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.

Ultrasound and the Evaluation of Pediatric Thyroid Malignancy: Current Recommendations for Diagnosis and Follow-up.

Ultrasound (US) plays a critical role in the evaluation, treatment, screening, and surveillance of thyroid malignancy in pediatric patients. This review aims to summarize recent advances in this topic. Improvements in imaging technology have amplified the advantage of US and US-guided fine-needle aspiration biopsy for thyroid nodule evaluation, cancer diagnosis, and surgical planning. Ultrasound has a definitive screening role for early cancer detection in high-risk patients, including those with a history of radiation exposure from childhood treatments, environmental radiation disasters, or hereditary/familial cancer syndromes. Finally, US is a key component of lifelong surveillance for recurrence among pediatric thyroid cancer survivors.

ACTIVE SURVEILLANCE FOR PAPILLARY THYROID MICROCARCINOMA: NEW CHALLENGES AND OPPORTUNITIES FOR THE HEALTH CARE SYSTEM.

OBJECTIVE: The dramatic increase in papillary thyroid carcinoma (PTC) is primarily a result of early diagnosis of small cancers. Active surveillance is a promising management strategy for papillary thyroid microcarcinomas (PTMCs). However, as this management strategy gains traction in the U.S., it is imperative that patients and clinicians be properly educated, patients be followed for life, and appropriate tools be identified to implement the strategy. METHODS: We review previous active surveillance studies and the parameters used to identify patients who are good candidates for active surveillance. We also review some of the challenges to implementing active surveillance protocols in the U.S. and discuss how these might be addressed. RESULTS: Trials of active surveillance support nonsurgical management as a viable and safe management strategy. However, numerous challenges exist, including the need for adherence to protocols, education of patients and physicians, and awareness of the impact of this strategy on patient psychology and quality of life. The Thyroid Cancer Care Collaborative (TCCC) is a portable record keeping system that can manage a mobile patient population undergoing active surveillance. CONCLUSION: With proper patient selection, organization, and patient support, active surveillance has the potential to be a long-term management strategy for select patients with PTMC. In order to address the challenges and opportunities for this approach to be successfully implemented in the U.S., it will be necessary to consider psychological and quality of life, cultural differences, and the patient's clinical status.

CIRCULATING THYROID-STIMULATING HORMONE RECEPTOR MESSENGER RNA AS A MARKER OF TUMOR AGGRESSIVENESS IN PATIENTS WITH PAPILLARY THYROID MICROCARCINOMA.

BACKGROUND: We have previously shown that thyroid-stimulating hormone receptor messenger RNA (TSHR mRNA) is detectable in the peripheral blood of patients with papillary thyroid microcarcinoma (PTmC). The aim of this study was to analyze the utility of TSHR mRNA status as a marker of tumor aggressiveness in patients with PTmC. METHODS: Preoperative TSHR mRNA values were obtained in 152 patients who underwent thyroidectomy and were found to have PTmC on final pathology. Clinical parameters were analyzed from an institutional review board-approved database using χ(2) and t tests. RESULTS: Preoperatively, TSHR mRNA was detected in the peripheral blood in 46% of patients, which was less than that for macroscopic papillary thyroid carcinoma (PTC) (80%) but higher than for benign thyroid disease (18%) (P<.001). The focus of cancer was larger in the TSHR mRNA-positive group compared to the negative group (0.41 vs. 0.30 cm, respectively, P = .015). The prevalence of tall-cell variant was higher in the TSHR mRNA positive group. The rates of lymph node (LN) metastasis (16% vs. 10%), multifocality (46% vs. 49%), and extra-thyroidal extension (10% vs. 5%) were similar between the TSHR mRNA-positive and-negative groups, respectively. In patients 45 years or older, rate of LN metastasis was higher in those who were TSHR mRNA positive (10%) versus negative (2%) (P = .039). TSHR mRNA positivity predicted a higher likelihood of radioactive iodine treatment (36% vs. 17%, P = .009) postoperatively. CONCLUSION: This study shows that TSHR mRNA, which is a marker of circulating thyroid cancer cells, is detectable in about half of patients with PTmC. The positivity of this marker predicts a higher likelihood of LN involvement in patients with PTmC who are 45 years or older.

Inherited cancer syndromes and the thyroid: an update.

PURPOSE OF REVIEW: Knowledge related to hereditary thyroid cancer syndromes has expanded enormously. This review identifies contributions that have changed approaches to diagnosis and broadened treatment options for patients with hereditary medullary and nonmedullary thyroid cancers related to multiple endocrine neoplasia type 2 (MEN2), Cowden syndrome, and familial adenomatous polyposis (FAP). RECENT FINDINGS: A new risk-stratification scheme based on type of RET gene mutation informs the age at which prophylactic thyroidectomy and diagnostic screening for MEN-associated endocrine diseases should occur. Two new US Food and Drug Administration-approved targeted medical therapies are now available for medullary thyroid cancer. There is better understanding of more aggressive clinical features and increased lifetime cancer risks for patients with well differentiated thyroid cancers as part of families with and without Cowden syndrome or FAP. This has led to a clearer appreciation for the role and timing of thyroid ultrasound screening in these populations. It has also informed the appropriate extent of thyroid surgery and the circumstances in which prophylactic thyroidectomy is reasonable to consider as part of hereditary syndromes other than MEN2. SUMMARY: Recognition and early diagnosis of these syndromes allows for comprehensive medical care and may improve thyroid cancer-related outcomes. Ultrasound-based screening programs to detect thyroid disease are advised for patients and family members with hereditary cancer syndromes.

Parathyroid nuclear scan. A focused review on the technical and biological factors affecting its outcome.

OBJECTIVE: Technetium Parathyroid Scintigraphy (TS) is the most popular noninvasive localization procedure in patients with primary hyperparathyroidism (PHPT). Awareness of various factors involved in technetium uptake helps understand the outcome of TS. METHODS: We utilize a case of changing TS scans in a patient to review the literature on the various biological and technical factors involved in technetium uptake by the abnormal parathyroid tissue. A 56 year female was diagnosed with PHPT and osteopenia. An initial scan using (99m)Tc-Tetrofosmin showed no definite areas of abnormal parathyroid tissue. Patient refused surgical exploration, was started on Bisphosponates and subsequently monitored. Five years later she suffered fracture of her right wrist. A repeat TS using (99m)Tc-Sestamibi revealed hypervascular parathyroid lesion in the right lower neck. She underwent successful removal of a right lower parathyroid adenoma. RESULTS: Technical factors like the type of Tc isotope used, imaging techniques and biological factors like biochemical parameters (calcium, vitamin D levels), adenoma size, content of oxyphilic cells, vascularity can affect the outcome of the scan. CONCLUSION: Clinicians should be aware of technical and biological factors that could result in negative scan in parathyroid nuclear scintigraphy.

Anaplastic thyroid cancer in young patients: a contemporary review.

PURPOSE: Little is known about prognostic factors and treatment outcomes in young patients with anaplastic thyroid cancer (ATC). The goal of this study is to define the clinical features of this subgroup. MATERIAL AND METHODS: Patients age 55 or younger with either ATC or well-differentiated thyroid cancer (WDTC) with anaplastic changes were identified using electronic medical record at the Cleveland Clinic. The same number of patients older than 55 was randomly selected to serve as control. Progression-free survival (PFS), overall survival time (OST) and cause-specific mortality (CSM) were measured against age, tumor histology, extent of disease, and treatment modalities. RESULTS: Twelve patients age 55 or younger were identified. The median age was 51 years. Four patients had WDTC with anaplastic components--mixed tumor group (MTG). Their median PFS, OST, and CSM at 24 months were 21.5 months, 51 months, and 25%, respectively. For the other 8 patients who had pure ATC, their median PFS, OST, and CSM were 3.5 months, 6 months, and 100%, respectively. Patients in the MTG had better survival compared to the pure ATC and control group in terms of PFS (p = 0.0047 and p = 0.0053), OST (p = 0.0028 and p = 0.0029) and the CSM at 24 months (p = 0.0339 and p = 0.0096). In the pure ATC group, patients with positive cervical lymph node and distant metastases had similar overall survival outcomes (6 vs. 8 months, p = 0.4995). CONCLUSION: Prognostic factors favoring survival in young patients with ATC include ATC arising within WDTC. Once full anaplastic transformation occurs, age was not a significant factor in survival.

The use of the harmonic scalpel versus knot tying for modified radical neck dissection.

BACKGROUND: Although the utility of the harmonic scalpel (HS) in thyroidectomy has been extensively demonstrated, there is little experience regarding its use for neck dissections. METHODS: Within 10 years, 119 patients underwent modified radical neck dissection (MRND) for thyroid cancer. In 51 patients, MRND was performed using conventional knot tying and in 68 using the HS. The number of lymph nodes (LNs) removed, operative time, estimated blood loss (EBL), drain output, duration of the drainage, and complications were compared for 47 patients undergoing first-time unilateral MRND without concomitant additional surgical procedures. RESULTS: The number of LNs removed, operative time, duration of drainage, and rate of lymphatic leak were similar between groups. For the HS group, EBL (5 ± 3 vs 32 ± 10; P = .006) and drain output on postoperative day 1 (51.7 ± 6.2 vs 78.9 ± 11.9; P = .02) and at 1 week (6.1 ± 1.2 vs 10.2 ± 1.8, respectively; P = .03) were significantly less. CONCLUSION: Despite the limitations of its retrospective nature, this study shows that the HS reduces EBL and the amount of lymphatic drainage compared to knot tying after MRND.

A multicenter evaluation of near-infrared autofluorescence imaging of parathyroid glands in thyroid and parathyroid surgery.

BACKGROUND: The usefulness of incorporating near-infrared autofluorescence into the surgical workflow of endocrine surgeons is unclear. Our aim was to develop a prospective registry and gather expert opinion on appropriate use of this technology. METHODS: This was a prospective multicenter collaborative study of patients undergoing thyroidectomy and parathyroidectomy at 7 academic centers. A questionnaire was disseminated among 24 participating surgeons. RESULTS: Overall, 827 thyroidectomy and parathyroidectomy procedures were entered into registry: 42% of surgeons found near-infrared autofluorescence useful in identifying parathyroid glands before they became apparent; 67% correlated near-infrared autofluorescence pattern to normal and abnormal glands; 38% of surgeons used near-infrared autofluorescence, rather than frozen section, to confirm parathyroid tissue; and 87% and 78% of surgeons reported near-infrared autofluorescence did not improve the success rate after parathyroidectomy or the ability to find ectopic glands, respectively. During thyroidectomy, 66% of surgeons routinely used near-infrared autofluorescence to rule out inadvertent parathyroidectomy. However, only 36% and 45% felt near-infrared autofluorescence decreased inadvertent parathyroidectomy rates and improved ability to preserve parathyroid glands during central neck dissections, respectively. CONCLUSION: This survey study identified areas of greatest potential use for near-infrared autofluorescence, which can form the basis of future objective trials to document the usefulness of this technology.

Diagnostic accuracy of surgeon-performed ultrasound-guided fine-needle aspiration of thyroid nodules.

BACKGROUND: There is scant data concerning surgeon-performed thyroid fine-needle aspiration (FNA), and controversy regarding its accuracy in larger nodules. This study aimed to specifically assess accuracy of surgeon-performed ultrasound (US)-guided FNA on a per-nodule basis, with a subanalysis of nodule size. METHODS: Data of 1,000 surgeon-performed US-guided thyroid FNAs at a single institution from 2000 to 2010 were prospectively collected. Standard clinical information, FNA results using the Bethesda criteria, and final histology were recorded. RESULTS: Fine-needle aspiration results were reported as: cancer (7%), suspicious for cancer (2%), suspicious for follicular neoplasm (17%), atypia of unknown significance (AUS) (1%), benign (67%), and insufficient (6%). Of nodules with FNA results of cancer, suspicious for cancer, suspicious for follicular neoplasm, and atypia of unknown significance, 94% were operated on, with malignancy rates of 97%, 58%, 21%, and 12%, respectively. Of nodules with benign FNA, 26% underwent surgery for associated symptoms, concerning features, or other remote pathology. A total of 56% were followed, and 18% were lost to follow-up. Of nodules with insufficient FNA, 46% had repeat FNA (yielding a diagnosis in 81%), 23% underwent surgery, 21% with hypocellular features were followed, and 9% were lost to follow-up. In size subanalysis, there was no statistically significant difference in risk of malignancy or increased rate of falsely negative FNA with increasing nodule size. CONCLUSIONS: The Bethesda system appropriately stratified lesions for risk of malignancy, and repeat FNA had high diagnostic yield in lesions with inadequate FNA. The results suggest no trend toward larger lesions harboring thyroid malignancy nor an increased likelihood of false-negative benign FNA.

A new classification of positive sestamibi and ultrasound scans in parathyroid localization.

BACKGROUND: Ultrasound (US) and sestamibi (MIBI) are traditionally considered positive or negative. The purpose of this study was to define and test a new scoring system for MIBI and US and to determine whether this can improve their accuracy for primary hyperparathyroidism. METHODS: This is a prospective study of 200 consecutive patients with primary hyperparathyroidism who had a single uptake on MIBI scans before bilateral neck exploration at a tertiary academic center between 2007 and 2008. These patients also had surgeon-performed neck US in the office, which was scored as "typical" or "atypical" based on how characteristic the image resembled a parathyroid gland. The MIBI uptake was scored by the nuclear medicine specialist as "weak," "moderate," or "strong" compared with the signal intensity of the thyroid. US and MIBI scoring was done preoperatively and their findings were compared with operative data. RESULTS: Of 200 patients, 71 % had a single adenoma, 12 % had double adenomas, and 17 % had four-gland hyperplasia. A weak, moderate, and strong signal on MIBI had an accuracy of 23, 47, and 72 %, respectively, in demonstrating single-gland disease. An atypical versus typical US appearance was accurate in 55 and 74 % of the time, in identifying single-gland disease. CONCLUSIONS: An appraisal of US and MIBI positivity in relation to image characteristics affects the reliability of both studies. This information should be kept in mind when selecting patients for focal neck exploration.

A Novel Missense CASR Gene Sequence Variation Resulting in Familial Hypocalciuric Hypercalcemia.

Background/Objective: Familial hypocalciuric hypercalcemia (FHH) is an uncommon cause of hypercalcemia; however, it is important to consider and rule out in patients with suspected primary hyperparathyroidism (PHPT), ideally, before proceeding with surgery. Herein, we present a patient where this process identified a calcium-sensing receptor gene (CASR) sequence variant currently labeled as a variant of unknown significance (VUS), yet the patient's family pedigree suggests that it is in fact a pathogenic CASR sequence variant. Case Report: A 35-year-old woman was referred to the Endocrine Surgery clinic for evaluation of "recurrent PHPT" and need for reoperative parathyroidectomy. Before referral, she was treated with subtotal parathyroidectomy for the presumed diagnosis of PHPT-related symptomatic hypercalcemia. Postoperatively, she had persistent symptoms. Upon referral, additional relevant information was elicited that suspected FHH instead of PHPT, including a family history of hypercalcemia with CASR VUS in multiple family members and hypocalciuria in the patient. She underwent genetic testing revealing a missense CASR VUS in exon 3 c.392C>A (p.Ala110Asp), the same as in her mother. Medical management instead of reoperation was advised for the diagnosis of FHH. Discussion: To our knowledge, this CASR sequence variation has not been previously reported in the literature. Reporting newly discovered sequence variations with the context of a family's medical history is important because it allows for the recognition of new pathogenic variants. This expands the registry of already known sequence variations and their associated clinical pathology for future patients undergoing genetic testing. Conclusion: This CASR variant represents a novel pathogenic sequence variation causing FHH.

Screening for thyroid cancer in patients with familial adenomatous polyposis.

OBJECTIVE: Clarify the incidence of thyroid cancer in patients with Familial adenomatous polyposis (FAP) in a prospective study of thyroid neck US screening. BACKGROUND: FAP is a hereditary disease predisposing to cancer in multiple organs, including the thyroid. However, routine thyroid screening for FAP patients is not generally practiced in the United States. Here, we report the initial results of a prospective thyroid cancer screening program in patients with FAP. METHODS: At the time of yearly gastrointestinal follow-up, every FAP patient in our registry was offered thyroid ultrasound (US) performed by experienced endocrine surgeons. Clinical findings related to thyroid disease were analyzed for those patients who completed screening from August 2008 to December 2009. RESULTS: : Of 192 screened FAP patients, 72 (38%) had thyroid nodules and 5 (2.6%) had thyroid cancer. Three of 5 patients with FAP and thyroid cancer were women. Four of 5 patients had the multifocal papillary type with mean size 15 mm. Clinical history and neck exam did not detect any of the 5 cancers. CONCLUSION: The incidence of thyroid cancer among FAP patients is high. Medical history and exam are inadequate to identify patients with thyroid cancer, thus thyroid screening with US is warranted.

Allotransplantation of cryopreserved parathyroid tissue for severe hypocalcemia in a renal transplant recipient.

We report the successful allotransplantation of cryopreserved parathyroid tissue to reverse hypocalcemia in a kidney transplant recipient. A 36-year-old male received a second deceased donor kidney transplant, and 6 weeks later developed severe bilateral leg numbness and weakness, inability to walk, acute pain in the left knee and wrist tetany. His total calcium was 2.6 mg/dL and parathormone level 5 pg/mL (normal 10-60 pg/mL). He underwent allotransplantation of parathyroid tissue cryopreserved for 8 months into his left brachioradialis muscle. Immunosuppression included tacrolimus (target C(0) 10-12 ng/mL), mycophenolate mofetil and steroids. Within 2 weeks, the left knee pain, leg weakness and numbness resolved, and by 1 month he could walk normally. After a peak at month 2, his parathyroid hormone (PTH) level fell to <10 pg/mL; therefore at month 3 he received a second parathyroid transplant from the same donor. Eight months later (11 months after initial graft) he has a total calcium of 9.3 mg/dL, PTH level 15 pg/mL and is clinically asymptomatic. The amount of parathyroid tissue needed to render a patient normocalcemic is not known. In our case, the need for second transplant suggests that the amount of tissue transferred for an allograft may need to be substantially greater than for an autograft.

Circulating thyrotropin receptor mRNA as a novel marker of thyroid cancer: clinical applications learned from 1758 samples.

OBJECTIVES: Since thyroglobulin, no new blood tests for differentiated thyroid cancer (DTC) have been introduced into routine clinical practice. In initial studies, the detection of circulating DTC cells by thyrotropin receptor (TSHR) mRNA measurement distinguished benign from malignant thyroid diseases. This prospective validation study tests the ability of TSHR mRNA to diagnose DTC preoperatively and to detect cancer recurrence. METHODS: TSHR mRNA was measured by quantitative RT-PCR from blood drawn perioperatively in patients undergoing thyroid surgery (n = 526), postoperatively in patients undergoing DTC follow-up (n = 418) and in patients monitored for known benign disease (n = 151). The reference range and applications for TSHR mRNA were previously defined from 663 samples from patients with normal, benign, and malignant thyroid disease. RESULTS: In patients with follicular neoplasms or suspicious cytology, preoperative TSHR mRNA >1 ng/µg had 96% predictive value for DTC, whereas 95% of patients with undetectable mRNA and benign thyroid sonography had benign disease. In patients with DTC, elevated TSHR mRNA levels became undetectable in all patients (n = 64) on the first postoperative day, except in 5 who manifested persistent or recurrent cervical disease within the year. In long-term follow-up of DTC patients with thyroglobulin antibodies, 96% with undetectable TSHR mRNA also had no evidence of cancer recurrence. CONCLUSIONS: TSHR mRNA provides an additional clinical tool for the evaluation of patients with thyroid nodules. It is particularly useful in guiding appropriate initial surgery for follicular neoplasms. TSHR mRNA also represents a new blood test to aid assessment of disease status in thyroid cancer follow-up.

Normalization of 2-week postoperative parathyroid hormone values in patients with primary hyperparathyroidism: four-gland exploration compared to focused-approach surgery.

BACKGROUND: Elevation of parathyroid hormone (PTH) levels is commonly seen in patients with primary hyperparathyroidism (PHPT) who have undergone parathyroidectomy. This study evaluates differences in 2-week postoperative PTH levels in patients having focused-approach surgery versus four-gland exploration. METHODS: Over 6 years, patients at Rhode Island Hospital (RIH) and the Cleveland Clinic (CCF) who had PHPT and underwent localization studies suggestive of single adenoma were analyzed. At RIH patients underwent focused-approach surgery, and at CCF routine four-gland exploration was performed. Postoperative calcium supplementation was routine at RIH and selective at CCF. RESULTS: There were 308 patients at RIH and 370 at CCF. They were similar in age (59.2 +/- 13.0 years at RIH and 60.4 +/- 12.9 years at CCF), and sex (76.9 and 80.0% female at RIH and CCF, respectively). The mean preoperative serum calcium measured 10.9 +/- 0.7 mg/dl at RIH and 11.1 +/- 0.7 mg/dl at CCF (P < 0.001). Preoperative PTH values were similar, measuring 143.8 +/- 104.8 pg/ml in the focused-approach group (RIH) and 157.6 +/- 150.3 pg/ml in the four-gland exploration group (CCF). Preoperative 25-hydroxyvitamin D (vitamin D-25) levels were 24.1 +/- 12.0 ng/ml at RIH and 27.4 +/- 10.6 ng/ml at CCF; and the prevalence of vitamin D-25 deficiency (level <20 ng/ml) was 43.9% at RIH and 27% at CCF (P = 0.017). The proportion of patients whose intraoperative PTH value dropped by >or=50% prior to completion of surgery was 95.0% at RIH and 95.5% at CCF. The total gland weight resected per patient was 942 mg at RIH versus 1,394 mg at CCF (P = 0.003). The 2-week postoperative serum PTH was >65 pg/ml in 18.8% at RIH and in 38.7% at CCF (P < 0.001). The 2-week postoperative serum calcium values dropped to 9.2 +/- 0.6 mg/dl at RIH and to 9.5 +/- 0.8 mg/dl at CCF (P < 0.001). The incidence of multigland disease was 5.8% at RIH and 21.9% at CCF (P

The role of parathyroidectomy in treating hypertension and other cardiac manifestations of primary hyperparathyroidism.

Among many recognized sequelae of primary hyperparathyroidism (PHPT), cardiovascular disease remains incompletely understood as a consequence of disordered calcium and parathyroid hormone (PTH) metabolism. While population studies have identified trends that associate PHPT with hypertension, metabolic syndrome, and vascular system calcifications, the fundamental pathophysiology, natural history, and opportunity to reverse or cure the cardiovascular effects with parathyroidectomy are not well established. This chapter reviews the current knowledge of this field of interest within PHPT and summarizes key findings from dedicated investigations that have addressed the impact of parathyroid surgery on the cardiovascular system.

Post-thyroidectomy emergency room visits and readmissions: Assessment from the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP).

BACKGROUND: This study analyzed independent factors associated with post-thyroidectomy Emergency Room (ER) visits and Hospital Readmissions (HR). METHODS: This is a retrospective review from the CESQIP registry of 8381 thyroidectomy patients by 173 surgeons at 46 institutions. A total of 7142 ER visits and 7265 HR were analyzed. Multivariable logistic regression analysis was performed to determine the risk factors for an ER visit or HR. RESULTS: Within 30-days of surgery, rates of all ER visits were 3.4% (n = 250) and all HR were 2.3% (n = 170). Hypocalcemia was the reason for 21.9% of ER encounters and 36.4% of HR. BMI >40 kg/m2 was a risk factor for both ER visit (OR1.86) and HR (OR1.94). Surgical duration >3 h (OR2.63), and transection of recurrent laryngeal nerve (OR4.58) were risk factors for HR. CONCLUSIONS: Strategies to decrease hypocalcemia and improve perioperative care of patients with BMI >40 kg/m2 may improve post-thyroidectomy outcome.