Value of Old Imaging for Patients Undergoing Parathyroidectomy for Primary Hyperparathyroidism.

INTRODUCTION: Although imaging plays no role in diagnosing primary hyperparathyroidism (PHPT), preoperative localization is essential for a focused parathyroidectomy. We hypothesized that reviewing imaging obtained prior to PHPT diagnosis can identify enlarged parathyroid glands and provide information that might potentially impact the preoperative evaluation and intraoperative course of patients undergoing parathyroidectomy. METHODS: We included adult patients with PHPT who underwent parathyroidectomy between October 2015 and October 2020 and had contrast-enhanced computed tomography (CT) imaging of the lower neck and upper chest obtained prior to diagnosis for unrelated indications. A radiologist reviewed the prediagnosis CTs blinded to subsequent parathyroid localization imaging and operative findings. A surgeon assessed the radiologist's findings in the context of each case to determine the potential impact of information from old imaging on surgical decision-making. RESULTS: We identified at least one enlarged parathyroid gland on prior contrast-enhanced CT in 30 (75%) of 40 included patients. Despite old imaging enabling correct localization, 60% of these 30 underwent dedicated parathyroid imaging prior to parathyroidectomy. Knowledge of the enlarged parathyroid(s) on prior imaging might have allowed a more focused approach in 10.0% and prompted a more thorough exploration in 13.3%. In the total cohort, reviewing prior imaging could have provided information capable of changing the preoperative evaluation in 52.5% and the operative course in 17.5%. CONCLUSIONS: The identification of enlarged parathyroid glands on contrast-enhanced CT imaging that predates a diagnosis of PHPT is possible. Prospective studies might verify the impact of these findings on the preoperative evaluation and operative course of patients undergoing parathyroidectomy.

Body Composition in Primary Hyperparathyroidism: A Potential Contributor to Weakness and Fatigue.

BACKGROUND: Primary hyperparathyroidism (PHPT) patients commonly report weakness and fatigue, though the underlying mechanisms are uncertain. Our purpose is to determine whether CT-derived muscle and adipose tissue metrics are associated with weakness and fatigue in PHPT patients. METHODS: For this retrospective study, cross-sectional muscle and adipose tissue metrics were derived from CTs in PHPT patients undergoing preoperative imaging within 1 year of parathyroid surgery. Skeletal muscle index (SMI) and visceral adipose tissue (VAT)/subcutaneous adipose tissue (SAT) ratio were calculated based on a single CT image at the level of the L3 vertebra. Established sex-specific SMI thresholds were used to define sarcopenia. Demographic and clinical data were collected from the electronic health record. When available, postoperative CT images were analyzed to assess for changes in body composition pre- and post-parathyroidectomy. RESULTS: The cohort comprised 53 PHPT patients (38 females, 15 males, mean age 61.4 years), of whom 24 (45%) reported weakness, 43 (81%) reported fatigue, and 31 (58%) met CT-based criteria for sarcopenia. Lower SMI was significantly associated with preoperative weakness in females but not males. For both weakness and fatigue, VAT/SAT ratios were higher in symptomatic females and lower in symptomatic males than their asymptomatic counterparts, though these differences were not statistically significant. In patients with postoperative CTs (n = 23), no significant changes in CT metrics were observed after parathyroidectomy. DISCUSSION: In females but not males with PHPT, subjective preoperative weakness was significantly associated with lower SMI. Effects of parathyroid hormone on skeletal muscle and visceral adiposity may differ by sex.

Opportunistic Parathyroid Gland Assessment on Routine CT Could Decrease Morbidity from Undiagnosed Primary Hyperparathyroidism.

RATIONALE AND OBJECTIVES: Gaps in primary hyperparathyroidism diagnosis are well-documented. End-organ damage correlates with disease duration and often occurs before diagnosis. We hypothesize that opportunistic parathyroid gland assessment on routine CT could decrease existing diagnosis gaps. Our purpose is to assess for enlarged parathyroid glands on contrast-enhanced CT acquired prior to biochemical screening and subsequent development of related morbidity. MATERIALS AND METHODS: This retrospective study included consecutive patients with primary hyperparathyroidism undergoing parathyroidectomy with contrast-enhanced CT including the lower neck and upper chest acquired prior to biochemical screening. One neuroradiologist retrospectively evaluated all CTs for enlarged (estimated weight greater than 60 mg) parathyroid glands. Gold standard operative and pathology reports were correlated with CT findings, and medical records were reviewed for development of primary hyperparathyroidism-related comorbidities. RESULTS: The sample comprised 38 patients (30 women, 8 men, median age 60 years) with 70 CTs of interest. The neuroradiologist identified 32 putative enlarged parathyroid glands (median estimated weight 307 mg) in 29 (76%) patients on CTs predating biochemical screening by a median of 30 months. Putative enlarged parathyroid glands on CT corresponded to pathologically proven parathyroid lesions in 26 (90%) patients. Of 26 patients with retrospectively identified pathologically proven parathyroid lesions, 12 (46%) developed at least 1 renal, bone, or neurocognitive comorbidity between CT and subsequent biochemical screening. CONCLUSION: Enlarged parathyroid glands are frequently visible on routine CTs acquired years prior to primary hyperparathyroidism diagnosis. Biochemical screening based on enlarged glands could potentially prevent associated morbidity in almost half of such patients.

Neck Imaging Reporting and Data System Category 3 on Surveillance Computed Tomography: Incidence, Biopsy Rate, and Predictive Performance in Head and Neck Squamous Cell Carcinoma.

OBJECTIVES: Neck Imaging Reporting and Data System (NI-RADS) is a radiology reporting system for head and neck cancer surveillance. Imaging findings of high suspicion for recurrence are assigned Category 3 and recommended for "Biopsy, if clinically indicated." After implementing NI-RADS for surveillance neck computed tomography (CT), our objectives are to determine the incidence of squamous cell carcinoma (SCC) Category 3 lesions in the year post-implementation, the associated biopsy rate, and the positive predictive value of NI-RADS 3 for SCC recurrence. STUDY DESIGN: Retrospective cohort study. METHODS: Neck CTs reported with NI-RADS between February 2020 and February 2021 were reviewed to identify patients undergoing surveillance for SCC assigned NI-RADS 3. Cancer recurrence, defined as positive biopsy result or treatment of clinically determined recurrence, was determined by electronic medical record review. RESULTS: During the study period, 580 neck CTs were reported with NI-RADS, of which 39 (7%) CTs obtained in 37 unique patients (28 male, 9 female, mean age 66.6 years) formed the study cohort. Biopsies were obtained in 23 lesions (45%), of which 17 (74%) were positive for recurrent SCC. One nondiagnostic biopsy was clinically determined to represent recurrence. Of 28 (55%) lesions not biopsied, 18 (64%) were ultimately treated as clinically determined recurrence. Thus, among 51 individual NI-RADS 3 lesions (32 primary, 19 neck), 36 (71%) represented recurrence. CONCLUSION: The incidence of NI-RADS 3 lesions in our cohort was 7%. The biopsy rate was 45%, and the overall positive predictive value of NI-RADS 3 for recurrent SCC was 71%. Category 3 lesions are associated with substantial SCC recurrence risk and should be managed accordingly. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1792-1797, 2022.

Acute Hepatitis B Surge: Opioid Epidemic Implication and Management Challenges.

We recognized a surge in acute hepatitis B at our institution and a link to the opioid epidemic since 2017. Among barriers to optimal management, we identified frequent deviations from national recommendations and patient noncompliance with follow-up.

Plasma angiopoietin-2 as a potential causal marker in sepsis-associated ARDS development: evidence from Mendelian randomization and mediation analysis.

PURPOSE: A causal biomarker for acute respiratory distress syndrome (ARDS) could fuel precision therapy options. Plasma angiopoietin-2 (ANG2), a vascular permeability marker, is a strong candidate on the basis of experimental and observational evidence. We used genetic causal inference methods-Mendelian randomization and mediation-to infer potential effects of plasma ANG2. METHODS: We genotyped 703 septic subjects, measured ICU admission plasma ANG2, and performed a quantitative trait loci (QTL) analysis to determine variants in the ANGPT2 gene associated with plasma ANG2 (p < 0.005). We then used linear regression and post-estimation analysis to genetically predict plasma ANG2 and tested genetically predicted ANG2 for ARDS association using logistic regression. We estimated the proportion of the genetic effect explained by plasma ANG2 using mediation analysis. RESULTS: Plasma ANG2 was strongly associated with ARDS (OR 1.59 (95% CI 1.35, 1.88) per log). Five ANGPT2 variants were associated with ANG2 in European ancestry subjects (n = 404). Rs2442608C, the most extreme cis QTL (coefficient 0.22, 95% CI 0.09-0.36, p = 0.001), was associated with higher ARDS risk: adjusted OR 1.38 (95% CI 1.01, 1.87), p = 0.042. No significant QTL were identified in African ancestry subjects. Genetically predicted plasma ANG2 was associated with ARDS risk: adjusted OR 2.25 (95% CI 1.06-4.78), p = 0.035. Plasma ANG2 mediated 34% of the rs2442608C-related ARDS risk. CONCLUSIONS: In septic European ancestry subjects, the strongest ANG2-determining ANGPT2 genetic variant is associated with higher ARDS risk. Plasma ANG2 may be a causal factor in ARDS development. Strategies to reduce plasma ANG2 warrant testing to prevent or treat sepsis-associated ARDS.