Clinico-pathologic profile and outcomes of pediatric endocrine patients managed by endocrine surgeons: Experience over three decades in a tertiary center in India.

BACKGROUND: Pediatric endocrine disorders requiring surgical intervention are rare and so are experienced surgeons dealing with these. The aim of the current study was to investigate disease profile and perioperative outcome of pediatric patients with surgical endocrine disorders in an endocrine surgery unit. METHODS: This retrospective study (Sep 1989-Aug 2019) consisted of pediatric endocrine surgery patients (<18 years) who were managed by a team of pediatric endocrinologists and endocrine surgeons at our center. Patients were divided into three cohorts consisting of a decade each. Clinico-pathologic variables, perioperative events operative and follow-up details were recorded. RESULTS: A total of 332 children were included and their mean age was 14.6 ± 3.9 years (M:F = 1:1.6). Thyroid disorders were most prevalent (59.8%), followed by adrenal (28.2%), parathyroid (10.4%), and pancreas (1.5%). Incidence of benign, malignant, and congenital/developmental disorders were 65.4, 28.1 and 8.3, respectively. Familial association was observed in 8.9% children, which is highest among pheochromocytoma patients. Overall, 201 thyroidectomies + associated procedures, 35 parathyroidectomies, 96 adrenal and paraganglioma resections, and 5 pancreatic procedures were performed. Median hospital stay was 5.6 ± 4.1 days. The number of cases increased significantly over 3 decades. Clinical profile and outcome did not vary except for significant decrease in incidence of malignant pathology (p = 0.04) and increase in VHL cases (p = 0.04) in the last decade though overall increase in familial cases was nonsignificant (p = 0.11). No perioperative mortality was observed except for 3% after adrenalectomy. CONCLUSION: A team of dedicated endocrine surgeons and pediatric endocrinologists is effective in management of pediatric endocrine surgery.

Total vs less than total thyroidectomy for benign multinodular non-toxic goiter: an updated systematic review and meta-analysis.

BACKGROUND: We have performed an updated meta-analysis of randomized controlled trials (RCT) comparing total thyroidectomy (TT) with less than total thyroidectomy (LTT) for benign multinodular non-toxic goiter (BMNG). OBJECTIVES: The objective was to evaluate the effects and outcomes of TT as compared to LTT. METHODS: Eligibility criteria: RCTs comparing TT vs LTT. INFORMATION SOURCES: PubMed, Embase, Cochrane Library and online registers were searched for articles comparing TT with LTT. Risk of bias: Articles were assessed for risk of bias using the Cochrane's revised tool to assess risk of bias in randomized trials (RoB 2 tool). SYNTHESIS OF RESULTS: The main summary measures were risk difference using a random effects model. RESULTS: Five randomized controlled trials were included in the meta-analysis. Recurrence rate was lower for TT compared to LTT. Adverse events like temporary or permanent recurrent laryngeal nerve (RLN) palsy and permanent hypoparathyroidism were similar in both groups except for the rate of temporary hypoparathyroidism which was lower in the LTT group. DISCUSSION: All studies had unclear risk of bias for blinding of the participants and personnel and high risk of bias for certain selective reporting. This meta-analysis did not show any clear benefit or harm of either procedure (TT vs LTT) for goiter recurrence and re-operation rates (for both recurrence and incidental thyroid cancer). However, re-operation for goiter recurrence was significantly higher in the LTT group based on a single RCT. Evidence suggests increased rates of temporary hypoparathyroidism with TT but there was no difference in the rate of RLN palsy and permanent hypoparathyroidism between the two methods. The overall quality of evidence was low to moderate.

Clinical, Biochemical, Tumoural and Mutation Profile of VHL- and MEN2A-Associated Pheochromocytoma: A Comparative Study.

OBJECTIVE: To compare clinical, biochemical, tumoural and mutational characteristics of Von Hippel Lindau Syndrome (VHL)-associated pheochromocytoma (PCC) to multiple endocrine neoplasia 2A (MEN2A)-associated pheochromocytoma. DESIGN: Retrospective study design in a tertiary health care centre in Northern India. METHODS: A total of 47 patients with biochemical and histologically proven pheochromocytoma/paraganglioma (PCC/PGL): 29 associated with VHL and 18 with MEN2A, were divided in two cohorts, respectively. Analysis of their medical records along with a prospective follow-up was done. RESULTS: There were more children <19 years in VHL group (13 vs 1). Despite majority of VHL-PCC showing elevation of normetanephrine (NMN) (93%) as compared to MEN2A-PCC (22.2%), 75.8% presented with hypertension as compared to MEN2A (33.3%). The average size of VHL-PCC tumours was 5.66 cm. VHL-PCC as compared to MEN2A-PCC were multifocal (75% vs 61.1%), bilateral synchronous (72.4 vs 61.1%) and extra-adrenal (17.2% vs 0%). Both VHL (24%) and MEN2A-PCC (27.7%) showed multiple nodules, but more MEN2A PCC showed extra-tumoural hyperplasia (44.4% vs. 6.8%). In VHL, the commonest mutation (n = 17) was missense mutation with a hot spot on exon 3, while in MEN2A-PCC majority (66.6%) had 634 mutation in exon 11 and only 2 patients had the rare 611 mutation in exon 10. CONCLUSION: In contrast to world literature, our study suggests Indian VHL-PCC can be symptomatic in spite of noradrenergic phenotype, large in size and multifocal. Multiple nodules in VHL-PCC could increase risk of recurrence following subtotal adrenalectomy.

Hereditary Medullary Thyroid Carcinoma: Genotype, Phenotype and Outcomes in a North Indian Cohort.

BACKGROUND: Aggressiveness of hereditary medullary thyroid carcinoma (hMTC) has been conventionally described to correlate with American Thyroid Association (ATA) risk groups based on RET mutations. Recent evidence increasingly contradicts this notion. We studied the RET genotype and its correlation with disease phenotype and survival outcomes in a cohort of hMTC patients. METHODS: In a retrospective cohort of 55 hMTC patients from 23 families treated at a north Indian tertiary care institute over 15-years, RET genotype was correlated with disease phenotype (clinical, biochemical, and pathological attributes) and outcomes in terms of biochemical cure (normalization of serum calcitonin), structural cure, overall survival (OS) and disease specific survival (DSS). RESULTS: Forty-nine patients had Multiple Endocrine Neoplasia (MEN)-type 2A syndrome, 02 had MEN-2B, and 4 had familial MTC. Two patients belonged to highest ATA risk, 41 to high-risk, and 12 to moderate risk categories. Age of the patients or stage of disease at presentation did not differ significantly between the ATA risk groups. Though the baseline serum calcitonin was significantly higher in highest risk category, the biochemical cure rates were not significantly different. At a median follow up of 48 months (Inter-quartile range 18-84, range 12-192) structural cure rates in ATA moderate and high risk groups were significantly higher than highest risk group (p = 0.04). No significant difference in OS between the three ATA groups of hMTC among the patients who underwent surgical treatment was observed (p = 0.098). CONCLUSIONS: The ATA moderate and high risk groups have better structural cure rates compared to ATA highest risk group. The biochemical cure and overall survival rates did not significantly differ between ATA risk-groups, and were impacted by the disease stage at presentation. The current ATA risk-groups do not reliably predict the outcomes in terms of biochemical cure and survival in hMTC patients.

Pediatric Primary Hyperparathyroidism: Experience in a Tertiary Care Referral Center in a Developing Country Over Three Decades.

BACKGROUND: There is limited experience in managing pediatric primary hyperparathyroidism (PHPT). The aim of this study was to analyze the clinical presentation and outcome of surgery in children with PHPT managed at a tertiary referral center. METHODS: This retrospective study (September 1989-August 2019) consisted of 35 pediatric PHPT patients (< 18 years) who underwent parathyroidectomy. Clinico-pathologic profile and outcome were noted. RESULTS: The mean age of cohort was 15.2±2.9 years and girls outnumbered boys (M:F = 1:1.9). Familial and symptomatic disease was noted in 8.5 and 94.3% cases, respectively. Skeletal manifestations (83%) were the commonest followed by renal (29%). Fifty-four percent children had skeletal fractures, and 23% were bed-ridden. Among rare manifestations, hypercalcemic crisis, recurrent pancreatitis and stigmata of rickets were observed in 2.8, 11.4 and 14.2% children, respectively. Mean calcium concentration was 12.1 ± 2.0 mg/dl and PTH 91.8 ± 66.5 pmol/L. The sensitivity of preoperative imaging in parathyroid localization was 91.4%. Minimally invasive parathyroidectomy (MIP) was performed in 40% cases. Parathyroid adenoma was observed in 91.4% patients, whereas remaining had hyperplasia. Thirty-four percent suffered from Hungry bone syndrome in postoperative period. The cure rate following primary surgery was 97%. One child with persistent PHPT had successful re-operation. Median follow-up was 5 (1-17) years, and no recurrence or familial disease was revealed during this period. CONCLUSION: Majority of pediatric patients present with symptomatic PHPT. Despite relatively high incidence of familial disease select pediatric patients can undergo successful MIP.

Smartphone-Based Application for Tele-follow-up of Patients with Endocrine Disorders in Context of a LMIC: A Compliance, Satisfaction, Clinical Safety and Outcome Assessment.

BACKGROUND: Remote video consultations are increasingly used in clinical practice, and a lot of data are emerging on its feasibility and acceptability. This study aims to bring out qualitative and quantitative data which will enhance our understanding of strengths and limitations of this media in the setting of a low- and middle-income country (LMIC). MATERIALS AND METHODS: This was a prospective study conducted from January 2017 to May 2018, at the Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India. A total of 107 patients were selected who chose remote follow-up care through social media (WhatsApp). Data were analyzed on feasibility, clinical safety, satisfaction and economic burden. RESULTS: A total of 107 postoperative patients were followed up using a social media tool. A total of 396 tele-sessions were held. The average number of tele-consultations per patient was 3.7 (range 2-6). Reasons for tele-follow-up included: confirmation of histology report (n = 92), medication dosage adjustments (n = 148), wound evaluation (n = 102), reporting of serum TSH and serum calcium levels (n = 296) and medical fitness certificate (n = 13). Wound evaluation through tele-follow-up was on par with the outpatient department (OPD) follow-up as no patient had to report to OPD for wound infection. Satisfaction level was excellent in 55% of patients and very good in 25%. 20% of the patients reported an average satisfaction level. If all of these 107 patients would have come to our OPD follow-up, they would have traveled 613.2 miles (908 km) per patient on an average, apart from losing work hours. Average cost and workdays saved per visit were $78 and 5.4 days, respectively. CONCLUSION: Video consultation using social media tools is clinically safe and cost effective. Economic benefits far outweigh the risk of missing an adverse event, especially in the setting of low- and middle-income countries.

Endoscopic versus Conventional Thyroid Surgery: A Comparison of Quality of Life, Cosmetic Outcomes and Overall Patient Satisfaction with Treatment.

BACKGROUND: Our aim was to investigate whether the surgical approach, i.e. endoscopic (ET) versus conventional/open thyroidectomy (ConT), contributes towards the improvement in quality of life (QoL), cosmetic outcomes and overall patient satisfaction with treatment. METHODS: We conducted a prospective study (October 2016-August 2018) consisting of patients undergoing hemithyroidectomy for euthyroid, non-malignant solitary thyroid nodules (STNs). Patients were divided into two groups: Group I (ET)-41 patients and Group II (ConT)-52 patients. ET was performed via bilateral-axillo breast approach (BABA). A thyroid disease-specific questionnaire "ThyPRO-39hin" was used to evaluate pre- and post-operative QoL. Visual analogue scale (VAS) was used for post-operative pain. Cosmetic satisfaction, paraesthesia and overall satisfaction with treatment were evaluated using Likert-type verbal response scales. Pre- and post-operative scores (>6 months) were compared, and p value < 0.05 was considered significant. RESULTS: Mean age (p = 0.26), gender distribution (p = 0.07), mean tumour size (p = 0.74) and preoperative scores of QoL were comparable between the two groups. Post-operatively scores of symptom domain (p = 0.03), tiredness (p = 0.03), impaired social life (p = 0.03), cosmetic complaints (p = < 0.001) and overall QoL (p = < 0.001) were significantly better in Group I. Also, post-operative pain perception at first follow-up visit (p = 0.001) was lower in patients undergoing ET/Group I, with higher scar satisfaction scores (p = < 0.001) and overall satisfaction with treatment (p = < 0.001). Post-operative paraesthesia perception was comparable (p = 0.06) amongst the two groups. CONCLUSION: In this cohort study, patients undergoing endoscopic thyroid surgery reported superior post-operative QoL, cosmetic and overall satisfaction with treatment as compared to conventional/open thyroidectomy.

Poorly differentiated thyroid carcinoma and poorly differentiated area in differentiated thyroid carcinoma: is there any difference?

PURPOSE: Poorly differentiated thyroid carcinoma (PDTC) patients have worse outcomes than patients with differentiated thyroid carcinoma (DTC), but the implication of poorly differentiated areas (PDAs) noted in DTC is not very well understood. The aim of the present study was to compare the clinicopathologic profiles and outcomes of PDTC and DTC with PDA. METHODS: A total of 142 patients, managed at out center between September 1989 and June 2016, were enrolled in this retrospective study. Histology was reviewed, and the patients were divided in the following three groups: poorly differentiated carcinoma [PDTC; group 1 (n = 27)]; papillary thyroid carcinoma with PDA [PTC with PDA; group 2 (n = 27)]; and follicular thyroid carcinoma with PDA [FTC with PDA; group 3 (n = 88)]. Clinico-pathologic profiles and outcomes were compared between the three groups. The Kaplan-Meier method was used for survival analysis. The log-rank test and Cox regression model were used to perform univariate and multivariate analyses of the factors affecting the overall survival (OS). RESULTS: The clinical profiles of the three groups were comparable except for significantly less incidence of lymph node involvement (p = 0.002) and extra-thyroidal invasion (p = 0.002) and higher incidence of distant metastases (p = 0.01) in group 3. Median follow-up period was 47.5 months, and 5- and 10-year OS were 57 and 14%, respectively. There was no difference between OS of PDTC and DTC (group 2 + 3), but group 3 patients had significantly better OS than group 2 patients. Univariate analysis revealed that tumor size (p = 0.04), extra-thyroidal invasion (p = 0.05), lateral compartment lymphadenopathy (p = 0.002), distant metastases (p = < 0.001), absence of encapsulation (p = 0.03), and > 75% PDA (p = 0.001) were associated with worse OS. Multivariate analysis revealed tumor size (p = 0.005), distant metastases (p = 0.012), lymphadenopathy (p = 0.017), TNM staging (p = < 0.001), and PDA > 75% (p = < 0.001) to be significantly associated with OS. CONCLUSION: There is no difference in the outcomes of PDTC and DTC with PDA. However, PTC patients with PDA have worse outcomes than FTC patients with PDA. Irrespective of tumor type, the presence of more than 75% PDA in DTC is associated with adverse outcomes.

Changing Profile of Primary Hyperparathyroidism Over Two and Half Decades: A Study in Tertiary Referral Center of North India.

BACKGROUND: Most of the cases of PHPT in developing countries present in symptomatic stage, some even in very advanced stage but in recent years the trend seems to be changing. This has been corroborated from few recently published literature from developing countries. The scope of this study is to further carry out an in-depth analysis of various clinical and biochemical parameters of PHPT patients at a tertiary care center of northern India. METHODS: In this retrospective analysis, a total of 333 patients with PHPT from the year 1990 to 2016 were studied. The study population was divided into three subgroups based on the time span; 1990-1999 (n = 34), 2000-2009 (n = 112), 2010-2016 (n = 187), and clinical and biochemical parameters were compared. RESULTS: The clinical presentation has evolved progressively with increase in older age group (35 vs 39 vs 43.85, p < 0.001), less patients with musculoskeletal symptoms (85.3 vs 76.8 vs 61%, p = 0.002) and less patients with severe bone disease (29.4 vs 10.7 vs 10.7%, p = 0.088). Biochemical parameters also showed a changing trend with significant decrease in mean S. Alkaline phosphatase (1393 vs 965 vs 414.8 IU/L, p < 0.001) and S. iPTH (837.52 vs 812.89 vs 635.74 pg/mL, p = 0.02). Vitamin D nutrition status is still suboptimal but shows improvement, and more patients are insufficient as compared to previous deficient state (mean S. Vitamin D-10.31 vs 16.16 vs 25.30 ng/mL, p < 0.001). CONCLUSIONS: Our study reveals a change in trend in PHPT which is similar to evolution of this disease in western population and positively corroborated with observations from China, Hong Kong and Turkey.

Genotype-Phenotype Correlation in Indian Patients with MEN2-Associated Pheochromocytoma and Comparison of Clinico-Pathological Attributes with Apparently Sporadic Adrenal Pheochromocytoma.

INTRODUCTION: Pheochromocytoma (PCC) manifests in up to 50% of MEN2 patients. We correlated the clinico-pathological features of MEN2-associated PCC (MEN-PCC) with RET mutations and compared them with non-MEN adrenal-PCCs. METHODS: In this retrospective single institution study on a large PCC database (n = 208, 1997-2014) 24 MEN-PCC patients with known RET mutations were reviewed. Excluding 7 with incomplete data, the study cohort of 17 MEN-PCC patients from 11 kindreds (M:F::7:10) was identified. Clinical, biochemical, pathological attributes, and outcomes in the MEN-PCC group were correlated with the genotype, and further compared with non-MEN, apparently sporadic adrenal-PCCs (n = 132, excluding 37 extra-adrenal and 15 VHL/NF1/SDH-associated PCC). RESULTS: Components of MEN2 encountered included MTC in 13(76.5%), Marfanoid habitus in 2, and PHPT, cutaneous lichen amyloidosis and mucosal neuromas in 1 patient each. In 11(64.7%), PCC was the first detected MEN2 component (Symptomatic:8, Incidentaloma:3). Four (23.5%) were normotensive; 8(47.1%) had bilateral PCC (7 synchronous, 1 metachronous). Surgery for PCC included laparoscopic adrenalectomy in 12; and cortical-sparing adrenalectomy in 2 of 8 bilateral PCC patients. Mean MEN-PCC tumor size was 6.9 ± 3.9 cm, and 6(35%) had additional adrenal medullary hyperplasia. Four different genotypes were encountered, commonest involving codon 634, others being 804 and 918. Mean age in MEN-PCC (27.7 ± 12.2 years) was lower than non-MEN PCC (39.4 ± 15.7, p = 0.018). Proportion of pediatric patients (35.3% in MEN-PCC vs. 12.9% in non-MEN-PCC, p = 0.007), bilateral tumors (47.1% in MEN-PCC, 4.5% in non-MEN-PCC, p < 0.001), and adrenal medullary hyperplasia (35.2% in MEN-PCC, 0.7% in non-MEN-PCC, p < 0.001) were different. Median 24-hour urinary metanephrines was significantly higher in index MEN-PCC patients, than non-MEN-PCC (634 vs. 214 mcg/24 h, p value = 0.006), but was non-significantly higher in non-index MEN-PCC patients. Mean tumor sizes were comparable in the two groups. None of MEN-PCC patients had malignant PCC, compared to 7(5.3%) in non-MEN-PCC. CONCLUSIONS: In this cohort of MEN-PCC from India, the commonest causative RET mutations for MEN-PCC involved codon 634. MEN-PCC patients were younger, and more frequently had bilateral PCC than non-MEN disease. MEN-PCC patients in India are diagnosed with large tumors and extremely high catecholamine/metanephrine levels.

Long-Term Outcome of Follicular Thyroid Carcinoma in Patients Undergoing Surgical Intervention for Skeletal Metastases.

BACKGROUND: A large proportion of follicular thyroid carcinoma (FTC) patients in developing countries present with overt skeletal metastases (SM). These patients often require surgical interventions for prevention of morbidity, palliation of symptoms, and facilitation of radioiodine therapy (RAIT). Scarce literature is available about the long-term outcome of such patients. The aim of this study was to evaluate the long-term outcome of FTC patients undergoing surgical intervention for SM. METHODS: We retrospectively reviewed the data of FTC patients with SM (January 1990-December 2011). Out of 91 patients with SM, 32 had surgical interventions for SM. All had total thyroidectomy performed. RESULTS: The mean age of the patients was 48.5 years (M:F = 1:2). Majority (93.7%) had synchronous metastases and 22% had multiple SM. The surgical interventions for SM included: laminectomy (50%), resection of skull metastases (18.8%), resection of manubrium sterni (18.8%), partial clavicle excision (9.4%), and hemimandibulectomy (3.1%). The main intents were palliation (50%) and facilitation of RAIT (37.5%). 84% patients received RAIT. Median follow-up was 52 months (mean = 50 ± 37). Five- (56 vs 63%) and 10-year (28 vs 23%) overall survival (OS) did not differ significantly (p = 0.968) from those not having interventions for SM. On univariate analysis tumor invasion (p = 0.006) and synchronous presentation of SM (p = 0.043) were significant risk factors for OS, whereas on multivariate analysis tumor invasion (p = 0.006) was significant. CONCLUSIONS: Surgical interventions directed at SM in FTC patients with overt multiple SM might not result in improve OS. However, considering reasonable long-term survival, interventions should be considered for desired palliation and preservation of body function.

Molecular Characteristics of Large Parathyroid Adenomas.

INTRODUCTION: The clinical entity of large parathyroid adenomas (LPTAs) has not been well defined. It is speculated that LPTAs would have biochemical, histological, and molecular characteristics different from small adenomas. Our study aimed to find out occurrence of atypia and carcinomas in large parathyroid lesions and the presence of distinct molecular abnormalities in LPTAs. MATERIALS AND METHODS: We divided the parathyroid lesions into large (>7 g, i.e., LPTAs) and small (<7 g) adenomas. We performed parafibromin, APC (adenomatous polyposis coli), galectin 3, and PGP9.5 (protein gene product 9.5) analysis by immunohistochemistry in adenomas without atypia, atypical adenomas, and carcinomas. RESULTS: Mean serum calcium, alkaline phosphatase, and intact PTH were significantly higher in large parathyroid tumor group. The presence of both atypical adenoma and carcinoma was higher in large parathyroid tumor group. There was higher percentage of atypia in patients with LPTAs >10 g (33%), and 68% of tumors showed at least one marker suggestive of malignancy in this group. Detailed analysis of immunohistochemical features of LPTA >10 g revealed that six patients showed complete loss of parafibromin immunoreactivity (out of these four showed atypia), while seven showed partial loss. In histopathologically proven malignancy (n = 9), six patients showed complete loss of parafibromin staining, 5 (55%) APC negativity, and 45% showed both galectin 3 and PGP9.5 positivity. Three out of these showed all IHC markers s/o malignancy, and all of them had evidence of metastases or recurrence. 32% of atypical adenoma and 13% of atypical adenoma showed complete loss of parafibromin staining, however none developed metastases or recurrence in follow-up (median follow-up 40 months). Loss of parafibromin staining (complete or partial) was higher in LPTA group (56%) than that in small adenoma (39%); however, it was not statistically significant. APC, galectin 3, and PGP9.5 markers suggestive were higher in LPTA group but were not significant. CONCLUSION: LPTAs may show some morphological and immunohistochemical features suggestive of malignancy and can be considered a separate entity. However, the immunohistochemical markers are unable to clearly segregate those LPTAs that may show premalignant potential. Further, we would like to recommend that LPTAs showing complete parafibromin loss together with atypia should be kept under close follow-up.

Prospective study to compare peri-operative hemodynamic alterations following preparation for pheochromocytoma surgery by phenoxybenzamine or prazosin.

BACKGROUND: Prospective studies comparing the efficacy of selective versus nonselective alpha blockers for preoperative preparation of pheochromocytoma (PCC) are lacking. In this prospective nonrandomized study, we compared the outcome of preoperative preparation with phenoxybenzamine (PBZ) and prazosin (PRZ) in terms of perioperative hemodynamic alterations. METHODS: The study was conducted at a tertiary referral center from July 2010 to December 2012. Thirty-two patients with PCC underwent operation after adequate preparation with PBZ (n = 15) or PRZ (n = 17). Five pediatric and adolescent patients were excluded because of different hemodynamics in this population. Perioperative monitoring was done for pulse rate (PR) and blood pressure(BP) alterations, occurrence of arrhythmias, and time taken to achieve hemodynamic stability. Groups were compared with the Mann-Whitney test, Student's t test, and the χ2 test as applicable. RESULTS: Patients in the two groups were similar in age,gender, 24 h urinary metanephrine and normetanephrine levels, and type of procedure. Patients prepared with PRZ had significantly more intraoperative episodes of transient hypertension (systolic BP ≥ 160 mmHg) and hypertensive urgency (BP >180/110 mmHg) (p 0.02, 0.03, respectively). More patients receiving PRZ suffered from transient severe hypertension (SBP ≥ 220 mmHg) (p 0.03). The PRZ group also had more median maximum SBP (233 mmHg vs PBZ 181.5 mmHg) (p = 0.01) and lesser median minimum SBP (71 mmHg vs PBZ 78 mmHg) (p 0.03). No significant differences were found between the study groups for changes in PR, postoperative BP alterations,occurrence of arrhythmias, and time taken to achieve hemodynamic stability. CONCLUSIONS: PBZ was found superior to PRZ in having fewer intraoperative hemodynamic fluctuations.

Role of telemedicine technology in endocrine surgery knowledge sharing.

INTRODUCTION: This retrospective study was designed to assess the outcome of telemedicine technology supportive of educational collaboration among endocrine surgery peers and its impact on knowledge and skill development. MATERIALS AND METHODS: The study was carried out in the Department of Endocrine Surgery in collaboration with School of Telemedicine and Biomedical Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, during October 1999-December 2012. Telemedicine activities were divided into various modules (e.g., case/problem-based learning, clinical grand rounds, postgraduate course/continuing medical education/conference). Endocrine surgeons participating in such sessions were divided into two groups (faculty and residents). A multimodule questionnaire was constructed based on a Likert scale (2-7 points) to test various aspects (e.g., technical performance, role in knowledge exchange, skill development, level of satisfaction, and future recommendations). Responses were expressed in proportions, and the chi-squared test was used to find the differences in opinions of the study groups. RESULTS: The questionnaire was sent to 38 surgeons, of whom 36 replied (response rate, 94.74%); of these respondents, 14 were faculty and 22 were residents. More than 80% of participants felt that the technology helped in learning new things and strengthening relations with peers, whereas >90% were of the view that it helped in knowledge exchange and development of skills as well as was helpful in supporting clinical decisions. More than 90% of participants were satisfied and enjoyed using this technology and also were of the opinion that the technology should be integrated into other specialties. Satisfaction with the technology was excellent to good for 94.44% of participants. Both faculty and residents were of the same opinion, and there was no significant difference in their replies. CONCLUSIONS: Knowledge sharing in a collaborative environment using telemedicine technology has been found successful in a low-resource setting and is now adopted in the departmental educational program.

Artificial intelligence predicts normal summer monsoon rainfall for India in 2023.

Inaccuracy in the All Indian Summer Monsoon Rainfall (AISMR) forecast has major repercussions for India's economy and people's daily lives. Improving the accuracy of AISMR forecasts remains a challenge. An attempt is made here to address this problem by taking advantage of recent advances in machine learning techniques. The data-driven models trained with historical AISMR data, the Niño3.4 index, and categorical Indian Ocean Dipole values outperform the traditional physical models, and the best-performing model predicts that the 2023 AISMR will be roughly 790 mm, which is typical of a normal monsoon year.

Intra-operative parathyroid hormone kinetics and influencing factors with high baseline PTH: a prospective study.

BACKGROUND AND OBJECTIVE: Intra-operative parathyroid hormone (IOPTH) kinetics and therefore the efficacy of IOPTH utilization as a predictor of cure are likely to be affected by baseline IOPTH levels, vitamin D deficiency and parathyroid weight. PATIENTS AND METHODS: Consecutive subjects with primary hyperparathyroidism (PHPT, n = 51) undergoing parathyroidectomy with IOPTH monitoring were studied prospectively during the period October 2009-November 2011. Samples were collected pre-incision, pre-excision and post-excision (5, 10, 15 min). Iterative analysis of IOPTH kinetics and half-life calculation was carried out in subgroups. Nonparametric testing was used for group statistics. RESULTS: Hypovitaminosis D (25(OH)D3 < 50 nm) was present in 39 (76%), serum PTH > 1000 ng/l in 23 (45%), and giant parathyroid adenoma (weight > 3000 mg) in 23 (45%). The percentage drop at 10 min was significantly higher in large adenomas (weight > 3000 mg). Miami and 5 min criteria showed the highest negative predictive value and maximum accuracy. The average percentage IOPTH drop observed at 5 min post-excision was 79.8%. Kinetic analysis showed a mean half-life of PTH of 2.57 ± 0.27 min (range: 0.07-11.55). CONCLUSION: IOPTH monitoring is reliable even in patients with extremely high baseline IOPTH value, with a greater percentage drop at 5 and 10 min post-excision. In patients with high baseline IOPTH, a 50% decay in PTH value at 5 min may be indicative of cure, obviating the need for 10 and 15 min samples. IOPTH kinetics are altered by adenoma weight but not affected by vitamin D status or baseline IOPTH levels.

Quality of life (QoL) in patients with benign thyroid goiters (pre- and post-thyroidectomy): a prospective study.

BACKGROUND: Preservation of quality of life (QoL) seems an important therapeutic goal in patients with benign thyroid diseases. The aim of the present study was to investigate the impact of thyroidectomy on QoL in patients with benign goiters and to assess the significance of various factors affecting the outcome. METHODS: A prospective study consisting of 100 patients with benign goiters was conducted between November 2009 and March 2011. Patients completed a disease-specific ThyPRO questionnaire to assess QoL before and 6 months after thyroidectomy. Preoperative and postoperative scores were compared; and univariate and multivariate analyses were performed. RESULTS: Mean age of the patients was 40.5 years (M:F = 1:4.3); 82 % of the patients had nodular goiters, and the remaining 18 % had diffuse disease. None of the patients had overt thyroid dysfunction at the time they completed the questionnaire. Operative treatment for 54 % of the patients involved total thyroidectomy, whereas 46 % underwent hemithyroidectomy. None of these patients developed any permanent morbidity following surgery. Mean scores of QoL in the 12 domains examined were low and improved significantly (p < 0.001) after surgery: symptoms, 19.4 versus 0.7; fatigue, 29.5 versus 1.5; vitality, 44.4 versus 3.0; memory and concentration, 25.7 versus 1.5; nervousness, 29.6 versus 1.8; psychological well-being, 33.9 versus 1.3; mood swings, 34.9 versus 0.8; relationship, 15.4 versus 1.4; daily activity, 18.7 versus 1.3; sex life, 20.9 versus 1.7; appearance, 14.7 versus 1.0; and overall, 27 versus 5.5. On univariate analysis, weight of goiter was found to be significantly associated with improvement in the scores of the memory and concentration domain (p = 0.03). On multivariate analysis, factors significantly associated with improvement in different domains were young age (nervousness, p = 0.009), female gender (fatigue, p = 0.02), and weight of goiter (symptoms, p = <0.001; vitality, p = <0.001; and memory and concentration, p = <0.001). CONCLUSIONS: Patients with benign goiters experience significant improvement in QoL after thyroidectomy.

Seasonal dependent suitability of physical parameterizations to simulate precipitation over the Himalayan headwater.

The Himalayan ecosystem is fragile and needs robust management strategies for sustainability of natural resources such as water and vegetation. Therefore, reliable precipitation estimation becomes quite important from operational and regulation standpoints. It is crucial for numerous activities including policy/planning, agriculture, reservoir operations, disaster management, and others. In addition, reliable information on temporal variability of precipitation is also crucial for various applications such as agricultural and hydrological. The western Himalaya receives two distinct weather systems during summer and winter. Summer is responsible (largely) for rainfall and winter is for snowfall. Therefore, we hypothesize that there may not be a single set of parameterization schemes that can represent well both the weather systems. To investigate, we set up the WRF modeling system and performed six experiments with a combination of three microphysics (MP3, MP3, and WSM6) and two cumulus schemes (KF, and BMJ). It was found that the precipitation along the Himalayan foothills (near to basin terminal) is underestimated in four out of six experiments. Only experiments with BMJ cumulus scheme along with WSM6 and MP8 microphysics were able to show a considerable amount of precipitation along these foothills. It was noted that all six experiments showed high precipitation in the upstream region and over the mountain peaks and ridges in North-Western Himalaya. For DJF, each experiment was found to have large biases and none of them represented the observation with high confidence. However, the selection of observation reference data itself is a challenging task because of data paucity in this region. Therefore, the closest experiment to the most appropriate observation was selected as the reliable configuration (MP8_KF: MP8 microphysics and KF cumulus scheme) for DJF precipitation simulation. In this study we have, for the first time, reported the role of seasonal sensitivity for the climate scale simulations as we found that different schemes were suitable for different weather systems.

Assessment of swallowing function impairment in patients with benign goiters and impact of thyroidectomy: a case control study.

BACKGROUND: Swallowing-related quality of life (QoL) in patients with benign thyroid goiters is not much studied. The aim of this study was to assess swallowing function impairment in patients with benign goiters, compare it to a control population, and also find the impact of thyroidectomy and various factors on the outcome of swallowing function. METHODS: We performed a prospective case-control study from September 2009 to September 2011 which consisted of 124 patients who were to undergo primary thyroid surgery and 100 age- and sex-matched controls. A translated and validated modified swallowing quality-of-life (SWAL-QOL) questionnaire was used to assess patients' perception of dysphagia. Presurgery scores of patients and controls and pre- and postsurgery scores (>6 months after surgery) of patients were compared. RESULTS: The mean age of males and females in the control and patient groups were 37.7 vs. 39.5 years and 37.4 vs. 39.8 years, respectively. Twelve patients (9.7%) complained of dysphasia at presentation. Sixty-three patients (50.8%) underwent total thyroidectomy and 61 (49.2%) had hemithyroidectomy at the time of initial evaluation, 75, 23.4, and 1.6% of patients were euthyroid, hyperthyroid, and hypothyroid, respectively. Presurgery scores of patients in all of the 11 domains of the SWAL-QOL were lower compared to those of controls. Comparing separately with the matched controls, females had significant differences in nine domains (except for sleep and fatigue) of the SWAL-QOL questionnaire but males did not. Postoperatively, both male and female patients showed significant improvement in the scores of all the domains. Female gender, hyperthyroidism, thyroid nodularity, retrosternal extension, procedure, and weight of the resected specimen were the factors associated with significant improvement in various domains. CONCLUSION: Dysphagia seems to be an underestimated problem in patients with benign goiters. Uncomplicated thyroidectomy results in significant improvement in swallowing-related QoL irrespective of patient profile and extent of thyroidectomy.

Telemedicine: History and Success Story of Remote Surgical Education in India.

Initiation of telemedicine in medical education in India was at par with developed countries but acceptance and progress have been slow. However, the recent coronavirus disease-19 (COVID-19) pandemic leading to disruption of Halstedian model of surgical teaching has changed the traditional dynamics of perception of this mode of education. Sanjay Gandhi PostGraduate Institute of Medical Sciences (SGPGIMS), has been a pioneer and introduced the telemedicine system into surgical education as early as in year 2001. In this article, we reviewed the literature on tele-education in surgical field in Indian scenario, with particular emphasis on tele-education activities at the SGPGIMS, with respect to current thinking and future prospects on surgical training.