT, these patients maintained cancer-free status. CONCLUSIONS Thyroid incidentalomas occurred at a rate of 2-3% in LDLT candidates. The malignant risk was 13.0% on CT incidentaloma, and 37.5% on PET incidentaloma with focal FDG uptake. Curative treatment of incidental thyroid cancer followed by LDLT without delay can achieve a favorable prognosis.

Changes in voice quality, swallowing, and pulmonary function after parathyroidectomy for secondary hyperparathyroidism.

OBJECTIVE: To find changes in voice quality, airway invasion during swallowing, pharyngeal residue after swallowing, acoustic and aerodynamic measurements and pulmonary function tests after total parathyroidectomy plus auto-transplantation for secondary hyperparathyroidism. METHODS: We recruited 38 patients who underwent successful surgery for secondary hyperparathyroidism in this study. Voice quality was evaluated using voice handicap index (VHI-10), eating assessment tool (EAT-10), voice impairment, and the grade, roughness, breathiness, asthenia, strain (GRBAS) scale. Acoustic and aerodynamic measurements included fundamental frequency (F0), maximal phonation time, high pitch, jitter, s/z, shimmer and noise-to-harmonic ratio. Vocal cord mobility, vocal cord closure, premature spillage, the penetration-aspiration scale and the Yale pharyngeal residue severity rating scale (PRSRS) after swallowing were examined using fiber-optic endoscopy. Pulmonary function tests included forced vital capacity, forced expiratory volume in 1 s, bronchodilator test, total lung capacity, diffusion capacity of the lung for carbon monoxide, alveolar volume, and distance and O2 desaturation of the 6 min walking test (6MWT). RESULTS: Four months after successful parathyroidectomy, VHI-10 improved significantly (p < 0.01); incomplete vocal cord closure decreased significantly (p < 0.01); the Yale PRSRS for vallecula and pyriform sinus improved significantly (p = 0.02 and p = 0.02); F0 and high pitch increased significantly (p < 0.01 and p = 0.01); O2 desaturation (<4%) of 6MWT improved significantly (p = 0.04). CONCLUSIONS: Parathyroidectomy for secondary hyperparathyroidism can improve the voice quality, vocal cord closure, the Yale PRSRS for vallecular and pyriform sinus and O2 desaturation of 6MWT, and increase F0 and high pitch.

Scarless Completion Thyroidectomy After Initial Transoral Approach for Differentiated Thyroid Cancer: How and When to Start?

BACKGROUND: With growing literature, the feasibility of transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been confirmed as a valid method for managing differentiated thyroid cancer. Completion thyroidectomy (CT) is recommended in patients who have been diagnosed with differentiated thyroid cancer after unilateral lobectomy by TOETVA. In this retrospective study, the authors addressed the critical questions of how and when to do the second operation of CT to avoid a neck scar. MATERIALS AND METHODS: The authors retrospectively reviewed our patients who had received TOETVA in our hospital from August 2016 to December 2019. Those who received CT after initial TOETVA as cTOETVA were further separated according to the approaching methods. Demographic data, operative variables, and postoperative variables were collected and analyzed. RESULTS: A total of 97 patients were enrolled using TOETVA. Malignancies were present in 42 patients (43.3%) using TOETVA. There were 3 approaching methods of cTOETVA and separated into reopen transcervical approach (re-TCA), retransoral TOETVA (re-TOETVA), and transaxillary approach (TAA) groups. There were no significant complications among patients for cTOETVA. Of the 8 patients for the cTOETVA, 3 received re-TCA, 3 re-TOETVA, and 2 TAA. CONCLUSIONS: The outcomes are encouraging and demonstrate the feasibility of scarless completion thyroidectomy after initial TOETVA. The re-TOETVA procedure should be completed within 14 days after the initial TOETVA procedure, TAA beyond 14 days, and re-TCA may be completed at any time. The cTOETVA techniques using re-TOETVA or TAA have better cosmetic results than re-TCA in oncological equivalency.

Real-world evidence and optimization of vocal dysfunction in end-stage renal disease patients with secondary hyperparathyroidism.

Patients with end-stage renal disease (ESRD) may demonstrate secondary hyperparathyroidism (SHPT), characterized by parathyroid hormone oversecretion in response to electrolyte imbalance (e.g., hypocalcemia and hyperphosphatemia). Moreover, this electrolyte imbalance may affect vocal cord muscle contraction and lead to voice change. Here, we explored the effects of SHPT on the voices of patients with ESRD. We used data of 147,026 patients with ESRD from the registry for catastrophic illness patients, a sub-database of Taiwan National Health Insurance Research Database. We divided these patients into 2 groups based on whether they had hyperparathyroidism (HPT) and compared vocal dysfunction (VD) incidence among them. We also prospectively included 60 ESRD patients with SHPT; 45 of them underwent parathyroidectomy. Preoperatively and postoperatively, voice analysis was used to investigate changes in vocal parameters. In the real-world database analysis, the presence of HPT significantly increased VD incidence in patients with ESRD (p = 0.003): Cox regression analysis results indicated that patients with ESRD had an approximately 1.6-fold increased VD risk (p = 0.003). In the clinical analysis, the "jitter" and "shimmer" factors improved significantly after operation, whereas the aerodynamic factors remained unchanged. In conclusion, SHPT was an independent risk factor for VD in patients with ESRD, mainly affecting their acoustic factors.

Being elderly is not a contraindication of parathyroidectomy for renal hyperparathyroidism and chronic kidney disease-mineral and bone disorder.

BACKGROUND: Chronic kidney disease-mineral and bone disorder (CKD-MBD) has more influence in the elderly. Parathyroidectomy remains the golden standard for this situation but has tended to be excluded for older patients for many reasons. This study aimed to evaluate the efficacy and safety of the surgery in the elderly population. METHODS: 156 patients were included and arranged into younger (≦65 years of age, n = 139) and elderly (>65 years of age, n = 17) groups. The change of bone mineral density (BMD) data, recovery potential {[(postoperative BMD) - (preoperative BMD)]/(preoperative BMD) ∗ 100%}, surgical successful rate and related complications were collected. RESULTS: Both groups exhibited significant postoperative improvement on the BMD results. The recovery potential of the elderly was not lower than the younger group. High success rate and none of persistent vocal palsy, hypocalcemia or any sequela were also observed in the elderly. CONCLUSIONS: Parathyroidectomy is an effective and safe intervention for the CKD-MBD in the elderly.

Aberrant Expression of Androgen Receptor Associated with High Cancer Risk and Extrathyroidal Extension in Papillary Thyroid Carcinoma.

Male gender is a risk factor for mortality in patients with papillary thyroid carcinoma (PTC). This study investigated the impact of androgen receptor (AR) gene expression on the clinical features and progression of PTC. The levels of AR mRNA and protein in frozen, formalin-fixed, paraffin-embedded tissue samples from PTC and adjacent normal thyroid tissue were assessed by quantitative real-time polymerase chain reaction and immunohistochemical staining, respectively, and the relationships between AR expression and clinical features were analyzed. The thyroid cancer cell lines, BCPAP and TPC-1, were used to evaluate the effects of AR on the regulation of cell migration, and key epithelial-mesenchymal transition (EMT) markers. AR mRNA expression was significantly higher in normal thyroid tissue from men than women. The sex difference in AR mRNA expression diminished during PTC tumorigenesis, as AR mRNA expression levels were lower in PTC than normal thyroid tissues from both men and women. AR mRNA expression was significantly decreased in PTC patients with higher risk and in those with extrathyroidal extension. Overexpression of AR in BCPAP cells decreased cell migration and repressed the EMT process by down-regulating mRNA expression of N-cadherin, Snail1, Snail2, Vimentin, and TWIST1 and up-regulating E-cadherin gene expression. These results suggest that suppression of the androgen-AR axis may lead to aggressive tumor behavior in patients with PTC.

Association Between Recurrent Laryngeal Nerve Calibre and Body Figure: A Preoperative Tool to Assess Thin-Diameter Nerves in Thyroidectomy.

Inadvertent recurrent laryngeal nerve (RLN) injury is a major complication of thyroidectomy. This study aimed to investigate the association between preoperative clinical parameters and RLN size prediction. Total thyroidectomy and thyroid lobectomy data were collected between January 2014 and April 2017. Routine identification of the recurrent laryngeal nerves was performed, while intraoperative findings (nerve diameter, thyroid gland weight, intraoperative neuromonitoring (IONM) use, and signal recording) and demographic data were collected for analysis. A total of 848 patients with 1357 RLNs at risk were enrolled in this study. RLN diameter was thinner in females, those with body height <160 cm, and those with a BMI <25 (all p < 0.001). RLN diameter was directly proportional to age, body weight, height, and BMI. RLN diameter was thinner (1.71 mm vs. 1.55 mm, p = 0.039) and branched nerve incidence was higher (18.5% vs. 29.7%, p = 0.09) in the postoperative RLN injury group. Branched nerves were more frequently encountered in female patients (female vs. male: 28.8% vs. 18.7%, p = 0.004). The risk of RLN palsy in intraoperative IONM loss patients was 27 times higher compared to that in IONM normal patients (1.55% vs. 30%, p < 0.001). Thinner nerves did not yield a higher rate of IONM signal loss. Thinner nerves and higher palsy rates could be anticipated in females, younger age groups, those with shorter stature, and those with low BMI. RLN diameter was not associated with the rate of IONM signal loss.

Successful Modified Transoral Endoscopic Parathyroidectomy Vestibular Approach For Secondary Hyperparathyroidism With Ectopic Mediastinal Glands.

BACKGROUND: Transoral endoscopic parathyroidectomy vestibular approach for secondary hyperparathyroidism (SHPT) is controversial with regard to the time consumed, safety, and feasibility. We present our initial experience with modified transoral endoscopic parathyroidectomy vestibular approach (m-TOEPVA) procedure for SHPT using total parathyroidectomy with autotransplantation. MATERIALS AND METHODS: We retrospectively reviewed 10 patients with SHPT who underwent the m-TOEPVA procedure from December 2017 to April 2018 at our center. RESULTS: There were a total of 6 male individuals and 4 female individuals with a median age of 58.5 years. Among whom, 5 were on hemodialysis and 5 on peritoneal dialysis. The median length of hospital stay and operative time was 5 (4, 5) days, and 321.5 (302.75, 362.25) minutes, respectively. Successful removal of 4 parathyroid glands was achieved in 8 of 10 patients (80%) and, in 8 patients (8/10, 80%), the intact parathyroid hormone successfully dropped to <300 pg/mL at 3 months postoperatively. Two patients with ectopic parathyroid gland in the superior mediastinum were noted preoperatively by MIBI scan and subsequently had successful removal. Except for 1 patient with prolonged hospital stay (11 d) due to hungry bone syndrome, there were no other major complications. CONCLUSION: m-TOEPVA by total parathyroidectomy with autotransplantation for SHPT is feasible, safe, and offers optimal cosmetic results. The most valuable part is that m-TOEPVA provides direct visualization and successful removal of the ectopic parathyroid glands in the superior mediastinum.

Changes in serum FGF23 and Klotho levels and calcification scores of the abdominal aorta after parathyroidectomy for secondary hyperparathyroidism.

BACKGROUND: Changes of calcification scores of the abdominal aorta (CSAA) after total parathyroidectomy plus autotransplantation (TPX + AT) for symptomatic secondary hyperparathyroidism (SSHP) have never been reported. METHODS: Forty-nine patients who successfully underwent TPX + AT for SSHP were enrolled; 13 patients who had regular hemodialysis were enrolled as controls. Preoperatively, patients' age, gender, and duration of dialysis were recorded. Serum Ca, P, alkaline phosphatase (Alk-ptase), intact parathyroid hormone (iPTH), vitamin D, FGF23, and Klotho levels, and CSAA were measured. One year postoperatively, these data were measured again. In the control group, these data were recorded and measured before and one year later. RESULTS: Serum iPTH, Alk-ptase and FGF23 levels and CSAA of the study group were significantly higher than those of the control group. One year postoperatively, serum Ca, P, Alk-ptase, iPTH, and FGF23 levels and CSAA were significantly lower than those before surgery. Except for FGF23 levels, other items of the control group did not change significantly one year later, whereas the study group decreased CSAA more than the control group. CONCLUSION: One year postoperatively, CSAA decreased.

What is the Appropriate Nodular Diameter in Thyroid Cancer for Extraction by Transoral Endoscopic Thyroidectomy Vestibular Approach Without Breaking the Specimens? A Surgicopathologic Study.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a novel technique with better cosmetic results. However, extraction of a large malignant thyroid nodule from the central incision of TOETVA necessitates breaking it into pieces to avoid mental nerve injury, a situation that may violate a proper oncological surgery. In this study, we sought the appropriate nodular diameter in thyroid cancer to be removed in an intact status through the central incision of the TOETVA technique. A total of 27 cases of thyroid nodules were operated using the TOETVA technique from Aug 2016 to July 2017. Excluding 10 benign goiters, the specimens of 17 thyroid cancer cases were divided into intact (group T, n=7) and fragmented (group F, n=10), with a median nodular diameter of 18.35 and 30.30 mm, respectively. Receiver operating characteristic (ROC) curve analysis revealed that the safest nodular diameter is 20 mm, with 100% sensitivity and 87.5% specificity.

Surgical management of primary hyperparathyroidism: A single-center experience.

BACKGROUND: Primary hyperparathyroidism (PHPT) can occur at any age. This study aimed to compare the necessity, feasibility, safety, and outcomes of parathyroidectomy in the management of minor-symptomatic or asymptomatic PHPT patients according to age (young vs. old). METHODS: We retrospectively reviewed the medical records of 146 consecutive patients who underwent surgery for PHPT from January 2005 to June 2016 in our institution. The patients ranged in age from 12 to 85 years. For the analysis, the included patients (n = 137) were separated into young (age <50 years; n = 31, 22.6%) and old (age ≥50 years; n = 106, 77.4%) patients. The biochemical characteristics (parathyroid hormone, calcium, and creatinine levels), T-score of bone densitometry, surgical reports, pathology reports, perioperative intensive care unit care, and 30-day mortality were reviewed. RESULTS: The average medical treatment course after diagnosis tended to be longer in the old group (33.3 vs. 26.2 weeks, p = 0.62). During the medical treatment course, the old group had a higher risk of developing new symptoms or severe complications (5.6% vs. 3.2%, p = 0.05), and the older patients seemed to have a longer postoperative hospitalization (p = 0.17). However, there were no significant differences in the 30-day mortality, immediate complications, and follow-up duration. CONCLUSION: In older patients, surgical treatment of PHPT is safe and feasible, with comparable outcomes to in younger patients, and helps prevent the development or progression of symptoms and complication. Hence, parathyroidectomy should be the recommended treatment and should be performed in PHPT patients as early as possible, regardless their age and initial symptoms.

Applying preoperative dipyridamole thallium-201 scintigraphy for preventing cardiac mortality and complications for patients with secondary hyperparathyroidism undergoing parathyroidectomy.

BACKGROUND: To evaluate the value of preoperative dipyridamole thallium-201 scintigraphy for reducing cardiovascular complication in secondary hyperparathyroidism (SHPTH) patients. METHODS: Thallium scintigraphy was arranged for all dialysis patients who underwent parathyroidectomy from Jan 2011 to July 2015. Management of defects on thallium scintigraphy included cardiac catheterization and ultrasonography. Analysis includes 30-day mortality, morbidity and the predicting factors for thallium scintigraphy defect. RESULTS: Of 249 patients with SHPTH, 19 (7.6%) had defects on thallium scintigraphy, 15 (88%) of whom had coronary artery disease on angiography. History of acute coronary syndrome (ACS, p < 0.001), diabetes mellitus (DM, p = 0.03), male sex (p = 0.03), and higher body mass index (BMI, p = 0.001) were significant predictors of positive thallium scintigraphy results. History of ACS was the most significant predictor after adjustment in the multivariate logistic analysis (odds ratio, 22.56; 95% confidence interval, 7.02-72.53). All the patients survived the 30-day postoperative period, with minimal cardiovascular morbidity. CONCLUSION: Preoperative dipyridamole thallium-201 scintigraphy is useful for SHPTH patients to minimized surgical mortality and morbidity.

Effect of Oral Nonionic Polymeric Micelles Delivered Parathyroid Hormone cDNA on Bone Density and Microarchitecture.

INTRODUCTION: Parathyroid Hormone (PTH) is an effective therapeutic agent for osteoporosis, but the treatment requires long-term daily injections. Oral gene delivery is a less invasive alternative to daily injections. OBJECTIVE: The aim of this study is to investigate the effect of orally administered nonionic polymeric micelles of plasmid cDNA containing human cytomegalovirus promoter (PCMV)-PTH (1-34) plus EDTA on body mineral density and bone microstructure in ovariectomized rats. MATERIAL AND METHODS: A total of 27 Spraque-Dawley female rats were subjected to a bilateral ovariectomy. One month following the ovariectomy, they were randomly assigned to three groups: (1) (PCMVPTH (1-34) cDNA in polyethylene oxide-polypropylene oxide-polyethylene oxide (PEO-PPO-PEO) polymeric micelle formations plus EDTA); (2) PCMV-PTH (1-34) cDNA and (3) drinking water. The treatment was administered by oral gavage on day 1, 2, 7, 14, and 21 at 8-hour intervals. Body mineral density, bone volume fraction, and trabecular thickness of the lumbar spine and femoral neck were examined with peripheral quantitative computed tomography at pre- and post-intervention (3 months after the start of the intervention) and analyzed using two-way repeated measures analysis of variance. RESULTS: Results showed that bone mineral density, bone volume fraction and trabecular thickness were significantly increased in Group 1 over time, compared with those in Group 2 and Group 3. CONCLUSION: In conclusion, significantly improved bone mineral density and bone microstructure were observed in ovariectomized rats treated with PTH (1-34) cDNA delivered by nonionic polymeric micelles.

High expression of endoglin in primary breast cancer may predict response to neoadjuvant chemotherapy.

Neoadjuvant chemotherapy (NAC) is a widely­used treatment for breast cancer, as it may render unresecta-ble breast tumors to become resectable. In addition, NAC provides the unique opportunity to assess response to treatments within months rather than years of follow­up. However, predictive markers of tumor response to NAC are lacking. Therefore, the present study aimed to investigate the expression of endoglin, a marker of angiogenesis, and its association with pathologic responses to NAC. Samples from 34 breast cancer patients were obtained prior to and following NAC treatment. Immunohistochemical staining for endoglin and the mechanistic target of rapamycin (mTOR) was performed, and the correlation between the expression of these markers and pathologic response was examined. The overall response rate to NAC of these 34 patients was 67.6%. A mean microvascular density value of 14 served as a threshold score for the increased expression of endoglin. Increased expression of endoglin in primary tumors prior to NAC correlated with improved response in primary tumors (P=0.019) or in primary tumors and regional lymph nodes (P=0.014), when compared with reduced expression of endoglin. Increased expression of mTOR following NAC was additionally correlated with improved response to NAC. The results of the present study demonstrated that the expression of endoglin in breast tumor samples prior to NAC may be a predictor of treatment response. Long­term follow­up of clinical outcome is required to explain the elevation of mTOR expression levels following NAC treatment in responsive tumors.

Bilateral vocal cord palsy after total thyroidectomy-A new treatment-Case reports.

INTRODUCTION: Dyspnea due to bilateral vocal cord palsy after total thyroidectomy (BVCPATT) is a life-threatening complication; nevertheless, we try to avoid tracheotomy. METHODS: Using normalized glottal area (NGA), we retrospectively studied 14 patients with BVCPATT. Nine patients without dyspnea were treated conservatively, while five with dyspnea received immediate bilevel positive air-way pressure (BiPAP) treatment. Both right and left recurrent nerves were grossly intact during surgery. RESULTS: The mean NGA during inspiration of five patients with dyspnea was less than that of nine patients without (6.21±1.57 (mean±standard deviation) vs. 20.5±9.5; p=0.001). The mean age of patients with dyspnea was more than that of patients without (61.6±15.6 vs. 38±10.2; p=0.007). Five patients with dyspnea that occurred at 0-8days post operation recovered within 3-17days after BiPAP. CONCLUSION: Dyspnea occurred in patients with BVCPATT who were relatively older. The mean NGA during inspiration in patients with dyspnea was less than that in patients without. BiPAP might be a new treatment for dyspnea.

Association between clinical variables and mortality after parathyroidectomy in maintenance hemodialysis patients.

BACKGROUND: We investigated factors associated with all-cause mortality and cardiovascular disease (CVD)-associated mortality after parathyroidectomy (PTX) in patients on maintenance hemodialysis (HD). METHODS: Our study population consisted of 161 consecutive HD patients who underwent PTX before 2009 and 354 consecutive HD patients without PTX as controls from those visiting the Kaohsiung Chang Gung Memorial Hospital, Taiwan between 2009 and 2013. All-cause and CVD mortality with clinical variables were compared in PTX and non-PTX HD patients. RESULTS: PTX patients had significantly lower all-cause and CVD mortality than controls. Multivariate logistic regression analyses showed PTX patients had a lower odds ratio for all-cause mortality than those without (odds ratio = .35, 95% confidence interval = .16 to .74). Association analysis based on clinical variables revealed patients with higher hemoglobin, albumin, creatinine, and HD adequacy index-Kt/V levels had significantly decreased risk of all-cause mortality. CONCLUSIONS: PTX in HD patients reduces the risk of death.

Changes in Serum Concentrations of Fibroblast Growth Factor 23 and Soluble Klotho in Hemodialysis Patients after Total Parathyroidectomy.

Background. We examined the changes in circulating fibroblast growth factor 23 (FGF23) and Klotho concentrations in hemodialysis patients after parathyroidectomy (PTX). Methods. We enrolled a cohort of hemodialysis patients who received PTX. Postoperatively, patients received calcium supplements and/or vitamin D analogue (calcitriol) to maintain serum calcium within 7.0-8.0 mg/dL. Information on clinical parameters including bone-mineral metabolic variables was collected pre-PTX and on days 5 and 90 after PTX. Concomitantly, serum full-length FGF23 and α-Klotho levels were measured. The relationship between FGF23 and clinical parameters was analyzed by single linear regression. Results. Forty-six participants (33 women; 13 men) were enrolled in the study. Their mean age was 56.49 years. Serum FGF23 and α-Klotho concentrations were elevated on days 5 and 90 after PTX compared to baseline (p > 0.05). Serum FGF23 concentrations negatively correlated with serum calcium concentrations pre-PTX (Beta -0.31; R2 0.0949; p = 0.040), day 5 post-PTX (Beta -0.31; R2 0.0982; p = 0.036), and day 90 post-PTX (Beta -0.39; R2 0.1528; p = 0.008). Conclusions. There was no change in circulating FGF23 and Klotho concentrations after PTX in hemodialysis patients given postoperative calcium supplements and/or vitamin D analogue. Serum FGF23 concentrations pre-PTX and at days 5 and 90 after PTX were inversely related to serum calcium concentrations.